Timing of upper gastrointestinal endoscopy does not influence short-term outcomes in patients with acute variceal bleeding

AIM To examine the association between the timing of endoscopy and the short-term outcomes of acute variceal bleeding in cirrhotic patients.METHODS This retrospective study included 274 consecutive patients admitted with acute esophageal variceal bleeding of two tertiary hospitals in Korea. We adjusted confounding factors using the Cox proportional hazards model and the inverse probability weighting(IPW) method. The primary outcome was the mortality of patients within 6 wk.RESULTS A total of 173 patients received urgent endoscopy(i.e., ≤ 12 h after admission), and 101 patients received nonurgent endoscopy( 12 h after admission). The 6-wk mortality rate was 22.5% in the urgent endoscopy group and 29.7% in the non-urgent endoscopy group, and there was no significant difference between the two groups before(P = 0.266) and after IPW(P = 0.639). The length of hospital stay was statistically different between the urgent group and non-urgent group(P = 0.033); however, there was no significant difference in the inhospital mortality rate between the two groups(8.1% vs 7.9%, P = 0.960). In multivariate analyses, timing of endoscopy was not associated with 6-wk mortality(hazard ratio, 1.297; 95% confidence interval, 0.806-2.089; P = 0.284).CONCLUSION In cirrhotic patients with acute variceal bleeding, the timing of endoscopy may be independent of short-term mortality.     

国内无痛胃肠镜开展近况调查

目的 调查国内医院无痛胃肠镜的开展近况.方法 以国内不同省份的各级医院消化内镜中心(室)为调查对象,采用电子邮件或电话问卷调查方式对无痛胃肠镜开展情况进行汇总分析.结果 共有169家医院纳入调查分析,分布于28个省(自治区或直辖市),占国内大陆省份的90.3％ (28/31),其中三级医院为46家,二级医院为91家,一级医院为32家.110家(65.1％,110/169)开展了无痛胃肠镜,其中93.5％ (43/46)的被调查三级医院、68.1％(62/91)的二级医院及15.6％ (5/32)的一级医院开展了无痛胃肠镜,三级医院开展率明显高于二级医院(P＜0.05),二级医院则显著高于一级医院(P＜0.05).在110家开展无痛胃肠镜的医院中,只有10家(9.1％)消化内镜室配备了专职麻醉医师,且这10家均为三级医院,占开展无痛胃肠镜三级医院的23.3％( 10/43).110家开展无痛胃肠镜的医院中,98家(89.1％)使用或联合使用丙泊酚作为镇静剂.结论 国内无痛胃肠镜在过去十余年内得到迅速发展,但一、二级医院开展率仍较低,且专职麻醉医师(或麻醉护士)普遍缺少是目前面临的主要问题.     

70岁以上老年患者静脉麻醉下胃肠镜检查的安全性

目的评价芬太尼和异丙酚静脉麻醉在≥70岁老年患者胃肠镜检查中的安全性。方法回顾分析826例采用静脉麻醉下胃肠镜检查且年龄≥70岁老年患者的临床资料,按年龄分成2组：A组,70～80岁,618例,其中接受胃镜检查者342例,肠镜检查者276例;13组,〉80岁,208例,其中接受胃镜检查者112例,肠镜检查者96例。另随机抽取同期接受静脉麻醉下胃肠镜检查的年龄〈70岁的患者600例（胃镜检查者400例,肠镜检查者200例）作对照。总结分析胃肠镜检查情况,比较相同检查方式下各组血压、心率、血氧饱和度（SpO2）变化情况以及不良反应发生情况。结果所有接受静脉麻醉患者均未发生胃肠镜检查穿孔及死亡等严重事件,亦无一例因麻醉并发症终止胃肠镜检查,均能达到胃肠镜检查的满意镇静程度。对应检查方式下,随年龄增加异丙酚用量均减小：胃镜检查时,异丙酚平均剂量A组为（54．22±21．36）mg,B组为（40．22±12．46）mg,对照组为（86．44±34．26）mg;肠镜检查时,A组为（82．56±40．64）mg,B组为（45．36±15．44）mg,对照组为（102．23±46．32）mg。相同检查方式下各组心率、血压变化程度不大,组内前后两观察时点比较差异均无统计学意义（P〉0．05）;但静脉麻醉对老年患者SpO2影响较大,A组和B组共18例出现SpO2〈90％,主要为唾液误吸入气管引起呛咳所致,予面罩呼吸气囊加压吸氧后短期内恢复。结论在严格控制适应证的条件下,适当剂量麻醉药静脉麻醉下老年患者胃肠镜检查是安全的、可行的。     

Does endoscopy improve prediction of the prognosis in upper gastrointestinal bleeding?

To evaluate the prognostic value of the endoscopic examination, we included 189 consecutive patients with upper gastrointestinal bleeding, in a prospective study. Rebleeding was more frequent in patients with endoscopic stigmata of hemorrhage. The prognostic prediction given by the physician was slightly, but not significantly, improved after the result of the endoscopy was available. However, when the clinical data were evaluated by computer, using the Bayes' theorem, the endoscopic findings provided no additional prognostic value. We conclude that the endoscopic findings have intrinsic prognostic value, but add little to clinical data obtained on admission.     

Alexithymia is associated with gastrointestinal symptoms, but does not predict endoscopy outcome in patients with gastrointestinal symptoms

BACKGROUND: Alexithymia, where a person has difficulty in distinguishing between emotions and bodily sensations, is considered to be a character trait and a vulnerability factor for various psychosomatic disorders. Assessing alexithymia in patients with gastrointestinal (GI) symptoms before endoscopy might therefore be useful in selecting patients who are more prone to functional GI disorders. GOAL: To determine whether alexithymia might be a useful factor in predicting GI endoscopy outcomes. STUDY: Patients referred for endoscopy between February 2002 and February 2004 were enrolled. They were asked to report alexithymia on the Toronto Alexithymia Scale-20 2 weeks before endoscopy. Information about endoscopic diagnoses was obtained from medical files. RESULTS: A total of 1141 subjects was included (49% male), of whom 245 (21%) reported alexithymia. There was no difference in mean+/-SD alexithymia scores between patients with (51+/-12) and without (50+/-12) an endoscopic organic abnormality at GI endoscopy. When divided into subgroups, according to the most prominent finding at either upper or lower GI endoscopy, there was no association with alexithymia. Patients with alexithymia reported a worse sensation of GI symptoms during the last weeks before enrollment in the study (mean+/-SD symptom severity score: 42+/-34 vs. 34+/-30, respectively; P<0.01). CONCLUSIONS: Alexithymia is not associated with endoscopic findings, and has therefore no additive value in predicting endoscopy outcomes. Patients with alexithymia more often present with a higher number and more severe GI symptoms.     

Use of the upper gastrointestinal endoscopy in dyspeptic patients

BACKGROUND AND AIMS: Dyspepsia is a common complaint that may signal the presence of diseases like cancer or peptic ulcer. The aim of our study was to assess if the clinical patterns of dyspepsia can be considered a valid guideline for the appropriate use of endoscopy. METHODS: According to the symptomatological patterns, our 243 patients were defined as sufferers from: ulcer-like (93 patients), reflux-like (25) and dismotility-like dyspepsia (125). Erosive gastritis and erosive duodenitis were regarded as minor inflammatory lesions. RESULTS: A negative endoscopy (normal or presenting minor inflammatory lesions) was found in 36.6% of ulcer-like dyspepsia patients: this rate was 52% in the reflux-like group, and 49.6% in the dismotility-like one. Duodenal ulcer was the most frequent abnormal lesion in the three groups. The frequency of negative endoscopies was significantly higher in dismotility-like than in ulcer-like (49.6% vs. 36.6%--P < 0.05) dyspepsia. In those patients with dismotility-like dyspepsia under 41 years, the rate of negative endoscopies was 72.7%, and neoplasms were not observed. CONCLUSION: Our data indicate that endoscopy could be considered inappropriate for patients under 41 years old with dismotility-like dyspepsia. These subjects account for 18.1% of the patients studied, what could lead to a good percentage of reduction in endoscopic service load.     

Evaluation of topical pharyngeal anesthesia for upper endoscopy including factors associated with patient tolerance

BACKGROUND: Topical pharyngeal anesthesia is generally used as a pretreatment for upper endoscopy. However its efficacy has not been established. METHODS: A randomized double-blind placebo-controlled study was undertaken. Subjects were 201 patients who underwent upper endoscopy and gave informed consent. Relative risks (RR) of patient discomfort were calculated for pharyngeal anesthesia, anxiety, and other potential confounding factors by using logistic regression analyses. RESULTS: The RR of patient discomfort on intubation was 0.56 for the anesthesia versus the placebo group (95% CI, 0.31-1.01). RR was higher in patients aged 39 or younger than in those 40 or over (RR = 2.22, 95% CI, 1.04-4.74). With subgroup analysis in those examinees less than 40 years old, the RR of patient discomfort was 0.21 for the topical anesthesia (95% CI, 0.04-0.99) versus the placebo group and 4.93 for patients undergoing upper endoscopy for the first time (95% CI, 1.13-21.60). In the first-time patients, the RR was lower in the topical anesthesia than in the placebo group (RR = 0.20; 95% CI, 0.04-0.93); it was higher in patients with a trait-anxiety score higher by 10 points than in those with a lower score (RR = 3.35, 95% CI, 1.01-11.15). With the Bonferroni correction for multiple testing of data, statistical significance is indicated by a CI of 97.5% in the subgroup analyses. CONCLUSIONS: Topical pharyngeal anesthesia appears to be effective in patients less than 40 years old and in those undergoing the procedure for the first time. A high trait-anxiety score could be a predictor of discomfort in first-time examinees.     

Premedication for upper gastrointestinal endoscopy

Premedication is not essential to endoscopy but patient tolerance is clearly improved and, thus, ease of examination. Although comparable results can be achieved through nonpharmacologic means, the time and effort involved precludes their widespread use. Despite near universal utilization of premedication in endoscopy, the associated risk is difficult to determine from the available literature. The reported data reveal nominal risk yet must be viewed as minimums. The ideal drug with predictable clinical effects, minimal postprocedure impairment, little respiratory compromise, and proven antagonist is not yet available. Although midazolam seems to represent an advance, recent emphasis on respiratory depression is particularly troublesome. Studies evaluating various agents have suffered from lack of quantitation of such parameters as patient tolerance, ease of examination, and postprocedure impairment. Development of proven standards for these parameters would have to occur before a definitive double-blind randomized trial could be undertaken. Suggested means of assessing these parameters are listed in Table I. Improvement in major morbidity would be difficult in light of its low incidence. As the search for the ideal drug continues, endoscopists must continue to use drugs whose full effects are incompletely understood. The ability to increase patient comfort must be balanced with the small, but ever present, risk of morbidity and mortality.     

Arrhythmias during upper gastrointestinal endoscopy

Electrocardiographic monitoring of 52 consecutive patients undergoing upper gastrointestinal endoscopy revealed that arrhythmias during the procedures were common (38.5%) and tended to occur more frequently in the elderly (75%), in persons with heart disease (54.5%), and in persons with chronic lung disease (89%). The incidence of ventricular premature contractions in patient with no evidence of heart or lung disease was 19%. In one patient with advanced chronic lung disease, the procedure had to be terminated because of development of high-degree atrioventricular block. A high incidence of arrhythmias during endoscopy has not been previously reported in patients with chronic lung disease.     

Eosinophilic esophagitis investigated by upper gastrointestinal endoscopy in Japanese patients

Background  

The prevalence of eosinophilic esophagitis (EE) is increasing rapidly in Western countries. Several case series of EE have also been reported in Japan. However, the prevalence of EE in Japanese patients as investigated by upper gastrointestinal endoscopy is unknown. Therefore, we carried out a prospective multicenter study to address this issue.