Blair Lewis | The Mount Sinai School of Medicine (original) (raw)

Papers by Blair Lewis

Springer eBooks, Sep 21, 2006

Summary The differential diagnoses of ulcers of the small bowel are well known. They include Croh... more Summary The differential diagnoses of ulcers of the small bowel are well known. They include Crohn&#x27;s disease, NSAIDs, radiation, vasculitis, medication effects, some infections and certain neoplasms. Yet when faced with the finding of ulceration in the small bowel, it ...

John Wiley & Sons, Ltd eBooks, Aug 1, 2016

The differential diagnoses of ulcers of the small bowel are well known. They include Crohn's dise... more The differential diagnoses of ulcers of the small bowel are well known. They include Crohn's disease, non-steroidal antiinflammatory drugs (NSAIDs), radiation, vasculitis, medication effects, some infections, and certain neoplasms (Table 98.1). Nonetheless, when faced with the finding of ulceration in the small bowel, it can be difficult to come up with a final diagnosis. Crohn's disease is most common, but NSAID use is also frequently seen. How, then, does a physician make the diagnosis of Crohn's disease based on the presence of ulcers seen only on endoscopy, capsule or otherwise? In the past, we were confident in making the diagnosis in the clinical setting of pain and diarrhea in a young person in whom a small bowel series showed ileitis. We clearly should be able to do the same with endoscopic findings; that is, to combine the clinical scenario with the endoscopic, rather than the radiographic, findings. There can be other evidence to support a diagnosis of Crohn's, including a family history of inflammatory bowel disease (IBD) and abnormal serologies of antineutrophil cytoplasmic antibodies (ANCA) and anti-Saccharomyces cerevisiae antibodies (ASCA), though this is not the intended use of these blood tests. Endoscopic biopsy typically cannot differentiate a Crohn's ulcer from an NSAID ulcer. Other testing, such as computed tomographic (CT) scanning, generally provides no additional information beyond what is supplied by endoscopy. Grading the severity of inflammatory findings on capsule endoscopy can provide more certainty in making a final diagnosis. Case A 45-year-old female presents with a history of obscure gastrointestinal (GI) bleeding. Her first episode was at 20 years of age. Since then, multiple episodes have occurred, occasionally requiring transfusion of packed red blood cells (RBCs). Evaluations, including colonoscopy, upper endoscopy, and bleeding scan, are unrevealing. Additionally, CT scan, Meckel's scan, and small bowel series are normal. Her history is otherwise remarkable, except for rare NSAID use and hypertension, for which she takes diuretics. Capsule endoscopy is performed and discloses diffuse mucosal edema and erythema associated with scattered ulceration and luminal narrowing at the mid-ileum (Figure 98.1). These findings correlate to an activity score of 1232. Serologies of ASCA and p-ANCA are negative. Other laboratory values are unremarkable. Following the capsule exam, a double-balloon enteroscopy (DBE) from the transrectal approach is performed. Endoscopically, the area and affected regions of the small bowel are identical to the capsule study. Biopsies reveal active inflammation. The clinical history, endoscopic appearance, and biopsies are consistent with Crohn's disease.

Springer eBooks, 2014

ABSTRACT

Disease Management, Dec 1, 2004

The purpose of this study was to review economic considerations related to establishing a diagnos... more The purpose of this study was to review economic considerations related to establishing a diagnosis of Crohn's disease, and to compare the costs of a diagnostic algorithm incorporating wireless capsule endoscopy (WCE) with the current algorithm for diagnosing Crohn's disease suspected in the small bowel. Published literature, clinical trial data on WCE in comparison to other diagnostic tools, and input from clinical experts were used as data sources for (1) identifying contributors to the costs of diagnosing Crohn's disease; (2) exploring where WCE should be placed within the diagnostic algorithm for Crohn's; and (3) constructing decision tree models with sensitivity analyses to explore costs (from a payor perspective) of diagnosing Crohn's disease using WCE compared to other diagnostic methods. Literature review confirms that Crohn's disease is a significant and growing public health concern from clinical, humanistic and economic perspectives, and results in a long-term burden for patients, their families, providers, insurers, and employers. Common diagnostic procedures include radiologic studies such as small bowel follow through (SBFT), enteroclysis, CT scans, ultrasounds, and MRIs, as well as serologic testing, and various forms of endoscopy. Diagnostic costs for Crohn's disease can be considerable, especially given the cycle of repeat testing due to the low diagnostic yield of certain procedures and the inability of current diagnostic procedures to image the entire small bowel. WCE has a higher average diagnostic yield than comparative procedures due to imaging clarity and the ability to visualize the entire small bowel. Literature review found the average diagnostic yield of SBFT and colonoscopy for work-up of Crohn's disease to be 53.87%, whereas WCE had a diagnostic yield of 69.59%. A simple decision tree model comparing two arms-colonoscopy and SBFT, or WCE-estimates that WCE produces a cost savings of $291 for each case presenting for diagnostic work-up for Crohn's. Sensitivity analysis varying diagnostic yields of colonoscopy and SBFT vs. WCE demonstrates that WCE is still less costly than SBFT and colonoscopy even at their highest reported yields, as long as the diagnostic yield of WCE is 64.10% or better. Employing WCE as a first-line diagnostic procedure appears to be less costly, from a payor perspective, than current common procedures for diagnosing suspected Crohn's disease in the small bowel. Although not addressed in this model, earlier diagnosis with WCE (due to higher diagnostic yield) also could lead to earlier management, improved quality of life and workplace productivity for people with Crohn's disease.

Gastrointestinal Endoscopy Clinics of North America, 1999

Enteroscopy was initially a technology with little application. The small intestine was thought t... more Enteroscopy was initially a technology with little application. The small intestine was thought to be a rare site for any pathology and the ability to look at the most proximal and distal ends, during upper endoscopy and colonoscopy, was all that was needed in the evaluation of most patients. The power to peer into the small bowel has changed medical practice. This is especially true when dealing with patients with unexplained gastrointestinal bleeding. Enteroscopy helped determine causes of bleeding in such cases, and helped determine the most appropriate treatment algorithms.

Journal of Clinical Gastroenterology, Sep 1, 1992

Sixty-four patients took part in a cohort study measuring the efficacy of daily hormonal therapy ... more Sixty-four patients took part in a cohort study measuring the efficacy of daily hormonal therapy in diminishing intestinal bleeding from small bowel angiodysplasia. Thirty patients received 5-10 mg norethynodrel either with mestranol, 0.075-0.15 mg (24 patients) or with conjugated estrogens, 0.625 mg (six patients). The cohort group consisted of 34 patients who either refused hormonal therapy (six patients) or were diagnosed early in our experience, before the resurgence of hormonal therapy (28 patients). Mean follow-up was 15.6 months (range 2-31 months) for the treated group and 13.4 months (range 1-23 months) for the untreated group. In addition, the change in monthly transfusion requirement with therapy was analyzed ("within group" analysis). Fifty percent (15 of 30) of the treated group required no further transfusion during therapy, while 44% (15 of 34) of the untreated group required no further therapy (not significant). During therapy, the mean monthly transfusion requirement of packed red blood cells in the treated group was not significantly different from that found before therapy (1.5 vs. 2.2 units, NS) or from that of the control group (1.5 vs. 1.6 units, NS). The findings do not support the use of hormonal therapy for bleeding from small intestinal angiodysplasia.

Surgical Clinics of North America, Feb 1, 1992

The mesenteric circulation is affected by many systemic diseases and physiologic states. Congenit... more The mesenteric circulation is affected by many systemic diseases and physiologic states. Congenital connective tissue disorders such as Ehlers-Oanlos syndrome and pseudoxanthoma elasticum can present with symptoms of gastrointestinal motility disturbance or bleeding. Metabolic conditions such as hypertension and diabetes mellitus; hematologic conditions such as hypercoagulable states; and vasculitides, either primary or secondary to infections or neoplasms, can affect the splanchnic vasculature, producing a variety of symptoms. Many biologic and chemical substances of endogenous and exogenous origin can also influence the mesenteric circulation, with either beneficial or catastrophic results. CONGENITAL DISORDERS OF THE VASCULATURE Ehlers-Oanlos syndrome is an uncommon disorder of the connective tissue that in rare cases involves the mesenteric vasculature. Transmitted as either an autosomal dominant or recessive trait, Ehlers-Oanlos syndrome is characterized by hyperextensible skin and hypermobile joints. Friability of the skin and subcutaneous structures with hernia formation and poor wound healing after surgery is well known in these patients." There are 11 types of Ehlers-Oanlos syndrome, each altering the connective tissue matrix metabolism in a different way. Type IV, also called the ecchymotic form, is the most common form influencing the vasculature. In type IV Ehlers-Oanlos syndrome, there

Inflammatory Bowel Diseases, Sep 1, 2022

Background: To demonstrate treatment efficacy in Crohn's disease (CD), regulatory authorities req... more Background: To demonstrate treatment efficacy in Crohn's disease (CD), regulatory authorities require that trials include an endoscopic remission/response end point; however, standardized endoscopic assessment of disease activity, such as the Simple Endoscopic Score for Crohn's Disease (SES-CD), is not typically recorded by clinicians in practice or outside of clinical trials. The novel Simplified Endoscopic Mucosal Assessment for Crohn's Disease (SEMA-CD) was developed to be easy to use in routine clinical practice and as a trial end point. We conducted a study to assess and validate the reliability and feasibility of SEMA-CD as a measure of endoscopic disease activity. Methods: Pre-and post-treatment ileocolonoscopy videos of pediatric (n = 36) and adult (n = 74) CD patients from 2 ustekinumab clinical trials were each scored with SEMA-CD by 2 to 3 professional central readers, blinded to clinical history and other video scorings; the correlation between SEMA-CD and SES-CD previously completed during the trials was assessed. Sensitivity to change, inter-and intrarater reliability, and comparative ease of scoring were also assessed. Results: The SEMA-CD strongly correlated with SES-CD (Spearman ρ = 0.89; 95% confidence interval, 0.86-0.92). Pre-to post-treatment changes in SEMA-CD vs in SES-CD were strongly correlated, and the correlation remained strong between the scores when compared by study population (pediatric, adult), disease severity, and video quality. Intra-and inter-rater reliability were good, and SEMA-CD was rated easier than SES-CD to score 63.0% of the time, although slightly more difficult than SES-CD to score <1.0% of the time. Conclusions: The SEMA-CD is reliable, reproducible, sensitive to change, and easy to use in both pediatric and adult patients with CD.

PubMed, 2000

Enteroscopy in the new millennium will involve the development of instruments and accessories to ... more Enteroscopy in the new millennium will involve the development of instruments and accessories to allow deeper therapeutic intervention in the small bowel. There are also four new areas of development that involve the field of enteroscopy. These areas are the development of improved push enteroscopes, the development of laparoscopically assisted enteroscopy, the development of virtual enteroscopy, and gene research in the field of vascular anomalies of the gut.

Endoscopy, May 1, 1989

A 76-year-old female presented with bright red rectal bleeding. Endoscopic evaluation revealed a ... more A 76-year-old female presented with bright red rectal bleeding. Endoscopic evaluation revealed a polypoid lesion sprouting hair in the sigmoid colon. Histologically the resected polyp was composed of elements of all three germ layers, fulfilling the criteria for a teratoma. The differential diagnosis of this benign polyp and its significance are discussed.

The American Journal of Gastroenterology, Mar 3, 2009

Mucosal Healing of Crohn's Disease Demonstrated by Capsule Endoscopy in a Woman With Obscure ... more Mucosal Healing of Crohn's Disease Demonstrated by Capsule Endoscopy in a Woman With Obscure Gastrointestinal Bleeding

Gastrointestinal Endoscopy Clinics of North America, Jul 1, 2009

Although the small intestine has long been considered the final frontier of endoscopy, a vast amo... more Although the small intestine has long been considered the final frontier of endoscopy, a vast amount of progress has led to increased diagnostic and therapeutic capabilities. With the increasing prevalence of capsule endoscopy, the need for enteroscopy also continues to increase. The endoscopic options currently available include double and single balloon-assisted enteroscopy, spiral enteroscopy, and lastly, intraoperative enteroscopy. The majority of published literature has focused on double balloon enteroscopy, but further studies have to provide information on the safety and yield of the newer techniques. Although intraoperative enteroscopy may be practiced less frequently, it has a role in the management of lesions that may not be approachable by other endoscopic means and a role in the guidance of surgical management.

The American Journal of Gastroenterology, Sep 1, 2006

PubMed, Dec 1, 1994

Objective: The combination of push and sonde enteroscopy permits endoscopic evaluation to extend ... more Objective: The combination of push and sonde enteroscopy permits endoscopic evaluation to extend the distal small bowel. Our objective was to determine the yields of both push and sonde enteroscopy in patients with obscure GI bleeding. Methods: We retrospectively reviewed 553 small bowel examinations performed with an orally passed 135-cm pediatric colonoscope in combination with a 2750-cm per nasal sonde enteroscope to investigate the small bowel for sources of gastrointestinal bleeding of obscure origin. Results: The examination reached the distal jejunum or beyond in over 90% of patients undergoing both push and sonde enteroscopy. The yield of these combined studies was 58% for identifying a possible source of gastrointestinal blood loss. In 40% of the examinations, the abnormality was found distal to the limits of routine upper gastrointestinal endoscopy. In 26% of all examinations, the lesion was detectable only by sonde enteroscopy. The most common small bowel findings were mucosal vascular lesions (31% of all exams) and tumors (6%). No major endoscopic complications occurred, and patients tolerated the procedures well. Conclusions: The combination of push and sonde enteroscopy is a valuable tool in the evaluation of obscure gastrointestinal bleeding and may provide useful information necessary to formulate treatment plans aimed at cessation of bleeding.

Gastrointestinal Endoscopy, 1992

Gastroenterology, Nov 1, 2007

This literature review and the recommendations therein were prepared for the AGA Institute Clinic... more This literature review and the recommendations therein were prepared for the AGA Institute Clinical Practice and Economics Committee. The paper was approved by the Committee on March 12, 2007, and by the AGA Institute Governing Board on May 19, 2007.

The American Journal of Gastroenterology, Oct 1, 2013