Decreasing Rates of Fracture-Related Hospitalization With Primary Biliary Cholangitis: Insights From the Nationwide Inpatient Sample.

Introduction Primary biliary cholangitis (PBC) is associated with an increased risk of developing fractures. Current guidelines recommend measures that can help prevent the development of fractures in these patients. The purpose of this study was to trend the rates of hospitalizations related to fractures and their burden on healthcare. Methods We performed a retrospective, cohort study of adults hospitalized in the United States with PBC between 2010 and 2014. Patients were identified using the Nationwide Inpatient Sample (NIS). Temporal analysis of PBC patients with a co-diagnosis of hip, vertebral, or wrist fractures (the study group) was performed with regards to the total number of inpatient admissions, inpatient mortality, length of stay, and total charges associated with hospitalization. Descriptive analyses were performed using the t-test for continuous data and the chi-square test for categorical data. Results During the five-year study period, there were 308,753 hospitalizations for PBC. There has been a downward trend (p=0.02) in fracture-related admissions among patients with PBC during this study period. Length of stay was higher in the PBC-fracture group (10.85 days vs 7.36 days; p<0.001). Total hospitalization charges were higher among the PBC-fracture patients when compared to the control group ($98,444 vs $72,964; p=0.004). Conclusion There has been a gradual reduction in the rate of fracture-related hospitalizations in patients with PBC. However, patients with PBC who have fractures have increased the utilization of health care resources as compared to their cohort admitted for reasons other than for a fracture.

Hemophagocytic Lymphohistiocytosis Masquerading as Alcoholic Hepatitis.

Hemophagocytic lymphohistiocytosis is a syndrome characterized by excessive immune activation. Timely diagnosis can be challenging, and prompt treatment is the only hope for survival. We present an adult patient with a history of alcohol dependence, who presented with fatigue, bilateral lower extremity edema, and orange-colored urine. Clinical workup revealed abnormal liver function tests, elevated ferritin, cytopenia, and lymphadenopathy. Eventually, he was diagnosed with hemophagocytic lymphohistiocytosis. This case report encourages gastroenterologists to maintain a high index of suspicion when a patient presents with liver failure, hyperferritinemia, and cytopenia because they may be the first healthcare professionals to evaluate these patients.

Immediate dilation in esophageal food impaction is safe and effective but performed infrequently: observations from a large Midwest US cohort.

This study aimed to determine the rate and safety of immediate esophageal dilation for esophageal food bolus impaction (EFBI) and evaluate its impact on early recurrence (i.e. prior to interval esophageal dilation) from a large Midwest US cohort. We also report practice patterns among community and academic gastroenterologists practicing in similar settings. We identified adult patients with a primary discharge diagnosis for EFBI from January 2012 to June 2018 using our institutional database. Pregnant patients, incarcerated patients, and patients with esophageal neoplasm were excluded. The primary outcome measured was rate of complications with immediate esophageal dilation after disimpaction of EFBI. Secondary outcomes were recurrence of food bolus impaction prior to scheduled interval endoscopy for dilation, practice patterns between academic and private gastroenterologists, and adherence to follow-up endoscopy. Two-hundred and fifty-six patients met our inclusion criteria. Esophageal dilation was performed in 46 patients (18%) at the time of disimpaction. A total of 45 gastroenterologists performed endoscopies for EFBI in our cohort. Twenty-five (62%) did not perform immediate esophageal dilation, and only 5 (11%) performed immediate dilation on greater than 50% of cases. Academic gastroenterologists performed disimpaction of EFBI for 102 patients, immediate dilation as performed in 20 patients and interval dilation was recommended in 82 patients. Of these 82, only 31 patients (38%) did not return for interval dilation. Four patients who did not undergo immediate dilation, presented with recurrent EFBI prior to interval dilation, within 3 months. None of the patients had complications. Complications with immediate esophageal dilation after disimpaction of EFBI are infrequent but are rarely performed. Failure of immediate dilation increases the risk of EFBI recurrence. Given poor patient adherence to interval dilation, immediate dilation is recommended.

Trends and Outcomes of Hospitalizations Related to Acute Pancreatitis: Epidemiology From 2001 to 2014 in the United States.

OBJECTIVES: The aim of this study was to determine the recent trends of the rates of hospitalization, mortality of hospitalized patients, and associated health care utilization in patients with acute pancreatitis (AP). METHODS: We identified adult patients with primary discharge diagnosis of AP from the National Inpatient Sample database. Patients with chronic pancreatitis and/or pancreatic cancer were excluded. Primary outcomes included age-adjusted incidence of AP and in-hospital mortality based on US standard population derived from the 2000 census data. Secondary outcomes were length of stay, inflation-adjusted hospital costs in 2014 US dollars, and procedural rates. Subgroup analysis included disease etiologies, age, race, sex, hospital region, hospital size, and institution type. RESULTS: From 2001 to 2014, the rate of primary discharge diagnosis for AP increased from 65.38 to 81.88 per 100,000 US adults per year. In-hospital case fatality decreased from 1.68% to 0.69%. Mortality rate is higher in patients with AP who are older than 65 years (3.4%). Length of stay decreased, with a median of 3.8 days; cost per hospitalization decreased since 2007 from $7602 to $6766 in 2014. CONCLUSIONS: The rate of hospitalization related to AP in the United States continues to increase. Mortality, length of stay, and cost per hospitalization decrease. The increase in volume of hospitalization might contribute to an overall increase in health care resource utilization.

Immunopathological and molecular basis of functional dyspepsia and current therapeutic approaches.

INTRODUCTION: Functional dyspepsia (FD) is widespread with 20% prevalence worldwide and a significant economic burden due to health care cost and constraints on daily activities of patients. Despite extensive investigation, the underlying causes of dyspepsia in a majority of patients remain unknown. Common complaints include abdominal discomfort, pain, burning, nausea, early satiety, and bloating. Motor dysfunction of the gut was long considered a major cause, but recent investigations suggest immune-based pathophysiological and molecular events in the duodenum are more probable contributing factors. Areas Covered: Inflammatory mediators and immune cells including duodenal eosinophils, intraepithelial lymphocytes, and T-cells have been implicated in the underlying cause of disease process, as have genetic factors. In this article, we critically reviewed findings, identified gaps in knowledge and suggested future directions for further investigation to identify targets and develop better therapeutic approaches. Expert commentary: Impaired gastric accommodation, slow gastric emptying, and increased visceral sensitivity have long been thought of as main causal factors of FD. However, more recent identification of eosinophilic degranulation and recruitment of T cells that induce mild duodenal inflammation are giving rise to new insights into immune-mediated pathophysiology. These insights offer promising avenues to explore for immune-mediated therapy in the future.

Coexisting Granular Cell Tumor and Tubular Adenoma of the Ileocecal Valve.

Granular cell tumors (GCTs) have been described as neoplasms of Schwann cell origin. They are often benign and notably uncommon in the gastrointestinal tract. Recently, their incidence has become more common, likely as a result of increased colonoscopy screenings. Very few data exist regarding their potential for malignancy, but malignant GCTs have been reported. Here, we report the case of a young female patient who was diagnosed with an atypical GCT on the ileocecal valve with an overlying tubular adenoma which was found incidentally on colonoscopy. This represents the first known report of a GCT with atypical features on the ileocecal valve, as well as a rare case of overlying adenomatous changes. Due to the paucity of cases, there is no clear modus operandi for their management. Furthermore, it is not clear whether surgical or endoscopic interventions or simple observation may be most appropriate. Further studies are needed to evaluate the potential for malignancy of this tumor, as well as its management.

Acute necrotising pancreatitis: a late and fatal complication of pancreaticoduodenal arterial embolisation.

A 70-year-old man was diagnosed with a massive bleeding duodenal ulcer which was refractory to emergency endoscopic management. Angiogram of the coeliac and superior mesenteric arteries revealed bleeding from the superior and inferior pancreaticoduodenal arteries. Transcatheter arterial embolisation of superior and inferior pancreaticoduodenal arteries along with the gastroduodenal artery was performed. Two weeks later he developed severe necrotising pancreatitis of the pancreatic head probably due to ischaemia, which was managed conservatively. Three months later the patient experienced another episode of pancreatitis which progressed into multiorgan dysfunction and the patient passed away.

Acute appendicitis: a potential complication of video capsule endoscopy.

A 69-year-old man presented to our emergency room with malena and symptoms suggestive of anaemia. He was on chronic anticoagulation with warfarin for a mechanical aortic valve. He was haemodynamically stable. Laboratory investigations revealed a low haemoglobin level of 7.1 g/dL and a low-ferritin level of 6 ng/dL suggesting chronic gastrointestinal bleeding. Oesophagogastroduodenoscopy and colonoscopy were performed to identify the source of bleeding but were unfruitful. Video capsule endoscopy was performed. Fifteen hours after ingesting the capsule endoscope, the patient started having severe abdominal pain, nausea and vomiting. Abdominal X-ray did not show any bowel perforation. CT of the abdomen revealed impaction of the capsule endoscope at the appendiceal orifice and an inflamed appendix. The patient underwent laparoscopic appendectomy and made a good recovery.

Incidence of pancreatic fistula after distal pancreatectomy and efficacy of endoscopic therapy for its management: results from a tertiary care center.

Pancreatic fistula is a known complication of distal pancreatectomy. Endotherapy with pancreatic duct stent placement and pancreatic sphincterotomy has been shown to be effective in its management; however, experience of endotherapy in the management of this complication has not been extensively reported from the United States. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic stent placement has also been proposed to prevent this complication after distal pancreatectomy. In our cohort of 59 patients who underwent distal pancreatectomy, 13 (22%) developed a pancreatic fistula in the immediate postoperative period, of whom 8 (14%) patients (5 female, mean age 52 years) were referred for an ERCP because of ongoing symptoms related to the pancreatic fistula. The pancreatic fistula resolved in all patients after a median duration of 62 days from the index ERCP. The median number of ERCPs required to document resolution of the pancreatic fistula was 2. Although a sizeable percentage of patients develop a pancreatic fistula after distal pancreatectomy, only a small percentage of patients require ERCP for management of this complication. Given the high success rate of endotherapy in resolving pancreatic fistula and the fact that the majority of patients who undergo distal pancreatectomy never require an ERCP, performing ERCP for prophylactic pancreatic duct stent prior to distal pancreatectomy might not be necessary.

Are endoscopic ultrasonography imaging characteristics reliable for the diagnosis of small upper gastrointestinal subepithelial lesions?

PURPOSE OF THE STUDY: To compare the accuracy of endoscopic ultrasonography (EUS) imaging with histopathology in the diagnosis of upper gastrointestinal subepithelial lesions. METHODS: Thirty-seven patients (21 female; mean age: 55 y) underwent endoscopic submucosal resection (ESMR) of upper gastro intestinal subepithelial lesions at a tertiary care facility. All patients underwent EUS before ESMR of the lesion. Information regarding location, size, echogenecity, layer of origin, presumptive diagnosis based on EUS imaging, and histopathology diagnosis after ESMR of the subepithelial lesion was recorded. RESULTS: Twenty-seven subepithelial lesions were resected from the stomach, 5 from the esophagus, and 5 from the duodenum. The mean size of the lesions was 9 mm (range, 6-18 mm). Thirty-six lesions originated from the submucosa, and 1 from the muscularis propria. Using histopathology as the gold standard, the overall diagnostic accuracy of EUS imaging was 49% (18 out of 37). The accuracy of EUS imaging for the diagnosis of esophageal, gastric, and duodenal subepithelial lesions was 20%, 56%, and 40%, respectively. One patient developed a microperforation, and 1 developed bleeding during the ESMR procedure. No complications were reported with the EUS procedure. CONCLUSIONS: The diagnostic accuracy of EUS imaging is inferior to histopathology in the diagnosis of small upper gastrointestinal subepithelial lesions. Endoluminal resection is a relatively safe and noninvasive modality that not only provides tissue sample for accurate diagnostic interpretation, but also aids in the complete removal of small subepithelial lesions of the upper gastrointestinal tract.

Pancreatic leak after endoscopic ultrasound guided fine needle aspiration managed by transpapillary pancreatic duct stenting.

CONTEXT: Endoscopic ultrasonography guided fine needle aspiration (EUS-FNA) is a front line test used for the diagnosis of solid as well as cystic lesions of the pancreas. This procedure is fairly well tolerated and associated with minimal complications. Local complications such as perforation and pancreatitis have been reported with EUS-FNA, albeit rarely. Although pancreatic duct injury can occur during EUS-FNA, symptomatic pancreatic duct leak as a complication of this procedure has never been reported. CASE REPORT: We present a 67-year-old patient who developed symptomatic ascites after EUS-FNA of a pancreatic neck lesion that required several paracenteses. Analysis of the ascitic fluid revealed that the fluid amylase and lipase levels were very high consistent with pancreatic ascites. An endoscopic retrograde pancreatography was subsequently performed that documented the presence of a pancreatic duct leak in the neck. The pancreatic duct leak and the ascites resolved after placing a pancreatic duct stent. CONCLUSION: A clinically significant pancreatic leak can occur as a rare complication of EUS-FNA that can be effectively managed by endoscopic retrograde pancreatography and placement of a transpapillary pancreatic duct stent.

Mediastinal schwannoma diagnosed by endoscopic ultrasonography-guided fine needle aspiration cytology.

Schwannoma is the most common neurogenic tumor that is derived from the peripheral nerve sheath. There are no specific serologic markers or characteristic imaging abnormalities associated with schwannoma. Tissue diagnosis and immunohistochemistry are required to diagnose this lesion. We describe a 65-year-old male with a finding of three mass lesions in the superior and middle mediastinum on computed tomography of the chest. The largest lesion measured 4.6 × 5 cm. The patient subsequently underwent endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) of the lesion and cytology was consistent with spindle cell neoplasm. Immunohistochemical staining of the cytologic specimen was positive for S-100 and negative for pan-cytokeratin, CD34, CD117, calcitonin, smooth muscle actin and desmin. These findings were consistent with schwannoma. This is the second reported case of a mediastinal schwannoma diagnosed by EUS-FNA.

A prospective, single-blind, randomized, controlled trial of EUS-guided FNA with and without a stylet.

BACKGROUND: Most endosonographers use an EUS needle with an internal stylet during EUS-guided FNA (EUS-FNA). Reinserting the stylet into the needle after every pass is tedious and time-consuming, and there are no data to suggest that it improves the quality of the cytology specimen. OBJECTIVE: To compare the samples obtained by EUS-FNA with and without a stylet for (1) the degree of cellularity, adequacy, contamination, and amount of blood and (2) the diagnostic yield of malignancy. DESIGN: Prospective,single-blind, randomized, controlled trial. SETTING: Two tertiary care referral centers. PATIENTS: Patients referred for EUS-FNA of solid lesions. INTERVENTION: Patients underwent EUS-FNA of the solid lesions, and 2 passes each were made with a stylet and without a stylet in the needle. The order of the passes was randomized, and the cytopathologists reviewing the slides were blinded to the stylet status of passes. MAIN OUTCOME MEASUREMENTS: Degree of cellularity, adequacy, contamination, amount of blood, and the diagnostic yield of malignancy in the specimens. RESULTS: A total of 101 patients with 118 lesions were included in final analysis; 236 FNA passes were made, each with and without a stylet. No significant differences were seen in the cellularity (P = .98), adequacy of the specimen (P = .26), contamination (P = .92), or significant amount of blood (P = .61) between specimens obtained with and without a stylet. The diagnostic yield of malignancy was 55 of 236 specimens (23%) in the with-stylet group compared with 66 of 236 specimens (28%) in the without-stylet group (P = .29). LIMITATIONS: Endosonographers were not blinded to the stylet status of the passes. CONCLUSIONS: Using a stylet during EUS-FNA does not confer any significant advantage with regard to the quality of the specimen obtained or the diagnostic yield of malignancy. ( CLINICAL TRIAL REGISTRATION NUMBER: NCT 01213290).

Pancreato-biliary malignancy diagnosed by endoscopic ultrasonography in absence of a mass lesion on transabdominal imaging: prevalence and predictors.

BACKGROUND AND AIMS: Pancreatic adenocarcinoma is the fourth leading cause of cancer-related death in the United States. Pancreatic cancer is diagnosed in some patients by endoscopic ultrasonography (EUS) even in the absence of an obvious mass lesion on transabdominal imaging studies. The purpose of this study was to estimate the prevalence of PBM on EUS-FNA in patients with no obvious mass on transabdominal imaging and identify possible predictors of PBM in this cohort of patients. METHODS: Three hundred and twenty-six patients (219 female; mean age: 57) with no obvious neoplastic lesion on trans-abdominal imaging underwent EUS. Demographic data, indication of EUS, history of weight loss, smoking, alcohol use, diabetes, cholecystectomy status, CT and USG findings, and liver function tests (LFTs) were reviewed. RESULTS: Thirty patients (9%) were diagnosed with a PBM by EUS-FNA (27 pancreatic adenocarcinoma, three ampullary adenocarcinoma). The mean age of patients diagnosed with PBM was significantly (P < 0.01) higher than controls. The mean size of the tumor was 2.8 cm (range: 0.9-7 cm). Male gender, presence of jaundice, abnormal LFTs, weight loss, and nonspecific trans-abdominal imaging results such as dilated common bile duct (CBD), and abnormal appearing pancreas predicted the presence (P < 0.05) of PBM, whereas patients with previous cholecystectomy and abdominal pain were less likely to have this diagnosis. CONCLUSIONS: Normal trans-abdominal imaging does not completely exclude the presence of PBM. Nonspecific pancreatic abnormalities and CBD dilation on trans-abdominal imaging, with jaundice, abnormal LFTs, weight loss, and lack of abdominal pain are predictors of PBM.

Patients with nondysplastic Barrett's esophagus have low risks for developing dysplasia or esophageal adenocarcinoma.

BACKGROUND & AIMS: The risks of dysplasia and esophageal adenocarcinoma (EAC) are not clear for patients with nondysplastic Barrett's esophagus (NDBE); the rate of progression has been overestimated in previous studies. We studied the incidences of dysplasia and EAC and investigated factors associated with progression of BE. METHODS: The BE study is a multicenter outcomes project of a large cohort of patients with BE. Neoplasia was graded as low-grade dysplasia, high-grade dysplasia (HGD), or EAC. Patients followed up for at least 1 year after the index endoscopy examination were included, whereas those diagnosed with dysplasia and EAC within 1 year of diagnosis with BE (prevalent cases) were excluded. Of 3334 patients with BE, 1204 met the inclusion criteria (93.7% Caucasian; 88% male; mean age, 59.3 y) and were followed up for a mean of 5.52 years (6644.5 patient-years). RESULTS: Eighteen patients developed EAC (incidence, 0.27%/y; 95% confidence interval [CI], 0.17-0.43) and 32 developed HGD (incidence, 0.48%/y; 95% CI, 0.34-0.68). The incidence of HGD and EAC was 0.63%/y (95% CI, 0.47-0.86). There were 217 cases of low-grade dysplasia (incidence, 3.6%/y; 95% CI, 3.2-4.1). Five and 10 years after diagnosis, 98.6% (n = 540) and 97.1% (n = 155) of patients with NDBE were cancer free, respectively. The length of the BE was associated significantly with progression (EAC <6 cm, 0.09%/y vs EAC ≥ 6 cm, 0.65%/y; P = 0.001). CONCLUSIONS: There is a lower incidence of dysplasia and EAC among patients with NDBE than previously reported. Because most patients are cancer free after a long-term follow-up period, surveillance intervals might be lengthened, especially for patients with shorter segments of BE.

Small intestinal bacterial overgrowth in irritable bowel syndrome: are there any predictors?

BACKGROUND: Small intestinal bacterial overgrowth (SIBO) is a condition in which excessive levels of bacteria, mainly the colonic-type species are present in the small intestine. Recent data suggest that SIBO may contribute to the pathophysiology of Irritable bowel syndrome (IBS). The purpose of this study was to identify potential predictors of SIBO in patients with IBS. METHODS: Adults with IBS based on Rome II criteria who had predominance of bloating and flatulence underwent a glucose breath test (GBT) to determine the presence of SIBO. Breath samples were obtained at baseline and at 30, 45, 60, 75 and 90 minutes after ingestion of 50 g of glucose dissolved in 150 mL of water. Results of the glucose breath test, which measures hydrogen and methane levels in the breath, were considered positive for SIBO if 1) the hydrogen or methane peak was >20 ppm when the baseline was <10 ppm, or 2) the hydrogen or methane peak increased by 12 ppm when baseline was >or=10 ppm. RESULTS: Ninety-eight patients were identified who underwent a GBT (mean age, 49 y; 78% female). Thirty-five patients (36%) had a positive GBT result suggestive of SIBO. A positive GBT result was more likely in patients >55 years of age (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.4-9.0) and in females (OR, 4.0; 95% CI, 1.1-14.5). Hydrogen was detected more frequently in patients with diarrhea-predominant IBS (OR, 8; 95% CI, 1.4-45), and methane was the main gas detected in patients with constipation-predominant IBS (OR, 8; 95% CI, 1.3-44). There was no significant correlation between the presence of SIBO and the predominant bowel pattern or concurrent use of tegaserod, proton pump inhibitors, or opiate analgesics. CONCLUSIONS: Small intestinal bacterial overgrowth was present in a sizeable percentage of patients with IBS with predominance of bloating and flatulence. Older age and female sex were predictors of SIBO in patients with IBS. Identification of possible predictors of SIBO in patients with IBS could aid in the development of successful treatment plans.

Disturbances of esophageal motility in eosinophilic esophagitis: a case series.

Esophageal manometry (EM) findings were reviewed in 14 (13 male) adults diagnosed with eosinophilic esophagitis (EE). One had complete nonperistaltic contractions (amplitude range = 30-180 mmHg) and incomplete relaxation of the lower esophageal sphincter (LES), suggesting vigorous achalasia. After 6 months of steroid therapy the repeat EM showed near-normal findings. One had total aperistalsis with contraction amplitudes less than 10 mmHg and a weak LES pressure (8 mmHg), criteria suggesting scleroderma. Two had low-amplitude (<30 mmHg) nonperistaltic contractions limited to the mid-esophagus. Criteria for nutcracker esophagus were met in two patients. Isolated low LES pressure (<15 mmHg) was observed in four patients who were also receiving proton pump inhibitors, and the remainder had normal EM findings. Our results found that EE can mimic all the categories of EM disturbances, with approximately 50% of our patients having a major impairment of smooth muscle function. The EM abnormality can be reversed to normal in some cases with appropriate treatment for EE.