Cesar J. Garcia

Endoscopic Retrograde Cholangiopancreatography in the Elderly

Background The use of gastrointestinal endoscopy in geriatric patients is rising as an increasing proportion of the population is reaching an advanced age. Most studies of endoscopic retrograde cholangiopancreatography (ERCP) in the elderly have been done in tertiary care or referral centers. Methods We analyzed the clinical and endoscopic data on all ERCPs in patients aged 65 years and older in a retrospective review of medical records of patients at the county hospitals in El Paso and Lubbock, Texas between 2004 and 2008. ERCP data in patients aged 75 years and older were compared with those who were 65–74 years. Results There were 125 ERCPs performed in 89 patients (74 procedures in 54 patients older than 75 years, 51 procedures in 35 patients younger than 75 years). The average age was 76.0 (range: 65‐94), 62.4% were female and 79.2% were Hispanic. Indications were similar between groups: jaundice (66.9%), abnormal liver tests (87.2%), abdominal pain (79.2%), cholangitis (24.0%), pancreatitis (32.8%) and stent change (12.9%). Concomitant illnesses were also similar. Lower doses of midazolam and meperidine were used for moderate sedation in the older group (P < 0.01). ERCP findings were similar in both groups: stones (40.8%), stricture (18.4%) and stent placement (30.4%). Complications occurred in 6.4%. Conclusions This study of ERCP in elderly predominantly Hispanic patients found similar indications, efficacy and safety in patients 75 years and older compared with those 65–74 years old. Advanced age is not a contraindication to ERCP, but issues related to sedation and the use of antithrombotic therapy need to be addressed in the elderly.

Interpreting the Lactulose Breath Test for the Diagnosis of Small Intestinal Bacterial Overgrowth

Introduction: Based on literature review, a positive lactulose breath test (LBT) for small intestinal bacterial overgrowth requires an initial peak value of hydrogen within 100 minutes of lactulose ingestion with a second peak before 180 minutes. However, using scintigraphic monitoring of lactulose transit time, mean oral‐cecal arrival time has been reported as 73 minutes. The goal was to propose new criteria for analysing the LBT to overcome false positive interpretations. Methods: LBTs from our referral center were interpreted as positive after ingestion of 10 g of lactulose using the following approach for hydrogen concentrations: (1) The literature guidelines: greater than 20 ppm from a baseline less than 10 ppm achieved within 100 minutes followed by a further rise of greater than 15 ppm within 180 minutes. (2) The proposed criteria: greater than 20 ppm from a baseline less than 10 ppm within either 60 or 80 minutes followed by a further rise of greater than 15 ppm during the 180‐minute test. Results: A total of 153 patients with symptoms suspicious for small‐bowel bacterial overgrowth underwent testing. Of all, 26.1% patients tested positive by 100 minutes, 11.8% patients tested positive by 60 minutes and 18.3% patients tested positive by 80 minutes. The percentage of positive LBTs at 60 and 80 minutes was significantly lesser than for the 100 minutes criteria (P < 0.05). Conclusions: The first hydrogen peak increase should occur by either 60 or 80 minutes to increase the specificity of LBT for small intestinal bacterial overgrowth based on the reality of lactulose cecal arrival times.

Massive Upper Gastrointestinal Bleed From Epiphrenic Diverticulum

Epiphrenic diverticula are outpouchings of the esophagus that retain some or all layers of the esophageal wall. Symptoms such as intermittent dysphagia and vomiting may occur. The authors present a case of an elderly woman with a history of dysphagia who presented with a massive upper gastrointestinal bleed because of a bleeding epiphrenic diverticulum seen at endoscopy who responded to conservative management. Bleeding epiphrenic diverticula should be considered as a cause of upper gastrointestinal bleeding.

Streptococcus bovis Bacteremia: Association with Gastrointestinal and Liver Disease in a Predominantly Hispanic Population.

Objectives Streptococcus bovis bacteremia has been associated with gastrointestinal diseases, especially colon cancer, neoplastic colon polyps, and other malignancies of the gastrointestinal tract. Studies have suggested an association with chronic liver parenchymal and biliary tract disorders. We report a series of patients with S. bovis bacteremia in a county hospital in a US city on the border of Mexico to examine the demographic and clinical associations. Methods We characterized the demographics, clinical features, and the endoscopic and histopathologic findings in all patients with blood cultures positive for S. bovis at University Medical Center in El Paso, Texas, between January 2000 and December 2010. Hospital records were systematically reviewed using a standardized protocol. Results A total of 21 episodes of S. bovis bacteremia were documented in 21 adult patients. The mean age was 61 (range 25–97), 12 were women, and 20 were Hispanic. Presenting illnesses in these patients were gastrointestinal bleed (4), sepsis (4), cholangitis (3), hepatic encephalopathy (2), altered mental status (2), spontaneous bacterial peritonitis (1), septic abortion (1), diarrhea (1), others (3). Chronic liver disease was present in 7 cases (33%), 6 of which were alcohol related (5 with concomitant hepatitis C infection). Infective endocarditis was found in 1 patient. Overall, 10 patients underwent either colonoscopy alone (3), upper endoscopy alone (3), or both (4), and 2 underwent endoscopic retrograde cholangiopancreatography. Of the 7 (33%) patients who had colonoscopy, pathology was identified in 4 of them, including colon polyps in 3 (43%) and colitis in 1 (14%). Mortality was 19% (4 patients). Conclusions Our finding in a series of predominantly Hispanic patients with S. bovis bacteremia in a county hospital setting was consistent with the previously reported association with gastrointestinal disease. Findings on colonoscopy included colonic polyps and colitis, although no cases of colon cancer were found. Chronic liver disease was a common concurrent illness and cholangitis also occurred. There was a significant mortality rate in adults.

Impairment of Salivary Mucin Production Resulting in Declined Salivary Viscosity During Naproxen Administration as a Potential Link to Upper Alimentary Tract Mucosal Injury

OBJECTIVES:Nonsteroidal anti-inflammatory drugs (NSAIDs) contribute to the esophageal mucosal injury through its direct topical impact on the luminal aspect of the surface epithelium. Its indirect, systemic impact, however, on salivary component of the esophageal pre-epithelial barrier remains to be explored. Therefore, salivary mucin secretion and viscosity at baseline and during naproxen-placebo, as well as naproxen-rabeprazole, administration were investigated.METHODS:Twenty-one asymptomatic volunteers were included in this double-blind, placebo-controlled, crossover designed study. Salivary samples were obtained in basal and pentagastrin-stimulated conditions (6 mg/kg s.c.) mimicking the food-stimulated conditions. Patients received 7 days of naproxen-placebo or naproxen-rabeprazole with a 2-week washout period in between. Salivary mucin content and viscosity were measured before and after treatment using periodic acid/Schiff’s methodology and Cone/Plate Digital Viscometer, respectively.RESULTS:The rate of salivary mucin secretion in basal condition declined by 32% during administration of naproxen-placebo (11.3±1.7 vs. 16.8±3.3 mg/h). Salivary mucin secretion in pentagastrin-stimulated condition declined significantly (by 34%) during the administration of naproxen-placebo (13.6±1.5 vs. 20.7±3.0 mg/h; P<0.05). Viscosity significantly decreased after naproxen-placebo administration in basal (by 60%) and stimulated conditions (by 56%) (P<0.001). Coadministration of rabeprazole at least partly restored the naproxen-induced decline of salivary mucin in basal condition (by 8%), and pentagastrin-stimulated conditions (by 30%).CONCLUSIONS:A significant decline of salivary mucin and viscosity during administration of naproxen may at least partly explain a propensity of patients on chronic therapy with NSAIDs to the development of esophageal mucosal injury and complications. In addition the trend to restorative capacity of rabeprazole on the quantitative impairment of salivary mucin during administration of naproxen may potentially translate into its tangible clinical benefit but it requires further investigation.