Rate of colorectal neoplasia in patients with Hodgkin lymphoma

AIM

Survivors of Hodgkin lymphoma (HL) are at increased risk of breast, lung, thyroid, stomach, pancreatic and colon cancer. There is limited information on the utility of endoscopic screening for colon cancer. We aimed to describe the adenoma detection rate (ADR) in patients with HL to determine the appropriate timing of colonoscopy screening.

METHOD

We retrospectively studied patients with HL who underwent colonoscopy between 2000 and 2017.

RESULTS

A total of 251 patients underwent colonoscopy. Eighty (32%) patients had 151 colonic polyps. Thirty per cent of the polyps exhibited high-grade dysplasia, and invasive colon adenocarcinoma was found in 10 patients. Patients with the nodular sclerosing subtype of HL had a significantly lower ADR than others (P = 0.002). The ADR was 5% in patients younger than 35 years (n = 64), 23% in patients between 35 and 40 years of age (n = 22), 39% in patients between 40 and 50 years of age (n = 51) and 46% in patients older than 50 years (n = 114).

Can Immune Checkpoint Inhibitors Induce Microscopic Colitis or a Brand New Entity?

BACKGROUND

Microscopic colitis (MC) has been described as 1 pattern of injury in immune checkpoint inhibitor (ICPI)-induced colitis. The main objective of this study was to characterize ICPI-induced MC by exploring the differences in risk factors, colitis treatments, endoscopic features, and clinical outcomes between cancer and noncancer patients with MC with and without exposure to ICPIs.

METHODS

A retrospective chart review was conducted among patients diagnosed with MC from our institutional pathology database from January 2012 to January 2018. Patients were categorized into MC in cancer patients with or without ICPI exposure and in noncancer patients. Risk factors (use of tobacco and certain medications), colitis treatments (antidiarrheals and immunosuppressants), endoscopic features (with or without mucosal abnormality), and clinical outcomes (diarrhea recurrence, hospitalization, mortality) were collected and compared among the 3 groups.

RESULTS

Of the 65 eligible patients with MC, 15 cancer patients had exposure to ICPI, 39 cancer patients had no exposure to ICPI, and 11 had no cancer diagnosis. Among the risk factors, proton pump inhibitor was more frequently used in the ICPI-induced MC cohort (P = 0.040). Furthermore, in this population, mucosal abnormality was the most common endoscopic feature compared with normal findings in the non-ICPI-induced MC groups (P = 0.106). Patients with ICPI-induced MC required more treatments with oral and intravenous steroids and nonsteroidal immunosuppressive agents (all P < 0.001) and had a higher rate of hospitalization (P < 0.001).

CONCLUSION

This study suggests that despite some similarities between MC with and without exposure to ICPIs, ICPI-induced MC has a more aggressive disease course that requires more potent immunosuppressive treatment regimens and greater need for hospitalization. 10.1093/ibd/izy240_video1izy240.video15828223597001.

Endoscopic resection is cost-effective compared with laparoscopic resection in the management of complex colon polyps: an economic analysis

BACKGROUND AND AIMS

Endoscopic resection (ER) is an efficacious treatment for complex colon polyps (CCPs). Many patients are referred for surgical resection because of concerns over procedural safety, incomplete polyp resection, and adenoma recurrence after ER. Efficacy data for both resection strategies are widely available, but a paucity of data exist on the cost-effectiveness of each modality. The aim of this study was to perform an economic analysis comparing ER and laparoscopic resection (LR) strategies in patients with CCP.

METHODS

A decision analysis tree was constructed using decision analysis software. The 2 strategies (ER vs LR) were evaluated in a hypothetical cohort of patients with CCPs. A hybrid Markov model with a 10-year time horizon was used. Patients entered the model after colonoscopic diagnosis at age 50. Under Strategy I, patients underwent ER followed by surveillance colonoscopy at 3 to 6 months and 12 months. Patients with failed ER and residual adenoma at 12 months were referred for LR. Under Strategy II, patients underwent LR as primary treatment. Patients with invasive cancer were excluded. Estimates regarding ER performance characteristics were obtained from a systematic review of published literature. The Centers for Medicare & Medicaid Services (2012-2013) and the 2012 Healthcare Cost and Utilization Project databases were used to determine the costs and loss of utility. We assumed that all procedures were performed with anesthesia support, and patients with adverse events in both strategies required inpatient hospitalization. Baseline estimates and costs were varied by using a sensitivity analysis through the ranges.

RESULTS

LR was found to be more costly and yielded fewer quality-adjusted life-years (QALYs) compared with ER. The cost of ER of a CCP was $5570 per patient and yielded 9.640 QALYs. LR of a CCP cost $18,717 per patient and yielded fewer QALYs (9.577). For LR to be more cost-effective, the thresholds of 1-way sensitivity analyses were (1) technical success of ER for complete resection in <75.8% of cases, (2) adverse event rates for ER > 12%, and (3) LR cost of <$14,000.

CONCLUSIONS

Our data suggest that ER is a cost-effective strategy for removal of CCPs. The effectiveness is driven by high technical success and low adverse event rates associated with ER, in addition to the increased cost of LR.

Severe obesity prior to diagnosis limits survival in colorectal cancer patients evaluated at a large cancer centre

Background:

In contrast to the consistent evidence for obesity and colorectal cancer (CRC) risk, the impact of obesity in CRC patients is less clear. In a well-characterised cohort of CRC patients, we prospectively evaluated class I and class II obesity with survival outcomes.

Methods:

The CRC patients (N=634) were followed from the date of diagnosis until disease progression/first recurrence (progression-free survival (PFS)) or death (overall survival (OS)). Body mass index (BMI) was calculated from reported usual weight prior to diagnosis. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated in models adjusted for clinicopathologic, treatment, and lifestyle factors.

Results:

Over a median follow-up of 4 years, 208 (33%) patients died and 235 (37%) recurred or progressed. Class II obesity, as compared with either overweight or normal weight, was associated with an increased risk of death (HR and 95% CI: 1.55 (0.97–2.48) and 1.65 (1.02–2.68), respectively), but no clear association was observed with PFS. In analyses restricted to patients who presented as stages I–III, who reported stable weight, or who were aged <50 years, obesity was associated with a significant two- to five-fold increased risk of death.

Conclusions:

In CRC patients evaluated at a large cancer centre, severely obese patients experienced worse survival outcomes independent of many other factors.

Endoscopic closure of acute esophageal perforations

Esophageal leak is a life-threatening problem that can result from spontaneous rupture of the esophagus, cancer, anastomotic dehiscence after surgery, or as a complication of endoscopy. During the last decade, developments in the minimally invasive endoluminal approach to the management of esophageal leaks include utilization of endoscopy not only for diagnosis but also for closure of leaks with clips or sutures, bypass of the leaks with stents, and/or endoluminal drainage of mediastinal infection. The aim of this review is to summarize recent advances and the principles of endoscopic management of acute esophageal perforations.

Predictors of colorectal cancer following a negative colonoscopy in the Medicare population

BACKGROUND

The incidence of colorectal cancer following a normal colonoscopy in the Medicare population is not known.

METHODS

A 5% national sample of Medicare enrollees from 1996 to 2005 was used to identify patients undergoing complete colonoscopy. A colonoscopy not associated with any procedure (e.g., biopsy, polypectomy or fulguration) was defined as a negative colonoscopy. Patients with history of inflammatory bowel disease, colorectal cancer or death within 12 months of colonoscopy were excluded. A multivariable model was constructed to evaluate the factors associated with a new diagnosis of colorectal cancer in the period from 12 to 120 months following the negative colonoscopy.

RESULTS

Among 200,857 patients (mean age 74 years, 61% female, 92% White) with a negative colonoscopy, the incidence of colorectal cancer was 1.8 per 1,000 person-years. The incidence rate for matched follow-up periods decreased from 2.0/1,000 person-years for patients undergoing colonoscopy during 1996-2000 to 1.2/1,000 person years during 2001-2005. Multivariate analysis revealed a significant regional variation in the incidence of colorectal cancer following a negative colonoscopy. The incidence was higher in patients >85 years, males and patients who underwent a negative colonoscopy by a non-gastroenterologist or endoscopist in the lowest volume quartile. On stratified analyses, endoscopist volume was a significant predictor for non-gastroenterologists only.

CONCLUSIONS

The specialty and experience of the endoscopist are significant predictors of the incidence rate of colorectal cancer in Medicare patients with a negative colonoscopy.

Endoscopic sutured closure of a gastric natural orifice transluminal endoscopic surgery access gastrotomy compared with open surgical closure in a porcine model. A randomized, multicenter controlled trial

BACKGROUND AND STUDY AIMS

In natural orifice transluminal endoscopic surgery (NOTES) procedures it is essential to be able to perform secure closure of the access perforation. The aim of this study was to compare endoscopically sutured closure of a gastric access gastrotomy using the tissue apposition system (TAS), with closure via laparotomy in a randomized multicenter study.

METHODS

A total of 32 pigs (18 - 42 kg) were used in this study. The gastric NOTES access was created using a needle knife and a 20-mm balloon. Following transgastric pelvic peritoneoscopy, the endoscope was withdrawn into the stomach. The animals were then randomized to endoscopic closure or laparotomy with surgical closure. Procedure time, recovery time, and weight gain were measured. At necropsy, adhesions, abscesses or peritonitis were recorded.

RESULTS

Of the 32 pigs, 29 survived 14 days without complications. All endoscopic and all open surgical closures were secure at postmortem. On average two suture pairs were used for endoscopic closure. Surgical closure was quicker (12.5 vs. 20.1 minutes). Recovery time and postoperative weight gain were similar for both groups. Two pigs in the endoscopic group died: one of gastric dilatation, without leakage from the gastrotomy; another was euthanized due to rectal prolapse. In the laparotomy group one pig was euthanized after 7 days due to abdominal wound dehiscence. At necropsy there were significantly more intra-abdominal adhesions in the laparotomized group.

CONCLUSION

This randomized controlled study of endoscopic and surgical closure of a gastrotomy made for transperitoneal access for NOTES procedures suggests that both techniques are comparable in technical closure rates, postoperative recovery, and prevention of peritonitis. There were fewer adhesions in the endoscopic group.

Endoscopic management of gastrointestinal leaks

Endoscopic closure of gastrointestinal perforations, fistulas, and anastomotic dehiscence is technically feasible. Endoluminal closure of the instrumental perforations of the gastrointestinal tract can be accomplished immediately after the recognition of perforation, while avoiding the delay of arranging surgery and the trauma associated with thoracotomy or laparotomy. In addition, endoscopic closure should be considered in patients with anastomotic dehiscence and chronic fistulas as this may avoid the risk associated with reoperation. The outcome of closure depends on the technical expertise in the proper selection and use of various endoluminal closure options. Training of the endoscopists in the use of this novel technology will enhance the quality of care of our patients.

The role of endoscopic ultrasound and endoscopic ultrasound-guided fine-needle aspiration in distinguishing pancreatic cystic lesions

Distinguishing mucinous from nonmucinous cystic lesions of the pancreas often constitutes a diagnostic dilemma. The clinical management differs between such lesions; therefore it is important to make an accurate preoperative diagnosis. Various centers have reported conflicting results regarding their ability to detect mucin-producing neoplastic cells and appropriately reach a diagnosis based on endoscopic ultrasound (EUS) guided FNA. The aim of this study is to assess the ability of EUS-FNA cytology to diagnose and differentiate mucinous from nonmucinous pancreatic cystic lesions. We reviewed records of patients who underwent EUS of pancreatic cystic lesions. If FNA was performed and mucinous neoplasm was suspected, aspirate was evaluated for cytomorphology and presence of mucin. FNA results were compared to final histologic diagnosis if surgery was performed. Cytologic diagnosis was provided for 28/30 (93%). By comparing EUS-FNA diagnoses with final surgical pathology, FNA accurately diagnosed in 10/11 cases with sensitivity and specificity for detection of malignancy of 100 and 89, respectively, while the accuracy for identification of mucinous cystic neoplasms was 100%. Our results indicate that in the appropriate clinical and imaging setting, EUS-FNA cytology with analysis for mucin production by tumor cells is an important test in distinguishing pancreatic cystic lesions and guiding further management.

Effect of a novel pancreatic stent design on short-term pancreatic injury in a canine model

BACKGROUND AND STUDY AIMS

Attempts to address the problem of injury to the pancreas by indwelling pancreatic stents are limited by our lack of knowledge of the pathogenesis of stent-induced injury and its relationship to stent morphology and the duration of stenting. The aim of our study was to evaluate pancreatic injury induced by 1 week of stenting with a 5F indwelling pancreatic stent of novel design, the "wing stent."

METHODS

Pancreatic stents (5F) were placed surgically in eight dogs; wing stents (WS-5F) were used in four dogs and conventional stents (CS-5F) in another four. Two dogs underwent duodenotomy without stent placement (controls). The pancreas was harvested for microscopy at 1 week. A pathologist who was unaware of the source of the specimens graded the pancreatic injury.

RESULTS

Although pancreatic injury was observed in both the CS-5F and WS-5F groups after 1 week of indwelling pancreatic stenting, it was considerably less severe in the WS-5F group compared with the CS-5F group (1.01 +/- 0.10 vs. 1.63 +/- 0.14, P < 0.01). All components of pancreatic injury were affected, with the most dramatic differences noted in inflammation, fibrosis, and edema. The differences were most marked in the stented segment ( P < 0.001) and in the upstream segment of the pancreas ( P < 0.05).

CONCLUSIONS

Indwelling conventional pancreatic stents can cause significant pancreatic injury even when left in place for only 1 week. A wing design can significantly ameliorate stent-induced changes.

Capsule endoscopy

Video capsule endoscopy is a major innovation that provides high-resolution imaging of the entire small intestine in its entirety. In the 4 years since its introduction, capsule endoscopy has demonstrated its viability as a first-line investigation in patients with obscure gastrointestinal bleeding after a negative esophagogastroduodenoscopy and colonoscopy, and it has a positive impact on the outcome. Video capsule endoscopy is also useful in the evaluation of inflammatory and neoplastic disorders of the small bowel. Its role in children and in the evaluation of esophageal disorders is currently being explored and defined.

Graded esophageal mucosal ablation with cryotherapy, and the protective effects of submucosal saline

BACKGROUND AND STUDY AIMS

Knowledge about the extent of damage with endoscopic cryotherapy is of critical importance before its potential as an ablative therapy is explored. The aims of this study were to evaluate the extent of transmural esophageal necrosis at 48 hours after cryospraying for varying durations, using a novel device based on the Joule-Thomson effect and with carbon dioxide as the refrigerant gas, and to examine the role of submucosal injection of saline in preventing deeper injury.

METHODS

Cryospray was applied to several different segments of the esophagus for various lengths of time (15, 30, 45, 60, and 120 seconds) in a pig model. In another set of experiments performed subsequently, 2 ml of saline was injected into the submucosa and cryospray was applied for 60 seconds.

RESULTS

Esophageal cryotherapy resulted in a dose-dependent injury to the esophagus: esophageal necrosis was minimal or limited to the mucosa after 15 seconds of cryospraying, extended to involve the submucosa after 30 seconds of cryospraying, and involved the muscularis propria also after 45 seconds, with frank transmural necrosis found after 120 seconds of cryotherapy. Prior submucosal saline injection protected against muscular necrosis from prolonged cryotherapy.

CONCLUSIONS

We have shown a dose-dependent effect of cryotherapy on esophageal mucosal ablation. When more extensive lesions are encountered, it may be advisable to consider using submucosal saline injections as an additional safeguard against deeper injury.

Gastric pacing is a new surgical treatment for gastroparesis

BACKGROUND

Gastroparesis is a chronic gastric motility disorder affecting mostly young and middle-aged women who present with nausea, abdominal pain, early satiety, vomiting, fullness, and bloating.

METHODS

From April 1998 to September 2000, 25 patients underwent gastric pacemaker placement. All had documented delayed gastric emptying by a radionucleotide study. Nineteen patients had diabetic gastroparesis, 3 had developed postsurgical gastroparesis, and 3 had idiopathic gastroparesis. Baseline and postoperative follow-ups were done by a self-administered questionnaire on which the patients rated the severity and frequency of nausea and vomiting. Gastric emptying times were also followed up using a radionucleotide technique.

RESULTS

Both the severity and frequency of nausea and vomiting improved significantly at 3 months and was sustained for 12 months. Gastric emptying time was also numerically faster over the 12-month period. Three of the devices have been removed. One patient died of causes unrelated to the pacemaker 10 months postoperatively.

CONCLUSIONS

After placement of the gastric pacemaker, patients rated significantly fewer symptoms and had a modest acceleration of gastric emptying.

Direct observation of counseling on colorectal cancer in rural primary care practices

To better understand colorectal cancer (CRC) screening practices in primary care, medical students directly observed physician-patient encounters in 38 physician offices. CRC was discussed with 14% of patients >or=50 years of age; 87% of discussions were initiated by the physician. The rate of discussions varied among the practices from 0% to 41% of office visits. Discussions were more common for new patient visits, with younger patients, and in the 24% of offices that utilized flow sheets. The frequency of CRC discussions in physician offices varies widely. More widespread implementation of simple office systems, such as flow sheets, is needed to improve CRC screening rates.

Bile acid malabsorption in persistent diarrhoea

We have investigated bile acid malabsorption (BAM), and its response to treatment, in patients seen in this district general hospital with chronic continuous or recurrent diarrhoea.

METHODS

Seven-day retention of 75-SeHCAT was measured (normal: > 10%).

TREATMENT

Patients were initially given conventional therapy (prednisolone +/- ASA drugs in Crohn's disease, and antidiarrhoeals in the others). If this therapy failed, bile acid sequestrants (BAS) were prescribed. The definition of successful response was based on the patient's perception of sustained improvement.

PATIENTS

The 304 patients were categorised as follows: Group 1: Crohn's disease patients with ileal resection, in clinical remission (n = 37). Group 2: Crohn's disease, unoperated and in clinical remission (n = 44). Group 3: vagotomy and pyloroplasty, with/without cholecystectomy (n = 26). Group 4: diarrhoea predominant 'irritable bowel syndrome' (IBS) (n = 197).

RESULTS

BAM was found in 97% (36/37), 54% (24/44) and 58% (15/26) of patients in groups 1, 2 and 3 respectively. One third (65/197) of patients with IBS had BAM. The outcome of treatment was available in 96 patients with BAM: of the patients with ileal resection 32% responded to antidiarrhoeals, 60% to BAS. Of the unoperated Crohn's patients 55% responded to disease-specific therapy, 40% to BAS. Of the gastric surgery patients 18% responded to conventional treatment, 64% to BAS. Of the IBS patients 15% of responded to conventional therapy, 70% to BAS.

CONCLUSIONS

This observational study indicates that BAM is common in patients with chronic diarrhoea, and is frequently found in IBS. The results of open treatment suggest that, where antidiarrhoeal drugs fail in such patients, BAS are often effective.

Giant gastric ulcer: its natural history and outcome in the H2RA era

OBJECTIVE

The aim of this paper is to study the natural history and outcome of medical treatment of giant gastric ulcer in the histamine H2-receptor antagonist era.

METHODS

All patients with gastric ulcer were prospectively followed. We assessed the special features (in particular, demography and treatment outcome) in patients with giant gastric ulcer, defined as ulcers large enough to occupy at least one wall.

RESULTS

Between 1976 and 1991, 537 patients with gastric ulcer were seen, of whom 129 (24%) had giant gastric ulcer. Giant gastric ulcer patients were significantly older (p < 0.05) than patients with smaller ulcers and had more aggressive disease, reflected by a higher incidence of bleeding, anorexia, weight loss, and emergency admission. More giant gastric ulcers were located in the body of the stomach and a higher proportion looked malignant. Four of 129 patients died immediately (bleed n = 3, unrelated cause n = 1), 15 had urgent surgery (bleed n = 11, perforation n = 2, suspected cancer n = 2) and 110 were treated medically, mainly with cimetidine 1 g daily. Healing occurred in 97 of 110 (88%), including 14 of 15 with refractory disease, i.e., healing took >3 months and/or needed cimetidine 2-3 g daily. Of the remaining 13 patients, six died (from unrelated causes), three had surgery for failed medical treatment, two defaulted, and two were still on treatment (one with refractory ulcer). Refractoriness was more common in patients with associated major medical illness (42% vs 12%, p < 0.01) or with giant gastric ulcers that looked malignant although they were benign (53% vs 21%, p < 0.01). Relapse off treatment was higher (13 of 26) than on maintenance treatment with cimetidine 0.4-2 g daily (14 of 70). Complications occurred in six patients: four off treatment and two on maintenance treatment. Only two giant gastric ulcers finally proved to be malignant. Of the 129 patients, 47 (36%) died, 14 within 3 months (two from bleeding, three postoperatively, nine from unrelated causes) and 33 later (two with gastric cancer and 31 from unrelated causes).

CONCLUSIONS

Giant gastric ulcer is uncommon. Patients are more seriously ill than those with smaller ulcers. Most giant gastric ulcers heal with histamine H2-receptor antagonist treatment. The condition is a marker of poor general health, reflected by the high long term mortality.

Pneumoperitoneum and ascites secondary to bacterial overgrowth

Abdominal bloating, weight loss, pneumoperitoneum, and ascites developed in a 73-year-old woman. She had scleroderma, megajejunum, small bowel dysmotility, and bacterial overgrowth. After treatment with a course of antibiotics, the pneumoperitoneum and ascites resolved, but her symptoms and the pneumoperitoneum recurred after the antibiotics were stopped. She was placed on cyclical antibiotics, and during a 2-year follow-up period she has remained well. The pneumoperitoneum and ascites may have been secondary to small bowel bacterial overgrowth. Ours is the first case that demonstrates this association.

Primary small intestinal adenocarcinoma

Seven patients with adeno-carcinoma of the small intestine were seen over a period of five years. Four were localized to the duodenum, the jejunum was involved in two and the ileum in one. Abdominal pain, weight loss, anemia and obstruction were the most common presenting complaints. Endoscopy was the primary diagnostic modality for the duodenal tumours. Diagnostic accuracy of barium contrast examination was 83%. Curative resections were performed in two patients and palliative surgery in the rest.

The management of refractory gastric ulcer using H2-receptor antagonists

BACKGROUND

There is little information on the natural history of refractory gastric ulcer, defined as non-healing on cimetidine > or = 1 g daily given for at least 3 months.

SETTING

A district general hospital serving an industrial population.

METHODS

Patients with refractory gastric ulcer had their treatment extended and/or the dose increased, and upon healing the majority were put on maintenance treatment with cimetidine 400 mg nightly or 1 g daily and their progress was followed.

RESULTS

Of 536 patients with gastric ulcer, 74 (14%) were refractory. Fifty of the 74 (68%) refractory gastric ulcer patients were refractory on their very first course of cimetidine. They had no distinguishing demographic features. Healing occurred in 62 patients (84%) after a mean treatment period of 11.1 months; 28 patients required cimetidine > or = 2 g daily. Eleven of 23 (48%) patients relapsed on maintenance with cimetidine 400 mg compared with seven of 24 (29%) on 1 g daily. A total of 22 out of 62 (35%) relapsed; nine had a second refractory recurrence but none thereafter. Eleven patients were operated upon, seven for failed medical treatment. Only two patients eventually proved to have malignant disease.

CONCLUSIONS

Refractory gastric ulcer is uncommon, transient and rarely malignant. Most patients can be satisfactorily managed medically.

Benign esophageal strictures in children and adolescents: etiology, clinical profile, and results of endoscopic dilation

BACKGROUND

The problem of dysphagia in children and adolescents differs from that in adults, and therefore requires special consideration.

METHODS

Forty-one consecutive children and adolescents 16 years of age or younger (mean, 7.2 years), with benign esophageal strictures were evaluated in a prospective manner over a 7-year period. The most frequent causes of esophageal strictures were caustic ingestion and complications of endoscopic sclerotherapy of esophageal varices. Dilation was done on a weekly basis using bougies and was considered adequate if the esophageal lumen could be dilated to 15 mm diameter (11 mm in children less than 5 years old) with complete relief of dysphagia.

RESULTS

Of the 30 patients who could be adequately followed after initial dilation, 16 had corrosive strictures and 14 had strictures due to other causes. Patients with corrosive strictures required a significantly higher number of sessions for adequate initial dilation (7.8 +/- 2.5 sessions vs 1.86 +/- 0.48 sessions; p < 0.01). Patients with corrosive strictures had a higher number of mean symptomatic recurrences per patient month as compared to the noncorrosive stricture group (0.15 +/- 0.01 vs 0.087 +/- 0.03, p < 0.01). Six esophageal perforations occurred during a total of 327 dilation sessions (1.8%); there was one fatality.

CONCLUSIONS

From our experience, we conclude that benign esophageal strictures in young patients can be treated effectively and with acceptable safety by means of endoscopic dilation.

Icterus due to tumor emboli--a rare presentation of hepatoma

Two cases of hepatocellular carcinoma presenting with features of obstructive jaundice are reported because of their unusual presentation. Both of them had obstruction of the common bile duct by tumor emboli and underwent palliation with surgical evacuation of the tumor thrombus.

Bile acid malabsorption associated with Graves' disease

A 40-year-old man developed dyspepsia, watery diarrhea, and weight loss. A clinical diagnosis of hyperthyroidism due to Graves' disease was confirmed [free thyroxine, 87 pmol/L (normal range, 8.6-27 pmol/L)]. Bile acid malabsorption was demonstrated by a low 23-selena-25-homocholyltauric acid retention of 7.1% (normal, > 15%). Antithyroid treatment (carbimazole and propranolol) was instituted, and his diarrhea subsided with the control of hyperthyroidism (free thyroxine, 15 pmol/L) along with an improvement of bile acid absorption (Se-HCAT retention, 14.7%). This case very strongly suggests the existence of bile acid malabsorption in hyperthyroidism. The temporal association suggests that the diarrhea may have been due at least in part to bile acid malabsorption, raising the possibility that the latter may be an etiological factor in thyrotoxic diarrhea. We believe this is the first such report.

Mini-dose (1-microCi) 14C-urea breath test for the detection of Helicobacter pylori

OBJECTIVES

To develop and evaluate a mini-dose (1-microCi) 14C-urea breath test (UBT), using a simplified protocol.

METHODS

Fasting patients (n = 95) were given a drink of 1 microCi (37 kBq) of 14C-urea. Samples of breath carbon dioxide (2 mmol) were collected at 10, 20, and 30 min later by trapping in hyamine solution; 14C activity was measured by liquid scintillation counting. Results were expressed as "CO2 recovery," i.e., [(% of administered dose recovered/mmol CO2 trapped) x body weight (kg)]. Reproducibility of the test was assessed by repeat studies on two consecutive days in 11 volunteers. All breath test results were compared with culture for Helicobacter pylori. In 27 patients, results also were compared with 13C-urea breath test (European protocol).

RESULTS

Using receiver operator characteristic (ROC) analysis, we selected a cut-off value of 0.55 at 20 min to separate those positive and negative for H. pylori. Sensitivity and specificity were 98% and 87%, respectively. Among four patients with negative culture but positive 14C-breath tests, three had evidence of infection by serology or 13C-UBT. Assuming that these three were genuinely positive, the recalculated specificity improved to 97%, sensitivity remaining at 98%. The reproducibility of the test was good, with only a minor day-to-day variation. Concordance with the 13C-UBT was excellent: there was 100% agreement in the diagnostic classification of all 27 patients (19 positive, eight negative).

CONCLUSIONS

The mini-dose 14C-urea breath test has a high diagnostic accuracy (sensitivity 98%, specificity 97%) with minimal radiation exposure. It is simple, rapid, and convenient for a busy general hospital.

Atypical presentation of Crohn's disease: severe, recurrent iron deficiency anemia dependent on blood transfusions

We report an unusual case of Crohn's disease. Our subject, a 43-yr-old lady, presented with severe iron deficiency anemia, hypoproteinemia and lymphocytopenia, but without any clinical manifestations of Crohn's disease either at presentation or during follow-up. She had recurrent episodes of severe iron deficiency anemia, repeatedly requiring blood transfusions (28 units in 20 months). She was found to have a short stricture with ulceration in the ileum due to Crohn's disease, and a blind loop with bacterial overgrowth above it. Resection of the affected area prevented further recurrence of anemia and corrected hypoproteinemia. We postulate that her anemia and hypoproteinemia were due to blood and protein (lymph) loss from the ulcerated area in the ileum. Such a presentation has not been described before.

Long term results of endoscopic dilatation for corrosive oesophageal strictures

Although dilatation is the treatment of choice for most patients with benign oesophageal strictures, there is little information on its efficacy and safety in corrosive oesophageal strictures. Of 123 adults with benign oesophageal strictures treated by endoscopic dilatation, 52 (42.3%) had strictures after corrosive ingestion and 39 (31.7%) had peptic strictures. Treatment was considered adequate if the oesophageal lumen could be dilated to 15 mm and there was complete relief of dysphagia. If dysphagia recurred after adequate initial dilatation, the stricture was dilated again up to 15 mm. Initial dilatation was adequate in 93.6% of patients with corrosive strictures and this success rate was comparable with that of the peptic stricture group (100%, p > 0.05). Long term success after adequate initial dilatation was studied in 36 patients with corrosive strictures (mean follow up 32.36 (17.12) months, range 6-60) and 33 patients with peptic strictures (mean follow up 36.32 (17.9) months, range 6-60). The mean (SEM) number of symptomatic recurrences per patient month during the total follow up period in the corrosive group was significantly higher than that in the peptic group (0.27 (0.04) v 0.07 (0.02), p < 0.001). The recurrence rate in the corrosive group, however, decreased over time, and after 12 months it was significantly (p < 0.001) lower than the recurrence rate in the first six months. After 36 months, the difference in the recurrence rate in the two groups was not significant (p > 0.05). Only nine oesophageal perforations occurred during a total of 1373 dilatation treatments (procedure related incidence 0.66%), and eight of these were in the corrosive stricture group. These patients were managed conservatively and subsequently strictures were dilated adequately in all. Endoscopic dilatation is safe and effective for short and long term relief of dysphagia in patients with corrosive oesophageal strictures.

Epidemiological study of parasitic infestations in lower socio-economic group in Chandigarh (north India)

When stool samples from 970 subjects belonging to lower socio-economic groups were examined for parasites, a total of 121 subjects (12.5%) i.e., 57 (12.1%) males and 64 (12.9%) females showed positive results. The overall prevalence of parasitic infestation did not correlate with sex, caste or religion and living conditions. However, the prevalence was higher in hospital employees residing in well sanitated area. Giardia lamblia (69.5%), Entamoeba, histolytica (15.7%), Hymenolepis nana (12.4%), Ancylostoma duodenale (10.7%), Ascaris lumbricoides (8.3%) and Taenia (0.8%) were the parasites seen. Mixed infections were seen in 9 subjects. Twenty families of the 196 studied had more than one family member positive for parasites. Asymptomatic positivity was high amongst all groups of subjects, and with all parasites.

Splenoportovenography in portal hypertension: a safe outpatient procedure

Splenoportovenography (SPV) was performed as an outpatient procedure in 172 patients to investigate portal hypertension. Careful technique and proper patient selection were responsible for the high success rate (95.3%) and the low complication rate (7.0%). We conclude that SPV done as an outpatient procedure is safe in expert hands and is economical.

Gastric acid response to modified sham feeding in patients with duodenal ulcer: is increased vagal tone the cause of basal acid hypersecretion?

In order to test the hypothesis that increased basal vagal tone causes basal acid hypersecretion in duodenal ulcer (DU), the effect of sham feeding on gastric acid secretion was studied in 26 patients with DU and 20 healthy controls. Basal acid output (BAO), sham feeding-stimulated acid output (SAO) and peak histamine-stimulated acid output (PAO) were significantly higher in DU patients compared with healthy controls (P less than 0.01). The BAO/PAO ratio in DU patients (0.28 +/- 0.03) was not significantly different from that of healthy subjects (0.19 +/- 0.03), indicating that the higher BAO in DU patients group, as a whole, was due to a higher parietal cell mass. The basal subtracted response to sham feeding expressed as a fraction of secretory capacity [(SAO-BAO)/PAO], which correlates inversely with the basal vagal tone, was not significantly different in the patients and control subjects (0.27 +/- 0.03 versus 0.3 +/- 0.03; P greater than 0.05). Based on the data from the healthy controls, a ratio of BAO/PAO greater than 0.44 was defined as abnormal (using 95% confidence limits) and it indicated marked basal acid hypersecretion. Four of 26 DU patients had basal acid hypersecretion (that is, BAO/PAO greater than 0.44), but only two of them did not show an increase over their basal rate of secretion in response to sham feeding. All other DU patients, including two with marked basal acid hypersecretion, and all healthy controls showed an appreciable increase in their acid secretion in response to sham feeding.(ABSTRACT TRUNCATED AT 250 WORDS)