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2. Stolte M, Wiesser V, Schaffner 0, Koch H. Vascularisation ofthe papilla of Vateri and bleeding risk of papillotomy. LeberMagen Darm 1980;10:293-301.3. Dunham F, Bourgeois N, Gelin M, Jeanmart J, Toussaint J,Cremer M. Retroperitoneal perforation following endoscopicsphincterotomy; clinical course and management. Endoscopy1982;14:92-6.

Upper gastrointestinal endoscopy inTurkey: a review of 5,000 casesTo the Editor:

The superiority of fiberoptic endoscopy over the bariumswallow technique has been well established in diagnosinggastrointestinal disease and the site of bleeding. This letterreviews our experience in Turkey with endoscopy and compares it with radiological and surgical findings.Five thousand upper gastrointestinal endoscopies wereperformed at Hacettepe University Hospital, Ankara, fromJanuary 1980 to December 1984. The patients' ages rangedfrom 17 to 81 and included 3,222 males and 1,778 females.184 out of 5,000 patients had an emergency endoscopicexamination for acute upper gastro in testinal bleeding(UGIB). Examinations wereperformedby trained endoscopists. The forward viewing panendoscope, Olympus modelGIF D3, was used to diagnose acute UGIB within 24 hoursof initial bleeding episodes. Upper gastrointestinal serieswas performed on all patients except those without UGIB,and the results were comparedwith endoscopic examination.A total of 1,685 (34%) patients had a normal endoscopicexamination. Three hundred eleven (7%) had hiatal hernia,which was the most common esophageal lesion seen, and224 (68%) had coexisting esophagitis; 11 patients had candidial esophagitis. Varices were diagnosed in 5% of patientsand graded according to severity.Gastritis was diagnosed in 489 (10%) patients. This wasthemost common typeof gastric lesion. One hundred eightythree (4%) had gastric carcinoma, and 2% of the patientswith gastric carcinoma had coexisting intestinal metaplasia.In this series, 151 (3%) presented with gastric ulcers and 55(1%) had gastric polyps.

The most common overall lesionwas duodenal ulcers (714or 16%). Five hundred forty (11%) patients had duodenitis,50 (1%) had pyloric stenosis, 15 had duodenal polyps, and 4had duodenal diverticula. Pyloric stenosis and duodenalpolyps were seen more commonly in men than in women;the male/female ratio was 17.1/1 and 14/1, respectively.Hiatal hernias were seen more commonly in our seriesthan in Europel and Africa.2 The frequency of gastric ulcerwas higher in our series than in Sudan.3 Our ratio of duo-Table 1.Endoscopic findings in postgastrectomy patients

No. of PercentcasesGastritis 94 35Anastomotic ulcer 44 15Esophagitis 6 2Intestinal metaplasia 4 1Hiatal hernia 2 1Gastric carcinoma 2 1Normal 134 45Total 286 100

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denal to gastric ulcers (7/1) was less than in Sudan (31/1)3but higher than in the United States (3/1):Diagnostic accuracy of radiology was 68% compared toendoscopy, whereas the accuracy of endoscopy was 93%compared to surgery. Comparison of endoscopywith surgeryat Mayo Clinic demonstrated that endoscopy missed fewerlesions.s Most of the missed lesions were found high in thegastric fundus, between large gastric folds or in a scarredduodenum. In our study, the majority of diagnostic errorsby x-ray examination occurred primarily with gastritis.Upper endoscopic examination in 152 (53%) postsurgicalpatients found definite abnormalities as indicated in Table1. In comparing x-ray and endoscopic examination, 77 patients (27%) were accurately diagnosed by both procedures.Endoscopic examination was established to be most helpfulin diagnosing postsurgical patients since radiology showedthe correct diagnosis in only 27% of the patients and thesewere predominant ly marginal ulcers. Hirschowitz andLuketic6 found radiologic results to be positive in only 36%of 111 patients with marginal ulcers. The result of our studyclearly indicates that an adequate evaluation of the postoperative stomach cannot be considered complete until fiberoptic examination has been carried out.Endoscopy was successfully performed on 184 patientswith acute UGIB, 220 lesions being identified in 171 patients, with a diagnostic accuracyof 93% proven by surgery.In 13 patients no bleeding site was found. The duodenumwas the most common site of bleeding, with duodenal ulceration in 68 (37%) patients. Fifty-one patients had erosivegastritis, the stomachbeing the second most common bleeding site. Esophageal varices accounted for 29 (16%), gastriculcers for 9 (5%), and gastric carcinoma for 8 (4%). Twogastric hemangiomas and 2 gastric polyps presented in thisseries. The ratio of duodenal to gastric ulcers was 7.6/1,which was higher than the 0.87/11 and 6.22/1 7 found inreports from Great Britain.Serious endoscopic complications occurred in 6 patients:2 cases of pseudo-acute abdomen, 1 of deep hematoma of

the neck, and 1 of mandibular dislocation. One patient diedof cardiac arrest during endoscopy; another patient withthrombocytopenia had a deep neck infectionwith hematomaas a major complication and died 6 days later. These complications represented 0.12% of 5,000 endoscopies.The experience withgastrointestinal endoscopy in Turkeyis similar to that reported from Europe and the UnitedStates. However, the incidence of duodenal ulcer appears tobe higher and that of esophageal varices lower, perhapsreflecting cultural influences.

Halis Simsek, MDHasan Telatar, MDSukran Karacadag, MDBurhan Kayhan, MDFigen Batman, MDSection of GastroenterologyHacettepeUniversity HospitalAnkara, Turkey

REFERENCES1. Cotton PB. Fiberoptic endoscopy and the barium meal. Resultsand implications. Br Med J 1973;2:161-5.2. Hoare AM. Comparative study between endoscopy and radiology in upper gastrointestinal hemorrhage. Br Med J 1975;1:27.3. Fedail SS, Homeida MM, Aneba BM, Ghandour ZM. Upper

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gastrointestinal fiberoptic endoscopy experience in the Sudan.Lancet 1985;15:2:897-9,4. McGuigan JE . Peptic ulcer in Harrison's principle of internalmedicine. NewYork: McGraw-Hill, 1987:1242.5. Cameron B, Ot t BJ. Th e value of gastroscopy in clinical diagnosis: a computer-assisted study. Mayo Clin Proc 1977;52:8068.6. Hirschowitz BI, Luketic BC. Endoscopy in the postgastrectomypatient, an analysis of 580 patients. Gastrointest Endosc1971;18:27.7. Jonston SJ, Jones PF , Kyle J, Needham CD. Epidemiology andcourse of gastrointestinal hemorrhage in northeast Scotland.Br Med J 1973;3:655-60.

Transillumination of l ight in the right lowerquadrant during total colonoscopyT o t he Editor:Transillumination of light in th e right lower quadrant isone of th e landmarks traditionally used to denote th e presence of th e endoscope tip being in th e cecum during totalcolonoscopy.l-4 Although transillumination has long beenused by colonoscopists to confirm reaching th e cecum, th eincidence of its occurrence during total colonoscopy hasnever been previously studied. We recently determined th eincidence of transillumination an d compared th e finding oflight in th e right lower quadrant between a standard fiberoptic colonoscope and video colonoscope.275 consecutive office patients having total colonoscopywere entered into the study. Th e cecal location was visuallyconfirmed in each case by identification of cecal anatomiclandmarks (appendiceal orifice, ileocecal valve, or junctionof th e teniae coli). All instruments were manufactured by

th e Olympus Corporation of America, an d th e CFLB3Wfiberendoscope was compared with th e colon video endoscope VIOL. The LB3W used th e CLV-10 light source anda video camera (OTV) attached to th e eye piece transmittedth e image to a television monitor. Th e light setting was onautomatic, set at th e minimal illumination level necessaryfor adequate operator visualization of intraluminal events.The video endoscope was at standard settings.169 patients were examined with th e fiberendoscope, and106 patients were examinedwith th e video endoscope. Lighttransillumination could be seen in th e right lower quadrantwhen the colonoscope tip was in th e cecum in 152 patientsexamined with th e fiberendoscope (90%) an d in 57 patientsexamined with th e video endoscope (54%). Whenever th etip of the endoscope was in th e cecum an d transilluminatedlight could no t be readily detected in th e right lower quadrant, th e room lightswere dimmed a nd a n attempt was madeto palpate the abdomen in various areas while observing th eabdominal wall. Frequently, moving th e instrument fromthe cecal pole to an area just above th e ileocecal valveresulted in transillumination that had no t been possiblebecause the endoscope t ip was deep in th e pelvis. Whentransillumination was present using th e video colonoscope,only a faint glow was seen as opposed to the more intenselight from the fiberoptic instrument.There are several endoscopic landmarks that are usefulfor cecal identification. These include a change in the colorof th e intraluminal fecal effluent in th e right colon, a notchor an indentation on a prominent fold in th e right colondenoting the superior lip of the ileocecal valve, the appen-VOLUME 34, NO.1, 1988

diceal orifice, and th e junction of the teniae coli, which mayproduce a crow's foot appearance as they conjoin at the baseof the cecum.1- 5 Transillumination of light in the right lowerquadrant is one of th e traditional landmarks used for cecalidentification. In many instances, light may be seen in theright lower quadrant, although the tip of the instrument isno t actually in th e cecum.45 Reliance on transilluminationcan result in spurious endoscope tip localization since rightlower quadrant light may be seen when th e tip of theendoscope is in th e sigmoid colon (pushed to the right) orin the midportion of th e transverse colon, which has beenpushed by th e advancing endoscope toward the right. Al-though light in the right lower quadrant is no t as useful noras reliable a parameter of total colonoscopic intubation asth e confirmatory endoscopic landmarks, this study was performed to ascertain th e frequency with which transillumination can be seen in th e right lower quadrant utilizingconventional fiberoptic and the newer video instruments.Th e light can be seen in 90% of cases when total colonoscopic intubation has been achieved using fiberendoscopes.In 10% of cases, either due to anatomic position, obesity, orother factors, light cannot be transilluminated in the rightlower quadrant when th e instrument tip is in the right lowerquadrant (in the cecal pole or just above the ileocecal valve).In comparison, the video endoscope with its less brilliantillumination results in transillumination through the abdominal wall in only 54% of patients when the t ip of theendoscope is in the cecum.

Jerome D. Waye, MDMary Ann E. Atchison, RN, GIAMaria C. Talbott, GIABlair S. Lewis, MDNew York, New York

REFERENCES1. Sugawa C, Schuman B. Primer of gastrointestinal endoscopy.Boston: Little, Brown, and Co, 1981:116-7.2. Cotton P, Williams C. Practical gastrointestinal endoscopy.London: Blackwell Scientific Publications, 1980:118-9.3. Shinya H. Colonoscopy: diagnosis an d t reat men t of colonicdiseases. New York: Igaku-Shoin, 1982:67-8.4. Waye J. Colonoscopy intubation techniques without fluoroscopy. In:Hunt R,Waye J, eds. Colonoscopy. London: Chapmanand Hall, 1981:174-6.5. Whalen J, Riemenschneider P. An analysis of the normalanatomic relationships of th e colon as applied to roentgenographic observations. Am J Roentgenol Radiat Ther Nucl Med1967;99:55-61.

Cecal perforation following flexiblesigmoidoscopyTo th e Editor:Flexible fiberoptic sigmoidoscopy is a routine study and,although it is a relatively innocuous procedure, hazardouscomplications can occur. Cecal perforation following flexiblesigmoidoscopy is an unusual complication.1An 80-year-oldwoman underwent flexible sigmoidoscopicexamination to ascertain the etiology of blood in her stool.

Th e procedure was performed to 25 em and revealed twopolyps and spasm of the sigmoid that did no t relax afterintravenous glucagon. Th e procedure was terminated, andno biopsies or polypectomies were attempted. Soon after,69