Small bowel ulcerative lesions are common in elderly NSAIDs users with peptic ulcer bleeding.

AIM: To determine the frequency of small bowel ulcerative lesions in patients with peptic ulcer and define the significance of those lesions. METHODS: In our prospective study, 60 consecutive elderly patients with upper gastrointestinal bleeding from a peptic ulceration (cases) and 60 matched patients with a non-bleeding peptic ulcer (controls) underwent small bowel capsule endoscopy, after a negative colonoscopy (compulsory in our institution). Controls were evaluated for non-bleeding indications. Known or suspected chronic inflammatory conditions and medication that could harm the gut were excluded. During capsule endoscopy, small bowel ulcerative lesions were counted thoroughly and classified according to Graham classification. Other small bowel lesions were also recorded. Peptic ulcer bleeding was controlled endoscopically, when adequate, proton pump inhibitors were started in both cases and controls, and Helicobacter pylori eradicated whenever present. Both cases and controls were followed up for a year. In case of bleeding recurrence upper gastrointestinal endoscopy was repeated and whenever it remained unexplained it was followed by repeat colonoscopy and capsule endoscopy. RESULTS: Forty (67%) cases and 18 (30%) controls presented small bowel erosions (P = 0.0001), while 22 (37%) cases and 4 (8%) controls presented small bowel ulcers (P < 0.0001). Among non-steroidal anti-inflammatory drug (NSAID) consumers, 39 (95%) cases and 17 (33%) controls presented small bowel erosions (P < 0.0001), while 22 (55%) cases and 4 (10%) controls presented small bowel ulcers (P < 0.0001). Small bowel ulcerative lesions were infrequent among patients not consuming NSAIDs. Mean entry hemoglobin was 9.3 (SD = 1.4) g/dL in cases with small bowel ulcerative lesions and 10.5 (SD = 1.3) g/dL in those without (P = 0.002). Cases with small bowel ulcers necessitate more units of packed red blood cells. During their hospitalization, 6 (27%) cases with small bowel ulcers presented bleeding recurrence most possibly attributed to small bowel ulcers, nevertheless 30-d mortality was zero. Presence of chronic obstructive lung disease and diabetes was related with unexplained recurrence of hemorrhage in logistic regression analysis, while absence of small bowel ulcers was protective (relative risk 0.13, P = 0.05). CONCLUSION: Among NSAID consumers, more bleeders than non-bleeders with peptic ulcers present small bowel ulcers; lesions related to more severe bleeding and unexplained episodes of bleeding recurrence.

Ischemic heart disease, factor predisposing to Barrett's adenocarcinoma: A case control study.

AIM: To define the significance of ischemic heart disease (IHD) (stable angina to infarction) co-existance in Barrett esophagus (BE) patients and patients with esophageal adenocarcinoma (AdE). METHODS: All BE/AdE patients in Blackpool-Wyre-Fylde area and Trikala prefecture identified from medical records. Patient clinical details were obtained from hospital and General Practitioner records. Additional information was gathered from validated questionnaire. RESULTS: Forty (33%) AdE and 83 (19%) BE patients had IHD (P = 0.002). Eighteen (15%) AdE and 34 (8%) BE patients had suffered a myocardial infarction (P = 0.03). Three (3%) AdE and 7 (2%) BE patients had severe heart failure (P = 0.82). Thirty-nine (47%) BE with IHD and 8 (20%) AdE patients with IHD consumed aspirin daily (P = 0.004). Seventh-seven (93%) BE patients with IHD and 36 (90%) AdE patients with IHD were on statins (P = 0.86). Logistic regression analysis: AdE was more frequent in the elderly, with long term reflux, long BE and concurrent IHD (odds ratio: 2.086, P = 0.001) not consuming statins. Eighteen (22%) BE patients with IHD [16 (84%) with myocardial infarction] vs 33 (10%) without IHD died from non-neoplastic causes within 24 mo from BE diagnosis (P = 0.005). CONCLUSION: IHD is more prevalent in AdE than BE patients. Increased prevalence of AdE is related with the presence of myocardial infarction but not severe heart failure, possibly because patients with BE and severe IHD have low life expectancy.

Patients with partial gastrectomy and Barrett esophagus are in higher risk to develop esophageal adenocarcinoma than those with Barretts without gastrectomy.

BACKGROUND/AIMS: Duodenogastric reflux is a possible risk factor for esophageal adenocarcinoma (CA) development. Gastric surgery that destroys or distorts the pylorus is a good model to study the effects of duodenogastric reflux. To define the consequences of gastrectomy in patients with Barrett esophagus (BE). METHODOLOGY: Records of all BE/CA patients examined in Blackpool-Wyre-Fylde area were reviewed. All surviving patients completed validated questionnaires. RESULTS: Gastrectomy was more prevalent in CA patients (14 (3.6%) BE vs. 15 (13.3%) CA, p=0.0002). Partial gastrectomy was more prevalent in CA patients, (7 (1.8%) BE vs. 10 (8.8%) CA, p=0.0004), while there was no difference in total gastrectomy between the two groups. Persistence of H. pylori infection after gastrectomy and smoking were more frequent among CA patients with gastrectomy. Mean follow-up time in patients with prior gastrectomy was 78 (SD=76.4) months for BE patients and 119.3 (SD=72.9) months for CA patients (p=0.07). In logistic regression analysis gastrectomy, in addition to old age, long-term reflux, absence of hiatal hernia and H. pylori infection were risk factors for CA. CONCLUSIONS: Gastrectomy and especially partial gastrectomy was more prevalent in CA patients.

Congenital bronchoesophageal fistula in a patient with Crohn's disease: a cautionary tale.

We present the case of a young lady suffering from Crohn's disease who was diagnosed as having a disabling bronchoesophageal fistula. This was mistakenly thought to be due to the Crohn's disease, and surgery was declined for fear of further complications. She required multiple admissions for frequent chest infections. At review, 5 years later for a second opinion, the fistula was deemed congenital in origin. The fistula was successfully resected, and the histology confirmed the diagnosis.