Ethnic Differences in Clinical Presentations and Esophageal High-Resolution Manometry Findings in Patients with Achalasia.

BACKGROUND: Ethnic differences in achalasia presentations have scarcely been described. The association between achalasia and immunologic HLA haplotypes suggests that there may be a genetic predisposition. We aimed to evaluate differences in demographic, clinical, endoscopic, and manometric findings between two distinct ethnic groups with achalasia-Israeli Arabs (IA) and Israeli Jews (IJ). METHODS: A retrospective study was performed at two medical centers. High-resolution manometry (HRM) reports were reviewed for newly-diagnosed achalasia patients. Demographic data, clinical presentations, endoscopy reports, and HRM metrics including the integrated relaxation pressure (IRP) were all reviewed. RESULTS: Overall, 94 achalasia patients were included (53.2% male; mean age 54.5 ± 18.0). 43 patients were IA (45.7%). Body mass index (BMI) was similar in both groups. Compared to IJ, the IA patients had more esophageal dysphagia (100% vs. 88.2%; P = 0.022), chest pain (46.5% vs. 25.5%; P = 0.033), and a tortuous esophagus on endoscopy (23.3% vs. 3.9%; p = 0.005). IA patients were also diagnosed at a younger age than IJ patients (50.9 ± 17.5 vs. 57.5 ± 18.0; p = 0.039). Furthermore, IRP values were higher among IA patients than IJ patients (32.2 ± 13.8 vs. 23.3 ± 8.4; p < 0.001). A regression model analysis found that ethnicity significantly predicted IRP (ß = - 10, p < .001). CONCLUSION: Ethnicity appears to affect achalasia clinical presentation and HRM findings. IA achalasia patients are diagnosed at a younger age, present with more severe esophageal symptoms, and have a higher IRP compared to IJ patients. Additional studies of diverse, multiethnic populations, especially with genetic evaluations, are required to further assess the role of ethnicity in achalasia.

The possible association of proton pump inhibitor use with acute cholangitis in patients with choledocholithiasis: a multi-center study.

BACKGROUND: Gallstone disease is common worldwide and can lead to severe complications, including cholangitis; thus, it is important to identify modifiable risk factors for cholangitis. Proton pump inhibitors (PPIs) are commonly prescribed to treat gastroenterological disorders. We aimed to explore whether PPI use is associated with an increased risk of acute cholangitis in patients with gallstone disease. METHODS: This retrospective multicenter study included all patients arriving to the hospital over a 10-year period with various presentations of choledocholithiasis. We compared active PPI use in two groups: those with cholangitis (group A) vs. without cholangitis (group B). RESULTS: Overall, 811 patients were included, 161 in group A and 650 in group B. The average age ± standard deviation (SD) in groups A and B was 74.5 ± 20.6 vs. 61.6 ± 20.9 years, respectively. PPI use in group A was higher vs. group B (42.9% vs. 29.1%, p = 0.001). On univariate analysis, male gender (OR 1.47, 95% confidence interval (CI) 1.04-2.08), age (OR 1.04, 95% CI 1.03-1.05), ischemic heart disease (IHD) (OR 1.68, 95% CI 1.07-2.64), hyperlipidemia (OR 1.59, 95% CI 1.11-2.29), hypertension (OR 1.81, 95% CI 1.28-2.57) and PPI use (OR 1.83, 95% CI 1.28-2.61), all were associated with acute cholangitis. On multivariate analysis, only PPI use kept its association after adjustment for age (OR 1.64, 95% CI 1.2-3.7). CONCLUSIONS: Active PPI use was associated with a higher rate of cholangitis among patients with choledocholithiasis. We advocate considering this risk before prescribing PPIs to patients with gallstones. TRIAL REGISTRATION NUMBER: NHR-0263-20 received on 14/01/2021 date 'retrospectively registered'.

The yield of solid swallows in high resolution esophageal manometry among patients with dysphagia and gastro-esophageal reflux symptoms.

BACKGROUND: Swallowing disorders are frequently reported esophageal symptoms and represent a common cause for referrals to gastroenterology consultations. Esophageal high-resolution manometry (HRM) is considered the gold standard modality for the evaluation of esophageal peristalsis and esophageal sphincter. The standard protocol of HRM includes water swallows only, that may not assess appropriately esophageal function and symptoms. Hence, we investigated the diagnostic yield of combining solid food swallows (SFS) to standard HRM. METHODS: We conducted a retrospective study at the Gastroenterology unit of EMMS Nazareth Hospital, Israel. Patients who underwent manometry mainly due to dysphagia or reflux symptoms between November 2019 and November 2020 were enrolled. All patients underwent routine HRM and completed ten 5 ml water swallows and 5 bread swallows. Analysis and reports were done by an expert gastroenterologist, based on the Chicago Classification version 3. RESULTS: Overall, 99 patients (45.5% men, mean age 52.1±16 years) who underwent HRM were included. The addition of solid swallows to the test changed manometry results in 43 patients (43.4%) (P<0.005). Furthermore, SFS improved the contractility in 26/42 cases of ineffective and/or absent motility (61%) (P< 0.005). Finally, SFS aggravated symptoms in 44 patients (44.6% more aggravation than in liquid only) (P<0.005). CONCLUSIONS: Combining SFS to HRM can improve the diagnostic yield of the study. Adding solid swallows is of special value in cases of ineffective esophageal motility but induces a high rate of symptoms aggravation.

The Yield of Endoscopy and Histology in the Evaluation of Esophageal Dysphagia: Two Referral Centers' Experiences.

Background and Objectives: The initial diagnostic test required to evaluate esophageal dysphagia is upper endoscopy (EGD) to assess the structure of the esophagus and the esophageo-gastric junction (EGJ). Taking biopsies during EGD has become a common practice in patients with dysphagia to rule out eosinophilic esophagitis (EoE). The aims of this study were to evaluate the endoscopic findings of patients who underwent EGD for esophageal dysphagia, to assess the rate of biopsy taking from the esophagus to diagnose/exclude EoE, and to report histology outcomes of these biopsies. Materials and Methods: This was a retrospective multicenter study that included individuals ≥18 years who underwent EGD due to esophageal dysphagia between the years 2015 and2020, (with no other alarm signs, such as weight loss, new iron deficiency anemia, and lymphadenopathy). We obtained data from patients' electronic files. The endoscopy and histology findings were obtained from endoscopy reports saved in our electronic files. Results: A total of 209 patients were included in the study. The average age was 57.1 ± 17.1 years. The most common endoscopic findings were normal endoscopy in 76 patients (36.4%) and erosive esophagitis in 75 patients (35.9%). Barrett's esophagus and esophageal malignancy were encountered in 11 patients (5.3%) and 2 patients (0.95%), respectively. Esophageal biopsies were taken in 50.2% of patients, and one patient had histological evidence of EoE (0.5%). On univariate analysis, there was a trend for association between proton pump inhibitors (PPIs) use and a normal EGD, but it was not statistically significant (OR 0.28, 95% CI 0.07-1.11, p = 0.07). Conclusions: Endoscopic findings were prevalent in dysphagia patients even when no other alarm symptoms exist. Neoplastic lesions and EOE were rare in our study.

Predictors of in-hospital mortality among patients with clostridium difficile infection: a multicenter study.

BACKGROUND: Clostridium difficile infection (CDI)-associated mortality is a major global health concern. Several clinical and laboratory parameters have been linked to poor prognosis in patients with CDI. In the current study, we aimed to assess the rate of in-hospital mortality among Israeli CDI patients and to look for clinical and laboratory parameters associated to death. METHODS: We performed a multicenter retrospective study enrolling all patients above 18-years old who were hospitalized for CDI or with diagnosis made during hospitalization in two regional, teaching hospitals in the north of Israel (Galilee Medical Center, Nahariya and the Nazareth Hospital, Nazareth, Israel), from January 1, 2015 until January 1, 2020. All files of eligible patients were reviewed for demographic (age, gender), medical history and laboratory tests. RESULTS: Overall, we included in the study 180 patients, among them 56 died in hospital due to CDI (group A) while 124 survived (group B). The average age in groups A and B was 77.02±13 vs. 71.5±19.1, respectively. On univariate analysis, several clinical and laboratory parameters were associated with in-hospital mortality, including: advanced age, renal failure, antibiotics treatment while on treatment for CDI, need for mechanical ventilation, level of hemoglobin, white blood cells (WBC) and neutrophils count, neutrophil/lymphocyte ratio, serum level of albumin, creatinine and C reactive protein. On multivariate logistic regression analysis, only 4 parameters showed statistically significant association with in-hospital mortality, including age (odds ratio [OR]: 6.97, 95%confidence interval [CI]: 4.94-8.72, P=0.003), renal failure (OR: 3.72, 95% CI: 1.22-11.24, P=0.02), WBC count (OR: 1.09, 95% CI: 1.02-1.16, P=0.008), and lower albumin level (OR: 47.62, 95% CI: 10.31-200, P<0.0001). CONCLUSIONS: In this retrospective, multicenter study, age, serum albumin level, leucocytes count, and renal failure were the main predictors of in-hospital mortality in patients with CDI. Thus, antibiotic use should be weighed carefully in elderly comorbid patients, at increased risk of mortality from CDI .Prospective multicenter randomized studies investigating the effect of albumin infusion on in-hospital death of CDI patients are needed, thus enabling us to direct monitoring and treatment accordingly.

The association between non-alcoholic fatty liver disease and valvular heart disease.

BACKGROUND: Non-alcoholic fatty liver (NAFLD) disease has become the commonest cause of end-stage liver disease. Patients with NAFLD have an increased risk of associated extrahepatic conditions, including structural and functional cardiovascular disease. Still, it is unknown if there is an association between NAFLD and valvular heart disease (VHD). The aim of this paper was to determine the association between NAFLD and VHD. METHODS: We performed a single center retrospective study in EMMS Nazareth Hospital from April 2010 to April 2018. All patients who were diagnosed with NAFLD and who had an echocardiography performed within one year were included. Subjects age and sex-matched, who had echocardiography performed in the same period were included in the control group. RESULTS: The mean age of the NAFLD group was 41.5±11.7 vs. 42.8±10.8 years of the control group (P=0.2). The prevalence of aortic stenosis, aortic insufficiency, mitral stenosis and mitral insufficiency were significantly higher in NAFLD patients compared to the control group (1.2% vs. 0.22%, 1.32% vs. 0.32%, 0.66% vs. 0.27%, and 1.87% vs. 0.41%, respectively; P<0.001). In the multivariate logistic regression analysis, NAFLD was found to be independent risk factor for VHD (OR 2.39, 95% CI 2.17-2.78, P<0.001). CONCLUSIONS: VHD was significantly seen more frequently in NAFLD patients compared to controls. Prospective studies are needed to validate our findings and to elucidate the pathogenesis of VHD in patients with NAFLD.

Non-alcoholic fatty liver disease: a survey of involvement of primary care physicians.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are neglected in most patients' electrical medical report by their family physicians (FP). We have assessed whether family physicians have the proper knowledge of NAFLD and accurate training to diagnose and treat NAFLD/NASH in overweight and obese patients. METHODS: We conducted an anonymous survey questionnaire. Family Physicians who participated completed 4 years of residency and have passed the final examination. Our survey contained questions to measure the physician's attitudes, source of knowledge and recommendation regarding NAFLD/NASH treatment and attitudes toward patients with NAFLD/NASH. Categorical variables were extracted and analyzed using SPSS. RESULTS: A total of 310 of 422 FPs were included in the study with a compliance rate of 73%. Our data suggests that 167 of the 310 FPs (55%) refer their patients to a specialist for consultations if they exhibited fatty liver disease. Yet, 284 of 310 send their patients to consolations if exhibiting elevated liver enzyme. Our data significantly suggests that 241 of 310 (78%) reported that they have limited efficacy in treating NAFLD/NASH and consider themselves not properly prepared, by medical schools, to treat NASH/NAFLD patients; as well as patients with obesity and metabolic syndrome without fatty liver. CONCLUSIONS: FPs are more likely to neglect proper treatment for NAFLD/NASH due to lack of proper knowledge and are more likely neglect referring patients to specialist. Patients with significant obesity and obesity related conditions are more likely to have proactive treatment plans by their FPs.