Unfavorable Experiences with the Ayre

Rotating Stomach Brush

LEON SASSON, M . D .

T HE AYRE rota t ing stomach brush, an ins t rument used to obtain specimens for exfoliative cytology, is attractively simple to use and

handle. However, in the experience of the author, the following four unfavorable incidents occurred within a short period of time. In one case, a core of gastric mucosa was accidentally obtained; in 2 others, serious t rauma of the gastric mucosa occurred; and in the fourth case, the brush unit became detached while in the stomach cavity. This paper describes these events and points out how they might have been pre- vented.

T h e ins t rument (Fig. 1) consists of a polyethylene tube with a handle at one end and a metall ic cylindrical terminal por t ion at the other, Wi th in the polyethylene tube is a steel cable connecting the handle at the proximal end with the brush unit at the distal end. Manipula t ing the handle controls the action of the brush unit, which can be wi thdrawn into a cylindrical endpiece (Fig. 1, inset) or extended from it and ro- tated. T h e brush unit consists of two tufts of soft bristle which are spread apar t by spring action when extended. T h e ins t rument is passed into the lower end of the stomach, and the brushes are extended and rotated as the ins t rument is slowly wi thdrawn the length of the stomach. T h e brushes are then retracted, and the whole ins t rument is withdrawn.

CASE R E P O R T S Case 1

A 70-year-old female was a d m i n e d wi th a 2 - m o n t h his tory of pos tprandia l epigastric pain, anorexia , weight loss, and melena . T h e positive f indings on physical examina t ion were pal lor and a ha rd liver pa lpab le three fingers below the costal border. He r hemo- globin was 6.8 gin. Gas t ro in tes t ina l series revealed a large fil l ing defect ar is ing from the lesser cu rva tu re of the s tomach.

T h e A~re ro ta t ing s tomach b r u s h was in t roduced by the resident , and obs t ruc t ion was m e t at the cardia. He exer ted gent le pressure such as is used in pass ing a gastro- scope, b u t the i n s t r u m e n t still could no t pass. U p o n wi thdrawal , it was noted that ,

F rom the D e p a r t m e n t s of Medicine and Gastroenterology, Bronx- I . e l )anon Hospi ta l Cente r a n d Morr i san ia Hospi ta l , New York, N. Y.

398 American Journal of Dicjestive Diseases

Ayre S÷omach Brush

within the opeu eud of the i n s t r u m e n t (Fig. 2) , a 0.5 × 0.5 × 6-cm. c,~lindrical piece of gastric mucosa was present tha t con 'esponded in m e a s u r e m e n t to the l eng th and bore of the endpiece of the i n s t r u m e n t (Fig. 2) . Pathologic s tudy re~ealed tha t the specimen was composed of mncosa only. t{yper t rophic polypoid gastric mucosa wi th scattered cystic g lands was present , wi th no evidence of mal ignancy .

Fig. 1. Ayre rotat ing, s tomach b rush wi th b ru sh un i t ex t ruded . Inset shows close-up of te rmina l end wi th b rush un i t retracted. Note tha t this is an open-end i n s t r u m e n t wi th metal edges.

It was believed tha t the t umor wi th in the s tomach elevated a shelf of gastric mucosa which obst ructed the passage of the i n s t r u m e n t jus t below the cardia, and tha t the open end of the i n s t r u m e n t had cored ou t a piece of the tissue as it me t and pushed against obs t ruc t ion in its downward passage. For tunate ly , the pa t ien t did no t suffer any after etfects, as is usua l in cases where mucosa is accidental ly scooped out by in- strtllnen tation.

A li~er biopsy suhsequen t ly re~ealed metas ta t ic sc i r rhous adenocarc inoma,

Case 2

A 73-)ear-ohl male was admi t t ed with a 2 -mon t h his tory of dyspnea on exer t ion and a 15-1b. weight loss, p lus a shor ter history of epigastric pain occurr ing 1l~ hr. after meals and par t ia l ly relieved by food. Physical examina t i on was essentially negative. T h e hemoglol) in was 14.,t gin. and the whi te blood count , 6300, wi th a no rma l differ- ential count . A gast rointes t inal series showed some i r regular i ty in the a n t r m n , which was in te rpre ted as ehro,dc gastr i t is or neoplast ic int i l t rat ion. At gastroscopy, only the

New Ser~es, Vol. 9, No. 6, 1964 399

Sasson

prox ima l por t ion of the a n t r u m ~as seen. Its mucosa was hyperemic and lusterless, and was coated wi th an exudate . A gas t r ic -brush biopsy was taken wi th the Ayre in- s t r umen t , and it showed no m a l i g n a n t cells.

Six days later, the pa t ien t exper ienced severe left lower q u a d r a n t pain, and 5 clays after this he was noted to be pale and in mi ld shock. His hemoglob in was 14.8 gin.

Fig. 2. (Top) Biopsy of gastric mucosa (6 cm. long) accidental ly ob ta ined from Case 1. (Bottom) Close-up of meta l endpiece of i n s t rumen t , 6 era. long.

and his whi te blood count was 75,000, wi th 12°,£-, po l ) 'morphonuc lea r leukocytes, 13% bands, 8 ~ l )mphocytes , 5!~, eosinophils , 12~g j m e n i l e forms, 19c~:~) myelocytes, and 31% blastocytes. T h e platele t coun t was 185,000. Sternal mar row aspirat ion showed 30% blasts and a marked shif t to the left. Stain of the per iphera l blood showed a h igh value for phosphatase . T h e pa t ien t ' s course was steadily downhil l . Nausea and vomi t ing were f requent , and his e lec t rocardiogram showed acute coronary insufficiency and ischemia. T h r e e days later he had an episode of hematemes is , and expired wi th in 2 days in coma, with a fever of 104 ° F., 17 da}s after the g a s t r i o b r u s h biopsy was taken.

Autopsy revealed the causes of dea th to be (1) acute l ympho id l eukemia wi th leu- kemoid react ion due to marrow i r r i ta t ion by leukemic infi l t rat ion; and (2) massive b leeding f rom the gas t ro in tes t ina l tract. T h e s tomach conta ined abou t 300 cc. of dark reddish s angu inous fluid and a large blood clot. Several abras ions were present in the u p p e r ha l f of the poster ior wall of the s tomach. A roughened area of mucosa at the prepyloric area revealed leukemic inf i l t ra t ion on section. N u m e r o u s petechiae were p resen t in the gastric rnucosa of the s tomach as well as in the mucosa of the small and large intestines. T h e pa thologis t was unab l e to state w h e t h e r the massive bleeding occurred because of t r aumat i c abras ions or because of diffuse gas t rointes t inal bleeding secondary to the leukemia.

I t is a p p r e c i a t e d b y t h e a u t h o r t h a t l e u k e m i a o r o t h e r h e m o r r h a g i c

d i s o r d e r s a r e c o n t r a i n d i c a t i o n s t o t h e u s e o f a b r a s i v e i n s t r u m e n t s , b u t i n

t h i s c a s e , t h e d i a g n o s i s o f l e u k e m i a w a s n o t e s t a b l i s h e d u n t i l a f t e r t h e

b i o p s y w a s t a k e n .

400 American Journal of Digestive Diseases

Ayre Stomoch Brush

Case 3

A 69-ycar-ohl male was adlni t ted with a 2-week history of lower abdomina l discom- fort and d ia r rhea of abou t 15 watery stools daily. T h e r e was also a history of arterio- sclerotic hear t disease with congestive fai lure control led by digital is and diuretics. Physical e x a m i n a t i o n was esscntially wi th in n o r m a l limits. B a r i u m e n e m a revealed diverticulosis, and a gas t rointes t inal series revealed n tmrerons fil l ing defects in the s t o m a c h - - e x t e n d i n g f rom the cardia to the py lorus - - sugges t i~e of a phytobezoar .

At gastroscopy, a large, firm whi te mass was seen wi th in the l u m e n of the s tomach. Gastric nlucosa was normal . A C r u m p tube was passed, man ipu l a t ed , and the s tomach lavaged. T h i s was product ive of large a m o u n t s of undiges ted vegetable mat te r . Pieces of celery measu r ing 21/2 × 4 cm. were identified. T h e gastroscope was reintro- duced, and the surface of the mass was seen to be f ragmented , wi th pieces of vegetable mat te r Itoating freely in the s tomach.

Since it was ohserved tha t the mass f r agmcn ted easily, it was decided to a t t e m p t a nonsurgical removal of the phytobezoar , In order to facili tate f r agmenta t ion of the foreign body, the Ayre ro ta t ing s tomach brush was introdHced and its brushes ro ta ted pr ior to lavage and aspirat ion. T h i s p rocedure was done 3 t imes on a l te rna te days, and each time, large a m o u n t s of vegetable m a t t e r were extracted. T h e fou r th lavage yielded a clear re turn , and gastroscopy was repeated. Inspect ion of the mucosa re- ~ealed n u m e r o u s abrasions. In the m u c o u s lake, a brown, smooth , sh iny "football- shaped" foreign body was seen. A gas t ro in tes t ina l series re~ealed the s tomach to be empty except for an ovoid object which had the appearance of a p r tme pit. Since the pa t ien t had been eden tu lons for some t ime before admiss ion and had been in the hab i t of swallowing large pieces of food wi thou t p roper mast icat ion, it was decided to p u t hint on a s t ra ined-food and h igh- l iqu id diet a nd wait for spon taneous passage of the p r u n e pit. However, 12 (lays fol lowing his first t r ea tment , he developed a sudden onset of severe chest pain , dyspnea, cyanosis, and profuse perspira t ion. Slight left calf muscle tenderness was prcscnt , and it was t h o u g h t tha t he had a p u l m o n a r y embotus or an acute myocacdial infarct ion; however, this was not suppor ted by X-ray or electrocardiographic tindings. T h e pa t ien t was p u t on ant ibiot ics and ant icoagulants , and 12 days later he had a sudden onset of me lena and shock and his hemoglob in was noted to be 3.6 gin. Despite m a n y blood t ransfusions, he expired 5 days later.

Autopsy findings revealed the cause of dea th to bc (1) generalized amyloidosis of the p r ima ly type; aml (2) t r aumat ic gastric ulcer, wi th massive hemor rbage . T h e s tomach conta ined abou t 3(10 cc. of blood and several large blood clots. T h e p r u n e pit was not p r e ~ n t , lu the posterior wall of the body of the s tomach, there was a large, oxat- shaped ulcer measu r ing 2 × 10 cm. T h e ulcer began at a po in t 2.5 cm. distal to the cardia and ex tended obl iquely towards the greater cu rva tu re (Fig. 3) . T h e marg ins were sl ightly elevated and sharply demarcated . T h e base was tan in color, modera te ly granular , and several s t u m p s of blood vessels were visible. T h e distal end of the ulcer was deeper, and c o m m u n i c a t e d wi th a perfora t ion which was sealed off on the serosal side by f ibrinous adhes ions of the o m e n t u m (Fig. 4) . Section of the s tomach wall re- xealed the muscu la r layer to have been replaced, to a great extent , by amvloid deposits.

S e v e r a l c r i t i c i s m s i n t h e m a n a g e m e n t o f t h i s c a s e c a n b e m a d e . F i r s t ,

a l t h o u g h t e m p t i n g , i t is u n d o u b t e d l y u n w i s e t o a t t e m p t t h e r e m o v a l o f

a p h y t o b e z o a r b y t h i s m e t h o d . S e c o n d , a n t i c o a g u l a t i o n t h e r a p y s h o u l d

b e w i t h h e l d i n t h e i m m e d i a t e p e r i o d a f t e r c y t o l o g i c a b r a s i o n is per-

New Series, Vol. 9, No. 6, 1964 401

Sassofl

formed. Third , amyloid infiltration of the stomach is a contraindication to the use of this instrument; however, in this case, as in Case 2, the diagnosis was not established prior to autopsy.

Fig. 3. (Case 3) Elongated oblique traumatic ulcer of posterior wall of stomach beginning 2.5 cm. below cardia. I,arge arrow points to cardia, Smaller arrows outline ulcer. Fig. 4. (Case 3) Photograph of ~rosal aspect of stomach. Probe enters perfora- tion sealed oil hy adherent omentum.

Case 4

A 66-year-old female was admitted with a history of three episodes of melena, over a period of 5 years, none of which had been severe enough to cause shock. There was a vague history of epigastric distress not related to meals. Her past history included diahetes mellitus and myocardial infarction. Physical examination was within normal limits. The hemoglobin was 7.9 gin. and the red blood count, 2,5 million. T h e rest of the laboratory workup, including liver function tests, was normal. A gastrointestinal

series revealed no abnormalities. At gastroscopy, normal gastric mucosa and good peristaltic waves were seen. The

Ayre rotating stomach brush was introduced and after the tirst few rotations, it was

402 Amerlcan Journal of Dicjes÷ive Diseases

Ayre Stomach Brush

noted that the handle rotated too freely. It was thought that the brush unit had be- come detached from the instrument and this was confirmed when tile instrument was withdrawn.

Three days later, a scollt filnl was taken and the brush was seen to he ill the region of the ascending cobra. Sext'n days after the loss of the brush, another scout tihn was

Fig. 5. (Case 4) Metallic por- tion of brush unit in pelvic colon. (Brush tufts are non- opaque.)

taken and the brush unit was visualized in the pehic colon (Fig. 5). Later that day, the brush was recovered ill the stool. Another gastric-brush biopsy was done and the specimen rmealed llo malignant cells. During the period that the brush was passing through her gastrointestinal tract, the patient experienced no symptoms.

Examination of the instrument and the recovered 1)rush revealed that the soldered joint between the cable and the metal link to which tile brush unit was attached had hroken.

D I S C U S S I O N

Such e x p e r i e n c e s h a v e n o t b e e n u n i q u e . R o s s m a n a n d W o l f t r e p o r t e d

tha t in t h e i r first 5 cases, t w o a c c i d e n t s o c c u r r e d i n w h i c h p ieces of

gas t r ic m u c o s a - - o n e m e a s u r i n g 2 × 4 X 0.5 cm., a n d one , 0.5 X 0.5 )< 0.5

c m . - - w e r e f o u n d in t h e t u b e u p o n w i t h d r a w a l . T h e y also r e p o r t e d a

p e r s o n a l c o m m u n i c a t i o n f r o m Z e r p a M o r a l e s of V e n e z u e l a , w h o acci-

d e n t a l l y o b t a i n e d five l a rge f r a g m e n t s of ga s t r i c m u c o s a in a ser ies of

50 cases on w h o m the A y r e b r u s h was used.

I t a p p e a r s to t h e a u t h o r t h a t these e v e n t s a r e caused by t h e s h e a r i n g

ac t ion of the a d v a n c i n g , m e t a l - e d g e d , o p e n e n d of t h e i n s t r u m e n t . T h e

mos t v u l n e r a b l e a rea is t h e p o s t e r i o r w a l l of t he s t o m a c h 2 - 3 cm. b e I o w

the cardia , for t he f o l l o w i n g r ea son : T h e l o n g i t u d i n a l axis of t he e sopha-

gus is in a d i f f e r e n t p l a n e f r o m t h a t o f t h e s t o m a c h , a n d a s e m i f l e x i b l e

i n s t r u m e n t pas s ing d o w n in t he axis of t he e s o p h a g u s t ends to i m p i n g e

on the p o s t e r i o r w a l l 2 - 3 cm. f r o m t h e ca rd ia . T h e p o s t e r i o r w a l l is

New Series, Vol. 9, No. 6, 1964 403

Sasson

relatively unyielding, since tile retrogastric structures do not permit back- ward displacement of the stomach wall. \Vith further introduction of the instrument, the latter bends slightly anteriorly and advances down- ward, in contact with the posterior wall. This is well known to gastro- scopists, and this pathway of the gastroscope explains the blind area of the posterior wall of the stomach (i.e., prior to the advent of the Bern- stein modification of the gastroscope) as well as the location of the rarely occurring accidental gastroscopic perforations which ahnost always occur in the same area--namely, 2-3 cm. below the cardia on the poste- rior wall. 2 Another feature of the instrument which appears to con- tr ibute to this problem is the relatively long length of the metal portion. T h e metal part measures 6 cm., but together with the connecting stiff cable, comprises a rigid segment requir ing a latitude of 10 cm. in order to negotiate the curve as it passes through the cardia before it can change its axis to conform with that of the stomach.

At the base of each of the two brush tufts are metallic cuffs which at first glance appear potentially traumatic since, during rotation, they describe an arc about twice the diameter of the instrument. However, they freely pivot on their hubs, antl the slightest resistance causes the brush unit to swing away in a different arc of rotation.

T h e injuries to the posterior gastric wall in Cases 2 and 3 were, in my opinion, produced by the mechanism as described above. Underlying disease of the gastric wall, leukemic infiltration in Case 2, and amyloid deposition in Case 3 unquest ionably were major contr ibutory factors as well, but at the time of the brush biopsy it was not known that compli- cating infiltration diseases which ordinarily would contraindicate this procedure were present.

A method of preventing shearing by the open end of the instrument has been devised by Zerpa Morales. He places a No. 1 gelatin capsule over the open end of the instrument prior to insertion. This capsule slips off easily when the brushes are extruded in the stomach cavity. T h e use of a protective capsule converts the open-end instrument into a closed-end instrument, and should add considerably to its safety. It would also pre- vent possible injuries to unsuspected varices, diverticula, and polyps, and prevent the type of injury that occurred in Case I, in which a shelf of gastric mucosa obstructed the opening of the cardia.

Further improvement in the design of the instrument may be accom- plished by shortening the terminal rigid portion, either by segmenting this port ion into three parts joined by a flexible plastic or rubber sheath, or by creating flexible joints between the segments. This would help to prevent impingement on the posterior wall, as previously discussed.

T h e loss of the brush unit in Case 4 was due to simple mechanical

404 American ,Journal of Digestive D~seases

Ayre Stomach Brush

failure, and after this accident was reported to the manufacturer, an additional small spring attachment which acts as a safety guard against accidental detachment of the brush was added to the tip of the cable.

SUMMARY

1. Four unfavorable experiences with the use o~ the Ayre rotating stomach brush are reported. In one case, a piece of gastric mucosa was accidentally obtained; in 2 others, serious trauma to the posterior wall in the stomach occurred, and in a fourth, the brush unit became detached in the stomach.

2. Mechanisms involved in these accidents and methods of prevention are discussed. In particular, (a) the brush should not be pushed through the cardia if resistance is met; (b) arnyloidosis, leukemia, or other hemor- rhagic disorders are contraindications to the use of the instrument; (c) anticoagulation therapy may be dangerous in the immediate period after cytologic abrasion is performed; and (d) the brush should not be used to break up gastric bezoars.

1475 Grand CoTwourse Bronx 52, N. Y.

REFERENCES

1. Ross.~Ax, M., and WOLF. J. Accidental gastric biopsies with the Ayre brush. Gastroemerology 30:686, 1956.

2. SCH~Xm.tR, R. Gastroscopy (ed. 2). Univ. Chicago Press, Chicago, 1950. Pp. 21, 94.

New Series, Vol. 9, No. 6, 1964 405