Joseph Zimmerman

Evidence of Intestinal Inflammation in Patients With Cystic Fibrosis

Objectives: Treatment with pancreatic enzymes fails to completely correct malabsorption and gastrointestinal symptoms in patients with cystic fibrosis (CF). The aim of the present study was to examine the small intestine of patients with CF without overt evidence of gastrointestinal disease using capsule endoscopy (CE). Methods: Patients with CF received the agile patency capsule and, depending on the result of that procedure, then underwent standard CE using the PillCam SB capsule (Given Imaging, Yokneam, Israel). A stool specimen was taken on the same day as the CE for determination of the calprotectin level. Results: Forty-two patients with CF ages 10 to 36 years were included; 29 had pancreatic insufficiency. One patient failed to excrete the patency capsule after 36 hours and was withdrawn from the study. Pulmonary function was mild to moderate with FEV1 68.5% ± 16% predicted. Review of the CE videos showed that most of the patients had varying degrees of diffuse areas of inflammatory findings in the small bowel including edema, erythema, mucosal breaks, and frank ulcerations. There were no adverse events. Fecal calprotectin levels were markedly high in patients with pancreatic insufficiency, 258 μg/g (normal <50). Conclusions: Small bowel mucosal pathology may be detected using CE in most of the patients with CF. The high fecal calprotectin levels found are suggestive of mucosal inflammation, which may correlate with the CE findings. Additional study is required to examine the possible relation of these mucosal lesions, which may be part of a newly identified enteropathy associated with CF, with persistent intestinal malabsorption in many of these patients.

Electromagnetic interference with implantable cardiac pacemakers by video capsule

BACKGROUND Electromagnetic fields, such as those generated by cellular phones and metal detectors, may interfere with normal pacemaker function. However, it remains unclear whether the wireless capsule endoscope interacts with implanted pacemakers. This prospective study evaluated potential interactions between the M2A video capsule (Given Imaging, Yoknam, Israel) and implanted pacemakers. METHODS A total of 100 consecutive patients (70 men, 30 women) with an implanted pacemaker (95 on bipolar mode) were studied. The testing was performed with a functional testing device (Test Cap) for the Given Diagnostic System that reproduces the effect of the video capsule by transmitting at exactly the same frequency. During continuous electrocardiographic monitoring and recording, 100 tests were carried out without changing the pacemaker settings. Those with a positive result were retested 1 week later. RESULTS The 100 pacemakers evaluated in the study population included the following: 70 dual chamber (11 DDD, 56 DDDR, 3 VDD) and 30 ventricular inhibited (12 VVI, 18 VVIR). In 4 of the 100 patients, pacemaker interference (noise-mode function forcing a synchronous mode) was registered during the Test Cap operation. Three patients had a dual-chamber pacemaker, and one had a single-chamber pacemaker. The interference was reproducible in all cases 1 week later. None of the implanted pacemakers tested was affected by oversensing. CONCLUSIONS Electromagnetic interferences with pacemakers from the M2A video capsule can occur, but this is without clinical significance. No potentially dangerous pacemaker inhibition was observed.

Guillain-barré Syndrome: A Possible Extraintestinal Manifestation of Ulcerative Colitis

In two elderly patients with ulcerative colitis, acute Guillain-Barré syndrome developed while the inflammatory bowel disease was in remission. The patients were treated with corticosteroids and recovered. Since both disorders are relatively uncommon, we suggest that the Guillain-Barré syndrome may have been causally related to the preexisting chronic inflammatory bowel disease. Guillain-Barré syndrome may be regarded as a possible extraintestinal complication of chronic ulcerative colitis.

Seasonal variations in the frequency of endoscopically diagnosed duodenal ulcer in Israel

The seasonal pattern of endoscopically diagnosed duodenal ulcer disease in a representative Israeli medical center was evaluated retrospectively for the period 1980-1986. We reviewed all 9861 endoscopy records and found 1692 duodenal ulcers. We calculated the percentage of duodenal ulcers of the total examinations performed each month. In Israel, the frequency of duodenal ulcers was significantly increased during January and February and was significantly lower during the months May-June and July-August when compared to the rest of the year.

Atypical auricular pyoderma gangrenosum simulating fungal infection.

We describe a patient with a highly unusual appearance of pyoderma gangrenosum. The pyoderma was located on the auricular region and preceded other manifestations of inflammatory bowel disease by 11 years. There was no correlation between the course of the pyoderma and the clinical activity of the associated bowel disease. Mycotic superinfections masked and delayed the diagnosis in our patient for several years. Only when typical pyoderma gangrenosum lesions developed on the legs at the site of trauma and responded dramatically to systemic corticosteroids was the correct diagnosis established. Pyoderma gangrenosum with secondary fungal infection was thus distinguished from deep ulcerated skin fungal infection simulating pyoderma.

Should We Worry About Gastric Cancer in Duodenal Ulcer Patients

In three patients with active duodenal ulcer, carcinoma of the stomach was detected early during routine endoscopic examination. In all patients subtotal gastrectomy was performed, and pathological examination of the resected stomach revealed carcinoma confined to the mucosa. We review evidence for and against any association between gastric carcinoma and peptic ulcer disease.

Vitamin C status and colonic neoplasia.

Purpose: A subnormal status of vitamin C has been associated with an increased risk for several malignant diseases and may play a causative role in their development. The aim of the present study was to investigate whether this occurs also in neoplasms of the colon. METHODS: We have studied dietary intake and status of vitamin C in a consecutive group of patients with adenomatous colonic polyps (n=31) and compared it with that of patients with no such history and a normal colonic mucosa, as confirmed by colonoscopy (n=54). RESULTS: Dietary intake of this vitamin, as assessed by the dietary recall method, was similar in the two groups, as were the levels of vitamin C in plasma and leukocytes. There were no significant differences in intake of dietary fiber, fat, vitamin A, or calcium between the two groups. Lack of association between vitamin C intake or status and colonic polyps persisted after adjustment for potential confounders. CONCLUSION: We conclude that in this population, a deficient status of vitamin C is not an important factor in colonic neoplasia.