Justin Cheung

Acute Management and Secondary Prophylaxis of Esophageal Variceal Bleeding: A Western Canadian Survey

BACKGROUND Acute esophageal variceal bleeding (EVB) is a major cause of morbidity and mortality in patients with liver cirrhosis. Guidelines have been published in 1997; however, variability in the acute management and prevention of EVB rebleeding may occur. METHODS Gastroenterologists in the provinces of British Columbia, Alberta, Manitoba and Saskatchewan were sent a self-reporting questionnaire. RESULTS The response rate was 70.4% (86 of 122). Intravenous octreotide was recommended by 93% for EVB patients but the duration was variable. The preferred timing for endoscopy in suspected acute EVB was within 12 h in 75.6% of respondents and within 24 h in 24.6% of respondents. Most (52.3%) gastroenterologists do not routinely use antibiotic prophylaxis in acute EVB patients. The preferred duration of antibiotic therapy was less than three days (35.7%), three to seven days (44.6%), seven to 10 days (10.7%) and throughout hospitalization (8.9%). Methods of secondary prophylaxis included repeat endoscopic therapy (93%) and beta-blocker therapy (84.9%). Most gastroenterologists (80.2%) routinely attempted to titrate beta-blockers to a heart rate of 55 beats/min or a 25% reduction from baseline. The most common form of secondary prophylaxis was a combination of endoscopic and pharmacological therapy (70.9%). CONCLUSIONS Variability exists in some areas of EVB treatment, especially in areas for which evidence was lacking at the time of the last guideline publication. Gastroenterologists varied in the use of prophylactic antibiotics for acute EVB. More gastroenterologists used combination secondary prophylaxis in the form of band ligation eradication and beta-blocker therapy rather than either treatment alone. Future guidelines may be needed to address these practice differences.

Spontaneous Intramural Esophageal Hematoma: Case Report and Review

Intramural esophageal hematoma is a rare form of esophageal injury. The presenting symptoms are nonspecific. Esophagogastroscopy and computed tomography scan are usually needed to establish the diagnosis of intramural esophageal hematoma. Presented here is a patient with spontaneous intramural esophageal hematoma who was successfully treated with conservative measures.

A Randomized Trial of Topical Anesthesia Comparing Lidocaine Versus Lidocaine Plus Xylometazoline for Unsedated Transnasal Upper Gastrointestinal Endoscopy

BACKGROUND The optimal topical anesthesia regimen for unsedated transnasal endoscopy is unknown. The addition of a nasal decongestant, such as xylometazoline (X), to a topical anesthestic may improve patient comfort. OBJECTIVE To determine the effectiveness of lidocaine (L) versus L plus X (LX) for anesthesia in unsedated transnasal endoscopy. METHODS Consecutive participants of the Aklavik Helicobacter pylori project were prospectively randomly assigned to receive LX or L for unsedated transnasal 4.9 mm ultrathin endoscopy. The primary outcome was overall procedure discomfort on a validated 10-point visual analogue scale (1 = no discomfort, 10 = severe discomfort). Secondary outcomes included pain, endoscope insertion difficulty, gagging, adverse events and encounter times. Results were presented as mean +/- SD, difference in mean, 95% CI. RESULTS A total of 181 patients were randomly assigned to receive LX (n=94) and L (n=87). Baseline characteristics between the two groups were similar (mean age 40 years, 59% women). Overall, patient procedural discomfort with LX and L were 4.2+/-2.4 versus 3.9+/-2.1, respectively (0.29; 95% CI -0.39 to 0.96). Transnasal insertion difficulty was significantly lower with LX than with L (2.4+/-2.1 versus 3.2+/-2.8, respectively [-0.80; 95% CI -1.54 to -0.06]). Compared with L, the use of LX was associated with significantly less time needed to apply anesthesia (2.4+/-1.8 min versus 3.5+/-2.2 min, respectively [-1.10; 95% CI -1.71 min to -0.50 min]) and less time for insertion (3.2+/-1.8 min versus 3.9+/-2.2 min, respectively [-0.70 min; 95% CI -1.30 min to -0.10 min]). Epistaxis was rare but occurred less frequently with LX (1.1%) than with L (4.6%) (P=0.19). CONCLUSIONS LX did not improve patient comfort for transnasal endoscopy compared with L alone. However, LX was associated with less difficulty with endoscope transnasal insertion and reduced insertion time. Further studies on the optimal regimen and dosing of anesthesia are required.

Management of polycystic liver disease

Polycystic liver disease (PCLD) is characterized by multiple cysts throughout the liver. Patients may develop chronic intractable symptoms that may be debilitating. Others may develop medical complications that necessitate intervention. There is a variety of nonsurgical and surgical treatment options for symptomatic or complicated PCLD, which range from cyst aspiration and fenestration to liver transplantation. Studies have described variable efficacy and morbidity. Currently, there are no guidelines for the management of PCLD patients and the optimal intervention is controversial. This article reviews the pathogenesis, classification and spectrum of treatment options for PCLD.

Jejunal Amyloidosis: A Rare Cause of Severe Gastrointestinal Bleeding

1Department of Medicine; 2Division of Pathology; 3Division of Gastroenterology, University of British Columbia, Royal Columbian Hospital, New Westminster, British Columbia Correspondence: Dr Justin Cheung, Department of Gastroenterology, Royal Columbian Hospital, 410-301 East Columbia Street, New Westminster, British Columbia V3L 3W5. Telephone 604-525-0155, fax 604-525-1699, e-mail justa48@hotmail.com Received for publication December 22, 2011. Accepted December 29, 2011 CASE PRESENTATION An 81-year-old Jamaican woman presented with melena and severe anemia, and a hemoglobin level of 47 g/L (normal range 115 g/L to 160 g/L). A gastroscopy and colonoscopy were negative for any lesions. Duodenal biopsies were normal. A subsequent computed tomography scan of the abdomen with contrast showed diffuse thickening from the jejunum to the distal small bowel and a small area of active bleeding in the mid small bowel. A technetium-99m red blood cell scan demonstrated active bleeding in the proximal jejunum. Push enteroscopy (120 cm to 150 cm below incisor) revealed mild diffuse friability starting from the proximal jejunum, as well as erosions, nodularities, polypoid protrusions and valvulae conniventes thickening in the remaining jejunum (Figures 1A and 1B). Jejunal biopsies showed extensive amyloid deposition in the lamina propria and submucosa, with Congo red stain demonstrating apple-green birefringence under polarized light (Figure 2), and hematoxylin counterstain revealing amorphous, salmon-pink, sparsely cellular hyaline material (Figure 3). Serum protein electrophoresis, immunofixation and a serum-free light chain assay confirmed the presence of monoclonal immunoglobulin G lambda paraprotein. The patient was transfused with packed red blood cells as needed (average one unit per day), and treated with bortezomib and dexamethasone for primary amyloidosis. By day 17 of hospitalization, the bleeding had resolved and the patient was subsequently discharged without any further bleeding episodes. DISCUSSION Amyloidosis is a multisystem disease characterized by extracellular deposition of abnormal protein fibrils in various tissues and organs. The protein fibrils are derived from monoclonal immunoglobulin light chains in primary amyloidosis (AL), acute phase reactant serum amyloid A in secondary amyloidosis (AA), and beta2-microglobulin in dialysis-related amyloidosis (Ab2m). Clinical manifestations in amyloidosis are variable, but the heart and kidneys are most commonly involved. Gastrointestinal symptoms due to bleeding, dysmotility and malabsorption are present in up to 60% of AA (1), but in only 1% of AL (2). The diagnosis of amyloidosis can only be confirmed by tissue biopsy because endoscopic and radiologic findings are nonspecific. Therapy is directed at the underlying cause in AL (plasma cell dyscrasia) and AA (infection, inflammation and malignancy), whereas treatment in Ab2m involves alteration of dialysis mode or consideration of renal transplantation (3). Severe gastrointestinal bleeding rarely occurs as the sole or initial manifestation of systemic amyloidosis (4). Mechanisms by which hemorrhage occurs in gastrointestinal amyloidosis have been postulated, including intestinal ischemia, necrotic ulceration, mucosal tearing, vascular fragility, abnormal platelet aggregation, and factor IX and X deficiencies (5,6). In addition to supportive care for bleeding, treatment must be tailored to the specific type of amyloidosis, as determined by endoscopy and histology. Endoscopy classically shows polypoid protrusions and valvulae conniventes thickening in AL; a imAge of the month

Practices in peptic ulcer bleeding controversies among university- versus nonuniversity-affiliated gastroenterologists.

BACKGROUND Practices relating to acute peptic ulcer bleeding (APUB) outside of guideline recommendations are unknown. OBJECTIVE To evaluate the practices of university-affiliated (UA) versus nonuniversity-affiliated (non-UA) gastroenterologists in controversial APUB issues. METHODS Gastroenterologists in Canada were mailed an anonymous questionnaire (January 2008) regarding APUB management. RESULTS Responses were received for 281 of the 530 questionnaires mailed (53%). There were no differences between the UA versus non-UA gastroenterologists regarding acid suppression medication and route of administration pre- and postendoscopy (all P>0.05). There were no differences in endoscopic practices between groups regarding large versus small volume injection, endoclip versus combination injection plus coagulation, endoclip versus endoclip plus injection, and management of adherent clots (all P>0.05). There was variability within each group regarding optimal empirical acid suppression pre- and postendoscopy, volume of injection therapy and endoclip use. The non-UA group had longer delays before restarting acetylsalicyclic acid (P=0.08) and warfarin (P=0.02) post-APUB. CONCLUSIONS UA and non-UA gastroenterologists have similar practices in acid suppression and endoscopic therapy for controversial APUB issues; however, non-UA gastroenterologists appear more cautious in restarting acetylsalicylic acid and warfarin. Further studies are needed to address the optimal empirical acid suppression pre- and postendoscopy, injection therapy volume, endoclip use, and timing of restarting antiplatelet and anticoagulation therapy.

M1058 Prevalence of Helicobacter pylori and Antibiotic Resistance in An Aboriginal Population in Canada's Arctic: Preliminary Results from the Aklavik H. pylori Project

Background: The rate of gastric cancer in the Northwest Territories Aboriginal population is higher than the rest of the Canada. The aims of this study were to determine theHelicobacter pylori (Hp) prevalence and antibiotic resistance pattern in this community. Methods: As part of a community health project focused on Hp risks, including urea breath test (UBT) screening, residents (age ≥ 9 yrs) of Aklavik, a remote town of 620 inhabitants in the Northwest Territories of Canada, were invited to undergo endoscopy in February 2008. An on-site unit was assembled in the local health centre to perform upper gastrointestinal endoscopy with gastric biopsies for Hp culture and antibiotic susceptibility. Positive Hp cultures were tested using the E-test method for susceptibility to metronidazole, clarithromycin, amoxicillin, ciprofloxacin, tetracycline, nitrofurantoin, and rifampin. Results: Hp prevalence was 55% among the 240 residents who had a UBT. Of all eligible participants, 35% (n = 194) underwent endoscopy and biopsies for culture, with UBT-positive residents more likely to consent to endoscopy. The mean (±SD) age of the participants was 40 (±17) years and 59% were female. Hp culture results were available from 170; 117 (69%) were Hp positive. Antibiotic resistance was found in 33% (n = 33) of 99 Hp-positive cultures tested. Resistance to only metronidazole, clarithromycin, or amoxicillin was present in 23% (n = 23), 4% (n = 4), 0% (n = 0), respectively. There were no cases of resistance to rifampin and tetracycline. Multi-drug (≥ 2) resistance was present in 6 cases (6%). Conclusion: There is a high prevalence of Hp infection with relatively low levels of antibiotic resistance and occasional multi-drug resistance to antibiotics among residents in this Canadian arctic hamlet. A randomized control trial is being conducted to determine the optimal treatment to cure Hp infection in this community.