Ileal pouch-anal anastomosis for ulcerative colitis: the University of Puerto Rico experience

OBJECTIVE: To review the experience with ileal pouch-anal anastomosis surgery for ulcerative colitis at the University Hospital. BACKGROUND: As many as 40 of patients with ulcerative colitis (UC) and 75 with Crohn's disease (CD) require some surgery for their disease. The number of patients referred to our clinics for evaluation and management of Inflammatory Bowel Disease (IBD) has risen in the past seven years. A multidisciplinary IBD service has been created at the University Hospital for the care of these patients, leading to a dramatic increase in the number of surgeries performed for IBD. Over the past decade the ileal pouch-anal anastomosis (IPAA) has emerged as the procedure of choice in most patients with ulcerative colitis requiring total colectomy for management of their disease. Even though the procedure is associated with a considerable morbidity rate, it has become very popular since it avoids the need for a permanent stoma and presumably rids the patient of disease and subsequent cancer risk. RESULTS: Twenty-five patients were identified as having IPAA for ulcerative colitis between 1993-2000. Indications for surgery were intractability and toxic megacolon. Complications were pouchitis in 11/25 (44), anastomotic stricture in 6/25 (24), small bowel obstruction in 4/25 (16), and pouch failure in 2/25 (8). Other complications included wound abscess in 1/25 (4), and sexual dysfunction in 1/25 (4) patients. There was no mortality; the patients' quality of life was rated as greatly improved in 14 of 17 patients interviewed (82.4) and 16 of 17 said they would recommend the surgery to others (94.1). CONCLUSIONS: The results of IPAA surgery, morbidity, mortality, and patient satisfaction in our series were similar to other centers around the world.

Profile of the inflammatory bowel disease patient with depressive disorders

OBJECTIVE: To describe the demographic and clinical characteristics of patients attending the Inflammatory Bowel Disease Clinic of the University of Puerto Rico School of Medicine and determine whether these characteristics are risk factors for the development of a depressive disorder. METHOD: Sixty-seven patients attending the Inflammatory Bowel Disease Clinic of the University of Puerto Rico School of Medicine were assessed for the presence of depressive symptoms using a simple questionnaire (CES-D) and a detailed diagnostic evaluation (CIDI-DSM IV Module E). Age, gender, education, time of IBD diagnosis, duration of treatment, psychiatric history, treatment with corticosteroids, and activity of IBD were determined and correlated with the presence of depressive symptoms and depressive diagnosis. Study data was tabulated on Epi-Info 6.0 and it was analyzed using SPSS version 10. Univariate (includes means and frequencies), bivariate (t-student, Kruskal Wallis and Chi-square) and multivariate analyses (logistic regression) were performed. RESULTS: Patients older than 34 years old had three times higher probability of developing a depressive disorder (p = 0.043, OR = 3.22). Patients with a psychiatric history had seven times higher probability of developing depressive disorder (p = 0.004, OR = 7). CONCLUSION: The risk factors identified with an increased probability of developing a depressive disorder were age older than 34 years and psychiatric history.

Seroprevalence of Schistosoma mansoni in Puerto Ricans with inflammatory bowel disease

BACKGROUND: The etiology of Inflammatory Bowel Diseases, Crohn's disease (CD) and ulcerative colitis (UC), is unknown. These diseases have a higher incidence in industrialized countries and their pathogenesis involves an over-reaction of the immune system. A genetic factor is believed to predispose to the development of chronic inflammation in response to an unidentified stimulus. Exposure to infections in childhood may modulate future immune responses. Parasitosis, particularly Schistosomiasis, stimulate Th2 immune responses. It has been hypothesized that the absence of these parasitic infections, as seen in economically developed countries, favors a Th1 response that may result in the clinical appearance of Crohn's disease later in life. OBJECTIVE: To determine the prevalence of Schistosoma mansoni antibodies in Puerto Ricans with Inflammatory Bowel Disease and controls. METHODS: Serum from 92 Puerto Ricans with IBD and 106 controls was screened for S. mansoni adult microsomal antigens (MAMA) using the FAST:ELISA assay. Those positive were confirmed with an enzyme-linked immunoelectrotransfer blot test. RESULTS: Seven serum samples (3 UC and 4 controls) were positive for S. mansoni antibodies. There was no significant difference between groups in gender, municipality of origin or seroprevalence of Schistosomiasis. The control group was slightly older than the IBD group. CONCLUSIONS: Our study did not demonstrate an inverse relation between Schistosomiasis and IBD. However, the decreasing prevalence of Schistosomiasis in the general population of Puerto Rico may account for this result.

Osteopenia in Puerto Ricans with Crohn's disease

BACKGROUND: Osteopenia has been reported in association to Inflammatory Bowel Disease, and in particular Crohn's disease. The use of corticosteroids, resection of the ileum, malabsorption, poor calcium intake, and the effect of inflammatory cytokines have all been considered as contributing factors. As Crohn's disease is more prevalent in young people, when peak bone mass is achieved, the presence of osteopenia is especially significant. OBJECTIVES: The aim of this study was to evaluate the bone density of patients with Crohn's disease in the University of Puerto Rico IBD Clinic; to determine the prevalence of osteopenia in these patients and to correlate bone mineral density with risk factors for osteopenia. METHODS: Sixty-six patients, 30 males and 36 females were included. After informed consent, demographic, clinical and metabolic data was obtained. Serum albumin, calcium, inorganic phosphorus and alkaline phosphatase were measured. Body mass index (BMI) was calculated. Bone density was determined by DEXA of the lumbar spine and femur and expressed as the Z score (standard deviations from normal correlated with sex and age). Severe osteopenia was a Z score > or = -2 and osteopenia was Z < or = -1.99 or > or = 1.01. Results were expressed in means. Pearson correlation coefficient was used for quantitative variables and Pearson chi-square for categorical values. RESULTS: Osteopenia was present in the hip in 69 and in the lumbar spine in 68. Most patients had received steroids; the difference between treated and not treated patients was not significant. Osteopenia did not correlate with ileal resection, gender, BMI, disease characteristics or biochemical parameters. CONCLUSIONS: Low bone density was frequent in patients with Crohn's disease, but no specific risk factors could be identified. Bone density should be determined in patients with Crohn's disease in order to institute appropriate therapeutic measures.

Fine-Needle aspiration diagnosis of hydatic cyst

The diagnosis of hydatid disease outside endemic areas is usually not suspected. Hydatid cysts in imaging studies can be confused with hepatic tumors, abscesses, cystadenomas, liver cysts or other lesions. Serology is the usual confirmatory test, but cytologic diagnosis has been described. Aspiration of the cysts has not been employed as a routine diagnostic method for fear of spillage and anaphylactic reactions. We report a case of unsuspected hepatic echinococcosis that was confirmed by fine-needle aspiration of the lesion and cytologic confirmation without complications

Chronic hepatitis C: treatment comparison between 3 and 5 million units of interferon alpha-2b

Interferon (IFN) is the only drug that has been approved by the FDA for therapy of chronic hepatitis C. However, optimal dose and duration of therapy are still controversial. This study compares the effectiveness of treatment of chronic hepatitis C patients with 3 vs. 5 million units (MU) of recombinant alpha-interferon 2-b three times per week. We also evaluated the relapse rate with a shorter 12 week-course of therapy in those patients who had normalization of aminotransferases by week 12. Seventy-five patients were randomized to receive either 3 vs. 5 MU of IFN; seventy-two completed the study. A complete response was seen in 11/35 (31 per cent) of those treated with 5 MU vs. 13/37 (35 per cent) in the 3 MU dose (p = 0.74). Patients were followed after IFN was withdrawn and only 2 had persistently normal aminotransferases. Analysis of multiple variables was done to predict response to FN and only elevations of GGT, ferritin and alkaline phosphatase were found to be predictors of a poor response. Therefore, we recommend initial therapy with 3 MU of IFN for a longer period than 12 weeks in patients who show a response.

Cerebral thrombosis associated with active Crohn's disease

An increased incidence of cerebral thromboembolic events has been reported in young patients with inflammatory bowel disease (IBD). It has been suggested that a hypercoagulable state is associated with clinical activity of the disease, with elevation of factors V, VIII, fibrinogen and platelets and a lowering of anti-thrombin III. We present the case of a 35 y/o male with refractory Crohn's disease who complained of headaches, blurred vision and tonic-clonic seizures. The studies demonstrated an ischemic stroke of the left cerebral hemisphere, without vascular abnormalities. Elevation of factor VIII, platelets, and antithrombin III were found. The symptoms were relieved with medical treatment and the patient has continued in good health after resection of the diseased terminal ileum.

Steroid therapy in fulminant hepatic failure secondary to autoimmune hepatitis

Autoimmune hepatitis is a chronic inflammatory liver disorder of unknown etiology associated with serum autoantibodies and hypergammaglobulinemia. This disease has a broad spectrum of presentations ranging from asymptomatic to fulminant hepatic failure. A 36 year old female with past history of hypothyroidism developed jaundice 2 months prior to admission. Outpatient evaluation revealed ANA and anti-SMA antibodies in high titers, negative viral markers for hepatitis, and hypergammaglobulinemia. A presumptive diagnosis of autoimmune hepatitis was made; steroids were recommended but the patient did not take them. She was admitted to the University Hospital due to increased jaundice, general malaise and ascites 5 weeks later. She deteriorated developing coagulopathy, encephalopathy and increasing hyperbilirubinemia. Intravenous corticosteroids were started. The patient improved and was discharged 3 weeks after admission. Fulminant hepatic failure has a high mortality and may require liver transplant. Our patient survived fulminant hepatic failure that resolved after corticosteroid therapy. It is important to identify and distinguish autoimmune hepatitis from other forms of liver disease because of the high percentage of response to immuno-suppressive therapy. Early diagnosis and treatment of this condition could improve survival, quality of life, and defer liver transplantation.

Esophageal motility patterns in a Puerto Rican population

One hundred consecutive patients underwent esophageal motility testing at the Gastroenterology Section of the University Hospital for symptoms of esophageal dysfunction. These were dysphagia (55), non cardiac chest pain (11), gastroesophageal reflux (32), and other (2). Fifty five studies were abnormal. The most frequent findings were achalasia in fourteen patients and nonspecific esophageal motility disorder in fourteen. When the clinical presentation was correlated with the results of the study, 35 of the 55 patients with dysphagia had an abnormal study, as compared with 5 of 11 with chest pain and only 12 of 32 with reflux symptoms. These findings compare with those reported elsewhere and suggest that esophageal motility studies are most useful in the diagnosis of patients presenting with dysphagia or non cardiac chest pain

Idiopathic hemochromatosis: a study in a large Puerto Rican family

We studied 13 first-degree relatives in a large family with an index case of idiopathic hemochromatosis to detect the relatives with evidence of iron overloading. Serum iron, total iron binding capacity (TIBC), and serum ferritin levels were measured in all family members. We also performed HLA typing to identify the relatives who are homozygous with the proband and genetically predisposed to develop the disease. The family was composed of the parents and 12 siblings including the index case. The mean age of the siblings was 25 years. None presented with evidence of iron overload by the iron biochemical tests. HLA typing demonstrated six homozygous siblings with the proband. In separate analysis these siblings did not present abnormalities in any of the iron biochemical tests. These homozygous relatives were followed for one year after initial evaluation and none presented abnormalities in the iron studies during this period. These results are contradictory to other previous studies done in families with idiopathic hemochromatosis. The most feasible explanations for these findings are the young age of these siblings and the predominance of females among them. We consider that these homozygous relatives must be followed for their life-times with iron studies to detect a possible increase in iron stores as expected in later ages

Idiopathic hemochromatosis in a young man presenting with palpitations

Un hombre de 32 años presentó con queja de palpitaciones y nivels elevados de hierro sérico. Evaluación posterior reveló elevación de la ferritina en suero, y una biopsia de hígado confirmó el diagnóstico de hemocromatosis. La evaluación cardiovascular fue normal excepto por bradicardia sinusal alternando con taquicardia sinusal en un Holter de 24 horas. El paciente se comenzó en tratamiento con flebotomías semanales y la familia se esta evaluando para detectar tempranamente cualquier otro caso. Las manifestaciones, evaluación diagnóstica e importancia del diagnóstico temprano son enfatizadas

Fulminant Wilson's disease: a report

A 21 y/o female presented with fulminante hepatic failure and hemolysis. On the basis of the clinical presentation, levels of ceruloplasmin and serum copper a presumptive diagnosis of Wilson's disease was made. In spite of upportive measures and hemodialysis, the patient died one week after admission. Postmortem examination showed cirrhosis and increased cooper stores in the liver, corroborating the clinical diagnosis of Wilson's disease. Study of the four siblings revealed that two are carriers, one is healthy and one may have the disease. Wilson's disease in a rare cause of fulminant hepatic failure that must be suspected specially when hemolysis is associated to the clinical picture. This mode of presentation is virtually fatal and early liver transplantation is the best form of therapy

Enfermedad inflamatoria del tracto gastrointestinal en el Hospital Universitario, Centro Médico, Puerto Rico, 1980-87 / Inflammatory disease of gastrointestinal tract in the Hospital Universitario, Centro Médico, Puerto Rico 1980-87

A pesar de ser conocidas la colitis ulcerativa y la enfermedad de Crohn hace mucho tiempo, continúa sin establecerse su etiología, y se dificulta muchas veces distinguir una de la otra. Además sus características dificultan el estudio epidemiológico de la enfermedad. En este trabajo se revisaron 70 expedientes con diagnóstico definitivo de enfermedad de Crohn y colitis ulcerativa y se compararon los resultados con la literatura de otras partes del mundo. Encontramos quem la proporción de colitis ulcerativa a enfermedad de Crohn es alta, 5.4:1, no hubo variación con respecto a los grupos etáreos ni a los síntomas más frecuentes; pero sí hubo variación en los patrones de enfermedad de Crohn, siendo el colónico el más frecuente. También se encontró un porcentaje bajo de manifestaciones extraintestinales. Esto hace pensar en la necesidad de seguir un protocolo adecuado para la evaluación de pacientes con enfermedad inflamatoria del intestino

Liver biopsy findings in the acquired immunodeficiency syndrome

Ocho pacientes con SIDA fueron sometidos a biopsia de hígado para determinar el espectro de enfermedad de hígado en esta condición. Las indicaciones para biopsua fueron fiebre, hepatomegalia o alteración en las enzimas hepáticas. En siete pacientes se realizó prueba de perfil de hepatitis. Las biopsias se tiñeron con H & E, reticulina, PAS, tinte FITE pra bacilos ácidos-resistentes y plata, se examinaron por microscopía electrónica y todas se cultivaron para bacilos ácido-resistentes y hongos. Cinco de 8 pacientes (62.5%) tenían historial de abuso de drogas intravenosas, 3(37.5%) eran homosexuales. La edad media era de 37 años (30-43), y la duración de enfermedad era de 8 meses (2-15). Siete (100%) tenían algún marcador de hepatitis B, 6 de 7 (85.7%) tenían anticuerpos de hepatitis A. Todos los pacientes estaban recibiendo por lo menos un agente hepatotóxico. Los hallazgos histológicos incluyeron hígado graso (2/8), granulomas de schistosomiasis (1/8), hepatitis crónica activa (3/8). Los estudios de bacteriológia fueron negativos en todos. Concluimos que los pacientes con SIDA tenían una incidencia alta de anormalidades hepáticas, pero no se identificaron cambios hepáticos específicos o patognomónicos

Prevalence of upper gastrointestinal mucosal-abnormalities at a rheumatology clinic

El propósito de este estudio fue determinar la prevalencia y el grado de severidad de daño a la mucosa gastrointestinal superior en pacientes con artritis reumatoide y osteoartritis recibiendo agentes antinflamatorios no esteroidales con o sin prednisona; y la correlación entre los medicamentos y las anormalidades encontradas. Pacientes de la Clínica de Reumatología fueron escogidos al azar para participar en el estudio. Ochenta y cinco de 123 fueron incluidos. La apariencia endoscópica de la mucosa se clasificó del 0 al 9. Dieciseis pacientes tenían mucosa normal, 69 (81.1%) tenían anormalidades la mayoría mínimas (51.8%). Cincuenta y ocho de 85 pacientes tenían síntomas, 22 (38%) de estos tenían cambios moderados o severos; mientras que solo 3 (11.1%) de 27 asintomáticos tenían cambios moderados o severos. Seis pacientes (6%) tenían úlceras activas. La mayoría de los pacientes recibiendo drogas antireumáticas tenían cambios mínimos en endoscopía, y no se encontró un riesgo mayor para enfermedad severa al añadir prednisona a la terapia de no esteroidales. La prevalencia de úlceras en esta población no fue más alta que en la población general

Incidence of spontaneous bacterial peritonitis in the University Hospital

Twenty three patientes evaluated for ascites in the Gastroenterology Section of the University Hospital between September 1985 and April 1986 were included in the study. Ascitic fluid was tested for pH, cell count and differential, LDH, proteín, amylase, cytology, microbial stains and cultures. Five patients had a clinical picture of spontaneous bacterial peritonitis, but only two had the ediagnosis confirmed by laboratory tests and positive cultures, for an incidence of 8%. The diagnostic value of ascitic fluid parameters is discussed, and the current literature on the subject is reviewed