liamps x seconds per patient reported equates to treating two hemorrhoids at about 10 ma for 4 min each in the "responder" and slightly less treatment in the "non-responder" group. Furthermore, the authors claim all patients suffered from discomfort during therapy. Although a trend in favor of direct current electrotherapy was noted in the 16 patients studied, statistical significance was not achieved. Therefore, it was stated that this therapy was no better than standard medical therapy. I propose that no patient received active direct current electrotherapy. The manufacturer details the effective use of Ultroid to require an average treatment time of 6 min for grade 1 disease and 9.5 min for grade 4 disease using 12 rna and 4.5 and 7.0 min, respectively, with the maximum current of 16 ma. 2 Other published reports have required longer application for successful therapy.a-s No report has demonstrated an effect using a shorter treatment time. Since even maximum milliamperage application at 4 min (maximum was not used in all patients) could not be expected to affect hemorrhoid disease, the treatment arm of the study was no different than applying no treatment at all. Furthermore, patients have discomfort thresholds to direct current application. Rapid milliamperage application will cause pain in most patients. If direct current is applied as recommended,2 in a slow graduated manner, with decrease in current if discomfort is noted, patients can be treated painlessly. The authors recognize the treatment application to be "somewhat lower than that in other studies" and rationalize this by stating: "physician tolerances must be considered." It would be more correct not to claim inadequate therapy is ineffective therapy. The available data to date will demonstrate the beneficial effect of direct current electrotherapy on symptomatic hemorrhoid disease. 3-5 This therapy should not be used by those intolerant to its proper application. Daniel A. Norman, MD Division of Gastroenterology Barton Memorial Hospital South Lake Tahoe, California

REFERENCES 1. Wright RA, Kranz KR, Kirby SL. A prospective crossover trial of direct current electrotherapy in symptomatic hemorrhoid disease. Gastrointest Endosc 1991;37:621-3. 2. The Ultroid manual, an instructional guide for the management and treatment of hemorrhoid disease. Watertown, MA: Microvasive Inc., 1988. 3. Jensen DM, Randall G, Machicado GA. Comparison of direct current (DC) vs BICAP probe for treatment of chronically bleeding internal hemorrhoids [Abstract]. Gastrointest Endosc 1988;34:196-7. 4. Norman DA, Newton R, Nicholas GV. Direct current electrotherapy of internal hemorrhoids: an effective, safe, and painless outpatient approach. Am J GastroenteroI1989;84:482-7. 5. Zinberg SS, Stern OH, Furman DS, Wittles JM. A personal experience in comparing three nonoperative techniques for treating internal hemorrhoids. Am J Gastroenterol 1989;84:488-92. Response

Dr. Norman has several valid points. The fact that patients received shorter treatment sessions than was recommended in his initial article is certainly true.! Other inves520

tigators have also indicated that the duration of direct current electrotherapy should be longer than described in our study.2,3 However, our limited duration of therapy was based on both the tolerance of the physician performing the procedure as well as that of the patient. Anyone who has utilized the Ultroid probe is extremely aware of the disadvantage of holding the probe in contact with a hemorrhoid for long periods of time. Furthermore, the procedure is not painless as claimed by Dr. Norman. Most patients were unable to tolerate the maximal amperage he recommended. Dr. Norman's study! had no placebo or control group. Our study is small, but is well controlled and statistically sound. 3 Richard A. Wright, MD University of Louisville Louisville, Kentucky

REFERENCES 1. Reference 4 above. 2. Reference 3 above. 3. Reference 1 above.

Parotid swelling after endoscopy To the Editor: We read with interest the recent report regarding parotid swelling after upper gastrointestinal endoscopy.! We would like to propose another mechanism for this clinical observation. The authors noted that the patient strained and coughed during the initial part of the endoscopy. It is possible that air was introduced into the parotid gland via Stenson's duct during her forced expiratory maneuver. This would explain the sudden swelling of the parotid gland and the gradual resolution of the condition secondary to decompression over a 3-hour period. A diagnostic clue to this possibility would have been the finding of crepitus on palpation. If crepitus is felt on palpation over the parotid gland, then consideration should be given to a short course of prophylactic antibiotic therapy to cover oral flora and warm compresses for symptomatic relief. Vincent Ziccardi, DDS Peter J. Molloy, MD Western Pennsylvania Hospital Pittsburgh, Pennsylvania

REFERENCE 1. Nijhawan S, Rai RR. Parotid swelling after upper gastrointestinal endoscopy [Letter]. Gastrointest Endosc 1992;38:94.

Basket impaction at the pancreatic head To the Editor: We recently experienced a unique location for basket impaction during therapeutic endoscopy. A 51-year-old female with a history of chronic alcohol abuse and recurrent pancreatitis was seen at another hospital with 1 month of worsening jaundice, pruritus, and weight loss. Their initial evaluation included abdominal ultrasound and CT scan GASTROINTESTINAL ENDOSCOPY