Impact of obesity on bowel preparation for colonoscopy.

BACKGROUND & AIMS: An inadequately cleansed colon can lead to missed lesions, repeat procedures, increased cost, and complications from colonoscopy. Because obesity, with its known link to colorectal neoplasia, might be associated with inadequate bowel cleansing, we investigated the impact of increased body mass index (BMI) on quality of bowel preparation at colonoscopy. METHODS: All colonoscopy procedures performed at a tertiary referral center during a 4-month period were evaluated. Bowel preparation was assigned a unique composite outcome score that took into account a subjective bowel preparation score, earlier recommendation for follow-up colonoscopy as a result of inadequate bowel preparation, and the endoscopist's confidence in adequate evaluation of the colon. Univariate and multivariate logistic regression analyses were performed to identify the role of BMI in predicting an inadequate bowel preparation. RESULTS: During the study period, 1588 patients (59.1% female; mean age, 57.4 +/- 0.34 years) fulfilled inclusion criteria. An abnormal BMI (> or =25) was associated with an inadequate composite outcome score (P = .002). In multivariate logistic regression analyses, both BMI > or =25 (P = .04) and > or =30 (P = .006) were retained as independent predictors of inadequate bowel preparation. Each unit increase in BMI increased the likelihood of an inadequate composite outcome score by 2.1%. Additional independent predictors of inadequate preparation exponentially increased the likelihood of an inadequate composite outcome score; 7 additional risk factors identified 97.5% of overweight patients with an inadequate composite outcome score. CONCLUSIONS: Obesity is an independent predictor of inadequate bowel preparation at colonoscopy. The presence of additional risk factors further increases the likelihood of a poorly cleansed colon.

Clinical recognition of Al type amyloidosis of the luminal gastrointestinal tract.

BACKGROUND & AIMS: Amyloidosis is characterized by the pathologic deposition of specific proteins throughout the body. Gastrointestinal involvement with amyloid associated with plasma cell dyscrasias (AL type amyloidosis) is common, but systematic description of the condition is lacking. The aim of this investigation was to characterize the clinical presentation, endoscopic findings, and histopathologic correlates in a series of patients with systemic AL amyloidosis of the luminal gastrointestinal tract. METHODS: Eligible patients were identified by interrogating the histopathology database of our institution during a 14-year time period. Medical record, histopathologic, and laboratory data were collected, analyzed, and correlated with endoscopic findings. RESULTS: Nineteen patients with systemic AL amyloidosis of the luminal gastrointestinal tract were identified. Gastrointestinal symptoms or signs related to amyloid involvement were noted in 95% of patients; abdominal pain, change in bowel habits, overt gastrointestinal bleeding, and complaints related to altered motility were the predominant presentations. Endoscopic abnormalities were found in nearly three fourths of patients, including ulcerations and submucosal hematomas. When gastrointestinal bleeding was the presenting symptom, submucosal hematomas were a common finding during endoscopic evaluation. CONCLUSIONS: AL type amyloidosis of the luminal gastrointestinal tract is a rare disease that presents with common, nonspecific complaints. The endoscopic detection of a submucosal hematoma in the setting of gastrointestinal bleeding in patients with plasma cell dyscrasias should raise suspicion for the disease.

Epstein-Barr virus gastritis: an underrecognized form of severe gastritis simulating gastric lymphoma.

We describe an exceedingly rare case of severe gastritis that was temporally associated with primary Epstein-Barr virus (EBV) infection. The patient was a 59-year-old immunocompetent man who presented with intermittent fever of unknown origin and epigastric pain for 18 days. A computed tomographic scan of the abdomen showed diffuse thickening of the gastric wall and esophagogastroduodenoscopy revealed numerous ulcers in the stomach. Histologic examination of gastric biopsies showed a dense and diffuse atypical lymphoid infiltrate in the lamina propria with erosions and focal lymphoepithelial lesions. No lymphoid follicles or Helicobacter microorganisms were identified. Immunohistochemical studies demonstrated the lymphoid infiltrate to consist of mixed T and B cells. Immunoglobulin heavy chain gene arrangement analysis showed a polyclonal pattern. The plasma cells present in the biopsies exhibited no light chain restriction as determined by in situ hybridization. Concurrent clinical work-up revealed peripheral lymphocytosis with atypical lymphocytes and positive serum IgM antibody to EBV capsid antigen in the absence of IgG antibody. These findings indicated that the gastric abnormalities were related to primary EBV infection as the predominant manifestation of infectious mononucleosis. This was further confirmed by subsequent in situ hybridization showing numerous EBV-positive lymphocytes in the gastric mucosa. The patient's symptoms were spontaneously resolved with only supportive treatment. A follow-up endoscopy 2 months later showed completely normal gastric mucosa and he remained well with no gastrointestinal complaints for 2 and a half years. This case illustrates the importance of a high index of suspicion to avoid misdiagnosis of gastric lymphoma that requires more aggressive therapies.

Disseminated histoplasmosis in a liver transplant recipient.

A 61-yr-old liver transplant recipient presented with abdominal cramping and nonbloody diarrhea resulting in orthostasis. Multiple ulcerations throughout the colon were seen during endoscopy, and biopsies from the ulcer edges revealed histoplasmosis. Treatment with a course of itraconazole improved the diarrhea. The patient later presented with pericarditis and symptomatic pleural effusions, the latter of which was confirmed to be a result of disseminated histoplasmosis. Treatment with amphotericin B led to resolution. Histoplasmosis should be considered in liver transplant patients with diarrhea and large ulcers in the colon. The presence of disseminated histoplasmosis should be ruled out once colonic histoplasmosis has been diagnosed.

Acute small bowel bleeding: a distinct entity with significantly different economic implications compared with GI bleeding from other locations.

BACKGROUND: Historically, acute lower intestinal bleeding has incorporated small bowel with colonic sources. This potentially obscures the unique characteristics of small bowel bleeding, which are eclipsed by the attributes of the much more common colonic bleeding. Separating acute lower intestinal bleeding into small bowel and colonic sources may delineate characteristics of each, thereby making it possible to determine whether clinical outcomes vary by anatomic level of bleeding. METHODS: A total of 29 consecutive patients (15 women, 14 men; age 68.6 +/-2.4 years) with acute small bowel bleeding were compared with two other groups, each with 29 consecutive patients, with either acute colonic bleeding or acute upper GI bleeding. Clinical presentation, outcomes, and resource utilization for small bowel bleeding were compared with similar parameters for acute colonic bleeding and upper GI bleeding. RESULTS: Although the clinical presentation did not always distinguish the 3 groups, resource utilization was significantly higher in the small bowel bleeding group. The latter group required a higher number of diagnostic procedures (p < 0.001) and blood transfusions (p < 0.001), remained in hospital longer (p < 0.05), and had a higher cost of hospitalization (p < 0.001) compared with the colonic bleeding and upper GI bleeding groups. The mortality rate for patients with small bowel bleeding was 10%. Although none of the patients with upper GI bleeding and only 14% of those with colonic bleeding required greater than 3 diagnostic procedures, 79% of patients with small bowel bleeding required 4 procedures for diagnostic localization (p < 0.0001). CONCLUSIONS: Small bowel bleeding ("mid-intestinal bleeding") is a distinct clinical entity with significantly worse outcomes compared with colonic bleeding and upper GI bleeding. The focus of the investigation should be directed to the small bowel, with enteroscopy or capsule endoscopy, when 3 investigative procedures fail to localize recurrent overt GI bleeding.

The colon single-stripe sign and its relationship to ischemic colitis.

OBJECTIVES: Endoscopic findings may assist in the clinical diagnosis of ischemic colitis but have not been systematically characterized. We noted that a single linear colonic ulcer could on occasion be found endoscopically after hypotension and proceeded to investigate its relationship to ischemic colitis. METHODS: Twenty-six patients (19 female and seven male, mean age 71 yr) with endoscopic evidence of a single linear ulcer running along the longitudinal axis of the colon (colon single-stripe sign (CSSS) were retrospectively studied. Colitis etiologies were determined in the CSSS patients and in 58 consecutive patients without a stripe forming a colitis comparison group; clinical course and outcome in CSSS patients subsequently were compared with those in 22 patients with circumferentially involved ischemic colitis. RESULTS: The CSSS was >/=5 cm in length in all instances and isolated to a segment of the left colon in 89%. Evidence of a preceding ischemic event was noted significantly more often in the CSSS (62%) patients than in the colitis comparison group (7%) (p < 0.0001). On blinded histopathological examination, 75% of CSSS cases had microscopic evidence of ischemic injury compared with 13% in the colitis comparison group (p < 0.0001). None of the CSSS patients required surgical intervention, whereas six (27%) patients from the circumferential ischemic colitis group underwent exploration (p < 0.05). Nine patients (41%) in the circumferential ischemic colitis group died, whereas there was one death in the CSSS group (4%) (p < 0.05). CONCLUSIONS: Ischemia can manifest endoscopically as the CSSS. This sign seems to characterize milder disease in the clinical spectrum of ischemic colitis.