A randomized single-blind trial of split-dose PEG-electrolyte solution without dietary restriction compared with whole dose PEG-electrolyte solution with dietary restriction for colonoscopy preparation

BACKGROUND

Colonoscopy preparation regimens are poorly tolerated, requiring the use of a large volume of an unpalatable solution and diet restriction for adequate cleansing. The aim of this study was to compare the efficacy of two regimens of bowel preparation before colonoscopy: a whole dose of polyethylene glycol electrolyte solution (PEG-E), with diet restriction vs. a split dose with no diet restriction.

METHODS

A total of 141 patients (ages 20-84 years, 81 men) were randomly assigned to receive either 4 L PEG-E, along with a liquid diet the day before colonoscopy (Group A) or 2 L PEG-E with a regular diet the day before colonoscopy followed by another 2 L PEG-E on the day of the procedure (Group B). The quality of the preparation was graded by the endoscopist (poor to excellent), who was blinded to the type of preparation. Tolerability of the assigned preparation and adverse effects were recorded by an independent investigator by using a questionnaire administered before colonoscopy. Intra- and interobserver variability was studied by using randomly chosen videotapes of colonoscopies performed as part of the study.

RESULTS

There were 73 patients in Group A and 68 patients in Group B. The quality of the preparation was significantly better in Group B ( p = 0.011). The tolerability of the preparation regimen was not different overall between study groups in terms of side effects (except for bloating, which was more frequent in Group B, p = 0.039) or willingness to repeat the preparation. There was a nonsignificant trend toward improved adherence to the assigned preparation in favor of Group B ( p = 0.062). Inter- and intraobserver variability analysis showed good to excellent correlation among endoscopists.

CONCLUSIONS

Colonic preparation with split-dose PEG-E and no dietary restriction provides better quality colon cleansing than whole-dose preparation, with no significant impact on patient tolerability and side effects.

A randomized single-blind trial of whole versus split-dose polyethylene glycol-electrolyte solution for colonoscopy preparation

BACKGROUND

Colonoscopy preparation regimens are often poorly tolerated because they require use of large-volume bowel preparation solution and diet restrictions for adequate cleansing. This study evaluated the efficacy and tolerability of a split-dose polyethylene glycol-electrolyte solution plus bisacodyl and a regular diet.

METHODS

A total of 187 patients (104 men, 83 women; age range 18-91 years) were randomly assigned to receive either 3 L of polyethylene glycol-electrolyte solution (n = 96; Group A) with a liquid diet on the day before colonoscopy, or 2 L of polyethylene glycol-electrolyte solution, one tablet of bisacodyl, and a minimally restricted diet on the day before colonoscopy, and then 1 L of the same solution on the day of colonoscopy (n = 91; Group B). Acceptability, adverse events, and willingness to retake the preparation were assessed by questionnaire. The quality of the preparation was graded by an endoscopist, blinded to the type of preparation, by using a previously described scale (excellent to poor).

RESULTS

There were 96 patients in Group A and 91 in Group B. Colon cleansing was significantly better in Group B with regard to the overall quality of the preparation (p lt; 0.05). Compliance was significantly higher in Group B as evidenced by the lower number of patients who discontinued the preparation (4 vs. 15; p = 0.02) because of side effects such as nausea or vomiting. The degree of discomfort, adverse events, and willingness to retake the preparation were not significantly different between the groups.

CONCLUSIONS

Colonic preparation with split-dose polyethylene glycol-electrolyte provided better quality colon cleansing and higher compliance, with less dietary restrictions, than preparation with whole-dose polyethylene glycol-electrolyte.

A randomized single-blind trial of standard diet versus fiber-free diet with polyethylene glycol electrolyte solution for colonoscopy preparation

BACKGROUND AND STUDY AIMS

Colonoscopy preparation usually involves the intake of large volumes of polyethylene glycol electrolyte solution (PEG-ES) in combination with a clear-liquid diet (CLD). Liberalization of the diet might enhance the tolerance to PEG-ES without compromising the quality of the preparation. The primary aims of this study were to evaluate the efficacy and tolerability of PEG-ES given with a CLD compared with a fiber-free diet (FFD) for colonoscopy preparation. The incidence of adverse events among patients in the two diet groups was also assessed as a secondary outcome.

METHODS

This was a single-center randomized, prospective, single-blind study. A total of 200 patients undergoing colonoscopy were randomized to either CLD or FFD in addition to PEG-ES.

RESULTS

Patients in the FFD group were able to drink more PEG-ES (mean +/- SD, 3.9 +/- 0.3 L) compared with those in the CLD group (3.3 +/- 0.7 L) ( P < 0.01). The quality of the preparation was significantly better in the FFD group, with more patients having satisfactory preparations than those in the CLD group (81.4 % vs. 52.0 %; P < 0.001). Tolerance to the preparation was higher in the FFD group compared with the CLD group, with significantly more patients adhering to the FFD regimen ( P < 0.001). There were more adverse events experienced in the CLD group, with odds ratios of 1.9 for nausea (95 % confidence interval [CI] 1.0 - 3.6), 3.8 for vomiting (95 % CI 1.3 - 11.3), and 3.0 for headache (95 % CI 1.5 - 5.9).

CONCLUSION

FFD given with PEG-ES on the day before colonoscopy is a more effective regimen than the standard CLD regimen, and is better tolerated by patients.

Celiac disease in Middle Eastern and North African countries: A new burden?

Celiac disease (CD) is now recognized as a common disorder among Middle Eastern (ME) and North African (NA) populations. The aim of this review is to assess the available data regarding CD in the ME and NA and to compare this information with that of Western countries. A literature review was performed using the electronic databases PubMed and Medline (1950-2008) as search engines, and “celiac disease” was used as a Mesh term. The search was limited to ME and NA countries. The prevalence of CD in ME and NA countries among low risk populations is similar to that of Western countries, but is higher in high risk populations such as those with type 1 diabetes. It is underestimated because of lack of clinical suspicion and lack of patient awareness. Clinical presentations in term of gastrointestinal, hematologic, skeletal, and liver manifestations are similar between both populations except for a high prevalence of short stature in some ME and NA countries. Few studies have addressed atypical or silent CD. As in the West, diagnosis is initially made by serological tests and is confirmed by small intestinal biopsies. Gluten-free diet is the main mode of treatment with a higher apparent adherence rate than in the West. Most disease complications result from malabsorption. The disease is strongly associated with HLA DQ2 and to a lesser extent with HLA DQ8 alleles. In conclusion, CD prevalence is underestimated, with little data available about its malignant complications. Disease parameters in the ME and NA are otherwise similar to those in Western countries.

A randomized, controlled, double-blind trial of the adjunct use of tegaserod in whole-dose or split-dose polyethylene glycol electrolyte solution for colonoscopy preparation

BACKGROUND

Problems of compliance, quality, and safety of colon preparation regimens have prompted continued investigation with alternative forms of cleansing.

OBJECTIVE

To evaluate the efficacy of tegaserod as an adjunct to a polyethylene glycol electrolyte solution (PEG-E), given as a whole dose or split dose, in colonoscopy preparation.

DESIGN

Randomized, placebo-controlled, double-blind trial.

SETTING

A single university-based hospital.

PATIENTS

Patients who were undergoing elective colonoscopy.

INTERVENTIONS

A 4-arm randomization scheme that compared tegaserod with a placebo, each with whole-dose or split-dose PEG-E preparation.

MAIN OUTCOME MEASUREMENTS

Efficacy of colon cleansing was the primary outcome. Secondary outcomes included adherence, tolerability, adverse effects, and patient perceptions of their preparation quality.

RESULTS

A total of 382 patients completed the trial. Patients who received the split-dose preparation had significantly better colon cleansing than those who received the whole-dose preparation (88.9% vs 42.6%, P < .001). The addition of tegaserod did not significantly improve the overall colonoscopy preparation quality compared with a placebo. However, there were fewer poor preparations in the whole-dose PEG-E group (12.4% vs 1.1%, P = .002, Bonferroni correction removes significance) and more excellent preparations in the split-dose group (53.3% vs 38.3%, P = .035, Bonferroni correction removes significance) in favor of tegaserod. Interobserver and intraobserver variability analysis showed substantial agreement among endoscopists. Adherence was significantly lower in the whole-dose group versus the split-dose PEG-E group (68.8% vs 91%, P < .001), independent of the use of tegaserod. Adverse effects were not different between study groups.

LIMITATIONS

A 4-arm randomization and the single-center nature of the study.

CONCLUSIONS

Tegaserod has a marginal effect on the quality of colonoscopy preparation when used as an adjuvant to PEG-E. The split-dose PEG-E was superior to the whole-dose PEG-E and resulted in better colon cleansing, adherence, and tolerance.

Clinical epidemiology of inflammatory bowel disease in Lebanon

BACKGROUND

The objectives of this study were to determine the prevalence and incidence of inflammatory bowel disease (IBD) in a representative Lebanese cohort and to describe practice prevalence trends, disease characteristics, and impact on quality of life (QoL) of IBD patients in Lebanon.

METHODS

All of a university-based health program's 2000-2004 computerized records that listed a diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) were reviewed. In addition, data on patients seen in the gastroenterology clinics and data from the IBD registry at the American University of Beirut Medical Center (AUBMC) from the same period were analyzed.

RESULTS

Of 15,073 insured individuals, 8 had a diagnosis of CD and 16 of UC, giving an age-adjusted prevalence of 53.1 per 100,000 people for CD and 106.2 per 100,000 people for UC. The mean age at diagnosis for patients with CD and UC was 28.8 +/- 11.1 and 32.0 +/- 13.4 years, respectively, and there was a slight female predominance. The mean annual incidence was 4.1 per 100,000 people for UC and 1.4 per 100,000 people for CD (range, 0-6.9/100,000 for both). Of the 10,383 patients seen in the gastroenterology clinic from 2000 to 2004, 251 (2.4%) had IBD (142 UC, 100 CD, and 9 indeterminate), a ratio that trended upward over time (range, 1.8%-2.7%). The median IBD Quality-of-Life (IBDQ) questionnaire score was 124.9 +/- 30.5, indicating that the disease had a moderately severe impact on QoL.

CONCLUSIONS

The prevalence of IBD in this representative Lebanese cohort falls in the intermediate range of that reported for white populations in Europe and North America. Future studies are needed to examine local risk factors, disease genotypes and phenotypes, and epidemiologic time trends. The psychosocial burden of IBD in Lebanon appears significant.

Up-regulation of nerve growth factor and interleukin-10 in inflamed and non-inflamed intestinal segments in rats with experimental colitis

Inflammatory bowel diseases are characterized by dysregulated immune response to the normal microflora and structural and functional changes of the enteric nervous system which occur in inflamed as well as non-inflamed areas of the bowel. This study describes the changes in the expression of nerve growth factor (NGF) and interleukin-10 (IL-10) in the colon and in various segments of the small intestine in two rat models of experimental colitis induced by iodoacetamide or 2,4,6-trinitrobenzene sulfonic acid (TNBS). Levels of NGF and IL-10 were measured by ELISA in tissue homogenate sampled from duodenum, jejunum, ileum and colon at different time intervals. NGF and IL-10 increased significantly in homogenates of strips isolated from all small intestinal segments, 3-6h after iodoacetamide or TNBS administration and remained elevated until the colonic inflammation subsided. Similar but more pronounced increase occurred in areas of the colon adjacent to the ulcer. Histologic examinations revealed inflammatory changes in the colon; however, examination of sections from the small intestines did not reveal significant differences between controls and rats with colitis. The marked up-regulation of nerve growth factor and interleukin-10 in colitis suggests that they play a role in limiting or resolving inflammation and in preventing it from becoming uncontrolled. It also suggests that experimental colitis may be associated with latent inflammation in the small bowel.

Alcohol consumption is a risk factor for colonic diverticulosis

BACKGROUND AND AIM

The exact factors predisposing to colonic diverticulosis other than age are unknown.

METHODS

Cross-sectional study of asymptomatic subjects undergoing screening colonoscopy. A detailed dietary and social questionnaire was completed on all participants. A worldwide review of the literature was performed to further investigate any association between identified risk factors and diverticulosis.

RESULTS

Seven hundred forty-six consecutive individuals were enrolled (mean age, 61.1±8.3 y; female: male=0.98). Overall, the prevalence of diverticulosis was 32.8% (95% CI, 29.5-36.2). Diverticula were left-sided, right-sided, or both in 71.5%, 5.8%, and 22.7% of affected subjects, respectively. On univariate analysis, age, sex, adenomatous polyps, advanced neoplasia (adenoma≥1 cm, villous histology, or cancer), aspirin, and alcohol use were significantly associated with diverticulosis. Diet, body mass index, physical activity, and bowel habits were not associated with the disease. On multivariate analysis, increasing age (P<0.001), advanced neoplasia (P=0.021), and alcohol consumption (P<0.001) were significantly associated with diverticulosis. The adjusted odds ratio for diverticulosis in alcohol users was 1.91 (1.36 to 2.69), with increasing prevalence with higher alcohol consumption (P-value for trend=0.001). When the prevalence of diverticulosis reported from 18 countries was analyzed against alcohol use, there was a strong correlation with national per-capita alcohol consumption rates (Pearson correlation coefficient r=0.68; P=0.002).

CONCLUSIONS

Alcohol use is a significant risk factor for colonic diverticulosis and may offer a partial explanation for the existing East-West paradox in disease prevalence and phenotype. Further studies are needed to investigate this association and its putative pathophysiological mechanisms.

Gastrointestinal bleeding in the setting of anticoagulation and antiplatelet therapy

GOAL

To review the literature on the significance, risk factors, and management of occult and gross gastrointestinal (GI) bleeding in patients on antiplatelets and/or anticoagulants.

STUDY

Relevant original and review articles and their bibliographies were analyzed. Estimates of risks and therapeutic outcomes were obtained from randomized trials, whereas risk factor identification was gathered from cross-control and prospective cohort studies.

RESULTS

Antiplatelets and anticoagulants do not diminish the positive predictive value of fecal occult blood testing to find GI pathology. They increase the risk of gross GI bleeding, and predictors of hemorrhage include history of GI bleeding or ulcer disease, higher intensity of anticoagulation, combination therapy, and presence of comorbid conditions. A bleeding site is identified in most patients with peptic ulcer being the most common. In case of significant bleeding, complete or partial reversal of anticoagulation is undertaken on the basis of the balance of risks between bleeding and thromboembolic events. Early endoscopy can reveal lesions requiring endoscopic hemostasis, which can be performed in the setting of low-intensity anticoagulation. In patients with history of peptic disease or bleeding from an acid-related lesion, proton-pump inhibitors and Helicobacter pylori eradication reduce the risk of upper GI bleeding even when antiplatelet therapy is continued.

CONCLUSIONS

Predictors of bleeding on antiplatelets and/or antithrombotics therapy have been identified, but formulation and validation of a GI bleeding index for stratification of risk in individual patients is suggested. Reversal of anticoagulation in bleeding patients is associated with a low risk of thromboembolic events and permits the performance of diagnostic and therapeutic endoscopy. Proton-pump inhibitors and H. pylori eradication reduce the risk of rebleeding in those with acid-related disease.

Interplay between nitric oxide and vasoactive intestinal polypeptide in inducing fluid secretion in rat jejunum

Nitric oxide (NO) and vasoactive intestinal polypeptide (VIP) interact in the regulation of neuromuscular function in the gut. They are also potent intestinal secretogogues that coexist in the enteric nervous system. The aims of this study were: (1) to investigate the interaction between NO and VIP in inducing fluid secretion in the rat jejunum, and (2) to determine whether the NO effect on intestinal fluid movement is neurally mediated. The single pass perfusion technique was used to study fluid movement in a 25 cm segment of rat jejunum in vivo. A solution containing 20 mM L-arginine, a NO precursor, was perfused into the segment. The effect of the NO synthase inhibitors (L-NAME and L-nitroindazole (L-NI)) and the VIP antagonist ([4Cl-D-Phe6,Leu17]VIP (VIPa)) on L-arginine-induced changes in fluid movement, expressed as microl min(-1) (g dry intestinal weight)(-1), was determined. In addition, the effect of neuronal blockade by tetrodotoxin (TTX) and ablation of the myenteric plexus by benzalkonium chloride (BAC) was studied. In parallel groups of rats, the effect of L-NAME and L-NI on VIP-induced intestinal fluid secretion was also examined. Basal fluid absorption in control rats was (median (interquartile range)) 65 (45-78). L-Arginine induced a significant fluid secretion (-14 (-20 to -5); P<0.01). This effect was reversed completely by L-NAME (60 (36-65); P<0.01) and L-NI (46 (39-75); P<0.01) and partially by VIPa (37 (14-47); P<0.01). TTX and BAC partially inhibited the effect of L-arginine (22 (15-32) and 15 (10-26), respectively; P<0.05). The effect of VIP on fluid movement (-23 (-26 to -14)) was partially reversed by L-NAME (24 (8.4-35.5); P<0.01) and L-NI (29 (4-44); P<0.01). The inhibition of VIP or NO synthase prevented L-arginine- and VIP-induced intestinal fluid secretion through a neural mechanism. The data suggest that NO enhances the release of VIP from nerve terminals and vice versa. Subsequently, each potentiates the other's effect in inducing intestinal fluid secretion.

Celiac disease in the developing world

The prevalence of celiac disease (CD) in many developing countries is similar to that of developed areas, in both low- and high-risk groups. The disorder is underestimated because of lack of disease awareness. CD is strongly associated with HLA-DQ2 in developing countries. Clinical presentation may be characterized by chronic diarrhea, anemia, stunting and increased mortality. Few studies have addressed atypical or silent CD. Diagnosis is initially made by serologic tests and is confirmed by small intestinal biopsies. In developing countries the adherence to the treatment is still difficult because of poor availability of dedicated gluten-free food.

Inhibitory effect of experimental colitis on fluid absorption in rat jejunum: role of the enteric nervous system, VIP, and nitric oxide

Impairment of small intestinal absorption has been described in patients with ulcerative colitis and in animal models of experimental colitis. The pathophysiology of this dysfunction has not been elucidated. The aim of this study was to investigate the effect of chemical colitis on jejunal fluid absorption and determine the role of the enteric nervous system and some putative neurotransmitters. In a rat model of iodoacetamide-induced colitis, jejunal net fluid absorption was evaluated by the in vivo single-pass perfusion technique. The effects of 1) tetrodotoxin (TTX), 2) benzylalkonium chloride (BAC), 3) capsaicin, 4) vasoactive intestinal polypeptide (VIP) antagonism, 5) nitric oxide (NO) synthase (NOS) inhibition, and 6) 5-hydroxytryptamine type 3 and 4 (5-HT(3) and 5-HT(4)) receptor antagonism on the changes in fluid movement were investigated. A significant decrease in jejunal net fluid absorption was found 2 and 4 days after colitis induction: 26 (SD 14) and 28 (SD 19) microl x min(-1) x g dry intestinal wt(-1), respectively [P < 0.0002 compared with sham rats at 61 (SD 6.5) microl x min(-1) x g dry intestinal wt(-1)]. No histological changes were evident in jejunal sections. TTX and BAC reversed this decrease in fluid absorption: 54 (SD 13) and 44 (SD 14) microl x min(-1) x g dry intestinal wt(-1) (P = 0.0005 and P = 0.019, respectively, compared with colitis). Ablation of capsaicin-sensitive primary afferent fibers had a partial effect: 45 (SD 5) microl x min(-1) x g dry intestinal wt(-1) (P = 0.001 and P = 0.003 compared with colitis and sham, respectively). Constitutive and neuronal NOS inhibition and VIP antagonism returned jejunal net fluid absorption to normal values: 66 (SD 19), 61 (SD 5), and 56 (SD 14) microl x min(-1) x g dry intestinal wt(-1), respectively. 5-HT(3) and 5-HT(4) receptor antagonism had no effect. Chemical colitis is associated with a significant decrease in jejunal net fluid absorption. This decrease is neurally mediated and involves VIP- and NO-related mechanisms.

Prediction of celiac disease at endoscopy

BACKGROUND AND STUDY AIMS

Celiac disease is increasingly recognized worldwide, but guidelines on how to detect the condition and diagnose patients are unclear. In this study the prevalence and predictors of celiac disease were prospectively determined in a cross-sectional sample of Lebanese patients undergoing esophagogastroduodenoscopy (EGD).

PATIENTS AND METHODS

Consecutive consenting patients (n = 999) undergoing EGD answered a questionnaire and had blood taken for serologic testing. Endoscopic markers for celiac disease were documented and duodenal biopsies were obtained. The diagnosis of celiac disease was based on abnormal duodenal histology and positive serology. Risk factors were used to classify patients to either high or low risk for celiac disease. Independent predictors of celiac disease were derived via multivariate logistic regression.

RESULTS

Villous atrophy (Marsh 3) and celiac disease were present in 1.8 % and 1.5 % of patients, respectively. Most were missed on clinical and endoscopic grounds. The sensitivity of tissue transglutaminase (tTG) testing for the diagnosis of villous atrophy and celiac disease was 72.2 % and 86.7 %, respectively. The positive predictive value of the deamidated gliadin peptide (DGP) test was 34.2 % and that of a strongly positive tTG was 80 %. While the strongest predictor of celiac disease was a positive tTG (odds ratio [OR] 131.7, 95 % confidence interval [CI] 29.0 - 598.6), endoscopic features of villous atrophy (OR 64.8, 95 %CI 10.7 - 391.3), history of eczema (OR 4.6, 95 %CI 0.8 - 28.8), anemia (OR 6.7, 95 %CI 1.2 - 38.4), and being Shiite (OR 5.4, 95 %CI 1.1 - 26.6) significantly predicted celiac disease. A strategy of biopsying the duodenum based on independent predictors had a sensitivity of 93 % - 100 % for the diagnosis of celiac disease, with an acceptable (22 % - 26 %) rate of performing unnecessary biopsies. A strategy that excluded pre-EGD serology produced a sensitivity of 93 % - 94 % and an unnecessary biopsy rate of 52 %.

CONCLUSION

An approach based solely on standard clinical suspicion and endoscopic findings is associated with a significant miss rate for celiac disease. A strategy to biopsy based on the derived celiac disease prediction models using easily obtained information prior to or during endoscopy, maximized the diagnosis while minimizing unnecessary biopsies.

Effect of mucin production on survival in colorectal cancer: a case-control study

AIM

To investigate the impact of mucin production on prognosis in colorectal cancer, in terms of overall survival (OS) and time to disease progression (TTP) in patients with mucinous compared to those with non-mucinous colorectal cancer (NMCRC), matched for age, gender, and tumor stage.

METHODS

Thirty five patients with mucinous colorectal cancer (MCRC) were matched for age, gender, and tumor stage with 35 controls having NMCRC. OS and TTP were compared among 4 groups divided according to mucin content: group A (50%-75% mucin), group B (75%-100% mucin), group C or controls (<50% mucin). Group D consisted of all patients with tumors having <75% mucin (controls and groups A together).

RESULTS

Median survival in MCRC and NMCRC groups was 46.2 and 112.9 mo, respectively (P=0.26). OS in groups A and B was 70.1 and 32.8 mo (P=0.46), and in groups B and D was 32.8 and 70.1 mo, respectively (P=0.143). TTP in MCRC and NMCRC was 50.17 and 44.77 mo, respectively (P=0.795). TTP in groups A, B, and D was 70.1, 24.8, and 65.5 mo, respectively. Twenty-eight percent of patients with MCRC had poorly differentiated adenocarcinoma versus 8.6% in NMCRC patients (P=0.028).

CONCLUSION

MCRC is associated with a non-significant decrease in median survival and TTP, particularly when mucin content is >75% of tumor volume. However, it tends to be more poorly differentiated. A larger study matching for stage and grade is needed.

Upper gastrointestinal bleeding in patients with acute coronary syndromes: clinical predictors and prophylactic role of proton pump inhibitors

OBJECTIVES

To determine the risk and the clinical predictors of in-hospital upper gastrointestinal (UGI) bleeding in patients with acute coronary syndromes (ACS), and to study the prophylactic role of proton pump inhibitors (PPI) in this setting.

BACKGROUND

Patients with ACS are usually treated by a combination of antiplatelet, antithrombotic and thrombolytic medications, thereby increasing the risk of bleeding.

STUDY

A retrospective study of 1023 patients hospitalized with ACS at the American University of Beirut Medical Center from September 2001 to November 2005. The main outcome measurements were the incidence of in-hospital UGI bleeding and its predictors; the utilization rate of PPI and its determinants.

RESULTS

Seven patients developed in-hospital UGI bleeding (0.7%) and 2 had major bleeding (0.2%). All required blood transfusion and none died in the hospital. Significant predictors of UGI bleeding were prior history of UGI bleeding or peptic ulcer disease (P<0.01), creatinine > 2 mg/dL (P=0.01), and home intake of aspirin, clopidogrel (P<0.05), or nonsteroidal anti-inflammatory drugs (P<0.05). Sixty-nine percent of patients received PPI during their hospital stay. There was no significant difference in the incidence of UGI bleeding between patients receiving and those not receiving PPI (0.7% vs. 0.6%, P= 0.88).

CONCLUSIONS

The risk of UGI bleeding is relatively low in patients hospitalized with ACS and does not appear to be significantly reduced by the use of PPI. The utilization rate of PPI was relatively high. Better patient selection and risk stratification for the prophylactic use of PPI are warranted.

Experimental colitis decreases rat jejunal amino acid absorption: role of capsaicin sensitive primary afferents

Ulcerative colitis and experimental colitis are known to be associated with functional and structural abnormalities of the small intestine. The aim of this study was to determine whether experimental colitis in the rat has any effect on jejunal amino acid absorption and to investigate the neural mechanisms involved. In Sprague Dawley rats, colitis was induced by intracolonic administration of 0.1 ml of 6% iodoacetamide. Alanine absorption in the jejunum was measured using the single pass intraluminal perfusion technique in vivo and the three-compartment model in vitro. Experiments were done in normal and sham treated rats, as well as in rats that underwent neonatal capsaicin treatment, adult capsaicin treatment, or subdiaphragmatic vagotomy. Colitis was more severe in rats subjected to neonatal or adult capsaicin treatment, but was not affected by subdiaphragmatic vagotomy. In rats with colitis, jejunal alanine absorption was reduced by 2% (P>0.05), 28%, 40%, and 18% (P<0.001) at 1, 1.5, 2, and 3 days post rectal iodoacetamide administration. A rebound increase of 12% above baseline was noted at 4 days (P<0.05). Similar results were noted in vitro. In rats that received two consecutive injections of iodoacetamide, the decrease in jejunal alanine absorption occurred earlier, was more severe, and persisted for more than 30 days. Neonatal as well as adult capsaicin treatment aggravated both the colitis and the decrease in jejunal alanine absorption. On the other hand, subdiaphragmatic vagotomy attenuated the decrease in jejunal alanine absorption, but had no significant effect on colitis severity. It is concluded that iodoacetamide induced colitis impairs jejunal amino acid absorption and that this effect involves vagal efferents as well as capsaicin sensitive primary afferents.

Prevalence of Helicobacter pylori resistance to metronidazole, clarithromycin, amoxycillin and tetracycline in Lebanon

The aim of this study was to determine the prevalence of antimicrobial resistance amongst Helicobacter pylori isolates cultured from gastric biopsies taken during routine endoscopies at the American University of Beirut Medical Center in Lebanon. Fifty-four consecutively recovered H. pylori isolates were tested against metronidazole, clarithromycin, tetracycline and amoxycillin using the epsilometer test. Resistance to metronidazole (MIC > 8 mg/l) was found in 29.5% of the isolates while resistance to clarithromycin (MIC > or =0.25 mg/l) and tetracycline (MIC > or =4 mg/l) was low (4 and 2%, respectively). All isolates were susceptible to amoxycillin (MIC < or =8 mg/l). These findings are comparable with those reported from Europe and the United States. The prevalence of metronidazole resistance in our study was lower than that from other parts of the Middle East and the developing world.

Gastrointestinal (GI) leiomyosarcoma (LMS) case series and review on diagnosis, management, and prognosis

This review of 76 gastrointestinal (GI) leiomyosarcoma (LMS) cases that include 11 cases from the American University of Beirut Medical Center represents, to our knowledge, the largest number of combined GI LMS cases reported. The age range of GI LMS is variable, and the presentation is non-specific, making pathological diagnosis essential. LMSs usually lack CD117 and CD 34 mutations and are usually positive for smooth muscle cell markers. The review highlights surgery as the mainstay of treatment with negative margins attained most of the times. Adjuvant chemotherapy is used in around 7-27 % of the cases mainly for small intestinal and colorectal LMS. The relatively small number of patients is a limitation on outcome analysis. However, LMS has a risk of recurrence reaching 39-80 % and secondary metastasis reaching 55-71 % in small intestinal and colorectal cases. In light of the high frequency of recurrence and metastasis, enrolling patients in clinical randomized trials to investigate the role of chemotherapy, radiation therapy, and targeted therapy is required for better control of this rare aggressive GI tumor.

Gross lower gastrointestinal bleeding in patients on anticoagulant and/or antiplatelet therapy: endoscopic findings, management, and clinical outcomes

OBJECTIVES

Gross gastrointestinal (GI) bleeding is a serious complication of anticoagulant/antiplatelet drug therapy. This study compares the frequencies of colorectal pathologies, endoscopic and resuscitative management measures, and clinical outcomes of patients hospitalized with lower GI bleeding (LGIB) while using anticoagulants/antiplatelets with those of patients not using them.

METHODS

A retrospective review of the records of 166 admissions for patients with gross LGIB over 12 years was conducted. The colonoscopic findings, management measures, and clinical outcomes were compared between 2 groups. Group A composed of 100 patients using any antiplatelet/anticoagulant, and group B 66 patients not using any such drugs. Independent t tests and chi were used to test for association between taking antiplatelet/anticoagulant and other variables.

RESULTS

Patients in group A were older and had more comorbidities than patients in group B. Severe LGIB occurred in 55.1% and 35.4% in groups A and B, respectively (P=0.01). Severity was not related to old age or the presence of comorbidities. A higher percentage of patients in group A had a hospital stay > or =6 days (44% vs. 27.3%; P<0.03), required blood transfusions (68% vs. 51.5%; P=0.03), and had in-hospital complications (37% vs. 22.7%; P=0.052). The most common source of bleeding was diverticulosis in both groups. Colorectal abnormalities were present in most patients; and in those using warfarin, colon cancer was common.

CONCLUSIONS

Use of antiplatelets/anticoagulant drugs is an independent predictor of severe LGIB and is associated with adverse outcomes. Colonoscopy is required in patients who bleed while using such drugs.

Effects of intravenous vasoactive intestinal peptide injection on jejunal alanine absorption and gastric acid secretion in rats

The effect of intravenous vasoactive intestinal polypeptide (VIP) injection on jejunal L-alanine absorption and gastric acid secretion in the rat was investigated. Continuous intravenous VIP infusion (11.2 ng/kg per min) throughout the experimental period (160 min) produced 60% decrease in alanine absorption and 40% decrease in gastric acid secretion during the second hour of the experiment. Subdiaphragmatic vagotomy reduced alanine absorption to 91% (P > 0.05) and 71.3% (P < 0.05) of control value during the first and second hours of perfusion, respectively. VIP infusion following vagotomy elicited a reduced effect when compared to that produced by similar injections in normal rats. Gastric secretion in vagotomized rats was reduced by 40% (P < 0.05) below control. VIP infusion in vagotomized rats exerted a significant decrease (P < 0.05) of gastric acid secretion. Moreover, water absorption was decreased by almost 10% (P < 0.05) after i.v. injection of VIP and was increased by 20-24% above control value following vagotomy. However, i.v. administration of VIP following vagotomy did not elicit any further change in water absorption. It can be concluded that VIP inhibits alanine absorption and gastric acid secretion in the rat and that these inhibitory effects might be partially mediated by the vagus nerve.

Homozygous mutations in the conserved ATP hinge region of the Wilson disease gene: association with liver disease

OBJECTIVE

To determine whether any correlation exists between the phenotype and genotype of 2 Lebanese families with members affected with Wilson disease (WD).

BACKGROUND

WD is an autosomal-recessive disorder of copper transport with significant phenotypic diversity. Most patients are compound heterozygous making it difficult to establish a clear link between phenotype and genotype.

STUDY

We investigated 14 members from 2 Lebanese families (H and Z) with 5 members affected with WD. Mutation analysis of the ATP7B gene, and clinical assessments were carried out for both families. We also performed a literature search retrieving reported phenotypes of all patients homozygous to mutations in any of the 21 exons of the ATP7B.

RESULTS

Patients of the H and Z-families were found homozygous for the respective Asn1270Ser and Pro1273Leu mutations in the adenosine triphosphate (ATP) hinge region of exon 18. Of the healthy members, 6 were heterozygous and 3 had normal sequences. Clinically, 4 patients had liver cirrhosis and 1 had asymptomatic transaminitis. One of the patients also had neurologic symptoms. Screening the literature for patients homozygous for mutations in the ATP hinge region identified 25 patients including ours. The overall prevalence of the hepatic phenotype among patients homozygous for mutation in exon 18 was 80% and was significantly higher than those in exons 7, 14, and 21.

CONCLUSIONS

We hereby report the association of liver disease with homozygous mutations in the conserved ATP hinge region of exon 18 of the ATP7B gene.

Inflammatory bowel disease in rats: Bacterial and chemical interaction

AIM: To develop a novel model of colitis in rats, using a combination of iodoacetamide and enteropathogenic E. coli (EPEC), and to elucidate the pathophysiologic processes implicated in the development of ulcerative colitis (UC).

METHODS: Male Sprague-Dawley rats (n = 158) were inoculated intrarectally on a weekly basis with 4 different combinations: (a) 1% methylcellulose (MC), (b) 100 &mgr;L of 6% iodoacetamide (IA) in 1% MC, (c) 200 &mgr;L containing 4 × 10⁸ colony factor units (CFU) of EPEC, and (d) combined treatment of (IA) followed by bacteria (B) after 2 d. Thirty days post treatment, each of the four groups was divided into two subgroups; the inoculation was stopped for one subgroup and the other subgroup continued with biweekly inoculation until the end of the experiment. Colitis was evaluated by the clinical course of the disease, the macroscopic and microscopic alterations, activity of myeloperoxidase (MPO), and by TNF-α gene expression.

RESULTS: Findings indicative of UC were seen in the combined treatment (IA + B) as well as the IA continued treatment groups: the animals showed slow rate of increase in body weight, diarrhea, bloody stools, high colonic ulcer score, as well as histological alterations characteristic of UC, with an extensive inflammatory reaction. During the course of the experiment, the MPO activity was consistently elevated and the TNF-α gene expression was upregulated compared to the control animals.

CONCLUSION: The experimental ulcerative colitis model used in the present study resembles, to a great extent, the human disease. It is reproducible with characteristics indicative of chronicity.

Prognostic factors in patients with advanced cholangiocarcinoma: Role of surgery, chemotherapy and body mass index

AIM: To study the factors that may affect survival of cholangiocarcinoma in Lebanon.

METHODS: A retrospective review of the medical records of 55 patients diagnosed with cholangio-carcinoma at the American University of Beirut between 1990 and 2005 was conducted. Univariate and multivariate analyses were performed to determine the impact of surgery, chemotherapy, body mass index, bilirubin level and other factors on survival.

RESULTS: The median survival of all patients was 8.57 mo (0.03-105.2). Univariate analysis showed that low bilirubin level (< 10 mg/dL), radical surgery and chemotherapy administration were significantly associated with better survival (P = 0.012, 0.038 and 0.038, respectively). In subgroup analysis on patients who had no surgery, chemotherapy administration prolonged median survival significantly (17.0 mo vs 3.5 mo, P = 0.001). Multivariate analysis identified only low bilirubin level < 10 mg/dL and chemotherapy administration as independent predictors associated with better survival (P < 0.05).

CONCLUSION: Our data show that palliative and postoperative chemotherapy as well as a bilirubin level < 10 mg/dL are independent predictors of a significant increase in survival in patients with cholangiocarcinoma.

Faecal impaction: in-hospital complications and their predictors in a retrospective study on 130 patients

AIM

Faecal impaction may be a medical emergency. The frequency of complications of this condition and their predictors are not known. We determined the clinical presentation, the in-hospital complications and their predictors in 130 patients diagnosed with faecal impaction.

METHOD

This was a retrospective study of the medical records of 130 patients who presented with faecal impaction to a tertiary care center in Beirut, Lebanon, between 1992 and 2009. The clinical outcome and complications were reviewed. The association between in-hospital complications and other variables was determined.

RESULTS

The mean age of the patients was 67.1 years. Ninety-eight (75.3%) patients had at least one of the following: heart disease (36.3%), neurological disease (28.8%) or diabetes (22.6%), and 26.7% were bedridden. The site of impaction was the rectum in 66.4%. The patients were treated by manual disimpaction (34.5%), enema (89.1%) or oral laxatives (84.0%). A delay in treatment of more than 6 h occurred in 70 (53.8%) patients. In-hospital complications occurred in 34 (24.6%) patients, the most common of which were infectious (16 cases), systemic inflammatory response syndrome (16 cases), cardiopulmonary (14 cases) and death (one patient). Time to the start of treatment was longer in patients who developed complications compared with those who did not (10.1 h vs 7.1 h; P = 0.02). Patients > 80 years of age, or patients with heart or neurological disease were at a higher risk of developing complications (P = 0.03, P = 0.03 and P = 0.02, respectively).

CONCLUSION

Treatment delay, increasing age and the presence of heart or neurological disease seem to be predictors of in-hospital complications in patients with faecal impaction.