Celiac Disease as a Cause of Anemia and Brittle Diabetes in Type 1 Diabetes Mellitus.

Untreated celiac disease (CD) leads to an increased risk for hypoglycemia and diabetic complications. However, the diagnosis of CD can be challenging and some extra-gastrointestinal tract manifestations could be a presenting symptom. We report a case of a 29-year-old Indian male with brittle T1DM whose underlying CD was discovered from a work-up for anemia. After an introduction of a gluten-free diet, he gained 5 kgs in two months, was responsive to oral iron supplement, and had stable glycemic control with much less hypoglycemia. Even though this disease is rare in Asian populations, the diagnosis of celiac disease should always be kept in mind when people with T1DM present with unexplained microcytic anemia and/or unexplained hypoglycemia.

Low rate of recurrent bleeding after double-balloon endoscopy-guided therapy in patients with overt obscure gastrointestinal bleeding.

BACKGROUND: Double-balloon endoscopy (DBE) provides both diagnosis and treatment in overt obscure gastrointestinal bleeding (OGIB). The aim of this study was to evaluate the rebleeding rate after DBE. METHODS: This retrospective review was conducted between January 2006 and July 2018, 166 patients with overt OGIB who underwent DBE were enrolled. Therapeutic intervention was defined as endoscopic treatment, embolization, or surgery. Primary outcome was rebleeding rate after DBE. The patients were divided into 3 groups based on their DBE; (1) positive DBE requiring therapeutic intervention (G1), (2) positive DBE without therapeutic intervention required (G2) and (3) negative DBE (G3). Cumulative incidence of rebleeding was estimated using the Kaplan-Meier method. Cox regression was used to assess the association of DBE with rebleeding risk. This study was approved by our Institutional Review Board. RESULTS: Sixty-eight patients (41%) were categorized in G1, 34 patients (20%) in G2 and 64 patients (39%) in G3. Overall rebleeding occurred in 24 patients (15%). The cumulative incidence of rebleeding for G1 was the lowest. The 1-year and 2-year cumulative probability of developing rebleeding after DBE in G1 were 3.5% and 3.5%, 8.2% and 14.0% in G2, and 18.2% and 20.6% in G3, respectively (p = 0.02). After adjusting for bleeding severity and comorbidities, patients with positive DBE requiring therapeutic intervention had a significantly lower rate of rebleeding when compared with patients who did not receive intervention (hazard ratio 0.17; 95% CI 0.03-0.90). CONCLUSION: DBE-guided therapeutic intervention was associated with a lower risk of rebleeding when compared with those with negative and positive DBE without therapeutic intervention. One-fifth of patients with overt OGIB had false negative after DBE.

The Secondary Quality Indicator to Improve Prediction of Adenoma Miss Rate Apart from Adenoma Detection Rate.

OBJECTIVES: Adenoma detection rate (ADR) cannot distinguish between endoscopists who detect one adenoma and those who detect ≥2 adenomas. Hypothetically, adenoma miss rate (AMR) may be significant for endoscopists with high ADRs who examine the rest of colon with less care after detecting first polyp. Our objective was to evaluate other quality indicators plus ADR vs. ADR alone in prediction of AMR. METHODS: We conducted a cross-sectional study of asymptomatic participants aged 50-75 years who underwent back-to-back screening colonoscopies by four faculty endoscopists. Each round of colonoscopy was performed by two of the endoscopists in a randomized order. During each round of colonoscopy, all detected polyps were removed. The second endoscopist was blinded to the results of the first. The total number of adenomas per positive participant (APP), the total number of adenomas per colonoscopy (APC), the additional adenomas found after the first adenoma per colonoscopy (ADR-Plus), and ADR were calculated for prediction of AMR. RESULTS: In all, 200 participants underwent back-to-back colonoscopies. There were no significant differences in ADRs of four endoscopists (44, 50, 54, and 46%). APPs were 1.91, 2.12, 2.19, and 2.43. APCs were 0.84, 1.06, 1.18, and 1.12. ADR-Plus were 0.40, 0.56, 0.64, and 0.66, respectively. AMRs differed significantly between the endoscopists (36, 27, 21, and 13%; P=0.01). There was no correlation between ADR and AMR (r=-0.25; P=0.75). Whereas APP exhibited a strong inverse correlation with AMRs (r=-0.99; P<0.01). APC and ADR-Plus appeared to be inversely correlated with AMR, however this was not statistically significant (r=-0.82; P=0.18 and r=-0.93; P=0.07, respectively). CONCLUSIONS: Among high-ADR endoscopists, AMRs still varied. APP may be a promising secondary indicator for distinguishing between the one-and-done polyp endoscopist and the meticulous endoscopist. The evaluation of influence of new metrics on colorectal cancer (CRC) prevention requires a larger population-based study.

The safety of propofol infusion compared to midazolam and meperidine intravenous bolus for patients undergoing double balloon enteroscopy.

OBJECTIVE: The double balloon enteroscopy (DBE) procedure is long and requires moderate sedation. We aim to determine whether the administration of propofol infusion is safe by comparing it to intravenous midazolam/meperidine in patients undergoing DBE. MATERIAL AND METHOD: A prospective study with 48 patients was conducted at King Chulalongkorn Hospital randomizing (block of four) patients into two groups. In group 1, 28 patients were enrolled for intravenous midazolam/meperidine, and one patient was dropped out before underwent DBE due to hemodynamic instability. Therefore, 27 (n = 27) participants were included in Group 1. In group 2, 28 patients were enrolled for propofol infusion, and seven patients were dropped out before underwent DBE, five due to hemodynamic instability (n = 5), and two refused treatment (n = 2). Therefore, 1 (n = 21) participants were included in Group 2. Vital signs and oxygen saturation were regularly monitored. RESULTS: Mean +/- SD age of patients was 56.8 +/- 9.2 years, and 41.7% of patients were male. There was no difference in demographic data between the groups. For the safety profile, 25.9% of the midazolam/meperidine group and 33.3% of the propofol group developed hypotension and/or desaturation (p = 0.45). The patients' satisfaction of group 1 and group 2 were 86.7 +/- 6.5% and 86.3 +/- 8.1%, respectively, and presented no significant difference (p = 0.89). CONCLUSION: Propofol infusion is safe and shows no difference in outcome from the midazolam and meperidine sedation for the DBE procedure.

Urgent double balloon endoscopy provides higher yields than non-urgent double balloon endoscopy in overt obscure gastrointestinal bleeding.

BACKGROUND AND STUDY AIMS: In overt obscure gastrointestinal bleeding (OV), double balloon endoscopy (DBE) is recommended as one of the most important investigations as it can provide both diagnosis and treatment. However, there is no set standard on the timing of DBE in OV. The aim of this study was to compare the diagnostic and therapeutic yields between urgent and non-urgent DBE in patients with OV. PATIENTS AND METHODS: Between January 2006 and February 2013, 120 patients with OV who underwent DBE were retrospectively reviewed. An urgent DBE was defined as DBE performed within 72 h from the last visible gastrointestinal bleeding (n = 74) whereas a non-urgent DBE was defined as DBE performed after 72 h (n = 46). Diagnostic yields, therapeutic impact and clinical outcomes were evaluated. RESULTS: Diagnostic yield in urgent DBE was significantly higher than that in non-urgent DBE (70 % versus 30 %; P < 0.05). Urgent DBE offered significantly more therapies including endoscopic, angiographic embolization, and surgery than non-urgent DBE (54 % versus 15 %; P < 0.001). Endoscopic therapy was performed in 43 % of urgent-DBE patients whereas only 13 % of patients in the other group received endoscopic therapy (P < 0.01). In patients with identified bleeding sources, the rebleeding rate was lower in patients who underwent urgent DBE than in those who underwent non-urgent DBE (10 % versus 29 %, NS). CONCLUSIONS: Regarding diagnostic and therapeutic impacts in OV, our retrospective study showed that urgent DBE is better than non-urgent DBE. The recurrent bleeding rate in patients undergoing urgent DBE tended to be lower.

Comparison of urgent video capsule endoscopy and urgent double-balloon endoscopy in massive obscure gastrointestinal bleeding.

BACKGROUND/AIMS: Urgent video capsule endoscopy (VCE) and urgent double-balloon endoscopy (DBE) provide high diagnostic yields in overt obscure gastrointestinal bleeding (OGIB). However, no studies have specifically compared VCE and DBE in massive OGIB. The aim of this study was to compare the diagnostic yield and clinical outcomes of the two approaches. METHODOLOGY: Between October 2010 and March 2013, there were 1,672 consecutive patients with gastrointestinal bleeding and 30 massive OGIB were identified. After non-diagnostic EGD and colonoscopy, VCE and DBE were performed in tandem within 72hr after hospitalization. RESULTS: Of these, 30 patients were identified as massive OGIB. DBE identified more bleeding lesions than VCE (26(87%) vs. 18(60%), p<0.05). Only DBE was positive in 8 patients (27%). No patient had positive VCE and negative DBE. VCE demonstrated only fresh blood without identifiable lesions in 8 (27%) patients, and all had bleeding lesions identified subsequently by DBE. The number of patients with therapeutic intervention guided by DBE was higher than those with VCE-guided intervention (17(57%) vs. 11(37%); p<0.05). Four patients (13%) had a negative study by both tests, and no further bleeding was reported. CONCLUSIONS: In massive OGIB, urgent DBE had a higher diagnostic yield than VCE. (ClinicalTrials.gov number, NCT01654770)