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1.  Recommendations for standards of sedation and patient monitoring during gastrointestinal endoscopy. 
Gut  1991;32(7):823-827.
(1) Safety and monitoring should be part of a quality assurance programme for endoscopy units. (2) Resuscitation equipment and drugs must be available in the endoscopy and recovery areas. (3) Staff of all grades and disciplines should be familiar with resuscitation methods and undergo periodic retraining. (4) Equipment and drugs necessary for the maintenance of airway, breathing, and circulation should be present in the endoscopy unit and recovery area (if outside the unit) and checked regularly. (5) A qualified nurse, trained in endoscopic techniques and adequately trained in resuscitation techniques, should monitor the patient's condition during procedures. (6) Before endoscopy, adverse risk factors should be identified. This may be aided by the use of a check list. (7) The dosage of all drugs should be kept to the minimum necessary. There is evidence that benzodiazepine/opioid mixtures are hazardous. (8) Specific antagonists for benzodiazepines and opioids exist and should be available in the event of emergency. (9) A cannula should be placed in a vein during endoscopy on 'at risk' patients. (10) Oxygen enriched air should be given to 'at risk' patients undergoing endoscopic procedures. (11) The endoscopist should ensure the well being and clinical observation of the patient undergoing endoscopy in conjunction with another individual. This individual should be a qualified nurse trained in endoscopic techniques or another medically qualified practitioner. (12) Monitoring techniques such as pulse oximetry are recommended. (13) Clinical monitoring of the patient must be continued into the recovery area. (14) Records of management and outcome should be collected and will provide data for appropriate audit.
PMCID: PMC1379003  PMID: 1855692
3.  Guidelines on appropriate indications for upper gastrointestinal endoscopy. Working Party of the Joint Committee of the Royal College of Physicians of London, Royal College of Surgeons of England, Royal College of Anaesthetists, Association of Surgeons, the British Society of Gastroenterology, and the Thoracic Society of Great Britain. 
BMJ : British Medical Journal  1995;310(6983):853-856.
Upper gastrointestinal endoscopy is a valuable diagnostic tool, but for an endoscopy service to be effective it is essential that it is not overloaded with inappropriately referred patients. A joint working party in Britain has considered the available literature on indications for endoscopy, assessed standard practice through a questionnaire, and audited randomly selected cases using an independent panel of experts and an American database system. They used these data to produce guidelines on the appropriate and inappropriate indications for referral for endoscopy, although they emphasise that under certain circumstances there may be reasons to deviate from the advice given. The need for endoscopy is most difficult to judge in patients with dyspepsia, and this aspect is discussed in detail. Early endoscopy will often prove more cost effective than delaying until the indications are clearer.
PMCID: PMC2549224  PMID: 7711627
4.  Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing, and sedation methods. 
Gut  1995;36(3):462-467.
A prospective audit of upper gastrointestinal endoscopy in 36 hospitals across two regions provided data from 14,149 gastroscopies of which 1113 procedures were therapeutic and 13,036 were diagnostic. Most patients received gastroscopy under intravenous sedation; midazolam was the preferred agent in the North West and diazepam was preferred in East Anglia. Mean doses of each agent used were 5.7 mg and 13.8 mg respectively, although there was a wide distribution of doses reported. Only half of the patients endoscoped had some form of intravenous access in situ and few were supplied with supplementary oxygen. The death rate from this study for diagnostic endoscopy was 1 in 2000 and the morbidity rate was 1 in 200; cardiorespiratory complications were the most prominent in this group and there was a strong relation between the lack of monitoring and use of high dose benzodiazepines and the occurrence of adverse outcomes. In particular there was a link between the use of local anaesthetic sprays and the development of pneumonia after gastroscopy (p < 0.001). Twenty perforations occurred out of a total of 774 dilatations of which eight patients died (death rate 1 in 100). A number of units were found to have staffing problems, to be lacking in basic facilities, and to have poor or virtually non-existent recovery areas. In addition, a number of junior endoscopists were performing endoscopy unsupervised and with minimal training.
PMCID: PMC1382467  PMID: 7698711
5.  Appropriate use of upper gastrointestinal endoscopy--a prospective audit. Steering Group of the Upper Gastrointestinal Endoscopy Audit Committee. 
Gut  1994;35(9):1209-1214.
Work by this group has shown that there is a wide range of opinion as to patients' suitability for endoscopy. In a recent study, 1297 questionnaires were sent to a random selection of doctors, including 350 general physicians, 400 surgeons, 477 gastroenterologists, and 70 general practitioners. The respondent was asked to indicate whether or not he would refer the patient described by each case vignette for endoscopy. Depending on the indication, the positive referral rate varied from 4.5% to 99% overall, and from 4.5% to 63.8% for all those clinical situations that the working party felt to be inappropriate. A second study examined the appropriateness of 400 consecutive cases referred from four units within one health region; these cases were judged independently, and without conferring, by a panel of seven gastroenterologists. The same cases were rated by software that incorporated American opinion (the Rand criteria). Although only 45 (11%) of the cases were classed as inappropriate by the British panel, 120 cases (31%) assessed by the American software were rated inappropriate. These differences occurred largely because in the USA it is recommended that one month's antiulcer treatment be tried before considering endoscopy for dyspepsia and thus many referrals were seen as inappropriate by the American database. Of the 45 cases found to be inappropriate by the British doctors no important abnormality was found at endoscopy; whereas of 120 cases judged inappropriate by the Rand criteria, three duodenal and two gastric ulcers, and one gastric cancer were diagnosed at gastroscopy. This study attempts a quantitative assessment of inappropriate use and serves to encourage further work to define appropriateness.
PMCID: PMC1375695  PMID: 7959225
6.  Preference for hot drinks is associated with peptic disease. 
Gut  1989;30(9):1201-1205.
The temperature at which people chose to take a hot drink was measured in 59 patients with endoscopically proven peptic disorders of the upper gastrointestinal tract and 65 asymptomatic controls. The patients in the disease group drank significantly hotter tea or coffee than the control group (medians 62 degrees and 56 degrees Celsius respectively, P less than 0.0001). The median temperatures of choice for subgroups of patients with oesophageal, gastric or duodenal disease were significantly higher than the control group (63.5 degrees, 63 degrees, 60.5 degrees C respectively). There was no relationship between a preference for hotter drinks with either the sex or smoking habits of the patient. In the control group the temperature of choice tended to decrease with age though linear regression just failed to reach statistical significance (p = 0.06); this trend was not apparent in the disease group (p = 0.64). Thermal injury as a result of drinking hot fluids may be a causative factor in some peptic disorders.
PMCID: PMC1434237  PMID: 2806987
7.  Electrodes for 24 hours pH monitoring--a comparative study. 
Gut  1987;28(8):935-939.
Three pH electrodes in clinical use were examined--(1) antimony electrode with remote reference electrode (Synectics 0011), (2) glass electrode with remote reference electrode (Microelectrodes Inc. MI 506) and (3) combined glass electrode with integral reference electrode (Radiometer GK2801C). In vitro studies showed that both glass electrodes were similar and superior to the antimony electrode with respect to response time, drift, and sensitivity. The effect of the siting of the reference electrode on the recorded pH was examined in five human volunteers. The pH reading using a remote skin reference electrode was higher by a mean of 0.3 pH units (range 0.0-0.6) in the stomach, lower by 0.65 pH units (0.5-0.8) in the duodenum and lower by 0.3 pH units (0.0-0.6) in the oesophagus than that simultaneously obtained with an intraluminal reference electrode. Buccal reference electrodes gave similar readings to skin. Combined reference and glass pH electrodes are recommended for 24-hour ambulatory pH monitoring.
PMCID: PMC1433138  PMID: 3666560
8.  Duodenal pH in health and duodenal ulcer disease: effect of a meal, Coca-Cola, smoking, and cimetidine. 
Gut  1984;25(4):386-392.
Intraluminal duodenal pH was recorded using a combined miniature electrode and logged digitally every 10 or 20 seconds for five hours (basal/meal/drink) in eight control subjects and 11 patients with duodenal ulcer (five on and off treatment with cimetidine). Over the whole test there were no significant differences in duodenal mean pH or log mean hydrogen ion activity (LMHa) between control subjects and patients with duodenal ulcer, but there were significantly longer periods of duodenal acidification (pH less than 4) and paradoxically more periods of duodenal alkalinisation (pH greater than 6) in the duodenal ulcer group compared with controls. After a meal duodenal mean pH and LMHa fell significantly in both controls and patients with duodenal ulcer, with more periods of duodenal acidification and alkalinisation in the duodenal ulcer group. An exogenous acid load (Coca-Cola) significantly increased the periods of duodenal acidification, and reduced alkalinisation, in both groups. Cimetidine significantly increased mean pH and LMHa and abolished the brief spikes of acidification in four of five patients with duodenal ulcer. Peak acid output (but not basal acid output) was significantly correlated with duodenal mean pH and LMHa but not with the periods of duodenal acidification. Smoking did not affect duodenal pH in either group.
PMCID: PMC1432343  PMID: 6706217
9.  Twenty-four hour gastric acidity after vagotomy. 
Gut  1978;19(7):664-668.
Twenty-four hour intragastric pH during normal daily activity has been studied by nasogastric intubation and aspiration of gastric samples in seven patients four years after vagotomy (four truncal, three selective). Two of these patients also had pre- and early postoperative studies. Mean pH was inversely correlated with basal, insulin- and pentagastrin-stimulated acid outputs. However, one of four patients after truncal vagotomy with drainage, and two of three after selective vagotomy and drainage had most of their hourly intragastric pH values more acidic than pH 3.5 despite more than 70% reductions in preoperative stimulated-acid outputs.
PMCID: PMC1412070  PMID: 680598

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