A diagnostic dilemma: How to differentiate sigmoid volvulus from pseudoobstruction in patients with acute colonic distention

of a severe flat lesion due to massive eosinophilic infiltrates. We studied the types of endoscopic lesions and their histological correlates in EG. Methods 4 patients with EG had video capsule endoscopy (Given M2A diagnostic imaging system) of the whole small bowel and push enteroscopy (to the proximal jejunum) and jumbo forceps biopsy. 3 of the 4 patients (2 men, 2 women, ages 29-59) had EG for > 10 yr All were off corticosteroids, with eosinophil counts ranging from 18-37% and 2 of the 4 with low serum albumin levels (1.6, 2.8 g/dl). The most distinctive lesions looked denuded: violaceous, linear (up to 3 cm) sausage-like, or round. Lesions of lesser severity included a coarse scalloping of valvulae. The more severe small bowel lesions appeared to taper off in the proximal 1/3 of the small intestine. 44 biopsies from the 2nd duodenum into proximal jgunum were evaluated, 20 from lesions and 24 from non-lesional mucosa, in general, biopsies from non-lesional mucosa were normal or mildly abnormal largely with pericryptaI mixed infiltrates Biopsies from the denuded appearing mucosae did not show erosions but rather an array of severely flat mucosae: a minority with the massive eosinophils, many with massive mixed mflammatory infiltrates, and others with total villous blunting but minimaIinflammation (reactive enteropathy). In biopsies not totally flat, the inflammation often spared villi and concentrated in the bottom half of the mucosa. Conclusion: Modem imaging technology reveals a much broader spectrum of small bowel disease in eosinophilic gastroenteritis than has been previously appreciated The denuded appearing lesions are associated with striking histologic findings but often with a mixed infiltrate or simple thinning. This diversity may reflect what others have postulated for some time,namely that EG is a group of disorders pathogeneticafiy.

activity of the intestinal disease (Group 1) and the TEE (Group 1 and Group 2) were specified Blood samples were obtained for measurement of coagulation factors I, 11, VIII, IX, Xl, XII, platelets, fibrinogen, C reactive protein, folate, B12, and homocystein levels, antithrombin 11I, protein C and protein S activities, determination of anticardiolipin and antibeta2glycoprotein antibodies. DNA studies were performed to detect factor V Leiden, MTHFR C677T, factor II G20210A, tactor Xll C46T and factor Xlll G163T mutations. RESULTS: In Group 1, 30 patients (24 CD, 6 UC) (Group 1A) were found to have a history of"fEE ( I I 7 %). Group 1 and 2 were similar for sex, age, and characteristics of TEE. Protein S deficiency (p<0 0005), anticardiofipin antibodies (p
S1301 $1304 Colonoscopy Evaluation of 314 Patients with Chronic Diarrhea Antonis K. Zacharof

Renal Tubular Proteinuria in the Irritable Bowel Syndrome Alastair O'Brien, Edmund Lamb, Andrew F. Muller

INTRODUCTION: Patients who had chronic diarrhea frequently undergo endoscopic evaluation of t~e colon. There are sparse data on the role for colonoscopy with biopsy for patients with chrome diarrhea. AIMS & METHODS: We reviewed the charts of 314 hospitalized patients with chronic diarrhea evaluated by colonoscopy between 1986 and 20019 Chronic diarrhea was defined as loose, frequent bowel movements for a minimum of 4 weeks. Patients were excluded from the study if biopsies were not performed in normal colons, if they had undergone previous surgery in large bowel, if they had a history of inflammatory bowel disease, HIV, or an mcomplete colonoscopy. RESULTS: Three hundred and fourteen patients were included in the analysis, of whom 245 (78%) had colonoscopy until the terminal ileum Colonoscopy and biopsy yielded a specific histological diagnosis in 145 (59%) patients These included Cmhn's disease (25), ulcerative colitis (34), lymphocytic colitis (12), collagenons colitis (6), isebemic colitis (16), infectious colitis (13), and miscellaneous diseases (39). Colonoscopy until the terminal ileum yielded significant findings in 3% of patients (four with Crohn's disease and one with infection). CONCLUSION: Colonoscopy and biopsy is useful in the investigation of patients with chronic diarrhea yielding a histological diagnosis in 61% d patients without a previous diagnosis. Colonoscopy until the terminal ileum disclosed findings in a minority of patients with chronic diarrhea and was essential for a diagnosis in only five patients.

Introduction: The irritable bowel syndrome (1BS) is a heterogeneous disorder involving genetics, infection, mucosal inflammation and visceral hypersensitivity (1) We have previonsly demonstrated tubular proteinuria in patients with inflammatory bowel disease (IBD, 2). This study examined whether tubular proteinuria may be a feature of IBS. Methods: 53 control subjects (age range 20-65 yrs) and 21 patients (pts) with IBS (M:P 9:12 age range 16-64 yrs ~NS*) were recruited. Subjects with known renal disease, hypertension, diabetes or microbiological evidence of urinary infection were excluded9 The IBS group pts all fulfille d the Rome II criteria for diagnos~s. None gave a history of preceding gastroenteritis. Many pts underwent radiological or endoscopic evaluation All subjects provided the second voided urine of the morning. Urinary concentrations of the protein al-microglobulin (al-M) were measured using rate nephelometnc immunoassay and corrected for urinary concentration by measurement of creatinine (upper reference limit 1.5 mg/mmol) Blood samples were analysed for biochemical and haematological indices including C-reactive protein, Statistical analysis was by unpaired T-test Results: None of the IBS pts over a 3 yr tollow-up period were reclassified with IBD All had normal haematochemical parameters. Mean (+/- SD) urinary al-M concentrations were significantly higher in IBS than controls (IBS (I 17 +/0.65 mg/mmol; Controls 0.75 +/- 0.36 mg/mmol, P<0.01) and exceeded 1.5 mg/mmol in 7 pts. Conclusions: Urinary al-M concentration is elevated in IBS, suggesting the presence of renal tubular injury. References: 1. Tafiey NJ, Spiller RC. 2002 Lancet 360:555-64.2 Fraser JS et al, 2001 Aliment Pharmacol "[her, 15:1131-37

$1302 A Diagnostic Dilemma: How to Differentiate Sigmoid Volvulus from Pseudoobstruction in patients with Acute Colonic Distention Sundararaman Swaminathan, Md, Pramod Joseph, Md, Mario Ricci, Md Jr., Ajit Kokkat, Md, Rajeev Jayadevan, Md, Nejat Kiyiei, Md, Edward Norkus, Phd, Hilary Hertan, Md, C S. Pitchumoni, Md, Macg

S1305 Oral Budesonide therapy improves quality of life in patients with collagenous colitis - results of placebo-controlled, muhicenter trial Ahmed Madisch, Stephan Miehlke, Peter Heyrner, B Bethke, Elke Baesdetn, Norbert Lehn, Ekkehard Bayerdoerfier, Manfred Stuhe

Background: Stratifying causes of acute colonic distention is vital to selecting an appropriate management strategy Surgeons, gastroenterologists and radiologists often have difficulty in distinguishing sigmoid volvufus from pseudoobstruction. Comprehensive history, thorough examination and radiological imaging are paramount; yet precise diagnosis remains a challenge. Our aim was to identify diagnostic parameters that differentiate between sigmoid volvulus and pseudoobstruction. Methods. Data from 31 patients with acute colonic distension m a city hospital collected over two years, were used. Information regarding clinical presentation and diagnostic tests were collected, as were data from laboratory tests, radiographic reports, medications, comorbidity, chief complaints, and vital signs. Results. Our sample had a mean age of 78.1 + 10.6 (SD) years; 15 patients were male. Signloid volvulns occurred in 17 patients with acute colonic distennon while 12 patterns had acute pseudoobstmction. Two patients bad uncertain etiology. The hematocnt was significantly lower in pseudoobstruction (34 +/- 8(SD)) compared to sigmoid volvulns (39 +t- 4(SD)) (P= 0032) Also, fever occurred more often in sigmoid volvulns than pseudooobstruction (30% vs 8% of cases)(P = 0 0 3 5 ) A trend towards low sodium levels in pseudoobstruction compared to sigmoid volvulus was observed (P= 0 055) Other parameters including WBC count, serum potassium, serum glucose levels, thyroid function tests, and renal function tests did not suggest any significant difference between these diagnostic categories. Curiously, 8 of these patients with acute colonic distention had underlying malignancy with or without distant metastases (prostate cancer n = 5, breast cancer n = 2 and Non Hodgkins kymphoma n = 1). The majority (n = 6) in this subgroup were finally diagnosed as pseudoobstruction Conclusion The presence of a low hematocrit and the absence of fever favors a diagnosis of pseudoobstmction over slgmoid volvulus. We are currently extending our data collection (5+ years; 100+ cases) to determine if our present findings can be substantiated in a larger sample.

Background & Aim: Coflagenous colitis (CC) is an idiopathic microscopic colitis characterized by chronic watery tharrhea, a typical thickened subepithdial collagen layer and lymphoplasmacellular infiltration9 The impact of CC on quality of life is largely unknown We investigated the effect of budesonide (capsules Entocort| AstraZeneca) on quality of life m patients with CC in a randomized placebo-controlled trial, Patients & Methods: Patients with chronic diarrhea and histologically proven cotlagenous colitis were randomized to receive either b~desonide (Emocort| capsules) 9 rag/day for 6 weeks or placebo. Stool frequency and consistency were assessed by standardized questionnaires Quality of life was measured by a validated gastrointestinal quality of fife-Index (GLQk score between 0 to 144) at baseline and after 6 weeks Results: 51 patients were randomized, 45 patiems (male 11, mean age 60) were available for per protocol analysis. Complete quality of life assessment was available in 29 patients (17 budesoinde group). At baseline quality of life was profoundly reduced in CC patients. A significantly larger proportion of patients in the budesonide group (86,9 %) experienced an improvement of stool consistency (15 pts vs. 0 pts) with significant mean reduction of stool frequency compared to placebo group (p < 09 for all) After 6 weeks the mean of GkQl-Score significantly increased in the budesonide group (67 to 92, p < 0001) while the score remained on the same level in the placebo group (86 to 88). Based upon the subscores, the dimensions symptoms (p = 0.001), emotional (p = 09 and physical functioning (p = 0.017) showed a significant increase of mean score in budesonide group compared to placebo No significant change was observed in dimension social functioning in both groups Conclusion: A 6 week therapy vath oral budesonide (Entoeort | capsules)significantly improved quality of life and clinical symptoms and was well tolerated in patients with collagenous colitis.

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The Spectrum of Endoscopic and Histologic Findings in Eosinophilic Gastroenteritis. A Video Capsule and Push Enteroscopic Study Wilfred M. Weinstein, Shendan D. Wiggett

Screening for Lactose Malabsorption: Hydrogen Breath Test vs. 13C Breath Test Juergen R. A Bamert, Jochen Weymayer, Jeannette Fischer, Jochen Piscfiel, Helmut Messmann

Background The classic description of the small bowel mucosa in eosinophdic gastroenteritis (EG) has changed little in the modem era of small bowel endoscopy it is accepted that the mucosa[ variant of the disease requires multiple biopsies to demonstrate the classic appearance

Background: Currently, the gold standard for diagnosing lactose malabsorption is the hydrogen breath test (HBT). But the accuracy of HBT is hampered by a considerable number of hydrogen (H2) non producers which comes to 31% of the persons tested Aim of the study

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AGA Abstracts