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Initial Experience With Biodegradable Stents in the Treatment of Refractary Benign Gastrointestinal Strictures
February 2011
Prevalence and Causes of Abdominal Pain Following Fully Divided Roux-EnY Gastric Bypass Surgery Bikram Bal, Timothy Shope, Frederick C. Finelli, Timothy R. Koch Abdominal pain is the most frequent presenting symptom in a gastroenterology clinic. In the United States, Roux-en-Y gastric bypass (RYGB) is the most commonly performed procedure for surgical treatment of medically-complicated obesity. The purpose of this study is to determine the prevalence of abdominal pain following RYGB, determine its causes and conceptualize a diagnostic algorithm for efficient management of abdominal pain in these patients. This is a prospective, cohort study performed in an urban community hospital. Consecutive RYGB patients (n ⫽ 147) seen at a new joint Medical/Surgical Bariatric Clinic from February 1, 2008, to January 31, 2009, were included in this study. Chief complaint and the location of abdominal pain were recorded. Information collected included date of surgery, duration of symptom, weight loss after surgery, smoking status, and the use of an NSAID/aspirin. Baseline demographics (ie, age, sex, and body mass index) were also recorded. In diagnostic evaluation, 25 patients underwent glucose hydrogen breath testing (GHBT), 19 completed upper endoscopy, 8 received empiric trials of metronidazole, and 4 underwent CT scan of the abdomen. Whole blood thiamine levels were measured in all patients. Re-examination of patients who were evaluated for abdominal pain was performed 1 year after completion of the patients’ initial evaluation (up to May 2010). Of the 147 patients, 49 reported a chief complaint of abdominal pain. Duration of abdominal pain ranged from 1 week to 7 years (median: 6 months). Following an initial evaluation, a diagnosis was established in 38 of 49 patients (77%). These diagnoses included: small intestinal bacterial overgrowth (SIBO; n ⫽ 25), thiamine deficiency (n ⫽ 5), marginal ulceration at the site of the gastrojejunal anastomosis (n ⫽ 3), cholecystitis (n ⫽ 2), and partial small intestinal obstruction (n ⫽ 1). One patient obtained prolonged pain relief after a nerve block for abdominal wall pain. Appropriate treatment was initiated based upon the initial diagnosis. During a 1 year follow-up period, 1 additional patient (2%) received relief of abdominal pain following cholecystectomy, 42 (85%) reported improvement in their abdominal pain, while 2 patients did not follow-up. This study demonstrates that abdominal pain is common after RYGB with a prevalence of 33%. SIBO (diagnosed by abnormal GHBT) was the commonest cause for chronic abdominal pain with thiamine deficiency, marginal ulcer and chronic cholecystitis being the other important causes. Diagnostic algorithm for chronic abdominal pain following RYGB should be initiated with a glucose-hydrogen breath test to diagnose SIBO. In patients with a normal GHBT, further evaluation should include upper endoscopy and consideration of abdominal imaging. Diagnosis may not be established in up to 25% of patients. However, the majority of RYGB patients will have sustained improvement in their abdominal pain after appropriate diagnosis and treatment. Drugs and Severity of an Emerging Disease—Clostridium difficile Associated Disease A. L. Sousa, C. T. Pinto, H. Santos, A. Ramos, C. Cabrita, D. Sousa, H. Guerreiro Introduction: The increased incidence and severity of Clostridium difficile associated disease (CDAD) is multifactorial. The previous antibiotic therapy is a risk factor, and there is also the suggestion of the involvement of proton-pump inhibitors (PPI). There are no evaluations of the relationship between prior therapy and severity of disease. The target of this study is to evaluate the role of antibiotics and PPI in the severity of the CDAD. Aims and Methods: We assessed (the files of) all patients diagnosed with CDAD in our hospital in 2009. Retrospective evaluation of antibiotic therapy in the previous 3 months, therapy with PPI, clinical severity of disease, mortality and Kaplan–Meier survival curves. Results: Eight patients (100 episodes); median age 78 years; the majority of patients were females (68.3%). Men had a risk 2.7 folds higher than women of dying (P ⫽. 052). In 54% of patients were involved more than one antibiotic and 69% patients were medicated with PPI. The antibiotics most commonly implicated were: co-amoxiclav (Ca) (38%), 2a/3a generation cephalosporins (Cp) (35%), aminoglycosides (24%) and macrolides (23%). Mean time between taking the antibiotic and onset of symptoms was 22.5 (⫾20.9) days. There was no stastical association between duration of antibiotic therapy with Ca (P ⫽ .317) or Cp (P ⫽ .569) and severity of disease, only a stastical trend with length of taking quinolones (P ⫽ .072). There was no association between prior use of at least two antibiotics or PPI and severe disease (P ⫽ .152 and P ⫽ .198, respectively). There was no statistical difference in survival of patients previously submitted to until one antibiotic and patients undergone at least two antibiotics (P ⫽ .339). Conclusion: It seems there is no clear association between antibiotic therapy (number and length of antibiotic) and the severity of CDAD. The PPI does not seem to be implicated in the severity of CDAD. Implications of Serum 25-hydroxyvitamin D on Prevalence of Neoplastic Polyps: A Cross-Sectional Study Charlene LePane, Gurpreet Singh, Jennifer Spanier-Stiansy, David Svinarich, Ronald Rasansky, Stephen Hoffman Objective: Vitamin D is believed to help in the suppression of malignant cells. Epidemiologic studies suggest that there is an association between vitamin D deficiency and an increased risk of colorectal cancer. The primary aim of this study is to determine if the prevalence of neoplastic polyps is inversely related to serum 25-hydroxyvitamin D levels 25(OH)D.
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187
Methods: A prevalence study conducted between April 2009 and October 2009 evaluated 651 patients undergoing colonoscopy in order to determine if an association existed between low 25(OH)D levels and the prevalence of neoplastic colon polyps. Multivariate logistic and linear regression analyses were used to establish an association between 25(OH)D levels and histology of colon polyp with gender, race, age and BMI. Results: The presence of tubular adenoma, villous adenoma, tubulo-villous adenoma, or malignancies did not differ (P ⫽ .5) among the stratified 25(OH)D groups (10ng, 10.1- 30ng, ⬎30ng). In addition, despite having more AfricanAmericans than Caucasians in the lowest 25(OH)D category (22.7% vs 7.7%), the presence of neoplastic polyps did not differ significantly (P ⫽ .8) between the categorized racial groups (Caucasians and African Americans). Conclusion: Low plasma 25(OH)D levels are not associated with an increased prevalence of neoplastic polyps.
Is Mycophenolate Mofetil and Sirolimus Combination a Safe Regimen for Maintenance Immunosuppression in Liver Transplant Patients? Ishfaq Bhat, Elizabeth Lyden, Timothy McCashland, Wendy Grant Background and Aims: Calcineurin inhibitors [CI] provide effective immunosuppression after liver transplantation [LT], but is often complicated by nephrotoxicity. To evaluate the outcomes of LT patients converted from maintenance calcineurin inhibitor immunosuppression to a combination of mycophenolate mofetil [MMF] and sirolimus. Methods: Using patient database, medical records of patients with post LT renal dysfunction transitioned to MMF and sirolimus from CIs were reviewed. Baseline characteristics, immunosuppression, renal function, patient and graft survival, adverse events and tolerability were analyzed. Results: Eleven LT patients were converted to MMF and sirolimus after a median duration of 60 [32–168] months on CI. Nine patients were on tacrolimus and two were on cyclosporine pre conversion. Post conversion median follow up on MMF and sirolimus was 18 months. Serum Cr improved from median of 1.85 mg/dl [SD 0.88] before conversion to 1.24 mg/dl [SD 0.15] at last follow up of 18 months [P ⱕ .01]. GFR based on MDRD improved from 31.5 ml/min/1.73m2[SD 9.45] pre conversion to 53 ml/min/1.73m2 [SD 13.87] at last follow up [P ⱕ .01]. One patient [9%] required hemodialysis after 16 months of MMF and sirolimus and one patient [9%] died because of complications of renal failure. There were no episodes of rejection. Median wbc count was 6600 /cu mm [SD 3.3] before and 5900/cu mm [SD 2.6] after conversion. Median hemoglobin value was 13.1 g/dl [SD 1.32] before and 13 g/dl at last follow up [SD 1.3]. Median LDL and triglyceride pre conversion were 193 mg/dl [SD 212.58] and 208 mg/dl [SD 359.97] while post conversion values were 118 mg/dl [SD 25.58] and 121.5 mg/dl [SD 22.58] respectively. Conclusions: Improvement in renal function was associated with conversion to MMF and sirolimus combination. No rejection was noted even in patients with prior history of rejection on CI. There was no significant anemia or leukopenia requiring blood transfusions or growth factors. One patient had significant hyperlipidemia needing treatment. There were no drug discontinuations. Combination MMF and sirolimus appears to be safe and effective in LT recipients with renal dysfunction. Larger studies are needed to substantiate these results.
Initial Experience With Biodegradable Stents in the Treatment of Refractary Benign Gastrointestinal Strictures M. J. Rodríguez Sánchez, B. López Viedma, Galván Fernández, R. Lorente Poyatos, F. Domper Bardají, E. de la Santa Belda, R. Patón Arenas, A. Bouhmidi Assakali, M. Alonso La Blanca, A. Hernández Albujar, C. Verdejo Gil, J. Olmedo Camacho, E. Rodríguez Sánchez Background: The use of self-expanding biodegradable prosthesis treatment of refractory benign stenosis is still undefined. Aims: To determine effectiveness and safety of biodegradable self-expanding polydioxanone prosthesis (ELLA-Cs, Kralove, Czech Republic) as treatment of refractory benign gastrointestinal stenosis. To evaluate placing success rate, migration rate, need for re-dilatation and relationship between prosthesis degradation and patient clinical evolution. Patients and methods: Patients with refractory benign gastrointestinal stenosis submitted for evaluation in our Endoscopy Unit were included consecutively. Refractory stenosis was defined as the one without clinical improvement after at least 5 endoscopic balloon dilatation in 2 preceding months measuring 15 mm in diameter at least once. BD-ELLA prosthesis were placed under endoscopic and fluoroscopic control, with the patient under conscious sedation medicated with propofol. Results: Seven male patients, with an average age of 49 yrs (range: 37–70 yrs), followed during 38 weeks on average (range: 12– 64 wks) were evaluated. Stenosis type was: anastomotic (n ⫽ 5), or peptic (n ⫽ 2), located on the proximal esophagus-hypofaringe (n ⫽ 2), mild-esophagus (n ⫽ 1), distal esophagus (n ⫽ 2), or rectum (n ⫽ 2). Prosthesis was properly placed in all cases. The stricture diameter prevented the prosthesis introductor passage in five cases which required previous dilation. Distal migration of the prosthesis was observed in two rectal anastomotic cases. Within 8 weeks of insertion all patients remained free of symptoms (including the patients with rectal anastomosis). At the end of the follow-up, five patients were free of symptoms, one suffered from restenosis and required further dilatations and one died due to unrelated digestive process. Four out of five patients with esophageal strictures experienced transitional hyperplasic mucosal tissue growth causing transient dysphagia grade 3 (n ⫽ 2), and requiring supplementary medical treatment for 2 weeks, without specifying endoscopic therapy. Complete prosthesis degradation was confirmed by endoscopy after 12 weeks. Conclusions: In our initial experience, the use of polydioxanone biodegradable prosthesis is a safe and effective therapeutic option for refractory benign
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CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 9, No. 2
Table 1. Mean⫾SD of Abnormal LFTs in Each Tropical Infectious Disease
Total bilirubin Direct bilirubin Aspartate aminotransferase Alanine aminotransferase Alkaline phosphatase Albumin Globulin
Leptospirosis
DHF
Scrub typhus
Malaria
Meliodosis
8.30⫾10.21 4.96⫾6.21 208.3⫾296.5 129.91⫾199.09 155.4⫾116.7 2.91⫾0.75 3.00⫾0.56
0.99⫾0.94 0.42⫾.63 289.2⫾396.7 161.16⫾177.59 84.6⫾72.4 3.68⫾0.60 3.10⫾0.60
3.48⫾5.50 2.04⫾3.93 158.8⫾127.4 130.3⫾120.6 221.4⫾163.4 3.10⫾0.63 3.13⫾0.57
3.49⫾3.60 1.77⫾2.35 73.4⫾35.1 56.92⫾65.81 98.6⫾61.89 3.12⫾0.53 2.93⫾0.58
1.62⫾2.17 0.80⫾1.16 47.4⫾33.16 36.77⫾38.98 196⫾282.8 3.01⫾0.83 3.94⫾0.84
gastrointestinal stenosis. In our experience, epithelial hyperplasia is frequent during stent degradation, but with low clinical impact. Tropical Infectious Diseases and Hepatoxicity: The Abnormal Liver Function Test Pattern Disaya Chavalitdhamrong, Mark A. Korsten, Badri Giri, Pongsaran Sripirom, Pises Pisespongsa, Objective: Early recognition and therapy are important for tropical infectious diseases. This study explored the typical pattern of abnormal liver function tests (LFTs) for each disease, which can ultimately speed up the diagnostic process for a better outcome. Methods: This retrospective study included 275 patients hospitalized at a tertiary care institute between 2004 and 2009 for confirmed diagnosis of tropical infectious diseases including dengue hemorrhagic fever (DHF,110 patients), scrub typhus (54 patients), malaria (49 patients), leptospirosis (32 patients) and melioidosis (30 patients). Demographic information, clinical presentation and liver function tests on admission were collected. Results: Mean ages for leptospirosis, malaria, and scrub typhus were similar (30 – 40 years) but the mean age for DHF was significantly lower (P ⬍ .001) and mean age for meliodosis was significantly higher (P ⬍ .001). DHF and Malaria were found equally in both sexes (P ⫽ .703) but leptospirosis, meliodosis and scrub typhus were found more in men (P ⬍ .001). Abnormal LFTs (at least one parameter) were found in 95.6% of all patients; 100%, 99.1%, 94.4%, 91.8%, and 86.7% in leptospirosis, DHF, scrub typhus, malaria and meliodosis repectively. Mean⫾SD for each parameter is shown in Table 1. Hyperbilirubinemia was common in leptospirosis, malaria and scrub typhus (59.4%, 59.2%, and 48.2% respectively). Mean⫾SD total bilirubin was highest in leptospirosis (8.30⫾10.21). Elevated alkaline phosphatase was highest and found mostly in scrub typhus (72.2%). Transaminitis was common and found in 70%–90% of patients except those with meliodosis. However, elevated aspartate aminotransferase was more common than elevated alanine aminotransferase. Conclusions: Tropical infectious diseases affect the liver and cause deranged LFTs in 95.6% of the patients. Hyperbilirubinemia was the most common
parameter in patients with leptospirosis and additionally they had the highest bilirubin levels. Elevated alkaline phosphatase was most common in patients with scrub typhus. Elevated aspartate aminotransferase was more common than elevated alanine aminotransferase and was prevalent in all disease groups mentioned except meliodosis.
Iatrogeny as a Cofactor in Acute Lower Gastrointestinal Bleeding—A Prospective Study in Portugal Regional Hospitals C. Cardoso, M. I. Cremers, B. Arroja, R. Ramos, J. Pedrosa, L. Glória, I. Rosa, L. Eliseu, E. Cancela, A. C. Rego Objectives: To determine the impact of the use of nonsteroidal anti-inflammatory, antiplatelet and anticoagulant agents in the severity and prognosis of acute lower gastrointestinal bleeding. Aims & Methods: A prospective multicenter study on acute lower gastrointestinal bleeding in Portugal Regional Hospitals for a year (May 2008 to April 2009). Results: 364 patients (51.6% male; mean age: 72 years) were included. 86.8% were outpatients at the onset of bleeding. The cause of bleeding was identified in 93.2% patients. The main endoscopic diagnoses were diverticulosis of the colon (39.3%), ischemic colitis(24.4%), colonic polyps (18.4%) and colorectal cancer (14%).197 patients (54.2%) were under at least one type of drug (35.2% antiplatelet, 15.4% nonsteroidal anti-inflammatory, 6.2% oral anticoagulant, 2.4% low molecular weight heparin and 1.1% unfractionated heparin). In this group blood pressure and hematocrit levels were lower (67.6 vs 70.7 mmHg, P ⫽ .044 and 32.8 vs 34.5%, P ⫽ .046) and in patients receiving heparin, the relative risk of rebleeding and mortality was 8 (P ⫽ .042) and 32 (P ⫽ .003) times higher in a multivariate analysis. Conclusion: More than half of the patients enrolled were taking at least one type of agent. In this subgroup there was a greater severity of bleeding which, in the case of heparin, was associated with higher rebleeding and mortality rates.
Prevalence and Causes of Abdominal Pain Following Fully Divided Roux-EnY Gastric Bypass Surgery Bikram Bal, Timothy Shope, Frederick C. Finelli, Timothy R. Koch Abdominal pain is the most frequent presenting symptom in a gastroenterology clinic. In the United States, Roux-en-Y gastric bypass (RYGB) is the most commonly performed procedure for surgical treatment of medically-complicated obesity. The purpose of this study is to determine the prevalence of abdominal pain following RYGB, determine its causes and conceptualize a diagnostic algorithm for efficient management of abdominal pain in these patients. This is a prospective, cohort study performed in an urban community hospital. Consecutive RYGB patients (n ⫽ 147) seen at a new joint Medical/Surgical Bariatric Clinic from February 1, 2008, to January 31, 2009, were included in this study. Chief complaint and the location of abdominal pain were recorded. Information collected included date of surgery, duration of symptom, weight loss after surgery, smoking status, and the use of an NSAID/aspirin. Baseline demographics (ie, age, sex, and body mass index) were also recorded. In diagnostic evaluation, 25 patients underwent glucose hydrogen breath testing (GHBT), 19 completed upper endoscopy, 8 received empiric trials of metronidazole, and 4 underwent CT scan of the abdomen. Whole blood thiamine levels were measured in all patients. Re-examination of patients who were evaluated for abdominal pain was performed 1 year after completion of the patients’ initial evaluation (up to May 2010). Of the 147 patients, 49 reported a chief complaint of abdominal pain. Duration of abdominal pain ranged from 1 week to 7 years (median: 6 months). Following an initial evaluation, a diagnosis was established in 38 of 49 patients (77%). These diagnoses included: small intestinal bacterial overgrowth (SIBO; n ⫽ 25), thiamine deficiency (n ⫽ 5), marginal ulceration at the site of the gastrojejunal anastomosis (n ⫽ 3), cholecystitis (n ⫽ 2), and partial small intestinal obstruction (n ⫽ 1). One patient obtained prolonged pain relief after a nerve block for abdominal wall pain. Appropriate treatment was initiated based upon the initial diagnosis. During a 1 year follow-up period, 1 additional patient (2%) received relief of abdominal pain following cholecystectomy, 42 (85%) reported improvement in their abdominal pain, while 2 patients did not follow-up. This study demonstrates that abdominal pain is common after RYGB with a prevalence of 33%. SIBO (diagnosed by abnormal GHBT) was the commonest cause for chronic abdominal pain with thiamine deficiency, marginal ulcer and chronic cholecystitis being the other important causes. Diagnostic algorithm for chronic abdominal pain following RYGB should be initiated with a glucose-hydrogen breath test to diagnose SIBO. In patients with a normal GHBT, further evaluation should include upper endoscopy and consideration of abdominal imaging. Diagnosis may not be established in up to 25% of patients. However, the majority of RYGB patients will have sustained improvement in their abdominal pain after appropriate diagnosis and treatment. Drugs and Severity of an Emerging Disease—Clostridium difficile Associated Disease A. L. Sousa, C. T. Pinto, H. Santos, A. Ramos, C. Cabrita, D. Sousa, H. Guerreiro Introduction: The increased incidence and severity of Clostridium difficile associated disease (CDAD) is multifactorial. The previous antibiotic therapy is a risk factor, and there is also the suggestion of the involvement of proton-pump inhibitors (PPI). There are no evaluations of the relationship between prior therapy and severity of disease. The target of this study is to evaluate the role of antibiotics and PPI in the severity of the CDAD. Aims and Methods: We assessed (the files of) all patients diagnosed with CDAD in our hospital in 2009. Retrospective evaluation of antibiotic therapy in the previous 3 months, therapy with PPI, clinical severity of disease, mortality and Kaplan–Meier survival curves. Results: Eight patients (100 episodes); median age 78 years; the majority of patients were females (68.3%). Men had a risk 2.7 folds higher than women of dying (P ⫽. 052). In 54% of patients were involved more than one antibiotic and 69% patients were medicated with PPI. The antibiotics most commonly implicated were: co-amoxiclav (Ca) (38%), 2a/3a generation cephalosporins (Cp) (35%), aminoglycosides (24%) and macrolides (23%). Mean time between taking the antibiotic and onset of symptoms was 22.5 (⫾20.9) days. There was no stastical association between duration of antibiotic therapy with Ca (P ⫽ .317) or Cp (P ⫽ .569) and severity of disease, only a stastical trend with length of taking quinolones (P ⫽ .072). There was no association between prior use of at least two antibiotics or PPI and severe disease (P ⫽ .152 and P ⫽ .198, respectively). There was no statistical difference in survival of patients previously submitted to until one antibiotic and patients undergone at least two antibiotics (P ⫽ .339). Conclusion: It seems there is no clear association between antibiotic therapy (number and length of antibiotic) and the severity of CDAD. The PPI does not seem to be implicated in the severity of CDAD. Implications of Serum 25-hydroxyvitamin D on Prevalence of Neoplastic Polyps: A Cross-Sectional Study Charlene LePane, Gurpreet Singh, Jennifer Spanier-Stiansy, David Svinarich, Ronald Rasansky, Stephen Hoffman Objective: Vitamin D is believed to help in the suppression of malignant cells. Epidemiologic studies suggest that there is an association between vitamin D deficiency and an increased risk of colorectal cancer. The primary aim of this study is to determine if the prevalence of neoplastic polyps is inversely related to serum 25-hydroxyvitamin D levels 25(OH)D.
ABSTRACTS
187
Methods: A prevalence study conducted between April 2009 and October 2009 evaluated 651 patients undergoing colonoscopy in order to determine if an association existed between low 25(OH)D levels and the prevalence of neoplastic colon polyps. Multivariate logistic and linear regression analyses were used to establish an association between 25(OH)D levels and histology of colon polyp with gender, race, age and BMI. Results: The presence of tubular adenoma, villous adenoma, tubulo-villous adenoma, or malignancies did not differ (P ⫽ .5) among the stratified 25(OH)D groups (10ng, 10.1- 30ng, ⬎30ng). In addition, despite having more AfricanAmericans than Caucasians in the lowest 25(OH)D category (22.7% vs 7.7%), the presence of neoplastic polyps did not differ significantly (P ⫽ .8) between the categorized racial groups (Caucasians and African Americans). Conclusion: Low plasma 25(OH)D levels are not associated with an increased prevalence of neoplastic polyps.
Is Mycophenolate Mofetil and Sirolimus Combination a Safe Regimen for Maintenance Immunosuppression in Liver Transplant Patients? Ishfaq Bhat, Elizabeth Lyden, Timothy McCashland, Wendy Grant Background and Aims: Calcineurin inhibitors [CI] provide effective immunosuppression after liver transplantation [LT], but is often complicated by nephrotoxicity. To evaluate the outcomes of LT patients converted from maintenance calcineurin inhibitor immunosuppression to a combination of mycophenolate mofetil [MMF] and sirolimus. Methods: Using patient database, medical records of patients with post LT renal dysfunction transitioned to MMF and sirolimus from CIs were reviewed. Baseline characteristics, immunosuppression, renal function, patient and graft survival, adverse events and tolerability were analyzed. Results: Eleven LT patients were converted to MMF and sirolimus after a median duration of 60 [32–168] months on CI. Nine patients were on tacrolimus and two were on cyclosporine pre conversion. Post conversion median follow up on MMF and sirolimus was 18 months. Serum Cr improved from median of 1.85 mg/dl [SD 0.88] before conversion to 1.24 mg/dl [SD 0.15] at last follow up of 18 months [P ⱕ .01]. GFR based on MDRD improved from 31.5 ml/min/1.73m2[SD 9.45] pre conversion to 53 ml/min/1.73m2 [SD 13.87] at last follow up [P ⱕ .01]. One patient [9%] required hemodialysis after 16 months of MMF and sirolimus and one patient [9%] died because of complications of renal failure. There were no episodes of rejection. Median wbc count was 6600 /cu mm [SD 3.3] before and 5900/cu mm [SD 2.6] after conversion. Median hemoglobin value was 13.1 g/dl [SD 1.32] before and 13 g/dl at last follow up [SD 1.3]. Median LDL and triglyceride pre conversion were 193 mg/dl [SD 212.58] and 208 mg/dl [SD 359.97] while post conversion values were 118 mg/dl [SD 25.58] and 121.5 mg/dl [SD 22.58] respectively. Conclusions: Improvement in renal function was associated with conversion to MMF and sirolimus combination. No rejection was noted even in patients with prior history of rejection on CI. There was no significant anemia or leukopenia requiring blood transfusions or growth factors. One patient had significant hyperlipidemia needing treatment. There were no drug discontinuations. Combination MMF and sirolimus appears to be safe and effective in LT recipients with renal dysfunction. Larger studies are needed to substantiate these results.
Initial Experience With Biodegradable Stents in the Treatment of Refractary Benign Gastrointestinal Strictures M. J. Rodríguez Sánchez, B. López Viedma, Galván Fernández, R. Lorente Poyatos, F. Domper Bardají, E. de la Santa Belda, R. Patón Arenas, A. Bouhmidi Assakali, M. Alonso La Blanca, A. Hernández Albujar, C. Verdejo Gil, J. Olmedo Camacho, E. Rodríguez Sánchez Background: The use of self-expanding biodegradable prosthesis treatment of refractory benign stenosis is still undefined. Aims: To determine effectiveness and safety of biodegradable self-expanding polydioxanone prosthesis (ELLA-Cs, Kralove, Czech Republic) as treatment of refractory benign gastrointestinal stenosis. To evaluate placing success rate, migration rate, need for re-dilatation and relationship between prosthesis degradation and patient clinical evolution. Patients and methods: Patients with refractory benign gastrointestinal stenosis submitted for evaluation in our Endoscopy Unit were included consecutively. Refractory stenosis was defined as the one without clinical improvement after at least 5 endoscopic balloon dilatation in 2 preceding months measuring 15 mm in diameter at least once. BD-ELLA prosthesis were placed under endoscopic and fluoroscopic control, with the patient under conscious sedation medicated with propofol. Results: Seven male patients, with an average age of 49 yrs (range: 37–70 yrs), followed during 38 weeks on average (range: 12– 64 wks) were evaluated. Stenosis type was: anastomotic (n ⫽ 5), or peptic (n ⫽ 2), located on the proximal esophagus-hypofaringe (n ⫽ 2), mild-esophagus (n ⫽ 1), distal esophagus (n ⫽ 2), or rectum (n ⫽ 2). Prosthesis was properly placed in all cases. The stricture diameter prevented the prosthesis introductor passage in five cases which required previous dilation. Distal migration of the prosthesis was observed in two rectal anastomotic cases. Within 8 weeks of insertion all patients remained free of symptoms (including the patients with rectal anastomosis). At the end of the follow-up, five patients were free of symptoms, one suffered from restenosis and required further dilatations and one died due to unrelated digestive process. Four out of five patients with esophageal strictures experienced transitional hyperplasic mucosal tissue growth causing transient dysphagia grade 3 (n ⫽ 2), and requiring supplementary medical treatment for 2 weeks, without specifying endoscopic therapy. Complete prosthesis degradation was confirmed by endoscopy after 12 weeks. Conclusions: In our initial experience, the use of polydioxanone biodegradable prosthesis is a safe and effective therapeutic option for refractory benign
188
ABSTRACTS
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 9, No. 2
Table 1. Mean⫾SD of Abnormal LFTs in Each Tropical Infectious Disease
Total bilirubin Direct bilirubin Aspartate aminotransferase Alanine aminotransferase Alkaline phosphatase Albumin Globulin
Leptospirosis
DHF
Scrub typhus
Malaria
Meliodosis
8.30⫾10.21 4.96⫾6.21 208.3⫾296.5 129.91⫾199.09 155.4⫾116.7 2.91⫾0.75 3.00⫾0.56
0.99⫾0.94 0.42⫾.63 289.2⫾396.7 161.16⫾177.59 84.6⫾72.4 3.68⫾0.60 3.10⫾0.60
3.48⫾5.50 2.04⫾3.93 158.8⫾127.4 130.3⫾120.6 221.4⫾163.4 3.10⫾0.63 3.13⫾0.57
3.49⫾3.60 1.77⫾2.35 73.4⫾35.1 56.92⫾65.81 98.6⫾61.89 3.12⫾0.53 2.93⫾0.58
1.62⫾2.17 0.80⫾1.16 47.4⫾33.16 36.77⫾38.98 196⫾282.8 3.01⫾0.83 3.94⫾0.84
gastrointestinal stenosis. In our experience, epithelial hyperplasia is frequent during stent degradation, but with low clinical impact. Tropical Infectious Diseases and Hepatoxicity: The Abnormal Liver Function Test Pattern Disaya Chavalitdhamrong, Mark A. Korsten, Badri Giri, Pongsaran Sripirom, Pises Pisespongsa, Objective: Early recognition and therapy are important for tropical infectious diseases. This study explored the typical pattern of abnormal liver function tests (LFTs) for each disease, which can ultimately speed up the diagnostic process for a better outcome. Methods: This retrospective study included 275 patients hospitalized at a tertiary care institute between 2004 and 2009 for confirmed diagnosis of tropical infectious diseases including dengue hemorrhagic fever (DHF,110 patients), scrub typhus (54 patients), malaria (49 patients), leptospirosis (32 patients) and melioidosis (30 patients). Demographic information, clinical presentation and liver function tests on admission were collected. Results: Mean ages for leptospirosis, malaria, and scrub typhus were similar (30 – 40 years) but the mean age for DHF was significantly lower (P ⬍ .001) and mean age for meliodosis was significantly higher (P ⬍ .001). DHF and Malaria were found equally in both sexes (P ⫽ .703) but leptospirosis, meliodosis and scrub typhus were found more in men (P ⬍ .001). Abnormal LFTs (at least one parameter) were found in 95.6% of all patients; 100%, 99.1%, 94.4%, 91.8%, and 86.7% in leptospirosis, DHF, scrub typhus, malaria and meliodosis repectively. Mean⫾SD for each parameter is shown in Table 1. Hyperbilirubinemia was common in leptospirosis, malaria and scrub typhus (59.4%, 59.2%, and 48.2% respectively). Mean⫾SD total bilirubin was highest in leptospirosis (8.30⫾10.21). Elevated alkaline phosphatase was highest and found mostly in scrub typhus (72.2%). Transaminitis was common and found in 70%–90% of patients except those with meliodosis. However, elevated aspartate aminotransferase was more common than elevated alanine aminotransferase. Conclusions: Tropical infectious diseases affect the liver and cause deranged LFTs in 95.6% of the patients. Hyperbilirubinemia was the most common
parameter in patients with leptospirosis and additionally they had the highest bilirubin levels. Elevated alkaline phosphatase was most common in patients with scrub typhus. Elevated aspartate aminotransferase was more common than elevated alanine aminotransferase and was prevalent in all disease groups mentioned except meliodosis.
Iatrogeny as a Cofactor in Acute Lower Gastrointestinal Bleeding—A Prospective Study in Portugal Regional Hospitals C. Cardoso, M. I. Cremers, B. Arroja, R. Ramos, J. Pedrosa, L. Glória, I. Rosa, L. Eliseu, E. Cancela, A. C. Rego Objectives: To determine the impact of the use of nonsteroidal anti-inflammatory, antiplatelet and anticoagulant agents in the severity and prognosis of acute lower gastrointestinal bleeding. Aims & Methods: A prospective multicenter study on acute lower gastrointestinal bleeding in Portugal Regional Hospitals for a year (May 2008 to April 2009). Results: 364 patients (51.6% male; mean age: 72 years) were included. 86.8% were outpatients at the onset of bleeding. The cause of bleeding was identified in 93.2% patients. The main endoscopic diagnoses were diverticulosis of the colon (39.3%), ischemic colitis(24.4%), colonic polyps (18.4%) and colorectal cancer (14%).197 patients (54.2%) were under at least one type of drug (35.2% antiplatelet, 15.4% nonsteroidal anti-inflammatory, 6.2% oral anticoagulant, 2.4% low molecular weight heparin and 1.1% unfractionated heparin). In this group blood pressure and hematocrit levels were lower (67.6 vs 70.7 mmHg, P ⫽ .044 and 32.8 vs 34.5%, P ⫽ .046) and in patients receiving heparin, the relative risk of rebleeding and mortality was 8 (P ⫽ .042) and 32 (P ⫽ .003) times higher in a multivariate analysis. Conclusion: More than half of the patients enrolled were taking at least one type of agent. In this subgroup there was a greater severity of bleeding which, in the case of heparin, was associated with higher rebleeding and mortality rates.