Endoscopic management of colovaginal fistulas in advanced cancer patients.

BACKGROUND AND AIMS: Colovaginal fistula (CVF) in cancer patients can cause significant morbidity. In addition to causing local symptoms and infections, the constant stool leakage contributes to a poor quality of life, psychological distress, and possible social isolation. Patients with CVFs often have advanced disease, poor nutrition, and complex anatomy, making them poor candidates for major surgical interventions. Advancement in endoscopic tools has made endoscopic management possible. Endoscopic management is less invasive, is associated with prompt recovery, and can significantly improve the quality of life of patients and possibly allow them to resume systemic therapy. METHODS: In this video case series, 3 cases of CVF patients treated endoscopically are presented to demonstrate the use of the currently available tools and techniques. The strategy used for the closure of the 3 CVFs was dependent on the size and etiology of the fistulas. RESULTS: Technical and clinical success was achieved in all 3 situations. There were no procedure-related adverse events. CONCLUSION: These cases demonstrate the use of the cap to perform vaginal endoscopy; the use of the over-the-scope clips, covered stents, and endoscopic suturing; and how they can facilitate the closure of fistulas in patients who are poor surgical candidates.

Increased prevalence of reduced estimated glomerular filtration rate in chronic hepatitis C patients.

BACKGROUND: To investigate the prevalence and severity of reduced estimated glomerular filtration rate (eGFR) in patients with chronic hepatitis C (CHC). METHODS: Medical record review of 831 consecutive CHC patients seen in our clinic between July 2000 and August 2003; eGFR was estimated using the abbreviated Modification of Diet in Renal Disease (aMDRD) equation. The stage of kidney disease was determined based on eGFR expressed in milliliters per minute per 1.73 m(2): stage 1 (signs of kidney damage but normal or elevated (eGFR >or= 90), stage 2 (eGFR 60-89), stage 3 (30-59), stage 4 (eGFR 15-29), stage 5 (eGFR < 15 or dialysis-dependent). RESULTS: A total of 522 patients had available data with using the aMDRD equation, 51% had abnormal eGFR (stage 1, 4.6%; stage 2, 36.4%; stage 3 or 4, 6.1%; stage 5, 3.8%). Of 190 patients with stage 2 kidney disease, 189 patients (99.5%) had normal serum creatinine and only one patient (0.5%) had elevated creatinine concentrations (>1.4 mg/dl). Of the 32 patients with stage 3 or 4 disease, 20 (62.5%) had a normal serum creatinine concentration. Of 349 patients without diseases known to cause renal insufficiency, 38% had stage 2-4 renal disease. In a subset of these patients, 95/522 (18%) the measured creatinine clearance showed good correlation with their aMDRD (R = 0.47, (p < 0.0001). CONCLUSIONS: In CHC patients, a normal serum creatinine concentration does not assure normal kidney function. Estimation of eGFR with the aMDRD equation is a more accurate method of identifying patients with chronic kidney disease and reduced eGFR. Therefore, CHC patients should be screened more rigorously for chronic kidney disease because of the high prevalence of reduced eGFR. Lastly, in all CHC patients, the aMDRD eGFR should be used in each encounter with these patients when assessing their renal function irrespective of their serum creatinine.

Capsule endoscopy: a review.

Capsule endoscopy (CE) is a novel technology that allows direct noninvasive visualization of the entire small intestine. CE permits a detailed examination in the ambulatory setting, allowing identification of clinically relevant lesions, and it is appealing to both patients and providers. There are two types of capsules that are currently commercially available: one specifically designed to view the small bowel and the other for the esophagus. Common indications for small bowel CE include obscure gastrointestinal bleeding, initial diagnosis of suspected Crohn's disease, and other small bowel pathology. The esophageal capsule is currently used to evaluate Barrett esophagus and esophageal varices. It is a well-tolerated procedure with relatively few complications. Although CE performance may be superior to existing technologies, its impact on clinical decision-making and patient outcomes are of even greater importance. Herein lies a review of the latest information on CE, its indications, complications, future utilities, and developing technology.

Sedation for upper endoscopy: comparison of midazolam versus fentanyl plus midazolam.

BACKGROUND: The benefit of using one or two drugs for conscious sedation in upper endoscopy remains unproven. This study evaluates the adequacy of conscious sedation during upper endoscopy using midazolam alone compared with midazolam plus fentanyl. METHODS: Patients older than 18 years of age who underwent elective, outpatient upper endoscopy were included. They were randomized to receive either a combination of midazolam/fentanyl or midazolam alone. The adequacy of sedation obtained was assessed using a questionnaire answered by the physician at the end of the procedure, and by the patient 24 to 72 hours after endoscopy. RESULTS: From the endoscopist's perspective, following an intention-to-treat analysis, patients had better tolerance in the combination group (78.3% excellent/good tolerance M/F group versus 55.8% M group) (P = 0.043) (Table 2). Per patient's assessment excellent/good tolerance was found in 93% of M group and 94% in F/M group (P = 1.0). No difference in duration of the procedure was found between the two groups. No complications during endoscopies were reported. CONCLUSIONS: In diagnostic upper endoscopy, an adequate level of sedation can be obtained safely either by midazolam or midazolam plus fentanyl. From an endoscopist's perspective, the combination is significantly better.

A prospective study of the utility of abdominal radiographs after capsule endoscopy for the diagnosis of capsule retention.

BACKGROUND: Capsule retention is a rare but serious complication of capsule endoscopy (CE). The utility of routine abdominal radiographs after CE for the diagnosis of capsule retention is not established. OBJECTIVE: To establish the utility of abdominal radiographs in the diagnosis of capsule retention in patients undergoing CE. DESIGN: Prospective cohort study. PATIENTS: Consecutive patients undergoing CE. SETTING: Mayo Clinic Scottsdale, Arizona, a multispecialty academic medical center. INTERVENTION: Abdominal radiographs were performed on days 3, 7, and 14 after CE. If the patient visualized passage of the capsule, the subsequent abdominal radiograph was cancelled. MAIN OUTCOME AND MEASUREMENTS: Capsule retention, defined as the capsule endoscope seen on the day-14 abdominal radiograph. RESULTS: A total of 115 patients (46% men; mean age 65 years, range 20-88 years) underwent CE, which was performed for obscure GI bleeding in 86%, for suspected Crohn's disease in 5%, and for other indications in 9%. Thirty-four patients (30%) reported spontaneous passage of the capsule by day 3 and an additional 2 patients by day 7. Of the 81 reporting nonpassage by day 3, 66 (82%) underwent abdominal radiographs. Abdominal radiographs in 14 of 66 patients (21%), 3 of 12 (25%), and 2 of 3 (66%) showed a retained capsule on day 3, 7, and 14, respectively. Three patients (2.6%) were diagnosed with capsule retention. Two had serial abdominal radiographs: capsule retention was detected on the day-14 radiographs, and both underwent surgery. Histopathology revealed diaphragm disease of the small intestine in both patients. One patient who did not have serial abdominal radiographs had a small-bowel tumor as the cause of his capsule retention. In all 3 patients, the colon was not visualized on CE. CONCLUSIONS: Capsule retention is a rare but serious complication of CE. Most patients do not visualize capsule passage. For patients who do not visualize capsule passage and, in whom the colon is not visualized on the video imaging, an abdominal radiograph on day 14 will help identify those with capsule retention.

Coccidioides immitis fungemia: clinical features and survival in 33 adult patients.

Coccidioides immitis is a fungus endemic to the southwestern United States. Susceptible hosts, including blacks, Hispanics, Filipinos, Native Americans, and those with compromised immunity, may develop disseminated disease, including fungemia. We retrospectively reviewed the records of all patients (n = 33) with Coccidioides immitis fungemia (CIF) at a 550-bed public hospital in Phoenix, Arizona, from 1990 to 2002. This is the largest reported series of CIF. The purpose of the study was to review the incidence, signs, symptoms, and outcomes of CIF. Twenty-nine patients had human immunodeficiency virus infection. CIF was associated with sepsis, end-stage alcoholic liver disease, and diabetes in four patients. Survival was poor; 24 of the 33 patients died within 28 days. CIF manifested as a systemic inflammatory response syndrome with progressive cardiorespiratory failure. Despite fluid loading, infusion of vasoactive agents, and mechanical ventilation with positive end-expiratory pressure, patients typically experienced a rapidly progressive course and death. CIF portends an ominous prognosis and typically occurs in the setting of advanced human immunodeficiency virus or medical or surgical crises.

Nonalcoholic fatty liver disease of obesity.

Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are part of the same continuum. They are a major, under-recognized cause of chronic liver disease. Good medical treatment options do not exist to date. The mainstay of treatment is weight loss. Bariatric surgery offers weight loss and improvement of NAFLD and NASH.