Celiac disease detection in hypothyroid patients requiring elevated thyroid supplementation: A prospective cohort study.

BACKGROUND: Celiac disease (CD) is associated with hypothyroidism, but the disease prevalence is not thought to be great enough to warrant testing all hypothyroid patients. We hypothesized that hypothyroid patients with concomitant CD would require elevated doses of levothyroxine, and there is a threshold daily dose, above which, hypothyroid patients should be tested for CD. METHODS: Hypothyroid patients presenting to the endoscopy or endocrinology clinics at the University of Vermont Medical Center were included. Patients were categorized by whether or not they required ≥125mcg/day of levothyroxine. A serum tissue transglutaminase (tTG) was performed on enrolled patients. Patients with an elevated serum tTG underwent endoscopy with duodenal biopsies. Symptoms were assessed by the Gastrointestinal Symptom Rating Scale. RESULTS: Overall, 500 patients were enrolled and 29% (144 patients) required ≥125mcg/day of levothyroxine. CD was detected in 9 patients. The prevalence of CD ranged from 1.8% in our entire cohort to 12.5% in patients requiring ≥200mcg/day of levothyroxine. Eight patients with CD (89%) required ≥125mcg/day of levothyroxine. Patients who required ≥125mcg/day of levothyroxine had a significantly increased risk of CD (p<0.001). CD was detected in 5.6% of patients requiring ≥125mcg/day of levothyroxine. CONCLUSIONS: Hypothyroid patients requiring elevated daily doses of levothyroxine are more likely to have CD. Hypothyroid patients requiring ≥125mcg/day of levothyroxine should undergo serologic testing for CD.

In vivo treatment of Propionibacterium acnes infection with liposomal lauric acids.

Propionibacterium acnes (P. acnes) is a Gram-positive bacterium strongly associated with acne infection. While many antimicrobial agents have been used in clinic to treat acne infection by targeting P. acnes, these existing anti-acne agents usually produce considerable side effects. Herein, the development and evaluation of liposomal lauric acids (LipoLA) is reported as a new, effective and safe therapeutic agent for the treatment of acne infection. By incorporating lauric acids into the lipid bilayer of liposomes, it is observed that the resulting LipoLA readily fuse with bacterial membranes, causing effective killing of P. acnes by disrupting bacterial membrane structures. Using a mouse ear model, we demonstrated that the bactericidal property of LipoLA against P. acne is well preserved at physiological conditions. Topically applying LipoLA in a gel form onto the infectious sites leads to eradication of P. acnes bacteria in vivo. Further skin toxicity studies show that LipoLA does not induce acute toxicity to normal mouse skin, while benzoyl peroxide and salicylic acid, the two most popular over-the-counter acne medications, generate moderate to severe skin irritation within 24 h. These results suggest that LipoLA hold a high therapeutic potential for the treatment of acne infection and other P. acnes related diseases.

Screening for pancreatic cancer in a high-risk population with serum CA 19-9 and targeted EUS: a feasibility study.

BACKGROUND: Earlier detection of pancreatic adenocarcinoma is needed. OBJECTIVE: To determine whether early pancreatic neoplasia can be detected in a high-risk population by using CA 19-9 followed by targeted EUS. DESIGN: Prospective cohort study. SETTING: Two academic medical centers. PATIENTS: Eligible patients met age criteria and had at least 1 first-degree relative with pancreatic adenocarcinoma. INTERVENTIONS: A serum CA 19-9 was performed on all patients. EUS was performed if the CA 19-9 level was elevated. FNA of identified lesions was performed. Patients with pancreatic cancer detected by using this screening protocol were compared with patients presenting off-protocol for staging data. Medicare reimbursement rates were used to derive cost data. MAIN OUTCOME MEASUREMENTS: Detection of early pancreatic neoplasia. RESULTS: A total of 546 patients were enrolled. CA 19-9 was elevated in 27 patients (4.9%, 95% CI, 3.2%-7.1%). Neoplastic or malignant findings were detected in 5 patients (0.9%, 95% CI, 0.3%-2.1%), and pancreatic adenocarcinoma in 1 patient (0.2%, 95% CI, 0.005%-1.02%). The patient with pancreatic cancer detected as part of this protocol was 1 of 2 patients presenting to the University of Vermont with stage 1 cancer. The cost to detect 1 pancreatic neoplasia was $8431. The cost to detect 1 pancreatic adenocarcinoma was $41,133. LIMITATIONS: The sample size is adequate only to demonstrate the feasibility of this approach. CONCLUSIONS: Potentially curative pancreatic adenocarcinoma can be identified with this screening protocol. Stage 1 pancreatic cancer is more likely to be detected by using this screening protocol than by using standard means of detection.

Endoscopic occlusion of cystic duct using N-butyl cyanoacrylate for postoperative bile leakage.

Bile leak after cholecystectomy is well described, with the cystic duct remnant the site of the leak in the majority of cases. Endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement has a high success rate in such cases. When ERCP fails, options include surgery, and percutaneous and endoscopic transcatheter occlusion of the site of bile leak. Here, we describe a case of endoscopic transcatheter occlusion of a persistent cystic duct bile leak after cholecystectomy using N-butyl cyanoacrylate glue. A 51-year-old man had persistent pain and bilious drainage following a laparoscopic cholecystectomy. The bile leak persisted after endoscopic placement of a biliary stent for a confirmed cystic duct leak. A repeat ERCP was carried out and the cystic duct was occluded with a combination of angiographic coils and N-butyl cyanoacrylate glue. The patient's pain and bilious drainage resolved. A follow-up cholangiogram confirmed complete resolution of the cystic duct leak and a patent common bile duct.

Esophageal squamous papillomatosis.

Esophageal squamous papillomatosis is rare and has been associated with gastroesophageal reflux and recurrent respiratory papillomatosis. We report a case of extensive esophageal papillomatosis, no airway involvement and a slowly progressive clinical course with progressive strictures and ultimately fatal squamous cell carcinoma. In-situ hybridization performed on biopsy specimens was negative for high-risk human papilloma virus types. Due to the paucity of reported cases, little is conclusively known about the etiology, natural course and best clinical management of this disease. Human papilloma virus has been linked to some, but not all, cases, and the clinical course has been reported to vary from spontaneous regression to malignant transformation. Surveillance for malignancy by conventional endoscopic biopsies or computed tomography scan appears to have low sensitivity. This case illustrates the difficulties in clinical management and establishing a definite etiology in esophageal squamous papillomatosis.

Seasonal pattern of onset in lymphocytic colitis.

BACKGROUND: The etiology of lymphocytic colitis, a microscopic colitis syndrome, has remained elusive. Because 1) many infectious enteritides exhibit seasonal variability in incidence and 2) a few investigators have proposed some infectious mechanism in lymphocytic colitis, our aim was to determine if any variability in symptom onset existed among lymphocytic colitis patients diagnosed at our institution. STUDY: We identified 71 nonduplicated, consecutive patients with lymphocytic colitis over a 4-year period using rigorous clinicopathologic inclusion criteria: 1) chronic watery diarrhea, 2) endoscopically normal colon, 3) no evidence for celiac sprue or drug-induced colitis, 4) diffuse colitis with increased intraepithelial lymphocytes of at least 10 lymphocytes per 100 epithelial cells, 5) evidence of surface epithelial damage, and 6) no significant neutrophilic infiltrates, architectural distortion of the mucosa, or subepithelial collagen deposits. The date of diagnosis was corrected for month of onset of symptoms. RESULTS: The distribution of month of onset of symptoms showed a statistically significant (chi test of homogeneity, P = 0.0008) temporal variability and seasonal incidence pattern with excess cases during summer and fall and a paucity of cases during colder months. CONCLUSIONS: To our knowledge, this is the first study to examine systematically and report a significant seasonal incidence pattern of lymphocytic colitis. Our observations may support a potential link to an infectious source in lymphocytic colitis.

Idiopathic myointimal hyperplasia of mesenteric veins: a rare mimic of idiopathic inflammatory bowel disease.

Idiopathic myointimal hyperplasia of mesenteric veins (IMHMV) is a rare and poorly understood disease that occurs in the rectosigmoid colon of predominantly young, previously healthy male patients. IMHMV typically requires segmental resection due to complications after a relatively protracted clinical course. This disease presents a challenging diagnostic dilemma for the clinician because it is initially often confused with chronic idiopathic inflammatory bowel disease. We report a case of IMHMV, illustrate endoscopic and histopathologic features, and review key characteristics of this rare entity.

Risk of early surgery for Crohn's disease: implications for early treatment strategies.

OBJECTIVES: In this study we aimed to define the rate of early surgery for Crohn's disease and to identify risk factors associated with early surgery as a basis for subsequent studies of early intervention in Crohn's disease. METHODS: We assembled a retrospective cohort of patients with Crohn's disease diagnosed between 1991 and 1997 and followed for at least 3 yr, who were identified in 16 community and referral-based practices in New England. Chart review was performed for each patient. Details of baseline demographic and disease features were recorded. Surgical history including date of surgery, indication, and procedure were also noted. Risk factors for early surgery (defined as major surgery for Crohn's disease within 3 yr of diagnosis, exclusive of major surgery at time of diagnosis) were identified by univariate analysis. Multiple logistic regression was used to identify independent risk factors. RESULTS: Of 345 eligible patients, 69 (20.1%) required surgery within 3 yr of diagnosis, excluding the 14 patients (4.1%) who had major surgery at the time of diagnosis. Overall, the interval between diagnosis and surgery was short; one half of all patients who required surgery underwent operation within 6 months of diagnosis. Risk factors identified by univariate analysis as significantly associated with early surgery included the following: smoking; disease of small bowel without colonic involvement; nausea and vomiting or abdominal pain on presentation; neutrophil count; and steroid use in the first 6 months. Disease localized to the colon only, blood in the stool, use of 5-aminosalicylate, and lymphocyte count were inversely associated with risk of early surgery. Logistic regression confirmed independent associations with smoking as a positive risk factor and involvement of colon without small bowel as a negative risk factor for early surgery. CONCLUSIONS: The rate of surgery is high in the first 3 yr after diagnosis of Crohn's disease, particularly in the first 6 months. These results suggest that improved risk stratification and potent therapies with rapid onset of action are needed to modify the natural history of Crohn's disease.