Suzanne Rose

GASTROINTESTINAL MANIFESTATIONS OF SCLERODERMA

The gastrointestinal tract is commonly involved in SSc. The esophagus is the most frequently affected, followed by the anorectal region, the small bowel, stomach, and colon. Smooth muscle atrophy and to a lesser degree fibrosis is the underlying defect responsible for the resulting abnormalities. These smooth muscle alterations have a significant impact on gastrointestinal motility, which results in secondary disorders of GER, pseudo-obstruction, bacterial overgrowth, and disordered bowel functions. The clinical presentation for these conditions ranges from asymptomatic to life-threatening. Thus, gastrointestinal evaluation and treatment of these conditions is an important aspect in the management of patients with SSc.

Fecal Incontinence in the Elderly: FAQ

Fecal incontinence (FI) is a common gastrointestinal (GI) complaint in patients aged 65 years and older. This evidence-based review article discusses the epidemiology, pathophysiology, evaluation, and management of FI in the geriatric population. We emphasize aging-related changes leading to and impacting evaluation and treatment of this symptom while incorporating the core geriatric principles of functional status and management aligned with patient preference and goals of care.

Quantitative endoscopy: Precise computerized measurement of metaplastic epithelial surface area in Barrett's esophagus

BACKGROUND/AIMS The inability to precisely measure the area of Barretts metaplasia has impaired the study of its natural history and response to therapy. This study used a novel computer program that creates two-dimensional maps of the esophagus allowing for calculation of the area of Barretts metaplasia. METHODS Endoscopic photographs of Barretts models and patients were obtained by independent endoscopists. The program transformed the photographs into maps, and the area of Barretts metaplasia was calculated. RESULTS Using models, calculated areas correlated with actual areas (r = 0.96) with an overall error of 5.2%. Color, size, shape, diameter of the model, or endoscopists experience did not affect the accuracy. Accuracy did improve by decreasing the interval between photographs from 4 cm (10.0% error) to 2 cm (4.8% error). In patients, area calculations from maps created by independent technicians correlated precisely (r = 0.99) at 1-cm (n = 22) and 2-cm (n = 40) intervals. Independent endoscopists correlated precisely in producing photographs for map construction (r = 0.99; n = 20). CONCLUSIONS This novel computer technology produces two-dimensional maps of Barretts metaplasia that can be used to accurately calculate area. Minimal interobserver variability in obtaining photographs is found.

Is functional dyspepsia of particular concern in women? A review of gender differences in epidemiology, pathophysiologic mechanisms, clinical presentation, and management

Dyspepsia is a remarkably common symptom in the general population. Although multiple definitions have been used to describe the symptom, the most common explanation is that of chronic or recurrent pain or discomfort (a subjective negative feeling that may be associated with early satiety, fullness, bloating, or nausea) centered in the upper abdomen. When a thorough evaluation of a dyspeptic patient fails to identify a cause for her symptoms, the label of nonulcer or functional dyspepsia is applied. Functional dyspepsia is a heterogeneous disorder characterized by relapsing and remitting symptoms. Treatment strategies should focus on alleviating the most bothersome symptom and can be based on the proposed underlying pathophysiology. The effect of gender on mechanisms of disease, symptom presentation, and treatment response is an area of increasing interest and study. As with other functional gastrointestinal disorders, there appear to be some gender-specific features of functional dyspepsia. Specifically, gender-related differences have been observed in some studies of both the prevalence of individual dyspepsia symptoms, and in gastric emptying and proximal gastric motor function. There also appear to be gender differences in the psychosocial realm, with dyspeptic women experiencing a lesser sense of well-being than dyspeptic men, as well as an association of an abuse history with functional dyspepsia. This review will highlight specific gender differences related to the symptom presentation, pathophysiology, and approach to treatment of functional dyspepsia, while noting where differences have not been found and where further investigation is warranted.

Extent of Barrett's metaplasia: a prospective study of the serial change in area of Barrett's measured by quantitative endoscopic imaging

BACKGROUND An accurate determination of the extent of Barretts metaplasia is critical to the study of its natural history and response to therapy. Our hypothesis is that area calculations offer advantages over length estimates of Barretts. METHODS Changes in both measures and estimates of progression or regression between two endoscopies in 17 patients were compared. Area was calculated using a computer image analysis technique. RESULTS Although there was no significant difference in length correlation versus area correlation between endoscopies (r = 0.90 vs 0.99), the mean change in absolute length (1.4 +/- 0.2 cm) was greater than the change in area (4.5 +/- 1.4 cm2, equivalent to a length of 0.67 +/- 0.2 cm, p = 0.001). The percent change in absolute length (26.9%) was greater than the change in area (16%, p = 0.001). Discordance of estimates of progression or regression between area and length was found in nine patients. The image technique detected no change in the area of squamous islands. CONCLUSIONS Imaging analysis can precisely measure the extent of Barretts including squamous islands. Area showed little change, whereas measures of length were more varied. Computer based image analysis provides a more precise estimate of interval change of Barretts.

Entrustable Professional Activities for Gastroenterology Fellowship Training

Office of Academic Affairs and Education and Department of Medicine, Division of Gastroenterology, University of Connecticut School of Medicine, Farmington, Connecticut; Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California; Henry D. Janowitz Division of Gastroenterology, and The Brookdale Department of Geriatrics and Palliative Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; American Gastroenterological Association, Bethesda, Maryland; and Division of Gastroenterology, Department of Medicine, State University of New York (SUNY), Upstate Medical University, Syracuse, New York

Spectrum of malignancy and premalignancy in Carney syndrome.

Carney syndrome is a rare, autosomal dominant, multi-system disorder comprising 8 well-characterized findings, only 2 of which need be present for a definitive diagnosis. Benign neoplasms are frequent, but malignancies are thought to be uncommon. We have studied a family to clarify the diagnosis and spectrum of clinical manifestations of the syndrome and to develop guidelines for management. The proposita, a 34-year-old woman had classic findings of Carney syndrome, invasive follicular carcinoma of the thyroid gland, Barrett metaplasia of the esophagus, neoplastic colonic polyps, bipolar affective disorder, and atypical mesenchymal neoplasm of the uterine cervix distinct from the myxoid uterine leiomyoma usually seen in this syndrome. Although thyroid gland neoplasm is rare in Carney syndrome, this patients most aggressive manifestation was her thyroid carcinoma. The diagnosis of Carney syndrome was established in her 9-year-old son and is a probable diagnosis in her 12-year-old daughter. Endocrine manifestations were prominent in the family with at least 9 relatives in 3 generations affected with various endocrine abnormalities. The findings in this family indicate that the spectrum of manifestations in this pleiotropic gene apparently includes a malignant course with premalignant and endocrinologic disorders not previously recognized.

Colonic Bacillary Angiomatosis

Bacillary angiomatosis is an infectious disease caused by small, fastidious, gram-negative bacilli known as Bartonella henselae and B. quintana (formerly Rochalimaea henselae and R. quintana) [1]. The infection is characterized by a vascular proliferation of the skin or visceral organs and usually occurs in immunosuppressed patients [2]. Cutaneous bacillary angiomatosis is the most common clinical form of bacillary angiomatosis. Skin lesions present as red papules, subcutaneous nodules, or cellulitic plaques [2-4]. Bartonella infection has also been seen in the lymph nodes, liver (bacillary peliosis hepatis), spleen, bone, heart, central nervous system, oropharynx, larynx, endobronchus, duodenum, and blood [3-5]. We report the first known case of bacillary angiomatosis of the colon. Our patient was a middle-aged man with the acquired immunodeficiency syndrome (AIDS), bloody diarrhea, and no cutaneous involvement. This case highlights a new treatable cause of diarrhea and intestinal bleeding in patients with AIDS. Case Report A 60-year-old homosexual man with AIDS and Crohn disease in remission was seen after having had abdominal cramps and pain, tenesmus, and bloody diarrhea for 8 weeks. Colonoscopy done 2 years earlier had shown deep serpiginous ulcerations in the rectosigmoid region. Biopsy specimens had shown mucosal erosions and hemorrhage and a lymphoplasmacytic infiltrate. The endoscopic and histologic features of the remainder of the colon and the terminal ileum were normal, compatible with Crohn proctosigmoiditis. The patient was treated with hydrocortisone enemas, which relieved his symptoms. No subsequent endoscopic evaluation was done. The patients diarrhea was small in volume and occurred several times per day. It did not correlate with meals or abate with fasting. The patients symptoms had begun during a trip to Korea and had not been alleviated by antidiarrheal agents and a 2-week course of ciprofloxacin hydrochloride. The patient had no known recent cat scratch or bite or exposure to lice. Laboratory tests showed a hemoglobin level of 730 g/L, a hematocrit of 0.22, a mean corpuscular volume of 71 fL, and a CD4+ count of 189 cells/mm3 (0.189 109/L). The results of stool specimen studies for culture, ova and parasites, Clostridium difficile toxin, cryptosporidium, and acid-fast bacilli were negative. We saw multiple erythematous nodules with intervening ulcerations in the rectosigmoid colon by sigmoidoscopy (Figure 1, top). The results of endoscopic biopsy cultures for cytomegalovirus and herpes simplex virus were negative. Histologic examination of the biopsy specimens showed ulceration with marked acute and chronic inflammation adjacent to mucosa that appeared normal (Figure 1, bottom left). Ulcerated areas contained prominent neovascular channels resembling those seen in granulation tissue (Figure 1, bottom left). Within the ulcers, many small, gram-negative, rod-shaped bacterial organisms were stained positive by Warthin-Starry silver stain (Figure 1, bottom right) but not by Ziehl-Neelsen or Grocott-Gomori methenamine silver stain. No representative tissue sample was available to further confirm Bartonella infection through electron microscopy, immunocytochemical staining, or polymerase chain reaction (PCR) detection of Bartonella-specific DNA sequences. Figure 1. Colonic bacillary angiomatosis. Top left and Top right. Bottom left. arrows Bottom right. arrows Treatment with erythromycin was changed after 2 days to doxycycline, 100 mg twice daily, because of gastrointestinal intolerance. The patients symptoms improved within 4 days, and the bloody diarrhea resolved within 2 weeks. Doxycycline therapy was maintained for 3 months. Three months after the diagnosis of colonic bacillary angiomatosis, the patient presented with intractable, nonbloody, small-volume diarrhea. Sigmoidoscopy showed persistent red nodules and ulcerations in the rectosigmoid colon and many small aphthous ulcers in the descending colon. Microscopic examination showed features of nonspecific colitis, including acute and chronic inflammation of the lamina propria. However, the histopathologic changes characteristic of bacillary angiomatosis were absent, and Warthin-Starry staining for organisms had negative results. Treatment of inflammatory bowel disease with steroids improved the diarrhea. Long-term follow-up was not possible because the patient had a fatal pulmonary embolus shortly there-after. Discussion In 1983, Stoler and colleagues [6] first described bacillary angiomatosis in a 32-year-old man with AIDS who presented with fever and multiple subcutaneous nodules. Histologic evaluation and Warthin-Starry staining confirmed the diagnosis, and erythromycin treatment was curative. Many extracutaneous sites of bacillary angiomatosis have since been described. A duodenal infection manifested by a single 3-mm red nodule [5] and an intra-abdominal mass associated with gastrointestinal hemorrhage [7] have both been reported. No cases of symptomatic colonic involvement had been reported before our case. In our patient, the colonic bacillary angiomatosis appeared as nonspecific ulceration on histologic examination (Figure 1, bottom left). The presence of lobular capillary proliferationcharacteristic of the condition in its involvement of skin and other sites [2-6]closely simulated granulation tissue (Figure 1, bottom left). Ulceration of individual lesions is likely to superimpose a nonspecific pattern of inflamed granulation tissue, complicating the etiologic diagnosis. These histopathologic considerations impede detection of the disease in tissue biopsy specimens. Histologic and endoscopic features along with clinical correlation are essential in making the diagnosis. When appropriate, Warthin-Starry staining with electron microscopic, immunocytochemical staining, or PCR detection of bartonella-specific DNA sequence confirmation should be done. Clinically and histologically, cutaneous bacillary angiomatosis and verruca peruana (Peruvian warts), the second stage of B. bacilliformis infection, are similar [8]. In chronic bartonellosis, an angiogenic factor is released that mediates vasoproliferation [9]. A similar angiogenic factor may be responsible for the vascular proliferation seen in bacillary angiomatosis [10]. Rochalimaea species were recently reclassified into the genus Bartonella because of similar genotypic and phenotypic characteristics [1]. Our patient had angiomatous nodules in the distribution of a Crohn proctosigmoiditis that had been described previously. Because the affected intestinal mucosa in inflammatory bowel disease contains oxygen-free radicals and activated B lymphocytes and T lymphocytes with the release of high levels of cytokines and inflammatory mediators, superinfection with bacillary angiomatosis would not have been expected [11, 12]. However, infection with the human immunodeficiency virus (HIV), by reducing the intestinal CD4 T-cell function, may have altered the intestinal mucosal immune response. In fact, remission in Crohn disease induced by HIV infection has been reported [13]. No cases of colonization with Bartonella in patients with inflammatory bowel disease have yet been reported. This is the first report of Bartonella infection of the colon. The histologic findings were similar to those seen in Bartonella infection of the skin and lymph nodes [2-6]. Physicians caring for immunocompromised patients and patients with AIDS should include bacillary angiomatosis in the differential diagnosis of diarrhea with gastrointestinal bleeding. Warthin-Starry staining is essential for confirming the diagnosis. The importance of making the diagnosis is underscored by the availability of effective treatment with erythromycin or doxycycline [3, 4, 6]. Dr. Hunt: University of Pittsburgh Medical Center, Division of Internal Medicine, 190 Lothrop Street, Room 166 Lothrop Hall, Pittsburgh, PA 15261. Dr. Finkelstein: University of Pittsburgh Medical Center, Department of Pathology, 200 Lothrop Street, A616 Scaife Hall, Pittsburgh, PA 15213.

Introducing the Gastroenterologist-accountable Professionalism in Practice (G-APP) Pathway: Bridging the G-APP-Replacing MOC With a Model for Lifelong Learning and Accountability

University of Connecticut School of Medicine, Academic Affairs and Education and Department of Medicine, Division of Gastroenterology and Hepatology, Farmington, Connecticut; Icahn Mount Sinai School of Medicine, Department of Medicine/ Henry D. Janowitz Division of Gastroenterology and Brookdale Department of Geriatrics and Palliative Medicine, New York, New York; Duke University School of Medicine, Department of Medicine, Division of Gastroenterology, Durham, North Carolina; Department of Medicine, Division of Gastroenterology and Hepatology, University of Rochester, Rochester, New York; American Gastroenterological Association, Bethesda, Maryland; Texas Digestive Disease Consultants, Dallas, Texas; South Denver Gastroenterology, Lone Tree, Colorado; and The Ohio State University College of Medicine, Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Columbus, Ohio

The impact of health care reform on gastroenterology fellows: Are training programs preparing them for the future?

The Impact of Health Care Reform on Gastroenterology Fellows: Are Training Programs Preparing Them for the Future?