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Background: Fundoplication is now almost exclusively a laparoscopic procedure. The aim of this study was the comparison of the diagnostic usefulness of endoscopy and barium esophagram in the detection of fundoplication abnormalities., Methods: Twenty-two patients presented with symptoms post-laparoscopic (Nissen) fundoplication that included dysphagia (14 patients), heartburn (5 patients), dyspepsia (2 patients), and chest pain (1 patient). Barium esophagram and upper endoscopy were performed in all patients and the results were compared. Key features included presence of esophagitis, resistance to endoscope passage, location of the wrap relative to the diaphragmatic hiatus, location of squamocolumnar junction greater than 1 cm proximal to the wrap zone, and the appearance of the wrap (intact, loose, disrupted, or tight)., Results: The key features explained symptoms in 20 of 22 patients. Endoscopy detected twice as many key features as radiography. Disruption of the wrap or excessive proximal location of the squamocolumnar junction proximal to the wrap zone were the most incriminating endoscopic findings. Resistance to endoscope passage was rarely encountered and the esophagram was more accurate in detecting an overly tight wrap., Conclusions: Endoscopic evaluation is more accurate than barium esophagram in detecting post-fundoplication abnormalities. The appearance of the fundoplication wrap and an abnormal proximal location of the squamocolumnar junction appear to be major endoscopic clues in diagnosis of post-fundoplication problems.

Background: When deployed across the gastroesophageal junction, self-expanding metal esophageal stents can predispose to gastroesophageal reflux. Our aim was to evaluate the efficacy of a self-expanding metal esophageal stent that was modified to prevent gastroesophageal reflux., Methods: The polyurethane coating of a metal Z-stent was extended beyond its lower end to form windsock-type valve. The anti-reflux property of this stent was studied in vitro by submerging the stent under water and measuring the pressure required to invert the valve. Esophageal acid exposure time was measured in 5 dogs with a standard and the modified stent placed across the gastroesophageal junction. The modified stent was also placed in 11 patients with cancer of the gastroesophageal junction who were prospectively followed., Results: The pressure required to invert the valve was directly proportional to the thickness of the valve membrane (48 +/- 0.4 cm water for a 0.0067-inch thick membrane). Esophageal acid exposure time was significantly less with the modified stent as compared with a standard stent (1% +/- 0.3%, 49% +/- 11%, respectively, p = 0.03). Dysphagia score in patients improved from 3.4 +/- 0.1 to 1.1 +/- 0.2 (p < 0.001). Daytime heartburn and regurgitation scores were less than 1 (score 10 = severe). No patient complained of nocturnal reflux symptoms. Karnofsky performance status scale did not improve significantly., Conclusions: The efficacy of the modified stent in relieving dysphagia is comparable with a standard stent. It also effectively prevents gastroesophageal reflux.

Background: The use of open access endoscopy is increasing. Its effect on the adequacy of patient informed consent, procedure acceptance and the impact on subsequent communication/transfer of procedure results to the patient have not been evaluated. The aim of our study was to compare the extent of preknowledge of procedures and test explanation, patient medical complexity, information transfer and overall patient satisfaction between a patient group referred for outpatient open access endoscopy versus a patient group from a gastrointestinal (GI) subspecialty clinic., Methods: Information was obtained from all patients presenting for outpatient upper and lower endoscopy by using a 1-page questionnaire. Patients from the two groups who had an outpatient upper/lower endoscopic procedure were contacted by phone after the procedure to obtain information with a standardized questionnaire., Results: The open access patients reported receiving significantly less information to help them identify the procedure (p < 0.01) and less explanation concerning the nature of the procedure than the group of patients referred from the subspecialty clinic (p < 0.005). There was no difference between the two groups in satisfaction scores for examinations performed under conscious sedation. For flexible sigmoidoscopy without sedation, however, the GI clinic patient group were more satisfied with their procedure. The majority of patients, regardless of access, were more likely to receive endoscopic results from a gastroenterologist than the referring physician. Furthermore, the patients in the GI clinic group who underwent colonoscopy felt significantly better at follow-up., Conclusions: Patients undergoing open access procedures are less likely to be properly informed about their endoscopic procedure. Our results indicate that with open access endoscopy, a defined mechanism needs to be in place for communication of endoscopic results to the patient.

Background: The current standard treatment of bleeding esophageal varices is band ligation. Although endoscopic sclerotherapy has largely been supplanted by band ligation, there are still clinical situations in which injection methods are useful. Endoscopic ultrasound (EUS) may allow for a more complete evaluation of esophageal varices and perforating veins and may allow for more effective delivery of sclerosant. Our aim was to evaluate the use of color Doppler EUS-guided sclerotherapy for the obliteration of esophageal varices., Methods: Five patients with esophageal varices (Child's A = 1, B = 2, C = 2) underwent dynamic EUS-guided sclerotherapy with color flow Doppler. EUS sclerotherapy was performed using Varijet (2.5 mm catheter) injector needles and sodium morrhuate directed at the perforating vessels until flow was completely impeded (2 to 4 mL per injection site). Data collected included (1) sessions to obliteration, (2) episodes of recurrent bleeding, (3) complications, and (4) mortality., Results: Patients undergoing EUS-sclerotherapy required 2.2 sessions to achieve obliteration of varices. No patient had a recurrence of bleeding and no deaths occurred. One patient developed an esophageal stricture that responded to balloon dilation., Conclusions: Dynamic EUS-guided sclerotherapy with color flow Doppler may be safely and effectively used for the treatment of esophageal varices. It allows for effective delivery of sclerosant with favorable outcomes. Prospective, multicenter, randomized trials are warranted.

Background: The clinical significance of incomplete pancreas divisum (IPD) has not been fully described. In this study we report the clinical presentation and results of endoscopic treatment of the 32 (0.6%) patients with IPD seen at our center over a 10-year period., Methods: The study population consisted of 24 women and 8 men (mean age 42 years, range 13 to 82 years). Ten (31%) patients presented with acute recurrent pancreatitis, 5 (16%) with chronic pancreatitis, and 3 (9%) with pancreatic type pain. Detailed history, laboratory tests, US, CT, and ERCP excluded other etiologies for their symptoms. The remaining 14 (44%) presented with biliary problems. The 18 symptomatic patients with IPD were treated as follows: 8 received dorsal duct stents, 3 underwent minor papilla endoscopic sphincterotomy and dorsal duct stent placement, 4 had minor papilla dilatation only, and 3 had ventral duct stents placed., Results: Patients were then followed for recurrence of pancreatitis and pancreatic-type pain. Mean follow-up was 15.5 months (range 3 to 30 months). Six (60%) of the patients with acute recurrent pancreatitis and 4 (80%) with chronic pancreatitis benefitted from the endoscopic therapy. However, only 1 (33%) of the patients with pancreatic-type pain benefitted., Conclusion: The clinical presentation and response to endoscopic therapy of patients with ICP appeared to be similar to that of patients with complete pancreas divisum.

Background: Obstructive disorders of the pancreas, including strictures, stones, sphincter of Oddi dysfunction, and pancreas divisum, are diagnostic and therapeutic challenges. Conventional extracorporeal ultrasound with secretin stimulation has been used as a noninvasive study to detect obstruction and predict outcome of therapy. Inconsistent results have been obtained because of the inherent limitations of standard ultrasonography. The aim of this study was to evaluate the behavior of the main pancreatic duct by endoscopic ultrasonography during secretin stimulation and to diagnose obstructive disorders of the pancreas., Methods: Secretin-stimulated endoscopic ultrasound (SSEUS, 1 IU/kg secretin) was performed in 20 control subjects (no pancreatic or biliary disease), 40 patients with symptomatic chronic pancreatitis, 40 patients with symptomatic pancreas divisum, 20 patients with suspected sphincter of Oddi dysfunction, and 20 patients with suspected occlusion of pancreatic duct stents. Ductal diameter was measured by endoscopic ultrasonography at baseline and at 1-minute intervals, after administration of secretin, for 15 minutes. A result was determined to be abnormal when a 1 mm or greater dilation of the pancreatic duct was observed from baseline after secretin administration., Results: Of the 40 patients with symptomatic chronic pancreatitis, SSEUS correctly predicted obstructive pathology (stones, strictures) in 12 of 13 patients (92%). Of the 40 patients with symptomatic pancreas divisum, 22 underwent stent therapy (16 of 22 with resolution of symptoms). SSEUS accurately predicted response to stent therapy in 13 patients (81%). Seven of twenty patients with suspected sphincter of Oddi dysfunction had abnormal sphincter manometry. SSEUS accurately predicted sphincter dysfunction in only 4 of 7 patients (57%). Finally, 20 patients with suspected occlusion of pancreatic duct stents were studied. Of the 14 stent occlusions confirmed at ERCP, SSEUS correctly predicted premature occlusion in 12 patients (86%)., Conclusions: SSEUS appears to be a useful diagnostic modality in the evaluation of patients with suspected obstructive disorders of the pancreas and it can predict which patients may respond to endoscopic therapy.

Background: Chronic pancreatitis in its early stages may defy diagnosis despite existing diagnostic modalities. Endoscopic retrograde pancreatography (ERCP), secretin test, and conventional ultrasound are insensitive in detecting the early stages of chronic pancreatitis. The aim of this study was to determine whether endoscopic ultrasonography (EUS) high-resolution imaging allows for the detection of chronic pancreatitis as compared with clinical history, ERCP, and secretin test., Methods: Eighty consecutive patients with recurrent pancreatitis underwent ERCP, EUS, and secretin test. EUS evaluated parenchymal changes: echogenic foci (calcification), prominent interlobular septae (fibrosis), small cystic cavities (edema), lobulated outer gland margin (fibrosis/atrophy), and heterogeneous parenchyma; and ductal changes: dilation, irregularity, echogenic wall (fibrosis), side-branch ectasia, and echogenic foci (stones). EUS criteria for chronic pancreatitis included mild (1 to 2 features), moderate (3 to 5 features), and severe (more than 5 features)., Results: Abnormal studies were EUS = 63, ERCP = 36, and secretin test = 25. Secretin test had 100% agreement with normal and severe chronic pancreatitis by EUS criteria, but agreement was poor for mild (13%) and moderate (50%) disease. Alternatively, the agreement between ERCP- and EUS-specific criteria was excellent for normal (100%), moderate (92%), and severe (100%) chronic pancreatitis and poor for mild (17%) disease. When the 2-test modality (ERCP and secretin test) was compared with EUS alone, no enhancement in agreement was seen., Conclusion: Using the above criteria EUS may assist in the diagnosis of chronic pancreatitis not established by ERCP or secretin test. Excellent agreement can be expected between EUS and ERCP in the diagnosis of chronic pancreatitis with the exception of mild changes noted on EUS (kappa statistics = 0.82: 95% CI [0.70, 0.95]). Long-term follow-up of the patients with mild EUS changes will determine the validity of EUS in diagnosing the early stages of chronic pancreatitis.

Background: Possible sources of post-ERCP pancreatitis were evaluated during a prospective, randomized, controlled study comparing different contrast media., Methods: A total of 1979 patients were randomized and subdivided into groups during the study. Patients were grouped for comparison depending on the type of procedure performed during ERCP. Diagnostic patients studied with pancreatograms (Group I) were compared with other groups, specifically, those not studied with pancreatograms (Group IV). All patients had subjective and objective estimates of the difficulty in cannulation of both ducts. The incidence of postprocedural pancreatitis was compared between and within each group., Results: In Group I there was a progressively higher incidence of pancreatitis with increased numbers of pancreatic duct injections. Patients with the highest (19.5%) frequency of pancreatitis received 10 or more injections into the pancreatic duct. Group I cases with difficult common bile duct cannulations had a higher frequency of post-ERCP pancreatitis (9.5%), as compared with the entire group (5.6%)., Conclusions: There was a higher incidence of pancreatitis associated with increased manipulation around the papillary orifice, especially with multiple pancreatic duct injections. There was also a slightly higher incidence of post-ERCP pancreatitis in cases with difficult common bile duct cannulation. Endoscopists are encouraged to evaluate and develop safer cannulation techniques that minimize the number of injections into the pancreatic duct and enhance selective cannulation.

Background: Glucagon is often used to inhibit duodenal motility and enhance cannulation during ERCP. Levsin is an antimuscarinic, anticholinergic agent that may be as effective as glucagon., Methods: Three hundred eight patients requiring an antimotility agent during ERCP were randomized in a double-blind prospective study to intravenous Levsin or glucagon. Parameters recorded included difficulty of procedure, predrug and postdrug motility grade, effectiveness of medication, patients requiring "crossover" drug, side effects, and cost per case., Results: One hundred fifty-three patients were randomized to glucagon and 155 to Levsin. The two groups were equally matched with regard to patient and procedure characteristics. Of statistical significance were the following: (1) 12 patients in the Levsin group required crossover compared to 1 patient in the glucagon group, (2) Levsin was slightly less effective in inhibiting motility, but this did not adversely influence procedure difficulty, (3) Levsin was associated with more minor side effects (nausea, vomiting, and pain) at 2 hours after the procedure (Levsin 36 of 143, glucagon 24 of 152, p = 0.045) but there was no difference in pancreatitis (glucagon 6, Levsin 8), (4) Levsin was associated with a significant cost advantage (Levsin $10.45/case, glucagon $29.51/case, p < 0.001)., Conclusion: Levsin may provide a reasonable alternative antimotility agent during ERCP. Levsin does not appear to alter the rate of significant postprocedure complications. The cost benefit advantage appears to be substantial.

Background: A significant portion of the cost and complications associated with conventional esophagogastroduodenoscopy (EGD) is attributed to conscious intravenous sedation, which usually results in loss of work on the day of the endoscopy. Earlier studies have described the feasibility and safety of unsedated transnasal EGD in normal volunteers., Methods: We compared the diagnostic yield and patient acceptability of this new technique performed first, with conventional EGD performed second in 24 outpatients., Results: The sensitivity of transnasal EGD was 89% and its specificity was 97%. Transnasal EGD was more acceptable and less stressful to the patients than conventional EGD (p < 0.05). Oxygen saturation and blood pressure did not change during transnasal EGD., Conclusion: Transnasal EGD is feasible, safe, and well tolerated by patients. Specificity of transnasal EGD is similar to, but its sensitivity is lower than, conventional EGD. By eliminating the need for sedation-related work loss and postprocedural monitoring, transnasal EGD potentially is more cost-effective than conventional EGD.

Background: Pancreatitis frequently complicates diagnostic and therapeutic ERCP. A variety of causes have been implicated. A number of different agents have been used, without success, in an attempt to prevent pancreatitis., Methods: In the current study, 824 patients with a history of iodine sensitivity were given preprocedure corticosteroid therapy (651 oral steroids and 173 intravenous steroids) in an attempt to prevent allergic reactions. These patients were retrospectively studied in an attempt to determine if corticosteroid administration prevents ERCP-related pancreatitis. Two control groups were used for comparison, including 1000 patients during the same study period (Control Group I) and 1954 patients from the Midwest Pancreaticobiliary Group (Control Group II)., Results: There was a significant difference in the overall incidence of post-ERCP pancreatitis in the corticosteroid treated group (4.6%) compared with either control group (Control Group I = 7.4% and Control Group II = 9.1%). Of those patients undergoing therapeutic ERCP, results were even more significant in favor of the steroid-treated group (5.2%) compared with Control Group I (9.7%) and Control Group II (11.2%)., Conclusions: These results demonstrate that the administration of corticosteroids prior to ERCP results in a decreased incidence of post-ERCP pancreatitis. A prospective, randomized, controlled trial is warranted.

Background: Pancreatitis is one of the most common complications associated with ERCP. Multiple factors have been implicated for this potentially serious complication. Numerous suggestions for minimizing risks at ERCP have been offered, one of which is to use nonionic, low osmolarity contrast agents for pancreatic injection. Results of previous studies comparing different contrast media have been inconclusive., Methods: To evaluate the role contrast material plays in the development of post-ERCP pancreatitis, the Midwest Pancreaticobiliary Group performed a prospective double-blind controlled study. A total of 1,979 consecutive ERCP patients were enrolled, and 1,659 patients with pancreatic duct injections were divided into subgroups according to the complexity of the ERCP. Post-ERCP pancreatitis was compared between similar groups. Patients were randomized to receive injections of nonionic, low osmolarity contrast or standard ionic contrast media., Results: The overall incidence of post-procedural pancreatitis was 10.2%. Those with diagnostic ERCP had the lowest incidence at 5.6%. Therapeutic procedures (12.3%) and sphincter of Oddi manometry (15.2%) had higher rates. Those injected with standard (ionic) contrast had an incidence of 10.4% and after injection with lower osmolar (nonionic) contrast, there was a 10% post-procedural pancreatitis rate., Conclusions: Patients with more complex procedures develop pancreatitis more frequently. The use of low osmolar (nonionic) contrast media does not decrease the incidence of post-ERCP pancreatitis.

Background: Endoscopic treatment of pancreatic pseudocysts via cystenterostomy has been recognized as a successful treatment option in carefully selected patients. Pancreatic transpapillary stenting as an alternative treatment option in patients with pancreatic pseudocysts directly communicating with the main duct has received little consideration. The aim of the current study was to assess the safety and utility of transpapillary pancreatic endoprosthesis in the treatment of communicating pseudocysts., Methods: Twenty-one patients underwent placement of 33 transpapillary endoprostheses for the treatment of symptomatic pancreatic pseudocysts. All pseudocysts communicated with the main pancreatic duct and ranged in size from 3 to 9 cm (mean 6 cm). Eight patients had associated pancreatic duct strictures., Results: Stent placement was successful in all cases: 13 directly into the pseudocyst, 8 beyond the stricture but not into the pseudocyst. Initial resolution of pseudocysts was seen in 17 patients, with 16 patients free of pseudocyst recurrence at mean follow-up of 37 months. All patients with associated strictures were treated successfully. Factors predictive of success included presence of strictures, size of pseudocyst greater than or equal to 6 cm, location in the body of the pancreas, and duration of pseudocyst less than 6 months. Complications included one episode of mild pancreatitis., Conclusions: Endoscopic treatment of symptomatic pancreatic pseudocysts with ductal communication by transpapillary pancreatic duct stenting is a safe, effective modality and should be considered a first line therapy.

Seventeen patients, 15 women and 2 men with upper abdominal pain categorized to biliary group I suspected sphincter of Oddi dysfunction, underwent thorough clinical evaluation including ERCP and endoscopic sphincter of Oddi manometry. All the patients were subsequently treated by endoscopic (n = 15) or surgical (n = 2) sphincterotomy. The mean age of patients studied was 62 years. They all had cholecystectomy several years previously (median, 18 years). At ERCP all patients showed a large common bile duct dilation (mean diameter, 18 mm) and delayed contrast drainage greater than 45 minutes. Sphincter of Oddi manometry, although abnormal in most patients, revealed normal sphincter of Oddi pressure in six patients (35%). Nonetheless, sphincterotomy resulted in relief of symptoms in all (mean follow-up, 28 months; range, 3 to 46 months), thus suggesting that their pain was indeed caused by the disordered sphincter of Oddi. These findings support the previous assumption that in symptomatic post-cholecystectomy patients the triad of elevated liver function tests, dilated common bile duct, and delayed contrast drainage at endoscopic retrograde cholangiopancreatography indicates a definitive sphincter of Oddi abnormality. The normal sphincter of Oddi pressures in many of these patients are probably due to a different, noncompliant type of sphincter of Oddi dysfunction. Because these patients invariably benefit from sphincterotomy, sphincter of Oddi manometry in this category is not only unnecessary, but it may also be misleading.

A symptomatic lower esophageal ring generally responds to standard bougienage therapy. However, a subset of patients with a lower esophageal ring defy dilation therapy. We have evaluated the efficacy of electrocautery incision of "defiant" lower esophageal rings, the data of which forms the basis of this report. Seven of 75 patients with a lower esophageal ring failed to respond to conventional esophageal dilation. All seven patients underwent electrocautery incision of a "defiant" lower esophageal ring with alleviation of dysphagia. One patient had recurrence of dysphagia that occurred 6 months after initial electrocautery incision. No major complication occurred, although one patient had transient chest pain. Subsequently, all patients have remained without symptoms at a mean follow-up of 36 months. Electrocautery incision of "defiant" lower esophageal ring is efficacious, safe, and results in long-term relief of dysphagia.

Patients with group II sphincter of Oddi dysfunction documented by elevated sphincter of Oddi pressure improve after endoscopic sphincterotomy. A large group II population was studied to determine the incidence of post-endoscopic sphincterotomy stenosis. Eighty-five patients (82 women and 3 men), ages 21 to 88 years (mean, 50 years), fulfilled the clinical criteria for group II sphincter of Oddi dysfunction; each had an elevated basal sphincter of Oddi pressure (> or = 40 mm Hg), and received endoscopic sphincterotomy. These patients were observed for a mean of 7 +/- 3 years. Four patients re-presented with clinical findings suggestive of recurrent sphincter of Oddi dysfunction; all were found to have a basal sphincter of Oddi pressure greater than or equal to 40 mm Hg. Symptoms re-developed within 4 months after endoscopic sphincterotomy (mean, 3.3 months). Endoscopic sphincterotomy was repeated in all four patients with one endoscopically treated complication. On 25-month mean follow-up, none of the patients had further signs or symptoms of papillary stenosis. Endoscopic sphincterotomy in patients with group II sphincter of Oddi dysfunction is associated with a low incidence of restenosis (4.7%). Repeat endoscopic sphincterotomy was found to be effective management in patients with papillary restenosis.

Despite widely available technology for removal of bile duct stones, endoscopists currently encounter approximately 3% of patients with stones that defy extraction. After sphincterotomy and unsuccessful attempts at extraction of "defiant" stones, biliary stents were placed in 22 patients. Ten patients were treated with ursodeoxycholic acid, and 12 patients treated only with stent served as control subjects. Ductal strictures preventing stone extraction were present in eight control patients and in six patients treated with ursodeoxycholic acid. The number of total calculi in the ursodeoxycholic acid group was slightly higher (4.2 per patient) than the number in the control group (3.3 per patient). Stone and bile duct dimensions were similar in each group. Nine of 10 patients in the ursodeoxycholic acid group had complete stone clearance, and 41 of 42 stones were removed during a follow-up period of 9 +/- 2 months; in contrast, no patient in the control group had complete clearance and only 6 of 40 stones were removed after a follow-up period of 31 +/- 6 months. Oral ursodeoxycholic acid facilitates extraction of defiant bile duct stones. This treatment is an effective alternative to high-tech extraction methods for large biliary stones.

With the advent of laparoscopic cholecystectomy, a number of patients with various postprocedure problems have been referred for endoscopic management. Thirty-five patients were evaluated. The group included 26 women and 9 men, ages 24 to 90 years (mean, 50 years). Twenty-five patients with retained common bile duct stones were successfully treated with endoscopic sphincterotomy and balloon or basket removal. Three patients with bile duct strictures had balloon dilation and endoprosthesis placement and were free of signs of obstruction on 9-month follow-up. Bile leaks were treated successfully with endoscopic sphincterotomy and endoprosthesis placement. Two patients with bile duct leaks and biloma formation required percutaneous or surgical drainage in addition to endoscopic treatment. Three patients had more than one complication. Two patients had strictures with retained stones above the stricture; dilation of the stricture was performed and the stones were removed. One patient with the complication of biliary leak and a long, irregular stricture was treated temporarily by sphincterotomy and stent placement while awaiting surgery. Therapeutic biliary endoscopy is a valuable, minimally invasive alternative to surgery in patients with problems arising after laparoscopic cholecystectomy.

Endoscopic endoprosthesis (stent) placement across the minor papilla has been shown to be beneficial in reducing abdominal pain and episodes of pancreatitis in a small group of patients with pancreas divisum and acute recurrent pancreatitis. In a randomized, controlled clinical trial, 19 patients with pancreas divisum and at least 2 documented episodes of pancreatitis were randomized to either dorsal duct stent placement (10 patients--5 women and 5 men) or controls (9 patients--6 women and 3 men). All other causes of pancreatitis were excluded. Patients were followed at 4-month intervals for evaluation and/or stent exchange during a 1-year period. The following criteria were evaluated during follow-up: number of hospitalizations or emergency room visits, the number of documented episodes of pancreatitis, and gradation of the patient's overall general feeling based on a visual analog scale. Mean follow-up times in the stent and control groups were 28.6 and 31.5 months, respectively (p greater than 0.05, NS). No patients in the stent group required hospitalization or emergency room visits for abdominal pain only during and following the treatment period. However, in the control group there were five hospitalizations and two emergency room visits for abdominal pain during a similar period (p less than 0.05). Pancreatitis was documented with an elevated amylase twice the normal range, one time in the stent group and seven times in the control group (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

We evaluated a computerized report-generating system using voice recognition technology (EndoSpeak) for producing therapeutic ERCP reports. For 30 consecutive ERCP cases, reports using both EndoSpeak and standard dictation were generated at the end of the procedure. The cases were scored for overall difficulty and the number of component procedures performed. The time to generate a report with EndoSpeak was significantly longer than with dictation (10.0 +/- 2.9 (SD) min vs. 6.5 +/- 1.6 min, p less than 0.0001), and this difference was greater for more lengthy reports (r = 0.85, p less than 0.001). The procedure difficulty score and the number of component procedures were both significant predictors of the physician's report generation time for EndoSpeak and dictation. Dictated reports were judged to have a higher information content than EndoSpeak reports for 90% of the cases (p less than 0.00001). Several specific difficulties were encountered with the EndoSpeak software. Although EndoSpeak offers promise, substantial software modifications will be required before this system can become competitive with dictation for therapeutic ERCP reports.

We report a group of 35 patients with primary sclerosing cholangitis who had long-term follow-up after endoscopic treatment of major ductal strictures in the primary or secondary biliary ducts. Our patients were all symptomatic with ascending cholangitis or jaundice. There was significant improvement as measured by clinical parameters of hospitalization rates and laboratory data and comparable radiography. Long-term follow-up averaged 24 (+/- 2.8 months). We believe endoscopic treatment of sclerosing cholangitis should be attempted in selected symptomatic cases with major ductal strictures before liver transplantation.

The reproduction of a patient's biliary-type pain upon initial injection of contrast material into the common bile duct during diagnostic ERCP is a dramatic experience for both patient and physician. The significance of this phenomenon is not clear, but it is touted by some to be a provocative test for sphincter of Oddi dysfunction. Sphincter of Oddi manometry was performed on 224 consecutive patients referred over a 2-year period for evaluation of post-cholecystectomy syndrome and suspected sphincter of Oddi dysfunction. All patients received only intravenous diazepam as premedication for ERCP. Delayed drainage time (greater than 45 min), bile duct dilation (greater than or equal to 12 mm), and a basal sphincter of Oddi pressure of greater than 40 mm Hg (mean +/- 3 SD) were considered elevated. We observed a reproduction of pain in 15 of 224 patients (6.7%) immediately following contrast injection. There was no correlation between pain on contrast injection and elevated basal sphincter of Oddi pressure, delayed common bile duct drainage, bile duct dilation, or abnormal liver enzymes. Therefore, we feel that reproduction of the patient's biliary-type pain associated with contrast injection of ERCP is not a provocative test for sphincter of Oddi dysfunction.

Endoscopic sphincterotomy was performed on 10 patients with sclerosing cholangitis to improve biliary tract drainage and to remove bile duct sludge and stones. In addition, Gruentzig-type balloons were placed endoscopically to dilate severe biliary duct strictures in eight of these patients, and endoprostheses were inserted to bridge high grade strictures in three patients. In order to assess the effectiveness of endoscopic treatment, we compared the number of hospitalizations for clinical episodes of cholangitis in this patient group for similar periods of time before and after therapy. Episodes of cholangitis requiring hospitalization decreased from 2.5 +/- 0.4 per patient in the 12 months prior to endoscopic therapy to 0.2 +/- 0.2 episodes per patient in the year following treatment and to 0.33 +/- 0.2 episodes per patient in the additional follow-up period during the second year. Liver function tests have improved significantly over the follow-up period of 19.1 +/- 2.6 months from the time of endoscopic treatment. The serum bilirubin decreased from 6.9 +/- 2.0 mg/dl to 2.7 +/- 1.4 mg/dl; serum alkaline phosphatase decreased from 959 +/- 214 IU to 385 +/- 89 IU; and serum transaminase decreased from 117 +/- 17 IU to 77 +/- 12 IU. Endoscopic treatment appears to be effective in patients with severe sclerosing cholangitis.