Darren C. Schwartz

Impact of a CT Colonography Screening Program on Endoscopic Colonoscopy in Clinical Practice

OBJECTIVEThe potential effect of CT colonography (CTC) on endoscopic colonoscopy (EC) has been the topic of much speculation. The aim of this study was to evaluate the impact of a CTC screening program on colonoscopy in clinical practice.METHODSAt our institution a third-party reimbursed CTC colorectal cancer (CRC) screening program was established in 2004. The number of CTC monthly exams performed, monthly EC total and screening exams performed, EC with polypectomy performed, and the number of referrals for EC screening exams requested were prospectively examined in the first 33 months after introduction of a CTC CRC screening program.RESULTSThe mean number of overall (378.5 vs 413.1) and screening (150.7 vs 162.9) colonoscopy exams performed per month did not change significantly after screening CTC was introduced. The mean number of monthly CTC exams performed rose significantly throughout the first year of the study from 39 initially to a peak of 147.6 cases per month but decreased slightly to 114.3 monthly exams at the end of 2006. A mean 10.0 patients per month were sent for EC after a positive CTC exam. The mean number of monthly colonoscopies with polypectomy remained constant after the introduction of CTC (197.0 vs 180.2). Monthly referrals for screening EC exams initially decreased but were unchanged 3 yr after institution of a CTC screening program (255.0 vs 253.5).CONCLUSIONS(a) In our tertiary care center the initiation of a screening CTC program did not result in a decrease in the number of total colonoscopy exams, screening colonoscopy exams performed, nor requests for screening colonoscopy. (b) Only a small number of CTC exams were referred for EC with polypectomy, therefore a CTC screening program may not increase the overall number of therapeutic colonoscopies performed.

Transgastric laparoscopic resection of a giant esophageal lipoma.

We present an unusual case of a giant, pedunculated esophageal lipoma originating in the mid-esophagus ball-valving through the gastroesophageal junction resulting in intermittent obstruction and hemorrhage. Endoscopic ultrasonography revealed a 1 cm in diameter vessel in the stalk of the polyp, and endoscopic resection was not performed. Transgastric laparoscopic resection with endoscopic guidance was successfully performed using 2 balloon-tipped laparoscopic trocars inserted laparoscopically into the gastric lumen through separate gastrotomies. Intraoperative esophagoscopy confirmed proper port placement and the exact location of the mass. Under direct visualization, a Snowden-Pencer grasper was used to pull the polyp down into the stomach and an Endo-GIA blue articulating stapler was used to transect its stalk. The polyp was retrieved via an endopouch placed through the intragastric laparoscopic port. We conclude that transgastric laparoscopy should be considered for the resection of a variety of pedunculated esophageal lesions when the use of standard endoscopic techniques is not possible.

Diffuse nodular lymphoid hyperplasia of the colon: polyposis syndrome or normal variant?

Diffuse nodular lymphoid hyperplasia (DNLH) has long been recognized in the pediatric population and in adults with common variable immunodeficiency (CVID).1 More recently, an association with HIV has been described.2 Little is known about the prevalence, natural history, and clinical significance of DNLH in immunocompetent adults. DNLH is a rare lymphoproliferative disorder of unknown etiology. Typically, numerous polypoid nodules composed of hyperplastic benign lymphoid tissue are present in the small and/or large intestinal mucosa.3 Although often an incidental finding, presentation is variable and depends on the size and extent of the nodules, as well as the presence or absence of underlying immunodeficiency. Treatment is directed at associated conditions because the disorder itself generally requires no intervention. Though considered benign by most investigators, several case reports document an association with malignant intestinal lymphoma.3,4 When DNLH is found predominantly in the colon, it can mimic a variety of polyposis syndromes but does not have the high risk of malignancy of familial adenomatous polyposis (FAP).5 This underscores the importance of obtaining biopsy specimens for histopathologic diagnosis and the need for increased awareness of this poorly understood entity.

Clinical Utility of Videofluorography with Concomitant Tensilon Administration in the Diagnosis of Bulbar Myasthenia Gravis

Myasthenia gravis (MG) classically presents with ocular, bulbar, and predominantly proximal muscle weakness. Isolated bulbar symptoms occur in less than 25% of cases and can mimic stroke (1–3). If left untreated, MG can lead to significant morbidity and mortality, including myasthenic crisis and recurrent aspiration pneumonia. We describe a case of a 68-year-old man who presented with isolated bulbar symptoms. We used a novel approach to diagnosis which included a videofluorographic swallow study with concomitant Tensilon (edrophonium) injection.

Collagenous Colitis Presenting After Orthotopic Liver Transplantation for α-1-Antitrypsin Deficiency

Inflammatory bowel disease (IBD) comprises a spectrum of diseases, including ulcerative colitis (UC), Crohn’s disease (CD), and microscopic colitis (MC). The various forms of IBD are believed to occur, in part, due to an inappropriate and enduring activation of the enteric immune system [1]. The cornerstone of therapy for IBD is immunomodulation, utilizing several agents routinely employed to maintain immune tolerance in post–organ transplantation patients. These include corticosteroids, azathioprine, cyclosporine, and tacrolimus, among others. Despite the convergence of treatment modalities, there are multiple studies documenting both the development and the progression of IBD follow-

CASE REPORT: Acute Sensorineural Hearing Loss as an Early Manifestation of Indeterminate Colitis

Historically, extraintestinal involvement in inflammatory bowel disease (IBD) manifests as inflammation of the skin, eyes, joints, and hepatobiliary system (1–3). Recent reports indicate that sensorineural hearing loss is a seldom recognized extraintestinal manifestation of both ulcerative colitis (UC) and Crohn’s disease (CD) (4). Though an autoimmune mechanism has been hypothesized, the exact pathophysiology has not been fully elucidated (5–8). Herein, we report what we believe to be the first case of inflammatory bowel disease presenting as acute sensorineural hearing loss (ASNHL). Moreover, to our knowledge, it is also the first case of ASNHL occurring in the setting of indeterminate colitis (IC).