A Case of Heyde Syndrome with Resolution of Gastrointestinal Bleeding Two Weeks After Aortic Valve Replacement.

BACKGROUND Heyde syndrome is the association between gastrointestinal (GI) bleeding from arteriovenous malformation (AVM) and aortic stenosis. The aim of this study was to review Heyde syndrome and to discuss the management of this condition. CASE REPORT A 56-year-old female with a history of severe aortic stenosis and recurrent GI bleeding secondary to small bowel AVM, presented for hospital admission with melena and maroon blood in her stool. The patient underwent esophagogastroduodenoscopy with push enteroscopy, full colonoscopy, and mesenteric angiogram with failure to identify any active bleeding sources. Her hemoglobin continued to drop, requiring daily transfusion of packed red blood cells (PRBCs). Von Willebrand factor (VWF) antigen was low at 37%, and VWF large multimers were low and consistent with acquired VWF disease. The patient was then transferred to a tertiary care center and underwent transcatheter aortic valve replacement. Two weeks after discharge, she presented again with an episode of melena, with hemoglobin of 7.6 gm/dL and hematocrit of 25.1%. She was transfused 4 units of PRBCs and monitored for 48 hours, and then discharged without further episodes of GI bleeding. At the 2-month follow-up, she had stable hemoglobin at 15.1 gm/dL without further episodes of GI bleeding. At the 6-month follow-up she showed stable hemoglobin at 14.3 gm/dL without further episodes of GI bleeding. CONCLUSIONS Physicians need to consider Heyde syndrome in patients with aortic stenosis and GI bleeding secondary to angiodysplasia. Physicians should also be attentive in patients with Heyde syndrome presenting with GI bleeding after undergoing aortic valve replacement, as GI bleeding might take time to resolve completely in these patients.

Potential use of telemedicine to provide outpatient care for inflammatory bowel disease.

OBJECTIVES: Patients with inflammatory bowel disease (IBD) often experience barriers to subspecialty access. We applied telemedicine, using a new computerized system called Collaborative Imaging, to resolve these barriers. We studied patients' experience and satisfaction, and clinic throughput. METHODS: We performed a prospective randomized controlled pilot study at a Veterans Affairs hospital, assigning patients into two groups: telemedicine encounter, with the IBD specialist remotely located, and standard encounter. We assessed patient experience and measured differences in satisfaction as well as clinic metrics such as appointment duration, wait time, and throughput. RESULTS: We enrolled 34 patients with Crohn's disease and ulcerative colitis who underwent 57 encounters in 9 months. Patients were mostly Caucasian men, with a mean age of 61 years. The two groups similarly rated as excellent their clinic experience and the major clinical satisfaction indices of attention to patient concerns, bedside manner, and perceived skill level of the doctor. The total clinic duration, wait time, and median number of patients per clinic were also similar. The fellow and subspecialist highly rated the technical and informational quality of the telemedicine sessions. CONCLUSIONS: IBD outpatient service may be delivered via a novel telemedicine system. In this pilot study, we observed a high level of patient satisfaction similar to that achieved with a direct clinical encounter.

The asymptomatic outpatient with abnormal liver function tests.

Traditionally, the constellation of biochemistry tests including liver enzymes, total bilirubin, and hepatic synthetic measures (prothrombin time (PT) and serum albumin level) are referred to as liver function tests (LFTs). Abnormal LFTs can be encountered during primary health care visits, routine blood donation, and insurance screening. A reported 1% to 4% of asymptomatic patients exhibit abnormal LFTs, leading to a sizeable number of annual consultations to a gastroenterology and/or hepatology practice. A cost-effective and systematic approach is essential to the interpretation of abnormal LFTs. A review of pattern of abnormal LFTs, detailed medical history, and a comprehensive physical examination help establish a foundation for further individualized testing. Further investigation often involves biochemical testing for disease-specific markers, radiographic imaging, and even consideration of a liver biopsy. In the following account, markers of hepatic injury are reviewed followed by a discussion on an approach to various patterns of abnormal LFTs in an asymptomatic patient.

Not your father's colonoscopy: a high-tech future for screening and surveillance of colorectal cancer.

The 20-year technology slump in endoscopic innovation is finally giving way to a flurry of technologies, of which many are directed specifically at improving or even replacing traditional colonoscopy. These technologies include "smart" overtubes, electronically mapped and driven instruments, and completely self-propelled devices. In addition to nonendoscopic technologies such as CT, these innovations may dramatically alter the practice of colorectal cancer screening, the "bread and butter" of gastroenterologists in this country. There are multiple and complex forces driving these changes, including a mismatch between the supply and demand in colonoscopy, patient convenience and comfort, costs, and more recently, a growing concern about the miss rate of conventional colonoscopy.