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Little data is available regarding the incidence of gastrointestinal bleeding in adults hospitalized with COVID-19 infection and the influence of patient comorbidities and demographics, COVID-19 therapies, and typical medications used. In this retrospective study, we utilized the National COVID Cohort Collaborative to investigate the primary outcome of the development of gastrointestinal bleeding in 512 467 hospitalized US adults (age >18 years) within 14 days of a COVID-19 infection and the influence of demographics, comorbidities, and selected medications. Gastrointestinal bleeding developed in 0.44% of patients hospitalized with COVID-19. Comorbidities associated with gastrointestinal bleeding include peptic ulcer disease (adjusted odds ratio [aOR] 10.2), obesity (aOR 1.27), chronic kidney disease (aOR 1.20), and tobacco use disorder (aOR 1.28). Lower risk of gastrointestinal bleeding was seen among women (aOR 0.76), Latinx (aOR 0.85), and vaccinated patients (aOR 0.74). Dexamethasone alone or with remdesivir was associated with lower risk of gastrointestinal bleeding (aOR 0.69 and aOR 0.83, respectively). Remdesivir monotherapy was associated with upper gastrointestinal bleeding (aOR 1.25). Proton pump inhibitors were more often prescribed in patients with gastrointestinal bleeding, likely representing treatment for gastrointestinal bleeding rather than a risk factor for its development. In adult patients hospitalized with COVID-19, the use of dexamethasone alone or in combination with remdesivir is negatively associated with gastrointestinal bleeding. Remdesivir monotherapy is associated with increased risk of upper gastrointestinal bleeding.
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COVID-19 , Pacientes Internos , Adulto , Humanos , Femenino , Adolescente , Estudios Retrospectivos , COVID-19/complicaciones , COVID-19/epidemiología , Hemorragia Gastrointestinal/epidemiología , Hemorragia Gastrointestinal/tratamiento farmacológico , Hemorragia Gastrointestinal/prevención & control , Factores de Riesgo , Dexametasona/uso terapéuticoRESUMEN
BACKGROUND: POEM has been successfully performed in patients with spastic esophageal disorders (SED), such as diffuse esophageal spasm, jackhammer esophagus, and type 3 achalasia. We performed a systematic review and meta-analysis to evaluate its efficacy in these patients and if total average myotomy length and prior medical or endoscopic treatments affected clinical success. METHODS: PubMed, EMBASE, Google-Scholar, Scopus, and Cochrane Review were searched for studies on POEM in SED from 2008 to September 2018. Clinical success was determined by Eckardt score (≤ 3) at follow-up. Sub-group analysis was performed based on myotomy length and evaluates the effect of prior treatments on clinical success. RESULTS: 9 studies with 210 patients were included in the final analysis. We found that the pooled rate of clinical success for POEM was 89.6% (95% CI 83.5-93.1, 95% PI 83.4-93.7, I2 = 0%). In three studies (50 patients), where total myotomy length was < 10 cm, the pooled rate of clinical success was 91.1% (95% CI 79.5-96.4, I2 = 0%). In six studies (160 patients), the length was > 10 cms and the pooled rate of clinical success was 89.1% (95% CI 83.0-93.2, I2 = 0%). The difference between these results was not statistically significant (p = 0.69). Additionally, a meta-regression analysis showed that prior treatment status did not significantly affect the primary outcome (p = 0.43). CONCLUSIONS: While it is well known that POEM is a safe and effective treatment for spastic esophageal disorders, we conclude that variation in total myotomy length and prior endoscopic or medical treatments did not have a significant effect on clinical success.
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Acalasia del Esófago/cirugía , Trastornos de la Motilidad Esofágica/cirugía , Espasmo Esofágico Difuso/cirugía , Esofagoscopía , Miotomía , Cirugía Endoscópica por Orificios Naturales , Esofagoscopía/efectos adversos , Esofagoscopía/métodos , Humanos , Miotomía/efectos adversos , Miotomía/métodos , Cirugía Endoscópica por Orificios Naturales/efectos adversos , Cirugía Endoscópica por Orificios Naturales/métodos , Resultado del TratamientoRESUMEN
BACKGROUND AND AIMS: Gastric peroral endoscopic myotomy (G-POEM) is a novel minimally invasive technique in endosurgery. Data is limited as to its efficacy, safety, and predictive factors. We conducted this meta-analysis to evaluate the clinical outcomes of G-POEM and used the outcomes of surgical pyloroplasty as a comparator group in the treatment of refractory gastroparesis. METHODS: We searched multiple databases from inception through March 2019 to identify studies that reported on G-POEM and pyloroplasty in gastroparesis. Our primary outcome was to analyze and compare the pooled rates of clinical success, in terms of Gastroparesis Cardinal Symptom Index (GCSI) score and 4-h gastric emptying study (GES) results, with G-POEM and pyloroplasty. RESULTS: Three hundred and thirty-two and 375 patients underwent G-POEM (11 studies) and surgical pyloroplasty (seven studies), respectively. The pooled rate of clinical success, based on the GCSI score, with G-POEM was 75.8% (95% CI 68.1-82.1, I2 = 50) and with surgical pyloroplasty was 77.3% (95% CI 66.4-85.4, I2 = 0), with no significance, p = 0.81. The pooled rate of clinical success, based on the 4-hour GES results, with G-POEM was 85.1% (95% CI 68.9-93.7, I2 = 74) and with surgical pyloroplasty was 84% (95% CI 64.4-93.8, I2 = 81), with no significance, p = 0.91. The overall adverse events were comparable. Based on meta-regression analysis, idiopathic gastroparesis, prior treatment with botulinum toxin and gastric stimulator seemed to predict clinical success with G-POEM. CONCLUSION: G-POEM demonstrates clinical success in treating refractory gastroparesis. Idiopathic gastroparesis, prior treatment with botulinum injections and gastric stimulator appear to have positive predictive effects on the 4-h GES results after G-POEM. Outcomes seem comparable to surgical pyloroplasty.
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Gastroparesia/cirugía , Piloromiotomia , Gastroplastia/efectos adversos , Gastroplastia/métodos , Gastroplastia/estadística & datos numéricos , Humanos , Complicaciones Posoperatorias , Piloromiotomia/efectos adversos , Piloromiotomia/métodos , Piloromiotomia/estadística & datos numéricos , Píloro/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND AND GOALS: Gastrointestinal bleeding (GIB) is a significant complication following left ventricular assist device (LVAD) implantation. We evaluated the incidence, predictors, endoscopic findings, and outcomes of GIB in LVAD recipients. STUDY: Retrospective review of 205 adult patients undergoing HeartMate II LVAD implantation from January 2012 to June 2016. Patients were reviewed and separated into GIB (n=57; 28%) and non-GIB (n=148; 72%) groups. RESULTS: Median time to GIB was 55 (range, 3 to 730) days. The GIB group patients were older (61±12 vs. 56±13, P=0.0042), more often underwent concomitant tricuspid valve (TV) repair (16% vs. 4%, P=0.007), and a higher percentage were assigned for destination therapy (75% vs. 55%, P=0.01). Angioectasia (33%) was the most common identified cause of GIB. Median time to endoscopic intervention was 1 day. The total number of hospital readmissions after LVAD was higher in the GIB group (median of 5 vs. 3, P=0.001), as was the total number of blood products transfused after LVAD (29 vs. 13, P≤0.0001). GIB was associated with an increased risk of death (hazard ratio, 1.94; 95% confidence interval, 1.16-3.25; P=0.01) and the mortality rate during hospitalization for GIB was 11% (P=0.0004). Receiving a heart transplant was associated with a decreased hazard of death (hazard ratio, 0.40; 95% confidence interval, 0.19-0.85; P=0.016). CONCLUSIONS: Older age and destination therapy as implant strategy were found to be associated with an increased risk of GIB, consistent with previous studies. A unique finding in our study is the association of TV repair with a higher incidence of GIB. Further studies are needed to investigate possible mechanisms by which TV repair increases the incidence of GIB.
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Hemorragia Gastrointestinal/epidemiología , Ventrículos Cardíacos , Corazón Auxiliar , Factores de Edad , Anticoagulantes/efectos adversos , Femenino , Hemorragia Gastrointestinal/etiología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Nebraska/epidemiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de RiesgoAsunto(s)
Enfermedades del Colon/complicaciones , Diarrea/etiología , Infecciones por Spirochaetales/complicaciones , Antibacterianos/uso terapéutico , Enfermedades del Colon/diagnóstico , Enfermedades del Colon/tratamiento farmacológico , Enfermedades del Colon/patología , Humanos , Masculino , Metronidazol/uso terapéutico , Persona de Mediana Edad , Infecciones por Spirochaetales/diagnóstico , Infecciones por Spirochaetales/tratamiento farmacológico , Infecciones por Spirochaetales/patologíaRESUMEN
BACKGROUND: Patient selection for the diverse surgical procedures for gastroparesis remains poorly defined. Our aim was to evaluate how patient factors have determined our surgical approach to gastroparesis. METHODS: 95 patients undergoing 105 surgical procedures for gastroparesis were reviewed. Patient factors were compared across six surgical procedures: gastric neurostimulator, pyloroplasty, neurostimulator plus pyloroplasty, sleeve gastrectomy, gastric bypass and gastrectomy. Global symptom severity was determined preoperatively and at last follow up. RESULTS: There were significant differences in etiology, BMI and gastroesophageal reflux across the various operations. Patients undergoing pyloroplasty and gastrectomy; were more likely to have a postsurgical etiology. (p < .05) Patients undergoing sleeve gastrectomy and gastric bypass were more likely to have BMI >35. (p <.05) Those undergoing sleeve gastrectomy were less likely to have gastroesophageal reflux preoperatively. (p <.05) There was no difference in preoperative clinical stage across the procedures. CONCLUSION: Patient factors influence choice of procedure in the surgical treatment of gastroparesis. Etiology of gastroparesis, BMI >35 and gastroesophageal reflux are important determinants.
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Toma de Decisiones , Gastrectomía/métodos , Derivación Gástrica/métodos , Vaciamiento Gástrico/fisiología , Gastroparesia/cirugía , Femenino , Gastroparesia/fisiopatología , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
There is an increasing number of confirmed cases and deaths caused by the Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) contributing to the Coronavirus disease 2019 (COVID-19) pandemic. At this point, the need for further disease characterization is critical. COVID-19 is well established as a respiratory tract pathogen; however, recent studies have shown an increasing number of patients reporting gastrointestinal manifestations such as diarrhea, nausea, vomiting, and abdominal pain. The time from onset of gastrointestinal symptoms to hospital presentation is often delayed compared to that of respiratory symptoms. It has been noted that SARS-CoV-2 RNA can be detected in fecal matter for an extended period of time, even after respiratory samples have tested negative and patients are asymptomatic. In this article, SARS-CoV-2 and its disease COVID-19 will be reviewed with consideration of the latest literature about gastrointestinal symptomatology, the mechanisms by which the virus may inflict damage, and the possibility of viral replication contributing to a fecal-oral route of transmission.
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Betacoronavirus/fisiología , Infecciones por Coronavirus/epidemiología , Diarrea/virología , Enfermedades del Sistema Digestivo/epidemiología , Pandemias , Neumonía Viral/epidemiología , Betacoronavirus/genética , Betacoronavirus/aislamiento & purificación , COVID-19 , Infecciones por Coronavirus/prevención & control , Infecciones por Coronavirus/transmisión , Infecciones por Coronavirus/virología , Enfermedades del Sistema Digestivo/prevención & control , Enfermedades del Sistema Digestivo/virología , Heces/virología , Tracto Gastrointestinal/virología , Humanos , Hígado/virología , Oxígeno/administración & dosificación , Páncreas/virología , Pandemias/prevención & control , Neumonía Viral/prevención & control , Neumonía Viral/transmisión , Neumonía Viral/virología , Respiración Artificial , SARS-CoV-2 , Replicación Viral , Vómitos/virologíaRESUMEN
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.
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Analgésicos Opioides/efectos adversos , Estreñimiento/tratamiento farmacológico , Defecación/efectos de los fármacos , Motilidad Gastrointestinal/efectos de los fármacos , Naltrexona/análogos & derivados , Antagonistas de Narcóticos/uso terapéutico , Estreñimiento/inducido químicamente , Estreñimiento/diagnóstico , Estreñimiento/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Naltrexona/efectos adversos , Naltrexona/uso terapéutico , Antagonistas de Narcóticos/efectos adversos , Recuperación de la Función , Resultado del TratamientoRESUMEN
Duodenum inversum (DI), also known as inverted duodenum or duodenum reflexum, is a congenital malformation in which the third portion of the duodenum, instead of continuing leftward to the ligament of Treitz, reverses direction and travels in a superior, posterior track prior to crossing the midline above the pancreas. We present a case of a 62-year-old woman presenting with chronic nausea and vomiting, subsequently found to have DI.
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A 55-year-old woman presented with persistent nausea, vomiting, and weight loss previously attributed to Ménétrier's disease. On further workup, she was found to have metastatic lobular breast carcinoma causing gastric outlet obstruction, diagnosed by endoscopic ultrasound with fine needle aspiration after previous gastric mucosal biopsies were unremarkable. In most reported cases of gastric metastasis from breast cancer, a diagnosis was established by mucosal biopsy. This case is an important reminder that mucosal biopsies can be negative in about 20% of patients with gastric metastasis, which may lead to a delay in diagnosis and treatment. Gastroenterologists should be diligent in taking deeper biopsies if there is a suspicion for gastric metastasis.
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The treatment of autoimmune hepatitis is evolving as the natural history of the disease and newer agents become available. This concise review will outline the various treatment options in these patients. Treatment with current corticosteroids and azathioprine works in most patients but issues of intolerance and incomplete response arise. These situations led to the investigation of newer immunosupressants including mycophenolate mofetil, budesonide cyclosporine, tacrolimus and ursodeoxycholic acid. The newer agents have been studied in small patient numbers so they are not first-line treatment yet but do have a clear role in those patients with intolerance of incomplete response to standard corticosteroids and azathioprine.
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Corticoesteroides/uso terapéutico , Hepatitis Autoinmune/tratamiento farmacológico , Inmunosupresores/uso terapéutico , Corticoesteroides/administración & dosificación , Hepatitis Autoinmune/inmunología , Humanos , Inmunosupresores/administración & dosificaciónRESUMEN
We describe two patients who developed gastrointestinal bleeding due to cytomegalovirus (CMV) colitis after placement of a HeartMate II left ventricular assist device (LVAD). We aim to raise awareness of CMV colitis as a possible cause of gastrointestinal bleeding after LVAD placement and discuss potential mechanisms for CMV reactivation and areas for future research.