C S Pitchumoni

Issues in hyperlipidemic pancreatitis.

Hypertriglyceridemia (HTG) is a rare cause of pancreatitis. Pancreatitis secondary to HTG, presents typically as an episode of acute pancreatitis (AP) or recurrent AP, rarely as chronic pancreatitis. A serum triglyceride (TG) level of more than 1,000 to 2,000 mg/dL in patients with type I, IV, or V hyperlipidemia (Fredricksons classification) is an identifiable risk factor. The typical clinical profile of hyperlipidemic pancreatitis (HLP) is a patient with a preexisting lipid abnormality along with the presence of a secondary factor (e.g., poorly controlled diabetes, alcohol use, or a medication) that can induce HTG. Less commonly, a patient with isolated hyperlipidemia (type V or I) without a precipitating factor presents with pancreatitis. Interestingly, serum pancreatic enzymes may be normal or only minimally elevated, even in the presence of severe pancreatitis diagnosed by imaging studies. The clinical course in HLP is not different from that of pancreatitis of other causes. Routine management of AP caused by hyperlipidemia should be similar to that of other causes. A thorough family history of lipid abnormalities should be obtained, and an attempt to identify secondary causes should be made. Reduction of TG levels to well below 1,000 mg/dL effectively prevents further episodes of pancreatitis. The mainstay of treatment includes dietary restriction of fat and lipid-lowering medications (mainly fibric acid derivatives). Experiences with plasmapheresis, lipid pheresis, and extracorporeal lipid elimination are limited.

Issues in Hypertriglyceridemic Pancreatitis - An Update

Hypertriglyceridemia (HTG) is a well-established but underestimated cause of acute pancreatitis and recurrent acute pancreatitis. The clinical presentation of HTG-induced pancreatitis (HTG pancreatitis) is similar to other causes. Pancreatitis secondary to HTG is typically seen in the presence of one or more secondary factors (uncontrolled diabetes, alcoholism, medications, pregnancy) in a patient with an underlying common genetic abnormality of lipoprotein metabolism (familial combined hyperlipidemia or familial HTG). Less commonly, a patient with rare genetic abnormality (familial chylomicronemic syndrome) with or without an additional secondary factor is encountered. The risk of acute pancreatitis in patients with serum triglycerides >1000 and >2000 mg/dL is ∼ 5% and 10% to 20%, respectively. It is not clear whether HTG pancreatitis is more severe than when it is due to other causes. Clinical management of HTG pancreatitis is similar to that of other causes. Insulin infusion in diabetic patients with HTG can rapidly reduce triglyceride (TG) levels. Use of apheresis is still experimental and better designed studies are needed to clarify its role in the management of HTG pancreatitis. Diet, lifestyle changes, and control of secondary factors are key to the treatment, and medications are useful adjuncts to the long-term management of TG levels. Control of TG levels to 500 mg/dL or less can effectively prevent recurrences of pancreatitis.

Percutaneous endoscopic gastrostomy and outcome in dementia

The use of percutaneous endoscopic gastrostomy for the administration of food and medications in patients with dementia has been on an increase. Many studies have failed to demonstrate the positive outcome expected of this feeding modality for the indications that required tube placement. Hence, the concept of feeding through gastrostomy tubes has become the subject of much discussion and controversy in recent times. We have reviewed the literature with regard to outcome in older patients with dementia and percutaneous endoscopic gastrostomy with respect to nutritional parameters, quality of life, and survival. A brief discussion on ethical and legal aspects is included. Much of the data do not suggest that outcome in dementia is favorably improved after percutaneous gastrostomy.

Racial factors and the risk of chronic pancreatitis

OBJECTIVE:It is unclear why some alcohol abusers develop alcoholic cirrhosis whereas others contract chronic pancreatitis. The aim of this study was to examine the importance of race as a risk factor for the development of chronic pancreatitis.METHODS:We compared the racial status of 1883 patients discharged with a first-listed diagnosis of two diseases strongly related to alcohol abuse: 433 patients with chronic pancreatitis (ICD 5771) and 1450 patients with alcoholic cirrhosis (ICD 5712). Information came from discharge statistics maintained by two acute care hospitals in New York City and one acute care hospital in Lisbon, Portugal. The study period included the years 1989–1996 in the US and 1989–1994 in Portugal.RESULTS:A total of 215 (50%) of the 433 chronic pancreatitis patients were black compared with 333 (23%) of the 1450 patients with alcoholic cirrhosis. When adjusted for sex and hospital site, patients with pancreatitis were significantly more likely to be black than patients with cirrhosis (odds ratio 2.5, 95% confidence interval 1.9–3.2, p < 0.001).CONCLUSIONS:In comparison with white patients, black patients are two to three times more likely to be hospitalized for chronic pancreatitis than alcoholic cirrhosis. This highly significant (p < 0.001) difference was observed in both men and women: in three different hospitals, and in two different countries. The explanation is unknown, but could be related to racial differences in diet, type or quantity of alcohol consumption, smoking, or ability to detoxify substances harmful to the liver or pancreas.

Clostridium difficile and vancomycin-resistant enterococcus: the new nosocomial alliance

OBJECTIVES:The aims of this study were to determine the frequency of the association between Clostridium difficile (C. difficile) and vancomycin-resistant Enterococcus (VRE) and delineate the role of C. difficile coinfection as a predictor of VRE infection versus colonization and adverse outcome.METHODS:Patients with both C. difficile colitis and VRE (CD/VRE) were compared to patients with VRE alone with regard to demographics, comorbidity, prior antibiotic therapy, and coinfection with methicillin-resistant Staphylococcus aureus and funguria. C. difficile as a predictor of VRE infection (VRE-I) versus colonization (VRE-C) and adverse outcome was also studied.RESULTS:Eighty-nine patients with VRE infection or colonization were studied. This included 31 cases of VRE-I and 58 VRE-C. C. difficile was isolated in 17 (19.1%) of patients; of these C. difficile was isolated before VRE in 9 patients and after VRE in 8. The two groups did not differ in age, residence, or comorbidity. C. difficile coinfection was not predictive of VRE-I versus VRE-C, nor was it associated with increased length of stay or mortality. However, the mortality rates in both groups was high, around 30%. A significant association was noted between the use of vancomycin and metronidazole (before the isolation of VRE) and C. difficile coinfection (p= 0.03 and p= 0.001, respectively). A high incidence of nosocomial coinfection with methicillin-resistant Staphylococcus aureus, funguria, and gram-negative sepsis was noted in both groups; the association with funguria was statistically significant (p= 0.029).CONCLUSIONS:In conclusion, C. difficile coinfection is common in patients with VRE infection or colonization and is significantly associated with other nosocomial dilemmas like funguria. This may result in the emergence of highly virulent pathogens including vancomycin-resistant C. difficile, posing new challenges in the management of nosocomial diarrheas.

Chronic cyanide poisoning: unifying concept for alcoholic and tropical pancreatitis

We hypothesize that chronic cyanide toxicity may explain the occurrence of calcific pancreatitis in chronic alcoholic individuals in affluent Western nations and malnourished children and young adults in developing tropical regions. In alcoholic persons the source of cyanide is cigarette smoke, and in tropical countries the source could be cassava or other plants. The cyanide hypothesis is consistent with the known epidemiologic and metabolic characteristics of these two contrasting forms of pancreatitis. We believe that continued chronic cyanide poisoning could reinforce any independent effect of alcohol or malnutrition on the pancreas, resulting in an exaggerated and perhaps irreversible form of the disease.

Gastrostomy, Esophagitis, and Gastrointestinal Bleeding in Older Adults

INTRODUCTION Percutaneous endoscopic gastrostomy tubes (PEG) are commonly used in older adults with dysphagia and poor nutrition. The association of PEG with upper gastrointestinal bleeding (UGIB) and role of gastroesophageal reflux disease (GERD) in relation to UGIB in patients with PEG are not well known. METHODS We conducted a retrospective analysis of older patients with PEG, hospitalized for UGIB, during a 1-year period between 1997 and 1998. The study was performed in a university teaching hospital involving residents from long-term care facilities (LTCF) of the Bronx. RESULTS A total of 38 patients with PEG were admitted for UGIB; 28 were evaluated with upper endoscopy. The mean age of the group who underwent endoscopy was 83.4 +/- 9.2 years, with 18 females and 10 males. In the same group, 13 patients were on H2 blockers and 4 patients used nonsteroidal antiinflammatory drugs before hospitalization. None of the residents were on proton pump inhibitors. The most common upper endoscopic findings were esophagitis, either alone (11 patients) or in association with other lesions (10 patients). Esophagitis predominantly involved the lower third of the esophagus. Other significant findings on endoscopy were gastric and duodenal ulcers, gastritis, and gastric erosions either alone or in combinations. CONCLUSIONS Esophagitis is a common occurrence and a significant contributor for UGIB in patients with PEG. Use of H2 blockers does not appear to be an effective preventive measure for UGIB in these patients.

Propofol is a safe, effective agent to be used by gastroenterologists for conscious sedation in GI endoscopy: a randomized double blind study

Propofol is a safe, effective agent to be used by gastroenterologists for conscious sedation in GI endoscopy: a randomized double blind study

Hepatitis C (HCV)|[mdash]|still an epidemic hidden from the public eye|[quest]|

Aim: Compare public awareness of HCV to the more publicized HIV epidemic. Methods: A two-part Survey Questionnaire was administered. Part 1 requested demographic information and asked general questions on attitudes and beliefs. Part 2 asked 10 HCV-related and 10 HIV-related questions based on NY State Health Department public information pamphlets. Chi-square analysis, ANOVA and Student t-tests were used for statistical comparison. Information pamphlets and counseling were provided to all participants after testing. Results: 606 individuals participated, 290 were hospital staff (92 physicians). Mean age was 38.7 6 14 yrs, 238 were male, 550 had 12 1 years of education.

Should we still look for causes other than HP and NSAID for PUD

To the Editor: The association between peptic ulcer disease (PUD) and Helicobacter pylori (HP) has been well established (1). However, in our clinical experience at Our Lady of Mercy Medical center, Bronx, NY, several patients with PUD did not have evidence of HP infection. We reviewed all upper endoscopy reports of patients who underwent the procedure between October 1994 to July 1997. There were a total of 1640 upper endoscopies done during this period of which 251 patients had ulcer disease on endoscopy. A chart review of these 251 patients was done. The following patients were excluded from the ulcer population: 1) those who had insertion of percutaneous endoscopic gastrostomy (PEG) tube; 2) those who underwent a previous Billroth-II resection; and 3) those who were treated with H-2 blockers, proton pump inhibitors, or antibiotics for HP infection 8 wk before the endoscopy. Fifty-six patients met the exclusion criteria mentioned above. One or two biopsies were taken from the antrum using a regular sized forceps (2.3 mm cup size). Testing for HP was done either with rapid urease test (CLO), histopathology, or both. A history of nonsteroidal antiinflammatory drug (NSAID) use was obtained at the time of endoscopy. Of the 110 gastric ulcers, 63 (57%) were negative for HP and history of NSAID use. Similarly, of the 85 duodenal ulcers, 33 (39%) were negative for HP and NSAID use. Both CLO test and histopathology carry a high degree of sensitivity in detecting HP (2) but almost 20% could be missed. If we recalculate the prevalence of HP negative PUD correcting for the above (Table 1 and 2), then the HP negative gastric ulcer prevalence would decrease to 49% and HP negative duodenal ulcer to 25%. The corrected numbers do not agree with current literature on prevalence of HP disease in PUD.