Bryan T. Green

Urgent Colonoscopy for Evaluation and Management of Acute Lower Gastrointestinal Hemorrhage: A Randomized Controlled Trial

OBJECTIVES:We hypothesized that early intervention in patients with lower gastrointestinal bleeding (LGIB) would improve outcomes and therefore conducted a prospective randomized study comparing urgent colonoscopy to standard care.METHODS:Consecutive patients presenting with LGIB without upper or anorectal bleeding sources were randomized to urgent purge preparation followed immediately by colonoscopy or a standard care algorithm based on angiographic intervention and expectant colonoscopy.RESULTS:A total of 50 patients were randomized to each group. A definite source of bleeding was found more often in urgent colonoscopy patients (diverticula, 13; angioectasia, 4; colitis, 4) than in the standard care group (diverticula, 8; colitis, 3) (the odds ratio for the difference among the groups was 2.6; 95% CI 1.1–6.2). In the urgent colonoscopy group, 17 patients received endoscopic therapy; in the standard care group, 10 patients had angiographic hemostasis. There was no difference in outcomes among the two groups—including: mortality 2% versus 4%, hospital stay 5.8 versus 6.6 days, ICU stay 1.8 versus 2.4 days, transfusion requirements 4.2 versus 5 units, early rebleeding 22% versus 30%, surgery 14%versus 12%, or late rebleeding 16% versus 14% (mean follow-up of 62 and 58 months).CONCLUSION:Although urgent colonoscopy identified a definite source of LGIB more often than a standard care algorithm based on angiography and expectant colonoscopy, the approaches are not significantly different with regard to important outcomes. Thus, decisions concerning care for patients with acute LGIB should be based on individual experience and local expertise.

Ischemic colitis: a clinical review.

Ischemic colitis is the most common form of intestinal ischemia. It manifests as a spectrum of injury from transient self-limited ischemia involving the mucosa and submucosa to acute fulminant ischemia with transmural infarction that may progress to necrosis and death. Although there are a variety of causes, the most common mechanism is an acute, self-limited compromise in intestinal blood flow. Patients typically have mild abdominal pain and tenderness over the involved segment of bowel. There is usually passage of blood mixed with stool, but hemodynamically significant bleeding is unusual. Although computed tomography may have suggestive findings, colonoscopy is the procedure of choice for diagnosis. Supportive care with intravenous fluids, optimization of hemodynamic status, avoidance of vasoconstrictive drugs, bowel rest, and empiric antibiotics will produce clinical improvement within 1 to 2 days in most patients. Twenty percent of patients will have development of peritonitis or may deteriorate despite conservative management and will require surgery.

Gastrointestinal endoscopic evaluation of premenopausal women with iron deficiency anemia

Goals To evaluate whether the gastrointestinal tract could be a source of chronic blood loss in premenopausal women with iron deficiency anemia. Background While premenopausal women with iron deficiency anemia are typically managed with simple iron replacement, the standard of care for postmenopausal women and men is to exclude a gastrointestinal source of bleeding. Study We identified 111 premenopausal women who underwent endoscopy for the sole indication of iron deficiency anemia. Results The mean age was 42.5 years. Lesions potentially causative of iron deficiency anemia were detected in 22 patients (20%). Upper gastrointestinal lesions were present in 14 patients (13%) and included only erosive lesions. Lower gastrointestinal lesions were detected in 8 patients (7.2%) and included colon cancer (2.7%), inflammatory bowel disease (3.6%), and a colonic ulcer >1 cm (0.9%). Patients with upper gastrointestinal lesions were more likely to use aspirin or nonsteroidal antiinflammatory drugs (11/14, 79%) than patients with no lesions (26/89, 23%; P = 0.043). Occult blood was more common in patients with lower gastrointestinal lesions 8/8 (100%) and patients with upper gastrointestinal lesions (9/14, 64%) than in patients without lesions (28/89, 31%; P = 0.037 and 0.039). Gastrointestinal symptoms were significantly more common in patients with gastrointestinal lesions than in patients without lesions. Conclusions A gastrointestinal source of chronic blood loss was identified in a substantial proportion of premenopausal women with iron deficiency anemia. Patients with gastrointestinal symptoms, fecal occult blood, and/or weight loss should undergo endoscopy.

Screening colonoscopy for the detection of neoplastic lesions in asymptomatic HIV-infected subjects

Background: Although non-AIDS defining malignancies are rapidly increasing as HIV-infected subjects live longer, little is know about the results of screening for colonic neoplasms (adenomatous polyps and adenocarcinomas) in this population. Methods: We conducted a screening colonoscopy study to determine the prevalence of colonic neoplasms in 136 asymptomatic HIV-infected subjects ⩾50 years of age and 272 asymptomatic uninfected control subjects matched for age, sex, and family history of colorectal cancer. Advanced neoplasms were defined as adenomas ⩾10 mm or any adenoma, regardless of size, with villous histology, high-grade dysplasia, or adenocarcinoma. Results: The prevalence of neoplastic lesions was significantly higher in HIV-infected subjects than in control subjects (62.5% vs 41.2%, p<0.001), and remained highly significant after adjustment for potential confounding variables (odds ratio  = 3.00; 95% confidence interval, 1.83 to 4.93). Among patients with colorectal adenocarcinoma, HIV-infected subjects were significantly younger (52.4 (SD 1.3) vs 60.3 (SD 4.0) years, p = 0.002) and were more likely to have advanced cancers (stage III or IV) than control subjects (60.0% vs 16.7%, p = 0.24). Of HIV-infected subjects with advanced neoplasms proximal to the splenic flexure, distal neoplastic lesions were absent in 88.9% of individuals and these would have been missed by flexible sigmoidoscopy. Conclusions: HIV-infected subjects have a higher prevalence of colonic neoplasms, and adenocarcinomas develop at a younger age and are more advanced than in uninfected subjects. Our findings suggest that screening colonoscopy should be offered to HIV-infected subjects, but the age of initiation and the optimal frequency of screening require further study.

Duodenal somatostatinoma presenting with complete somatostatinoma syndrome

Somatostatinomas are the rarest pancreatic endocrine tumors and can arise in the pancreas or duodenum. Duodenal somatostatinomas are less common than, and are distinguished from, their pancreatic counterparts by a frequent association with type I neurofibromatosis, the presence of psammoma bodies, the less frequent presence of metastatic disease, and the absence of somatostatinoma syndrome (diabetes mellitus, steatorrhea, and cholelithiasis). We report a case of somatostatinoma with metastases and psammoma bodies presenting with all three features of the syndrome in a patient with neurofibromatosis. Although several reports have documented portions of the syndrome in patients with duodenal somatostatinomas, to our knowledge, this is the first report of the complete syndrome associated with a duodenal lesion.

Massive gastrointestinal hemorrhage due to rupture of a donor pancreatic artery pseudoaneurysm in a pancreas transplant patient.

Abstract:  Enteric drainage of secretions by anastomosing the donor duodenum to the recipients small bowel has become common in pancreatic transplantation. While it eliminates many problems, endoscopic access to the transplanted duodenum and pancreas is made difficult. After a pancreas kidney transplant, the patient presented with massive hematochezia. Upper and lower endoscopy revealed large amounts of red blood in the colon but no specific bleeding site. Mesenteric angiography was normal but pelvic angiography showed rapid extravasation of contrast from a pseudoaneurysm of the pancreatic transplant artery. This was successfully embolized with coils. To the best of our knowledge, this is the first case of massive gastrointestinal hemorrhage because of rupture of a pseudoaneurysm of the donor pancreatic artery in a pancreas transplant patient. We report this case and review our institutions experience with all forms of gastrointestinal bleeding in pancreas transplant patients.

Most GERD symptoms are not due to acid reflux in patients with very low 24–hour acid contact times

Ambulatory esophageal 24-hr pH monitoring is used to diagnose GERD by determining the total acid contact time and/or symptom index (SI). The aim of this study was to compare the relationship between total acid contact times and SI in two groups: patients with very low vs. very high total acid contact times. We reviewed 973 consecutive 24-hr pH studies and compared patients with the lowest and highest 5% of total acid contact times. The low reflux group was significantly younger (median 50 vs. 54 years) and more predominantly female (78 vs. 47%) than the high reflux group. Median total acid contact time was 0.6 and 26.4% in the low and high reflux groups, respectively. The median SI was significantly lower in the low vs. high reflux groups for all symptoms (heartburn, 0 vs. 100%; regurgitation, 20 vs. 100%; cough, 0 vs. 55%; chest pain, 0 vs. 75%; nausea, 0 vs. 100%; and total SI, 12 vs. 86%). In patients with very low total acid contact times, only 12% of symptoms (typical or atypical) are associated with acid reflux, compared to 86% in patients with very high acid contact times. Younger females are overrepresented in the very low reflux, low SI group.

Spontaneous resolution of a pancreatic–colonic fistula after acute pancreatitis

1. Turner MW, Hamvas RM. Mannose-binding lectin: Structure, function, genetics and disease associations. Rev Immunogenet 2000;2:305–22. 2. Mäki M, Collin P. Coeliac disease. Lancet 1997;349:1755–9. 3. Boniotto M, Braida L, Spanò A, et al. Variant mannose-binding lectin alleles are associated with celiac disease. Immunogenetics 2002;54:596–8. 4. Walker-Smith JA, Guandalini S, Schmitz J, et al. Revised criteria for diagnosis of celiac disease. Arch Dis Child 1990; 65:909–11. 5. Miller SA, Dykes DD, Polesky HF. A simple salting out procedure for extracting DNA form human nucleated cells. Nucleic Acids Res 1988;16:1215. 6. Madsen HO, Garred P, Kurtzhals JAL, et al. A new frequent allele is the missing link in the structural polymorphism of the human mannan-binding protein. Immunogenetics 1994;40:37–44. 7. Iltanen S, Holm K, Partanen J, et al. Increased density of jejunal gammadelta T cells in patients having normal mucosa— marker of operative autoimmune mechanisms? Autoimmunity 1999;29:179–87. 8. Lipscombe RJ, Sumiya M, Summerfield JA, et al. Distinct physicochemical characteristics of human mannose binding protein expressed by individuals of differing genotype. Immunology 1995;85:660–7.

Diffuse Mucosal Hemorrhage After Air Insufflation During Endoscopy for PEG Placement

glandular epithelium in the mucosa, and a dense lymphocytic and plasma cell infiltrate. We recently encountered a Somalian immigrant who had endoscopic and histopathological findings of nontropical sprue without any clinical or laboratory evidence characteristic of this disorder. The duodenal mucosa was flat (Fig. 1c) because of surface epithelial injury, and histologically there was total villous atrophy (Fig. 1d), but cellular infiltration was minimal. In contrast, the duodenal mucosa in a native U.S. citizen has a typical “shaggy-carpet” appearance stained with bile (Fig. 1a) and has good histological correlation (Fig. 1b) because villous structures are intact. These contrasting endoscopic pictures of duodenal mucosa in patients from two different climates suggest that, besides clinical and laboratory information, the endoscopic appearance of the duodenal mucosa may also be helpful in correct interpretation of the duodenal biopsy findings.

Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: A randomized controlled trial

RESULTS: A total of 50 patients were randomized to each group. A definite source of bleeding was found more often in urgent colonoscopy patients (diverticula, 13; angioectasia, 4; colitis, 4) than in the standard care group (diverticula, 8; colitis, 3) (the odds ratio for the difference among the groups was 2.6; 95% CI 1.1–6.2). In the urgent colonoscopy group, 17 patients received endoscopic therapy; in the standard care group, 10 patients had angiographic hemostasis. There was no difference in outcomes among the two groups—including: mortality 2% versus 4%, hospital stay 5.8 versus 6.6 days, ICU stay 1.8 versus 2.4 days, transfusion requirements 4.2 versus 5 units, early rebleeding 22% versus 30%, surgery 14% versus 12%, or late rebleeding 16% versus 14% (mean follow-up of 62 and 58 months).