Evaluating a combined bowel preparation for small-bowel capsule endoscopy: a prospective randomized-controlled study.

BACKGROUND: Capsule endoscopy (CE) is frequently hindered by intra-luminal debris. Our aim was to determine whether a combination bowel preparation would improve small-bowel visualization, diagnostic yield, and the completion rate of CE. METHODS: Single-blind, prospective randomized-controlled study of outpatients scheduled for CE. Bowel-preparation subjects ingested 2 L of polyethylene glycol solution the night prior to CE, 5 mL simethicone and 5 mg metoclopramide 20 minutes prior to CE and laid in the right lateral position 30 minutes after swallowing CE. Controls had no solid food after 7 p.m. the night prior to CE and no liquids 4 hours prior to CE. Participants completed a satisfaction survey. Capsule readers completed a small-bowel-visualization assessment. RESULTS: Fifty patients were prospectively enrolled (56% female) with a median age of 54.4 years and 44 completed the study (23 patients in the control group and 21 in the preparation group). There was no significant difference between groups on quartile-based small-bowel visualization (all P > 0.05). There was no significant difference between groups in diagnostic yield (P = 0.69), mean gastric (P = 0.10) or small-bowel transit time (P = 0.89). The small-bowel completion rate was significantly higher in the preparation group (100% vs 78%; P = 0.02). Bowel-preparation subjects reported significantly more discomfort than controls (62% vs 17%; P = 0.01). CONCLUSIONS: Combined bowel preparation did not improve small-bowel visualization but did significantly increase patient discomfort. The CE completion rate improved in the preparation group but the diagnostic yield was unaffected. Based on our findings, a bowel preparation prior to CE does not appear to improve CE performance and results in decreased patient satisfaction (ClinicalTrials.gov, No. NCT01243736).

Severe spruelike enteropathy associated with olmesartan.

OBJECTIVE: To report the response to discontinuation of olmesartan, an angiotensin II receptor antagonist commonly prescribed for treatment of hypertension, in patients with unexplained severe spruelike enteropathy. PATIENTS AND METHODS: All 22 patients included in this report were seen at Mayo Clinic in Rochester, Minnesota, between August 1, 2008, and August 1, 2011, for evaluation of unexplained chronic diarrhea and enteropathy while taking olmesartan. Celiac disease was ruled out in all cases. To be included in the study, the patients also had to have clinical improvement after suspension of olmesartan. RESULTS: The 22 patients (13 women) had a median age of 69.5 years (range, 47-81 years). Most patients were taking 40 mg/d of olmesartan (range, 10-40 mg/d). The clinical presentation was of chronic diarrhea and weight loss (median, 18 kg; range, 2.5-57 kg), which required hospitalization in 14 patients (64%). Intestinal biopsies showed both villous atrophy and variable degrees of mucosal inflammation in 15 patients, and marked subepithelial collagen deposition (collagenous sprue) in 7. Tissue transglutaminase antibodies were not detected. A gluten-free diet was not helpful. Collagenous or lymphocytic gastritis was documented in 7 patients, and microscopic colitis was documented in 5 patients. Clinical response, with a mean weight gain of 12.2 kg, was demonstrated in all cases. Histologic recovery or improvement of the duodenum after discontinuation of olmesartan was confirmed in all 18 patients who underwent follow-up biopsies. CONCLUSION: Olmesartan may be associated with a severe form of spruelike enteropathy. Clinical response and histologic recovery are expected after suspension of the drug.

Constrictive pericarditis in chronic ulcerative colitis.

Acute pericarditis has been described as an extraintestinal manifestation of inflammatory bowel disease (IBD), as well as a consequence of IBD treatment, specifically sulfasalazine and mesalamine. Until now, there have been no reported cases of constrictive pericarditis associated with IBD or its treatment. A 37-year-old woman with a 24-year history of chronic ulcerative colitis (CUC) presented with a 3-month history of fevers, palpitations, dyspnea, syncope, and retrosternal chest pain. Two weeks before symptoms, she had initiated oral mesalamine for an ongoing CUC flare. Physical examination suggested constrictive pericarditis. An echocardiogram revealed a thickened pericardium with a nearly circumferential fibrinous effusion, with Doppler confirming diastolic compromise. The patient proceeded to radical pericardectomy. Pathological examination showed grossly hemorrhagic acute and chronic pericarditis, with cultures and cytology negative. To date, only 104 cases of IBD with acute pericarditis have been reported, with fewer than 10 cases of mesalamine-induced acute pericarditis reported. This is the first reported case of constrictive pericarditis related to IBD or its treatment. Although our patient may have had IBD-associated constrictive pericarditis, her mesalamine use raises the possibility of a drug-induced constrictive pericarditis.