Hazem T. Hammad

Erythromycin prior to endoscopy in acute upper gastrointestinal bleeding: A meta-analysis

Abstract Objective. Upper gastrointestinal bleeding (UGIB) is a medical emergency requiring urgent endoscopy and diagnosis. However, adequate visualization is a necessity. Studies have been performed evaluating the efficacy of erythromycin infusion prior to endoscopy to improve visibility and therapeutic potential of esophagogastroduodenoscopy (EGD) with varied results. Therefore, a meta-analysis was performed comparing the efficacy of erythromycin infusion prior to endoscopy in acute UGIB. Materials and methods. Multiple databases were searched. Meta-analysis for the effect of erythromycin prior to endoscopy in UGIB was analyzed by calculating pooled estimates of visualization of gastric mucosa, need for second endoscopy, and units of blood transfused using odds ratio (OR) and weighted mean difference (WMD). Results. Four studies (N = 269) met the inclusion criteria. Erythromycin prior to endoscopy in UGIB demonstrated a statistically significant improvement in visualization of the gastric mucosa (OR 4.89; 95% CI 2.85–8.38, p < 0.01), a decrease in the need for a second endoscopy (OR 0.42; 95% CI 0.24–0.74, p < 0.01), and a trend for less units of blood transfused (WMD −0.48; 95% CI −0.97 to 0.01, p = 0.05) with erythromycin as compared with no erythromycin. Conclusions. Erythromycin infusion prior to endoscopy in acute UGIB significantly improves visualization of gastric mucosa while decreasing the need for a second endoscopy. Based upon these results, erythromycin should be strongly considered prior to endoscopy in patients with UGIB.

Ursodeoxycholic acid in patients with ulcerative colitis and primary sclerosing cholangitis for prevention of colon cancer: a meta-analysis

Purpose/AimColon cancer risk is high in patients with ulcerative colitis (UC) and primary sclerosing cholangitis (PSC). Ursodeoxycholic acid has been shown to have some promise as a chemopreventive agent. A meta-analysis was performed to compare the efficacy of ursodeoxycholic acid in the prevention of colonic neoplasia in patients with UC and PSC.MethodsMultiple databases were searched (January 2011). Studies examining the use of ursodeoxycholic acid vs. no ursodeoxycholic acid or placebo in adult patients with UC and PSC were included. Data were extracted in standard forms by two independent reviewers. Meta-analysis for the effect of ursodeoxycholic acid was performed by calculating pooled estimates of adenoma or colon cancer formation by odds ratio (OR) with random effects model. Heterogeneity was assessed by calculating the I2 measure of inconsistency. RevMan 5 was utilized for statistical analysis.ResultsFour studies (nu2009=u2009281) met the inclusion criteria. The studies were of adequate quality. Ursodeoxycholic acid demonstrated no overall improvement in adenoma (OR 0.53; 95xa0% CI: 0.19−1.48, pu2009=u20090.23) or colon cancer occurrence (OR 0.50; 95xa0% CI: 0.18−1.43, pu2009=u20090.20) as compared to no ursodeoxycholic acid or placebo in patients with UC and PSC.ConclusionUrsodeoxycholic acid use in patients with UC and PSC does not appear to decrease the risk of adenomas or colon cancer.

Endoscopic assessment and management of early esophageal adenocarcinoma.

Esophageal carcinoma affects more than 450000 people worldwide and the incidence is rapidly increasing. In the United States and Europe, esophageal adenocarcinoma has superseded esophageal squamous cell carcinoma in its incidence. Esophageal cancer has a high mortality rates secondary to the late presentation of most patients at advanced stages. Endoscopic screening is recommended for patients with multiple risk factors for cancer in Barretts esophagus. These risk factors include chronic gastroesophageal reflux disease, hiatal hernia, advanced age, male sex, white race, cigarette smoking, and obesity. The annual risk of esophageal cancer is approximately 0.25% for patients without dysplasia and 6% for patients with high-grade dysplasia. Twenty percent of all esophageal adenocarcinoma in the United States is early stage with disease confined to the mucosa or submucosa. The significant morbidity and mortality of esophagectomy make endoscopic treatment an attractive option. The American Gastroenterological Association recommends endoscopic eradication therapy for patients with high-grade dysplasia. Endoscopic modalities for treatment of early esophageal adenocarcinoma include endoscopic resection techniques and endoscopic ablative techniques such as radiofrequency ablation, photodynamic therapy and cryoablation. Endoscopic therapy should be precluded to patients with no evidence of lymphovascular invasion. Local tumor recurrence is low after endoscopic therapy and is predicted by poor differentiation of tumor, positive lymph node and submucosal invasion. Surgical resection should be offered to patients with deep submucosal invasion.

Perforation upon retroflexion: an endoscopic complication and repair

ported to cause perforation in a small number of cases [1,2]. Of these, only one case, in which the perforation occurred below the peritoneal reflection, was repaired endoscopically [2]. We report a case of perforation above the peritoneal reflection upon colonoscope retroflexion with endoscopic closure in a healthy colon. A 73-year-old man with a history of hypertension and coronary artery disease underwent a diagnostic colonoscopy for iron-deficiency anemia. The patient’s physical exam and digital rectal exam were normal. The colonoscopy revealed sigmoid diverticulosis and two small polyps, which were removed. Retroflexion of the colonoscope was performed. Upon straightening the colonoscope, a 2cm circular perforation near the rectosigmoid junction, approx. 10– 12 cm from the anal verge, was visualized (l Fig. 1). Upon identification, ten endoscopic clips were placed sequentially from the ends of the perforation toward the center to close the perforation (l Fig. 2 and 3). Although the patient experienced a distended abdomen and mild epigastric abdominal pain, his vital signs were within normal parameters during and after the procedure. The patient was admitted to the hospital for 5 days and given nothing by mouth for about 48 hours and antibiotics. Two weeks after discharge, he continued to do well without complaints. Four cases of rectal perforation with retroflexion have been reported, with this case representing the fifth (l Table 1) [1, 2]. Surgery or endoscopic closure with observation are the therapeutic options for such perforations. This case represents the second successful demonstration of endoscopic repair using endoclips for a perforation formed upon retroflexion, but the first case occurred above the peritoneal reflection. In addition, this case represents the largest retroflexion-induced perforation (2 cm) to be endoscopically closed. Although colonoscope retroflexion in the rectum improves rectal visualization, the risk of perforation is apparent and should be considered.

Malnutrition secondary to non-compliance with vitamin and mineral supplements after gastric bypass surgery: What can we do about it?

Summary Background: Nutritional deficiency due to loss of follow up and non-compliance with routine mineral and multivitamin supplements is not uncommonly encountered following bariatric surgery. In this report, and utilizing a case study, we will address issues related to loss of long term medical follow up and the measures that can be taken to prevent it in this patient population. Case Report: The case of a 38-year-old female patient who was recently managed for severe vitamin deficiency and iron deficiency anemia following bariatric surgery is presented. Non-compliance with routine vitamin and mineral supplements was believed to be the main culprit of her condition. Articles published in English addressing issues related to non-compliance with supplementations and regular follow up after bariatric surgery were accessed from PubMed and are discussed. Conclusions: Multiple factors affecting long term follow up and compliance have been studied including age, financial costs, distance from the clinic and psychiatric comorbidities. Preventive measures have also been tested and some of them have shown significant benefit. More research is needed to identify other modifiable factors and preventive measures influencing compliance and long term follow up following bariatric surgery.

Uncommon Cause of Acute Drug-induced Liver Injury Following Mammoplasty

Cephalexin is a well tolerated antimicrobial and hepatic injury is an infrequent occurrence with its use. We here describe a 21-year-old female who presented with jaundice and elevated liver enzymes after 4 weeks completion of 10 day course of cephalexin, prescribed prophylactically after mammoplasty. Extensive work up including all causes of hepatitis was within normal limits and she improved with conservative management. This case highlights the need to suspect drug induced liver injury in cases of jaundice and cephalexin use.

Mantle cell lymphoma of the colon

An 81-year-old man with a history of stage IV mantle cell lymphoma (MCL) diagnosed from a submental lymph node biopsy in 2006 was evaluated for new-onset melena and blood clots with bowel movements. He had been treated for his MCL with 6 cycles of CHOP-R (cyclophosphamide, doxorubicin, vincristine, prednisone, and rituximab) in 2006, followed by 13 cycles of maintenance rituximab. In 2012, he was started on lenalidomide (Revlimid), but decided to stop after an exacerbation of his heart failure. On presentation, his hemoglobin was 5.2g/dL. Colonoscopy showed a 4-cm mass in the cecal base (● Fig.1), a 5-cm ulcerated mass encircling the ileocecal valve, and six sessile odd-looking polypoid masses in the cecal base. Biopsy was consistent with MCL (● Fig.2, ● Fig.3, ● Fig.4,● Fig.5). Because of the patient’s heart failure, surgical resection was not favored. He was started on radiotherapy and chlorambucil. MCL is one of the mature B-cell nonHodgkin lymphomas. Most patients with MCL present with advanced-stage disease, and up to 80% have involvement of extranodal sites, including the spleen, bone marrow, and gastrointestinal tract. Gastrointestinal tract involvement was detected in 10%–28% of MCL cases in various series [1,2]. The typical appearance of intestinal MCL is multiple lymphomatous polyposis. Less commonly, it appears as protruded lesions or superficial lesions. MCL expresses pan-B-cell antigens, CD5, and FMC7. Cyclin D1 is helpful to distinguish MCL from other lymphomas.

Upper gastrointestinal tract metastasis from lung cancer.

A 62 year-old female with a history of smoking presented ith abdominal pain, melena, and cough for one month. She was ypotensive and tachycardic. Her haemoglobin was 9 g/dl. Esophgogastroduodenoscopy showed multiple odd-looking lesions in he mid-gastric body measuring 1.5 cm with heaped up edges and entral ulceration (Fig. 1). Similar lesions were noted throughout he duodenum. One of the lesions in proximal D2 had a large cenral ulceration and a prominent vessel in the base. Biopsy of the astric lesion showed poorly differentiated large cell carcinoma Fig. 2). Helicobacter pylori was not detected. Computed Tomogaphy/Positron Emission Tomography scan showed avid uptake in he left hilum, adrenal glands and numerous osseous and soft tisue lesions. The overall condition was consistent with lung cancer ith metastasis to the upper gastrointestinal tract. A similar picure might be seen with gastrointestinal stromal tumours which

Unusual cause of constipation: sunflower seeds bezoar.

Bezoars are accumulated foreign material that forms concretions in the gastrointestinal tract, inducing abdominal pain, constipation, obstruction, and even peritonitis. This case report describes a rare rectal bezoar in a healthy young woman who had recently consumed large quantities of sunflower seeds. A 21-year-old healthy woman was admitted with abdominal pain, rectal pain, and constipation for 5 days which had not improved with laxatives. On admission, her vital signs were normal and examination revealed lower abdominal tenderness with no peritoneal signs. Rectal examination revealed tenderness and sharp debris. Laboratory tests and an abdominal X-ray were essentially normal. On further questioning, the patient reported consuming large quantities of sunflower seeds and shells in the past week. Flexible sigmoidoscopy revealed circumferential inflammation with impacted sunflower seeds in the anorectal area up to 10cm in the rectum (● Fig.1a). Multiple attempts at removalwith different modalities (including rectal overtube, net removal, snare removal, soap suds enema, andmanual disimpaction) resulted in little success (● Fig.1b). Laxatives were also ineffective. A rigid proctoscopy and examination under anesthesia were carried out with manual disimpaction of the large bezoar. The patient was given one smog enema to remove any residual sunflower husks. She didwell and was discharged after 2 days. At 1 week follow-up, the patient reported normal bowelmovements and had no complaints. Rectal bezoars from sunflower seed shells requiring disimpaction have been reported in children but are very rare in adults [1,2]. The diagnosis is made by clinical history or imaging, such as computed tomography (CT) [3,4]. Treatment may be conservative with laxatives, manual or endoscopic disimpaction, or surgery for severe cases [3,4]. The present case is unusual in that the adult healthy patient had no risk factors for bezoar formation. Although rectal bezoars are rare, early diagnosis and treatment are essential in preventing more serious complications.

Gastrointestinal: Penile prosthesis reservoir appearing as a cecal submucosal mass

A 49-year-old male with history of prostate cancer who has had radical prostatectomy was being evaluated for a new-onset anemia. As part of his work-up, colonoscopy was performed to rule out colorectal cancer. It showed a small sessile ascending colon polyp in addition to a large submucosal lesion in the cecal base adjacent to the appendiceal orifice (Fig. 1). The mass measured 3 cm and was firm on probing with forceps. Tunneled biopsies were obtained. The biopsy came back negative. Computed tomography (CT) scan of the abdomen and pelvis was done to evaluate for external compression. CT scan revealed a penile prosthesis with a reservoir in the right lower quadrant causing the external compression (Figs 2–4). Penile prostheses have been used for the treatment of erectile dysfunction since the 1950s. They vary in their design and number of pieces. Our patient had a three-piece implant that consists of penile cylinders, a scrotal pump, and retropubic reservoir. Erection is achieved by repeatedly squeezing the pump; each compression transfers fluid from the reservoir to the intracorporeal cylinders until adequate rigidity is achieved. The reservoir is placed preperitoneally behind the rectus muscle, either through the external inguinal ring or via a separate lower abdominal incision. Apparently, the reservoir could cause bulging into the cecum, which might be mistaken for a submucosal mass on colonoscopy. Knowledge about these prostheses is crucial for endoscopists to avoid unnecessary biopsies and imaging.