Non invasive estimation of mean right atrial pressure utilizing the 2D-Echo transverse diameter of the left hepatic vein

Aim of our study was to assess if the 2D-Echo transverse diameter of the left hepatic vein (LHV) obtained from the subcostal approach is correlated with invasive mean right atrial pressure (RAP). Thirty-two consecutive patients with acute myocardial infarction were studied by simultaneous 2D-Echo and right heart catheterization. LHV could be adequately imaged in 90% of patients. Mean RAP values at catheterization ranged from 0 to 15mmHg (mean 6±3.5 mmHg). A correlation was found between mean RAP and LHV diameter calculated after inspiration (r=0.81, SEE=1.54 mm, slope=0.71,p< 0.001) as well as after expiration (r=0.82, SEE=1.32mm, slope=0.62,p< 0.001) or during post-expiratory apnoea (r=0.85, SEE=1.3 mm, slope=0.71,p< 0.001). Moreover, percent increments of LHV diameter correlated well with percent changes of mean RAP during rapid infusion of 250–500 cc of saline in 4 patients (r=0.98,p< 0.001). Thus, the 2D-Echo LHV diameter is a feasible measurement that seems to correlate well with invasive mean RAP over a wide range of mean RAP values in patients with myocardial infarction; the changes in LHV diameter correlate well with the percent increase in central venous pressure obtained with saline infusion. Underestimation of invasive RAP occurs when mean RAP value exceeds 12 mmHg and can be explained by limited venous compliance. However these preliminary results suggest that this method may represent a valid alternative to obtain a non invasive estimate of mean RAP with 2D-Echocardiography.     

Prospective audit of gastroscopy under the 'three-day rule': a regional initiative in Italy to reduce waiting time for suspected malignancy

BACKGROUND: A regional initiative, called the 'three-day rule', has recently been introduced in Italy to facilitate the earlier diagnosis of malignancy. It requires patients with suspected severe diseases to have a diagnostic procedure performed within three working days of referral by a general practitioner. AIM: To assess prospectively the effectiveness and compliance with the three-day rule for upper digestive malignancies. METHODS: We compared patients referred for gastroscopy under the three-day rule initiative with contemporaneous open access referrals over a 12-month period at a single large teaching hospital in west Milan. We compared the prevalence of malignancies and other serious non-neoplastic diseases as well as the waiting times in the two groups. The appropriateness of the indications for each referral was also reviewed by a gastroenterologist blind to the outcome of the test. RESULTS: One hundred and forty-two patients referred for gastroscopy under the three-day rule scheme and 767 routine referrals were studied. Significantly more oesophageal/gastric cancers (6% vs. 1%) and serious benign gastrointestinal lesions (grade II-III oesophagitis or peptic ulcer) were diagnosed in three-day rule patients in comparison with routine referrals (P < 0.05). The rate of inappropriate referral was significantly lower in the three-day rule group than in the open access group (39% vs. 22%) (P < 0.01). The estimated cost of the three-day rule scheme (in extra list examinations alone) was 10 780 euros, with about 1198 euros per diagnosis of cancer, but only 229.5 euros per 'useful' diagnosis (including peptic ulcer disease and oesophagitis). CONCLUSIONS: Significantly more upper gastrointestinal cancers and serious benign diseases can be found within a short period to comply with the three-day rule scheme. However, some general practitioners appear to over-interpret alarm symptoms, leading to some inappropriate referrals. Better awareness of appropriate urgent referral criteria is needed in order to ensure that the best use is made of the resources available.     

Sonographic prevalence of liver steatosis and biliary tract stones in patients with inflammatory bowel disease: study of 511 subjects at a single center

GOALS: Inflammatory bowel diseases (IBDs) are associated with pathologic findings in the liver and biliary tract. Ultrasonography (US) represents a noninvasive means to study hepatobiliary abnormalities. This study evaluated the prevalence of US hepatobiliary changes and their relationship to clinical variables in a large IBD patient population followed in a single center. STUDY: Five hundred eighty-three consecutive IBD patients were studied with US. After excluding patients with preexisting acute or chronic hepatitis, metabolic disorders, or obesity, 511 patients were investigated for age, duration, site, and severity of the disease, history of surgery, and present medical treatment. At US, liver size, echogenicity (graded as mild-to-moderate or severe indicating a corresponding degree of hepatic steatosis), focal lesions of the liver and gallbladder, and biliary tract abnormalities were recorded. RESULTS: Three hundred eleven patients with Crohn disease (CD) and 200 patients with ulcerative colitis (UC) were recruited for the study. Hepatobiliary abnormalities were found at US in 54.2% and 55.9% of CD and UC patients, respectively. Liver enlargement and mild-to-moderate to severe liver steatosis were found in 25.7% and 39.5% of CD patients and in 25.5% and 35.5% of UC patients, respectively, a higher prevalence than among healthy controls (P < 0.001). The prevalence of gallstones among CD patients was 11%, higher than that among UC patients (7.5%) and controls (5.5%) (P = 0.016). The higher risk of gallbladder stones in CD was related to age, female sex, and previous surgery. CONCLUSION: The prevalence of liver enlargement and liver steatosis was higher among IBD patients. The prevalence of gallstones was increased in CD patients only. This risk was related to age, female sex, and previous surgery.     

Non invasive estimation of mean right atrial pressure utilizing the 2D-Echo transverse diameter of the left hepatic vein

Aim of our study was to assess if the 2D-Echo transverse diameter of the left hepatic vein (LHV) obtained from the subcostal approach is correlated with invasive mean right atrial pressure (RAP). Thirty-two consecutive patients with acute myocardial infarction were studied by simultaneous 2D-Echo and right heart catheterization. LHV could be adequately imaged in 90% of patients. Mean RAP values at catheterization ranged from 0 to 15mmHg (mean 6±3.5 mmHg). A correlation was found between mean RAP and LHV diameter calculated after inspiration (r=0.81, SEE=1.54 mm, slope=0.71,p< 0.001) as well as after expiration (r=0.82, SEE=1.32mm, slope=0.62,p< 0.001) or during post-expiratory apnoea (r=0.85, SEE=1.3 mm, slope=0.71,p< 0.001). Moreover, percent increments of LHV diameter correlated well with percent changes of mean RAP during rapid infusion of 250–500 cc of saline in 4 patients (r=0.98,p< 0.001).Thus, the 2D-Echo LHV diameter is a feasible measurement that seems to correlate well with invasive mean RAP over a wide range of mean RAP values in patients with myocardial infarction; the changes in LHV diameter correlate well with the percent increase in central venous pressure obtained with saline infusion. Underestimation of invasive RAP occurs when mean RAP value exceeds 12 mmHg and can be explained by limited venous compliance. However these preliminary results suggest that this method may represent a valid alternative to obtain a non invasive estimate of mean RAP with 2D-Echocardiography.     

Eradication ofHelicobacter pylori and long-term outcome of functional dyspepsia

The aim of this study was to assess the effect of colloidal bismuth subcitrate (CBS) and metronidazole on Helicobacter pylori eradication and on the course of symptoms due to functional dyspepsia. Forty-one patients with functional dyspepsia were entered into the study and randomized to treatment with CBS (120 mg four times a day) for four weeks combined with metronidazole (250 mg four times a day) for one week (group A,N=21) or matching placebo (group B,N=20). The severity of gastritis and of bacterial colonization and the symptom score was assessed by endoscopy and clinical evaluation at baseline and after four, eight, and 24 weeks from the start of the treatment. With intent-to-treat analysis eradication was achieved in 16/25 (64%) patients in group A and in 6/24 (25%) in group B. At eight and 24 weeks the gastritis score was significantly lower only in those patients with eradication. No change was seen in patients in whom the bacteria was not eradicated. The symptom score at eight weeks was considerably lower both in patients with eradication and in those with infection. However, at 24 weeks a gradual decrease in the symptom score in patients with eradication and a worsening of symptoms in controls was observed. No differences were observed between patients with ulcerlike and those with dysmotility-like dyspepsia. The study confirms the need for a long observation period after antibacterial treatment in patients with functional dyspepsia and suggests thatHelicobacter pylori-eradicating treatment improves the course of this functional syndrome.     

The role of echocardiography and pulsed Doppler in the congenital absence of the pericardium. Description of 2 cases

Congenital absence of the left pericardium, partial or complete, is an uncommon cardiac defect. Most patients affected by this abnormality are asymptomatic. Usually it is suspected on the basis of a chest X-ray showing a normal sized cardiac shadow projecting entirely to the left of the spine. Computed axial tomography confirmed the absence of the left pericardium detecting the interposition of the left lung between the ascending aorta and main pulmonary artery. The M-mode, two-dimensional, and Doppler-cardiographic findings of complete congenital absence of the left pericardium are described in two cases. Imaging seems to be not specific for this abnormality; however in both cases pulsed Doppler detected mild tricuspid and pulmonic valve regurgitation.     

Outcome of non-variceal acute upper gastrointestinal bleeding in relation to the time of endoscopy and the experience of the endoscopist： A two-year survey

AIM: To prospectively assess the impact of time of endoscopy and endoscopist's experience on the outcome of non-variceal acute upper gastrointestinal (GI) bleeding patients in a large teaching hospital. METHODS: All patients admitted for non-variceal acute upper GI bleeding for over a 2-year period were potentially eligible for this study. They were managed by a team of seven endoscopists on 24-h call whose experience was categorized into two levels (high and low) according to the number of endoscopic hemostatic procedures undertaken before the study. Endoscopic treatment was standardized according to Forrest classification of lesions as well as the subsequent medical therapy. Time of endoscopy was subdivided into two time periods: routine (8 a.m.-5 p.m.) and on-call (5p.m.-8a.m.). For each category of experience and time periods rebleeding rate, transfusion requirement, need for surgery, length of hospital stay and mortality we compared. Multivariate analysis was used to discriminate the impact of different variables on the outcomes that were considered. RESULTS: Study population consisted of 272 patients (mean age 67.3 years) with endoscopic stigmata of hemorrhage. The patients were equally distributed among the endoscopists, whereas only 19% of procedures were done out of working hours. Rockall score and Forrest classification at admission did not differ between time periods and degree of experience. Univariate analysis showed that higher endoscopist's experience was associated with significant reduction in rebleeding rate (14% vs 37%), transfusion requirements (1.8±0.6 vs 3.0±1.7 units) as well as surgery (4% vs 10%), but not associated with the length of hospital stay nor mortality. By contrast, outcomes did not significantly differ between the two time periods of endoscopy. On multivariate analysis, endoscopist's experience was independently associated with rebleeding rate and transfusion requirements. Odds ratios for low experienced endoscopist were 4.47 for rebleeding and 6.90 for need of transfusion after the endoscopy. CONCLUSION: Endoscopist's experience is an important independent prognostic factor for non-variceal acute upper GI bleeding. Urgent endoscopy should be undertaken preferentially by a skilled endoscopist as less expert staff tends to underestimate some risk lesions with a negative influence on hemostasis.