Bijo K. John

Low vitamin D level is an independent predictor of poor outcomes in Clostridium difficile-associated diarrhea

Background: The incidence, recurrence, and all-cause mortality rate for Clostridium difficile-associated diarrhea (CDAD) has increased markedly over the past 10 years despite treatment. Low vitamin D levels are known to impair immune responses to infection and are associated with increased mortality. We compared the role of patient comorbidity measured by the Charlson Comorbidity Index (CCI) with vitamin D levels to ascertain whether vitamin D levels were an independent variable affecting the outcome of CDAD or a marker of overall comorbidity. Methods: A prospective cohort study studied 62 patients hospitalized between 2008 and 2009 with manifestations of CDAD and a positive C. difficile toxin assay. All patients received standard antibiotics (metronidazole and/or vancomycin). Their status at 30-day follow up was classified as resolved or recurred/expired. Patients’ CCI was calculated using their medical history. Logistic regression analysis of variables including 25-hydroxyvitamin D, CCI, age, gender, white blood cell count (WBC), albumin and residence type were performed. Results: There were 62 patients (43.6% men, 56.4% women) with CDAD; mean age was 75 ± 17 years. At 30-day follow up, 28 (45.2%) expired, 10 (16.1%) had persistent or recurrent diarrhea and 24 (38.7%) resolved. Nonresolution was seen in 38 (61.3%). There was no significant association between 30-day resolution status and CCI, gender, WBC, albumin level or residence type. Two variables were found to be independent predictors of resolution of CDAD: normal vitamin D levels (p = 0.028) and age <70 years (p = 0.024). Subjects with low vitamin D were 4.75 times more likely to fail to resolve CDAD than subjects with normal Vitamin D. Conclusion: In this study, vitamin D level and age are independent predictors of CDAD resolution in hospitalized patients. Low vitamin D levels and age >70 years old are associated with increased likelihood of recurrence. Low vitamin D levels are not a marker of comorbidity or advanced age.

Multifocal Granular Cell Tumor Presenting as an Esophageal Stricture

IntroductionGranular cell tumors are uncommonly found in the gastrointestinal tract with slow progression and are usually benign though they may have propensity for malignant transformation. Initially attributed to neuronal origin through immunohistochemistry, there has been controversy with increasing reports of granular cell tumors of non-neural origin.Case ReportWe report a case of multifocal granular cell tumor involving the esophagus and stomach in a young female with history of dysphagia for 9 years with worsening symptoms. She had been managed at another facility with repeated dilations for presumed benign peptic stricture. Radial endosonography (EUS) of the proximal end of stricture showed a posterior submucosal esophageal mass that was heterogeneous and invaded into the muscularis propria. Fine-needle aspiration (FNA) showed large cells with granular cytoplasm along with spindle nuclei. Cells were initially checked for CD117 stain alone and found to be negative. A follow-up CT-guided core needle biopsy revealed similar granular cells that were positive for S-100. She underwent a two-stage transhiatal esophagogastrectomy as the tumor circumferentially involved the cervical esophagus and was adherent to the trachea and recurrent laryngeal nerve bilaterally. At surgery, there were two additional foci palpable in the proximal stomach.Discussion and ConclusionAs these tumors may have potential for malignant transformation and locoregional invasion, they should be considered while evaluating submucosal lesions of the esophagus even in young patients. A large number of granular cell tumors may be missed in the absence of S-100 staining, which should be requested when granular cells are seen on cytology obtained by EUS FNA as this can be a minimally invasive diagnostic modality for these tumors. Other foci should be sought at surgery as they have a propensity for locoregional spread.

Successful closure of a rectovaginal fistula by using an endoscopically placed Resolution clip.

BACKGROUND Rectovaginal fistula (RVF) is an abnormal epithelium-lined communication between the wall of the rectum and the posterior vaginal wall. The incidence of RVFs is low and accounts for about 5% of all anorectal fistulas. Women who suffer from an RVF complain of uncontrollable passage of gas or feces from the vagina. This remains a major contributor to morbidity associated with this condition in terms of social, psychologic, and sexual dysfunction. OBJECTIVE RVFs may be managed both medically and surgically, with the latter being the preferred option. A number of different surgical techniques that pertain to fistula closure were described in various literature; however, very little has been said of much-less-invasive techniques and alternatives to surgical correction if the patient is a poor candidate or prefers not to have surgery. The purpose of our article is to show our approach in treating an RVF, given the fact that our patient was a poor surgical candidate and, moreover, refused more-invasive techniques for treatment. DESIGN A case report. The patient described in this article is a 77-year-old woman with comorbidities that limited her as a candidate for less-invasive techniques rather than surgery. SETTING An inpatient at New York Hospital Queens, Flushing, New York. PATIENT A 77-year-old woman, with a medical history of 2 myocardial infarctions, congestive heart failure, 2 cardiac stents, multiple urinary-tract infections, and diverticulitis, presented to the hospital with a fever of 38.3 degrees C (101 degrees F) for 2 days. On the second day of admission, the patient complained of passing stool and flatus from the vagina. A subsequent workup and sigmoidoscopy revealed an RVF. INTERVENTION A sigmoidoscopy was performed, and fistula closure was achieved in 2 phases with the use of a Resolution clip. MAIN OUTCOME MEASUREMENTS Complications and resolution of symptoms after the procedure were the primary end points. RESULTS No complications were noted post procedure, and the patient has remained free of any complaints now for 12 months. LIMITATIONS The main limitation of the study is that this is a case report limited to a single patient, and outcomes of the procedure were concluded based on this particular patient. The endoscopic technique described here may be limited to readily visualized fistulas at endoscopy that are amenable to this treatment option. CONCLUSIONS The technique described, closing an RVF with the use of an endoscopically placed Resolution clip, shows great promise and could be applied to treating uncomplicated fistulas.

Antiplatelet agents do not impact the hospital course in patients with gastrointestinal bleeding.

Background Use of antiplatelet agents (APAs) have been shown to increase the risk of gastrointestinal (GI) bleeding despite their cardiovascular benefits. Aim To understand the impact of APAs, we assessed the outcomes in patients admitted with acute GI bleeding to our hospital. We hypothesized there is no difference among GI bleeders admitted to the hospital while bleeding on or off APAs. Methods In an observational prospective cohort study, 104 sequential patients admitted with a diagnosis of GI bleeding were followed. Patients were classified as either on APA or not. Results Thirty of 104 (29%) patients were on long-term aspirin and/or clopidogrel on admission and 5 were taking nonaspirin nonsteroidal anti-inflammatory drugs, total of 35 (34%). There was no difference between patients using APA and those not using APA with regard to admission hemoglobin, age, presentation, source of bleed, total number of units transfused, intensive care unit admission rates, and overall length of stay. There was, however, a significant difference in the presence of hemodynamic compromise on initial presentation, with a higher proportion of APA users being orthostatic (51.4% vs 26% in nonusers, with P=0.02, by Fisher exact test). Clopidogrel was safely restarted in high-risk patients with significant cardiac history. Conclusions This study demonstrated that APA use did not significantly alter the course or outcome in GI bleeders admitted to our institution during their hospital stay.

T1224 The Utility of Computed Tomographic Colonography in Minority Patients

Background: Flexible sigmoidoscopy (FS) increases the polyp and carcinoma detection yield when used in addition to double contrast Barium enema (DCBE).1 The addition of FS to DCBE has therefore been advised as standard practice.2 CT colonography (CTC) has replaced DBCE mas in many hospitals. We aim to explore whether FS increases the polyp and carcinoma detection yield when used in addition to CTC. Methods: Using endoscopy and radiology databases patients who underwent both FS and CTC between 2007 and 2009 were identified. Data was collected from those databases and the electronic patient records. Yields of polyp, adenoma and carcinoma detection were calculated. Serious pathology was defined as cancers and adenomas greater than 9 mm. Results: A total of 294 patients (179 female; 60.8%), with a mean age of 67 years were included. CTC detected 36 patients with carcinomas while FS detected 26. One rectal cancer not seen on CTC was diagnosed by FS. Polyps were seen by CTC in 71 and by FS in 47 patients. In 5 patients FS found polyps that were not detected by CTC, 3 of which were small (5mm) adenomas. FS detected extra adenomas or carcinomas in 4 of 294 cases, producing a yield of 1.36%. The number needed to endoscope to detect one extra adenoma was 74. Serious additional pathology was detected by FS in a single case, producing a yield of 0.34%. The number needed to endoscope to detect one extra serious pathological finding was 294. Conclusions: FS has a low yield of adenomas when used as an additive to CTC. The yield for serious pathology was very small in our series. Based on these findings the usefulness of routine use of FS as a supplement to CTC for adenoma and carcinoma detection is questionable. FS can however provide valuable additional information about inflammation, infection or vascular lesions depending on indication. References: 1. Jensen J, Kewenter J, Asztely M et al. Double contrast barium enema and flexible rectosigmoidoscopy: A reliable diagnostic combination for detection of colorectal neoplasm. Br J Surg 1990;77:270-2. 2. SIGN guideline number 67 Available at: http://www.sign.ac.uk. Analysis by indication