Newly Diagnosed Idiopathic Liver Abscess: Colonoscopy Required!

Liver abscess is the most common type of visceral abscess reported in the United States. Biliary tract disease is the most common cause of the development of liver abscess. In the last decade, many cases of liver abscesses silently manifesting as colon cancer have been reported in East Asian countries. We herein describe a case of an immunocompetent man who immigrated from East Africa to Unites States and presented with a suspicion of colon mass with metastasis to the liver, and who was later diagnosed to have a colonic malignancy with a concomitant liver abscess. Our aim was to make clinicians aware of the importance of ruling out occult colonic malignancy in patients with idiopathic liver abscess.

Evolving role of computed tomographic colonography in colon cancer screening and diagnosis.

Computed tomographic colonography (CTC) is a relatively new imaging modality for the examination of patients for colorectal polyps and cancer. It has been validated in its accuracy for the detection of colon cancer and larger polyps (more than likely premalignant). CTC, however, is not widely accepted as a primary screening modality in the United States at present by many third-party payers, including Medicare, and its exact role in screening is evolving. Moreover, there has been opposition to incorporating CTC as an accepted screening instrument, especially by gastroenterologists. Heretofore, optical colonoscopy has been the mainstay in this screening. We discuss these issues and the continuing controversies concerning CTC.

Retrograde submucosal tunneling technique for management of complete esophageal obstruction.

Complete esophageal obstruction is a challenging problem that is not amendable to standard dilation techniques. Multiple endoscopic techniques as well as radical surgical procedures have been developed with the goal of restoring a patent esophageal lumen. In patients with complete esophageal obstruction, an antegrade-retrograde technique has been described, but this generally depends on the ability to transilluminate across the stricture. Successful transillumination allows for safe direct puncture across the stricture, followed by dilation. In long-segment strictures (greater than 2-3 cm), transillumination may not be possible. We report a case of a 63 year-old woman who developed a complete esophageal obstruction from radiation therapy (RT) for hypopharyngeal squamous cell carcinoma. She did have enteral access via a percutaneous endoscopic gastrostomy (PEG) tube which had been placed prior to beginning RT. A combined antegrade (through the mouth) and retrograde (through PEG site) approach was done, but transillumination across the stricture failed. Fluoroscopy demonstrated a 4 cm long stricture. The creation of a submucosal tunnel from the retrograde direction decreased the stricture length to 15 mm and transillumination was achieved. This allowed safe puncture of the stricture, placement of a guidewire, then successful dilation. The patient can now tolerate soft foods and maintain her weight. Submucosal tunneling can be used to achieve transillumination for the combined antegrade-retrograde approach to complete esophageal obstruction.

Endoscopist's approach to nutrition in the patient with pancreatitis.

Nutritional therapy has an important role in the management of patient with severe acute pancreatitis. This article reviews the endoscopist's approach to manage nutrition in such cases. Enteral feeding has been clearly validated as the preferred route of feeding, and should be started early on admission. Parenteral nutrition should be reserved for patients with contraindications to enteral feeding such as small bowel obstruction. Moreover, nasogastric feeding is safe and as effective as nasojejunal feeding. If a prolonged course of enteral feeding (> 30 d) is required, endoscopic placement of feeding gastrostomy or jejunostomy tubes should be considered.

Does deep sedation impact the results of 48 hours catheterless pH testing?

AIM: To study a cohort of patients undergoing 48 h Bravo pH testing receiving deep sedation with propofol. METHODS: We retrospectively reviewed the charts of 197 patients (81 male, 116 female) who underwent Bravo esophageal pH monitoring from July 2003 to January 2008. All patients underwent Bravo pH probe placement via esophagogastroduodenoscopy (EGD) and received propofol for sedation. Patients on a proton pump inhibitor (89 patients) were excluded. Acid reflux variables measured included the total, upright, and supine fractions of time at pH < 4 and DeMeester score, and were compared between day 1 and day 2. RESULTS: Of the 108 patients that were included in the study, the most common indication for Bravo pH monitoring was heartburn, with chest pain being the second most common. A signed rank test revealed no statistically significant difference between day 1 and day 2 reflux episodes. CONCLUSION: Patients who received propofol for sedation for EGD with Bravo pH capsule placement did not experience any significant difference in reflux episodes from day 1 to day 2.

Endoscopic approach to pancreatic pseudocysts: An American perspective.

Pancreatic pseudocysts, abscesses, and walled-off pancreatic necrosis are types of pancreatic fluid collections that arise as a consequence of pancreatic injury. Pain, early satiety, biliary obstruction, and infection are all indications for drainage. Percutaneous-radiologic drainage, surgical drainage, and endoscopic drainage are the three traditional approaches to the drainage of pancreatic pseudocysts. The endoscopic approach to pancreatic pseudocysts has evolved over the past thirty years and endoscopists are often capable of draining these collections. In experienced centers endoscopic ultrasound-guided endoscopic drainage avoids complications related to percutaneous drainage and is less invasive than surgery.

Endoscopic removal of a brunneroma with EUS guidance.

Brunner glands are compound tubular submucosal glands typically found in the duodenal bulb. The most common benign tumors of the small intestine are adenoma, and 25% of these occur in the duodenum. Among the benign tumors of the duodenum, 30-50% arise from the Brunner glands. Most of the literature describes their presentations as ranging from benign, nonspecific, epigastric discomfort to obstruction and intestinal bleeding. A good percentage of them are surgically resected; however, there has been an advancement to remove them endoscopically. We present one of the first cases of an endoscopic ultrasound (EUS) approach to the diagnosis and therapeutic removal of a brunneroma.

Radiology-Pathology Conference: Colonic schwannoma.

We report the radiology and pathology findings on a patient with colonic schwannoma, and review the literature on this very rare tumor.

Cardiovascular reactivity in fibromyalgia: evidence for pathogenic heterogeneity.

OBJECTIVE: To evaluate disease-specific cardiovascular reactivity patterns in patients with fibromyalgia (FM) using a recently described method called fractal and recurrence analysis score (FRAS). METHODS: The study group included 30 women with FM, average age 46.7 years (SD 7.03). An age matched group of 30 women with other rheumatic disorders or having a dysautonomic background [chronic fatigue syndrome (CFS), non-CFS fatigue, neurally mediated syncope, and psoriatic arthritis (PsA)] served as controls. Subjects were evaluated with a head-up tilt test with beat-to-beat recording of the heart rate (HR) and pulse transit time. A 10-minute supine phase was followed by 600 cardiac cycles recorded on tilt. Data were processed by recurrence plot and fractal analysis. Variables acting as independent predictors of the cardiovascular reactivity were identified in FM patients versus controls. RESULTS: No statistically significant differences were found between the groups by univariate analysis comparing 92 variables of cardiovascular reactivity in FM patients compared to controls. CONCLUSION: Study of cardiovascular reactivity utilizing a head-up tilt test and processing the data using the FRAS method did not reveal a specific FM-associated abnormality. Our data confirm studies that utilized other methodologies and reached similar conclusions. Patients with FM represent a heterogenous group with respect to their pattern of cardiovascular reactivity.

Search for disease-specific cardiovascular reactivity patterns: developing the methodology.

Aberrations of CVR (cardiovascular reactivity), an expression of autonomic function, lack specificity for a particular disorder. Recently, a CVR pattern particular to chronic fatigue syndrome has been observed. In the present study, we aimed to develop methodologies for assessing disease-specific CVR patterns. As a prototype, a population of 50 consecutive patients with FMF (familial Mediterranean fever) was studied and compared with control populations. A 10 min supine/30 min head-up tilt test with recording of the heart rate and blood pressure or the pulse transit time was performed. Five studies were conducted applying different methods. In each study, statistical analysis identified independent predictors of CVR in FMF. Based on regression coefficients of these predictors, a linear DS (discriminant score) was computed for every subject. Each study established an equation to assess CVR, calculate DS for FMF and determine the sensitivity and specificity of the DS cut-off. In each of the five studies, abnormal CVR was observed in FMF patients. The best accuracy (88% sensitivity and 90.1% specificity for FMF) was obtained by a method based on beat-to-beat heart rate and pulse transit time recordings. Data was processed by fractal and recurrence quantitative analysis with recordings in FMF patients compared with a mixed control population. Identification of disease-specific CVR patterns was possible with the methodologies described in the present study. In FMF, disease-specific CVR may be explained by the interplay between neuroendocrine loops specific to FMF with cardiovascular homoeostatic mechanisms. Recognition of disease-specific CVR patterns may advance the understanding of homoeostatic mechanisms and have implications in clinical practice.

The feeling of fatigue--fatigue severity by unidimensional versus composite questionnaires.

The authors' purpose in this study was to compare the perception of fatigue severity as measured by different fatigue questionnaires. The authors evaluated 3 groups of patients in a cross-sectional study: chronic fatigue syndrome (CFS, n = 20), non-CFS fatigue (n = 20), and familial Mediterranean fever (FMF n = 25). In addition, the authors tracked 7 patients with CFS longitudinally for severity of fatigue. The severity of fatigue-related symptoms was assessed with 2 questionnaires: the unidimensional Chalder's Fatigue Severity Scale (CH) and the composite Fatigue Impact Scale (FI) which has 3 subscales--cognitive, physical, and social--and a total score. In the cross-sectional study, correlations between CH and FI cognitive scores were r = .78 (p < .0001), CH versus FI physical scores r = .603 (p < .0001), CH versus FI social scores r = .66 (p < .0001), and CH versus FI total scores r = .74 (p < .0001). In the longitudinal survey of CFS patients, the authors compared 30 questionnaires revealing correlations of CH versus FI cognitive scores r = .64 (p = .0004), CH versus FI physical r = .68 (p = .0001), CH versus FI social r = .87 (p < .0001), and CH versus FI total r = .90 (p < .0001). Fatigue severity as assessed by the unidimensional CH scale and the composite FI scale is comparable. The simple CH scale may be adequate for the assessment of the feeling of fatigue, in general, and for monitoring the severity of fatigue in CFS, in particular.

Garlic: a way out of work.

Two 18-year-old men were seen for second-degree burns to the dorsum of their knees, ankles, and feet. Upon investigation, it was revealed that the burns were self-inflicted and resulted from the application of crushed garlic with the intent of exemption from work. Reviews of the literature reveal that garlic-induced burns have been previously reported; however, only once before as a factitious dermatitis. The sharp demarcation line between normal and abnormal skin should suggest that a burn is not from hot liquids. Health care providers had best be advised of the side effects of natural remedies and be aware of how garlic may be abused to the advantage of an individual.