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Gastroenterology, Volume 134, Issue 4, Pages A-164, April 2008, Authors:Bani Chander; Robert Kule; Peter J. Baiocco; Sita S. Chokhavatia; Donald P. Kotler; Michael Poles; Sondra Zabar; Elizabeth H. Weinshel. Gastroenterology ...
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Identifying the source of lower gastrointestinal hemorrhage in patients with chronic liver disease and portal hypertension can be challenging. We present 2 cases of hemorrhage from rectal varices and a discussion on the differences... more
Identifying the source of lower gastrointestinal hemorrhage in patients with chronic liver disease and portal hypertension can be challenging. We present 2 cases of hemorrhage from rectal varices and a discussion on the differences between simple hemorrhoids and rectal varices. Evaluation of rectal bleeding in patients with portal hypertension is discussed and possible therapeutic options are described.
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Objectives:In patients with chronic human immunodeficiency virus (HIV)-related diarrhea undergoing lower endoscopy, the decision to perform flexible sigmoidoscopy or colonoscopy is controversial. The purpose of this study is twofold: 1)... more
Objectives:In patients with chronic human immunodeficiency virus (HIV)-related diarrhea undergoing lower endoscopy, the decision to perform flexible sigmoidoscopy or colonoscopy is controversial. The purpose of this study is twofold: 1) to evaluate the diagnostic yield of colonoscopy in a large group of patients with chronic HIV-related diarrhea and negative stool studies, and 2) to determine whether colonoscopy is superior to flexible sigmoidoscopy in this setting.Methods:All HIV-infected patients with chronic diarrhea who were referred for diagnostic colonoscopy at Bellevue Hospital Center between January 1992 and December 1996 were identified. Patient charts, pathology reports, and endoscopy records were reviewed.Results:During the 5-yr study period, 317 consecutive patients with chronic unexplained diarrhea undergoing colonoscopy were identified. A potential cause of diarrhea was found in 116 patients (36.6%). Cytomegalovirus was the most common pathogen detected (24%). The yield of colonoscopy was significantly higher in patients with a CD4 count of < 100 cells/mm3 than in those with higher CD4 counts (44.8%vs 6.4%, p < 0.0001). Thirty percent of pathogens and 75% of lymphomas were identified only on biopsies taken from the proximal colon, well beyond the reach of the flexible sigmoidoscope. Importantly, 94% of the pathogens that were found only in the proximal colon were organisms for which effective therapy is currently available.Conclusions:Colonoscopy is superior to flexible sigmoidoscopy in HIV-infected patients with chronic unexplained diarrhea. If flexible sigmoidoscopy had been performed instead of colonoscopy, 30% of pathogens would have been missed and 75% of lymphomas would have escaped detection.
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To assess and teach cultural competency skills at the fellowship training level through the use of objective structured clinical examinations (OSCEs). We revised four scenarios to infuse a specific focus on cross-cultural care, and to... more
To assess and teach cultural competency skills at the fellowship training level through the use of objective structured clinical examinations (OSCEs). We revised four scenarios to infuse a specific focus on cross-cultural care, and to render them appropriate for gastroenterology fellows. Three are discussed here: (1) Poor Health Literacy; (2) Disclosing/Apologizing for a Complication to a Patient Who Mistrusts the Healthcare System; and (3) Breaking Bad News to a Fatalistic Patient. A fourth case emphasizing shared decision-making will be described elsewhere. Four stations were completed by fellows and observed live by four faculty members, and the fellows' performance was assessed. Eleven fellows from four programs participated in the four OSCE. In the "Poor Health Literacy" case, 18% (2/11) of participants recognized that the standardized patient (SP) had below-basic health literacy. None successfully evaluated the SP's reading skills in a culturally-sensitive ma...
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The aim of this study was to determine the outcome of patients with HIV-associated esophageal disease refractory to empiric antifungal therapy, both before and after the introduction of protease inhibitors. We reviewed the medical records... more
The aim of this study was to determine the outcome of patients with HIV-associated esophageal disease refractory to empiric antifungal therapy, both before and after the introduction of protease inhibitors. We reviewed the medical records of 629 consecutive HIV-infected patients with odynophagia, dysphagia, or both esophageal symptoms refractory to at least one week of empiric antifungal therapy who underwent endoscopy between January 1992 and January 1997 at Bellevue Hospital Center. Endoscopy identified an etiology in 96.2% of patients, with cytomegalovirus ulcers (40.0%) and idiopathic ulcers of the esophagus (26.67%) being the most common lesions found. Overall, 91.4% of patients had a response to disease-specific therapy. In patients taking protease inhibitors, recurrent symptoms were less common (26.5% vs 36.7%, P = 0.03) and median survival was longer (172 vs 125 weeks. P = 0.006) than in those who were not treated with these potent antiretroviral medications. Protease inhibi...
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In the general population, acute upper gastrointestinal hemorrhage (UGIH) is a common problem that results in significant morbidity and mortality. The aim of this study was to determine the etiology, clinical outcome, and risk factors for... more
In the general population, acute upper gastrointestinal hemorrhage (UGIH) is a common problem that results in significant morbidity and mortality. The aim of this study was to determine the etiology, clinical outcome, and risk factors for rebleeding and mortality in a large cohort of human immunodeficiency virus (HIV)-infected patients with acute UGIH. We reviewed the medical records of consecutive HIV-infected patients with acute UGIH who were referred for an endoscopic evaluation from January 1992 through January 1997 at Bellevue Hospital Center. During the 5-yr study period, 297 HIV-infected patients with acute UGIH were evaluated by endoscopy. Gastroduodenal ulcers (25.6%), esophageal ulcers (21.5%), and Kaposi's sarcoma (19.2%) were the three most common causes of acute UGIH. Fifteen percent of patients rebled within 30 days and independent predictors of rebleeding included a CD4 count of <200 cells/mm3, inpatient status, a hemoglobin of <8 g/dl, major stigmata of hem...
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Patients infected with human immunodeficiency virus (HIV) are at risk for a variety of liver diseases. We undertook a retrospective study of 501 HIV-seropositive patients to assess the yield of percutaneous liver biopsy. The most common... more
Patients infected with human immunodeficiency virus (HIV) are at risk for a variety of liver diseases. We undertook a retrospective study of 501 HIV-seropositive patients to assess the yield of percutaneous liver biopsy. The most common indications for liver biopsy were liver test abnormalities (89.5%), fever for 2 weeks (71.9%), and hepatomegaly (52.0%). The most common biopsy-derived diagnosis was Mycobacterium avium complex (MAC), seen in 87 (17.4%) biopsies. Mycobacterium tuberculosis was found in 13 biopsies (2.6%). In 28 biopsies (5.6%) mycobacteria was seen, but speciation of the organism was not possible. Chronic active viral hepatitis was seen in 60 biopsies (12.0%). Opportunistic hepatic infection from other organisms was found in 14 biopsies (2.8%). The most common neoplasm was lymphoma, which was seen in 12 biopsies (2.4%). MAC infection of the liver was associated with elevated alkaline phosphatase (p = 0.01). Among patients with fever for 2 weeks after an extensive negative workup including bone marrow biopsy, 58.2% had a diagnosis by liver biopsy. Overall, 64.3% of liver biopsies yielded a histopathological diagnosis, 45.7% of which were potentially treatable. We could not evaluate whether liver biopsy had a positive effect on patient outcome and survival, nor did we attempt to prove that liver biopsy resulted in a change in treatment or a change in preprocedure clinical diagnosis. Thus, questions about the efficacy of liver biopsy cannot be answered. Liver biopsy may be a helpful diagnostic tool in HIV-positive patients with fever, liver test abnormalities or hepatomegaly.
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Research Interests: Bariatric Surgery, Risk assessment, Humans, United States, Female, and 18 moreMale, Registries, Obesity Surgery, Clinical Sciences, Middle Aged, Gastrointestinal Endoscopy, Adult, Public health systems and services research, Cost Benefit Analysis, Retrospective Studies, Group, Morbid Obesity, Risk Assessment, Gastric Bypass, Gastric Ulcer, Medical Records, Sensitivity and Specificity, and Gastroscopy
We hypothesized that laparoscopic adjustable gastric banding (LAGB) reduces weight and modulates ghrelin production, but largely spares gastrointestinal endocrine function. To examine this hypothesis, we determined plasma concentrations... more
We hypothesized that laparoscopic adjustable gastric banding (LAGB) reduces weight and modulates ghrelin production, but largely spares gastrointestinal endocrine function. To examine this hypothesis, we determined plasma concentrations of appetite-control, insulinotropic, and digestive hormones in relation to LAGB. Twenty-four patients undergoing LAGB were prospectively enrolled. Body mass index (BMI) was measured and blood samples obtained at baseline and 6 and 12 months post-surgery. Plasma concentrations of leptin, acylated and total ghrelin, pancreatic polypeptide (PP), insulin, glucose-dependent insulinotropic peptide (GIP), active glucagon-like peptide-1 (GLP-1), gastrin, and pepsinogens I and II were measured using enzyme-linked immunoassays. Median percent excess weight loss (%EWL) over 12 months was 45.7% with median BMI decreasing from 43.2 at baseline to 33.8 at 12 months post-surgery (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). Median leptin levels decreased from 19.7 ng/ml at baseline to 6.9 ng/ml at 12 months post-surgery (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). In contrast, plasma levels of acylated and total ghrelin, PP, insulin, GIP, GLP-1, gastrin, and pepsinogen I did not change in relation to surgery (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; 0.05). Pepsinogen II levels were significantly lower 6 months after LAGB but returned to baseline levels by 12 months. LAGB yielded substantial %EWL and a proportional decrease in plasma leptin. Our results support the hypothesis that LAGB works in part by suppressing the rise in ghrelin that normally accompanies weight loss. Unchanged concentrations of insulinotropic and digestive hormones suggest that gastrointestinal endocrine function is largely maintained in the long term.
Research Interests: Bariatric Surgery, Prospective studies, Humans, Weight Loss, Female, and 15 moreBlood sampling, Male, Follow-up studies, Body Mass Index, Gastric banding, Obesity Surgery, Clinical Sciences, Middle Aged, Body mass index (BMI), Adult, Public health systems and services research, Time Factors, Appetite Regulation, Peptide hormones, and Laparoscopy
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Interferon-alpha is used by physicians to treat numerous common medical disorders; however, therapy is often limited by side effects. Pulmonary complications, such as interstitial pneumonitis and bronchiolitis obliterans organizing... more
Interferon-alpha is used by physicians to treat numerous common medical disorders; however, therapy is often limited by side effects. Pulmonary complications, such as interstitial pneumonitis and bronchiolitis obliterans organizing pneumonia, have been described in patients receiving interferon-alpha therapy. Exacerbation of asthma induced by subcutaneous administration of interferon-alpha has not been previously reported. We describe two patients with mild asthma in whom treatment with interferon-alpha for chronic hepatitis C resulted in exacerbation of the underlying asthma. The severe asthmatic symptoms resolved promptly after use of interferon-alpha was discontinued and corticosteroid therapy was initiated. Repeated treatment with interferon-alpha several months later resulted in a rapid, more severe exacerbation of asthma in both patients. Patients undergoing therapy with interferon-alpha, especially those with chronic asthma, should be monitored closely for pulmonary symptoms. If these symptoms develop, patients should be instructed to discontinue use of interferon-alpha and seek medical attention immediately.
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The effect of protease inhibitors (PIs) on the outcome of AIDS-associated cytomegalovirus (CMV) colitis is unknown. The aim of this study was to determine the impact of PIs on the recurrence of CMV disease and long-term survival in a... more
The effect of protease inhibitors (PIs) on the outcome of AIDS-associated cytomegalovirus (CMV) colitis is unknown. The aim of this study was to determine the impact of PIs on the recurrence of CMV disease and long-term survival in a large cohort of acquired immunodeficiency syndrome (AIDS) patients with CMV colitis. We reviewed the medical records of 252 AIDS patients who were diagnosed with CMV colitis by colonoscopy between January 1992 and January 1997 at Bellevue Hospital (New York, NY, U.S.A.). Follow-up data were obtained from chart review and direct telephone contact. A complete response to ganciclovir and/or foscarnet therapy was seen in 87.0% of the patients. Recurrence of CMV colitis occurred in 53.1% of patients and was significantly less common in those who received maintenance therapy (36.1% vs. 56.7%; p = 0.03) and in those who were treated with PIs (22.8% vs. 71.9%; p &lt; 0.001). During follow-up. 69.3% of patients died. Multivariate analysis using Cox regression showed that mortality was increased in patients with recurrent CMV colitis (relative risk [RR] of death, 1.7: 95% CI, 1.1-2.6; p = 0.02) and comorbid disease (RR, 1.5: 95% CI, 1.1-2.2; p = 0.02), and decreased in those who were treated with PIs (RR, 0.42; 95% CI, 0.3-0.7; p = 0.001). The median survival was 71 weeks and was significantly longer in patients who were treated with PIs than in those who did not receive these potent anti-retroviral medications (99 vs. 51 weeks; p &lt; 0.001). PIs significantly improve the outcome of AIDS-associated CMV colitis.
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Meckel&#39;s diverticulum, which is the most common congenital anomaly of the gastrointestinal tract, occurs when the vitelline duct persists past the 7th week of gestation. Although complications may occur in 8% to 22% of patients... more
Meckel&#39;s diverticulum, which is the most common congenital anomaly of the gastrointestinal tract, occurs when the vitelline duct persists past the 7th week of gestation. Although complications may occur in 8% to 22% of patients with Meckel&#39;s diverticula, adenocarcinoma is very uncommon. We describe a patient with early gastric cancer who was incidentally found to have a superficial adenocarcinoma arising from ectopic gastric mucosa within a Meckel&#39;s diverticulum. To the best of our knowledge, synchronous gastric adenocarcinoma in a patient with Meckel&#39;s diverticulum has not been previously reported.
Research Interests: Humans, Male, Clinical Sciences, Aged, Stomach, and 3 moreAdenocarcinoma, Ileum, and Meckel diverticulum
Herbal therapies are used by a substantial proportion of persons in the United States, and use of these supplements may be even higher in those with chronic liver disease. The aims of this study were to prospectively determine the... more
Herbal therapies are used by a substantial proportion of persons in the United States, and use of these supplements may be even higher in those with chronic liver disease. The aims of this study were to prospectively determine the proportion of US veterans with chronic hepatitis C that are currently taking vitamins and herbal medications and to evaluate factors associated with use of herbal preparations. Patients with hepatitis C who were seen in the gastroenterology, infectious disease, and primary care clinics at the VA New York Harbor Healthcare System were invited to participate in this prospective study. For comparison, healthy patients without hepatitis C were enrolled from the primary care clinics at the same medical center. Patients were interviewed by trained research coordinators who obtained detailed demographic and clinical data, as well as information on the use of antioxidants (vitamin C and E), multivitamins, and herbal medications. Use of vitamin C (34.8% vs. 19.6%, P &amp;amp;amp;amp;amp;amp;lt; 0.001), vitamin E (25.8% vs. 13.2%, P &amp;amp;amp;amp;amp;amp;lt; 0.001), multivitamins (43.6% vs. 28.0%, P &amp;amp;amp;amp;amp;amp;lt; 0.001), and herbal therapies (21.0% vs. 10.4%, P &amp;amp;amp;amp;amp;amp;lt; 0.001) was significantly higher in the 500 patients with hepatitis C compared with the 250 healthy controls. The most common herbal medications taken by hepatitis C patients were milk thistle (12.2%), ginseng (4.6%), and echinacea (3.0%). After adjusting for age and gender, multivariate logistic regression identified 12 or more years of education (OR 2.7; 95% CI 1.6-4.3; P &amp;amp;amp;amp;amp;amp;lt; 0.001) and annual income of at least 20,000 US dollars (OR 2.0; 95% CI 1.3-3.2; P = 0.004) as the only significant predictors of herbal medication use in patients with hepatitis C. The use of herbal preparations is prevalent among veterans with chronic hepatitis C, especially those with higher levels of education and higher incomes. Obtaining a detailed medical history and documentation of the use of these supplements is critical to determine the potential for herbal-drug interactions and hepatotoxicity.
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Although physicians often perform fecal occult blood testing at the time of hospital admission, the practice of admission stool guaiac (ASG) testing has not been evaluated prospectively. The aim of this study was to determine the... more
Although physicians often perform fecal occult blood testing at the time of hospital admission, the practice of admission stool guaiac (ASG) testing has not been evaluated prospectively. The aim of this study was to determine the frequency and outcomes of digital rectal examination (DRE) and ASG testing in patients admitted to the hospital. We prospectively evaluated 2143 patients admitted to the medical service at our hospital over a 1-year period. A detailed clinical history was obtained, and the proportion of patients who had DRE and ASG testing, the frequency of positive tests, and the results of follow-up testing were determined. A DRE was performed in 1539 of the 2143 subjects (71.8%), and 1.8% had abnormal findings, 21.8% had a normal examination, and the result of ASG testing was the only documented finding in the remaining 76.4% of patients. ASG testing was performed in 1342 of the 2143 subjects (62.6%), and the ASG test was positive in 237 persons (17.7%). However, only 161 (67.9%) of those with a positive ASG test had further diagnostic testing and a colonic source of occult gastrointestinal blood loss was detected in 68 (42.2%) of these 161 persons. Although DRE and ASG testing are commonly performed on admission to the hospital, documentation of the findings and follow-up of positive tests are poor. These findings highlight the need to improve physician training on the appropriate use and documentation of the DRE and fecal occult blood testing.
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To determine the frequency of gastrointestinal lesions detected by upper endoscopy and colonoscopy in patients who developed iron deficiency anemia after Billroth II surgery. The authors reviewed the medical records of 116 consecutive... more
To determine the frequency of gastrointestinal lesions detected by upper endoscopy and colonoscopy in patients who developed iron deficiency anemia after Billroth II surgery. The authors reviewed the medical records of 116 consecutive patients with a Billroth II partial gastrectomy and 232 age- and gender-matched controls without gastric surgery who were referred for endoscopy to evaluate iron deficiency anemia over a 5-year period. Clinically important lesions were detected in 22.4% of the patients with gastric surgery and in 59.5% of those with intact stomachs (p &amp;amp;amp;amp;amp;amp;lt; 0.001). In the gastric surgery group, clinically important lesions were found more often in the upper gastrointestinal tract than in the colon (19.0% vs. 3.4%, p &amp;amp;amp;amp;amp;amp;lt; 0.001). In the nonsurgical group, the diagnostic yields of upper endoscopy and colonoscopy were not significantly different (38.4% vs. 32.8%, p = 0.24). Synchronous lesions in the upper and lower gastrointestinal tract were significantly less common in the group of patients with gastric surgery compared with those without gastric surgery (0.0% vs. 11.6%, p &amp;amp;amp;amp;amp;amp;lt; 0.001). Small bowel biopsies and small bowel follow-through did not identify any additional lesions. In the gastric surgery group, multivariate analysis identified abdominal symptoms (OR = 11.2, 95% CI 3.2-39.2, p &amp;amp;amp;amp;amp;amp;lt; 0.001), a positive result on fecal occult blood testing (OR = 6.4, 95% CI 2.0-20.3, p = 0.002), and Billroth II surgery at least 10 years before evaluation (OR = 5.4, 95% CI 1.7-16.7, p = 0.004) as independent predictors of identifying a clinically important lesion by endoscopy. Upper endoscopy had a significantly higher diagnostic yield than colonoscopy in patients who developed iron deficiency anemia after Billroth II surgery. Prospective studies are necessary to determine the role and cost-effectiveness of colonoscopy in the evaluation of iron deficiency anemia in this patient population.
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ABSTRACT
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Managed care has strongly discouraged generalists from referring patients to specialists in an effort to reduce the costs of health care. The aim of this study was to compare patient outcomes when generalists work together with... more
Managed care has strongly discouraged generalists from referring patients to specialists in an effort to reduce the costs of health care. The aim of this study was to compare patient outcomes when generalists work together with gastroenterologists or alone in the management of patients admitted to the hospital with decompensated cirrhosis. Consecutive patients admitted to the hospital with decompensated cirrhosis over a 1-year period were identified. We compared the length of stay, cost of hospitalization, incidence of hospital readmission, and mortality for patients who did and those who did not have a gastroenterology (GI) consultation. A GI consultation was requested for 107 of the 197 patients (54.3%). Patients who had a GI consultation had a significantly shorter length of stay (5.6 +/- 3.5 vs. 10.1 +/- 5.8 days, P &lt;.001) and a lower cost of hospitalization ($6,004 +/- $4,994 vs. $10,006 +/- $6,183, P &lt;.001) than those patients who were managed by generalists alone. The 30-day incidence of readmission (13.3% vs. 27.8%, P =.01) and mortality (7.5% vs. 16.7%, P =.045) were significantly lower in the GI consultation group. During a median follow-up of 618 days (range, 2-970), patients who had a GI consultation during hospitalization had a significantly longer time to hospital readmission (P &lt;.001) and improved survival (P =.02) compared with those who were managed by generalists alone. In conclusion, for patients admitted to the hospital with decompensated cirrhosis, individuals who were managed by generalists in conjunction with gastroenterologists had better outcomes than those who were managed by generalists alone.
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Research Interests: Probability, Prospective studies, Humans, Female, Male, and 12 morePatient Satisfaction, Cost effectiveness, Clinical Sciences, Aged, Middle Aged, Gastrointestinal Endoscopy, Flexible Sigmoidoscopy, Phosphates, Combination drug therapy, Chi Square Distribution, Sensitivity and Specificity, and Fiber Optic Technology
Research Interests: Gastroenterology, Treatment Outcome, Logistic Regression, Prospective studies, Humans, and 17 moreFemale, Male, Patient Satisfaction, Anticoagulants, Risk factors, Clinical Sciences, Aged, Questionnaires, Gastrointestinal Endoscopy, Flexible Sigmoidoscopy, Warfarin, Gastrointestinal, Adverse Event, Risk Factors, Clinical Competence, Emergency Department, and Midazolam
Research Interests: Multivariate Analysis, Humans, Portal hypertension, Liver Cirrhosis, Intestinal Mucosa, and 13 moreFemale, Male, Risk factors, Irritable Bowel Syndrome, Colonoscopy, Clinical Sciences, Gastrointestinal Endoscopy, Adult, Gastrointestinal, Retrospective Studies, Risk Factors, Colon, and Medical Records
Little is known about lower gastrointestinal (GI) hemorrhage in the human immunodeficiency virus (HIV) infected population. Our aim was to determine the underlying causes, the clinical outcome, and the risk factors for recurrent bleeding... more
Little is known about lower gastrointestinal (GI) hemorrhage in the human immunodeficiency virus (HIV) infected population. Our aim was to determine the underlying causes, the clinical outcome, and the risk factors for recurrent bleeding and mortality in HIV-infected patients with acute LGIH. We reviewed the medical records of consecutive HIV-infected patients with acute lower GI hemorrhage who were evaluated with endoscopy from January 1992 through January 1997 at Bellevue Hospital Center. During the 5-year study period, 312 patients with acute lower GI hemorrhage underwent colonoscopy (n = 233) or flexible sigmoidoscopy (n = 79). Cytomegalovirus colitis (25.3%), lymphoma (12.2%), and idiopathic colitis (12.2%) were the most common causes identified. Within 30 days of presentation, recurrent bleeding occurred in 17.6% of patients. Independent predictors of recurrent bleeding included the presence of at least one comorbid illness, a hemoglobin level of less than 8 gm/dL, a platelet count of less than 100,000/mm3, and major stigmata of hemorrhage. The 30-day mortality from lower GI hemorrhage was 14.4%, and the presence of comorbid disease, recurrence of bleeding, and surgical intervention were found to be the only independent predictors of mortality in this patient population. Acute lower GI hemorrhage in HIV-infected patients is most commonly caused by cytomegalovirus colitis and is associated with a high short-term morbidity and mortality.
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In clinical practice, some physicians discontinue warfarin prior to fecal occult blood testing (FOBT). Although anticoagulant use is associated with an increased risk of overt gastrointestinal bleeding, the impact of warfarin on the... more
In clinical practice, some physicians discontinue warfarin prior to fecal occult blood testing (FOBT). Although anticoagulant use is associated with an increased risk of overt gastrointestinal bleeding, the impact of warfarin on the positive predictive value of FOBT is unknown. During a 5-yr period, we prospectively studied all patients taking warfarin who were referred for the evaluation of a positive FOBT. For each patient taking warfarin, we enrolled one age- and gender-matched control subject with a positive FOBT who was not taking anticoagulants. A detailed clinical history was obtained, and all subjects underwent colonoscopy and esophagogastroduodenoscopy. Lesions consistent with occult bleeding were identified in 59.0% of the 210 patients in the warfarin group and 53.8% of the 210 control subjects (p= 0.27). Although more lesions were identified by colonoscopy in the warfarin group than in control subjects (36.2%vs 25.7%, p= 0.02), there was no difference in the frequency of lesions identified by esophagogastroduodenoscopy (35.2%vs 39.5%, p= 0.43). Overall, adenomas &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or =1 cm in diameter (16.2%) and colorectal carcinoma (9.5%) were the most common lesions identified by colonoscopy, while erosive gastritis (15.5%) and erosive duodenitis (11.0%) were the most frequent lesions found by esophagogastroduodenoscopy. Among individuals with colorectal cancer, 83.3% of patients in the warfarin group had early cancers (Dukes&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; stage A or B) compared with 50.0% of control subjects (p= 0.046). Warfarin use did not decrease the positive predictive value of FOBT. These findings suggest that warfarin should not be discontinued prior to FOBT.
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Testing stool for occult blood at the time of digital rectal examination (DRE) has been discouraged because it is thought to increase the number of false-positive test results. To compare the diagnostic yield of colonoscopy and the cost... more
Testing stool for occult blood at the time of digital rectal examination (DRE) has been discouraged because it is thought to increase the number of false-positive test results. To compare the diagnostic yield of colonoscopy and the cost per cancer detected in asymptomatic patients with a positive fecal occult blood test result obtained by DRE with that obtained from spontaneously passed stool (SPS) samples. We reviewed the medical records of consecutive asymptomatic patients at average risk for colorectal cancer who were referred for colonoscopy to evaluate a positive fecal occult blood test result obtained by DRE (n = 282) or SPS samples (n = 390). The cost of colonoscopy was estimated by adding the physician fee under Medicaid reimbursement, the facility fee for endoscopy, and the pathology fee for the biopsy specimens. During the 5-year study period, 672 patients were evaluated and a colonic source of occult bleeding was identified in 145 patients (21.6%). The predictive value of a positive fecal occult blood test result (22.0% vs 21.3%, P = .85) and the cost per cancer detected ($7604.80 vs $7814.54) were no different in the DRE and SPS groups, with carcinomas being detected in 11.7% and 11.3% of patients, respectively. Testing stool for occult blood at the time of DRE does not increase the number of false-positive test results or the cost per cancer detected in asymptomatic patients at average risk for colorectal cancer. In this patient population, all individuals should be evaluated by full colonoscopy regardless of the method of stool collection.