Clinical Gastroenterology and Hepatology - Articles in Press

Gastrointestinal and hepatic complications of sickle cell disease - Accepted Manuscript

Ellen C. Ebert, Michael Nagar, Klaus D. Hagspiel — 2010-03-08

Abstract: Sickle cell disease (SCD) is an autosomal recessive abnormality of the ß-globin chain of hemoglobin (Hb) resulting in poorly-deformable sickled cells that cause microvascular occlusion and hemolytic anemia. The spleen is almost always affected by SCD with microinfarcts within the first 36 months of life resulting in splenic atrophy.Acute liver disorders causing right-sided abdominal pain include acute vaso-occlusive crisis, liver infarction, and acute hepatic crisis. Chronic liver disease may be due to hemosiderosis and hepatitis and possibly to SCD itself if small, clinically silent microvascular occlusions occur chronically.Black pigment gallstones due to elevated bilirubin excretion are common. Their small size permits them to travel into the common bile duct but cause only low-grade obstruction, so hyperbilirubinemia rather than bile duct dilatation is typical. Whether cholecystectomy should be done in asymptomatic individuals is controversial.The most common laboratory abnormality is an elevation of unconjugated bilirubin. Bilirubin and lactic dehydrogenase levels correlate with one another, suggesting that chronic hemolysis and ineffective erythropoiesis, rather than liver disease, are the sources of hyperbilirubinemia.Abdominal pain is very common in SCD and usually due to sickling which resolves with supportive care. CT scans may be ordered for severe or unremitting pain. The liver typically shows sickled erythrocytes and Kupffer cell enlargement acutely and hemosiderosis chronically. The safety of liver biopsies has been questioned, particularly during acute sickling crisis.Treatments include blood transfusions, exchange transfusions, iron-chelating agents, hydroxyurea, and allogeneic stem-cell transplantation.

Endoscopic ultrasound in a case of widened mediastinum - Accepted Manuscript

Malay Sharma, Aravindh Somasundaram, Balakrishnan Mahadevan — 2010-03-08

Meta analysis shows Colon Capsule Endoscopy is effective in detecting Colorectal polyps - Accepted Manuscript

2010-03-08

Abstract: Background & Aims:: Colon capsule endoscopy (CCE) is a non-invasive and painless technique used to explore the colon without sedation or air insufflation. We performed a systematic review and meta-analysis to assess the accuracy of CCE in detecting colorectal polyps.Methods:: The MEDLINE, EMBASE, and SCOPUS databases were searched, from 2006–2009, for the terms ‘colon capsule’ and ‘Pillcam colon’; searches included abstracts. Studies were included that focused on detecting colorectal polyps with CCE and that were verified using within-subject reference colonoscopy. The risk of bias within each study was ascertained according to QUADAS recommendations. The per-patient sensitivity and specificity were calculated for polyps of any size and for significant findings (polyps ≥6 mm in size or >3 in number). Forest plots were produced based on random-effect models. The risk of bias across studies was assessed using the I2 statistic, meta-regression, and Egger’s test.Results:: Eight studies provided data on 837 patients; the prevalences of polyps and significant findings were 57% and 27.4%, respectively. CCE sensitivity for polyps of any size and significant findings were 71% and 68%, respectively. CCE specificity for polyps of any size and significant findings were 75% and 82%, respectively. High levels of heterogeneity (I2>75%) were not detected. Moderate heterogeneity was partially explained by the different design of individual studies. CCE identified 16 of the 21 cancerous lesions detected by colonoscopy (pooled sensitivity=76%).Conclusions:: CE sensitivity for polyps and significant findings compares favorably with other noninvasive CRC screening strategies. CCE specificity is likely to be underestimated because reference colonoscopy examination results are blinded.

Spontaneous intramural esophageal hematoma in association with ITP: an unusual presentation of non-cardiac chest pain - Accepted Manuscript

Ted Xenodemetropoulos, Khurram J. Khan, Premsyl Bercik — 2010-03-04

Uncorrected Proof

2010-03-03

Upper gastrointestinal bleeding continues to be an evolving area. An international consensus conference convened to update the prior 2003 recommendations. These recommendations included the following: A variety of prognostic scales are available to help stratify patients, and it is recommended to apply those to predict the outcome. Low risk patients with ulcer-related bleeding based on clinical and endoscopic criteria can be discharged promptly after endoscopy. Pre-endoscopic proton pump inhibitor (PPI) therapy can be considered to downstage the endoscopic lesion, thereby reducing the need for endoscopic intervention. Regarding endoscopic management, epinephrine injection alone provides suboptimal efficacy and should be used in combination with another method. High-risk bleeding stigmata should undergo endoscopic treatment. Routine second-look endoscopy is not currently recommended. Continuous infusion PPI therapy should be used to decrease rebleeding and mortality in patients with high-risk ulcer stigmata who have undergone successful endoscopic therapy. Patients with bleeding ulcers should be tested for Helicobacter pylori and receive eradication therapy if present with confirmation of eradication. If a nonsteroidal anti-inflammatory drug (NSAID) is required, a combination of standard NSAID or even Cox-2 agent supplemented by a PPI (the better regimen in the high risk patient) can still result in clinical risk of recurrent bleeding. For those requiring aspirin, aspirin therapy should be restarted as soon as the risks for cardiovascular complication are thought to outweigh the risk for bleeding.

Complications with Pneumatic Dilation - Accepted Manuscript

Fouad J. Moawad, Corinne L. Maydonovitch, John David Horwhat, Roy K.H. Wong — 2010-03-03

Crohn's Disease is a Risk Factor for Preterm Birth - Accepted Manuscript

2010-03-03

Abstract: Background & Aims:: Women with Crohn’s disease (CD) are considered to be at increased risk for adverse outcomes of pregnancy. However, the few studies assessing this risk have had small sample sizes and limitations. We examined outcomes of pregnancy among a large cohort of primiparous women with CD.Methods:: Our population-based prevalence study utilized data from medical birth registries in Sweden and Denmark during the time period of 1994–2006. Linking birth registry data with national patient registries, we identified 2,377 women with a hospital diagnosis of CD prior to delivery and 869,202 women with no diagnosis of CD. Using logistic regression analysis, we estimated relative risks with 95% confidence intervals (CI) for preeclampsia, preterm birth, 5-minute Apgar scores below 7, Cesarean section, small size for gestational age (SGA), stillbirth, and congenital malformations.Results:: Maternal CD was associated with increased risk of moderately and very preterm birth (prevalence odds ratio [POR]=1.76, 95% CI=1.51–2.05 and POR=1.86, 95% CI=1.38–2.52, respectively). Maternal CD was also associated with increased risk for Cesarean section (POR=1.93, 95% CI=1.76–2.12). The strongest associations with CD were observed for pre-labor Cesarean section and induced preterm delivery. Risk of SGA birth was slightly increased among women with CD, especially during the time period of 2002–2006 (POR=1.43, 95% CI= 1.09–1.89). We found no increased risks for preeclampsia, low 5-minute Apgar score, stillbirth, or congenital malformations.Conclusions:: Maternal CD is a risk factor for preterm birth, but not birth defects.

Prevalence, Diagnosis, and Profile of Autoimmune Pancreatitis Presenting with Features of Acute or Chronic Pancreatitis - Accepted Manuscript

Khurram J. Khan — 2010-03-02

Henoch-Schönlein Purpura - Accepted Manuscript

Huan-Lun Hsu, Cheng-Hsiang Hsiao, Kao-Lang Liu — 2010-03-02

Reply. Dr Kisloff - Accepted Manuscript

Spencer D. Dorn — 2010-03-02

Rapid Response to Cognitive Behavior Therapy Predicts Treatment Outcome in Patients With Irritable Bowel Syndrome - Uncorrected Proof

2010-02-18

Background & Aims: Cognitive behavior therapy (CBT) is an empirically validated treatment for irritable bowel syndrome (IBS), yet it is unclear for whom and under what circumstances it is most effective. We investigated whether patients who achieved a positive response soon after CBT onset (by week 4), termed rapid responders (RRs), maintain treatment gains compared with non–rapid responders. We also characterized the psychosocial profile of RRs on clinically relevant variables (eg, health status, IBS symptom severity, distress).Methods: The study included 71 individuals (age, 18–70 y) whose IBS symptoms were consistent with Rome II criteria and were of at least moderate severity. Patients were assigned randomly to undergo a wait list control; 10 weekly 1-hour sessions of CBT; or four 1-hour CBT sessions over 10 weeks. RRs were classified as patients who reported adequate relief of pain, adequate relief of bowel symptoms, and a decrease in total IBS severity scores of 50 or greater by week 4.Results: Of patients undergoing CBT, 30% were RRs; 90% to 95% of the RRs maintained gains at the immediate and 3-month follow-up examinations. Although the RRs reported more severe IBS symptoms at baseline, they achieved more substantial, sustained IBS symptom reduction than non–rapid responders. Both dosages of CBT had comparable rates of RR.Conclusions: A significant proportion of IBS patients treated with CBT have a positive response within 4 weeks of treatment; these patients are more likely to maintain treatment gains than patients without a rapid response. A rapid response is not contingent on the amount of face-to-face contact with a clinician.

Important Elements for the Diagnosis of Drug-Induced Liver Injury - Uncorrected Proof

2010-02-18

Background & Aims: Drug-induced liver disease is the leading cause of acute liver failure in the United States. Accurate reporting of drug-induced liver injury is essential for early detection of hepatotoxicity and for developing reliable, interpretable literature. We assessed the extent to which published case reports of drug-induced liver disease include sufficient clinical data for interpreting the cause of toxicity.Methods: We developed a list of 42 predetermined, specific minimal elements necessary in evaluating causality of drug-induced liver injury. We then analyzed 97 published case reports or series studies of hepatotoxicity from 6 drugs (from 3 classes): amoxicillin/clavulanic acid (n = 35), troglitazone (n = 32), rosiglitazone (n = 10), pioglitazone (n = 8), zafirlukast (n = 8), and montelukast (n = 4).Results: Patient age, sex, primary disease, and drug name were reported in most, if not all, published case reports. However, many elements were underreported; some publications did not mention initial bilirubin levels (12%), many did not provide initial alkaline phosphatase levels (58%), and others provided vague descriptions of how certain diagnoses were excluded, that is, tests for hepatitis A, B, and C were negative. Data on abnormal results from serial liver tests frequently were absent. Exclusions of competing viral etiologies were reported in less than 50% of the studies.Conclusions: Reports of drug-induced liver diseases often do not provide the data needed to determine the causes of the adverse effects. Efforts to promote and include a list of essential diagnostic elements in research articles could increase the quality and clinical utility of published case reports of drug toxicity.

Reduction of Insulin Resistance With Effective Clearance of Hepatitis C Infection: Results From the HALT-C Trial - Uncorrected Proof

2010-02-15

Background & Aims: Hepatitis C virus (HCV) infection is associated with an increased prevalence of diabetes and insulin resistance (IR); whether this is a causal relationship has not been established.Methods: We performed a longitudinal study within the lead-in phase of the Hepatitis C Antiviral Long-Term Treatment against Cirrhosis (HALT-C) Trial to evaluate whether suppression of hepatitis C is associated with improvement in IR. Participants had advanced hepatic fibrosis and carried non-3 HCV genotypes (n = 96). Patients underwent 24 weeks of pegylated interferon and ribavirin therapy and were categorized into HCV clearance groups at week 20 on the basis of HCV RNA levels; null responders had <1 log10 decline (n = 38), partial responders had ≥1 log10 decline (n = 37) but detectable HCV RNA, and complete responders had no detectable HCV RNA (n = 21). The primary outcome was change (week 20 minus week 0) in IR by using the homeostasis model assessment (HOMA2-IR).Results: Adjusting only for baseline HOMA2-IR, mean HOMA2-IR differences were −2.23 (complete responders), −0.90 (partial responders), and +0.18 (null responders) (P = .036). The observed differences in mean HOMA2-IR scores were ordered in a linear fashion across response groups (P = .01). The association between HCV clearance and improvement in HOMA2-IR could not be accounted for by adiponectin or tumor necrosis factor–alpha and was independent of potential confounders including age, gender, ethnicity, body mass index, duration of infection, medications used, and fibrosis.Conclusions: HCV suppression correlates with improvement in IR. These data provide further support for a role of HCV in the development of insulin resistance.

Use of Computed Tomography with Reformatted Imaging to Identify Ingested Drug Packets - Accepted Manuscript

Jörg G. Albert, Thomas Vogel, Stefan Zeuzem, Jörg Bojunga — 2010-02-15

Eosinophilic Cholangitis - Accepted Manuscript

Derek DuBay, Nirag Jhala, Mohamad Eloubeidi — 2010-02-15

Low dose maintenance therapy with infliximab prevents postsurgical recurrence of Crohn’s disease - Accepted Manuscript

2010-02-08

Abstract: Background & Aims:: Infliximab might prevent post-surgical recurrence of Crohn’s disease. However, it is unclear whether long term therapy with this drug is necessary and whether alternative strategies could be applied, to minimize potential side effects and reduce the costs of treatment.Methods:: We performed a prospective cohort study in 12 consecutive patients, treated immediately after surgery with maintenance infliximab (5 mg/Kg), who did not have clinical or endoscopic evidence of disease recurrence after 24 months; they were followed for an additional year. Treatment with infliximab was then discontinued; patients with disease recurrence, based on endoscopy results (Rutgeerts score ≥2), were given lower doses of infliximab (starting with 1 mg/Kg) in an attempt to re-establish mucosal integrity. Surrogate markers of disease activity (fecal calprotectin [FC], CRP, and ESR) were assessed after each dose of infliximab.Results:: None of the patients had clinical or endoscopic recurrence of Crohn’s disease 3 years after surgery. However, discontinuation of infliximab therapy caused endoscopic recurrence after 4 months in 10/12 patients (83%). All these 10 patients were then treated again with infliximab which, at a dose of 3 mg/Kg every 8-week, restored and mantained mucosal integrity for 1 year. Among the surrogate markers, FC levels correlated with endoscopic scores (Wald test, p < 0.0001).Conclusions:: Long-term maintenance therapy with infliximab is required to maintain mucosal integrity in patients following surgery for Crohn’s disease. However, a dose of 3 mg/Kg (a 40% reduction from the standard dose) was sufficient to avoid disease recurrence, determined by endoscopy, in all patients at one year. FC levels correlate with mucosal status at different infliximab doses.

Sildenafil has no Effect on Portal Pressure but Lowers Arterial Pressure in Patients With Compensated Cirrhosis - Accepted Manuscript

2010-02-08

Abstract: The reduction of portal pressure in patients with early compensated cirrhosis may be more responsive to drugs increasing intrahepatic vasodilatation than those reducing portal venous inflow. The PDE-V inhibitor sildenafil can potentially reduce portal pressure by decreasing intrahepatic resistance, but its systemic vasodilatory effects may be deleterious.Aim:: Evaluate the effect of sildenafil on systemic and portal hemodynamics in an open-label pilot study.Results:: Twelve patients with compensated cirrhosis and baseline hepatic venous pressure gradient (HVPG) >5 mmHg received 25mg of oral sildenafil. Mean arterial pressure(MAP), heart rate (HR) and HVPG were repeated after 30 and 60 minutes and in 9/12 patients at 90 minutes (after an additional 25mg of sildenafil). HVPG tracings were read by 3 blinded observers.Results:: All 12 patients were Child A with median MAP 92 mm Hg(83-94) and median HVPG 10.4 mmHg(6.6-13.0). While MAP decreased significantly at all time points, sildenafil had no effect on HVPG.Conclusion:: As shown with other vasodilators, in compensated cirrhotic patients, sildenafil at therapeutic doses for erectile dysfunction reduces MAP without reducing portal pressure. The search should continue for specific intrahepatic vasodilators.

Abdominal Visceral Adipose Tissue Predicts Risk of Colorectal Adenoma in Both Sexes - Accepted Manuscript

2010-02-08

Abstract: Background & Aims:: Small studies have shown inconsistent results regarding the association between abdominal visceral adipose tissue and colorectal adenomas. We evaluated the effects of visceral adipose tissue volume on the development and growth of colorectal adenomas.Methods:: A total of 3922 participants underwent colonoscopy and computed tomography from February to November 2008. The associations between waist circumference, visceral adipose tissue volume, and colorectal adenomas were estimated with adjusted odds ratios (OR) and 95% confidence intervals (CI). In addition, the association between characteristics of colorectal adenomas and visceral adipose tissue volume were evaluated.Results:: Compared with participants who had visceral adipose tissue volume < 500 cm3, the OR for colorectal adenoma was 1.09 (95% CI, 0.87 to 1.36) for volume of 500–999 cm3, 1.33 (95% CI, 1.04 to 1.69) for volume of 1000–1499 cm3, and 1.43 (95% CI, 1.06 to 1.94) for volume ≥ 1500 cm3. The risk of colorectal adenomas increased with increasing visceral adipose tissue volume in both sexes (P trend = .004 in men and .009 in women). Waist circumference was associated with colorectal adenomas in men (P trend = .02), but not in women. High volume of visceral adipose tissue (≥1000 cm3) had a positive association with larger adenomas (≥10 mm) and multiple adenomas.Conclusions:: Abdominal visceral adipose tissue volume can contribute to the development and growth of colorectal adenomas, and it was a better predictor for risk of colorectal adenomas than body mass index or waist circumference in both sexes.

Tension Hemothorax: A Dreaded Complication of Percutaneous Liver Biopsy - Uncorrected Proof

Ka–Ho Lok, Kin–Kong Li — 2010-02-08

A 52-year old man was admitted to our hospital for percutaneous liver biopsy. The indication was to assess his fibrosis stage to determine his treatment for genotype 1b chronic hepatitis C. Informed consent was obtained. Prebiopsy preparation was performed in accordance with recent guidelines. The optimal position for needle puncture was marked with ultrasound guidance. The patient was taught to hold his breath in full expiration immediately before biopsy. The liver biopsy was performed with a 16G spring-loaded cutting needle. The first needle pass yielded a small amount of darkish tissue of uncertain nature. A second needle pass was attempted and a core of liver tissue was obtained. The patient developed hypovolemic shock 2 hours after the procedure. He did not complain of any abdominal pain or shortness of breath. Immediate assessment with bedside abdominal ultrasound did not reveal any free intra-abdominal fluid. An urgent computerized tomography scan showed a massive right hemothorax with tension effect. Active contrast extravasation was noted in the right lower lobe of the lung (). An aggressive blood transfusion was given and a chest drain was inserted to relieve the tension effect. An emergent thoracotomy was performed. Laceration of the medial basal segment of the right lower lobe of the lung was found. Hemostasis was achieved by suturing the parenchymal tear. The patient recovered uneventfully after the surgery. The liver biopsy result was a stage 2 liver fibrosis (Metavir scale) compatible with chronic hepatitis C. A small piece of normal lung tissue (length, 3 mm) also was included in the liver biopsy specimen (Figure B).

Pancreatic Endocrine Carcinoma Protruding From the Major Papilla - Uncorrected Proof

Junko Umeda, Takao Itoi, Nobuhito Ikeuchi — 2010-02-08

A 33-year-old man presented with obstructive jaundice and fever. Duodenoscopy revealed a tumor protruding from the papilla of Vater ( A). However, biopsy specimens showed only necrotic tissue. Abdominal computed tomography showed an enhanced pancreatic head mass and dilated PD. But we could not find any relationship between primary mass and an intraductal tumor (IDT) in the PD. Endoscopic ultrasound examination showed a dilated bile duct and a hypoechoic mass in the main pancreatic duct (PD) ( B) continuous with a 30-mm hypoechoic primary mass (t) ( C) in the head of the pancreas. Endoscopic retrograde pancreatography revealed a PD filling defect. Because we thought an IDT derived from pancreatic endocrine tumor caused occlusion of a bile duct, pylorus-preserving pancreaticoduodenectomy was performed. Macroscopic findings showed a solid tumor in the head of pancreas continuous with an IDT in the PD. The macroscopic findings showed the yellowish mass in the PD continuous with a primary mass ( D). The microscopic findings revealed tumor cells showing round-shape nuclear, were arranged in a neuroendocrine tumor pattern such as trabecular, and ribbon-like appearance both in a primary tumor ( E, H&E staining, magnification, 400×) and an intraductal tumor ( F, H&E staining, left upper corner, magnification, 400×). The surface of an intraductal tumor at the duodenal portion was covered by thick necrotic tissue ( F, H&E staining, magnification, 1×). Immunohistochemical staining was positive for chromogranin A ( G, magnification, 400×) but negative for insulin, glucagon, gastrin, somatostatin, and pancreatic polypeptide. The Ki-67 labeling index was 15%. The final diagnosis was well-differentiated endocrine carcinoma. The patient recovered uneventfully and 1 year after surgery there has been no recurrence or any symptoms.

Encapsulating Peritoneal Sclerosis - Uncorrected Proof

Huan–Lun Hsu, Kao–Lang Liu, Jenq–Wen Huang — 2010-02-08

A 31-year-old woman had been treated with peritoneal dialysis (PD) for 10 years after bilateral nephrectomy for renal transitional cell carcinoma. The PD catheter was removed in March of 2009 because of refractory fungal peritonitis and she switched to hemodialysis. Six months later, the patient reported abdominal pain, anorexia, and weakness. On physical examination, her abdomen was distended, diffuse tenderness without guarding or rebound was present, and bowel sounds were hypoactive. The laboratory findings were unremarkable except for an increased C-reactive protein level (16.8; normal level, <0.8 mg/dL). A non–contrast-enhanced computed tomography scan () showed massive and loculated ascites in the peritoneal cavity with small bowels encapsulated. Magnetic resonance imaging (Figure B) further showed the thickened peritoneal membrane, and the bowel loops were encased within a cocoon-like sac rather than floating in the ascites. Encapsulating peritoneal sclerosis (EPS) was diagnosed and we treated the patient with tamoxifen plus prednisolone. She improved and the amount of ascites decreased.

The Hide-Bound Bowel - Uncorrected Proof

Seth Sweetser, Michael D. Leise — 2010-02-08

A 47-year-old woman with scleroderma was referred for evaluation of recurrent episodes of small-bowel obstruction. Physical examination revealed sclerodactyly and the abdomen was distended with tympany to percussion and a paucity of bowel sounds. On computed tomographic enterography there was dilatation of the entire small bowel with narrow separation between valvulae conniventes ( A and B; arrows). This radiographic finding is termed the hide-bound bowel sign and is the radiographic representation of the smooth muscle atrophy and fibrosis that occurs as a result of foreshortening of small bowel in scleroderma. The description “hide-bound” originally was used to describe the thickened and adherent skin changes of scleroderma given the similarity to the skin of cattle. The term subsequently was applied to the characteristic mucosal fold pattern in the small bowel. This radiographic sign illustrates the underlying pathologic process of scleroderma characterized by widespread collagen deposition with resultant tissue and organ fibrosis. Small intestinal involvement may lead to delayed transit, dilatation of small-bowel loops, and secondary bacterial overgrowth. Our patient was given a diagnosis of intestinal pseudo-obstruction based on history and radiographic findings. She was treated conservatively with dietary modification and given antibiotics for small-bowel bacterial overgrowth.

Exam 1: The Role of Colonoscopy and Other Procedures in the Management of Acute Lower Intestinal Bleeding - Uncorrected Proof

Charles O. Elson — 2010-02-08

Exam 2: Reduced Hospitalization Cost for Upper Gastrointestinal Events That Occur Among Elderly Veterans who Are Gastroprotected - Uncorrected Proof

Charles O. Elson — 2010-02-08

Reply - Uncorrected Proof

George Triadafilopoulos, Gaurav Arora, Gurkirpal Singh — 2010-02-08

We very much appreciate the comments of van Oijen and colleagues regarding our article on the gastroduodenal damage of aspirin and welcome their overview and suggestions in their submitted Table. We based our suggestion in Figure 2 of our article on evidence that enteric-coated aspirin reduces acute gastric mucosal injury to placebo levels, despite its inhibition of prostaglandin synthesis. Hence our approach represents an appropriate strategy for the prevention of gastric mucosal damage and possible complications, not necessarily dyspepsia only. In a double blind study by Dammann HG et al, enteric-coated aspirin 100 mg/day caused significantly less gastro-duodenal damage over 7 days than the same dose of plain aspirin, when given to healthy subjects. In another short-term study in healthy volunteers, gastric toxicity from aspirin was largely topical, independent of inhibition of prostaglandin synthesis, and could be virtually eliminated by the use of an enteric-coated preparation. At least 5 randomized controlled trials of healthy volunteers undergoing endoscopy after a period of either enteric-coated aspirin or plain aspirin administration all demonstrated a clear reduction of gastric mucosal injury. Further studies will be undoubtedly necessary to clarify these issues while individual patient tolerability and risk will continue to play a role in our decision-making. In the meantime, the suggestion of van Oijen et al is welcome.

Success of self-administered home fecal transplantation for chronic Clostridium difficile infection - Accepted Manuscript

Michael S. Silverman, Ian Davis, Dylan R. Pillai — 2010-02-01

Abstract: Clostridium difficile infection (CDI) can relapse in patients with significant comorbidities. A subset of these patients becomes dependent on oral vancomycin therapy for prolonged periods with only temporary clinical improvement. These patients incur significant morbidity from recurrent diarrhea and financial costs from chronic antibiotic therapy. We sought to investigate whether self- or family-administered fecal transplantation could be used to definitively treat refractory CDI. We report a case series (n=7) where 100% clinical success was achieved in treating these individuals with up to 14 months follow up.

High Risk Ulcer Bleeding: When Is Second-Look Endoscopy Recommended? - Uncorrected Proof

Philip Wai Yan Chiu, Joseph Jao Yiu Sung — 2010-02-01

A 78-year-old gentleman with background history of ischemic heart disease and diabetes mellitus, presents with passage of tarry stool for 2 days. He is taking regular aspirin 80 mg daily. Upon admission he has blood pressure of 90/60 and pulse rate of 120 beats per minute. An emergency upper endoscopy performed at 3 am by the on-call gastrointestinal fellow showed a visible vessel beneath a 2 cm gastric ulcer (A). There was 500 ml of fresh blood in the fundus obscuring the endoscopic view. Endoscopic injection of epinephrine followed by application of hemoclips achieved hemostasis (B and C). He is given intravenous omeprazole infusion 80 mg bolus followed by 8 mg per hour for 72 hours. A second endoscopy was scheduled and performed on the next day which showed persistent stigmata of visible vessel. Endoscopic therapy with further injection of epinephrine and heater probe is applied. Rapid urease test results are negative and the ulcer biopsy confirmed benign gastric ulcer. He sustained an episode of acute coronary syndrome with elevation of troponin on day 5 after the ulcer bleeding and aspirin was restarted. He is discharged from hospital 3 weeks afterwards without rebleeding.

Langerhans Cell Histiocytosis of the Stomach Mimicking Early Gastric Cancer - Uncorrected Proof

Yuichi Nozaki, Hisashi Oshiro, Atsushi Nakajima — 2010-02-01

A 48-year-old man was admitted to our hospital for further examination of an abnormality detected on an upper gastrointestinal (GI) examination. He had no symptoms and his vital signs were normal. Physical examination revealed no abnormalities. Laboratory examination findings also mostly were normal. Upper-GI endoscopy showed a superficially elevated reddish lesion, less than 1 cm at the lesser curvature, in the region of the body of the stomach, suggestive of early gastric cancer, type 0-IIa (). A tumor biopsy was performed and the histopathologic findings revealed many histiocytoid cells with indented nuclei and abundant eosinophilic infiltration in the lamina propria of the mucosa (). Immunohistochemically, the majority of the cells were strongly and diffusely positive for CD1a () and S-100, and negative for cytokeratin. We therefore made the diagnosis of Langerhans cell histiocytosis (LCH) of the stomach. The presence of systemic lesions was excluded by further exploratory examinations, including capsule endoscopy, fiberoptic colonoscopy, computed tomography, magnetic resonance imaging, and 67Ga-scintigraphy. After obtaining informed consent from the patient, conservative treatment was begun and the patient has been followed up for more than a year without any evidence of disease progression.

Letter to the Editor - Uncorrected Proof

Charles Maltz — 2010-02-01

Dear Editor: I was shocked to see a quote by a Nazi General, Heinz Guderian, chosen by Dr George Triadafilopoulos as the lead in to his editorial on treatment of Barrett's esophagus containing early neoplasia, Blitzkrieg for Barrett's Esophagus Containing Early Neoplasia, in the January 2010 issue of Clinical Gastroenterology and Hepatology. Is Dr Triadafilopoulos not aware that General Guderian commanded the initial invasion forces that attacked Poland starting World War II, as well as Panzergruppe 2 in its criminal invasion of the Soviet Union in 1941? Among his other activities he served on an army court that expelled hundreds of German officers thought to be opposed to Hitler's policies after the plot against Hitler in 1944. These officers were then turned over to the notorious people's court with many being executed. It is true he was not tried as a war criminal, although this was protested by both the Polish and Soviet governments. Although Guderian had his quarrels with Hitler leading to his eventual dismissal from the army, these related to disagreements about military tactics. He had no quarrel with Hitler's murderous criminal policies which led to the killing of millions. I would hope Dr Triadafilopoulos can find a more suitable quote (and more suitable title) for his editorial. I would also suggest avoiding another Guderian quote: “It is decisive to completely destroy Warsaw.”

What Are the Risks of General Surgical Abdominal Operations In Patients With Cirrhosis? - Uncorrected Proof

J. Michael Henderson — 2010-02-01

The report in this issue from the Mount Sinai group on “Improved patient selection and operative outcome following abdominal operations in patients with advanced cirrhosis,” raises old, and new questions. What are the salient points, and are there indeed new lessons to learn along this oft trod path? The main lessons for the general surgeon faced with this problem and for the gastroenterologist and/or hepatologist asked to help take care of such patients are in patient selection and management.

Diaphragm-Like Stricture of the Small Intestine Related to Cytomegalovirus Infection - Uncorrected Proof

Takahiro Shimizu, Hiroyuki Marusawa, Yukitaka Yamashita — 2010-02-01

A53-year-old man was referred to our hospital for evaluation of fever, abdominal pain, diarrhea, and vomiting approximately 1 year after receiving an allogeneic bone marrow transplantation for acute myeloid leukemia. Laboratory studies revealed a normal white blood cell count (5.4 × 109/L), but an increased C-reactive protein level (8.3 mg/dL). Computed tomography revealed an area of increased wall thickness indicating an ileocecal lesion suspicious for graft-versus-host disease or infectious enterocolitis. A colonoscopy revealed multiple erosions and small ulcers in the ileum and a circumferential diaphragm-like stricture caused by an ulcer approximately 5 cm from the oral side of the terminal ileum ( A), whereas the colon mucosa was normal. Based on biopsy of the strictured lesion that revealed a cytomegalic inclusion ( B, arrow) and a blood test that revealed circulating cytomegalovirus (CMV) antigenemia (9 pp65-positive peripheral blood leukocytes/5 × 104 cells), the patient was diagnosed with CMV infection. Intravenous ganciclovir did not improve his symptoms and a small-bowel series with contrast medium revealed at least 2 strictured lesions in the distal ileum. Therefore, the diseased segment was resected by laparotomy. The resected specimen included multiple ulcers with 2 stenotic lesions with a thickened wall ( C, arrow) and a number of cytomegalic inclusions were detected around the ulcers.

Level of Fellowship Training Increases Adenoma Detection Rates - Uncorrected Proof

Stevany L. Peters, Aliya G. Hasan, Nichole B. Jacobson, Gregory L. Austin — 2010-02-01

Background & Aims: The adenoma detection rate (ADR) is critical to the success of colonoscopy for colorectal cancer screening. The effects of involving gastroenterology fellows in screening colonoscopies are uncertain. We assessed the effects of gastroenterology fellow participation on ADR and whether outcomes vary with year of fellowship training.Methods: We performed a retrospective review of all average-risk screening colonoscopies performed from April 2005–April 2007 at the University of Colorado Hospital. A gastroenterology attending physician alone performed 2895 colonoscopies; 699 were performed by a gastroenterology fellow supervised by an attending physician. Statistical analyses of polyp, adenoma, and advanced adenoma (or cancer) detection were performed by using logistic regression.Results: The ADR was significantly higher (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.10–1.59) among colonoscopies that included a gastroenterology fellow compared with those performed by only a gastroenterology attending physician. Similarly, the polyp detection rate was higher (OR, 1.28; 95% CI, 1.08–1.52) among colonoscopies involving a gastroenterology fellow. There was no difference in the detection of advanced adenomas or cancers (OR, 1.05; 95% CI, 0.77–1.44) among colonoscopies involving a gastroenterology fellow. The ADR differed greatly by year of training. Compared with colonoscopies performed by an attending gastroenterologist alone, the ADR increased with each year of training: OR, 0.89 (95% CI, 0.66–1.22) for first-year fellows; OR, 1.31 (95% CI, 0.89–1.93) for second-year fellows; and OR, 1.70 (95% CI, 1.33–2.17) for third-year fellows.Conclusions: Involvement of fellows in screening colonoscopies increases the ADR, primarily because of the increased ADR in procedures involving third-year gastroenterology fellows.

Continuous Therapy With Certolizumab Pegol Maintains Remission of Patients With Crohn's Disease for up to 18 Months - Uncorrected Proof

2010-02-01

Background & AIMS: The safety and efficacy of maintenance therapy with the anti–tumor necrosis factor antibody fragment certolizumab pegol has not been reported beyond 6 months. We assessed the long-term efficacy, safety, and immunogenicity of continuous versus interrupted maintenance therapy with subcutaneous certolizumab pegol in patients with Crohn's disease.Methods: Patients who responded to induction therapy at week 6 of the PEGylated Antibody Fragment Evaluation in Crohn's Disease: Safety and Efficacy (PRECiSE) 2 trial were assigned randomly to groups given certolizumab pegol (continuous) or placebo (drug-interruption) during weeks 6 to 26. Patients who completed PRECiSE 2 were eligible to enter PRECiSE 3, an ongoing, open-label extension trial in which patients have received certolizumab pegol (400 mg) every 4 weeks for 54 weeks to date (total, 80 wk). Disease activity was measured by the Harvey–Bradshaw Index. PRECiSE 3 is a prospective trial in which patients received continuous or interrupted anti–tumor necrosis factor-α therapy longer than 12 months and were not offered the option to increase their dose.Results: Harvey–Bradshaw Index responses at week 26 for the continuous and drug-interruption groups were 56.3% and 37.6%, respectively; corresponding remission rates were 47.9% and 32.4%, respectively. Of patients responding at week 26, response rates at week 80 in the continuous and drug-interruption groups were 66.1% and 63.3%, respectively; among patients in remission at week 26, week 80 remission rates were 62.1% and 63.2%, respectively. More patients in the drug-interruption group developed antibodies against certolizumab pegol (and had lower plasma concentrations of certolizumab pegol) than the continuously treated group.Conclusions: Certolizumab pegol effectively maintains remission of Crohn's disease for up to 18 months. Continuous therapy is more effective than interrupted therapy.

Correlation Between the Crohn's Disease Activity and Harvey–Bradshaw Indices in Assessing Crohn's Disease Severity - Corrected Proof

2010-01-21

Background & Aims: Clinical trials of Crohn's disease generally use the Crohn's Disease Activity Index to assess disease activity; these calculations are complex, time-consuming, and impracticable. We investigated whether a simpler tool, the Harvey–Bradshaw Index, was equally effective in assessing disease severity.Methods: Crohn's Disease Activity and Harvey-Bradshaw Index scores were collected from 2 large multicenter Crohn's disease studies. The PEGylated antibody fragment evaluation in Crohn's disease: safety and efficacy (PRECiSE) 1 and 2 trials assessed efficacy and tolerability of certolizumab pegol (PEGylated, humanized, Fab' fragment of an antitumor necrosis factor α antibody). PRECiSE 1 and 2 data were analyzed to determine if results from the Crohn's Disease Activity Index correlated with those from the Harvey-Bradshaw Index criteria for defining response and remission.Results: Analysis of almost 1000 data pairs showed a positive correlation between scores. The correlation between the indices for pooled data from PRECiSE 1 and PRECiSE 2 was 0.800 (Spearman correlation coefficient). The correlations between indices for the PRECiSE 1 or PRECiSE 2 were 20.698 and 0.716, respectively (Kronecker product variance). A 3-point change in the Harvey-Bradshaw Index score corresponded to a 100-point change in the Crohn's Disease Activity Index (clinical response); scores ≤4 points corresponded to a Crohn's Disease Activity Index score ≤150 points (clinical remission).Conclusions: Results from the Crohn's Disease Activity Index correlate with those from the Harvey-Bradshaw Index; use of the Harvey-Bradshaw Index might permit simpler Crohn's disease activity assessment in long-term clinical trials, and facilitate standardized disease activity measurements and cross-center comparisons.

Reduced Hospitalization Cost for Upper Gastrointestinal Events That Occur Among Elderly Veterans Who Are Gastroprotected - Corrected Proof

Neena S. Abraham, Christine Hartman, Jennifer Hasche — 2010-01-21

Background & Aims: Despite prescription of gastroprotection among elderly nonsteroidal anti-inflammatory drug (NSAID) users, residual bleeding can still occur. We sought to determine the effect of proton pump inhibitors (PPI) on hospitalization and resource use among veterans in whom an upper gastrointestinal event (UGIE) occurred.Methods: We identified from national pharmacy records veterans ≥65 years prescribed an NSAID, cyclooxygenase-2 selective NSAID (coxib), or salicylate (>325 mg/day) at any Veterans Affairs (VA) facility (01/01/00–12/31/04). Prescription fill data were linked longitudinally to a Veterans Affairs-Medicare dataset of inpatient, outpatient, and death files, and demographic and provider data. Among veterans in whom a UGIE occurred, we assessed the effect of prescription strategy on hospitalization, using a multivariate logistic regression model.Results: A total of 3566 UGIEs occurred among a cohort that was predominantly male (97.5%), white (77%), with a mean age of 73.5 (SD, 5.7). Hospitalization occurred in 47.5%, and gastroprotection was associated with a 30% reduction in hospitalization compared with no PPI. Five-year pharmacy costs associated with the PPI strategy exceeded the no-PPI strategy ($742,406 vs $184,282); however, a substantial reduction in medical costs was observed with PPI ($9,948,738 vs $18,686,081).Conclusions: Even if an NSAID-UGIE occurs in the PPI-protected older veteran, the reduction in need for hospitalization results in a cost saving to the Department of Veterans Affairs.

Duodenal Ulceration Following Variceal Embolization with Coils and Vascular Plugs - Uncorrected Proof

Anshu Mahajan, Sean C. Kumer, Andrew Y. Wang — 2010-01-07

A 28-year-old woman with congenital hepatitis C-induced cirrhosis underwent orthotopic living-donor liver transplant, which was complicated by a biliary leak that was repaired via Roux-en-Y hepaticojejunostomy. Her postoperative course was further complicated by recurrent episodes of gastrointestinal bleeding. She was initially found to have a splenic artery aneurysm that was embolized. One month later, an evaluation for melena revealed large duodenal varices, and the patient underwent transjugular intrahepatic portosystemic shunting (TIPS) and simultaneous embolization of the duodenal varices utilizing a combination of coils and Amplatzer vascular plugs (AGA Medical Corporation, Plymouth, MN).

Gastric Anisakiasis - Uncorrected Proof

Mamatha Bhat, Paul Cleland — 2010-01-07

A 40-year-old Inuk woman was seen at the Gastroenterology clinic in northern Quebec, Canada, for marked epigastric pain of 3 days duration. There was associated fatigue and malaise. She also complained of mild anorexia and a 10 lb weight loss over a few weeks. In the past 2 months, she had been found to have a microcytic anemia with an iron deficiency profile and stools positive for occult blood. She was known for Type 2 diabetes and a history of pulmonary tuberculosis. She lived in a small village, and had eaten raw arctic char fished from a local river 2 weeks prior to developing pain. The patient had not consumed any other raw meat or fish products in the preceding few months, and had not traveled elsewhere. Physical examination was unremarkable except for mild diffuse abdominal tenderness. Blood tests were significant for a Hgb of 100 g/L and mean corpuscular volume of 71.6 fmol with no peripheral eosinophilia.

Necrolytic Migratory Erythema Due To Glucagonoma - Uncorrected Proof

Guido Michels, Dirk Nierhoff, Hans-Michael Steffen — 2010-01-07

A 66-year-old patient presented with weight loss (10 kg in 2 years), anemia, diabetes mellitus, and skin manifestations on the lower abdomen (), lower extremities (), and genital areas.

Increased Incidence of Small Intestinal Bacterial Overgrowth During Proton Pump Inhibitor Therapy - Uncorrected Proof

Lucio Lombardo, Monica Foti, Olga Ruggia, Andrea Chiecchio — 2010-01-07

Background & AIMS: Proton pump inhibitors (PPIs) can cause diarrhea, enteric infections, and alter the gastrointestinal bacterial population by suppressing the gastric acid barrier. Among patients that received long term PPI treatment, we evaluated the incidence of small intestinal bacterial overgrowth (SIBO; assessed by glucose hydrogen breath test [GHBT]), the risk factors for development of PPI-related SIBO and its clinical manifestations, and the eradication rate of SIBO after treatment with rifaximin.Methods: GHBTs were given to 450 consecutive patients (200 with gastroesophageal reflux disease who received PPIs for a median of 36 months; 200 with irritable bowel syndrome [IBS], in absence of PPI treatment for at least 3 years; and 50 healthy control subjects that had not received PPI for at least 10 years). Each subject was given a symptoms questionnaire.Results: SIBO was detected in 50% of patients using PPIs, 24.5% of patients with IBS, and 6% of healthy control subjects; there was a statistically significant difference between patients using PPIs and those with IBS or healthy control subjects (P < .001). The prevalence of SIBO increased after 1 year of treatment with PPI. Bloating and weight loss were more frequent among patients with PPI-related SIBO than those with IBS-related SIBO. The eradication rate of SIBO was 87% in the PPI group and 91% in the IBS group.Conclusions: SIBO, assessed by GHBT, occurs significantly more frequently among long term PPI users than patients with IBS or control subjects. High dose therapy with rifaximin eradicated 87%–91% of cases of SIBO in patients who continued PPI therapy.

Gluten-Free Diet and Steroid Treatment Are Effective Therapy for Most Patients With Collagenous Sprue - Uncorrected Proof

2010-01-07

Background & aims: Collagenous sprue (CS) is characterized by the presence of a distinctive band of subepithelial collagen deposition in the small bowel. We evaluated the clinical characteristics, treatments, and outcomes of patients with CS.Methods: Thirty patients with CS were identified at the 3 Mayo Clinic sites between 1993 and 2009. Clinical data from medical records were reviewed.Results: The study cohort was 70% female (age range, 53–91 years). Most patients had severe diarrhea and weight loss. Hospitalization to treat dehydration was necessary in 16 (53%) patients. Associated immune-mediated diseases were noted in 70% of the patients; celiac disease was the most frequent. Other associated diseases were microscopic colitis, hypothyroidism, and autoimmune enteropathy. The median thickness of the layer of subepithelial collagen deposition in the small bowel was 29 μm (20–56.5 μm). Subepithelial collagen deposition in the colon or stomach was noted in 8 patients. A clinical response was observed in 24 (80%) patients after treatment with a combination of a gluten-free diet and immunosuppressive drugs. Histologic improvement was confirmed in 9 patients, with complete remission in 5. Two patients died (1 of complications of CS and 1 of another illness).Conclusions: Most patients with CS are treated effectively with a combination of gluten-free diet and steroids. CS is often associated with collagen deposition or chronic inflammation in other segments of the gastrointestinal tract as well as other immune-mediated disorders.

Systematic Review of the Quality of Patient Information on the Internet Regarding Inflammatory Bowel Disease Treatments - Corrected Proof

2010-01-07

Background & aims: Patients use the Internet as a resource for information about their diseases. A systematic review evaluating the quality of information available for inflammatory bowel disease patients on the Internet regarding treatment options was performed.Methods: Google was used to identify 50 websites on 3 occasions. A data quality score (DQS) (potential score, 0–76) was developed to evaluate the content of websites that scores patient information on indications, efficacy, and side effects of treatment. Other outcome measures were a 5-point global quality score, a drug category quality score, the DISCERN instrument, a reading grade level score, and information about integrity.Results: The median DQS was 22, range 0–74, median global quality score was 2.0, and median Flesch-Kincaid reading grade level was 12.0, range 6.9–13.7. Eight websites achieved a global quality score of 4 or 5. The DQS was highly associated with the global quality score (r = 0.82) and the DISCERN instrument (r = 0.89). There was poor association between the DQS and the rank order in all 3 Google searches. Information on funding source (59%) and date of last update (74%) were often lacking.Conclusions: There is marked variation in the quality of available patient information on websites about the treatment options for Crohn's disease and ulcerative colitis. Few websites provided high quality information. There is a need for high quality accredited websites that provide patient-oriented information on treatment options, and these sites need to be updated regularly.

Reflux Is Unlikely to Occur During Stable Sleep - Uncorrected Proof

John Dent — 2010-01-07

Dear Editor: Regrettably, the article by Gagliardi et al in the September 2009 issue of Clinical Gastroenterology and Hepatology inappropriately reinforces, both in its title and in its contents, the unproven assertion that reflux occurs during stable sleep. Also regrettably, the accompanying editorial by Harding endorses the concept that nocturnal reflux occurs predominantly during stable sleep, even though the important interaction of sleep with transient lower esophageal relaxations is recognized in this editorial.

Osteonecrosis and Panniculitis as Life-Threatening Signs - Corrected Proof

Masaki Kuwatani, Hiroshi Kawakami, Yosuke Yamada — 2010-01-07

A 58-year-old male presented with polyarthritis in the bilateral wrists and ankles, and elevated serum pancreatic enzymes (amylase, 4292 IU/L; lipase, 6000 IU/L). He previously had several episodes of acute pancreatitis, and had undergone cholangiojejunostomy for alcoholic chronic pancreatitis with a pseudocyst and stricture of the lower bile duct 6 years ago. Although pancreatic enzymes were temporarily normalized, roentgenograms exhibited osteonecrosis in 4 extremities 1 year after the development of polyarthritis (). Examination of a biopsy specimen of the left femur revealed intraosseous fat necrosis. A computerized tomography scan performed just before admission to our department revealed slight dilatation of the main pancreatic duct and a cystic lesion adjacent to the superior mesenteric vein (SMV) in the pancreas head (). On admission, serological examinations indicated liver and renal dysfunction (elevated serum levels of aspartate aminotransferase [238 IU/L], alanine aminotransferase [167 IU/L], γ-glutamyltransferase [101 IU/L], blood urea nitrogen [49 mg/dL], and creatinine [1.9 mg/dL]), and elevated levels of pancreatic enzymes (amylase, 7966 IU/L; lipase, 12,904 IU/L). Physical findings were erythema in the abdomen () and purpura in bilateral lower extremities. Renal dysfunction rapidly exacerbated and he died 5 days after admission to our department. After informed consent from his family, autopsy was done. Gross findings of specimens of the pancreas head and the peripancreatic tissue showed a fistula between the cystic lesion in the pancreas head and SMV, and exposure of debris from the cystic lesion. Microscopically, the cystic lesion was a pseudocyst connecting to the SMV, and the debris was protein plaque. The pancreas tissue surrounding the lower bile duct showed fibrous change and atrophy of the acini. In the kidneys, glomerular crescent formation was diffusely found, and a part of basement membrane was necrotic. In the skin, fibrinoid changes and infiltration of inflammatory cells were found in the walls of small arteries, and there was nodular fat necrosis with calcification (), which was also found in other organs including gastric subserosa and bone marrow. Finally, we made a diagnosis of pancreatitis, panniculitis, and polyarthritis (PPP) syndrome caused by pancreatic pseudocyst-portal vein fistula.

Positive Response to Steroid Therapy for Autoimmune Pancreatitis Evaluated With Fluorodeoxyglucose Positron Emission Tomography - Corrected Proof

Kensuke Takuma, Terumi Kamisawa, Takao Itoi — 2010-01-07

A 45-year-old man with a history of excessive alcohol consumption visited a general practitioner due to sudden severe abdominal and back pain. Moderately elevated serum amylase indicated acute pancreatitis. Although the symptoms were relieved by conservative medical management within a few days, he was referred to our hospital because a computerized tomography (CT) scan revealed a mass in the pancreatic tail. A detailed CT scan showed an enlarged pancreas with encasement of the splenic artery, obstruction of the splenic vein, a growth that had invaded the retroperitoneum (), a hepatic mass of 2 cm, and parabronchial lymphadenopathy. The main pancreatic duct was not detected in the pancreatic tail on magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP) failed. The pancreatic and hepatic lesions appeared as high-intensity areas on diffusion-weighted magnetic resonance imaging (MRI). Positron emission tomography (PET) scans also revealed intense fluorodeoxyglucose (FDG) uptake in the pancreatic ( and , long arrow) and hepatic lesions (, short arrow), as well as in the parabronchial and mediastinal lymph nodes (, arrow heads). The imaging findings indicated advanced pancreatic cancer with hepatic and extensive lymph node metastases, but laboratory findings, including tumor markers such as CA19.9 and CEA, and serum IgG4 levels were normal. However, because the enhancement was delayed in the enlarged pancreas, we performed endoscopic ultrasonography (EUS)-guided fine needle aspiration before administrating chemotherapy. Histological examination of the obtained pancreatic tissue revealed dense fibrosis with abundant infiltration of lymphocytes and IgG4-positive cells, but no cancer cells (). Steroid therapy with oral prednisolone (30 mg/day) was started considering a diagnosis of autoimmune pancreatitis with extensive extrapancreatic lesions. Two months later, FDG uptake had vanished on FDG-PET scan ( and ).

An Unusual Presentation of Hematemesis: Maxillary Metastasis from Hepatocellular Carcinoma - Uncorrected Proof

Ming-Jong Bair, Wei-Yi Lei, Chien-Lin Chen — 2010-01-07

A 52 year-old man with a past medical history of alcoholic liver cirrhosis presented with production of increasing volume of blood-stained sputum and hematemesis. Physical examination disclosed pale conjunctiva, jaundice, and a 2.0 cm, firm, protruding mass with surrounding erythema on his upper anterior maxilla ().

Refractory Lymphocytic Enterocolitis and Tumor Necrosis Factor Antagonist Therapy - Uncorrected Proof

2009-12-28

Background & Aims: Lymphocytic enterocolitis is a malabsorptive syndrome characterized by severe small-bowel villous abnormality and crypt hyperplasia and dense infiltrate of lymphocytes throughout the gastrointestinal tract.Methods: We present 2 patients with lymphocytic enterocolitis refractory to usual medical therapy who were treated with tumor necrosis factor antagonists.Results: Both patients had clinical improvement in diarrheal symptoms and intestinal histologic abnormalities.Conclusions: Tumor necrosis factor-α antagonists such as infliximab or adalimumab may be a new treatment option for patients with severe refractory lymphocytic enterocolitis not responding to corticosteroids.

Terminology of World War II and Medicine - Corrected Proof

2009-12-28

Dear Editor: We have read the editorial by Triadafilopoulus with interest. It covers the important results of the European multicenter study using radiofrequency for treatment of neoplastic Barrett's esophagus. To our surprise, the author quotes the German general Heinz Wilhelm Guderian several times. Heinz Wilhelm Guderian was responsible for the severe attacks on the Polish and Russian civilian population during World War II and was appointed by Hitler to the position of Chief of General Staff of the German Wehrmacht after the failed assassination attempt on Hitler June 20th 1944 (Operation Walküre). After the war, he was a prisoner of war until 1948 and thereafter supposed to be a member of the “Bruderschaft” (fraternity), an organization of elder Nazis founded to sabotage the newly formed Federal Republic of Germany (West Germany).

Cardiac Dysphagia - Corrected Proof

Klaus Mönkemüller, Klaus Feldmann, Ludger J. Ulbricht — 2009-12-28

An 82-year-old woman was admitted to the hospital because of failure to thrive and dysphagia to solids. The patient complained of decreased appetite and a 15-lb weight loss over a 10-month period. In addition, she complained of hoarseness for about 2 years. Her past medical history was significant for chronic atrial fibrillation and mitral regurgitation grade II caused by a mitral valve prolapse of the anterior leaflet. The atrial fibrillation was treated medically and with a 1-chamber pacemaker, after a failed electric cardioversion 12 years previously. Clinical examination revealed an elderly woman in no apparent distress. The heart showed a paced regular rhythm at the cut-off rate of the implanted pacemaker. A radiograph of the chest showed cardiomegaly and moderate pulmonary edema. Echocardiography showed a giant left atrium measuring 7.5 × 9.0 cm and the underlying mitral valve prolapse with regurgitation II ( A). An esophagogastroduodenoscopy disclosed a partially paralyzed left vocal cord and esophageal stenosis caused by extrinsic compression located from 28 to 33 cm from the incisors ( B). The esophageal lumen could be expanded partially by giving constant air insufflation and the stenosis could be passed easily by gently pushing and advancing the scope distally. The distal 5 cm of esophagus were normal. A computed tomography of the chest excluded mediastinal tumors and confirmed the giant left atrium. The giant left atrium sandwiched the esophagus against the aorta and the spine, completely compressing the esophageal lumen for a segment of about 5 to 6 cm ( C). The patient was treated for heart failure with gradual improvement of her symptoms. However, the vocal cord paralysis persisted.

Factors That Predict Outcome of Abdominal Operations in Patients With Advanced Cirrhosis - Corrected Proof

2009-12-28

Background & Aims: Patients with cirrhosis have an increased risk of complications during surgery that is relative to the severity of liver disease; it is a challenge to determine which patients are the best candidates for surgery. We performed a hospital-based study to identify factors that might facilitate selection of operative candidates and guide their management.Methods: A retrospective review was performed of 100 cirrhotic patients (50 classified as Child–Turcotte–Pugh [CTP] A, 33 as CTP B, and 17 as CTP C) who underwent abdominal surgery at an institution specializing in liver medicine and transplant from 2002–2008. Significant univariate variables were evaluated by multivariate logistic regression models to identify factors that correlate with outcome.Results: The overall, 30-day postoperative mortality rate was 7%. The mortality for patients who were CTP A was 2%, CTP B was 12%, and CTP C was 12%; 33 patients had a Model for End-Stage Liver Disease (MELD) score ≥15, with 29% mortality. On the basis of multivariate analyses, risk factors for adverse outcome were American Society of Anesthesiologists (ASA) score >3; procedures being emergent; intraoperative blood transfusion; intraoperative blood loss >150 mL; presence of ascites; total bilirubin level >1.5 mg/dL; and albumin level <3 mg/dL. Addition of serum albumin to MELD score showed that patients with MELD score ≥15 and albumin ≤2.5 mg/dL (vs >2.5 mg/dL) had significantly increased mortality (60% vs 14%, P < .01) and independently increased probability of adverse outcome (odds ratio, 8.4; P = .015).Conclusions: For patients with MELD scores ≥15, the preoperative albumin level correlates with outcome and could guide operative decisions. Intraoperative packed red blood cell transfusion correlates with adverse outcome and should be limited.

Danish Patients With Chronic Pancreatitis Have a Four-Fold Higher Mortality Rate Than the Danish Population - Corrected Proof

2009-12-28

Background & Aims: We investigated mortality of patients with chronic pancreatitis (CP), compared with the Danish population and sought to determine whether clinical presentations of CP can be used in prognosis. We also investigated clinical factors associated with mortality and causes of death among these patients.Methods: The Copenhagen Pancreatitis Study is a prospective study of patients admitted from 1977 to 1982 to the 5 main hospitals in Copenhagen with a diagnosis of acute pancreatitis or CP. In 2008, follow-up data were collected from these patients from the Danish Registries; this subcohort comprised 290 patients with probable (n = 41) or definite CP (n = 249).Results: The mortality of patients with definite CP was 4-fold that of the Danish population and significantly higher than that of patients with probable CP (P = .003; 95% confidence interval [CI], 1.21–2.57); patients with probable CP had a 2- to 3-fold higher mortality rate than the population. In patients with definite CP, factors significantly associated with mortality included non-employment (P = .015; 95% CI, 0.53–0.93), and being underweight (P = .020; 95% CI, 0.52–0.95). Sex, alcohol use, smoking, single versus co-living, exocrine insufficiency, diabetes, pancreatic calcification, CP inheritance, painless CP, acute exacerbation of CP, or surgery for CP had no impact on survival. The most frequent causes of death were digestive diseases (19.5%), malignancies (19.5%), and cardiovascular diseases (11.3%).Conclusions: Danish patients with definite CP had a 4-fold higher mortality rate compared with the background population and a higher mortality rate than patients with probable CP. Being nonemployed or underweight had significant impact on survival.