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BACKGROUND AND AIMS: Bleeding from the gastrointestinal tract can contribute to the development of iron deficiency anemia (IDA) among individuals without another obvious source of bleeding. In order to identify patients most likely to benefit from examination of the small bowel, our aim was to create a risk score for positive video capsule endoscopy (VCE) in IDA utilizing a multicenter collection of studies. METHODS: We performed a retrospective multicenter study utilizing VCE studies performed for an indication of IDA between 1/1/2005 and 7/31/2018. VCE findings were graded based on the P0-P2 grading system. The primary outcome of interest was a positive (P2) VCE. Data were analyzed with Student's t test for continuous variables and the Fisher's exact test for categorical variables. Logistic regression was used to identify independent associations with positive VCE. RESULTS: In total, 765 VCE procedures were included with 355 (46.5%) male subjects and a median age of 63.2 (SD 15.3) years. One hundred ninety studies (24.8%) were positive (P2) for small bowel bleeding. Four variables associated with positive VCE which were incorporated into a point scoring system: (+) 1 for age ≥ 66 years, active smoking and cardiac arrythmia and (-) 1 for preceding hemoglobin level ≥ 8.5. The risk probabilities for positive VCE-assigned scores - 1, 0, 1, and 2 + were 12.3% (95% CI 7.3-17.3%), 20% (14.9-25.1%), 34.8% (28.6-41%), and 39% (30-47.8%). CONCLUSION: In order to improve the diagnostic yield of capsule examinations, risk factors should be applied to clinical decision-making. We created a risk score for positive VCE in IDA, including the risk factors of age, smoking, history of cardiac arrythmia, and preceding hemoglobin level.
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Anemia Ferropriva , Endoscopia por Cápsula , Humanos , Masculino , Pessoa de Meia-Idade , Idoso , Feminino , Endoscopia por Cápsula/métodos , Anemia Ferropriva/etiologia , Anemia Ferropriva/complicações , Intestino Delgado , Trato Gastrointestinal , Estudos Retrospectivos , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/complicações , HemoglobinasRESUMO
Cystic Fibrosis is a chronic disease affecting multiple systems, including the GI tract. Clinical manifestation in patients can start as early as infancy and vary across different age groups. With the advent of new, highly effective modulators, the life expectancy of PwCF has improved significantly. Various GI aspects of CF care, such as nutrition, are linked to an overall improvement in morbidity, lung function and the quality of life of PwCF. The variable clinical presentations and management of GI diseases in pediatrics and adults with CF should be recognized. Therefore, it is necessary to ensure efficient transfer of information between pediatric and adult providers for proper continuity of management and coordination of care at the time of transition. The transition of care is a challenging process for both patients and providers and currently there are no specific tools for GI providers to help ensure a smooth transition. In this review, we aim to highlight the crucial features of GI care at the time of transition and provide a checklist that can assist in ensuring an effective transition and ease the challenges associated with it.
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Fibrose Cística , Gastroenterologistas , Gastroenteropatias , Humanos , Adulto , Criança , Fibrose Cística/terapia , Fibrose Cística/complicações , Transferência de Pacientes , Qualidade de Vida , Gastroenteropatias/complicaçõesRESUMO
BACKGROUND: Colorectal cancer (CRC) is the second-leading cause of death in the USA. CRC screening remains underutilized, especially in underinsured populations. Screening has been heavily disrupted during the COVID-19 pandemic. PURPOSE: The goal is to explore the impact of the pandemic on ethnic and gender disparities in CRC screening. METHODS: Patients were identified 1 year before and after COVID-19 precautions began, using March 1, 2020, as the inflection point. The primary inclusion criterion was an ordered colonoscopy. The outcome of interest was a colonoscopy performed. Differences by year and race were assessed using chi-square analysis. A cohort of 1549 patients (899 in pre-COVID; 650 in post-COVID) between age 45 and 75 for whom a colonoscopy was ordered was selected from EHR at a large institution. RESULTS: There was a 51% reduction in screening colonoscopies performed. White patients had a decrease of 49%, and African Americans had a 55% reduction. Stool testing increased from 47% prior to the pandemic to 94% during the pandemic representing a greater than 100% increase in stool testing uptake. CONCLUSION: The true impact of COVID-19 on colorectal cancer is yet to be uncovered as future mortality estimates from CRC are ongoing. Due to the widespread closure of endoscopy centers and delay in screening, we believe that the pandemic worsened the screening disparities most prevalent among minority populations. Our study points to the drastic reduction of screening for all races, especially for African Americans.
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COVID-19 , Neoplasias do Colo , Neoplasias Colorretais , Idoso , COVID-19/epidemiologia , Estudos de Coortes , Neoplasias do Colo/diagnóstico , Neoplasias do Colo/epidemiologia , Colonoscopia , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/epidemiologia , Detecção Precoce de Câncer , Humanos , Programas de Rastreamento , Pessoa de Meia-Idade , Pandemias , Estudos RetrospectivosRESUMO
Article Title: ACG Clinical Guideline: Colorectal Cancer Screening 2020.
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PURPOSE OF REVIEW: People with cystic fibrosis (CF) are living longer. General age-related and CF-specific gastrointestinal symptoms are increasingly recognized. In this article, we review the latest data on luminal gastrointestinal manifestations in CF. RECENT FINDINGS: People with CF have increased incidence of gastroesophageal reflux disease symptoms and often prescribed proton-pump inhibitors (PPI). PPI use may increase risk of pulmonary exacerbations. Evidence to support gastric fundoplication to improve pulmonary outcomes is limited. Features of intestinal dysmotility are common. There are distinct differences in the gut microbiome in the CF population which may have clinical implications. CF is a possible hereditary digestive cancer syndrome, particularly in regard to colorectal cancer (CRC) with earlier incidence of CRC and advanced colonic neoplasia. Early screening colonoscopy is warranted in the CF population. Gastrointestinal manifestations in CF are prevalent across all digestive organs. More study on the effect of interventions for symptomatic treatment and cancer screening is needed.
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Neoplasias do Colo , Fibrose Cística , Colonoscopia , Fibrose Cística/complicações , Detecção Precoce de Câncer , Fundoplicatura , HumanosRESUMO
PURPOSE OF REVIEW: This article reviews iron deficiency anemia (IDA) and suspected small bowel bleeding (SSBB) from initial consultation through laboratory evaluation, endoscopic evaluation, and therapeutic options. RECENT FINDINGS: Recent guidelines on management of SSBB, IDA, video capsule endoscopy (VCE), and device-assisted enteroscopy (DAE) are reviewed. The advantages and limitations of VCE, DAE, and imaging are discussed. Medical treatment for refractory small bowel bleeding is discussed. Evaluation of IDA starts with a detailed history and physical exam. Additional lab work can establish the diagnosis of IDA and evaluate for associated conditions. If initial endoscopic tests are unrevealing, SSBB should be ruled out. Further investigation can be performed using video capsule endoscopy (VCE), device-assisted enteroscopy (DAE), and imaging. The mainstay of medical treatment of IDA secondary to SSBB is iron supplementation. Additional treatment is tailored to the pathology and may include medical, endoscopic and surgical options.
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Anemia Ferropriva , Endoscopia por Cápsula , Anemia Ferropriva/diagnóstico , Anemia Ferropriva/etiologia , Anemia Ferropriva/terapia , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/terapia , Humanos , Intestino DelgadoRESUMO
INTRODUCTION: Peptic ulcer disease (PUD) develops in approximately 25% of chronic users of non-steroidal anti-inflammatory drugs (NSAIDs). The incidence of uncomplicated PUD has been declining over the past 3 decades unlike that of complicated PUD in the elderly. An expert consensus document published jointly in 2008 by the American College of Gastroenterology (ACG), the American College of Cardiology Foundation (ACCF), and the American Heart Association (AHA) provided recommendations on prevention of PUD among users of antiplatelets and anticoagulants. This work aimed to evaluate physicians' compliance with these guidelines in a tertiary academic setting. METHODS: We examined our medical record database for the 9 month period extending from April 2018 until December 2018. Using this database, we identified elderly patients (> 64 years old) who were chronic (> 3 months) users of low dose aspirin (81 mg once daily) and had an indication for PUD prophylaxis as per the ACG-ACCF-AHA guideline document. We performed a retrospective chart review of patients included in this study. Descriptive statistics were compared using χ2 and independent sample t tests. RESULTS: A total of 852 patients were included in this study. The mean age was 75 years old, and 43% of patients were females. In addition to aspirin, patients were prescribed P2Y12 inhibitors (45.5%), direct oral anticoagulants (DOACs) (23%), warfarin (12%), steroids (9%) or enoxaparin (1%). Users of DOACs were most commonly prescribed apixaban (16%), followed by rivaroxaban (6%) and dabigatran (1%). Overall, only 40% of patients with an indication for PUD prophylaxis received a proton pump inhibitor. CONCLUSION: PUD prophylaxis may be underutilized in elderly patients. This finding, along with increasing rates of NSAID use and an aging population, may help explain the increased incidence of complicated PUD in the elderly. Efforts are needed to raise physician awareness of PUD prophylaxis guidelines.
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Anticoagulantes/efeitos adversos , Fármacos Gastrointestinais/uso terapêutico , Úlcera Péptica/prevenção & controle , Inibidores da Agregação Plaquetária/efeitos adversos , Idoso , Feminino , Humanos , Masculino , Estudos RetrospectivosRESUMO
The prevalence of Barrett's esophagus is increasing in the United States and is a major risk factor for esophageal adenocarcinoma. This review serves to help primary care physicians and family practitioners better understand who should be screened for Barrett's esophagus, know the appropriate surveillance intervals for repeat endoscopy, and understand therapeutic options for the management of Barrett's esophagus.
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Esôfago de Barrett/diagnóstico , Atenção Primária à Saúde/métodos , Vigilância de Evento Sentinela , Adenocarcinoma/diagnóstico , Adenocarcinoma/etiologia , Esôfago de Barrett/complicações , Esôfago de Barrett/terapia , Detecção Precoce de Câncer/métodos , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/etiologia , HumanosRESUMO
Gastroesophageal reflux disease (GERD) is a common clinical problem, affecting millions of people worldwide. Patients are recognized by both classic and atypical symptoms. Acid suppressive therapy provides symptomatic relief and prevents complications in many individuals with GERD. Advances in diagnostic and therapeutic modalities have improved our ability to identify and manage disease complications. Here, we discuss the pathophysiology and effects of GERD, and provide information on the clinical approach to this common disorder.
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Gerenciamento Clínico , Refluxo Gastroesofágico , Refluxo Gastroesofágico/tratamento farmacológico , Refluxo Gastroesofágico/fisiopatologia , HumanosRESUMO
A complaint of dysphagia suggests difficulty in swallowing and is characterized based on the symptoms and location of pathology. Oropharyngeal dysphagia is typically due to difficulty initiating a swallow and is generally due to structural, anatomic or neuromuscular abnormalities. Esophageal dysphagia arises after the swallow and causes include intrinsic structural pathology, extrinsic compression, or disruption in normal motility. Etiologies, methods of evaluation, and management options of dysphagia are reviewed here.
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Transtornos de Deglutição/diagnóstico , Avaliação de Sintomas/métodos , Deglutição , Diagnóstico Diferencial , HumanosRESUMO
Heartburn is among the most common gastrointestinal symptoms presenting to both generalist physicians and gastroenterologists. Heartburn that does not respond to traditional acid suppression is a diagnostic and therapeutic dilemma. In the era of high utilization of proton pump inhibitors, a substantial proportion of patients presenting to the gastroenterologist with chronic symptoms of heartburn do not have a reflux-mediated disease. Subjects without objective evidence of reflux as a cause of their symptoms have "functional heartburn". The diagnostic role of endoscopy, reflux and motility testing in functional heartburn (FH) patients is discussed. Lifestyle modifications, pharmacological interventions, and alternative therapies for FH are also presented. Recognition of patients with FH allows earlier assignment of these patients to different treatment algorithms, which may allow greater likelihood of success of treatment, diminished resource utilization and improved quality of life. Further data on this large and understudied group of patients is necessary to allow improvement in treatment algorithms and a more evidence-based approach to care of these patients.
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Azia/diagnóstico , Azia/terapia , Algoritmos , HumanosRESUMO
Advances in treatment for cystic fibrosis (CF), including cystic fibrosis transmembrane conductor regulator (CFTR) modulators, have ushered in an era where patients with CF have much longer life expectancies. This shift in life expectancy demands increased attention to diseases of aging in patients with CF. A notable complication of CF is early-onset colorectal cancer (CRC), which is especially prevalent in patients with severe mutations and after transplant. CFTR acts as a tumor suppressor gene based on knockout models. Lack of CFTR expression promotes carcinogenic processes such as intestinal inflammation and deleterious gut microbiome changes. The consensus Cystic Fibrosis Foundation recommendations advocate treating this population as a high-risk group, using a colonoscopy-only screening strategy starting at age 40 in patients without transplant and at age 30 after transplant. Screening should be considered every 5 years if negative and every 3 years or sooner for patients with adenomatous polyps. Future research will determine the role of noninvasive CRC screening tools in this population, as well as the effects of CFTR modulators on the risk of developing CRC.
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Neoplasias Colorretais , Regulador de Condutância Transmembrana em Fibrose Cística , Fibrose Cística , Detecção Precoce de Câncer , Humanos , Fibrose Cística/complicações , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/etiologia , Detecção Precoce de Câncer/métodos , Regulador de Condutância Transmembrana em Fibrose Cística/genética , Colonoscopia , Transplante de Pulmão , Adulto , Fatores de Risco , Guias de Prática Clínica como AssuntoRESUMO
Background and Objective: As life expectancy in cystic fibrosis (CF) has increased over the years, a shift in focus toward extra-pulmonary comorbidities such as gastrointestinal (GI) disease has become a topic of particular importance. Although not well-defined in the current literature, GI dysmotility is thought to significantly contribute to GI symptomatology in the CF population. The objective of this article was to provide a comprehensive review of diagnostic modalities at the disposal of the clinician in the evaluation of patients with CF (pwCF) presenting with GI complaints. Furthermore, we aimed to highlight the available literature regarding utilization of these modalities in CF, in addition to their shortcomings, and emphasize areas within the motility literature where further research is essential. Methods: A comprehensive review of all available literature in the English language through December 1, 2022 utilizing PubMed was conducted. Our search was limited to GI motility/transit and dysmotility in pwCF. Two researchers independently screened references for applicable articles and extracted pertinent data. Key Content and Findings: Several diagnostic imaging and manometry options exist in the evaluation of dysmotility; however, the literature is lacking in high-quality, prospective studies to validate such testing in pwCF. Common symptoms experienced and diagnostic motility tools available based on segment of the GI tract as related to pwCF are explored in the current review. Shortcomings in the current literature are identified and future direction to enhance research efforts within the field of CF-related dysmotility is provided. Conclusions: The influence of CF on GI integrity and motility is far-reaching. Despite improvements in longevity and advancement of pulmonary-specific treatment strategies, further high-quality research targeting the evaluation and management of GI dysmotility in pwCF is needed.
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BACKGROUND: Although cystic fibrosis (CF) is widely considered a lung disease, the prevalence of CF-specific gastrointestinal symptoms and diseases has continued to rise. Peptic ulcer disease (PUD) has not been well-studied among people with CF (PwCF) and may be a common cause of abdominal symptoms. In PwCF, impaired bicarbonate secretion and unbuffered gastric acid production have been attributed to the development of ulcers, although ulcers remain uncommon. The objective of this study was to evaluate the prevalence of PUD in PwCF and assess for possible contributing factors. METHODS: This study utilized the National Inpatient Sample (NIS) database. All patients 18 years or older with CF were identified from 2014 to 2019. Relevant patient characteristics and procedures were identified using ICD-9 and ICD-10 codes. Linear trend, bivariate analyses, and multiple regression analysis were performed. The outcomes of interest were peptic ulcer disease, pancreatic insufficiency, and nonalcoholic steatohepatitis or NASH. All analyses accounted for complex sampling scheme of the NIS. RESULTS: The total prevalence of PwCF in the National Inpatient Sample (NIS) database was 0.08%, and the number was stable year to year from 2014 to 2019. Hispanic patients were more likely to be diagnosed with PUD than other white (aOR 1.802 [1.311,2.476]). Multiple regression analysis indicated that PUD in PwCF was strongly associated with a diagnosis of NASH (aOR 2.421[1.197, 4.898]). PUD patients were less likely to have pancreatic insufficiency compared to the non-PUD group (aOR 0.583 [0.455, 0.745]). CONCLUSION: Although cystic fibrosis has been historically known as a disease of childhood, advancements in therapy have led to prolonged life expectancy and higher prevalence for cystic fibrosis-related digestive diseases. This study revealed a low prevalence of PUD in PwCF. Hispanics and those with NASH are more likely to develop peptic ulcers.
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Background: Colonic diverticulosis and colon polyps are common findings on colonoscopy. There is currently no consensus regarding a possible connection between the development of polyps and diverticulosis. Multiple research studies have sought to analyze whether the presence of both conditions is associated with the development of colorectal cancer. Our study aims to add to this body of data and to better assess the relationship between diverticulosis and colon polyps. Methods: A retrospective chart review was performed of all patients who underwent screening and diagnostic colonoscopies between January 2011 and December 2020. Data collection included patient demographics; number, pathology, and location of colon polyps; incidence of colon cancer; and presence and location of colonic diverticulosis. Results: Our study demonstrated that the overall presence of diverticulosis in any location increases the likelihood of having nearby colon polyps, regardless of subtype. The presence of left colonic diverticulosis was particularly associated with adjacent adenomatous and non-adenomatous colon polyps. Conclusions: Colonic diverticulosis in any location may lead to an increased incidence of adenomatous colon polyps. It is important to perform careful examination of the mucosa surrounding colon diverticulosis to avoid missing colon polyps.
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UNLABELLED: Coinfection with hepatitis A virus (HAV) or hepatitis B virus (HBV) in patients with chronic hepatitis C virus (HCV) is associated with increased morbidity and mortality. The Center for Medicare and Medicaid Services has identified HAV and HBV vaccination as a priority area for quality measurement in HCV. It is unclear to what extent patients with HCV meet these recommendations. We used national data from the Department of Veterans Affairs HCV Clinical Case Registry to evaluate the prevalence and predictors of meeting the quality measure (QM) of receiving vaccination or documented immunity to HAV and HBV in patients with chronic HCV. We identified 88,456 patients who had overall vaccination rates of 21.9% and 20.7% for HBV and HAV, respectively. The QM rates were 57.0% and 45.5% for HBV and HAV, respectively. Patients who were nonwhite or who had elevated alanine aminotransferase levels, cirrhosis, or human immunodeficiency virus were more likely to meet the HBV QM. Factors related to HCV care were also determinants of meeting the HBV QM. These factors included receiving a specialist consult, genotype testing, or HCV treatment. Patients who were older, had psychosis, and had a higher comorbidity score were less likely to meet the HBV QM. With a few exceptions, similar variables were related to meeting the HAV QM. The incidence of superinfection with acute HBV and HAV was low, but it was significantly lower in patients who received vaccination than in those who did not. CONCLUSION: Quality measure rates for HAV and HBV are suboptimal for patients with chronic HCV. In addition, several patient-related factors and receiving HCV-related care are associated with a higher likelihood of meeting QMs.
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Vacinas contra Hepatite A/uso terapêutico , Vacinas contra Hepatite B/uso terapêutico , Hepatite C Crônica/imunologia , Garantia da Qualidade dos Cuidados de Saúde , Adulto , Idoso , Feminino , Anticorpos Anti-Hepatite A/sangue , Anticorpos Anti-Hepatite B/sangue , Hepatite C Crônica/terapia , Humanos , Masculino , Medicare/normas , Pessoa de Meia-Idade , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Estados Unidos/epidemiologia , United States Department of Veterans Affairs , Vacinação/estatística & dados numéricosRESUMO
Intussusception more commonly occurs in pediatrics but is a rare cause of bowel obstruction and gastrointestinal bleeding in adults. It typically occurs in adults due to a malignancy, which serves as a pathologic lead point. We present a case of a 64-year-old female with nausea, vomiting, and melena who was found to have intussusception associated with a primary jejunal amelanotic melanoma. Both intussusception and primary small bowel melanomas are rare causes of obstruction and bleeding. Intussusception occurring as a result of a primary small bowel amelanotic melanoma is exceedingly rare with very few reported cases. We provide a case report and review of the literature.