No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Endoscopic examination of the duodenal bulb: clinical evaluation of forward- and side-viewing fibreoptic systems in 200 cases
Abstract
Two-hundred fibreoptic examinations of the duodenal bulb were carried out on 149 patients. The importance of combining the initial examination with a general endoscopic survey of the oesophagus and stomach is stressed. At the present time full examination of the duodenal bulb requires the use of both a side-viewing and forward-viewing endoscope in more than a quarter of cases. The safety and acceptability to the patient of multiple endoscopic examinations carried out as an outpatient procedure has been demonstrated, and the value of the procedure in x-ray negative dyspepsia, in the follow up of ulcer therapy, and in acute upper gastrointestinal haemorrhage has been shown.
... This revealed limited available data on orientation within the UGI tract. One paper was identified from 1992 showing only a 28% accuracy in endoscopists identifying the posterior duodenal bulb [11]. ...
Background:
Oesophagogastroduodenoscopy is the gold standard investigation for the upper gastrointestinal (UGI) tract. Orientation during endoscopy is challenging and United Kingdom training focusses on technical competence and procedural safety. The reported location of UGI pathologies is crucial to post-endoscopic planning.
Aim:
To evaluate endoscopists' ability to spatially orientate themselves within the UGI tract.
Methods:
A cross sectional descriptive study elicited, using an anonymised survey, the ability of endoscopists to orientate themselves within the UGI tract. The primary outcome was percentage of correct answers from all surveyed; secondary outcomes were percentage of correct answers from experienced vs novice endoscopists. Pearson's χ 2 test was applied to compare groups.
Results:
Of 188 respondents, 86 were experienced endoscopists having completed over 1000 endoscopies. 44.4% of respondents correctly identified the anterior stomach and 47.3% correctly identified the posterior of the second part of the duodenum (D2). Experienced endoscopists were significantly more likely than novice to identify the anterior stomach correctly [61.6% vs 31.3%, X 2 (1, n = 188) = 11.10, P = 0.001]. There was no significant difference between the two groups in identifying the posterior of D2.
Conclusion:
The majority of endoscopists surveyed were unable to identify key landmarks within the UGI tract. Endoscopic orientation appears to improve with experience yet there are some areas still not well recognised. This has potential considerable impact on post-endoscopic management of patients with posterior duodenal ulcers being more likely to perforate and associated with a higher rebleeding risk. We suggest the development of a consensus statement on endoscopic description.
... Furthermore, many patients with indirect radiological signs suggestive of ulceration, such as pylorospasm and irritability of the duodenal cap, may not have an active ulcer crater when examined endoscopically or at operation. Since the value of fibreoptic endoscopy in the diagnosis of upper gastrointestinal disease has been clearly demonstrated (McColl, 1972; Morrissey, 1972; Salmon et al., 1972; Cotton, 1973) pandendoscopy and biopsy have become routine in most gastroenterological clinics during the last four years. This present paper reports an analysis of the clinical features and laboratory data in a consecutive series of patients with peptic ulceration in whom an active benign gastric ulcer or duodenal ulcer had been seen endoscopically. ...
Clinical features and laboratory data are presented for 100 patients with benign gastric ulceration and 150 patients with duodenal ulceration confirmed endoscopically in a district general hospital unit. Abdominal pain was the commonest indication for endoscopy, but one third of examinations were performed for acute gastrointestinal haemorrhage. Although the patients were selected by referral for endoscopy their clinical presentation, age, and sex distribution were similar to those reported in previous general surveys. There were no clinical features which clearly distinguished gastric from duodenal ulceration. However, of those with gastric ulceration younger patients more often had distal ulcers and presented with pain, while elderly subjects tended to have high lesser curve involvement and presented with haemorrhage. Moreover, all females presenting with haemorrhage were aged over 50 years, while 6% of males bleeding from gastric ulceration and 40% of males bleeding from duodenal ulceration were under this age. Anaemia when present, except in two premenopausal females, indicated either a recent acute gastrointestinal haemorrhage or a coexistent second diagnosis.
... The techniques required for choledocho-pancreatography are both endoscopic and radiographic so that close cooperation with an interested radiologist employing equipment of high quality invariably produces better results. The technical details of endoscopy are now widely agreed (Cotton and colleagues, 1972; Salmon and colleagues, 1972; Blumgart and Salmon, 1973; Salmon, 1974). ...
With the advance of the fiberscope, the duodenofiberscope has become used routinely for the diagnosis of duodenal ulcers. The duodenofiberscope (Olympus JF type B) was used and 212 fiberoptic examinations were carried out in 174 patients who were clinically diagnosed as duodenal ulcers. Endoscopically, 72 of them (41%) were diagnosed as active duodenal ulcers and 36 of them (21%) were diagnosed as healing duodenal ulcers. We discussed clinical symptoms of the patients, comparisons between X-ray findings of the duodenal ulcers and serial endoscopical follow-up examinations of the active or healing duodenal ulcers. The conclusions were as follows: 1. Seventy percent of patients out of 72 who were diagnosed as active duodenal ulcers endoscopically, had epigastric pain as their chief complaints, 10 percent had melena, but 14 percent of them had no symptoms at all. On the other hand, half of the 36 patients who were diagnosed as healing ulcers endoscopically still had sympotoms, most of which were epigastric pains. 2. Compare to the X-ray examinations, more detailed inf ormations such as location, morphorogical characteristics such as active or healing, single, multiple or linear, had been obtained by the duodenofiberscope. 3. Twenty percent of patients who had duodenal ulcer endoscopically had no deformity of duodenal bulb on X-ray examinations. In the early stage of the multiple duodenal ulcer there was no deformity of the bulb noted. 4. The round or irregular shape of duodenal ulcers had tendency to repair easily. On the other hand, linear ulcers remained unchanged or recurred in a few month.
Fiberoptic examination of the upper gastrointestinal tract were carried out on 279 consecutive patients using a newly devised forward-oblique viewing endoscope (GIF-Type K), which has angles of view directed obliquely 30 degrees from the longitudinal axis of the instrument. In this series, a forward viewing instrument (GIF-D2) and side viewing ones (GTF-S2, GF-B2, and JF-B2) were also employed with GIF-K in 85 and 110 patients respectively to evaluate this new instrument in comparison with other ones. Moreover, in order to campare the diagnosis in the upper gastrointestinal tract by x-ray with those by endoscopy, GIF-K was employed in 134 of 279 patients of this series without previous reading of the x-ray pictures taken before endoscopy. The following conclusions were obtained from the data and pictures presented here. (1) The new scope (GIF-K) presented no difficulty in introduction into the esophagus, in routine manners in the stomach, and in entry into the bulb and descending duodenum because of its finger-shaped tip. (2) This scope was suitable for observing the esophagus with slightly downward flection of the tip as well as a forward viewing instrument (GIF-D2). (3) The instrument was very satisfactory and much better than GIF-D2 in the observation of the entire stomach because of its forward-oblique viewing system with wider visual/field and stronger upward flection of the tip. (4) In most cases the duodenal bulb was/easily examined wth GIF-K as well as GIF-D2; frequently the superior or anterior aspects of the bulb was better visualized by this new instrument. (5) The biopsy forceps could be oriented directly and less obliquely toward a mucosal surface because of the device for forceps elevation. (6) The instrument was not satisfactory for ductal cannulation in routine manners, however, it was very suitable for cannulation in patients with gastrojejunostomy. (7) Endoscopy with GIF-K made better results than x-ray in the examination of the upper gastrointestinal tract. (8) GIF-K was suitable not only for/diagnosis but also for therapeutic and other special employments in the upper gastrointestinal tract. © 1975, Japan Gastroenterological Endoscopy Society. All rights reserved.
Das peptische Ulcus ist eine morphologische Läsion der Schleimhaut, die sicherste diagnostische Methode ist daher die morphologische Untersuchung mit Endoskopie und Biopsie. Andere diagnostische Verfahren treten daneben in den Hintergrund.
Das peptische Ulcus ist eine gastrale oder duodenale morphologische Läsion der Schleimhaut und tieferen Wandschichten, die sicherste diagnostische Methode ist daher die morphologische Untersuchung mittels Endoskopie und Biopsie. Andere diagnostische Verfahren treten daneben in den Hintergrund.
The diagnosis of gastrointestinal disease has been influenced profoundly by the introduction of fiber-optic endoscopy. Although endoscopic examination of the interior of the bowel was first recorded by Bozzini (1807), Kussmaul (1869) was the first to examine successfully the interior of the stomach employing a 13 mm diam hollow metal tube which was swallowed by a cooperative sword swallower. The illumination source, devised by Desormeux of Paris, was, however, insufficient for the purpose.
Acid tests may be helpful in patients with X ray negative dyspepsia by suggesting that a particular patient probably has, or probably has not, duodenal ulcer disease. There is only a minimal tendency for patients with higher acid outputs to have a worse prognosis, and to be operated upon than those with lower acid outputs. This limited prognostic information does not justify routine gastric function tests on patients with known duodenal ulcer, except as part of a research program, or where the type of surgery is to be based in part on the secretory results. Acid tests are of special help to surgeons in the investigation of ulcer like symptoms after gastric surgery, both in diagnosis and in the planning of revision surgery. Routine acid tests after vagotomy may be more helpful in the assessment of the trainee vagotomist than in the assessment of the prognosis of the patient.
An improved design for fiber bundle fluorescence endomicroscopy is demonstrated. Scanned illumination and detection using coherent fiber bundles with 30,000 elements with 3 μm resolution enables high speed imaging with reduced pixel cross talk.
Upper gastrointestinal endoscopy is a valuable aid in the diagnosis of mucosal diseases involving the stomach and duodenum. Technical advances in the design of fiber optic equipment1 combined with increasing physician experience in their use have led to a safe and accurate procedure that can be accomplished quickly with only minimal discomfort to the patient. Visualized lesions are accessible to biopsy, and can be documented for future reference with still or movie photography.
A series of recent articles shows the importance of endoscopy in the evaluation of patients with diverse gastrointestinal symptoms who have normal results from barium studies of the stomach and duodenum. This is a common problem in the everyday practice of medicine.
Schuman2 reviewed the gastroscopic findings in 843 patients with persistent complaints and normal upper-gastrointestinal x-ray films. One hundred sixty-three, or 20%, were found to have mucosal diseases, including 59 patients with ulcers and
There is debate on whether the adoption of new medical technologies has been a contributing factor to rising health expenditures. This literature is critically reviewed and another approach is advocated. This alternative approach rests on the distinction between product and process innovations. It is argued that the relationship between innovations and health expenditures can be illuminated, for process innovations, by determining if they are used as substitutes. The empirical results provide no indication that alternative technologies for diagnosing diseases/conditions of the upper gastrointestinal tract have been utilised by Australian medical practitioners, operating on a fee-for-service basis, as substitutes. The study provides new empirical support for the view that medical innovations contribute to rising health expenditures.
This paper is concerned with one aspect of the assessment of a new technology — describing the temporal utilisation of the technology in use. The technologies that are considered here are barium meal radiology and fibre optic endoscopy, two major diagnostic procedures for the upper gastrointenstinal tract. The data employed relate to private fee-for-service medicine in Australia and have been collected under Australia's health insurance arrangements. Statistically significant differences in utilisation rates for these diagnostic procedures are found between the states of Australia. Also it is shown that per capita use of these procedures is rising at an annual rate of 2.4 per cent per annum. Although it is not possible from the data employed here to specify what factors have determined these utilisation rates, some possible explanations are considered. A secondary aspect of the paper is that it demonstrates how data from the Health Insurance Collection can be analysed despite the changes to health insurance arrangements introduced by the Commonwealth government since 1975–76.
Newer diagnostic procedures useful in establishing accurate indication for surgical intervention in pancreatobiliary system
have been reviewed during a five year period from 1968 to 1972.
Several organizations worldwide have developed procedure-based guidelines and/or position statements regarding various aspects of quality and safety indicators, and credentialing for endoscopy. Although important, they do not specifically address patient needs or provide a framework for their adoption in the context of endoscopy services. The consensus guidelines reported in this article, however, aimed to identify processes and indicators relevant to the provision of high-quality endoscopy services that will support ongoing quality improvement across many jurisdictions, specifically in the areas of ethics, facility standards and policies, quality assurance, training and education, reporting standards and patient perceptions.
The health sectors in many countries have been increasing in relative size, and medical innovations have been identified by some as a factor contributing to the rise in health expenditures. This paper begins by reviewing the various approaches that economists have employed to determine the connection, if any, between rising health expenditures and new medical technologies. It is then argued that another way to approach the issue is to determine if innovations have substituted for previously existing technologies. Thus this method cannot be applied to product innovations: it is restricted to process innovations. This procedure is applied to the innovation of fibre optic colonoscopy, a procedure for diagnosing diseases/conditions in the lower gastrointestinal tract. The data relate to private medical practice in Australia which operates on a fee-for-service basis. The empirical results indicate no evidence of substitution of the 'new' for the 'old' technology. Thus, there is some reason to believe that this innovation will have contributed to rising health expenditures for diagnosis of the lower gastrointestinal tract. The paper concludes by considering policy options that could address the issue.
A double-contrast barium meal has been carried out on 37 patients in whom there had been disagreement in diagnosis between the routine barium meal and subsequent oesophago-gastro-duodenoscopy. There was an 81% agreement between the endoscopic diagnosis and the diagnosis obtained with double-contrast barium meal. Confirmation of the endoscopic and double-contrast radiological diagnosis was obtained all 11 patients who had surgical treatment. These findings suggest that a double-contrast barium meal should be routinely used in the diagnosis of dyspepsia.
Forty-six patients suffering from chronic duodenal ulcer, proven endoscopically, were treated in a randomized double-blind cross-over trial with either tri-potassium di-citrato bismuthate (De-Nol) or placebo for four weeks and assessed symptomatically and endoscopically. Those patients who failed to heal after treatment with either agent were crossed over to the alternative preparation and reassessed after a further 28 days. Forty-two patients completed the study involving 57 patient treatments. A highly significant improvement in both symptomatic response (P less than 0.01) and endoscopic healing (P less than 0.01) was seen in those patients receiving tri-potassium di-citrato bismuthate (De-Nol) as against placebo therapy.
We reviewed the records of 100 consecutive patients who had gastroscopy. All endoscopic work was done by our four-man surgical group. Roentgenographic and endoscopic diagnoses are compared with reference to degree of accuracy. The expanded uses of gastroscopy in surgical practice are illustrated and a plea is made for increased involvement of surgeons in the rapidly expanding field of endoscopy.
A prospective study of the endoscopic, radiological, and surgical features of chronic duodenal ulceration has been performed. Double contrast barium meal and upper gastrointestinal endoscopy were both performed within five days of elective surgery for chronic duodenal ulceration on 50 patients. The surgical diagnosis correlated with endoscopy in 88% and radiology in 82%, but if both techniques were employed, an accurate pre-operative diagnosis was achieved in 96% of cases. There was poorer correlation in determining the position of the ulcer within the bulb, with only 41% correlation between all three parameters and complete disagreement in 24%. Surgery correlated with endoscopy in 71% but with radiology in only 41%. The correlation between endoscopy and surgery in the diagnosis of duodenitis was only 42%, suggesting that this should be a histological diagnosis. This study suggests that endoscopy is slightly more precise than radiology in the diagnosis of chronic duodenal ulceration, but with a combination of the two techniques almost 100% accuracy can be achieved.
Smoking, heredity, aspirin ingestion, and various diseases are associated with increased prevalence of peptic ulcer disease. Significant pathophysiologic differences between ulcer patients and normal subjects have been shown to exist, but many of the observed abnormalities are still poorly understood and require further study. Prospective studies are also needed to quantitate the role of psychologic factors in the pathogenesis of ulcer disease. Ulcer disease is diagnosed by history, physical examination, upper gastrointestinal radiography, and endoscopy. In some patients measurements of serum gastrin levels and gastric acid secretion at rest and after stimulation give significant information. Antacids and anticholinergics remain the primary therapeutic agents; new therapeutic agents are currently under study.
Laparotomy performed for bleeding duodenal ulcer after diagnostic/therapeutic endoscopy revealed a disparity in location of the lesion on several occasions at our institution. The position of the duodenal lesion is important in assessing bleeding potential. Twenty consecutive patients underwent upper gastrointestinal endoscopy by a staff and trainee gastroenterologist to evaluate the ability to determine the true posterior position of the duodenal bulb. Documentation of the posterior bulb location was verified by pooled colored fluid with the patient in a supine position. True posterior location was chosen only 30% of the time by an experienced gastroenterologist. This observation may have clinical implications in assessing the patient's bleeding potential and in the use of coaptive coagulation for control of ulcer bleeding.
Eight-thousand-six-hundred-and-eighty patients were examined endoscopically over a period of six years. Significant pathological lesions were detected in 79.6% of the cases. While duodenal ulcers were seen at the same frequency as in the West, the number of gastric ulcers were considerably fewer, the ratio of gastric to duodenal ulcer being 1:8.4. Gastric cancer was also observed less commonly than in the West, but gastric lymphoma constituted 21% of all gastric malignancies. By endoscoping all bleeders within 24 hours we were able to identify the source of bleeding in 90.9% of the cases, and a lesion was detected in 96.8%. Direct visualisation of the duodenal and jejunal mucosa supported by histological examination was of paramount importance in the early detection of Immunoproliferative Small Intestinal Disease (IPSID) and its differentiation from other diseases such as tuberculosis, bilharzial jejunitis and Crohn's disease which are seen in our population.
In the context of rising health expenditures it is relevant to consider the behavior of those who, in large part, determine what medical procedures are performed on patients. The purpose of this paper is to describe the utilization of diagnostic tests of the colon in Australia. The study is restricted to private medical practitioners operating on a fee-for-service basis. Diagnosis of the gastrointestinal tract is of some interest because the new technology of fiber optic endoscopy has provided an alternative means of diagnosing diseases or conditions. The results presented here indicate rising per capita utilization rates for both the "new" technology and the "old" techniques of barium enema radiology and sigmoidoscopy. There is no evidence of the "new" technology displacing the "old" in terms of per capita use. The data may be consistent with the hypothesis that process innovations in medicine do not displace alternative products: rather they are "added on" to the existing products.
The introduction of fiberoptic endoscopy has altered the relative importance of ulcer symptoms in the diagnosis of peptic ulcer disease. Interestingly, we now realize that 50% of ulcer patients do not have the classical ulcer symptoms and that 25% of peptic ulcers are asymptomatic. Modern forward-viewing endoscopes of small diameter enable precise diagnosis with little discomfort in 95% of all duodenal ulcer patients. A biopsy is only recommended in rare cases (giant ulcers) because the malignancy rate is only 0.024% in duodenal ulcers. The diagnostic accuracy of endoscopy in detecting gastric ulcer is as high as that for duodenal ulcer, but for this ulcer type it is absolutely necessary to exclude malignancy by obtaining a minimum of six biopsies (four from the ulcer margin and two from the ulcer base), since approximately 10% of all gastric ulcers are actually carcinomas. Whereas in duodenal ulcer repeat endoscopy is seldom necessary, it is mandatory in gastric ulcer since ulcer healing is not proof of a benign ulcer. In experienced hands endoscopy is superior to radiography in duodenal and in gastric ulcer, although there is still a place for radiography as a supplementary investigation or if the patient rejects endoscopy. When selecting patients for treatment of peptic ulcer the following aspects must be considered: natural history of the disease, effectiveness of treatment, and risks and costs of treatment. Treatment goals (relief of symptoms, ulcer healing) can be achieved as far as the acute ulcer is concerned but as yet we have no evidence that we can cure chronic ulcer disease.
Duodenoscopy, cannulation of the Summary papilla of Vater, and retrograde choledochopancreatography have been attempted in 87 jaundiced patients in whom the diagnosis remained in doubt after standard investigations. Duodenoscopy and/ or retrograde choledochopancreatography gave a definitive diagnosis in 66 (75%) patients and useful information in a further 5 cases. In 15 patients, demonstration of a normal biliary ductal system excluded extrahepatic cholestasis and saved unnecessary laparotomy. Duodenoscopy and cannulation of the papilla of Vater were relatively free of complications and reduced the need for percutaneous transhepatic cholangiography. This technique offers an early definitive diagnosis in the jaundiced patient and is a welcome advance in a difficult clinical area.
In 100 consecutive major upper gastrointestinal bleeders, panendoscopy (esophagogastroduodenoscopy) was employed as the initial diagnostic procedure, and documented the source of hemorrhage in 92% of cases. The 'emergency' upper gastrointestinal series added another 2 diagnoses (duodenal ulcers missed on endoscopy). Emergency surgery also added 2 diagnoses, and in both of these patients endoscopy had directed the surgeon to the correct area of bleeding (gastric fundal ulcers). 19 fewer diagnoses would have been made if endoscopy had been limited to visualization of the esophagus and stomach.
Johansen, Aa. & Hart Hansen. O. 1973. Macroscopically Demonstrable Heterotopic Gastric Mucosa in the Duodenum. Scand. J. Gastroent. 8, 59-63.
Six cases of heterotopic gastric mucosa forming macroscopically demonstrable polyps in the duodenum are presented. The clinical features were dyspepsia and haemorrhage. Fiberoptic examination of the duodenum was performed in three patients. The polypoid structures could be visualized clearly, and the diagnosis was made by target biopsies. The microscopical examination disclosed a histological pattern indistinguishable from homotopic corpus mucosa. A pathogenetic relation to a high acid secretion is supposed. The significance of the condition with special reference to duodenoscopy and biopsies is stressed.
11 patients with upper gastrointestinal problems and normal upper gastrointestinal roentgenograms were found to have hemorrhagic duodenitis unassociated with peptic ulcer disease. The total number of patients evaluated by fiberoptic esophagogastroduodenoscopy was 135, with a frequency of 12% for hemorrhagic duodenitis. Alcohol, aspirin and other irritants may be contributory factors in some of these patients.
The endoscopic experience in a district general hospital is described in two consecutive six monthly periods during the first of which 112 patients were examined using the Olympus Duodenofiberscope model JF-B and during the the second of which 148 patients were examined using this instrument in conjunction with the Olympus Gastrointestinal Fiberscope model GIF-D. The cases examined were a group of dyspeptic patients (patients with suspected peptic ulceration with chronic anaemia, weight loss or suspected carcinoma), a group of patients with gastrointestinal bleeding and a group of patients who had undergone gastric surgery. In this total of 260 patients the duodenal bulb was examined in 169 cases. During the period when both instruments were available there was a preference for using the end viewing Olympus GIF but for a complete examination both instruments are required in a very significant proportion of cases. During the period when both instruments were available, examination of the duodenal bulb was possible in every case apart from two in which there was organic obstruction. In general with either instrument adequate histological material was obtained.
When the endoscopic and radiological results are compared it is seen that the radiologist and the endoscopist agree in over half of the cases examined. However, in the others the endoscopist plays an important part in establishing the presence of radiologically undetected or undetectable disease and in confirming or excluding radiologically doubtful disease.
A high-dose double-blind trial of carbenoxolone sodium capsules (Duogastrone) in the treatment of duodenal ulceration was combined with endoscopic diagnosis and follow-up. Thirty-one ambulant patients with an endoscopically visible duodenal ulcer were allocated at random to a 12-week course of treatment with either carbenoxolone sodium 300 mg daily or a placebo. Symptomatic and endoscopic follow-up was performed at 2-4 weeks, 6-8 weeks, and 12-16 weeks. Carbenoxolone was shown to increase the rate of healing of duodenal ulcers in the early stages of treatment, but by 12 weeks there was no difference between the two groups. There was no significant difference in symptomatic improvement between the two groups at any stage of treatment. Side effects, especially hypokalaemia, were prominent in the patients treated with carbenoxolone. There was a poor relation between endoscopic and symptomatic improvement in patients on either form of treatment.
A double-blind, placebo-controlled trial of colloidal bismuth (De-Nol) was performed on 20 patients with active duodenal ulceration employing endoscopic selection and follow up after a treatment period of 28 days. By these means it was shown that healing of ulcers was significant in those patients treated with the active compound. In addition a greater number (9/10) of patients treated with colloidal bismuth showed symptomatic improvement than those receiving placebo (6/10) but this difference did not reach statistical significance. The results of endoscopic and symptomatic assessment of the patients receiving colloidal bismuth were in complete agreement although there was a poor correlation between these results in those receiving the placebo. This supports the results from a previous study that endoscopic assessment of duodenal ulcer healing provides a more objective assessment than do clinical methods.
Establishment of an accurate indication for surgical intervention in pancreatobiliary system can only be achieved by utilizing careful case history, physical examination, biochemical test, x ray diagnostic procedures and endoscopy. Recently an array of diagnostic procedures became available in assessing pancreatobiliary lesions. Among these, the newer procedures like retrograde endoscopic pancreatography which can be used advantageously in establishing indication for surgical intervention have been reviewed during the 5 yr period from 1968 to 1972. (Journal received: July 27, 1974)
Ninety-three patients were referred to the authors for Endoscopic Retrograde Choledocho-Pancreatography (E.R.C.P.). Cannulation of the papilla of Vater was achieved in 72 of these and additional information of clinical or diagnostic value was obtained by endoscopy in 16 patients.
In 48 patients the E.R.C.P. diagnosis was confirmed at subsequent surgery or follow-up and in 8 of these cases intended laparotomy was avoided by the demonstration of normal ducts. Useful, though in some cases unconfirmed, diagnostic information was achieved in all but one of the patients where successful E.R.C.P. was carried out. Many individual cases are illustrated and discussed.
E.R.C.P. represents a major advance in the diagnosis of biliary and pancreatic disease and it has now become a well-established examination in many centres. The literature relating to E.R.C.P. has been reviewed, with particular reference to the clinical value and radiological significance of the technique.
Description of the authors' apparatus, equipment and techniques is given. The authors present a detailed critical analysis of their preferred techniques, their indications, contra-indications and complications.
A prospective study of the endoscopic, radiological, and surgical features of chronic duodenal ulceration has been performed. Double contrast barium meal and upper gastrointestinal endoscopy were both performed within five days of elective surgery for chronic duodenal ulceration on 50 patients. The surgical diagnosis correlated with endoscopy in 88% and radiology in 82%, but if both techniques were employed, an accurate preoperative diagnosis was achieved in 96% of cases. There was poorer correlation in determining the position of the ulcer within the bulb, with only 41% correlation between all three parameters and complete disagreement in 24%. Surgery correlated with endoscopy in 71% but with radiology in only 41%. The correlation between endoscopy and surgery in the diagnosis of duodenitis was only 42%, suggesting that this should be a histological diagnosis. This study suggests that endoscopy is slightly more precise than radiology in the diagnosis of chronic duodenal ulceration, but with a combination...
A multi-centre uncontrolled assessment of tri-potassium di-citrato bismuthate in the treatment of 161 ambulatory peptic ulcer patients (26 gastric, 114 duodenal, and 21 'indefinable’) was carried out under the conditions of general practice. The intensity of pain and vomiting were assessed before and after a 28-day course of treatment, as was the degree of overall symptomatic relief.
Full or great symptomatic relief was reported in 96.3% of patients, many of whom had failed previously to respond adequately to antacid or other forms of treatment.
To evaluate the impact of panendoscopy on diagnosis and management, we asked several gastroenterologists to state their diagnoses, management plans, and confidence in these plans before performing endoscopy in patients with chronic abdominal or thoracic pain; and to repeat the same decisions after endoscopy. To evaluate acceptance of the procedure, patients were later interviewed about their discomfort during its performance. To check the way that changes in diagnosis may have affected patient management, we formed six diagnostic groups that roughly correspond to differing treatments. The postendoscopic diagnostic groupings revealed two unsuspected cancers and disagreed with the original classification in 38 (45%) of 84 patients. Dramatic or substantial changes in management occurred in 37 (44%) patients, but often did not correspond to changes in diagnosis. Conversely, management was often unchanged despite alterations in diagnosis. Patients expressed about equal preferences for barium meal as for panendoscopy, and 75% would have agreed to a repeat endoscopy without hesitation. Although the ultimate benefits of postendoscopy management changes were not ascertained, we believe that these results support the use of panendoscopy in patients with persistent and unexplained symptoms.
Post-bulbar ulceration is uncommon, but a pilot study in Hyderabad showed a high incidence. We therefore carried out a prospective endoscopic study of the distribution of peptic ulceration and its relation to symptoms and demography. Of the 360 consecutive patients referred for endoscopy, 113 (92 men, 21 women) had peptic ulceration. Median age 35 years, median duration one year. Five patients (4%) had gastric ulcer, 77 (68%) had duodenal ulcer, and 31 (28%) had coexisting gastric and duodenal ulcer. The duodenal ulcer was found in the pyloric canal in 14% of patients, in the bulb in 80%, and the post-bulbar region in 56% of patients. Sixty seven per cent of duodenal ulcers were located at more than one site. The incidence of post-bulbar v bulbar ulcer was 1:1.5. Deformed bulb was seen in 50% of duodenal ulcer patients, but haemorrhage and stenosis were uncommon. Except for nocturnal pain, there were no differences in symptoms between the groups. Forty two per cent of patients smoked, 15% chewed tobacco, and 18% drank alcohol; almost all were men. Sixty four per cent drank tea. The staple diet (85%) was rice, and 70% used tamarind and spices daily. Duodenal ulcer was three times more common than gastric ulcer with a high incidence of post-bulbar and coexisting ulcer. It affected a younger and predominantly male population, and was not associated with a higher rate of complication.
The Olympus JFB fiber-duodenoscope has been used in sixty sedated hospital patients with undiagnosed persistent jaundice, recurrent biliary-tract symptoms, or suspected pancreatic disease. The descending duodenum was visualised in all patients; the papilla of Vater was cannulated under direct vision in forty-four patients (73%) and retrograde radiographs were obtained of biliary and pancreatic duct systems. This new diagnostic technique is a welcome advance in a difficult clinical area.
The Olympus JFB fiber-duodenoscope has been used in sixty sedated hospital patients with undiagnosed persistent jaundice, recurrent biliary-tract symptoms, or suspected pancreatic disease. The descending duodenum was visualised in all patients; the papilla of Vater was cannulated under direct vision in forty-four patients (73%) and retrograde radiographs were obtained of biliary and pancreatic duct systems. This new diagnostic technique is a welcome advance in a difficult clinical area.
One hundred and sixty patients have been examined with the flexible gastroduodenoscope. Passage of this instrument is easier than of the conventional gastroscope, and the stomach can be examined down to the pyloric canal and pylorus. Duodenoscopy is sometimes possible but some modification is required in order to guarantee success. Examination of a gastrojejunal stoma is practically always possible and is superior to that obtained with the gastroscope. The fibrescope can be used in patients with haematemesis within a few hours of their admission to hospital, and with it definitive early diagnosis is possible in two out of three patients.
Trial photography of the duodenal mucosa, particularly of the duodenal cap
- F Matsunaga
- Matsunaga, F.
Matsunaga, F. (1962). Trial photography of the duodenal mucosa, particularly of the duodenal cap. Endoscopy, 4, 59-63
Study of duodenoscopy by using fibergastroscope Paper read at 11th General Meeting of the
- K Takagi
Takagi, K. (1969). Study of duodenoscopy by using fibergastroscope. In Endoscopy of the Digestive System (Proceedings of the first European Congress of Digestive Endoscopy, Prague, 1968), edited by Z. Maratka and J. S6tka, pp. 70-71. Karger, Basel. S. (1969). Paper read at 11th General Meeting of the
Paper read at 4th General Meeting of the Japanese Society of Gastroenterological Endoscopy
- Ishihara, K.
Ishihara, K. (1962). Paper read at 4th General Meeting of the
Japanese Society of Gastroenterological Endoscopy.
3rd Conference of the European Association for Gastrocamera Diagnosis
- P R Salmon
- T Htut
- A E Read
Salmon, P. R., Htut, T., and Read, A. E. (1971). 3rd Conference of
the European Association for Gastrocamera Diagnosis. Walter
de Gryter, Berlin.
Paper read at 11th General Meeting of the Japanese Society of Gastroenterological Endoscopy
- Shindo, S.
Shindo, S. (1969). Paper read at 11th General Meeting of the
Japanese Society of Gastroenterological Endoscopy.
Study of duodenoscopy by using fibergastroscope
- K Takagi
- Takagi, K.