Serious gastrointestinal pathology found in patients with serum ferritin values < or = 50 ng/ml.

OBJECTIVE: Our aim was to evaluate the gastrointestinal tract in patients with serum ferritin values < or = 50 ng/ml for the presence of serious gastrointestinal pathology, including neoplasia and acid peptic disease. METHODS: In this prospective observational study, patients with serum ferritin values < or = 50 ng/ml who did not have an obvious cause of iron deficiency underwent colonoscopy and/or esophagogastroduodenoscopy. RESULTS: Between October 1, 1994, and February 29, 1996, 725 of 3015 patients who had serum ferritin determinations were found to have values < or = 50 ng/ml. To date, 143 patients have been fully evaluated and 77 were found to have serious gastrointestinal pathology including acid peptic disease (N = 46), cancer (N = 15), and large adenomas (N = 6). Colon cancer was discovered in five asymptomatic patients. The prevalences of serious gastrointestinal pathology did not differ between patients with serum ferritin values < or = 20 ng/ml and those with values between 21-50 ng/ml (63% vs 48%, p = 0.07). However, multivariate analysis showed that the presence of upper or lower gastrointestinal symptoms and serum ferritin value < or = 20 ng/ml is predictive of finding serious pathology (p = 0.0002 for the whole model), with odds ratios of 3.8 (95% confidence interval of 1.84-7.70) for presence of gastrointestinal symptoms and 2.2 (95% confidence interval of 1.09-4.57) for serum ferritin value < or = 20 ng/ml. CONCLUSIONS: Endoscopic examination is warranted in patients with serum ferritin values < or = 50 ng/ml to detect serious gastrointestinal pathology, present in 54% of such patients.

Timing and severity of initial hepatitis C recurrence as predictors of long-term liver allograft injury.

BACKGROUND: The majority of patients infected with hepatitis C virus (HCV) undergoing liver transplantation develop evidence of histologic recurrence, and multiple mechanisms are likely poised to affect long-term allograft injury. The purpose of this analysis was to study the hypothesis that histologic and biochemical features at the onset of HCV recurrence predict the long-term evolution of allograft hepatitis. METHODS: We studied 34 consecutive liver transplant recipients with evidence of histologic HCV recurrence and with a minimal histologic follow-up of 1 year (up to 6.2 years; mean: 696+/-83.2 days). Two-hundred and seventy-eight serial allograft biopsies (mean: 6.85+/-0.62 per patient, range: 4-21) were analyzed. The hepatic activity index was utilized to quantitate piecemeal necrosis, intralobular degeneration, portal inflammation, and hepatic fibrosis. The presence of hepatocyte ballooning degeneration and cholestasis was also assessed. RESULTS: Although there was no significant difference with regard to initial hepatic activity index scores between patients who ultimately developed allograft cirrhosis (group 1; n=8) versus those with milder hepatitis (group 2; n=26), the finding of ballooning degeneration/cholestasis was more frequent in the former group (P=0.04). The distribution of HCV genotypes, the mean follow-up after orthotopic liver transplantation, the mean number of allograft biopsy specimens per patient, basal immunosuppression, and incidence of rejection were comparable in both groups. Patients who ultimately developed allograft cirrhosis had significantly higher initial total bilirubin at the onset of histologic recurrence and peak total bilirubin (pT. Bili, the highest value in the ensuing month). Actuarial rates of moderate-to-severe allograft hepatitis were significantly greater in patients with pT. Bili > or = 3.5 mg/dl (P=0.004). Multiple regression analysis identified pT. Bili as the only independent predictor of allograft cirrhosis. CONCLUSIONS: Features at the onset of histologic HCV recurrence predict the natural history of allograft injury; specifically, marked, transient hyperbilirubinemia is associated with the subsequent development of allograft cirrhosis.

Management of symptoms of gastroesophageal reflux disease: does endoscopy influence medical management?

OBJECTIVES: The purpose of this study was to examine the theories that underlie the clinical decision to perform endoscopy in patients with symptoms of gastroesophageal reflux disease (GERD). Physicians reported that they use endoscopic findings to modify medical treatment of GERD. This study was undertaken to test this hypothesis in clinical practice. METHODS: A consortium of community specialists in gastrointestinal disease was formed. Physicians completed a database on patients undergoing elective endoscopy for symptoms of GERD, which includes symptom severity, endoscopic findings, and medical treatment before and after endoscopy. An increase in medical treatment was defined as an increase in acid suppression therapy, and/or the addition of a promotility drug, and/or referral for surgery. RESULTS: Data were collected prospectively over 6 months on 664 patients with symptoms of GERD, and complete data were available on 598 patients. Barrett's esophagus or active esophagitis (erythema, erosions, or ulceration) was present in 374 patients. Of these patients, 74% had an increase in therapy after endoscopy; for only 5% did therapy decrease. In contrast, among 224 patients with a normal-appearing esophagus, 35% had an increase in treatment and 65% had either a decrease in treatment or no change. In most cases, the increase in treatment was due to persistence of symptoms or because of endoscopic findings in the stomach or duodenum. The differences in treatment changes between the two groups was highly significant (p < 0.0001). CONCLUSION: The results support the theory that physicians often use endoscopic results to tailor medical therapy in patients with symptoms of GERD.

Risk factors for Barrett's esophagus in community-based practice. GORGE consortium. Gastroenterology Outcomes Research Group in Endoscopy.

OBJECTIVES: Endoscopy is often performed in patients with gastroesophageal reflux (GER) disease because of concern about the presence of Barrett's esophagus (BE). The purpose of this study was to determine whether the duration of GER symptoms and/or a history of esophagitis was associated with an increased risk of BE. METHODS: This was an observational, prospective, community-based study. Consecutive patients undergoing elective endoscopy because of GER symptoms were enrolled. Endoscopy reports and pathological findings were reviewed to classify patients as having no esophagitis, esophagitis, or probable BE. Correlations with duration of symptoms and a history of esophagitis were analyzed. RESULTS: In all, 701 of 2641 patients (27%) undergoing elective endoscopy had GER symptoms, and 77 of these patients had probable BE. Compared with patients with GER symptoms for less than 1 yr, the odds ratio for BE in patients with GER symptoms for 1-5 years was 3.0 and increased to 6.4 in patients with symptoms for more than 10 yr (p < 0.001). A history of esophagitis was not an independent risk factor for BE (p = 0.17). CONCLUSIONS: Prevalence of BE is strongly associated with duration of GER symptoms.

Community-based research--a framework for problem formulation: the case of upper endoscopy for gastroesophageal reflux disease.

OBJECTIVE: To identify clinical hypotheses and information gaps underlying disagreement about the use of upper gastrointestinal endoscopy (EGD) for the diagnosis of gastroesophageal reflux disease (GERD), and to design a registry study to test these hypotheses. DESIGN AND SETTING: Structured group discussions with community-based practicing gastroenterologists. RESULTS: Thirty-three gastroenterologists from 17 sites discussed a set of clinical scenarios concerning the use of EGD in GERD patients with different clinical histories. Clinicians identified patient characteristics and outcome variables missing from the original problem formulation. Using decision tables, the combinations of patient characteristics that provoked disagreement among clinicians were determined. The resulting decision tables specified which characteristics and outcome variables should be measured to test competing clinical theories of when to use EGD in patients with GERD. Subsequently, the clinicians conducted a practice-based study measuring uncertain variables associated with disagreement about the need for EGD in specific clinical situations. CONCLUSION: A structured, but flexible, approach to group discussion may help identify factors that are important in decision making and the hypotheses that should be addressed in resolving variations in practice styles. Technology assessors can use these methods to identify variables underlying clinicians' concerns about the clinical validity of recommendations about practice. This experience with eliciting patient characteristics and uncertain variables underscores the importance of involving practicing clinicians in the process and could be a useful model for problem formulation in guideline development and in community-based research.

Psychological distress in patients with gastroesophageal reflux disease.

BACKGROUND: Psychological factors play a role in a variety of gastrointestinal illnesses, including esophageal diseases. The role of psychological factors in gastroesophageal reflux disease (GERD) is not known. The purpose of this study was to determine if psychological distress is present in patients with reflux disease. METHODS: We performed psychological assessments in 51 patients with documented gastroesophageal reflux disease and in 43 age-matched controls using a battery of instruments. RESULTS: Patients with reflux differed from controls on scales of depression, somatization, anxiety, and intensity of reporting symptom distress. However, a secondary analysis revealed that it was a subset of reflux patients (30%) that accounted for the differences between the two groups. CONCLUSIONS: These results suggest that although most patients with GERD are psychologically similar to patients without GERD, a subset of psychologically distressed patients are more likely to be found among patients with GERD. They suffer from general psychological distress rather than a specific psychiatric disorder. This psychological factor could affect the clinical manifestations of reflux disease in these individuals. Recognition and management of psychological distress in this subgroup may aid in the management of reflux disease.