Enteroscopy as a tool for diagnosing gastrointestinal bleeding requiring blood transfusion

Iron-deficiency anemia secondary to gastrointestinal blood loss is a common cause of hospitalization. In many cases, the bleeding site cannot be defined despite thorough routine examination of the gastrointestinal tract. The aim of this study was to evaluate push enteroscopy as a diagnostic tool in patients with severe anemia, secondary to recurrent gastrointestinal bleeding, that required management by transfusion. Thirty-five consecutive push enteroscopy investigations were performed in 1998 and 1999 on 25 patients (15 men, 10 women). Mean age was 57 +/- 16 years (range, 33-83). All patients had received blood transfusions because of pronounced anemia secondary to gastrointestinal bleeding. Before push enteroscopy, all patients had been investigated with esophagogastroduodenoscopy, colonoscopy, and small-bowel radiography using the double contrast technique; no bleeding site was found. In addition, 10 of 25 patients had been investigated beforehand with 99mTc-labelled red blood cell scintigraphy, and 5 of 25 with scintigraphy for Meckel diverticulum. Two patients were also investigated with angiography before the push enteroscopy, and in six patients an additional total intraoperative enteroscopy was performed, preceded by a new colonoscopy, esophagogastroduodenoscopy, and push enteroscopy. A bleeding site was disclosed in 15 of 25 (60%) patients. In 7 of 25 patients (28%) the bleeding site was found in the stomach or esophagus. even though the patients had undergone one or two esophagogastroduodenoscopies earlier with normal findings. Total intraoperative enteroscopy identified a bleeding site in four of six (67%) patients studied. Two patients had bleeding hemangiomas that were resected surgically. Two patients had small intestinal adenomas, one with adenocarcinoma in situ. Push enteroscopy performed with an overtube inserted under fluoroscopic guidance is an important diagnostic tool in patients in whom conventional examinations do not disclose bleeding sites. Interestingly, 28% of patients had bleeding within reach of the gastroscope, indicating that a new upper endoscopy should be recommended before push enteroscopy is performed. When no positive findings are seen on push enteroscopy and the patient is affected by severe, recurrent iron-deficiency anemia, total intraoperative enteroscopy should be considered.     

Gallstones are associated with carotid atherosclerosis

Background/Aims: Gallstone disease (GD) and cardiovascular disease (CD) are common diseases worldwide with considerable economical impact and they are strongly associated. Carotid atherosclerosis is an excellent marker of risk for CD like stroke and myocardial infarction. The aim of this study was to assess the association between gallstones and carotid atherosclerosis. Methods: A cross‐sectional study was conducted. We evaluated subjects with ultrasonographical evidence of GD and asymptomatic subjects without such evidence. Anthropometric, clinical and biochemical variables were collected. The Metabolic syndrome was evaluated using adult treatment panel III criteria. Carotid artery intima–media thickness (CIMT) was determined by a standard ultrasound protocol. Insulin‐like growth factor‐1 (IGF‐1) serum levels were measured in all subjects. Results: We studied 191 subjects: 62 subjects with GD (53.2% males) and 129 asymptomatic subjects without GD (65.9% males). Subjects with GD exhibited a higher body mass index, body fat percent, insulin serum levels and CIMT (P<0.05 for all). The prevalence of GD was higher in subjects with a CIMT>0.75 independently of other factors [odds ratio (OR) 2.12, 95% confidence interval (CI) 1.04–4.34; P=0.039], and for every 0.1 mm increase in CIMT the independent probability to be a case of GD increased by a factor of 1.25 (95% CI 1.02–1.53; P=0.027). IGF‐1 levels did not differ among groups. Conclusions: Subjects with GD exhibit greater carotid atherosclerosis, and therefore have a higher risk for stroke and myocardial infarction.     

Alternating proliferative capacity in the rat gastrointestinal mucosa. Effects of E2 prostaglandins and indomethacin

Having previously observed an apparent uneven distribution of proliferating cells in the gastric corporic mucosa of the rat, we examined the mitotic distribution along 8-mm sections of gastric and jejunal epithelia. Metaphases were arrested with vincristine to facilitate mitotic count, and the effects of treatment with a prostaglandin E2 analogue and a cyclooxygenase blocker were examined. Clusters of mitotic figures alternating with non-proliferating areas were observed in the gastric corporic epithelium of control rats. During 4 h mitotic activity was absent over 21% of the corporic mucosa. Extending the examined area to about 240 glands reduced substantially the error of mitotic counts. An uneven distribution of mitoses was found in the antral and jejunal epithelium, but areas without proliferating cells were uncommon. Treatment with the prostaglandin E2 analogue reduced the number of mitosis-free areas in the gastric corpus to 13%, and clusters were less easily identified. The total mitotic count was unaffected by treatment. In the jejunum prostaglandin increased the absolute number of mitoses. The mitotic span was also increased, reflecting the uneven distribution. Indomethacin produced the opposite effects to the prostaglandin analogue, including reduction of epithelial height. Of the gastric corporic mucosa 35% was non-proliferating during the observation period, but the clustering phenomenon was still apparent. Absence of dose relationship was attributed to ulcerogenic actions of high doses of indomethacin. It is concluded that mitoses are unevenly distributed in the upper gastrointestinal epithelium of the rat and that safe estimates of mitotic count require examination of large corporic areas.(ABSTRACT TRUNCATED AT 250 WORDS)     

Outcomes of a Peritoneal Dialysis Program in Remote Communities Within Colombia

♦ Background and Objective: Colombia is a country of diverse geographic regions, some with mountainous terrain that can make access to urban areas difficult for individuals who live in remote areas. In 2005, a program was initiated to establish remote peritoneal dialysis (PD) centers in Colombia to improve access to PD for patients with end-stage renal disease who face geographic or financial access barriers.♦ Patients and Methods: The present study was a multi-center cohort observational study of prevalent home PD patients who were at least 18 years of age and were being managed by one of nine established remote PD centers in Colombia over a 2-year period. Data were collected from clinical records, databases, and patient interviews. Patient survival, incidence of peritonitis, and rate of withdrawal from PD therapy were assessed.♦ Results: A total of 345 patients were eligible for the study. The majority (87.8%) of patients lived on one to two times a minimum monthly salary (equivalent to US$243 – US$486). On average, patients traveled 1.2 hours and 4.3 hours from their home to their remote PD center or an urban reference renal clinic, respectively. The incidence rate of peritonitis was 2.54 episodes per 100 patient-months of therapy. A bivariate analysis showed a significantly higher risk of peritonitis in patients who were living on less than one times a monthly minimum salary (p < 0.05) or who had a dirt, cement, or unfinished wood floor (p < 0.05). The 1-year and 2-year patient survival rates were 92.44% and 81.55%, respectively. The 1-year and 2-year technique survival rates were 97.27% and 89.78%, respectively.♦ Conclusions: With the support of remote PD centers that mitigate geographic and financial barriers to healthcare, home PD therapy is a safe and appropriate treatment option for patients who live in remote areas in Colombia.     

Apical Hypertrophic Cardiomyopathy: Preliminary Attempt at Palliation with Use of Subselective Alcohol Ablation

We report a case of severe apical hypertrophic cardiomyopathy in order to discuss the nature of this unusual condition and the possibility of using selective alcohol ablation to effectively treat symptomatic hypertrophic cardiomyopathy that presents with apical aneurysm. A 73-year-old woman with severe, progressive dyspnea and intermittent chest pain was found to have localized left ventricular apical dyskinesia distal to an obstructive mid-distal muscular ring. The ring caused total systolic obliteration of the apical left ventricular cavity. Apical cavity pressure was extremely high, up to 330 mmHg—200 mmHg above that in the main left ventricular cavity. Because of the danger of apical rupture and clot formation, we attempted the experimental use of alcohol ablation for effective palliation. We present our pilot experience, offer a novel interpretation of the nature of this obscure entity, and possibly justify a new catheter treatment. In addition, we discuss the developmental, pathophysiologic, and clinical implications of this unusual form of hypertrophic cardiomyopathy. To our knowledge, ours is the first reported use of subselective, modified-protocol alcohol septal ablation to treat an obstructive mid-apical muscular ring in a patient with apical hypertrophic cardiomyopathy.Key words: Cardiomyopathy, hypertrophic/complications/epidemiology/physiopathology/therapy; ethanol/administration & dosage/therapeutic use; heart septum/pathology; hypertrophy, left ventricular/diagnosis; myocardial ischemia/complications; treatment outcomeHypertrophic obstructive cardiomyopathy (HOCM) is a congenital heart condition characterized by ventricular hypertrophy and a progressive worsening of symptoms, as related to the worsening of the subaortic gradient.^1,2 Either traditional surgical septal myomectomy^3,4 or alcohol septal ablation (ASA)^2,4,5 can be used to treat HOCM by effectively reducing the subaortic gradient.^1,2 We describe the case of an elderly woman who had the rarer variant of hypertrophic cardiomyopathy (HCM)—that with apical aneurysm and mid-ventricular obstruction. We describe in detail the experimental use of subselective alcohol ablation to treat the obstructive mid-apical muscular ring in this patient, and we revisit the nature of apical HCM.     

Health-related Quality of Life After Pediatric Liver Transplant: Single-Center Experience in Chile

IntroductionOrthotopic liver transplantation is the treatment of choice for most terminal liver diseases in children. Currently, the improved survival of these patients is well documented, but their quality of life post-transplant is not described. In Chile, Hospital Luis Calvo Mackenna (HLCM) has performed pediatric liver transplantation in children from around the country since 1994. The aim of this study is to evaluate our patients' and parents' current quality of life.MethodsA cross-sectional study was conducted between July 2010 and June 2011. All liver transplant patients currently in control at HLCM were invited to complete the PedsQL 4.0 report (Pediatric Quality of Life Inventory). For each group, average score was calculated and comparisons were done using Student t and χ² tests.ResultsForty-nine patients were enrolled. One-third of the patients were between 2 and 4 years, one-third between 5 and 12, and the rest were 13 to 18 years old. Half of the patients had their transplants for more than 3 years, 53% were female, 53% lived in cities far from the transplant center, 72.5% had chronic liver disease, 53% had received a liver from cadaveric donor, and 21% had received more than 1 liver transplant. Patients under 4 years referred good health-related quality of life (HRQOL) in all categories. All school-age patients had poor or very poor psychosocial HRQOL.DiscussionOur good results obtained in transplant patients under 4 years may be because the questionnaire was completed by caregivers. The school-age patients were affected in terms of school functioning, as they were not able to participate in all the activities. These findings need to be compared with HRQOL perception in other groups, such as children with other chronic conditions, and evaluated with other broader factors, as reported in international HRQOL publications.