- Email: [email protected]
Successful Endoscopic Management of Bleeding From Colonic Dieulafoy Lesion: A Case Review of Six Years' Experience
Abstracts
W1128 Successful Endoscopic Management of Bleeding From Colonic Dieulafoy Lesion: A Case Review of Six Years’ Experience Wan Sik Lee, Chang Hwan Park, Young Eun Joo, Hyun Soo Kim, Sung Kyu Choi, Jong Sun Rew, Sei Jong Kim Background: Dieulafoy lesion is a relatively uncommon disease which is a potential source of life threatening gastrointestinal hemorrhage. The lesions outside of the stomach are rare occurrences. Colorectal Dieulafoy lesions typically present with painless, massive hemorrhage, and difficult to be located during endoscopy. Materials: Over 6 years (July 1999 to October 2004), eleven colorectal Dieulafoy lesions were identified at our tertiary referral center, and received endoscopic treatment. Mean age was sixty-nine years. Results: Seven cases were located at sigmoid colon and four cases at the distal rectum. Four patients were in end stage renal disease and three patients were at the condition of multiple organ failure due to various causes. In all of the patients, endoscopic treatment was successful. Six patients received epinephrine-saline injection followed by hemoclipping and remaining patients were treated by rubber band ligation. None of the patients experienced recurrent bleeding. Three patient died, but none as a result of hemorrhage. Conclusion: The fact that colorectal Dieulafoy lesion is one of the cause of massive hemorrhage should be reminded when initial diagnostic workup failed to elucidate the bleeding source, especially in elderly patients with end stage renal disease and multi-organ failure. Endoscopic mechanical hemostatic method is effective for permanent treatment of colorectal Dieulafoy leions.
Introduction: Pilot studies showed that leukocyte adsorptive type apheresis (LAA) treatments induced clinical remission in ulcerative colitis (UC) pts with chronic disease that had not responded to intensive corticosteroid treatment. Since these studies suggested that clinical benefit was achieved after stopping LAA treatments, a previously reported series of pts with chronic active UC despite intensive corticosteroid treatment were followed for up to one year after LAA treatments to determine the duration of clinical benefit. Methods: A prospective, open-label study assessed the safety and efficacy of LAA treatments using the Adacolumn system [Otsuka Pharmaceutical Europe, Ltd], administered once each week for five consecutive weeks. Eligible pts were aged 18 to 75 yr with moderately active UC, determined by Rachmilewitz Index with Clinical Activity Index (CAI) score 6-8 and Endoscopic Activity Index (EA) score O4, despite continuous use of steroids (min. 400 mg prednisone or equiv. within the last 4 wk; steroid dose unchanged for 2 wk prior to study entry). In the main study, treatment efficacy was assessed by comparing CAI score, EA score, and steroid consumption at baseline (wk 0) and end of treatment (wk 6). In the follow-up study, CAI score and steroid consumption were assessed every 2 mo for up to 12 mo. Results: 35 pts were enrolled; all had CAI 6-8 at screening, but at baseline 3 were in clinical remission (CR: CAI%4) and 4 had severe disease (CAI O 8). Excluding the 3 CRs at baseline, CRs were achieved by 15 pts during LAA and 11 during long-term follow-up, for an overall 81% CR rate. Steroid doses were reduced in 54% of pts during or immediately following LAA. Median CR duration was 6 months, distributed bimodally: 12 CRs %2 mo and 13 CRs R6 mo. After relapsing, 11 pts again achieved CRs, often following adjustment in treatment, including additional LAA; in several cases, 2nd CRs lasted R6 mo. Conclusions: Long-term follow-up suggests that LAA induces CRs, often with delayed onset, in the majority of pts with moderately active steroid-dependent UC.
W1129 Prevalence of Ischemic Colitis in Asymptomatic Patients Undergoing Colonoscopy David Lieberman, Glenn Eisen, Jennifer Holub, Nora Mattek, LeAnn Michaels The purpose of this analysis was to determine the prevalence of ‘‘suspected’’ ischemic colitis (IC) in asymptomatic patients undergoing routine screening colonoscopy. This is the first analysis of IC in a large asymptomatic cohort. Methods: The CORI consortium includes more than 70 diverse practices which use a computerized endoscopic report generator, and transmit report data electronically to a central data repository. We surveyed colonoscopy procedures performed from 1/1/00 to 12/31/03 in adults (age 20 years); 74% come from private practice, and 26% from academic and VA settings. Patients receiving asymptomatic screening or colonoscopy for positive FOBT without other symptoms were included. The diagnosis of suspected ischemic colitis was based on the impression of the endoscopist. The description of endoscopic findings and pathology was reviewed in each case to determine if findings were consistent with a diagnosis of IC. Endoscopic findings were considered to be consistent with IC if there was segmental colon involvement with inflammation, submucosal hemorrhage, edema or ulceration, in the absence of any other reason. Pathology consistent with IC included acute inflammation, submucosal hemorrhage and edema. Results: During the study period, 347,672 unique patients were reported to have colonoscopy for any indication. 560 (0.16%) had suspected ischemic colitis based on the endoscopic report. Among 100,173 patients who did not have reported GI symptoms, 21 (0.02%) had suspected ischemic colitis. All patients were greater than 50 years old, and most were 60 years or older (71.4%). Endoscopic descriptions included focal areas of erythema or inflammation located most commonly in the splenic flexure (7) or sigmoid colon (7). In 6 cases, there was erythema noted only in the region of diverticulosis. Pathology was available in 17 of 21 cases (81%). Pathology revealed findings consistent with ischemia in 8, focal acute colitis in 5, and normal histology in 4. In conclusion, the finding of suspected IC is an uncommon finding at colonoscopy in asymptomatic individuals, but does occur rarely (0.02%). In most cases, the endoscopic findings and pathology were consistent with IC. Future studies should determine rates of IC in symptomatic patients receiving colonoscopy and ascertain risk factors for IC in patients receiving colonoscopy.
W1130 Long-Term Follow-Up of Leukocyte Adsorptive Apheresis (LAA) Treatment in Patients (PTS) with Moderately Active Steroid-Dependent Ulcerative Colitis (UC) Robert Loefberg, Axel Dignass, Norbert Hittel, Alberto Malesci, Joachim Moessner, Max Reinshagen, Maurizio Vecchi, Wolfgang Kruis
www.mosby.com/gie
W1131 Simultaneous Ischemic Colitis and Myocardial Infarction Presents as a Distinct Clinical Subgroup of Ischemic Colitis: A Study of Twenty-Two Patients with Comparison to a Control Group of Patients with Ischemic Colitis without Myocardial Infarction Mitchell S. Cappell, Deepak S. Mahajan, Vinod Kurupath, Andrea Culliford Introduction: We have previously shown that ischemic colitis is the most common endoscopic diagnosis in patients undergoing sigmoidoscopy or colonoscopy within 30 days of myocardial infarction. The subgroup of patients with acute myocardial infarction and simultaneous ischemic colitis is clinically characterized as a distinct clinical subset of patients with ischemic colitis. Methods: Comparison of 17 clinical parameters in 22 patients presenting with acute myocardial infarction and with simultaneous ischemic colitis confirmed by sigmoidoscopy or colonoscopy (study patients) versus 20 patients with ischemic colitis without acute myocardial infarction (control patients). Results: Study patients were statistically significantly older than the controls (mean age 75.2 G 9.0 vs 68.3 G 11.4 years, p ! 0.04, Student’s t test). Study patients had a significantly lower mean arterial blood pressure on clinical presentation than the controls (75.6 G 17.9 vs 101.8 G 16.5 mmHg, p ! 0.0001). Nearly all patients in both groups had gross or occult gastrointestinal bleeding. Study patients had a significantly lower hematocrit at presentation than the controls (28.6 G 5.9 vs 34.2 G 7.0, p ! 0.01), and were transfused significantly more units of packed erythrocytes (2.2 G 2.5 vs 1.0 G 1.5 units, p Z 0.05). Study patients had more risk factors for ischemic colitis than controls (3.4 vs 2.4 per patient, p Z 0.04). Study patients had a much higher incidence of complications. For example, they had a higher incidence of respiratory failure (59% vs 10%, p ! 0.003, OR Z 13.0, ORCI: 2.6-62), and tended to have a higher incidence of renal insufficiency or renal failure (54% vs 30%, p Z 0.20, OR Z 2.8, ORCI: 0.80-9.74). Study patients tended to have a higher mortality than the controls (36% vs 15% died, OR Z 3.24, ORCI: 0.76-13.4), but this difference did not reach statistical significance. Conclusions: Patients with ischemic colitis and myocardial infarction present as a clinically distinct group from patients with ischemic colitis alone. They more frequently have significant lower gastrointestinal bleeding requiring more blood transfusions. They have significantly more risk factors for ischemic colitis. They more frequently have systemic hypotension as the primary risk factor, with nonocclusive mesenteric ischemia as the mechanism, for the ischemic colitis. They have significantly more frequent complications (e.g. respiratory failure), and tend to have a higher mortality.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB259
W1128 Successful Endoscopic Management of Bleeding From Colonic Dieulafoy Lesion: A Case Review of Six Years’ Experience Wan Sik Lee, Chang Hwan Park, Young Eun Joo, Hyun Soo Kim, Sung Kyu Choi, Jong Sun Rew, Sei Jong Kim Background: Dieulafoy lesion is a relatively uncommon disease which is a potential source of life threatening gastrointestinal hemorrhage. The lesions outside of the stomach are rare occurrences. Colorectal Dieulafoy lesions typically present with painless, massive hemorrhage, and difficult to be located during endoscopy. Materials: Over 6 years (July 1999 to October 2004), eleven colorectal Dieulafoy lesions were identified at our tertiary referral center, and received endoscopic treatment. Mean age was sixty-nine years. Results: Seven cases were located at sigmoid colon and four cases at the distal rectum. Four patients were in end stage renal disease and three patients were at the condition of multiple organ failure due to various causes. In all of the patients, endoscopic treatment was successful. Six patients received epinephrine-saline injection followed by hemoclipping and remaining patients were treated by rubber band ligation. None of the patients experienced recurrent bleeding. Three patient died, but none as a result of hemorrhage. Conclusion: The fact that colorectal Dieulafoy lesion is one of the cause of massive hemorrhage should be reminded when initial diagnostic workup failed to elucidate the bleeding source, especially in elderly patients with end stage renal disease and multi-organ failure. Endoscopic mechanical hemostatic method is effective for permanent treatment of colorectal Dieulafoy leions.
Introduction: Pilot studies showed that leukocyte adsorptive type apheresis (LAA) treatments induced clinical remission in ulcerative colitis (UC) pts with chronic disease that had not responded to intensive corticosteroid treatment. Since these studies suggested that clinical benefit was achieved after stopping LAA treatments, a previously reported series of pts with chronic active UC despite intensive corticosteroid treatment were followed for up to one year after LAA treatments to determine the duration of clinical benefit. Methods: A prospective, open-label study assessed the safety and efficacy of LAA treatments using the Adacolumn system [Otsuka Pharmaceutical Europe, Ltd], administered once each week for five consecutive weeks. Eligible pts were aged 18 to 75 yr with moderately active UC, determined by Rachmilewitz Index with Clinical Activity Index (CAI) score 6-8 and Endoscopic Activity Index (EA) score O4, despite continuous use of steroids (min. 400 mg prednisone or equiv. within the last 4 wk; steroid dose unchanged for 2 wk prior to study entry). In the main study, treatment efficacy was assessed by comparing CAI score, EA score, and steroid consumption at baseline (wk 0) and end of treatment (wk 6). In the follow-up study, CAI score and steroid consumption were assessed every 2 mo for up to 12 mo. Results: 35 pts were enrolled; all had CAI 6-8 at screening, but at baseline 3 were in clinical remission (CR: CAI%4) and 4 had severe disease (CAI O 8). Excluding the 3 CRs at baseline, CRs were achieved by 15 pts during LAA and 11 during long-term follow-up, for an overall 81% CR rate. Steroid doses were reduced in 54% of pts during or immediately following LAA. Median CR duration was 6 months, distributed bimodally: 12 CRs %2 mo and 13 CRs R6 mo. After relapsing, 11 pts again achieved CRs, often following adjustment in treatment, including additional LAA; in several cases, 2nd CRs lasted R6 mo. Conclusions: Long-term follow-up suggests that LAA induces CRs, often with delayed onset, in the majority of pts with moderately active steroid-dependent UC.
W1129 Prevalence of Ischemic Colitis in Asymptomatic Patients Undergoing Colonoscopy David Lieberman, Glenn Eisen, Jennifer Holub, Nora Mattek, LeAnn Michaels The purpose of this analysis was to determine the prevalence of ‘‘suspected’’ ischemic colitis (IC) in asymptomatic patients undergoing routine screening colonoscopy. This is the first analysis of IC in a large asymptomatic cohort. Methods: The CORI consortium includes more than 70 diverse practices which use a computerized endoscopic report generator, and transmit report data electronically to a central data repository. We surveyed colonoscopy procedures performed from 1/1/00 to 12/31/03 in adults (age 20 years); 74% come from private practice, and 26% from academic and VA settings. Patients receiving asymptomatic screening or colonoscopy for positive FOBT without other symptoms were included. The diagnosis of suspected ischemic colitis was based on the impression of the endoscopist. The description of endoscopic findings and pathology was reviewed in each case to determine if findings were consistent with a diagnosis of IC. Endoscopic findings were considered to be consistent with IC if there was segmental colon involvement with inflammation, submucosal hemorrhage, edema or ulceration, in the absence of any other reason. Pathology consistent with IC included acute inflammation, submucosal hemorrhage and edema. Results: During the study period, 347,672 unique patients were reported to have colonoscopy for any indication. 560 (0.16%) had suspected ischemic colitis based on the endoscopic report. Among 100,173 patients who did not have reported GI symptoms, 21 (0.02%) had suspected ischemic colitis. All patients were greater than 50 years old, and most were 60 years or older (71.4%). Endoscopic descriptions included focal areas of erythema or inflammation located most commonly in the splenic flexure (7) or sigmoid colon (7). In 6 cases, there was erythema noted only in the region of diverticulosis. Pathology was available in 17 of 21 cases (81%). Pathology revealed findings consistent with ischemia in 8, focal acute colitis in 5, and normal histology in 4. In conclusion, the finding of suspected IC is an uncommon finding at colonoscopy in asymptomatic individuals, but does occur rarely (0.02%). In most cases, the endoscopic findings and pathology were consistent with IC. Future studies should determine rates of IC in symptomatic patients receiving colonoscopy and ascertain risk factors for IC in patients receiving colonoscopy.
W1130 Long-Term Follow-Up of Leukocyte Adsorptive Apheresis (LAA) Treatment in Patients (PTS) with Moderately Active Steroid-Dependent Ulcerative Colitis (UC) Robert Loefberg, Axel Dignass, Norbert Hittel, Alberto Malesci, Joachim Moessner, Max Reinshagen, Maurizio Vecchi, Wolfgang Kruis
www.mosby.com/gie
W1131 Simultaneous Ischemic Colitis and Myocardial Infarction Presents as a Distinct Clinical Subgroup of Ischemic Colitis: A Study of Twenty-Two Patients with Comparison to a Control Group of Patients with Ischemic Colitis without Myocardial Infarction Mitchell S. Cappell, Deepak S. Mahajan, Vinod Kurupath, Andrea Culliford Introduction: We have previously shown that ischemic colitis is the most common endoscopic diagnosis in patients undergoing sigmoidoscopy or colonoscopy within 30 days of myocardial infarction. The subgroup of patients with acute myocardial infarction and simultaneous ischemic colitis is clinically characterized as a distinct clinical subset of patients with ischemic colitis. Methods: Comparison of 17 clinical parameters in 22 patients presenting with acute myocardial infarction and with simultaneous ischemic colitis confirmed by sigmoidoscopy or colonoscopy (study patients) versus 20 patients with ischemic colitis without acute myocardial infarction (control patients). Results: Study patients were statistically significantly older than the controls (mean age 75.2 G 9.0 vs 68.3 G 11.4 years, p ! 0.04, Student’s t test). Study patients had a significantly lower mean arterial blood pressure on clinical presentation than the controls (75.6 G 17.9 vs 101.8 G 16.5 mmHg, p ! 0.0001). Nearly all patients in both groups had gross or occult gastrointestinal bleeding. Study patients had a significantly lower hematocrit at presentation than the controls (28.6 G 5.9 vs 34.2 G 7.0, p ! 0.01), and were transfused significantly more units of packed erythrocytes (2.2 G 2.5 vs 1.0 G 1.5 units, p Z 0.05). Study patients had more risk factors for ischemic colitis than controls (3.4 vs 2.4 per patient, p Z 0.04). Study patients had a much higher incidence of complications. For example, they had a higher incidence of respiratory failure (59% vs 10%, p ! 0.003, OR Z 13.0, ORCI: 2.6-62), and tended to have a higher incidence of renal insufficiency or renal failure (54% vs 30%, p Z 0.20, OR Z 2.8, ORCI: 0.80-9.74). Study patients tended to have a higher mortality than the controls (36% vs 15% died, OR Z 3.24, ORCI: 0.76-13.4), but this difference did not reach statistical significance. Conclusions: Patients with ischemic colitis and myocardial infarction present as a clinically distinct group from patients with ischemic colitis alone. They more frequently have significant lower gastrointestinal bleeding requiring more blood transfusions. They have significantly more risk factors for ischemic colitis. They more frequently have systemic hypotension as the primary risk factor, with nonocclusive mesenteric ischemia as the mechanism, for the ischemic colitis. They have significantly more frequent complications (e.g. respiratory failure), and tend to have a higher mortality.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB259