Clinical Gastroenterology and Hepatology - Articles in Press

Melanosis ilei - Accepted Manuscript

Jun Nishikawa, Tomonori Tanaka, Toshiro Sugiyama — 2012-04-27

Abstract: Melanosis in the gastrointestinal tract consists of the accumulation of pigment deposits in the mucosa. Although melanosis of the large intestine is not an uncommon condition, melanosis of the small intestine is extremely rare. We report a case in which we observed melanosis not only in the colon, but in the ileum as well. Because the patient had a history of chronic use of laxatives, and characteristic of the pigment was identical in the ileum and colon, we suppose that long-term use of anthraquinone-containing medications could have been the major cause of pigment deposition of ileum.

Small Bowel Pancreatitis - Accepted Manuscript

Klaus Mönkemüller, Isabella Werecki, Roger Kuhn — 2012-04-27

Ethnic and Sex Disparities in Colorectal Neoplasia Among Hispanic Patients Undergoing Screening Colonoscopy - Uncorrected Proof

2012-04-27

Background & Aims: Colorectal cancer (CRC) has a high prevalence among the US Hispanic population. In Puerto Rico, CRC is the third leading cause of cancer death in men and the second in women. There are limited published data on the prevalence of colorectal neoplasia (CRN) among the US Hispanic population. We determined the prevalence of CRN (colorectal adenomas and cancer) among asymptomatic, Hispanic subjects who were screened in Puerto Rico and evaluated risk factors associated with CRN. Methods: We performed a retrospective review of the medical, endoscopic, and pathology records of individuals who underwent first-time screening colonoscopies at an ambulatory gastroenterology practice from January 1, 2008 to December 1, 2009. The prevalence of CRN (overall and advanced), documented by colonoscopy and pathology reports, was calculated for the complete cohort and by sex. Results: Of the 745 Hispanic individuals who underwent screening colonoscopies during the study period, the prevalence for overall CRN was 25.1% and for advanced CRN (≥1 cm and/or with advanced histology) was 4.0%. The prevalence of CRN was higher for men than women (32.0% vs 20.6%; P = .001; odds ratio, 1.92; 95% confidence interval, 1.4–2.6). CRN was more frequently located in the proximal colon (67.7% proximal vs 32.3% distal). A family history of CRC was associated with advanced CRN (odds ratio, 2.73; 95% confidence interval, 1.10–6.79). Conclusions: CRN was more common among Hispanic men than women and increased with age. CRNs among Hispanic individuals were predominantly located in the proximal colon. These findings indicate that there are ethnic and sex disparities in patterns of CRN that might be related to genomic admixture and have important implications for screening algorithms for Hispanic individuals.

Ability of Rabeprazole to Prevent Gastric Mucosal Damage from Clopidogrel and Low Doses of Aspirin Depends on CYP2C19 Genotype - Accepted Manuscript

2012-04-27

Abstract: Background & Aims: Low doses of aspirin can injure the gastric mucosa. It is not clear if other drugs, such as the anti-platelet agent, clopidogrel, also cause gastric mucosal injury or exacerbate aspirin-induced injury, or if proton-pump inhibitors prevent damage. Methods: Twenty Japanese subjects with different CYP2C19 genotypes were randomly assigned to groups that were given a low dose of aspirin (100 mg; A), clopidogrel (75 mg; C), the low dose of aspirin and clopidogrel (AC), or the low dose of aspirin in combination with clopidogrel and rabeprazole (10 mg; ACR), once daily for 7 days. Subjects underwent gastroduodenoscopy and platelet tests on days 3 and 7; gastric mucosal damage was assessed using the modified LANZA score (MLS). We performed 24 h intragastric pH monitoring on day 7 of each regimen. We also analyzed the effects of the AC regimen on 30 patients with different CYP2C19 genotypes. Results: Subjects in groups A, C, and AC had significantly higher levels of gastric mucosal damage days 3 and 7, compared with baseline. The median MLS for the AC group was similar to that of the A group. Helicobacter pylori -negative subjects in the ACR group with different CYP2C19 genotypes had significant differences in MLSs, intragastric pH, and platelet function. Gastric mucosal injury was inhibited equally among H pylori -positive subjects in the ACR group. Rabeprazole did not appear to affect platelet function or intragastric pH in patients given clopidogrel. Conclusions: Clopidogrel and low doses of aspirin cause a similar degree of gastric mucosal damage. Rabeprazole prevented this damage without reducing the anti-platelet function of clopidogrel. However, its prophylactic effect varies with CYP2C19genotype in H pylori-negative subjects.

Persistent Hyperammonemia Is Associated with Complications and Poor Outcomes in Patients with Acute Liver Failure - Accepted Manuscript

2012-04-19

Abstract: Background & Aims: Patients admitted to the hospital with acute liver failure (ALF) and high arterial levels of ammonia are more likely than patients with lower levels of ammonia to have complications and poor outcomes. ALF is dynamic process; ammonia levels can change over time. We investigated whether early changes (first 3 days after admission) in arterial levels of ammonia were associated with complications and outcomes, and identified factors associated with persistent hyperammonemia. Methods: We performed a prospective observational study, measuring arterial ammonia levels each day, for 5 days, in 295 consecutive patients with ALF. We analyzed associations of changes in ammonia levels during first 3 days with complications and outcomes. Results: Patients with persistent arterial hyperammonemia (≥122 μmol/L for 3 consecutive days), compared to those with decreasing levels, had lower rates of survival (23% vs 72%; P<.001) and higher percentages of cerebral edema (71% vs 37%; P<.001) infection (67% vs 28%; P=.003) and seizures (41% vs 7.7%; P<.001). Patients with persistent hyperammonemia had greater mortality, with an odds ratio (OR) of 10.7, compared to patients with baseline levels of ammonia ≥122 μmol/L (OR, 2.4). Patients with persistent hyperammonemia were more likely to progress to and maintain advanced hepatic encephalopathy than those with decreasing levels. Patients with persistent, mild hyperammonemia (≥85 μmol/L for 3 days) were also more likely to have complications or die (P<.001) than patients with serial ammonia levels <85μmol/L. Infections (OR 4.17), renal failure (OR, 2.20), and decreased arterial pH (OR, .003) were independent predictors of persistent hyperammonemia. Conclusion: Patients with ALF and persistent arterial hyperammonemia for 3 days after admission are more likely to develop complications and have greater mortality than patients with decreasing levels or high baseline levels. Infection, renal failure, and decreased arterial pH are independent predictors of persistent hyperammonemia.

Multiple polyposis of the esophagus: Mantle cell lymphoma - Accepted Manuscript

Ko-Hung Shen, Chih-Jung Chen, Hsu-Heng Yen — 2012-04-18

Helicobacter pylori Infection and Nonsteroidal Anti-inflammatory Drug Use: Eradication, Acid-Reducing Therapy, or Both? - Uncorrected Proof

En–Ling Leung Ki, Francis K.L. Chan — 2012-04-18

A general health practitioner calls you regarding 3 of his patients on nonsteroidal anti-inflammatory drugs (NSAIDs). He asks you if they could benefit from Helicobacter pylori testing and treating. He also asks you if he should prescribe prophylactic acid-reducing therapy. Patient 1 is a 68-year-old woman recently diagnosed with rheumatoid arthritis in whom your colleague wishes to commence regular NSAIDs. She has a history of uncomplicated peptic ulcer more than a decade ago. Patient 2 is a 71-year-old man on long-term, low-dose aspirin (acetylsalicylic acid [ASA]) for ischemic heart disease. He has a history of peptic ulcer bleed 3 years ago. He reports self-medicating regularly with over-the-counter NSAIDs for osteoarthritis-related pain. Patient 3 is a 40-year-old man with ankylosing spondylitis who is a long-term NSAID user in whom your colleague wishes to up-titrate the dose for better analgesic control. He has no history of peptic ulcer disease and consumes no other medications.

Correction - Corrected Proof

2012-04-18

Sahebjalal M, Blackman J, McLaughlin S. The reintroduction of antiplatelet agents post gastrointestinal haemorrhage: a retrospective cross-sectional study and proposed management algorithm. Clin Gastroenterol Hepatol 2012;10:331.

Uncorrected Proof

2012-04-16

Proton pump inhibitor (PPI) therapy revolutionized management of gastroesophageal reflux disease (GERD). Despite the potency of these agents, there remains a subgroup of patients with reflux-type symptoms in whom single- or double-dose therapy remains ineffective. Generally, 24-hour esophageal pH monitoring has been used to assess for the presence of reflux in such patients. Limited data are available on the role of impedance monitoring in this setting. In this study from 3 university hospitals from France, consecutive patients referred for 24-hour pH impedance monitoring off therapy included those who were PPI responders, those who were nonresponders but improved following appropriate treatment, and thosex who were clearly nonresponders. They assessed 24-hour pH impedance patterns as well as clinical factors predicting nonresponse. They found that no reflux pattern on 24-hour pH impedance monitoring performed off therapy was predictive of response to PPI therapy in patients with GERD. PPI failure was mainly associated with low body mass index and the presence of functional digestive disorders, even when pathologic reflux was demonstrated by impedance monitoring. Twenty-five percent of responders had functional dyspepsia or irritable bowel syndrome in contrast to 65% and 44%, respectively, in nonresponders. Esophagitis at endoscopy was seen in 23% of responders as compared to only 7% of nonresponders (P = .021).

Delayed and Unsuccessful Endoscopic Retrograde Cholangiopancreatography Are Associated with Worse Outcomes in Patients with Acute Cholangitis - Uncorrected Proof

2012-04-16

Background & Aims: Acute ascending cholangitis usually is treated with antibiotics and biliary drainage is treated by endoscopic retrograde cholangiopancreatography (ERCP). We investigated the effects of the timing of ERCP on outcomes of patients with acute cholangitis factors that predict prolonged hospital stays, increased costs of hospitalization, and composite clinical outcomes (death, persistent organ failure, and admission to the intensive care unit). Methods: We performed a retrospective analysis of data from 90 patients (mean age, 60 y; 48% female) admitted to Johns Hopkins Hospital from January 1994 to June 2010 who were diagnosed with acute cholangitis and underwent ERCP. A delayed ERCP was defined as one performed more than 72 hours after admission. Electronic and paper medical records were reviewed and relevant data were abstracted. Results: ERCP was performed successfully in 92% of the patients, at a mean time period of 38 hours after admission (14% of ERCPs were delayed). Factors that were associated independently with prolonged length of hospital stay (top 10%) included unsuccessful ERCP (odds ratio [OR], 52.5; P = .002) and delayed ERCP (OR, 19.8; P = .008). Factors associated with increased hospitalization cost (top 10%) included unsuccessful ERCP (OR, 33.8; P = .004) and delayed ERCP (OR, 11.3; P = .03). Factors associated with composite clinical outcome included age (OR, 1.1; P = .01), total level of bilirubin (OR, 1.36; P = .002), and delayed ERCP (OR, 7.8; P = .04). Conclusions: Delayed and failed ERCP are associated with prolonged hospital stays and increased costs of hospitalization. Delayed ERCP is associated with composite clinical outcome (death, persistent organ failure, and/or intensive care unit stay). Older age and higher levels of bilirubin also are associated with patients' composite end point.

Waiving Cost Sharing for Screening Colonoscopy; Free, but Not Clear - Corrected Proof

Spencer D. Dorn, A. Mark Fendrick — 2012-04-16

Colonoscopy is a recommended, cost-effective colorectal cancer screening modality that likely reduces mortality, yet only half of Americans older than age 50 report having undergone colonoscopy or any other colorectal cancer screening test. One barrier to screening is cost; beneficiaries of health plans with high out-of-pocket costs are less likely to undergo screening colonoscopy. Thus, reducing cost sharing may increase screening rates.

Management of High-Grade Dysplasia and Intramucosal Adenocarcinoma in Barrett's Esophagus - Uncorrected Proof

Sachin Wani, Dayna Early, Steve Edmundowicz, Prateek Sharma — 2012-04-16

A 62-year-old Caucasian male with chronic long-standing gastroesophageal reflux disease and a history of nondysplastic Barrett's esophagus (BE) undergoes surveillance upper endoscopy with biopsies at an outside facility. Biopsies revealed high-grade dysplasia (HGD) and the patient is referred to a tertiary care referral center for endoscopic eradication therapy (EET). His symptoms are adequately controlled on twice daily proton pump inhibitor therapy and he denies any alarm symptoms. His physical examination is unremarkable with the exception of mild obesity. Repeat endoscopy revealed proximal displacement of the squamocolumnar junction by 4 cm above the most proximal extent of the gastric folds (circumferential segment, 2 cm; maximal extent, 4 cm; Prague C2M4) and a medium-sized sliding hiatal hernia. The BE segment was carefully inspected with standard white light high-resolution endoscopy and narrow band imaging (NBI). Although no obvious visible lesions were identified, an area of abnormal mucosal and vascular pattern was detected with NBI. Endoscopic mucosal resection (EMR) of this area was performed and pathology was consistent with intramucosal esophageal adenocarcinoma (IMC) with negative deep and lateral margins confirmed by 2 expert gastrointestinal pathologists. Random surveillance biopsies were obtained from the remaining Barrett's segment that showed intestinal metaplasia with no dysplasia. How should you counsel this patient with Barrett's esophagus and IMC regarding therapeutic options? What are the treatment options to achieve endoscopic eradication of BE? What are the complications of EET and how should this patient be followed after treatment?

Colonic Angiosarcoma: A Rare Cause of Bleeding - Uncorrected Proof

Ronak Modi, Bhavik Bhandari, Daniel Ringold — 2012-04-16

A 73-year-old woman with blindness, hypertension, and diabetes was diagnosed with new-onset atrial fibrillation requiring anticoagulation with dabigatran. During the admission, she had painless hematochezia and a decrease in her hemoglobin levels requiring transfusion with 3 U of packed red cells. She denied a history of anemia, and she had never had a colonoscopy. A colonoscopic evaluation revealed a 1.5-cm ulcerated, heaped-up, submucosal lesion in the transverse colon. At the biopsy examination of the lesion there was profuse bleeding requiring hemostasis with the placement of several endoscopic clips.

Similar Risk of Renal Events Among Patients Treated with Tenofovir or Entecavir for Chronic Hepatitis B - Accepted Manuscript

2012-04-16

Abstract: Background and Aims: Tenofovir is a nucleotide reverse-transcriptase inhibitor approved for treatment of HIV infection, as well as chronic hepatitis B (CHB). We evaluated nephrotoxicity among patients with CHB treated with tenofovir. Methods: We performed a community-based, retrospective cohort study of 80 patients with CHB who received tenofovir, alone or in a combination regimen; they were matched for age and sex with 80 CHB patients who received only entecavir. Incidences of serum creatinine (SCr) increase ≥ 0.2 mg/dL and new SCr levels of 1.5, 2.0, or 2.5 mg/dL were assessed. Patients with an estimated glomerular filtration rate (eGFR) < 60 mL/min, calculated using the Modification of Diet in Renal Disease (MDRD) or Cockcroft-Gault (CG) formula, or who had ≥ 20% decrease in eGFR were also recorded. Results: More patients given entecavir had increases in SCr ≥ 2.5 mg/dL (1 vs 6;P = .053), whereas more patients given tenofovir had a new CG eGFR of < 60 mL/min (15 vs 6; P=.022) and at least one dose adjustment (13 vs 4;P =.021). By multivariate analysis, the only significant factors associated with an increase in SCr were a history of organ transplantation (adjusted odds ratio [OR] 6.740; 95% confidence interval [CI], 1.799 – 28.250;P =.005) and pre-existing renal insufficiency (adjusted OR 10.960; 95% CI, 2.419 – 48.850;P =.002). No factors, including therapy assignment, were associated with a new eGFR < 60 ml/min. Conclusion: Markers of renal function indicated that patients who received tenofovir were no more likely to have changes in renal function than patients treated with entecavir. History of transplant and pre-existing renal insufficiency were the only factors independently associated with increases in SCr.

Reply - Corrected Proof

Susana Seijo, María Gabriela Delgado, Juan Carlos Garcia–Pagan — 2012-04-13

We thank Dr Rodriguez–Castro et al and Dr Qi et al for their interest in our study in Clinical Gastroenterology and Hepatology. In our study, 27 patients stopped anticoagulation before the end of the study or before liver transplantation. Unfortunately, due to the retrospective nature of the study, the decision to stop anticoagulation was not predefined and was based on physician preferences at different centers (it was related to a bleeding complication in only 3 patients). As mentioned in our original manuscript, a complete study of prothrombotic disorders was performed in 78% of patients and was positive in 16% of them. Interestingly, a complete prothrombotic study was done in 8 of the 13 patients that stopped anticoagulation after achieving complete recanalization, and a prothrombotic disorder was not found in any of them. In our opinion, the absence of a prothrombotic disorder could probably favor stopping anticoagulation. In addition, although the presence of an underlying prothrombotic disorder may be associated with recurrent thrombosis after recanalization, our results show that this event may also occur when cirrhosis is the only prothrombotic condition.

Reply - Uncorrected Proof

Jing H. Ngu, Richard B. Gearry, Catherine A.M. Stedman — 2012-04-13

We thank Dr Tabibian and colleagues for their interest in our study and their helpful comments and queries. We have recently published detailed survival information and cancer incidence of patients with autoimmune liver diseases, including primary sclerosing cholangitis (PSC), in Canterbury. We have shown that the standardized mortality ratio (SMR) of PSC patients when compared to the age and gender matched Canterbury population was 4.1, and Kaplan–Meier estimate of 15 years transplant-free survival was 45% (95% confidence interval, 26%–64%), although the focus of the study was not on the difference between PSC with and without inflammatory bowel disease (IBD). When we specifically looked at the mortality of the PSC-IBD group, SMR and median transplant-free survival were 5.0 and 14 years, respectively. The mortality of the PSC without IBD group was more favorable, with an SMR of 3.0. As greater than half of the PSC without IBD group (70%) survived till the end of the follow-up period (up to 17 years), median survival was not available for this group. As expected, total patient-years follow-up was much higher in the PSC-IBD group (498 vs 115 patient-years), as they represented 76% of our population-based cohort. The risks of death/transplant for PSC-IBD and PSC without IBD groups were 5.2% and 2.6% per patient-year, respectively. None of the patients who developed cholangiocarcinoma had preceding colorectal cancer. The distribution of PSC–autoimmune hepatitis cases was comparable between the 2 groups with 5 cases in the PSC-IBD group (8%) compared to 2 cases in the PSC without IBD group (11%).

Uncorrected Proof

C. Mel Wilcox — 2012-04-12

Exam 2: Patients Whose First Episode of Bleeding Occurs While Taking a β-Blocker Have High Long-Term Risks of Rebleeding and Death - Uncorrected Proof

C. Mel Wilcox — 2012-04-12

Prognostic Value of Muscle Wasting in Cirrhotic Patients - Corrected Proof

Edward W. Holt, R. Todd Frederick, Michael S. Verhille — 2012-04-12

It was with great interest that we read the study by Montano–Loza et al reporting an independent association between sarcopenia and mortality among cirrhotic patients. This measurement helps to codify a previously subjective component of the gastroenterologist's clinical evaluation of the cirrhotic patient. If validated, these findings might help to better identify patients with the highest risk of mortality, with or without liver transplantation. We noted 2 important issues that were not addressed in the text of the article.

For Celiac Disease, Diagnosis Is Not Enough - Corrected Proof

Peter R. Gibson, Susan J. Shepherd, Jason A. Tye–Din — 2012-04-12

Ever since gluten was identified as the causative antigen of celiac disease (CD) in the 1950s, the mainstay of therapy has been life-long gluten elimination. Its success in reversing the severe malabsorption and reducing the sizeable mortality rate not uncommonly seen in young children half a century ago ironically has limited rigorous and systematic evaluation of the gluten-free diet (GFD) as a therapy. Instead, research has focused on improving diagnosis and understanding disease epidemiology. However, with the growing understanding of the clinical burden of untreated or poorly treated CD, efforts now should be harnessed toward establishing exactly what constitutes appropriate CD management and follow-up evaluation. Current guidelines are vague and/or not evidence-based. With such a background, it not surprising that the study by Herman et al revealed haphazard and deficient follow-up evaluation of patients in a population-based study.

The Importance of Quality Appraisal in Meta-analysis - Corrected Proof

Suzanne E. Mahady, Angela C. Webster — 2012-04-12

The recent meta-analysis by Deshpande et al found a more than 2-fold risk of Clostridium difficile infection among those using proton pump inhibitors. While this meta-analysis has addressed an important area, there are methodological issues that limit the interpretation of the findings.

Individualizing Therapy for Chronic Pancreatitis - Corrected Proof

D. Nageshwar Reddy, Mohan J. Ramchandani, Rupjyoti Talukdar — 2012-04-12

Chronic pancreatitis (CP) is a complex, multifactorial, and progressive inflammatory disease of the pancreas characterized by pain and damage to endocrine and exocrine pancreatic tissue. CP can have a debilitating clinical course due to chronic abdominal pain, malnutrition, and related complications. Therapeutic efforts have centered on palliative treatment of the severe pain associated with CP. Pain in CP is multifactorial in origin and can result from increased pressure in the main pancreatic duct (PD) leading to intraparenchymal/interstitial hypertension, and from peripancreatic neural inflammation. Intraductal hypertension occurs primarily due to obstruction of pancreatic juice outflow from PD strictures, intraductal stones, and major/minor papillary stenosis. Complications contribute to abdominal pain. Three modalities of treatments are available to tackle these problems viz medical, endoscopic, and surgical. These modalities of treatment aim at control of symptoms, probable prevention of disease progression, and correction of complications. Endotherapy (ET) and surgery are considered the treatment modalities of choice in the case of painful pancreatitis with ductal obstruction. The aim of both modalities is to alleviate the pressure in the pancreatic duct and ensure adequate drainage of pancreatic secretions. Medical management is preferred in patients with small duct disease. There had been much debate whether ET or surgery should be the optimal initial therapy for CP. ET plays a specific role in carefully selected patients as primary interventional therapy when medical measures fail. It can eliminate or reduce the need for surgical interventions, serve as a bridge to surgery in poor operative candidates, and predict the response to surgical therapy. Multiple studies have evaluated endoscopic sphincterotomy and removal of pancreatic duct stones in CP patients. Success rates of stone removal with a combination of extracorporeal shock wave lithotripsy (ESWL) followed by basket extraction have been reported to be 50%–70%, and pain relief in these patients are even higher, ranging from 60% to 80%.

Endoscopic Ultrasound Guided Fine Needle Aspiration of Peritoneal Deposit in Otherwise Resectable Pancreatic Cancer - Uncorrected Proof

Surinder Singh Rana, Deepak Kumar Bhasin, Nalini Gupta — 2012-04-12

A 62-year-old male chronic alcohol consumer, presented to us with abdominal pain and loss of appetite. His clinical examination was unremarkable. His hematological and biochemical investigations did not reveal any abnormality. Ultrasound examination of the abdomen revealed a 3 cm mass lesion in the body of the pancreas. A contrast enhanced computed tomography (CECT) scan of the abdomen was performed. It confirmed the presence of mass lesion in the body of the pancreas. There was no vascular invasion, no distant metastasis observed, and the lesion appeared resectable. The patient underwent endoscopic ultrasound (EUS) with a linear echoendoscope for locoregional staging and fine needle aspiration (FNA) from the mass in the pancreas. The mass lesion could be well delineated on EUS ( A) and there was no vascular invasion or locoregional lymphadenopathy. However, minimal ascites was present. Also, peritoneal deposits, noted as hyperechoic rounded lesions compared with the surrounding anechoic ascitic fluid, were present ( B, arrow). EUS-guided FNA was done from the mass lesion as well as the peritoneal deposit ( C). The cytologic examination of EUS FNA from the mass lesion was suggestive of adenocarcinoma and the FNA from the peritoneal deposit revealed metastatic adenocarcinoma ( D; cluster of malignant cells exhibiting moderate nuclear pleomorphism; May Grünwald Geimsa stain; 40×). The patient was subsequently referred to oncology services.

A Gastroenterologist’s Guide to Probiotics - Accepted Manuscript

Matthew A. Ciorba — 2012-04-12

Abstract: The enteric microbiota contributes to gastrointestinal health and its disruption has been associated with many disease states. Some patients consume probiotic products in attempts to manipulate the intestinal microbiota for health benefit. It is important for gastroenterologists to improve their understanding of the mechanisms of probiotics and the evidence that support their use in practice. Clinical trials have assessed the therapeutic effects of probiotics for several disorders, including antibiotic- or Clostridium difficile-associated diarrhea, irritable bowel syndrome, and the inflammatory bowel diseases. Although probiotic research is a rapidly evolving field, there are sufficient data to justify a trial of probiotics for treatment or prevention of some of these conditions. However, the capacity of probiotics to modify disease symptoms is likely to be modest and varies among probiotic strains—not all probiotics are right for all diseases. The current review provides condition-specific rationale for using probiotics as therapy and literature-based recommendations.

Analyses of Hospital Administrative Data that Use Diagnosis Codes Overestimate the Cases of Acute Pancreatitis - Uncorrected Proof

Shreyas Saligram, David Lo, Melissa Saul, Dhiraj Yadav — 2012-04-12

Background & Aims: Although widely used, little information exists on the validity of using hospital administrative data to code acute pancreatitis (AP). We sought to determine if discharge diagnosis codes accurately identify patients whose clinical course met the standard for AP diagnosis. Methods: We analyzed data from 401 unique patients admitted through the emergency department who received a primary inpatient discharge diagnosis of AP at 2 University of Pittsburgh Medical Center hospitals in the years 2000, 2002, and 2005. Each patient was matched with a control patient who was admitted with abdominal pain and then discharged without a diagnosis of AP. Patients were matched based on demographics, testing for serum levels of pancreatic enzymes, year of visit to the emergency department, admission to the intensive care unit, and performance of abdominal computed tomography scan. The standard used to diagnose AP was the presence of 2 of 3 features (abdominal pain, ≥3-fold increase in serum levels of pancreatic enzymes, and positive results from imaging analysis). Results: The median age of AP cases was 53 years (interquartile range, 41.5–67 years); 47.1% were male, 85% were white. The most common etiologies were biliary (33.4%), alcohol-associated (16.2%), and idiopathic (24.2%). Serum levels of pancreatic enzymes were increased by any amount, and by ≥3-fold, in 95.3% and 68.6% of patients diagnosed with AP and in 13.8% and 2.2% of controls, respectively. The standard for diagnosis of AP was met in 80% of cases diagnosed with this disorder; they had no history of pancreatitis. The sensitivity, specificity, and positive and negative predictive values of the AP diagnosis code were 96%, 85%, 80%, and 98%, respectively. Conclusions: Approximately 1 of 5 patients diagnosed with AP upon discharge from the hospital do not meet the guidelines for diagnosis of this disorder. Efforts should be made to more consistently use guidelines for AP diagnosis.

Endoscopic Skipping of the Distal Terminal Ileum in Crohn’s Disease can Lead to Negative Results from Ileocolonoscopy - Accepted Manuscript

2012-04-12

Abstract: Background & Aims: Crohn's disease often involves the terminal ileum but skipping of the distal terminal ileum can occur. This can lead to negative results from ileocolonoscopy. We analyzed advanced cross-sectional images to determine how frequently this occurs. Methods: We analyzed data from 189 consecutive patients (55% women) with Crohn's disease, evaluated in 2009 by computed tomography enterography (CTE) and ileocolonoscopy. The discharge impression of the gastroenterologist that treated the patients was used as the reference standard for Crohn's disease activity. Results: Of the patients evaluated, 153 underwent terminal ileum intubation during endoscopy; 67 (43.8%) of these had normal results from ileoscopy, based on endoscopic appearance. Despite their normal results from ileoscopy, 36 of these patients (53.7%) had active, small-bowel Crohn's disease. The ileum appeared normal at ileoscopy because the disease had skipped the distal ileum of 11 patients (30.6%), developed only in the intramural and mesenteric distal ileum of 23 patients (63.9%), and appeared only in the upper gastrointestinal region of 2 patients (5.6%). These patients had a shorter duration of disease (61.1% for less than 5 years) compared to those found to have Crohn’s disease based on ileoscopy (41.1% for less than 5 years; P<.05). CTE detected extra-colonic Crohn's disease in 26% of patients; 14% of patients were found to have disorders unrelated to IBD that warranted further investigation or consultation (including 4 cancers). Conclusions: Ileoscopy examination can miss Crohn's disease of the terminal ileum because the disease can skip the distal ileum or is confined to the intramural portion of the bowel wall and the mesentery. CTE complements ileocolonoscopy in assessing disease activity in patients with Crohn's disease.

Burden of Nonsteroidal Anti-inflammatory and Antiplatelet Drug Use in Asia: A Multidisciplinary Working Party Report - Corrected Proof

2012-04-12

Background & Aims: We established a working group to examine the burden of atherothrombotic and musculoskeletal diseases in Asia and made recommendations for safer prescribing of nonsteroidal anti-inflammatory drugs (NSAIDs) and low-dose aspirin. Methods: By using a modified Delphi process, consensus was reached among 12 multidisciplinary experts from Asia. Statements were developed by the steering committee after a literature review, modified, and then approved through 3 rounds of anonymous voting by using a 6-point scale from A+ (strongly agree) to D+ (strongly disagree). Agreement (A+/A) by ≥80% of panelists was defined a priori as consensus. Results: We identified unique aspects of atherothrombotic and musculoskeletal diseases in Asia. Asia has a lower prevalence of degenerative arthritis and coronary artery disease than Western countries. The age-adjusted mortality of coronary artery disease is lower in Asia; cerebrovascular accident has higher mortality than coronary artery disease. Ischemia has replaced hemorrhage as the predominant pattern of cerebrovascular accident. Low-dose aspirin use is less prevalent in Asia than in Western countries. Traditional Chinese medicine and mucoprotective agents are commonly used in Asia, but their efficacy is not established. For Asian populations, little is known about complications of the lower gastrointestinal tract from use of NSAIDs and underutilization of gastroprotective agents. Our recommendations for preventing ulcer bleeding among users of these drugs who are at high risk for these complications were largely derived from Asian studies and are similar to Western guidelines. Conclusions: By using an evidence-based, multidisciplinary approach, we have identified unique aspects of musculoskeletal and atherothrombotic diseases and strategies for preventing NSAID-related and low-dose aspirin–related gastrointestinal toxicity in Asia.

Questions About Calculating the Effects of Albumin Therapy for Spontaneous Bacterial Peritonitis - Corrected Proof

Bulent Baran, Filiz Akyuz, Bayarmaa Khishigsuren — 2012-04-12

We read with special interest the recent article by Poca et al regarding the role of albumin treatment in spontaneous bacterial peritonitis (SBP). The authors defined a subset of patients (urea >11 mmol/L and/or bilirubin >68 μmol/L) with SBP who have a higher risk for renal impairment and mortality. They concluded that these patients benefit most from albumin treatment while hazard potential is already small in low-risk patients despite not receiving albumin treatment. However, there are questions that arise because of the method used and results obtained. First, benefits of albumin treatment in SBP are well established since the first report by Sort et al in 1999. There is a need for explanation about why high-risk patients did not receive albumin between 2001 and 2008. Second, the authors reported a number needed to treat (NNT) of 5.5 to prevent 1 death during hospitalization. When we analyzed the study by Sort et al, we have calculated an NNT of 5.26 to prevent in-hospital mortality. If only high-risk patients were included in the analysis, NNT would be 3.7.

High Rates of Viral Suppression After Long-term Entecavir Treatment of Asian Patients With Hepatitis B e Antigen–Positive Chronic Hepatitis B - Corrected Proof

2012-04-03

There are limited data on the effects of long-term entecavir therapy in Asian patients with chronic hepatitis B (CHB). We performed a post hoc analysis of 94 Asian hepatitis B e antigen–positive (HBeAg+), nucleos(t)ide analogue-naive patients who received 5 years of therapy with entecavir (up to 2 years in study ETV-022 and the remainder in study ETV-901). Among patients completing week 240, 95% (63 of 66) had levels of hepatitis B virus DNA <300 copies/mL, and 76% (50 of 66) had normalized levels of alanine aminotransferase. In addition to patients who achieved a serologic response during ETV-022, a further 40% (26 of 65) achieved HBeAg loss, and 18% (12 of 65) underwent HBeAg seroconversion through year 5 of entecavir therapy. No resistance to entecavir was detected, and the safety profile was consistent with previous reports. The long-term efficacy and safety of entecavir are therefore comparable between Asians and the overall population of HBeAg+ patients with CHB.

Best Practices in Endoscopic Ultrasound–Guided Fine-Needle Aspiration - Uncorrected Proof

Shyam Varadarajulu, Paul Fockens, Robert H. Hawes — 2012-04-03

Over the past 2 decades, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has evolved to become an indispensable tool for tissue acquisition in patients with gastrointestinal tumors. The technique is useful for biopsy of mucosal and submucosal lesions in which prior endoscopic biopsies have been nondiagnostic, to sample peri-intestinal structures such as lymph nodes, and to sample masses in the pancreas, liver, adrenal glands, gallbladder, and bile duct. Also, with the advent of neoadjuvant therapies for diseases such as pancreatic cancer, most patients require a tissue diagnosis before initiating treatment. This review provides a perspective on technical issues that are key for best practices in EUS-guided FNA.

Swallowed Fluticasone Improves Histologic but Not Symptomatic Responses of Adults with Eosinophilic Esophagitis - Uncorrected Proof

2012-04-03

Background & Aims: We evaluated the effect of aerosolized fluticasone therapy on symptomatic dysphagia and histologic eosinophilia in adults with eosinophilic esophagitis (EoE). Methods: We performed a double-blind, randomized, placebo-controlled trial of fluticasone in 42 adult patients with a new diagnosis of EoE (30 men; mean age, 37.5 y). Participants were assigned randomly to groups that swallowed 880 μg of aerosolized fluticasone twice daily (n = 21), or took a placebo inhaler twice daily (n = 15) for 6 weeks. End points of the study were symptomatic and histologic response. Results: A complete histologic response (>90% decrease in mean eosinophil count) was observed in 11 of 15 subjects who received 6 weeks of fluticasone (62%), compared with none of the 15 subjects who received placebo (P < .001), based on intention-to-treat analysis; histologic responses were observed in 68% of subjects who received fluticasone (13 of 19) compared with none of those who received placebo (0 of 15) by per-protocol analysis (P < .001). Intracellular staining for eosinophil-derived neurotoxin was reduced in 81% of subjects who received fluticasone (13 of 16) compared with 8% who received placebo (1 of 13) (P < .001). Dysphagia was reduced in 57% of subjects who received fluticasone (12 of 21) compared with 33% who received placebo (7 of 21) (P = .22) by intention-to-treat analysis; dysphagia was reduced in 63% of patients who received fluticasone (12 of 19) and 47% of those who received placebo (7 of 15) (P = .49) based on per-protocol analysis. Oral thrush developed in 26% of subjects who received fluticasone (5 of 19), but none of the subjects in the placebo group (P = .05). Conclusions: Aerosolized, swallowed fluticasone leads to a histologic but not a symptomatic response in adults with EoE.

Intestinal tuberculosis in an HIV-infected patient with advanced immnosuppression - Accepted Manuscript

Akihito Kawazoe, Naoyoshi Nagata — 2012-04-01

Diagnostic Accuracy of Computed Tomography Using Lower Doses of Radiation for Patients With Crohn's Disease - Uncorrected Proof

2012-04-01

Background & Aims: Magnetic resonance and ultrasonography have increasing roles in the initial diagnosis of Crohn's disease, but computed tomography (CT) with positive oral contrast agents is most frequently used to identify those with acute extramural complications. However, CT involves exposure of patients to radiation. We prospectively compared the diagnostic accuracy of low-dose CT (at a dose comparable to that used to obtain an abdominal radiograph) with conventional-dose CT in patients with active Crohn's disease. Methods: Low and conventional dose CT of the abdomen and pelvis were acquired from 50 patients with Crohn's disease, referred from an inflammatory bowel disease service (20 male; median age, 34 years). Acute complications of Crohn's disease were suspected. Iterative reconstruction was performed on all CT datasets to facilitate dose reduction. Three radiologists reviewed the low-dose CT images before the conventional-dose CT images. Results: The median effective dose (interquartile range) of radiation for the low-dose CT was reduced by 72% from that of conventional CT: from 3.5 mSv (3–5.08 mSv) to 0.98 mSv (0.77–1.42 mSv) (P < .001). As expected, the quality indexes of the low-dose images were inferior to those of the conventional-dose images, but no clinically significant diagnostic findings were missed with low-dose imaging. Follow-up CT examinations were recommended for 5 patients; 1 had a cervical tumor, 1 had a pancreatic lesion, and 3 had intra-abdominal abscess. In each case, the image obtained by low-dose CT was considered sufficient for diagnosis. Conclusions: Although low-dose CT images are of lower quality than images obtained with conventional doses of radiation, no clinically significant diagnostic findings were missed from low-dose CT images of patients with Crohn's disease. The low-dose CT was obtained at a median effective dose equivalent to 1.4 abdominal radiographs.

Anticoagulation for Cirrhotic Portal Vein Thrombosis: Bold, Brave, and Possibly Beneficial - Uncorrected Proof

Stewart Campbell, Neil J. Lachlan — 2012-04-01

All gastroenterologists have had bad experiences—often in the middle of the night—with bleeding in cirrhotic patients. It is therefore understandable that there is extreme reluctance to consider anticoagulation for treatment or prophylaxis in patients with cirrhosis, even for conditions in which the benefits are well-established in the general population, eg, femoral deep vein thrombosis. However, the liver is a fickle organ, and we are now beginning to understand that the tendency to bleeding induced by portal hypertension is matched by a tendency to thrombosis, and because it is the more silent partner, thrombosis might be often overlooked and rarely treated.

Features, Diagnosis, and Treatment of Nonalcoholic Fatty Liver Disease - Accepted Manuscript

Dawn M. Torres, Christopher D. Williams, Stephen A. Harrison — 2012-03-26

Abstract: As the global incidence of obesity has increased, nonalcoholic fatty liver disease (NAFLD) has become a worldwide health concern. NAFLD occurs in children and adults of all ethnicities, and includes isolated fatty liver and nonalcoholic steatohepatitis (NASH). Patients with NASH are at risk for developing cirrhosis, hepatic decompensation, and hepatocellular carcinoma (HCC) and have increased all-cause mortality. NAFLD is associated with a variety of clinical conditions and is an independent risk factor for HCC. The pathogenesis of NAFLD and the specific steps that lead to NASH and advanced fibrosis are not fully understood, although researchers have found that a combination of environmental, genetic, and metabolic factors lead to advanced disease. There have been improvements in non-invasive radiographic methods to diagnose NAFLD—especially for advanced disease. However liver biopsy is still the standard method of diagnosis for NASH. There are many challenges to treating patients with NASH, and no therapies have been approved by the US Food and Drug Administration; multi-modal approaches are being developed and becoming the standard of care. We review pathogenesis and treatment approaches for the West’s largest liver-related public health concern.

Tropical Calcific Pancreatitis - Accepted Manuscript

R. Subhash, V.A. Iyoob, Bonny Natesh — 2012-03-26

Colorectal Cancer Screening: How to Stop a Moving Target - Uncorrected Proof

Leo G.M. van Rossum — 2012-03-22

Population-based colorectal cancer screening by testing for blood in stool with fecal occult blood tests was started around the 1980s. At that time only the so-called guaiac-based fecal occult blood tests (gFOBTs) were available for colorectal cancer screening. GFOBTs are manually developed and then subjectively evaluated for a blue discoloration that occurs if enough blood is present in the stool. A single gFOBT is not very sensitive. However, according to the criteria by Wilson and Jungner, screening “should be a continuing process and not a ‘once and for all’ project.” Therefore, for each gFOBT, 3 samples are taken on consecutive days with bowel movement, and gFOBT screening is repeated biennially. GFOBT screening results in about 15%–20% reduction in cancer-specific mortality, however only after 10–15 years of biennial screening. Because colorectal cancer therapy is very expensive, even expensive procedures such as colonoscopy can be cost-saving screening tests. Therefore, many alternative screening tests such as a complete colonoscopy, the somewhat less complicated sigmoidoscopy, pillcams (ie, a small video camera in a pill), computed tomography colonography (or virtual colonoscopy), and several DNA tests and DNA panels were considered for colorectal cancer screening. However, the sensitivity, the specificity, the invasiveness, and complications of the procedure, the acceptability of the tests by the public, or the investment costs proved to be disappointing, and colorectal cancer screening remained a “moving target.”

Development of a Hybrid Percutaneous-Endoscopic Approach for the Complete Clearance of Gallstones - Corrected Proof

Barham K. Abu Dayyeh, Todd H. Baron — 2012-03-19

Cholecystitis is common and costly to the health care system. Cholecystectomy is curative and the treatment of choice. Alternatives to cholecystectomy, however, are needed for patients who cannot undergo this surgery. However, procedures such as percutaneous cholecystostomy, endoscopic transpapillary and transduodenal gallbladder drainage, and dissolution therapy have limitations such as continued gallstone burden. More effective and minimally invasive alternatives, therefore, are needed. We developed a hybrid percutaneous-endoscopic approach for complete gallstone clearance in an elderly patient who was not a candidate for surgery. If replicated and proven to be safe, this technique could be a minimally invasive alternative to cholecystectomy for patients with symptomatic gallstone disease who are not good candidates for surgery.

Global Prevalence of and Risk Factors for Irritable Bowel Syndrome: A Meta-analysis - Uncorrected Proof

Rebecca M. Lovell, Alexander C. Ford — 2012-03-19

Background & Aims: Many cross-sectional surveys have reported the prevalence of irritable bowel syndrome (IBS), but there have been no recent systematic review of data from all studies to determine its global prevalence and risk factors. Methods: MEDLINE, EMBASE, and EMBASE Classic were searched (until October 2011) to identify population-based studies that reported the prevalence of IBS in adults (≥15 years old); IBS was defined by using specific symptom-based criteria or questionnaires. The prevalence of IBS was extracted for all studies and based on the criteria used to define it. Pooled prevalence, according to study location and certain other characteristics, odds ratios (ORs), and 95% confidence intervals (CIs) were calculated. Results: Of the 390 citations evaluated, 81 reported the prevalence of IBS in 80 separate study populations containing 260,960 subjects. Pooled prevalence in all studies was 11.2% (95% CI, 9.8%–12.8%). The prevalence varied according to country (from 1.1% to 45.0%) and criteria used to define IBS. The greatest prevalence values were calculated when ≥3 Manning criteria were used (14%; 95% CI, 10.0%–17.0%); by using the Rome I and Rome II criteria, prevalence values were 8.8% (95% CI, 6.8%–11.2%) and 9.4% (95% CI, 7.8%–11.1%), respectively. The prevalence was higher for women than men (OR, 1.67; 95% CI, 1.53–1.82) and lower for individuals older than 50 years, compared with those younger than 50 (OR, 0.75; 95% CI, 0.62–0.92). There was no effect of socioeconomic status, but only 4 studies reported these data. Conclusions: The prevalence of IBS varies among countries, as well as criteria used to define its presence. Women are at slightly higher risk for IBS than men. The effects of socioeconomic status have not been well described.

High Rate of Advanced Adenoma Detection in 4 Rounds of Colorectal Cancer Screening With the Fecal Immunochemical Test - Corrected Proof

2012-03-19

Background & Aims: Few data have been published on the performance of colorectal cancer (CRC) screens that use multiple rounds of the fecal immunochemical test (FIT). We evaluated outcomes of 4 screening rounds in over 7 years in an Italian population-based program. Methods: We conducted a prospective cohort study of 2959 average-risk subjects, aged 50–74 years, who were invited for the first screening round in 2001. We assessed the participation rate, the yield of advanced adenomas and CRC detected in the screening examinations, and we collected information about interval CRCs, with a follow-up period of 8.5 years. Results: Participation in each round varied from 56% to 63%; 48.1% of eligible subjects attended all 4 invitations. The positive predictive value of the FIT for advanced neoplasia (CRC or advanced adenoma) was 40% at the first round, and approximately 33% in the subsequent rounds. This decrease was attributable mainly to a decrease in the detection of CRC, although a high rate of advanced adenomas (range, 0.8%–1.7%) was observed over all rounds. To find one advanced neoplasia in the study period the number of people that needed to be screened was 28, and the number of tests needed was 74. Conclusions: About 60% of invited individuals participated in every single round of FIT screening for CRC, but less than 50% attended all 4 tests. A high detection rate of advanced adenomas in all rounds indicates that FIT screening could have a higher impact on incidence of CRC than the guaiac fecal occult blood test.

Aspirin Protects Against Barrett's Esophagus in a Multivariate Logistic Regression Analysis - Uncorrected Proof

2012-03-19

Background & aims: Better criteria are needed to identify patients who should be screened for Barrett's esophagus (BE) to reduce overtesting and improve the cost effectiveness. There is evidence that chemopreventive agents such as nonsteroidal anti-inflammatory drugs, particularly aspirin, reduce the risk of esophageal adenocarcinoma (EAC), but little is known about their effects on BE. We analyzed characteristics of patients with BE for factors that might be used in screening and management. Methods: In this case-controlled study, we identified 434 patients with BE diagnosed at the first endoscopy (incident cases) at a single institution (1997–2010). BE cases were matched with controls on the basis of indication for endoscopy, year of endoscopy, and endoscopist. Risk factors analyzed included age, gender, body mass index, medical and social history, and medications. We performed a multivariate logistic regression analysis to identify clinical risk factors for BE. Results: In a multivariate regression model, men had a greater risk for developing BE (odds ratio, 3.2; 95% confidence interval, 2.3–4.4), whereas current aspirin users had a lower risk than nonusers (odds ratio, 0.56; 95% confidence interval, 0.39–0.80). A subset analysis, limited to patients who had endoscopies for symptoms of gastroesophageal reflux disease, yielded similar findings. No interactions were found between aspirin use and smoking or use of acid-suppressive medications. Conclusions: In a case-controlled study of 434 patients with BE, current aspirin use appeared to reduce the risk of BE; previous studies associated aspirin use with a reduced risk of EAC. Although efforts were made to minimize biases in our analysis, the possibility of residual confounding remains.

Distribution of Body Fat and Its Influence on Esophageal Inflammation and Dysplasia in Patients With Barrett's Esophagus - Uncorrected Proof

2012-03-19

Background & Aims: Increased waist circumference and visceral fat are associated with increased risk of Barrett's esophagus (BE) and esophageal adenocarcinoma. This association might be mediated by mechanical and endocrine mechanisms. We investigated the distribution of fat in subjects with BE and its association with esophageal inflammation and dysplasia. Methods: We collected data from 50 BE cases and 50 controls (matched for age and sex, identified from a radiology trauma database) seen at the Mayo Clinic in 2009. Abdominal (subcutaneous and visceral) and gastroesophageal junction (GEJ) fat area was measured using computed tomography with standard techniques. Esophageal inflammation (based on a histologic score) and dysplasia grade were assessed from esophageal biopsies of BE cases by a gastrointestinal pathologist. Conditional logistic regression was used to assess the association of body fat depot area with BE status, esophageal inflammation, and dysplasia. Results: All BE subjects had controlled reflux symptoms without esophagitis, based on endoscopy. The GEJ fat area (odds ratio [OR], 6.0; 95% confidence interval [CI], 1.3–27.7; P = .02), visceral fat area (OR, 4.9; 95% CI, 1.0–22.8; P = .04), and abdominal circumference (OR, 9.1; 95% CI, 1.4–57.2; P = 0.02) were associated with BE, independent of body mass index (BMI). The subcutaneous fat area was not associated with BE. Visceral and GEJ fat were significantly greater in BE subjects with esophageal inflammation (compared with those without, P = .02) and high-grade dysplasia (compared with those without, P = .01), independent of BMI. Conclusions: GEJ and visceral fat are associated with BE, and with increased esophageal inflammation and high-grade dysplasia in BE subjects, independent of BMI. Visceral fat therefore might promote esophageal metaplasia and dysplasia.

Detection, Treatment, and Prevention of Clostridium difficile Infection - Corrected Proof

David L. McCollum, J. Martin Rodriguez — 2012-03-19

Clostridium difficile is a gram-positive anaerobic bacillus responsible for approximately 1 of 5 cases of antibiotic-associated diarrhea. C difficile infection (CDI) is defined by at least 3 unformed stools in a 24-hour period and stool, endoscopic, or histopathologic test results that indicate the presence of this bacteria. The history of CDI research can be divided into early (before 2000) and modern eras (after 2000). C difficile was first described in 1935, and the characteristics and causes of CDI as well as therapies were identified during the early era of research. During the modern era, CDI has become a more common, aggressive nosocomial infection. Our understanding of the epidemiology, diagnosis, treatment, and prevention of CDI has increased at a rapid pace. We review features of CDI diagnosis, treatment, and prevention.

Systematic Review: Patterns of Reflux-Induced Symptoms and Esophageal Endoscopic Findings in Large-Scale Surveys - Uncorrected Proof

John Dent, Anja Becher, Joseph Sung, Duowu Zou, Lars Agréus, Franco Bazzoli — 2012-03-09

Background & Aims: This systematic review assesses findings of endoscopic surveys in the general population with regard to gastroesophageal reflux disease (GERD). Methods: Systematic searches were conducted in PubMed and EMBASE. Authors were contacted for additional, unpublished data. Results:: Data on 61,281 individuals were included from 3 general population studies (Kalixanda study [Sweden], Loiano–Monghidoro study [Italy], SILC study [China]) and 8 health-check studies (Japan, n = 1; China, n = 1; Taiwan, n = 4; Korea, n = 2). The prevalence of reflux esophagitis was 15.5% (Kalixanda), 11.8% (Loiano–Monghidoro), and 6.4% (SILC); it ranged from 3.4% to 8.5% in health-check studies in Japan, China, and Korea (n = 4), but was higher (mean, 15.6%; range, 9.0%–24.6%; n = 4) in Taiwan. Hiatus hernia prevalence was 23.9% (Kalixanda), 43.0% (Loiano–Monghidoro), and 0.7% (SILC), and 0.8%–19.5% in health-check studies (n = 7). For endoscopically suspected esophageal metaplasia (ESEM), the prevalence was 10.3% (Kalixanda), 3.6% (Loiano–Monghidoro), and 1.8% (SILC), and 0.0%–3.4% in health-check studies (n = 4). The prevalence of reflux esophagitis among individuals without symptom-defined GERD was 12.1% (Kalixanda), 8.6% (Loiano–Monghidoro), 6.1% (SILC), and 1.6%–22.8% (health-check studies; n = 6). For individuals without symptom-defined GERD, the prevalence of ESEM was 9.4% (Kalixanda), 2.8% (Loiano–Monghidoro), and 1.8% (SILC). Conclusions: The prevalence of reflux esophagitis is higher in Sweden and Italy than in China, Korea, and Japan, but is within the range reported in Taiwan. Hiatus hernia and ESEM are generally more prevalent in Europe than in Asia. A considerable proportion of individuals without symptom-defined GERD has reflux esophagitis or ESEM.

Modestly Increased Use of Colonoscopy When Copayments Are Waived - Uncorrected Proof

2012-03-07

Background & Aims: Colorectal cancer (CRC) screening with colonoscopy often requires expensive copayments from patients. The 2010 Patient Protection and Affordable Care Act mandated elimination of copayments for CRC screening, including colonoscopy, but little is known about the effects of copayment elimination on use. The University of Texas employee, retiree, and dependent health plan instituted and promoted a waiver of copayments for screening colonoscopies in fiscal year (FY) 2009; we examined the effects of removing cost sharing on colonoscopy use. Methods: We conducted a retrospective cohort study of 59,855 beneficiaries of the University of Texas employee, retiree, and dependent health plan, associated with 16 University of Texas health and nonhealth campuses, ages 50–64 years at any point in FYs 2002–2009 (267,191 person-years of follow-up evaluation). The primary outcome was colonoscopy incidence among individuals with no prior colonoscopy. We compared the age- and sex-standardized incidence ratios for colonoscopy in FY 2009 (after the copayment waiver) with the expected incidence for FY 2009, based on secular trends from years before the waiver. Results: The annual incidence of colonoscopy increased to 9.5% after the copayment was waived, compared with an expected incidence of 8.0% (standardized incidence ratio, 1.18; 95% confidence interval, 1.14–1.23; P < .001). After adjusting for age, sex, and beneficiary status, the copayment waiver remained significantly associated with greater use of colonoscopy, with an adjusted hazard ratio of 1.19 (95% confidence interval, 1.12–1.26). Conclusions: Waiving copayments for colonoscopy screening results in a statistically significant, but modest (1.5%), increase in use. Additional strategies beyond removing financial disincentives are needed to increase use of CRC screening.

Clinicians Poorly Assess Health Literacy–Related Readiness for Transition to Adult Care in Adolescents With Inflammatory Bowel Disease - Corrected Proof

Jeannie S. Huang, Allison Tobin, Trevor Tompane — 2012-03-05

Background & Aims: To prepare for the transition from pediatric to adult-oriented health care systems, adolescents must develop the ability to obtain, process, and understand basic health information; make appropriate health decisions; and interact effectively with health care professionals. However, physicians use subjective methods to determine patients' readiness for this transition. We investigated health care literacy–related readiness for transition of children and adolescents with inflammatory bowel disease (IBD) to identify determinants and compare actual levels with clinicians' opinions. Methods: The study included 74 pediatric patients with IBD ≥10 years old who were recruited from a pediatric hospital–based clinic. We evaluated their functional and interactive health literacy and recorded clinicians' perceptions of literacy and readiness for transition among pediatric patients. Relationships between health literacy measures, demographic variables, and clinician perceptions were determined. Results: Health literacy–related readiness for transition was observed in 11% of the patients analyzed. However, clinicians found 47% of the cohort ready for the transition, on the basis of literacy standards. Health literacy–related readiness for transition was associated with older age (P < .01), white race (P = .03), and low income (P < .02). Agreement was poor between measures-defined and clinician-defined levels of health literacy–related readiness for transition (P = .18). Conclusions: Clinicians inadequately judge the health literacy–related readiness for transition to adult care of pediatric IBD patients. Improved awareness of health literacy issues among adolescents with IBD is needed among health care providers and health care systems.

Common Features of Patients With Autoimmune Atrophic Gastritis - Corrected Proof

2012-03-05

Background & Aims: Autoimmune atrophic gastritis (AIG) is characterized by immune-mediated chronic inflammation of the gastric body and fundus, leading to hypo-achlorhydria and vitamin B12 deficiency. We analyzed the clinical features of AIG and sought to identify factors that might be used in diagnosis. Methods: We collected and analyzed clinical data from 99 consecutive patients (age, 59 ± 17 y) who were diagnosed with AIG, based on histologic factors and the presence of autoantibodies against gastric parietal cells. Results: Clinical factors that led to a diagnosis of AIG included hematologic findings related to vitamin B12 deficiency (n = 37), incidental histologic evidence in gastric biopsy specimens (n = 34), immune disorders (n = 18; 9 were celiac disease), neurologic symptoms (n = 6), and a family history of AIG (n = 4). Conclusions: Based on an analysis of 99 consecutive patients with AIG, this disorder is not solely a condition of the elderly. Other features to look for in making a diagnosis of AIG include vitamin B12 deficiency, histologic factors, and immune disorders.

Association Between Volume of Endoscopic Retrograde Cholangiopancreatography at an Academic Medical Center and Use of Pancreatobiliary Therapy - Uncorrected Proof

2012-03-05

Background & Aims: Many advances have been made in pancreatobiliary imaging and endoscopy techniques. However, little is known about trends in use of endoscopic retrograde cholangiopancreatography (ERCP). Methods: We performed a retrospective cohort study that analyzed data from 33,596 ERCPs performed at Indiana University Medical Center from 1994 to 2009. Data from all patients were entered into an endoscopy database. We compared changes in patient demographics, indications for ERCP, and utilization of specific ERCP therapies during this time period. Results: The annual volume of ECRP increased steadily from 1175 in 1994 to 2802 in 2009 (P < .0001). Of all patients, 33.9% had previously undergone an ERCP at a different facility; 42.3% of these were unsuccessful. The odds of having undergone a failed ERCP at another facility increased slightly each year (odds ratio, 1.02; P < .001). Among patients who had a failed ERCP elsewhere, the success rate at Indiana University Medical Center was 96.1%. The frequency of patients with American Society of Anesthesiologists class ≥3 (odds ratio, 1.12; P < .001) who received anesthesia-administered sedation increased each year (odds ratio, 1.25; P < .001). Most ERCPs were performed for common bile duct stones or strictures and suspected sphincter of Oddi dysfunction (77.2%). The most rapid increase was among procedures for common bile duct strictures or leaks, pancreatic duct stones or strictures, and suspected sphincter of Oddi dysfunction. Rates of biliary sphincterotomy did not change (P = .252), but the frequency of pancreatic sphincterotomy, common bile duct, or pancreatic duct stent placement and pancreatic duct stricture dilation increased during this time (P < .001 for each). Conclusions: At a referral center, ERCP has become increasingly complex. From 1994 to 2009, increasing numbers of ERCPs have been performed for patients with more comorbidities, higher-grade disease, history of failed ERCPs, and on those receiving endotherapy.

Duodenal Metastasis of Cervical Adenosquamous Carcinoma - Uncorrected Proof

Imad Elkhatib, Thomas Savides, Abbas Fehmi — 2012-03-05

A 44-year-old woman presented to the emergency department with several weeks of progressive epigastric pain, nausea, and emesis. The pain was described as a deep ache in the subxiphoid region without radiation and preceded the nausea and nonbloody emesis. The patient denied abdominal distention or decreased stool output and noted a 14-pound weight loss during the past 8 weeks.

Optimal Length of Anticoagulant Therapy in Cirrhotic Patients With Portal Vein Thrombosis - Corrected Proof

Kryssia Isabel Rodríguez–Castro, Marco Senzolo, Maria Teresa Sartori — 2012-03-05

The article by Delgado et al reported on the safety and efficacy of anticoagulation in portal vein thrombosis (PVT) in a retrospective multicenter study. Despite the heterogeneity of the cohorts as a result of the inclusion of 3 patients without PVT, 4 with previous transjugular intrahepatic portosystemic shunt, recent or progressive thrombosis, and the use of different anticoagulation regimens (vitamin K antagonist and/or low-molecular-weight heparin), the authors made some important observations that, in our opinion, merit further comments. A high incidence (38%) of early thrombosis recurrence after complete PV repermeation after discontinuation of anticoagulation therapy was described. However, in the article it was not clear which was the stopping rule for anticoagulation and for how long those patients were treated. In fact, despite the median anticoagulation time of 6.2 months, there was wide variability (range, 2.2–30 mo). Moreover, it was not specified if the group of patients with rethrombosis included the 7 patients with genetic thrombophilia. Data on noncirrhotic patients with VTE showed that a duration of anticoagulation shorter than 6 months is associated with a greater incidence of recurrent thrombosis. In a prospective study from our group on the treatment of PVT in cirrhosis, we used a therapeutic dose of low-molecular-weight heparin until PV repermeation and a prophylactic dose for 6 months thereafter. After discontinuation of the therapy, among the 12 patients with complete repermeation, at 18 ± 9.6 months of follow-up evaluation, only 1 patient presented rethrombosis. Therefore, lifelong anticoagulation may be required only in those patients with underlying thrombophilic conditions, and dose variation for a period after repermeation seems efficient in preventing thrombosis recurrence.