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bowel preparation kit versus customary preparation for colonoscopy
AJG – September, Suppl., 2001
461 Unusual presentation of a true cecal diverticulum-RLQ mass and cecal ulceration Virat R Dave, MD1, Vajravel M Prasad, MD2*, Eric Rachut, MD2 and Theodore Hopens, MD2. 1Department of Medicine, Scott & White/Texas A&M University, Temple, TX, United States; and 2Section of Gastroenterology, VA Medical Center/Texas A & M University, Temple, TX, United States. Purpose: To report an unusual presentation of a true cecal diverticulum. Methods: A literature review was performed regarding colonic diverticulosis and unusual presentations. Case report: 69 year-old male presented to GI clinic with RLQ mass and anemia. He denied abdominal pain, GI bleeding, weight loss or change in bowel habits. His past medical history was significant for chronic bronchitis, hypertension, chronic atrial fibrillation on coumadin, and transanal resection of a large rectal villotubular polyp one year ago. Colonoscopy performed prior to surgery showed sigmoid diverticulosis and the rectal polyp. Patient had a significant family history for colon cancer (father). His abdominal exam was normal except for a 4 cm RLQ mass. No lymphadenopathy was noted on exam. His labs revealed a Hgb of 9.6 gm/dL, MCV of 89.9 fl, RDW of 13.6%, CEA of 1.1 ng/ml and a protime of 2.01 INU. Iron was 47 ug/dL, TIBC was 365 ug/dL, and iron saturation was 13%. Stool for occult blood was positive in 3/3 samples. A barium enema showed left sided diverticulosis and a large cecal diverticulum, 3 cm, which was only faintly coated with barium suggesting a large fecalith. A subsequent colonoscopy performed showed left sided diverticulosis and a 2 cm ulceration with central dark material near the ileocecal valve. Biopsies from the ulcer showed no malignancy. Patient underwent right hemicolectomy without complications. Gross examination of the resected surgical specimen showed a large cecal diverticulum with an impacted fecalith measuring 3.5 cm. Microscopic examination revealed a true diverticum with presence of all colonic layers and intense inflammation throughout the mucosa. Patient had an uneventful recovery and was subsequently placed back on coumdain for his chronic atrial fibrillation. Conclusions: This patient had a single true diverticulum of the cecum apart from the usual left-sided pseudo-diverticulosis. True diverticulum is usually congenital. It is believed to be a form of a communicating bowel duplication cyst. The usual complications of diverticulosis are diverticulitis and bleeding. However, this patient’s cecal diverticulum was complicated by a fecalith impaction, which presented with RLQ mass and cecal ulceration. This is an unusual presentation of a true cecal diverticulum.
462 A pilot study to assess the efficacy of bowel preparation with the use of a pre-packaged diet/bowel preparation kit versus customary preparation for colonoscopy Mark H DeLegge1*, Gregory F Buck1, Melinda Lewin1 and Winnie Hennessey1. 1Digestive Disease Center, Medical University of South Carolina, Charleston, SC, United States. Purpose: The efficacy of standard bowel preparation for colonoscopy is often limited by patient compliance. Patient compliance is often impacted by their tolerance of the prescribed cathartic and also by the discomfort of maintaining a clear liquid diet on the day of bowel preparation. Our study evaluated the effect of a pre-packaged food kit on the day of bowel preparation coupled with a magnesium citrate, bisacodyl tablet, bisacodyl suppository colon cleansing regimen as compared to a standard clear liquid diet and Fleet Phospha-Soda colon regimen. Methods: 35 patients were prospectively randomized to one of three bowel preparations on the day prior to colonoscopy. Active group 1 (A1) received magnesium citrate, oral bisacodyl tablets, a bisacodyl suppository and a
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pre-packaged combination of a low residue solid and liquid food diet. Active group 2 (A2) received magnesium citrate, oral bisacodyl tablets, a bisacodyl suppository and a low-residue liquid food diet. The control group (C) received Fleet Phospha-Soda and a clear liquid diet, representing our standard bowel cleansing regimen. Patient tolerance of the preparations and efficacy of the preparations, often related to patient compliance, was measured by 2 endoscopists. Results: 35 patients (average age 54.2 years) completed the study. There were 11 patients in group A1, 12 patients in group A2 and 12 patients in group C. The preparation was rated as tolerable or very tolerable by the patients in 100% of groups A1 and A2 and in 91% of group C. The preparation was rated as intolerable in 0% of groups A1 and A2 and in 9% of group C. Overall visualization of the colon was determined to be adequate in all groups. However, 18% of group A1, 25% of group A2 and 50% of group C had a significant amount of retained stool requiring aggressive bowel washing and aspiration. Cramping was reported in 18% of group A1, 25% of group A2 and 18% of group C Conclusions: A pre-packaged food bowel preparation kit containing low residue solids and liquids in combination with magnesium citrate, bisacodyl tablets and bisacodyl suppository was rated as more tolerable and resulted in less quantities of retained stool in the colon as compared to a standard Fleet Phospha-Soda and clear liquid diet colon preparation. Reported cramping ranged from 18 –25% with the use of these preparations.
463 Small bowel tumor presenting as a case of obscure gastrointestinal bleeding Bhargab M Dixit M.D., Ramin farboudmanesch M.D., Gary Thompson M.D., Robert Burakoff FACG. Section of Gastroenterology, Washington Hospital Center, Washington, D.C. Introduction: Although the small intestine represents 90 percent of the gastrointestinal mucosal surface area, small bowel tumors account for only 2 percent of all gastrointestinal neolpasm. We present a case of metastatic adenocarcinoma of small bowel presented as obscure GI bleeding. Obscure GI bleeding is defined as failure to reveal source of bleeding after routine upper endoscopy, colonoscopy, and radiological evaluation. Case report: This is a 54 year old male without significant prior medical history presented with several days of black stool, fatigue and hematocrit of 19%. Initial upper endoscopy and colonoscopy was normal except few diverticulosis on left colon. Small bowel follow through X-ray was normal. Patient presented 3 months later with another episode of black stool followed by hematochezia after admission to the hospital. Repeat upper endoscopy with pediatric colonoscopy up to proximal jejunum was normal. Patient continued to bleed actively. Surgical exploration with intra operative enteroscopy was performed after red cell tagged bleeding scan showed flash of activity possibly from small bowel. Intra operative enteroscopy revealed bleeding ulcerated nodules at mid jejunum with multiple other nodules in small bowel. Histology of surgical specimen was consistent with metastatic adenocarcinoma. Work up for primary tumor were negative. Discussion: The incidence of small bowel tumor is 1.6 per 100,000 population. Small bowel tumor is divided into primary benign, primary malignant and metastatic tumor. The prevalence of benign tumor is greater in African Americans (61%) than Caucasians (39%) where as primary malignant or metastatic tumors are evenly distributed. The commonest primary site of the tumor is colon (almost 40% in one series) and other primary sites are pancreas, ovaries, lungs and melanoma. Summary: Small bowel tumors are rare but diagnosis and accurate localization remains a diagnostic challenge due to relative inaccessibility. If initial routine endoscopic evaluation is negative, repeat study combines with advanced small bowel diagnostic modalities usually help the diagnosis.
461 Unusual presentation of a true cecal diverticulum-RLQ mass and cecal ulceration Virat R Dave, MD1, Vajravel M Prasad, MD2*, Eric Rachut, MD2 and Theodore Hopens, MD2. 1Department of Medicine, Scott & White/Texas A&M University, Temple, TX, United States; and 2Section of Gastroenterology, VA Medical Center/Texas A & M University, Temple, TX, United States. Purpose: To report an unusual presentation of a true cecal diverticulum. Methods: A literature review was performed regarding colonic diverticulosis and unusual presentations. Case report: 69 year-old male presented to GI clinic with RLQ mass and anemia. He denied abdominal pain, GI bleeding, weight loss or change in bowel habits. His past medical history was significant for chronic bronchitis, hypertension, chronic atrial fibrillation on coumadin, and transanal resection of a large rectal villotubular polyp one year ago. Colonoscopy performed prior to surgery showed sigmoid diverticulosis and the rectal polyp. Patient had a significant family history for colon cancer (father). His abdominal exam was normal except for a 4 cm RLQ mass. No lymphadenopathy was noted on exam. His labs revealed a Hgb of 9.6 gm/dL, MCV of 89.9 fl, RDW of 13.6%, CEA of 1.1 ng/ml and a protime of 2.01 INU. Iron was 47 ug/dL, TIBC was 365 ug/dL, and iron saturation was 13%. Stool for occult blood was positive in 3/3 samples. A barium enema showed left sided diverticulosis and a large cecal diverticulum, 3 cm, which was only faintly coated with barium suggesting a large fecalith. A subsequent colonoscopy performed showed left sided diverticulosis and a 2 cm ulceration with central dark material near the ileocecal valve. Biopsies from the ulcer showed no malignancy. Patient underwent right hemicolectomy without complications. Gross examination of the resected surgical specimen showed a large cecal diverticulum with an impacted fecalith measuring 3.5 cm. Microscopic examination revealed a true diverticum with presence of all colonic layers and intense inflammation throughout the mucosa. Patient had an uneventful recovery and was subsequently placed back on coumdain for his chronic atrial fibrillation. Conclusions: This patient had a single true diverticulum of the cecum apart from the usual left-sided pseudo-diverticulosis. True diverticulum is usually congenital. It is believed to be a form of a communicating bowel duplication cyst. The usual complications of diverticulosis are diverticulitis and bleeding. However, this patient’s cecal diverticulum was complicated by a fecalith impaction, which presented with RLQ mass and cecal ulceration. This is an unusual presentation of a true cecal diverticulum.
462 A pilot study to assess the efficacy of bowel preparation with the use of a pre-packaged diet/bowel preparation kit versus customary preparation for colonoscopy Mark H DeLegge1*, Gregory F Buck1, Melinda Lewin1 and Winnie Hennessey1. 1Digestive Disease Center, Medical University of South Carolina, Charleston, SC, United States. Purpose: The efficacy of standard bowel preparation for colonoscopy is often limited by patient compliance. Patient compliance is often impacted by their tolerance of the prescribed cathartic and also by the discomfort of maintaining a clear liquid diet on the day of bowel preparation. Our study evaluated the effect of a pre-packaged food kit on the day of bowel preparation coupled with a magnesium citrate, bisacodyl tablet, bisacodyl suppository colon cleansing regimen as compared to a standard clear liquid diet and Fleet Phospha-Soda colon regimen. Methods: 35 patients were prospectively randomized to one of three bowel preparations on the day prior to colonoscopy. Active group 1 (A1) received magnesium citrate, oral bisacodyl tablets, a bisacodyl suppository and a
Abstracts
S147
pre-packaged combination of a low residue solid and liquid food diet. Active group 2 (A2) received magnesium citrate, oral bisacodyl tablets, a bisacodyl suppository and a low-residue liquid food diet. The control group (C) received Fleet Phospha-Soda and a clear liquid diet, representing our standard bowel cleansing regimen. Patient tolerance of the preparations and efficacy of the preparations, often related to patient compliance, was measured by 2 endoscopists. Results: 35 patients (average age 54.2 years) completed the study. There were 11 patients in group A1, 12 patients in group A2 and 12 patients in group C. The preparation was rated as tolerable or very tolerable by the patients in 100% of groups A1 and A2 and in 91% of group C. The preparation was rated as intolerable in 0% of groups A1 and A2 and in 9% of group C. Overall visualization of the colon was determined to be adequate in all groups. However, 18% of group A1, 25% of group A2 and 50% of group C had a significant amount of retained stool requiring aggressive bowel washing and aspiration. Cramping was reported in 18% of group A1, 25% of group A2 and 18% of group C Conclusions: A pre-packaged food bowel preparation kit containing low residue solids and liquids in combination with magnesium citrate, bisacodyl tablets and bisacodyl suppository was rated as more tolerable and resulted in less quantities of retained stool in the colon as compared to a standard Fleet Phospha-Soda and clear liquid diet colon preparation. Reported cramping ranged from 18 –25% with the use of these preparations.
463 Small bowel tumor presenting as a case of obscure gastrointestinal bleeding Bhargab M Dixit M.D., Ramin farboudmanesch M.D., Gary Thompson M.D., Robert Burakoff FACG. Section of Gastroenterology, Washington Hospital Center, Washington, D.C. Introduction: Although the small intestine represents 90 percent of the gastrointestinal mucosal surface area, small bowel tumors account for only 2 percent of all gastrointestinal neolpasm. We present a case of metastatic adenocarcinoma of small bowel presented as obscure GI bleeding. Obscure GI bleeding is defined as failure to reveal source of bleeding after routine upper endoscopy, colonoscopy, and radiological evaluation. Case report: This is a 54 year old male without significant prior medical history presented with several days of black stool, fatigue and hematocrit of 19%. Initial upper endoscopy and colonoscopy was normal except few diverticulosis on left colon. Small bowel follow through X-ray was normal. Patient presented 3 months later with another episode of black stool followed by hematochezia after admission to the hospital. Repeat upper endoscopy with pediatric colonoscopy up to proximal jejunum was normal. Patient continued to bleed actively. Surgical exploration with intra operative enteroscopy was performed after red cell tagged bleeding scan showed flash of activity possibly from small bowel. Intra operative enteroscopy revealed bleeding ulcerated nodules at mid jejunum with multiple other nodules in small bowel. Histology of surgical specimen was consistent with metastatic adenocarcinoma. Work up for primary tumor were negative. Discussion: The incidence of small bowel tumor is 1.6 per 100,000 population. Small bowel tumor is divided into primary benign, primary malignant and metastatic tumor. The prevalence of benign tumor is greater in African Americans (61%) than Caucasians (39%) where as primary malignant or metastatic tumors are evenly distributed. The commonest primary site of the tumor is colon (almost 40% in one series) and other primary sites are pancreas, ovaries, lungs and melanoma. Summary: Small bowel tumors are rare but diagnosis and accurate localization remains a diagnostic challenge due to relative inaccessibility. If initial routine endoscopic evaluation is negative, repeat study combines with advanced small bowel diagnostic modalities usually help the diagnosis.