Capsule endoscopy: single center experience

Objective: capsule endoscopy [CE] has revolutionized the evaluation of small bowel disorders, particularly obscure gastrointestinal bleeding [OGIB]. The aim of this study was to determine the findings and the diagnostic yield of CE in a large series of patients with suspected small bowel disease mainly OGIB; as well as to compare our results to that of other reported centers

Methods: data on 230 patients who underwent capsule endoscopy for suspected small bowel related symptoms and/ or signs mainly overt [81 patients] or occult [66 patients] OGIB were obtained by retrospective chart review and review of an internal computer database of capsule endoscopy patients. Data presented as percentages, p value used to show differences whenever relevant

Results: out of 230 patients investigated for small bowel related symptoms and /or signs, 7 patients excluded mainly due to improper preparation, of the remaining 223, 128 [57.3%] had some lesion detected by CE,80 [35.8%] had definite lesions detected that could unequivocally explain patients' complaints. Patients with overt GI bleeding had the highest diagnostic yield [64.1%], this was significantly greater [P < 0.001] compared to that in patients with occult bleeding [43.9%] as well as those with abdominal pain and/or diarrhea [33.3%]. Angiodysplasia is the most common cause of OGIB [26.5%]

Conclusions: the yield of clinically important findings on CE in patients with OGIB is 55% and is greater in patients with obscure-overt than obscure-occult GI bleeding. Angiodysplasia account for the majority of significant lesions in both groups

Assessment of gastric emptying in normal Jordanian individuals

To obtain normal values of gastric emptying in normal Jordanian individuals using a simple and standardized method. The study was performed during 2005-2007 at Jordan University Hospital. Gastric emptying in 36 normal healthy subjects without gastrointestinal symptoms was assessed using standardized radioisotope scintigraphy with egg-based meal. Measured points were obtained at one hour, two hours and three hours. Lag phase and half time were calculated using a modified power exponential function. Results were analyzed for correlation of gastric retention with gender, body mass index and smoking. Median gastric retention at the first, second and third hour was 67%, 30% and 11.7% respectively. The median for lag phase and T1/2 was 15.7 minutes and 89.3 minutes respectively. For all variables examined smoking was the only factor that affected significantly gastric emptying; however its effect was limited to the first and second hours [P value 0.007, 0.026 respectively]. We obtained normal gastric emptying parameters using a simple standardized technique in Jordanian population. Our results represent the basis for future clinical and research studies in this part of the world

Comparison of gastric emptying parameters between asymptomatic volunteers and patients with functional dyspepsia in Middle Eastern population

To derive the normal reference values for Middle East population using a standard method, and to validate its performance in functional dyspepsia. A prospective study was designed to derive gastric emptying parameters in 36 healthy control. We measured the lag phase, half time, and gastric retention at the first, second, and third hours. Values were compared to 49 patients with functional dyspepsia. This study was carried out between July 2005 and August 2009 at Jordan University Hospital, Amman, Jordan. There were no statistically significant differences between the 2 groups at lag phase. Dyspeptic patients had significantly higher gastric retention at the first, second, and third hours [p=0.045> p=0.003, p=0.002]. Gastric retention at the third hour was the most sensitive parameter detecting 16 patients [32.6%]. Only 3 patients [6.1%] had increased gastric retention at the first hour and normal retention at the third hour. Twelve patients [24.5%] had delayed half time; these patients had increased gastric retention either at the first or third hour. Measurement of gastric retention at the first, second, and third hour is enough to identify delayed-early and late phases of gastric emptying in functional dyspepsia patients

Thiopurines treatment for inflammatory bowel disease in current clinical practice

Thiopurines, or purine analogues, are immunomodulators used in the treatment of malignancies, rheumatic diseases, dermatologic conditions, inflammatory bowel disease and in solid organ transplantation. These agents include azathioprine [AZA], mercaptopurine [6-MP] and thioguanine [6- TG]. Thiopurines are converted by the enzyme thiopurine methyltransferase [TPMT] into metabolites. Measurement of TPMT activity may help identify patients at risk for excessive toxicity, most often myelosuppression, after receiving standard doses of thiopurine medications. Measurement of metabolites [metabolite markers] may help tailor individualized drug therapy. Azathioprine, which is a prodrug of 6-mercaptopurine [6-MP], is considered an effective immunosuppressive treatment of inflammatory bowel disease, particularly in patients with steroidresistant disease. For example, in the course of 1 year, 50% of patients with Crohn's disease will require steroids for its treatment; of these, 50% will either be steroid resistant or steroid dependent, and thus candidates for immunosuppressive therapy. Azathioprine therapy eliminates the need for corticosteroids in about 75% of patients; azathioprine is also considered an effective therapy for fistulizing disease. A recent randomized clinical trial of children with Crohn's disease suggests that compared to prednisone alone, the inclusion of azathioprine with prednisone at the time of initial diagnosis is associated with improved maintenance of remission, while simultaneously decreasing the dose of prednisone. However, the use of azathioprine is limited by both its long onset of action [3-4 months] and drug toxicities, which include hepatotoxicity, bone marrow suppression, pancreatitis and allergic reactions. Long-term drug use has been associated with neoplasia. The purpose of this comprehensive review is to suggest guidelines for the application of azathioprine and 6-mercaptopurine in the treatment of inflammatory bowel disease

Current advances in the management of Crohn's disease

Crohn's disease is a chronic relapsing and remitting inflammatory bowel disease believed to develop as a result of the stimulation of a dysfunctional immune response in genetically susceptible individuals. Crohn's disease is most commonly diagnosed in young adults [15 to 30 years] with a female-to-male ratio between unity and 1.2:1. Prevalence of Crohn's disease rapidly increased all through the world as different countries adopt a Western Lifestyle. The incidence is 5.8 cases per 100,000 people per year and the prevalence is 133 cases per 100,000 people. Mortality in Crohn's disease is now low, but morbidity is considerable, Thirty to sixty per cent of patients with Crohn's disease who attain medically induced remission will relapse within 1 year. It is estimated that 50% and 75% of Crohn's disease patients will require surgery within 5 to 15 years of diagnosis. Surgical resection is not curative as evidenced by the near universal recurrence of neoterminal ileal Crohn's disease following ileocolonic resection. In the absence of a definitive cure, the aim of therapy is to induce and maintain clinical remission at an acceptable cost, avoidance of surgeries, and improvement of health-related quality of life. The first line treatment is still based on combinations of steroids, amino-salicylic acid derivatives, imunomodulators, and nutritional regimens. Biological drugs have opened new therapeutic horizons for treating Crohn's disease, but have also brought with them issues related to immunogenicity, long-term efficacy, safety and cost. This review will highlight the current advances in the management of Crohn's disease as well as discuss areas that remain controversial and are awaiting resolution

Advances in management of ulcerative colitis

Ulcerative colitis [UC] is a chronic inflammatory disease that primarily affects the colonic mucosa; it is most commonly diagnosed in patients aged 15-35 years, although the condition can affect patients of any age and of either sex. It's exact etiology remains uncertain. The annual incidence of ulcerative colitis in western countries is estimated to be 6-8 cases per 100,000 individuals, with the prevalence reaching 70-150 cases per 100,000 individuals. The disease course is generally relapsing-remitting, with patients experiencing few or no gastrointestinal symptoms between symptomatic relapses. As medical options increase, decisions about the sequence and timing of therapy and surgery in particular become more difficult. Consequently, a therapeutic strategy is necessary, keeping an eye on the direction of travel to avoid going round in circles from one incompletely effective therapy to another. Patients live with a considerable symptom burden despite medical treatment in the hope that a cure for ulcerative colitis will emerge. This article reviews the new advances in ulcerative colitis, epidemiology, pathogenesis, diagnosis, new therapeutic goals, as well as therapy that occurred in the past year

Clinico-radiological correlates of achalasia

To study the clinical and radiographic characteristics of achalasia in a cohort Jordanian patients and to investigate the presence of any clinico-radiological relationships. Thirty-five cases of recently diagnosed untreated achalasia patients were studied at Jordan University Hospital, Amman, Jordan during the period of January 1999 to December 2002. Measurements of maximum esophageal and gastroesophageal [GE] junction diameters, as radiographic features, were obtained from films. The clinical features included age; gender; nature; frequency and duration of typical and atypical symptoms; total number of symptoms; calculated typical symptoms score; and diagnostic delay. Pearson correlation coefficients were calculated between radiographic and clinical features, and among the radiographic features themselves. Using Spearman's correlation coefficients, the later analysis was repeated for patients with diagnostic delay of 2 years or less and patients with more than 2 years. All results were evaluated based on the 0.05 level of significance. There were 35 consecutive achalasia patients enrolled in this study [20 females and 15 males] with a mean age of 42.3 +/- 15.6 years and diagnostic delay of 29 +/- 26 months. On average, each patient has presented 2 typical symptoms and 2 atypical symptoms. The mean typical symptoms score was almost 3 out of the full score of 6. The mean GE junction diameter was 2.4 mms and maximum esophageal diameter was 29 mms. Maximum esophageal diameter was significantly correlated with the number of typical, atypical and total symptoms as well as with the typical symptom score and diagnostic delay. Negative correlation was found between GE junction diameter and maximum esophageal diameter; but only statistically significant for patients with diagnostic delay of more than 2 years. Statistically significant relationship exists between maximum esophageal diameter and all clinical variables. Negative correlation exists between maximum esophageal diameter and GE junction diameter; however, only significant for patients with a diagnostic delay more than 2 years. The possibility of achalasia is high in patients with longer diagnostic delay who demonstrate negative relationship between maximum esophageal diameter and GE junction diameter

Novopen acceptance during injections in NIDDM patients: a multicenter open randomized, cross-over study

This multicenter, open, randomized, cross-over study compared the acceptance of insulin therapy started using the pen injector NovoPen 3 with that of syringes/vials in 50 NIDDM patients. It consisted of a 4- week run-in and two consecutive 8-week periods of insulin administration [Periods 1 and 2]. Group A used NovoPen 3 during the run-in phase and Period 1, and then conventional administration in Period 2; Group B used conventional administration during the run-in phase and Period 1 and NovoPen 3 in Period 2. Acceptance was evaluated by the questionnaires at the end of periods 1 and 2. Regardless of the sequence of use, patients perceived NovoPen 3 as easier and faster to use than syringes/vials. Injection pain was also reduced with NovoPen 3 [p=0.00003]. At the end of the study, most patients [90%] preferred to continue on NovoPen 3. Glycemic control showed a similar improvement in both groups during the study In conclusion, when starting insulin therapy, NovoPen 3 is better accepted by NIDDM patients than syringes /vials. Use of pen devices such as NovoPen 3 may help improve acceptance of insulin therapy in NIDDM patients, who are often reluctant to begin and continue with insulin injection

Etiology of upper gastrointestinal bleeding in Jordanian patients: a prospective study

Endoscopy within 24 hours from the onset of upper gastrointestinal [UGI] bleeding was carried out on 853 Jordanian patients. Lesions as a bleeding source were identified in 799 [93.7%] patients. Radioactively tagged red blood cell [RBC] scan, angiography and upper gastrointestinal follow-through radiography were complementary studies in endoscopy negative patients. Etiology remained unidentified in 16 patients. The six most common causes of UGI bleeding in this study were duodenal ulcer, gastric erosions, duodenal erosions, esophagitis, gastric ulcer and esophageal varices. Nonsteroidal anti-inflammatory drugs [NSAID[s]] were a significant predisposing factor for UGI bleeding [28.6%]. Mortality at the first admission was 3.4% and increased during 12 month follow-up to 6.9%. To our knowledge, this is the first study from Jordan concerning the causes of upper GI bleeding of all clinical types

Endoscopic retrogade cholangiopancreatography [ERCP] in the diagnosis of biliary and pancreatic duct disease: a prospective study on 668 Jordanian patients

Endoscopic retrograde cholangiopancreatography [ERCP] is the method of choice in establishing the nature and the site of common bile and pancreatic duct disease and related complications. It was used in 668 Jordanian patients who presented with biliary or pancreatic disease and unexplained upper abdominal pain. Common bile duct [CBD] stones, postsurgical traumatic CBD strictures, papillary stenosis and malignant strictures were the most common findings in this study. The incidence of malignant strictures was less and the postsurgical CBD injuries, mainly CBD complete ligation, were more than what was reported by others. This procedure was also valuable in the investigation of unexplained upper abdominal pain and pancreatic disease

Foreign bodies on the upper gastro intestinal tract: a prospective study on the use of fiberoptic endoscopic extraction

A prospective study on fiberoptic endoscopic management of 39 consecutive patients who presented with gastro-intestinal [GI] tract foreign body ingestion during the last five years is presented. Patients age range from 3-74 years with a mean age of 22.3 years. Foreign bodies were ingested 1-14 days prior to admission. Attempts at foreign bodies extraction with different models of forward-viewing fiberoptic endoscopes were successful in 34 [87%] patients. Laparotomy had to be performed in the remaining five patients

Double-blind comparison of loperamide and placebo against acute diarrhoea in adults

In a randomized double-blind study involving 93 adult patients, loperamide significantly reduced the number of loose stools and the time until the first solid stool, but there was no significant effect on fluid requirements. Side-effects were limited to two patients: one receiving placebo developed a rash, and one patient taking loperamide reported constipation on the second day of treatment

Sucralfate in duodenal ulcer disease: a double-blind trial

Seventy-five patients with endoscopically confirmed duodenal ulcer disease received either sucralfate [34 patients] or placebo [41 patients] for 6 weeks in a double-blind clinical trial. Nineteen males and 15 females received sucralfate, and 29 males and 12 females received placebo. At 6 weeks significantly more complete ulcer healing had occurred in patients receiving sucralfate [82.4%] compared with those receiving placebo [24.4%]. The sucralfate group had a significant reduction in their symptoms after 1 week of the drug intake, compared to the placebo group in which the reduction did not reach significance. Constipations, nausea, dry mouth, and skin reach occurred more in patients taking sucralfate compared to the placebo group; in one patient constipation was severe enough to stop the medicine and drop out of the trial. Systemic aluminum toxicity, hypophosphatemia, and diarrhea were not reported in any patient in the sucralfate group