Clinical Update最新文献

Commentary

Chronic pancreatitis is a chronic inflammatory disorder characterized by intermittent or continuous abdominal and/or back pain, eventual exocrine and endocrine insufficiency, and complications ranging from biliary strictures and pancreatic pseudocysts to pseudoaneurysms of related arteries. The goals of pancreatic endotherapy include relief of chronic pain from pancreatic duct (PD) obstruction (secondary to stones, strictures, papillary stenosis, and anatomic abnormality), stent placement for ductal disruptions, and treatment of related complications, including biliary obstruction and pseudocysts. John Baillie, MD, discusses the indications for endoscopic intervention in chronic pancreatitis patients.

Grace Elta, MD

Editor

Commentary

In the United States, upper GI (UGI) bleeding is a common clinical problem requiring more than 300,000 hospitalizations annually. Changes in practice over the last 10 years show that hospitalization days have significantly decreased and that the majority of patients with UGI bleeding undergo endoscopy within 24 hours of admission. Of these endoscopies, 20% to 35% include endoscopic hemostatic therapy. Early endoscopy (within 24 hours of hospital admission) has a greater impact than later endoscopy on length of hospital stay and requirements for blood transfusion. Dr. Lee discusses the value of preadmission endoscopy as a triage tool. The prognostic accuracy of the endoscopic results is sufficient to safely prevent hospitalization for a large number of patients.

Grace Elta, MD

Editor

Commentary

Nonsteroidal anti-inflammatory drugs (NSAIDs) may cause adverse GI effects, e.g., dyspepsia (persistent pain or discomfort in the upper abdomen), and serious complications, e.g., bleeding and perforation. Although the probability is low that any individual user will suffer a complication, the huge patient exposure translates into a major health care problem. Dr. Scheiman presents a thoughtful review on the GI effects of NSAIDs, low-dose aspirin, COX-2 inhibitors, and the combination of more than one of these therapies. The recent withdrawal of rofecoxib from the market because of an increased risk of thrombotic cardiovascular events should lead clinicians to carefully consider whether this class of agents designed to reduce GI adverse events is appropriate for their patients, especially those with underlying cardiovascular risk. Dr. Scheiman emphasizes that because aspirin use substantially reduces the GI benefit of COX-2 inhibitors, alternative strategies to reduce GI toxicity should be used.

Grace Elta, MD

Editor

Commentary

GERD is the third most common GI disorder in the United States, affects 19 million US adults, and accounts annually for 4,590,000 outpatient visits and 96,000 hospitalizations, amounting to $19 billion in annual costs. The majority of patients have complete relief of symptoms on long-term medical therapy with proton pump inhibitors. However, as much as 20% continue to have a detriment in quality of life scores caused by GERD symptoms. These refractory patients, or patients who do not want to take long-term medications, may benefit from the plethora of new endoscopic therapies for GERD. Although long-term follow-up and sham-controlled studies are, in general, not yet available, Dr. Triadafilopoulos reviews the currently available techniques and offers a unique perspective on their potential role in GERD therapy.

Grace Elta, MD

Editor

Commentary

A cause for acute pancreatitis is not identified in 10% to 30% of patients after careful history, physical examination, laboratory testing, and radiologic evaluation. These patients are conventionally classified as having idiopathic acute pancreatitis (IAP). Patients with recurrent episodes of IAP are diagnosed with idiopathic acute recurrent pancreatitis (IARP). IAP and IARP are challenging clinical problems for the physician and often frustrating for the patient. Dr. Stuart Sherman has reviewed the role of ERCP and ancillary endoscopic techniques in the evaluation and therapy of these patients.

Grace Elta, MD

Editor

Commentary

Dysphagia is a common esophageal symptom with nearly 1 in 5 subjects older than 50 years describing this symptom in epidemiologic surveys. It is the second most common indication for upper endoscopy in the United States. There is a myriad list of possible etiologies for dysphagia. Consequently, a systematic approach to the differential diagnosis resulting in a well planned investigation is important. As described by Drs. Katzka and Kochman, a carefully obtained medical history is the initial step. Upper endoscopy is almost always indicated as part of the evaluation and treatment.

Grace Elta, MD

Editor

Commentary

Irritable bowel syndrome (IBS) is the most common condition encountered in general gastroenterology practice. IBS has protean manifestations but is typically characterized by abdominal pain, bloating, and disturbed defecation. The prevalence of IBS is estimated to be between 14% and 24% in women and 5% and 19% in men in the United States and Britain and is responsible for 2.4 to 3.5 million physician visits per year. The estimated total direct cost associated with IBS was $1.6 billion in 1998 with medication costs and the costs associated with diagnostic testing comprising the largest components of this estimate. Drs Cash and Chey focus on the role of endoscopy in a cost-effective diagnostic evaluation of IBS.

Grace Elta, MD

Editor

Commentary

Pancreatic cancer is the second most frequent gastrointestinal malignancy with approximately 29,000 new cases occurring annually in the United States. Almost all of these patients will die from the disease, making pancreatic cancer the fourth leading cause of cancer death for both men and women. Since surgical resection of the tumor offers the only chance for a cure, modalities for early diagnosis and accurate preoperative staging have continued to evolve. In this review, Drs. Mallery and Baron discuss the role of new diagnostic modalities including helical or multi-detector CT scan, endoscopic ultrasound (EUS), EUS-guided fine needle aspirate, and MRI, MRCP, and MR angiography. ERCP is now primarily relegated to a therapeutic palliative role in inoperable patients. A clinical management algorithm for patients with suspected pancreatic cancer is provided.