Straight from the Big Apple: endoscopic retrieval of a whole apple from the sigmoid colon

Video 1Endoscopic retrieval of a whole apple from the sigmoid colon.

Anal polyp

Our case accurately describes a not infrequent finding that is not well understood by endoscopists. Fibroepithelial polyps are benign and should be considered in the differential diagnosis of anorectal polyp.

Juxta-papillary duodenal diverticula are associated with pyogenic liver abscesses: a case control study

BACKGROUND

Juxta-papillary duodenal diverticulum (JPDD) has been associated with obstructive jaundice and ascending cholangitis. Potential mechanisms include periampullary colonization of pathogenic bacteria and mechanical obstruction. However, the relation of JPDD with pyogenic liver abscess (PLA) has not been reported. Moreover, approximately one third of patients with PLA have no identifiable risk factors and are labelled as "cryptogenic". We hypothesized that JPDD is an unidentified risk factor for cryptogenic PLA and the aim of this study was to examine this association.

METHODS

We conducted a retrospective chart review to identify cases of PLA (n = 66) and compare those to matched controls (n = 66). 66 patients met the study inclusion criteria of a diagnosis of PLA using computerized tomography (CT) imaging and either positive culture or confirmed resolution after antibiotic therapy. Patients with diagnoses of amebic liver abscess, traumatic liver abscess, post cholecystectomy liver abscess, concurrent acute cholecystitis, and hepatobiliary malignancy were excluded. Controls were identified from a radiology database and matched one-to-one with the cases by age and sex. Demographic and clinical data was extracted from electronic medical records. CT scan images of all cases and controls were reviewed by a single expert radiologist to identify the presence of JPDD. Statistical tests including Chi-square and t-test with multiple logistic regression were used to examine the group differences in JPDD and other factors.

RESULTS

Among 132 study samples, 13.6% (9/66) of the cases were found to have JPDD, compared to 3.0% (2/66) among controls (p = 0.03). This corresponded to an odds ratio (OR) of 5.05 [OR 5.05; CI 1.05-24.4] on multiple logistic regression analysis. In addition, 1/3rd of PLA cases with JPDD had no other traditional risk factors (cryptogenic PLA). However, a statistically significant association of JPDD with cryptogenic PLA could not be established possibly because of a small number of cases. We found significantly high rate of diabetes mellitus (DM) (42.4%; n = 28/66) among cases compared to controls (21.2%; n = 14/66; p = 0.01).

CONCLUSION

We found a significant association between JPDD and PLA. We need studies with larger sample sizes to confirm this relationship and to explore if JPDD could be related to cryptogenic liver abscesses.

A Rare Presentation of Sarcomatoid Carcinoma of Duodenum: A Case Report

Sarcomatoid tumors are very rare biphasic tumors characterized by a mixture of malignant epithelial and mesenchymal cells that have been usually identified in the lungs with other documented cases in skin, bone, thyroid gland, salivary glands, breast, and genitourinary and gastrointestinal systems. They have an incidence estimated to be 0.5 to 0.8 per 100 000 per year. Three classic features include the presence of a genuine sarcomatous component, no transitional zone between carcinomatous and sarcomatous components, and immunohistochemistry of the sarcomatous component that is positive for mesenchymal markers and negative for epithelial markers. Sarcomatoid carcinoma of the gastrointestinal tract is rare but more commonly found within the stomach, gallbladder, and esophagus. Small bowel involvement is very rare.

Another Case of Lisinopril-Induced Acute Pancreatitis

Lisinopril as a cause for acute drug-induced pancreatitis is an emerging phenomenon that due to its generally low-risk profile often goes unnoticed. The true incidence of drug-induced pancreatitis is unknown, probably because of its nonrecognition among differential diagnosis. Only a handful of lisinopril-induced pancreatitis has been discussed in the literature, and little epidemiological evidence exists to establish true causality. Additionally, many of these reports have been met with skepticism claiming that it is difficult to isolate a true cause since many of these patients had comorbidities or were concomitantly taking other medications that may have contributed to the pancreatitis. Here, we report a case in which a generally otherwise healthy patient presented with acute drug-induced pancreatitis caused by an angiotensin-converting enzyme (ACE) inhibitor taken eight weeks prior to the onset of symptoms. The drug was immediately stopped, and the patient recovered well, with no complications.

Obesity in Inflammatory Bowel Disease Is Associated with Early Readmissions Characterised by an Increased Systems and Patient-level Burden

BACKGROUND AND AIMS

Rates of obesity are rising in patients with inflammatory bowel disease [IBD]. We conducted a US population-based study to determine the effects of obesity on outcomes in hospitalised patients with IBD.

METHODS

We searched the Nationwide Readmissions Database 2016-2017 to identify all adult patients hospitalised for IBD, using ICD-10 codes. We compared obese (body mass index [BMI] ≥ 30) vs non-obese [BMI < 30] patients with IBD to evaluate the independent effects of obesity on readmission, mortality, and other hospital outcomes. Multivariate regression and propensity matching were performed.

RESULTS

We identified 143 190 patients with IBD, of whom 9.1% were obese. Obesity was independently associated with higher all-cause readmission at 30 days {18% vs 13% (adjusted odds ratio [aOR] 1.16, p = 0.005)} and 90 days (29% vs 21% [aOR 1.27, p < 0.0001]), as compared with non-obese patients, with similar findings upon a propensity-matched sensitivity analysis. Obese and non-obese patients had similar risks of mortality on index admission [0.24% vs 0.31%, p = 0.18] and readmission [1.5% vs 1.8% p = 0.3]. Obese patients had longer [5.3 vs 4.9 days] and more expensive [USD12,195 vs USD11,154] hospitalisations on index admission. Obesity did not affect the risk of intestinal surgery or bowel obstruction. Compared with index admissions, readmissions were characterised by increased mortality [6-fold], health care use, and bowel obstruction [3-fold] [all p < 0.0001].

CONCLUSIONS

Obesity in IBD appears to be associated with increased early readmission, characterised by a higher burden, despite the introduction of weight-based therapeutics. Prevention of obesity should be a focus in the treatment of IBD to decrease readmission and health care burden.

Aggressive primary gastric lymphoma (PGL) masquerading as hepatocellular cancer (HCC) in alcoholic cirrhosis

Background

The gastrointestinal tract is sa well-known site for extranodal Non-Hodgkin lymphomas, with the stomach is known to be the most common site on lymphoma, primary gastric lymphoma (PGL). The lymphoproliferative disorder rarely occurs in patients with cirrhosis. We report a unique case of metastatic PGL in a patient with cirrhosis.

Case presentation

A middle-aged male with decompensated alcoholic cirrhosis presented with two weeks of epigastric abdominal pain, abdominal distension, and jaundice. Abdominal triple-phase CT scan was consistent with cirrhosis, ascites, and multiple new hypodense liver lesions classified as an intermediate probability for HCC based on the LI-RADS classification system (LI RADS 3). Due to the CT findings in the setting of cirrhosis, a provisional diagnosis of HCC was made. Upper endoscopy revealed new multiple umbilicated submucosal nodules in the gastric body. Biopsy and immunostaining consistent with high-grade B-cell lymphoma. Targeted liver biopsy with similar morphology and immunostaining profile consistent with metastatic primary gastric DLBCL.

Conclusions

The case highlights the importance of recognizing metastatic PGL in patients with underlying cirrhosis to differentiate lymphoma from hepatocellular cancer. Targeted liver biopsies with lymphoma immunostaining are required to make a diagnosis.

A Case of Gastric Emphysema: Incidental Findings or Serious Illness

Gastric emphysema (GE) or gastric pneumatosis is a rare entity defined as air within the gastric wall. Etiologies include pneumothorax, instrumentation, infection, gastric wall ischemia, and mechanical injury. Several theories exist as to how the air disrupts the integrity of the gastric wall. These include a bacterial infection with Clostridium species and other gas-forming aerobic colonic bacilli, instrumentation with direct submucosal gastric wall injury, mechanical injury following increased intra-abdominal pressure, penetrating air through the mediastinum from increased intrapulmonary pressure or, gastric wall ischemia, which may be secondary to an underlying process. The diagnostic test of choice is CT of the abdomen. A hypodense linear fringe on the gastric wall is seen in GE, associated with gastric distention without thickening. In emphysematous gastritis, there is gastric wall thickening. There are no standardized guidelines for GE, but most cases have a good prognosis with a spontaneous resolution with conservation treatment. However, emphysematous gastritis management requires aggressive treatment due to the mortality rate of emphysematous gastritis approaching 60%. Patients are often considered for surgical intervention with total gastrectomy, given that active infection could delay or prevent healing. It is imperative to differentiate GE and emphysematous gastritis and understand the underlying pathogenesis as clinical outcomes are vastly different.

Small Bowel Amyloidosis

PURPOSE OF REVIEW

The goal of this paper is to review the literature on small bowel amyloidosis. Our review focuses on the underlying etiology, histopathology, clinical features, endoscopic and radiologic findings, and the mainstay of management.

RECENT FINDINGS

The latest research shows changing epidemiological trends of different types of amyloidosis. It also reveals a better understanding of its pathophysiology and shows improvement in treatment outcomes. Amyloidosis is a group of diseases of multiple etiologies and clinical presentations. It is characterized by pathological deposition of insoluble fibrillar proteins within various organs leading to disruption of their structure and function. The classification of amyloidosis includes primary, secondary, dialysis-related, senile, and hereditary. Amyloidosis can be systemic or localized. The incidence of AA amyloidosis is declining in frequency. If the gastrointestinal (GI) tract is involved, the small intestine is the most commonly affected site. Overall, outcomes among patients with newly diagnosed amyloidosis have improved. This article focuses on small bowel amyloidosis.

Acute hepatitis E presenting with clinical feature of autoimmune hepatitis

A 32-year-old immigrant man presented with new onset jaundice. His past medical history was significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. His initial laboratory finding and liver biopsy were suggestive of autoimmune hepatitis (AIH). The plan was to start steroids pending negative results for viral serology, but it came back positive for hepatitis E virus. The patient's liver function test and clinical condition improved significantly on conservative management over a period of 1 month. Therefore, we suggest testing for hepatitis E especially in immigrants or recent travelers to endemic areas who presents with clinical features suggestive of AIH.

Association between serum vitamin D levels and gastric cancer: A retrospective chart analysis

AIM

To determine whether there is an increased risk of gastric adenocarcinoma associated with vitamin D deficiency (VDd).

METHODS

A retrospective case control study was performed of all patients diagnosed with gastric adenocarcinoma between 2005 and 2015. After we excluded the patients without a documented vitamin D level, 49 patients were included in our study.

RESULTS

The average age of patients with gastric adenocarcinoma and documented vitamin D level was 64 years old (95%CI: 27-86) and average vitamin D level was 20.8 mg/dL (95%CI: 4-44). Compared to a matched control group, the prevalence of VDd/insufficiency in patients with gastric adenocarcinoma was significantly higher than normal vitamin D levels (83.7% vs 16.3%). Forty-one patients (83.7%) with adenocarcinoma showed VDd/insufficiency compared to 18 (37%) patients with normal vitamin D level without gastric cancer (OR: 8.8, 95%CI: 5-22, P value < 0.0001). The average age of males with gastric adenocarcinoma diagnosis was 60 years old vs 68 years old for females (P = 0.01). Stage II gastric adenocarcinoma was the most prevalent in our study (37%).

CONCLUSION

We reported a positive relationship between VDd and gastric adenocarcinoma, that is to say, patients with decreased VDd levels have an increased propensity for gastric adenocarcinoma.

Primary squamous cell carcinoma of the rectum: a case report and literature review

Squamous cell carcinoma (SCC) of the rectum is a rare occurrence with an incidence rate of 0.1–0.25% per 1,000 cases. Herein, we report a case of a 52-year-old female who presented with a 2-month history of diffuse lower abdominal pain and hematochezia. Abdominal CT scan revealed a 7-cm irregular rectal mass, and the biopsy showed SCC.

Diverticulitis in the Young Population : Reconsidering Conventional Recommendations

BACKGROUND

In the past diverticulitis was believed to be uncommon in the young population. However, there is growing concern suggesting that these patients develop more severe clinical symptoms and may require more frequent intervention.

METHOD

We performed a retrospective chart review of patients with diverticulitis in individuals with age less than 40 years over an 8 year period (2007-2015). Diagnosis was confirmed with a CT scan. In addition to age we took into consideration race, gender, anemia (hematocrit< 41), leukocytosis (WBC > 12), BMI and whether it was an initial episode or recurrence. Our outcome variables were complications (abscess, fistula, and perforation, results of colonoscopy (polyps or colon cancer)) and whether the patient required surgery.

RESULTS

We identified 123 patients who were less than 40 years old with the diagnosis of diverticulitis. There was greater than a 3:1 ratio of males to females (77% males and 23% females) with an average age of 32.6 year. The race of the patients was nearly entirely Hispanic (88.6%). With regards to the outcome variables, 18.7% had abscesses as a complication. Perforations were observed in 26% of the patients, of which one was complicated by a fistula. A total of 25 (20%) patients went to surgery. Of these, 21 had an abscess, perforation, or tubular adenomatous polyps (TAP). Follow-up colonoscopy post-diverticulitis results were available for 42 patients. Of those patients, 9 had hyperplastic polyps and 3 had TAP. The remaining 30 patients had no polyps. No colon cancer or villous polyps were found in the entire cohort.

CONCLUSION

Our study highlights that young patients who have an index case of uncomplicated diverticulitis with no other risk factors or complications may not gain further benefit from routine colonoscopy as once traditionally thought. (Acta gastroenterol. belg., 2016, 79, 435-439).

Video capsule endoscopy: is bowel preparation necessary?

There is no standardized protocol for bowel preparation prior to video capsule endoscopy, although one is strongly recommended. The purpose of our study was to see if there was a statistical significance between small bowel mucosal visualization rates for those who received bowel preparation and those who did not. We retrospectively analyzed all patients who had a video capsule endoscopy from August 2014 to January 2016 at a tertiary care center. All patients fasted prior to the procedure. Bowel preparation when used consisted of polyethylene glycol. A long fast consisted of 12 or more hours. The grading system used to assess the small bowel was adapted from a previously validated system from Esaki et al. Statistical analyses were performed using Fisher's exact test or Welch's 2-sample t-test and statistical significance was present if the p value was ≤0.05. 76 patients were carried forward for analysis. Small bowel mucosal visualization rates were similar between those who received bowel preparation and those who did not (92.5% vs 88.9%, p=0.44). Small bowel mucosal visualization rates were significantly better in those patients who had a long fast compared with those who had a short fast (97.7% vs 81.3%, p=0.019). Our study demonstrates that the addition of bowel preparation prior to video capsule endoscopy does not significantly improve small bowel mucosal visualization rates and, in addition, there is a statistically significant relationship between increased fasting time and improved small bowel mucosal visualization. A prolonged fast without bowel preparation might be satisfactory for an adequate small bowel visualization but further randomized, prospective studies are necessary to confirm these findings.

ID: 37: SILENT BUT DEADLY CYTOMEGALOVIRUS TRIGGERING AUTOIMMUNE HEPATITIS

Introduction

To consider that viruses, more specifically cytomegalovirus (CMV), can trigger autoimmune hepatitis.

Case Report

54 year-old female presents with new onset jaundice, which was associated with abdominal distension, lower extremity edema and 10 pound weight gain. She has no history of intravenous drug use, blood transfusions, any new sexual partners in over 8 years or a family history of liver disease. The physical examination was remarkable for spider angiomata, icteric sclera, ascites, and edema.

The results of the biochemical analysis of the blood were the following: Liver enzymes were all elevated ALP 162 U/L, GGT 65 U/L, AST 154 U/L, ALT 72 U/L. Furthermore, her autoimmune workup was significant for an elevated ANA titer of 1:640, anti-smooth muscle ab titer 1:40 and a significant increase in immunoglobulins specifically IgG which was 4100 mg/dL. Interestingly, CMV Ab IgM was positive at 36.6 u/mL as well as CMV Ab IgG, which was positive at >10.00 u/mL. The rest of the work up was unremarkable in regards to hepatitis A, B, C, HIV, HSV, Epstein Barr virus (EBV), alpha1 antitrypsin, ceruloplasmin, iron level, ferritin and antimitochondrial ab. A liver biopsy was performed which showed heavy infiltration with lymphoplasmacytic inflammatory cells, interface hepatitis, bridging necrosis, and fibrosis. These pathologic and laboratory findings led us to a definitive diagnosis of autoimmune hepatitis (AIH) Type 1. In the setting of positive CMV IgG and IgM ab titers, we suggest that the trigger for AIH in this case was a preceding CMV infection. Her evolution was satisfactory under corticosteroid and azathioprine therapy.

Discussion

Autoimmune hepatitis is a chronic hepatocellular inflammation and necrosis of unknown cause. The most supported pathogenesis of AIH postulates that a combination of environmental triggers, failure of immune system tolerance and a genetic predisposition that may induce a T cell–mediated immune attack against the liver. Case studies in the literature report AIH being triggered by virus and drugs. There is evidence of cross-reactivity between anti-LKM1 and antibodies against homologous regions of cytomegalovirus (exon CMV130-135). This case could explain an association between cytomegalovirus infection and autoimmune hepatitis.

As clinicians, it is difficult to diagnose autoimmune hepatitis because its presentation can be acute, severe, asymptomatic or chronic. Diagnosis requires multiple findings and exclusions of similar diseases. When excluding, make sure viral etiologies are part of the differential, which in this case is CMV. If indeed a trigger is required to set off a sequence of events leading to autoimmune hepatitis in these predisposed individuals, viruses are among the most likely candidates.

Abstract ID: 37 Figure 1

ID: 34: ASSOCIATION BETWEEN VITAMIN D AND GASTRIC CANCER

Background and Objectives

Vitamin D deficiency is linked to several gastrointestinal malignancies including gastric cancer and affects a multitude of cellular processes involved in tumorigenesis. Vitamin D is presumed to have anticancer actions by inducing differentiation and cell cycle arrest in malignant cells. Furthermore, it significantly promotes apoptosis in the undifferentiated gastric cancer cell line HGC-27. The aim of this study was to determine whether there is an increased risk of gastric adenocarcinoma (GA) associated with vitamin d deficiency.

Methodology

A retrospective case-control study was conducted at Elmhurst Hospital Center from 2005–2015. Three hundred and four patients who were diagnosed with GA were selected as cases. Of 304 individuals with GA, 255 were excluded, because they did not have vitamin D levels, 49 patients were included in our study. The data was compared to a matched control group of 49 patients with no known malignancies who had vitamin D levels. Prevalence of vitamin D deficiency was compared between cases and controls using odds ratios (ORs) and 95% confidence intervals.

Results

The mean age of the case sample was 63.96 vs 60.43% in the control group. The gender distribution was the same, 49% male and 51% female. Hispanic patients were predominant in both samples accounting for 61.2% of the groups (table 1). Of 49 patients with GA included in our study, 20.48% were stage I; 36.7% were stage II; 24.9% were stage III, and 18.4% were stage IV. The prevalence of vitamin D deficiency in the case group (GA) was significantly higher than in the control group 19[38.8%] vs 7[14.3%] respectively (OR: 3.8, 95% CI 1.42–10.18, P value 0.0079) figure 1.

Conclusion

The results of our study suggest that there is a positive correlation between vitamin D deficiency and gastric adenocarcinoma. More specifically patients with vitamin D deficiency have an increased association with GA. Additional multicenter randomized double blind clinical trials are required to further assess this association and the potential benefit of vitamin D supplementation in preventing gastric adenocarcinoma.

Abstract ID: 34 Figure 1

ID: 35: ASSOCIATION BETWEEN HELICOBACTER PYLORI INFECTION WITH CORONARY ARTERY DISEASE AND ACUTE MYOCARDIAL INFARCTION: A RETROSPECTIVE CHART ANALYSIS

Introduction

Helicobacter pylori (HP) infection is known to target the gastrointestinal system and is associated with extra gastrointestinal manifestations, but there is limited literature on cardiac associations. The most supported pathogenesis uses chronic inflammation as a risk factor causing atherosclerosis resulting in cardiovascular disease. Our aim is to evaluate whether there is an association between HP infection and acute myocardial infarction (AMI) and coronary artery disease (CAD).

Method

We performed a retrospective single center study at our medical center from 2005 to 2014 consisting of 1,671 patients who underwent Coronary Angiography (CA). We divided these patients into two groups based on CA reports. Patients with CAD defined as left main stenosis of ≥50% or any stenosis of ≥70% versus normal coronaries. We reviewed each patient chart to determine the prevalence of positive serum HP IgG antibody. Smoking, hypertension, dyslipidemia and obesity were also considered in each group.

Results

Of 1,671 patients, 1,237 had evidence of CAD vs 434 with normal coronary arteries. Twelve percent of CAD patients were found to have seropositive HP (SPHP) versus 1% in the control group (OR: 7.3, 95% CI: 3.5–15, p<0.0001) as depicted in figure 1. When we looked at the CAD group and compared SPHP patients to seronegative HP (SNHP) patients we found a greater amount of multiple coronary vessels disease in the SPHP group (OR: 1.4, 95% CI: 1.1–2, P=0.04). With regards to AMI, 30% of the SPHP group presented with AMI versus 10% seen in the SNHP group (OR: 4.3, 95% CI: 3–6.5, p<0.0001). In the CAD group with SPHP there was more hyperlipidemia and a higher BMI than in the CAD SNHP group (p<0.0001 and <0.0001, respectively), but there was no statistical difference between the two groups for the risk factors of smoking, hypertension and diabetes.

Conclusion

According to this study, the results showed a correlation with SPHP patients and CAD. Patients with HP seropositivity also tend to have multiple coronary artery vessel disease. In addition, our results also confirmed that there is an association between with HP infection and AMI. We hypothesize that the associated maybe secondary to inflammatory reaction associated with HP. Additional studies with larger sample groups are needed to investigate the possible role of this pathogen as a risk factor for heart disease.

Abstract ID: 35 Figure 1

Twelve percent of CAD patients were found to have seropositive HP (SPHP) versus 1% in the control group (OR: 7.3, 95% CI: 3.5–15, p<0.0001).

ID: 36: PEGASPARGASE INDUCED SEVERE PANCREATITIS. FRIEND OR FOE?

Introduction

Pegaspargase (Oncaspar) is a modified version of L-asparaginase conjugated with polyethylene glycol. In leukemic cells, asparaginase hydrolyzes L- asparagine to ammonia and L-aspartic acid leading to depletion of asparagine. Despite its potential benefits there are a wide range of side effects. One rare but potentially deadly complication is severe pancreatitis.

Case

The patient was a 24 year old Mexican male with a history of Acute T-Cell Lymphoblastic Leukemia (ALL) on recent chemotherapy including pegaspargase, admitted for abdominal pain, found to have acute pancreatitis secondary to hypertriglyceridemia. Heart rate was 127 bpm, chest revealed decreased air entry in right lung bases, and a distended severely tender abdomen. Laboratory tests were remarkable for elevated liver enzymes ALP 360 U/L, AST 310 U/L, GGT 216 U/L, ALT 44 U/L, LDH 829 U/L, elevated lipase 228 U/L, and hypertriglyceridemia >3,000 mg/dL. Abdominal CT showed pancreatitis with necrosis; peripancreatic, intraperitoneal and extensive retroperitoneal fluid. Subsequently his severe pancreatitis was associated with acute kidney injury and respiratory failure which is illustrated by his (BUN 22 Creatinine 2.16, and persistent hypoxia.) According to the Atlanta Classification, patient is classified under severe acute pancreatitis.

Discussion

Pegaspargase is used for treatment of ALL and is gaining in popularity over Asparaginase therapy due to it having fewer incidences of hypersensitivity reactions and because of its long half life (367 hrs) allowing dosing every 14 days as opposed to Asparaginase which is dosed daily. Pegaspargase definitely has its benefits but we can't lose sight of one of its rare, but potentially deadly complications, pancreatitis. In one study nine of the 50 patients (18%) with ALL treated with pegaspargase were diagnosed to have pancreatitis. In contrast, only one out of 52 (1.9%) ALL patients who received native E. coli L-asparaginase during the same time period developed pancreatitis. One proposed mechanism of this drug-induced pancreatitis is hypertriglyceridemia, which is seen in our case. It is suggested that apolipoprotein E polymorphism may influence the development of hyperlipidemia in ALL patients receiving pegaspargase therapy.

We report a case to increase the awareness of higher incidence of pegaspargase-induced pancreatitis, which is a rare but potentially deadly complication. Clinicians should monitor triglycerides while on treatment and suspect pancreatitis if patient develops abdominal pain. If pancreatitis occurs, therapy should be stopped and not reinstituted. For patients with hypertriglyceridemia without pancreatitis discontinuation of therapy should be considered.

Abstract ID: 36 Figure 1

Impression: Severe acute pancreatitis. Significant interval worsening.

Factors predicting early discharge and mortality in post-percutaneous endoscopic gastrostomy patients

BACKGROUND

The aim of our study was to ascertain factors that favor early discharge and predict mortality in post-percutaneous endoscopic gastrostomy (PEG) patients.

METHODS

Successive patients who underwent successful PEG placement during a 10-year period in a single New York City hospital were included in the study. Data was retrospectively extracted from hospital electronic medical records.

RESULTS

Two hundred and eighty-four patients underwent successful PEG placement. Forty-six patients (16%) were discharged within 3 days of PEG placement (early discharge). Two hundred and thirty six patients (84%) remained in hospital from 4 to 244 days (median 13.5) after PEG insertion (late discharge). Twenty-six (9%) patients died in-house after PEG placement. A serum albumin level <2.2 g/dL (P=0.007) and presence of 2 or more co-morbidities (P=0.019) were predictors of late discharge. A dementia indication was twice as likely to result in an early discharge compared to a stroke indication (OR 2.39; 95% CI 1.07-5.36; P=0.033). Female sex, positive urine cultures and low serum albumin levels were independent predictors of in-house mortality.

CONCLUSION

Clinical and laboratory markers may predict post-PEG mortality as well as early patient discharge.

An unusual cause of upper gastrointestinal bleeding: duodenal GIST. A case report and literature review

A duodenal GIST is an unusual cause of upper gastrointestinal bleeding. Duodenal GISTs are rare and constitute 5% of all GISTs. A significant percentage of duodenal GISTs are located in the third and fourth portion of the duodenum and may not be detected on routine upper endoscopy. Push enteroscopy is necessary to locate these lesions. It is extremely important to differentiate a duodenal GIST from other submucosal tumors like leiomyomas, leiomyosarcomas or leiomyoblastomas which may present in a similar manner, because the treatment and prognosis differ significantly. Appropriate histological and immunohistiochemical staining is required to confirm the diagnosis. Surgical resection is the treatment of choice and may involve limited resection or a pancreaticoduodenectomy. Adjuvant therapy with Imatinib has been shown to prolong survival in patients with GIST in general.

Phenotype classification in IBD: Is there an impact on therapy?

This review summarizes the current phenotypic classifications of inflammatory bowel disease (IBD) and outlines their implications for diagnosis, therapy, prognosis, clinical trial design, and genotype-phenotype correlations.

Correlation between beta-lipoprotein levels and outcome of hepatitis C treatment

The low-density lipoprotein receptor (LDLR) has been proposed as a candidate receptor for the hepatitis C virus (HCV). Competitive inhibition of HCV binding to the LDLR by low-density lipoprotein (LDL) has been shown in vitro. If similar inhibition occurs in vivo, an elevated serum concentration of beta-lipoproteins may reduce the efficiency of infecting hepatocytes with HCV by competitively inhibiting HCV viral receptor binding. We investigated the role of baseline lipid values in influencing the outcome of HCV treatment. We conducted a retrospective chart review of patients treated with an interferon-based regimen at our liver and gastroenterology clinics between 1998 and 2004. Of 99 patients enrolled in the study, 49 (49.5%) had HCV genotype 1 (LDL 100.2 +/- 30.2 mg/dL [mean +/- SD]), and 50 patients (50.5%) had genotype 2 or 3 (LDL 110.1 +/- 40 mg/dL) infection. Early viral response (EVR), end-of-treatment response (ETR), and sustained viral response (SVR) were documented in 99, 88, and 77 patients, respectively. LDL and cholesterol levels prior to treatment were found to be higher in patients with positive EVR, ETR, and SVR. This difference remained significant independent of age. Multivariate analysis controlling for genotype and age showed that the higher the cholesterol and LDL levels prior to treatment, the greater the odds of responding to treatment. In conclusion, having higher serum LDL and cholesterol levels before treatment may be significant prognostic indicators for treatment outcome of those with chronic hepatitis C infection, particularly in genotypes 1 and 2.