An Investigation Into What Factors Influence Patterns of Clinical Presentation in Adult-Onset Celiac Disease.

Introduction Anxiety and depression are common in patients with celiac disease (CD), and many psychosocial explanations have been considered. However, as the gut-brain axis is becoming increasingly understood, biological mechanisms have been proposed, including vitamin or mineral deficiencies and gut inflammation. Aim To investigate associations between anxiety/depression and symptom severity, vitamin status, and gut inflammation in untreated adult patients presenting with a serologic indication of celiac disease. Methods The Hospital Anxiety and Depression Scale (HADS), Celiac Symptom Index (CSI), and Perceived Stress Scale (PSS) questionnaires were administered to 17 patients over a 14-month period. Duodenal biopsies were obtained to determine histological Marsh scores. Iron, B12, folate, vitamin D, and thyroid function tests were reviewed. Results HADS-Anxiety (HADS-A) scores correlated with symptom severity (rs = 0.62, P = 0.008), but not with any hematological investigations or degree of intestinal inflammation. No patients scored highly for depression. Iron deficiency was the most common deficiency observed (n = 6). Greater symptomatology was associated with female sex (females versus males: average CSI scores, 32.1 versus 23.6; t17 = 2.1, P < 0.05), younger age at presentation (rs = -0.55, P = 0.02), and lower Marsh score (Marsh 0 versus Marsh 3C: mean scores, 36 versus 24.5; t5 = 6.2, P = 0.009). Conclusions The anxiety experienced by patients with CD at presentation is likely a reactive form due to gastrointestinal symptoms rather than a biological process specific to CD. Older patients tend to present less symptomatically, highlighting the need for screening of at-risk individuals. The degree of villous atrophy does not correlate well with clinical presentation. Highly symptomatic patients should be screened for anxiety at presentation.

Stomal varices: a rare cause of stomal hemorrhage. A report of three cases.

Stomal varices secondary to portal hypertension are a rare but potentially fatal cause of hemorrhage. Management, determined by the site of the bleeding, centers on preventing additional bleeds and may include providing local pressure, applying silver nitrate, injection sclerotherapy, suture ligation of the bleeding point, and/or the placement of transjugular intrahepatic portosystemic shunts and refashioning the stoma. Two patients (60- and 69-year-old women) had panproctocolectomy for inflammatory bowel disease and presented at the authors' hospital with bleeding from the ileostomy 1 and 19 years, respectively, following the creation of their stomas. A third patient (a 72-year-old man) bled from an end colostomy following an abdominoperineal resection for Duke's C rectal adenocarcinoma performed 3 years previous. All three patients had recurrent admissions for stomal bleeding and stomal varices secondary to portal hypertension and were initially treated with local measures (pressure, silver nitrate, and suture ligation). Two had undergone revision of their stomas prior to current treatment. One patient responded to local treatment but later died due to liver failure, one stopped bleeding after transjugular portosystemic shunt placement, and one died from metastatic cancer. Clinicians should maintain a high index of suspicion of stomal varices in patients with underlying liver disease who present with recurrent stomal bleeds and provide appropriate treatment to stop active bleeding and reduce portal venous pressure.

Management of minor upper gastrointestinal haemorrhage in the community using the Glasgow Blatchford Score.

BACKGROUND: The Glasgow Blatchford Score (GBS) is a validated risk assessment tool in primary upper gastrointestinal haemorrhage, which accurately predicts the need for intervention (endoscopic therapy, blood transfusion or surgery) or death. AIMS: To identify the GBS that predicts lack of intervention or death and to apply this to clinical practice by managing low-risk patients in the community. METHODS: GBSs prospectively calculated on 232 patients with upper gastrointestinal haemorrhage to identify low-risk score. Patients with low-risk of requiring intervention (GBS

Insertion of expandable metallic stents in esophageal cancer without fluoroscopy is safe and effective: a 5-year experience.

BACKGROUND: Self-expanding metallic stent (SEMS) placement is an important method of dysphagia palliation for patients with inoperable esophageal cancer. In most institutions, it is performed with fluoroscopic guidance; however, in 2001, we described a novel, direct-vision approach to SEMS placement, which does not require fluoroscopy. Here we report an audit of our experience over the last 5 years when using this methodology. OBJECTIVE: To describe our 5-year experience of 98 patients in whom esophageal stents were inserted when using the direct-vision technique and compare outcomes with published series of radiography-guided stents. DESIGN: Retrospective review of single-center experience. SETTING: English National Health Service Cancer Centre Hospital. PATIENTS: All patients who underwent esophageal stent insertion for a primary esophageal malignancy. INTERVENTIONS: SEMS insertion by direct endoscopic vision. RESULTS: Ninety-eight patients underwent SEMS insertion for malignant dysphagia during the study period, 92% of which were inserted without fluoroscopy. The technique had a low complication rate, which was consistent with published fluoroscopic data, and the median survival beyond stent insertion was 100 days (interquartile range, 62, 256; range, 4-921 days). In 59 patients, no further endoscopic palliative procedure was required. LIMITATIONS: Retrospective data collection. CONCLUSIONS: This series confirms direct-vision SEMS placement as a safe and efficacious method of malignant dysphagia palliation, providing definitive treatment in almost two thirds of cases.