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Changing etiology of upper GI bleeding in AIDS patients
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Abstracts
the submucosal layer. After EUS, saline and epinephrine (1/10,000 solution) was injected to elevate these lesions, followed by snare piecemeal resection using a diathermy snare. Cauterization of the base of the lesion was then performed using argon plasma coagulation (60 wt, 1.0 L/min). Results: All lesions were successfully removed in 1–3 sessions (mean 1.2 sessions). We placed a pancreatic stent in one case prior to endoscopic therapy as the lesion was close to the papilla. No complications were reported. Follow up endoscopy after 8 –12 months (mean 10 months) showed no recurrence of these adenomas. Conclusions: Non-ampullary duodenal adenomas and carcinoma in situ can be successfully treated by endoscopic means. EUS provides detailed information on the depth of invasion prior to endoscopic therapy. A combination of snare polypectomy and argon plasma coagulation appears to be useful in managing these lesions.
276 Mycophenolate mofetil-associated gastrointestinal hemorrhage in renal transplant recipients, a 3 year prospective evaluation of clinical and endoscopic findings at a large community transplant center RM Bashir, MD, S Ressaiah, MD, M Ali, MD, O Grandes, MD, S Karokozis, MD, M White, T Sasaki, MD, A Aquino, J Light, MD. Depts. of Medicine and Surgery, Washington Hospital Center, Washington, DC. Background: Mycophenolate mofetil (CellCept; Roche Pharmaceuticals, Nutley, NJ) has been associated with gastrointestinal (GI) hemorrhage; however, prospective clinical findings have not been reported. Methods: From December 1996 through December 1999, renal transplant recipients receiving CellCept who presented with GI bleeding were identified. All patients underwent upper endoscopy (EGD) and, if negative, colonoscopy for evaluation of GI bleeding. Patients with a history of peptic ulcer disease, prior to GI bleeding, and patients on nonsteroidal antiinflammatory (NSAIDs) medications were excluded. All patients subsequently included for analysis were biopsy negative for H. pylori and viral culture negative. Results: During the 36 month study period, 267 transplant recipients received CellCept. Among 23 patients (8.6%) receiving CellCept who presented with GI bleeding, 7 were excluded: NSAIDs (3); H. pylori (1); prior GI bleeding (1); CMV biopsy or culture positive (2). Of the 16 patients included (6.2% overall), 12 (75%) presented predominantly with melena; 4 (25%) with hematochezia. All 16 patients underwent EGD; 10/16 also underwent colonoscopy. EGD demonstrated distinct raised, friable gastric antral nodules with ulceration in 10/16 patients (62.5%), esophageal erosions in one (6%), and duodenal ulcer in one (6%). Colonoscopy demonstrated ileocecal valve ulceration in 6/10 patients (60%) (with additional cecal ulcers in 2/6), and was negative in 40%. Patients presenting with melena tended to be receiving CellCept for a shorter average duration from transplant to initial GI bleeding episode than those presenting with hematochezia (76 vs 164 days). Discontinuation of CellCept led to cessation of GI bleeding in all patients. Conclusions: The prospective incidence of CellCept-associated GI bleeding (8.6% overall) was higher than that reported in prerelease clinical trials (3%) and occurred relatively soon after transplantation (usually 2– 6 months). Distinct endoscopic findings, gastric ulcerated nodules and/or ileocecal valve ulcers, accounted for 14/16 (88%) of all cases. CellCept should be considered a likely and endoscopically identifiable cause of GI bleeding in renal transplant recipients.
277 Turbulent two phase flow; a novel method for cleaning and high grade disinfection of flexible endoscopies and internal channels Stanley Benjamin, MD, Mohamed Labib, Ph.D. Georgetown University and Novaflux Technologies, Washington, DC and Princeton, NJ.
AJG – Vol. 95, No. 9, 2000
One of the major obstacles to high grade disinfection (HGD) of flexible endoscopies is the biofilm layer that forms on the internal channels of flexible endoscopies (FE). Recently introduced, turbulent two phased flow (TTFF), has been shown to eliminate biofilm from the inside of dental tubing and other long tubular channels. Preliminary work has demonstrated the ability of this technology to remove biofilm from endoscope channels. Aim: To determine the ability of TTFF to provide high level disinfection (⬎106 reduction in organisms) to endoscopies and endoscope channels. Methods: Two previously used endoscopes and two endoscope channels were provided by Pentax Precision Instrument Co., Orangeburg, NY). The endoscopes and channels were contaminated with B. subtilis var. niger at a concentration of 107 CFU/scope and channel by an independent laboratory (Nelson Labs, Inc., Salt Lake City, UT). Scopes and channels were processed using two phase flow of air and surfactant/detergent mixture by Novaflux technologies, Inc. (Princeton, NJ) and sent to Nelson Labs for evaluation. Results:
#1 air/water #1 suction/bx #2 air/water #2 suction/bx* control
Cts/initial
Cts/post-TTFF
% reduction
Log reduction
7.0 ⫻ 10 7.0 ⫻ 107 7.0 ⫻ 107 7.0 ⫻ 107 7.0 ⫻ 107
20 43.7 20 436.6 7 ⫻ 107
⬎99.9% ⬎99.9% ⬎99.9% ⬎99.9% 0
6.1 6.2 6.1 5.2 0
7
* post procedure a leak was found in the channel.
Conclusions: 1) At a minimum TTFF can provide mechanical cleansing of endoscopes, eliminating the need for committed staff and reducing the risk of non-compliance; 2) with appropriate design modifications the technology appears to be able to provide HLD; 3) damaged endoscope channels cannot be cleaned/disinfected appropriately.
278 Changing etiology of upper GI bleeding in AIDS patients Faraz F Berjis, Adnan M Khdair*, Irwin M Grosman. Long Island College Hospital, Brooklyn, NY. Purpose: To compare the etiology of upper GI bleeding (UGIB) in AIDS patients during two time intervals and to assess the impact of contemporary HIV therapy on etiology and prognosis. Methods: Retrospective analysis of 50 patients with AIDS as defined by the CDC criteria who presented to a single center with UGIB (hematemesis and/or melena with a positive nasogastric lavage) and were evaluated by upper endoscopy. Group 1 consists of 27 patients evaluated from 1987– 1993 and group 2 consists of 23 patients from 1996 –2000. Results: 12/27 patients in group 1 (44%) had an AIDS related etiology for the UGIB (8 Candida esophagitis, 3 idiopathic esophageal ulcer and 1 with Kaposi’s sarcoma) while only 1 patient from group 2 (4%) had an AIDS related diagnosis (CMV gastric ulcer). The first group had 15 non-AIDS related causes for UGIB (7 gastric ulcer, 5 erosive gastritis, 2 MalloryWeiss tear and 1 duodenal ulcer). The second group had 22 non-AIDS related causes for UGIB as follows: 9 gastric ulcer, 4 erosive esophagitis, 4 erosive gastritis, 2 duodenitis, 2 bleeding esophageal varices, and 1 Mallory-Weiss tear. The 7 day mortality was 11% in the first group compared to 0% in the second group. Conclusions: We observed a changing pattern of etiology for UGIB in our 2 series of patients with AIDS. Our earlier cohort had a high prevalence of AIDS related causes for GI bleeding while our recent patients had bleeding from causes similar to the general hospitalized population. With better therapy of HIV disease the pattern of UGIB in AIDS patients is changing to become similar to their non-HIV infected peers. The study also shows improved short term mortality in these patients and confirms our previous conclusion that UGIB in AIDS is not a terminal event and these patients should be promptly assessed and treated.
Abstracts
the submucosal layer. After EUS, saline and epinephrine (1/10,000 solution) was injected to elevate these lesions, followed by snare piecemeal resection using a diathermy snare. Cauterization of the base of the lesion was then performed using argon plasma coagulation (60 wt, 1.0 L/min). Results: All lesions were successfully removed in 1–3 sessions (mean 1.2 sessions). We placed a pancreatic stent in one case prior to endoscopic therapy as the lesion was close to the papilla. No complications were reported. Follow up endoscopy after 8 –12 months (mean 10 months) showed no recurrence of these adenomas. Conclusions: Non-ampullary duodenal adenomas and carcinoma in situ can be successfully treated by endoscopic means. EUS provides detailed information on the depth of invasion prior to endoscopic therapy. A combination of snare polypectomy and argon plasma coagulation appears to be useful in managing these lesions.
276 Mycophenolate mofetil-associated gastrointestinal hemorrhage in renal transplant recipients, a 3 year prospective evaluation of clinical and endoscopic findings at a large community transplant center RM Bashir, MD, S Ressaiah, MD, M Ali, MD, O Grandes, MD, S Karokozis, MD, M White, T Sasaki, MD, A Aquino, J Light, MD. Depts. of Medicine and Surgery, Washington Hospital Center, Washington, DC. Background: Mycophenolate mofetil (CellCept; Roche Pharmaceuticals, Nutley, NJ) has been associated with gastrointestinal (GI) hemorrhage; however, prospective clinical findings have not been reported. Methods: From December 1996 through December 1999, renal transplant recipients receiving CellCept who presented with GI bleeding were identified. All patients underwent upper endoscopy (EGD) and, if negative, colonoscopy for evaluation of GI bleeding. Patients with a history of peptic ulcer disease, prior to GI bleeding, and patients on nonsteroidal antiinflammatory (NSAIDs) medications were excluded. All patients subsequently included for analysis were biopsy negative for H. pylori and viral culture negative. Results: During the 36 month study period, 267 transplant recipients received CellCept. Among 23 patients (8.6%) receiving CellCept who presented with GI bleeding, 7 were excluded: NSAIDs (3); H. pylori (1); prior GI bleeding (1); CMV biopsy or culture positive (2). Of the 16 patients included (6.2% overall), 12 (75%) presented predominantly with melena; 4 (25%) with hematochezia. All 16 patients underwent EGD; 10/16 also underwent colonoscopy. EGD demonstrated distinct raised, friable gastric antral nodules with ulceration in 10/16 patients (62.5%), esophageal erosions in one (6%), and duodenal ulcer in one (6%). Colonoscopy demonstrated ileocecal valve ulceration in 6/10 patients (60%) (with additional cecal ulcers in 2/6), and was negative in 40%. Patients presenting with melena tended to be receiving CellCept for a shorter average duration from transplant to initial GI bleeding episode than those presenting with hematochezia (76 vs 164 days). Discontinuation of CellCept led to cessation of GI bleeding in all patients. Conclusions: The prospective incidence of CellCept-associated GI bleeding (8.6% overall) was higher than that reported in prerelease clinical trials (3%) and occurred relatively soon after transplantation (usually 2– 6 months). Distinct endoscopic findings, gastric ulcerated nodules and/or ileocecal valve ulcers, accounted for 14/16 (88%) of all cases. CellCept should be considered a likely and endoscopically identifiable cause of GI bleeding in renal transplant recipients.
277 Turbulent two phase flow; a novel method for cleaning and high grade disinfection of flexible endoscopies and internal channels Stanley Benjamin, MD, Mohamed Labib, Ph.D. Georgetown University and Novaflux Technologies, Washington, DC and Princeton, NJ.
AJG – Vol. 95, No. 9, 2000
One of the major obstacles to high grade disinfection (HGD) of flexible endoscopies is the biofilm layer that forms on the internal channels of flexible endoscopies (FE). Recently introduced, turbulent two phased flow (TTFF), has been shown to eliminate biofilm from the inside of dental tubing and other long tubular channels. Preliminary work has demonstrated the ability of this technology to remove biofilm from endoscope channels. Aim: To determine the ability of TTFF to provide high level disinfection (⬎106 reduction in organisms) to endoscopies and endoscope channels. Methods: Two previously used endoscopes and two endoscope channels were provided by Pentax Precision Instrument Co., Orangeburg, NY). The endoscopes and channels were contaminated with B. subtilis var. niger at a concentration of 107 CFU/scope and channel by an independent laboratory (Nelson Labs, Inc., Salt Lake City, UT). Scopes and channels were processed using two phase flow of air and surfactant/detergent mixture by Novaflux technologies, Inc. (Princeton, NJ) and sent to Nelson Labs for evaluation. Results:
#1 air/water #1 suction/bx #2 air/water #2 suction/bx* control
Cts/initial
Cts/post-TTFF
% reduction
Log reduction
7.0 ⫻ 10 7.0 ⫻ 107 7.0 ⫻ 107 7.0 ⫻ 107 7.0 ⫻ 107
20 43.7 20 436.6 7 ⫻ 107
⬎99.9% ⬎99.9% ⬎99.9% ⬎99.9% 0
6.1 6.2 6.1 5.2 0
7
* post procedure a leak was found in the channel.
Conclusions: 1) At a minimum TTFF can provide mechanical cleansing of endoscopes, eliminating the need for committed staff and reducing the risk of non-compliance; 2) with appropriate design modifications the technology appears to be able to provide HLD; 3) damaged endoscope channels cannot be cleaned/disinfected appropriately.
278 Changing etiology of upper GI bleeding in AIDS patients Faraz F Berjis, Adnan M Khdair*, Irwin M Grosman. Long Island College Hospital, Brooklyn, NY. Purpose: To compare the etiology of upper GI bleeding (UGIB) in AIDS patients during two time intervals and to assess the impact of contemporary HIV therapy on etiology and prognosis. Methods: Retrospective analysis of 50 patients with AIDS as defined by the CDC criteria who presented to a single center with UGIB (hematemesis and/or melena with a positive nasogastric lavage) and were evaluated by upper endoscopy. Group 1 consists of 27 patients evaluated from 1987– 1993 and group 2 consists of 23 patients from 1996 –2000. Results: 12/27 patients in group 1 (44%) had an AIDS related etiology for the UGIB (8 Candida esophagitis, 3 idiopathic esophageal ulcer and 1 with Kaposi’s sarcoma) while only 1 patient from group 2 (4%) had an AIDS related diagnosis (CMV gastric ulcer). The first group had 15 non-AIDS related causes for UGIB (7 gastric ulcer, 5 erosive gastritis, 2 MalloryWeiss tear and 1 duodenal ulcer). The second group had 22 non-AIDS related causes for UGIB as follows: 9 gastric ulcer, 4 erosive esophagitis, 4 erosive gastritis, 2 duodenitis, 2 bleeding esophageal varices, and 1 Mallory-Weiss tear. The 7 day mortality was 11% in the first group compared to 0% in the second group. Conclusions: We observed a changing pattern of etiology for UGIB in our 2 series of patients with AIDS. Our earlier cohort had a high prevalence of AIDS related causes for GI bleeding while our recent patients had bleeding from causes similar to the general hospitalized population. With better therapy of HIV disease the pattern of UGIB in AIDS patients is changing to become similar to their non-HIV infected peers. The study also shows improved short term mortality in these patients and confirms our previous conclusion that UGIB in AIDS is not a terminal event and these patients should be promptly assessed and treated.