Case report of acute-on-chronic liver failure secondary to diffuse large B-cell lymphoma.

Acute liver failure is a rare presentation of hematologic malignancy. Acute on chronic liver failure (ACLF) is a newly recognized clinical entity that describes acute hepatic decompensation in persons with preexisting liver disease. Diffuse large B-cell lymphoma (DLBCL) is an aggressive non-Hodgkin's lymphoma (NHL) with increasing incidence in older males, females and blacks. However, it has not yet been reported, to present with acute liver failure in patients with preexisting chronic liver disease due to human immunodeficiency virus (HIV)/hepatitis C virus (HCV) co-infection. We describe a case of ACLF as the presenting manifestation of DLBCL in an elderly black man with HIV/HCV co-infection and prior Hodgkin's disease in remission for three years. The rapidly fatal outcome of this disease is highlighted as is the distinction of ACLF from decompensated cirrhosis. Due to the increased prevalence of HIV/HCV co-infection in the African American 1945 to 1965 birth cohort and the fact that both are risk factors for chronic liver disease and NHL we postulate that the incidence of NHL presenting as ACLF may increase.

Novel approach to treatment of rectal mucosa-associated lymphoid tissue lymphoma.

A 78-year-old Hispanic woman with a medical history of osteoporosis, hyperlipidaemia and dyspepsia presented to a gastrointestinal clinic complaining of a small amount of rectal bleeding following bowel movements for 6 months. Colonoscopy demonstrated a 3×3 cm submucosal rectal mass. Pathological analysis revealed ulcerated colonic mucosa with diffuse proliferation suggestive of a lymphoproliferative process. Immunohistochemistry and flow cytometry of the specimen supported a diagnosis of mucosa-associated lymphoid tissue lymphoma. The patient was treated with amoxicillin, clarithromycin and lansoprazole for 2 weeks. A C-14 urea breath test confirmed eradication of Helicobacter pylori. Repeat colonoscopy showed no regression of the tumour. The patient received external beam radiation treatment. Subsequent positron emission tomography/CT scans demonstrated no evidence of viable tumour tissue and no regional or distant metastasis. Follow-up sigmoidoscopy with biopsy revealed no evidence of lymphoma.

Does constipation predict the quality of bowel preparation during colonoscopy?

BACKGROUND: Suboptimal bowel preparation has several consequences, including reduced polyp detection rate and increased cost of colorectal cancer screening. The presence of constipation is thought to be a feature associated with poor bowel preparation. OBJECTIVES: To characterise the relationship between features of constipation and the quality of bowel preparation during colonoscopy. DESIGN: Patients presenting for an outpatient colonoscopy were asked to complete a questionnaire which included demographics, type of bowel purgative and features of bowel movements (BMs)-derived from the ROME III criteria for diagnosis of chronic constipation. PATIENTS: 101 patients from the community undergoing surveillance colonoscopy completed the study. INTERVENTIONS: Patients underwent standard bowel preparation, completed a pre-endoscopy survey, followed by routine surveillance colonoscopy. MAIN OUTCOME MEASUREMENTS: The endoscopist rated the quality of bowel preparation using the previously validated Ottawa scoring scale. Statistical analysis was performed to characterise the relationship between the existence of chronic constipation and quality of bowel preparation. RESULTS: BM frequency of <1/day, 1/day, 2/day, or 3/day was inversely correlated with average total Ottawa score (range 5.93 to 4.00), p=0.028) as well as recto-sigmoid Ottawa score (range 1.8 to 1.0, p=0.006). Among women, there was a statistically significant (p=0.025) association between those who reported hard stools (Ottawa=6.3) and those who denied hard stools (4.5). CONCLUSION: Eliciting features of BMs before colonoscopy may predict those at risk for poor bowel preparations and increase cost effectiveness of colonoscopy.

Acute esophageal necrosis: a rare syndrome.

BACKGROUND: Acute esophageal necrosis, which presents as a black esophagus on endoscopy, is a rare disorder that is poorly described in the medical literature. In this study, we analyze all cases reported to date to define risk factors, clinical presentation, endoscopic features, histologic appearance, treatment, complications, outcome and etiopathogenesis of the disease and to describe a distinct medical syndrome and propose a staging system. METHODS: We searched Medline and PubMed from January 1965 to February 2006 for English-language articles using the key words "acute esophageal necrosis," "necrotizing esophagitis," and "black esophagus." RESULTS: A total of 88 patients were reported in the literature during the 40 years, 70 men and 16 women with an average age of 67 years. Patients were generally admitted for gastrointestinal bleeding and cardiovascular event/shock. Patients presented with hematemesis and melena in more than 70% of the cases. Upper endoscopy showed black, diffusely necrotic esophageal mucosa predominantly affecting the distal third of the organ. Necrosis was confirmed histologically in most cases. Complications included strictures or stenoses, mediastinitis/abscesses, and perforations. Overall mortality was 31.8%. CONCLUSIONS: This study provides a structured approach to identifying risk factors, diagnosis, and pathogenesis of the acute esophageal necrosis. Risk factors include age, male sex, cardiovascular disease, hemodynamic compromise, gastric outlet obstruction, alcohol ingestion, malnutrition, diabetes, renal insufficiency, hypoxemia, hypercoagulable state, and trauma. Mechanism of damage is usually multifactorial secondary to ischemic compromise, acute gastric outlet obstruction, and malnutrition. Overall, acute esophageal necrosis should be viewed as a poor prognostic factor, associated with high mortality from the underlying clinical disease.

Colorectal carcinoma in young females.

BACKGROUND: We sought to study the clinicopathologic characteristics of colorectal cancer in young female patients. We also wanted to determine the association of colorectal cancer with anemia in these female patients and, finally, to determine the effect of gender on prognosis in young patients with colorectal cancer. METHODS: We performed a retrospective analysis of all young patients diagnosed with colorectal cancer between 1982 and 1999 in two teaching hospitals in New York City. RESULTS: A total of 3,546 cases of colorectal cancer were diagnosed. Sixty-one (1.63%) of these patients were young patients and 32 (0.85%) were female. Young refers to all patients in the study who were younger than 40 years of age. The clinical presentation and mean age at presentation were very similar in both male and female patients. At presentation, 87.5% of female patients had anemia compared with only 69% of male patients. Males had a statistically significant higher mean hemoglobin level compared with females (12.87 versus 10.29 g) at P = 0.0001. Seventy-nine percent of female patients compared with 86% of male patients presented with left-sided tumors. Fifty-five percent of males presented with late stage disease compared with 68% of females (P = 0.27). Female sex seemed to adversely affect the prognosis, although this did not reach statistical significance (P = 0.08). Stage of disease was associated with worse prognosis and this was independent of sex. Age and hemoglobin were not independent predictors of mortality. CONCLUSION: Colorectal cancer does occur in females of childbearing age who might have a tendency to present with late stage disease as evidence from this study. Young female patients with anemia should be questioned about gastrointestinal symptoms, and colorectal cancer should definitely be in the differential diagnoses. This might conceivably allow for earlier diagnosis and potential for cure in this patient group.