Michael J. Komar

Nutrition and enterocutaneous fistulas

Enterocutaneous fistulas (ECFs) are a complex topic in terms of classification. ECF-related morbidity and mortality can be high due to fluid loss and electrolyte imbalance, sepsis, and malnutrition. Most prognostic factors influencing the outcome of ECF are now well-known. ECF treatment is complex; and, based on various situations, it can be surgical or conservative/medical. Depending on fistula site and nutritional status, clinicians have to decide whether total parenteral or enteral nutrition should be established. In cases where total parenteral nutrition alone for 7 days has failed to influence the high output fistulas, overall data support the use of adjuvant drug, somatostatin, or its synthetic analogue, octreotide. Somatostatin 250 &mgr;g/d and octreotide 300–600 &mgr;g/d have been tried along with total parenteral nutrition to decrease the healing time of ECFs and to reduce the number of complications.

Risk factors for colonoscopic perforation: A population-based study of 80118 cases

AIM To assess the incidence and risk factors associated with colonic perforation due to colonoscopy. METHODS This was a retrospective cross-sectional study. Patients were retrospectively eligible for inclusion if they were 18 years and older and had an inpatient or outpatient colonoscopy procedure code in any facility within the Geisinger Health System during the period from January 1, 2002 to August 25, 2010. Data are presented as median and inter-quartile range, for continuous variables, and as frequency and percentage for categorical variables. Baseline comparisons across those with and without a perforation were made using the two-sample t-test and Pearsons χ² test, as appropriate. RESULTS A total of 50 perforations were diagnosed out of 80118 colonoscopies, which corresponded to an incidence of 0.06% (95%CI: 0.05-0.08) or a rate of 6.2 per 10000 colonoscopies. All possible risk factors associated with colonic perforation with a P-value < 0.1 were checked for inclusion in a multivariable log-binomial regression model predicting 7-d colonic perforation. The final model resulted in the following risk factors which were significantly associated with risk of colonic perforation: age, gender, body mass index, albumin level, intensive care unit (ICU) patients, inpatient setting, and abdominal pain and Crohns disease as indications for colonoscopy. CONCLUSION The cumulative 7 d incidence of colonic perforation in this cohort was 0.06%. Advanced age and female gender were significantly more likely to have perforation. Increasing albumin and BMI resulted in decreased risk of colonic perforation. Having a colonoscopy indication of abdominal pain or Crohns disease resulted in a higher risk of colonic perforation. Colonoscopies performed in inpatients and particularly the ICU setting had substantially greater odds of perforation. Biopsy and polypectomy did not increase the risk of perforation and only three perforations occurred with screening colonoscopy.

Early initiation of enteral feeding after percutaneous endoscopic gastrostomy tube placement.

Enteral feeding through the percutaneous endoscopic gastrostomy (PEG) tube is usually initiated about 12 to 24 hours after insertion of the tube. There have been earlier studies evaluating the efficacy of early initiation of enteral feedings that had encouraging results. However, delayed initiation of feeding following PEG placement continues to be practiced widely. We believe that feeding can be done earlier without any increase in associated morbidity or mortality and with obvious reduction in the need for parenteral nutrition and healthcare costs. We evaluated a protocol to initiate enteral nutrition 4 hours after the PEG tube insertion with subsequent discharge of the outpatients on the same day. We conducted a prospective study to assess the efficacy of early initiation of PEG feeding. We enrolled 77 patients in our study who were having PEG tubes placed for enteral feeding. Only patients who had a PEG placed for gastric venting procedures were excluded from our study. During the course of our study, no patient had to be excluded for the latter reason. Patients were evaluated by the physician performing the procedure, 4 hours after the tube was inserted. Their vital signs were checked, and a thorough abdominal examination was performed. Minimal tenderness around the PEG site was the most frequent finding. Otherwise, all the patients had a benign abdominal examination. The tube was flushed with 60 mL of sterile water. Following the examination, orders were given to restart the feedings. These patients were followed for a 30-day period to evaluate complications associated with PEG tube placement and early initiation of PEG feeding. There was one case of aspiration pneumonia (1.3%) and one death that was attributed to the underlying disease out of our 77 patients. Early initiation of enteral feeding after PEG tube placement can be successfully completed with a systematic protocol and close observation. Not only was this protocol found to be safe, it can also have significant cost savings by eliminating the need for inpatient hospitalization for the procedure.

Plummer-Vinson Syndrome and Postcricoid Carcinoma: Late Complications of Unrecognized Celiac Disease

Plummer-Vinson Syndrome and Postcricoid Carcinoma: Late Complications of Unrecognized Celiac Disease

A tubular adenoma arising in a colonic interposition.

other splenic abscesses, splenectomy is the gold standard of treatment of actinomycotic spleen abscess. Diagnostic aspiration of the abscess might be attempted but early splenectomy is recommended once the diagnosis is made to avoid splenic rupture. Penicillin is the drug of choice and it should be maintained for 6 months to prevent relapse or recurrence of actinmycosis. In conclusion, though this is a rare presentation of actinomycosis, we recommend to have a high suspicion of splenic actinomycosis in immunocompromised patients with indolent symptoms as above.

Gastric angiomyolipoma : A previously undescribed cause of upper GI hemorrhage

Angiomyolipomas are rare lesions often arising in the kidney. We describe the first documented case of symptomatic gastric angiomyolipoma.

Predicting the Risk of Recurrent Adenoma and Incident Colorectal Cancer Based on Findings of the Baseline Colonoscopy

Objectives:The decision tree underlying current practice guidelines for post polypectomy surveillance relies on risk stratification based on predictive attributes gleaned from adenomas removed on screening colonoscopy examination. Our primary aim was to estimate the magnitude of association between baseline adenoma attributes and the risk of adenoma recurrence and invasive colorectal adenocarcinoma (CRC). Our secondary aims were to estimate the adenoma detection rate (ADR) of surveillance compared with screening colonoscopies and describe time trends in preventive colonoscopy utilization.Methods:We used prospective analyses of retrospectively collected clinical data from electronic health records. A cohort of primary care patients eligible for colorectal cancer screening was assembled encompassing 110,452 subjects, of which 3,300 had adenomas removed on screening examination. Of those patients who had a follow-up surveillance colonoscopy (defined as a patient with a documented adenoma on prior colonoscopy) recorded during the study period, 537 had a recurrent adenoma.Results:Of those recurrent adenomas, 354 had a high-risk attributes. High-risk attributes were described at >3 adenomas, at least one adenoma >10 mm in size, high-grade dysplasia, or villous features. The risk of developing invasive CRC among post polypectomy patients was significantly higher if the baseline adenomas displayed any of the following attributes: more numerous than 3 (4.3-fold higher risk, 95% confidence interval (CI) low, high 1.4, 12.9), larger than 10 mm in size (5.2-fold higher risk, 95% CI low, high 1.8, 15.1), high-grade dysplasia (13.2-fold risk, 95% CI low, high 2.8, 62.1), or villous features (7.4-fold higher risk, 95% CI low, high 2.5, 21.5). These attributes combined added a net value of 22.8% to the probability of correctly predicting CRC. There was a threefold increase in surveillance utilization relative to screening from 2005 to 2011. The ADR of surveillance (34.1%) was 1.5-fold higher than that of screening (23.1%).Conclusions:These results emphasize the need to mitigate excessive risk by performing timely surveillance colonoscopies in patients with baseline adenomas displaying high-risk attributes as recommended in practice guidelines.

A Disease That Is Often Missed Without Gastrointestinal Symptoms.

DIS 5.4.0 DTD YGAST60353 proof 28 March 2016 12:45 pm ce Gastr 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 Question: A 58year-old woman presented with years of migratory polyarthralgias in her knees, ankles, elbows, and wrists. She had a large effusion in the right knee, tenosynovitis in the left hand and skin hyperpigmentation. Labs were negative for rheu85 86 87 88 89 90 91 92 matoid factor, anti-cyclic citrullinated peptide antibody and anti-nuclear antibody. She was diagnosed with seronegative rheumatoid arthritis and was initially treated with hydroxychloroquine. Ten months later, prednisone and methotrexate were added for refractory symptoms. She started etanercept six months later with little improvement in symptoms. Six months later she developed fatigue, depression and mild cognitive dysfunction. One year later, she started having epigastric abdominal pain with nausea, diarrhea and weight loss. CT scan of the chest and abdomen demonstrated a left pleural effusion with mediastinal and mesenteric lymphadenopathy. Laparoscopic mesenteric lymph node biopsy revealed histiocytes (Figure A) with periodic acid-Schiff positive globules (Figure B). What is the likely cause of her symptoms? 93 94 95 96 97 A. Inflammatory bowel disease with migratory polyarthropathy

Treatment of cutaneous Crohn's disease with infliximab

Purpose: Cutaneous or metastatic Crohns disease is extremely rare. Treatment to this date has been sub optimal, but normally consists of steroids, immunosuppression, and occasionally intralesional injection of steroids. We present a case of cutaneous Crohns disease that was successfully treated with Infliximab.

Intrabiliary application of fibrin glue: a novel approach

Introduction: The wireless capsule endoscopy has revolutionized the study of the small bowel. It enables clinicians to diagnose and to localize all types of gastrointestinal pathologies, including obscure gastrointestinal bleeds, tumors, and inflammatory diseases. When a patient presents with lymphadenopathy it often suggest malignancy. However, there are cases of benign lymphadenopathy, seen in patients with celiac sprue. Case Report: A previously healthy 34 year old male presented with diarrhea, joint pain, night sweats, weight loss and diffuse lymphadenopathy for several months. His physical exam was unremarkable. A computed tomography (CT) scan of the chest, abdomen, and pelvis revealed enlarged mesenteric lymph nodes and jejunal fold thickenening. A lymph node biopsy, showed non specific inflammatory changes and was negative for malignant cells. A wireless capsule endoscopy was preformed to further evaluate the abnormal jejunal thickenening seen on CT scan, using the M2A capsule. It demonstrated villous atrophy, with flattened mucosa in the proximal small bowel diagnostic of celiac sprue. The diagnosis was confirmed with endoscopic biopsy. The patient started a gluten free diet with resolution of his symptoms. Discussion: The most common malignancy associated with celiac sprue is malignant T-cell lymphoma. Mesenteric lymphadenopathy is often negative prognostic factor, but this is a case of benign lymphadenopathy. Lymphadenopathy seen in untreated celiac patients is thought to be a reactive lymphadenopathy from a chronic inflammatory process in the bowel wall. When a gluten free diet is followed, the lymphadenopathy often resolves over several months. The capsule endoscopy is proving a useful diagnostic tool for evaluating pathologies of the small bowel.