Cronkhite-Canada Syndrome Masquerading as Inflammatory Bowel Disease.

Cronkhite-Canada syndrome (CCS) is a rare nonhereditary gastrointestinal polyposis syndrome. We illustrate a case with clinical presentation of dysgeusia, chronic diarrhea and weight loss, and endoscopic features of diffuse gastric mucosa nodularity with circumferential nodular pancolitis and a solitary colonic polyp initially mimicking inflammatory bowel disease. After multidisciplinary discussion, the diagnosis of CCS was made. The patient received steroids with resultant clinical, endoscopic, and histological improvement. We discuss the treatment and risk of neoplasia in CCS.

Lessons of the month 1: When what you see is not UC (ulcerative colitis): an unusual presentation of pancolitis in a developed country.

The misdiagnosis of intestinal schistosomiasis is not uncommon given its variety of clinical manifestations and often shares similarities with ulcerative colitis. While endoscopy aids in diagnosis, findings are often non-specific and correlation with histopathological features is crucial in arriving at an accurate diagnosis which is confirmed by the presence of schistosome ova within the lamina propria. In this case study, we report our experience with a 50-year-old woman, who had been residing in Singapore for more than a decade, presenting with recurrent episodes of bloody diarrhoea.

Efficacy of small-volume simethicone given at least 30 min before gastroscopy.

AIM: To evaluate the efficacy of 5 mL simethicone solution in decreasing gastric foam if given at least 30 min before gastroscopy. METHODS: This was a randomized, placebo controlled, endoscopist blinded study performed at Changi General Hospital. Patients were at least 21 years old, had no prior surgical resection of the upper gastrointestinal tract, and scheduled for elective diagnostic gastroscopies. The primary outcome was the total mucosal visibility score (TMVS) which was evaluated using McNally score. The sample size was calculated to be 24 per group (SD 2.4, 80% power, P < 0.05, 2-sample t test). RESULTS: Fifty-four patients were randomised to receive either simethicone [1 mL liquid simethicone (100 mg) in 5 mL of water] or placebo (5 mL of water) at least 30 min before their gastroscopy. Six accredited consultants conducted the gastroscopy, and the interobserver agreement of scoring TMVS was good with a Kappa statistic of 0.73. The simethicone group had significantly better mean TMVS compared to placebo (5.78 ± SD 1.65 vs 8.89 ± SD 1.97, P < 0.001). The improvement was statistically significant for the duodenum and the gastric antrum, angularis, body, and fundus. Percent 51.9 of patients in the simethicone group had a TMVS of 4 (no bubbles at all) to 5 (only 1 area with minimal bubbles), while in the placebo group 3.7% of patients had TMVS of 4 or 5. The number needed to treat was 2.1 to avoid a TMVS of 6 and more. The simethicone group also had a significantly shorter procedure time with less volume of additional flushes required during gastroscopy to clear away obscuring gastric foam. CONCLUSION: With a premedication time of at least 30 min, 5 mL simethicone can significantly decrease gastric foam, decrease the volume of additional flushes, and shorten gastroscopy time.

The Use of Parenteral Nutrition Support in an Acute Care Hospital and the Cost Implications of Short-term Parenteral Nutrition.

INTRODUCTION: Parenteral nutrition (PN) is indicated for patients who are unable to progress to oral or enteral nutrition. There are no local studies done on estimating the cost of PN in acute settings. The aims of this study are to describe the demographics, costs of PN and manpower required; and to determine the avoidable PN costs for patients and hospital on short-term PN. MATERIALS AND METHODS: Patient data between October 2011 and December 2013 were reviewed. Data collected include demographics, length of stay (LOS), and the indication/duration of PN. PN administration cost was based on the cost of the PN bags, blood tests and miscellaneous items, adjusted to subsidy levels. Manpower costs were based on the average hourly rate. RESULTS: Costs for PN and manpower were approximately S$1.2 million for 2791 PN days. Thirty-six cases (18.8%) of 140 PN days were short-term and considered to be avoidable where patients progressed to oral/enteral diet within 5 days. These short-term cases totalled $59,154.42, where $42,183.15 was payable by the patients. The daily costs for PN is also significantly higher for patients on short-term PN (P <0.001). CONCLUSION: In our acute hospital, 90% of patients referred for PN were surgical patients. Majority of the cost comes from the direct daily cost of the bag and blood tests, while extensive manpower cost was borne by the hospital; 18.8% of our cohort had short-term avoidable PN. Daily PN may cost up to 60% more in patients receiving short-term PN. Clinicians should assess patient's suitability for oral/enteral feeding to limit the use of short-term PN.

A multicenter randomized comparison between high-definition white light endoscopy and narrow band imaging for detection of gastric lesions.

OBJECTIVE: Narrow band imaging (NBI) is generally considered to be useful for lesion characterization, but not enhanced detection of gastric lesions, because of the dark endoscopic view. We tested whether the new generation of NBI (190-NBI or 290-NBI), which is twice as bright as the previous version, would improve detection of premalignant gastric lesions compared with high-definition white light endoscopy (HD-WLE). PATIENTS AND METHODS: This was a multicenter prospective randomized study involving five tertiary institutions in the Asia-Pacific region. A total of 579 patients aged older than 50 years who underwent diagnostic upper gastrointestinal endoscopy were randomized to either HD-WLE or NBI. The outcome measurements were detection of intestinal metaplasia (IM), focal gastric lesions, and gastric cancers. RESULTS: Focal gastric lesions were detected in 83/286 (29%) and 119/293 patients (40.6%) by HD-WLE and by NBI, respectively (P=0.003). IM was detected in 22/286 patients (7.7%) by HD-WLE and in 52/293 patients (17.7%) by NBI (P<0.001). Gastric cancer were found in 7/286 (2.4%) and 3/293 patients (1%) in HD-WLE and NBI groups, respectively (P=0.189). CONCLUSION: NBI increased the detection rate of IM compared with HD-WLE.

Risk of Major Abdominal Surgery in an Asian Population-based Crohn's Disease Cohort.

BACKGROUND: Crohn's disease (CD) is increasing in incidence and prevalence in Asia, but there is a paucity of population-based studies on risk factors for surgery in Asian patients with CD. This will be useful to identify patients who may benefit from top-down treatment. This study describes the rates of abdominal surgery and identifies associated risk factors in Singaporean patients with CD. METHODS: This was a retrospective observational study. The medical records of Singaporeans diagnosed with CD from 1970 to 2013 were reviewed from 8 different hospitals in Singapore. The cumulative probability of CD-related abdominal surgery was estimated using the Kaplan-Meier method. The logistic regression model was used to assess associations between independent risk factors and surgery. RESULTS: The cohort of 430 Singaporean patients with CD included 63.5% Chinese, 11.9% Malay, and 24.7% Indians, with a male to female ratio of 1.6; median follow-up was 7.3 years (range, 2.9-13.0 yr) and median age at diagnosis 30.5 years (range, 19.5-43.7 yr). One hundred twelve patients (26.0%) required major abdominal surgery: the cumulative risk of surgery was 14.9% at 90 days, 21.2% at 5 years, 28.8% at 10 years, 38.3% at 20 years, and 50.6% at 30 years from diagnosis. Of the surgical patients, 75.0% were Chinese, 10.7% Malays, and 14.3% Indians; 21.4% underwent surgery for inflammatory disease, 40.2% for stricturing disease, and 38.4% for penetrating disease. Age at diagnosis (A2 17-40 yr, OR: 2.75, 95% confidence interval [CI], 1.14-7.76), ileal disease (L1 location, OR: 2.35, 95% CI, 1.14-5.0), stricturing (B2 OR: 6.09, 95% CI, 3.20-11.8), and penetrating behavior (B3 OR: 21.6, 95% CI, 9.0-58.8) were independent risk factors for CD-related abdominal surgery. Indian patients were less likely to require surgery (OR: 0.40, 95% CI, 0.19-0.78). CONCLUSIONS: Age at diagnosis, L1 location, B2, and B3 disease behavior are independent risk factors for abdominal surgery. Interestingly, despite a higher prevalence of CD in Indians, a smaller proportion of Indian patients required surgery. These findings suggest that both environmental and genetic factors contribute to the risk of surgery in Asian patients with CD.

Ten-day triple therapy versus sequential therapy versus concomitant therapy as first-line treatment for Helicobacter pylori infection.

BACKGROUND AND AIM: Clarithromycin-based triple therapy (TT) is the first-line treatment for Helicobacter pylori infection in Singapore. There is awareness that TT may no longer be effective due to increased clarithromycin resistance rates. Sequential therapy (ST) and concomitant therapy (CT) are alternative treatment regimens. This study aimed to compare the efficacy of 10-day TT, ST, and CT as first-line treatment for H. pylori infection. METHODS: A randomized study conducted in a teaching hospital. Patients aged 21 years and older with newly diagnosed H. pylori infection were randomized to 10-day TT, ST, or CT. Treatment outcome was assessed by 13-carbon urea breath test at least 4 weeks after therapy. Intention to treat (ITT), modified ITT (MITT), and per protocol (PP) analyses of the eradication rates were performed. RESULTS: A total of 462 patients were enrolled (ST: 154; TT 155; CT 153). Patient demographics were similar. Eradication rates for ST versus TT versus CT: ITT analysis: 84.4% versus 83.2% versus 81.7% (P = not significant [NS]); MITT analysis: 90.3% versus 92.1% versus 94.7% (P = NS); PP analysis: 94.1% versus 92.8% versus 95.4% (P = NS). Antibiotic resistance rates for amoxicillin, clarithromycin, and metronidazole were 4.7%, 17.9%, and 48.1%, respectively. Dual clarithromycin and metronidazole resistance occurred in 7.5%. Dual resistance and lack of compliance were predictors of treatment failure. CONCLUSIONS: TT, ST, and CT all achieved eradication rates above 80% on ITT and above 90% on MITT and PP analyses. Dual resistance and lack of compliance were predictors of treatment failure (clinicaltrials.gov: NCT02092506).

Disposition of linezolid or daptomycin in Enterococcal bloodstream infections according to vancomycin resistant Enterococcus colonization.

Vancomycin resistant Enterococcus (VRE) colonized patients are likely to receive VRE targeted Gram-positive antibiotics and may not be de-escalated appropriately once final cultures are available. A retrospective cohort study was conducted in VRE-colonized and non-VRE colonized patients with Enterococcal bloodstream infections. Of 101 patients (n = 50 VRE-colonized; n = 51 non-colonized), empiric therapy with linezolid or daptomycin was started more often in VRE-colonized than non-colonized patients (n = 8, 15.5% vs n = 27, 54%, p < 0.01). There was no difference in de-escalation once VRE infection was ruled out (non-colonized, n = 2, 66.7% vs VRE-colonized, n = 2, 50%, p = 0.09). This study encourages continued stewardship vigilance to decrease inappropriate antibiotic use.

Nutritional support in acute pancreatitis.

Acute pancreatitis can present as a mild or severe disease. Most patients have a mild disease and recover without requiring nutritional support. Patients with severe acute pancreatitis may develop systemic inflammatory response syndrome and progress to multi-organ failure. These ill patients have high metabolism and protein catabolism. Hence, the nutritional management of these patients can be challenging. The aim of nutritional support is to meet the elevated metabolic demands as far as possible without stimulating pancreatic secretion and yet maintaining the gut integrity. The concept of pancreatic rest has evolved over the years. To date, there is a substantial scientific proof that enteral nutrition (EN) in comparison to parenteral nutrition significantly reduces infectious complications, surgical interventions and mortality in predicted severe acute pancreatitis. EN may be able to improve outcome in these patients if given early. In this review, we summarized the current knowledge on nutrition in acute pancreatitis and shared our local experience.

The diagnostic utility of narrow band imaging magnifying endoscopy in clinical practice in a population with intermediate gastric cancer risk.

OBJECTIVE: Narrow band imaging (NBI) and NBI-magnifying endoscopy (ME) have been reported to facilitate the diagnosis of intestinal metaplasia (IM) and early gastric cancer (EGC) in high-risk populations. This study aimed at comparing the detection rate of focal gastric lesions by NBI against white light endoscopy (WLE), and examined the utility of NBI-ME in differentiating gastric mucosal pathology in a population with intermediate gastric cancer risk. METHODS: Chinese patients aged 35-70 years undergoing diagnostic gastroscopy (GIF FQ260Z) by six experienced endoscopists were enrolled prospectively. The sequence of endoscopic evaluation was WLE followed by NBI. Focal lesions were re-examined by NBI-ME. The incremental diagnostic yield of NBI over WLE and ability of NBI-ME to differentiate gastric mucosal pathology were analyzed. RESULTS: Over a 30-month period, 458 patients (mean age: 52 years; men: 53.7%; Helicobacter pylori positive: 20.1%) were recruited. WLE detected a focal gastric lesion in 43.7% (200/458). WLE made a definitive diagnosis in 148 out of 200 patients (147 benign lesions and one gastric cancer), whereas NBI-ME correctly clarified the nature of the remaining 52 lesions (benign: 51; EGC: one). NBI detected an additional 69 out of 458 lesions (type 0_IIa: 91.3%; type 0_IIb: 8.7%) missed by WLE; the diagnoses based on NBI-ME were IM (67/69), EGC (1/69), and benign lesion (1/69). Interobserver agreement study revealed a κ statistic of 0.71. CONCLUSION: NBI detected IM missed by WLE. NBI-ME was useful in differentiating the pathology of focal gastric mucosal lesions.

Is impedance pH monitoring superior to the conventional 24-h pH meter in the evaluation of patients with laryngorespiratory symptoms suspected to be due to gastroesophageal reflux disease?

OBJECTIVE: Cough and laryngo-pharyngeal symptoms (LPS) are associated with gastroesophageal reflux disease (GERD). The role of acid reflux (AR) and non-acid reflux (NAR) in atypical GERD pathogenesis is controversial. The aims of the study were to determine the prevalence of high esophageal acid exposure time (AET) in patients presenting with cough or LPS and determine the incremental yield of multichannel intraluminal impedance-pH (MII-pH) monitoring. METHODS: We undertook a prospective study of patients with cough or LPS referred for GERD evaluation between January 2009 and May 2011. All patients underwent esophageal manometry, gastroscopy and MII-pH. Patients' characteristics, gastroscopy findings, distal esophageal AET, bolus exposure (BE) time and numbers of AR and NAR episodes in the proximal and distal esophagus were studied. RESULTS: Overall 50 patients (22 male, mean age 47.5 ± 14.2 years) were evaluated for unexplained chronic cough (n = 23, 46.0%), and LPS symptoms including globus (n = 10, 20.0%), sore throat (n = 12, 24.0%) and hoarse voice (n = 5, 10.0%). A normal gastroscopy, Los Angeles grade A and B esophagitis occurred in 44 (88.0%), 5 (10.0%) and 1 (2.0%) patient, respectively. Seven (14.0%) recorded elevated AET (chronic cough, 4; sore throat, 2; and hoarse voice, 1). Nine patients recorded abnormal impedance characteristics (raised BE time and/or increased reflux numbers) despite a normal AET leading to an incremental diagnostic yield of 18%. CONCLUSION: An isolated high AET is uncommon in patients with cough or LPS. Combined MII-pH improves the diagnostic yield in patients with atypical GERD manifestations.

To Bravo or not? A comparison of wireless esophageal pH monitoring and conventional pH catheter to evaluate non-erosive gastroesophageal reflux disease in a multiracial Asian cohort.

OBJECTIVE: Non-erosive reflux disease (NERD) constitutes the majority of patients with gastroesophageal reflux disease (GERD). Esophageal pH monitoring is useful in distinguishing patients with NERD from functional heartburn. The gastroenterologist often faces the dilemma of choosing the most appropriate investigative modality. The wireless Bravo capsule allows prolonged 48 hour monitoring with improved patient tolerance, but concerns regarding its reduced sensitivity compared to conventional pH catheter have been raised. We compared the prevalence of high esophageal acid exposure and positive symptom correlation profiles (using the symptom index [SI] and symptom association probability [SAP]) in patients who underwent Bravo compared to patients who underwent conventional pH catheter, and evaluated the efficacy of Bravo monitoring in a multiracial Asian cohort. METHODS: Retrospective analysis of all pH studies performed between January 2004 and February 2009 for patients with persistent reflux symptoms and a normal gastroscopy. RESULTS: 66 (27 Male, 42.4 +/- 13.4 years) and 55 (24 Male, 47.1 +/- 13.3 years) patients underwent wireless and pH catheter evaluation respectively. "True NERD" (abnormal acid exposure) was diagnosed in 26 (39.4%) and 20 (36.4%) patients (pNS) while "acid-sensitive esophagus" (SI > or = 50% and/or SAP > or = 95%) occurred in 14 (21.2%) and 12 (21.8%) patients (pNS) using the wireless and pH catheter respectively. Extended recording time with Bravo led to an incremental diagnostic yield of 30%. CONCLUSION: The wireless capsule was well tolerated. The diagnostic yield was similar using both modalities. With the increasing availability of impedance-pH technology, it is uncertain if devices that detect only acid-reflux events will be surpassed.