Rosemarie L. Fisher

Home Parenteral Nutrition for Patients with Inoperable Malignant Bowel Obstruction

The use of home parenteral nutrition (HPN) in patients with inoperable malignant bowel obstruction (IMBO) is controversial. The efficacy, safety, and indications for HPN in these patients is uncertain, and its benefit is difficult to demonstrate. The records of 17 patients (9, ovarian cancer; 4, colon cancer; 4, other) with IMBO receiving HPN managed by the Nutrition Support Team (NST) at Yale-New Haven Hospital from 1980 to 1989 were reviewed. Median survival was 53 days and was longest in the two patients with appendiceal carcinomatosis (208 and 159 days), intermediate in patients with colon cancer (median 90 days), and shortest in patients with ovarian cancer (median 39 days). Survival was unrelated to age or sex. All patients died of their underlying disease; 82% of deaths occurred at home. Only one treatment-related complication requiring readmission occurred. Fourteen patients and their families (82%) perceived their therapy as highly beneficial or beneficial. The NST agreed with this assessment in 11 patients but did not share this perception in three patients. These three patients had a short duration of HPN (less than 25 days) or minimal rehabilitation. It is concluded that HPN for patients with IMBO is associated with a low complication rate, may be most beneficial for those patients with gastrointestinal tract primary tumors, and is usually perceived by patients and care providers as beneficial. HPN has palliative benefit and facilitates compassionate home care for carefully selected patients with IMBO.

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.

Nutrition support in inflammatory bowel disease

The mechanisms of nutritional therapy in inflammatory bowel disease have not been thoroughly established. It is likely that a further understanding of the underlying disease process will allow better understanding of these forms of therapy, with a sounder rationale for the construction of specific diet constituents for therapy. Regardless, nutritional therapy is likely to be multidimensional, and various forms may affect different aspects of the disease process. Decreased inflammatory factors, decreased antigenic stimuli, provision of essential nutrients, improved immune function, and other factors may all be of varying importance in different patients with inflammatory bowel disease. Little work has been done on the role of diet therapy in the long-term treatment of patients with inflammatory bowel disease as a method of preventing relapse. Parenteral nutrition and elemental diets appear to have limited roles in this area. Some investigation has been done to see if minor modifications of the normal diet can prolong remission periods. Low-fiber diets are frequently recommended for patients with strictures. Whether this has any significant effect on symptoms, inflammation, or complications is unclear. Heaton et al suggested that a high-fiber, unrefined carbohydrate diet resulted in fewer and shorter hospitalizations. In a prospective follow-up study by Ritchie et al, however, these results were not able to be reproduced. Exclusion diets have also been suggested as a means of reducing relapse rates in patients with Crohns disease. In a small, randomized, controlled trial of an exclusion diet versus an unrefined carbohydrate, fiber-rich diet, there were significantly fewer relapses among the patients treated with the exclusion diet at 6 months. These diets require intensive patient cooperation, but the potential side effects are minimal. Clearly, these findings need to be reproduced in large, prospective, randomized, controlled studies before widespread use can be advocated. A great deal of data exists on the use of nutritional supplementation in the treatment of inflammatory bowel disease, although little of it is in the form of large, randomized, controlled studies. Nutritional manipulation currently has a limited role in patients with ulcerative colitis; a much broader role exists in patients with Crohns disease. The mechanisms by which nutritional therapy affects these diseases may include a combination of factors--decreased antigenic exposure, improved immune function, and provision of essential nutrients and calories needed for bowel regeneration.(ABSTRACT TRUNCATED AT 400 WORDS)

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.

Filiform polyposis: an unusual complication of inflammatory bowel disease

Filiform polyposis is an unusual form of inflammatory polyposis which complicates inflammatory bowel disease. Recognition of this variant is important in that its radiographic and endoscopic picture may mimic villous adenoma or adenocarcinoma. Filiform polyposis may precipitate obstruction by stricture formation or give rise to major hemorrhage. We report five patients with inflammatory bowel disease complicated by asymptomatic filiform polyposis to emphasize the pathology of this lesion. We also review the literature regarding this topic.

Duodenal ulcer. Incidence, risk factors, and predictive value of plasma pepsinogen.

In 1958 the Yale freshman class gave blood samples as part of a study intended to determine the predictive value of plasma pepsinogen (PP) for the subsequent development of duodenal ulcer (DU). We report a long-term follow-up of this cohort. A selfadministered questionnaire designed to ascertain information about the development of peptic ulcers, and the presence of risk factors was mailed to 861 subjects with “active” addresses. A second questionnaire was mailed to each respondents physician(s) to verify the diagnosis of DU. Completed questionnaires were returned, after three mailings, by 604 (70%) of the subjects. They reported 18 documented DUs, 15 since 1958, for an incidence of 1.1/1000 person years. Only smoking (P<0.05) and undergraduate physical inactivity (P<0.01) were identified as risk factors for DU. Family history; blood type; blood antigen secretor status; ingestion of coffee, alcohol, milk, salicylates, soda, or tea; and COPD were not identified as risk factors for DU. Patients with DU had higher mean PP values than those who did not (391.6±99.6 vs 346.6±106.7, mean ±sd) but this was not statistically significant (P>0.05). The predictive value of an elevated PP(>450) for the development of DU was 7.9%, but a low or normal PP predicted the absence of a DU in 97.5% of subjects over a 22-year span. We conclude that in a selected population followed for 22 years there is a low incidence of DU, supporting the general belief that duodenal ulcer is declining, that smoking and undergraduate physical inactivity are risk factors for duodenal ulcer, and that a low or normal PP may be useful as a predictor for a low susceptibility to duodenal ulcer disease.

What and whom to treat with metaplasia

Cyrus Kapadia: Knowing that there are about four or five studies in the literature that suggest that metaplasia might be a sinister lesion, my previous bias was to follow patients with metaplasia closely. Two things have happened since my previous bias. First, the insurance companies have come into play, and you can’t always get endoscopy sanctioned. Second, there have been some studies from David Graham’s group that tell me the risk may have been overplayed. I am ambivalent now, and I would love to hear what other people are doing in regard to metaplasia. Certainly, we don’t survey type I and type II. That is my definitive answer, but I don’t think there is a simple one.

Enhancing the Voice of Faculty in the Association of American Medical Colleges: The Evolution of Faculty in U.S. Medical Schools and the Transformation of the Council of Academic Societies Into the Council of Faculty and Academic Societies.

Since its inception in 1966, the Council of Academic Societies (CAS) represented academic faculty in the governance structure of the Association of American Medical Colleges (AAMC). As the role of faculty in the academic health center of the 21st century has evolved (e.g., the number of faculty members has increased, contact hours with trainees per individual faculty member have decreased, the faculty has aged), new models for representation have become necessary. Because of the structure and requirements for organizational membership, CAS was not representing faculty as broadly as possible, so a redesign was necessary. In November 2012, the AAMC Assembly adopted changes to its bylaws creating the new Council of Faculty and Academic Societies. The new design increases the opportunity for all schools to be represented by both junior and senior faculty members while retaining society membership and, therefore, representation of the breadth of specialties in academic medicine. The new councils structure better facilitates meeting its charge: to identify critical issues facing academic medicine faculty members; to provide faculty with a voice as the AAMC addresses those issues through the creation and implementation of AAMC programs, services, and policies; and to serve as a communications conduit between the AAMC and faculty regarding matters related to the core missions of academic medicine.

In memoriam: Howard M. Spiro, MD 1924-2012.

Howard M. Spiro, MD, who served as the founding section chief of gastroenterology at the Department of Internal Medicine at Yale from its start in 1955 until 1982 and as Director of the Yale Program for Humanities in Medicine from 1983 until his retirement from the faculty in 1999, died on March 11, 2012, in Branford, CT, after a brief illness. Dr Spiro was born in Cambridge, MA, on March 23, 1924. He graduated from Harvard College in 1944 and received his medical degree from Harvard Medical School in 1947. Upon graduation, his first impulse was to pursue a career in psychiatry. However, it is said that he felt he could not spend the rest of his life “just talking.” Acknowledging the relationship that he believed existed between visceral symptoms and the psyche, he decided to pursue a career in gastroenterology. After completing an internship at the Peter Bent Brigham Hospital (now the Brigham and Women’s Hospital), he remained there to pursue research in that field. During this early period, he focused his research primarily on gastrointestinal physiology. His interest soon began to turn to the relationship between the mind and the gastrointestinal tract. After serving for 2 years (1951 to 1953) in the military as chief of gastroenterology at Madigan Army Hospital, he returned to Boston to spend 2 additional years in research at the Massachusetts General Hospital along with his wife Marian Spiro. In 1955, Dr Spiro was recruited to Yale by Dr Paul Beeson to establish the first full-time academic Gastroenterology Section at Yale. His ambition at that time was to establish a nationally recognized academic research section of gastroenterology and incorporate both medical and psychological concerns in the teaching and provision of patient care. The activities of the West Haven Veterans Administration became part of this new division, adding a wide variety of patients and research opportunities. Dr Spiro was well known for his strong dedication to patients and bedside teaching. Teaching communication skills was a major part of his education of fellows, residents, and students. Interactions with other specialties were also of key importance, as evidenced by weekly teaching rounds between the surgical and gastrointestinal trainees and a dedicated social worker in the clinic. In 1965, Dr Spiro established the Yale-Affiliated Gastroenterology Program, a unique educational collaboration between fellowship training programs in south-central Connecticut. As Dr Spiro traveled to these institutions with fellows from Yale accompanying him, it allowed his trainees to observe a master clinician and diagnostician eliciting a complicated history from a