Gastrointestinal Endoscopy - part 5 potx

97 Lasers in Endoscopy 13 •Photodynamic therapy. Largest clinical experience to date. Best technique for circumferential areas of Barrett’s esophagus ≥ 3 cm in length. Small area of Barrett’s, i.e., finger-like projections, < 3 cm circumferential involvement, can be treated with Nd:YAG laser. • Risks. Perforation, stricture (common), Barrett’s epithelium retained under new squamous mucosa. • Bottom line. Still experimental. Patients with large areas of Barrett’s with se- vere dysplasia who are acceptable risks should undergo surgery. Early Gastric Carcinoma Rare in the U.S. Small lesions, ≤ 3 cm. Japanese studies show good results with PDT and Nd:YAG used for superficial carcinoma (staged by endoscopic ultrasound) in poor operative risk patients. Raised lesions with discrete margins: Nd:YAG. Flat, ulcerated lesions with indiscrete margins: PDT. Complete remission at 2 years in 80%. Advanced Gastric Carcinoma YAG laser generally not very helpful. Minimal PDT experience; stents best for extensive antral lesions that cause partial gastric outlet obstruction. Figure 13.3. Treatment of rectal adenoma, polypoid and sessile components. (top left) remove polypoid portion via standard snare technique, specimen to Pathol- ogy; (bottom left) begin endoscopic laser treatment of sessile area; (top right) make sure area is examined in retroflexion because tumor often is not seen in end-on view; and (bottom left) treat, if necessary, in retroflexion and torque scope to get best angle; avoid scope shaft; may need to alter patient position. 98 Gastrointestinal Endoscopy 13 Table 13.4. Endoscopic laser therapy for rectal and rectosigmoid villous adenomas and its relationship to the circumference of the tumor base Size of Tumor Base Less than More than One-Third Two-Thirds Circumference Circumference Number of patients 114 39 Laser treatments per patient 3.2 13.5 Recurrence rate (%) 12 21 Stenosis needing dilation (%) 0 15 Subsequent carcinoma detection (%) 3 24 Table 13.5. Indications for endoscopic laser therapy for benign rectal and rectosigmoid adenomas in patients who are operative candidates and those who are not Operative Candidate Nonoperative Candidate • Avoid interference with sphincteric function • Control bleeding • Recurrence following surgery • Control of diarrhea • “Certainty” of endoscopic cure • Dehydration • Relatively low cancer risk • Hypokalemia (size, appearance, sampling) • Incontinence • Patient refuses surgery • Alleviation of obstruction Table 13.3. Complications of endoscopic laser therapy for colorectal cancers Number % Pain requiring narcotic analgesia 3 0.6 Bleeding requiring transfusion 10 2.0 ≥ 10 ml 16 3.2 Perforation (local) 15 3.0 Perforation (free) 5 1.0 Anal stenosis 21 4.2 Fecal incontinence 5 1.0 Need for surgery 19 3.8 Death 6 1.2 *Survey by author involving 500 patients. (Contributors to the survey: Drs. Harvey Jacobs, Stephen Bown, Richard Dwyer, David Fleischer, Victor Grossier and Mark Mellow.) 99 Lasers in Endoscopy 13 Duodenal Malignancies Laser occasionally of value. PDT better than Nd:YAG because of ease of treat- ment application. Palliation for bleeding and/or obstructive symptoms. Stents may be best for partially obstrcuting lesions. Difficult to treat this region with any modality. Benign Duodenal Polyps Isolated or with familial polyposis syndromes. Side viewing scope best. Lesions in ampulla common and, unfortunately, most difficult to ablate. Can invade or originate in distal CBD. May need Whipple operation. Colorectal Cancer •Background. Primary treatment of colorectal cancer is surgical, based on prin- ciples of relief and prevention of bleeding or obstruction and debulking pri- mary tumor mass. However, approximately 10-15% of all patients with rectal cancer are better managed nonoperatively. This includes certain elderly pa- tients, those with severe, associated medical conditions or with widespread Figure 13.4a,b. Sessile rectal villous adenoma before treatment (top) and immedi- ately after treatment (bottom). 100 Gastrointestinal Endoscopy 13 metastases, and the occasional patient who refuses surgery. Rectal cancer is much more frequently treated with endoscopic laser therapy than more proxi- mal colonic lesions because of: ease of access, need for more drastic surgery, less chance of severe complication (free perforation). -Goal is usually palliative. Results: bleeidng controlled in 90%; obstruction man- aged in 75%. -Treatment technique like that for esophageal cancer: IV sedation, coaxial CO2, Nd:YAG laser, 60-80 watts. Treat proximal tumor margin first (that portion furthest from anus) and work distally. Treat q2-4 days until lumen patency achieved or bleeding areas treated, usually accomplished in 2-3 sessions. (Fig. 13.2) Retreat approximately every 10 weeks. Most difficult to treat are circum- ferential lesions that traverse the rectosigmoid angle (stent preferable); lesions that extend to the anus, especially if circumferential; anastomotic recurrence since this is primarily extraluminal (stent preferable). - The goal is cure in certain lesions, ie, ≤ 3 cm in length, ≤ one-thord of circumference, purely exophytic without ulceration. Brunetaud treated 19 such patients, 18 of whom had no local recurrence of clinically evident metastases at average follow-up of 37 months. However, since currently no fool-proof way to stage accurately to exclude nodal involvement (even with endoscopic ultrasound and/or radiolabeling with antitumor antibodies), patients still need at a relative surgicla contraindication to be considered for curative laser therapy forcolorectal cancer. - Complications (Table 13.3) Figure 13.4c. Sessile rectal villous adenoma. Total ablation, after treatment. 101 Lasers in Endoscopy 13 Benign Colorectal Neoplasms •Technique goal. Total ablation when possible, but ablation difficult with cir- cumferential lesions and large circumferential lesions increase hidden carcinoma potential (Table 13.4). Therefore an otherwise healthy patioent with an extensive lesions should undergo surgery, even if it means AP resection with colostomy. The less extensive the lesion and the higher the surgical risk, the more appealing is laser treatment. •Technique. (Fig. 13.3) Snare polypoid segments by standard snare polypec- tomy technique. Then treat remaining sessile tumor with laser. Purely sessile lesions are laser-treated (Fig. 13.4). In large lesions, obtain biopsy samples frequently to minimize the chance of missing carcinoma. For summary of indications for endoscopic laser therapy of benign rectosigmoid lesions see Table 13.5. With sessile villous adenomas, rationale for laser therapy versus surgery is similar, but lesions ≥ 4 cm (≥ one-half circumference) favor surgery. • Alternative treatment. “Strip biopsy”. Injection of normal saline into submu- cosa for “lif up” neoplasm, then polypectomy via standard snare technique. Good for smaller lesions. Very difficult for circumferential lesions and/or le- sions near anal verge. Can inject saline into submucosa prior to laser treat- ment as well, which may decrease perforation risk. Laser lithotripsy. Fragmentation of gallstones by laser. Larger common bile duct stones not amenable to removable via sphincterotomy or mechanical lithotripsy. Choledochoscope passed via biopsy channel of duodenoscope directly into com- mon bile duct. Fiber placed in direct contact with stone. Not first-line therapy for choledocholithiasis. Vascular Malformations of GI Tract •Goal. Photocoagulation of mucosal vessels and, in some instances, submu- cosal feeder vessels. •Indications for treatment. Severe iron deficiency anemia or acute bleeding. 50% present with occult bleeding; 50% with acute, sometimes recurrent, bleeding. •Technique, Nd:YAG laser. 50-60 watts, 0.5-1,0 sec pulse duration. Aim to produce blanching of the surface yet coagulate down to submucosa. The mucosal lesion is often tip of the iceberg. Lesions that bleed spontaneously or ooze with initial treatment need the most aggressive therapy. Treat for at least 4 wk with acid suppressant therapy for iatrogenic, post-treatment ulcerations. •Treatment pearls. Examine patient euvolemic. Hypovolemia cause blanching of vessels, hard to see. Water jet red spots, often AVMs, are mistaken for focal gastritis. If oozes blood with water jet, need to treat. Examine carefully on scope entry since scope trauma marks are easily confused with AVMs. Use glucagon or atropine to minimize gut motility on UGI exams. If barcotics are given for the procedure, reverse with Narcan; makes vessel easier to see. Check for coagulation defects, NSAID use, portal hypertension. These conditions drastically increase bleeding potential of AV malformations. •Subgroups of AV malformations. Single, multiple, hereditary hemorrhagic telangiectasia; gastric antral vascular ectasia (GAVE, watermelon stomach). •Results. Sustained reduction in transfusion requirements after laser treatment in approximately 75%. GAVE usually requires 2-3 treatments and sometimes repeat treatments at a later date. HHT patients most difficult to treat and may need adjunctive pharmacotherapy (estrogen-progesterone, danazol). 102 Gastrointestinal Endoscopy 13 • Complications. Continued bleeding, not controlled (10%), perforation 2- 3% in UGI tract and higher in right colon; antral narrowing, not clinically significant. Need for surgery, usually with GAVE, approximately 15%. Radiation Proctitis •Really a vasculopathy, after radiation to area of rectum (pelvic malignancies), resulting in chronic bleeding. Anemia is due to bleeding and radiation effect on pelvic bone marrow. •Enema techniques rarely effective and can increase bleeding. • Nd:YAG treatment -Treat as one treats AVMs. Coagulate surface vessel and submucosal feeder. Power 50-60 watts, 0.5-1.0 sec pulse duration at 1 cm distance to target. Anal verge most difficult. -Results. Decrease bleeding in many patients. However, sizeable minority of patients are not improved. - Complications. Perforation (3-5%); rectovaginal fistula; temporary increased bleeding from iatrogenic ulcer at treatment site. • KTP laser. Similar goals and results to YAG. May be better at anal verge. Selected References 1. Sargeant IR, Loizou LA, Rampton D et al. Laser ablation of upper gastrointestinal vascular ectasias: ;ong term results. Gut 1993; 34:470-475 2. Fleischer D, Sivak MV. Endoscopic Nd:YAG laser therapy as palliation for esoph- ageal cancer—parameters affecting initial outcome. Gastroenterology 1985; 89:827-831 3. Sibille A, Descamps C, Jonard P et al. Endoscopic Nd:YAG treatment of superfi- cial gastric carcinoma: Experience in 18 Western inoperable patients. Gastrointes- tinal Endosc 1995; 42:340-345 4. Brunetaud JM, Maunoury V, Cochelard D. Lasers in rectosigmoid tumors. Sem Surg Oncol 1995; 11:319-327 5. Laukka MA, Wand KK. Endoscopic Nd:YAG laser palliation of malignant duode- nal tumors. Gastrointestinal Endosc 1995; 41:225-229 6. Overholt BF, Panjepour M. Photodynamic therapy in Barrett’s esophagus: Reduc- tion of specialized mucosa, ablation of dysplasia and treatment of superficial esoph- ageal cancer. Sem Surg Oncol 1995; 11:372-376 7. Spinelli P, Mancini A, DalFante M. Endoscopic teatment of gastrointestinal tumors. Sem Surg Oncol 1995; 11:307-317 8. Mellow MH. Endoscopic laser therapy for colorectal neoplasms. Pract Gastroenterol 1997; 8:9-20 9. Van Cutsem E, Boonen A, Geboes K. Risk factors which determine the long term outcome of Nd:YAG laser palliation of colorectal cancer. Int J Colorect Dis 1989; 4:9-11 10. Mellow MH. Endoscopic laser therapy as an alternative to palliative surgery for adenocarcinoma of the rectun—Comparison of costs and complications. Gas- trointestinal Endosc 1989; 35:283-287 11. Patrice T, Foultier MT, Yatayo S. Endoscopic photodynamic therapy with HPD for primary treatment of gastrointestinal neoplasms in inoperable patients. Dig Dis Sci 1990; 35:545-552 12. Brunetaud JM. Endoscopic laser treatment for a rectosigmoid villous adenoma: Factors affecting results. Gastroenterology 1989; 97:272-277 13. Barbatza C, Spencer GM, Thorpes M et al. Nd:YAG laser treatment for bleeidng from radiation proctitis. J Endosc 1996; 28:497-500 CHAPTER 1 CHAPTER 14 Gastrointestinal Endoscopy, edited by Jacques Van Dam and Richard C. K. Wong. ©2004 Landes Bioscience. Endoscopy of the Pregnant Patient Laurence S. Bailen and Lori B. Olans Introduction Endoscopy is performed infrequently during pregnancy. Due to this limited number of procedures and the ethical considerations associated with clinical studies in gravid women, little published data are available on endoscopy in pregnancy. When considering upper or lower endoscopy in the gravid patient, special attention should be given to the diagnostic and therapeutic utility of the procedure and to the safety of the mother and fetus during the examination. Clearly, the threshold for performing endoscopy in the pregnant patient should be higher than in the non- pregnant patient given the potential risks. Nevertheless, in certain clinical situations endoscopy may be indicated to improve maternal and fetal well-being. This chapter will review the indications, techniques, findings, and outcomes of endoscopy per- formed during pregnancy. Indications • Endoscopy during pregnancy may play a role in making a definitive diagnosis in patients who are unresponsive to standard therapy or who have atypical symp- toms. Endoscopy can also provide a safer alternative than more invasive ap- proaches such as surgery. 1 Indications for esophagogastroduodenoscopy (EGD), flexible sigmoidoscopy, colonoscopy, and endoscopic retrograde cholangio- pancreatography (ERCP) are considered below. EGD 2 • Upper gastrointestinal bleeding with hemodynamic compromise. Endoscopic therapeutic intervention may be possible. • Symptoms of dysphagia, odynophagia, gastroesophageal reflux, nausea, vomit- ing, or abdominal pain which are severe, persistent, or refractory to empiric treatment. • Suspected esophageal or gastric malignancy in which biopsy prior to postpartum period would influence management. Flexible Sigmoidoscopy 2 -Refractory distal colonic gastrointestinal bleeding (e.g., suspected colitis) -Suspected rectal or sigmoid mass, stricture, or other obstructing lesion where biopsy prior to postpartum period would influence management. -Severe refractory diarrhea of unclear etiology 104 Gastrointestinal Endoscopy 14 Colonoscopy 2 -Suspected proximal colonic malignancy or other mass of unclear etiology where biopsy prior to postpartum period would influence management. -Severe, refractory bleeding due to proximal colonic source unreachable by flexible sigmoidoscope. ERCP 2 • Suspected refractory symptomatic choledocholithiasis, cholangitis, or gallstone pancreatitis. Technique • Special consideration should be given to medications used in preparation for (Table 14. 2) and during (Table 14.3) endoscopic examination of the pregnant patient. Noninvasive monitoring including blood pressure, pulse oximetry, and electrocardiography can aide in assessing the well-being of both mother and fetus. Medication Safety • The fetal safety of medications used during endoscopy is often determined by case reports in the medical literature and Food and Drug Administration (FDA) categorization. 1-4 Drugs are classified as category A, B, C, D, or X based on the level of risk to the fetus (Table 14.1). 4 Preparation • EGD and ERCP -Nothing to eat or drink for 8-12 hours prior to procedure. - Assure adequate hydration with intravenous fluids if necessary. • Flexible sigmoidoscopy - Clear liquid diet day prior to examination. - Choices for distal bowel cleansing may include enemas, suppositories, and / or oral cathartics such as the following: Tap water or Fleet’s enemas, dulcolax suppositories or tablets, and magnesium citrate oral solution. The FDA categorization for these medications regarding risk to the fetus is summa- rized in Table 14.2. -Safest options based on limited data: Gentle tap water enemas and/or dulcolax suppositories or tablets. 2 • Colonoscopy (See Table 14.2) -Polyethylene glycol (PEG) solution (e.g., GoLytely, CoLyte, NuLytely). Pa- tients must drink approximately 4 L of this isosmotic solution to achieve adequate bowel cleansing. No study on safety of PEG during pregnancy but limited data suggest safety when used in the puerperium. 5, 2 -Sodium phosphate solution (Fleet’s PhosphoSoda). Patients often prefer this poorly absorbed salt solution which causes an osmotic diarrhea because the volume required for bowel cleansing is less than the volume of PEG solu- tion needed. Little data on safety available. One case report of bone growth failure in an infant born to an anorexic mother with maternal phosphate overload due to excessive phosphate enema use during pregnancy. 6, 2 105 Endoscopy of the Pregnant Patient 14 Drugs Used as Premedications and During Endoscopy • Flexible sigmoidoscopy is routinely performed without premedication. How- ever, given the discomfort associated with upper endoscopic and colonoscopic procedures, only rare patients are able to complete these procedures without medications. • Table 14.3 outlines common medications used during endoscopy to enhance patient comfort along with the associated FDA categorization. • Diazepam is a benzodiazepine which may cause neonatal floppy infant syn- drome (hypotonia, lethargy, irritability) if given to mothers during labor. 4, 2 There is a suggested but not proved increased risk of congenital malformations and central nervous system problems when given to pregnant women. 2, 4 • Midazolam is a newer benzodiazepine compared to diazepam. Less data on its use in pregnancy are available. Midazolam prior to caesarean section may have a depressant effect on newborns. 4 2 In many reports of use during endoscopy in pregnancy, midazolam caused no obvious illeffects. 79 • Meperidine is commonly used for endoscopic premedication during pregnancy. No known fetal problems during pregnancy except when given during labor when it may cause transient respiratory depression and impaired alertness. 4, 2 • Fentanyl is a Category B drug with no known associated congenital defects. One case of respiratory depression in an infant born to a mother who received epidural fentanyl during labor. 4, 2 Table 14.1. FDA categorization based on fetal effects Category A Controlled studies in women fail to demonstrate a risk to the fetus in the first trimester (and there is no evidence of a risk in later trimesters), and the possibility of fetal harm appears remote. Category B Either animal-reproduction studies have not demonstrated a fetal risk, but there are no controlled studies in pregnant women or animal-reproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in women in the first trimester (and there is no evidence of a risk in later trimesters). Category C Either studies in animals revealed adverse effects on the fetus (teratogenic or embryocidal, or other) and there are no controlled studies in women or studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the fetus. Category D There is positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk (e.g., if the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective). Category X Studies in animals or human beings have demonstrated fetal abnormalities, or there is evidence of fetal risk based on human experience, or both, and the risk of the use of the drug in pregnant women clearly outweighs any possible benefit. The drug is contraindicated in women who are or may become pregnant. 106 Gastrointestinal Endoscopy 14 • Droperidol is a butyrophenone derivative with sedative and antiemetic effects. It has been used as an adjunct to sedation in caesarean sections and in the man- agement of hyperemesis gravidarum without documented fetal harm. 4 • Simethicone is a silicon product which eliminates gas bubbles that may impair endoscopic visualization. Use of this Category C drug during pregnancy is usu- ally avoided due to limited data reporting a possible increase in birth defects. 4, 2 • When necessary, medications administered during pregnancy should be given judiciously due to the lack of definitive studies regarding fetal outcome. Based on the available data, meperidine and fentanyl are likely safer medications when compared with diazepam and midazolam. 1 Monitoring • Noninvasive monitoring provides valuable information prior to and during en- doscopic procedures to assist in maximizing maternal and fetal well-being. • Recommended monitoring includes the following: 2 • Supplemental oxygen with continuous pulse oximetry • Blood pressure and telemetry monitoring. • Continuous fetal heart monitoring or, when not technically possible, intermit- tent fetal monitoring. • Anesthesia support may be helpful for long or complicated procedures to assist with medication administration and monitoring. • Abdominal pelvic shielding with lead should be used when fluoroscopy is needed during ERCP. Procedures should be performed by experienced endoscopists in order to minimize fluoroscopy time. Results and Outcomes of Endoscopy During Pregnancy • Esophagogastroduodenoscopy - The largest series of EGD during pregnancy, a case control study, included 83 procedures. 8 -Gastrointestinal bleeding was the most common indication. - The most frequent finding for this indication was reflux esophagitis. Other findings included Mallory-Weiss tear, gastritis, and duodenal ulcer. - Common findings for symptoms of nausea, vomiting, and abdominal pain were esophagitis and gastritis. -Meperidine, midazolam, diazepam, and naloxone were all used with- out incident. Table 14.2 Bowel preparation prior to colonoscopy in the pregnant patient Medication Category Polyethylene glycol (GoLytely, CoLyte, NuLytely) Category C Magnesium citrate Unlabeled Sodium phosphate solution Unlabeled (Fleets Phospho-Soda, Fleet’s enema) Dulcolax suppositories/tablets Category B [...]... both surgical and nonsurgical techniques 15 116 Gastrointestinal Endoscopy Table 15. 3 Complications of PEG placement - Infectious (local cellulitis, abscess, necrotizing fasciitis) - Tube migration (proximal, distal) - Separation of stomach from abdominal wall - Fistulae (gastrocolic, colocutaneous) - Enlargement of gastrostomy site - Implantation metastases - Others: small bowel fistula, intestinal... obtain informed consent -inability to approximate anterior abdominal and gastric walls -nonfunctioning or obstructed gastrointestinal tract -uncorrectable coagulopathy -gastric varices -chronic peritoneal dialysis -absence of stomach Relative: -previous gastric or major abdominal surgery -ventriculoperitoneal shunt -recent myocardial infarction tissue ischemia with subsequent ulceration/pain, infection,... (Fig 15. 3) It is important to insure that the crossbar is not positioned too tightly as this can lead to local 15 112 Gastrointestinal Endoscopy Table 15. 2 Contraindications to PEG placement for purposes of enteral feeding Absolute: -patients not expected to live for any significant length of time -patients who are unlikely to benefit from enteral feedings -inability to obtain informed consent -inability... N 19 95; 49:22 4-2 26 Rimensberger P, Schubiger G, Willi U Connatal rickets following repeated administration of phosphate enemas in pregnancy: A case report Eur J Pediatr 1992; 151 :5 4 -5 6 Endoscopy of the Pregnant Patient 7 8 9 109 Cappell MS, Colon VJ, Sidhom OA A study at 10 medical centers of the safety and efficacy of 48 flexible sigmoidoscopies and 8 colonoscopies during pregnancy with follow-up... obstetrician is essential Selected References 14 1 2 3 4 5 6 Olans LB, Wolf JL Gastroesophageal reflux in pregnancy Gastrointest Endosc Clin N Am 1994; 4:69 9-7 12 Cappell MS The safety and efficacy of gastrointestinal endoscopy during pregnancy Gastroenterol Clin North Am 1998; 27:3 7-7 1 Koren G, Pastuszak A, Ito S Drugs in pregnancy N Engl J Med 1998; 338:112 8-1 137 Briggs GG, Freeman RK, Yaffe SJ Drugs in pregnancy... examination - No reported fetal or maternal complications related to the procedure 14 108 Gastrointestinal Endoscopy • Endoscopic retrograde cholangiopancreatography - The largest published series of ERCP during pregnancy included 29 procedures performed throughout gestation.9 - Indications for ERCP included abdominal pain with abnormal liver function tests with or without abnormal abdominal ultrasound - The... 1996; 41:23 5- 3 61 Cappell MS, Colon VJ, Sidhom OA A study of eight medical centers of the safety and clinical efficacy of esophagogastroduodenoscopy in 83 pregnant females with followup of fetal outcome with comparison control groups Am J Gastroenterol 1996; 91:34 8-3 54 Jamidar PA, Beck GJ, Hoffman BJ et al Endoscopic retrograde cholangiopancreatography in pregnancy Am J Gastroenterol 19 95; 90:12 6-1 37 14... Direct percutaneous endoscopic jejunostomies for enteral feeding Gastrointest Endosc 1996; 44 :53 6 -5 40 This article describes the technique of single-step, direct PEJ placement American Gastroenterological Association Medical Position Statement: Guidelines for use of enteral nutrition Gastroenterology 19 95; 108:128 0-1 281 Position Statement by the AGA on use of enteral nutrition American Gastroenterological... Gastroenterological Association technical review on tube feeding for enteral nutrition Gastroenterology 19 95; 108:128 2-1 301 Detailed review on the technical aspects of enteral tube feeding 15 CHAPTER 16 Small Bowel Endoscopy Jeffery S Cooley and David R Cave Introduction Standard upper and lower gastrointestinal endoscopy effectively evaluates a variety of pathologic conditions affecting the esophagus, stomach,... Occult gastrointestinal bleeding This is the most common indication for enteroscopy The small intestine is the source of gastrointestinal bleeding in less than 5% of cases However, when the bleeding is chronic and undiagnosed after standard endoscopy, the proportion of cases is larger Patients with bleeding, presumed to be of small intestinal origin, have usually undergone an array of Gastrointestinal Endoscopy, . Gastroenterol 1996; 91:34 8-3 54 . 9. Jamidar PA, Beck GJ, Hoffman BJ et al. Endoscopic retrograde cholangio- pancreatography in pregnancy. Am J Gastroenterol 19 95; 90:12 6-1 37. CHAPTER 15 Gastrointestinal Endoscopy, . 19 95; 49:22 4-2 26. 6. Rimensberger P, Schubiger G, Willi U. Connatal rickets following repeated ad- ministration of phosphate enemas in pregnancy: A case report. Eur J Pediatr 1992; 151 :5 4 -5 6. 109 Endoscopy. patients. Dig Dis Sci 1990; 35: 54 5- 5 52 12. Brunetaud JM. Endoscopic laser treatment for a rectosigmoid villous adenoma: Factors affecting results. Gastroenterology 1989; 97:27 2-2 77 13. Barbatza C, Spencer