Glenn L. Alexander

Management and long-term prognosis of Dieulafoy lesion

BACKGROUND The Dieulafoy lesion is an important cause of gastrointestinal (GI) hemorrhage. Optimal treatment and long-term outcome are unknown. This study aimed to characterize the presentation of the Dieulafoy lesion and to summarize the results and report the long-term outcome of endoscopic therapy. METHODS Data regarding diagnosis, treatment and outcomes were derived from our GI Bleed Team database, patient records and follow-up correspondence. RESULTS Ninety Dieulafoy lesions were identified in 89 patients after a mean of 1.9 endoscopies. Their mean age was 72 years. Thirty-four percent of lesions were extragastric. Median transfusion requirement was 5 units. Two patients exsanguinated and 3 required surgery; all others were initially successfully treated endoscopically (with or without epinephrine injection): heat probe (71 patients), band ligation (3), hemoclip (1), laser (2), bipolar probe (4), sclerotherapy (2) and epinephrine alone (2). Gastric perforation occurred in 1 patient following sclerotherapy. Thirty-day mortality was 13%, 4 related to hemorrhage and 5 related to comorbidity. During median follow-up of 17 months, 34 patients (42%) died. One patient had recurrent bleeding 6 years after operation. CONCLUSIONS Dieulafoy lesion is relatively common and often extragastric. Endoscopic therapy is safe and effective. Long-term recurrence was not evident following endoscopic ablation. Follow-up after ablative therapy appears unnecessary.

Acute major gastrointestinal hemorrhage in inflammatory bowel disease

BACKGROUND Acute major gastrointestinal hemorrhage is uncommon in inflammatory bowel disease. METHODS We characterized the clinical features and course of such hemorrhage in patients at our institution from 1989 to 1996. RESULTS Thirty-one patients had acute lower gastrointestinal bleeding from inflammatory bowel disease and one had upper gastrointestinal bleeding from duodenal Crohns disease. Three patients had ulcerative colitis and 28 had Crohns disease, representing 0.1% of admissions for ulcerative colitis and 1.2% for Crohns disease. In addition, another patient bled from an ileal J-pouch. In patients with Crohns disease, the site of bleeding was duodenal in 1, small intestinal in 9, ileocolonic in 8, and colonic in 10. All ulcerative colitis patients had pancolitis. Medical therapy was initiated in 27 patients, including endoscopic therapy in 3. Five patients underwent surgery immediately, and 7 medically treated patients eventually required surgery for ongoing or recurrent bleeding. CONCLUSIONS Acute major gastrointestinal bleeding is uncommon in inflammatory bowel disease. Most cases are due to Crohns disease, without a predilection for site of involvement. The presence of an endoscopically treatable lesion is uncommon, and surgery is required in less than half of cases during the initial hospitalization. Recurrent hemorrhage is not rare, and for these cases surgery may be the most appropriate treatment.

Cytomegalovirus as an exacerbating factor in ulcerative colitis

Cytomegalovirus (CMV) colitis has been reported infrequently in patients with underlying inflammatory bowel disease, and usually in those who are taking long-term corticosteroid drugs and who are potentially immunosuppressed. We report a 39-year-old man with long-standing ulcerative colitis, taking only sulfasalazine, who developed a viral prodrome followed by bloody diarrhea. Severe colitis was noted on endoscopy. He worsened with intravenous steroid and antibiotic drugs. Flexible sigmoidoscopy with biopsy before a contemplated colectomy revealed a moderately active colitis with large cells containing intranuclear inclusions scattered throughout the biopsies, characteristic of CMV colitis. Serologic and immunologic studies suggested recent CMV infection. The patient improved with intravenous ganciclovir and a steroid taper, and colectomy was avoided. CMV colitis is a potentially treatable cause of fulminant colitis.

Endoscopic Treatment of Major Bleeding From Advanced Gastroduodenal Malignant Lesions

OBJECTIVE To summarize the results of endoscopic therapy for acute hemorrhage from gastroduodenal malignant lesions. DESIGN The 3-year experience (1989 through 1991) of a specialized gastrointestinal (GI) bleeding team in the endoscopic treatment of acute upper GI bleeding from gastroduodenal malignant tumors was retrospectively reviewed. MATERIAL AND METHODS Of 1,083 consecutive patients with acute major upper GI hemorrhage, 21 (1.9%) were found to have advanced tumors of the stomach and duodenum, 15 of whom received endoscopic therapy. In this study group of 15 patients, the tumors were gastric in 11 and duodenal in 4. Endoscopic treatment consisted of injection of epinephrine, heater probe coagulation, neodymium:yttrium-aluminum-garnet laser coagulation, or injection of sodium tetradecyl sulfate. RESULTS Initial endoscopic hemostasis was achieved in 10 of the 15 patients (67%); however, bleeding recurred in 8 of 10 (80%), and all 5 in whom endoscopic hemostasis was not achieved continued to bleed. Mean transfusion requirements for the 30 days before and the 30 days after the first endoscopic treatment were 7.6 and 6.4 units of packed erythrocytes, respectively (P > 0.10). Five major procedure-related complications occurred, two of which were fatal. The median duration of survival after the first endoscopic treatment was 39 days (range, 1 to 1,414). CONCLUSION In patients with major bleeding from advanced gastroduodenal malignant lesions, endoscopic therapy seems to provide limited benefit.

A case of Cronkhite–Canada syndrome presenting with adenomatous and inflammatory colon polyps

Background. A 72-year-old man was referred for evaluation of dysgeusia, diarrhea and anorexia. 3 months prior he began to experience taste changes, a decline in appetite and 3–7 loose, non-bloody stools per day. Nausea and lower abdominal cramping subsequently developed and he lost 22.68 kg in weight. His past medical history included atrial fibrillation treated with anticoagulation and digoxin. In the past, he had experienced markedly increased levels of triglycerides and was being treated for this condition with a lipid-lowering agent. There was no family history of colorectal neoplasia or IBD. He was a non-smoker and did not drink alcoholic beverages.Investigations. Medical history, physical examination, laboratory evaluation (including 72 h stool collection), upper endoscopy, colonoscopy and histologic analysis of biopsy samples.Diagnosis. Cronkhite–Canada syndrome.Management. Prednisone (40 mg orally once daily, eventually tapered to 10 mg orally once daily), a histamine-2-receptor blocker and oral micronutrient supplementation (iron, vitamins A, E and D and a multivitamin). Removal of all visible polyps from the anal verge to 25 cm endoscopically by snare polypectomy or with hot biopsy forceps, followed by subtotal colectomy with end-to-side ileorectostomy.

Primary Aldosteronism in a Patient With Familial Adenomatous Polyposis

Patients with familial adenomatous polyposis (FAP) frequently have extracolonic manifestations of their disease. Prior reports have indicated an increased prevalence of adrenal lesions in patients with FAP. Although most of the adrenal lesions represent nonfunctioning adenomas, some patients have had hypercortisolism due to adrenocortical carcinoma or bilateral nodular hyperplasia. We present a case of a patient with FAP who had mineralocorticoid excess due to an aldosterone-producing adrenocortical adenoma.

An Unusual Referral for Epigastric Pain, Nausea, Abdominal Bloating, Diarrhea, and Weight Loss

Question: A 30-yearold woman with a past medical history of hypothyroidism presents for evaluation of epigastric discomfort, nausea without emesis, abdominal bloating, and watery, nonbloody diarrhea for 5 months. This was associated with a 15-pound weight loss. Complete blood count, liver function tests, thyroid-stimulating hormone, immunoglobulin (Ig) levels, and IgG/IgA tissue transglutaminase (tTG) were within normal limits. Stool studies for bacterial pathogens, giardia, Clostridium difficile toxin, and ova/ parasites were negative. An upper endoscopy revealed minimal antral erythema and abnormal duodenal bulb (Figure A) with a normal-appearing postbulbar duodenum (Figure B). Biopsies of the stomach, duodenal bulb, and second portion of the duodenum were obtained. What is the diagnosis? Look on page 1692 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information n submitting your favorite image to Clinical Challenges and Images in GI.

Hodgkin's lymphoma presenting with hearing loss, paresthesias and intestinal pseudo-obstruction

Hodgkins lymphoma presenting with hearing loss, paresthesias and intestinal pseudo-obstruction

Perforation of the sigmoid colon after therapeutic UGI endoscopy

We report two cases of perforation of the sigmoid colon after therapeutic UGI endoscopy. In both cases, melena developed while the patients were already hospitalized, and findings on abdominal examinations before endoscopy were normal. At endoscopy, the two patients underwent heater probe therapy with or without injection o f epinephrine for nonbleeding lesions with stigmata of recent hemorrhage; during the 12 hours after endoscopy, surgical abdomens developed in both. In each case a perforated sigmoid diverticulum was found at s urgical exploration.