Myron H. Brand

Gastrointestinal angiodysplasia: A possible component of von Willebrand's disease

Evidence in the literature suggests that von Willebrands disease constitutes part of a mesenchymal syndrome accompanied by coagulopathy. The cases of two patients with symptomatic intestinal angiodysplasia and concurrent von Willebrands disease are summarized along with the eight cases previously reported in the literature. All ten cases were in adults ranging in age from 34 to 80 years (average, 58 years). The vascular lesions were located in the stomach or duodenum (four cases), right colon (three cases), and terminal ileum (two cases). One patient had angiodysplasia of the stomach, jejunum, and sigmoid colon. While the prevalence is unknown, these ten cases linking gastrointestinal angiodysplasia with von Willebrands disease appear to reflect an association greater than more coincidence. Coagulation testing, including determination of template bleeding time and partial thromboplastin time, should probably be performed in all patients bleeding from gastrointestinal angiodysplasia to screen for von Willebrands disease.

Gastrointestinal bleeding in competitive runners

Competitive runners have been shown to develop previously undescribed clinical conditions, including “runners anemia.” This has been shown to be an iron-deficiency anemia of several etiologies including gastrointestinal bleeding. Although 8–23% of runners have been shown to have guaiac-positive stools after a marathon, the incidence of significant and prolonged bleeding is unknown. We report four cases of competitive runners with iron-deficiency anemia, gastrointestinal bleeding coinciding with running, and no definitive gastrointestinal pathology despite extensive evaluation.

Fecal carriage of Streptococcus bovis and colorectal adenomas

An association between fecal carriage of Streptococcus bovis and colorectal carcinoma has been reported. A relationship between S. bovis and colorectal adenomas has also been suggested. In the present study, the relationship between S. bovis and adenomas was investigated. Two of 18 current adenoma patients (11%) were found to have S. bovis in their stool compared with 12 of 84 controls (14%). Six of 38 patients who had ever had a diagnosis of adenoma (16%) had S. bovis compared with 8 of 64 controls (13%). These results rule out a strong association between fecal carriage of S. bovis and adenomas; however, because of the relatively small sample size, a weak to moderate association cannot be excluded.

Small intestinal angiodysplasia in the elderly.

The predominant site of bleeding intestinal angiodysplasia in elderly patients will be the cecum or ascending colon, but recent experience in the Yale-Affiliated Gastroenterology Program in 1 year indicates that elderly patients may have bleeding acquired angiodysplasia (AD) confined to the small intestine only. A review of the literature confirms that symptomatic small intestinal AD is infrequent and occurs at an average age of 32 years in some series. Five patients with symptomatic small intestinal AD diagnosed during 1981 at Yale were older, with an average of 62 years. Three of the five cases (all female) had lesions in the duodenum, with two (males) having lesions in the ileum. Noncolonic AD in the elderly may be acquired during life, as in the classic situation in the right colon, but may be difficult to distinguish clinically and pathologically from the vascular lesions of hereditary hemorrhagic telangiectasia.

Hydrogen peroxide colitis: a report of three patients.

We have seen three patients with acute ulcerative colitis after hydrogen peroxide enemas. The colitis is probably the result of the explosive entrance of gas into the loose connective tissues of the mucosa and submucosa of the rectum and sigmoid. Fortunately, it is transitory in nature, but it should be distinguished from ulcerative, ischemic, or pseudomembranous colitis.

The inflammatory bowel disease Live Interinstitutional and Interdisciplinary Videoconference Education (IBD LIVE) series

Background:Managing patients with inflammatory bowel disease requires multidisciplinary coordination. Technological advances have enhanced access to care for patients and improved physician interactions. The primary aim of our project was to convene diverse institutions and specialties through a multisite virtual conferencing platform to discuss complex patient management. Methods:The case conference is designed to include multiple institutions to exchange ideas, review evidence-based data, and provide input on the management of patients with Crohns disease and ulcerative colitis. Technology is supplied and coordinated by an information technology specialist and Chorus Call, Inc., an international teleconferencing service provider. The Inflammatory Bowel Disease Live Interinstitutional Interdisciplinary Videoconference Education (IBD LIVE) initiative is accredited by the University of Pittsburgh Medical Center (UPMC) Center for Continuing Education in the Health Sciences for 1 AMA PRA Category 1 Credit per weekly session. Results:IBD LIVE began in 2009 comprising only adult gastroenterology and pediatric gastroenterology from UPMC Presbyterian and Childrens Hospitals. Participation steadily increased from 5 sites in 2010 to 11 sites in 2014. Maximum attendance for a single conference was 73 participants with a median of 48. The Continuing Medical Education scores (1 = worst to 5 = best) have a high median overall score (4.6, range 3.2–5.0) with positive responses with regard to the degree to which the conference changed practice. Conclusions:IBD LIVE has been successful and continues to grow. Implementation of the Crohns and Colitis Foundation of America Virtual Preceptor Program using the IBD LIVE platform will provide expanded national physician access to this professional education activity.

Seizures During Pegylated Interferon and Ribavirin Therapy for Chronic Hepatitis C Observations From the WIN-R Trial

Background Seizures are reported as an uncommon side effect of interferon therapy. Aim To determine the frequency and presentation of seizures occurring during pegylated interferon-&agr; (PEG-IFN&agr;) and ribavirin therapy for chronic hepatitis C. Methods Patients were identified using data from the WIN-R trial database, a US multicenter study comparing fixed (800 mg) versus weight-based (800 to 1400 mg) daily dosing of ribavirin in combination with PEG-IFN&agr;-2b (1.5 &mgr;g/kg/wk). Results Of the 4913 enrolled patients, 8 (0.16%) had a seizure. Three patients had a grand mal seizure and the seizure type was unknown in 5 patients. At the time of seizure, 6 patients were taking antidepressants (including 3 on bupropion), 1 was hyponatremic, and 1 had consumed a significant amount of alcohol. One patient had a history of seizures. Neuroimaging and electroencephalographic studies were negative. Antiepileptic medications were continued in the patient with a history of seizures and initiated in 1 patient. PEG-IFN&agr;-2b plus ribavirin therapy was continued in 2 patients following seizure and neither experienced a recurrent seizure. Conclusions Seizures occur infrequently in patients receiving PEG-IFN&agr;-2b plus ribavirin, and appear to be associated with other risk factors including antidepressant use.

IBD LIVE Case Series-Case 4: Worms in IBD: Friend or Foe.

LEARNING OBJECTIVES After completing this journal-based activity, physicians should be better able to: 1. Define the “hygiene hypothesis” of autoimmune diseases. 2. Understand the reasoning behind Trichuris suis ova (TSO) therapy for inflammatory bowel disease. 3. Know the key findings of trials using TSO in patients with Crohn’s disease and ulcerative colitis. 4. Be aware of the potential risks regarding helminth therapy. 5. Know the current opinion regarding TSO treatment in inflammatory bowel disease. 6. Be aware of the scope of complementary and alternative medicine (CAM) use in the United States, particularly among individuals with inflammatory bowel disease.

Yellow Fever Vaccination of a Primary Vaccinee During Adalimumab Therapy.

In this case report, we describe a 63-year-old female with Crohns disease since age 16 years, and on adalimumab therapy, who inadvertently received a yellow fever vaccine (YFV) 4 days before her next dose of adalimumab. She had never received YFV. Her next dose of tumor necrosis factor (TNF) antagonist was held. She did not report any adverse effects referable to the vaccine. Reverse transcriptase-polymerase chain reaction (RT-PCR) for yellow fever (YF) viral RNA on days 12 and 18 postvaccination was negative. Neutralizing antibody to YF virus vaccine was immunoprotective on day 18 following vaccination, which further increased by day 26. A neutralizing antibody obtained 2 years following vaccination also remained immunoprotective.

IBD LIVE Case Series: Case 9: Do Race and Extraintestinal Manifestations Affect Treatment of Severe Crohn’s Colitis?

1. Characterize the age distribution of inflammatory bowel disease (IBD). 2. Illustrate differences between pediatric-onset and adult-onset IBD, particularly amongst Crohn’s disease patients. 3. Describe how the incidence of IBD in racial minorities has changed over time and state the current understanding of the incidence in this cohort. 4. Identify management discrepancies that young, African American IBD patients may experience in the hospital setting. 5. List challenges in access to healthcare that racial minorities encounter. 6. Define pathergy and identify clinical settings in which pathergy may occur. 7. Compare and contrast the ‘top-down’ versus ‘step-up’ medication approaches for treating IBD. 8. Identify the benefits of proactive therapeutic monitoring of anti-tumor necrosis factor (anti-TNF) medications in IBD patients.