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Outcome of endoscopic dilation in 34 patients (PTS) with colonic anastomotic strictures (STX)
STOMACH AND DUODENUM~ COLON AND RECTUM 319
317 UPPER GASTROINTEBTINI~L (UGI) HEMORRHAGE CI%NCER P ~ T I E N T S = ETIOLOGY ~ PROGNOSIS.
IN
J. Zimmerman, T. Jonas, R. Arnon, E. Tsvang, R. Safadi, D. Wengrowsr. H a d a s s a h Univ. Hospital, Jerusalem, Israel. T h e risk of m o r t a l i t y a s s o c i a t e d w i t h acute UGI b l e e d i n g is s i g n i f i c a n t l y increased in c a n c e r patients. The aims of t h i s s t u d y w e r e to c h a r a c t e r i z e the causes of b l e e d i n g in cancer p a t i e n t s w i t h respect t o m a t c h e d c o n t r o l s and to c l a r i f y the independent p r o g n o s t i c factors. Methods: From a cohort of 860 c o n s e c u t i v e p a t i e n t s w i t h UGI b l e e d i n g s t u d i e d p r o s p e c t i v e ly, w e h a v e selected all the p a t i e n t s w i t h a h i s t o r y of cancer. For each such patient, a control was m a t c h e d by age (• years), sex, use of NSAIDs, liver disease, r e n a l f u n c t i o n and o n s e t of b l e e d i n g (as inpatient or outpatient). R@aults: There were if4 p a t i e n t s w i t h cancer: 30% GI tract; 24% genito-urinary; 14% pancreas; 10% hepatobiliary. The m e a n age was 67• (SE) and 60% were males. 36% had m e t a s t a t i c disease. T h e r e w e r e no s i g n i f i c a n t d i f f e r e n c e s between the cancer patients and the c o n t r o l s in the c o n c o m i t a n t diseases, clinical presentation, coagulation p r o f i l e cr the d i s t r i b u t i o n of p e p t i c ulcers (DU-25%; GU-19%). T w e l v e p e r c e n t cf the cancer p a t i e n t s bled from a tumor. The rate cf rebleeding was s i g n i f i c a n t l y higher In cancer p a t i e n t s (27 vs 14%; p=0.013), as was the overall m o r t a l i t y (23% and 8% respectively; p=0.003). This increased m o r t a l i t y p e r s i s t e d in all types of malignancies. The independent predictors of mortality were cancer and h y p e r b i l i r u b i n e m i a (~x2 the normal; a d j u s t e d odds ratios 3.0 and 9.5 respectively, p<0.02). Conclusions: In cancer patients with UGI bleeding: i: the risk of rebleeding and m o r t a l i t y was increased, i r r e s p e c t i v e of the t y p e of malignancy. 2: A t u m o ~ w a s the cause of b l e e d i n g in 12%. 3: The d i s t r i b u t i o n of peptic u l c e r s was similar to that of m a t c h e d controls.
I"318
Abbasi J. Akhtar. CharlesR. Drew University of Medicine and Science and UCLA School of Medicine, Los Angeles, California. We reviewed the frequency and causes of LGIH in 90 Black (50 males, 40 females) and 30 Hispanic (18 males, 12 females) eldedy patients (age 65-98 years) during a 51 month period (Aug 92-Oct 96). Endoscopic results were available in 100 patients and included: internal hemorrhoids 30 (30%), evidence of bleeding only in 10, Angiodysplasias 20 (20%), diverticular bleeding 18 (18%), polyps 15 (15%), cancer 10 (10%), ischemic colitis 5 (5%), drug (Nonsteroidal Anti-Inflammatory Drugs and/or Anticoagulants) induced bleeding 5 (5%), solitary rectal ulcer 3 (3%), ulcerative colitis 3 (3%), colonic varices 3 (3%). in 12 patients LGIH was due to proximal source of bleeding (gastdc ulcer 5, duodenal ulcer 3, esophageal vadces 2, erosive esophago-gastroduodenitis 2. There were 12 patients who had more than one source of bleeding. Endoscopic therapy was successful in stopping bleeding and/or delaying surgery in 25 patients (25%). 30 patients underwent surgery, 26 died (12 in surgical and 14 in nonsurgical group), most of the deaths were due to multisystem disease. Conclusion: Acute LGIH s a serious disease in Black and Hispanic elderly patients and is associated with high morbidity and mortality. Early diagnoms and prompt therapy is essential Endoscopy should not be withheld because of age alone.
+320
OUTCOME OF ENDOSCOPIC DILATION IN 34 PATIENTS (PTS) W I T H COLONIC ANASTOMOTIC STRICTURES (STX) M Abedi. GB Haber, P Kortsn, life Mareon, GA DuVall, JA Martin. The Wellesley Hospital, Toronto, Canada. Anastomotie strictures develop in 2-5% of patients who have coloreetal surgery. These are multifaetorial and may be due to ischemia, hemorrhage, infection. recurrence of the underlying pathology, or the use of stapling devices. The published experience on long term outcome of endoscopic anastomotie dilation is sparse. Study Design: We undertook a retrospective review of all eonseeutave pts undergoing endoscopic dilation over a 40 mo period. Pt ehar~ were retrospectively reviewed. Pts and their physicians were contacted re. relevant colonic symptoms or subsequent intervention. Result of any recent eolonoscopy or Ba enema was noted. Patients & Methods: Forty-one pts were identified among whom 35 had post-operative anastomotie stx. Thirty-four (18 M, mean age 53.6yrs) were available for follow up. Major symptoms included change of bowel habits or narrow caliber stool (24), cramps (15), and bloating (9). Six were asymptomatie and diagnosed at surveillance eolonoscopy. Ten had ileocolonie stx post ileal resection for Crohn's disease (CD). Twenty-four had a left colon resection for cancer (18), diverticulitis (4), and iatrogenic injury (2). We routinely used Rigiflexr~(Bosten Scientific, MA) TTS balloons (10 to 25 mm) under direct endoscopic visualization (30), as well as SavaryTM (Bard, MA) dilators alone (2), or in combination (2). Results: Mean # of treatment sessions was 2.0 (range 1-7). Overall 17 patients were treated in a single session, 10 had 2 sessions, and 7 had 3 or more sessions. Maximum diameter of halloon dilation achieved was: 15 (3), 18 (9), 20 (18), and 25 (2) ram. Mean follow up was 16.4 mo (range 2 d-38.2 mo).The results are tabulated: Etiology
N
Mean of sessions
CD
10
1.8
12.9
1
2/10
7/10
1
Cancer
Mean PerfoFZU(mo) ration
Recur sx
Sueeess
Surg F/U
18
1.9
15.1
0
2/9*
7/9
1
Other 6 2,2 21.2 0 1/6 5/6 0 * "Excluded asymptomatie (6), early death (2), and colostomy 2" to bleed (1). Conclusion: Endoscopic balloon dilation is an effective means to manage benign colonic anastomotic strictures. There was only 1 perforation among 67 dilations. Symptom recurrence requinng surgery is uncommon.
ABI04
LOWER GASTROINTESTINAL HEMORRHAGE (LGIH) IN BLACK AND HISPANIC ELDERLY PATIENTS.
GASTROINTESTINAL
ENDOSCOPY
COLONOSCOPY IS SUPERIOR TO FLEXIBLE SIGMOIDOSCOPY IN HIV-POSITIVE PATIENTS WITH CHRONIC DIARRHEA E.J. Bini and E. Weinshe[ Division of Gastroenterology, New York University Medical Center/Bellevue Hospital, New York, NY. Background: Data comparing eolonoscopy and flexible sigmoidoscopy in HIV-positive patients with diarrhea is limited. The aim of this study was to determine whether eolonoseopy is superior to flexible sigmoidoseopy in HlV-positive patients with chronic diarrhea and negative stool studies. Methods: Patients with documented HIV infection and chronic diarrhea who had colonoseopy with biopsy to evaluate their symptoms between October 1, 1993 and October 31, 1996 were retrospectively identified. Colonoscopy was performed to the cecum, and multiple biopsies were taken from normal-appearing mucosa in the right and left colon in all patients. In addition, any areas of abnormalities were biopsied. Results: Colonoseopy was performed in 191 HIV-positive patients with chronic diarrhea. All patients had a negative stool assessment prior to colonoseopy. There were 156 males (82%) and 35 females (18%). The mean age was 37.8 z 7.6 years (range, 19-63) and the mean CD4 lymphocyte count was 95.4 :z 124.5 cells/ram 3 (range, 0-500). Of'the 191 patients, 74 [38.7%) had a pathogen identified by colonoscopy. NUMBEROF PATHOGENSIDENTIFIEDACCORDINGTO LOCATION Pathogen Identified Right Right and Left Colon Total Colon Onl~r Left Colon Only CytomeF~alovirus(CMV) 17 11 24 52 M. avium Complex 1 0 12 13 Hymenolepis nana 0 0 3 3 S. stercoralis 0 0 2 2 M.tuberculosis (MTB) 2 0 0 2 Clostridium diff~cile 0 0 1 1 CMV and MTB 1 0 1 0 TOTAL 21 (28%) 11 (15%) 42 (57%) 74 Conclusions: Full colonoscopy with multiple biopsies from the right colon is essential in HIV-positive patients with chronic diarrhea. If flexible sigmoidoscopy had been performed instead of colonoscopy, 28% of pathogens would have been missed and 33% of patients with CMV would have failed to have a diagnosis established.
V O L U M E 45, N O . 4, 1997
317 UPPER GASTROINTEBTINI~L (UGI) HEMORRHAGE CI%NCER P ~ T I E N T S = ETIOLOGY ~ PROGNOSIS.
IN
J. Zimmerman, T. Jonas, R. Arnon, E. Tsvang, R. Safadi, D. Wengrowsr. H a d a s s a h Univ. Hospital, Jerusalem, Israel. T h e risk of m o r t a l i t y a s s o c i a t e d w i t h acute UGI b l e e d i n g is s i g n i f i c a n t l y increased in c a n c e r patients. The aims of t h i s s t u d y w e r e to c h a r a c t e r i z e the causes of b l e e d i n g in cancer p a t i e n t s w i t h respect t o m a t c h e d c o n t r o l s and to c l a r i f y the independent p r o g n o s t i c factors. Methods: From a cohort of 860 c o n s e c u t i v e p a t i e n t s w i t h UGI b l e e d i n g s t u d i e d p r o s p e c t i v e ly, w e h a v e selected all the p a t i e n t s w i t h a h i s t o r y of cancer. For each such patient, a control was m a t c h e d by age (• years), sex, use of NSAIDs, liver disease, r e n a l f u n c t i o n and o n s e t of b l e e d i n g (as inpatient or outpatient). R@aults: There were if4 p a t i e n t s w i t h cancer: 30% GI tract; 24% genito-urinary; 14% pancreas; 10% hepatobiliary. The m e a n age was 67• (SE) and 60% were males. 36% had m e t a s t a t i c disease. T h e r e w e r e no s i g n i f i c a n t d i f f e r e n c e s between the cancer patients and the c o n t r o l s in the c o n c o m i t a n t diseases, clinical presentation, coagulation p r o f i l e cr the d i s t r i b u t i o n of p e p t i c ulcers (DU-25%; GU-19%). T w e l v e p e r c e n t cf the cancer p a t i e n t s bled from a tumor. The rate cf rebleeding was s i g n i f i c a n t l y higher In cancer p a t i e n t s (27 vs 14%; p=0.013), as was the overall m o r t a l i t y (23% and 8% respectively; p=0.003). This increased m o r t a l i t y p e r s i s t e d in all types of malignancies. The independent predictors of mortality were cancer and h y p e r b i l i r u b i n e m i a (~x2 the normal; a d j u s t e d odds ratios 3.0 and 9.5 respectively, p<0.02). Conclusions: In cancer patients with UGI bleeding: i: the risk of rebleeding and m o r t a l i t y was increased, i r r e s p e c t i v e of the t y p e of malignancy. 2: A t u m o ~ w a s the cause of b l e e d i n g in 12%. 3: The d i s t r i b u t i o n of peptic u l c e r s was similar to that of m a t c h e d controls.
I"318
Abbasi J. Akhtar. CharlesR. Drew University of Medicine and Science and UCLA School of Medicine, Los Angeles, California. We reviewed the frequency and causes of LGIH in 90 Black (50 males, 40 females) and 30 Hispanic (18 males, 12 females) eldedy patients (age 65-98 years) during a 51 month period (Aug 92-Oct 96). Endoscopic results were available in 100 patients and included: internal hemorrhoids 30 (30%), evidence of bleeding only in 10, Angiodysplasias 20 (20%), diverticular bleeding 18 (18%), polyps 15 (15%), cancer 10 (10%), ischemic colitis 5 (5%), drug (Nonsteroidal Anti-Inflammatory Drugs and/or Anticoagulants) induced bleeding 5 (5%), solitary rectal ulcer 3 (3%), ulcerative colitis 3 (3%), colonic varices 3 (3%). in 12 patients LGIH was due to proximal source of bleeding (gastdc ulcer 5, duodenal ulcer 3, esophageal vadces 2, erosive esophago-gastroduodenitis 2. There were 12 patients who had more than one source of bleeding. Endoscopic therapy was successful in stopping bleeding and/or delaying surgery in 25 patients (25%). 30 patients underwent surgery, 26 died (12 in surgical and 14 in nonsurgical group), most of the deaths were due to multisystem disease. Conclusion: Acute LGIH s a serious disease in Black and Hispanic elderly patients and is associated with high morbidity and mortality. Early diagnoms and prompt therapy is essential Endoscopy should not be withheld because of age alone.
+320
OUTCOME OF ENDOSCOPIC DILATION IN 34 PATIENTS (PTS) W I T H COLONIC ANASTOMOTIC STRICTURES (STX) M Abedi. GB Haber, P Kortsn, life Mareon, GA DuVall, JA Martin. The Wellesley Hospital, Toronto, Canada. Anastomotie strictures develop in 2-5% of patients who have coloreetal surgery. These are multifaetorial and may be due to ischemia, hemorrhage, infection. recurrence of the underlying pathology, or the use of stapling devices. The published experience on long term outcome of endoscopic anastomotie dilation is sparse. Study Design: We undertook a retrospective review of all eonseeutave pts undergoing endoscopic dilation over a 40 mo period. Pt ehar~ were retrospectively reviewed. Pts and their physicians were contacted re. relevant colonic symptoms or subsequent intervention. Result of any recent eolonoscopy or Ba enema was noted. Patients & Methods: Forty-one pts were identified among whom 35 had post-operative anastomotie stx. Thirty-four (18 M, mean age 53.6yrs) were available for follow up. Major symptoms included change of bowel habits or narrow caliber stool (24), cramps (15), and bloating (9). Six were asymptomatie and diagnosed at surveillance eolonoscopy. Ten had ileocolonie stx post ileal resection for Crohn's disease (CD). Twenty-four had a left colon resection for cancer (18), diverticulitis (4), and iatrogenic injury (2). We routinely used Rigiflexr~(Bosten Scientific, MA) TTS balloons (10 to 25 mm) under direct endoscopic visualization (30), as well as SavaryTM (Bard, MA) dilators alone (2), or in combination (2). Results: Mean # of treatment sessions was 2.0 (range 1-7). Overall 17 patients were treated in a single session, 10 had 2 sessions, and 7 had 3 or more sessions. Maximum diameter of halloon dilation achieved was: 15 (3), 18 (9), 20 (18), and 25 (2) ram. Mean follow up was 16.4 mo (range 2 d-38.2 mo).The results are tabulated: Etiology
N
Mean of sessions
CD
10
1.8
12.9
1
2/10
7/10
1
Cancer
Mean PerfoFZU(mo) ration
Recur sx
Sueeess
Surg F/U
18
1.9
15.1
0
2/9*
7/9
1
Other 6 2,2 21.2 0 1/6 5/6 0 * "Excluded asymptomatie (6), early death (2), and colostomy 2" to bleed (1). Conclusion: Endoscopic balloon dilation is an effective means to manage benign colonic anastomotic strictures. There was only 1 perforation among 67 dilations. Symptom recurrence requinng surgery is uncommon.
ABI04
LOWER GASTROINTESTINAL HEMORRHAGE (LGIH) IN BLACK AND HISPANIC ELDERLY PATIENTS.
GASTROINTESTINAL
ENDOSCOPY
COLONOSCOPY IS SUPERIOR TO FLEXIBLE SIGMOIDOSCOPY IN HIV-POSITIVE PATIENTS WITH CHRONIC DIARRHEA E.J. Bini and E. Weinshe[ Division of Gastroenterology, New York University Medical Center/Bellevue Hospital, New York, NY. Background: Data comparing eolonoscopy and flexible sigmoidoscopy in HIV-positive patients with diarrhea is limited. The aim of this study was to determine whether eolonoseopy is superior to flexible sigmoidoseopy in HlV-positive patients with chronic diarrhea and negative stool studies. Methods: Patients with documented HIV infection and chronic diarrhea who had colonoseopy with biopsy to evaluate their symptoms between October 1, 1993 and October 31, 1996 were retrospectively identified. Colonoscopy was performed to the cecum, and multiple biopsies were taken from normal-appearing mucosa in the right and left colon in all patients. In addition, any areas of abnormalities were biopsied. Results: Colonoseopy was performed in 191 HIV-positive patients with chronic diarrhea. All patients had a negative stool assessment prior to colonoseopy. There were 156 males (82%) and 35 females (18%). The mean age was 37.8 z 7.6 years (range, 19-63) and the mean CD4 lymphocyte count was 95.4 :z 124.5 cells/ram 3 (range, 0-500). Of'the 191 patients, 74 [38.7%) had a pathogen identified by colonoscopy. NUMBEROF PATHOGENSIDENTIFIEDACCORDINGTO LOCATION Pathogen Identified Right Right and Left Colon Total Colon Onl~r Left Colon Only CytomeF~alovirus(CMV) 17 11 24 52 M. avium Complex 1 0 12 13 Hymenolepis nana 0 0 3 3 S. stercoralis 0 0 2 2 M.tuberculosis (MTB) 2 0 0 2 Clostridium diff~cile 0 0 1 1 CMV and MTB 1 0 1 0 TOTAL 21 (28%) 11 (15%) 42 (57%) 74 Conclusions: Full colonoscopy with multiple biopsies from the right colon is essential in HIV-positive patients with chronic diarrhea. If flexible sigmoidoscopy had been performed instead of colonoscopy, 28% of pathogens would have been missed and 33% of patients with CMV would have failed to have a diagnosis established.
V O L U M E 45, N O . 4, 1997