Elizabeth H. Weinshel

Endoscopy Plays an Important Preoperative Role in Bariatric Surgery

Background: The role of upper endoscopy (EGD) in obese patients prior to bariatric surgery is controversial. The aim of this study was to evaluate the diagnostic yield and cost of routine EGD before bariatric surgery. Methods: The medical records of consecutive obese patients who underwent EGD prior to bariatric surgery between May 2000 and September 2002 were reviewed. Two experienced endoscopists reviewed all EGD reports, and findings were divided into 4 groups based on predetermined criteria: group 0 (normal study), group 1 (abnormal findings that neither changed the surgical approach nor postponed surgery), group 2 (abnormal findings that changed the surgical approach or postponed surgery), and group 3 (results that were an absolute contraindication to surgery). Clinically important findings included lesions in groups 2 and 3. The cost of EGD (US

Evaluation of the gastrointestinal tract in premenopausal women with iron deficiency anemia

430.72) was estimated using the endoscopist fee under Medicare reimbursement. Results: During the 28-month study period, 195 patients were evaluated by EGD prior to bariatric surgery. One or more lesions were identified in 89.7% of patients, with 61.5% having a clinically important finding. The prevalence of endoscopic findings using the classification system above was as follows: group 0 (10.3%), group 1 (28.2%), group 2 (61.5%), and group 3 (0.0%). Overall, the most common lesions identified were hiatal hernia (40.0%), gastritis (28.7%), esophagitis (9.2%), gastric ulcer (3.6%), Barretts esophagus (3.1%), and esophageal ulcer (3.1%). The cost of performing routine endoscopy on all patients prior to bariatric surgery was US

Liver biopsy findings in 501 patients infected with human immunodeficiency virus (HIV)

699.92 per clinically important lesion detected. Conclusions: Routine upper endoscopy before bariatric surgery has a high diagnostic yield and has a low cost per clinically important lesion detected.

Hemorrhoids or Rectal Varices: Defining the Cause of Massive Rectal Hemorrhage in Patients With Portal Hypertension

PURPOSE Iron deficiency anemia is often attributed to menstrual blood loss in premenopausal women. The aims of this study were to determine the diagnostic yield of endoscopy and to evaluate the clinical outcome in these women. METHODS Charts, endoscopy records, and pathology reports were reviewed in consecutive premenopausal women with documented iron deficiency anemia who were referred for diagnostic endoscopy. Follow-up was obtained by telephone contact and review of medical records. RESULTS Endoscopy revealed a clinically important lesion in 23 (12%) of 186 patients. An upper gastrointestinal source was identified in 12 patients, most commonly due to gastric cancer (3%) or peptic ulcer disease (3%). A colonic lesion was detected in 11 patients, with colon cancer in six (3%). No patient had a lesion identified in both the upper and lower gastrointestinal tract. Small bowel biopsies and radiography were normal in all patients in whom they were obtained. Independent predictors for having a gastrointestinal lesion identified by endoscopy include a positive fecal occult blood test, a hemoglobin of <10 g/dL, and abdominal symptoms. Long-term follow-up data suggested a favorable prognosis, and iron deficiency anemia resolved with appropriate therapy in nearly all patients. CONCLUSIONS Endoscopy yields important findings in premenopausal women with iron deficiency anemia, which should not be attributed solely to menstrual blood loss.

Severe Exacerbation of Asthma: A New Side Effect of Interferon-α in Patients With Asthma and Chronic Hepatitis C

Patients infected with human immunodeficiency virus (HIV) are at risk for a variety of liver diseases. We undertook a retrospective study of 501 HIV-seropositive patients to assess the yield of percutaneous liver biopsy. The most common indications for liver biopsy were liver test abnormalities (89.5%), fever for 2 weeks (71.9%), and hepatomegaly (52.0%). The most common biopsy-derived diagnosis was Mycobacterium avium complex (MAC), seen in 87 (17.4%) biopsies. Mycobacterium tuberculosis was found in 13 biopsies (2.6%). In 28 biopsies (5.6%) mycobacteria was seen, but speciation of the organism was not possible. Chronic active viral hepatitis was seen in 60 biopsies (12.0%). Opportunistic hepatic infection from other organisms was found in 14 biopsies (2.8%). The most common neoplasm was lymphoma, which was seen in 12 biopsies (2.4%). MAC infection of the liver was associated with elevated alkaline phosphatase (p = 0.01). Among patients with fever for 2 weeks after an extensive negative workup including bone marrow biopsy, 58.2% had a diagnosis by liver biopsy. Overall, 64.3% of liver biopsies yielded a histopathological diagnosis, 45.7% of which were potentially treatable. We could not evaluate whether liver biopsy had a positive effect on patient outcome and survival, nor did we attempt to prove that liver biopsy resulted in a change in treatment or a change in preprocedure clinical diagnosis. Thus, questions about the efficacy of liver biopsy cannot be answered. Liver biopsy may be a helpful diagnostic tool in HIV-positive patients with fever, liver test abnormalities or hepatomegaly.

Radiologic assessment of the upper gastrointestinal tract: does it play an important preoperative role in bariatric surgery?

Identifying the source of lower gastrointestinal hemorrhage in patients with chronic liver disease and portal hypertension can be challenging. We present 2 cases of hemorrhage from rectal varices and a discussion on the differences between simple hemorrhoids and rectal varices. Evaluation of rectal bleeding in patients with portal hypertension is discussed and possible therapeutic options are described.

Is upper gastrointestinal endoscopy indicated in asymptomatic patients with a positive fecal occult blood test and negative colonoscopy

Interferon-alpha is used by physicians to treat numerous common medical disorders; however, therapy is often limited by side effects. Pulmonary complications, such as interstitial pneumonitis and bronchiolitis obliterans organizing pneumonia, have been described in patients receiving interferon-alpha therapy. Exacerbation of asthma induced by subcutaneous administration of interferon-alpha has not been previously reported. We describe two patients with mild asthma in whom treatment with interferon-alpha for chronic hepatitis C resulted in exacerbation of the underlying asthma. The severe asthmatic symptoms resolved promptly after use of interferon-alpha was discontinued and corticosteroid therapy was initiated. Repeated treatment with interferon-alpha several months later resulted in a rapid, more severe exacerbation of asthma in both patients. Patients undergoing therapy with interferon-alpha, especially those with chronic asthma, should be monitored closely for pulmonary symptoms. If these symptoms develop, patients should be instructed to discontinue use of interferon-alpha and seek medical attention immediately.

CASE REPORT: Endoscopic Band Ligation of Bleeding Rectal Varices

Background: The role of upper GI series (UGIS) before bariatric surgery is controversial. The aim of this study was to evaluate the diagnostic yield and cost of routine UGIS prior to bariatric surgery. Methods: The medical records of consecutive obese patients who underwent UGIS before bariatric surgery between April 2001 and October 2002 were reviewed. UGIS reports were reviewed by 2 experienced gastroenterologists, and the findings were divided into 4 groups based on predetermined criteria: group 0 (normal study), group 1 (abnormal findings that neither changed the surgical approach nor postponed surgery), group 2 (abnormal findings that changed the surgical approach or postponed surgery), and group 3 (results which were an absolute contraindication to surgery). Clinically important findings included lesions in groups 2 and 3. The cost of an upper GI series (

Prevalence and predictors of herbal medication use in veterans with chronic hepatitis C.

154.80) was estimated from the published 2002 New York State Medicare reimbursement schedule. Results: During the 18-month study period, 171 patients were evaluated by UGIS prior to bariatric surgery. One or more lesions were identified in 48.0% of patients, with only 5.3% having clinically important findings. The prevalence of radiologic findings using the classification system above was as follows: group 0 (52.0%), group 1 (42.7%), group 2 (5.3%), and group 3 (0.0%). The most common findings identified were esophageal reflux (21.6%) and hiatal hernias (18.7%). The cost of performing routine UGIS on all patients before bariatric surgery was

Natural History of HIV-Associated Esophageal Disease in the Era of Protease Inhibitor Therapy

2,941.20 per clinically important finding detected. Conclusions: Routine preoperative upper GI series before bariatric surgery had a low diagnostic yield, rarely revealing pathology that changed the surgical approach or postponed surgery.