Ischemic colitis is the most common form of intestinal ischemia. It manifests as a spectrum of injury from transient self-limited ischemia involving the mucosa and submucosa to acute fulminant ischemia with transmural infarction that may progress to necrosis and death. Although there are a variety of causes, the most common mechanism is an acute, self-limited compromise in intestinal blood flow. Patients typically have mild abdominal pain and tenderness over the involved segment of bowel. There is usually passage of blood mixed with stool, but hemodynamically significant bleeding is unusual. Although computed tomography may have suggestive findings, colonoscopy is the procedure of choice for diagnosis. Supportive care with intravenous fluids, optimization of hemodynamic status, avoidance of vasoconstrictive drugs, bowel rest, and empiric antibiotics will produce clinical improvement within 1 to 2 days in most patients. Twenty percent of patients will have development of peritonitis or may deteriorate despite conservative management and will require surgery.

Although acute LGIB is only about one fifth as common and is usually less hemodynamically significant than upper gastrointestinal bleeding, it presents numerous unique clinical challenges. The best diagnostic approach for patients with active bleeding is unknown, but urgent prepared colonoscopy is safe and likely to be beneficial (Fig. 3, Table 2). In patients who have aggressive bleeding or recurrent bleeding, it is critical for the practitioner to judge when angiography and surgery are necessary.

Enteric drainage of secretions by anastomosing the donor duodenum to the recipient's small bowel has become common in pancreatic transplantation. While it eliminates many problems, endoscopic access to the transplanted duodenum and pancreas is made difficult. After a pancreas kidney transplant, the patient presented with massive hematochezia. Upper and lower endoscopy revealed large amounts of red blood in the colon but no specific bleeding site. Mesenteric angiography was normal but pelvic angiography showed rapid extravasation of contrast from a pseudoaneurysm of the pancreatic transplant artery. This was successfully embolized with coils. To the best of our knowledge, this is the first case of massive gastrointestinal hemorrhage because of rupture of a pseudoaneurysm of the donor pancreatic artery in a pancreas transplant patient. We report this case and review our institution's experience with all forms of gastrointestinal bleeding in pancreas transplant patients.

Ambulatory esophageal 24-hr pH monitoring is used to diagnose GERD by determining the total acid contact time and/or symptom index (SI). The aim of this study was to compare the relationship between total acid contact times and SI in two groups: patients with very low vs. very high total acid contact times. We reviewed 973 consecutive 24-hr pH studies and compared patients with the lowest and highest 5% of total acid contact times. The low reflux group was significantly younger (median 50 vs. 54 years) and more predominantly female (78 vs. 47%) than the high reflux group. Median total acid contact time was 0.6 and 26.4% in the low and high reflux groups, respectively. The median SI was significantly lower in the low vs. high reflux groups for all symptoms (heartburn, 0 vs. 100%; regurgitation, 20 vs. 100%; cough, 0 vs. 55%; chest pain, 0 vs. 75%; nausea, 0 vs. 100%; and total SI, 12 vs. 86%). In patients with very low total acid contact times, only 12% of symptoms (typical or atypical) are associated with acid reflux, compared to 86% in patients with very high acid contact times. Younger females are overrepresented in the very low reflux, low SI group.

GOALS:To evaluate whether the gastrointestinal tract could be a source of chronic blood loss in premenopausal women with iron deficiency anemia.BACKGROUND:While premenopausal women with iron deficiency anemia are typically managed with simple iron replacement, the standard of care for postmenopausal women and men is to exclude a gastrointestinal source of bleeding.STUDY:We identified 111 premenopausal women who underwent endoscopy for the sole indication of iron deficiency anemia.RESULTS:The mean age was 42.5 years. Lesions potentially causative of iron deficiency anemia were detected in 22 patients (20%). Upper gastrointestinal lesions were present in 14 patients (13%) and included only erosive lesions. Lower gastrointestinal lesions were detected in 8 patients (7.2%) and included colon cancer (2.7%), inflammatory bowel disease (3.6%), and a colonic ulcer >1 cm (0.9%). Patients with upper gastrointestinal lesions were more likely to use aspirin or nonsteroidal antiinflammatory drugs (11/14, 79%) than patients with no lesions (26/89, 23%; P = 0.043). Occult blood was more common in patients with lower gastrointestinal lesions 8/8 (100%) and patients with upper gastrointestinal lesions (9/14, 64%) than in patients without lesions (28/89, 31%; P = 0.037 and 0.039). Gastrointestinal symptoms were significantly more common in patients with gastrointestinal lesions than in patients without lesions.CONCLUSIONS:A gastrointestinal source of chronic blood loss was identified in a substantial proportion of premenopausal women with iron deficiency anemia. Patients with gastrointestinal symptoms, fecal occult blood, and/or weight loss should undergo endoscopy.

et al. A case of a pedunculated angiodysplasia in the colon, successfully resected by colonoscopic polypectomy [in Japanese with English abstract]. Gastroenterol Endosc 1998;40:2143-8. 5. Moore JD, Thompson NW, Appelman HD, Foley D. Arteriovenous malformations of the gastrointestinal tract. Arch Surg 1976;111:381-9. 6. Boley SJ, Sammartano R, Adams A, Dibiase A, Kleinhaus S, Sprayregen S. On the nature and etiology of vascular ectasias of the colon: Degenerative lesions of aging. Gastroenterology 1977;72:650-60. 7. Hemingway AP. Angiodysplasia: current concepts. Postgrad Med J 1988;64:259-63. 8. Krevsky B. Detection and treatment of angiodysplasia. Gastrointest Endosc Clin North Am 1997;7:509-24.

s Submitted for the 68th Annual Scientific Meeting of the American College of Gastroenterology October 10-15, 2003, Baltimore, Maryland: OUTCOMES RESEARCH: PDF Only

1. Turner MW, Hamvas RM. Mannose-binding lectin: Structure, function, genetics and disease associations. Rev Immunogenet 2000;2:305–22. 2. Mäki M, Collin P. Coeliac disease. Lancet 1997;349:1755–9. 3. Boniotto M, Braida L, Spanò A, et al. Variant mannose-binding lectin alleles are associated with celiac disease. Immunogenetics 2002;54:596–8. 4. Walker-Smith JA, Guandalini S, Schmitz J, et al. Revised criteria for diagnosis of celiac disease. Arch Dis Child 1990; 65:909–11. 5. Miller SA, Dykes DD, Polesky HF. A simple salting out procedure for extracting DNA form human nucleated cells. Nucleic Acids Res 1988;16:1215. 6. Madsen HO, Garred P, Kurtzhals JAL, et al. A new frequent allele is the missing link in the structural polymorphism of the human mannan-binding protein. Immunogenetics 1994;40:37–44. 7. Iltanen S, Holm K, Partanen J, et al. Increased density of jejunal gammadelta T cells in patients having normal mucosa— marker of operative autoimmune mechanisms? Autoimmunity 1999;29:179–87. 8. Lipscombe RJ, Sumiya M, Summerfield JA, et al. Distinct physicochemical characteristics of human mannose binding protein expressed by individuals of differing genotype. Immunology 1995;85:660–7.

HP positive patients, the time to complete symptom relief was RAB(3.0 +/-0.8 days)OME>LAN>PLC.T1665

s Submitted for the 68th Annual Scientific Meeting of the American College of Gastroenterology October 10-15, 2003, Baltimore, Maryland: ESOPHAGUS: PDF Only

Diabetic foot disease in the form of ulceration, charcot joint fracture, and amputation affects 20% of patients with diabetes. This results in tremendous morbidity, mortality, and health care cost. The magnitude of this problem has been underrecognized by health care professionals. Impaired glucose control over a period of years affects peripheral nerve function by loss of protective sensation, muscle atrophy, foot deformity, and neuropathic fractures. Yearly foot examinations can identify risk factors. Regular nail care, callus removal, and education can prevent plantar ulceration. Protective footwear and custom orthotics improve function by reducing force and shear impact on the fragile foot and accommodate the patient's deformities. A cost-effective strategy of yearly comprehensive foot examinations, education, and appropriate interventions can improve both the quality and duration of life for those with diabetes mellitus.

BACKGROUND:Nocturnal gastroesophageal reflux (nGER) is common in patients with obstructive sleep apnea (OSA). Small, short-term studies have shown that treatment with nasal continuous positive airway pressure (CPAP) decreases esophageal acid exposure.OBJECTIVE:To examine the relationship between OSA and nGER, and the effect of CPAP on nGER, in a long-term follow-up study of a large cohort of patients with OSA and nGER.METHODS:We prospectively studied 331 patients diagnosed as having OSA between October 1, 1993, and November 30, 2000. At baseline, patients graded their frequency of nGER symptoms on a scale of 1 (never) to 5 (always). All patients were prescribed CPAP for their OSA. At follow-up, the frequency of nGER symptoms was obtained by telephone interview.RESULTS:Of the 331 patients with OSA, nGER was present in 204 (62%) before treatment with CPAP. Follow-up was obtained in 181 patients (89%). Of these 181 patients, 165 (91%) were still using CPAP and 16 (9%) were not, forming the treatment and control groups, respectively. The patients compliant with CPAP had a significant improvement in nGER score, from a mean of 3.38 before CPAP treatment to 1.75 after treatment (48% improvement; P<.001), while patients not using CPAP (control subjects) showed no improvement (mean, 3.56 to 3.44; P =.55). There was a strong correlation between CPAP pressure and improvement in nGER score (correlation, r = 0.70; P<.001), with patients with higher CPAP pressures demonstrating a greater improvement in nGER score.CONCLUSIONS:Nocturnal GER is common in patients with OSA. Treatment with nasal CPAP decreases the frequency of nGER symptoms by 48%. Higher nasal CPAP pressures are associated with greater improvement in nGER.

Somatostatinomas are the rarest pancreatic endocrine tumors and can arise in the pancreas or duodenum. Duodenal somatostatinomas are less common than, and are distinguished from, their pancreatic counterparts by a frequent association with type I neurofibromatosis, the presence of psammoma bodies, the less frequent presence of metastatic disease, and the absence of somatostatinoma syndrome (diabetes mellitus, steatorrhea, and cholelithiasis). We report a case of somatostatinoma with metastases and psammoma bodies presenting with all three features of the syndrome in a patient with neurofibromatosis. Although several reports have documented portions of the syndrome in patients with duodenal somatostatinomas, to our knowledge, this is the first report of the complete syndrome associated with a duodenal lesion.