Practice Trends among US Gastroenterologists following the 2020 American Gastroenterological Association Guidelines on Gastric Intestinal Metaplasia: Data from a Tertiary Care Center.

BACKGROUND AND AIMS: Studies show variability in gastroenterologists' management of gastric intestinal metaplasia (GIM) in the United States. In 2020, the American Gastroenterological Association published GIM guidelines, recommending physician-patient shared decision-making on GIM surveillance based on risk factors. We compared gastroenterologists' communication trends of a GIM finding and surveillance recommendations before and after 2020 and evaluated patient and provider factors associated with a surveillance recommendation. METHODS: A sample of patients diagnosed with GIM on biopsies from upper endoscopies performed in 2018 (cohort A) and 2021 (cohort B) were included. Logistic regression analysis assessed the association between patient/provider characteristics and surveillance recommendations in the overall cohort and over time. MATERIALS: In all, 347 patients were included: 175 in cohort A and 172 in B. Median age was 65.7 (56.0, 73.4), and 54.5% were females. Communication to patients about GIM findings and surveillance recommendations increased from 24.6% <2020 to 50% >2020 (P<0.001) and 20% <2020 to 41.3% >2020 (P<0.001), respectively. Overall, endoscopy >2020, family history of gastric cancer, autoimmune gastritis, female providers, and gastroenterologists with 10 to 20 years of experience were associated with a surveillance recommendation. The effect of family history of gastric cancer and the effect of the patient's female sex on surveillance was significantly different between both cohorts [Odds ratio (OR): 0.13, 95% (Confidence interval) CI: 0.02, 0.97 and OR 3.39, 95% CI: 1.12, 10.2, respectively). CONCLUSIONS: Despite a 2-fold increase in surveillance recommendations after 2020, there was no meaningful effect of any of the patients' factors on a recommendation for surveillance over time, which raises the question as to whether surveillance is being offered to both average and high-risk patients without thorough risk stratification.

Comparative Effectiveness of Virtual Versus In-person Visits for Abdominal Pain During the COVID-19 Pandemic.

BACKGROUND AND AIMS: The COVID-19 pandemic has highlighted the importance of telemedicine in improving healthcare access and reducing costs. This study aimed to assess order compliance in the virtual versus in-person setting for the initial evaluation of abdominal pain (AP) prior to and during the pandemic. METHODS: A retrospective evaluation of virtual and in-person outpatient gastroenterology visits for AP were identified through natural language processing from January 2019 through September 2021 at the Cleveland Clinic main campus and regional hospitals in Ohio. We assessed the number and type of orders placed for patients and measured compliance through order completion. This study received Institutional Review Board approval (IRB 21-514). RESULTS: Among 20,356 patients at their initial visit, 79% had orders placed, of which 40% had pandemic in-person visits, 13% had pandemic virtual visits, and 47% had pre-pandemic in-person visits. Patients seen virtually were 65.1% less likely to complete orders compared to patients seen in-person (p < 0.001) during the pandemic. Patients seen in a pandemic virtual setting were 71.0% less likely to complete imaging orders (p < 0.001), 82.6% less likely to complete procedure orders (p < 0.001), and 60.5% less likely to complete lab orders (p < 0.001). CONCLUSION: Compared with in-person visits, patients seen virtually for their first presentation of AP were less likely to complete labs, imaging, and endoscopic evaluations. In-person visits were more successful with patient order completion during the pandemic. These findings highlight that virtual visits for AP, despite convenience, may compromise care delivery and warrant additional care coordination to achieve compliance with medical recommendations.

Challenges in and Opportunities for Electronic Health Record-Based Data Analysis and Interpretation.

Electronic health records (EHRs) have been increasingly adopted in clinical practices across the United States, providing a primary source of data for clinical research, particularly observational cohort studies. EHRs are a high-yield, low-maintenance source of longitudinal real-world data for large patient populations and provide a wealth of information and clinical contexts that are useful for clinical research and translation into practice. Despite these strengths, it is important to recognize the multiple limitations and challenges related to the use of EHR data in clinical research. Missing data are a major source of error and biases and can affect the representativeness of the cohort of interest, as well as the accuracy of the outcomes and exposures. Here, we aim to provide a critical understanding of the types of data available in EHRs and describe the impact of data heterogeneity, quality, and generalizability, which should be evaluated prior to and during the analysis of EHR data. We also identify challenges pertaining to data quality, including errors and biases, and examine potential sources of such biases and errors. Finally, we discuss approaches to mitigate and remediate these limitations. A proactive approach to addressing these issues can help ensure the integrity and quality of EHR data and the appropriateness of their use in clinical studies.

Accuracy of ChatGPT in Common Gastrointestinal Diseases: Impact for Patients and Providers.

Since its release in 2022, Chat Generative Pre-Trained Transformer (ChatGPT) became the most rapidly expanding consumer software application in history,1 and its role in medicine is underscored by its potential to enhance patient education and physician-patient communication. Previous studies in gastroenterology and hepatology have focused primarily on the earlier Generative Pre-Trained Transformer 3 (GPT-3) model, with none investigating ChatGPT's ability to generate supportive references for its responses, or its applicability as a physician educational tool.2-6 Our study evaluated the accuracy of the more recent ChatGPT, powered by GPT-4, in addressing frequently asked questions by patients on irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), colonoscopy and colorectal cancer (CRC) screening, questions on CRC screening from a physician perspective, and reference generation and suitability.

Impact of Clinical and Endoscopic Features on the Development of Metachronous Colorectal Advanced Serrated Lesions.

BACKGROUND AND AIMS: High-risk adenomas predict metachronous advanced adenomatous neoplasia. Limited data exist on predictors of metachronous advanced serrated lesions (mASLs). We analyzed clinical and endoscopic predictors of mASLs. METHODS: In this retrospective cohort study, adults with >1 outpatient colonoscopy between 2008 and 2019 at a tertiary center were included. Serrated lesions (SLs) included sessile SLs (SSLs), traditional serrated adenomas (TSAs), and hyperplastic polyps (HPs). Patient and endoscopic characteristics were obtained using electronic medical records. Five-year cumulative incidence of mASL (HP ≥10 mm, SSL ≥10 mm or with dysplasia, any TSA) and factors associated with mASL were evaluated using Kaplan-Meier estimates and Cox proportional hazards models. RESULTS: A total of 4990 patients were included and 45.4% were women. Mean age was 60.9 ± 9.2 years and median follow-up time was 3.7 years. Female sex and active smoking were associated with mASL. Endoscopically, any SSL and TSA were associated with mASL. The 5-year cumulative incidence for mASL was 26% (95% confidence interval [CI], 18%-32%) for SSL ≥10 mm, 17% (95% CI, 3.5%-29%) for HP ≥10 mm, 21% (95% CI, 0%-42%) for 3-4 SSLs <10 mm, 18% (95% CI, 0%-38%) for TSA, and 27% (95% CI, 3.6%-45%) for SSL with low-grade dysplasia. Baseline synchronous nonadvanced SL and nonadvanced adenoma were not associated with mASL. CONCLUSIONS: Our data support current recommendations for a 3-year surveillance interval in patients with baseline SSL ≥10 mm, SSL with dysplasia, and TSA. A 3-year interval may be more appropriate than 3-5 years for patients with baseline HP ≥10 mm or 3-4 SSLs <10 mm. Patients with synchronous nonadvanced SLs and adenomas do not appear to be at increased risk of mASL.

Association between baseline hyperplastic polyps and metachronous serrated lesions.

BACKGROUND AND AIMS: Some data suggest that individuals with numerous, <10-mm, rectosigmoid hyperplastic polyps (HPs) are at average risk for the development of metachronous advanced adenomatous neoplasia. Guidelines suggest that these individuals do not need surveillance colonoscopy and should be followed akin to individuals with a normal colonoscopy. Less is known of the risk of metachronous neoplasia because of ≥1 HPs <10 mm proximal to the sigmoid colon. We compared the risk of metachronous neoplasia between individuals with small HPs and those with normal colonoscopy, specifically addressing the impact of location and number of HPs on risk. METHODS: Colonoscopy and pathology reports from patients with ≥2 colonoscopies between 2004 and 2014 were reviewed. Exclusions included inpatients; age <40 or >75 years; and family or personal history of colorectal cancer, inflammatory bowel disease, previous colorectal surgery, or a previous colonoscopy with any adenoma, sessile serrated lesion (SSL), or HP ≥10 mm. The risk of metachronous neoplasia, including adenomas and SSLs, was compared in individuals with a normal index colonoscopy and those with <10-mm HPs stratified by location and number of HPs. RESULTS: After exclusion, 1795 patients were included. At index colonoscopy, 82% (n = 1469) had a normal examination, 12% (219) had only 1, and 6% (107) had between 2 and 9 HPs <10 mm. Compared with patients with a normal index colonoscopy, patients with a proximal (odds ratio, 3.82; 95% confidence interval, 1.77-7.53) or distal HP (odds ratio, 2.23; 95% confidence interval, 1.18-4.00) had an increased risk of metachronous SSLs but not adenomas. CONCLUSIONS: Patients with small proximal and distal HPs are at increased risk of metachronous SSLs. These preliminary findings warrant consideration during surveillance recommendations and future studies in larger cohorts.

≥3 Nonadvanced Adenomas are More Common in the Era of Contemporary Colonoscopy and Not Associated With Metachronous Advanced Neoplasia.

INTRODUCTION: Data from standard definition colonoscopy era demonstrate patients with an advanced adenoma (≥10 mm, villous features or high-grade dysplasia) or ≥3 nonadvanced adenomas are considered high-risk for metachronous advanced neoplasia (MAN). Low-risk adenoma (LRA) patients are those with 1 to 2, <10 mm tubular adenomas. High definition colonoscopy, split-dose bowel preparation, and attention to adenoma detection enhance diminutive adenoma detection. We compared baseline adenoma characteristics between patients undergoing colonoscopy in a historic cohort (HC) and contemporary cohort (CC) to determine if number of patients with ≥3 nonadvanced adenomas are increased in CC, and if those features are associated with MAN in CC. MATERIALS AND METHODS: Patients undergoing their first colonoscopy in HC (<2006) and CC (≥2006) at age 50 and above were identified through natural language processing. Multivariable regression analysis compared baseline adenoma characteristics between HC and CC, and determined the association between baseline characteristics and MAN in CC patients. RESULTS: In total, 255,074 colonoscopies were performed between 1990 and 2015. A total of 9773 colonoscopies performed in the HC and 59,531 in the CC were included. At baseline, CC patients were more likely to have ≥3 nonadvanced adenomas [odds ratio (OR): 2.1, 95% confidence interval (CI): 1.7-2.6]. In 3,377 CC patients undergoing follow-up colonoscopy, the risk of MAN did not differ between patients with LRA versus those with ≥3 nonadvanced adenomas (6.3% vs. 4.6%, OR: 1.4, CI: 0.58-3.5) including 3-4 (6.1%, OR: 1.4, CI: 0.52-3.6) and ≥5 (7.7%, OR: 1.8, CI: 0.23-14.6), although few patients had ≥5 nonadvanced adenomas. CONCLUSIONS: Colonoscopy in the contemporary era increases detection of patients with ≥3 nonadvanced adenomas, which do not increase the risk of MAN compared with LRA patients. A similar surveillance to LRA patients should be considered for those patients.

Successful orthotopic liver transplantation in a patient with a positive SARS-CoV2 test and acute liver failure secondary to acetaminophen overdose.

SARS-CoV2, first described in December 2019, was declared a pandemic by the World Health Organization in March 2020. Various surgical and medical societies promptly published guidelines, based on expert opinion, on managing patients with COVID-19, with a consensus to postpone elective surgeries and procedures. We describe the case of an orthotopic liver transplantation (OLT) in a young female who presented with acute liver failure secondary to acetaminophen toxicity to manage abdominal pain and in the setting of a positive SARS-CoV2 test. Despite a positive test, she had no respiratory symptoms at time of presentation. The positive test was thought to be residual viral load. The patient had a very favorable outcome, likely related to multiple factors including her young age, lack of respiratory COVID-19 manifestations and plasma exchange peri-operatively. We recommend a full work-up for OLT in COVID-19 patients with uncomplicated disease according to standard of care, with careful interpretation of COVID-19 testing in patients presenting with conditions requiring urgent or emergent surgery as well as repeat testing even a few days after initial testing, as this could alter management.

Severe gastroparesis is associated with an increased incidence of slow-transit constipation as measured by wireless motility capsule.

BACKGROUND: Dysmotility in one region of the gastrointestinal tract has been found to predispose patients to developing motility disorders in other gastrointestinal segments. However, few studies have evaluated the relationship between gastroparesis and constipation. METHODS: Retrospective review of 224 patients who completed 4-hour, solid-phase gastric emptying scintigraphy (GES), and wireless motility capsule (WMC) testing to evaluate for gastroparesis and slow-transit constipation, respectively. When available, anorectal manometry data were reviewed to evaluate for dyssynergic defecation. Patients were divided into two groups based on the results of the GES: 101 patients with normal gastric emptying and 123 patients with gastroparesis (stratified by severity). Differences in constipation rates were compared between the groups. KEY RESULTS: Slow-transit constipation was more common in the gastroparesis group, but statistical significance was not reached (42.3% vs 34.7%, p = 0.304). Univariate logistical regression analysis found no association between slow-transit constipation and gastroparesis (OR 1.38, 95% CI 0.80-2.38, p = 0.245) nor dyssynergic defecation and gastroparesis (OR 0.88, 95% CI 0.29-2.70, p = 0.822). However, when stratifying gastroparesis based on severity, slow-transit constipation was found to be associated with severe gastroparesis (OR 2.45, 95% CI 1.20-5.00, p = 0.014). This association was strengthened with the exclusion of patients with diabetes mellitus (OR 3.5, 95% CI 1.39-8.83, p = 0.008) - a potential confounder. CONCLUSIONS & INFERENCES: Patients with severe gastroparesis (>35% gastric retention at the 4-hour mark on solid-phase GES) have an increased likelihood of having underlying slow-transit constipation. Dyssynergic defecation does not appear to be associated with gastroparesis (of any severity).

A Rare Case of Takotsubo Cardiomyopathy-Induced Acute Liver Failure

Hypoxic hepatitis is a common cause of abnormal liver biochemistries in hospitalized patients. It is important clinicians maintain a high index of suspicion for diagnosis so that appropriate supportive therapies may be implemented in a timely manner. We present a rare case of takotsubo cardiomyopathy-induced hypoxic hepatitis and resultant acute liver failure in a patient after an intentional drug overdose. Once competing etiologies of acute liver failure were excluded and the diagnosis of hypoxic hepatitis was established, therapy was focused on the patient's cardiomyopathy in an effort to simultaneously improve her liver function.

Correction to: Takotsubo Cardiomyopathy Causing Induced Acute Liver Failure.

[This corrects the article DOI: 10.14309/crj.0000000000000413.].

Indications, contraindications and limitations of endoscopic therapy for Barrett's esophagus and early esophageal adenocarcinoma.

Endoscopic eradication therapy (EET) has revolutionized management of Barrett's esophagus (BE)-associated neoplasia, traditionally treated by esophagectomy, which carries very high mortality and morbidity. EET, usually performed in the outpatient setting, has a safe risk profile. It is indicated in patients with BE with high-grade dysplasia and intramucosal cancer, confirmed, and persistent low-grade dysplasia, and in highly selected cases of non-dysplastic BE and submucosal cancers. Multiple EET modalities are available and can be categorized into two groups: ablation therapies and resection techniques with resection techniques usually reserved for nodular/raised lesions or lesions with suspected neoplasia. Patients usually require multiple ablation sessions with a goal of achieving complete eradication of metaplasia. Despite very good results, EET has its limitations and is not 100% effective: it targets a small subset of patients along the spectrum of BE and esophageal adenocarcinoma, as most patients with esophageal adenocarcinoma remain asymptomatic until the disease has progressed to advanced stages. Post-ablation surveillance is mandatory, as recurrences are common. An area of concern is buried metaplasia reported to occur following ablation therapy and thought to be from de novo growth of metaplastic tissue underneath the neosquamous epithelium, following ablation. The focus of this review article is to present the indications, contraindications and limitations of EET.

Pyloroplasty and the risk of Barrett's esophagus in patients with gastroparesis.

Barrett's esophagus (BE), a consequence of gastroesophageal reflux disease (GERD), is a premalignant condition for esophageal adenocarcinoma. Impaired gastric emptying leads to increased gastric volume and therefore more severe reflux. We seek to investigate the association between gastroparesis and BE and the predictors of BE among patients with gastroparesis. This is a retrospective review of patients seen at Cleveland Clinic between 2011 and 2016 who had an upper endoscopy and a gastric emptying study. Demographics, symptoms, medications, endoscopic and histological findings, and therapeutic interventions were abstracted. Risk of BE among gastroparesis group and control group was assessed, and logistic regression analysis was performed to identify predictors of BE among gastroparesis patients. Of the 4,154 patients, 864 (20.8%) had gastroparesis and 3, 290 (79.2%) had normal gastric emptying. The mean age was 51.4 ± 16.4 years, 72% were women and 80% were Caucasians. Among the gastroparesis group, 18 (2.1%) patients had BE compared to 71 (2.2%) cases of BE in the control group, P = 0.89. There were no differences in gender, race, reflux symptoms, or esophageal findings between the two groups. Among gastroparesis group, predictors of developing BE were a history of alcohol use (odds ratio [OR] 6.76; 95% confidence intervals [CI]: 1.65-27.67, P = 0.008), history of pyloroplasty (OR: 8.228; CI: 2.114-32.016, P = 0.002), and hiatal hernia (OR: 8.014; CI: 2.053-31.277, P = 0.003). Though gastroparesis is a known contributing factor for GERD, there was no increased prevalence of BE in gastroparesis. Among patients with gastroparesis, predictors of BE are history of alcohol use, hiatal hernia, and pyloroplasty.

Successful liver transplantation for acute sickle cell intrahepatic cholestasis: A case report and review of the literature.

BACKGROUND: Sickle cell hepatopathy (SCH) is an inclusive term referring to any liver dysfunction among patients with sickle cell disease. Acute sickle cell intrahepatic cholestasis is one of the rarest and most fatal presentations of SCH. We present the 23rd reported case of liver transplantation (LT) for SCH; a rare case of acute sickle cell intrahepatic cholestasis managed with LT from a hepatitis C virus (HCV) nucleic acid amplification test positive donor. CASE SUMMARY: A 29-year-old male with a past medical history of sickle cell disease presented with vaso-occlusive pain crisis. On examination, he had jaundice and a soft, non-tender abdomen. Initially he was alert and fully oriented; within 24 h he developed new-onset confusion. Laboratory evaluation was notable for hyperbilirubinemia, leukocytosis, anemia, thrombocytopenia, acute kidney injury and elevated international normalized ratio (INR). Imaging by ultrasound and computed tomography scan suggested a cirrhotic liver morphology with no evidence of biliary ductal dilatation. The patient was diagnosed with acute sickle cell intrahepatic cholestasis after excluding competing etiologies of acute liver injury. He underwent LT from an HCV nucleic acid amplification test positive donor 9 d after initial presentation. The liver explant was notable for widespread sinusoidal dilatation with innumerable clusters of sickled red blood cells and cholestasis. On postoperative day 3, HCV RNA was detectable in the patient's peripheral blood and anti-HCV therapy with glecaprevir/pibrentasvir was initiated on postoperative day 23. He subsequently achieved sustained virologic response after completing 3 mo of therapy and has been followed clinically for 12 mo post-transplant. CONCLUSION: This case highlights the utility of LT as a viable treatment option for acute sickle cell intrahepatic cholestasis.

Esophageal dysmotility and other preoperative factors associated with acid suppressive therapy after fundoplication.

Background and aims: Acid suppressive therapy (AST) is frequently used after fundoplication. Prior studies show that most patients requiring AST after fundoplication have normal esophageal acid exposure and therefore do not need AST. Our aim was to determine the indications for AST use following fundoplication and the associated factors.Methods: Retrospective analysis of patients who underwent fundoplication at our institution between 2006 and 2013 with pre and postoperative esophageal physiologic studies was performed. Demographic data, symptoms, and findings on high resolution manometry, esophageal pH monitoring and upper endoscopy were collected.Results: Three hundred and thirty-nine patients were included with a median follow up time of 12.8[2.6, 47.7] months. Mean age was 59.6 ± 13.3 years and 71.4% were women. Of those, 39.5% went on AST following fundoplication with a median time to AST use of 15.7[2.8, 36.1] months. The most common reason for AST use was heartburn. Only 29% of patients had objective evidence of acid reflux. Preoperative factors associated with AST use following fundoplication were male gender (HR1.6, p = 0.019), esophageal dysmotility (HR1.7, p = 0.004), proton pump inhibitor use (HR2.3, p < 0.001) and prior history of fundoplication (HR1.8, p = 0.006). In those with paraesophageal hernia repair with Collis gastroplasty (N = 182), esophageal dysmotility (HR1.7, p = 0.047) and NSAID use (HR1.9, p = 0.023) were associated with AST use postoperatively.Discussion: AST use is common after fundoplication. Male gender, preoperative esophageal dysmotility, proton pump inhibitor use and redo fundoplication were associated with AST use following fundoplication. In those undergoing combined Collis gastroplasty, preoperative NSAID use and esophageal dysmotility predicted AST use.