Hilary I Hertan

Propofol versus midazolam and meperidine for conscious sedation in GI endoscopy

OBJECTIVE:Propofol (2,6-diisopropyl phenol) is a relatively new intravenous sedative hypnotic with an ideal pharmacokinetic profile for conscious sedation. In this study, we compared the safety and efficacy of propofol versus the conventional regimen of midazolam and meperidine for conscious sedation in GI endoscopy.METHODS:In this prospective study, 274 patients that included many elderly patients with multiple comorbid conditions underwent GI endoscopic procedures at our hospital. A total of 150 patients received propofol (20–120 mg) and fentanyl (0.25–1.5 mg). The control group of 124 patients was given midazolam (2–6 mg) and meperidine (25–75 mg). The dose of medication was titrated according to patient need and the duration of the procedure. A “comfort score” on a scale of 1–4 assessed the efficacy of the drugs based on pain or discomfort to the patient and ease of endoscopy. A “sedation score” was used to assess the degree of sedation on a scale of 1–5. The Aldrete score was used to measure recovery from anesthesia at 5 and 10 min after the procedure.RESULTS:After controlling for age, American Society of Anesthesiologists’ Physical Status Classification (ASA grade), and type and duration of procedure, logistic regression analysis determined that propofol resulted in 2.04 times better patient comfort (p = 0.033, 95% CI = 1.058–3.923). Propofol was 1.84 times more likely to produce deeper sedation than the regimen of midazolam and meperidine (p = 0.027, 95% CI = 1.071–3.083). The recovery from sedation was faster in patients receiving propofol, although this did not reach statistical significance. The safety parameters between the two groups were comparable.CONCLUSION:Propofol was associated with a statistically significant improvement in comfort and sedation score when compared to midazolam and meperidine.

Serum and liver micronutrient antioxidants and serum oxidative stress in patients with chronic hepatitis C

OBJECTIVES:The exact pathogenesis of liver injury and fibrosis in chronic hepatitis C (CHC) is unclear. Free radicals play a role in CHC liver damage. Antioxidants (AO) (enzymatic and nonenzymatic) scavenge free radicals and prevent tissue injury. The aims of our study were to estimate serum levels of malondialdehyde (MDA), serum and liver levels of nonenzymatic fat-soluble AO, and to correlate the liver AO levels with the degree of inflammation and fibrosis on biopsy.METHODS:AO levels were estimated by high-pressure liquid chromatography in the pretreatment serum and liver biopsy specimen of 20 treatment-naïve patients with CHC who were not on vitamin supplements. Serum levels of MDA were measured as a marker of increased oxidative stress. Twenty-two healthy individuals with no history of vitamin supplementation served as controls. AO analyzed were: retinol, α- and γ-tocopherol, lutein, β-cryptoxanthin, lycopene, and α- and β-carotene.RESULTS:Twenty CHC patients (11 men, nine women, mean age 48.5 ± 7.9 yr) were studied. Patients and controls were comparable in age and sex. Serum MDA levels were significantly higher in CHC patients compared with controls (1.62 ± 0.57 vs 0.23 ± 0.15 μmol/L, p = < 0.0000). Serum levels of all AO except lutein were significantly decreased in CHC patients, and their levels were two to ten times lower than serum levels in controls. Liver levels of α-carotene (p = 0.0004), β-carotene (p = 0.006), and lutein (p = 0.002) correlated with the serum levels, whereas the levels of retinol, α-tocopherol, lycopene, and β-cryptoxanthin showed no correlation. Serum MDA levels were significantly higher in patients with moderate-to-severe inflammation or fibrosis compared with those with mild inflammation or fibrosis. The levels of all liver AO except α-carotene were significantly lower in patients with moderate-to-severe fibrosis. The severity of inflammation (portal or lobular) did not affect liver AO levels.CONCLUSIONS:Our findings suggest that increased oxidative stress is present in patients with CHC. Micronutrient AO are severely depleted in serum and liver tissue of patients with CHC, and liver levels of some AO appear to reflect serum levels. Increasing fibrosis is associated with decreased liver AO levels indicating that severe disease may be a consequence of AO depletion or decreased liver storage resulting from fibrosis.

Henoch-Schonlein Purpura—A Case Report and Review of the Literature

We describe a case of an adolescent male with Henoch-Schonlein purpura (HSP), presenting with cutaneous and gastrointestinal manifestations. Endoscopy revealed diffuse ulcerations in the stomach, duodenum, and right colon. Biopsies revealed a leukocytoclastic vasculitis in the skin and gastrointestinal tract. Steroid therapy led to complete resolution of the symptoms. HSP is the most common childhood vasculitis, and is characterized by the classic tetrad of nonthrombocytopenic palpable purpura, arthritis or arthralgias, gastrointestinal and renal involvement. It is a systemic disease where antigen-antibody (IgA) complexes activate the alternate complement pathway, resulting in inflammation and small vessel vasculitis. Mild disease resolves spontaneously, and symptomatic treatment alone is sufficient. Systemic steroids are recommended for moderate to severe HSP. The prognosis depends upon the extent of renal involvement, which requires close followup. Early recognition of multiorgan involvement, especially outside of the typical age group, as in our adolescent patient, and appropriate intervention can mitigate the disease and limit organ damage.

Serum and colon mucosa micronutrient antioxidants: differences between adenomatous polyp patients and controls.

Serum and colon mucosa micronutrient antioxidants: differences between adenomatous polyp patients and controls

Micronutrient antioxidants in gastric mucosa and serum in patients with gastritis and gastric ulcer: Does Helicobacter pylori infection affect the mucosal levels?

Free radicals (FRs) play an important role in the pathogenesis of gastroduodenal mucosal inflammation, peptic ulcer disease, and probably even gastric cancer. Various micronutrients protect the gastric mucosa by scavenging FRs. Only limited data is available regarding the concentration of micronutrients in the gastric mucosa in patients with gastritis and peptic ulcer disease. Our aim was to analyze micronutrient antioxidant concentrations in the antral mucosa in patients with gastritis and gastric ulcer and to determine the influence of Helicobacter pylori infection on gastric mucosal antioxidants in patients with gastritis and gastric ulcer. Patients who underwent upper endoscopy for evaluation of dyspepsia were included in the study. Ascorbic acid, alpha-tocopherol, alpha-carotene, beta-carotene, total carotenoids, lutein, cryptoxanthin, and lycopene levels were measured in the sera and antral mucosal biopsies in these patients. The diagnosis of H. pylori was confirmed by histology, urease test (CLO) and serology. Patients with negative endoscopic findings and normal histology and no H. pylori infection served as controls. In patients with gastritis, alpha-tocopherol levels were reduced in serum and mucosa irrespective of H. pylori status, whereas carotenoids and ascorbic acid levels were similar to controls. However, in patients with gastric ulcer, serum and mucosal levels of all micronutrient antioxidants were markedly decreased compared with both controls and patients with gastritis. The degree of depletion of antioxidants was similar in patients with either H. pylori-induced or nonsteroidal antiinflammatory drug (NSAID)-induced ulcers. Patients with gastric ulcer have very low gastric antioxidant concentrations compared to patients with gastritis and normal mucosa. This depletion in antioxidants seems to be a nonspecific response and was not related to H. pylori infection.

Progressive gastrointestinal histoplasmosis leading to colonic obstruction two years after initial presentation.

A 37-yr-old man from Ecuador presented with abdominal pain, diarrhea, and weight loss. Endoscopy revealed duodenal histoplasmosis. The patient improved with antifungal therapy but was readmitted 2 yr later with diarrhea and fever. Colonoscopy revealed histoplasmosis lesions, including a constricting transverse colon lesion. The patient refused surgery and died of colonic perforation. We discuss the diagnosis and management of gastrointestinal histoplasmosis in this report.

A giant Brunner's gland adenoma presenting as gastrointestinal hemorrhage

Brunners gland adenomas are rare tumors of the duodenum that are usually small in size. Only a few cases of tumors more than 4 to 5 cm in size are reported in the literature. Although the majority of patients are asymptomatic, hemorrhage and obstruction are the most clinically significant manifestations. We report a case of Brunners gland adenoma in which the patient presented with major gastrointestinal bleeding. Endoscopic, radiologic, and endosonographic appearances are illustrated.

Presence of hiatal Hernia does not adversely affect treatment response in GERD

Purpose: To study the effect of hiatal Hernia on the symptomatology and treatment response in patients with GERD.

Extensive retroperitoneal abscess in a patient on steroids

A 60 year-old Hispanic woman visiting from Puerto Rico was admitted with abdominal pain, low-grade fever and significant weight loss for one month. Comorbid conditions included diabetes, psoriasis, hypertension and depression. She had partial colectomy performed elsewhere for unclear indications, several years ago. Medications included insulin, prednisone, fluoxetine and captopril. On examination, she was febrile (102 F), inspection of the skin revealed psoriatic lesions.She had a heart rate of 98 beats per minute and a blood pressure of 160/90. Abdomen examination revealed fullness in the right lower quadrant and in the right flank, with associated tenderness. Bowel sounds were present. Labs: Hb: 11.0 g/dl Hct: 34.7 WBC: 15.6 BUN: 9 mg/dl Creatinine:0. 8mg/dl LFT: normalIgA: 539 mg/dl (80–450) IgM: 163 mg/dl (40–240) IgG: 2661 mg/dl (600–1600)C4 complement: 16.0 mg/dl (N=16–45) C3 complement: 78 mg/dl (N=62–212) CT scan: Fluid collections in the right psoas muscle extending inferiorly into the right iliacus muscle and into the groin involving the right gluteal muscles. MRI of the spine did not show any evidence of spinal tuberculosis.The PPD test was negative and chest X ray was normal. Hospital course: open surgical drainage of the psoas abscess yielded 400cc of white pus. She underwent a second drainage procedure 10 days later due to persistent fever. The fluid culture revealed Klebsiella sensitive to Ceftriaxone, Gentamicin and Ciprofloxacin. AFB and fungal culture was negative. At discharge, she was afebrile and asymptomatic. Retroperitoneal abdominal abscesses often develop in the immunocompromised patient and pose a diagnostic challenge due to atypical symptoms. Conditions like diabetes mellitus, chronic alcoholism and malnutrition may promote the development and progression of such abscesses. Our patients immunosupression from diabetes mellitus was probably aggravated by chronic steroid use. Percutaneous catheter drainage guided by ultrasonography or CT is successful in selected patients. Nevertheless, surgical drainage with concomitant antimicrobial therapy remains the gold standard for treatment.