Reuben J. Garcia-Carrasquillo

Combined magnification endoscopy with chromoendoscopy in the evaluation of patients with suspected malabsorption

BACKGROUND Magnification endoscopy and chromoendoscopy together have been used to evaluate mucosal detail in a number of conditions, including Barretts esophagus and flat colonic polyps, but they have not been used to evaluate villous atrophy in the proximal small intestine. METHODS Thirty-four patients suspected of having a malabsorption syndrome (either celiac disease or tropical sprue) were evaluated using an Olympus magnification gastroscope in both normal and high magnification settings. Indigo carmine dye spraying techniques were used to assist in evaluating duodenal mucosa for evidence of villous atrophy. The accuracy of endoscopically predicted villous atrophy was assessed by histologic evaluation of biopsy specimens taken in the descending duodenum. RESULTS Magnification endoscopy with dye spraying was both highly sensitive (94%) and specific (88%) in identifying patients with villous atrophy. This technique was more accurate (91%) in identifying patients with partial atrophy than standard endoscopy (9%, p < 0.01) and was also useful in identifying patients with patchy villous atrophy (5 of 5) to allow directed biopsies of abnormal tissue. CONCLUSION Magnification endoscopy with chromoendoscopy is a promising technique for the evaluation of patients with suspected malabsorption. This technique is especially valuable in patients with partial atrophy, where villous abnormalities can be patchy and the duodenum usually appears normal during standard endoscopy.

Hematemesis due to prolapse gastropathy: An emetogenic injury

Hematemesis after vomiting or recurrent retching is usually considered to be due to a MalloryWeiss tear of the mucosa at the gastroesophageal junction.1 These tears account for about 5% of patients presenting with upper gastrointestinal bleeding.2 We have encountered 7 patients who presented with hematemesis after periods of vomiting or retching who had a localized area of congested or hemorrhagic mucosa in the upper stomach as the main finding at endoscopy. This lesion has been described as an emetogenic injury or prolapse gastropathy3-7 and is thought to arise as a result of forceful retrograde prolapse of the gastric mucosa into the gastroesophageal junction. We identified 475 patients who underwent endoscopy for upper gastrointestinal bleeding between November 1995 and September 1996. Seven patients (2%) were considered to have gastric mucosal prolapse as the cause of their bleeding. All patients experienced hematemesis after a variable period of retching and emesis. The clinical presentation and endoscopic findings of the seven patients are described in Table 1. Patient No. 6 is described in detail below.

Incidence and risk factors for gastrointestinal bleeding among patients admitted to medical intensive care units

Objectives To identify incidence and risk factors for new-onset gastrointestinal bleeding (GIB) in a medical intensive care unit (ICU), a topic for which there is a paucity of recent studies. Design Retrospective cohort study. Setting Medical ICUs at our tertiary-care hospital, from 2007 to 2013. Patients Patients who developed clinically significant GIB after entering the ICU. Interventions Univariable and multivariable analyses. Main outcome measures Incidence and risk factors for development of GIB. Results 4439 patients entered the medical ICU without a pre-existing GIB and 58 (1.3%) developed GIB while in the ICU. Risk factors included length of ICU stay (OR per additional day 1. 06; 95% CI 1.04 to 1.09) and elevated creatinine on ICU admission (OR 2.35; 95% CI 1.18 to 4.68, p=0.02). Elevated bilirubin on ICU admission (OR 2.08; 95% CI 0.97 to 4.47, p=0.06), and elevated aspartate transaminase (AST) on ICU admission (OR 2.20; 95% CI 0.96 to 5.03, p=0.06) trended towards increased risk of GIB that did not meet statistical significance. Age, gender, admission coagulation studies and mechanical ventilation were not predictive of GIB. Among those patients with new-onset GIB in the ICU, 47% died during that hospitalisation, as compared with those 30% of those without a GIB, p<0.01. Conclusions Onset of GIB is now an infrequent occurrence in the ICU setting; however those with elevated bilirubin, AST and creatinine upon admission, and with longer length of ICU stay appear at increased risk and may benefit from closer monitoring.