Is the Medium Still the Message? Culture-Independent Diagnosis of Gastrointestinal Infections.

Infectious diarrhea is caused by a variety of pathogens, including viruses, bacteria, and parasitic organisms. Though the causative agent of diarrhea has historically been evaluated via stool cultures, recently, culture-independent diagnostic tests (CIDT) have been developed and utilized with increasing frequency. Current practice guidelines recommend their use as adjuncts to stool cultures for diagnosing acute and chronic diarrhea. The three principal CIDT are microscopy, enzyme-based immunoassays (EIAs), and molecular based polymerase chain reaction (PCR). This review explores the common causes of infectious diarrhea, the basics of stool culture, the diagnostic utility of these three culture-independent modalities, and the strengths and weaknesses of all currently available clinical techniques. It also outlines considerations for specific populations including returning travelers and those with inflammatory bowel disease.

Nationwide estimate of emergency department visits in the United States related to caustic ingestion.

INTRODUCTION: Caustic ingestion, whether intentional or unintentional, may result in significant morbidity. Our aim was to provide an estimate of the incidence and outcomes of caustic ingestion among emergency department (ED) visits across the United States. METHODS: The Nationwide Emergency Department Sample (NEDS) is part of the family of databases developed for the Healthcare Cost and Utilization Project. We analyzed NEDS for the period 2010-2014. Adults (≥18 years of age) with a diagnosis of caustic ingestion were identified by ICD-9 codes. The weighted frequencies and proportions of caustic ingestion-related ED visits by demographic characteristics and disposition status were examined. A weighted multivariable logistic regression model was performed to examine factors associated with inpatient admission for caustic ingestion-related visits. RESULTS: From 2010 to 2014, there were 40,844 weighted adult ED visits related to caustic ingestion among 533.8 million visits (7.65/100,000, 95% CI 7.58/100,000-7.73/100,000), resulting in over $47 million in annual cost. Among ED visits related to caustic ingestion, 28% had comorbid mental and substance use disorders. Local and systemic complications were rare. There was significant regional, gender, and insurance variability in the decision as to perform endoscopy. Males, insured patients, patients domiciled in the Southeast region of the United States, and patients with mental or substance use disorders had significantly higher percentages of receiving endoscopic procedures. Overall, 6,664 (16.27%) visits resulted in admission to the same hospital and 1,063 (2.60%) visits resulted in transfer to another hospital or facility. The risk factors for admission were increasing in age, male gender, local or systemic complications related to caustic ingestion, and comorbid mental and substance use disorders. A total of 161 (0.39%) patients died related to caustic ingestion. CONCLUSION: Our results from NEDS provide national estimates on the incidence of caustic ingestions involving adults seen in US EDs. Further studies are needed to examine the standard management of caustic ingestion and investigate the factors causing variability of esophagogastroduodenoscopy performance and caustic ingestion care.

Chronic Abdominal Wall Pain: An Under-Recognized Diagnosis Leading to Unnecessary Testing.

Chronic abdominal wall pain (CAWP) refers to a condition wherein pain originates from the abdominal wall itself rather than the underlying viscera. According to various estimates, 10% to 30% of patients with chronic abdominal pain are eventually diagnosed with CAWP, usually after expensive testing has failed to uncover another etiology. The most common cause of CAWP is anterior cutaneous nerve entrapment syndrome. The diagnosis of CAWP is made using an oft-forgotten physical examination finding known as Carnett's sign, where focal abdominal tenderness is either the same or worsened during contraction of the abdominal musculature. CAWP can be confirmed by response to trigger point injection of local anesthetic. Once diagnosis is made, treatment ranges from conservative management to trigger point injection and in refractory cases, even surgery. This review provides an overview of CAWP, discusses the cost and implications of a missed diagnosis, compares somatic versus visceral innervation, describes the pathophysiology of nerve entrapment, and reviews the evidence behind available treatment modalities.

Administrative Database Research Overestimates the Rate of Interval Colon Cancer.

GOALS: Our study reexamines the prevalence of interval colorectal cancer (I-CRC) by manually reviewing CRC cases at a single institution. BACKGROUND: In 2% to 8% of patients with CRC, diagnosis occurs during the interval 6 to 36 months after a cancer-free colonoscopy. Rates are often determined by linking the date of colonoscopy with cancer registry information. STUDY: We examined all colonoscopies from 1993 to 2011. These examinations were linked with Pennsylvania Cancer Registry data. Matched charts were manually reviewed. We determined whether the CRC was "prevalent" or, for patients with a previous colonoscopy, whether they were interval or noninterval based on time from last colonoscopy. For interval cases, we identified "administrative errors" that could falsely increase the number of reported I-CRC. RESULTS: Over the study period, 43,661 colonoscopies were performed, with 1147 (2.6%) positive for CRC after excluding cases (n=52) in which patients had IBD, previous surgery, or nonadenocarcinoma malignancy. Prevalent CRCs totaled 1062 (92.6%). Noninterval CRCs (diagnosed over 36 mo from index colonoscopy) were present in 40 (3.5%). There remained 45 (3.9%) potential I-CRC cases. However, after manual review, 21 cases were found to be administrative errors. Therefore, the accurate proportion of colonoscopies that found an I-CRC was 2.1% (95% confidence interval, 1.5%-3.2%). CONCLUSIONS: The prevalence of I-CRC at our institution before adjustment was comparable with previously reported rates. This proportion was 47% lower after adjusting for administrative errors placing our figure at the lower end of reported I-CRC incidence. Reported rates of I-CRC may be falsely elevated due to errors unique to merging administrative databases.

Double balloon enteroscopy: effective and minimally invasive method for removal of retained video capsules.

BACKGROUND AND AIM: Prior case series document removal of retained video capsules predominantly via surgical intervention. Data on endoscopic removal of retained capsules are limited. Our aim was to describe an endoscopic method of retrieval using double balloon enteroscopy (DBE). METHODS: A retrospective case series examination found 10 patients who underwent DBE for retrieval of a retained video capsule at two large tertiary referral academic centers from May 2007 to June 2013. RESULTS: Mean age of patients was 64.9 ± 18.1 years (four females, six males). Five patients failed to pass the capsule as a result of an ileal or jejunal stricture (one patient with ulcerative colitis; four patients with Crohn's disease); two patients had a small bowel stricture as a result of non-steroidal anti-inflammatory drug enteropathy; one patient had intermittent partial small bowel obstruction without evidence of a stricture; one patient had an obstructing malignant jejunal mass and one patient had a small bowel stricture as a result of radiation enteritis. Endoscopic removal via DBE was successful in eight of 10 patients (80%). The remaining two patients underwent surgical removal of the retained capsule. The two failed cases of capsule retrieval were both patients with suspected ileal disease. CONCLUSIONS: The most common cause of capsule retention was underlying Crohn's disease. DBE is an effective and minimally invasive method of capsule retrieval, including those patients with ileal disease, which has not been previously described. DBE can prevent unnecessary surgery while providing endoscopic therapy of inflammatory strictures by dilation.

The influence of race on symptom severity and quality of life in gastroparesis.

BACKGROUND: The majority of clinical studies for gastroparesis have primarily included white women. Our aim was to compare the etiology, clinical characteristics, healthcare utilization, symptom profile, and quality of life (QOL) in white and nonwhite patients with gastroparesis. METHODS: Newly referred patients with gastroparesis completed: (1) a comprehensive demographic profile, (2) the Patient Assessment of Upper Gastrointestinal Disorder Symptoms (PAGI-SYM), and (3) the Patient Assessment of Upper Gastrointestinal Disorders QOL (PAGI-QOL). All patients had confirmed delayed gastric emptying as measured by 4-hour scintigraphy. RESULTS: A total of 255 patients were enrolled; mean age was 42.5 years and 83.3% were females. There were 44 (17%) nonwhites (33 African American and 11 Hispanic) and 211 (83%) whites. The proportion of nonwhite patients with gastroparesis secondary to diabetes was 55% compared with 19% of white patients (P<0.001). The total PAGI-SYM score was higher in nonwhite patients. Nonwhite patients had higher PAGI-SYM subscale scores for nausea/vomiting, upper abdominal pain, and lower abdominal pain. The 2 groups differed in health care utilization: 49% of nonwhite patients reported ≥4 gastroparesis-related emergency department visits and 42% reported more ≥4 gastroparesis-related hospitalizations, as compared with 20% and 14% of white patients, respectively. Total PAGI-QOL scores were lower in nonwhite patients. Linear regression showed that nonwhite race, sex, age, and age of onset were independently associated with symptom scores, whereas etiology of gastroparesis and gastric emptying times were not. CONCLUSIONS: Nonwhite patients with gastroparesis had more severe symptoms, poorer QOL, and utilized more health care resources than white. Nonwhites were more likely to have diabetes as the etiology.

Colonoscopy preparation: polyethylene glycol with Gatorade is as safe and efficacious as four liters of polyethylene glycol with balanced electrolytes.

BACKGROUND: Four liters of polyethylene glycol 3350 (PEG) with balanced electrolytes for colonoscopy preparation has had poor acceptance. Another approach is the use of electrolyte-free PEG combined with 1.9 L of Gatorade. Despite its widespread use, there are no data on metabolic safety and minimal data on efficacy. Our aim was to assess the efficacy and electrolyte safety of these two PEG-based preparations. METHODS: This was a prospective, randomized, single-blind, non-inferiority trial. Patients were randomized to 238 g PEG + 1.9 L Gatorade or 4 L of PEG-ELS containing 236 g PEG. Split dosing was not performed. On procedure day blood was drawn for basic chemistries. The primary outcome was preparation quality from procedure photos using the Boston Bowel Preparation Scale. RESULTS: We randomized 136 patients (66 PEG + Gatorade, 70 PEG-ELS). There were no differences in preparation scores between the two agents in the ITT analysis (7.2 ± 1.9 for PEG-ELS and 7.0 ± 2.1 for PEG + Gatorade; p = 0.45). BBPS scores were identical for those who completed the preparation and dietary instructions as directed (7.4 ± 1.7 for PEG-ELS, and 7.4 ± 1.8 for PEG + Gatorade; p = 0.98). There were no statistical differences in serum electrolytes between the two preparations. Patients who received PEG + Gatorade gave higher overall satisfaction scores for the preparation experience (p = 0.001), and had fewer adverse effects. CONCLUSIONS: Use of 238 g PEG + 1.9 L Gatorade appears to be safe, better tolerated, and non-inferior to 4 L PEG-ELS. This preparation may be especially useful for patients who previously tolerated PEG-ELS poorly.

Prevalence and distribution of adenomas in black Americans undergoing colorectal cancer screening.

BACKGROUND: The American College of Gastroenterology recommends colorectal cancer (CRC) screening for average-risk black Americans ages 45-49. This is based on this group's younger age for the development of adenomas and CRC. Our purpose was to determine the yield of CRC screening in average-risk black Americans including those

The impact of functional constipation on quality of life of middle-aged Black Americans: a prospective case-control study.

PURPOSE: To quantify the impact of constipation on health-related quality of life (HRQoL) in Black Americans. METHODS: Case-control design. Black subjects referred for colon cancer screening with a Bristol Stool Score of 3-5 for >75% of bowel movements served as controls. Frequency-matched functional constipation subjects had to fulfill Rome III criteria. Both groups completed demographic and health surveys. Short Form-36 assessed HRQoL. RESULTS: We recruited 102 constipated patients and 100 controls. The groups were well matched demographically. After adjustment for comorbidities, SF-36 scores for vitality, bodily pain, social functioning, and role-emotional were significantly lower in constipated patients. Unadjusted physical and mental component summary scores (PCS and MCS) were significantly higher in the control group (47.1 ± 10.6 vs. 43.3 ± 8.6; P = 0.005 and 50.6 ± 12.4 vs. 43.4 ± 11.8; P < 0.001, respectively). After adjustment for comorbidities, PCS differences were no longer significant (P = 0.54); however, MCS differences were significant (P = 0.004). Marginal mean scores for the MCS for controls and constipated subjects were 49.9 ± 1.2 and 43.6 ± 1.2, respectively. The presence of a comorbidity was independently associated with PCS (P < 0.001) and MCS (P = 0.026) results. CONCLUSIONS: Functional constipation has a significant impact on HRQoL in middle-aged Black Americans, particularly in regard to mental well-being.

Wireless capsules for esophageal pH monitoring: are we placing them correctly?

BACKGROUND: Recommended Bravo capsule placement is 6 cm proximal to the squamocolumnar junction. This is because the junction resides 1 cm distal to the lower esophageal sphincter. AIM: To determine the positional accuracy of capsule placement compared with the ideal location in symptomatic patients. METHODS: Retrospective analysis of consecutive symptomatic outpatients undergoing both capsule placement and esophageal manometry on the same day. Error in capsule placement (ECP) was calculated as the actual capsule position (ACP) minus the ideal capsule position (ICP) based on manometry results. An error in positioning < or =3 cm was deemed an accurate placement. RESULTS: Accurate placement of the capsule occurred in 91/147 (62%) patients. In patients with inaccurate placement, 92.9% were placed >3 cm proximal to the ICP. Only longer esophageal length correlated with the severity of proximal misplacement. There was no relationship between severity of ECP and whether the study demonstrated acid reflux. CONCLUSIONS: Our results suggest that endoscopic misplacement of Bravo capsules is common. Capsule misplacement proximally occurred far more frequently than distal misplacement. Capsule misplacement was not associated with pH study results.

Trends in gastroesophageal reflux disease as measured by the National Ambulatory Medical Care Survey.

BACKGROUND: The prevalence of reflux disease is increasing. Health-care utilization including physician visits for this disorder is lacking. Our purpose was to analyze the trend in physician visits for GERD from the period 1995-2006 using the National Ambulatory Medical Care Survey. We also sought to determine health-care utilization for GERD indirectly by assessing prescription trends for proton-pump inhibitors and H2 receptor blockers during the period. METHODS: The National Ambulatory Medical Care Survey is a survey of approximately 3,000 office-based physicians that uses a three-stage probability sampling procedure to allow extrapolation to the US population. All visits between 1995 and 2006 for symptoms and/or diagnoses compatible with GERD were combined into a single categorical variable. Weighted data was utilized for descriptive and inferential statistical analysis. RESULTS: After weighting, there were N = 321,513 adult ambulatory care encounters for all diagnoses. Visits for reflux increased throughout the examined period. Using logistic regression, visits for reflux were associated with female gender, age over 40, and calcium channel blocker use. Proton-pump inhibitor use increased substantially during the study period while H2 blocker use declined. Family practitioners and internists saw the majority of reflux patients. CONCLUSIONS: The frequency of ambulatory visits in the United States for gastroesophageal reflux disease increased significantly between 1995 and 2006. The use of PPI therapy is increasing even more substantially. Older age, female gender, and use of calcium channel blockers were associated with a higher frequency of GERD visits. Health-care utilization for this disorder is increasing perhaps due to our ever-increasing epidemic of obesity.

Wireless capsule motility: comparison of the SmartPill GI monitoring system with scintigraphy for measuring whole gut transit.

INTRODUCTION: Assessment of whole gut transit, by radio-opaque markers or scintigraphy, is used to evaluate patients with constipation for slow gastrointestinal transit. Wireless capsule motility, using the SmartPill GI monitoring system, samples and transmits intraluminal pH, pressure, and temperature data from a capsule at regular intervals as it traverses through the gastrointestinal tract; from these, gastric emptying and whole gastrointestinal tract transit can be assessed. The objective of this study was to compare the SmartPill with whole gut transit scintigraphy to determine whether the SmartPill system could serve as a test for measurement of whole gut motility and transit. METHODS: Ten healthy, asymptomatic subjects underwent simultaneous whole gut scintigraphy and SmartPill assessment of whole gut transit. RESULTS: All subjects completed the study per protocol and experienced natural passage of the pill. Capsule residence time in the stomach correlated very strongly with percent gastric retention of the Tc-99 radiolabel at 120 min (r = 0.95) and at 240 min (r = 0.73). Small bowel contraction-min(-1) measured by the SmartPill correlated with small bowel transit % (r = 0.69; P = 0.05) and with isotopic colonic geometric center at 24 h after ingestion (r = 0.70, P = 0.024). Capsule transit time correlated with scintigraphic assessment of whole gut transit. CONCLUSIONS: SmartPill capsule assessment of gastric emptying and whole gut transit compares favorably with that of scintigraphy. Wireless capsule motility shows promise as a useful diagnostic test to evaluate patients for GI transit disorders and to study the effect of prokinetic agents on GI transit.

Incidence and risk factors of dysphagia after variceal band ligation.

BACKGROUND AND AIM: There is a lack of data on long-term morbidity, particularly dysphagia, following endoscopic variceal band ligation (EVL). The aim of this study are to assess the incidence of dysphagia and variables associated with this complication after EVL. METHODS: We identified individuals who completed at least one session of EVL as their sole treatment for varices from August 2012 to December 2017. Included patients achieved "complete eradication" of varices not requiring further therapy. Patients ≥90 days from their last EVL session completed a modified version of the Mayo Clinic Dysphagia Questionnaire. Individuals with dysphagia were invited to undergo a barium esophagram. Patients with pre-EVL dysphagia were excluded. RESULTS: Of the patients, 68 possessed inclusion criteria, nine (13.2%) died and 20 (29.4%) were lost to follow up. For the remaining 39 (57.4%) patients, 23 were males, mean age of 61.7±8.6 years. The most common etiology of liver disease was hepatitis C virus (n=18; 46.2%). The median number of banding sessions was 2.0 (interquartile range [IQR], 1.0-4.0) with a median of 9.0 bands placed (IQR, 3.0-14.0). Twelve patients (30.8%) developed new-onset dysphagia post-EVL. In univariate analysis, pre-EVL MELD score and non-emergent initial banding were associated with long-term dysphagia. In a regression model adjusted for age, sex, number of bands, and use of acid suppression after EVL, no factor was independently associated with dysphagia (all P>0.05). No strictures were identified on subsequent esophageal evaluation. CONCLUSION: Approximately 30% of patients developed new-onset, chronic dysphagia post-EVL. Incident dysphagia was associated with a non-emergent initial banding session. The mechanism for dysphagia remains unknown.

Recent use of NSAID and NOAC medications are associated with a positive CT arteriogram.

BACKGROUND: Computed tomography angiography (CTA) is a diagnostic modality utilized in patients with suspected active lower gastrointestinal (GI) bleeding. CTA use in clinical practice is limited by the risk of contrast-induced nephropathy, and the loss of patients from direct physician observation while undergoing the test. Identifying clinical predictors of a positive result would be useful in guiding physician utilization of CTA studies. METHODS: We performed a single-center retrospective study to determine which clinical predictors are associated with a positive CTA. Binary logistical regression modeling was used to identify the independent predictors and the results were expressed as adjusted odds ratios with corresponding 95% CI . RESULTS: 262 patients met inclusion criteria and there were 61 (23.3%) positive CTA exams. In unadjusted analysis those who were CTA positive were more likely to require management in the intensive care unit (85.2% vs. 14.8%, p < 0.01) and being CTA positive was associated with a significantly increased in-hospital mortality (14.8% vs. 4.5%, p < 0.01). The use of a novel oral anticoagulant (NOAC) in the week prior to presentation was associated with a positive CTA after adjustment for confounders (adjusted odds ratio = 3.89; 95% CI 1.05-14.43). Similarly, the use of a non-steroidal anti-inflammatory drug (NSAID) was associated with a positive CTA (OR 2.36; 1.03-5.41). Only 8% of patients experienced contrast-induced nephropathy. CONCLUSION: Use of either NOACs or NSAIDs in the previous week is independently associated with a positive CTA in the setting of acute lower GI bleeding. CTA exams appear to confer a low risk of contrast-induced nephropathy.

Trends of Heller myotomy hospitalizations for achalasia in the United States, 1993-2005: effect of surgery volume on perioperative outcomes.

OBJECTIVES: Achalasia is a rare chronic disorder of esophageal motor function. Single-center reports suggest that there has been greater use of laparoscopic Heller myotomy for achalasia in the United States since its introduction in 1992. We aimed to study the trends of Heller myotomy and the relationship between surgery volume and perioperative outcomes. DATA AND METHODS: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS) is a 20% stratified sample of all hospitalizations in the United States. It was used to study the macro-trends of Heller myotomy hospitalizations during 1993-2005. We also used the NIS 2003-2005 micro-data to study the perioperative outcomes of Heller myotomy hospitalizations, using other achalasia and laparoscopic cholecystectomy hospitalizations as control groups. The generalized linear model with repeated observations from the same unit was used to adjust for multiple hospitalizations from the same hospital. RESULTS: The national estimate of Heller myotomy hospitalizations increased from 728 to 2,255 during 1993-2005, while its mean length of stay decreased from 9.9 to 4.3 days. Of the 1,117 Heller myotomy hospitalizations in the NIS 2003-2005, 10 (0.9%) had the diagnosis of esophageal perforation at discharge. Length of stay was negatively correlated with a hospital's number of Heller myotomy per year (correlation coefficient -0.171, P < 0.001). In multivariate log-linear regressions with a control group, a hospital's number of Heller myotomy per year was negatively associated with length of stay (coefficient -0.215 to -0.119, both P < 0.001) and total charges (coefficient -0.252 to -0.073, both P < 0.10). These findings were robust in alternative statistical models, specifications, and subgroup analyses. CONCLUSIONS: On a national level, the introduction of laparoscopic Heller myotomy for achalasia was associated with greater use of surgery and shorter length of stay. A larger volume of Heller myotomy in a hospital was associated with better perioperative outcomes in terms of shorter length of stay and lower total charges.

The association between gastroesophageal reflux disease and obesity.

Nearly all epidemiologic studies have found an association between increasing body mass index (BMI) and symptoms of gastroesophageal reflux disease (GERD). Changes in gastroesophageal anatomy and physiology caused by obesity may explain the association. These include an increased prevalence of esophageal motor disorders, diminished lower esophageal sphincter (LES) pressure, the development of a hiatal hernia, and increased intragastric pressure. Central adiposity may be the most important risk for the development of reflux and related complications such as Barrett's esophagus and esophageal adenocarcinoma. Weight loss, through caloric restriction and behavioral modification, has been studied infrequently as a means of improving reflux. Bariatric surgery and its effects on a number of obesity-related disorders have been studied more extensively. Roux-en-Y gastric bypass (RYGB) has been consistently associated with improvement in the symptoms and findings of GERD. The mechanism of action through which this surgery is successful at improving GERD may be independent of weight loss and needs further examination. Current evidence suggests that laparoscopic adjusted gastric banding should be avoided in these patients as the impact on gastroesophageal reflux disease appears unfavorable.

Symptoms of gastroparesis: use of the gastroparesis cardinal symptom index in symptomatic patients referred for gastric emptying scintigraphy.

BACKGROUND/AIM: The Gastroparesis Cardinal Symptom Index (GCSI) was developed to assess symptoms of gastroparesis. The aim of this study was to correlate symptoms using the GCSI with delayed gastric emptying (DGE) in symptomatic patients referred for gastric emptying scintigraphy (GES). METHODS: A total of 226 consecutive symptomatic patients referred for GES completed the 9-question GCSI. GES was performed using a (99)Tc-labeled egg meal. Gastroparesis was defined as DGE at 2 h and/or 4 h. RESULTS: Using linear regression, nausea (p = 0.09), not able to finish a normal-size meal (p = 0.005), postprandial fullness subscore (p = 0.01), and total GCSI score (p = 0.06) were predictors of the gastric retention values at 2 h, but not at 4 h. Patients with gastroparesis had significant higher symptom scores for nausea (p = 0.035) and vomiting (p = 0.040) compared to patients with normal gastric emptying. The positive predictive value varied between 51 and 61% for total GCSI scores between 20 and 35, respectively. CONCLUSION: The individual symptoms of nausea, vomiting, and early satiety were associated with DGE at 2 h but not at 4 h. In contrast, the total or average GCSI score did not reliably predict the diagnosis of gastroparesis in symptomatic patients referred for GES.

Chemoprevention of colorectal cancer in inflammatory bowel disease.

INTRODUCTION: Patients with inflammatory bowel disease are at an increased risk of colorectal cancer when compared to the general population. Chronic inflammation is thought to be the underlying cause, and medications that reduce inflammation have the potential to reduce the risk of colorectal cancer. Areas covered: After conducting a PubMed search for relevant literature, we examined several classes of medications that have been studied as potential chemopreventive agents. These include 5-aminosalicylates, thiopurines, tumor necrosis factor antagonists, ursodeoxycholic acid, NSAIDs, and statins. Expert commentary: While each class of medications has some data to support its use in chemoprevention, the majority of the evidence in each case argues against the routine use of these medications solely for a chemopreventive benefit.