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Retroversion examination of the duodenal bulb
foration rate of 0.033 to 0.1%.2-4 Most perforations are of the stomach, hypopharnyx, and upper esophagus. Perforation of the normal ileum has been recorded after colonoscopy where adhesions from previous surgery allowed excessive small bowel distension. 5 Duodenal perforation has occurred after endoscopic retrograde cholangiopancreatography, also in the presence of adhesions. 6 Perforation of a cecal adenocarcinoma has followed esophagogastroscopy.7 Three cases of perforation of jejunal diverticulosis have followed obstruction of a distal hernia. s Distension alone does not appear to cause perforation. Provided there is no endoscopic trauma, an anatomical or pathologic abnormality must also be present. Distension in the presence of incipient obstruction caused this perforation. All patients with suspected gastrointestinal malignancy should therefore be warned of this potential risk. N. O. Aston, FRCS
A. D. Houghton, FRCS Department of Surgery Guy's Hospital London, England
REFERENCES 1. Cotton PB, Williams CB. Practical gastrointestinal endoscopy. 2nd ed. London: Blackwell Scientific Publications, 1982. 2. Sivis SE, Nebel 0, Rogers G, Sugawa C, Mandelstam P. Endoscopic complications. Results of the 1974 American Society for Gastrointestinal Endoscopy Survey. JAMA 1976;235:92830. 3. Shahmir M, Schuman BM. Complications of fiberoptic endoscopy. Gastrointest Endosc 1980;26:86-91. 4. Reiertsen 0, Skjrlltrll J, Jacobsen CD, Rosseland AR. Complications of fiberoptic gastrointestinal endoscopy-five years' experience in a central hospital. Endoscopy 1987;19:1-6. 5. Razzak lA, Millan J, Schuster MM. Pneumatic ileal perforation; an unusual complication of colonoscopy. Gastroenterology 1976;70:268-71. 6. lhre T, Hellers G. Complications and endoscopic retrograde cholangio-pancreatography. Review of the literature and presentation of a duodenal perforation. Acta Chir Scand 1977;143:167-71. 7. Weiner BC. Complications of routine diagnostic upper endoscopy. Gastrointest Endosc 1987;33:53. 8. Durning P. Surgical problems of jejunal diverticulosis. Ann R Coli Surg Engl 1988;70:185.
Retroversion examination of the duodenal bulb
Figure 1. View of the area behind the pyloris produced by
videoendoscope retroversion in the duodenal bulb.
one recent endoscopy textbook. 1 However, retroversion in the duodenal bulb is discussed in Blackstone's textbook on endoscopy.2 He does not recommend routine duodenal bulb retroversion because of the slight chance of perforation, particularly in patients with a scarred bulb, but Blackstone does recommend duodenal retroversion examination in select patients with a pediatric endoscope. Retroversion in the duodenal bulb is not regularly taught in most gastrointestinal training programs because the endoscope is too large to turn around in the confined space of the bulb without difficulty. Furthermore, the lens system may limit the view of the proximal bulb. However, with the Olympus EVIS endoscope, the combination of wide-angle lens and easy capacity to retrovert makes it simple to examine the entire duodenal bulb. Edward Burkhalter, MD Gastroenterology Service William Beaumont Army Medical Center EI Paso, Texas
REFERENCES 1. Sivak MV. Gastroenterologic endoscopy. Philadelphia: WB Saunders, 1987. 2. Blackstone MO. Endoscopic interpretation. Normal and pathologic appearances of the gastrointestinal tract. New York: Raven Press, 1984:221-2.
To the Editor: Retroversion of the endoscope in the stomach cardia and the rectum are well-established parts of routine endoscopy which allow a complete examination and reduce the chance of missing a significant lesion. Recently, we used the Olympus GIF-XV10 multipurpose videoimage gastroscope to examine the duodenum, and found it very easy to fully retrovert in the duodenal bulb. This allowed thorough examination of the area around the pyloric opening (Fig. 1). Retroversion in the duodenal bulb is not mentioned in The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or Department of Defense. VOLUME 35, NO.6, 1989
Fatal cerebral herniation from brain metastasis following fiberoptic endoscopy To the Editor: Distant metastasis related symptoms are rarely the first manifestation of gastric cancer, although headache and neurological signs suggest brain metastasis. Esophagogastroduodenoscopy (EGD) is a sensitive and accurate method for diagnosis of gastric cancer and complications are uncommon and usually minor. 1 However, fatal complications following EGD may occur at the rate of 3 per 10,000, most frequently 587
A. D. Houghton, FRCS Department of Surgery Guy's Hospital London, England
REFERENCES 1. Cotton PB, Williams CB. Practical gastrointestinal endoscopy. 2nd ed. London: Blackwell Scientific Publications, 1982. 2. Sivis SE, Nebel 0, Rogers G, Sugawa C, Mandelstam P. Endoscopic complications. Results of the 1974 American Society for Gastrointestinal Endoscopy Survey. JAMA 1976;235:92830. 3. Shahmir M, Schuman BM. Complications of fiberoptic endoscopy. Gastrointest Endosc 1980;26:86-91. 4. Reiertsen 0, Skjrlltrll J, Jacobsen CD, Rosseland AR. Complications of fiberoptic gastrointestinal endoscopy-five years' experience in a central hospital. Endoscopy 1987;19:1-6. 5. Razzak lA, Millan J, Schuster MM. Pneumatic ileal perforation; an unusual complication of colonoscopy. Gastroenterology 1976;70:268-71. 6. lhre T, Hellers G. Complications and endoscopic retrograde cholangio-pancreatography. Review of the literature and presentation of a duodenal perforation. Acta Chir Scand 1977;143:167-71. 7. Weiner BC. Complications of routine diagnostic upper endoscopy. Gastrointest Endosc 1987;33:53. 8. Durning P. Surgical problems of jejunal diverticulosis. Ann R Coli Surg Engl 1988;70:185.
Retroversion examination of the duodenal bulb
Figure 1. View of the area behind the pyloris produced by
videoendoscope retroversion in the duodenal bulb.
one recent endoscopy textbook. 1 However, retroversion in the duodenal bulb is discussed in Blackstone's textbook on endoscopy.2 He does not recommend routine duodenal bulb retroversion because of the slight chance of perforation, particularly in patients with a scarred bulb, but Blackstone does recommend duodenal retroversion examination in select patients with a pediatric endoscope. Retroversion in the duodenal bulb is not regularly taught in most gastrointestinal training programs because the endoscope is too large to turn around in the confined space of the bulb without difficulty. Furthermore, the lens system may limit the view of the proximal bulb. However, with the Olympus EVIS endoscope, the combination of wide-angle lens and easy capacity to retrovert makes it simple to examine the entire duodenal bulb. Edward Burkhalter, MD Gastroenterology Service William Beaumont Army Medical Center EI Paso, Texas
REFERENCES 1. Sivak MV. Gastroenterologic endoscopy. Philadelphia: WB Saunders, 1987. 2. Blackstone MO. Endoscopic interpretation. Normal and pathologic appearances of the gastrointestinal tract. New York: Raven Press, 1984:221-2.
To the Editor: Retroversion of the endoscope in the stomach cardia and the rectum are well-established parts of routine endoscopy which allow a complete examination and reduce the chance of missing a significant lesion. Recently, we used the Olympus GIF-XV10 multipurpose videoimage gastroscope to examine the duodenum, and found it very easy to fully retrovert in the duodenal bulb. This allowed thorough examination of the area around the pyloric opening (Fig. 1). Retroversion in the duodenal bulb is not mentioned in The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or Department of Defense. VOLUME 35, NO.6, 1989
Fatal cerebral herniation from brain metastasis following fiberoptic endoscopy To the Editor: Distant metastasis related symptoms are rarely the first manifestation of gastric cancer, although headache and neurological signs suggest brain metastasis. Esophagogastroduodenoscopy (EGD) is a sensitive and accurate method for diagnosis of gastric cancer and complications are uncommon and usually minor. 1 However, fatal complications following EGD may occur at the rate of 3 per 10,000, most frequently 587