Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial.

OBJECTIVES: We hypothesized that early intervention in patients with lower gastrointestinal bleeding (LGIB) would improve outcomes and therefore conducted a prospective randomized study comparing urgent colonoscopy to standard care. METHODS: Consecutive patients presenting with LGIB without upper or anorectal bleeding sources were randomized to urgent purge preparation followed immediately by colonoscopy or a standard care algorithm based on angiographic intervention and expectant colonoscopy. RESULTS: A total of 50 patients were randomized to each group. A definite source of bleeding was found more often in urgent colonoscopy patients (diverticula, 13; angioectasia, 4; colitis, 4) than in the standard care group (diverticula, 8; colitis, 3) (the odds ratio for the difference among the groups was 2.6; 95% CI 1.1-6.2). In the urgent colonoscopy group, 17 patients received endoscopic therapy; in the standard care group, 10 patients had angiographic hemostasis. There was no difference in outcomes among the two groups-including: mortality 2%versus 4%, hospital stay 5.8 versus 6.6 days, ICU stay 1.8 versus 2.4 days, transfusion requirements 4.2 versus 5 units, early rebleeding 22%versus 30%, surgery 14%versus 12%, or late rebleeding 16%versus 14% (mean follow-up of 62 and 58 months). CONCLUSION: Although urgent colonoscopy identified a definite source of LGIB more often than a standard care algorithm based on angiography and expectant colonoscopy, the approaches are not significantly different with regard to important outcomes. Thus, decisions concerning care for patients with acute LGIB should be based on individual experience and local expertise.

Lower gastrointestinal bleeding--management.

Although acute LGIB is only about one fifth as common and is usually less hemodynamically significant than upper gastrointestinal bleeding, it presents numerous unique clinical challenges. The best diagnostic approach for patients with active bleeding is unknown, but urgent prepared colonoscopy is safe and likely to be beneficial (Fig. 3, Table 2). In patients who have aggressive bleeding or recurrent bleeding, it is critical for the practitioner to judge when angiography and surgery are necessary.

Ischemic colitis: a clinical review.

Ischemic colitis is the most common form of intestinal ischemia. It manifests as a spectrum of injury from transient self-limited ischemia involving the mucosa and submucosa to acute fulminant ischemia with transmural infarction that may progress to necrosis and death. Although there are a variety of causes, the most common mechanism is an acute, self-limited compromise in intestinal blood flow. Patients typically have mild abdominal pain and tenderness over the involved segment of bowel. There is usually passage of blood mixed with stool, but hemodynamically significant bleeding is unusual. Although computed tomography may have suggestive findings, colonoscopy is the procedure of choice for diagnosis. Supportive care with intravenous fluids, optimization of hemodynamic status, avoidance of vasoconstrictive drugs, bowel rest, and empiric antibiotics will produce clinical improvement within 1 to 2 days in most patients. Twenty percent of patients will have development of peritonitis or may deteriorate despite conservative management and will require surgery.

Most GERD symptoms are not due to acid reflux in patients with very low 24-hour acid contact times.

Ambulatory esophageal 24-hr pH monitoring is used to diagnose GERD by determining the total acid contact time and/or symptom index (SI). The aim of this study was to compare the relationship between total acid contact times and SI in two groups: patients with very low vs. very high total acid contact times. We reviewed 973 consecutive 24-hr pH studies and compared patients with the lowest and highest 5% of total acid contact times. The low reflux group was significantly younger (median 50 vs. 54 years) and more predominantly female (78 vs. 47%) than the high reflux group. Median total acid contact time was 0.6 and 26.4% in the low and high reflux groups, respectively. The median SI was significantly lower in the low vs. high reflux groups for all symptoms (heartburn, 0 vs. 100%; regurgitation, 20 vs. 100%; cough, 0 vs. 55%; chest pain, 0 vs. 75%; nausea, 0 vs. 100%; and total SI, 12 vs. 86%). In patients with very low total acid contact times, only 12% of symptoms (typical or atypical) are associated with acid reflux, compared to 86% in patients with very high acid contact times. Younger females are overrepresented in the very low reflux, low SI group.

Massive gastrointestinal hemorrhage due to rupture of a donor pancreatic artery pseudoaneurysm in a pancreas transplant patient.

Enteric drainage of secretions by anastomosing the donor duodenum to the recipient's small bowel has become common in pancreatic transplantation. While it eliminates many problems, endoscopic access to the transplanted duodenum and pancreas is made difficult. After a pancreas kidney transplant, the patient presented with massive hematochezia. Upper and lower endoscopy revealed large amounts of red blood in the colon but no specific bleeding site. Mesenteric angiography was normal but pelvic angiography showed rapid extravasation of contrast from a pseudoaneurysm of the pancreatic transplant artery. This was successfully embolized with coils. To the best of our knowledge, this is the first case of massive gastrointestinal hemorrhage because of rupture of a pseudoaneurysm of the donor pancreatic artery in a pancreas transplant patient. We report this case and review our institution's experience with all forms of gastrointestinal bleeding in pancreas transplant patients.

Gastrointestinal endoscopic evaluation of premenopausal women with iron deficiency anemia.

GOALS: To evaluate whether the gastrointestinal tract could be a source of chronic blood loss in premenopausal women with iron deficiency anemia. BACKGROUND: While premenopausal women with iron deficiency anemia are typically managed with simple iron replacement, the standard of care for postmenopausal women and men is to exclude a gastrointestinal source of bleeding. STUDY: We identified 111 premenopausal women who underwent endoscopy for the sole indication of iron deficiency anemia. RESULTS: The mean age was 42.5 years. Lesions potentially causative of iron deficiency anemia were detected in 22 patients (20%). Upper gastrointestinal lesions were present in 14 patients (13%) and included only erosive lesions. Lower gastrointestinal lesions were detected in 8 patients (7.2%) and included colon cancer (2.7%), inflammatory bowel disease (3.6%), and a colonic ulcer >1 cm (0.9%). Patients with upper gastrointestinal lesions were more likely to use aspirin or nonsteroidal antiinflammatory drugs (11/14, 79%) than patients with no lesions (26/89, 23%; P = 0.043). Occult blood was more common in patients with lower gastrointestinal lesions 8/8 (100%) and patients with upper gastrointestinal lesions (9/14, 64%) than in patients without lesions (28/89, 31%; P = 0.037 and 0.039). Gastrointestinal symptoms were significantly more common in patients with gastrointestinal lesions than in patients without lesions. CONCLUSIONS: A gastrointestinal source of chronic blood loss was identified in a substantial proportion of premenopausal women with iron deficiency anemia. Patients with gastrointestinal symptoms, fecal occult blood, and/or weight loss should undergo endoscopy.

Acute gastrointestinal bleeding.

Acute gastrointestinal bleeding is a common disorder with a wide spectrum of presentations that may encompass multiple clinical scenarios. Initial hemodynamic assessment and resuscitation are critical. Once accomplished, the source of bleeding should be localized, active bleeding should be stopped, the underlying abnormality should be treated, and recurrent bleeding should be prevented. The means to accomplish these goals depends on the specific clinical situation. For most forms of upper gastrointestinal bleeding, early endoscopy is the cornerstone of diagnosis and management. It can predict and improve clinical outcomes. A variety of endoscopic and pharmacologic modalities are effective at achieving and maintaining hemostasis. The optimum means of evaluation and treatment of acute lower gastrointestinal bleeding is less clear and is now evolving. Endoscopy (usually expectant, less often early) is widely used and effective for diagnosis but has unproven therapeutic benefits. Angiography is effective (diagnostically and/or therapeutically) in certain situations. Surgery offers the opportunity for definitive therapy at the cost of higher morbidity. At this time, the approach to evaluation and management should be based on the specific clinical situation and available local expertise.

Marked improvement in nocturnal gastroesophageal reflux in a large cohort of patients with obstructive sleep apnea treated with continuous positive airway pressure.

BACKGROUND: Nocturnal gastroesophageal reflux (nGER) is common in patients with obstructive sleep apnea (OSA). Small, short-term studies have shown that treatment with nasal continuous positive airway pressure (CPAP) decreases esophageal acid exposure. OBJECTIVE: To examine the relationship between OSA and nGER, and the effect of CPAP on nGER, in a long-term follow-up study of a large cohort of patients with OSA and nGER. METHODS: We prospectively studied 331 patients diagnosed as having OSA between October 1, 1993, and November 30, 2000. At baseline, patients graded their frequency of nGER symptoms on a scale of 1 (never) to 5 (always). All patients were prescribed CPAP for their OSA. At follow-up, the frequency of nGER symptoms was obtained by telephone interview. RESULTS: Of the 331 patients with OSA, nGER was present in 204 (62%) before treatment with CPAP. Follow-up was obtained in 181 patients (89%). Of these 181 patients, 165 (91%) were still using CPAP and 16 (9%) were not, forming the treatment and control groups, respectively. The patients compliant with CPAP had a significant improvement in nGER score, from a mean of 3.38 before CPAP treatment to 1.75 after treatment (48% improvement; P<.001), while patients not using CPAP (control subjects) showed no improvement (mean, 3.56 to 3.44; P =.55). There was a strong correlation between CPAP pressure and improvement in nGER score (correlation, r = 0.70; P<.001), with patients with higher CPAP pressures demonstrating a greater improvement in nGER score. CONCLUSIONS: Nocturnal GER is common in patients with OSA. Treatment with nasal CPAP decreases the frequency of nGER symptoms by 48%. Higher nasal CPAP pressures are associated with greater improvement in nGER.

Pasteurella multocida meningitis: case report and review of the last 11 y.

Pasteurella multocida meningitis is a rare clinical occurrence. We report a new case and review the 28 other cases described in the English literature. A history of recent animal contact remains strongly associated with P. multocida meningitis (noted in 89% of all cases), with licking of mucus surfaces or injured skin being most common. Bacteremia was present in 63% of all patients. Spread from an adjacent site of infection continues to be an important factor, with otitis media being documented or strongly suspected in 24% of all cases. The presenting signs and symptoms were characteristic of bacterial meningitis, with fever, headache, nucal rigidity and an altered level of consciousness being present in most patients. Cerebrospinal fluid analysis was typical for bacterial meningitis. Penicillin G or ampicillin was the most common definitive treatment; however, third-generation cephalosporins have been successful. The mean duration of treatment was 14 d. Neurologic complications were present in 17% of patients overall and mortality remains substantial at 25%. Although not statistically significant, there is a trend toward decreased neurologic complications and mortality during the last 11 y.

Diabetic foot: evaluation and management.

Diabetic foot disease in the form of ulceration, charcot joint fracture, and amputation affects 20% of patients with diabetes. This results in tremendous morbidity, mortality, and health care cost. The magnitude of this problem has been underrecognized by health care professionals. Impaired glucose control over a period of years affects peripheral nerve function by loss of protective sensation, muscle atrophy, foot deformity, and neuropathic fractures. Yearly foot examinations can identify risk factors. Regular nail care, callus removal, and education can prevent plantar ulceration. Protective footwear and custom orthotics improve function by reducing force and shear impact on the fragile foot and accommodate the patient's deformities. A cost-effective strategy of yearly comprehensive foot examinations, education, and appropriate interventions can improve both the quality and duration of life for those with diabetes mellitus.