Ian Grimes

Predictors of recurrent ingestion of gastrointestinal foreign bodies.

BACKGROUND Gastrointestinal foreign bodies are commonly encountered; however, little knowledge exists as to the causes of foreign body ingestions and why they occur repeatedly in some patients. OBJECTIVE To identify and define patients at high risk for recurrent foreign body ingestion. METHODS A retrospective chart review of foreign body ingestion was conducted at a tertiary care medical centre over an 11-year period. Variables analyzed included age, sex, incarceration status, Diagnostic and Statistical Manual of Mental Disorders-IV diagnosis, success of endoscopy, type of sedation used, method of extraction, complications, presence of gastrointestinal pathology, and incidence of recurrent food impaction or foreign body. RESULTS A total of 159 patients with a foreign body ingestion were identified. One hundred fourteen (77%) experienced a single episode of ingestion and 45 (23%) experienced multiple ingestions. Of the patients with multiple ingestions, 27 (60%) had recurrent food impactions while 18 (40%) ingested foreign objects. In the recurrent ingestor group, a psychiatric disorder had been diagnosed in 16 patients (35.6%) and there were 13 incarcerated individuals (28.9%). The average number of recurrences was 2.6 per patient (117 total recurrences). Individuals with a psychiatric disorder experienced 3.9 recurrences per patient, while prisoners averaged 4.1 recurrences per patient. The combination of a psychiatric disorder and being incarcerated was associated with the highest recurrence rate (4.33 per patient). Multivariable logistic regression revealed that male sex (OR 2.9; P=0.022), being incarcerated (OR 3.0; P=0.024) and the presence of a psychiatric disorder (OR 2.5; P=0.03) were risk factors for recurrent ingestion. CONCLUSION Risk factors for recurrent ingestion of foreign bodies were male sex, being incarcerated and the presence of a psychiatric disorder.

Influence of Previous Night Call and Sleep Deprivation on Screening Colonoscopy Quality

OBJECTIVES:There are few studies evaluating the influence of sleep deprivation on endoscopic outcomes. To evaluate the effect of a previous night call on the quality of screening colonoscopies performed the following day.METHODS:Average-risk patients undergoing screening colonoscopies were included. Quality metrics were retrospectively compared between two groups of post-call colonoscopies and colonoscopies performed by the same individuals not on call the night before: those performed by gastroenterologists who were only on call the night prior and those performed by gastroenterologists who performed emergent on-call procedures the night prior.RESULTS:Between 1 July 2010 and 31 March 2012, 447 colonoscopies were performed by gastroenterologists who were on call only the night prior, 126 colonoscopies were performed by gastroenterologists who had completed on-call emergent procedures the night prior, and 8,734 control colonoscopies were completed. There was a lower percent of patients who were screened with adenomas detected in procedures performed by endoscopists who had performed emergent on-call procedures the night prior compared with the controls (30 vs. 39%, respectively; P=0.043). The mean withdrawal time for these colonoscopies was significantly longer than that for the control procedures (15.5 vs. 14.0 min; P=0.025). For the colonoscopies performed by endoscopists who were on call only the night prior, there was no significant difference in the percent of patients screened with adenomas detected compared with controls (42 vs. 39%, respectively; P=0.136).CONCLUSIONS:(1) Despite longer withdrawal times, being on call the night prior and performing an emergent procedure lead to a significant 24% decrease in the adenoma detection rates. (2) It is imperative for screening physicians to be aware of the influence of sleep deprivation on procedural outcomes and to consider altering their practice accordingly.

Improved Detection of Microsatellite Instability in Early Colorectal Lesions

Microsatellite instability (MSI) occurs in over 90% of Lynch syndrome cancers and is considered a hallmark of the disease. MSI is an early event in colon tumor development, but screening polyps for MSI remains controversial because of reduced sensitivity compared to more advanced neoplasms. To increase sensitivity, we investigated the use of a novel type of marker consisting of long mononucleotide repeat (LMR) tracts. Adenomas from 160 patients, ranging in age from 29–55 years old, were screened for MSI using the new markers and compared with current marker panels and immunohistochemistry standards. Overall, 15 tumors were scored as MSI-High using the LMRs compared to 9 for the NCI panel and 8 for the MSI Analysis System (Promega). This difference represents at least a 1.7-fold increase in detection of MSI-High lesions over currently available markers. Moreover, the number of MSI-positive markers per sample and the size of allelic changes were significantly greater with the LMRs (p = 0.001), which increased confidence in MSI classification. The overall sensitivity and specificity of the LMR panel for detection of mismatch repair deficient lesions were 100% and 96%, respectively. In comparison, the sensitivity and specificity of the MSI Analysis System were 67% and 100%; and for the NCI panel, 75% and 97%. The difference in sensitivity between the LMR panel and the other panels was statistically significant (p<0.001). The increased sensitivity for detection of MSI-High phenotype in early colorectal lesions with the new LMR markers indicates that MSI screening for the early detection of Lynch syndrome might be feasible.

Reactivation of latent tuberculosis in a Crohn's patient after TB prophylaxis treated with adalimumab.

Reactivation of Latent Tuberculosis in a Crohns Patient After TB Prophylaxis Treated With Adalimumab

Reactivation of Latent Tuberculosis After Treatment With Biologic Therapy: P-1 YI

Anti-tumor necrosis factor (TNF) therapy is associated with increased infectious risk including reactivation of latent tuberculosis infection (LTBI). It is recommended that patients with risk factors for tuberculosis (TB) be evaluated for LTBI prior to initiation of anti-TNF therapy. Patients with evidence of LTBI undergo treatment before initiation of biologic therapy. The risk of disseminated TB after treatment and initiation of biologic therapy is not well characterized in patients with inflammatory bowel disease. We present a patient who developed disseminated TB as a complication of anti-TNF therapy after completing appropriate treatment for LTBI Case Report: A 52 yo Sri Lankan male with clinical and pathologic evidence of Crohn colitis is found to have asymptomatic LTBI. Treatment with isoniazid (INH) was initiated. After 6 weeks of therapy he was started on infliximab. The patient had a good initial response to therapy but required intermittent prednisone for control of his symptoms. After a viral URI, infliximab was discontinued and not restarted. He completed a 9-month course of INH and was feeling well on no anti-TB treatment. The patients Crohn disease flared and he was initiated on adalimumab after a colonoscopy confirmed active disease. Three months after adalimumab initiation and 4 months after completion of INH for LTBI he had a febrile illness, diarrhea and weight loss. A CT abdomen/pelvis was obtained and showed multiple lesions throughout the spleen and liver. The adalimumab was stopped and he was admitted to hospital for further work-up. After an extensive work-up including evaluation for fungal etiologies and a spleen biopsy he was initiated on empiric anti-TB treatment. After several weeks the AFB smear from both sputum and spleen were positive for pan-susceptible TB. While undergoing treatment for active TB he has been maintained on mesalamine based therapy with marginal control of his Crohn disease. Discussion: Prior to initiation of anti-TNF treatment patients with IBD should be evaluated for active and latent TB1. The risk of disseminated TB after treatment for LTBI and initiation of biologic therapy is unknown. If evidence of LTBI is found, treatment is recommended prior to starting biologic therapy2,3. Recommendations from the ATS and BTS vary from 1-9 months of treatment prior to starting anti-TNF therapy, even though chemoprophylaxis is only effective 70% of the time after 9 months. 4,5 We present the case of a patient with Crohn disease, found to have LTBI and initiated on therapy. After completion of LTBI treatment anti-TNF therapy was instituted. He became ill and was admitted to hospital where he was found to have disseminated TB. Though this patients TB presented after completion of therapy for LTBI most cases of disseminated TB are discovered early in the treatment course of anti-TNF therapy. Close monitoring for reactivation is warranted even if patients have undergone treatment, since treatment is not always effective. We present a case report of a patient with Crohn disease and treated LTBI who developed disseminated disease after completion of treatment and initiation of a biologic agent.

Endoscopic Management of Food Impaction and Foreign Bodies

Endoscopy plays an important role in the management of ingested foreign bodies and impacted food boluses. The safe and effective use of endoscopic therapy requires proper patient assessment and an adequately trained personnel and equipment availability. The endoscopist should be familiar with commonly used devices for food disimpaction and foreign body extraction and recognize pitfalls associated with endoscopic intervention for particular objects. Whenever feasible, pre-procedural simulation for object retrieval, especially for the novice endoscopist, can facilitate a successful endoscopic outcome.

Gastrointestinal: A rare complication of esophageal band ligation.

Figure 2 Esophagram showing distal esophageal obstruction. A 51-year-old man with history of alcoholic cirrhosis presented to the hospital with worsening hepatic encephalopathy and suspected gastrointestinal bleeding. While in the hospital, he underwent upper endoscopy with band ligation of large esophageal varices. During the procedure six bands were placed (Fig. 1). Following the endoscopy, the patient did well and was discharged to home. The following day, he returned to the hospital complaining of inability to swallow solids or liquids. A barium esophagram demonstrated complete obstruction at the level of the gastroesophageal junction (Fig. 2). Within 48 h, he was swallowing liquids, and by day 4, he was tolerating a soft diet and was discharged. Only five cases of complete esophageal obstruction secondary to esophageal band ligation have been reported in the literature. Band ligation is a relatively common procedure, and providers should be aware of esophageal obstruction as a complication. Complete esophageal obstruction secondary to band ligation typically occurs in the setting of large varices with placement of multiple bands. It can also occur if the opposite wall of the esophagus is suctioned into the banding cap. Patients present with inability to swallow liquids or solids and is diagnosed with an esophagram. Complete obstruction related to band ligation generally resolves

Esophageal Foreign Bodies: Food Impaction and Foreign Bodies

Esophageal foreign bodies and food bolus impactions occur frequently and are a common endoscopic emergency. Though the vast majority of gastrointestinal bodies do not result in serious clinical sequelae or mortality, it has been estimated that 1,500–2,750 patients die annually in the United States because of the ingestion of foreign bodies. More recent studies have suggested the mortality from GI foreign bodies to be significantly lower, with no deaths reported in over 850 adults and one death in approximately 2,200 children with a GI foreign body. As a result of the frequency of this problem and the rare but possible negative consequences, it is important to understand the patients at risk for food impactions and ingestion of foreign bodies, the best method for a prompt diagnosis, and the correct management with avoidance of unwanted complications.