Pathogenesis, diagnosis, and management of gastric ischemia.

BACKGROUND & AIMS: Gastric ischemia is infrequently reported in the medical literature and under-recognized clinically and histopathologically. Various medical terms are used to describe gastric ischemia. We define and review the pathogenesis, diagnosis, and management of gastric ischemia. METHODS: We describe 6 cases of gastric ischemia. We discuss features of the gastric vascular supply and review literature on this disorder. RESULTS: Gastric ischemia results from diffuse or localized vascular insufficiency caused by etiologies such as systemic hypotension, vasculitis, or disseminated thromboembolism. The disorder is managed by fluid resuscitation, nasogastric tube placement (for intermittent air and fluid aspiration, to prevent or reduce gastric distention), aggressive acid reduction (via intravenous administration of proton pump inhibitors), and selective use of broad-spectrum antibiotics for patients with sepsis or gastric pneumatosis. CONCLUSIONS: Gastric ischemia has a poor prognosis. Early diagnosis is required for appropriate patient management.

Interview from anywhere: feasibility and utility of web-based videoconference interviews in the gastroenterology fellowship selection process.

OBJECTIVES: Traditional personal interviews are subject to limitations imposed by geographic, financial, and scheduling constraints. Web-based videoconferencing (WVC) has the potential to simplify the interview process. This study was intended to evaluate the feasibility and utility of WVC using standard tablets/computers with videoconferencing capability in gastroenterology (GI) fellowship interviews. METHODS: At a single institution, 16 GI fellowship applicants participated in WVC with one interviewer, who was present at a remote location 750 miles away. In addition, each of the candidates underwent traditional interviews with four faculty members at the program site. All study interviewees used an iPad2 (Apple, iOS 5.1; Apple) with a videoconferencing application (Facetime). The interviewer (SRD) used Facetime on a MacBook Pro (Apple, Mac OS X 10.7.3). Each candidate completed a voluntary paper survey after completion of all assigned faculty interviews. RESULTS: The average age of the candidates was 30 years (range, 27-37 years). Fourteen candidates were native English speakers. Candidates expressed a high level of satisfaction, with 13 candidates (81%) stating that their WVC experience met or exceeded their expectations, and 87% of candidates stating that WVC should be an option in fellowship interviews. In addition, 25% of candidates felt that their WVC experience was equivalent to or better than their traditional interview experience on the same day. CONCLUSIONS: WVC can be an effective and useful tool in the fellowship interview process. It affords candidates increased flexibility, cost saving, convenience, and provides an option for participating in the selection process at more programs. For the programs and faculty, WVC has a potential to be an effective screening tool, can help minimize loss of clinical revenue and can also be an acceptable alternative to in-person interviews.

Gastrointestinal cancers in Mississippi.

OBJECTIVES: According to a 2007 US Census Bureau report, Mississippi is the poorest state in the United States and is ranked last among all 50 states for overall quality of health. The objective of the study was to describe gastrointestinal (GI) cancers in Mississippi overall and the Mississippi Delta region in particular. METHODS: The age-adjusted incidence rates for GI cancers for 2003-2007, compiled from the Mississippi Cancer Registry and the Centers for Disease Control and Prevention's National Program of Cancer Registries, were retrieved and compared among 18 Mississippi Delta counties, 64 non-Delta counties, the entire state of Mississippi, and the United States. Colorectal cancer incidence rates and national rankings were correlated with influencing factors of race, obesity, diabetes mellitus, education, unemployment rate, availability of health insurance and primary care physicians, physical activity, diet, and per capita income. RESULTS: Compared with the United States as a whole, Mississippi had higher rates of colon and rectal cancers and a lower overall rate of gallbladder cancers in both whites and African Americans. Of all GI cancers, only liver, intrahepatic bile duct, and gallbladder cancers had lower age-adjusted incidence rates in the Mississippi Delta region. There was a large difference between African Americans and whites in the Delta region. Whites residing in the Delta counties had higher incidence rates than African Americans of all cancers except liver and intrahepatic bile duct cancers. CONCLUSIONS: The majority of GI cancers had higher incidence rates in the Mississippi Delta than non-Delta counties and in the entire state than the United States. These disparities observed on a regional and ethnic basis call for targeted prevention efforts to eliminate disparities in GI cancer incidence rates.

Benchtop testing and comparisons among three types of through-the-scope endoscopic clipping devices.

BACKGROUND: Through-the-scope (TTS) endoscopic clipping devices are widely used. No benchtop testing or direct comparisons of these endoclips have been performed to show their rotational ability and inherent mechanical strengths during closure and after deployment. This study aimed to provide benchtop data that can be used to guide clinical applications and to promote future device research and development. METHODS: Benchtop testing and comparisons were performed for three groups of TTS clips: QuickClip2 long, resolution, and instinct clips. The main outcome measurements were device-in-endoscope retroflection angles (DIERA), opening strength, "snapping" force of acute clip closure, and neoprene pulling strength. RESULTS: The achievable gastroscope DIERA was 10° for QuickClip2, 3° for the resolution clip, and 10° for the instinct clip. The QuickClip and the Instinct clip rotated almost equally well under all endoscope configurations, including endoscopic retrograde cholangiopancreatography (ERCP). With or without a sheath, the resolution clip lacked the ability to rotate. During clip opening force testing (the amount of force required to force open the jaws of a deployed clip by 3.2 mm; 3.2 mm was chosen due to the standard dimension of the gauge used for the measurement), the Instinct clips were the strongest. For the Instinct clips, an opening force of 404 ± 124 g was needed to open the closed clip, and an additional 386 ± 133 g was required to open the clip jaws to 3.2 mm. In terms of snapping force during acute closure and neoprene pulling strength, the instinct and resolution clips performed almost equally. The limitations of the study were the benchtop testing and the finite sample size for closing and pulling strength comparisons. CONCLUSIONS: The QuickClip2 and the Instinct clip rotate equally well under different endoscope configurations. The resolution clips lack rotational ability. The instinct clips are stronger mechanically than the other two TTS clips. Stronger clips are perhaps associated with higher therapeutic efficacy and retention rates.

Novel application of GI electrical stimulation in Roux stasis syndrome (with video).

BACKGROUND: About one-third of patients undergoing a Roux-en-Y anastomosis develop Roux stasis syndrome, likely because of disordered electrical conduction. GI electrical stimulation has been previously used successfully in the management of postsurgical gastroparesis. OBJECTIVE: Endoscopic placement of temporary electrodes and GI electrical stimulation in the management of severe Roux stasis syndrome in a patient with esophagojejunostomy and to determine whether the patient would be a candidate for surgical permanent electrode placement. DESIGN: Case report. SETTING: Academic medical center. PATIENTS: This study involved a patient with Roux stasis syndrome. INTERVENTION: Upper endoscopy was performed, followed by endoscopic placement of two temporary electrodes, one each in the two jejunal limbs. Electrical stimulation was provided by an external stimulation device. The patient was re-evaluated 5 days later. MAIN OUTCOME MEASUREMENTS: Electrogastrogram (EGG) parameters including frequency, amplitude, and frequency-amplitude ratio and total symptom score and health-related quality of life score. RESULTS: There was a significant improvement in EGG parameters with electrical stimulation. Also, the patient had a marked improvement in total GI symptom score, from 11 to 4, with a dramatic improvement in the health-related quality of life score from -3 to +3. LIMITATIONS: Single case report. CONCLUSION: Endoscopic placement of temporary electrodes is feasible and safe. GI electrical stimulation of the jejunal limb is a potentially effective treatment for Roux stasis syndrome.

Video: temporary gastric electrical stimulation for gastroparesis: endoscopic placement of electrodes (ENDOstim).

BACKGROUND: Studies have shown high-frequency, low-energy gastric electrical stimulation (GES) to be an effective management strategy for patients with medication refractory gastroparesis. However, placement of a permanent GES device requires surgery and has considerable cost considerations. More importantly, however, this mode of therapy may not be successful for all patients. Patients likely to benefit from such an invasive and expensive procedure could be selected on the basis of their response to temporary GES. Electrodes for the purpose of temporary GES usually are placed percutaneously or through a percutaneous endoscopic gastrostomy (PEG) tube (PEGStim). This study demonstrated an easier and less cumbersome placement of these electrodes endoscopically [1-3]. METHODS: The current case involved a 32-year-old man with diabetic gastroparesis. The endoscopic methods and protocol were approved by the Institutional Review Board at the University of Mississippi, Jackson, Mississippi. Informed consent was obtained before the procedure. Standard upper endoscopy was performed initially. A temporary cardiac pacing lead (Model 6414-200; Medtronic, Minneapolis, MN, USA) was used as the electrode. The video demonstrates an innovative technique of endoscopic placement of electrodes for temporary GES. The external stimulation device used was the standard GES device (Enterra; Medtronic). RESULTS: Temporary GES produced a rapid and marked improvement in the patient's intractable symptoms, improvement in his health-related quality-of-life score, electrogastrography parameters, and gastric emptying. Although the temporary electrodes could have been removed easily by gentle traction in a counterclockwise direction, the patient desired that the electrodes be left in place until permanent electrode placement. CONCLUSION: For patients such as the man in the current case, who do not have a preexisting PEG tube, the authors demonstrated that endoscopic placement of electrodes is technically feasible. The reported patient likely will benefit from surgical placement of a permanent GES device. Thus, the authors propose ENDOStim as the preferred method for placement of electrodes for temporary GES.

Hypophosphatemia associated with paraproteinemia: a case report and review of the literature.

The differential diagnosis for hypophosphatemia is long, and involves complex, overlapping physiological systems. Practitioners are often guilty, however, of simply supplementing phosphate without fully investigating the etiology of the problem. The purpose of this case presentation is to illustrate a case of spurious hypophosphatemia that initially led to unnecessary phosphate replacement in a woman with undiagnosed multiple myeloma. An 85-year-old African American woman was admitted to the hospital for congestive heart failure exacerbation. The patient was incidentally found to be profoundly hypophosphatemic and was also diagnosed with multiple myeloma at this hospitalization. Normal phosphorus levels were difficult to maintain despite aggressive replacement. A serum sample initially reported to have an abnormally low phosphorus concentration on the Beckman CX7 analyzer was reanalyzed with the Kodak Ektachem 700 system, revealing the phosphorus concentration to be towards the higher limit of the normal range on the same sample. We conclude that clinicians should proceed with caution before aggressively treating abnormal phosphorus levels in patients with known paraproteinemia. Conversely, unexplained phosphorus abnormalities should bring disorders associated with paraproteinemia, such as multiple myeloma, into the differential diagnosis. Knowledge of how various phosphorus assays are affected by paraproteins is essential to guiding diagnosis and treatment. We also review mechanisms of reported interference with common assays.

Nephrogenic fibrosing dermopathy/nephrogenic systemic fibrosis: report of a new case with literature review.

Nephrogenic fibrosing dermopathy (NFD) is a fibrosing condition of the skin that is being described increasingly in patients with renal diseases, many of whom are on dialysis therapy or have undergone renal transplantation. Its etiopathology is unknown, and no standard therapy currently exists. We describe a patient with NFD for whom histopathologic studies indicated that the fibrotic process affected subcutaneous tissue, striated muscles, diaphragm, pleura, pericardium, great vessels of the heart, left ventricle and septum, and tunica albuginea in addition to the dermis. Fibroblast-like cells positive for CD34 and CD45RO and scattered CD68-positive cells were found in affected tissues. The presentation of our case is unusual in that the disease process started in the lower abdomen and upper extremities and involved the upper extremities to a greater extent than the lower extremities. Our findings indicate that the fibrosis associated with NFD can extend beyond dermis and, as part of a systemic fibrosing disorder, can involve subcutaneous tissues, striated muscles, diaphragm, pleura, pericardium, and myocardium. We therefore suggest that "nephrogenic systemic fibrosis" would be a more appropriate term for this disease entity.