Mucosal abnormalities of the colon in patients with portal hypertension: an endoscopic study.

BACKGROUND: Controversy still exists regarding colonic mucosal abnormalities in patients with portal hypertension (portal colopathy). The aims of this study were to better define portal colopathy and to identify risk factors for these colonic mucosal abnormalities. METHODS: We reviewed the medical records of 437 patients with cirrhosis and portal hypertension and 224 with irritable bowel syndrome (control patients) who underwent colonoscopy over a 6-year period. RESULTS: Individuals with portal hypertension were significantly more likely than control patients to have colitis-like abnormalities (38% vs. 3%, p < 0.001) and vascular lesions (13% vs. 3%, p < 0.001). In the multivariate model, portal hypertensive gastropathy (odds ratio 5.64: 95% CI [3.39, 9.41]; p < 0.001), 2+ or larger esophageal varices (odds ratio 4.76: 95% CI [2. 78, 8.15]; p < 0.001), and Child-Pugh class C cirrhosis (odds ratio 2.64: 95% CI [1.40, 4.97]; p = 0.003) were independently associated with an increased risk of having portal colopathy, whereas the use of beta-blockers independently decreased the risk of having these findings (odds ratio 0.23: 95% CI [0.13, 0.40]; p < 0.001). Mucosal biopsies of the colon in patients with colitis-like abnormalities revealed a mild, nonspecific inflammatory infiltrate with edema and vascular ectasias in the majority of cases. CONCLUSIONS: Mucosal abnormalities in portal colopathy include edema, erythema, granularity, friability, and vascular lesions, findings that may be confused with colitis. A standardized grading system to classify the endoscopic appearance and severity of portal colopathy should be adopted.

Natural history of HIV-associated esophageal disease in the era of protease inhibitor therapy.

The aim of this study was to determine the outcome of patients with HIV-associated esophageal disease refractory to empiric antifungal therapy, both before and after the introduction of protease inhibitors. We reviewed the medical records of 629 consecutive HIV-infected patients with odynophagia, dysphagia, or both esophageal symptoms refractory to at least one week of empiric antifungal therapy who underwent endoscopy between January 1992 and January 1997 at Bellevue Hospital Center. Endoscopy identified an etiology in 96.2% of patients, with cytomegalovirus ulcers (40.0%) and idiopathic ulcers of the esophagus (26.67%) being the most common lesions found. Overall, 91.4% of patients had a response to disease-specific therapy. In patients taking protease inhibitors, recurrent symptoms were less common (26.5% vs 36.7%, P = 0.03) and median survival was longer (172 vs 125 weeks. P = 0.006) than in those who were not treated with these potent antiretroviral medications. Protease inhibitors have had a positive impact on the outcome of HIV-associated esophageal disease.

Risk factors for rebleeding and mortality from acute upper gastrointestinal hemorrhage in human immunodeficiency virus infection.

OBJECTIVES: In the general population, acute upper gastrointestinal hemorrhage (UGIH) is a common problem that results in significant morbidity and mortality. The aim of this study was to determine the etiology, clinical outcome, and risk factors for rebleeding and mortality in a large cohort of human immunodeficiency virus (HIV)-infected patients with acute UGIH. METHODS: We reviewed the medical records of consecutive HIV-infected patients with acute UGIH who were referred for an endoscopic evaluation from January 1992 through January 1997 at Bellevue Hospital Center. RESULTS: During the 5-yr study period, 297 HIV-infected patients with acute UGIH were evaluated by endoscopy. Gastroduodenal ulcers (25.6%), esophageal ulcers (21.5%), and Kaposi's sarcoma (19.2%) were the three most common causes of acute UGIH. Fifteen percent of patients rebled within 30 days and independent predictors of rebleeding included a CD4 count of <200 cells/mm3, inpatient status, a hemoglobin of <8 g/dl, major stigmata of hemorrhage, and lymphoma. The 30-day mortality from UGIH was 11.4% and a hemoglobin of <8 g/dl, a platelet count of <100,000/mm3, major stigmata of hemorrhage, rebleeding within 30 days, and lymphoma were independent predictors of mortality. The introduction of protease inhibitors in December 1995 resulted in a reduction in 30-day mortality from 13.5% to 4.4% (p = 0.04) without affecting the etiology of UGIH or the incidence of rebleeding. CONCLUSIONS: Acute UGIH in HIV-infected patients is most commonly due to gastroduodenal ulcers, esophageal ulcers, and Kaposi's sarcoma. In this patient population, the introduction of protease inhibitors has had a positive impact on the outcome of UGIH.

Evaluation of the gastrointestinal tract in premenopausal women with iron deficiency anemia.

PURPOSE: Iron deficiency anemia is often attributed to menstrual blood loss in premenopausal women. The aims of this study were to determine the diagnostic yield of endoscopy and to evaluate the clinical outcome in these women. METHODS: Charts, endoscopy records, and pathology reports were reviewed in consecutive premenopausal women with documented iron deficiency anemia who were referred for diagnostic endoscopy. Follow-up was obtained by telephone contact and review of medical records. RESULTS: Endoscopy revealed a clinically important lesion in 23 (12%) of 186 patients. An upper gastrointestinal source was identified in 12 patients, most commonly due to gastric cancer (3%) or peptic ulcer disease (3%). A colonic lesion was detected in 11 patients, with colon cancer in six (3%). No patient had a lesion identified in both the upper and lower gastrointestinal tract. Small bowel biopsies and radiography were normal in all patients in whom they were obtained. Independent predictors for having a gastrointestinal lesion identified by endoscopy include a positive fecal occult blood test, a hemoglobin of <10 g/dL, and abdominal symptoms. Long-term follow-up data suggested a favorable prognosis, and iron deficiency anemia resolved with appropriate therapy in nearly all patients. CONCLUSIONS: Endoscopy yields important findings in premenopausal women with iron deficiency anemia, which should not be attributed solely to menstrual blood loss.