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Background & Aims: The treatment of patients with extensive pancreatic necrosis remains controversial; a subpopulation of patients with extensive acute pancreatic necrosis develop complex, organized collections. This study examined the feasibility of endoscopic drainage in patients with extensive organized pancreatic necrosis., Methods: Eleven patients with organized pancreatic necrosis (8 sterile and 3 infected) after severe acute necrotizing pancreatitis underwent attempted endoscopic drainage. Dynamic contrast-enhanced computerized tomography showed > or = 50% pancreatic necrosis in 10 of 11 patients in whom endoscopic drainage was performed. In 8 patients, an intrapancreatic nasobiliary lavage catheter was placed into the collection concurrently with 10F stents., Results: Complete resolution was achieved nonoperatively in 9 patients. At a mean follow-up of 12 months, 1 patient developed a pseudocyst, which was successfully drained endoscopically. Complications occurred in 5, including bleeding that precluded entry into one collection., Conclusions: Endoscopic therapy may be a viable management option for a subset of patients who remain symptomatic after an episode of acute pancreatic necrosis after the necrosis has become organized and partially liquefied. Intrapancreatic lavage catheter placement is essential to the success of this procedure. Further evaluation of this technique is needed before this method can be adopted into clinical practice.

Pancreatic cancer usually requires palliative rather than curative therapy. Palliative procedures should have low morbidity and mortality, provide a good quality of life, and necessitate minimal hospitalization. The surgeon, endoscopist, and radiologist all play a role in delivering effective palliation to properly selected patients.

Since its introduction in 1989, laparoscopic cholecystectomy has rapidly become the preferred alternative to open cholecystectomy for symptomatic cholelithiasis. Although possible complications of laparoscopic cholecystectomy are essentially the same as for open cholecystectomy, we report a case of an inadvertent subtotal cholecystectomy, a complication that we believe has not been previously reported.

A 75-year-old woman with known systemic mastocytosis presented with abdominal pain, ascites, and bile duct thickening on computed tomography and ultrasonography. A liver biopsy specimen showed infiltration with mast cells. Endoscopic retrograde cholangiography showed ductal changes compatible with those found in primary sclerosing cholangitis. Brush cytology of the intrahepatic bile ducts confirmed mast cell infiltration. Systemic mastocytosis can infiltrate the biliary system, producing a cholangiopathy radiographically similar to primary sclerosing cholangitis.

Endoscopic retrograde brush cytology is useful for the evaluation of biliary strictures. Access across a stricture can be maintained by removing the cytology brush while leaving the sheath in the bile duct. We examined the potential for loss of diagnostic cellular material in this setting using the canine biliary system. Twenty consecutive samples were randomly collected by (1) pushing the brush from the end of the sheath or (2) pulling the brush through the length of the sheath. Slides prepared from cell suspensions were scored by a cytopathologist blinded to the collection method. Pulling the brush resulted in a significant loss of cellular material (p < 0.001). In a second phase, 23 consecutive samples were randomly obtained in the same fashion. Combining salvage cytology of material from the sheath with cytology of the pulled-brush specimens produced cellular yields similar to those of specimens obtained by pushing the brush from the sheath. If the brush is pulled from the sheath during bile duct brush cytology, we suggest that salvage cytology be performed in order to maximize the diagnostic sensitivity.

To assess the effect of propofol on the canine sphincter of Oddi(SO), sphincter of Oddi manometry (SOM) was performed in fasting dogs which had undergone cholecystectomy and placement of modified Thomas duodenal cannulae. Using two water-perfused, single-lumen manometric catheters, SO and duodenal pressures were measured simultaneously. Baseline SO activity was recorded for at least one complete interdigestive cycle followed by bolus injections of propofol (Diprivan) (N = 31) from 0.1 to 4.0 mg/kg during Phase I of the Migrating Motor Complex (MMC). When propofol was administered in bolus doses < or = 0.4 mg/kg, no change in SO or duodenal motor function was seen. In doses > or = 0.5 mg/kg, SO basal pressure, amplitude, and frequency of contractions increased significantly. Increases in duodenal activity paralleled SO activity. Our results suggest that propofol in low doses may be useful for sedation during Sphincter of Oddi manometry in humans. Further studies of the effect of propofol on the human sphincter of Oddi are warranted.

The purpose of this study was to evaluate the efficacy and safety of low-dose weekly, oral methotrexate in patients with steroid-dependent or steroid-refractory inflammatory bowel disease (IBD). Oral methotrexate was given weekly at 15 mg/week. The primary criterion of response was based on steroid withdrawal. Of the 10 patients with Crohn's disease, daily prednisone dosage dropped from a mean of 37 +/- 9.6 mg to 8.3 +/- 2.1 mg/day (P < 0.02); two had a complete withdrawal and four a partial response (< 7.5 mg/day). In the eight patients with ulcerative colitis, daily prednisone dose dropped from a mean of 26.3 +/- 3.2 mg/day to 12.7 +/- 2.0 mg/day (P < 0.001); three had a partial response. Adverse effects due to methotrexate were mild in both groups. We conclude that oral methotrexate may be useful and reasonably safe as a steroid-sparing agent in patients with refractory IBD.

Purpose: To review the pathophysiology of gastrointestinal motility disorders during pregnancy, their clinical manifestations, and their management., Data Sources: Studies published from 1963 to 1992 identified by computerized literature searches of Index Medicus and MEDLINE; hand searches; contact with pharmaceutical representatives for information on drug therapy during pregnancy; and selected texts on drugs and obstetrics., Study Selection: Selected studies were those involving controlled design of physiology related to pregnancy or to hormonal effects on the gastrointestinal tract or both, and clinical studies or previous reviews that contributed to the understanding of the gastrointestinal effects of pregnancy., Data Extraction: Data concerning the epidemiology, causes, clinical manifestations, and complications of altered gastrointestinal motility during pregnancy as well as the strength of association between gastrointestinal disorders of pregnancy and hormonal changes were evaluated and used to develop a practical approach to evaluate and manage these patients., Results of Data Synthesis: Effects on the gastrointestinal tract during pregnancy are caused primarily by hormonal changes and not the physical effects of the gravid uterus. Motility changes occur throughout the gastrointestinal tract, including a reduction in lower esophageal sphincter pressure and its physiologic function with resulting gastroesophageal reflux and the risk for aspiration; alterations in gastric motor function associated with nausea and vomiting; and a decrease in the rate of small-bowel and colonic transit manifested primarily as abdominal bloating and constipation. These effects are mediated by progesterone, with estrogen probably acting as a primer., Conclusions: Given the large number of pregnancies each year complicated by gastrointestinal motility disorders, many physicians (including internists and gastroenterologists) must manage these problems. Knowledge of the underlying physiologic alterations in gastrointestinal motility during pregnancy and of safe treatment options is essential to the care of the pregnant patient.

We report an unusual presentation of gastroesophageal reflux disease in a 14-yr-old boy with cervical dysphagia and vomiting immediately after swallowing. Reflux disease was diagnosed by the combination of eosinophils on esophageal biopsies and abnormal 24-h pH results. The cervical site of dysphagia demonstrated acid-induced hypersensitivity to esophageal distension with water or air. The patient's symptoms resolved with marked acid suppression, which was made difficult because intact capsules of omeprazole initially could not be ingested.

Endoscopic sclerotherapy has been the therapy of choice for controlling acute variceal hemorrhage. Recently, endoscopic band ligation has been utilized for the management of esophageal varices with fewer complications and greater efficacy. We report the pathologic findings in the human esophagus 5 days after esophageal variceal band ligation.

The esophagus is subject to a variety of disorders that can be mechanical or functional in origin. In addition, GERD is quite common and can present with atypical manifestations. Mirroring these disorders, the esophageal function tests can likewise be broken down into anatomic and functional studies. The barium esophagogram, when properly performed, is probably the single most important test because it evaluates both oropharyngeal and esophageal anatomy and motility as well as the presence or absence of GERD. Endoscopy allows direct inspection and sampling of the esophagus. Esophageal scintigraphy and manometry play less important but well defined roles. Finally, the advent of prolonged ambulatory esophageal pH monitoring has advanced our knowledge about GERD and has particularly helped in the diagnosis of patients with atypical reflux presentations such as chest pain and pulmonary or otolaryngologic symptoms.

Heartburn during pregnancy occurs in approximately two thirds of all pregnancies. The origin is multifactorial, but the predominant factor is a decrease in LES pressure resulting from female sex hormones, especially progesterone. Mechanical factors play a small role. Serious reflux complications during pregnancy are rare outside the obstetric setting. Therapy involves lifestyle modifications and nonsystemic medications as the initial choices. H2 blockers are probably safe in severe and refractory cases.