Gregory F. Bonner

Prospective, randomized, endoscopic-blinded trial comparing precolonoscopy bowel cleansing methods

PURPOSE: Recent reports have suggested that precolonoscopy bowel preparation is easier to tolerate if a small volume solution is used. Therefore, the aim of this study was to compare three oral solutions for colonoscopy to determine any changes in either patient compliance or cleansing ability. METHODS: Four hundred fifty patients were prospectively randomized to receive either a standard 4-liter polyethylene glycol solution, a newer sulfatefree 4-liter polyethylene giycol solution, or a 90-ml oral sodium phosphate preparation. Before and after bowel preparation all patients were weighed, and serum electrolytes as well as phosphate, magnesium, calcium, and osmolarity were measured. In addition, a detailed questionnaire was used to assess side effects and patient satisfaction. Endoscopists blinded to the type and quantity of preparation used scored the type of residual stool and the percentage of bowel wall visualized for each segment of colon and for the overall examination. Nurses recorded all procedure times as well as the quantity of irrigation and aspiration. RESULTS: Four hundred twenty-two agematched and sex-matched patients completed all phases of the trial. There were no clinically significant changes in weight or in any biochemical parameters. There was, however, asymptomatic hyperphosphatemia in the sodium phosphate group (P<0.01).The length of time to the cecum was similar for all three groups, with a higher volume of fluid suctioned for sodium phosphate (P< 0.01).Overall, endoscopists scored sodium phosphate as “excellent” or “good” in 90 percentvs.70 percent and 73 percent after the polyethylene glycol or sulfate-free lavage, respectively (P<0.01). Paniculate or solid stool was found in all segments of the colon more frequently after both large volume preparations than after sodium phosphate (P<0.05). There were no significant differences in the frequency or intensity of any of the 11 side effects questioned. Eighty-three percent of the patients who received the sodium phosphate preparation stated they would take this same preparation again,vs.only 19 percent and 33 percent for polyethylene glycol and the sulfate-free lavage, respectively (P<0.01). CONCLUSION: The smaller volume oral sodium phosphate was not associated with any clinically significant problem, caused no increase in the incidence of side effects, was preferred by patients, and was more effective in colonic cleansing. However, the hyperphosphatemia seen may limit its use in patients with impaired renal function.

A long-term cohort study of nonsteroidal anti-inflammatory drug use and disease activity in outpatients with inflammatory bowel disease

Background and Aims:We examined whether use of nonsteroidal anti-inflammatory drugs (NSAIDs) in outpatients with inflammatory bowel disease was associated with increased severity of disease activity. Methods:Outpatients with Crohn’s disease (CD; n = 426) and with ulcerative colitis (UC; n = 203) were seen between November 1997 and April 2002. Patients were questioned at each visit regarding use of prescription or over-the counter NSAIDs and a clinical disease activity index (modified Harvey Bradshaw [MHB] or Lichtiger score) was obtained. Results:For the Crohn’s patients, for 1315 visits no NSAIDs were used, on 215 visits low-dose NSAIDs were used, and for 139 visits high-dose NSAIDs were taken. For UC patient visits, 495 used no NSAIDs, 112 low-dose NSAIDs, and 49 high-dose NSAIDs. Average MHB score was 4.07 for the no-NSAID group, 4.24 for low-dose NSAIDs (P = 0.46), and 4.78 for high-dose (P = 0.0072 versus no NSAIDs). For the ulcerative colitis patients corresponding scores were 5.64, 5.46, and 6.20, respectively (P = not significant). The probability of moderately active disease as defined by crossing a threshold MHB or Lichtiger score, however, was not significantly affected by NSAID use. Subgroup analysis indicated the increase in disease activity among CD patients taking high-dose NSAIDs was limited to patients with colonic involvement. Conclusions:Use of low-dose NSAIDs was not associated with an increase in disease activity for these outpatients with either CD or UC. Use of high-doses of NSAIDs was associated with a higher numerical disease activity index score among CD patients with colonic involvement, but this was not reflected by an increase in significant disease flares.

Exacerbation of inflammatory bowel disease associated with use of celecoxib

liquids or solid food despite ongoing therapy for 12 days. After the patient’s informed consent was obtained, thalidomide was started at a dose of 200 mg. Three days after this initial dose, the dose was decreased to 100 mg/day because of excessive drowsiness. Institution of thalidomide therapy was almost immediately followed by partial resolution of the pain with swallowing such that she was able to complement her tube feeds with oral supplements. The intravenous Solu-Medrol was subsequently discontinued, and the patient was begun on an oral prednisone taper with continued improvement in symptoms. After 7 days of thalidomide, the patient was tolerating a low residue diet with minimal esophageal pain or dysphagia. She was discharged on thalidomide 100 mg/day and prednisone 40 mg/day. Improvement continued over the next 4 wk and included complete resolution of odynophagia off pain medications, prednisone dose reduction to 20 mg/day, and the advancement of her diet to three regular meals/day with no complaints. This clinical remission was sustained at 12 wk until her untimely death from an unrelated cause. Thalidomide treatment for CD targets TNFa, an inflammatory mediator known to play a role in the pathogenesis of inflammatory bowel disease (3–5). We and others have recently demonstrated in open label trials the successful use of thalidomide in treating patients with refractory CD of the lower GI tract (6, 7). To our knowledge, this unusual case represents the first reported use of thalidomide treatment for severe refractory esophageal CD. The successful response to its use in this instance illustrates that thalidomide should be considered in selected patients with comparable features.

Serum electrolyte abnormalities secondary to Fleet’s Phospho-Soda colonoscopy prep: A review of three cases

Abstract. The authors report three cases of adverse reactions to commonly used lavage solutions generally believed harmless.

Use of Azathioprine or 6-mercaptopurine for treatment of steroid-dependent lymphocytic and collagenous colitis

azathioprine and died. His colitis was in remission by that time, and death was not due to the hemophagocytic syndrome. Another two patients stopped azathioprine 8 months later because of persistently elevated liver enzymes and leucopenia, respectively. Twenty-one patients are well and disease is maintained in remission on azathioprine alone for a mean of 6 yr (range 2.5–9). Sixteen patients did not respond or deteriorated within 1–2 wk after onset of azathioprine and underwent colectomy without any perioperative or late deaths. Unfortunately, we were unable to measure red blood cell thiopurine methyltransferase activity and red blood cell 6-thioguanine nucleotide levels in all of these patients. Thus, a remarkable proportion of patients with steroid refractory severe ulcerative colitis achieved remission on oral azathioprine after a mean period of 8 (6–12) wk. This suggests that azathioprine may act quicker than previously believed. Therefore, controlled clinical trials are urgently needed to evaluate the efficacy of azathioprine in this group of patients with steroid refractory ulcerative colitis.

Gastric MALT lymphoma in a Helicobacter pylori-negative patient: a case report and review of the literature.

Helicobacter pylori (H. pylori), a gram-negative spiral bacterium only recently recognized, has been associated with many gastric pathologies, including peptic ulcer disease, chronic gastritis, gastric lymphoma, and gastric adenocarcinoma. Eradication of H. pylori is now considered essential for the treatment of these pathologies, and usually consists of antibiotic therapy, combined with acid suppression by a proton pump inhibitor. This simple treatment can often obviate the need for surgical intervention. In the case of gastric mucosa-associated lymphoid tissue (MALT) lymphoma, it can replace the use of radiotherapy or chemotherapy. In a small percentage of the above-mentioned gastric pathologies, no evidence of H. pylori is found. In these cases, H. pylori eradication therapy seems to be irrelevant, and other therapeutic modalities are required. We present a case of gastric MALT lymphoma in an H. pylori-negative patient, in whom partial gastric resection was carried out. We review the literature and discuss the possible therapeutic options in this situation.

A tale of two cities: typical celiac sprue presenting symptoms are significantly more common in Turkish than in US Patients.

Goal Recent studies suggest an increasing prevalence of atypical initial symptoms in patients with celiac disease (CD). The aim of this study was to compare the presenting symptoms of CD at 2 comparable referral institutions in South Florida, and in Ankara, Turkey. We retrospectively reviewed the records of patients with an initial diagnosis of CD by small bowel biopsy during the same (1991 to 2001) 10-year period at Cleveland Clinic Florida and University of Ankara, Turkey. A numerical score was assigned to presenting symptom and signs. Results There were 28 patients in the South Florida group (51% men) and 40 patients in the Turkish group (35% men) (P=NS). The Turkish patients were significantly younger at diagnosis (36±2 y vs. US patients 66±3 y) (P<0.0001). Typical celiac symptom scores were similar (Turkey 1.1±0.2 vs. South Florida 1.3±0.3) (P=NS). Atypical symptom scores were significantly higher in the US patients (1.9±0.2) versus those from Turkey (1.2±0.1) (P<0.01). The Turkish patients were significantly more likely (P<0.01) to present with chronic diarrhea, hypoalbuminemia, and mactocytosis at the time of diagnosis. Conclusions Although retrospective, this study points to striking differences in the clinical presentation of CD in individuals in South Florida, United States, and Ankara, Turkey, diagnosed during the same time period at both institutions. Turkish patients were younger, and more likely to present with chronic diarrhea, hypoalbuminemia, and microcytosis—as was more commonly seen in the United States in the 1960s and 70s. These findings raise the question of an interplay of demographics with diet and genetics in the presenting symptoms of CD in these 2 distant geographic areas.

Upper Gastrointestinal Evaluation Related to the Pelvic Floor

A variety of upper GI motility disorders have been described. These conditions are known to occur in high frequency in patients with irritable bowel syndrome and may be associated with other disorders of pelvic floor dysfunction.

Tolerance and efficacy of 6MP/Azathioprine with respect to age among patients with inflammatory bowel disease

Purpose: We retrospectively examined the effectiveness and tolerance of 6MP/Azathioprine treatment with respect to age in outpatients with inflammatory bowel disease. Methods: We reviewed the charts of 150 patients with inflammatory bowel disease who were treated with 6mp/Azathioprine. Only patients who were started on the medication at Cleveland Clinic Florida (CCF) were included. Those who were on the medication prior to CCF care were excluded. Adverse events and the time of their appearance in relation to starting the medication were noted. Successful treatment was defined by a three point decrease in the disease activity index (modified Harvey Bradshaw (MHB) or Lichtiger score) 6 months after starting the medication. Results: One hundred patients with Inflammatory Bowel disease were included in the study, 28 ulcerative colitis and 72 patients with Crohn’s disease. The mean age was 45. 4 patients had a length of follow-up adequate to assess adverse events but not response to treatment. 22 (22%) patients had adverse events to 6MP/Azathioprine requiring discontinuation of the drug. The likelihood of an adverse event did not vary with patient age. (age 45 19.6%, age 45 24.5%, P NS). When analyzed based on intention to treat, 50/100 patients had positive response to treatment as opposed to 46/100 had no response to treatment. Among patients tolerating the drug the response rate was 48 of 72 (67%). Patients who were younger than 45 years old had significantly better chance of responding to treatment than patients older than 45 years old. (Age 45 64.5%, age 45 39.6%, P 0.014, intention to treat analysis.) For patients age 65 the positive response was only 25%, P 0.06. When performing a per protocol analysis of patients tolerating drug, the mean age of responders was 41.0 years while the mean age of nonresponders was 51.4 years (P 0.015). Conclusions: The adverse events in patients with IBD treated with 6MP/ Azathioprine was not related to the patients’ age. However, the response to treatment with 6MP/Azathioprine was significantly associated with patients’ age. Patients younger than age 45 have a 65% higher chance of responding to treatment than patients older than 45.

A tale of two cities: typical celiac sprue presenting symptoms are signficantly more common in Turkish than in U.S. patients

A tale of two cities: typical celiac sprue presenting symptoms are signficantly more common in Turkish than in U.S. patients