Unexplained fever in a young man with Crohn's disease: a case report and review of literature.

A 23-year-old man with a known history of Crohn's disease (CD), who underwent an ileocaecal resection for localized disease activity three months ago, suffered from persistent fever with chills since 10 days. Despite the empirical antibiotic therapy that was started, his fever remained. A computed tomography (CT) angiography of the thorax and abdomen revealed a thrombosis of the iliacal veins bilateral and a pulmonary embolism (PE) in the right lower lobe with adjacent infiltrate. Venous thromboembolism (VTE) can be a life-threatening extraintestinal manifestation of inflammatory bowel disease (IBD). The risk that IBD patients develop a VTE is three times higher in comparison with healthy controls. They have a higher risk of recurrence and a higher mortality ratio. The pathogenesis of VTE in IBD is complex and until now not fully understood. More awareness should be raised, given the fact that it can be prevented by appropriate thromboprophylaxis.

Value of preoperative esophagogastroduodenoscopy in morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Roux-en-Y gastric bypass hinders post-operative endoscopic evaluation of the upper gastrointestinal tract. Our aims were to determine the prevalence of preoperative endoscopic findings in morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) and to determine the proportion of patients in which these findings changed surgical management. METHODS: We retrospectively evaluated electronic medical records of patients undergoing esophagogastroduodenoscopy (EGD) with routine antral biopsy for Helicobacter pylori (HP) detection, prior to LRYGB between January 2003 and January 2010 at our institution. The prevalence of all endoscopic findings was determined. RESULTS: 652 underwent preoperative endoscopy prior to LRYGB. The mean age was 39.5 +/- 11.3 years and mean body mass index was 42.8 +/- 5.0 kg/m2. Abnormalities were found in 444 patients (68.1%). Findings at EGD were hiatal hernia 24.3% (n = 159), esophagitis 30.8% (n = 201), Barrett's esophagus 0.8% (n = 5), gastritis 36.2% (n = 236), gastric or duodenal ulcers 7.5% (n = 69) and 2 cases of gastric cancer. The prevalence of HP infection was 17.6% (n = 115). In 51 patients (7.8%), endoscopic findings led to postponement of surgery: in 49 patients, gastric or duodenal ulcer had to be treated prior to surgery, in 2 patients, gastric cancer led to changement in surgical approach. CONCLUSIONS: Routine preoperative EGD detects different abnormalities which need a specific approach prior to bariatric surgery. EGD with routine biopsies for HP detection should be included in the preoperative workup prior to LRYGB. Positive EGD findings led to a change in medical treatment in a quarter (24.3%) of patients. Postponement of surgery due to the EGD findings was less frequent (7.8%).

Influence of low-dose oral contraceptives, alcohol, and grapefruit on.

The aminopryine breath test (ABT) measures hepatic reserve in patients with acute and chronic liver disease and gives an assesment of the hepatic function in patients undergoing major liver surgery. Aminopyrine is metabolized by the mixed cytochrome P-450 system, which can be influenced by many foreign compounds and drugs. Whether these foreign compounds and drugs can influence the results of the ABT has seldomly been tested. We studied three groups: Healthy female volunteers, either normally menstruating or taking oral contraceptives, were asked to perform a [13C]ABT during the time of the menses and at midcylce. Healthy volunteers were asked to perform a ABT after consuming 30 g of alcohol. Healthy volunteers were asked to perform a ABT after consuming 250 ml of grapefruit juice. The 13C/12C ratio in expired air was measured by gas isotope ratio mass spectrometry.

Long term response to interferon treatment in chronic hepatitis C patients is associated with a significant reduction in anti-E1 envelope antibody titers.

Interferon (IFN) alfa has been used widely for the treatment of chronic hepatitis C virus (HCV) infections but only a small number of patients treated have shown a sustained biochemical and virological response. Anti-envelope E1 and E2 antibody titers were assessed retrospectively before, during, and after treatment with IFN in order to evaluate their usefulness for the prediction and monitoring of therapy outcome in 115 patients infected chronically with HCV genotype 1b. At baseline, E2 induced more frequent and stronger immunogenic responses than E1, irrespective of patient response to therapy. E1 and E2 antibodies also tended to be higher in patients with a long-term or a transient response to IFN treatment than in patients who were absolute non-responders. In most patients, E1 and E2 antibody levels tended to be lower after treatment. This reduction was most pronounced and occurred most frequently in long-term responders to therapy. In this patient group, the reduction of E1 antibodies was more pronounced than that of E2 antibodies. In contrast to E2 antibodies, the decrease of E1 antibodies could already be observed at the end of therapy (week 24) and was significantly larger (p<0.05) than that observed in relapsers and non-responders. Thus, a sustained elevation of E1 antibodies seems to be associated with ongoing infection even when HCV RNA levels were undetectable in serum. Monitoring of E1 antibody titers may represent a useful additional marker to discriminate sustained responders from those who relapse in patients receiving interferon therapy.

Prevalence of the Cys282Tyr and His63Asp mutation in Flemish patients with hereditary hemochromatosis.

UNLABELLED: Recently Feder et al. have identified the gene responsible for hereditary hemochromatosis; it is located 3 Mbp telomeric of the MHC region on chromosome 6p and is called the HFE gene. The majority of the patients with hemochromatosis harbour the same missense mutation, Cys282Tyr. A second missense mutation (His63Asp) of which the significance is less clear, has also been described. To our knowledge the percentage of these two missense mutations in Flemish hemochromatosis patients is not known. MATERIALS AND METHODS: Forty nine (49) unrelated patients with the clinical diagnosis of hemochromatosis were screened for the two missense mutations. The missense mutations were diagnosed with a PCR technique. RESULTS: Of the 49 patients, 46 patients were homozygous for the Cys282Tyr mutation (94%), 2 were heterozygous (4%) and 1 carried two normal alleles (2%). Of the 3 patients not homozygous for the Cys282Tyr mutation, 3 were heterozygous for the His63Asp mutation (2 patients were 'compound heterozygotes'). DISCUSSION: The percentage of homozygotes (Cys282Tyr) in a Flemish hemochromatotic population is comparable with the figures published in the literature. The second missense mutation (His63Asp) could be of importance in association with the Cys282Tyr missense mutation.

Severe bleeding following endoscopic variceal ligation: should EVL be avoided in Child C patients?

In the last decade there has been an evolution in the treatment of bleeding oesophageal varices. Endoscopic variceal ligation (EVL) is one of those new techniques that not only has shown to be more effective than sclerotherapy, but also causes less side effects, resulting in less episodes of rebleeding and improving survival. We describe severe bleeding in 3 patients after EVL, occurring between 5 and 10 days after the initial ligation. Two Child C patients could not be resuscitated and died shortly after this event. Severely impaired clotting function as a result of the liver disease and the greater size of the ulcers induced by EVL may contribute to this dramatic complication. Severe bleeding due to postligation ulceration may lead to death, which occurred in 2 of our Child C patients. Since more and more endoscopists are using EVL in the treatment of oesophageal variceal bleeding, they should be aware of the possible complications caused by this rather new technique.

Gallstone recurrence after successful shock wave therapy: the magnitude of the problem and the predictive factors.

OBJECTIVE: Reports concerning long term recurrence of gallstones after successful extracorporeal shock wave lithotripsy (ESWL) show a high probability of stone recurrence. There is still discussion on the factors influencing stone recurrence. In this study we wanted to evaluate the long term recurrence of gallstones after stone clearance with ESWL and oral bile acids, and to assess possible risk and preventive factors of stone recurrence. METHODS: A total of 322 consecutive patients with stone clearance between December 1988 and December 1995 were included. All patients were contacted for ultrasonography and were interviewed for additional information on daily intake of aspirin, NSAIDs, cholesterol lowering medication, estrogen therapy, and biliary pain during follow-up. RESULTS: A total of 187 patients were still stone-free after a mean follow-up of 35 months (range: 3-89 months); 135 patients had recurrence. There was a significant association between stone recurrence and estrogen intake (p = 0.04), number of lithotripsy sessions (p = 0.0007), time until stone disappearance (p = 0.0003), and biliary pain (p < 0.0001). There was no difference in recurrence rate between solitary and multiple stones. CONCLUSIONS: Long-term recurrence of gallstones after lithotripsy is high: < or = 69% after 6 yr. We found a significant association of stone recurrence with estrogen intake, number of lithotripsy sessions, and time until stone disappearance. Intake of aspirin or NSAIDs was not associated with decreased stone recurrence. Of the patients with recurrent stones, 57% had biliary pain.

Abdominal pain with anorexia in patients with breast carcinoma.

Breast cancer is the second commonest primary tumour responsible for gastrointestinal metastases after malignant melanoma. The real incidence of gastrointestinal metastases in breast cancer patients is probably underestimated owing to the non-specific presenting symptoms and death of patients caused by other more obvious metastases. The predominant histological subtype of gastrointestinal metastases of breast cancer is invasive lobular carcinoma and the median interval from diagnosis of primary breast cancer to gastrointestinal metastases is five years. We report two cases of disseminated breast cancer with gastrointestinal involvement with a rather long survival.

Multifocal fatty infiltration of the liver; an aspecific presentation form of hepatitis C infection.

We present the case report of a 60 year old man with multiple focal echogenic lesions on ultrasound. While CT and MRI suggested the diagnosis of focal fatty infiltration of the liver, histology and serology showed a chronic hepatitis C infection. This is to our knowledge the first case of a patient with hepatitis C infection in whom focal steatosis could be seen on different imaging techniques.

Treatment of pancreatic pseudocysts by percutaneous drainage. Review and personal experience.

Pseudocysts are serious complications of acute and chronic pancreatitis. Asymptomatic pseudocysts require no specific treatment. Symptomatic pseudocysts can be decompressed by surgical, ultrasonographically and endoscopically guided methods. In the absence of randomised prospective trials it can not be stated that one of these technique is superior to others. Ultrasonographic and endoscopic approaches should be confined to centres with particular expertise in these techniques.

Ultrarapid hepatitis C virus clearance by daily high-dose interferon in non-responders to standard therapy.

BACKGROUND/AIMS: To analyze the kinetics of the hepatitis C virus and the patterns of resistance to interferon alpha, we assessed HCV RNA levels early during retreatment with high-dose interferon in patients who did not respond to standard treatment. METHODS: Eleven non-responders to previous therapy with 3-6 MU interferon three times a week were retreated with daily 10 MU. Plasma was sampled at days 0, 1, 2, 3, 14 and 28; all samples were prepared within 2 h and stored at -70 degrees C without thawing until analysis. The quantitative HCV RNA level was assessed by the Superquant assay (NGI, USA). The Eurohep reference panel, tested blindly, confirmed the linearity of the assay with a detection limit for genotypes 1 and 3 between 10(2) and 10(3) copies/ml. RESULTS: All patients showed a fall in viral load between week 0 and week 2 (2.6 log, i.e. 99.7%, range 1.3-4.7 log), whereas no fall was detected after week 2. Closer examination in nine patients revealed that all had a dramatic fall in the first 2 days (first day 1.8 log, 0.8-3.5; second day 0.8 log, -0.2-1.3), without any significant fall thereafter. The calculated half-life of viral decay in plasma was 5 (2-8.9) h, corresponding to a clearance of 2.4 (0.2-13.7) x 10(11) virions per day. Sustained responders showed a significantly greater fall in viral load in the first day (3.2 log, 2.8-3.5) than those who did not respond (1.4 log, 0.8-2.1, p=0.001). All three sustained responders had undetectable plasma HCV RNA at day 14. CONCLUSION: In patients without a response to standard interferon, the hepatitis C virus has a high daily turnover rate similar to that reported in naive patients. Our findings suggest that an early clearance of HCV RNA from the circulation is the key to a sustained response, which might be induced in about 25% of these patients by treatment with high (10 MU) daily doses of interferon. These findings have important implications for the concept of treatment of hepatitis C, which should shift its focus from long-term mild treatment towards aggressive therapy aiming at a fast viral disappearance within the first few days.

Efficacy of interferon dose and prediction of response in chronic hepatitis C: Benelux study in 336 patients.

BACKGROUND/AIMS: In an attempt to improve the limited efficacy of treatment of chronic hepatitis C with interferon-alpha 3 MU tiw, we studied the effects of double-dose therapy followed by downward titration, and analyzed the pre- and pertreatment factors associated with response or non-response. METHODS: Three hundred and fifty-four consecutive patients in 19 centers were randomized to interferon-alpha 3 MU tiw for 6 months or 6 MU tiw for 8 weeks followed by down-titration (3,1 MU tiw) till alanine aminotransferase remained normal and plasma HCV RNA was repeatedly undetectable. The primary outcome measure was sustained alanine aminotransferase and HCV RNA response 6 months after treatment. RESULTS: Three hundred and thirty-six patients received treatment. The sustained response rate for patients receiving 3 MU tiw for 6 months was 14% (9-21%,) and for patients receiving double dose tiw for 8 weeks and thereafter titrated therapy 15% (10-21%) (p=0.8). Pretreatment factors associated with a sustained alanine aminotransferase plus HCV RNA response were the absence of cirrhosis, presence of genotype 2 or 3, a low viral load and, in addition, a low alanine aminotransferase/aspartate aminotransferase ratio; a model was developed to allow estimation of the chance of response for the individual patient. The most powerful predictor of sustained response, however, was plasma HCV RNA at week 4; a positive test virtually precluded a sustained response (1.7%, 0.4-5.0%). If week 4 HCV RNA was not detectable, the chance of a sustained response was 21% (12-34%) for genotype 1 versus 40% (28-54%) for the others (p=0.02). Six MU tiw led to a significantly higher week 4 HCV RNA response (47% not detectable) than 3 MU (37%) (p=0.02). During down-titration this difference in viral on-treatment response was lost. CONCLUSIONS: In the treatment of hepatitis C, an early HCV RNA response is a prerequisite for long-term efficacy. Doubling the initial interferon dose increases this early response, but subsequent downward titration negates this effect, especially in genotype 1.

Pelvic floor function in patients with clinically complete spinal cord injury and its relation to constipation.

PURPOSE: Constipation is a common problem in patients with spinal cord injury. The aim of this study is to analyze the role of pelvic floor dysfunction in the development of constipation. METHODS: Twenty-five patients with clinically complete supraconal spinal cord injury were studied by means of colonic transit time, anal manometry, electrophysiologic testing, and sensory-evoked potentials. RESULTS: Sixteen patients had prolonged total and segmental colonic transit times (Group C), and nine patients had normal colonic transit times (Group NC). Basal pressure and anal pressure during coughing, Valsalva's maneuver, and rectal distention were diminished in all patients, but no differences were observed between Group C and Group NC. Rectal sensation was preserved in eight patients, but this was not related to the absence of constipation. In seven of these eight patients, somatosensory-evoked potentials could be recorded, which indicated an incomplete cord lesion. Synergic relaxation of the pelvic floor during straining was never observed; dyssynergia was seen in ten (7 in Group C and 3 in Group NC; P = not significant) patients. Associated peripheral nerve damage was present in 40 percent of patients but did not predispose these patients to constipation. CONCLUSIONS: Loss of rectal sensation, dyssynergic pelvic floor contraction during straining, associated peripheral nerve damage, and insufficient rise of intraabdominal pressure could not be held responsible for constipation as a result of spinal cord injury. A prolongation of the colonic transit time is the most important mechanism, and therapy should be directed toward it.

Hepatitis C virus genotypes: epidemiological and clinical associations. Benelux Study Group on Treatment of Chronic Hepatitis C.

In a cohort of 292 chronic hepatitis C patients living in the Benelux countries the relationship between viral genotype and geographical origin, route of transmission, clinical characteristics and severity of liver disease was analyzed. HCV-RNA isolates could be classified by the Line Probe Assay (LiPA) as 1a, 1b, 2, 3, 4 or 5 in 286 (98%) cases. Patients of European origin were predominantly infected with HCV subtype 1b (164/254, 65%, CI 58-70%), as were patients of Asian origin (7/13, 54%). Patients originating from Surinam (South America) had predominantly type 2 (9/10, 90%), whereas Africans were mainly infected with type 4 (7/9, 77%). Blood transfusion was the mode of transmission in 142 (50%) patients, intravenous drug abuse (IVDA) in 40 (14%), occupational needle accident or tattoo in 11 (4%); no obvious source of infection was found in 93 (33%). In patients infected by blood transfusion, subtype 1b was predominant (70%, CI 61-77%), whereas subtypes la and 3 were predominant in those infected by IVDA (25% and 45%, respectively, p<0.001). Cirrhosis was observed in 68 (24%) patients; in multivariate analysis, factors independently related to cirrhosis were: the duration of infection, age and prior hepatitis B. No significant relationship was found between the severity of fibrosis or liver inflammation and the HCV (sub)types. In summary, in this large cohort of patients in the Benelux countries the hepatitis C virus (sub)type present was clearly related to the country of origin and the route of transmission, but not to the severity of liver disease.

Constipation and other chronic gastrointestinal problems in spinal cord injury patients.

From a questionnaire sent to 90 spinal cord injury (SCI) patients it is concluded that 58% of patients with a complete SCI above L2 suffer from constipation, defined as two or fewer bowel movements per week, or the use of aids such as laxatives, manual evacuation or enemas. Tetraplegic patients had the highest prevalence of constipation, while patients with low paraplegia were less prone to constipation. The use of anticholinergic drugs was found to predispose to constipation. Preserved rectal sensation did not influence the presence of constipation. Faecal incontinence was rare. Regular abdominal pain was present in one third of SCI patients and might be caused by an irritable bowel syndrome in 62% of these.