David Widjaja

Erythropoiesis-Stimulating Agents in Anemia: Use and Misuse

Erythropoiesis-stimulating agents (ESAs) have been in use for 2 decades. After the initial introduction for their use in anemia of end-stage renal disease, indications for the use of ESAs have widened to anemia of predialysis chronic kidney disease, cancer chemotherapy, HIV disease and orthopedic surgery. Along with the considerable benefits associated with the use of ESAs, adverse events have become apparent, in large part from overcorrection of the anemia. Data from recent studies have prompted several FDA warnings imposing the health provider to follow stringent criteria for the use of ESAs; these include close follow-up of patients, along with use of specific laboratory tests and criteria for dosing. Although adverse effects may partly relate to misuse, when appropriately administered, ESAs are useful agents in the medication armamentarium in the treatment of certain forms of anemia, with potential to improve outcomes and quality of life in some anemic individuals.

Significance of Bowel Wall Thickening on Computed Tomography Scan: Higher Risk of Pathology Among African Americans Compared to Hispanics

PURPOSE The aims of our study were to examine the role of colonoscopy as further workup for bowel wall thickening reported on computed tomography (CT) scans and to investigate whether there were significant differences in pathology found among the racial groups in our study population. METHODS This is a retrospective study from March 2005 and January 2007 of all patients who have undergone colonoscopy for bowel wall thickening found on CT scans of the abdomen. RESULTS Of 94 patients with bowel wall thickening on CT scans, 7 (8%) had adenocarcinoma, 5 (5%) had large adenomas, 3 (3%) had infectious colitis, 2 (2%) ischemic colitis, 1 (1%) had inflammatory bowel disease, and 1 (1%) had a benign stricture. Bowel wall thickening on CT scan predicted clinical pathology in 34% of African Americans, as compared to 14% of Hispanics. Patients with significant pathology were more likely to have anemia and lower albumin levels. CONCLUSION Patients with bowel wall thickening found on CT scans should be referred for colonoscopy, given that significant pathology is found in 20% of the cases. African Americans were 2.5 times more likely to have clinically significant pathology as compared to Hispanics.

Complete remission of primary hepatic lymphoma in a patient with human immunodeficiency virus

Diffuse large B cell primary hepatic lymphoma is a rare disease with limited available information regarding treatment strategy. Although the liver contains lymphoid tissue and is an important site for lymphocytes activation, primary hepatic lymphoma is rare. Host factors make the liver a poor environment for malignant lymphoma development. Its coexistence with human immunodeficiency virus (HIV) infection increases morbidity and mortality risks. Additionally, jaundice increases chances of developing adverse effects from chemotherapy. Here, we report a case of diffuse large B cell primary hepatic lymphoma in a 32-year-old HIV positive man. Due to elevated liver enzyme levels and jaundice, the patient was initially treated with an R-DHAP regimen, which was replaced with an R-CHOP regimen. Restaging images with a positron emission tomography scan after the latest chemotherapy cycle confirmed remission. This is the first report of complete remission of primary hepatic diffuse large B cell lymphoma in an HIV positive patient in the English literature.

Withdrawal time in excellent or very poor bowel preparation qualities

AIM To evaluate association(s) between withdrawal time and polyp detection in various bowel preparation qualities. METHODS Retrospective cohort analysis of screening colonoscopies performed between January 2005 and June 2011 for patients with average risk of colorectal cancer. Exclusion criteria included patients with a personal history of adenomatous polyps or colon cancer, prior colonic resection, significant family history of colorectal cancer, screening colonoscopy after other abnormal screening tests such as flexible sigmoidoscopy or barium enema, and screening colonoscopies during in-patient care. All procedures were performed or directly supervised by gastroenterologists. Main measurements were number of colonic segments with polyps and total number of colonic polyps. RESULTS Multivariate analysis of 8331 colonoscopies showed longer withdrawal time was associated with more colonic segments with polyps in good (adjusted OR = 1.16; 95%CI: 1.13-1.19), fair (OR = 1.13; 95%CI: 1.10-1.17), and poor (OR = 1.18; 95%CI: 1.11-1.26) bowel preparation qualities. A higher number of total polyps was associated with longer withdrawal time in good (OR = 1.15; 95%CI: 1.13-1.18), fair (OR = 1.13; 95%CI: 1.10-1.16), and poor (OR = 1.20; 95%CI: 1.13-1.29) bowel preparation qualities. Longer withdrawal time was not associated with more colonic segments with polyps or greater number of colonic polyps in bowel preparations with excellent (OR = 1.07, 95%CI: 0.99-1.26; OR = 1.11, 95%CI: 0.99-1.24, respectively) and very poor (OR = 1.02, 95%CI: 0.99-1.12; OR = 1.05, 95%CI: 0.99-1.10, respectively) qualities. CONCLUSION Longer withdrawal time is not associated with higher polyp number detected in colonoscopies with excellent or very poor bowel preparation quality.

Shifting from Normal to Abnormal: Transformation of Clinical Presentation of Post-Laparoscopic Roux-en-Y Gastric Bypass Surgery Complications

Bariatric surgery can lead to considerable weight loss in patients with morbid obesity who have failed to achieve or maintain weight loss with supervised programs. Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding are common bariatric surgeries. The former results in better weight loss and a reduced number of failures compared with the latter, despite its significantly longer operative time and life-threatening complications (1). We present a case involving a 32-year-old woman with history of LRYGB who presented with intractable abdominal pain. The initial abdominal imaging study was unremarkable; however, subsequent imaging studies showed volvulus of the midgut requiring surgical intervention.

Role of Alendronate in Managing Osteoporosis in Celiac Disease - Illustrative Case Report

Management of bone density loss, as the result of calcium malabsorption in celiac disease, is critical in preventing premature bone fracture. As many of these patients need follow-up with primary care providers, internists are expected to be aware of screening and prompt management of osteopenia or osteoporosis in celiac disease. We present a case of a 32-year-old man with celiac disease who was diagnosed with osteoporosis. He was treated with calcium, vitamin D and alendronate which improved bone mineral density. This case illustrates the importance of using bisphosphonate in treating osteoporosis in celiac disease.

Intermittent invagination of a terminal ileal carcinoid tumor

1 Kiesslich R, Goetz M, Vieth M, Galle PR, Neurath MF. Confocal laser endomicroscopy. Gastrointest. Endosc. Clin. N. Am. 2005; 15: 715–31. 2 Li C, Kim S, Lai JF et al. Advanced gastric carcinoma with signet ring cell histology. Oncology 2007; 72: 64–8. 3 Hoffman A, Goetz M, Vieth M, Galle PR, Neurath MF, Kiesslich R. Confocal laser endomicroscopy: Technical status and current indications. Endoscopy 2006; 38: 1275–83.

Life-Threatening Manifestation of Diarrhea

Acute diarrhea is usually mild and self-limited in normally healthy individuals. Further diagnostic evaluation is indicated in patients with severe diarrhea. We present a case of a 46-year-old woman who presented with dehydration and acute renal failure due to acute severe diarrhea. Initial stool study was suggestive of Aeromonas. Further stool test revealed offending bacteria, which led to appropriate antibiotic use. This paper emphasizes the importance of complete history and correlation between clinical data and laboratory tests.

Increased Willingness to Undergo Colorectal Cancer Screening When Offered a Paid Day Off from Work Among Inner City Hospital Employees

Background: Though several modalities are available for colorectal cancer screening, only about half of adults are being screened. Barriers to compliance include fear of diagnosis, lack of motivation and logistical difficulties, includ- ing taking time off work. The aim of the study was to evaluate whether offering a paid day off from work would motivate more patients to undergo screening. Methods: A questionnaire was administered to employees at the the Bronx-Lebanon Hospital Center in 2007. Results: Of the 916 surveys returned, we focused on the 438 responders who needed a screening test due to age greater than 50, or less than 50 but with a family history of colon cancer. Of the 438, fifty responders were not sure or not willing to undergo screening. The remainder were willing or had been screened and were excluded from the analysis. Among the fifty, 17 (34%) were more willing to undergo screening when they were offered a paid day off from work. Six out of ten men (60%) changed their mind based on this incentive while only 11 out of 40 women (27%) did so (p= 0.05). Conclusions: A paid day off from work may increase screening compliance. This effect was more pronounced in men.