Volume 100, Issue s12

Endoscopic retrograde cholangiopancreatography (ERCP) is a unique specialty tool used for the diagnosis and treatment of biliary and pancreatic disease. The procedure is much more available now and can be used in place of surgery or in conjunction with surgery. This article reviews the indications, applications, and personal experiences with the procedure in a rural referral hospital. Discussion includes the risks and complications of ERCP. Also included are explanations of therapeutic interventions. After reading this article, primary care physicians should have greater familiarity with the utility of this endoscopic tool.

Acute gastrointestinal bleeding is a common medical emergency that frequently results in hospitalization. Rapid initial assessment of clinical parameters such as estimated volume of blood lost, appearance of expelled blood, hypotension, mental status changes, and coagulopathy should all be evaluated as part of the outcomes prediction equation. For upper gastrointestinal bleeding, early endoscopy of the upper gastrointestinal tract will also provide important information to aid in efforts to predict risk. Endoscopic evidence of ongoing rapid bleeding or the presence of a "visible vessel" or adherent clot on the ulcer base are findings that are associated with a high likelihood of continued bleeding or recurrent bleeding. Endoscopic therapy can reduce the rates of recurrent bleeding, surgery, and length of hospital stay in patient with these "stigmata of recent bleeding." Other endoscopic ulcer appearances such as brown or black pigment in the ulcer base or a clean ulcer base do not require endoscopic therapy, as rates of recurrent bleeding are very low for these lesions. Use of these clinical and endoscopic outcome predictors can also be useful in refining triage decisions as to which patients need to be in the intensive care unit, which need to be admitted to the hospital, and which can have early oral feeding and expedited hospital discharge or outpatient care.

Although we spend approximately one third of our lives sleeping, rarely do we consider that sleep may contribute to medical conditions. For gastroesophageal reflux, sleep or physiologic changes associated with the sleep state often promote or increase the likelihood of reflux and aspiration. These changes include the assumption of the supine position, a decrease in the arousal threshold, mechanical effects of the abdomen, and disorders associated with sleep. Of the sleep disorders, obstructive sleep apnea is associated with a high frequency of gastroesophageal reflux, probably due to the generation of negative intrathoracic pressures and obesity associated with the disease. Obstructive sleep apnea in patients with gastroesophageal reflux can lead to difficult-to-treat or refractory gastroesophageal reflux, predominantly nocturnal or early-morning symptoms, and unusual or uncommon manifestations that do not appear to reflect the underlying pathologic process. Under most circumstances, aggressive treatment regimens must be instituted for both disorders in order to effectively control symptoms. This article reviews the major information that is currently available on the relationship between obstructive sleep apnea and gastroesophageal reflux.

Gastroesophageal reflux is a common problem that occurs in the pediatric population. Gastroesophageal reflux refers to the retrograde passage of gastric contents into the esophagus. Current thinking implicates transient lower esophageal sphincter relaxations as a major cause for reflux. Infants generally present with symptoms of regurgitation, whereas symptoms of esophagitis are more common in older children. When there are dangerous consequences secondary to gastroesophageal reflux, it is termed gastroesophageal reflux disease (GERD). GERD has been shown to manifest with respiratory symptoms and a pathologic process. A variety of diagnostic procedures are available for the assessment of GERD which include barium swallow, pH probe, scintigraphy, and endoscopy with esophageal biopsy. Medical management of GERD primarily involves prokinetic agents and acid suppression therapy. Surgical therapy, albeit less common, now still has its role in the treatment of GERD.