Impact of bowel preparation on surveillance colonoscopy interval.

BACKGROUND/AIMS: Atpresent there are no guidelines for colonoscopy surveillance interval in subjects with unsatisfactory bowel preparation. Study was designed to compare outcomes of repeat colonoscopy at different surveillance intervals in patients with unsatisfactory preparation on index exam. METHODS: Ten thousand nine hundred and eight colonoscopies were done during the study period. Patients with index colonoscopy exam complete up to cecum but suboptimal bowel prep were included. RESULTS: Two hundred and ninety-seven patients met the inclusion criteria. The interval for repeat colonoscopy was <1 year in 38.5%, 1-2 years in 33.3%, 2-3 years in 16.7%, and 3-5 years in 11.5% subjects. Adenoma detection rate (ADR) was 24%, high-risk adenoma detection rate (HR-ADR) was 8.4%, and colorectal cancer detection rate was 1.7%. The HR-ADR based on surveillance intervals <1 year, 1-2 years, 2-3 years, and 3-5 years was 8%, 7.9%, 2%, and 19.4%, respectively. The HR-ADR was significantly higher at surveillance interval 3-5 years (p < 0.05). CONCLUSION: Colonoscopies repeated at interval >3 years showed a significant HR-ADR. The study indicates that a surveillance interval of 3 years can be reasonable for subjects having an index colonoscopy with suboptimal/fair/poor bowel prep and complete colon examination. Colonoscopy should be repeated earlier if symptoms develop.

Clostridium difficile colitis: review of the therapeutic approach.

Clostridium difficile infection (CDI) is the leading cause of antibiotic-associated and nosocomial infectious diarrhea. Presenting as clostridium difficile colitis, it is a significant cause of morbidity and mortality. Metronidazole is regarded as the agent of choice for CDl therapy and also for the first recurrence in most patients with mild to moderate CDI. Vancomycin is recommended as an initial therapy for patients with severe CDI. With recent Food and Drug Administration-approval fidaxomicin is available for clinical use and is as effective as vancomycin with lower relapse rates. Rifaximin and fecal bacteriotherapy are alternative approaches in patients with severe or refractory CDI, before surgical intervention. Antibiotic research is ongoing to add potential new drugs such as teicoplanin, ramoplanin, fusidic acid, nitazoxanide, rifampin, bacitracin to our armamentarium. Role of toxin-binding agents is still questionable. Monoclonal antibody and intravenous immunoglobulin are still investigational therapies that could be promising options. The ongoing challenges in the treatment of CDI include management of recurrence and presence of resistance strains such as NAP1/BI/027, but early recognition of surgical candidates can potentially decrease mortality in CDI.

Biliary stent migration: a brief review of potential complications and possible etiological factors.

Biliary endoprostheses continue to demonstrate their utility and simplicity in daily therapeutic endoscopy. However, the transient nature of these foreign bodies also underscores their potential detrimental effects even after successful deployment. Stent related factors, such as type, length and caliber offer potential avenues to minimize the risk of migration. However, a patient related factor such as the presence of prior abdominal surgeries makes it paramount for endoscopists to ascertain the location of a migrated stent. There is a ripe niche for continued research and development in biodegradable stents.

Hepatic hydrothorax.

Hepatic hydrothorax is defined as a pleural effusion in patients with liver cirrhosis in the absence of cardiopulmonary disease. The estimated prevalence among patients with liver cirrhosis is approximately 5-6%. The pathophysiology involves the passage of ascitic fluid from the peritoneal cavity to the pleural space through diaphragmatic defects. The diagnosis is made from clinical presentation and confirmed by diagnostic thoracentesis with pleural fluid analysis. The initial medical management is sodium restriction and diuretics, but liver transplantation provides the only definitive therapy. For patients who are not transplant candidates and those who await organ availability, other therapeutic modalities that are to be considered include transjugular intrahepatic portosystemic shunt placement, videoassisted thoracoscopic surgery repair, pleurodesis, and vasoconstrictors (eg, octreotide and terlipressin). The primary therapeutic goals are to reduce ascitic fluid production and improve symptoms to bridge the time for liver transplantation.

Over the scope clip: technique and expanding clinical applications.

BACKGROUND: Advances in endoscopic and surgical techniques have increased the frequency and complexity of these procedures, and thus, the incidence of associated complications. AIMS: To describe the use and clinical applications of the Over the Scope Clip (OTSC) system. METHODS: An English language literature search was conducted using the key words "endoscopy" and "over the scope clip" in order to identify human studies evaluating the application of OTSC from January 2001 to August 2012. The indication, efficacy, complications, and limitations were recorded. RESULTS: Overall success rates of OTSC based on current literature range are in the range of 75% to 100% for closure of iatrogenic gastrointestinal perforations, 38% to 100% for closure of gastrointestinal fistulas, 50% to 100% for anastomotic leaks, and 71% to 100% for bleeding lesions. OTSCs have shown 100% success rates in managing postbariatric surgery weight gain secondary to dilation of the gastrojejunal pouch. CONCLUSION: OTSC is easy to use with good results, thus decreasing the morbidity and mortality associated with the complications secondary to both diagnostic and therapeutic endoscopy and avoiding surgery in many situations.

The skin: a mirror to the gut.

INTRODUCTION: This review discusses the diseases with involvement of both skin and gut. GI manifestations of vesicobullous disorders and systemic diseases and syndromes involving skin and gut, dermatologic manifestations of inflammatory bowel disease (IBD), polyposis syndromes, and GI malignancies have been discussed. Diagnostic and treatment approaches towards these disorders are summarized. CONCLUSIONS: Interaction of the skin and gut has always been an area of inquisitiveness. Gastrointestinal (GI) tract can be involved in dermatological disorders or GI diseases can have a dermatological manifestation.

Barriers to screening colonoscopy in an urban population: a study to help focus further efforts to attain full compliance.

BACKGROUND: Awareness of colorectal cancer and decision for colorectal cancer screening is influenced by multiple factors including ethnicity, level of education, and adherence to regular medical follow up. OBJECTIVE: Our survey aimed at assessing barriers to colorectal cancer screening among urban population. DESIGN: This study is a survey of the general population. SETTING: This study was made at a local community in the downtown area of a metropolitan city. PATIENTS/SUBJECTS: The study population for this survey included 2000 non-institutionalized residents from local community of Brooklyn downtown area of City of Brooklyn, NY, USA. All participants were 50 years or older. INTERVENTION: No intervention was done. MAIN OUTCOME MEASUREMENT: The survey questionnaire collected information about demographic, socioeconomic level, awareness of various cancers and their screening methods, and awareness of screening colonoscopy. RESULTS: Colonoscopy was identified as the best screening test by 31 % of the subjects. Pain and discomfort was the major reason for not having a colonoscopy. The fear of a complication declined significantly after the first colonoscopy but fear of pain and discomfort increased. Difficulty with bowel preparation before a colonoscopy was a significant problem; it discouraged significant number of participants from having another colonoscopy. LIMITATION: This study is limited by its small sample size. CONCLUSION: Physician/family and peer influence seems important but influencing only a minority of subjects. Fear of complications should be allayed using accurate statistical information. Pain should be significantly diminished and/or eliminated during colonoscopy. Future research should focus to minimize complexity and discomfort associated with bowel preparation.

Acute fatty liver of pregnancy.

Acute fatty liver of pregnancy is a rare but serious and potentially fatal complication of pregnancy. It typically presents in the third trimester with microvesicular fatty infiltration of the liver and can lead to multiorgan failure and death. Differentiation from hemolysis-elevated liver enzymes-low platelets syndrome can guide management. A high index of suspicion is necessary in the appropriate clinical setting to identify clinical manifestations and complications and manage them appropriately. In severe cases, prompt delivery can be lifesaving for the mother and fetus. Liver transplantation remains controversial and must be considered individually. Defects in fatty acid oxidation secondary to various enzymatic deficiencies have been associated with acute fatty liver of pregnancy. Women or couples with known defects in fatty acid oxidation and women with a history of previous liver disease during pregnancy or sudden death of a child within the first 2 years of life should be assessed for a defect in fatty acid oxidation and monitored carefully. Our review summarizes the current knowledge in pathophysiology, diagnostic approach and management of this disorder.

Novel anti-diabetic agents in non-alcoholic fatty liver disease: a mini-review.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) encompasses a spectrum that ranges from simple steatosis to non-alcoholic steatohepatitis (NASH) and to cirrhosis. The recommended treatment for this disease includes measures that target obesity and insulin resistance. The present review summarizes the role of newer anti-diabetic agents in treatment of NAFLD. DATA SOURCES: PubMed, MEDLINE and Ovid databases were searched to identify human studies between January 1990 and January 2013 using specified key words. Original studies that enrolled patients with a diagnosis of NAFLD or NASH and involved use of newer classes of anti-diabetic agents for a duration of at least 3 months were included. RESULTS: Out of the screened articles, four met eligibility criteria and were included in our review. The classes of newer anti-diabetic medications described were dipeptidyl peptidase IV inhibitors and glucagon-like peptide-1 analogues. CONCLUSIONS: Liraglutide and Exenatide showed improvement in transaminases as well as histology in patients with NASH. Sitagliptin showed improvement in transaminases but limited studies are there to access its effect on histology. Further studies are needed to support use of newer anti-diabetic medications in patients with NAFLD.

Management of refractory ascites.

Ascites that does not respond or recurs after high-dose diuresis and sodium restriction should be considered refractory ascites. As cirrhosis advances, the escaping fluid overwhelms the lymphatic return. Decrease in renal plasma flow leads to increased sodium reabsorption at the proximal tubule leading to decreased responsiveness to loop diuretics and mineralocorticoid antagonists, which work distally. These complex hemodynamic alterations lead to refractory ascites. In refractory ascites, high-dose diuresis (400 mg of spironolactone and 160 mg of furosemide) and sodium restriction (<90 mmol/d) result in inadequate weight loss and sub optimal sodium excretion (<78 mmol/d). Further use of diuretics is limited by complications such as encephalopathy, azotemia, renal insufficiency, hyponatremia, and hyperkalemia. Therapy for refractory ascites is limited. The available therapies are repeated large volume paracentesis (LVP), transjugular intrahepatic portosystemic shunts, peritoneovenous shunts, investigational medical therapies, and liver transplantation. LVP with concomitant volume expanders is the initial treatment of choice. Transjugular intrahepatic portosystemic seems to be superior to LVP in reducing the need for repeated paracentesis and improves the quality of life. Several treatments that act at different steps in the pathogenesis of ascites are investigational, and some show promising results. Splanchnic and peripheral vasoconstrictors (Octreotide, Midodrine, and Terlipressin) increase effective arterial volume and decrease activation of the renin-angiotensin system with resultant increase in renal sodium excretion. Clonidine when given with spironolactone has been shown to cause rapid mobilization of ascites by significantly decreasing the sympathetic activity and renin-aldosterone levels. Natural aquaretics and synthetic V2 receptor antagonists (satavaptan) are being evaluated for mobilization of ascites by increasing the excretion of solute-free water. Liver transplantation remains the only definitive therapy for refractory ascites. Because refractory ascites is a poor prognostic sign, liver transplantation should be considered and incorporated early in the treatment plan.

A short primer on the calcium sensing receptor: an important cog in the colon cancer wheel?

The gastrointestinal (GI) tract handles a complex task of nutrient absorption and excretion of excess fluid, electrolytes, and toxic substances. GI epithelium is under constant proliferation and renewal. Differentiation of colonocytes occurs as they migrate from the basal layer to the apex of the crypt. Cells of the basal layer are highly proliferative but less differentiated, whereas apical cells are highly differentiated but non-proliferative. Alterations of this intricate process lead to abnormal proliferation and differentiation of colorectal mucosa leading to development of polyps and neoplasia. The effects of calcium (Ca) on colorectal mucosal growth have been extensively studied after the discovery of the calcium sensing receptor (CaSR). Fluctuation in extracellular Ca can induce hyperproliferation or quiescence. Disruption in the function of CaSR and/or changes in the level of CaSR expression can cause loss of growth suppressing effects of extracellular Ca. This review addresses the role of Ca and CaSR in the physiology and pathophysiology of colonocyte proliferation.

Splenic injury from colonoscopy: a review and management guidelines.

Splenic injury is an uncommon complication of colonoscopy. Less than 100 cases are reported in the English language literature. The exact mechanism of injury to the spleen during colonoscopy is unknown; various authors propose several risk factors and possible mechanisms. Splenic injury can be graded or classified according to the extent of laceration and the severity of the resultant hematoma. The management options range from observation to emergency splenectomy. Computed tomography scan is the most important imaging modality to diagnose splenic injury. Early recognition and appropriate management is of paramount importance in the management of this condition. A high index of suspicion in a patient with persistent abdominal pain after colonoscopy is key especially when a perforated viscous is ruled out. This article outlines the clinical presentation of splenic injury after colonoscopy and delineates a management algorithm.

Management of biliopleural fistula after transarterial chemoembolization of a liver lesion.

A case of a biliopleural fistula with a biloma occurring after superselective hepatic transarterial chemoembolization ablation of a metastatic hepatic carcinoid is described. The presentation was complicated by choledocholithiasis. The biloma was successfully treated with endoscopic drainage.

Percutaneous endoscopic suturing: an effective treatment for gastrocutaneous fistula.

BACKGROUND: Development of persistent gastrocutaneous fistula and leakage after the removal of a PEG tube is a well-known complication. Various treatments including medications to alter gastric pH, prokinetic agents, endoscopic clipping/suturing, electric and chemical cauterization, argon plasma coagulation, and fibrin sealant, have been used with variable success. Although surgical closure is the current treatment of choice, most of the elderly patients are poor surgical candidates because of multiple comorbid conditions. OBJECTIVE: We describe a method of endoscopic suturing of a gastrocutaneous fistula that is a safe and cost-effective alternative to surgical closure. DESIGN: Individual case. SETTING: Community hospital. PATIENT: One elderly patient. INTERVENTIONS: By using a trocar, we placed multiple, long monofilament sutures from the skin around the gastrocutaneous fistula in criss-cross fashion. Gastric ends of these sutures were pulled from the stomach with a snare under endoscopic visualization. Suture knots were made at the gastric end of the sutures and then were pulled back from the cutaneous side. Multiple biopsy specimens were obtained from both ends of the fistula to promote granulation tissue. Final knots were made at skin level to obliterate the fistula. RESULT: Our procedure resulted in complete closure of a large, persistently leaking gastrocutaneous fistula in an elderly patient within 7 days. The patient tolerated the optimal rate of enteral nutrition without further leakage. LIMITATION: Only 1 patient. CONCLUSION: We believe that this method of endoscopic suturing along with de-epithelialization of the fistula tract for persistent gastrocutaneous fistula is a safe and cost-effective alternative to surgical closure.

Treatment of persistently leaking post PEG tube gastrocutaneous fistula in elderly patients with combined electrochemical cautery and endoscopic clip placement.

OBJECTIVES: Persistent leakage from a gastrocutaneous fistula (GCF) created for the purpose of percutaneous endoscopic gastrostomy (PEG) tube placement is a common problem in elderly patients. Conservative methods often prove unsuccessful and surgical closure is usually not performed because of poor surgical risk. With advances in endoscopic technology, several nonsurgical approaches have emerged. These new methods have been reported in the past as case reports. The purpose of this study is to report a case series of eleven elderly patients with persistent leakage from gastrocutaneous fistulas who underwent combined electrochemical cautery and endoscopic clip placement. METHODS: Eleven patients had failed conservative therapy and were deemed unsuitable candidates for surgical closure. Electric and chemical cauterization was used to de-epithelialize the fistulous tract. The edges of the internal orifice of the gastrocutaneous fistula were approximated using endoclips during an esophagogastroduodenoscopy. Patients were observed postprocedure for leakage. RESULTS: This procedure resulted in complete closure of the gastrocutaneous fistula in nine patients (82%). One patient had partial closure of the fistula which was sealed using a new PEG tube. CONCLUSION: Gastrocutaneous fistula is a common complication in elderly patients after removal of gastrostomy tubes. Simple endoscopic procedures have shown promising results in the treatment of this complication.

Carcinoid tumors of the gastrointestinal tract.

The gastrointestinal tract is the largest neuroendocrine system in the body. Carcinoid tumors are amine precursor uptake decarboxylase (APUD) omas that arise from enterochromaffin cells throughout the gut. These tumors secrete discrete bioactive substances producing characteristic immunohistochemical patterns. Most tumors are asymptomatic and detected at late stages. Hepatic metastases are commonly responsible for carcinoid syndrome. The small bowel is the most common location of carcinoids. Computed tomography scan and magnetic resonance imaging are useful in the detection of these tumors. The measurement of bioactive amines is the initial diagnostic test. Various treatment options, including somatostatin analogs, interferon, chemotherapy, surgery, hepatic artery chemoembolization, and surgery have emerged in the past two decades. However, the incidence and prevalence of carcinoid tumors has increased, while mean survival time has not changed significantly. The lack of standardized classification, federal support, and an incomplete understanding of the complications of this disease are some of the impediments to progress in treatment.

Correlation of incidental colorectal wall thickening at CT compared to colonoscopy.

Incidental colon wall thickening is a common finding on computed tomography (CT) scans obtained in patients presenting to the emergency department. Currently, there are no guidelines for the emergency department physician or primary care physician regarding the need for further evaluation, specifically colonoscopy, in these patients. A retrospective review of 2,850 abdominopelvic CT scans performed from April 2006 to September 2006 was conducted. Three hundred twenty-two patients had incidental colon wall thickening and 150 of these patients had a subsequent colonoscopy. This study focused on those 150 patients and analyzed the correlation between the CT scan findings of wall thickening of the colon and the findings on colonoscopy. The CT scan findings correlated with abnormal colonoscopic findings in 96 out of 150 (64%) of our cases. In a specific subgroup, 12 out of 12 (100%) of these CT scans were also noted to have a mass lesion, as well as colon wall thickening, all of which were consistent with an adenoma or carcinoma found on colonoscopy. Incidental colorectal wall thickening at CT scan is due to nonspecific colitis in majority of the cases. Admission to the hospital should be based upon criteria other than this incidental radiological finding. However, patients with colorectal wall thickening with a mass lesion at CT scan should be followed closely as inpatient or outpatient given the high correlation with significant findings on colonoscopy.

Colonic Granular Cell Tumor: An Endoscopic and Histopathologic Review with Case Illustration.

Granular cell tumors (GCTs) are rare and benign tumors that can occur at any anatomical site. GCTs are thought to originate from nerve cells, particularly Schwann cells. Their name derives from the fact that an accumulation of cytoplasmic lysosomes imparts the tumor with a granular appearance. They are most commonly observed in the oral cavity, skin and subcutaneous tissue, breast, and respiratory tract. Granular cell tumors rarely affect the gastrointestinal tract. We report a 58-year-old female with a past medical history of hypertension, mitral valve prolapse, and depression who presented for surveillance colonoscopy. A single firm sessile polypoid lesion, with overlying pale tan color mucosa, measuring approximately 1 to 1.5 cm, was found in the ascending colon. Biopsy of the nodule followed by histopathology was positive for S100 and CD68, but negative for AE1/AE3, CD117, smooth muscle actin, and desmin, consistent with the diagnosis of GCT. We review the clinicopathologic features of GCTs.

Gastric adenocarcinoma with features of endodermal sinus tumor.

Extragonadal germ cell tumors are rare. The most common sites for EGGCTs are in midline locations such as the mediastinum, retroperitoneum and pineal gland. These tumors rarely present in the stomach. We describe here a case where a middle aged man presented with typical symptoms of gastric cancer. After extensive workup, which included blood work, CT abdomen scan, upper endoscopy, and endoscopic ultrasound, the patient was diagnosed with gastric cancer. However, due to very high blood levels of alpha-fetoprotein, the specimen was sent for special histochemical staining, which demonstrated that the tumor had features of both adenocarcinoma and endodermal sinus tumor. This is a very aggressive tumor with a very poor prognosis.