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Volume 2, No 4 - Fall 2002

Volume 2, No 4 - Fall 2002

Table of Contents

Adverse Outcomes of Endoscopic Retrograde Cholangiopancreatography
Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic tool into a primarily therapeutic procedure for a variety of biliary and pancreatic problems. ERCP can, however, cause a wide range of short-term complications, including pancreatitis, hemorrhage, and perforation. In general, complications appear to be associated primarily with patient-related factors and the technical skill of the endoscopist. Overall, the risk factors for complications include suspected sphincter of Oddi dysfunction and technique-related variables, such as difficult cannulation, precut sphincterotomy in inexperienced hands, failure to achieve drainage, and percutaneous transhepatic biliary access. Reviewed here are specific risk factors for post-ERCP pancreatitis and hemorrhage. A risk-factor assessment may be useful to help the endoscopist decide whether or not to perform ERCP and aids in making decisions regarding the techniques to be used. The principal strategies to reduce complications of ERCP include improving the training and education of endoscopists regarding risk factors; avoiding marginally indicated ERCP and preferentially using alternative imaging techniques; making referrals to advanced centers for complex or highrisk cases; and, in due course, concentrating ERCP practices among fewer endoscopists performing more ERCPs. [Rev Gastroenterol Disord. 2002;2(4):147–168]
Gastrointestinal Imaging Update: Swallowing Disorders and Sphincter of Oddi Dysfunction
This update focuses on swallowing disorders and sphincter of Oddi dysfunction. Anatomy and physiology of swallowing are described, as are the signs, symptoms, and etiology of swallowing disorders. The imaging of these patients, particularly with videofluoroscopic swallowing study and fiberoptic endoscopic examination of swallowing, is then discussed. Sphincter of Oddi dysfunction as a cause of postcholecystectomy syndrome as well as its classification is described. This is followed by an explanation of the roles of fatty meal sonography and hepatobiliary scintigraphy in patients with sphincter of Oddi dysfunction, particularly type II and type III. [Rev Gastroenterol Disord. 2002;2(4):169–175]
Evaluation of Chronic Diarrhea in Patients with Human Immunodeficiency Virus Infection
Chronic diarrhea is a common problem for patients with human immunodeficiency virus infection, especially those with advanced disease. The extent of evaluation and whether to do flexible sigmoidoscopy, colonoscopy, and/or upper endoscopy have been areas of significant debate. Based upon the marked improvement in long-term survival since the introduction of highly active antiretroviral therapy, a comprehensive evaluation is currently justified. A stepwise approach to the evaluation of chronic diarrhea appears to be the best approach. The first step is a history, with a focus on any association between the onset of diarrhea and the institution of protease inhibitor therapy, which is associated with significant diarrhea in many patients. If there is no temporal association with antiretroviral therapy, the next step is examination of stool for bacterial and protozoal pathogens. If the stool studies are negative, the next step is to proceed to colonoscopy. Flexible sigmoidoscopy alone has been noted to miss up to 39% of cases of cytomegalovirus colitis. The inclusion of ileoscopy and biopsy of the terminal ileum during colonoscopy has a significant yield for microsporidiosis, which may obviate the need for upper endoscopy. The highest yield can be expected in patients with fever, weight loss, and a CD4 count of under 200 cells/mm3, especially those with a CD4 count less than 50 cells/mm3. [Rev Gastroenterol Disord. 2002;2(4):176–188]
Esomeprazole: Update and Clinical Review
The U.S. Food and Drug Administration’s Nonprescription Drugs Advisory Committee and Gastroenterological Drugs Advisory Committee recommended approval of omeprazole as an over-the-counter treatment of heartburn in patients who have at least two episodes of heartburn each week. The consumer studies that have been conducted indicate that the majority of patients understand the proposed labeling and could use the proposed label to determine if the omeprazole therapy was appropriate for them. Esomeprazole is an effective agent in the treatment of gastroesophageal reflux disease (GERD) and erosive esophagitis. Newer studies continue to support its efficacy and safety in the treatment of these conditions. Several of the most recent studies have included comparisons with other proton pump inhibitors. The results of these studies indicate that all the proton pump inhibitors are effective in treating GERD and erosive esophagitis and that some patients would benefit from esomeprazole therapy. [Rev Gastroenterol Disord. 2002;2(4):189–199]