Hospital management of colonic perforations complicating ambulatory outpatient colonoscopy via over-the-scope clips or surgery: a case series.

BACKGROUND: Colonoscopy is the standard of care for the diagnosis and treatment of many colonic disorders. Over the past few years, endoscopic closure of colonoscopy-related perforation has become more common. Endoscopic closure of perforation secondary to colonoscopy has been undertaken in patients in the hospital setting and often during the same colonoscopic procedure in which the perforation itself occurred. The aim of our study was to analyze our experience with emergency endoscopic closure of colonoscopy-related perforation with over-the-scope clip (OTSC) technique. METHODS: We report five cases of colonic perforation that occurred during colonoscopy in an outpatient facility remotely located from our hospital and then referred as an emergency to our institution for endoscopic closure. RESULTS: Bowel preparation was reported to be adequate in all cases. Prior to attempting endoscopic closure of colonic perforation, all patients were in stable clinical condition, early broad-spectrum antibiotic coverage was initiated, and a surgical consult was obtained. All patients had sigmoidoscopy and were found to have sigmoid colon perforations. In three cases, the perforations were closed successfully using an OTSC clip device 14 mm type t. Two patients were found to have greater than 4-cm sigmoid perforations with irregular margins, incompatible with OTSC closure, and were referred for emergency surgery. All patients had an uneventful course following either OTSC closure or surgery. CONCLUSIONS: Based on the characteristics of the five cases and a review of the literature, we suggest a practical approach for undertaking closure of colonic perforations occurring during colonoscopy in the outpatient setting, focusing on clinical criteria to determine eligibility of patients for attempted endoscopic closure and outlining required therapeutic and monitoring steps needed to optimize outcomes.

The clinical spectrum of cytomegalovirus colitis in adults.

BACKGROUND: Colonic cytomegalovirus reactivation rarely occurs in adults without inflammatory bowel disease or a known immunosuppressive state. AIM: To describe our experience with such patients. METHODS: All consecutive admissions of patients with possible cytomegalovirus colitis, between 1995 and 2006, were reviewed retrospectively. RESULTS: Nineteen patients were studied. Most of the patients were elderly with multiple co-morbidities. Three main forms of disease presentation were recognized: acute diarrhoea, chronic diarrhoea and lower gastrointestinal bleeding. Colonic mucosal intranuclear inclusion bodies were found in 12 patients. Thirteen patients had cytomegalovirus viraemia (either by polymerase chain reaction and/or by white blood cell-cytomegalovirus antigenaemia test). Ganciclovir therapy was given to only eight patients; only five of these patients survived. The other subgroup of 11 patients received only supportive therapy. Most of the patients from this subgroup had a prolonged and complicated hospital course; only nine patients survived. Follow-up colonoscopies were performed only in five patients (out of the 14 patients who survived). In four of these patients, chronic mucosal inflammatory changes were noted. CONCLUSIONS: Cytomegalovirus colitis occurs rarely in adult individuals. The disease may have various and multiple acute and/or chronic clinical manifestations. Clinical awareness of this condition is needed.

Chronic diarrhea--induced by celiac plexus block?

A 59-year-old man had severe chronic diarrhea after a celiac plexus block. The block was performed because of unbearable abdominal pain caused by a benign cyst in the lesser sac. The patient also had diabetes mellitus and was treated with metformin. Thorough investigation and various therapeutic trials failed to detect the cause for the diarrhea or to improve it. Based on the temporal relationship we wonder whether the diarrhea was induced by the celiac block procedure. The relevant literature is reviewed.

Esophagitis is a major cause of upper gastrointestinal hemorrhage in the elderly.

BACKGROUND: The risk of death in patients presenting with upper gastrointestinal (UGI) hemorrhage increases with age. Our aims were to define the background characteristics, causes, course, and outcome in patients aged > or = 80 years admitted to hospital because of acute UGI bleeding (n = 115) in relation to patients aged 60-69 years admitted for the same reason (n = 133). METHODS: A prospective, longitudinal study with a nested case-control analysis was carried out. RESULTS: In the elderly patients there was a female preponderance and a significantly higher prevalence of atherosclerotic cardiovascular disease. By contrast, use of tobacco and alcohol, diabetes mellitus, and chronic liver disease were significantly commoner in the controls. The use of nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, anticoagulants, and corticosteroids was similar in the two groups. Esophagitis was the cause of bleeding in 21.1% of the elderly, as compared with 3.3% in the controls. The relative risk of developing esophagitis in the elderly was increased and was independent of gender, smoking, alcohol consumption, use of NSAIDs, aspirin, or corticosteroids, diabetes mellitus, atherosclerotic cardiovascular disease and liver disease. (Adjusted odds ratio, 18.1; P = 0.0002). The rates of persistent or recurrent bleeding and emergency surgery to control bleeding were similar. However, the mortality in the elderly was higher (13 versus 6.1%; P = 0.09). CONCLUSIONS: Age > or = 80 years is an independent determinant of esophagitis, a major cause of UGI bleeding in the elderly.

Mesalamine-induced hypersensitivity pneumonitis. A case report and review of the literature.

A 49-year-old man with Crohn's disease treated with prednisone and mesalamine (5-ASA) developed worsening respiratory distress and fever. Symptoms improved after discontinuation of mesalamine. A rechallenge 3 months later caused similar pulmonary symptoms, confirming the association between the drug and the respiratory system. Mesalamine may cause hypersensitivity pneumonitis in patients with Crohn's disease.

Reduced glutamine content in colonic polyps.

BACKGROUND: Glutamine is the most abundant amino acid in the body. It has a key role in nitrogen metabolism and is a major source of energy for the enterocyte and many other cells. Glutamine is also essential for tumor growth, and marked changes in organ glutamine metabolism are characteristic in cancer patients. METHODS: We have investigated the catabolism of glutamine in a classic premalignant condition: the colonic adenomatous polyp. The content of glutamine and activity of two catabolic enzymes, glutamine transferase and phosphate-dependent glutaminase, were studied in normal colon and in polyp mucosa. RESULTS: Free glutamine content and activity of glutaminase were significantly lower in polyps than in their adjacent mucosa. Glutamine transferase activity was significantly lower in polyp mucosa than in normal colon controls. CONCLUSIONS: Adenomatous polyps might behave as a glutamine trap, channeling glutamine to protein and nucleic acid synthesis. These changes in glutamine catabolism could play a role in colonic neoplasia pathogenesis.

Upper gastrointestinal hemorrhage associated with cutaneous application of diclofenac gel.

We present four cases of upper gastrointestinal hemorrhage associated with the cutaneous application of diclofenac (Voltaren Emulgel). The patients' ages ranged from 24 to 85 yr. Three of the patients had used the medication three times daily for at least 2 wk before the onset of bleeding. In two cases, the treatment was indicated for backache which, retrospectively, was attributable to a peptic ulcer. In those two patients, the hemorrhage was massive, requiring blood transfusions. Because systemic absorption of nonsteroidal anti-inflammatory drugs from topical formulations has been documented, caution should be exercised when prescribing these formulations to patients with a history of peptic ulcer.

Predictors of mortality in patients admitted to hospital for acute upper gastrointestinal hemorrhage.

BACKGROUND: We wanted to identify features of prognostic significance in patients admitted to hospital because of acute upper gastrointestinal (UGI) hemorrhage. METHODS: A prospective, longitudinal study of 321 consecutive cases admitted during 1988-91 was carried out. The relative risk of mortality associated with each of the background, laboratory, and endoscopic features and the hospital course was calculated. Multiple stepwise logistic regression was used to define factors independently associated with mortality. Two models were evaluated, the first based on the data at presentation (history, physical findings, initial laboratory data) and the second based on the first, plus the endoscopic and follow-up data. RESULTS: The overall mortality was 7.8%. At presentation the features associated with a significantly (p < 0.05) increased risk of mortality were (adjusted odds ratios in parentheses) age > or = 75 years (11.2), a history of cancer (12.1), blood in the gastric aspirate (9.6), and a systolic blood pressure < or = 90 mm Hg (6.4). The overall predictors of mortality were age > or = 75 years (12.7), blood in the gastric aspirate (18.9), serum creatinine level > or = 150 mumol/l (14.8), increased serum aminotransferase level (20.2), and persistent or recurrent bleeding (57.3). CONCLUSIONS: In patients admitted to hospital because of UGI hemorrhage the prognosis depends on age, underlying diseases, hemodynamic status, and the persistence or recurrence of bleeding. The causes of bleeding were not relevant to the prognosis.

Predictors of mortality in hospitalized patients with secondary upper gastrointestinal haemorrhage.

OBJECTIVES: To identify clinical, laboratory and endoscopic features of prognostic implication in patients who suffer an upper gastrointestinal haemorrhage whilst hospitalized for other causes. DESIGN/SETTING: A prospective longitudinal study of 125 consecutive cases (89 males, 36 females) seen during 1988-1991 in a tertiary care university hospital. MAIN OUTCOME MEASURES: The crude and adjusted relative risk of mortality associated with each of the various clinical, laboratory and endoscopic variables. RESULTS: The rates of endoscopic haemostasis, persistent or recurrent bleeding and surgery to control bleeding were 48, 37 and 12%, respectively; the overall mortality was 28%. A significantly increased risk of mortality was associated with shock prior to onset of bleeding, sepsis, renal failure, cirrhosis, encephalopathy, presence of red blood in the nasogastric aspirate or per rectum, thrombocytopenia, hypoalbuminaemia, elevation of serum bilirubin, aminotransferases or urea levels, endoscopic evidence of active bleeding, the application of endoscopic haemostasis, rebleeding, transfusion of > or = 6 units of blood, surgical treatment or any subsequent complication. Use of nonsteroidal anti-inflammatory drugs (27%) was associated with a decreased mortality risk (odds ratio 0.2; P = 0.03). A multivariate analysis showed that the features at presentation which were independently associated with an increased risk of mortality were: a history of cirrhosis, sepsis, shock prior to onset of bleeding, hypo-albuminaemia and elevated serum aminotransferases. CONCLUSION: The prognosis of secondary upper gastrointestinal haemorrhage depends on the underlying diseases and on the general condition of the patient, rather than on the actual cause of bleeding.

Upper gastrointestinal hemorrhage. Comparison of the causes and prognosis in primary and secondary bleeders.

BACKGROUND: Hemorrhage from the upper gastrointestinal (UGI) tract is defined as primary when it is the cause of admission to hospital and as secondary when it complicates the course of patients admitted to hospital for other causes. The objective of this study was to compare the background features, course, and outcome of patients with primary and secondary bleeding. METHODS: All patients who underwent upper endoscopy because of acute UGI bleeding during 1988-91 in a tertiary care university hospital were studied longitudinally. The background features of primary bleeders (n = 321) were compared with those of secondary bleeders (n = 125). From the primary bleeders, a group was matched to the secondary bleeders by age, sex, use of nonsteroidal anti-inflammatory drugs (NSAIDs), and liver disease. The laboratory and endoscopic findings, hospital course, and mortality were compared in the two groups. RESULTS: Secondary bleeders were on the average 5 years older than primary bleeders and were significantly more likely to have ischemic heart disease, chronic lung disease, and chronic renal failure. Use of corticosteroids, H2 blockers, antacids, and anticoagulants in this group was significantly more prevalent, whereas the use of NSAIDs was similar in the two groups. The case-control analysis showed a similar distribution of the causes of bleeding in the two groups. However, rebleeding, endoscopic hemostasis, and complications were more frequent in secondary bleeders. The mortality in secondary bleeders was 28%, compared with 10% in matched primary bleeders, for a relative risk of 3.8 (p = 0.0002). CONCLUSION: Secondary hemorrhage is associated with an increased mortality, which is related to the underlying diseases and not to a difference in the causes of bleeding.

Acute upper gastrointestinal bleeding in Jerusalem 1988-91: causes, characteristics and relation to nonsteroidal anti-inflammatory drugs.

We analyzed 321 consecutive episodes of community-based acute upper gastrointestinal bleeding admitted to the Hadassah University Hospital in Jerusalem during 1988-91. Of these 71% were in males aged 56.2 +/- 1.2 years (mean +/- SE) and 29% were in females (67.9 +/- 1.7 years, P < 0.001). The main diagnoses were duodenal ulcer (39.5%), gastric ulcer (16.9%), esophageal varices (10.0%), erosive gastritis (8.2%) and esophagitis (7.5%). The distribution of these diagnoses differed significantly between the genders (P = 0.0003). In males the prevalence of duodenal ulcer and of esophageal varices was higher, and that of gastric ulcer and esophagitis lower, than in females. Gastric ulcer patients were oldest, were the least likely to have received anti-ulcer medications prior to admission, and had the highest levels of urea and the lowest levels of hemoglobin on admission. Use of nonsteroidal anti-inflammatory drugs increased significantly with age and was reported in 35% of the cases (aspirin in doses < 1.0 g/day in 21%, nonsalicylate anti-inflammatory agents in 11%, aspirin plus other anti-inflammatory drugs in 3%). Use of systemic corticosteroids was reported in 4%. The most distinctive features of the population with acute upper gastrointestinal bleeding in the present study compared to other series were the significantly higher proportion of duodenal ulcers and the lower proportion of Mallory-Weiss tears.