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  The American Journal of GastroenterologyVolume 100 Issue s9, Pages S91 - S103 Published Online: 2 Sep 2005 © 2008 American College of Gastroenterology/Blackwell Publishing Official publication of the American College of Gastroenterology
Abstract | Full Text: PDF (Size: 245K) | Related Articles | Citation Tracking  SMALL INTESTINE/UNCLASSIFIED Copyright 2005 by the American College of Gastroenterology 206
ABSTRACTEric L. Tatar, M.D.*, Eric H. Shen, M.D.*, C. S. Pitchumoni, M.D.* *Gastroenterology & Hepatology, UMDNJ Robert Wood Johnson Medical School, New Brunswick, NJ and Gastroenterology & Hepatology, Saint Peter's University Hospital, New Brunswick, NJ. Purpose: Small bowel tumors (SBT) are uncommon, representing less than 2–3% of all tumors of the gastrointestinal tract. SBT are frequently found late in their development and often carry a poor prognosis. Wireless capsule endoscopy (WCE) (PillCam SB) is a new tool in the evaluation of the small bowel diseases that may allow early and accurate SBT detection. In a recent series of 562 patients referred for gastrointestinal hemorrhage, Cobrin et al found SBT in 8.9% of patients receiving PillCam SB (Gastroenterology 2004;126:A-194). Adenocarcinomas were the most commonly represented tumor (22% of SBT), followed by carcinoids (14%), and GISTS (6%). The aim of our study is to provide the incidence rate of symptomatic and asymptomatic small bowel tumors in a series of 240 WCE studies. Methods: 240 PillCam SB studies conducted between September 2003 and March 2005 were retrospectively reviewed for the incidence of small bowel tumors. Patients received PillCam SB for various indications, including anemia (66%), GI hemorrhage (31%), Abdominal pain (21%), and diarrhea (11%). Results: We detected 4 tumors (1.6% of all studies). Of these, 2 were in patients with symptomatic gastrointestinal hemorrhage. Tumors therefore represented the etiology in 3% of all GI hemorrhage cases. The other 2 tumors were incidental findings in patients without hemorrhage or anemia (0.8% of all patients). These incidental tumors appeared as submucosal lesions, presumably gastrointestinal stromal tumors (GIST). Neither patient was recommended for resection, so a definitive diagnosis could not be made. Of the two bleeding tumors, one was found to be consistent with a primary malignant melanoma, and the second a carcinoid tumor. Conclusions: SBT represented the etiology of 3% of gastrointestinal hemorrhage cases referred to our institution for WCE. SBT appeared as incidental findings in 0.8% of patients undergoing PillCam SB. 207
ABSTRACTGregg A. Valenzuela, M.D.* *Internal Medicine, Henrico Doctors Hospital, Richmond, VA. Purpose: Pill cam studies are compromised by slow transit times which necessitate long reading times and by incomplete studies which fail to evaluate the terminal ileum. Transit times were compared for patients with(ZEL+) and without Zelnorm(ZEL-) premedication to see if these end points would be effected. Zelnorm(tegaserod) is an HT3 agonist which has been shown to enhance motility in the colon and also in the small bowel and stomach. Methods: Consecutive patients, without a history of stricture or surgical alteration of the gastrointestinal tract, were included. All were studied after an overnight fast; one group was given Zelnorm 6 mg one hour before the studies. All tests were performed with Givens M2A Capsule and read with Rapid Reader. Mouth to pylorus(MP), pylorus to cecum(PC), mouth to cecum(MC) times in minutes and study completion(SC) were compared. Differences were evaluated with the t-test; values are given as the mean. Results: There were 28 ZEL- patients, age 69. There were 20 ZEL+ patients, age 60.
Conclusions: There was no difference in transit times or study completion when premedication with Zelnorm was compared to no premedication. Zelnorm does not effect more efficient M2A capsule examination of the small bowel. 208
ABSTRACTGregg A. Valenzuela, M.D.* *Internal Medicine, Henrico Doctors Hospital, Richmond, VA. Purpose: Pill cam studies are compromised by slow transit times which necessitate long reading times and by incomplete studies which fail to evaluate the terminal ileum. Transit times were compared for patients with(MET+) and without metoclopramide(MET-) premedication to see if these end points would be effected. Metoclopramide is a promotility agent which has been shown to have activity in the esophagus, stomach and small bowel. Methods: Consecutive patients, without a history of stricture or surgical alteration of the gastrointestinal tract, were included. All were studied after an overnight fast; one group was given metoclopramide 20 mg one hour before the studies. All tests were done with Givens M2A Capsule and read with Rapid Reader. Mouth to pylorus(MP), pylorus to cecum(PC), mouth to cecum(MC) times in minutes and study completion(SC) were compared. Differences were evaluated with the t-test; values are given as the mean. Results: There were 28 MET − patients, age 69. There were 26 MET + patients, age 61.
Conclusions: Significantly more studies were completed with metoclopramide premedication. There was a trend for faster mouth to cecum times. A larger study group may show a difference as well as in mouth to pylorus time. Metoclopramide can be recommended as premedication for M2A capsule studies to help insure a complete small bowel examination 209
ABSTRACTJohn R. Stroehlein, M.D.*, Dharmendra Verma, M.D.* *GI Medicine and Nutrition, Univ.TX MD Anderson Cancer Center, Houston, TX and Internal Medicine, Univ.TX School of Medicine-Houston, Houston, TX. Purpose: To advance our knowledge of epidemiological features of small bowel adenocarcinoma (SBA) utilizing 60 years of data derived from the MD Anderson Cancer Center (MDACC) cancer registry. Methods: Data entered in the MDACC registry from 1944 to 2003 was extracted for all microscopically proven adenocarcinomas of the small bowel excluding ampullary and periampullary cancers and non-adenocarinomas. Codes utilized by the MDACC registry were cross-referenced for age, gender, ethnicity, anatomic site, and analyzed for differences related thereto plus epidemiological trends during the sixty year specified interval. Distribution and trends were correlated with the published literature for comparative analysis. Results: The data base included 523 cases of SBA of which 460 were classified for specific anatomic site. Peak incidence occurred in the sixth decade (mean 54.4 ±13.2 yrs), with decreasing incidence at extremes of ages. The relative incidence at different anatomic sites remained constant over the period of 60 years whereas site-specific incidence showed an interesting trend when cross-referenced with age at diagnosis. Jejunal SBA comprised 21% of the site-specific total (SST); however, 49% of all jejunal SBA occurred in the 0–49 age group. Duodenal SBA (59% of SST) and ileal SBA (20% of SST) were more uniform in age related distribution. SBA occurred more frequently in males (58%vs. 42%), with M:F ratio unity below age 50 and increasing with advancing age. Subsite distribution was similar for both genders. Caucasian ethnicity comprised 82% of the study, which is almost identical to the NCDB (80%) and SEER (84%) distribution; however, within the African-American subset, 51% occurred before age 50. Overall M:F ratio for Caucasian was 1.5; African American 0.7 and Hispanic 0.9. Ileal SST was 22% for Caucasians, 7% for African American, and 6% for Hispanics. Conclusions: Significant differences exist in SBA prevalence and sub-site distribution within different age, gender, and ethnic groups. These features have been relatively preserved during the last six decades. Our observations a.) provide insight from which further studies can be focused on presumed etiological factors and b.) site-specific / age related distribution impacts on clinical practice related to diagnosis and screening for SBA. 210
ABSTRACTEric L. Tatar, M.D.*, Eric H. Shen, M.D.*, C.S. Pitchumoni, M.D.* *Gastroenterology & Hepatology, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ. Purpose: To assess the incidence of small bowel ulcers in a series of 194 patients undergoing wireless capsule endoscopy, and to evaluate for association with use of non-steroidal anti-inflammatory medications (NSAIDs). Methods: 194 sequential patients who underwent wireless capsule endoscopy (WCE) were used to evaluate the incidence of small bowel ulcer occurrence. For the purpose of this study, the definition of "ulcers" included superficial erosions. Patients with ulcers in the duodenal bulb or with suspected inflammatory bowel disease were excluded from the study. The association of ulcer occurrence with age, gender, NSAID use, proton pump inhibitor (PPI) use, and body mass index (BMI) were investigated. Results: Patient indications for WCE were anemia (66%), gastrointestinal hemorrhage (30%), diarrhea (11%), abdominal pain (20%), and other (9%). At least one small bowel ulcer was present in 36% of all patients, and in 39% of patients with anemia. Small bowel ulcers were not found to be associated with age (p = 0.69), male gender (p = 0.36), or BMI (p = 0.84). Although occurrence of ulcers in patients on NSAIDs were 10% greater than those not on NSAIDs, this difference was not statistically significant (p = 0.37). A large proportion of patients not taking NSAIDs had small bowel ulcers (32%). Patients on both NSAIDS and proton pump inhibitor medications did not have a lower incidence of small bowel ulcers than patients on NSAIDS alone (48% vs 40% respectively, p = 0.56). Conclusions: 1). Small bowel ulcers occur commonly in WCE patients not taking NSAIDs. This high rate occurrence may be idiopathic, due to medications, or due to unknown factors. 2). Proton pump inhibitor treatment is not associated with lower small bowel ulcer occurrence. 3). Because NSAID and PPI use are not associated with small bowel ulcer occurrence, the mechanism of ulcer formation in the small bowel is likely to be different from the gastric model, which involves prostaglandin inhibition and acid injury. 4). Given the remarkable high incidence of small bowel ulcers in this study, an examination of small bowel ulcer incidence in the asymptomatic general population would be warranted. 211
ABSTRACTShanti L. Eswaran, M.D.*, William D. Chey, M.D.*, Fredrick Askari, M.D.*, Anna S. Lok, M.D.*, Robert J. Fontana, M.D.*, Jorge A. Marerro, M.D.* *Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, MI. Purpose: Celiac disease (CD) is one of the most common autoimmune diseases in the United States. Even though liver chemistry abnormalities are commonly reported in European patients with CD, the prevalence, the response to gluten-free diet (GFD) and its severity in the United States is unknown. Methods: This is a retrospective study of patients with CD diagnosed from January 2000 to December 2004. CD was based on duodenal biopsy. Laboratory and clinical data was obtained at diagnosis and after GFD. Results: A total of 123 patients with CD were identified. The symptoms at diagnosis were abdominal pain (49%), diarrhea (63%), weight loss (49%) and iron deficiency (28%). Eighty-four patients had liver chemistries drawn before and after GFD therapy, and 57 (68%) were found to have abnormalities. Elevated aspartate aminotransferase (AST) or alanine aminotransferase (ALT) were seen in 21, both ALT and AST in 23, alkaline phosphatase only in 5, and AST, ALT and alkaline phosphatase in 8 patients. The total bilirubin and prothrombin time were normal. After GFD, 88% normalized their abnormal liver biochemistries. Liver histology was performed in 8 patients, 2 had developed cirrhosis and 1 had moderate fibrosis at the time of CD diagnosis. No patient developed hepatic failure after a median follow up of 18 months. Conclusions: Liver abnormalities are commonly seen in CD and the majority improved after GFD. Significant histological hepatic injury can occur in patients with CD but the clinical course appears benign in our cohort. Further studies should evaluate the natural history of the hepatic involvement in CD. 212
ABSTRACTAdil M. Choudhary, M.D.*, Frederick French, M.D.*, Shams Tabrez, M.D.* *Division of Gastroenterology, Digestive Disease Institute, Roswell, NM. Purpose: Video Capsule Endoscopy is a noninvasive diagnostic imaging procedure allowing proper visualization of entire small bowel. Currently the most common medicare approved indications include heme positive stools, unexplained iron deficiency anemia and gastrointestinal bleeding of obscure origin when upper GI endoscopy and colonoscopy fail to explain the cause. Methods: We would like to present our experience over a one year period (November 2003 to November 2004). A total of 80 patients underwent this procedure using the Given M2A video capsule. The indications were: Obscure GI bleeding (41 patients), Iron deficiency anemia (32 patients), Change in bowel habit with unexplained diarrhea (4 patients), Inflammatory bowel disease (1 patient), Celiac disease (1 patient), Unexplained abdominal pain (1 patient). Results: The findings were: Angiodysplasia (32 patients), Normal study (33 patients), Ulceration (6 patients), Mild diffuse erythema (8 patients), Tumor (1 patient). There were no complications except for one patient with a previously unknown stricture where the capsule got stuck in mid small bowel. Patient refused surgical intervention. Eventually the capsule passed on its own and the patient recovered uneventfully. Conclusions: The diagnostic yield was highest in patients with unexplained iron deficiency anemia and obscure GI bleeding. We conclude that video capsule endoscopy is safe and the investigation of choice for GI bleeding of obscure etiology and unexplained iron deficiency anemia. 213
ABSTRACTTimothy B. Gardner, M.D.*, Jeffrey A. Oringer, M.D.*, Douglas J. Robertson, M.D.* *Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, NH and Gastroenterology, White River Junction VA Medical Center, White River Junction, VT. Purpose: Previous investigations determined that both generalists and gastroenterologists demonstrate significant knowledge deficits regarding the diagnosis and management of patients with celiac disease. No studies have examined knowledge of celiac disease among resident physicians. We aimed to determine exposure to and knowledge of celiac disease in a cohort of internal medicine residents at a tertiary care center. Methods: A sixteen-item survey was mailed to all current internal medicine housestaff at our medical center. The survey evaluated exposure to and basic knowledge of celiac disease. Knowledge questions were based on a recent widely circulated review on celiac disease. Results: 63 surveys were mailed and 61 were returned for a response rate of 96.8%. 45.9% of respondents were first-year residents, 27.9% were in their second year, and the remainder were in their third year. 42.6% recalled receiving a lecture mentioning celiac disease in medical school, 68.8% had ordered a blood test to diagnose celiac disease, 37.7% had cared for a patient with celiac disease, and 9.8% had diagnosed a patient with celiac disease. Less than one quarter of respondents knew the prevalence of celiac disease in North America or that the most common presenting symptom of the disease in adults is iron deficiency anemia. Most respondents did not know that the tissue transgluatminase test can be falsely negative in IgA-deficient individuals (45.9%) or that tissue transglutaminase can be followed serially to monitor dietary compliance (26.2%). Most respondents (59.1%) knew that celiac disease is associated with other autoimmune diseases. The average score on the knowledge component was 50.7%, although more time in residency was significantly associated with higher scores. Resident physicians who had cared for a patient with (66.3%vs. 51.6%, p = 0.047) and made the diagnosis of (77.6%vs. 55.3%, p < 0.01) celiac disease scored better on the knowledge exam. There was no statistically significant difference in scores between those who had received a medical school lecture and those who had not (59.6%vs. 55.4%, p = 0.11). Conclusions: Resident physicians' knowledge pertaining to the diagnosis and management of celiac disease is often deficient. Exposure to patients with celiac disease improves general knowledge. More efforts are needed to educate resident physicians about this common disease. 214
ABSTRACTNirmal S. Mann, M.D.*, Rafael E. Diaz, Ph.D.* *Gastroenterology, University of California, Davis, Davis, CA and Statistics, University of California, Davis, Davis, CA. Purpose: Colonoscopy is considered the preferred method for colon cancer screening. Since July 2001, medicare program reimburses for screening colonoscopy every 10 years in average-risk persons, resulting in the increase in the number of colonoscopies performed (AJG 2003; 98:194–199), causing increased demands for gastroenterologists' services. We evaluated the no. of classified advertisements (Ads) for Gastroenterology (G) in NEJM and compared them with Ads for Cardiology (C), the other procedure-oriented subspecialty of Internal Medicine, over the 20 year period from 1985–2004. Methods: Ads for C and G from NEJM were manually counted on a weekly basis. The C/G ratio was calculated. The smallest and largest no. of Ads for C and G in a week were noted. The total no. of Ads for C and G were added up. Statistical method used for evaluating mean monthly Ads was time series analysis. The changes in C/G ratio during different periods were evaluated by first order auto-correlation model. The Shapiro-Wilk test statistics using the lower and upper Scheffe band was utilized. Results: During these 1042 weeks there were 76713 Ads for C; mean 73.76 (range 14–218) per week. There were 26130 Ads for G; mean 25.12 (range 1–122) per week. The C/G ratio was 2.93 (range 1.37 – 18.20) per week. The smallest no. of Ads for G (one) occurred in 6/13/85 issue; the largest no. of Ads for G (122) occurred in the 11/4/99 issue. The smallest no. of Ads for C (14) occurred in the 1/24/85 issue and the largest no. of Ads for C (218) occurred in the 11/4/99 issue. The largest no. of Ads for both C and G occurred in the months of September to November; the smallest no. of Ads for C and G occurred in April to July. Probably these Ads are targeted to Fellows in training. The C/G ratio from 1985 to 1997 was in the range of 3.10 – 5.81 (95% confidence) and it was significantly higher than the C/G ratio from 1998 to 2004 which was in the range of 1.85 – 2.79 (95% confidence). The mean C/G ratio from 1997 to 2001 was 2.40 which was not different from the one from 2002 to 2004 which was 2.48. However, C/G ratio from 2002 to 2004 did not decrease any further. Conclusions: The no. of Ads (and presumably demand for GI services) have increased since 1997 correlating with the use of screening colonoscopy. 2. The number of Ads for C is three times that for G. 3. The largest no. of Ads for C and G are placed during Sept. to Nov; the lowest in April to July. 215
ABSTRACTNirmal S. Mann, M.D.*, Eddie C. Cheung, M.D.* *Gastroenterology, University of California, Davis, Davis, CA and Gastroenterology, VA Medical Center, Martinez, CA. Purpose: Some patients complain of abd cramps and diarrhea after ingesting certain fruit e.g. mango. We evaluated the Breath Hydrogen, no. of flatus passage and bloating score after 20 gm of oral fructose and compared them with healthy controls. Methods: There were 4 normal male volunteers (Group 1) and there were 8 men with h/o fruit intolerance (Group II) in this study. All the subjects fasted overnight. The fasting breath hydrogen was measured using an EC 60 gastrolyzer (Bedfont Scientific, Medford, N.J.), which has a sealed electrochemical sensor specific for H2. They ingested fructose 20 gm in 30 ml of water. Thereafter, breath H2 was recorded every 15 min for the next 8 hours (480 minutes). Number of flatus passage over 8 hours was recorded as was a bloating score (on a scale of 1–10). Cumulative H2 over 8 hours was calculated by area under the curve (AUC). The data are reported as mean ± standard error of the mean (SEM) and were compared using t-test; p value of <0.05 was considered significant. Results: The age of Group I subjects was 48.7 ± 3.5 (range 34–63) years was not different from the Group II patients 53.8 ± 5.2 (range 24–71) years. The mean bloating score of Group II 5.7 ± 0.1 (range 4–7), the no. of flatus passage 13.8 ± 0.3 (range 6–24) and cumulative H2 1745.2 ± 7.8 (range 1065–2147) ppm in 8 hours was significantly higher compared to Group I subjects who had a bloating score of 2.7 ± 0.2 (range 2–4), no. of flatus passage 7.2 ± 0.5 (range 5–9) and cumulative H2 of 712.5 ± 5.8 (range 393–1066) ppm in 8 hours. Conclusions: Compared to healthy controls, patients with h/o fruit intolerance, after fructose ingestion produce more breath H2, pass a larger no. of flatus and have more bloating. Such patients should avoid fruits with high fructose content. 216
ABSTRACTAshwini Sahni, M.D.*, Sudipta Mazumder, M.D.*, Matthew Tangorra, D.O.*, Muhammad Abdullah, M.D.* *Gastroenterology, Coney Island Hospital, Brooklyn, NY. Purpose: Direct use of attenuation values from CT in the form of Hounsfield units (HU) is yet to be established for the measure of ascitic fluid density. The aim of the study was to determine if density of ascitic fluid as measured by HU on abdominal CT correlates with the protein and albumin content of ascitic fluid; a non-invasive approach. Methods: 48 patients with ascites who had abdominal CT and paracentesis were identified and retrospectively evaluated. Patients were analyzed using ascitic fluid protein, ascitic fluid albumin and serum ascites albumin gradient (SAAG). Ascitic fluid density using HU was calculated on abdominal CT by a single radiologist as a mean of fluid density taken at five points on the CT. Results: The ascitic fluid with protein > 2g/dl had a mean attenuation value density of 21HU (± 9 SD) which was significantly higher than that of the fluid with protein less than 2 g/dl 8.2HU (±6) (p < 0.05). Ascitic fluid with albumin > 2g/dl had a mean HU density of 18.8HU (± 8.6) which was significantly higher than that of the fluid with albumin less than 2 g/dl 7.6HU (± 6) (p < 0.05).). 35/37 (94.6%) patients with ascitic fluid with protein less than 2g/dl, and 23/25 (92%) patients with ascitic fluid with albumin less than 2g/dl had an attenuation value lower than 20HU on CT. Attenuation values of ascitic fluid with SAAG >1.1 did not differ significantly from fluid with SAAG <1.1, 13.6 HU (± 10.7) vs. 12.5HU (± 8.0) (p = 0.68). Conclusions: Attenuation values of ascitic fluid (HU) on CT abdomen correlates with the protein and albumin content of ascites, and hence can be a useful tool to estimate the protein and albumin content of ascitic fluid in the event of inability to perform paracentesis. 217
ABSTRACTDouglas J. Sprung, M.D.* *Medicine, Gastroenterology Group, Maitland, FL. Purpose: Endoscopic evaluation of the terminal ileum (TI) is not a routine part of colonoscopy, yet it is important to examine the TI in circumstances when Crohn's disease, small bowel tumors or angiomas are suspected. Familiarity with the normal endoscopic anatomy is therefore essencial. Methods: A study was undertaken to evaluate and describe the terminal ileum in 100 consecutive patients, providing macroscopic endoscopic findings. Results: Colonoscopic entry into the TI was possible 90% of the time, therefore a total of 110 patients were examined. Presence of obvious visible villi and Peyer's patches (lymphocytic aggregates) were noted 12% and 14% of the time respectively. The remainder of the patients had a smooth, granular appearance to their TI. Conclusions: Examination of the TI in patients without clinical suspicion of Crohn's disease or enterocolitis is usually normal. Overt lymphoid aggregates (Peyer's patches) are present 14% of the time and may be mistaken for polyps or an abnormality,prompting unnecessary biopsies in the inexperienced endoscopist. 218
ABSTRACTKoji Ito, M.D. Ph.D.*, Susumu Hiranuma, M.D.*, Saburo Horikawa, Ph.D.* *Surgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan and Pathological Biochemistry, Tokyo Medical and Dental University Medical Research Institute, Tokyo, Japan. Purpose: Intestinal ischemia/reperfusion (I/R) is a critical and triggering event in the development of distal organ dysfunction, frequently involving the lungs. Respiratory failure is a common cause of death and complications after intestinal I/R. We have shown that pharmacological preconditioning with doxorubicin, an anticancer drug, protects the acute lung injury induced by intestinal I/R. This effect is due to the induction of antioxidant protein heme oxygenase-1. But the procedure of the preconditioning needs to be conducted before the intestinal ischemia. In this study we investigated the effects of edaravone (3-methyl-1-phenyl-2-pyrazoline-5-one), a newly developed hydroxyl radical scavenger which has been widely used for protection against I/R injury in patients with cerebral infarction, on the prevention of lung injury induced by intestinal I/R in rats. Methods: Male Wistar rats were used. Under anesthesia, SMA was occluded with a small clamp. Following occlusion for 2 or 3 hours, reperfusion was initiated by removing the clamp. Administration of edaravone was intravenously injected into rats before reperfusion. Survival rate, histopathology, lung myeloperoxidase activity, lung malondialdehyde levels etc were analized. Results: When rats were subjected to 3 h of intestinal ischemia, a high incidence of mortality was observed within 24 h. Under this situation, intravenous administration of edaravone just before the start of reperfusion reduced the mortality. To examine the efficacy of edaravone on the lung injury induced by intestinal I/R in more detail, we performed 2 h of intestinal ischemia followed by 2 h of reperfusion. Edaravone treatment decreased the neutrophil infiltration into the lungs and the levels of lipid membrane peroxidation in the lungs after intestinal I/R as compared to the I/R-treated rat lungs without edaravone treatment. Histopathological analysis also showed that edaravone treatment improved the lung injury induced by the intestinal I/R. Conclusions: In this study, we demonstrated that administration of the novel radical scavenger, edaravone, attenuated acute lung injury induced by intestinal I/R. Application of the newly developed free radical scavenger, edaravone shows promising results in animal models of lung injury induced by intestinal I/R and may become powerful tools in the treatment of acute lung injury that occurs in intestine transplantation and intestinal surgery. 219
ABSTRACTTimothy C. Johnson*, Pauline Suwandhi*, Michelle Lieberman*, Aaron Walfish*, Kavitha Gopal*, Debbie Kryszak*, Allesio Fasano*, David J. Clain*, Douglas Meyer*, Henry C. Bodenheimer, Jr *, Pardeep Brar*, Robert Brown*, Peter H. Green*, Albert D. Min*. *Digestive Diseases, Beth Israel Medical Center; University of Maryland and Columbia Presbyterian Hospital. Purpose: Celiac disease (CD) is associated with various liver diseases including hepatitis C virus (HCV) and has developed in those receiving interferon-based treatments for HCV. The aims of the study are to determine the prevalence of CD in HCV patients in the New York City area and to determine if CD is precipitated by interferon treatment. Methods: Cross-sectional study of 12 months duration. All HCV patients at the liver clinics at Beth Israel and Columbia Presbyterian Medical Center from May 2004 to June 2005 were offered enrollment. Celiac serologies: TTG IgA, EMA IgA, anti-gliadin(AGA)IgA/IgG, (total IgA in selected cases) were obtained and biopsies if positive. CD positivity was defined as TTG IgA +, EMA IgA +, AGA IgG + and total IgA negative. Demographics, viral load, genotype, treatment regimen and length, ethnicity were recorded. Data were analyzed by chi square analysis. Prevalence of CD in the general population is 1 in 133(0.8%), (Fasano, 2003). Results: One hundred and eighty-two subjects and 78 controls were enrolled. Characteristics are in the table below. All those on treatment received pegylated interferon (PEG-IFN) plus ribavirin.
AGA IgA serologies were significantly more common in HCV patients. CD was only identified in patients with HCV. Of the four TTG IgA positive HCV patients only one has had a biopsy, this was negative. The others are to be biopsied. The prevalence of CD is at least 0.6% (1 EMA positive patient), possibly 1.6% (3/182). Conclusions: CD is more prevalent in our chronic HCV patients compared to the general population. IgA AGA is common in this population. The prevalence of CD in our HCV patients is not significantly increased compared to non-HCV controls. These patients will be followed while receiving PEG-IFN to determine if this treatment causes the development of CD. 220
ABSTRACTRobert F. Wong, M.D.*, Ashok K. Tuteja, M.D.*, Derrick S. Haslem, M.D.*, Lisa Pappas*, Aniko Szabo*, Maydeen Ogara*, James A. DiSario, M.D.* *Internal Medicine, University of Utah, Salt Lake City, UT. Purpose: Compare video capsule endoscopy (VCE) to standard endoscopy for the diagnosis of small bowel polyps. Methods: This was a single center, prospective study. Eligible patients had a clinical diagnosis of FAP. Most patients were concurrently enrolled in a NIH study and had at least 20 polyps in the duodenum and prior placement of a tattoo in the proximal small bowel (n = 28). Four FAP patients referred for routine VCE evaluation for small bowel polyps were also included. VCE was performed followed by push enteroscopy (PE) and lower endoscopy (LE). Two VCE readers independently determined the number and sizes of polyps in the following regions of small bowel: 1) defined segment of small bowel from the duodenal bulb to the tattoo and 2) quarters of small bowel determined by small bowel transit time. A single endoscopist blinded to VCE determined the number and sizes of polyps in the following regions: 1) defined segment of small bowel from the duodenal bulb to the tattoo; 2) maximum insertion length of PE; and 3) maximum insertion length of LE. The primary outcome was the number of polyps in the defined segment of small bowel, comparing VCE to the gold standard of PE. Agreement was calculated utilizing kappa coefficients. Results: Thirty two patients participated in the study (median age 45 years, 41% female). On VCE, 94% of patients had polyps proximal to the tattoo compared to 100% on PE. VCE diagnosed less polyps in this region (median 10 and 9 for each reader) compared to PE (median 41) (p = 0.002). Agreement between VCE and PE was fair for polyp counts (k = 0.34, 0.36). Agreement for determining the size of the largest polyp was poor to fair (k = 0.10, 0.22). VCE and PE disagreed for detecting large polyps (≥1cm) (k =−0.20, −0.27). For the entire small bowel, VCE detected significantly less polyps (median 38 and 54 for each reader) compared to combined (PE+LE) endoscopy (median 138) (p < 0.001). Agreement was fair to moderate between VCE and combined endoscopy (k = 0.21, 0.56). On VCE, the percentage of patients with polyps in the first, second, third and last quarter of small bowel was: 100%, 35%, 15% and 46%, respectively. Polyps were more common in the first quarter than in the remaining quarters combined (p < 0.0001). Mean size of polyps was less than 5 mm in each quarter. Conclusions: VCE underestimates the number of small bowel polyps in patients with FAP and does not reliably detect large polyps. 221
ABSTRACTAsma P. Khapra, M.D.*, Richard R.P. Warner, M.D.*, Blair Lewis, M.D.* *Division of Gastroenterology, The Mount Sinai Hospital, New York, NY. Purpose: Carcinoid tumors are a heterogeneous group. Midgut carcinoid accounts for approximately 50% of all carcinoid tumors in adults, the majority of which arise in the ileum. Since the clinical symptoms are often vague and unrecognized until disease becomes advanced, a majority of patients have metastatic disease at time of diagnosis. It is important to determine the location of the primary since, to a considerable degree, it directs management and predicts outcome. The aim of this study was to assess the utility of wireless video capsule endoscopy in identifying a suspected intestinal primary in patients with demonstrated metastatic carcinoid and no detectable primary on standard investigation.
Methods: A retrospective chart review was performed and 24 patients with metastatic carcinoid of unknown primary origin were encountered. Patients' baseline characteristics, clinical presentations, radiological evaluations, chemistries, and therapies were all recorded. All patients underwent wireless video capsule endoscopy in search of a primary lesion after having negative localizing or nonspecific findings on EGD/Colonoscopy, Small Bowel Series, CT scan and OctreoScan Results: Of the 24 patients, 8 (33.3%) had positive findings on capsule examination, suggesting a primary carcinoid tumor. All had previously diagnosed metastatic carcinoid on needle biopsy. 5 of these (62.5%) had an ileal primary, 1 (12.5%) had a jejeunal primary, and 2 (25%) were simply classified as a mid small bowel primary. In all cases this positive finding changed management. 7 of the 8 patients (87.5%) underwent surgery and had confirmed small bowel carcinoid tumors. 1 patient who had very advanced disease and was not operated upon had a change in his chemotherapy regimen after the positive capsule finding. Of the 16 patients who had negative capsule studies, 6 had metastatic carcinoid diagnosed by liver biopsy, 1 had an orbit biopsy, 1 had a mesenteric mass biopsy, 1 had a lymph node biopsy, and 3 had significantly abnormal chemical markers (urine 5-HIAA, chromogranin A, and serotonin) strongly indicating carcinoid. No primary was found in 12 of the 16 patients, whereas in 4 patients the primary was proven by biopsy to be in the pancreas. Conclusions: We conclude that wireless video capsule endoscopy is useful in detecting carcinoid tumors originating in the small bowel and not detected by any other conventional method. This localization is significantly important in directing treatment and management of these patients. 222
ABSTRACTSadiya Sarij, M.D.*, Bethany DeVito, M.D.* *Department of Gastroenterology, Hepatology and Nutrition, North Shore University Hospital, Manhasset, NY. Purpose: Nongranulomatous ulcerative jejunoileitis (NGUJI) is a rare, often fatal disorder that produces multiple nonmalignant small bowel ulcerations. The diagnosis is often missed or delayed because of the non-specific clinical features, limited usefulness of available radiologic tests, and failure to identify the lesions on endoscopy. Here, we describe a patient whose first presentation of NGUJI was massive gastrointestinal bleeding (GIB), diagnosed by wireless capsule endoscopy (WCE). Case Report: A 75 year old female presented with melena, lethargy and anemia. She had a history of HIV (CD4<200) and remote history of anal cancer and breast cancer. She had been on anti-retroviral medications and did not use NSAIDs. On presentation, the patient had a blood pressure of 92/38 mmHg and pulse 104. Physical exam was significant for pallor, mild abdominal distension and melanotic stool. Initial hemoglobin was 3.9g/dl. She required transfusion of 24 units of packed red blood cells and was placed on IV proton pump inihibitor and parenteral nutrition. Melena persisted. Small bowel radiographs were normal. Serology for inflammatory bowel disease and celiac disease were negative. Upper endoscopy was normal. Colonoscopy, with terminal ileum intubation, demonstrated mild left sided colitis and ileitis. Biopsies taken during endoscopy revealed non-specific inflammation. No infectious agents were found. The patient was placed on Rowasa enemas but with continued bleeding. Bleeding scan was positive for small bowel bleed. Angiogram was normal. M2A WCE was performed, which revealed NGUJI, i.e. flattened jejunal mucosa and ulcerations. The patient was placed on IV steroids with clinical improvement and a decreased need for PRBC transfusions. Conclusions: NGUJI is a rare cause of small intestinal ulceration. The clinical features of NGUJI are fever, pain, steatorrhea, and protein-losing enteropathy with an unremitting downhill course. GIB is a rare manifestation of this disorder, more common in the patients without underlying disease. The course is usually quite severe. This report describes a patient with massive GIB from NGUJI, which was diagnosed by WCE after numerous other studies failed to demonstrate pathology. To date, major focus of WCE has been in the evaluation of occult GIB. We demonstrate WCE diagnosis of disease involvement in areas of the small bowel, i.e the jejunum and proximal ileum, that traditionally have been less directly accessible. 223
ABSTRACTJuan A. Valcarce-Leon*, Student*, Mariana Santiago-Lomeli, Ph.D.*, Max Schmulson, M.D.*, Aldo J. Montano-Loza, M.D.*, Dana Lau-Corona*, Sudent*, Guillermo B. Robles-Diaz, M.D.* *Experimental Medicine, Faculty of Medicine, Universidad Nacional Autonoma de Mexico-UNAM, Mexico City, Mexico and Gastroenterology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico. Purpose: Celiac disease (CD) is one of the most common chronic conditions worldwide. The disease develops following gluten ingestion in genetically susceptible individuals. Because of the wide clinical spectrum of CD ranging from latent, silent and atypical to classic cases with malabsorption syndrome, the overall frequency can only be determined by screening a given target population using a sensitive serological test, such as IgA tissue-transglutaminase (tTG) antibodies. Overall, the prevalence of CD in Western populations is close to 1% and may be higher in Northern European countries, whereas the disease is uncommon among people from purely African-Caribbean, Chinese, or Japanese background. Studies on CD prevalence in the Mexican population have not been reported but there seems to be a wide gap in the frequency of CD between Europe and Mexico. Therefore our aim was to determine the seroprevalence of IgA anti-tTG antibodies in a population from Mexico City. Methods: Professors, students and workers from a public university (Universidad Autonoma Metropolitana) were invited to voluntarily participate in the study. Serum was tested for anti IgA tTG antibodies using an enzyme linked immunosorbent assay (INOVA Diagnostics, Inc). A positive result was considered when a value of more than 20 units was obtained. Positive cases were confirmed by duplicate testing. Results: So far 553 subjects have been studied, 336 females (60.7%) and 217 males (39.3%) with an overall median age of 29 years (range: 17 – 69). Four subjects had positive serology (3 males and one female). This result provides an estimated prevalence of 0.72% (95% CI 0.31–1.13). Conclusions: Preliminary results of this ongoing study, show a seroprevalence of CD in Mexico based on Anti-tTG to be in the range of 0.5% to 1%, affecting 1 of every 138 subjects, which is similar to the prevalence estimates in western populations. Additional tests such as duodenal biopsies are still required to ascertain the diagnosis of CD in these cases. These findings may increase the degree of awareness for this under diagnosed disease in clinical practice in Mexico. 224
ABSTRACTVisvanathan Muralidharan, M.D., M.R.C.P.*, Dhanpat Jain, M.D.*, Ronald Salem, M.D.*, Pars Ravichandran, M.D.* *Gastroenterology, Bridgeport Hospital, Yale New Haven Health, Bridgeport, CT; Pathology, Yale University Hospital, New Haven, CT; Surgery, Yale University Hospital, New Haven, CT and Pathology, Bridgeport Hospital, Yale New Haven Health, Bridgeport, CT. Purpose: Sclerosing Mesenteritis (SM) is characterized by a necro-inflammatory lesion of unknown etiology and shows a spectrum of pathologic changes including prominent fibrosis, fat necrosis and chronic inflammation. Various other terms such as retractile mesenteritis, mesenteric panniculitis and mesenteric lipodystrophy have been used to describe this entity. The purpose of this retrospective study was to identify patients with the diagnosis of SM and perform a clinico-pathologic correlation. We also wished to address the relationship between SM and alfa 1 anti-trypsin (AAT) deficiency and lympho-proliferative disorders, both of which have been associated with mesenteric panniculitis. Methods: The patient records of both our hospitals were searched for cases of SM. Detailed analysis of the histopathologic features, immunohistochemical staining and clinical findings and radiographic features were carried out. Results: A total of 5 cases were identified during the peroid from 1994 to 2005. Findings are summarized in the Table 1.
Conclusions: The pathologic features of SM consistently show fibrosis, fat necrosis and chronic inflammation. The most common presentation is as an intra-abdominal mass. The etio-pathogenesis of fat necrosis and subsequent fibrosis remains unclear. In most reported cases including our case series the intra-operative findings and gross pathology often mimic a malignant neoplasm such as sarcoma. In our series two cases were considered unresectable. The apparent discrepancy between the intra-operative findings and pathologic features of benign fibro-inflammatory lesion makes pathologic evaluation challenging. Gene rearrangement studies done in 2 cases did not suggest any lymphoproliferative disorder. There was no demonstrable association with AAT deficiency. The entity of SM should be considered in the work up of intra-abdominal masses and retroperitoneal lesions. 225
ABSTRACTGary Fanjiang, M.D., M.B.A.*, Aubrey J. Katz, M.D.* *Pediatric Gastroenterology & Nutrtion, Tufts-New England Medical Center, Boston, MA. Purpose: Tissue transglutaminase IgA (TTG) is currently considered the best available screening test for celiac disease. We evaluate the positive predictive value (PPV) of TTG and endomysial IgA (EMA) for the diagnosis of celiac disease in pediatric patients. Methods: The charts of 122 pediatric patients who screened positive for celiac disease with TTG and/or EMA were reviewed. Only patients with duodenal biopsies were included. Asymptomatic patients were screened because of family history or comorbid diagnoses such as diabetes or hypothyroidism. Biopsies were characterized using Marsh criteria. PPV and 95% confidence intervals (CI) were calculated. Results: Ninety-five patients had positive TTG (TTG>20), with 59 confirmed biopsies (PPV = 0.62). Eighteen of 26 asymptomatic TTG positive patients were true positives (PPV = 0.69). Forty-one of 69 symptomatic TTG positive patients were true positives (PPV = 0.59). Forty-nine TTG positive patients had levels >100, with 44 confirmed biopsies (PPV = 0.90). Thirty-eight TTG positive patients had levels >150, with 37 confirmed biopsies (PPV = 0.97). Forty-one patients had a positive EMA, with 36 confirmed biopsies (PPV = 0.88). Eleven of 12 patients who screened positive with both TTG and EMA had confirmed biopsies (PPV = 0.92).
Conclusions: EMA seems to have a greater PPV compared to TTG. Increasing the cutoff for TTG to 100 or 150 increases its PPV to a level comparable to EMA. There is little difference in the PPV of TTG for screening symptomatic patients versus those screened only because of family history or comorbid diagnoses. This data suggests using both TTG and EMA for screening celiac disease and that screening does not obviate the need for duodenal biopsies. 226
ABSTRACTNatalya Baker, M.D.*, Roger E. Mendis, M.D.* *Gastroenterology, New York Hospital Medical Center of Queens, Flushing, NY. Purpose: Diagnosis of Obscure Jejunal Bleeding Methods: Capsule Endoscopy, Push Enteroscopy Results: A 77 year old woman from the Dominican Republic presented with profound anemia (Hgb 6 g/dL, Hct 17%), melenic stool and generalized weakness. Work up included EGD, colonoscopy and push enteroscopy; all were unremarkable. She was transfused 2 units of pRBCs. Outpatient capsule endoscopy revealed active bleeding in the proximal jejunum within 6 minutes of the capsule entering the duodenum. Repeat push enteroscopy revealed fresh blood in the jejunum and a large clot. The area was not able to be consistently be reached by the enteroscope for performance of endoscopic therapy. Bleeding scan was performed with visualization of extravazation in the left upper quadrant (proximal jejunum), but angiogram of the superior mesenteric artery was negative. Repeat push enteroscopy did not show the bleeding site. 3units of pRBC were transfused. Three weeks later she presented again with melena. Her hemoglobin and hematocrit were 9 g/dL and 30%. Push enteroscopy was performed showing fresh blood and a large clot in the jejunum. Again, the lesion could not effectively be reached for endoscopic therapy, but endoclips were successfully placed proximally and distally to the lesion for identification of the bleeding site during surgery. The patient underwent exploratory laparotomy with intraoperative enteroscopy with subsequent segmental resection of the jejunum. Pathology showed a focus with a fibrin exudate adjacent to a hyalinized area, representing the remnant of a ruptured vessel in proximity to an endoclip. The patient was discharged home and experienced no further bleeding. Conclusions: This case illustrates the utility of capsule endoscopy in diagnosing the etiology of obscure, active gastrointestinal bleeding and the use of endoscopic clips to mark a site of bleeding for surgical resection. The bleeding site in this case may have been a small bowel Dieulafoy lesion which may have accounted for the repeated episodes of bleeding and difficulty in consistently identifying the area. 227
ABSTRACTNikos G. Christopoulos, M.D.*, Michael A. Mirro, B.S.*, Jonathan A. Rosenberg, M.D.*, Karen Bednar, R.N.*, Russell D. Brown, M.D.*, Jay L. Goldstein, M.D., F.A.C.G.* *Section of Digestive Diseases and Nutrition, University of Illinois Medical Center at Chicago, Chicago, IL. Purpose: Aspirin (ASA) and (ns) NSAIDs are associated with the development of dose dependent gastroduodenal ulcers and ulcer complications. In a recent placebo (P) controlled trial using video capsule endoscopy (VCE), full dose naproxen (500 mg bid) was associated with an approximately 27 fold increased rate of endoscopic small bowel (SB) mucosal injury as compared to those subjects randomized to P. Hypothesis: Compared to P, over-the-counter (OTC) ns NSAIDs or low dose ASA use is associated with a dose dependent increased incidence of SB mucosal injury. Methods: In a single center, two independent, prospective, double blind, P controlled trials using VCE, evaluated the incidence of SB mucosal breaks (MBs) in healthy subjects treated with P or naproxen sodium (NapNa) (220 mg/day or 440 mg/day; Trial 1) or with P or ASA (81 mg/day or 325 mg/day; Trial 2). In each study, subjects underwent a 2 week run-in period followed by a baseline VCE. Subjects without MBs, and who met inclusion criteria, were randomized to blinded drug for 2 weeks and then underwent a second VCE. The primary endpoint was the mean number of MBs/subject. The secondary endpoint was the percent of subjects with at least one or more SB MBs. Results: Combining the results of baseline exams in both studies, 7.9% (n = 14/177) of subjects had at ≥1 MBs and were excluded from randomization. Of the 56 subjects randomized in the NapNa trial, the mean number of MBs/subject was 0.16 in the P group (n = 3/19), 0.11 in the 220 mg/day group (n = 2/19), and 0.22 in the 440 mg/day group (n = 4/18). The percent of subjects with ≥ 1 MBs was 10.5% (P), 5.3% (220 mg/day), and 16.7% (440 mg/day). Of the 80 subjects randomized in the ASA trial, the mean number of MBs/subject was 0.43 in the P group (n = 12/28), 0.22 in the 81 mg/day group (n = 6/27), and 0.32 in the 325 mg/day group (n = 8/25). The percent of subjects with ≥ 1 SB MB was 28.6% (P), 11.1% (81 mg ASA), and 16% (325 mg ASA). The differences comparing either dose of ASA or NapNa to P were not statistically significant. Conclusions: Our data suggest that at OTC doses, NapNa and ASA are not associated with an increased incidence of SB mucosal injury. The results of earlier studies together with our data suggest that there may be a threshold dose of NapNa and ASA that must be reached in order to cause detectable SB mucosal injury using VCE. 228
ABSTRACTUday Chand Ghoshal, D.M.*, Kshaunish Das, M.D.*, Asha Misra, Ph.D.*, Gourdas Choudhuri, D.M.* *Gastroenterology, SGPGI, Lucknow, UP, India. Purpose: Obscure gastrointestinal bleed (OGIB) is difficult problem requiring extensive investigations. Capsule endoscopy, a new and potentially effective method to evaluate small bowel, may be useful for patients with OGIB. Methods: 16 patients with OGIB were evaluated using capsule endoscopy (Given Imaging Ltd., Yoqneam, Israel) during 19-mo period (from November 2003 to May 2005) after standard bowel preparation. Each patient was clinically evaluated. The images were downloaded to a computer after 8-h and examined by single investigator using a software (Rapid Reader). The patients with a definite diagnosis on capsule endoscopy received specific treatment and were followed-up. Results: Of 16 patients (median age 57-y, range 25 to 76; 9 males), symptomatic for a median duration of 15 months (range: 0.5 to 240), bleed was occult, overt or combined in 4, 9 and 3, respectively requiring blood transfusions (median 11 units, range 0 to 30). One patient presented with recurrent bleed after right-hemicolectomy and one other had negative exploratory laparotomy, both done elsewhere. Capsule endoscopy could detect the lesions potentially causing OGIB in 13 of 16 (81%) patients and these included isolated bleeding lesion in distal small bowel in one (ulcerated Meckel's diverticulum with bleeding at surgery), ulcerated stricture in small bowel in three patients (verified at surgery in two and one responded to anti-tubercular drugs), worms infestation (successfully treated with ivermectin), anastomotic ulcer in one, multiple angiodysplasia in two (verified by colonoscopy in both), isolated bleeding spot in duodenum in one, multiple small intestinal varices in two, small intestinal tumor in two (both verified by surgery) and no specific lesion in three patient. Though one patient had delayed capsule expulsion, none developed intestinal obstruction due to retained capsule. Conclusions: Capsule endoscopy is effective and safe for diagnosing lesions causing OBGIB. 229
ABSTRACTEdson Jurado da Silva, M.D.*, Dirce B. de Lima, Ph.D.*, Valeria R. Gomes, M.D.*, Marcio N. Boia, Ph.D.*, Gustavo Albino P. Magalhaes, M.D.* *Digestive Endoscopy, Casa de Portugal, Rio de Janeiro, Brazil and Internal Medicine, State University of Rio de Janeiro, Rio de Janeiro, Brazil. Purpose: The aim of this study was to evaluate the usefulness of trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis for Pneumocystis carinii (P. jiroveci) pneumonia (PCP) in reducing the incidence of isosporiasis in patients with advanced AIDS and chronic diarrhea. Methods: Adult AIDS patients with persistent diarrhea seen in our hospitals from 1985 to 1992 without PCP prophylaxis Group A were compared with adult AIDS patients with chronic diarrhea been followed with TMP-SMX prophylaxis for PCP from 1996 to 2004 Group B.The diagnosis of protozoa was based on identification of the organism in stool by the modified acid-fast method. Student t test was used for means and chi-square to compare frequency. A p < 0.05 was considered significant. Results: Ninety four adult AIDS patients Group A, age 42 ± 8.7 and 170 Group B, age 40± 9 p > 0.05 were submitted to stool examination for Isospora belli, being positive in 21 (22.3%) for the first Group and 5 (2.9%) for the second one p < 0.01. Conclusions: The reduced incidence of isosporiasis in advanced AIDS might be related to PCP prophylaxis with TMP-SMX. The Highly Active Antiretroviral Therapy (HAART) regimen could be another possible reason. 230
ABSTRACTShilen V. Lakhani, M.D.*, Hiral N. Shah, M.D.*, Kenneth Alexander, R.N.*, Frederick C. Finelli, M.D., J.D.*, John R. Kirkpatrick, M.D.*, Timothy R. Koch, M.D.* *Section of Gastroenterology, Washington Hospital Center, Washington, DC; Department of Medicine, Washington Hospital Center, Washington, DC and Department of Surgery, Washington Hospital Center, Washington, DC. Purpose: Present evidence supports a saturable, carrier-mediated exchange mechanism for thiamine transport across jejunum. It is proposed that thiamine deficiency after gastric bypass surgery results from prolonged nausea and emesis. We observed that individuals after gastric bypass surgery developed thiamine deficiency and elevation of serum folate levels, a proposed marker for small bowel bacterial overgrowth. We hypothesized that small bowel bacterial overgrowth interferes with absorption of thiamine from the small intestine. Methods: We performed a retrospective review of consecutive patients who underwent Roux-en-Y gastric bypass surgery from 2002–2004 in our institution. To eliminate immediate, post-operative changes, we included patients who received evaluation at 3 months or longer after surgery. There were 75 patients with determination of serum thiamine and folate levels. This included 48 females and 27 males with an average age of 46 years (range 21 to 68). Five patients with low serum thiamine and elevated serum folate levels had undergone glucose-hydrogen breath testing. Results: There were 37 patients with serum folate levels greater than the upper limit of normal; among these patients, 23 (62%) had serum thiamine levels below the lower limit of normal. There were 38 patients with serum folate levels within normal range; 11 (29%) had serum thiamine levels below the lower limit of normal (Chi-squared test comparing thiamine deficiency in the normal folate group to the elevated folate group: p<.01). All 5 patients who underwent glucose-hydrogen breath testing had abnormal findings supporting a diagnosis of small bowel bacterial overgrowth: 4 patients had a significant rise (>10 ppm) in breath hydrogen within 45 minutes after glucose ingestion, while 1 had an elevated fasting breath hydrogen level of 57 ppm. Conclusions: Thiamine deficiency is common after Roux-en-Y gastric bypass surgery. Small bowel bacterial overgrowth appears to be common after gastric bypass surgery, as determined by elevation of serum folate levels or the presence of abnormal glucose-hydrogen breath testing. The results support the hypothesis that small bowel bacterial overgrowth following gastric bypass surgery can interfere with thiamine absorption. 231
ABSTRACTColm J. OLoughlin, M.D.*, Nathan E. Slinde, M.D.* *Gastroenterology & Hepatology, Medical College of Wisconsin, Milwaukee, WI. Purpose: To evaluate (1) the effect on the gastric emptying time(GET), (2) the proportion of complete SI studies and (3) the diagnostic yield of WCE in patients placed in the right lateral position (RLP) compared with the standing/sitting position post CE ingestion (SSP). Methods: 67 consecutive studies in patients undergoing WCE for investigation of Obscure Gastrointestinal Bleeding (OGIB) from 9/03 – 9/04 were analyzed retrospectively. 9 patients were excluded, 5 (endoscopic placement of the CE), 3 (h/o gastric surgery), 1 (gastroparesis). Patients remained in the RLP or in the sitting/standing position for 30 mins post CE ingestion. Major findings were defined as ulcers, AVMs, strictures, and active bleeding. Results: The 58 remaining studies (31 men, 27 women, age range 16–80), included 35 patients from the RLP group and 23 from the SSP group. The mean GET (time from the first image of the stomach to the first image of the duodenum)in the RLP grp was 27 mins compared with 52 mins in the SSP grp(P < 0.05). The mean small intestinal emptying time was similar in both groups, RLP 207 mins and SSP 203 mins. Major findings were reported in 57% of the RLP grp and 43% of the SSP grp(NS). Stricturing of the SI precluding passage of the CE occurred in 4 cases and 1 case in the RLP and SSP grps respectively. 2 battery failures occurred in the SSP. Otherwise incomplete examinations of the SI were reported in 6% of the RLP grp and 9% of the SPP grp(NS). Conclusions: Positioning patients to the RLP facilitated passage of the CE into the SI without need for promotility agents and should be considered an initial option in the clinical setting. Although there was a numerical trend toward increased diagnostic yield and complete examations of the SI in the RLP grp these were not significant. 232
ABSTRACTBarbara Bizzarri, M.D.*, Benedetta Ghidini, M.D.*, Francesca Vincenzi, M.D.*, Nicola de' Angelis, M.D.*, Valentina Maffini, M.D.*, Fabiola Fornaroli, M.D.*, Francesca Guatelli, M.D.*, Gian Luigi de' Angelis, Prof.* *Paediatric, Gastroenterology and Endoscopic Unit, Parma, Italy. Purpose: Aim: to evaluate the necessity to introduce capsule endoscopy (CE) in diagnosis and follow-up of polyposis. Methods: October 2001–May 2005: 22 patients with polyposis (7–45 years; 10 females, 12 males). Six patients were affected by Peutz Jeghers syndrome (PJS), 13 by Familial Adenomatous Polyposis (FAP), 1 by SAPHO Syndrome, 1 by Familial Colic Polyposis, 1 by Neurofibromatosis (NF) type 1. Ten out of 13 PAF underwent surgery before the execution of CE. Eleven patients (50%) repeated the procedure yearly (Group A: 5 PAF, 1 Neurofibromatosis, 5 PJS), while 11 (50%) patient underwent the exam just once (Group B: 8 PAF, 1 Familial Colic Polyposis, 1 SAPHO syndrome, 1 PJS). We use the GIVEN Workstation. Older patients spontaneously swallowed the capsule. In infants unable to swallow the capsule, it can be brought in the proximal duodenum endoscopically in general anaesthesia. Results: We performed 39 exams totally. All patients, except 2, swallowed spontaneously the capsule. Group A: a) 5 colectomized PAF: P.M. underwent 4 CE: lasting multiple ileal polyps; B.E. underwent 3 CE: worsening results from micro to macro ileal polyps which needed surgery; M.P. underwent 2 CE: both negative; P.M. underwent 2 CE: lasting diffuse polyps; V.V. underwent 2 CE: in the first, rectal fragment polyps, in the second the capsule remained in the stomach. b) 5 PJS: D.A. underwent 2 CE: lasting duodenal-jejunal micropolyps; F.P. underwent 2 CE: lasting ileal polyps; F.E. underwent 4 CE: worsening gastric-ileal pattern; E. F. underwent 4 CE: lasting gastric-ileal micropolyps; P.M. underwent 2 CE: lasting ileal polyps; c) 1 NF: C.A. underwent 2 CE. The first showed an occludent distal ileum neoformation, surgically removed with the capsule (histologically: adenocarcinoma). The second exam showed diffuse micropolyps. Group B: a) 8 PAF: 4 diffuse polyps, 1 duodenal polyps, 1 pouch polyps, 1 negative, 1 the capsule remained in the stomach; b)1 PJS: diffuse polyps; c)1 SAPHO: ileal and cecal polyps; d) 1 familial colic polyposis: diffuse right colic polyps, which needed total colectomy. Conclusions: CE, in our experience, is essential, with upper and lower endoscopy, to diagnose and follow up poliposis. It permits a global visualization of the small bowel and allows the polyps' count. Its use is, therefore,diriment to decide if continue a clinical follow-up or to address the patient to surgery. Therefore CE is, in our experience, a gold standard for polyposis. 233
ABSTRACTNayan Ranjan Nanda, M.S.* *Gastroenterology Surgery, Kalinga Hospital, Sun-Apollo Hospital, Bhubaneswar/Cuttack, Orissa, India. Purpose: Laparoscopic cholecystectomies & Appendectomies are being routinely performed round the Globe. Key to successful lap'scopic surgery is in avoiding mishaps by intuisively apprehending it in certain susceptible,complicated cases,while doing the endo-dissection. Methods: In these video clips I did encounter certain difficulties,due to reasons as follows— # straying while dissecting inside the distorted & unusual anatomical plane,resulted by the disease process. # opening up an incidental Duodenal perforation,which was already sealed by adhesions including the hanging Gallblader packed with multiple calculi. # entering into a Pericholecystic phlegmon containing gangrenous, perforated G.B & adhesions. #entering inside a pyoperitoneum,caused by a ruptured Appendix with peri appendicular lump. All these cases were tried & managed laparoscopically without compromising on patients safety & surgical principles, as follows— *In the 1 *The perforation was suture closed & a lap'choley was done as well. *The gangrenous phlegmon was carefully dissected safeguarding the adjacent colon, duodenum etc.Gangrenous gallbladder was taken out in piecemeal in an endopouch.A 32F tube drain was placed in subhepatic area after peritoneal toileting. Friable neck area of the Gallblader was managed by endosuture. *suction of the entire pus from all the gutters & pouches of peritoneal cavity was carried out first,thorough irrigation, lavage done with normal saline. Appendix was located,the surrounding adhesions were dissected safe. Meso appendix was dissected satisfactorily & root of the disesed organ was suture ligated,secured & taken out. Results: The Cases Discussed were Successfully Operated by Laparoscopic Method. Their Post Op'n Period was Uneventful. Post-Op'n Hospital Stay was Within 24 to 72 Hours. Conclusions: The key to tide over such ontoward encounters/disease mishaps lies in it's timely anticipation, on the spot decision to proceed,taking each individual case as a different one & of course with incisively meticulous endodissection,thus developing a gentle rapport with the diseased tissue & one's instruments,which eventually result in a friendly outcome. 234
ABSTRACTEric H. Shen, M.D.*, Eric L. Tatar, M.D.*, C.S. Pitchumoni, M.D.* *Gastroenterology and Hepatology, Robert Wood Johnson Medical School, New Brunswick, NJ and Gastroenterology and Hepatology, St. Peters University Hospital, New Brunswick, NJ. Purpose: The purpose of this study was to determine and explore the various findings of celiac disease detected on capsule endoscopy (CE). Methods: Up until the present time, the small bowel mucosa distal to the duodenum has been very difficult to evaluate. Capsule endoscopy is now a well-established means to evaluate the entire small bowel. There have been a few studies on the utility of capsule endoscopy in celiac disease. We sought to describe and examine the different findings of celiac disease detected on CE. We marked all reports where findings suggestive of celiac disease were mentioned. We also examined all reports where the indication was to evaluate previously-diagnosed celiac disease or to rule out celiac disease. Results: Out of 280 CE tests performed at our institution, 13 had findings suggestive of celiac disease. These findings included scalloping of folds, mucosal atrophy in association with segments of normal mucosa, and intussusception in one case confirmed by CT scan. Of these patients, 6 were referred for anemia, 3 for GI bleeding, 3 for abdominal pain, and 1 for chronic diarrhea. Three patients with a known history of celiac disease underwent CE for anemia. Only 1 of these had findings suggestive of celiac disease. Three patients were referred for CE to rule out sprue. Only 1 of these had findings of celiac disease on examination. One patient referred for abdominal pain initially had a normal capsule endoscopy. However, on repeat examination 2 months later, she was found to have focal areas of scalloping and mucosal atrophy. Conclusions: 1.Celiac disease is becoming increasingly recognized as a cause of anemia, abdominal pain, and diarrhea. 2.Wireless capsule endoscopy is a useful tool to aid in the evaluation of a patient with possible celiac disease. 3.In those patients who are found to have celiac disease on capsule endoscopy, anemia is the most likely indication. 4.Findings of celiac disease detected on CE include mucosal atrophy in association with normal mucosa, scalloping of folds, and rarely intussusception. 235
ABSTRACTKuldip S. Banwait, M.D.*, Kuntal M. Thaker, M.D.*, Stephanie McConnell, M.D.*, Ricardo Lafleur, M.D.*, David Kastenberg, M.D.*, Mitchell Conn, M.D.*, Anthony J. DiMarino, M.D.*, Sidney Cohen, M.D.*, Anthony Infantolino, M.D.* *Department of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA. Purpose: In recent years video-capsule endoscopy has revolutionized the investigation of obscure gastrointestinal bleeding (OGIB). Multiple studies have shown superiority over conventional modalities, including push enteroscopy and small bowel radiography. Wireless video capsule endoscopy (VCE) is a new technology that enables us to visualize the entire small bowel mucosa. It involves swallowing a video capsule endoscope, which is painless. Aim: To investigate etiologies of obscure gastrointestinal bleeding in a large tertiary care institution. Methods: All charts of patient who underwent VCE between 2001 and 2005 were retrospectively reviewed. There were 466 charts available with the complete VCE reports. Results: Total of 466 patients with nondiagnostic upper and lower endoscopies underwent VCE. The mean age was 59.5 years (range 7–90). There were 265 female patients and 201 male patients. The most common indication for the procedure was OGIB in 366 patients (84.9%). A possible cause of OGIB was identified in 304/366 (76.8%) of patients. The most common cause of the bleeding was angioectasias, which were identified in 42.1% of patients. Gastritis was identified in 21% and small bowel ulcerations were visualized in 11% of the patients. Small bowel erosion and duodenitis were present in 9% and 8% of patients respectively. Active bleeding without any identifiable cause was seen in 8% of the patients. 4.9% of patients were diagnosed with a small bowel mass. Conclusions: VCE identifies a possible etiology of OGIB in majority of the patients. Angioectasias is the most common finding. Small bowel masses are identified in nearly 5% of patients undergoing VCE for OGIB. VCE is a diagnostic modality of choice for investigating obscure gastrointestinal bleeding with a significant yield for previously unrecognized small bowel tumors. 236
ABSTRACTVasu Appalaneni, M.D.*, Sherin John, M.D.*, Mark Walsh, M.D.* *Gastroenterology, Dayton Veterans Affairs Medical Center, Wright State University School of Medicine, Dayton, OH and Gastroenterology, Wright State University School of Medicine, Dayton, OH. Purpose: Hereditary nonpolyposis colorectal cancer is an autosomal dominant disorder that accounts for 3 to 6 percent of the colorectal cancers. Here, we report a case of adenocarcinoma of the duodenum associated with microsatellite instability (MSI) in a patient with HNPCC. Case Presentation: A 60-year-old woman presented with a one-month history of epigastric tenderness, decreased apatite, postprandial nausea, vomiting and 5 pound weight loss. The patient has history of HNPCC – MLHI gene mutation which was diagnosed when she developed endometrial cancer and two other family members were diagnosed with colon cancer. Patient had a colonoscopy nine months ago which showed a single colorectal adenoma. The physical examination showed normal vital signs, epigastric fullness with tenderness and hyperactive bowel sounds. The computed tomographic scanning of the abdomen showed dilatation of the stomach and the proximal duodenum. An upper endoscopy revealed a circumferential friable mass lesion obstructing the lumen at the third portion of the duodenum. An exploratory laparotomy showed a hard mass involving the small bowel, pancreas and the celiac axis, encasing the major vessels to the viscera and fixing the retroperitoneum. The biopsies of this lesion revealed moderately differentiated adenocarcinoma with abundant mucin production and glandular architecture. The biopsies also showed microsatellite instability with six of nine markers tested (MSI-H), a feature associated with HNPCC. A gastrojejunal bypass procedure was done for palliative relief secondary to inability of resection for cure. Discussion: Small bowel adenocarcinoma is quite rare, accounting for less than 5 percent of all the gastrointestinal malignancies. The incidence of small intestinal tumors is greatly increased in patients with the HNPCC due to an inherited mutation of genes (specifically MLH1 and MSH2) responsible for DNA mismatch repair function during the cell replication. The adenocarcinomas associated with HNPCC are highly mucinous and associated with microsatellite instability (MSI). This patient has no prior history of colon cancer, which is more common than small bowel malignancy in patients with HNPCC. 237
ABSTRACTJohn C. Byrn, M.D.*, Ju-Lin Wang, M.D.*, Celia M. Divino, M.D., F.A.C.S.*, Richard R.P. Warner, M.D., F.A.C.G.* *Department of Surgery, Mt. Sinai Medical Center, New York, NY; Division of Gastroenterology, Department of Medicine, Mt. Sinai Medical Center, New York, NY and Chief, Division of General Surgery, Department of Surgery, Mt. Sinai Medical Center, New York, NY. Purpose: Goblet cell carcinoid tumors of the gastrointestinal tract have attracted attention as a unique neoplastic entity since the 1970's. While the debates over histopathologic classification have been largely resolved, knowledge of the clinical behavior of these tumors relies on case series observation. More importantly, surgical recommendations of right hemicolectomy, regarding unexpected goblet cell carcinoid tumors of the appendix, remain vague and inconsistently followed. Methods: A review of the literature and 16 cases from a single institution/referral center was performed. Results: Median age was 52.2 yrs with a slight female preponderance (9:7). Clinical presentation was dominated by appendicitis, however, 6 patients presented with chronic symptoms attributed to an abdominal mass or concurrent diagnosis. Two patients were known to have Crohn's disease. Six patients had second operations for formal right hemicolectomy. In 4 patients the initial operation was a right hemicolectomy or ileo-colic resection. In these cases the diagnosis of goblet cell carcinoid was not known preoperatively and the indications for the more formal resections were 1 Crohn's disease and 3 with abdominal mass. The mean time for follow-up after undergoing surgery in our 16 patients was 1.39 years. Two patients were metastatic at presentation and 4 patients are known to be alive with metastatic disease at last follow up. Two patients died from their disease and 1 patient died from unrelated causes. Four patients are known to be free of disease at last follow up. Conclusions: Goblet cell carcinoid is a rare subset of carcinoid tumors largely affecting the appendix. Scarcity of cases and long-term follow up remain a consistent weakness in the goblet cell carcinoid literature. The preponderance of metastatic disease at presentation and with short term follow up indicates the appropriateness of formal right hemicolectomy in these appendiceal tumors. 238
ABSTRACTPaul Sweetnam, Ph.D.*, Enoch Kim, Ph.D.*, Yingfei Yang, M.S.*, Stewart Campbell, Ph.D.* *Pharmacology, Surface Logix, Inc., Brighton, MA. Purpose: Microsomal triglyceride transfer protein (MTP), found primarily in the small intestine and the liver, is essential for the uptake of dietary triglycerides and cholesterol, and for secretion of VLDL in the liver. Potent small molecule inhibitors of intestinal and hepatic MTP effectively reduce plasma levels of chylomicrons, VLDL, and cholesterol without affecting HDL levels, but have been associated with a mechanism-based side-effect in the liver: steatosis. The aim of this program was to generate novel MTP inhibitors that specifically target the activity of MTP in intestinal epithelial cells without affecting hepatic MTP. SLx-4090 emerged as a lead compound having the desired pharmaceutical properties. Methods: Intestinal-specificity was achieved using a proprietary technology platform based on biophysical chemistry designed to limit systemic availability; compounds were optimized to retain potency to inhibit MTP and for their pharmacokinetic properties, including luminal accumulation and no systemic distribution. MTP inhibitors were characterized in vitro using triglyceride transfer and ApoB secretion assays and Caco-2 permeability assays. The compounds were characterized in vivo for their effects on absorption of triglycerides and cholesterol, for systemic exposure, and for safety. Results: Predictions from an absorption model based on differential permeability of MTP inhibitors across apical and basolateral lipid bilayers were consistent with experimental observations leading to the identification of a novel class of potent, small molecule MTP inhibitors. These inhibitors accumulated within intestinal epithelial cells, but were not absorbed into systemic circulation. A lead compound in this series, SLx-4090, displayed low nanomolar potency against MTP in vitro and inhibited chylomicron secretion in vivo. When administered orally to rats, SLx-4090 lowered plasma triglyceride and cholesterol levels, but was undetectable in plasma. In a chronic in vivo study, SLx-4090 did not alter liver AST or ALT, and liver triglyceride and cholesterol remained at baseline levels. Conclusions: A novel class of small intestine-specific MTP inhibitors has been identified. The lead compound, SLx-4090, effectively reduced plasma triglyceride and cholesterol levels and demonstrated an excellent safety profile based upon its lack of systemic exposure. SLx-4090 may enable novel therapies for dyslipidemia, either as a monotherapy or as a combination with existing drugs. 239
ABSTRACTMichael D. Kappelman, M.D.*, John B. Watkins, M.D.*, Timothy M. Buie, M.D.* *Pediatrics, MGH, Boston, MA and Medicine, Children's Hospital Boston, Boston, MA. Purpose: The estimated prevalence of celiac disease (CD) in the United States is 1:150. The incidence is higher in patients with Type 1 diabetes and hypothyroidism. Less appreciated are the associations with Down Syndrome, Williams Syndrome, and Turner Syndrome. We report a child with Down Syndrome and CD who presented with profound coagulopathy. Case Presentation: An 11 year-old female with Trisomy 21 presented with significant epistaxis. Past medical history was notable for Down Syndrome, duodenal atresia, and Tetralogy of Fallot. She received no medications. Family history, review of systems, and dietary history were unremarkable. Diagnostic Evaluation: The hematocrit was 28. WBC and platelets were normal. PT was 22.4 (INR = 3.3) and PTT was 41.6. Albumin was 1.3. Transaminases, bilirubin, and alkaline phosphatase were normal. Urinalysis was negative for hematuria or proteinuria. Mixing studies of both PT and PTT were consistent with a factor deficiency, and factor analysis revealed deficiency of factors II, VII, IX, and X. Anti-endomysial antibody was positive at 1:1280, and TTG was greater than 125. Duodenal biopsies demonstrated flattened villi, crypt hyperplasia, and increased intraepithelial lymphocytes (Figure 1), confirming the diagnosis of CD. The patient received 3 doses of subcutaneous vitamin K with normalization of the PT and PTT. Discussion: CD occurs in approximately 5 percent of patients with Down Syndrome. Affected children may also have anatomic GI tract abnormalities or exhibit restricted growth. Physicians caring for patients with Down Syndrome should maintain a high level of suspicion for gastrointestinal comorbidities including CD because symptoms are often difficult to illicit in this population. [figure 1][figure 2]. 240
ABSTRACTAlexander J. Eckardt, M.D.*, Rashmi Patwardhan, M.D.*, Dianne Messersmith, M.D.*, Kanishka Bhattacharya, M.D.* *Division of Gastroenterology, UMass Memorial Medical Center, Worcester, MA and Division of Gastroenterology, Worcester Medical Center, Worcester, MA. Purpose: Capsule endoscopy has been widely used for the evaluation of obscure GI-bleeding. A case of recurrent massive GI bleeding from portal hypertensive enteropathy, as visualized by capsule endoscopy, is presented. TIPS- placement led to cessation of hemorrhage, and complete reversal of the "snake skin"-appearance on capsule endoscopy. Case Presentation: A 44-year-old woman presented with a 2 day history of maroon stools. Her past medical history was significant for chronic hepatitis B with biopsy proven cirrhosis. Physical examination revealed pallor and marked ascites. Laboratory investigations revealed a hematocrit of 22%. Her INR was 1.2 and her albumin was 2.1. This was the patient's fifth admission for massive gastrointestinal bleeding within 6weeks. EGDs, colonoscopy and a push enteroscopy revealed no source of bleeding. Tagged RBC scans localized the bleeding to the small intestine, but angiograms failed to further delineate the source of bleeding. Capsule endoscopy showed a "snake skin" appearance of the small bowel (Figure 1) and a possible small bowel varix. TIPS placement led to cessation of bleeding. A follow up capsule endoscopy showed reversal of the previous findings (Figure 2). Discussion: Portal hypertensive enteropathy is a rare cause of gastrointestinal bleeding and may be difficult to visualize with standard endoscopic techniques. Capsule endoscopy showed a "snake skin"-appearance of the small bowel thus directing the appropriate treatment with subsequent reversal of the clinical and endoscopic findings. [figure 1][figure 2] 241
ABSTRACTS. Akram, M.D.*, J. A. Murray, M.D.*, P. S. Darrell, M.D.*, S. C. Abraham, M.D.*, G. L. Alexander, M.D.*, J. A. Schaffner, M.D.* *Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN and Division of Anatomic Pathology, Mayo Clinic, Rochester, MN. Purpose: Autoimmune enteropathy (AIE) is a rare cause of intractable diarrhea associated with circulating gut autoantibodies and a predisposition to autoimmunity. It is rarely observed in adults with only nine cases reported to date. Current study is the largest series of adult cases of AIE diagnosed at a single institution. Methods: 15 adults with AIE were identified at Mayo Clinic, Rochester, between May, 2001 to May, 2005. The demographic, clinical and treatment data were abstracted from their records. Results: The study population was predominantly Caucasian 12/15 (80%) with median age of 46 years (range: 33 to 76 years). 8/15 (53%) were females. All patients had protracted diarrhea, weight loss and malnutrition. Celiac disease (CD) was excluded by lack of response to gluten free diet or absence of the CD susceptibility HLA genotypes. Concomitant lymphocytic colitis was present in 7/15 (46%) and chronic gastritis in 2/15 (13%). 11/15 (73%) were tested for gut epithelial cell antibodies (GECA), 9/11 (81%) were positive for anti-enterocyte and/or anti-goblet cell antibodies which were predominantly IgG type. Predisposition to autoimmune diseases was noted in 8/15 (53%), as indicated by a host of circulating autoantibodies. Various mild immunoglobulin deficiencies of either IgG subtype or IgM were noted in 5/15 (33%). Characteristic small intestinal histopathologic findings were subtotal villous atrophy and lymphocytic infiltration in the lamina propria with relatively few intraepithelial lymphocytes. Immunophenotyping of intestinal lymphocytes revealed a predominance of CD3+ and CD4+ T cells most of which were also positive for T-cell receptor αβ. T-cell receptor gene rearrangement studies were negative in all. 11/15 (73%) received immunosuppressive therapy. Clinical improvement was noted in 4/11 (36%) after 4–6 weeks of steroids therapy. Long-term clinical remission was maintained in 2/11 with low dose prednisone or budesonide. In one refractory case, Tacrolimus and in another Infliximab were successful in inducing clinical remission. Median duration of follow-up was 24 months (range: 4 to 60 months). One death occurred from complications of severe malnutrition and volume depletion. Conclusions: AIE is a heterogenous disease and should be considered in the differentials of refractory enteropathy. Presence of GECA can help confirm the diagnosis. No single agent is unequivocally effective in inducing remission and immunosuppressive therapy is required in most cases. 242
ABSTRACTKanwar R.S. Gill, M.D.*, Christine Pizzute, M.D.*, Shunpei K. Iwata, M.D.*, Margaret Allen, L.V.N.*, Kenneth F. Binmoeller, M.D.* *Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, CA. Purpose: Capsule endoscopy is a revolutionary new diagnostic tool for the detection of small bowel disease. We describe our cumulative clinical experience of 594 wireless capsule endoscopy (WCE) procedures performed in one community hospital. Methods: Over a 4 year period (2001–2004), 594 WCE were done for suspected SB diseases [443 obscure gastrointestinal (GI) bleeding (247 overt/171 occult/25 iron deficiency anaemia), 102 abdominal pain, 12 diagnosed and 9 suspected Crohn's disease, 14 chronic diarrhea, 14 others]. 47 patients had an incomplete examination(Non-transit, poor visulisation). All patients had undergone upper GI endoscopy and colonoscopy. WCE findings were characterized as specific or non-specific, depending on whether the patient's signs and symptoms could be sufficiently attributed to them or not. Results: One or more abnormal findings were detected in 393/547 (72%) of patients; these were classified as specific in 315/547 (58%). The diagnostic yield of WCE (in terms of specific findings) was significantly higher when evaluating patients with obscure GI bleeding, compared with chronic abdominal pain (62%vs. 25%, respectively, p = 0.0001) and diarrhea (62%vs. 7%, p = 0.0001). Among obscure GI bleeders, specific findings were not significantly different in the group of overt vs. occult bleeders (61%vs. 63% respectively, p = 0.76. In patients referred for diagnosed or suspected Crohn's disease, WCE findings were compatible with the diagnosis in 8/12 cases (67%) and in 4/9 cases (44%), respectively. Among 13 patients evaluated for other findings, specific findings were identified only in 3 (21%). 18 patients (3%) underwent repeat capsule procedure (malfunction or nontransit). 17 patients (3%) had a capsule impacted in the small bowel at the time of the dictation. Conclusions: This is one of the largest WCE experience in a single community hospital by one gastroenterologist. WCE was found to be very sensitive in identifying the source of obscure GI bleeding and was equally effective in identifying the source in patients presenting with occult vs. overt bleeding. In unexplained chronic diarrhea, abdominal pain the senstivity of WCE is poor, so the utility of WCE for these indications need further evaluation. 243
ABSTRACTS. K. Lo, M.D.*, A. A. Ross, M.D.*, J. A. Leighton, M.D.*, L. Gerson, M.D.*, A. Chen, M.D.*, D. Schembre, M.D.*, S. Mehdizadeh, M.D.*, B. H. Jones, M.D.*, A. Kamal, M.D.*, I. Waxman, M.D.*, K. F. Binmoeller, M.D.*, R. Kozarek, M.D.*, G. Chen, M.D.*, C. Semrad, M.D.*, T. L. Tio, M.D.* *Cedars-Sinai, Los Angeles, CA; University of Chicago, Chicago, IL; Mayo Clinic, Scotsdale, AZ; Stanford University, Palo Alto, CA; California Pacific, San Francisco, CA and Virginia Mason, Seattle, WA. Purpose: To report early DBE technical experience in multiple U.S. centers. Methods: 8 experienced endoscopists in 6 tertiary care centers were trained (May. Wiesbaden, Germany) to perform DBE. Observations were documented in detail. Results: 129 patients had 164 DBE: 101 per-orally, 54 per-rectally, 6 via stoma, 3 for ERCP. Mean age was 57 (19–94). Mode of sedation: general anesthesia-52, MAC-59 and conscious sedation-53. Maneuvers: India ink injection in most patients, biopsies-49, argon plasma coagulation-21, electrocautery-7, balloon dilation-1, and polypectomy-2. Mean procedure time was 99 min (per-oral-98, ERCP-105, per-rectal-105, and per-stomal-63). Mean time of the first 47 cases was 115 min. Two methods were used to report the max distance reached per-orally: mean 389 cm numerically and distal jejunum anatomically. 30% of per-rectal exams failed to pass the ileocecal valve, whereas only 1 per-oral case could not reach the jejunum. Indications: GI bleeding/iron deficiency anemia -90 patients (70%), suspected Crohn's -12, abdominal pain -9, neuroendocrine tumor search -3, small bowel obstruction -3, facilitate ERCP in the Roux-en-Y -3, stricture dilation -1 and others. For bleeding/iron deficiency anemia, the findings were: AVM-23% (mostly treated), ulcers-8%, ulcerated masses-2%, polyps-2%, strictures-2%, and varices-1%. 88 patients had previous capsule endoscopy (CE) done, and the two tests correlated significantly (p = 0.004). 65% of CE findings were confirmed by DBE; 10% of DBE findings were missed on CE. 6 patients experienced complications: abdominal pain at 24 hours-2, aspiration pneumonia-1, presumed asymptomatic microscopic perforation-1, mucosal tear-1, and stomal perforation-1. No prolonged ileus, commonly seen after operative enteroscopy, was reported. Conclusions: Although experience has shortened procedure time, DBE is still time-consuming. DBE usually reaches the mid small bowel but a total intestinal examination is not achieved with initial endoscopist experience. The technique or instrument for per-rectal examination needs improvement for better technical success. DBE reults for bleeding/anemia directed therapy in about half of patients, and its yield is comparable to that of CE. |  | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
