Erratum: Radiation therapy-induced aortoesophageal fistula: a case report and review of literature.

[This corrects the article DOI: 10.1093/gastro/gou081.].

Liver abscess and bacteremia caused by lactobacillus: role of probiotics? Case report and review of the literature.

BACKGROUND: Lactobacilli are non-spore forming, lactic acid producing, gram-positive rods. They are a part of the normal gastrointestinal and genitourinary microbiota and have rarely been reported to be the cause of infections. Lactobacilli species are considered non-pathogenic organisms and have been used as probiotics to prevent antibiotic associated diarrhea. There are sporadic reported cases of infections related to lactobacilli containing probiotics. CASE PRESENTATION: In this paper we discuss a case of an 82 year old female with liver abscess and bacteremia from lactobacillus after using probiotics containing lactobacilli in the course of her treatment of Clostridium difficile colitis. The Lactobacillus strain identification was not performed and therefore, both commensal microbiota and the probiotic product should be considered as possible sources of the strain. CONCLUSION: Lactobacilli can lead to bacteremia and liver abscesses in some susceptible persons and greater awareness of this potential side effect is warranted with the increasing use of probiotics containing lactobacilli.

Risk of Gastrointestinal Bleeding with Rivaroxaban: A Comparative Study with Warfarin.

Introduction. The risk of gastrointestinal (GI) bleeding with rivaroxaban has not been studied extensively. The aim of our study was to assess this risk in comparison to warfarin. Methods. We examined the medical records for patients who were started on rivaroxaban or warfarin from April 2011 to April 2013. Results. We identified 300 patients (147 on rivaroxaban versus 153 on warfarin). GI bleeding occurred in 4.8% patients with rivaroxaban when compared to 9.8% patients in warfarin group (p = 0.094). GI bleeding occurred in 8% with therapeutic doses of rivaroxaban (>10 mg/d) compared to 9.8% with warfarin (p = 0.65). Multivariate analysis showed that patients who were on rivaroxaban for ≤40 days had a higher incidence of GI bleeding than those who were on it for >40 days (OR = 2.8, p = 0.023). Concomitant use of dual antiplatelet agents was associated with increased risk of GI bleeding in the rivaroxaban group (OR = 7.4, p = 0.0378). Prior GI bleeding was also a risk factor for GI bleeding in rivaroxaban group (OR = 15.5). Conclusion. The incidence of GI bleeding was similar between rivaroxaban and warfarin. The risk factors for GI bleeding with rivaroxaban were the first 40 days of taking the drug, concomitant dual antiplatelet agents, and prior GI bleeding.

Comparison of Ischemic Colitis in the Young and the Elderly.

BACKGROUND: Ischemic colitis is traditionally known as a disease of the elderly; however, its recognition among the young recently has increased. The aim of this study was to illustrate the features of ischemic colitis in a younger population. METHODS: Medical records of patients with ischemic colitis from January 2007 to January 2013 were reviewed. The study was conducted in 2 hospitals, and the patients were divided into 2 groups: < 50 and ≥ 50 years old. RESULTS: A total of 118 patients with ischemic colitis were identified. Fifteen patients (12.7%) were < 50 years of age; 103 patients (87.3%) were ≥ 50 years old. While drugs and vasculitis­as a group­was the most common precipitating factor for ischemic colitis in the younger age group, constipation was the most common precipitating factor in the older age group. All patients in the younger group had rectal bleeding vs 70.9% in the older group (P = 0.009). History of coronary artery disease, dyslipidemia, and hypertension were higher in the older group. Length of hospital stay was shorter in the younger group (3.4 days) than the older group (7.2 days). CONCLUSION: In this study, 12.7% of the patients were under age 50. All patients in this "young" age group experienced rectal bleeding and their hospital stay was shorter.

Radiation therapy-induced aortoesophageal fistula: a case report and review of literature.

Aortoesophageal fistula (AEF) is a rare cause of massive upper gastrointestinal hemorrhage. Thoracic aortic aneurysm, esophageal foreign body, esophageal cancer and post-surgical complications are common causes of AEF; however, AEF induced by radiation therapy is a rare phenomenon and seldom described in the literature. It is a catastrophic condition which requires rapid implementation of resuscitative measures, broad-spectrum antibiotics and surgical or endovascular intervention. Transthoracic endovascular aortic repair (TEVAR) is a newer and less invasive technique, which helps to achieve rapid hemostasis in patients with severe hemodynamic instability and offers advantages over conventional repair of the aorta in emergency situations. However initial TEVAR should be followed up with a more definitive surgical repair of the aorta and the esophagus, to lower the mortality rate and achieve better outcomes. We describe here a case of a seventy-year-old male who presented with massive upper gastrointestinal bleeding due to AEF induced by radiation therapy, and his subsequent successful initial management with TEVAR.

Basaloid Squamous Cell Carcinoma of the Sigmoid Colon.

Basaloid squamous cell carcinoma (BSCC) of the colon is rarely found proximal to the anal canal. We report a case of an 81-year-old woman who was diagnosed with squamous cell carcinoma (SCC) of the lung without metastasis and BSCC of the sigmoid with differing histologic findings suggesting that these tumors were separate primary neoplasms. SCC of the colon has a dismal prognosis. Surgery is the primary method of treatment when feasible, in addition to chemotherapeutic agents.

Gastrointestinal bleeding with dabigatran, a comparative study with warfarin: a multicenter experience.

BACKGROUND/AIMS: The risk of gastrointestinal (GI) bleeding with dabigatran when compared to warfarin has been controversial in the literature. The aim of our study was to assess this risk with the use of dabigatran. METHODS: We examined the medical records of patients who were started on dabigatran or warfarin from October 2010 to October 2012. The study was conducted in two hospitals. RESULTS: A total of 417 patients were included (208 dabigatran vs. 209 warfarin). GI bleeding occurred in 10 patients (4.8%) in the dabigatran group compared to 21 patients (10.1%) in the warfarin group (p=0.0375). Multivariate analysis showed that patients who were on dabigatran for ≤ 100 days had a higher incidence of GI bleeding than those who were on it for >100 days (p=0.0007). The odds of GI bleeding in patients who were on dabigatran for ≤ 100 days was 8.2 times higher compared to those who were on the drug for >100 days. The incidence of GI bleeding in patients >65 years old was higher than in those <65 years old (p=0.0453, OR=3). History of previous GI bleeding was another risk factor for GI bleeding in the dabigatran group (p=0.036, OR=6.3). The lower GI tract was the most common site for GI bleeding in the dabigatran group (80.0% vs. 38.1%, p=0.014). CONCLUSIONS: The risk of GI bleeding was lower with dabigatran. The risk factors for GI bleeding with dabigatran were the first 100 days, age >65 years, and a history of previous GI bleeding.

Vomiting-induced gastric emphysema and hepatoportal venous gas: a case report and review of the literature.

Gastric pneumatosis is the presence of air within the wall of the stomach. It represents a spectrum of conditions ranging from benign disease to septic shock and death. Etiopathologically, it can be classified into emphysematous gastritis or gastric emphysema (GE). Along with hepatoportal venous gas (HPVG), it was considered as an ominous radiological sign and warranted an emergent surgical exploration; however, with widespread use of computerized tomographic (CT) scan, an increasing number of benign causes of GE and HPVG have been reported in the literature, where patients can be managed by noninvasive and conservative measures. We hereby describe a case where recurrent episodes of vomiting led to development of GE and HPVG and the patient was managed successfully by conservative measures.

Risk of gastrointestinal bleeding with dabigatran: a head-to-head comparative study with rivaroxaban.

INTRODUCTION: The risk of gastrointestinal (GI) bleeding of dabigatran and rivaroxaban is relatively unexplored. The aim of our study was to compare this risk in both drugs. METHODS: We examined the medical records of patients on either dabigatran or rivaroxaban from October 2010 to April 2013 in two hospitals. RESULTS: A total of 374 patients (147 rivaroxaban vs. 227 dabigatran) were identified. GI bleeding occurred in 5.3% in the dabigatran when compared to 4.8% in the rivaroxaban group (p = 0.8215). Multivariate analysis showed that the odds of GI bleeding while on dabigatran for ≤40 days when compared to ≥40 days was 8.3 (p < 0.0001). In the rivaroxaban group, patients who were on the drug for ≤40 days had a higher incidence of bleeding when compared to those >40 days (OR = 2.8, p = 0.023). Concomitant use of antiplatelets (single or dual) or non-steroidal anti-inflammatory drugs was not associated with increased bleeding in the dabigatran group; however, the use of dual antiplatelet agents with rivaroxaban was associated with an increased risk of GI bleeding (OR = 7.4, p = 0.0378). Prior GI bleeding had a higher risk of bleeding in the rivaroxaban group (OR = 15.5, p = 0.0002). CONCLUSION: Dabigatran was not associated with a higher incidence of GI bleeding. Both drugs had a higher bleeding risk in the first 40 days.

Ischemic colitis: A forgotten entity. Results of a retrospective study in 118 patients.

OBJECTIVE: The aim of our study was to document our 6-year experiences in identifying the clinical characteristics, laboratory findings, risk factors and the outcomes of patients with ischemic colitis (IC) in a community hospital setting. METHODS: The medical records of patients who were diagnosed with IC from 2007 to 2013 in two community hospitals were retrospectively reviewed. Their clinical characteristics, laboratory results, radiological, endoscopic and histological evidence, anatomic location of the lesion, comorbidities, concomitant use of drugs, and so on, were collected. RESULTS: A total of 118 patients with IC was identified, most were elderly individuals with a female predominance. The most common symptoms were abdominal pain, rectal bleeding and diarrhea. Hypertension, hyperlipidemia, coronary artery disease and diabetes mellitus were the most common comorbidities. Erythema, edema and erosions/ulcerations were the most common endoscopic findings. Left colon was the most affected location of lesion (84.8%), and there was one case of pancolitis. The descending colon was the most common affected segment, while rectum was the least affected segment. Severe IC occurred in 12.7% of the patients. Death within 30 days from the diagnosis of the disease occurred in 4.2%. CONCLUSIONS: IC is majorly occurred in elderly with a female predominance. Cardiovascular disease and its associated risk factors are the most common comorbidities. Left colon is the most affected location of the disease and the overall mortality rate was 4.2%. Physicians should make every effort to identify these patients, especially those with high risks.

Is CT Angiogram of the Abdominal Vessels Needed following the Diagnosis of Ischemic Colitis? A Multicenter Community Study.

Background. CT angiogram is frequently obtained after diagnosis of ischemic colitis (IC). Aims. To investigate the vascular findings of CT angiogram as compared to contrast-enhanced CT scan and whether this modality changes the management or prognosis of IC. Methods. We conducted a retrospective analysis of patients with IC from 2007 to 2013. Results. CT angiogram was performed in 34 patients (28.81%), whereas contrast-enhanced CT scan was performed in 54 patients (45.76%). In CT angiogram group, 8 patients (23.5%) had atherosclerotic changes. Stenosis was found in 12 patients (35.3%) (9: celiac trunk, 3: SMA). Among this group, one patient underwent colectomy and another underwent angioplasty of the celiac trunk who died within 30 days. Among contrast-enhanced CT scan group, 5 patients (9.3%) had atherosclerotic changes. Stenosis was found in 5 patients (9.3%) (3: celiac trunk, 1: SMA, and 1: IMA). Among this group, 3 patients had colectomy and one died within 30 days. There was no statistical difference between both groups in all vascular findings except the stenosis which was higher in CT angiogram group (P = 0.0025). Neither the need for surgery nor all-cause mortality was different between both groups. Conclusion. CT angiogram did not provide any useful findings that altered the management or the prognosis of IC.

Risk factors of recurrent ischemic colitis: a multicenter retrospective study.

BACKGROUND/AIMS: Recurrence of ischemic colitis (IC) has not been studied extensively. The aim of this study was to investigate the characteristics of recurrent IC in the community setting and to identify any risk factors. METHODS: We conducted a retrospective study in two community hospitals. Medical records of patients with IC from January 2007 to January 2013 were reviewed. Demographic details, clinical features, co- morbidities, concomitant use of medications,laboratory studies, imaging findings, endoscopic and histological features, surgery, hospital stay, and death within 30 days were collected. Patients were divided into two groups (recurrent IC group, non-recurrent IC group). RESULTS: A total of 118 patients with IC were identified. IC recurred in 10 patients (8.5%) during the study period. Half of the patients in the recurrent IC group were current smokers as compared to only 18.7% of patients in the non-recurrent group. In the recurrent IC group, 20.0% of patients never smoked as compared to 61.7% in the non-recurrent group (p=0.027).Abdominal aortic aneurysm (AAA) was more frequent in the recurrent IC group (40.0% vs. 4.7%; p=0.003). No differences in other clinical symptoms, CT scan findings, comorbidities, endoscopic features, or use of concomitant medications were observed between the two groups. The need for surgical intervention, blood transfusion, intensive care unit stay, mechanical ventilation,length of hospital stay, and anatomic location of affected segments did not differ between the two groups. CONCLUSIONS: IC recurred in 8.5% of patients during the six-year study period. Current smoking status and presence of AAA were identifying risk factors for recurrence of IC.

Metastatic infiltrating ductal carcinoma of the breast to the colon: a case report and literature review.

True metastatic involvement of the colon is rare. Colonic metastases occur most commonly secondary to peritoneal metastases from intra-abdominal malignancies. Breast cancer is the most common malignancy that metastasizes hematogenously to the colon. Colonic metastatic disease mimics primary colonic tumors in its presentation. Colonic metastatic involvement is a poor prognostic sign, and the pathologist should be informed about the history of the primary breast cancer when examining the pathologic specimens. In this paper, we report a case of an ileocecal mass found to be histologically consistent with metastatic ductal breast cancer, and then we review the literature about breast cancer metastases to the gastrointestinal tract in general and colon in particular.

Klippel-Trenaunay Syndrome Causing Life-Threatening GI Bleeding: A Case Report and Review of the Literature.

Klippel-Trenaunay syndrome (KTS) is a rare congenital syndrome of vascular malformations and soft tissue and bone hypertrophy. Vascular malformations can affect multiple organ systems. Involvement of the gastrointestinal (GI) tract is uncommon in KTS, but it can be a source of life-threatening bleeding. We report a case of a 32-year-old male with a known diagnosis of KTS who presented with a life-threatening rectal bleeding and was treated with proctosigmoidectomy and massive blood products transfusion. He expired after a long hospitalization. We then review the literature on KTS and management of some of its complications.

What's new about inflammatory bowel diseases in Ischemic colitis induced by the newly reformulated multicomponent weight-loss supplement Hydroxycut(®).

Ischemic colitis accounts for 6%-18% of causes of acute lower gastrointestinal bleeding. It is more often multifactorial and more common in elderly. Drugs are considered important causative agents of this disease with different mechanisms. In this paper, we describe a 37-year-old otherwise healthy female presented with sudden onset diffuse abdominal pain and bloody stool. Radiologic, colonoscopic and histopathologic findings were all consistent with ischemic colitis. Her only suspected factor was hydroxycut which she had been taking for a period of 1 mo prior to her presentation. Her condition improved uneventfully after cessation of hydroxycut, bowel rest, intravenous hydration, and antibiotics. This is a first case of ischemic colitis with clear relationship with hydroxycut use (Naranjo score of 7). Our case demonstrates the importance of questioning patients regarding the usage of dietary supplements; especially since many patients consider them safe and do not disclose their use voluntarily to their physicians. Hydroxycut has to be considered as a potential trigger for otherwise unexplained ischemic colitis.

Clinical and endoscopic features of angiosarcoma of the colon: two case reports and a review of the literature.

BACKGROUND: Angiosarcoma of the gastrointestinal tract is an extremely rare tumor. We present two cases of angiosarcoma of the colon. One patient developed syncope and anemia and the other had rectal bleeding. DISCUSSION: Endoscopic findings of the colon were different; the first case demonstrated a reddened colonic fold without an obvious mass and the other had an ulcerated friable mass. Both of the tumors had positive immunohistochemical stains for CD31 and CD34 (one was also positive for CD117). Surgery was not performed in either case. Treatment included chemotherapy with imatinib for the first patient and paclitaxel for the second. Prognosis for this tumor is generally poor; in our cases, one patient was still alive after 5 months of follow-up and the other died within 2 months of diagnosis. After presenting our cases, we reviewed the current literature on angiosarcoma of the colon.

Lubiprostone induced ischemic colitis.

Ischemic colitis accounts for 6%-18% of the causes of acute lower gastrointestinal bleeding. It is often multifactorial and more commonly encountered in the elderly. Several medications have been implicated in the development of colonic ischemia. We report a case of a 54-year old woman who presented with a two-hour history of nausea, vomiting, abdominal pain, and bloody stool. The patient had recently used lubiprostone with close temporal relationship between the increase in the dose and her symptoms of rectal bleeding. The radiologic, colonoscopic and histopathologic findings were all consistent with ischemic colitis. Her condition improved without any serious complications after the cessation of lubiprostone. This is the first reported case of ischemic colitis with a clear relationship with lubiprostone (Naranjo score of 10). Clinical vigilance for ischemic colitis is recommended for patients receiving lubiprostone who are presenting with abdominal pain and rectal bleeding.