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The concept of direct endoscopic application of a therapeutic agent on bleeding erosions at the time of diagnostic endoscopy seems rational, expedient, and readily available. Preliminary investigations indicated that certain commercially available polymers may be beneficial in coating erosions and thus preventing further acid peptic damage. In addition, the tight polymer film may aid local hemostasis. To be clinically applicable, the polymer should ideally have the characteristics listed in Table I. A mixture of equal parts of Carboset resins 514 and 525 (B. F. Goodrich Chemical Company) as a 25 g percent solution in 95% alcohol has been shown to satisfy most of these criteria well.' These compounds are non-toxic, preformed acrylic polymers which are soluble above pH 7.5 and insoluble at pH below 7.5. Thus, in the acid pH of the stomach they rapidly come out of solution to form an even, adhesive film of good tensile strength which is impermeable to hydrogen ion. Studies in rats, dogs, and pigs indicated that the polymer would not adhere to normal intact gastric mucosa. However, the polymer film was repeatedly observed to be intact 48 hours after being applied to salicylate-induced erosions in mongrel dogs. Furthermore, the polymer would be sloughed as regeneration of gastric epithelium occurred beneath the polymer film. In the above case, a terminally ill patient with recurrent hemorrhage from erosive gastritis was treated with the direct endoscopic application of this polymer after ordinary therapeutic measures had failed. The bleeding was observed to cease as the polymer spread over the erosion and solidified. At postmortem examination, 18 hours after the application of the polymer, a tightly adherent film was still present over the treated erosion, and there was no gross evidence of further bleeding from the treated area. No polymer could be observed on the adjacent intact normal gastric mucosa.
Table I Characteristics of ideal polymer for application to eroded gastric mucosa. 1. Polymer lattice structure must be impermeable to hydrogen ion.
Spontaneous gastrojejunal fistula diagnosed by endoscopy: a case report and review
CASE REPORT A 43 year old white woman had been institutionalized for several years because of schizophrenia. She was transferred to the University of Oregon Medical School Hospital in December 1973 because of a massive upper gastrointestinal hemorrhage. In March 1973 she underwent aortic and mitral valve replacement and since that time had been taking approximately 2.5 mg of sodium warfarin a day. At Dammasch State Psychiatric Hospital her medications were provided to her in daily allotments, making ingestion of aspirin or excess sodium warfarin unlikely. In addition to sodium warfarin her medications included digoxin, hydrochlorthiazide, potassium chloride solution, and trifluoperazine hydrochloride. On the day before admission she vomited 1 to 2 pints of bright red blood and passed several tarry diarrheal stools. Her blood pressure was recorded as 90170. She was given vitamin K, 10 mg 1M, digoxin 0.5 mg 1M, and metaraminol IV. Blood transfusions could not be obtained, and she was transferred to the University of Oregon Medical School Hospital the next morning. She denied any abdominal pain, heartburn, or dysphagia. There had been no past symptoms of gastrointestinal disease and no previous upper gastrointestinal series or barium enema.
Robert B. Ruskin MD Mark D. Fischer BS John R. Sandilands MD Lawrence R. Eidemiller MD Ronald M. Katon MD* Departments of Medicine and Surgery University of Oregon Medical School Portland, Oregon An institutionalized schizophrenic patient was admitted to the University of Oregon Medical School Hospital with massive upper gastrointestinal hemorrhage and was discovered to have a benign gastric ulcer and gastrojejunal fistula. Review revealed only 7 reported cases of spontaneous gastrojejunal fistula in patients with benign gastric ulcer who had not undergone previous gastric surgery.'-7 Spontaneous fistulas from benign gastric ulcer are very uncommon, although gastrocolic fistual and gastrojejunocolic fistula are more frequent than the gastrojejunal variety. The rarity of this condition and, in our case, the diagnosis by endoscopy prompted this case report and brief review.
2. Polymer cannot interfere with local hemostasis. 3. Viscosity of solution should be less than 500 centipoise to be applied through endoscopic catheter. 4. Polymer and solvenT must be non-toxic. 5. Must be stable in acid-peptic media. 6. Should adhere 10 eroded mucosa. 7. Should not adhere to normal mucosa. 8. Stable in acid-peptic environment. 9. Not absorbable by gastrointestinal mucosa. 10. Will not damage endoscopic equipment.
Our animal observations indicated that the direct endoscopic application of preformed polymers on gastric erosions was feasible and potentially of clinical benefit. Double-blind, controlled studies need to be performed to determine whether treatment with the polymer increases the rate of healing of the erosion. Our limited clinical experience with this therapeutic technic must be viewed as experimental and unproved. However, we feel that further observations and studies are warranted.
REFERENCES 1. ATHASOULIS CA, BAUM S, WALTMAN AC, RING EJ, IMBEMBa A, VANDER SALM TJ: Intra-arterial posterior pituitary extract for acute gastric mucosal hemorrhage. N EnglJ Med 290:597.1974 2. ROSCH J, DOTER CT, BROWN MJ: Selective arterial embolization: new method for control of acute gastro-intestinal bleeding. Radiology 102:303, 1972 3. BLACKWOOD WD, SILVIS SE: Electrocoagulation of hemorrhagic gastritis. Gastrointestinal Endoscopy 18:53, 1971 4. LOGAN GM: Preformed acrylic polymers in treatment of gastric lesions. Presentation-American Chemical Society meeting, Cleveland Section (unpublished), 1973 ACKNOWLEDGEMENT: The authors are indebted to David Skirball and R.). Meyer for their assistance.
GASTROINTESTINAL ENDOSCOPY
77
Figure 1. (a) Large greater curvature ulcer (arrows marking the border) with friable tissue (triangle) surrounding the fistula. (b) Plicae circularis of small bowel (arrow) seen beyond friable inflammatory tissue. On examination she was a very pale, obese woman who was alert but had poor peripheral perfusion. Atrial fibrillation with a pulse of 110 was present. Blood pressure was 80/50 supine. Neck veins were flat. There was marked cardiomegaly with a right ventricular lift. There was a grade IIINI systolic murmur at the left sternal border. The liver was not enlarged or tender, and there was no peripheral edema. The abdomen was obese, soft, and nontender. There were no abdominal scars, and her stool was melanotic. Admission laboratory data included hematocrit 15%, WBC 18,400, and BUN 26 mg. The prothrombin-proconvertin activity was 23% of normal 12 hours after receiving 10 mg of vitamin K1. Aspiration by nasogastric tube returned small amounts of blood. Three hours after admission an upper panendoscopy was performed. There was a large amount of old blood in the stomach. On the greater curvature of the antrum there was a 3 em x 4 cm ulcer with a mass of heaped up friable tissue along one border (Figure 1a). Adjacent to the friable tissue was an opening into what appeared to be the deeending duodenum (Figure 1b). The duodenal bulb could not be identified and no other outlet from the stomach was noted. Endoscopic biopsies and brushing cytology were taken from the ulcer margins. There was no further significant bleeding, and, because of the unusual and uncertain endoscopic findings, upper gastrointestinal radiography was performed without delay. It was interpreted as normal. The failure to identify the ulcer and the presence of a normal duodenal bulb on x-ray necessitated a second endoscopy on the fourth hospital day. During this examination we noted a normal pyloric channel and
Figure 2. Second barium study demonstrating fistula tract (arrow) from greater curvature to jejunum. VOLUME 21. NO.2, 1974
duodenal bulb about 5 cm distal to the ulcer crater. The ulcer itself and the opening into the small bowel were as described before, i.e., intestinal plicae immediately adjacent to the greater curvature ulcer. These findings were consistent with a gastroenteric fistula. Another barium study revealed early passage of contrast from the stomach into the proximal jejunum (Figure 2). Later review of the biopsies taken at the initial endoscopy revealed granulation tissue consistent with the base of a peptic ulcer and portions of jejunal mucosa. Brushing cytology was reported as class II. Laparotomy confirmed the diagnosis of gastrojejunal fistula extending from the greater curvature of the antrum through the transverse mesocolon to the proximal jejunum (Figure 3). There was no evidence of old inflammatory disease, tumor, adhesions or abscess formation. The fistula was divided sharply, the involved segment of jejunum resected, and enteroenterostomy performed. Hemigastrectomy, removing the involved portion of stomach, was also carried out with a Billroth II anastomosis. The patient was well without hemorrhage 3 months after operation.
Figure 3. Jejunal fistula at surgery with stomach (long arrow) separated from jejunum (short arrow).
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DISCUSSION Of the 7 perviously reported cases of spontaneous benign gastrojejunal fistula, 1 was due to a greater curvature ulcer. 7 The other ulcers were on the posterior wall of the stomach with the exception of 1 on the anterior wall. All patients had large gastric ulcers, as was the case with our patient. All had pain, vomiting, or indigestion for at least 1 week and, in most cases, for several years previous to diagnosis of the fistula. The failure of our patient to express an awareness of such symptoms prior to the hemorrhage might be explained by her severe psychiatric disorder. A large scale autopsy survey of schizophrenic males who died over 40 years of age at 29 Veterans Administration psychiatric hospitals revealed a frequency of healed and active ulcer of 6%." The authors found that the reported necropsy prevalence of peptic ulcer in the general population was 1% to 5%, with an average of 3%. This increased frequency of peptic ulcer disease in schizophrenic patients contrasts with the previously reported rarity of peptic ulcer in clinical surveys of schizophrenics. One explanation for this disparity would be failure to communicate symptoms to the physician, resulting in many ulcers' being undiagnosed at the time of death. It is also of interest that 2.4% of the patients in the study had died of direct complications of peptic ulcer. This is compared to U.S. vital statistics that show that only 1.1 % of white males over 40 who died during the years of the study had died because of peptic ulcer disease. This supports the hypothesis that early symptoms are not reported by schizophrenic patients who then developed advanced disease, as did this patient. The presence of a gastrojejunal fistula was suggested before surgery by upper gastrointestinal radiography in l3 of the 7 previously reported cases. It was missed initially in this case because ofthe superimposition of contrast in the stomach and small bowel on late films and failure of the fluoroscopist to note abnormal passage of barium earlier in the procedure. The repeated barium study located the fistula after the fluoroscopist was alerted to its presence by the second endoscopic examination. Endoscopy failed to demonstrate the fistula in the 2 previous cases in which it was performed.
Cytology
In
laparoscopic liver biopsy Nikolaus Thurnherr William H. Knapper Paul Sherlock Sidney J. Winawer
MD MD MD MD*
Gastroenterology Service Department of Medicine Memorial Sloan-Kettering Cancer Center New York
Cytologic examination of aspirates obtained by percutaneous liver biopsy has proven to be a valuable addition to histologic examination in the diagnosis of liver disease."2 The present case illustrates the application of this technic to laparoscopic liver biopsy. 'Reprint requests: Sidney J. Winawer, M.D., Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, N.Y. 10021.
Gastrocolic fistulae may occur with benign peptic disease," or malignancy of the stomach or transverse colon. 9 Gastrojejunocolic fistula is a well known complication of anastomotic ulcer repair. ' ° Gastrocolic fistulae are more common than gastrojejunal fistulas. The explanation for this may be simply anatomical, i.e., the transverse colon is in closer proximity to the stomach, whereas the transverse mesocolon must be eroded before jejunum is perforated. Operation is usually necessary in the management of gastrojejunal fistulas. Five of the 7 previously reported cases required operative intervention for intractable pain or persistent blood loss. One healed but later developed a gastrocolic fistula requiring repair.' Only 1 healed with medical therapy alone and did not recur. 2 All 6 who underwent operation did well without recurrence. Appropriate management of this patient was directed by an aggressive diagnostic evaluation including both panendoscopy and upper gastrointestinal barium study and even repeated studies as indicated. REFERENCES 1. HERTZ AF, FAGGE CH: Gastric ulcer, spontaneous gastrojejunostomy, perforation of gastrojejunal ulcer, operation and recovery. Proc Roy Soc Med 8 (1):26,1914-1915 2. CASELLAS PRo An unusual pathologic condition of the stomach with abnormal opening into the jejunum. JAMA 87:1393, 1926 3. TROITSKIY AA: Case of ulcerous gastrojejunal fistula. Vestnik Khir 60:610, 1940 4. SWARTZ WT, SHOLITON Lj: Spontaneous gastro-jejunostomy. Surgery 30:1021,1951 5. DAVEY WWP: Spontaneous gastro-jejunostomy. Proc Roy Soc Med 50:881, 1957 6. VALENTE P: Perforation of round ulcer of the stomach into a jejunal loop. Riforma Medica 72:921, 1958 7. SWARTZ Mj, PAUSTIAN FF, CHLEBORAD Wj: Recurrent gastric ulcer with spontaneous gastrojejunal and gastrocolic fistulas. Gastroenterology 44:527, 1963 8. HITCHENS EM: Benign gastric ulcer as a cause of gastrocolic fistula: Report of a case and review of the literature. Arch Surg 104:108, 1972 9. SMITH DL, DOCKERTY MB, BLACK BM: Gastrocolic fistulas of malignant origin. Surg Gynecof Obstet 134:829, 1972 10. VERBRUGGE j: Gastrojejunocolic fistulas. Arch Surg 11 :790,1925 11. HUSSAR AE: Peptic ulcer in long-term institutionalized schizophrenic patients. Psychosomatic Med 30:374, 1968 'Reprint requests: Dr. Ronald M. Katon, Department of Medicine, University of Oregon Medical School, Portland, Oregon 97201.
CASE REPORT A 60 year old white woman was admitted because of right upper quadrant pain of 3 months' duration. The only pertinent physical finding was an enlarged, firm liver extending 8 cm below the right costal margin. There was no splenomegaly or other abnormal findings in the abdomen. Rectal examination was normal. A liver scan revealed a cold area in the right lobe, and celiac angiography showed a vascular mass, 10 cm in diameter, in the same area. No abnormalities were detected in the left lobe. Percutaneous liver biopsy revealed adenocarcinoma in the right lobe (Figure 1) compatible either with bile duct carcinoma or possibly metastatic pancreatic carcinoma. Laparoscopy was performed to determine whether we were dealing with a potentially resectable primary liver tumor limited to the right lobe. At laparoscopy, the liver was noted to be diffusely enlarged with the right lobe more prominent than the left. The liver surface was smooth with no obvious metastatic deposits, and GASTROINTESTINAL ENDOSCOPY