AIM:To evaluate the completion rate and diagnostic yield of the PillCam SB2-ex in comparison to the PillCam SB2.METHODS:Two hundred cases using the 8-h PillCam SB2 were retrospectively compared to 200 cases using the 12 h PillCam SB2-ex at a tertiary academic center. Endoscopically placed capsules were excluded from the study. Demographic information, indications for capsule endoscopy, capsule type, study length, completion of exam, clinically significant findings, timestamp of most distant finding, and significant findings beyond 8 h were recorded.RESULTS:The 8 and 12 h capsule groups were well matched respectively for both age (70.90 ± 14.19 vs 71.93 ± 13.80, P = 0.46) and gender (45.5% vs 48% male, P = 0.69). The most common indications for the procedure in both groups were anemia and obscure gastrointestinal bleeding. PillCam SB2-ex had a significantly higher completion rate than PillCam SB2 (88% vs 79.5%, P = 0.03). Overall, the diagnostic yield was greater for the 8 h capsule (48.5% for SB2 vs 35% for SB2-ex, P = 0.01). In 4/70 (5.7%) of abnormal SB2-ex exams the clinically significant finding was noted in the small bowel beyond the 8 h mark.CONCLUSION:In our study, we found the PillCam SB2-ex to have a significantly increased completion rate, though without any improvement in diagnostic yield compared to the PillCam SB2.

Purpose: A 39-year-old male presented with dyspnea and recurrent hematochezia. Colonoscopy 10 years prior showed vascular lesions and hemorrhoids. He had no follow up since then. Physical exam revealed axillary lymphadenopathy. Laboratory evaluation revealed severe iron deficiency anemia (Hct 16, MCV 52, Iron 12). CT revealed a right hilar mass compressing the right mainstem bronchus and multiple lung nodules. Rectum was diffusely thickened extending into the sigmoid colon, associated with numerous phleboliths. (Figure 1) Several hepatic lesions were seen. Colonoscopy showed increased mucosal vascular pattern from the rectum to distal sigmoid (Figure 2) and a patchy area in transverse colon. Endoscopic ultrasound demonstrated edematous vascular structures in this distribution. A heterogeneous, hypoechoic, circumferential lesion measuring 18 mm in maximal thickness involving all layers was noted. Doppler ultrasound showed vascular flow in the lesion (Figure 3). Calcified phleboliths were seen in the rectal wall. The patient was diagnosed with cavernous hemangiomatosis of the colon and pulmonary non-small cell carcinoma. Colonic cavernous hemangiomatosis is rare and benign, with infrequent simultaneous liver involvement. There is frequent delay in diagnosis. Surgical resection is the preferred treatment modality for diffuse disease.Figure 1: No Caption available.Figure: [1178] Figure 2Figure: [1178] Figure 3

Purpose: The operation time of capsule endoscopy has increased since its original design. The PillCam SB2-ex is a new formulation which offers 12 hours of operation, 4 more than the original design. It is unknown whether more recording improves outcomes such as procedure completion rates and sensitivity for pathology. Methods: 100 cases of 8-hour PillCam SB2 from November 2010 to August 2011 were retrospectively reviewed as a control group. In comparison, 100 cases of 12 hour PillCam SB2-ex were prospectively reviewed from July 2011 to May 2012. Endoscopically placed capsules were excluded from the study. An Excel file was created to record demographic information, indications for capsule endoscopy, capsule type, study length, completion of exam, clinically significant findings, timestamp of most distant finding, and significant findings beyond 8 hours. Results: The two groups were well matched for both age (72.96 +/- 13.56 in the 8 hour capsule group vs 71.79 +/- 13.61 in the 12 hour capsule group; p value = 0.54) and gender (50% male for 8 hour capsule vs 48% male for 12 hour capsule; p value = 0.89). The most common indications for the procedure in both groups were anemia and obscure gastrointestinal bleeding. PillCam SB2-ex had a higher completion rate than PillCam SB2 (89% vs. 79%, p value = 0.08) though without reaching statistical significance. The mean small bowel viewing time was 4:09:15 and 4:56:09 for PillCam SB2 and PillCam SB2-ex, respectively. The diagnostic yield between the differing capsules was not statistically significant (44% for SB2 vs 35% for SB2-ex, p value = 0.25). Of note, in 3/35 (8.6%) SB2-ex exams there was a clinically significant positive finding noted beyond the 8 hour mark. Conclusion: In our study, the PillCam SB2-ex was shown to have a similar diagnostic yield to the PillCam SB2, despite a higher exam completion rate. Despite these findings, there were a small number of patients who had clinically significant findings beyond the 8 hour mark. Performing further studies utilizing larger sample sizes may provide more detailed information regarding the optimal patient population to perform 12 hour capsule endoscopy preferentially to standard 8 hour capsule endoscopy.

Purpose: A 41-year-old man with no prior medical history developed fatigue and lightheadedness, prompting an evaluation. He was found to be anemic with a hemoglobin level ˜8 mg/dl, and FOBT positive. He denied any abdominal symptoms nor prior similar symptoms. The patient was transfused multiple units of packed red blood cells. He underwent upper endoscopic and colonoscopic evaluation, without findings to explain his initial presentation. A small bowel capsule endoscopy was performed and an area in mid-jejunum was identified with “abnormal tissue and bleeding.” Subsequent CT images confirmed an abnormal segment in the jejunum, without extra-intestinal abnormalities. A spiral enteroscopy exam was performed, and a ˜10cm circumferential polypoid lesion was visualized. The area proximal and distal to the lesion was tattooed, and biopsies were taken which revealed lymphangiectasia. The patient underwent segmental resection, and the final pathology confirmed a giant lymphangioma. Giant Lymphangioma accounts for 5% of benign tumors in the pediatric population and is most commonly found in the neck and axilla. There are few case reports in adults, mostly of mesenteric lesions. Symptoms commonly reflect space-occupying effects within the local area. Two cases reported a small bowel mesenteric lesion presenting with volvulus, one each in the adult and pediatric populations. Another reported abdominal pain due to local hemorrhage. Other sites that have been reported are intra-splenic and intra-pancreatic, as well as stomach, esophagus and one case in the colon. This is the third published report of an entirely luminal giant lymphangioma. A prior report discussed a patient with chronic abdominal pain and an episode of melena. Our case is unique in its presentation of anemia and bleeding of an occult nature leading to the finding of a benign tumor, in a patient without prior anemia and no abdominal symptoms. Given the concern for malignancy, occult bleeding and symptomatic anemia, surgical resection was executed. The surgery was successful and the patient has made a full recovery. Conclusion: Occult blood loss often prompts evaluation of the small bowel. Using newer methods including capsule endoscopy, the small bowel can be visualized in its entirety, and enteroscopy can be utilized to obtain a tissue diagnosis for abnormal lesions. In addition to the more common causes of bleeding in the small bowel, the diagnostic possibilities include both benign and malignant tumors. Lymphangiomas are rare benign tumors in adults, but may present as a possible etiology of occult anemia in an otherwise healthy adult.

Purpose: Narcotic Bowel Syndrome (NBS) is a variant of opioid induced bowel dysfunction involving a progressive increase of abdominal pain and associated with an increasing need for pain medication in those receiving opioid analgesics. Typically patients either have no medical diagnosis to explain their pain, or their diagnosis does not clinically explain the severity of their complaints. Recent reports have begun to explore the prevalence of NBS within the community; however, no data exists on the prevalence of NBS in the hospital setting. We believe that it comprises a significant, under-recognized disease burden on the inpatient setting. Methods: We performed a prospective analysis of patients seen by the general gastroenterology service at a tertiary care medical center over a trial 6 month period, identifying those patients who met the four commonly cited criteria for NBS. 1. Pain worsens or incompletely resolves with continued or escalating doses of narcotics. 2. Marked worsening of pain when the narcotic dose wanes and improves when narcotics are reinstituted (“soar and crash”). 3. Progression of the frequency, duration, and intensity of pain episodes. 4. The nature and intensity of the pain is not explained by a current or previous gastrointestinal diagnosis. Data was also obtained on the number of hospitalizations, Rome III IBS criterion and history of abuse. Results: Over the study period, the general gastroenterology consult service evaluated 354 new patients. This service excludes patients seen and followed specifically for liver, pancreatico-biliary disease, and parenteral nutrition who are followed by specific consult services. Of the 354 new consultations, 66 patients were evaluated for abdominal pain. Five patients were identified, each of whom met all four criteria for NBS, for a prevalence of 1.4% (7.5% of the total consults for abdominal pain). Table 1 provides specific demographic and clinical data over the 6 month study period. Two of five patients met Rome III criterion and no patients reported any personal history of abuse.Table: Patient characteristicsConclusion: Our study is the first to document the prevalence of NBS in an inpatient gastroenterology service. While the prevalence appears low, it is higher than recent outpatient community data from Olmstead County MN which showed a prevalence of 0.17%. This is not surprising considering the concentration of severe, chronic disease typically found in the tertiary care setting. Though the absolute numbers of patients with NBS are small, their number of admissions and length of stay tend to be high, making their impact on the gastroenterology service and hospital length of stay disproportionately high.

Purpose: A 56-year-old man presented with one episode of hematemesis and multiple episodes of melena. He reported intermittent epigastric discomfort, bloating, and nausea for five days prior to the admission. He denied any early satiety, weight loss, diarrhea or any prior history of hematemesis. His past medical history was significant for chronic lymphocytic leukemia which was diagnosed 6 years ago for which he received chemotherapy one year prior. His clinical course after chemotherapy was complicated with traumatic rupture of the spleen leading to splenectomy and splenic artery embolization from blunt abdominal trauma. On admission, he was afebrile (98 F), non-tachycardic, non-orthostatic. Physical examination was unremarkable. Gastric lavage showed 250 ml of dark blood. The complete blood count revealed normocytic anemia (Hb 12.4g/dL), Hct 38.2%, leukocytosis 60.15 K (Lymphocyte 85.1%, Neutrophil 11.8%, Monocyte 2.1%). His basic metabolic panel showed mild hyperkalemia (K+ 5.6), other electrolytes and hepatic function panel were within normal limit. He underwent emergent esophagogastroduodenoscopy. A large submucosal mass (7 x 5 cm) was noted in the duodenal bulb. The mass had an ulcer with an overlying adherent clot that could not be dislodged by washing. No active bleeding was noted. Six ml of epinephrine (1:10,000) was injected around the ulcer to prevent any further eminent bleeding. CT abdomen pelvis with IV contrast was performed for further evaluation of the mass, which revealed a 2.5 x 1.8 cm pseudoaneurysm off of an aberrant hepatic artery off the superior mesenteric artery. A surrounding hematoma measured 6 x 5 cm which was causing mass effect on the duodenum. The liver, gallbladder, pancreas, adrenal glands, and kidneys were normal. CT Angiogram revealed multilobed pseudoaneurysms arising off the proper and right hepatic arteries. Coil embolization was performed with complete obliteration of the hepatic artery pseudo aneurysm. Two months later, patient presented with recurrent episodes of melena. CT angiogram showed no active extravasations. Esophagogastroduodenoscopy findings were large amount of coffee ground and dark clot in fundus and body, long segment of coil protruding from pylorus into the stomach. There was large mound like focal bulge at superior aspect of bulb with 6 mm defect at upper aspect with protruding coil. He underwent an emergent exploratory laparotomy which showed hepatic artery pseudoaneurysm eroding into duodenum. Distal gastrectomy, Billroth II gastrojejunostomy, tube duodenostomy, and ligation of gastroduodenal artery were performed. He was discharged on after 5 days of observation and remained well without further episodes of bleeding at 3 months of follow up.

Small bowel video capsule endoscopy has become an increasingly used diagnostic procedure. The most frequently cited complication is capsule retention. Missed small bowel lesions, capsule failure, and concerns for interactions with implanted cardiac devices are often discussed.1Ho K.K. Joyce A.M. Complication of capsule endoscopy.Gastrointest Endosc Clin N Am. 2007; 17: 169-178Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar Difficulty swallowing the capsule has a reported incidence of 2%.2Rondonotti E. Herrerias J.M. Pennazio M. et al.Complication, limitation, and failures of capsule endoscopy: a review of 733 cases.Gastrointest Endosc. 2005; 62: 712-716Abstract Full Text Full Text PDF PubMed Scopus (261) Google Scholar Aspiration of the capsule has been reported in 9 cases in the literature.3Koulaouzidis A. Pendlebury J. Douglas S. et al.Aspiration of video capsule: rare but potentially life-threatening complication to include in your consent form.Am J Gastroenterol. 2009; 104: 1602-1603Crossref PubMed Scopus (14) Google Scholar Most cases of aspiration result with spontaneous ejection of the capsule. We report a unique case of small bowel video capsule aspiration detected by using a real-time video capsule imager and subsequent bronchoscopic-assisted capsule extraction.A 73-year-old man presented with urinary sepsis to our hospital. His medical history included renal cell carcinoma, bovine mitral valve replacement, and hyperlipidemia. The patient developed melena during his hospitalization that required red blood cell transfusions. Upper gastrointestinal endoscopy and colonoscopy did not reveal a source of gastrointestinal blood loss. Because of persistent transfusion-dependent anemia with obscure gastrointestinal blood loss, a small bowel video capsule endoscopy was performed. The patient denied history of dysphagia and tolerated his medications, including a daily large multivitamin, without prior incident. After informed consent was obtained, the patient was placed in the upright position and swallowed the video capsule pill with a few sips of water on his first attempt. After 2 minutes, he developed a mild nonproductive cough that lasted for 20 seconds. He then reported a sensation of capsule impaction in the back of his throat. A real-time video capsule imager was subsequently attached to the recording device to view the capsule location. The initial images clearly revealed the capsule within the trachea at the level of the carina (FigureA). The patient denied any dyspnea and had no evidence of stridor, with an oxygen saturation of 98% on room air. An immediate pulmonology consultation was obtained, and an emergency bronchoscopy revealed an impacted video capsule in the right main-stem bronchus. By using a retrieval basket, the capsule was extracted from the bronchial tree after several attempts (FigureB). Analysis of the video capsule data revealed multiple spontaneous ejections of the capsule from the trachea, but ultimately the capsule became impacted in the bronchial tree (Video A). The patient recovered uneventfully and underwent subsequent swallow evaluation for oral-pharyngeal dysphagia.Small bowel video capsule endoscopy has improved the diagnostic evaluation of the gastrointestinal tract. Identification of appropriate candidates for testing and recognition of contraindications are critical in the safe use of this technology. Patients with known oral-pharyngeal dysphagia requiring small bowel video capsule endoscopy should undergo endoscopic-assisted capsule deployment.4Nathan S.R. Biernat L. Aspiration: an important complication of small-bowel video capsule endoscopy.Endoscopy. 2007; 39: E343Crossref PubMed Scopus (28) Google ScholarWhen capsule aspiration does occur, most cases have resulted in spontaneous capsule ejection. Aspiration times have varied, ranging from a few seconds through the entire video capsule recording time before aspiration is clinically recognized. Complaints of cough, dyspnea, or a sensation of capsule impaction in the throat are clinically suggestive symptoms of capsule aspiration,3Koulaouzidis A. Pendlebury J. Douglas S. et al.Aspiration of video capsule: rare but potentially life-threatening complication to include in your consent form.Am J Gastroenterol. 2009; 104: 1602-1603Crossref PubMed Scopus (14) Google Scholar and close immediate post-ingestion monitoring of patients should be routine. Real-time video capsule imager should be used in cases in which suggestive symptoms of aspiration are present during this monitoring period. It can provide an almost immediate and accurate diagnosis and expedite medical management. In cases of failed capsule expulsion from the bronchial tree, immediate bronchoscopic evaluation should be obtained to limit any pulmonary complications to patients. Small bowel video capsule endoscopy has become an increasingly used diagnostic procedure. The most frequently cited complication is capsule retention. Missed small bowel lesions, capsule failure, and concerns for interactions with implanted cardiac devices are often discussed.1Ho K.K. Joyce A.M. Complication of capsule endoscopy.Gastrointest Endosc Clin N Am. 2007; 17: 169-178Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar Difficulty swallowing the capsule has a reported incidence of 2%.2Rondonotti E. Herrerias J.M. Pennazio M. et al.Complication, limitation, and failures of capsule endoscopy: a review of 733 cases.Gastrointest Endosc. 2005; 62: 712-716Abstract Full Text Full Text PDF PubMed Scopus (261) Google Scholar Aspiration of the capsule has been reported in 9 cases in the literature.3Koulaouzidis A. Pendlebury J. Douglas S. et al.Aspiration of video capsule: rare but potentially life-threatening complication to include in your consent form.Am J Gastroenterol. 2009; 104: 1602-1603Crossref PubMed Scopus (14) Google Scholar Most cases of aspiration result with spontaneous ejection of the capsule. We report a unique case of small bowel video capsule aspiration detected by using a real-time video capsule imager and subsequent bronchoscopic-assisted capsule extraction. A 73-year-old man presented with urinary sepsis to our hospital. His medical history included renal cell carcinoma, bovine mitral valve replacement, and hyperlipidemia. The patient developed melena during his hospitalization that required red blood cell transfusions. Upper gastrointestinal endoscopy and colonoscopy did not reveal a source of gastrointestinal blood loss. Because of persistent transfusion-dependent anemia with obscure gastrointestinal blood loss, a small bowel video capsule endoscopy was performed. The patient denied history of dysphagia and tolerated his medications, including a daily large multivitamin, without prior incident. After informed consent was obtained, the patient was placed in the upright position and swallowed the video capsule pill with a few sips of water on his first attempt. After 2 minutes, he developed a mild nonproductive cough that lasted for 20 seconds. He then reported a sensation of capsule impaction in the back of his throat. A real-time video capsule imager was subsequently attached to the recording device to view the capsule location. The initial images clearly revealed the capsule within the trachea at the level of the carina (FigureA). The patient denied any dyspnea and had no evidence of stridor, with an oxygen saturation of 98% on room air. An immediate pulmonology consultation was obtained, and an emergency bronchoscopy revealed an impacted video capsule in the right main-stem bronchus. By using a retrieval basket, the capsule was extracted from the bronchial tree after several attempts (FigureB). Analysis of the video capsule data revealed multiple spontaneous ejections of the capsule from the trachea, but ultimately the capsule became impacted in the bronchial tree (Video A). The patient recovered uneventfully and underwent subsequent swallow evaluation for oral-pharyngeal dysphagia. Small bowel video capsule endoscopy has improved the diagnostic evaluation of the gastrointestinal tract. Identification of appropriate candidates for testing and recognition of contraindications are critical in the safe use of this technology. Patients with known oral-pharyngeal dysphagia requiring small bowel video capsule endoscopy should undergo endoscopic-assisted capsule deployment.4Nathan S.R. Biernat L. Aspiration: an important complication of small-bowel video capsule endoscopy.Endoscopy. 2007; 39: E343Crossref PubMed Scopus (28) Google Scholar When capsule aspiration does occur, most cases have resulted in spontaneous capsule ejection. Aspiration times have varied, ranging from a few seconds through the entire video capsule recording time before aspiration is clinically recognized. Complaints of cough, dyspnea, or a sensation of capsule impaction in the throat are clinically suggestive symptoms of capsule aspiration,3Koulaouzidis A. Pendlebury J. Douglas S. et al.Aspiration of video capsule: rare but potentially life-threatening complication to include in your consent form.Am J Gastroenterol. 2009; 104: 1602-1603Crossref PubMed Scopus (14) Google Scholar and close immediate post-ingestion monitoring of patients should be routine. Real-time video capsule imager should be used in cases in which suggestive symptoms of aspiration are present during this monitoring period. It can provide an almost immediate and accurate diagnosis and expedite medical management. In cases of failed capsule expulsion from the bronchial tree, immediate bronchoscopic evaluation should be obtained to limit any pulmonary complications to patients. Supplementary data Download .mpg (18.5 MB) Help with mpg files Video A Download .mpg (18.5 MB) Help with mpg files Video A

Purpose: This paper evaluates the specific indications and outcomes of patients who had percutaneous endoscopic gastrostomy (PEG) tubes placed at our institution over a one year period. Methods: Medical records of all patients undergoing PEG placement from the period of August 2006 through September 2007 were reviewed. Data was collected and entered into a specifically designed PEG registry. Telephone inquiries following 1 year were made to determine long term outcome. Results: 281 PEG tubes were place at our institution with 32 lost to follow up. The results are outlined in the Table, describing survival and mean age for each indication described.TableConclusion: The greatest 1-year survival was seen in patients who had PEGs placed for dysphagia (66.7%) and for a persistent vegetative state (75%). No other indication had a 1 year survival of greater than 50%. The poorest 1-year survival was seen for the patients with advanced CHF/COPD (4.3%), failure to thrive (17.4%), long term ventilation (17.6%) and malignancy (20%). These groups also had the greatest number of patients die within 6 months, specifically those with advanced CHF/COPD (56.5%), failure to thrive (65.2%), long term ventilation (52.9%) and malignancy (42%). Our results suggest that specific indications for PEGs should be examined closely before making the decision to proceed with placement.

Purpose: To evaluate the indications, complications and survival of patients undergoing percutaneous endoscopic gastrostomy (PEG) tube placement over a one-year period in a large academic community hospital. Methods: Medical records of all patients undergoing PEG placement from August 2006 through September 2007 were reviewed. Data was collected and entered into a PEG registry. Telephone follow up was made after a 1 year period to determine long term outcome. Results: 281 PEGs were performed during the study period. 52.3% were males with a mean age of 71.5 yrs. The indications for PEG placement were as follows: dysphagia 24.5%, organic brain injury 13.1%, dementia 12%, malignancy 16.3%, long term ventilation 8%, CHF/COPD 9.3%, failure to thrive 8.5%, persistent vegetative state 1.4% and other 5%. 52.3% of PEGs were performed by a gastroenterologist, 19% by a surgeon and 28.7% by a combination of surgeon/gastroenterologist. 57 (20.2%) of the cases had reported complications. Complications were as follows: 17 aspirations, 18 peristomal infections, 6 bleeding episodes, 4 cases of gastroparesis, 3 cases of peritonitis, 3 stomal leakage, 3 interval development of gastric ulcers, 7 cases of inadvertent removal, 2 cases of extra-gastric placement, 3 perforations, and 1 case each of bowel obstruction, acute renal failure and necrotizing fasciitis. 87 (31%) and 67 (23.8%) died within 6 and 6-12 months of PEG placement, respectively. 154 (54.8%) patients died within 12 months of PEG placement. 95 (33.4%) survived greater than 12 months. 32 (11.4%) were lost to follow up. Of the 147 procedures performed by a gastroenterologist, 22 cases had 27 reported complications (15%). Of the 81 procedures done by the combination of a gastroenterologist/surgeon, 27 cases had 34 reported complications (33%). Of the 53 procedures done by surgeons alone, 8 cases had 8 reported complications (15%). No patient died as an immediate result of any complication or immediately following PEG placement. Conclusion: The overall complication rate for PEG placement at our institution was 20.2% with the majority of these complications being mild. The fact that 31% of the patients died within 6 months and 23.8% died between 6 and 12 months following PEG placement suggests that PEG tube placement did not alter the course of the underlying disease or improve long-term outcomes. These results bring into question the appropriateness of patient selection and the indications for PEG placement. PEG placement by a combination of gastroenterologist and surgeon had the highest number and percentage of complications. Further analyses should be performed to determined specific risk factors for predicting poor survival following PEG tube placement.

A 90-year-old woman was admitted for a 2-week history of fever and persistent peristomal leakage. A percutaneous endoscopic gastrostomy (PEG) was placed a year earlier as a result of multiple strokes resulting in dysphagia. During the ensuing year, the gastrostomy tube was replaced multiple times at the bedside as a result of minor complications. The physical exam revealed a macerated peristomal site with surrounding erythema, induration, and serosanguineous drainage. The abdominal exam was otherwise normal without evidence of obstruction. An upper endoscopy was performed for placement of a new PEG; however, on examination, absence of the pyloric opening was noted (Figure A). Furthermore, the PEG tube was extending from the gastrocutaneous site to the opposite wall, with torsion of the distal stomach (Figure B). A subsequent gastrostomy tube study revealed contrast extrusion into the duodenum, suggesting the balloon was inflated in the small bowel. It was suspected that as a result of persistent manipulation of the PEG tube, torsion of the distal stomach and duodenum ensued, with a resultant anatomic gastric outlet obstruction. The wound dehiscence and cellulitis were believed to be a result of leakage of gastric secretions around the peristomal site caused by the obstruction. Repeat esophagogastroduodenoscopy after deflation of the balloon bumper revealed normal anatomy. Intubation of the duodenum noted a clean based ulcer attributed to pressure necrosis from the inflated balloon. A replacement PEG tube was inserted through the tract and anchored securely to the abdominal wall without any complication. The localized wound infection has since healed.PEG tube placement is a low-risk procedure routinely performed for patients who are unable to take food orally. Common indications for placement include neurologic conditions with associated impaired swallowing, oropharyngeal, laryngeal, and esophageal neoplasms, facial trauma, and the need for supplemental feedings in patients with miscellaneous catabolic conditions. Overall, the complication rate ranges from 3%–14%, and mortality approaches 1%.1Ibegbu E. Relan M. Vega K.J. Retrograde jejunoduodenogastric intussusception due to a replacement percutaneous gastrostomy tube presenting as upper gastrointestinal bleeding.World J Gastroenterol. 2007; 13: 5282-5284PubMed Google Scholar Various major and minor complications have been described in the literature. Commonly encountered problems include pain at the insertion site, leakage around PEG tube, tube displacement by patient or health care personnel, tube obstruction, and local ulceration or wound infection.2DeLegge M.H. Endoscopic enteral access for enteral nutrition.ASGE Clinical Update. 2007; 15: 2Google ScholarThis case is an example of an anatomically created gastric outlet obstruction, without the typical symptoms of nausea, vomiting, and distention. Two theories have been postulated to explain the above. As described by Lamont and Rode,3Lamont A.C. Rode H. Retrograde jejuno-duodeno-gastric intussusception.Br J Radiol. 1985; 58: 559-561Crossref PubMed Scopus (6) Google Scholar passage of a gastrostomy tube past the pylorus into the small bowel with insufflation of the balloon can result in fixation within the small bowel. The second theory implicates migration of the PEG tube through the pylorus as a result of improper anchoring to the abdominal wall. Fortunately in this patient, absence of obstruction at the distal tip of the gastrostomy tube allowed for unimpeded feedings, and the stoma provided an exit for air release and excess gastric secretions. A 90-year-old woman was admitted for a 2-week history of fever and persistent peristomal leakage. A percutaneous endoscopic gastrostomy (PEG) was placed a year earlier as a result of multiple strokes resulting in dysphagia. During the ensuing year, the gastrostomy tube was replaced multiple times at the bedside as a result of minor complications. The physical exam revealed a macerated peristomal site with surrounding erythema, induration, and serosanguineous drainage. The abdominal exam was otherwise normal without evidence of obstruction. An upper endoscopy was performed for placement of a new PEG; however, on examination, absence of the pyloric opening was noted (Figure A). Furthermore, the PEG tube was extending from the gastrocutaneous site to the opposite wall, with torsion of the distal stomach (Figure B). A subsequent gastrostomy tube study revealed contrast extrusion into the duodenum, suggesting the balloon was inflated in the small bowel. It was suspected that as a result of persistent manipulation of the PEG tube, torsion of the distal stomach and duodenum ensued, with a resultant anatomic gastric outlet obstruction. The wound dehiscence and cellulitis were believed to be a result of leakage of gastric secretions around the peristomal site caused by the obstruction. Repeat esophagogastroduodenoscopy after deflation of the balloon bumper revealed normal anatomy. Intubation of the duodenum noted a clean based ulcer attributed to pressure necrosis from the inflated balloon. A replacement PEG tube was inserted through the tract and anchored securely to the abdominal wall without any complication. The localized wound infection has since healed. PEG tube placement is a low-risk procedure routinely performed for patients who are unable to take food orally. Common indications for placement include neurologic conditions with associated impaired swallowing, oropharyngeal, laryngeal, and esophageal neoplasms, facial trauma, and the need for supplemental feedings in patients with miscellaneous catabolic conditions. Overall, the complication rate ranges from 3%–14%, and mortality approaches 1%.1Ibegbu E. Relan M. Vega K.J. Retrograde jejunoduodenogastric intussusception due to a replacement percutaneous gastrostomy tube presenting as upper gastrointestinal bleeding.World J Gastroenterol. 2007; 13: 5282-5284PubMed Google Scholar Various major and minor complications have been described in the literature. Commonly encountered problems include pain at the insertion site, leakage around PEG tube, tube displacement by patient or health care personnel, tube obstruction, and local ulceration or wound infection.2DeLegge M.H. Endoscopic enteral access for enteral nutrition.ASGE Clinical Update. 2007; 15: 2Google Scholar This case is an example of an anatomically created gastric outlet obstruction, without the typical symptoms of nausea, vomiting, and distention. Two theories have been postulated to explain the above. As described by Lamont and Rode,3Lamont A.C. Rode H. Retrograde jejuno-duodeno-gastric intussusception.Br J Radiol. 1985; 58: 559-561Crossref PubMed Scopus (6) Google Scholar passage of a gastrostomy tube past the pylorus into the small bowel with insufflation of the balloon can result in fixation within the small bowel. The second theory implicates migration of the PEG tube through the pylorus as a result of improper anchoring to the abdominal wall. Fortunately in this patient, absence of obstruction at the distal tip of the gastrostomy tube allowed for unimpeded feedings, and the stoma provided an exit for air release and excess gastric secretions.

3 72-year-old woman was admitted for rectal bleeding. The patient was at 3 weeks after ventral hernia repair. After onsultation, a decision was made to perform a colonoscopy, hich revealed diverticulosis that was presumed to be the culprit t presentation. The service was reconsulted a few days later for ersistent decrease in hemoglobin. No rectal bleeding, melena, or ematemesis was noted. A decision was then made to perform an pper endoscopy. The exam noted a large duodenal ulcer (3 4 m) with overlying clot. A total of 23 mL of 1:10,000 epinephrine as injected around the ulcer base, and the clot was removed. A isible vessel was identified (Figure A), and an attempt at bipolar oagulation was done to ablate the vessel. Cessation of bleeding ailed, and active spurting was noted. An attempt to irrigate the esion for revisualization and repeat bipolar coagulation was unuccessful as a result of the large amount of blood within the orking field. Injection of an additional 20 mL of 1:10,000 epiephrine around the ulcer base succeeded in reducing the volume f active bleeding. An attempt at clot removal was unsuccessful. nterventional radiology was then consulted, and the patient unerwent emergency mesenteric angiography with coil embolizaion of the culprit vessels. A total of 14 coils (4 VORTX-18 iamond shape, 3.3 mm unrestrained coil length, Boston Scienific, Marlborough, MA; 12 Tornado coil, 5 mm proximal iameter, Cook, Bloomington, IN) were used to occlude the proxmal right gastroepiploic artery to the proximal gastroduodenal rtery. Bleeding was successfully attenuated. Five days after emboization, another episode of hematochezia was reported. An upper ndoscopy was repeated, and a clean based bulbar ulcer was idenified, with a visible coil extruding from the ablated vessel (Figures and C). No active bleeding was noted. A decision was made to epeat the colonoscopy; however, because of emerging complicaions from the recent hernia repair, the procedure was deferred. uring the next week, no further bleeding episodes were noted; he hemoglobin level remained stable, and follow-up as an outpaient was recommended. Peptic ulcer bleeding is a common medical emergency that esults in approximately 300,000 admissions per year in the United tates.1 The treatment of choice for upper gastrointestinal bleedng after adequate resuscitation is endoscopy with therapeutic ntervention. A combination of injection, thermal coagulation, and emostasis clips is typically used to effect therapy. For those who ave failed endoscopic therapy, emergent surgical intervention is he next step, which commonly entails a high operative mortality.2 oday, selective transcatheter arterial embolization (TAE) has been dded as an alternative modality or rescue therapy to surgery in he control of upper gastrointestinal hemorrhage. Originally inroduced in 1972 by Schenker et al,2 TAE has evolved into a highly elective, life-saving modality that complements the medical and urgical options in catastrophic, unrelenting bleeding. TAE inolves the selective catheterization of a desired vessel followed by ontrast injection. Occlusion of a culprit vessel is then mediated by aterials such as absorbable gel foam or steel coils, when contrast xtrusion is identified. Although not effective in all cases, studies have shown that hen successfully performed in high-risk patients (advanced age, leeding recurrence, multiple comorbidities), operative intervenion is avoided, and mortality is decreased by half.2 On the other and, studies have also shown no difference in clinical outcomes bleeding recurrence, death, need for further surgery) between urgical intervention and embolotherapy.3 The benefit, however, is ased on therapeutic success and the avoidance of any postopertive complications from surgery.

Disseminated Herpes Simplex 2 (HSV 2) infections are infrequent and have a guarded prognosis. We report a patient with psoriasis receiving Alefacept who developed HSV 2 hepatitis. Case Report: A 50-year old woman presented with complaints of fever, epigastric pain, fatigue, and anorexia. Five days prior to admission, the patient had received the 11th weekly injection of Alefacept for the management of psoriasis. Initial physical exam was significant for fever of 40.6°C, tenderness in the epigastrium and RUQ, and hepatomegaly. Laboratory data revealed an AST of 1799 U/L, ALT 1891 U/L, total bilirubin 2.1 mg/dL, alkaline phosphatase 152 U/L. The PT was mildly elevated but corrected with Vitamin K. On the second day of hospitalization, the patient developed pustular erythematous lesions on her face, chest, arms, and legs. Viral cultures of the skin lesions revealed HSV 2 by immunofluorescence. IV Acyclovir was initiated. Serologic tests for routine causes of hepatitis were negative. Sonogram revealed a distended gallbladder with wall edema but no gallstones and normal ducts. The total bilirubin peaked at 10.9 mg/dL at which time the AST was 352 U/L, ALT 330 U/L, and alkaline phosphatase 832 U/L. The patient was HIV seronegative. The patient had no history of genital herpes but her partner was seropositive for HSV 2. The fever resolved, liver tests gradually declined, and the skin lesions improved after the initiation of Acyclovir. After 20 days of hospitalization, the patient was discharged on po Valacyclovir to complete 6 weeks of anti-viral therapy. Alefacept is an immunosuppressive medication indicated for moderate to severe chronic plaque psoriasis. The mechanism of action involves binding to the CD2 receptor of lymphocytes and inhibiting their interaction with leukocyte function antigen 3. This interaction is necessary for the activation of T lymphocytes which leads to the secretion of numerous inflammatory mediators involved in psoriasis. In most cases, disseminated HSV 2 infections are infrequent and have a guarded prognosis. HSV hepatitis should be considered on initial presentation of immunosuppressed patients with abnormal liver tests even in the absence of mucocutaneous lesions. This is the first report of herpes hepatitis associated with Alefacept.

Background: Gastric retention and increased gastric transit time adversely affect the outcome of capsule endoscopy. However, adequate data is not available in the literature at present. Aim: The aim of the study was to identify factors that may predict gastric retention and gastric transit time during capsule endoscopy examination. Methods: Records of all patients who underwent capsule endoscopy in a single center between March 2003 and October 2005 were retrospectively evaluated to identify gastric retention, gastric transit time, small bowel retention and small bowel transit time. Each case was recorded for age, gender, indication of procedure, in-patient vs. outpatient setting, and diagnosis. Results: During the period, 172 patients had capsule endoscopy. 27 cases were excluded due to technical failure, prokinetic therapy prior to the examination, suspected gastroparesis, previous gastric surgery, or endoscopic placement of capsule into the duodenum. The most common indication for capsule study was overt gastrointestinal bleeding (n = 78, 54%), followed by occult bleeding (n = 58, 35%). Out of 145 cases, gastric retention of capsule was noted in 8 (5.5%). All 8 cases of gastric retention occurred when the capsule endoscopy was done as in-patient (n = 94, retention in 8.5%), as compared to none with an out-patient examination (n = 51), This difference was found to be statistically significant (p < 0.05). However, in-patient vs. out-patient examination did not show any difference in gastric transit time (37.6+/- 51.2 mins vs. 44.5+/- 52.2 mins respectively, p = 0.45). It also did not predict increased small bowel retention (22 out of 137 cases, 15 cases as in-patient vs. 7 as outpatient, p = 0.64), or any difference in small bowel transit time (225.7+/-105.6 mins vs. 239.8+/-79.1 mins respectively, p = 0.43). Age >75 yrs, female sex, indication of procedure, or diagnosis did not predict gastric retention or increased gastric transit time.Conclusions: Gastric retention of capsule was found to be significantly common more when capsule endoscopy is utilized in the in-patient setting. This may be due to poor mobility and acute illness. A prokinetic agent used as an adjunct may be appropriate prior to the examination in this setting.

Primary amyloidosis is a rare disease which can present with a myriad of gastrointestinal symptoms. We present a patient with symptoms consistent with constipation predominant irritable bowel syndrome (IBS) who was ultimately determined to have gastrointestinal amyloidosis. Case Report: A 40 year-old woman presented with complaints of long-standing gas, bloating, abdominal discomfort, and constipation associated with nausea. Her abdominal discomfort was exacerbated by stress and relieved by defecation. Occasionally, she reported small amounts of red blood per rectum after defecation. Her physical examination was unremarkable. Routine laboratory data and celiac serologies were within normal limits. Colonoscopy was normal and a benign appearing 0.5 cm sigmoid polyp was removed and sent for pathologic examination. The preliminary diagnosis was constipation predominant IBS. However, further examination of the polyp by both light and electron microscopy with congo red staining was consistent with amyloidosis. An additional work-up for cardiac, pulmonary, or renal involvement was negative. Primary amyloidosis is a rare clonal plasma cell disorder characterized by extracellular deposition of protein. Unlike our patient, most cases are diagnosed once the disease has reached advanced stages and rapidly progress to multi-organ failure. We propose that our patient developed intestinal dysmotility related to amyloidosis and therefore presented with complaints of bloating and constipation. The clinical manifestations of GI amyloidosis can be mistaken for other disease processes such as the irritable bowel syndrome. The endoscopic appearance also varies widely, as our patient developed a polypoid lesion related to amyloid deposition. Despite the high prevalence of the irritable bowel syndrome, clinicians must maintain a high index of suspicion for gastrointestinal amyloidosis in order to make the correct diagnosis and treat patients accordingly.

Cytomegalovirus (CMV) infection of the gastrointestinal tract is commonly seen in immunocompromised patients. There have been few reported cases of CMV enterocolitis in immunocompetent patients. The reported cases of CMV proctitis in immunocompetent patients are typically elderly patients or patients who have had a preceding infectious, allergic, or traumatic insult. We report a case of a cytomegalovirus (CMV) rectal ulcer and CMV hepatitis in a healthy 22 year-old woman without a preceding insult to her gastrointestinal tract. Case Report: A 22 year-old female presented to the emergency room with complaints of fever, intermittent blood per rectum, tenesmus, and multiple constitutional complaints including anorexia, lethargy, and arthralgias. Physical exam was significant for fever of 39° C. She was mildly ill appearing with exam notable for scattered sub-cm posterior cervical adenopathy and a tender rectal exam with bright red blood. Initial laboratory data was unremarkable. During her hospital course, the patient developed a marked reactive lymphocytosis and elevated liver tests with an AST 506 U/L and ALT 834 U/L. The bilirubin and alkaline phosphatase remained normal. Contrast enhanced abdominal computed tomography was significant for a hazy appearance of the soft tissues adjacent to the distal rectum. Colonoscopy revealed severe rectal inflammation with nearly circumferential ulceration. Pathologic examination of the rectal ulcer revealed diffuse active inflammation without signs of chronicity. Viral inclusions were not seen, yet further histochemical staining was positive for CMV. CMV by PCR, CMV IgM Ab, and CMV viral blood cultures were positive. The patient was diagnosed with primary CMV proctitis and presumed hepatitis. Valacyclovir was initiated. The patient was HIV seronegative and T cell subsets were within normal range. Protein electrophoresis did not disclose an immunodeficient state. Her fever, constitutional symptoms, and rectal bleeding gradually resolved and her liver tests normalized. We report a case of primary CMV infection with rectal ulceration and acute CMV hepatitis in an otherwise healthy young woman. Gastroenterologists should be aware of the possibility of CMV colitis and CMV hepatitis in immunocompetent patients even if they have not had a preceding gastrointestinal illness.

Introduction: ESWL is a relatively noninvasive and effective procedure for the management of nephrolithiasis. Given its widespread use, increased numbers of serious complications are being reported in both the kidney and <1% of the time in surrounding organs. Injuries reported to the gastrointestinal tract include gastric erosions, retroperitoneal hemorrhage, splenic rupture, hepatic hematoma, bile duct injury and bowel perforation. We report the case of a patient who developed acute pancreatitis after undergoing ESWL for left-sided nephrolithiasis. Case Report: A 35-year-old male presented with persistent, severe, diffuse abdominal pain, left flank pain and two episodes of painless hematuria with associated nausea, constipation, and bloating. The patient had undergone ESWL for left-sided nephrolithiasis one day prior to admission with a total of 500 shocks at 22kV. Physical exam was significant for an abdomen that was diffusely tender to palpation, greatest in the left upper quadrant without rebound tenderness or guarding. Urinalysis was significant for hematuria. The patient had an elevated white blood cell (WBC) count of 15000 (mL, and an elevated serum amylase of 251 U/L (normal 25–125 U/L) and lipase of 406 U/L (normal 7–60 U/L) respectively. CT scan with contrast was significant for a small hematoma in the left kidney and small amount of fluid in the tail of the pancreas without evidence of necrosis. A clinical and radiologic diagnosis of acute pancreatitis was made. Gallstones, alcohol abuse, drugs, hypertriglyceridemia and hypocalcaemia were ruled out as etiology of his pancreatitis. Given the patient's history and chronologic clinical course the patient was diagnosed with ESWL induced pancreatitis. He improved clinically with conservative bowel rest. TheWBC count normalized and the amylase and lipase values continued to trend down at the time of his discharge from the hospital. Discussion: Mild elevations of serum and urinary amylase and serum lipase have been noted after ESWL but clinically significant pancreatitis is rare. Shock wave energy at the stone's surface produces mechanical compressive and tensile forces producing stone fragmentation. Shear forces produced by transient cavitation may damage nearby organs. With an increasing number of ESWL procedures being performed these days, consulting gastroenterologists need to be mindful of the collateral damage.

AIDS associated arteriopathy (AAA) of the gastrointestinal tract in adults has not been previously reported. We report the case of a young adult with AIDS and non-infectious recto-colonic ulcerations and postulate that the ulcerations may constitute a complication of AAA. Case Report: A 35 yo male with history of HIV with AIDS, non-Hodgkin's lymphoma, and MAI presented with fever, rectal pain and bleeding. Four months prior to admission, the patient underwent excision of a rectal ulcer, which revealed thick walled vessels with medial hypertrophy and intimal fibrosis within the granulation tissue. A few beaded acid-fast rods, consistent with Nocardia species were noted in adjacent crypts. Follow up colonoscopy revealed multiple ulcerations throughout the colon characterized microscopically as Candida associated colitis. The patient was treated for Nocardia and had complete resolution of his symptoms. 10 weeks later, he presented with diffuse abdominal pain and hematochezia. A repeat colonoscopy revealed a large, irregular fungating, friable cecal mass with biopsy changes similar to those in the rectal ulcer as well as luminal obliteration by organizing thrombi and no inflammation in the adjacent non-ulcerated cecal mucosa. Infectious, inflammatory and neoplastic etiologies were ruled out. The patient underwent a right hemicolectomy with ileo-colonic anastomosis with complete resolution of his pain. Microscopically, the cecal mass had vascular changes similar to those of the biopsy. AAA was the presumed etiology. Discussion: AAA is characterized by intimal fibrosis and fragmentation of the elastic fibers of medium sized arteries as well as fragmentation and calcification of the internal elastic membrane, with luminal narrowing. These changes have been described in children in organs such as the heart, lung, kidney, intestine, brain and spleen. Isolated cases complicated by coronary artery aneurysm, esophageal stricture and colonic perforation have been reported. Increased exposure to endogenous and exogenous elastases resulting from multiple infections secondary to the immunodeficiency in AIDS have been postulated as the pathogenetic mechanism. We report the first case of these vascular changes in the gastrointestinal tract of an adult with AIDS.

Purpose: Nongranulomatous ulcerative jejunoileitis (NGUJI) is a rare, often fatal disorder that produces multiple nonmalignant small bowel ulcerations. The diagnosis is often missed or delayed because of the non-specific clinical features, limited usefulness of available radiologic tests, and failure to identify the lesions on endoscopy. Here, we describe a patient whose first presentation of NGUJI was massive gastrointestinal bleeding (GIB), diagnosed by wireless capsule endoscopy (WCE). Case Report: A 75 year old female presented with melena, lethargy and anemia. She had a history of HIV (CD4<200) and remote history of anal cancer and breast cancer. She had been on anti-retroviral medications and did not use NSAIDs. On presentation, the patient had a blood pressure of 92/38 mmHg and pulse 104. Physical exam was significant for pallor, mild abdominal distension and melanotic stool. Initial hemoglobin was 3.9g/dl. She required transfusion of 24 units of packed red blood cells and was placed on IV proton pump inihibitor and parenteral nutrition. Melena persisted. Small bowel radiographs were normal. Serology for inflammatory bowel disease and celiac disease were negative. Upper endoscopy was normal. Colonoscopy, with terminal ileum intubation, demonstrated mild left sided colitis and ileitis. Biopsies taken during endoscopy revealed non-specific inflammation. No infectious agents were found. The patient was placed on Rowasa enemas but with continued bleeding. Bleeding scan was positive for small bowel bleed. Angiogram was normal. M2A WCE was performed, which revealed NGUJI, i.e. flattened jejunal mucosa and ulcerations. The patient was placed on IV steroids with clinical improvement and a decreased need for PRBC transfusions. Conclusions: NGUJI is a rare cause of small intestinal ulceration. The clinical features of NGUJI are fever, pain, steatorrhea, and protein-losing enteropathy with an unremitting downhill course. GIB is a rare manifestation of this disorder, more common in the patients without underlying disease. The course is usually quite severe. This report describes a patient with massive GIB from NGUJI, which was diagnosed by WCE after numerous other studies failed to demonstrate pathology. To date, major focus of WCE has been in the evaluation of occult GIB. We demonstrate WCE diagnosis of disease involvement in areas of the small bowel, i.e the jejunum and proximal ileum, that traditionally have been less directly accessible.

Cancers form more prostaglandins than the normal tissues from which they arise. Cyclooxygenase-2 (prostaglandin H synthase-2, PGHS-2, EC 1.14.99.1), an enzyme that catalyzes the formation of prostaglandins from arachidonic acid, is inducible in epithelial cells. We investigated whether transformation of mammary cells was associated with up-regulation of Cox-2 as a basis for increased production of prostaglandin E2 (PGE2) by these cells. This hypothesis was tested in two pairs of mammary cell lines between which the mode of transformation (viral versus oncogene) differed. Virally transformed RIII/Pr1 cells, which are highly tumorigenic in mice, produced markedly increased amounts of PGE2 compared to virally initiated RIII/MG cells, a weakly tumorigenic strain. Cox-2 mRNA and protein were increased concomitantly in RIII/Pr1 cells. Similarly, Ras-induced transformation of C57/MG cells resulted in increased levels of Cox-2 mRNA and protein and increased production of PGE2. Nuclear run-offs revealed increased rates of Cox-2 transcription in the virally transformed and oncogene-transformed cell lines. Transient transfection experiments demonstrated that the oncogenes src and ras up-regulated Cox-2 promoter activity. Src-mediated up-regulation of Cox-2 promoter activity was suppressed by dominant negative ras. Our data indicate that cellular transformation is associated with enhanced transcription of Cox-2 and increased production of PGE2.