Epiploic Appendagitis, an Uncommon Cause of Abdominal Pain: A Case Series and Review of the Literature.

OBJECTIVE: Epiploic appendagitis (EA) is a rare entity caused by the inflammation of the appendix epiploica. It is a benign and self-limited condition presenting as acute onset abdominal pain. The inaccurate diagnosis of EA can lead to unnecessary hospitalization, antibiotic therapy, and surgery. Our aim is to describe the common clinical features of patients who were diagnosed with EA over a 2-year period at the San Juan Veterans Administration Hospital. METHODS: A retrospective descriptive review of the records of all patients diagnosed with EA from 2007 to 2009. The clinical data was obtained through record review. Diagnoses were confirmed by 2 radiologists reviewing imaging studies. RESULTS: Eight patients were included in the study. All were male with a mean age of 58 years. Seven patients were overweight as per body mass index (BMI) scale. All had localized focal, non-migratory abdominal pain, most (75%) in the left lower quadrant. Nausea (37.5%), anorexia (12.5%), constipation (12.5%), and diarrhea (25%) were documented as well. Only 2 patients demonstrated mild elevations in WBC, but none of the 8 had a fever. During the study period, all the patients' symptoms resolved without documented recurrence. CONCLUSION: In our small case series, overweight was a common finding, supporting the described association between EA and obesity. History and physical exam should prompt the clinician to consider EA in the differential diagnosis of acute abdominal pain, particularly in those who are obese and who have pain localized to the left lower quadrant.

Relationship between sporadic hyperplastic polyps and colorectal neoplasia in Hispanic veterans.

OBJECTIVE: Hyperplastic polyps (HP) traditionally have been regarded as having no malignant potential. Some studies have suggested that HP in the distal colon may predict presence of adenomatous polyps in the proximal colon. Other studies have failed to show this relationship. The purpose of this study was to evaluate for the first time in our Hispanic veterans population if there was a relationship between the presence of sporadic HP and colorectal neoplasia (CRN) and to evaluate if proposed risk factors for CRN are also risk factors for sporadic HP. METHODS: The study consisted of a retrospective review of all the medical records of patients who underwent a colonoscopy for the first time during the calendar year 2005 and had a pathologic diagnosis of HP, tubular adenoma (TA), tubulovillous adenoma (TVA), villous adenoma (VA) and/or colon adenocarcinoma at the VA Caribbean Healthcare System. Patient's age, BMI, smoking and alcohol use history, presence of DM, cholesterol and triglyceride levels, use of aspirin and the size and location of the lesions were recorded. Records with incomplete data and patients with a prior colonoscopy were excluded. RESULTS: 861 patient records were reviewed of which 405 met the inclusion criteria. Most patients (99%) of the patients were males, mean age 67.5 (range 36-87). The total number of colonic lesions was 1,065 (240 hyperplastic, 825 CRN). Histologic evaluation of lesions revealed: 121 patients who had HP, 331 with TA, 33 with TVA, 12 with VA, 13 with serrated adenomas and 61 patients had adenocarcinoma. Univariate analysis revealed that patients with HP appeared to have a lower likelihood of having TA (p < 0.001), adenocarcinoma (p = 0.002), and CRN in general (P < 0.001) as compared to patients without HP. Multivariate analysis with logistic regression revealed that patients with HP had a significantly lower likelihood of having TA (adjusted OR = 0.21; 95% CI 0.12-0.37), and adenocarcinoma (adjusted OR = 0.33; 95% CI 0.15-0.73) compared to patients without HP. No correlation was found between DM, use of alcohol, smoking, or aspirin use and the presence of sporadic HP. CONCLUSION: The present study suggests that the presence of HP is not associated with CRN in our veteran population. None of the risk factors proposed for CRN appear to be also risk factors for developing HP. The results of this study support current colon cancer guidelines in which surveillance for HP is not recommended.

Is barium enema an adequate diagnostic test for the evaluation of patients with positive fecal occult blood?

BACKGROUND: This study aimed to assess the diagnostic accuracy of double contrast barium enema (DCBE) compared to colonoscopy among Hispanic patients with positive fecal occult blood testing (FOBT). Secondary objectives were to determine: the diagnostic accuracy according to adenoma location, size, and pathologic characteristics; and patient satisfaction with each procedure METHODS: Cross-sectional study comparing the ac curacy of DCBE and colonoscopy in detecting adenomatous polyps and/or colorectal cancer in patients with positive FOBT. DCBE and a colonoscopy were performed in all patients. Polyps identified during colonoscopy were removed and classified by histology. Tolerability and patient's satisfaction with study procedures was assessed. RESULTS: Fifty patients were enrolled, mainly men with a mean age of 63 years old. Polyps were fou in 40/50 (80%) patients in colonoscopy, compared to 19/50 (38%) in DCBE. Eighty-four percent of polyps were missed by DCBE. Sensitivity of DCBE was 45% and specificity 90% for all adenomas. Diagnostic accuracy of DCBE was 54% for any size adenomas, and 72% for >10 mm adenomas. Sensitivity increased from right to left colon while specificity decreased. Patients preferred colonoscopy over DCBE. CONCLUSIONS: This study supports the use of colo noscopy as the gold standard test for the evaluation of positive FOBT and was preferred over DCBE b the patients. Diagnostic accuracy of DCBE was inferior to colonoscopy, for all size polyps and larg adenomas. Compared to colonoscopy, DCBE is a substandard test for colorectal cancer screening and may result in ineffective outcomes.

Small Bowel Bleeding: A Challenging Diagnosis.

The small intestine is an uncommon site for acute gastrointestinal (GI) bleeding. However, it is responsible for most cases in which the etiology of bleeding is not identified through endoscopy or colonoscopy. Despite great advances in technology, small bowel bleeding (SBB) is often a challenging diagnosis, requiring multiple blood transfusions, diagnostic procedures, and re-admissions. Consequently, it increases comorbidities, complications, and costs to the health care system. The presentation of SBB is diverse, and the etiology is dependent on the patient's age. It may require aggressive resuscitation and immediate bleeding-site localization for proper and successful care. The management is based on the etiology, the available technology, and physician expertise. We present a case of SBB in which multiple imaging and endoscopic procedures were required to identify the culprit lesion. Additionally, we review the most common etiologies, radiologic modalities, and endoscopic procedures available.

Anti-Hu-Mediated Paraneoplastic Chronic Intestinal Pseudo-Obstruction Arising From Small Cell Prostate Cancer.

Chronic intestinal pseudo-obstruction is a rare syndrome with high morbidity and mortality. The pathophysiology is not well understood, although it is postulated that it involves some sort of neuropathic and/or myopathic dysfunction resulting in intestinal dysmotility. We present the first case of chronic intestinal pseudo-obstruction secondary to a paraneoplastic syndrome associated with a primary small cell prostate cancer.

Hepatocellular carcinoma: ten years experience among veterans in Puerto Rico.

PURPOSE: The aim of our study is to determine the characteristics of hepatocellular carcinoma (HCC) as well as risk factors, demographics, survival rates and the use of diagnostic and therapeutic modalities among veteran patients in Puerto Rico. METHODS: A retrospective study of 114 patients with Hispanic background and biopsy-proven HCC diagnosed at the VA Caribbean Healthcare System from 1992 to 2002 was performed. Demographics data, Child-Turcotte-Pugh (CTP) score, presence of cirrhosis, viral serology, alcohol and/or other liver diseases history, diagnostic modalities, lesion size, therapy, and overall survival were examined. RESULTS: The mean age was 66.6 years old. 82% had known underlying cirrhosis. 60% had alcoholic liver disease (ALD), 33% positive serology for hepatitis C (HCV) and 21% both. 5.3% had chronic hepatitis B virus (HBV) infection. Additional causes were not present. CTP classification was: A (42%), B (44%) and C (14%). Abdominal CT scan demonstrated most of the lesions, while ultrasound only 57%. Alfa-fetoprotein was diagnostic in 32%. Mean survival was 10.3 months, better for those with CTP score A. Only 42% of the patients received any kind of therapy. CONCLUSIONS: ALD is the principal underlying liver disease in our HCC patients, closely followed by chronic HCV infection. Less than half of our patients received treatment mainly due to advanced disease for which the over survival was less than a year. HCC continues to be a dreadful disease with poor prognosis for which aggressive screening should be considered for all patients with cirrhosis and advanced liver disease regardless of the cause.

Anaplastic T-cell lymphoma presenting as fatal acute liver failure.

Acute liver failure (ALF) is an uncommon manifestation of liver disease and constitutes a medical emergency for which early identification is necessary. Hepatic involvement by hematologic malignancies although frequent, rarely causes severe hepatic dysfunction. Even more, acute hepatic failure as the first manifestation of a hematologic malignancy is extremely uncommon, although some cases have been reported in the literature. We describe the case of a 61 y/o puertorrican veteran who developed acute hepatic failure secondary to massive infiltration of the liver by a recurrent non-Hodgkin's lymphoma.

Elevated prevalence of hepatitis C infection in users of United States veterans medical centers.

Several studies suggest veterans have a higher prevalence of hepatitis C virus infection than nonveterans, possibly because of military exposures. The purpose of this study was to estimate the prevalence of anti-hepatitis C antibody and evaluate factors associated with infection among users of Department of Veterans Affairs medical centers. Using a two-staged cluster sample, 1288 of 3863 randomly selected veterans completed a survey and underwent home-based phlebotomy for serological testing. Administrative and clinical data were used to correct the prevalence estimate for nonparticipation. The prevalence of antihepatitis C antibody among serology participants was 4.0% (95% CI, 2.6%-5.5%). The estimated prevalence in the population of Veterans Affairs medical center users was 5.4% (95% CI, 3.3%-7.5%) after correction for sociodemographic and clinical differences between participants and nonparticipants. Significant predictors of seropositivity included demographic factors, period of military service (e.g., Vietnam era), prior diagnoses, health care use, and lifestyle factors. At least one traditional risk factor (transfusion or intravenous drug use) was reported by 30.2% of all subjects. Among those testing positive for hepatitis C antibody, 78% either had a transfusion or had used injection drugs. Adjusting for injection drug use and nonparticipation, seropositivity was associated with tattoos and incarceration. Military-related exposures were not found to be associated with infection in the adjusted analysis. In conclusion, the prevalence of hepatitis C in these subjects exceeds the estimate from the general US population by more than 2-fold, likely reflecting more exposure to traditional risk factors among these veterans.

Malignant tumors of the small intestine.

SUMMARY: Malignant tumors of the small bowel are unusual and account for only 1% to 5% of all gastrointestinal tract malignancies. Thirteen cases of malignant tumors of the small bowel identified at the VAMC in Puerto Rico from January 1999 to September 2001 and a review of the literature are presented. The mean age of our cases was 67 (range: 45-78). Vague abdominal pain, nausea, vomiting, and melena were the most frequently reported symptoms. The average time from first symptoms to diagnosis was 3.2 months. A positive test for occult blood or hypochromic microcytic anemia was invariably present. Hyperbilirubinemia and increased alkaline phosphatase were warning signs that allowed earlier diagnosis in patients with duodenal tumors. Fifty-four percent of the lesions were detected by endoscopic examination while 46% relied on radiographic studies. Eleven had carcinomas and two malignant gastrointestinal stromal tumors. Neither carcinoids nor lymphomas were identified. Our report of thirteen cases of malignant small bowel tumors is unusual and exhibits differences with the previously reported data. The cases were identified in a limited Hispanic population in a short period of time. Aggressive evaluation and a high suspicion of these malignancies should be entertained whenever subtle symptoms and unexplained gastrointestinal blood loss are assessed.