An apparently novel entity, diffuse hemorrhagic gastroenteropathy (DHG), in a 70-year-old female who had an unremitting course of chronic gastrointestinal blood loss for 3 years requiring transfusion of more than 200 units of packed red blood cells over this period is reported here. Endoscopy showed diffusely hemorrhagic mucosa in the stomach, duodenum, and small bowel. Full-thickness biopsy of the stomach and small intestine revealed luminal narrowing of capillaries and post-capillary venules within the lamina propria due to swelling and some proliferation of the endothelial cells with margination and emigration by neutrophils as well as partial occlusion of some vessels by fibrin thrombi. DHG may represent a new entity characterized by mucosal hemorrhage due to local mucosal ischemia of the gastrointestinal tract secondary to a small vessel "vasculopathy" apparently restricted to this site.

Endoscopy has revolutionized the management of digestive diseases in general and ulcer disease in particular. It allows the physician to view the pathologic process directly, and with biopsy and cytology techniques, to obtain histological samples. Endoscopy helped to usher in the field of minimally invasive therapy and endoscopic treatment of bleeding ulcers and is now a standard form of treatment. This overview is divided into three parts: first, the current diagnostic and therapeutic endoscopic management of ulcer disease will be addressed; second, some of the current work that should have future applications in the same area will be discussed. Finally, some conceptual ideals that look further beyond future applications will be addressed.

logical way from the very nature of the organization.The A/S/G/E retreat provided the occasion to examine these principles in relation to the actual activities of the Society, but it also offered the opportunity to evaluate the state of the Society itself.This is the context that brought the words of General Smith to mind.The perspective of a President is distinct in that it is possible to form a complete picture of the structure and activities of an organization.More to the point perhaps is the unique knowledge a President may derive of the methods that an organization uses to get things done.The A/S/GjE is an all volunteer outfit, and things get done by virtue of the contributions of capable individuals who share in the ideals of the Society.The future success of the A/S/G/E will relate directly to the ability of the organization to incorporate the ideas of its members and to focus their efforts.It was especially gratifying, therefore, to watch this process in action at the retreat as this inspired a substantial degree of confidence in the future of the Society.As this is my final From the Rostrum column, I will permit myself a few lines of reflection on my association with the A/S/G/E.One may ponder the "worth" of all of the time and effort devoted to an all volunteer organization.The force of this question was always especially exquisite when trips to committee meetings ended with a night landing in bad weather in the dead of winter in Cleveland.However, work with competent people toward the achievement of worthwhile goals is a source of great satisfaction, and one of the best parts of the medical profession for me is to be among good colleagues in the pursuit of a common purpose.General Smith, who retired from the Marine Corps a few years after the Korean conflict, must have regarded the organization he served in such a way.To those who would seek a similar experience, the A/S/G/E is a splendid opportunity.

A letter that I wrote to the editor of the New England Journal of Medicine, entitled “Unclogging the Obstructed Biologic Cylinder,” was published earlier this year.1Fleischer D Unclogging the obstructed biologic cylinder (letter to the editor).N Engl J Med. 1990; 322: 477PubMed Google Scholar It emphasized that a wide variety of physicians deal on a daily basis with a similar problem—the clogged biologic cylinder. The letter generated a large amount of correspondence attesting to the universality of the medical dilemma. I was prompted by the interest shown in the subject matter to expand the letter into a more formal editorial. In the past, the distinction among surgeons, internists, and radiologists was precise. Surgeons cut. Internists diagnosed and prescribed medications. Radiologists took x-ray films. No longer are the divisions so black and white, and the lines are becoming increasingly blurred. A new breed of subspecialists has emerged—gastrointestinal endoscopists, endourologists, interventional radiologists, cardiac angiographers, and therapeutic bronchoscopists—who often have more in common with each other than with other members of their own specialties. In many cases, the focus of their attention is the obstructed biologic cylinder. Therefore, although a gastrointestinal endoscopist may be treating a patient with dysphagia because of esophageal cancer, the urologist may be relieving an obstructed ureter, the radiologist may be intervening to bring patency to a peripheral vessel or a bile duct, the cardiologist may be dilating a coronary artery, and the pulmonologist or thoracic surgeon may be coring out a bronchus blocked by malignant tissue, their goals are actually similar: to establish flow in an occluded biologic cylinder. Not surprisingly, the tools of the trade of these subspecialties are also similar—lasers, guide wires, balloons, stents, and thermal probes. Although the properties of atherosclerotic plaques in a blood-filled coronary artery are clearly different from those of a necrotic tumor obstructing an esophagus, the therapeutic dilemma is the same: how can patency best be achieved (by dilation, thermal or mechanical destruction, dissolution, or stenting)? How can pathologic tissue be distinguished from normal tissue so that therapy can be selective? How can restenosis be prevented? And, finally, what is the best method of accomplishing these goals safely, effectively, and in a way that reduces rather than increases costs? The colonoscopic polypectomy is a straightforward example of a new technology ideally suited to deal with a pathologic process. In the past, if a patient had hematochezia and a barium enema study revealed a 2-cm pedunculated polyp, the patient would be hospitalized to undergo a laparotomy so that the polyp could be removed through a colectomy. This treatment would entail several days in the hospital and, in addition, a few weeks for recuperation. Access to that same polyp is now available through a colonoscope; the polyp can be removed through the colonoscope with an electrocoagulating snare. This technique for managing this pathologic condition is an appealing alternative to surgical treatment. Because the pathologic process (the polyp on a pedicle) is discrete from normal tissue, no confusion exists about what should be treated and what should not. Access to the lesion is generally easy, and available good tools facilitate removal. Importantly, a complete specimen can be delivered to the pathologist for histologic evaluation, and the physician and the patient can both be confident that no abnormal (that is, neoplastic) tissue remains. Furthermore, the procedure can be performed in an outpatient setting, and the patient is able to return to work the next day. Additionally, the procedure is less expensive than the older approach. In most other situations, especially those facing therapeutic cloggologists, the task is not so simple. Obstructing esophageal, bronchial, or intestinal neoplasms not only are sessile rather than pedunculated but also are infiltrating. Coronary and peripheral vascular atheromas are heterogeneous, are often embedded, and may be asymmetric. Clearly, if therapeutic cloggologists are aiming to achieve more than a coarse plumbing procedure, they must change the equation. For treatment of these obstructed biologic cylinders, more ingenuity will be needed. There are two keys to the solution. First, the pathologic process must in some way be made discrete from normal tissue. Second, there must be a way to deliver energy to the target lesion selectively. By whatever means these two goals are achieved, they then must be combined to allow the overall objective to be attained. Several technologies might allow the pathologic process to be defined by application of a variety of scientific principles. Some depend on imaging for definition, and others require physical labeling to be accomplished. Endoscopic ultrasonography differs from conventional extracorporeal ultrasonography in that the transducer actually operates within the digestive tract. Similar units are available for use in the vascular tree. With these instruments, a precise real-time picture is obtained; thus, distinction of the pathologic lesion is possible. (Cardiologists, realizing the proximity that the esophagus offers, are now passing their probes into the digestive tract.) This is another example of how the technologies of the individual subspecialties are overlapping. Electronic videoendoscopy offers several advantages over conventional fiberoptic endoscopy; eventually, it is likely to replace it. Some of its immediate benefits relate to the ability to view the process on a television monitor (hence, teaching advantages are inherent, and gastrointestinal assistants can view the procedure) and to the ability to record the procedure (by such documentation, sharing with other physicians is possible). Because it delivers a digital signal, it can be used in conjunction with a computer, and the possibility of harnessing its analytic potential exists. By using techniques that have long been applied in the space program to perform soil analysis below the earth's surface from thousands of feet above the earth, it should be possible to view below the mucosal surface of the gastrointestinal tract and thereby fully characterize a neoplastic process. Other adaptations of endoscopes that incorporate potentially useful technologies (that is, holography and infrared identification) may be of value. Indeed, three-dimensional reconstructions from the digital components of computed tomography and other imaging modalities may have far-reaching implications not only for the methods by which we treat patients but also for the ways in which we teach anatomy to medical students. Labeling the target tissue may also be possible. Groundwork laid in oncology and immunology may be applicable for this purpose. A variation on that theme is photodynamic therapy. Some chemical substances (such as hematoporphyrins) are preferentially concentrated in neoplastic tissue. The product is delivered intravenously and then localizes in the tumor after several hours. When a light of the appropriate wavelength is directed at the tumor, the segments that have taken up the substance fluoresce, and it is also possible for selective destruction to take place when the tissue is irradiated. Spectral fluoroscopy is another technique that may be used to “image” the area under consideration. It has already been established that atheromatous plaques, normal arterial wall, and blood have different spectral patterns, a feature that allows separation of desirable and undesirable targets. Some preliminary investigative work has suggested that the reflectance patterns of colonic cancer and normal human colonic mucosa may differ. These exciting preliminary results suggest that the surface of a very powerful technology is just being scratched. Different disease processes may well have different spectral signatures; this finding, of course, would have major implications for diagnosis, surveillance, and therapy. A prototype system exists wherein tissue is selectively identified and then treated. Currently, investigation with a “smart” laser system in the vascular tree is in progress. A fiber is delivered into the blood vessels and aimed internally. A different spectral pattern is generated by the various components (blood, vessel wall, plaque). This fluoroscopic pattern is then read by a computer-driven processor, which directs a laser whose beam is carried through the same fiber that was used diagnostically. The defined target can then be treated. Although first applied angiographically, this principle or a similar template is broad enough to be used by other cloggologists. The main problem is that little “cross-fertilization” exists between subspecialists addressing, in principle, similar challenges. Seldom do a gastrointestinal endoscopist and a urologist working endoscopically collaborate. More likely, each works independently with a developer and manufacturer of medical devices in an attempt to solve only one piece of the puzzle. The lack of collaborative effort is intellectually and financially wasteful. What can be done to improve this situation? The first step must be for subspecialists working in different fields to become aware of the problem. Opportunities for collaboration should be explored. Device manufacturers also should advance this cause. It would seem prudent for research and development divisions of the manufacturers of medical devices to sponsor interspecialty conferences to explore wider applications for their own products. Specialties that cross traditional subspecialty boundaries (for example, oncology, surgery, and laser therapy) and their national societies should encourage such interaction by developing forums at national meetings. Funding from the National Institutes of Health could be preferentially directed to investigators who establish collaborative programs. With a diminishing amount of national resources devoted to health, with the importance of technology assessment being increasingly realized, and with general industrial tools being applied to medicine, investigators with similar interests should have every incentive to collaborate. Cloggologists unite!

This work describes the initial results using a laser balloon in a canine model in an attempt to deliver the energy in a circumferential pattern. A balloon catheter, 2 cm long and 3 mm in diameter, was developed. Using a standard cw 100 watt Nd:YAG laser, a 600 micron fiber was tapered to 200 microns and passed through the proximal end of the balloon. Laparotomies were performed on mongrel dogs 14-18 kg in weight. After a gastrotomy, the gastric mucosa was exposed and rugal folds were pulled over the balloon to create a cylinder. Using power settings between 10 and 60 watts, and pulse durations between 10 and 40 seconds, radial energy was delivered and the tissue was examined for both gross and histologic effects. Circumferential zones of coagulation and necrosis were demonstrated.

Although the major initial application for endoscopic laser therapy was for the management of gastrointestinal hemorrhage, it is now more common to use the laser endoscopically for the treatment of gastrointestinal neoplasms. A major body of literature surrounds the use of endoscopic laser therapy for esophageal cancer. The initial patient evaluation to determine if laser therapy is indicated includes a contrast radiograph, a screening endoscopy, and an imaging study. After these tests have been performed, it can be determined whether endoscopic laser therapy (ELT) is the best of the many endoscopic options. There is some difference of opinion as to the specifics of the treatment technique, and these are described. There is general agreement from reviewing the clinical data that it is possible to open the obstructed lumen in a large majority of cases and that functional success (the ability to achieve technically good results as well as clinical improvement without complications) is also possible in the majority of patients. Despite the information suggesting the benefits of ELT for esophageal cancer, there are both conceptual and technical limitations to the current approach to therapy. These limitations as well as potential future applications are discussed.