Jeffrey Gill

Safety of conscious sedation in patients with sleep apnea in a veteran population.

Objectives: Due to the presumed higher risk of cardiopulmonary complications in patients with obstructive sleep apnea (OSA), many endoscopy centers consider OSA a contraindication to using conscious sedation. We evaluated the safety of conscious sedation during endoscopy for patients with OSA in a veteran population, and compared this to patients without OSA. Methods: Polysomnography studies were reviewed from 2004 to 2009 to identify 200 patients with OSA who had undergone endoscopy. Controls included the last 200 consecutive endoscopies in this institution for patients without OSA. Sixty-three upper endoscopies, 136 colonoscopies, and one enteroscopy were included in the OSA group. Sixty-five upper endoscopies, 133 colonoscopies, one sigmoidoscopy, and one endoscopic ultrasound comprised the control group. Data obtained included demographics, medications prescribed, and any complication noted in the procedure report. Results: No complications occurred in the control group. In the OSA group, a patient experienced oxygen desaturation during an upper endoscopy and required oxygen supplementation. The procedure was completed and did not require an extended stay in the endoscopy suite. Conclusion: This study demonstrated that endoscopy can be safely done in OSA patients using conscious sedation, and the complication rate is not significantly different than patients without OSA.

Safety of Gastrointestinal Endoscopy With Conscious Sedation in Patients With and Without Obstructive Sleep Apnea.

Background and Study Aims: Patients with obstructive sleep apnea (OSA) undergoing endoscopy with sedation are considered by practitioners to be at a higher risk for cardiopulmonary complications. The aim of the present study was to evaluate the safety of conscious sedation in patients with OSA undergoing gastrointestinal endoscopy. Patients and Methods: This is an IRB-approved prospective cohort study performed at the James A. Haley VA. A total of 248 patients with confirmed moderate or severe OSA by polysomnography and 252 patients without OSA were enrolled. Cardiopulmonary variables such as heart rate, blood pressure, and level of blood oxygen saturation were recorded at 3-minute intervals throughout the endoscopic procedure. Results: In total, 302 colonoscopies, 119 esophagogastroduodenoscopies, 6 flexible sigmoidoscopies, and 60 esophagogastroduodenoscopy/colonoscopies were performed. None of the patients in the study required endotracheal intubation, pharmacologic reversal, or experienced an adverse outcome as a result of changes in blood pressure, heart rate, or blood oxygen saturation. There were no significant differences in the rate of tachycardia (P=0.749), bradycardia (P=0.438), hypotension (systolic/diastolic, P=0.460; mean arterial pressure, P=0.571), or hypoxia (P=0.787) between groups. The average length of time spent in each procedure and the average dose of sedation administered also did not differ significantly between the groups. Conclusions: Despite the presumed increased risk of cardiopulmonary complications, patients with OSA who undergo endoscopy with conscious sedation have clinically insignificant variations in cardiopulmonary parameters that do not differ from those without OSA. Costly preventative measures in patients with OSA are not warranted.

Microscopic colitis that is not so microscopic

Dear Editor: Microscopic colitis (MC) was formerly considered rare but is now gaining recognition as a common cause of chronic nonbloody diarrhea. When other causes of chronic diarrhea such as inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), and infectious colitis have been ruled out, a colonoscopy with multiple biopsies of the colon and rectum is indicated to evaluate for MC. Typically, the diagnosis of MC is made after normal macroscopic colonoscopy findings with biopsies evident for either lymphocytic or collagenous colitis. We present a unique case of a patient with macroscopic features of nodular and erythematous colonic mucosa found to have MC on histopathology.

Evaluating bone health in inflammatory bowel disease--a single tertiary care Veterans Hospital experience.

Dear Editor, At a time with increasingly important emphasis on preventative care, we wanted to share our experience with prevention of low bone density in veterans with inflammatory bowel disease (IBD). In 2003, the American Gastroenterological Association (AGA) made recommendations to screen IBD patients with at least one other risk factor for osteoporosis with a dual-energy X-ray absorptiometry (DXA) examination [1]. Despite this, and other literature supporting a relatively high incidence of osteoporosis in IBD patients, many gastroenterologists are still not adhering to these guidelines. We reviewed the charts of 172 IBD patients at the James A. Haley VA. Our study included all IBD clinic patients seen for follow up over 2 years, including 79 with Crohn’s disease, 92 with ulcerative colitis, and 1 with indeterminate colitis. Our primary outcome was the rate of adherence to AGA recommendations to order DXA scans for patients with IBD that have at least one strong risk factor for osteoporosis. Strong risk factors include age >50 years old, postmenopausal status, hypogonadism, steroid use for more than 3 months, and a history of a low-trauma fracture. Eighty-eight percent (152/ 172) of our patients had at least one strong risk factor for osteoporosis, and 26 % (39/152) had multiple strong risk factors. Of the 152 patients with an indication for DXA scanning, only 30% (46/152) had received one, which is similar to the 23 % of Khan et al. presented earlier this year in the American Journal of Gastroenterology among patients with Crohn’s disease in a veteran population [2]. Of our 46 patients scanned, nearly 85% (39/46) had at least osteopenia and 21% (10/46) had progressed to osteoporosis. Steroid use >3months seemed to prompt providers to order a DXA scan with 18/33 having a DXA completed. Indeed this population needs it, as nearly 93 % of these patients with documented results (13/14) had a low bone density. Small bowel resection and age >50 were also impressive risk factors, associated with an incidence of osteopenia of 69 % and 73 %, respectfully. Full results of DXA scanning and documentation of results in relation to osteoporosis risk factors can be seen in Table 1. The incidence of osteoporosis and osteopenia in IBD patients has been estimated to range from 13 % to 50 %. Due to the higher incidence of low bone density, these patients have up to a 40 % greater incidence of fractures compared to the general population. This is due to many factors including the use of steroids to treat the disease, immobilization, a possible decrease in intestinal absorption of calcium and vitamin D, and a state of chronic inflammation [3]. Our study demonstrated that a low percentage of our IBD patients are getting screened for low bone density, and those which are screened are showing a high incidence of osteoporosis and osteopenia. We do not believe that these practices are isolated to our facility, but rather a broader problem which needs to be addressed. This was reinforced in a 2009 survey of AGA members showing that the guidelines for ordering DXA scans are not routinely followed [4]. Since our review was completed, J. A. Gill (*) : S. Goldsmith James A. Haley VA, 13000 Bruce B. Downs Blvd, Tampa, FL 33612, USA e-mail: jeffreygill23@gmail.com

Ischemic Colitis, the Great Imitator: A Mass Completely Resolved

Ischemic colitis (IC) is the most common type of intestinal ischemia, with a vast clinical spectrum of injury ranging from mild and transient ischemia to acute fulminant colitis. The pattern of injury is usually segmental, but it is mainly dictated by individual anatomy, duration of ischemia, and degree of re-perfusion injury. Analysis of clinical presentation, early endoscopic evaluation, and biopsy are all essential for prevention of misdiagnosis. We present a unique case of IC with mass-like features on regular imaging, emphasizing the importance of endoscopy and biopsy for accurate diagnosis.

Idiopathic Esophageal Ulcers in AIDS Completely Healed With Highly Active Anti-Retroviral Therapy.

A 51-year-old white man presented to the emergency department with a 3-month history of atypical chest pain, odynophagia to solids and liquids, and a 18-kg weight loss. He was febrile to 39oC and tachycardic. Physical exam was remarkable for bilateral submandibular lymphadenopathy and thrush in the posterior oropharynx. He was diagnosed with AIDS with CD4 count 146 cells/mm3 and viral load 423,000 copies/mL. Esophagogastroduodenoscopy (EGD) showed a large, deep, irregular esophageal ulcer (Figure 1). Biopsies of the ulcer margins and bases were negative for malignancy or infection. He was diagnosed with an idiopathic esophageal ulcer (IEU) secondary to AIDS. He was started on a proton pump inhibitor and highly active anti-retroviral therapy (HAART). Three weeks later, repeat EGD revealed complete resolution of the esophageal ulcer (Figure 2). More than 1 year after diagnosis, he continued to do well with a viral load of 53, CD4 count of 708, and without any recurrence of odynophagia.

Atypical Locations of Primary Squamous Cell Carcinoma of the Gastrointestinal Tract: a Case Series and Review of Literature

An 87-year-old African-American male with a past medical history of Alzheimer’s disease was admitted from his nursing home for vague abdominal pain and unintentional weight loss. Adequate history was difficult to obtain secondary to patient’s underlying dementia. Physical examination was notable for a thin cachectic male with scleral icterus, a non-tender abdomen, and a palpable right-sided abdominal mass. Laboratory results were significant for elevated total bilirubin of 4.5 mg/dL, aspartate aminotransferase of 238 IU/L, alanine aminotransferase of 263 IU/L, and alkaline phosphatase of 499 IU/L. The remainder of the labs including lipase and carbohydrate antigen 19-9 (CA 19-9) were unremarkable. Subsequent computed tomography (CT) scan revealed a pancreatic head mass with areas of internal necrosis resulting in biliary and pancreatic ductal dilation (Fig. 1a). Esophagogastroduodenoscopy (EGD) showed an infiltratingmass in the duodenal bulb extending for approximately 7 cm into the second portion of the duodenum, from which multiple biopsies were taken (Fig. 1b). The major papilla was edematous and abnormal appearing from tumor infiltration. We were unable to endoscopically place a biliary stent for decompression; therefore, a percutaneous biliary drain was placed by interventional radiology. Pathology of the infiltrating duodenal mass revealed only squamous features, however likely adenosquamous pancreatic carcinoma (Fig. 1c). Thorough investigation including full body CT did not reveal any metastatic disease. The patient was not a candidate for surgical resection, and his family wished against chemotherapy. He was made comfort measure only and was discharged under hospice care, eventually succumbing to this condition within 3 months.