Endoscopic ultrasound for the evaluation of Nissen fundoplication integrity: a blinded comparison with conventional testing

BACKGROUND

For patients whose symptoms develop after Nissen fundoplication, the precise mechanism of anatomic failure can be difficult to determine. The authors have previously reported the endosonographic hallmarks defining an intact Nissen fundoplication in swine and the known causes of failure. The current clinical trial tested the hypothesis that a defined set of endosonographic criteria can be applied to determine fundoplication integrity in humans.

METHODS

The study enrolled seven symptomatic and nine asymptomatic subjects at a mean of 6 years (range, 1-30 years) after Nissen fundoplication. A validated gastroesophageal reflux disease (GERD)-specific questionnaire and medication history were completed. Before endoscopic ultrasound (EUS), all the patients underwent complete conventional testing (upper endoscopy, esophagram, manometry, 24-h pH). A diagnosis was rendered on the basis of combined test results. Then EUS was performed by an observer blinded to symptoms, medication use, and conventional testing diagnoses. Because EUS and esophagogastroduodenoscopy (EGD) are uniformly performed in combination, the EUS diagnosis was rendered on the basis of previously established criteria combined with the EGD interpretation. The diagnoses then were compared to examine the contribution of EUS in this setting.

RESULTS

The technique and defined criteria were easily applied to all subjects. All symptomatic patients had heartburn and were taking proton pump inhibitors (PPI). No asymptomatic patients were taking PPI. All diagnoses established with combined conventional testing were detected on EUS with upper endoscopy. Additionally, EUS resolved the etiology of a low lower esophageal sphincter pressure in two symptomatic patients and detected the additional diagnoses of slippage in two subjects. Among asymptomatic subjects, EUS identified additional diagnoses in two subjects considered to be normal by conventional testing methods.

CONCLUSION

According to the findings, EUS is a feasible method for evaluating post-Nissen fundoplication hiatal anatomic relationships. The combination of EUS and EGD allows the mechanism of failure to be detected in patients presenting with postoperative symptoms after Nissen fundoplication.

The role and clinical value of EUS in a multimodality esophageal carcinoma staging program with CT and positron emission tomography

BACKGROUND

EUS, CT, and positron emission tomography (PET) have all been used in the preoperative staging of esophageal cancer separately or in various combinations.

OBJECTIVE

Our purpose was to determine the value and role of EUS when used in conjunction with CT and PET imaging in staging cancer of the esophagus and gastroesophageal junction.

DESIGN

Retrospective single-center clinical trial.

SETTING

Academic tertiary care center.

PATIENTS

Data were examined for 56 patients who concomitantly underwent examination with EUS, CT, and PET in a multimodality staging program.

MAIN OUTCOME MEASUREMENTS

EUS, CT, and PET were examined for their ability to detect the primary tumor, local tumor stage, locoregional adenopathy, and distant metastases. With use of surgical resection as baseline therapy, the frequency at which EUS, CT, and PET affected and changed management was examined.

RESULTS

EUS is the only imaging test that identified all primary tumors and provided tumor staging. EUS identified a significantly greater number of patients (58.9%) with locoregional nodes than did CT (26.8%), P = .0006, or PET (37.5%), P = .02. CT identified 14.3% and PET identified 26.8% of patients with distant metastases. With CT alone, 15.2% of patients were not taken to surgery, whereas PET affected management by preventing surgery because of metastatic disease in 28.3% of patients. EUS changed management by guiding the need for neoadjuvant therapy in 34.8% of patients.

LIMITATIONS

Retrospective study, nonblinded study, lack of pathologic reference standard.

CONCLUSION

The primary strength of EUS in a multimodality staging strategy is in identifying patients with locally advanced disease and guiding the need for preoperative neoadjuvant therapy. EUS is not suited to determine resectability of esophageal cancer alone and thus is most effective when used in conjunction with other imaging tests such as CT and PET.

Placement of gastrostomy tubes in patients with ventriculoperitoneal shunts does not result in increased incidence of shunt infection or decreased survival

The objective of this study was to examine if G-tube (G-tube) placement in patients with ventriculoperitoneal (VP) shunts results in shunt infection or impacts patient survival. We performed a retrospective cohort study. Patients underwent VP shunt and G-tube placement. Incidence of shunt infection and patient survival were calculated. Fifty-five patients qualified for the study. Shunt infection occurred in seven patients (12.5%). The incidence of shunt infection did not differ between surgically placed G-tubes (2/7=29%) and PEG tubes (5/7=71%; P=0.69). There was no difference in the risk of VP infection based on the order of placement (OR=0.61 [0.12-3.02]; P=0.69). No predictors for shunt infection were identified. Kaplan-Meier mortality estimates demonstrated a 21% 1-year mortality rate. There were no predictors of patient survival. We conclude that placement of G-tubes in patients with shunts is safe. The order of placement of G-tube and VP shunt does not affect the incidence of shunt infection or survival.

Extracolonic tumors of the gastrointestinal tract detected incidentally at screening CT colonography

PURPOSE

The aim of this article is to report our experience with incidental detection of extracolonic tumors of the gastrointestinal tract identified prospectively at screening CT colonography.

METHODS

A total of 2014 patients (1097 females, 917 males; mean age, 56.9 years) underwent primary CT colonography evaluation at our institution over an 18-month period. Following cathartic preparation and colonic distention, supine and prone multidetector CT scans were obtained with thin-collimation low-dose technique without intravenous contrast. We reviewed our database for lesions of the extracolonic gastrointestinal tract that were detected during the prospective reading.

RESULTS

Focal extracolonic gastrointestinal tract lesions were prospectively detected in 10 (0.5 percent) of 2014 patients (8 females; 2 males; mean age, 58.5 years). All patients were asymptomatic. Tumor locations included ileum (n = 3), stomach (n = 3), jejunum (n = 2), and appendix (n = 2). Mean tumor size was 2.2 (range, 0.8-3.4) cm. Lesions in eight patients were subsequently confirmed by conventional or capsule endoscopy and/or by intravenous contrast-enhanced CT. Seven lesions were surgically excised and one was removed at endoscopy; two patients with lipomas did not undergo further evaluation or treatment. Final diagnoses were benign in all cases and included lipoma (n = 3), small-bowel hamartoma (n = 2), appendiceal mucinous cystadenoma (n = 2), gastric leiomyoma (n = 1), small-bowel lymphangioma (n = 1), and gastric fundic gland polyp (n = 1).

CONCLUSIONS

Incidental extracolonic tumors of the gastrointestinal tract detected at screening CT colonography were all asymptomatic and benign but often prompted more invasive workup. Although the incidence of these tumors was relatively low, widespread population screening with CT colonography would result in new surgical referrals for these findings.

Screening for colorectal neoplasia with CT colonography: initial experience from the 1st year of coverage by third-party payers

PURPOSE

To evaluate our experience in the 1st year of computed tomographic (CT) colonography screening since the initiation of local third-party payer coverage.

MATERIALS AND METHODS

This HIPAA-compliant study was approved by the institutional review board, and informed consent was waived. Over a 1-year period that ended on April 27, 2005, 1110 consecutive adults (585 women, 525 men; mean age, 58.1 years) underwent primary CT colonography screening. More than 99% were covered by managed care agreements. CT colonographic interpretation was performed with primary three-dimensional polyp detection, and the final results were issued within 2 hours. Patients with large (> or =10-mm) polyps were referred for same-day optical colonoscopy, and patients with medium-sized (6-9-mm) lesions had the option of immediate optical colonoscopy or short-term CT colonography surveillance.

RESULTS

Large colorectal polyps were identified at CT colonography in 43 (3.9%) of 1110 patients. Medium-sized lesions were identified in 77 (6.9%) patients, 31 (40%) of whom chose optical colonoscopy and 46 (60%) of whom chose CT colonography surveillance. Concordant lesions were identified in 65 of 71 patients who underwent subsequent optical colonoscopy (positive predictive value, 91.5%). Sixty-one (86%) of 71 optical colonoscopic procedures were performed on the same day as CT colonography, thereby avoiding the need for repeat bowel preparation. The actual endoscopic referral rate for positive findings at CT colonography was 6.4% (71 of 1110 patients). The demand for CT colonography screening from primary care physicians and their patients increased throughout the study period.

CONCLUSION

As a primary colorectal screening tool, CT colonography covered by third-party payers has an acceptably low endoscopic referral rate and a high concordance of positive findings at optical colonoscopy.

Surface visualization at 3D endoluminal CT colonography: degree of coverage and implications for polyp detection

BACKGROUND & AIMS

Effective colonoscopic screening for polyps, whether by optical or virtual means, requires adequate visualization of the entire colonic surface. The purpose of this study was to assess prospectively the degree of surface coverage at 3-dimensional (3D) endoluminal computed tomography colonography (CTC) after retrograde fly-through, combined retrograde-antegrade fly-through, and review of remaining missed regions.

METHODS

The study group consisted of 223 asymptomatic adults (mean age, 57.8 +/- 7.2 y; 111 men, 112 women) undergoing primary CTC screening. CTC studies were interpreted by experienced readers using a primary 3D approach. The CTC software system that was used continually tracks the percentage of endoluminal surface visualized. The degree of coverage was assessed prospectively after retrograde and combined retrograde-antegrade navigation. The added effect of reviewing missed regions was also assessed prospectively.

RESULTS

The mean surface coverage after only retrograde 3D endoluminal fly-through from rectum to cecum was 76.6% +/- 4.8% (range, 63%-92%); coverage was 80% or less in 181 (81.2%) patients. Antegrade navigation back to the rectum increased the overall coverage to 94.1% +/- 2.3% (range, 84%-99%; P < .0001). A review of missed regions 300 mm(2) or larger increased coverage to 97.9% +/- 1.1% (range, 93%-99%; P < .0001) and added 21.4 +/- 11.4 seconds to the interpretation time (range, 3-67 s).

CONCLUSIONS

Combined bidirectional retrograde and antegrade 3D navigation, supplemented by rapid review of missed regions, effectively covers the entire evaluable surface at CTC. Unidirectional retrograde 3D fly-through typically excludes 20% or more of the endoluminal surface, which may provide insight into potential limitations at optical colonoscopy.

Comparison of the effect of non-ionic and ionic contrast agents on pancreatic histology in a canine model

CONTEXT

Pancreatitis is the most frequent complication of endoscopic retrograde cholangiopancreatography. Controversy exists whether low osmolarity non-ionic contrast agents lessen the rate of pancreatitis and pancreatic injury. To evaluate we used a canine model to compare pancreatography performed with ionic and non-ionic contrast.

DESIGN

Dogs were anesthetized and underwent open transduodenal cannulation of the main pancreatic duct under fluoroscopic control until complete acinarization was achieved to maximize injury. Three dogs received diatrozate, an ionic contrast agent with osmolarity of 1,415 mosM and three dogs were injected with omnipaque a non-ionic agent with osmolarity of 672 mosM.

MAIN OUTCOME MEASURES

Serial amylase and white cell counts were followed for 48 hours at which time dogs were sacrificed. Each pancreas was then examined for evidence of pancreatitis and cellular injury with both light and electron microscopy.

RESULTS

All animals developed significant hyperamylasemia and elevated white blood cell counts, without significant difference in the mean peak amylase (10,721 U/L vs. 9,367 U/L, P=0.876) or white cell counts (25.8 k/mL vs. 24.1 k/mL, P=0.586) between the ionic and non-ionic contrast groups. Light microscopy showed no evidence of pancreatitis in either group of dogs. Electron microscopy showed cellular injury of the ductal cells in two dogs injected with non-ionic contrast.

CONCLUSION

In a pancreatic canine model, low osmolarity, non-ionic contrast does not appear to lessen cellular injury.

EUS characteristics of Nissen fundoplication: normal appearance and mechanisms of failure

BACKGROUND

In patients who develop symptoms after Nissen fundoplication, the precise mechanism of failure can be difficult to determine. Current testing modalities do not demonstrate sufficient anatomic detail to definitively determine the mechanism. This observational study establishes that EUS can determine fundoplication integrity and hiatal anatomic relationships after Nissen fundoplication.

METHODS

EUS was performed on the native esophagogastric junction and after Nissen fundoplication in two swine. The EUS characteristics of a properly performed fundoplication were determined. Subsequently, complications of Nissen fundoplication were created, and EUS was performed on each. The EUS criteria of each mechanism of failure were defined.

RESULTS

EUS provided sufficient axial resolution to distinguish the esophagus, the fundoplication, and the surrounding hiatal structures within a single image. US of the native esophagogastric junction discerned the length of intra-abdominal esophagus, esophagogastric junction, crura, and anterior hiatus, and, thus, the point of entry into the abdominal cavity. EUS of Nissen fundoplication revealed a 5-layered pattern in a 360 degree configuration. These layers represent the following: (1) the esophageal wall, (2) the space between the esophagus and the fundoplication, (3) the inner gastric wall of the fundoplication, (4) the gastric lumen, and (5) the outer gastric wall of the fundoplication. A slipped repair was identified by the presence of an echogenic gastric serosa within the fundoplication. A tight fundoplication results in attenuation of the gastric walls, thickening of the esophageal wall, and loss of the 5-layer pattern secondary to obliteration of the potential spaces of the gastric lumen. Dehiscence of the fundoplication was evidenced by a less than 360 degree 5-layer pattern.

CONCLUSIONS

EUS of hiatal anatomic relationships is feasible and provides detailed information regarding the integrity and the position of a Nissen fundoplication. EUS may enable a precise determination of the anatomic causes of failure after antireflux surgery.

Laryngopharyngeal reflux symptoms better predict the presence of esophageal adenocarcinoma than typical gastroesophageal reflux symptoms

OBJECTIVE

To determine whether the presence of laryngopharyngeal reflux symptoms is associated with the presence of esophageal adenocarcinoma (EAC).

BACKGROUND

Most patients diagnosed with EAC have incurable disease at the time of detection. The majority of these patients are unaware of the presence of Barrett's esophagus prior to cancer diagnosis and many do not report typical symptoms of gastroesophageal reflux disease (GERD). This suggests that the current GERD symptom-based screening paradigm may be inadequate. Data support a causal relation between complicated GERD and laryngopharyngeal reflux symptoms. We theorize that laryngopharyngeal reflux symptoms are not recognized expeditiously, resulting in chronic esophageal injury and an unrecognized progression of Barrett's esophagus to EAC.

METHODS

This is a case-comparison (control) study. Cases were patients diagnosed with EAC (n = 63) between 1997 and 2002. Three comparison groups were selected: 1) Barrett's esophagus patients without dysplasia (n = 50), 2) GERD patients without Barrett's esophagus (n = 50), and 3) patients with no history of GERD symptoms or antisecretory medication use (n = 56). The risk factors evaluated included demographics, medical history, lifestyle variables, and laryngopharyngeal reflux symptoms. Typical GERD symptoms and antisecretory medication use were recorded. Multivariate analysis of demographics, comorbid risk factors, and symptoms was performed with logistic regression to provide odds ratios for the probability of EAC diagnosis.

RESULTS

The prevalence of patients with laryngopharyngeal reflux symptoms was significantly greater in the cases than comparison groups (P = 0.0005). The prevalence of laryngopharyngeal reflux symptoms increased as disease severity progressed from the non-GERD comparison group (19.6%) to GERD (26%), Barrett's esophagus (40%), and EAC patients (54%). Symptoms of GERD were less prevalent in cases (43%) when compared with Barrett's esophagus (66%) and GERD (86%) control groups (P < 0.001). Twenty-seven percent (17 of 63) of EAC patients never had GERD or laryngopharyngeal reflux symptoms. Fifty-seven percent of EAC patients presented without ever having typical GERD symptoms. Chronic cough, diabetes, and age emerged as independent risk factors for the development of EAC.

CONCLUSIONS

Symptoms of laryngopharyngeal reflux are more prevalent in patients with EAC than typical GERD symptoms and may represent the only sign of disease. Chronic cough is an independent risk factor associated with the presence of EAC. Addition of laryngopharyngeal reflux symptoms to the current Barrett's screening guidelines is warranted.

Endoscopic appraisal of the gastroesophageal valve after antireflux surgery

OBJECTIVES

Little consensus exists regarding the endoscopic assessment of the esophagogastric junction after antireflux surgery. The purpose of this report is to characterize the gastroesophageal valve appearance unique to each type of antireflux procedure and to introduce an endoscopic lexicon by which to describe this anatomic region.

METHODS

Endoscopic images were obtained from patients who had undergone any one of the following procedures: Nissen, Collis-Nissen, Toupet, and Dor fundoplications and Hill repair. Images were excluded if patients had any symptoms of heartburn, regurgitation, dysphagia, chest pain, or gas bloat or if they were using antisecretory medication. Seven photographs per operation type were evaluated by experienced surgeons and gastroenterologists tasked with describing defining characteristics of each procedure.

RESULTS

Ten valve criteria were developed to uniquely identify and quantify the ideal endoscopic appearance of each procedure. Illustrations were created to clearly depict those traits.

CONCLUSIONS

Using 10 gastroesophageal valve criteria, the key components of a successful functional repair of the esophagogastric junction were defined. These criteria can be employed when evaluating upper gastrointestinal complaints after antireflux surgery and may ultimately serve as a dependable outcome measure.

Endoscopic Management of Biliary Complications After Orthotopic Liver Transplantation

After orthotopic liver transplantation (OLT), biliary duct complications can occur in as many as 10% to 35% of patients. In the early medical and surgical literature, surgical therapy was the primary mode of management of biliary tract complications and was the eventual course of operative intervention in up to 70% of cases. However, with recent advances in therapeutic biliary endoscopy, the current endoscopic and transplantation literature suggests that endoscopic management with techniques such as endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy, biliary stenting, and stone removal techniques can be successfully applied for the majority of post-OLT biliary complications. The most common biliary complications after OLT include biliary strictures (anastomotic and nonanastomotic); bile duct leaks, common bile duct stones, and biliary casts; sphincter of Oddi/ampullary muscle dysfunction/spasm; and disease recurrence (eg, primary sclerosing cholangitis). Predisposing factors for biliary complications after OLT include hepatic artery thrombosis, impaired perfusion of the biliary tree, portal vein thrombosis, and preservation or harvesting injuries, which can increase the incidence of complications as much as 40%. Use of immunosuppressive agents such as cyclosporine can lead to cholesterol/bile stasis and stone formation. Outside of endoscopic therapy, there is little medical or dietary management that can be applied for post-OLT biliary complications. Ursodiol (ursodeoxycholic acid) has often been used as a neoadjuvant to ERCP therapy in the setting of common bile duct stones/casts, and low-fat diets may be recommended in this setting, but no large, randomized trials have advocated medical or conservative management alone.

Graft failure from severe recurrent primary sclerosing cholangitis following orthotopic liver transplantation

Speculation that primary sclerosing cholangitis (PSC) may recur in the transplanted liver is based on the relative increase in frequency of biliary abnormalities and histologic evidence of periportal fibrosis without other causes. A recent study demonstrated almost 9% of patients undergoing liver transplantation (OLT) for primary sclerosing cholangitis (PSC) develop recurrent sclerosing cholangitis although the patient and graft survival is not different from those in whom recurrence does not develop. Most reports of PSC recurrence post-OLT estimate rates of 1% to 14%, but to date, no center has reported rapidly progressive fibro-obliterative cholangitis leading to graft failure.

CASE REPORT

DV was a 39-year-old white man with ulcerative colitis, since age 21, who developed jaundice and pruritus in 1992. ERCP and liver biopsy were consistent with PSC, and he developed thrombocytopenia and bleeding esophageal varices. He underwent an uneventful OLT in May 1994 with an ABO-compatible organ and normal ischemic times. There was no evidence of postoperative cytomegalovirus infection, hepatic artery thrombosis, or rejection. In October 1994, mild abnormalities of liver function tests (LFTs) led to liver biopsy that revealed inflammatory infiltrate in triad with spillover into lobules and mild periportal fibrosis. LFTs normalized without any treatment, but in February 1995 repeat liver biopsy for increased LFTs revealed moderate periportal fibrosis with inflammatory cells in triads and lobules. Viral shell and CMV titers were negative. No evidence of infectious etiology or rejection was noted. The patient was started on ursodeoxycholic acid at that time and percutaneous transhepatic cholangiogram (PTC) revealed marked narrowing of the intrahepatic ducts. Esophagogastroduodenoscopy (EGD) revealed esophageal varices. Hepatic arteriogram and Doppler ultrasound were negative. He developed progressive graft failure, and died at home while awaiting re-transplant.

CONCLUSIONS

Although most series report mild recurrence of PSC following OLT, this case illustrates that early, severe recurrence of PSC may occur, leading to graft failure and need for re-transplantation.

Risk factors for dysplasia in patients with Barrett's esophagus (BE): results from a multicenter consortium

Studies show Barrett's esophagus prevalence increases with age, while mean length of Barrett's esophagus is unchanged. Few data are available about the relationship between age and length on the development of dysplasia. Our aim was to assess age and length as risk factors for dysplasia. Consecutive patients with Barrett's esophagus were enrolled in a multicenter study establishing a tissue bank of Barrett's esophagus patients 1994 and 1998. Demographics, length of Barrett's esophagus (centimeters), and histology were recorded. Risk factors for dysplasia were assessed, including patient age, gender, and length of Barrett's esophagus. Statistical analysis was performed comparing prevalence of dysplasia (which included the presence of any carcinoma and high- or low-grade dysplasia) to age and length. In all, 309 patients were studied [278 (90%) male and 31 (10%) female]: 5 had adenocarcinoma of the esophagus, 11 had high-grade dysplasia, and 29 had low-grade dysplasia. Patients with Barrett's esophagus without dysplasia were younger than those with dysplasia [62 +/- 0.8 years vs 67 +/- 1.7 years (mean +/- SEM, P = 0.02)]. The risk of dysplasia increased by 3.3%/yr of age. Mean length of Barrett's esophagus in patients with Barrett's alone vs dysplasia was 4.0 +/- 0.2 cm vs 5.4 +/- 0.4 cm (P = 0.003). Patients with Barrett's esophagus length > or = 3 cm had a significantly greater prevalence of dysplasia compared to length < 3 cm (23% vs 9%, P = 0.0001). The risk of dysplasia increased by 14%/cm of increased length. Multivariate analysis showed age and length to be independent risk factors. In conclusions: prevalence of dysplasia is strongly associated with age and length of Barrett's esophagus. These preliminary results can be used to develop a strategy for screening/surveillance based on age and length of Barrett's epithelium.

Risk factors for dysplasia in patients with Barrett's esophagus (BE): results from a multicenter consortium

Studies show Barrett's esophagus prevalence increases with age, while mean length of Barrett's esophagus is unchanged. Few data are available about the relationship between age and length on the development of dysplasia. Our aim was to assess age and length as risk factors for dysplasia. Consecutive patients with Barrett's esophagus were enrolled in a multicenter study establishing a tissue bank of Barrett's esophagus patients 1994 and 1998. Demographics, length of Barrett's esophagus (centimeters), and histology were recorded. Risk factors for dysplasia were assessed, including patient age, gender, and length of Barrett's esophagus. Statistical analysis was performed comparing prevalence of dysplasia (which included the presence of any carcinoma and high- or low-grade dysplasia) to age and length. In all, 309 patients were studied [278 (90%) male and 31 (10%) female]: 5 had adenocarcinoma of the esophagus, 11 had high-grade dysplasia, and 29 had low-grade dysplasia. Patients with Barrett's esophagus without dysplasia were younger than those with dysplasia [62 +/- 0.8 years vs 67 +/- 1.7 years (mean +/- SEM, P = 0.02)]. The risk of dysplasia increased by 3.3%/yr of age. Mean length of Barrett's esophagus in patients with Barrett's alone vs dysplasia was 4.0 +/- 0.2 cm vs 5.4 +/- 0.4 cm (P = 0.003). Patients with Barrett's esophagus length > or = 3 cm had a significantly greater prevalence of dysplasia compared to length < 3 cm (23% vs 9%, P = 0.0001). The risk of dysplasia increased by 14%/cm of increased length. Multivariate analysis showed age and length to be independent risk factors. In conclusions: prevalence of dysplasia is strongly associated with age and length of Barrett's esophagus. These preliminary results can be used to develop a strategy for screening/surveillance based on age and length of Barrett's epithelium.

Diseases of the rectum and anus: a clinical approach to common disorders

Diseases of the rectum and anus are common, and the prevalence in the general population is probably much higher than that seen in clinical practice since most patients with symptoms referable to the anorectum do not seek medical attention. The examination and diagnosis of certain anorectal disorders can be challenging, and the physical examination of the anorectum is often inadequately performed in clinical practice. This article reviews the important features of the anorectal examination and the diagnosis and treatment of benign anorectal disorders such as hemorrhoids, fissures, fistulas, solitary rectal ulcer syndrome, fecal incontinence, and pruritus ani. Approaches to staging and managing malignant neoplasms of the anus and rectum are outlined.

Duration of antiviral therapy for cholestatic HCV recurrence may need to be indefinite

Progressive liver allograft injury related to hepatitis C virus (HCV) recurrence occurs in 20% to 30% of liver transplant recipients within the first 5 years. In particular, the subset of patients who develop the severe cholestatic variant has an extremely high mortality. We report our center's experience with 7 cholestatic patients who were treated with interferon alfa-2b (3 million IU three times per week initially) in combination with ribavirin. In 4 of the 7 patients, HCV-RNA in serum became undetectable, and in an additional patient, normalization of serum bilirubin was achieved despite persistent viremia. Discontinuation of antiviral therapy by patient choice, intolerance of side effects, or occurrence of infection were followed temporally by rapid relapses of the cholestatic syndrome, allograft failure, and death. The only 2 patients alive in remission of this syndrome have been maintained on antiviral therapy for an average of 32 months. Thus, based on our experience, we recommend that duration of antiviral therapy in the subset of patients with cholestatic HCV recurrence should be indefinite.

Brunner's gland hamartoma: a rare cause of gastrointestinal bleeding -- case report and review of the literature

An unusual cause of upper gastrointestinal bleeding is described in a previously healthy 45-year-old man who was admitted to hospital with weakness and fatigue, and had experienced an episode of melena two days before admission. His medical and surgical history was unremarkable. Upon admission to hospital, he showed evidence of iron-deficiency anemia, with a hemoglobin concentration of 61 g/L (normal range 135 to 175 g/L), a mean corpuscular volume of 73 fL (normal range 85.0 to 95.0 fL) and a ferritin concentration of 1.0 microg/L (normal range in males 15 to 400 microg/L). Upper gastrointestinal endoscopy revealed a 3.5 cm ulcerated submucosal mass in the third portion of the duodenum, for which mucosal biopsies were nondiagnostic. A subsequent endoscopic ultrasound revealed a 2.7 x 4.0 cm hyperechoic, cystic, submucosal tumour in the third portion of the duodenum. Endoscopic ultrasound-guided fine needle aspiration revealed no malignant cells. The patient eventually underwent a resection of the third portion of his duodenum. Surgical pathology revealed that this tumour was a Brunner's gland hamartoma, 4.5 cm in its greatest dimension.

Another look at Barrett's esophagus. Current thinking on screening and surveillance strategies

Barrett's esophagus remains a major health problem and a risk factor for the development of esophageal adenocarcinoma. Given the low incidence of this disorder, efforts should be made to identify risk factors that target patients with GERD or known Barrett's esophagus who would most benefit from screening and surveillance strategies. It is clear that identifying esophageal adenocarcinoma at an early and treatable stage reduces morbidity and mortality. However, currently available screening tools (endoscopy with surveillance biopsies every 2 years) are expensive and not easily applied. Identification of tumor markers and other specific risk factors may be helpful in predicting who is at risk for dysplasia. Current therapeutic strategies are successful in the treatment of GERD symptoms, but further research and longer follow-up studies are needed to determine if these strategies bring about regression of Barrett's esophagus, reversal of dysplasia, or prevention of cancer.

Solitary rectal ulcer syndrome presenting with rectal prolapse, severe mucorrhea and eroded polypoid hyperplasia: case report and review of the literature

A case of solitary rectal ulcer syndrome in a 36-year-old woman presenting with severe, persistent mucorrhea and eroded polypoid hyperplasia as the predominant clinical features, who was ultimately noted to have symptoms of rectal prolapse, is presented. Endoscopically, she had multiple (50 to 60) small, whitish polypoid lesions in the rectum that were initially misinterpreted as being a carpeted villous adenoma, juvenile polyposis or atypical proctitis. The lesions were treated with argon plasma coagulation with resolution, but a solitary rectal ulcer developed. The patient then admitted to a history of massive rectal prolapse over the preceding six months and underwent surgical treatment. Severe mucorrhea as the presenting feature and the presence of multiple polypoid lesions consistent with a histological diagnosis of eroded polypoid hyperplasia make the present case unique.

Treatment of progressive hepatitis C recurrence after liver transplantation with combination interferon plus ribavirin

Hepatitis C virus (HCV) recurrence after orthotopic liver transplantation (OLT) is common, although the majority of cases are mild. A subset of transplant recipients develops progressive allograft injury, including cirrhosis and allograft failure. Minimal data are available on the safety and efficacy of antiviral treatment in this group of patients. The aim of this study is to review our experience in the treatment of moderate to severe HCV recurrence with combination interferon-alpha2b and ribavirin (IFN/RIB). Between October 1993 and October 1999, a total of 197 patients underwent OLT for HCV-related liver failure. This study describes 12 transplant recipients with moderate to severe recurrence treated with IFN/RIB. All patients met at least 1 of the following inclusion criteria: (1) moderate to severe inflammation (grade III to IV) on allograft biopsy, (2) bridging fibrosis on allograft biopsy, or (3) severe cholestasis attributable solely to HCV recurrence. Two patients had undergone re-OLT for allograft cirrhosis secondary to HCV recurrence and now had evidence of progressive HCV in their second allografts. Appropriate dose reductions of both IFN and RIB, as well as initiation of granulocyte colony-stimulating factor (G-CSF), for marked leukopenia were recorded. IFN/RIB therapy was started 60 to 647 days post-OLT, and duration of therapy ranged from 39 to 515 days. Seven patients were administered G-CSF to successfully treat leukopenia. Six of the 12 patients (50%) became HCV RNA negative by polymerase chain reaction. One of these 6 patients (no. 1) was HCV RNA negative at 6 months but chose to discontinue therapy because of intolerable side effects, experienced a relapse, and was HCV RNA positive at 12 months. Two of the remaining 5 patients were HCV RNA negative at 2 and 9 months off therapy. For the entire group, there was a statistically significant decrease in serum biochemical indices assessed at initiation of therapy and 1, 3, and 6 months into therapy. Most patients required dose reductions of both IFN and RIB. Five patients died; 3 patients died of liver-related complications that included severe intrahepatic biliary cholestasis, severe HCV recurrence, and chronic rejection with profound cholestasis. In the subset of HCV-positive liver transplant recipients with moderate to severe recurrence, combination IFN/RIB therapy resulted in complete virological response (serum RNA negative) in 6 of 12 patients ( approximately 50%). However, only 1 of 12 patients (8.3%) had sustained virological clearance after cessation of IFN/RIB therapy. Dose reductions of both IFN and RIB were required in most patients. The use of G-CSF (sometimes preemptively) allowed correction of leukopenia and full-dose antiviral therapy. Multicenter trials using combination therapy to identify factors predictive of response are needed in the subset of patients with progressive allograft injury.

Abnormal findings on liver function tests. Interpreting results to narrow the diagnosis and establish a prognosis

Evaluating abnormal liver test results requires careful attention to the corresponding clinical data obtained during history taking and physical examination. Generally, it is helpful to separate liver tests into three categories: tests that assess synthetic function, tests that assess hepatocellular necrosis (hepatocellular enzymes), and tests that assess cholestasis. The clinical setting together with the specific pattern of liver function abnormalities can narrow differential diagnosis and provide a cost-effective approach to assessing patients and identifying those who need liver biopsy.