A 53-Year-Old Man Presenting with Pancreatic Exocrine Insufficiency 7 Years After Gastric Bypass Bariatric Surgery.

BACKGROUND Pancreatic exocrine insufficiency (PEI) is a clinical condition characterized by reduced or inappropriate pancreatic enzymes and secretions. It can have a variable clinical presentation and can affect patient quality of life. PEI can be associated with pancreatic and nonpancreatic disorders. Pancreatic insufficiency is a recognized complication of bariatric surgery, but there is limited awareness. This report is of a 53-year-old man who presented with PEI 7 years after his initial bariatric surgery. Revision surgery resulted in the resolution of chronic diarrhea and progressive weight loss. CASE REPORT A 53-year-old man who had gastric bypass surgery had developed pancreatic insufficiency 7 years after the surgery. This diagnosis was a challenge to make and therefore treat. A multi-modal approach and revision surgery helped resolve his symptoms. CONCLUSIONS Pancreatic insufficiency is a challenging complication to treat after bariatric surgery. Its management includes a multi-disciplinary approach, and such cases should be managed in dedicated bariatric units. This report has highlighted the importance of excluding PEI as a complication of bariatric surgery and its management.

Patients with Endoscopically Visible Polypoid Adenomatous Lesions Within the Extent of Ulcerative Colitis Have an Increased Risk of Colorectal Cancer Despite Endoscopic Resection.

OBJECTIVES: Ulcerative colitis (UC) is associated with an increased risk of colorectal cancer (CRC). Few studies have looked at long-term outcomes of endoscopically visible adenomatous lesions removed by endoscopic resection in these patients. We aimed to assess the risk of developing CRC in UC patients with adenomatous lesions that develop within the segment of colitis compared to the remainder of an ulcerative colitis cohort. METHODS: We identified patients with a confirmed histological diagnosis of UC from 1991 to 2004 and noted outcomes till June 2011. The Kaplan-Meier method was used to estimate cumulative probability of subsequent CRC. Factors associated with risk of CRC were assessed in a Cox proportional hazards model. RESULTS: Twenty-nine of 301 patients with UC had adenomatous lesions noted within the segment of colitis. The crude incidence rate of developing colon cancer in patients with UC was 2.45 (95 % CI 1.06-4.83) per 1000 PYD and in those with UC and polypoid adenomas within the extent of inflammation was 11.07 (95 % CI 3.59-25.83) per 1000 PYD. Adjusted hazards ratio of developing CRC on follow-up in UC patients with polypoid dysplastic adenomatous lesions within the extent of inflammation was 4.0 (95 % CI 1.3-12.4). CONCLUSIONS: The risk of developing CRC is significantly higher in UC patients with polypoid adenomatous lesions, within the extent of inflammation, despite endoscopic resection. Patients and physicians should take the increased risk into consideration during follow-up of these patients.

A patient with odynophagia and unusual endoscopic findings.

The case describes a 50-year-old woman presenting with a severe painful dysphagia to solids, impacting on her nutritional intake. She had a history of pemphigus vulgaris maintained in remission with azathioprine, with no evidence of active oral or cutaneous disease at the time of presentation. Endoscopy and histology from the distal oesophagus revealed oesophageal involvement of pemphigus vulgaris. This is a relatively rare clinical form of the disease, with only 58 cases reported worldwide. Patients with pemphigus vulgaris are also prone to infective or steroid-induced gastritis, which present in the same way. Early endoscopic evaluation is therefore essential to distinguish between oesophageal involvement of pemphigus vulgaris and other pathologies, which warrant significant differences in management.

Spontaneous cerebrospinal fluid leak following a pilates class: a case report.

INTRODUCTION: A spinal cerebrospinal fluid leak is the most common cause of spontaneous intracranial hypotension which is an uncommon but increasingly recognized cause of headache. This article describes the first reported case of pilates being associated with a spontaneous spinal cerebrospinal fluid leak whilst also highlighting the key information about spontaneous cerebrospinal fluid leaks that will be useful to the general clinician. CASE PRESENTATION: We present the case of a 42-year-old Caucasian woman who developed a low-pressure headache following a pilates class. A computed tomography scan of her head demonstrated bilateral chronic subdural hematomas and cerebellar descent. Magnetic resonance imaging of her spine revealed the presence of extensive extradural cerebrospinal fluid collections. She responded to conservative management and repeat neuroimaging after symptom resolution revealed no abnormalities. CONCLUSIONS: Awareness and early recognition of spontaneous intracranial hypotension is important to prevent unnecessary investigations and delay in treatment. Pilates may be a risk factor for the development of a spontaneous cerebrospinal fluid leak.

The impact of timing and duration of thiopurine treatment on first intestinal resection in Crohn's disease: national UK population-based study 1989-2010.

OBJECTIVES: The efficacy of thiopurines (TPs) in altering the risk of surgery in Crohn's disease (CD) remains controversial. We evaluated the impact of TP therapy, optimal timing, and duration of TP therapy on first intestinal resection rates using a population-based cohort. METHODS: We constructed a population-based cohort of incident cases of CD between 1989 and 2005. We used the Kaplan-Meier analysis to calculate time trends in TP use and first intestinal resection in three groups defined by time period of diagnosis: 1989-1993, 1994-1999, and 2000-2005 groups A, B, and C, respectively. We quantified impact of duration and timing of TP treatment on likelihood of surgery using Cox regression and propensity score matching. RESULTS: We identified 5,640 eligible patients with CD. The 5-year cumulative probability of TP use increased from 12, 18, to 25% ( P<0.0001) while probability of first intestinal resection decreased from 15, 12 to 9% (P<0.001) in groups A, B, and C, respectively. Patients treated with at least 6 months of TP therapy had a 44% reduction in the risk of surgery (hazards ratio (HR): 0.56; 95% confidence interval (CI): 0.37-0.85) and those receiving at least 12 months of TP therapy had a 69% reduction in the risk of surgery (HR: 0.31; 95% CI: 0.22-0.44). Early treatment (<12 months from diagnosis) vs. late treatment with TP showed no additional benefit in reducing risk of surgery (HR: 0.41; 95% CI: 0.27-0.61 vs. 0.21; 95% CI: 0.13-0.34). CONCLUSIONS: Over the past 20 years, TP use has doubled, whereas intestinal surgery has fallen by one-third among the UK population of Crohn's patients. Prolonged exposure is associated with a reduced likelihood of surgery whereby more than 12 months TP therapy reduces the risk of first intestinal surgery two-fold; however, early initiation of TP treatment offered no apparent additional benefit.

The role of thiopurines in reducing the need for surgical resection in Crohn's disease: a systematic review and meta-analysis.

OBJECTIVES: The thiopurine (TP) analogs azathioprine and mercaptopurine have proven efficacy in inducing and maintaining clinical remission in Crohn's disease (CD). Their impact on the long-term need for surgery is uncertain since studies have reported conflicting results. The aim of this systematic review was to summarize and evaluate evidence of the published literature regarding those studies assessing the impact of TPs on the risk of first surgical resection in CD. METHODS: We searched Medline, EMBASE, CINAHL, and hand searched reference lists of identified articles, without language restrictions in August 2013. RESULTS: Seventeen retrospective observational studies (eight population based, three multicenter, and six referral center) representing 21,632 participants met our inclusion criteria. Of these 10 studies involving 12,586 participants provided data on the hazard ratio (HR) and 95% confidence intervals (CIs) evaluating use of TPs and surgical risk. The combined pooled HR of first intestinal resection with TP use was 0.59 (95% CI 0.48-0.73). CONCLUSIONS: TP use is associated with a 40% lowered risk of surgical resection in patients with CD. Despite significant reductions in rates of surgical resection in patients with CD over the last 5 decades and increasing use of TPs, a large proportion of patients with CD still require resectional surgery.

A rare cause of rectal bleeding masquerading as proctitis.

BACKGROUND AND AIMS: Diffuse cavernous haemangioma of the rectum (DCHR) is a rare benign vascular neoplasm that affects mainly young adults and can present with rectal bleeding or massive haemorrhage. We report a case of DCHR masquerading as proctitis which was diagnosed many years ago following colonoscopy. This is the first case where the DCHR was resected with subsequent formation of a colonic J pouch versus conventional colo-anal anastomosis in order to maintain good bowel function. METHOD: Clinical case report including a review of current literature regarding DCHR. RESULTS: This is one of few cases of DCHR reported that was initially misdiagnosed as proctitis. CONCLUSIONS: Awareness of this rare condition is important when investigating patients presenting with rectal bleeding to prevent unnecessary treatment and delay surgery. Prompt intervention is necessary to prevent severe rectal haemorrhage.

Factors associated with vitamin D deficiency in a multicultural inflammatory bowel disease cohort.

OBJECTIVE: The aim of this study was to determine the prevalence of vitamin D deficiency in a multicultural inflammatory bowel disease (IBD) cohort and determine predictors of deficiency including ethnicity. DESIGN: Patients with IBD were recruited into a dedicated database over a 6-month period and evaluated retrospectively. SETTING: Department of Gastroenterology, St George's University Hospital, London, UK. OUTCOMES MEASURED: Clinical data including demographics, ethnic group, disease phenotype by the Montreal classification, vitamin D level and season tested were recorded from clinical and electronic medical records. Vitamin D levels were classified as normal (≥50 nmol/l) and deficient (<50 nmol/l). RESULTS: 168 patients had a vitamin D level measured subsequent to diagnosis. There was no significant difference in the median vitamin D level between patients with Crohn's disease (CD) and ulcerative colitis (UC) (39 nmol/l (IQR 23-56) vs 28 nmol/l (IQR 17-51), p=0.35). Overall the median vitamin D level was significantly lower in non-Caucasians (Asian and Black) versus Caucasians (28 nmol/l (IQR 17-41) vs 41 nmol/l (IQR 25-63), p<0.0001). Multiple regression analysis revealed IBD related surgery (OR 2.9) and ethnicity (OR 6.0 non-Caucasian vs Caucasian) in CD and ethnicity (OR 5.0 non-Caucasian vs Caucasian) in UC were independently associated with vitamin D deficiency. CONCLUSIONS: Vitamin D deficiency is common in IBD patients; therefore, we suggest monitoring of vitamin D levels and correction with supplements especially in non-Caucasians and those with a history of IBD related surgery.

Retrospective pilot feedback survey of 200 users of the AIDA Version 4 Educational Diabetes Program. 1--Quantitative Survey Data.

This column reports a detailed, questionnaire-based, post-release feedback survey of 200 users of the AIDA version 4 educational diabetes simulator. AIDA is a freeware computer program that permits the interactive simulation of plasma insulin and blood glucose profiles for educational, demonstration, self-learning, and research purposes. Since its Internet launch in 1996 over 700,000 visits have been logged to the AIDA Websites-including www.2aida.org-and over 200,000 program copies have been downloaded free-of-charge. The main goals of the current study were: (1) to establish what people have thought about the AIDA program, (2) to assess the utility of the software, and (3) to ascertain how much people have actually used it. An analysis was therefore undertaken of the first 200 feedback forms that were returned by AIDA users. The questionnaire-based survey methodology was found to be robust and reliable. Feedback forms were received from participants in 21 countries. One hundred six of 209 responses (50.7%) were received from people with diabetes, and 36 of 209 (17.2%) from relatives of patients, with lesser numbers from doctors, students, diabetes educators, nurses, pharmacists, and other end users. Please note some respondents fulfilled more than one end-user category, hence the denominator <200; for example, someone with diabetes who was also a doctor. This study has established the feasibility of using a simple feedback form to survey a substantial number of diabetes software users. In addition, it has yielded interesting data in terms of who are the main users of the AIDA program, and has also provided technical (computer) information that has aided the release of a freeware upgrade to the software. In general, users reported finding the program to be of educational value. The majority also felt it would be of interest to diabetes educators and people with diabetes. Most were clear about its limitations as a simulator-based learning tool. The implications of these findings will be discussed.