Erosive Esophagitis in the Obese: The Effect of Ethnicity and Gender on Its Association.

Background. Data examining the association between obesity and erosive esophagitis (ErE) have been inconsistent, with very little known about interracial variation. Goals. To examine the association between obesity and ErE among patients of different ethnic/racial backgrounds. Methods. The study sample included 2251 patients who underwent esophagogastroduodenoscopy (EGD). The effects of body mass index (BMI) on ErE were assessed by gender and in different ethnic groups. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using multivariate logistic regression analysis. Results. The prevalence of ErE was 29.4% (661/2251). Overweight and obese subjects were significantly more likely to have ErE than individuals with a normal BMI, with the highest risk seen in the morbidly obese (OR 6.26; 95% CI 3.82-10.28; p < 0.0001). Normal weight Black patients were less likely to have ErE as compared to Caucasians (OR 0.46; 95% CI 0.27-0.79; p = 0.005), while the odds ratio comparing normal weight Hispanics to normal weight Whites was not statistically significant. No effect modification was seen between BMI and race/ethnicity or BMI and gender. Significant trends were seen in each gender and ethnicity. Conclusions. The effect of BMI on ErE does not appear to vary by race/ethnicity or gender.

Low bone mineral density linked to colorectal adenomas: a cross-sectional study of a racially diverse population.

BACKGROUND: Epidemiologic studies suggest that lower bone mineral density (BMD) is associated with an increased risk for colorectal adenoma/cancer, especially in postmenopausal women. The aim of this study is to investigate the association between osteopenia and/or osteoporosis and colorectal adenomas in patients from a New York community hospital. METHODS: We performed a cross-sectional observational study on 200 patients who underwent screening colonoscopies and bone density scan (dual-energy X-ray absorptiometry) at Nassau University Medical Center from November 2009 to March 2011. Among these, 83 patients were identified as osteoporosis (T score of -2.5 or below) and 67 were osteopenia (T score between -1.0 and -2.5). Logistic regression model was performed to assess the association between osteopenia and/or osteoporosis and colorectal adenomas. RESULTS: Among the patients with osteopenia and osteoporosis, the mean ages were 59.1 years [standard deviation (SD) =8.9] and 61.5 (SD =8.9), respectively. There were 94.0%, 85.1% and 74.7% women, respectively, in normal BMD, osteopenia and osteoporosis groups. The prevalence of colorectal adenomas was 17.9% and 25.3% in the osteopenia and osteoporosis groups, respectively, and 18.0% in the normal BMD group. After adjustment for potential confounders including age, sex, race, body mass index (BMI), tobacco use, alcohol use, history of diabetes, hypertension, or dyslipidemia, osteoporosis was found to be associated with presence of colorectal adenomas more than 2, compared to the normal BMD group. No significant associations were found for the prevalence, size, and location of adenomas. CONCLUSIONS: Our study suggests that osteoporosis is significantly associated with the presence of multiple colorectal adenomas. Prospective studies with a larger sample size are warranted in the future.

Ethnic disparities in the risk of colorectal adenomas associated with lipid levels: a retrospective multiethnic study.

BACKGROUND: Although data exists showing that uncontrolled lipid levels in white and black patients is associated with colorectal adenomas, there are currently no studies looking only at the Hispanic population. PURPOSE: With the rapid increase in the Hispanic population, we aimed to look at their risk of colorectal adenomas in association with lipid levels. METHODS: We retrospectively analyzed 1473 patients undergoing colonoscopy from 2009 to 2011 at a community hospital. Statistical analysis was performed using Chi-squared for categorical variables and t test for continuous variables with age-, gender-, and race-adjusted odds ratios. Unconditional logistic regression model was used to estimate 95 % confidence intervals (CI). SAS 9.3 software was used to perform all statistical analysis. RESULTS: In our general population, there was an association with elevated triglyceride levels greater than 150 and presence of multiple colorectal adenomas with odds ratio (OR) 1.60 (1.03, 2.48). There was an association with proximal colon adenomas and cholesterol levels between 200 and 239 with OR 1.57 (1.07, 2.30), and low-density lipoprotein (LDL) levels of greater than 130 with OR 1.54 (1.04, 2.30). There was no association between high-density lipoproteins (HDL) levels and colorectal adenomas. The Hispanic population showed no statistical correlation between elevated triglycerides, cholesterol, or LDL with the presence, size, location, or multiplicity of colorectal adenomas. CONCLUSIONS: We found a significant correlation between elevated lipid levels and colorectal adenomas in white and black patients; however, there was no such association in the Hispanic population. This finding can possibly be due to environmental factors such as dietary, colonic flora, or genetic susceptibility, which fosters further investigation and research.

The association of H. pylori and colorectal adenoma: does it exist in the US Hispanic population?

BACKGROUND: Although data on the association between colorectal adenomas and Helicobacter pylori (H. pylori) exists in White and Black patients, there is no data on this association in a US Hispanic population. Our aim was to study the association of adenoma detection and biopsy proven H. pylori infection in a cohort of US Hispanics. METHODS: Data were collected from Nassau University Medical Center, a 530-bed tertiary care teaching hospital in East Meadow, New York. Patients who underwent both an esophagogastroduodenoscopy (EGD) and colonoscopy from July 2009 to March 2011 were pulled from an electronic database. A total of 1,737 patients completed colonoscopies during this time with 95 excluded: 17 inflammatory bowel disease, 12 malignancy, 22 prior history of colorectal adenoma, and 44 incomplete. Among the colonoscopies, 799 patients had EGD's performed prior to colonoscopies that were eligible for our study. RESULTS: H. pylori prevalence was highest in Hispanics 40.9%, followed by Blacks 29.1% (OR 0.59, 95% CI: 0.42-0.84), then Whites 7.9% (OR 0.12, 95% CI: 0.06-0.24). The adenoma detection rate was significantly higher in Whites 23.2% and Blacks 21.8% compared to Hispanics 14.5%, P=0.0002 respectively. Smoking and alcohol were lower in the H. pylori group, 18.6% (n=44) vs. 26.1% (n=147) for smoking (P=0.02) and 14.4% (n=34) vs. 19% (n=107) for alcohol (P=0.12), respectively. There was no evidence in the Hispanics for an association between adenoma detection and H. pylori infection. Furthermore size, location, and multiple polyps did not differ between the two groups. CONCLUSIONS: While data has shown an association between H. pylori and colorectal adenomas, we did not find this in our Hispanic population. With the growing population of Hispanics in the U.S, large scale studies are needed to conclusively characterize the role of H. pylori infection in colorectal adenoma and adenocarcinoma in this group of patients.

Ethnic disparities in the risk of colorectal adenomas associated with aspirin and statin use: a retrospective multiethnic study.

BACKGROUND: Although data on the inverse association between colorectal adenomas (CRA) and daily aspirin or statin therapy exists in white and black patients, scarce data exists on these associations in the Hispanic population. With a rapidly increasing Hispanic population in the United States, defining the association in Hispanics is crucial. METHODS: The study sample included 1,843 consecutive patients who underwent a colonoscopy (screening or diagnostic) from 2009 to 2011 at a community hospital in East Meadow, New York. Data was then extracted from patient charts regarding aspirin and/or statin use. Adjusted odds ratios (OR) and their 95% confidence intervals (CI) were calculated to assess the association between colonoscopy findings and aspirin, statin, or aspirin/statin use. RESULTS: In our total population including all races, aspirin user had an increased risk for having two or more adenomas (OR =1.73, 95% CI: 1.00, 2.99, P=0.05) and presence of an adenoma in the proximal colon (OR =1.66, 95% CI: 1.07, 2.58, P=0.02). In the total study population, those who used both statin and aspirin had an increased risk for having two or more adenomas (OR =2.56, 95% CI: 1.21, 5.39, P=0.01). In the Hispanic population, users of both medications had an increased risk for having two or more adenomas (OR =19.04, 95% CI: 1.30, 280.09, P=0.03), adenoma present in the distal colon (OR =5.75, 95% CI: 1.64, 20.21, P=0.01) and largest adenoma in distal colon (OR =5.75, 95% CI: 1.64, 20.21, P=0.01). CONCLUSIONS: Aspirin use and aspirin/statin use was associated with abnormal colonoscopy findings, particularly in the Hispanic population. These findings may be due to environmental factors such as dietary, colonic flora, or genetic susceptibility. The findings warrant further investigational research, particularly in Hispanics.

Acute respiratory failure secondary to mesalamine-induced interstitial pneumonitis.

Interstitial pneumonitis as an adverse effect of mesalamine therapy is a rare but potentially serious complication. Patients typically have a mild disease course with no documented cases of respiratory failure in published literature. Given its variable latent period and non-specific signs and symptoms, it may be difficult to diagnose. We present the case of a 65-year-old man who presented with symptoms of fever, shortness of breath and a non-productive cough, 2 weeks after initiation of therapy with mesalamine. His hospital course was complicated by acute respiratory failure requiring intubation and mechanical ventilation. Radiographic studies revealed bilateral lower lobe infiltrates and bronchosopy with bronchoalveolar lavage and transbronchial biopsy were consistent with a diagnosis of drug-induced interstitial pneumonitis. The aim of this paper is to highlight the importance of considering a diagnosis of mesalamine-induced lung injury in patients presenting with respiratory symptoms while on mesalamine therapy and to review relevant literature.

Esophageal sarcoidosis: a review of cases and an update.

Sarcoidosis is a chronic disorder that can virtually affect any organ system in the body. Histologically, it is characterized by the presence of T lymphocytes, mononuclear phagocytes, and noncaseating granulomas. Most commonly affected are the intrathoracic structures, with 90% of the reported cases involving the lungs. Esophageal involvement in sarcoidosis is extremely rare. Dysphagia is the most common presentation in these patients and can be attributed to various mechanisms such as direct esophageal wall infiltration, extrinsic compression, cranial neuropathy, and brainstem involvement. A thorough online literature review revealed only 23 reported cases of esophageal involvement in sarcoidosis. This paper reviews these reported cases in detail along with newer diagnostic and treatment options, including direction of future therapy.

A Rare Case of Pneumonia Caused by Shewanella putrefaciens.

Shewanella putrefaciens is a gram-negative, nonfermentative, oxidase positive, motile bacillus that produces hydrogen sulphide. It is found widely in the nature especially in marine environments. In some very rare cases Shewanella putrefaciens can be a human pathogen. It can produce a wide variety of clinical syndromes including bacteremia as well as skin and soft tissue infections. However, pneumonia due to S. putrefaciens is rare; there are a total of 4 reported cases in the literature. We present a case of 63-year-old male who was presented to emergency room status after cardiac arrest, fell into sea water face down. On the second day of hospitalization, he was diagnosed to have pneumonia based on the clinical, radiological, and laboratory findings. Empirical antibiotic treatment with vancomycin and piperacillin/tazobactam combination was initiated. Gram-stained smear of endotracheal aspirate yielded gram-negative bacteria, and the isolate grown from endotracheal aspirate culture was identified as S. putrefaciens by Biomerieux API 20 NE technique. On review of the literature and according to culture and sensitivity results, therapy in our patient was changed to cefepime. Patient's pneumonia improved with treatment with cefepime. We believe that our patient developed pneumonia evidently caused by S. putrefaciens, after near drowning in sea water. The pneumonia resolved after treatment with cefepime.

Gastrobronchial fistula following laparoscopic sleeve gastrectomy.

Acquired fistulas between the tracheobronchial tree and the gastrointestinal tract are rare but serious complications of laparoscopic sleeve gastrectomies with significant morbidity and mortality. With the rising popularity and widespread acceptance of bariatric surgery techniques, the occurrence of gastrobronchial fistulas is being increasingly recognised. We present the case of a 26-year-old woman who underwent laparoscopic sleeve gastrectomy for morbid obesity and presented later with a history of chronic productive cough. Upper gastrointestinal series showed the presence of a communicating fistula between the stomach and the lung, with extravasation of contrast into the lung. The aim of this paper is to highlight the importance of considering the diagnosis of a gastrobronchial fistula in cases of persistent respiratory infections in the postoperative period following bariatric surgery and to review its incidence, clinical manifestations and treatment.

Successful management of a gastric sleeve leak with an endoscopic stent.

Laparoscopic sleeve gastrectomy has been a recently developed technique for treating morbid obesity. Gagner and Patterson performed the first laparoscopic sleeve gastrectomy as part of a duodenal switch procedure at Mount Sinai Hospital in New York in 1999. Since then many surgeons and institutions have adopted this technique. One of the most dreaded complications of sleeve gastrectomy is a leak along the staple line. We present the case of a 23-year-old female with gastric sleeve leak managed successfully with a fully covered wall flex stent. Our aim is to examine the incidence, causes, classification, and presentation of gastric sleeve leaks and to evaluate the use of endoscopic stents in its management.

Endoscopic management of a primary duodenal carcinoid tumor.

Carcinoids are rare, slow-growing tumors originating from a variety of different neuroendocrine cell types. They are identified histologically by their affinity for silver salts and by positive reactions to neuroendocrine markers such as neuron-specific enolase, synaptophysin and chromogranin. They can present with various clinical symptoms and are difficult to diagnose. We present the case of a 43-year-old woman who was referred for evaluation of anemia. Upper endoscopy showed a duodenal bulb mass around 1 cm in size. Histopathological and immunohistochemistry staining were consistent with the diagnosis of a carcinoid tumor. Further imaging and endoscopic studies showed no other synchronous carcinoid lesions. Endoscopic ultrasound (EUS) revealed a 1 cm lesion confined to the mucosa and no local lymphadenopathy. Successful endoscopic mucosal resection of the mass was performed. Follow-up surveillance 6 months later with EUS and Octreoscan revealed no new lesions suggestive of recurrence. No consensus guidelines exist for the endoscopic management of duodenal carcinoid tumors. However, endoscopic resection is safe and preferred for tumors measuring 1 cm or less with no evidence of invasion of the muscularis layer.

Acute pancreatitis induced by methimazole therapy.

Among the causative factors for acute pancreatitis, adverse drug reactions are considered to be rare. The diagnosis of drug-induced pancreatitis (DIP) is challenging to establish, and is often underestimated because of the difficulties in determining the causative agent and the need for a retrospective re-evaluation of the suspected agent. We present the case of an 80-year-old woman who presented with complaints of abdominal pain. Her medications included methimazole (MMI) which she had been on for the past 3 months. Computed tomography of her abdomen showed peripancreatic fat stranding with trace amount of surrounding fluid, along with amylase and lipase levels suggestive of acute pancreatitis. In the absence of classical risk factors for acute pancreatitis, a diagnosis of DIP secondary to MMI use was made. Withdrawal of the drug from her medication regimen was accompanied by relief of symptoms and resolution of clinical evidence of pancreatitis. The aim of this paper is to report only the fourth case of MMI-induced pancreatitis in the published literature, and to illustrate the significance of an appropriate and timely diagnosis of DIP.

Pain from a Bullet Lingers on: An Uncommon Case of Lead Toxicity.

Lead toxicity from a retained bullet as a cause for abdominal pain is rarely considered. Given its unpredictable latent period and nonspecific clinical symptoms, such cases are difficult to diagnose but may be fatal if unrecognized. We present the case of a 48-year-old man who presented with complaints of abdominal pain, weight loss and constipation. His past history was significant for a gunshot wound to the left hip about 20 years before. Radiographic studies confirmed the same with the presence of numerous intra-articular bullet fragments and a calcified hemarthrosis surrounding the left femoral head. Blood lead levels were elevated following which the patient was started on chelation therapy with succimer which resulted in symptomatic improvement. The aim of this paper is to highlight the importance of considering lead toxicity from a retained bullet as a cause of abdominal pain and to review the relevant literature.