2. Cohen FL, Koerner RS, Taub SJ. Solitary brain abscess follow­ing endoscopic injection sclerosis of esophageal varices. Gas­trointest Endosc 1985;31:331-3.

3. Monroe P, Morrow CF, Millen JE, et a1. Acute respiratoryfailure after sodium morrhuate esophageal sclerotherapy. Gas­troenterology 1983;85:693-9.

4. Seidman E, Weber AM, Morin CL, et a1. Spinal cord paralysisfollowing sclerotherapy for esophageal varices. Hepatology1984;4:950-4.

5. Barsoum MS, Mooro MA, Bolous FI, et a1. The complicationsof injection sclerotherapy of bleeding esophageal varices. Br JSurg 1982;69:79-81.

6. Sukigara M, Omoto R, Miyamae T. Systemic dissemination ofethanolamine oleate after injection sclerotherapy for esophagealvarices. Arch Surg 1985;120:833-6.

7. Snell AM. The effects of chronic disease of the liver on thecomposition and physicochemical properties of blood: changesin proteins; reduction in oxygen saturation of the arterial blood.Ann Intern Med 1935;9:690.

8. Calabresi P, Abelmann WHo Porto-caval and porto-pulmonaryanastomosis in Laennec's cirrhosis and in heart failure. J ClinInvest 1957;36:1257-65.

Advantages of using an injection pistolduring sclerotherapy of esophagealvarices

To the Editor:

Although endoscopic sclerotherapy is being increasinglyemployed in the management of bleeding esophageal varices,the technique is still evolving.1 Although the actual tech­nique may vary, the sclerosing agent has to be injectedthrough a long cannula (200 cm) that has a small caliberneedle (23-25 gauge) attached to its distal end. Injection ofthe sclerosing agent through this needle-catheter assemblyrequires significantly high pressure. The situation is com­parable to contrast injection during ERCP. Three to 10times atmospheric pressure may be required to inject con­trast through the ERCP catheter.2 Although the sclerosantsolution is less viscous than contrast material, higher pres­sures are needed to force it through the injector because ofthe smaller caliber of the needle and the relatively rapidspeed with which a given volume is to be injected.

In a recent article Zimmon2 described the use of an"injection pistol" for injecting contrast material duringERCP to overcome problems related to injection of contrastduring the procedure. I would like to bring to the attentionof your readers another important use of this pistol injector.Although it is named an ERCP hand injector pistol by itsmanufacturer3 (Wilson-Cook), I have found it very usefulfor injecting controlled volumes of sclerosing agents duringsclerotherapy of esophageal varices. The details of the injec­tion pistol, its assembly, and preparation for use are welldescribed by Zimmon.2 For sclerotherapy the unit volumedelivered with each trigger pull is set at 0.6 cc.

The desired volume can be injected in multiples of 0.6(0.6 to 3.0 cc) with relative ease and rapidity. The clickaudible with each trigger pull gives the endoscopists and hisGI assistant an easy account of the volume injected. Ofcourse, the injection is effortless, requiring only a pull of thetrigger. In the King Fahd Hospital endoscopy unit at Medinaal Munawara, the injector pistol is now routinely used forall cases of sclerotherapy. In the past year sclerotherapy wasperformed on 34 patients. Free-hand injection technique

153

was used, employing a Macron-Haber sclerotherapy needle(Wilson-Cook). Intravariceal injection were performed with0.6 to 2.4 cc of 5% etholamine oleate at each injection site.During this period no complications directly attributable tothe injection pistol were noted.

Repeated injections during sclerotherapy consume consid­erable physical strength. Problems may arise as a result offatigue of the endoscopy assistant. Toward the end of theprocedure the individual injection time may be unduelyprolonged. The increased puncture time exposes the patientto a higher risk of esophageal laceration resulting from anysudden or unexpected movement. There is an increased riskof inadvertent disengagement of the syringe from the injec­tor and spraying of the sclerosing agent onto the attendingbedside personnel. This may cause serious injury to thecornea, the so-called "sclerotherapist's eye."4

At our unit the syringe disengaged from the injector onthree different occasions prior to the use of injection pistol.Fortunately, no serious injury occurred, but this promptedus to look for an alternate method. Since the use of theinjection pistol this problem has not arisen.

Fazallmtiaz Khawaja, FACP, FACGGastroenterology Division

King Fahd HospitalMedina al Munawara. Kingdom of Saudi Arabia

REFERENCES1. Sivak MV. Sclerotherapy of esophageal varices. In: Silvis SE,

ed. Therapeutic gastrointestinal endoscopy, 1st ed. New York:Igaku-Shoin,1985:31-66.

2. Zimmon DS. Injection pistol for volume control of contrastinjection during endoscopic retrograde cholangiopancreatogra­phy. Gastrointest Endosc 1987;33:238-40.

3. Wilson-Cook introduces ERCP hand injector. Endoscopy Rev1986;3:36.

4. Herlihy KJ, Bozymski EM. Sclerotherapist's eye. GastrointestEndosc 1982;28:42-3.

Giant esophageal ulcers in AIDS-relatedcomplex

To the Editor:

The esophagus of the immunocompromised host is thepotential target of a variety of pathogens. Candida albicansand herpes simplex virus are the most frequently foundorganisms.1

-4 Other herpesvirus, particularly cytomegalovi­rus (CMV), have been associated with ulcerations in otherparts of the gastrointestinal tract but only rarely causeesophageal disease. This report describes a patient withAIDS-related complex (ARC)5 in whom a giant esophagealulcer was seen.

A 36-year-old black male was admitted with hematemesisfor 1 day and hiccups for 30 days' duration. He had a longhistory of intravenous drug abuse and alcoholism. A monthprior to admission a diagnosis of spinal tuberculosis wasmade and the patient was started on antituberculosis medi­cation (INH, rifampin, ethambutol). On admission he ap­peared cachectic, was febrile, and had persistent hiccups.There was generalized lymphadenopathy. The abdomen wassoft with an enlarged firm liver. Initial laboratory datarevealed a hemoglobin level of 9.39 gjdl, hematocrit 27%,and WBC 2,800. T-cell studies revealed a significant reversal

GASTROINTESTINAL ENDOSCOPY