Accuracy of liver stiffness, spleen stiffness, and LS-spleen diameter to platelet ratio score in detection of esophageal varices: Systemic review and meta-analysis.

BACKGROUND AND AIM: There is increasing evidence of non-invasive measurement using elastography such liver stiffness (LS), spleen stiffness (SS), and LS-spleen diameter to platelet ratio score (LSPS) for detection of esophageal varices (EV); however, data regarding comparison between these three parameters are limited. METHODS: We performed a systemic review and meta-analysis of studies evaluating performance of LS, SS, and LSPS for detection of EV and high risk/clinically significant EV (HREV). Pooled sensitivity, specificity, log diagnostic odd ratio (LDOR), and area under the receiver operating characteristic curve (AUC) of LS, SS, and LSPS for detection of EV and HREV were analyzed and compared. Publication bias was assessed by Deeks' funnel plot. RESULTS: SS and LSPS were superior to LS for detection of EV with higher sensitivity (0.90 and 0.91 vs 0.85), specificity (0.73 and 0.76 vs 0.64), LDOR (3.24 and 3.35 vs 2.26), and AUC (0.899 and 0.851 vs 0.817). For HREV, SS had the highest sensitivity (0.87) followed by LS (0.85) and LSPS (0.82); however, SS had the lowest specificity (0.52), LDOR (2.09), and AUC (0.807) whereas LSPS had the highest specificity (0.77), LDOR (2.74), and AUC (0.861). CONCLUSION: For detection of EV, we prefer using LSPS and SS over LS when available, while LS, SS, and LSPS cannot be recommended for detection of HREV due to their moderate sensitivity and specificity.

Endoscopic surveillance for gastric ulcers.

OBJECTIVE: Gastric ulcers (GUs) can be caused by a malignancy, and endoscopists are challenged with the question of how to rule out underlying malignancy. Although routine endoscopic surveillance is not advised, it is still overused. The purpose of this study was to explore the practice in our tertiary referral center during the last 3 years. METHODS: We retrospectively reviewed all inpatient and outpatient esophagogastroduodenoscopies (EGDs) that were performed between November 2009 and November 2012 for GUs. Patients with GUs who normally would not undergo biopsy, such as patients who present with bleeding or had stigmata of high-risk bleeding, were excluded. RESULTS: A total of 165 patients were diagnosed between November 2009 and November 2012 as having GUs on EGD. Fifty-two patients were excluded because they presented with bleeding or had GUs that had stigmata of high-risk bleeding. We reviewed the charts of 113 patients and endoscopic surveillance was recommended for 96 (85%). Of those 96 patients, 72 (64%) underwent repeat EGD. In those 72 patients, GU was still present in 9 patients and was completely healed or healing in 63 patients. Only 25 (22%) GUs were biopsied at initial EGD, 23 of which were benign and 2 were adenocarcinomas. No additional malignancy was found on surveillance EGD. CONCLUSIONS: EGD surveillance for GUs is a common practice, although the guidelines discourage such a practice. Our rate of endoscopic surveillance was significantly higher than reported previously (64% vs 25%). In our experience, such a high rate of surveillance did not reveal any additional gastric malignancy. Alternatively, the rate of biopsy of GUs at initial EGD is low (22%), which also reflects endoscopists' preference for endoscopic surveillance.

Efficacy of naldemedine for the treatment of opioid-induced constipation: A meta-analysis.

BACKGROUND AND AIM: Opioid induced constipation (OIC) is the most common side effect of opioid therapy. It can lead to a decreased quality of life. Naldemedine is a peripherally acting µ-opioid receptor antagonist that has been recently studied in randomized controlled trials (RCTs) for the management of OIC. The aim of this study is to perform a meta-analysis of existing clinical trials to estimate the efficacy and safety of naldemedine in opioid-induced constipation. METHODS: A systematic search of PubMed, CINAHL, Scopus, Cochrane database of systematic reviews, and ClinicalTrials.gov registry was performed in March 2018. Two independent reviewers systematically identified prospective RCTs published in the English language that compared the effect of oral naldemedine versus placebo in adults with OIC. Meta-analysis was performed using a random effects model to assess the primary outcome: spontaneous bowel movement (SBM) responder rates. Assessed secondary outcomes were: a change in SBM frequency per week from baseline during the treatment period, change from baseline in the frequency of complete SBM and incidence of treatment-emergent adverse events. Review Manager 5.3 software program was utilized for statistical analysis. RESULTS: Six RCTs met the inclusion criteria. A total of 2,762 patients were included in the meta-analysis. The proportion of SBM responders was significantly higher in the naldemedine group compared to the placebo group (56.4%, vs. 34.7%, p<0.00001). There was no statistically significant difference in treatment-emergent adverse events between naldemedine group and placebo group (mean odds ratio=1.18, p = 0.25, 95% CI: 0.89-1.55). Change in SBM frequency was higher in the naldemedine group versus placebo group (p<0.00001), as well as the change in complete SBM frequency. CONCLUSIONS: Naldemedine 0.2 mg daily significantly improved symptoms in patients with opioid-induced constipation and was generally well tolerated. These results support the use of naldemedine for the treatment of opioid-induced constipation.

Performance of ultrasound for detection of transjugular intrahepatic portosystemic shunt dysfunction: a meta-analysis.

PURPOSE: Although ultrasound has been widely used to evaluate transjugular intrahepatic portosystemic shunts (TIPS) patency, several studies have reported conflicting data regarding its performance. Therefore, we aimed to evaluate performance of ultrasound for detection of TIPS dysfunction by performing a meta-analysis. METHODS: Literature search was performed for studies evaluating ultrasound for TIPS dysfunction, stenosis, and occlusion using PubMed, EMBASE, Scopus, and Cochrane Library through February 2019. Pooled sensitivity, specificity, log diagnostic odds ratio (LDOR), and area under curve (AUC) of summary receiver-operating characteristic were calculated. Subgroup analyses were performed according to ultrasonographic criteria and type of stent. RESULTS: In total, 21 studies were evaluated. Pooled sensitivity, specificity, and LDOR of ultrasound for detection of TIPS dysfunction were 0.82 (0.67, 0.93), 0.58 (0.46, 0.70), and 1.77 (1.20, 2.35). Pooled sensitivity, specificity, and LDOR for TIPS stenosis were 0.80 (0.69, 0.90), 0.80 (0.69, 0.91), and 2.83 (1.88, 3.78). Pooled sensitivity, specificity, and LDOR for TIPS occlusion were 0.96 (0.92, 0.99), 1 (0.99, 1.00), and 6.28 (4.96, 7.60). AUCs of ultrasound for TIPS dysfunction, stenosis, and occlusion were 0.77, 0.86, and 0.95, respectively. CONCLUSIONS: Although ultrasound had excellent performance for TIPS occlusion and acceptable performance for TIP stenosis, most studies utilized bare metal stent, and therefore, application to current practice is limited. Ultrasound for TIPS dysfunction in the setting of covered metal stent appeared to have acceptable sensitivity of 0.82, but limited specificity of 0.58 and low LDOR of 1.77. A new noninvasive tool is needed for detection of TIPS dysfunction in the era of covered metal stent.

The effect of indomethacin in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis.

OBJECTIVES: Acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) is a severe complication with substantial morbidity and mortality. Indomethacin has been identified to prevent this complication; however, the results using indomethacin have varied. Therefore, we performed a meta-analysis on the efficacy of rectally administered indomethacin in the prevention of post-ERCP pancreatitis (PEP). METHODS: A systematic search was performed in November 2012. Randomized, placebo-controlled trials (randomized controlled trials) in adult patients that compared rectally administered indomethacin versus placebo in prevention of PEP were included. Meta-analysis was performed using a fixed-effects model to assess the primary outcome (PEP) and secondary outcomes (mild or moderate to severe PEP) using Review Manager 5.1. RESULTS: Four randomized controlled trials met the inclusion criteria (n = 1422). The use of indomethacin near the time of ERCP demonstrated a statistically significant decrease in PEP (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.34-0.71; P < 0.01), mild PEP (OR, 0.52; 95% CI, 0.32-0.86; P = 0.01), and moderate to severe PEP (OR, 0.45; 95% CI, 0.24-0.83; P = 0.01) as compared with placebo. The number needed to treat with indomethacin to prevent 1 episode of pancreatitis is 17 patients. CONCLUSIONS: Rectal indomethacin significantly reduced the incidence of PEP. We recommend using indomethacin before or just after the procedure in patients undergoing ERCP.

Idiopathic CD4 Lymphocytopenia: Spectrum of opportunistic infections, malignancies, and autoimmune diseases.

Idiopathic CD4 lymphocytopenia (ICL) was first defined in 1992 by the US Centers for Disease Control and Prevention (CDC) as the repeated presence of a CD4+ T lymphocyte count of fewer than 300 cells per cubic millimeter or of less than 20% of total T cells with no evidence of human immunodeficiency virus (HIV) infection and no condition that might cause depressed CD4 counts. Most of our knowledge about ICL comes from scattered case reports. The aim of this study was to collect comprehensive data from the previously published cases to understand the characteristics of this rare condition. We searched the PubMed database and Science Direct for case reports since 1989 for Idiopathic CD4 lymphocytopenia cases. We found 258 cases diagnosed with ICL in 143 published papers. We collected data about age, sex, pathogens, site of infections, CD4 count, CD8 count, CD4:CD8 ratio, presence of HIV risk factors, malignancies, autoimmune diseases and whether the patients survived or died. The mean age at diagnosis of first opportunistic infection (or ICL if no opportunistic infection reported) was 40.7 ± 19.2 years (standard deviation), with a range of 1 to 85. One-sixty (62%) patients were males, 91 (35.2%) were females, and 7 (2.7%) patients were not identified whether males or females. Risk factors for HIV were documented in 36 (13.9%) patients. The mean initial CD4 count was 142.6 ± 103.9/mm(3) (standard deviation). The mean initial CD8 count was 295 ± 273.6/mm(3) (standard deviation). The mean initial CD4:CD8 ratio was 0.6 ± 0.7 (standard deviation). The mean lowest CD4 count was 115.4 ± 87.1/mm(3) (standard deviation). The majority of patients 226 (87.6%) had at least one infection. Cryptococcal infections were the most prevalent infections in ICL patients (26.6%), followed by mycobacterial infections (17%), candidal infections (16.2%), and VZV infections (13.1%). Malignancies were reported in 47 (18.1%) patients. Autoimmune diseases were reported in 37 (14.2%) patients.

Cystic avascular necrosis of the triquetrum.

Carpal bones are rarely affected by avascular necrosis (AVN) in the absence of fractures. The lunate is the most frequently affected carpal bone, followed by the scaphoid and the capitate. The triquetrum is rarely affected by AVN. We report a case of multiple cystic changes in the triquetrum in a patient with a history of trauma. He was treated by below elbow Colles plaster cast for 3 months, with no improvement. Cystic changes resulted from irreversible AVN of the triquetrum. This is the first case to be reported in the literature with cystic AVN changes in the triquetrum.

Multiloculated pleural effusion detected by ultrasound only in a critically-ill patient.

BACKGROUND: Multiloculated pleural effusion is a life-threatening condition that needs early recognition. Drainage by chest tube might be difficult which necessitates a surgical intervention. While x-ray typically does not show loculations, CT scan might not also identify the loculations. Ultrasound has a high sensitivity in detecting pleural diseases including multiloculated pleural effusion. CASE REPORT: A 55-year-old female presented with dyspnea, cough and yellowish sputum for 3 days. Her heart rate was 136 bpm ,O2 saturation 88%, and WBC 21,000/mcL. Chest x-ray showed complete opacification of right lung. A chest tube insertion was unsuccessful. CT scan of the chest showed large pleural effusion occupying the right hemithorax with collapse of the right lung. Bedside ultra-sound showed a multiloculated pleural effusion with septations of different thickness. The patient subsequently underwent thoracotomy which showed multiple, fluid-filled loculations with significant adhesions. The loculations were dissected along with decortications of thick a pleural rind. Blood and pleural fluid cultures grew Streptococcus pneumoniae and the patient was treated successfully with Penicillin G. CONCLUSIONS: We advocate bedside ultrasound in patients with complete or near complete opacification of a hemithorax on chest x-ray. CT scan is less likely to show septations within pleural effusions compared to ultrasounnd. Therefore, CT scan and ultrasound are complementary for the diagnosis of empyema and multiloculated pleural effusion.

Malnutrition secondary to non-compliance with vitamin and mineral supplements after gastric bypass surgery: What can we do about it?

BACKGROUND: Nutritional deficiency due to loss of follow up and non-compliance with routine mineral and multivitamin supplements is not uncommonly encountered following bariatric surgery. In this report, and utilizing a case study, we will address issues related to loss of long term medical follow up and the measures that can be taken to prevent it in this patient population. CASE REPORT: The case of a 38-year-old female patient who was recently managed for severe vitamin deficiency and iron deficiency anemia following bariatric surgery is presented. Non-compliance with routine vitamin and mineral supplements was believed to be the main culprit of her condition. Articles published in English addressing issues related to non-compliance with supplementations and regular follow up after bariatric surgery were accessed from PubMed and are discussed. CONCLUSIONS: Multiple factors affecting long term follow up and compliance have been studied including age, financial costs, distance from the clinic and psychiatric comorbidities. Preventive measures have also been tested and some of them have shown significant benefit. More research is needed to identify other modifiable factors and preventive measures influencing compliance and long term follow up following bariatric surgery.

Superior and Inferior Extension of Carotid Body Tumors.

Carotid body tumors typically arise at the level of the common carotid bifurcation where the carotid body exists. Superior and inferior extension beyond the carotid body may occur as well, especially if the tumor is long-standing. We herein describe a case of carotid body tumor in a patient who presented with a right-sided neck mass for 30 years. Computed tomography angiography (CTA) and B-mode sonography with color-coded Doppler sonography showed a vascular tumor arising at the level of the right common carotid artery bifurcation with superior and inferior extension beyond the bifurcation. This report emphasizes the utility of computed tomography angiography (CTA) and B-mode sonography with color-coded Doppler sonography as non-invasive modalities in visualizing the extension of carotid body tumors.

Sarcoidosis: an extremely rare cause of granulomatous enterocolitis.

Clinically recognizable gastrointestinal (GI) system involvement with sarcoidosis is extremely rare. We present a case of a 51-year-old Caucasian male who was evaluated for abdominal pain, elevated liver enzymes, leukopenia, thrombocytopenia, severe peripheral arthralgias, and chronic watery diarrhea. He had a history of mediastinal and periaortic lymphadenopathy. Extensive laboratory work up for liver diseases, infections, malabsorption and a bone marrow biopsy was essentially unremarkable. Eso-gastroduodenoscopy was unremarkable. Colonoscopy showed scattered right colon ulcerations and erythema. The terminal ileum appeared normal. Biopsies from the duodenum, terminal ileum, and colon showed intramucosal non-caseating granulomas with focal multinucleate giant cell formation in a background of chronic active duodenitis, ileitis, and colitis. Liver biopsy showed moderate non-specific chronic hepatitis with non-caseating granulomas present within portal and lobular parenchyma. The clinical presentations, along with biopsy results were suggestive of sarcoidosis. The patient was started on prednisone and had a significant improvement in his symptoms including diarrhea.