Segmental Withdrawal During Screening Colonoscopy Does Not Increase Adenoma Detection Rate.

OBJECTIVES: The aim of this study was to compare a standard versus segmental withdrawal during screening colonoscopy and its effect on the adenoma detection rate (ADR). METHODS: We performed a single-center clinical trial of average-risk patients 50 years of age and older undergoing screening colonoscopy. Patients were randomized into four groups: a standard withdrawal of at least 6 or 8 minutes and a segmental withdrawal, in which ≥3 or ≥4 minutes were dedicated to the right side of the colon, with a minimum withdrawal time of at least 6 or 8 minutes, respectively. RESULTS: There were 311 patients in the study. There was no difference in ADR between the standard and segmental groups (relative ratio [RR] 0.91, P = 0.50), even after stratifying for right-sided adenomas. During standard withdrawal, an increased continuous withdrawal time was associated with a higher ADR (RR 1.08, P <0.001) and total adenomas per patient (RR 1.12, P < 0.001). A binary analysis of ≥8 minutes or <8 minutes withdrawal was associated with an increased adenomas per colonoscopy (RR 1.86, P = 0.04). These differences were not observed in the segmental group. CONCLUSIONS: Overall, there was no benefit from a segmental withdrawal protocol on ADR, but this may have been the result of the inherent limitations in the study design. After sensitivity analysis, a segmental withdrawal protocol led to an improvement in the detection of adenomas per colonoscopy and polyps per colonoscopy. A larger sample size is needed to confirm these findings.

Interpreting the Lactulose Breath Test for the Diagnosis of Small Intestinal Bacterial Overgrowth.

INTRODUCTION: Based on literature review, a positive lactulose breath test (LBT) for small intestinal bacterial overgrowth requires an initial peak value of hydrogen within 100 minutes of lactulose ingestion with a second peak before 180minutes. However, using scintigraphic monitoring of lactulose transit time, mean oral-cecal arrival time has been reported as 73minutes. The goal was to propose new criteria for analysing the LBT to overcome false positive interpretations. METHODS: LBTs from our referral center were interpreted as positive after ingestion of 10g of lactulose using the following approach for hydrogen concentrations: (1) The literature guidelines: greater than 20ppm from a baseline less than 10ppm achieved within 100minutes followed by a further rise of greater than 15ppm within 180minutes. (2) The proposed criteria: greater than 20ppm from a baseline less than 10ppm within either 60 or 80minutes followed by a further rise of greater than 15ppm during the 180-minute test. RESULTS: A total of 153 patients with symptoms suspicious for small-bowel bacterial overgrowth underwent testing. Of all, 26.1% patients tested positive by 100minutes, 11.8% patients tested positive by 60minutes and 18.3% patients tested positive by 80minutes. The percentage of positive LBTs at 60 and 80minutes was significantly lesser than for the 100minutes criteria (P < 0.05). CONCLUSIONS: The first hydrogen peak increase should occur by either 60 or 80minutes to increase the specificity of LBT for small intestinal bacterial overgrowth based on the reality of lactulose cecal arrival times.

Transfusion Related Acute Lung Injury (TRALI): A Single Institution Experience of 15 Years.

Transfusion related acute Lung injury (TRALI) though a serious blood transfusion reaction with a fatality rate of 5-25 % presents with acute respiratory distress with hypoxaemia and noncardiac pulmonary oedema within 6 h of transfusion. In non fatal cases, it may resolve within 72 h or earlier. Although reported with an incidence of 1:5000, its true occurrence is rather unknown. Pathogenesis is believed to be related to sequestration and adhesion of neutrophils to the pulmonary capillary endothelium and its activation leading to its destruction and leaks. The patient's underlying condition, anti-neutrophil antibody in the transfused donor plasma and certain lipids that accumulate in routinely stores blood and components are important in its aetiopathogenesis. Patient's predisposing conditions include haematological malignancy, major surgery (especially cardiac), trauma and infections. The more commonly incriminated products include fresh frozen plasma (FFP), platelets (whole blood derived and apheresis), whole blood and Packed RBC. Occasional cases involving cryoprecipitate and Intravenous immunoglobulin (IVig) have also been reported. We present a 15 year single institution experience of TRALI, during which we observed 9 cases among 170,871 transfusions, giving an incidence of 1:19,000. We did not encounter cases of haematological malignancy or cardiac surgery in our TRALI patients. Among the blood products, that could be related to TRALI in our patients included solitary cases receiving cryoprecipitate, IVIg, and recombinant Factor VII apart from platelets and FFP. All patients were treated with oxygen support. Six patients required mechanical ventilation. Off label hydrocortisone was given to all patients. There were no cases of fatality among our patients.

Long term oral anticoagulant therapy with warfarin: experience with local patient population in kuwait.

Warfarin (Coumadin) continues to remain the mainstay of oral anticoagulant therapy (OACT) for thromboprophylaxis for both venous thromboembolic disease (VTD) and cardiac indications. However it needs careful monitoring because of its narrow window of target activity level, interaction with numerous medications and food items, caution for use in patients with co-morbidities like hepatic and renal impairment and bleeding lesions and the risk of major hemorrhage. A large part of its success and safety requires the patients own understanding and participation in its control. In a retrospective study on 153 patients on long term OACT with warfarin, we have analyzed the influence of various personal characteristics of the local patient population like age, gender, nationality, education and financial status, family size, family style, manner of drug administration and number of other medications prescribed for co-morbidities. Ability to achieve consistently efficacious target level of anti coagulant activity is adversely affected by older age, female gender, lower education status, larger family size, joint family setting, dependence on domestic servants to administer warfarin and larger number of other medications taken for co-morbidities. Thirty-seven patients were identified from such vulnerable personal characteristics and assigned to a separate anticoagulant therapy control clinic with specific arrangements for stricter control. This group of patients was studied prospectively for 18 months. Significant improvement was apparent on comparison of their performance before and after assignment to the separate clinic.

Esophageal perforation post pneumatic dilatation for achalasia managed by esophageal stenting.

PATIENT: Female, 82 FINAL DIAGNOSIS: Achalasia Symptoms: Nocturnal regurgtation • weight loss MEDICATION: - Clinical Procedure: Esophageal stenting Specialty: Gastroenterology • Hepatology Objective: Unusual or unexpected effect of treatment. BACKGROUND: Pneumatic dilatation is one of the most effective methods for treating achalasia. Esophageal perforation is the most serious complication after pneumatic dilatation and has been reported to occur in the range of 1 to 4.3%. The appropriate management of esophageal perforation can range from conservative medical treatment to surgical intervention. CASE REPORT: We report a case of an 82-year-old male who had an 8 month history of dysphagia for solid and liquids, a 10 lb weight loss and nocturnal regurgitation. The diagnosis of achalasia was established by endoscopic; barium and manometric criteria. He underwent a pneumatic dilation with a 30 mm Rigiflex balloon. A confined or limited esophageal perforation projecting into the mediastinum and located 1-2 cm above the diaphragm was confirmed by a gastrografin swallow study performed immediately after the procedure. There was some accompanying epigastric abdominal pain. PATIENT was treated later that day by placing a fully covered metallic esophageal stent in addition to antibiotics, proton pump inhibitor, and fasting. PATIENT was discharged home 3 days later able to eat liquid-soft foods. Follow up endoscopy 2 weeks later and a gastrografin swallow showed a completely healed perforation and the stent was removed. Symptomatically he has done well, with no dysphagia or heartburn at six and twelve months follow up. CONCLUSIONS: Early esophageal stenting for esophageal perforation after pneumatic dilation for achalasia is a treatment option which accelerates healing shortens recovery period, as well as decreasing hospital stay and costs.

Essential thrombocythaemia: a single institution experience of 16 years.

This presentation is a clinical narrative and long term follow up (6-16 years) of 21 prospectively studied patients with essential thrombocythaemia (ET) in Kuwait. The median age (55.9 years) is younger than reported by others. Two patients were below the age of 40 years with one of them presenting as post-polycytheamia ET at 16 years of age. Twelve patients (57.1 %) remained asymptomatic throughout the period of follow up. Four patients complained of erythromelalgia, three (19 %) suffered from thrombotic episodes and only one (4.3 %) had excessive bleeding. Four patients presented with splenomegaly. Intensity of thrombocytosis or duration of very high platelet count had no relationship with these complications. Two patients transformed to post-ET myelofibrosis and one patient developed chronic myeloid leukaemia (CML). None transitioned to acute leukaemia. All patients are still alive after follow up for 6-16 years. Janus kinase 2 mutation was positive in eight (38 %) patients. It had no bearing on transition of our ET patients to post-ET myelofibrosis or CML. Platelet aggregation tests were performed in 14 patients. Six (42.9 %) showed defective response to ADP. Only one of these patients suffered from bleeding. All patients were given aspirin (81 mg/day). Cyto-reductive therapy with hydroxyurea was taken by six (42.9 %) subjects. Two patients who were treated with anagrelide and one with alpha-interferon did not continue treatment for long.