Mazer R. Ally

Extracolonic Findings on CT Colonography Increases Yield of Colorectal Cancer Screening

OBJECTIVE The purpose of this study is to evaluate the impact of extracolonic findings when screening is undertaken by CT colonography (CTC). MATERIALS AND METHODS We performed a retrospective cohort study of patients completing a screening CTC from August 2003 to June 2006 at Walter Reed Army Medical Center. Extracolonic findings were categorized using a CTC reporting and data system that classifies findings as highly significant, likely significant, and insignificant. All final diagnoses, surgeries, malignancies, and costs of diagnostic radiology procedures were calculated for each category. RESULTS Of 2,277 patients (mean +/- SD age, 59 +/- 11 years; 60% white; 56% male) undergoing CTC, extracolonic findings were identified in 1,037 (46%) patients, with 787 (34.5%) insignificant and 240 (11.0%) significant findings. Evaluation of significant findings generated 280 radiology procedures and 19 surgeries over a mean follow-up time of 19 +/- 10 months. The total cost of the radiology studies was

Safety of dilation in adults with eosinophilic esophagitis.

113,179; the studies added approximately

Prevalence of eosinophilic esophagitis in a United States military health-care population

50 extra per patient. Seven high-risk lesions were identified (six extracolonic malignancies and one large aortic aneurysm) in patients with significant findings. CTC also identified six intracolonic malignancies and three adenomas with high-grade dysplasia. When considering extracolonic findings, CTC increased the odds of identifying high-risk lesions by 78% (nine intracolonic lesions vs 16 intracolonic plus extracolonic lesions; p = 0.0156). Of the 16 intracolonic and extracolonic high-risk lesions, 11 (69%) underwent curative resection, and 5 of 11 (44.4%) were extracolonic. CONCLUSION CTC increased the odds of identifying high-risk lesions by 78%. CTC should be considered as an alternative to optical colonoscopy for colorectal cancer screening or as a onetime procedure to identify significant treatable intracolonic and extracolonic lesions.

The Sloughing Esophagus: A Report of Five Cases

Esophageal dilation is an effective therapy for dysphagia in patients with stenosing eosinophilic esophagitis (EoE). Historically, there have been significant concerns of increased perforation rates when dilating EoE patients. More recent studies suggest that improved techniques and increased awareness have decreased complication rates. The aim of this study was to explore the safety of dilation in our population of EoE patients. A retrospective review of all adult EoE patients enrolled in a registry from 2006 to 2010 was performed. All patients who underwent esophageal dilation during this time period were identified and included in the analysis. Our hospital inpatient/outpatient medical records, radiology reports, and endoscopy reports were searched for evidence of any complication following dilation. Perforation, hemorrhage, and hospitalization were identified as a major complication, and chest pain was considered a minor complication. One hundred and ninety-six patients (41 years [12]; mean age [standard deviation], 80% white, 85% male) were identified. In this cohort, 54 patients (28%) underwent 66 total dilations (seven patients underwent two dilations, one patient underwent three dilations, and one patient underwent four dilations). Three dilation techniques were used (Maloney [24], Savary [29] and through-the-scope [13]). There were no major complications encountered. Chest pain was noted in two patients (4%). There were no endoscopic features (rings, furrows, plaques) associated with any complication. Type of dilator, size of dilator, number of prior dilations, and age of patient were also not associated with complications. Endoscopic dilation using a variety of dilators can be safely performed with minimal complications in patients with EoE.

Treatment of intractable rectal stump drainage with cryoablation.

Eosinophilic esophagitis (EoE) is a rapidly emerging chronic immune-mediated condition affecting children and adults, both genders, and all races. A large variation in the prevalence of EoE exists in the literature. The aim of this study is to establish the prevalence of EoE in a military health-care population in the United States using a comprehensive electronic medical record search. Using the International Classification for Diseases-9 code for EoE (530.13), the total number of EoE patients enrolled in the military health-care system from October 1, 2008 to September 30, 2009 including active-duty military, dependents of military personnel, and retirees were identified. For each case of EoE identified, demographic data (age, gender, and race) and geographic location was obtained. The overall prevalence of EoE was calculated as well as the prevalence within subgroups. The geographic regional locations were reported per the U.S. Census Bureau regions (Northeast, South, Midwest, and West). A total of 987 EoE patients were identified from 10,180,515 military health-care beneficiaries, establishing an overall prevalence of 9.7 per 100,000 (95% confidence interval [CI] 9.1-10.3). Seven hundred twenty-eight out of 7,707,372 adult patients were identified, establishing a prevalence of 9.5 per 100,000 (95% CI 8.8-10.1). Two hundred fifty-nine out of 2,473,143 pediatric patients were identified, establishing a prevalence of 10.5/100,000 (95% CI 9.2-11.8). EoE was more prevalent in males (odds ratio [OR] 2.03 [95% CI 1.78-2.32]) and higher in Caucasian versus African Americans (18.1 vs. 5.2/100,000, OR 3.47 [95% CI 2.40-5.03]). EoE was more prevalent in the Western region of the United States compared with the Northeast, South, and Midwest regions, with a prevalence of 11.9 versuss 5.2, 9.6, and 9.2 per 100,000, respectively. When comparing Northern with Southern states, there was an increased prevalence in the North (10.9 vs. 7.2/100,000, P < 0.05). In this large nationwide study, increase in prevalence of EoE was seen in younger adults, with a higher prevalence in Caucasians. Geographically, the western United States had a significantly higher prevalence with a slightly higher prevalence in the Northern latitude.

Treatment of Recurrent Crohn's Uveitis With Infliximab

New South Wales , Australia ; 6 Discipline of Surgery, University of Western Sydney , Campbelltown , New South Wales , Australia ; 7 Department of Anatomical Pathology, South Western Area Pathology Service , Liverpool , New South Wales , Australia ; 8 School of Human Life Sciences, University of Tasmania , Launceston , Tasmania , Australia . Correspondence: Shanmugarajah Rajendra, MBBCh, MSc, MD, FRCP, FRCPE, FRACP , Department of Gastroenterology and Hepatology, Bankstown-Lidcombe Hospital, South Western Sydney Local Health Network , Bankstown , Sydney, New South Wales 2200 , Australia . E-mail: Shan.Rajendra@sswahs.nsw.gov.au

Su1845 Eosinophilic Esophagitis and Proton Pump Inhibitor Responsive Esophageal Eosinophilia: Are They One and the Same?

To the Editor: We read with great interest the study by Hernandez-Gea et al. ( 1 ). Th e same group had previously found hemodynamic response to a combination of nadolol and isosorbide mononitrate to be predictive of a reduced risk of decompensation in the setting of secondary prophylaxis of variceal bleeding ( 2 ). In the current study, they investigated patients given nadolol for primary prophylaxis. Th ose who obtained a hemodynamic response (defi ned diff erently as an hepato-venous pressure gradient (HVPG) reduction of ≥ 10 % ) were not only at reduced risk of fi rst variceal bleeding (as might have been expected), but also of developing ascites and death. Th is study makes an important contribution to defi ning the role of non-selective beta blockade in the management of patients with cirrhosis, while highlighting certain aspects that need to be defi ned further. Non-selective beta blockers, such as propranolol and nadolol, have a wide range of diff erent benefi cial eff ects in patients with cirrhosis that go beyond the reduction of portal pressure ( 3 ). While an HVPG decrease of ≥ 20 % or to < 12 mm Hg has been found benefi cial both in terms of preventing rebleeding and in reducing the incidence of other complications, even a lesser reduction of ≥ 10 % was suffi cient to decrease the risk of spontaneous bacterial peritonitis (SBP) ( 4 ). Other protective eff ects of non-selective beta blockers (on intestinal function, bacterial translocation and infection, immune function, and collateral blood fl ow) seem to be independent of reduction of portal pressure. In the fi rst study, the benefi t of hemodynamic response was also seen without improvement of liver function (e.g., due to alcohol abstinence) or even worsening thereof ( 2,5 ). Th e role of liver function however remains important, and in the current study non-responders had a worse baseline North Italian Endoscopic Club (NIEC) index (which, as all patients had large varices, is only subject to variation by the presence of red signs and Child class) and a statistically non-signifi cant trend toward higher Model for End-Stage Liver Disease (MELD) scores and less patients in Child class A. It would be of interest to see whether the additional prognostic value of an MELD of > 10 was also present in non-responders — in other words, how many non-responders had an MELD score of > 10. In addition, there might be a difference in bacterial infections in the two groups — these have a major prognostic signifi cance in the natural history of cirrhosis ( 6 ) and at least for SBP their incidence is reduced by non-selective beta blockers. Compliance is also important. Seven non-responders (or maybe eight — six due to side eff ects and two due to nonadherence) vs. two responders did not adhere to treatment. Table 1 ( 1 ) reports the percentages as 8 and 5 % , respectively, but these are 18 and 5 % — this almost reaches statistical signifi cance. In responders, there was a greater change in heart rate, a surrogate of compliance. Th is study lends further support to the use of non-selective beta blockers as the Hepatologist ’ s Aspirin ( 5 ). Prognostic information will not only be derived from assessing hemodynamic response, but gauged indirectly from the degree of compliance.