6. Hurwitz A, Robinson RG, Sheridan M, et al. Prolongation ofgastric emptying by sucralfate in man [Abstract). Gastroenter­ology 1982;82:1088.

Esophageal "tattooing"

To the Editor:

We recently had the opportunity to evaluate a 76-year­old man with epigastric abdominal pain. In performing anesophagogastroduodenoscopy we were surprised to find ap­parent lettering in the patient's distal esophagus (Fig. 1).The surrounding mucosa was noted to be entirely normal.Gentle washing of the mucosa did not dislodge the lettering.Subsequent review of his medication identified the apparentsource of the lettering (Fig. 2). The manufacturer was con­tacted and indicated that the lettering was imprinted afterproduction of the hard gelatin capsule. The most recent doseof the medication had been administered more than 12 hoursearlier as a bedtime dose. This piqued our interest into apossible esophageal motility disorder. Esophageal manome-

Figure 1. Endoscopic view of tattoo demonstrating invertedmirror image of capsule lettering.

Figure 2. Capsule identified as source of mucosal imprint.

VOLUME 35, NO.5, 1989

--"---- ------_ .._-------------

Figure 3. Esophageal manometry demonstrating prolonged,mUltiple peak contractions.

try demonstrated findings compatible with the diagnosis ofdiffuse esophageal spasm (Fig. 3). Further careful historytaking did not disclose a history of dysphagia or chest pain.The patient admitted to only occasional heartburn. Of in­terest was a past history of heavy alcohol abuse resulting ina severe peripheral neuropathy.

This patient demonstrates an unusual endoscopic findingwhich we have termed an esophageal "tattoo." This mostlikely represents a prolonged period of pill-mucosa contact.

The clinical correlate of this fmding appears to be anesophageal motility disorder, although we are unable toclassify the findings as diffuse esophageal spasm in theabsence of symptoms. l

The patient also demonstrates that manometric findingsof diffuse esophageal spasm can be fOlmd in patients withmotility abnormality but no symptoms. Pain and/or dys­phagia are required for the clinical diagnosis of diffuseesophageal spasm.

Timothy C. Jahraus, MDWilliam A. Knight, Jr, MDDivision of Gastroenterology

St. Mary's Health CenterSt. Louis University School of Medicine

St. Louis, Missouri

REFERENCE1. Richter JE, Castell DO. Diffuse esophageal spasm: a reap­

praisal. Ann Intern Med 1984;100:242-5.

Colonoscopic priapism

To the Editor:

Manual abdominal compression is commonly utilized dur­ing colonoscopy when difficulty in advancing the endoscopeis encountered. By using specific manual compression whichserves as an external splint,! the skillful endoscopist canadvance the endoscope further in the colon by limiting thesize of a loop and by pushing the more proximal bowel overthe tip of the colonoscope. Although the hazards and com­plications of colonoscopy have been previously well de­scribed,1 there has been no reported morbidity associated

475

with the use of abdominal compression. We report a case inwhich manual abdominal compression resulted in an un­usual occurrence during colonoscopy.

A 62-year-old white man with a 2-year history of adenom­atous colonic polyps and a 22-year history of insulin-de­pendent diabetes mellitus, controlled by split doses of insu­lin, was admitted for surveillance colonoscopy. His diabeteswas complicated by neuropathy, retinopathy, and vasculo­pathy, resulting in impotence necessitating the insertion ofan inflatable penile prosthesis.

After routine preparation and sedation with intravenousmeperidine and diazepam, colonoscopy was performed. Dur­ing the procedure, manual suprapubic pressure was per­formed by the technician because of the difficulty advancingthe colonoscope through a redundant sigmoid loop. Despitesedation, the patient indicated discomfort with this maneu­ver and developed a notable penile erection. At this time,the patient informed the surprised endoscopist and techni­cian of the presence of an inflatable penile prosthesis andthe apparent pump activation that occurred during the ma­neuver. After the patient operated the release valve on thepump and reduced the erection, total colonoscopy was com­pleted with care, avoiding abdominal compression over thesuprapubic area.

Although it is estimated that approximately 10 millionmen in the United States have erectile dysfunction, by April1985 only 100,000 have had any type of penile prosthesisplaced.2 The outcome of diabetic men who receive penileprosthesis for impotence is generally good, with satisfactionrates among patient and their partners reported to be 81and 83%, respectively.3 Mechanical complications have beenreported3

.4 and include pump failure (as seen in our patient),

leak in the reservoir, cylinder rupture (from unspecifiedcauses, trauma, and a bite), tube kinking, and unequalcylinder inflation.

As inflatable penile prostheses for the therapy of maleimpotence become more common and widely used in thediabetic patient and population at large, endoscopists shouldbe aware of their presence and the reservoir location priorto colonoscopy, to avoid manual compression over the res­ervoir. Inadvertent iatrogenic colonoscopic priapism can beavoided by having a high index of suspicion and by obtaininga careful, detailed medical history, especially in our malediabetic patient population.

Jeffrey J. Bilotta, MDAndrew Goldenberg, MD

Jerome D. Waye, MDDivision of GastroenterologyMt. Sinai School of Medicine

New York, New York

REFERENCES1. Hunt RH, Waye JD. Colonoscopy techniques: clinical practice

and color atlas. London: Chapman and Hall, 1981.2. Nelson RP. Male sexual dysfunction: evaluation and treatment.

South Med J 1987;80:69-74.3. Beaser RS, Van der Hoek C, Jacobson AM, Flood TM, Desau­

tels RE. Experience with penile prostheses in the treatment ofimpotence in diabetic men. JAMA 1982;248:943-8.

4. Fishman IR, Scot FB, Light JK. Experience with inflatablepenile prosthesis. Urology 1984;13:86-92.

476

Pneumatic dilation of achalasia without theaid of fluoroscopy

To the Editor:

Pneumatic dilation of achalasia is done by pneumaticdilators, including the Rider-Moeller. Usually dilation isperformed as an in-patient procedure, and requires flouros­copy for positioning the bag across the lower esophagealsphincter.'-3 We performed pneumatic dilation of achalasiaon three occasions, without the use of fluoroscopy when ourimage intensifier was not functioning.

After performing an endoscopy, the guidewire was passedinto the stomach and the Rider-Moeller dilator was guidedover it and the balloon inflated. It was then pulled to abutthe balloon against the cardioesophageal junction (like theSengstaken-Blakemore tube). The balloon was then deflatedand pulled about 3 to 4 em, so as to position it across thelower esophageal sphincter. The balloon was then inflatedto 300 mm Hg for 15 sec. All three patients experienced painand there was blood streaking of the balloon on withdrawal.Subsequently, all three patients reported relief of dysphagia.

It is clear from the above observations that pneumaticdilation of achalasia can be performed without the use offluoroscopy, thereby preventing radiation exposure to thepatient and the endoscopist, and also lowering the cost ofthe procedure. In addition, it can also be performed athospitals where an image intensifier is not available.

S. P. Misra, MD, OMM. Dwivedi, MD, OM

Unit of GastroenterologyPostgraduate Department of Medicine

M. L. N. Medical CollegeAllahabad, India

REFERENCES1. Vantrappen G, Hellemans J. Treatment ofachalasia and related

motor disorders. Gastroenterology 1980;79:144-54.2. Pope II CEo In: Sleisenger MH, Fordtran JS, eds. Gastrointes­

tinal diseases: pathophysiology, diagnosis, management. 3rd ed.Philadelphia: WB Saunders, 1983:424-8.

3. Ouyang A, Cohen S. In: Haubrich WS, Kaiser MH, Roth JLA,Schaffner F, Berk JE, eds. Bockus gastroenterology. 4th ed.Philadelphia: WB Saunders, 1985:690-704.

Endoscopic management of esophagealmeat impaction using a splay-mouthforceps

To the Editor:

Meat impaction in the esophagus has been termed the"steakhouse syndrome." Various methods of treatment havebeen described including intravenous glucagon, topical pro­teolytic enzymes, gas-forming agents, extraction with aFoley catheter and endoscopic extraction.' It is the purposeof this communication to describe successful endoscopicmanagement of meat impaction in the esophagus using asplay-mouth forceps, and to review cases of esophageal meatimpaction in the Japanese literature.

A 76-year-old man began to complain of retrosternal painand inability to swallow saliva after eating a piece of beef at

GASTROINTESTINAL ENDOSCOPY