take an active role in the specific design or control of the individual teaching experience. The Society's Committee on Training will, however, monitor the program carefully to ensure general conformance with these guidelines, assess the level of participation, and evaluate the effectiveness of the training. Following recruitment of an adequate number of teachers, applications for member candidates interested in obtaining advanced training will be available from the A/S/G/E office. Applicants will be provided a copy of the program guideline, appropriate application forms, and a list of teachers in their area specifying the procedures each are prepared to teach. The last, and most essential ingredient which will ultimately determine the success or failure of this program, is the level of commitment of members of the A/S/G/E. Both teachers and students must be willing to enter into a good faith contract in sufficient numbers to make the effort worthwhile. Some creativity, flexibility, mutual trust, hard work, and an element of selflessness will be required if we're to make this experiment succeed. The common goal we all strive for is one of the main purposes of the A/S/G/E as stated in our constitution, "to establish and maintain the highest standards of practice for the diagnostic and therapeutic use of gastrointestinal endoscopic methods" and "to assist all those involved with health care as it relates to gastrointestinal endoscopy."3
REFERENCES 1. Frank BB. The 1983 A/S/G/E membership survey. Gastrointest Endosc 1984;30:206-12. 2. Borland JL Jr. The next 50. Gastrointest Endosc 1990;36: 416-7. 3. American Society for Gastrointestinal Endoscopy Constitution, A/S/G/E Membership Roster, Constitution and By-Laws, 131 Elm Street, Manchester, MA, June 1991.
Letters to the Ed itor Viral esophagitis: the endoscopic appearance To the Editor: I enjoyed reading the excellent article by McBane and Gross describing the clinical syndrome, endoscopic findings, and diagnosis of herpes virus (HSV) esophagitis in 23 patients.! As pointed out in the Discussion, the authors found a "typical" endoscopic appearance in 4 of 23 cases. However, they have not described the typical endoscopic findings of their 4 patients and how they differed from 16 patients with endoscopic findings "suggestive" of HSV infection. I believe, it is most likely due to the retrospective nature of their study. The typical endoscopic appearance in HSV esophagitis is the presence of discrete vesicles. In the absence of discrete vesicles, there is no typical endoscopic appearance, and apparently only one of their four patients had endoscopically typical HSV esophagitis. We have previously described five immunocompromised patients with viral esophVOLUME 38, NO.5, 1992
agitis. 2 All patients had ulcers and four patients had vesicles at endoscopy. McDonald et al. 3 have found a high incidence of viral esophagitis in 46 patients after bone marrow transplantation with equal distribution of HSV and cytomegalovirus esophagitis. Only one of their patients with HSV infection had discrete vesicles noted during endoscopic examination. They described three stages of HSV esophagitis: an early stage with vesicles, an intermediate stage with erosions and ulcers, and a late stage with mucosal necrosis. 3, 4 I share their opinion that the finding of vesicles should strongly suggest HSV infection, since neither cytomegalovirus nor fungal organisms appear to cause vesicular lesions. I would like to make few additional comments: 1. Vesicles probably are the only typical endoscopic findings of HSV esophagitis. During this early vesicular stage, biopsies and cultures may be negative for HSV as shown in our study.2 McBane and Gross! found positive culture or biopsies in all patients. I suspect this to be due to the late stage of infection. 2. It is likely that the vesicles were seen in only a fraction of patients reported by McBane and Gross! and by McDonald et al. 3 because endoscopy was performed after longstanding symptoms. In our study,2 the mean duration of odynophagia was 6.8 days (range, 4 to 10 days). The authors do not mention the duration of symptoms in their patient population. 3. Early endoscopy plays an important role in immunocompromised patients with esophageal symptoms, especially odynophagia. As shown in our study,2 if vesicles are found at early endoscopy, the diagnosis of viral esophagitis may be presumed and treatment with acyclovir may be initiated immediately even before biopsy and culture results are available. All of our patients had rapid improvement of odynophagia within 1 to 5 days and complete resolution within 3 to 7 days with acyclovir therapy. It would be interesting to know the results of acyclovir treatment in the patients reported by McBane and Gross.! Shailesh C. Kadakia, MD Department of Medicine Gastroenterology Service Brooke Army Medical Center San Antonio, Texas
REFERENCES 1. McBane RD, Gross JB. Herpes esophagitis: clinical syndrome, endoscopic appearance, and diagnosis in 23 patients. Gastrointest Endosc 1991;37:600-3. 2. Kadakia SC, Oliver GA, Peura DA. Acyclovir in endoscopically presumed viral esophagitis. Gastrointest Endosc 1987;33:33-5. 3. McDonald GB, Sharma P, Hackman RC, Meyers JD, Thomas ED. Esophageal infection in immunosuppressed patients after bone marrow transplantation. Gastroenterology 1985;88: 1111-7. 4. McDonald GB. Esophageal disease caused by infection, systemic illness, and trauma. In: Sleisenger MH, Fordtran JS, eds. Gastrointestinal disease. Philadelphia: WB Saunders, 1989:640-56.
The opinions and assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Department of the Army or the Department of Defense.
633
REFERENCES 1. Frank BB. The 1983 A/S/G/E membership survey. Gastrointest Endosc 1984;30:206-12. 2. Borland JL Jr. The next 50. Gastrointest Endosc 1990;36: 416-7. 3. American Society for Gastrointestinal Endoscopy Constitution, A/S/G/E Membership Roster, Constitution and By-Laws, 131 Elm Street, Manchester, MA, June 1991.
Letters to the Ed itor Viral esophagitis: the endoscopic appearance To the Editor: I enjoyed reading the excellent article by McBane and Gross describing the clinical syndrome, endoscopic findings, and diagnosis of herpes virus (HSV) esophagitis in 23 patients.! As pointed out in the Discussion, the authors found a "typical" endoscopic appearance in 4 of 23 cases. However, they have not described the typical endoscopic findings of their 4 patients and how they differed from 16 patients with endoscopic findings "suggestive" of HSV infection. I believe, it is most likely due to the retrospective nature of their study. The typical endoscopic appearance in HSV esophagitis is the presence of discrete vesicles. In the absence of discrete vesicles, there is no typical endoscopic appearance, and apparently only one of their four patients had endoscopically typical HSV esophagitis. We have previously described five immunocompromised patients with viral esophVOLUME 38, NO.5, 1992
agitis. 2 All patients had ulcers and four patients had vesicles at endoscopy. McDonald et al. 3 have found a high incidence of viral esophagitis in 46 patients after bone marrow transplantation with equal distribution of HSV and cytomegalovirus esophagitis. Only one of their patients with HSV infection had discrete vesicles noted during endoscopic examination. They described three stages of HSV esophagitis: an early stage with vesicles, an intermediate stage with erosions and ulcers, and a late stage with mucosal necrosis. 3, 4 I share their opinion that the finding of vesicles should strongly suggest HSV infection, since neither cytomegalovirus nor fungal organisms appear to cause vesicular lesions. I would like to make few additional comments: 1. Vesicles probably are the only typical endoscopic findings of HSV esophagitis. During this early vesicular stage, biopsies and cultures may be negative for HSV as shown in our study.2 McBane and Gross! found positive culture or biopsies in all patients. I suspect this to be due to the late stage of infection. 2. It is likely that the vesicles were seen in only a fraction of patients reported by McBane and Gross! and by McDonald et al. 3 because endoscopy was performed after longstanding symptoms. In our study,2 the mean duration of odynophagia was 6.8 days (range, 4 to 10 days). The authors do not mention the duration of symptoms in their patient population. 3. Early endoscopy plays an important role in immunocompromised patients with esophageal symptoms, especially odynophagia. As shown in our study,2 if vesicles are found at early endoscopy, the diagnosis of viral esophagitis may be presumed and treatment with acyclovir may be initiated immediately even before biopsy and culture results are available. All of our patients had rapid improvement of odynophagia within 1 to 5 days and complete resolution within 3 to 7 days with acyclovir therapy. It would be interesting to know the results of acyclovir treatment in the patients reported by McBane and Gross.! Shailesh C. Kadakia, MD Department of Medicine Gastroenterology Service Brooke Army Medical Center San Antonio, Texas
REFERENCES 1. McBane RD, Gross JB. Herpes esophagitis: clinical syndrome, endoscopic appearance, and diagnosis in 23 patients. Gastrointest Endosc 1991;37:600-3. 2. Kadakia SC, Oliver GA, Peura DA. Acyclovir in endoscopically presumed viral esophagitis. Gastrointest Endosc 1987;33:33-5. 3. McDonald GB, Sharma P, Hackman RC, Meyers JD, Thomas ED. Esophageal infection in immunosuppressed patients after bone marrow transplantation. Gastroenterology 1985;88: 1111-7. 4. McDonald GB. Esophageal disease caused by infection, systemic illness, and trauma. In: Sleisenger MH, Fordtran JS, eds. Gastrointestinal disease. Philadelphia: WB Saunders, 1989:640-56.
The opinions and assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Department of the Army or the Department of Defense.
633
