Capsule endoscopy of the small bowel in the clinical practice: outpatient management is feasible and cheaper.

AIM: Four Italian regions have cost coding for outpatient capsule-endoscopy. Elsewhere it is performed in ordinary hospital admission. To identify, in a cohort of patients of a Gastroenterology Unit, those feasible for outpatient versus inpatient treatment; to analyze costs distribution in both management areas. METHODS: We retrospectively analysed 100 clinical records of admissions to A.O. San-Carlo-Borromeo, Milan between 2005-2008. Hospitalization criteria (at least 3): 1) occult/obscure gastrointestinal bleeding; 2) hemoglobin ≤ 8 gr/dL; 3) indication for blood transfusions; 4) urgent hospital admission. RESULTS: A total of 62 patients had urgent admission, 60 blood transfusions, 81 underwent EGD and colonoscopy, 8 enteroscopy and 5 surgery. Mean haemoglobin value was 8.67 g/dL. Capsule-endoscopy was positive in 70, uncertain in 8, negative in 22. Positive cases: 33 angiodyplasia, 18 ulcers/erosions, 13 polyps/masses, 5 overt bleeding, 1 celiac disease. 47/100 were appropriate as outpatient, saving 432 days of hospital stays. Admission coding was grouped into 7 DRGs (overall expense: 98,366 Euros). Considering EGD/colonoscopy outpatient costs and 1.100 euros as estimated value for capsule-endoscopy, the total expense could be 53.919. CONCLUSION: Outpatient capsule-endoscopy small bowel examination is feasible in half of the cases. It is cost saving, (about 45.000 Euros/100 patients), reducing inappropriate hospital stays.

A puzzling jaundice.

In an adult beta-thalassaemic patient admitted on account of the sudden onset of nausea, vomiting and biliary pain, the concomitant jaundice was considered "obstructive" on the basis of ultrasonographic evidence of cholecysto-choledocal stones. However, when the patient was re-evaluated it was found that concomitant Gilbert's disease, hepatitis C virus related cirrhosis and dilated cardiomyopathy had a detrimental effect on clinical and laboratory findings.

Gallstone disease and related risk factors in patients with Crohn disease: analysis of 330 consecutive cases.

BACKGROUND: The reported prevalence of gallstone disease (GD), defined as current gallstones or previous cholecystectomy for gallstones, in patients with Crohn disease ranges from 13% to 34%. The aim of this study was to characterize the still undefined risk factors of this complication. METHODS: A total of 330 consecutive patients with Crohn disease (189 males and 141 females aged 17-82 years, mean +/- SD age, 41 +/- 14 years) underwent liver ultrasonography. RESULTS: A diagnosis of GD was made in 78 patients (24%), 54 with current gallstones and 24 who had undergone previous cholecystectomy. Its frequency was comparable in males and females (23% vs 25%), but was significantly associated with age (P =.001), being 13%, 36%, and 51% in patients aged 44 years and younger, 45 to 59 years, and 60 years and older, respectively (P =.001). Its prevalence significantly differed according to the site of the disease at diagnosis (P =.02) and was unrelated to disease duration. Gallstone disease was more frequent in patients who had undergone surgery (34% vs 14%; P =.001) and was significantly associated with the number (P =.001) and site of bowel resections (P =.001), increasing from 28% in the patients who had undergone 1 resection to 53% in those having had 2 or more resections (P =.005) and being significantly higher in patients with a resection involving the ileocecal region. Multivariate analysis showed that age; site of disease at diagnosis; and the presence, number, and site of bowel resections were significantly related to GD. CONCLUSIONS: In patients with Crohn disease, the frequency of GD is significantly higher than that reported in the general population with comparable characteristics (z = 5.04, P<.001). Age; site of disease at diagnosis; and the history, number, and site of bowel resections are independently associated with GD.

"Hepatitic flare", asthenia, peripheral polyneuropathy and diffuse liver steatosis in a hepatitis C virus asymptomatic chronic carrier.

In July 2000, a 62-year-old female, with a ten-year history of chronic hepatitis C virus infection and persistently normal aspartate amino-transferase and alanine aminotransferase levels, presented with asthenia, weight loss, peripheral polyneuropathy and increased levels of aspartate aminotransferase (8 times upper normal limit), alanine aminotransferase (10 times upper normal limit) and gamma glutamyl-transferase (6 times upper normal limit). The ultrasound findings were consistent with massive liver steatosis. The patient had been previously diagnosed elsewhere as having hepatitis C virus-related "hepatitic flare" with neurological involvement related to concomitant mixed type-III cryoglobulinaemia. However intense exposure to trichloroethylene since April 2000 was revealed and liver histology was fully consistent with non-alcoholic steatohepatitis. The pathogenetic role of the solvent was definitely supported by the complete clinical and biochemical remission within six months of trichloroethylene withdrawal.

Renovascular impedance and esophageal varices in patients with Child-Pugh class A cirrhosis.

PURPOSE: To evaluate the frequency of increased renovascular impedance and its relationship with the presence of esophageal varices in patients with Child-Pugh class A cirrhosis without ascites. MATERIALS AND METHODS: The intraparenchymal renal resistive index (RI) (reference value, <0.7) and portal congestive index (ie, the ratio between the portal cross-sectional area and mean flow velocity; reference value, <0.07) were measured by using duplex Doppler ultrasonography in 50 consecutive patients. The frequency of varices was assessed endoscopically. The data were analyzed with the Fisher exact test. RESULTS: The renal RI was consistent with increased impedance (ie, >0.7) in 18 (36%) patients and was normal in 32 (64%). The proportion of patients with varices was significantly higher in the former group: 14 (78%) versus 10 (31%) (P =.002). In detection of the presence of varices, the renal RI was uniformly better than the portal congestive index in terms of sensitivity (58% vs. 48%), specificity (84% vs 54%), and positive (3.60 vs 1.04) and negative (0.50 vs. 0.96) likelihood ratios. RI determination improved the ability to exclude the presence of varices from a basal pretest probability of 52% (26 of 50 patients) to a final one of 69% (22 of 32 patients) and that of predicting the presence of varices from 48% (24 of 50 patients) to 78% (14 of 18 patients). CONCLUSION: A substantial proportion of patients with Child-Pugh class A cirrhosis without ascites have increased renovascular impedance; this significantly correlates with the presence of varices.

Recurrent cholestasis and hypereosinophilia in a young female.

A 22-year-old female presented, in December 1998, with asthenia, itching and hypereosinophilia. In January 1997, due to the same clinical picture, the patient had inappropriately been diagnosed elsewhere to have an "idiopathic eosinophilic syndrome" and complete remission was obtained after short-term steroid treatment. Upon admission, physical examination was negative and blood tests revealed absolute eosinophilia [42%, i.e., 3,800 of 9,600 white blood cells], aspartate aminotransferase 4 x upper limits of normal, alanine aminotransferase 5 x upper limits of normal and alkaline phosphatase 2 x upper limits of normal. Both liver biopsy and endoscopic retrograde cholangiopancreatography findings were totally consistent with primary sclerosing cholangitis, while all known causes of hypereosinophilia and alteration in liver function tests were carefully excluded. The clinical course was characterized by complete clinical and biochemical normalization in absence of any treatment and further follow-up was completely negative.

Mistaken diagnosis of eosinophilic colitis.

A 69-year-old male chronic alcohol abuser suffering from diarrhoea and with a number of discrete pruriginous and erythematous lesions of the trunk was referred to our Unit with a diagnosis of idiopathic eosinophilic colitis in order that we might determine corticosteroid treatment. Diagnosis was based on the presence of marked peripheral eosinophilia and massive eosinophilic infiltration at colonic biopsy, and the exclusion of parasitic infection by means of two different microscopic stool examinations of five samples. However, repeated stool examinations of ten samples collected on separate days and evidence of impaired cell-mediated immunity allowed a definite diagnosis of Strongyloides stercoralis autoinfection or hyperinfection. Due to the poor sensitivity of stool examination in the diagnosis of Strongyloides stercoralis infection, a careful search for this parasite should be made in all patients with comparable clinical findings before formulating a diagnosis of idiopathic eosinophilic colitis, because consequent steroid treatment may have a fatal outcome by inducing widespread dissemination of the parasite.

Severe hypopharyngeal dysphagia in a patient on chronic steroid treatment.

A 44-year-old Caucasian male who had been on long-term steroid treatment for an unspecified collagen disease was referred to our Unit because of fever, severe hypopharyngeal dysphagia, night sweats and evidence of marked superior vena cava compression. Extrapulmonary disseminated tuberculosis also involving bone and liver was eventually diagnosed and proven by means of specific polymerase chain reaction assay. Antimycobacterial treatment, which led to a dramatic improvement within two months, was protracted for 18 months until the complete return to normal of both clinical and laboratory findings.

Response of monocyte iron regulatory protein activity to inflammation: abnormal behavior in genetic hemochromatosis.

In genetic hemochromatosis (GH), iron overload affects mainly parenchymal cells, whereas little iron is found in reticuloendothelial (RE) cells. We previously found that RE cells from GH patients had an inappropriately high activity of iron regulatory protein (IRP), the key regulator of intracellular iron homeostasis. Elevated IRP should reflect a reduction of the iron pool, possibly because of a failure to retain iron. A defect in iron handling by RE cells that results in a lack of feedback regulation of intestinal absorption might be the basic abnormality in GH. To further investigate the capacity of iron retention in RE cells of GH patients, we used inflammation as a model system as it is characterized by a block of iron release from macrophages. We analyzed the iron status of RE cells by assaying IRP activity and ferritin content after 4, 8, and 24 hours of incubation with lipopolysaccharide (LPS) and interferon-gamma (IFN-gamma). RNA-bandshift assays showed that in monocytes and macrophages from 16 control subjects, IRP activity was transiently elevated 4 hours after treatment with LPS and IFN-gamma but remarkably downregulated thereafter. Treatment with NO donors produced the same effects whereas an inducible Nitric Oxide Synthase (iNOS) inhibitor prevented them, which suggests that the NO pathway was involved. Decreased IRP activity was also found in monocytes from eight patients with inflammation. Interestingly, no late decrease of IRP activity was detected in cytokine-treated RE cells from 12 GH patients. Ferritin content was increased 24 hours after treatment in monocytes from normal subjects but not in monocytes from GH patients. The lack of downregulation of IRP activity under inflammatory conditions seems to confirm that the control of iron release from RE cells is defective in GH.