Serum-Derived Bovine Immunoglobulin as Novel Adjunct in Complicated Clostridium difficile Colitis Treatment.

Clostridium difficile infection (CDI) is a well-known complication of antibiotic therapy. It is associated with significant morbidity, mortality, and cost in the hospital setting. The main symptoms include watery diarrhea, abdominal pain, and distension, but CDI can also present as toxic megacolon, bowel perforation with peritonitis, sepsis and renal failure. Therapy includes metronidazole and oral vancomycin, with rectal vancomycin and fecal transplant reserved for more complicated cases. Adjunctive treatments such as probiotics have been tried with mixed results. We present a patient with complicated CDI treated with adjuvant serum-derived bovine immunoglobulin, a novel approach in this context.

Pillcam ESO(®) is more accurate than clinical scoring systems in risk stratifying emergency room patients with acute upper gastrointestinal bleeding.

BACKGROUND: Upper gastrointestinal bleeding (UGIB) accounts for 400,000 hospital admissions in the US each year. Despite advances, mortality rates remain high and are estimated to be 5-10%. Early therapeutic endoscopy is widely recommended as a means of reducing morbidity and mortality. The Rockall and Blatchford scores are clinical scoring systems devised to assist in risk stratifying patients with UGIB. In a prior study we found that rapid live bedside video capsule endoscopy (VCE) utilizing Pillcam ESO(®) correctly identified patients with high-risk stigmata of bleeding seen on upper endoscopy. In this study, we compare the accuracy of the Rockall and Blatchford scores with Pillcam ESO(®) in predicting high-risk endoscopic stigmata. METHODS: Pre-endoscopy Blatchford and Rockall scores were calculated for 25 patients (14 males, 11 females) presenting to the emergency room with acute UGIB. The average patient was 66 years of age. A total of 24 out of 25 patients underwent upper endoscopy within 24 hours. One patient did not undergo endoscopy due to clinical instability. The timing of endoscopy was based on clinical parameters in 12 patients, and on live view VCE with Pillcam ESO(®) in the other 13 patients. Positive VCE was defined as red blood, clot or coffee grounds. Mean Rockall and Blatchford scores for all 24 patients were compared to determine potential differences between high- and low-risk patients. Rockall and Blatchford scores were also compared with VCE findings. RESULTS: Of 24 patients, 13 had high-risk stigmata on upper endoscopy. The mean Rockall and Blatchford scores were 3 and 13, respectively. In the 11 patients without stigmata, the mean Rockall and Blatchford scores were 2 and 11, respectively. There was no statistically significant difference between the Blatchford scores of the two groups (95% confidence interval [CI] -5.1 to 1.3; p = 0.22). There was no statistically significant difference between the Rockall scores of the two groups (95% CI -2.3 to 0.3; p = 0.11). In the subgroup of 12 patients who underwent VCE prior to endoscopy, 8/12 had positive findings, which were all confirmed at endoscopy. All 4 patients with negative VCE had no high-risk stigmata at endoscopy. CONCLUSION: In emergency room patients with acute UGIB, neither the Rockall nor the Blatchford scores were able to differentiate high- and low-risk patients identified at endoscopy. Live view VCE, however, was accurate in predicting high-risk endoscopic stigmata, and may be better suited as a risk stratification tool. Additional studies with a larger cohort will be required to validate these findings.

A novel endoscopic treatment of hemosuccus pancreaticus: a stent tree tamponade.

CONTEXT: Hemosuccus pancreaticus is a rare cause of intermittent upper gastrointestinal bleeding, commonly caused by aneurysmal rupture. Prompt diagnosis and treatment is required. The standard treatment involves embolization via interventional radiology or a surgical approach. CASE REPORT: We report a novel endoscopic approach to hemosuccus pancreaticus with a successful tamponade via pancreatic biliary stents and resolution clips. CONCLUSION: This is the only report of endoscopy as a therapeutic modality in a case of hemosuccus pancreaticus.

Prevalence of Adenomas Found on Colonoscopy in Patients With HIV.

BACKGROUND: The life expectancy of patients with HIV has increased significantly since the introduction of highly active antiretroviral therapy in 1995. Although this population of patients now carries less risk for the development of AIDS defining illnesses and malignancies, they are still at risk for non-AIDS defining cancers, such as colon, prostate, and breast. Several studies have shown that HIV infected patients have a higher prevalence of advanced colonic neoplasia which occur at a younger age. Our aim is to examine the prevalence of adenomas and adenocarcinoma in HIV patients undergoing colonoscopy. METHODS: HIV patients seen in our gastroenterology clinic and inpatient service undergoing colonoscopy were identified from 2010 - 2011. Indication was screening in 27 patients and diagnostic in 23 patients. Significant lesions were defined as adenomas, serrated polyps, and adenocarcinoma. RESULTS: Total 50 patients were included in the study, 32 male and 18 female (mean age: 53.6; range 37 - 72 years), 25 patients were African American, 21 were Hispanic, 3 were Caucasian, and one was Indian, 39 patients had undetectable HIV RNA, 30 patients had CD4 lymphocyte counts greater than 500, 20 had CD4 lymphocyte counts less than 500, and 4 patients had CD4 lymphocyte counts less than 200, 52% (26/50) of patients had polyps. Significant lesions (adenomas and serrated polyps) were seen in 34% (17/50) of patients, 39% in diagnostic and 30% in screening procedures (P = 0.56). Males were found to have significant lesions 28% of the time as compared to 44% of females (P = 0.35), 43% of Hispanics had significant lesions versus 24% of African Americans (P = 0.22), 25% of the patients under age 50 were found to have significant lesions, 45% of the patients with detectable HIV RNA levels were found to have significant lesions vs 31% (P = 0.48). Surprisingly, patients with CD4 counts > 500 had significantly more adenomas than those with CD4 counts < 500, 47% vs 15% (P = 0.03). No adenocarcinomas were seen in our patient population. CONCLUSION: In our case series of HIV patients the adenoma detection rate was 34% overall, 45% in the patients with detectable HIV RNA levels, and 47% in patients with CD4 counts > 500. Additionally, there was a 25% adenoma detection rate in patients less than fifty years of age. This data reinforces the need for aggressive colon cancer screening in the HIV population.

The Successful Treatment of Chronic Cholecystitis with SpyGlass Cholangioscopy-Assisted Gallbladder Drainage and Irrigation through Self-Expandable Metal Stents.

A 34-year-old female with a history of advanced pulmonary sarcoidosis and right-sided heart failure presented with chronic, postprandial right upper quadrant pain, and weight loss. Endoscopic biliary drainage was deemed to be the most appropriate therapeutic option for her chronic cholecystitis. Endoscopic retrograde cholangiopancreatography utilizing the SpyGlass cholangioscopy system allowed us to access the cystic duct through which the gallbladder was ultimately decompressed, via biliary stent placement and gallstone irrigation. This is the first report of SpyScope assisted placement of fully covered self-expandable metal biliary stents into the cystic duct enabling definitive treatment of symptomatic chronic cholecystitis and cholelithiasis without cholecystectomy.

High rates of advanced gastric cancer in community of Flushing, New York.

BACKGROUND: Gastric cancer remains a major public health issue and is a leading cause of death worldwide, accounting for 600,000 deaths annually. Over the last decades, there has been a steady decline in the incidence rates of gastric cancer. Furthermore, the incidence rates of gastric cancer in different parts of the country vary due to epidemiological and migration trends. Despite these trends, several studies that have continued to observe high rates of gastric cancer in populations that come from high-risk regions. AIM OF THE STUDY: The aim of the study was to describe the gastric cancer patients presenting NYHQ with an emphasis on those presenting at a young age and advanced disease. A subanalysis of the Asian population was also done, which is considered a high-risk group. METHODS: Consecutive chart review of patients admitted with gastric cancer from January 2000 to August 2008 was extracted from the Oncology registry at NYHQ. Parameters that were evaluated were age, sex, race, type of gastric cancer, and stage of gastric cancer at initial presentation. The SAS/PC software package (SAS Institute Inc., Cary, NC) was employed for statistical analyses. RESULTS: Four hundred fifty-seven patients were diagnosed with gastric cancer. Approximately one third of the total patients were younger than 60 years of age. Of the Asian patients, almost half the patients (48.8%) had advanced disease of which two thirds were under the age of 60 years. CONCLUSION: The rates of advanced gastric cancer observed at NYHQ are significant and comparable to recent epidemiology literature on rates in Asian populations in Asia. Communities, like Flushing, NY, may benefit from early detection of gastric cancers, similar to those instituted in Japan and Taiwan.

Ketamine-induced biliary dilatation: from Hong Kong to New York.

Ketamine is a popular drug of abuse in China, especially for young adults between the 18 and 30 years. It produces desirable short-term sensations of excitement, dream-like states, hallucinations, and vivid imagery, but is also responsible for untoward effects of the gastrointestinal and urinary tracts. Abusers often present with severe abdominal pain and dysuria. In addition to its excretion in urine, ketamine is also excreted in bile and can lead to biliary dilatation. Sixteen reports of this phenomenon have been described in the literature, mostly in China. To date, this phenomenon has not been described in the United States. We present 2 cases of ketamine-induced biliary dilatation in young adult Asian patients. It is a new entity in the United States but should be recognized early, as it may prevent unnecessary investigation with blood work, imaging, therapeutic endoscopy, or even surgery.

Gastroesophageal junction tear from HALO 90 System: A case report.

Gastric antral vascular ectasia often results in chronic gastrointestinal bleeding with few options for effective treatment. The Halo(®) 90 system has been newly approved for this indication. A 56 year old male with ETOH cirrhosis and gastrointestinal bleeding from gastric vascular ectasia presented for endoscopy with Halo(®) 90 radiofrequency ablation. Over the past two years he had undergone multiple bipolar electric coagulation and argon plasma coagulation treatments. Despite this therapy, he con-tinued to receive monthly blood transfusions. We therefore opted to treat the vascular anomalies with the Halo(®) 90 system utilizing radiofrequency ablation. Upon withdrawal of the endoscope post procedure, mild resistance and bleeding was noted at the gastroesophageal junction. Repeat endoscopy revealed a submucosal tear at the gastroesophageal junction. This is the first reported complication of the Halo(®) 90 system when used for gastric antral vascular ectasia.