Tuyyab Hassan

A Not So Benign Abdomen

Question: A 55-year-old Egyptian woman with a history of migraine, B-cell lymphoma (in remission), and depression was admitted with diffuse abdominal pain after 2 presentations to the emergency department within 1 week with similar complaints. She denied nausea, vomiting, hematochezia or fever. She had been seen in the GI clinic over many years with postprandial epigastric pain and nausea with negative imaging and endoscopic testing and had been diagnosed with functional dyspepsia. Physical examination revealed the patient looked pale and was in distress with mild tenderness to deep palpation in the left upper abdominal quadrant, with no guarding or rebound and a generally soft abdomen. Rectal examination was negative for masses and blood. Laboratory testing was pertinent for a decrease in hemoglobin from 12 to 9 g/dL. Other routine laboratory tests were normal. She underwent computed tomography scanning of the abdomen/pelvis, which revealed intraabdominal hemorrhage in the left upper quadrant around the body and tail of the pancreas, between stomach and spleen with extension to the pararenal space (Figure A). What is the etiology of the patient’s intraabdominal hemorrhage? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Many factors affecting the quality of bowel preparation need to be discussed when comparing different regimes.

Many Factors Affecting the Quality of Bowel Preparation Need to be Discussed When Comparing Different Regimes

Low-Residue Diet With Bowel Prep: Not for Everyone!

on chronic liver failure, with sepsis, spontaneous bacterial peritonitis, and variceal bleed being the acute insult on underlying chronic liver disease. Mortality in patients with HE varies from 14 % to 62 % according to the severity of liver disease and the grade of HE, as did the results in our study (lactulose and placebo) group ( 3 – 5 ). Our protocol in this study was to take cultures at the time of admission from the patient ’ s blood, the endotracheal tube if the patient is intubated, the urine, the ascitic fl uid if ascitis is present, and from any central line if present before coming to our hospital. When the patient was admitted in the intensive care unit, repeat cultures were taken every fourth day, and if the patient was in the ward cultures were taken only in case of suspicion of disease. Results of these cultures were available to us within 48 hours and the antibiotics were changed accordingly in both groups within 72 h. However, in case of negative cultures and clinical suspicion of infection, the antibiotics were upgraded. Results of this study showed that a combination of therapy (rifaximin and lactulose) was more eff ective in management of overt HE and it decreased hospital stay and in-hospital mortality. However, we agree with the concerns of Congly et al. ( 1 ) that the results of this study should be verifi ed in large multicentre trials with further follow-up at 1,3, and 6 months.

When It Comes to Gastric Cancer, There Is More to It Than H. pylori !

To the Editor: We read with interest the article by Bae et al. ( 1 ) regarding the eff ect of Helicobacter pylori eradication on metachronous recurrence of gastric cancer. Th e article does not provide adequate information regarding additional factors that may aff ect the recurrence rate of metachronous gastric cancer. We also describe the importance of explaining why a signifi cant percentage of patients were not eradicated and how chromoendoscopy has increased the yield in detecting early gastric cancer compared with conventional methods. Although tobacco use was listed as one of the baseline characteristics, no information regarding the number of pack-years was noted. Several meta-analyses demonstrate the eff ect that smoking has on the development of gastric cancer and that the risk increases signifi cantly with increasing number of pack-years ( 2 ). Obesity has been associated with an increased risk for gastric cancer. In a meta-analysis of cohort studies ( 3 ), excess body weight (body mass index (BMI) ≥ 25 kg / m 2 ) was associated with an increased risk for gastric cancer (odds ratio (OR) = 1.22, 95 % confi dence interval (CI) 1.06 – 1.41) and the strength of the association increased with increasing BMI. In addition, there are associations between gastric cancer and socioeconomic status. Several studies ( 4,5 ) discovered that the risk for distal gastric cancer is increased by approximately twofold in populations with low socioeconomic status, whereas proximal gastric cancers have been associated with higher socioeconomic class. antibiotic resistance, proper education, and fi nancial issues could contribute to eradication failure. Several stains have been used to increase the detection rates of early gastric cancer ( 14 ). It is possible that, without these stains, several cancers that were too small to visualize initially may have been undetected, resulting in synchronous gastric cancers in the follow-up period, which were then subsequently misclassifi ed as metachronous cancer. Two studies have shown the utility of these stains ( 15,16 ). Th e detection rate of early gastric cancers increased from 28 % under standard white-light imaging to 89 % aft er methylene blue-Congo red staining in one study ( 15 ). Th is staining technique also facilitated the detection of carcinomatous foci 4 – 10 mm in size not visible with conventional endoscopy ( 16 ). To conclude, Bae et al. ( 1 ) have conducted an important study, but as mentioned there are several other reasons why patients may have a recurrence of gastric cancer.

Re: proton pump inhibitors and risk for recurrent Clostridium difficile infection among inpatients.

Re: Proton Pump Inhibitors and Risk for Recurrent Clostridium difficile Infection Among Inpatients

Nurse observers: feasible and safe?

To the Editor: Aslanian et al. (1) produced an interesting study highlighting improved adenoma detection rates (ADR) using nurses as second observers during endoscopy in an academic setting.

When It Comes to Reducing Cholesterol, Not All Statins Are the Same

McDermott et al have done well to raise the issue of ptimizing patient compliance with statin therapy to achieve herapeutic goals in the peripheral arterial disease populaion. However, their data did not differentiate between types f lipid-lowering therapy or detail the doses that may have ffected the response to the intervention, although the auhors did document change in dose at 12-month follow-up. If the intervention group had a higher number of patients eceiving rosuvastatin or combination lipid-lowering therpy, one might expect the decrease in low-density lipoproein (LDL) to be more significant. The STELLAR trial revealed that the rosuvastatin group was more likely to achieve LDL 100 mg/dL when compared with patients on atorvastatin, simvastatin, and pravastatin. In a recent metaanalysis of 13 studies with over 5000 patients, it was discovered that a combination of a statin with ezetimibe was more effective in reaching LDL target goals compared with doubling of statins alone. Secondly, the authors document that patients who dropped out were more likely to be older and have a lower educational level. Indeed, in the demographics, the authors document that 12.4% of patients in the intervention group had less than a high school education. Education level also was found to be a significant effect on compliance with osteoporosis medication in a small Turkish trial following patients up over a 3-year period. These are precisely the very groups that need our help and further support as physicians when it comes to health literacy and compliance, and as such, the intervention there-