Add-on cases in the endoscopy unit: Factors that affect volume.

BACKGROUND: Although most procedures in the endoscopy clinic are elective, emergency add-on cases in hospital-based endoscopy clinics are common, frequently consuming a great deal of time and resources relative to elective endoscopy procedures. OBJECTIVE: To determine which specific factors correlate with the high volume of add-on emergency cases in a tertiary care, hospital-based endoscopy unit. METHODS: A retrospective chart review of all gastrointestinal add-on, and electively booked cases of esophagastroduodenoscopy (EGD), colonoscopy(C) and flexible sigmoidoscopy(FS)procedures from September 2006 to May 2007, was conducted. The day of the week, month, type of procedure and physician were recorded. Emergency add-on procedures performed during the weekends were not assessed. These cases were then compared with elective cases during a similar time frame to determine differences in the aspects of add-on cases versus those that were elective. RESULTS: Seven hundred twenty-one add-on cases were reviewed (mean patient age 57.4 years; 46% women) and compared with 736 elective cases (mean age 56 years; 49% women; P not significant). Of the add-on cases, 377 (52%) were EGD, 216 C (30%) and 105 (15%) were FS, with 23 combined procedures (3.2%) versus 202 (27%) EGD, 442 (60%) C and 74 (10%) FS in the elective group. Add-on cases were more likely to be EGDs than elective cases (OR 2.7; 95% CI 1.8 to 4.3; P<0.0001) and less likely to be Cs (OR 0.24; 95% CI 0.15 to 0.38; P<0.0001). There were significantly more add-on cases on Mondays (OR 1.7; 95% CI 1.0 to 2.28; P>0.03). Conversely, there were significantly fewer procedures added on Fridays (OR 0.31; 95% CI 0.16 to 0.57; P=0.0001). There were statistically fewer add-on cases in September compared with the other months that were evaluated (OR 0.31; 95% CI 0.11 to 0.78; P=0.0006). CONCLUSION: With the present system of performing only emergency cases on the weekend, Monday tends to have more add-on cases. Consistent with the fact that upper gastrointestinal bleeding is the most common emergency condition, EGD is more common in add-on cases than with elective cases. Although speculative, the reasons for Friday having fewer add-on cases may be the result of a change of physician on call that day; consequently, most cases may be performed earlier in the week. For unknown reasons, fewer cases tend to be added on in September than in the other months evaluated. These data demonstrate that even in the same institution with similar patients, variability in the number of add-on cases likely is a result of many additional factors governing add-on cases, which require appropriate resource planning to ensure adequate allocation of services to ensure ideal patient care.

Clinical and histological predictors of response to medical therapy in collagenous colitis.

OBJECTIVES: Collagenous colitis (CC) is an uncommon form of inflammatory bowel disease. The response to typical medical therapies (antimotility agents, 5-aminosalicylic acid [5-ASA], and corticosteroids) is variable. We aimed to determine if there are clinical or histological variables that can predict response to medical therapy. METHODS: All cases of CC were identified in three tertiary care medical centers. All charts of included patients were reviewed and clinical variables (age, gender, duration of symptoms, frequency of bowel movements, and the use of nonsteroidal anti-inflammatory drugs [NSAIDs]) were recorded. Available histology slides were reviewed by one GI pathologist. Intraepithelial inflammation, epithelial loss or detachment, inflammation in the lamina propria, presence of eosinophilia, crypt inflammation, Paneth's cell metaplasia, and collagen layer thickness were recorded. Depending on their response to therapy, patients were divided into three groups: 1) spontaneous recovery or response to antidiarrheal agents alone, 2) response to 5-ASA agents, and 3) response to corticosteroids after failure of antidiarrheal agents and 5-ASA. RESULTS: Ninety-four patients with CC were identified. Of these, 62 patients were included. The median age was 58 (range = 20-85), and 88% were female. Among the histological parameters only the degree of inflammation in the lamina propria significantly differed between the three response groups (p = 0.007). Patients who required corticosteroids had greater inflammation. Among the clinical parameters age at presentation and use of NSAIDs significantly differed between groups. In the antidiarrheal group, patients tended to be more elderly, and in the corticosteroid group, more patients were on NSAIDs. CONCLUSIONS: 1) The degree of lamina propria inflammation can be used as a histological predictor to guide treatment in patients with CC. 2) Patients who responded to antidiarrheal agents or had spontaneous remissions were significantly older than those patients requiring 5-ASA compounds or corticosteroids. 3) Patients who were taking NSAIDs were more likely to require corticosteroid therapy, presumably reflecting more severe disease.

Familial microscopic colitis.

Collagenous and lymphocytic colitis are two inflammatory conditions of the colon that are often collectively referred to as microscopic colitis. The present report describes what is believed to be the third published case of familial microscopic colitis. A 55-year-old woman who suffered from chronic diarrhea was diagnosed with lymphocytic colitis on colonic biopsy. Subsequently, her 36-year-old daughter was diagnosed with collagenous colitis. The familial occurrence of these diseases may support an immunological hypothesis for their etiology. In addition, it supports the assumption that collagenous and lymphocytic colitis are two manifestations of the same disease process rather than two completely separate entities. The familial tendency of this disease may make a case for early colonoscopy and biopsy in relatives of patients diagnosed with microscopic colitis if they present with suggestive symptoms.

High resolution endoluminal ultrasonography in the staging of esophageal carcinoma.

Small catheters containing 20 MHz transducers have recently become available for high resolution endoluminal ultrasound. We report our early use of this technique to image and stage esophageal carcinoma. Fifteen patients undergoing high resolution endoluminal ultrasonography for suspected esophageal carcinoma were studied. Twelve of these patients also underwent computed tomography and pathologic correlation was available in seven. Satisfactory esophageal examination was possible in 14 of 15 patients. Of those with pathologic correlation, the depth of tumor invasion was correctly staged by high resolution endoluminal ultrasonography in six of seven patients and by computed tomography in only three of seven patients. Lymph node assessment correlated poorly with pathologic findings for both high resolution endoluminal ultrasound and computed tomography. With the increasing use of preoperative radiation therapy, we believe these early results predict a potential role for high resolution endoluminal ultrasonography in the staging of esophageal carcinoma.

Probable ticlopidine-induced cholestatic hepatitis.

OBJECTIVE: To report a case of probable ticlopidine-induced cholestatic hepatitis. CASE SUMMARY: A 76-year-old man with no known history of liver disease developed painless jaundice approximately 3 weeks after starting ticlopidine 250 mg bid. After ticlopidine was discontinued, the jaundice resolved and serum liver enzyme concentrations returned toward normal. A diagnosis of probable ticlopidine-induced cholestatic hepatitis was made. The patient was not rechallenged with ticlopidine. DISCUSSION: A literature search produced 6 case reports describing 7 patients in whom probable ticlopidine-induced cholestatic hepatitis had been diagnosed. Only 1 of these reports appeared in the North American literature. Jaundice developed within 1 to 3 months of starting ticlopidine at less than or equal to the recommended daily dose. In all cases, jaundice resolved and serum liver enzyme concentrations normalized over a period of months after drug discontinuation. CONCLUSIONS: Routine monitoring of serum liver enzyme concentrations is not recommended. However, patients should be instructed to watch for signs and symptoms of liver injury. Should they occur, patients should stop taking the ticlopidine and consult their physician immediately.

Duodenopancreatic fistula accompanying Crohn's disease of the distal duodenum.

A 47-yr-old male with known Crohn's disease involving the third and fourth part of the duodenum and terminal ileum presented to hospital with nausea and vomiting due to duodenal obstruction. An upper gastrointestinal series revealed a clinically unsuspected fistula joining the duodenum and pancreatic duct. He subsequently underwent vagotomy and gastroenterostomy to bypass the obstructed segment of duodenum. The duodenopancreatic fistula was not disturbed. Post-operatively, his symptoms resolved, he gained 30 pounds of weight, and manifested no ill effect secondary to the fistula. A repeat upper gastrointestinal series 9 months postoperatively revealed the fistula to have closed, although marked duodenal narrowing remained.

Fine needle aspiration cytology of fibrolamellar hepatocellular carcinoma.

The major cytologic features seen in fine needle aspirates from two cases of fibrolamellar hepatocellular carcinoma were: liver-like tumor cells, characterized by plump, polygonal forms with eosinophilic, granular cytoplasm; large oval nuclei with extremely prominent solitary nucleoli; and parallel bands of fibrous tissue and fibrocytes seen within the tumor fragments. Other helpful features included intracytoplasmic hyaline globules and well-delineated pale bodies. Clinically, the tumors occurred in young patients with noncirrhotic livers and ran a more favorable course than do other types of hepatocellular carcinoma.