Epidemiology and Racial Differences of EoE Patients in a U.S. Veterans Population.

BACKGROUND: Eosinophilic esophagitis (EoE) is increasing in prevalence but there is a lack of population-based studies. We sought to determine the prevalence, demographics, and associated atopic diseases in the Veterans Affairs (VA) population. METHODS: A nationwide analysis of data from the VA patient population was done using a Veterans Health Administration database. EoE was identified using ICD9 (530.13) and ICD10 (K20.0) codes from October 2008 to June 2020. Demographic data, smoking status, BMI, treatment, and ICD codes for atopic diagnoses were collected. Two sample proportion z-tests, Chi-square tests, two-sample t tests, and one-way ANOVA were used to assess associations across demographic categories. RESULTS: We identified a total of 11,775 patients with an EoE diagnosis: 91% male, 83% White, 8.6% Black, and 5% were of Hispanic ethnicity. The prevalence of EoE increased over time. At diagnosis, the mean age was 48.5 years overall, 51.6 years for Black patients, 45.3 years for Hispanic patients, and 48.2 years for Whites. Dysphagia was the most common symptom overall, but a higher percentage of Blacks and females were found to report chest pain (p < 0.0001, h = 0.32). With the exception of urticaria and atopic dermatitis, both Blacks and Hispanics had a higher incidence of atopic conditions compared to other races and ethnicities (p < 0.0001). CONCLUSION: While EoE is seen primarily in White males, our study shows that a notable percentage of patients were Black or Hispanic, suggesting that EoE should be considered in non-white patients. The later age of diagnosis in this group could represent a lack of awareness about EoE among non-white patients. More research is needed to study these associations.

The 2022 top 10 list of endoscopy topics in medical publishing: an annual review by the American Society for Gastrointestinal Endoscopy Editorial Board.

Using a systematic literature search of original articles published during 2022 in Gastrointestinal Endoscopy and other high-impact medical and gastroenterology journals, the 10-member Editorial Board of the American Society for Gastrointestinal Endoscopy composed a list of the 10 most significant topic areas in GI endoscopy during the study year. Each Editorial Board member was directed to consider 3 criteria in generating candidate lists-significance, novelty, and global impact on clinical practice-and subject matter consensus was facilitated by the Chair through electronic voting. The 10 identified areas collectively represent advances in the following endoscopic spheres: artificial intelligence, endoscopic submucosal dissection, Barrett's esophagus, interventional EUS, endoscopic resection techniques, pancreaticobiliary endoscopy, management of acute pancreatitis, endoscopic environmental sustainability, the NordICC trial, and spiral enteroscopy. Each board member was assigned a consensus topic area around which to summarize relevant important articles, thereby generating this précis of the "top 10" endoscopic advances of 2022.

Management of Opioid-induced Constipation in Older Adults.

Opioid-induced constipation (OIC) is a common condition in older adults who may not be responsive to traditional laxative therapy. OIC is defined as new or worsening constipation symptoms that occur with initiation of or altering the dose of opioid analgesia. For adult patients with OIC and noncancer pain, we recommend considering nonpharmacologic interventions (eg, dietary measures, increased physical activity, and biofeedback training) and over-the-counter laxatives, followed by prescription opioid receptor antagonists (methylnaltrexone, naloxegol, and naldemedine) if traditional over-the-counter laxatives fail. Other options may include lubiprostone, linaclotide, plecanatide, and prucalopride; however, these are not indicated for OIC specifically or studied in older adults. Because of the complex nature of absorption, distribution, metabolism, and excretion in the aging population, all agents used to treat OIC must be evaluated individually and reevaluated as patients continue to age. This review will serve as a guide to managing OIC in older adults.

The Impact of Obesity on the Fibrostenosis Progression of Eosinophilic Esophagitis in a U.S. Veterans Cohort.

Whether obesity is protective against progression of EoE is unknown. The aim of this study was to assess factors that alter the progression of EoE and determine if BMI is correlated with reduced disease severity. In this retrospective analysis of the Department of Veterans Affairs electronic health records, patients with EoE who received at least one dilation were identified using ICD and CPT codes. Kaplan-Meier curves determined the relationship between BMI and time to second esophageal dilation as a measurement of severity of disease. Cox proportional hazards models assessed the risk of second dilation adjusted for potential confounders. Of 2890 patients with EoE and at least one dilation, 40% were obese (n = 1165). There were no clinically significant differences in demographics between obese and non-obese patients. Non-obese patients were more likely to be smokers and had a higher mean average of the number of dilation visits compared to obese patients (p < 0.05). When stratified by obesity, non-obese individuals had a median time to next dilation of 6.53 years (95% CI (5.83, 7.79)) compared to 9.24 years for obese individuals (95% CI (7.40, 15.04)). When stratified by six BMI categories, median time to second dilation increased with increasing BMI. The hazard ratio of second dilation for obese individuals was 0.81 (95% CI (0.72-0.92)). EoE patients with a higher BMI were less likely to undergo a second dilation compared to those with a lower BMI. Obesity may have a protective role in EoE or severe strictures may lead to malnourishment. Further research into these possibilities is needed.

The Impact of Patient Education Level on Split-Dose Colonoscopy Bowel Preparation for CRC Prevention.

INTRODUCTION: AGA guidelines emphasize split-dose bowel preparation (BP) to ensure high-quality colonoscopy for the prevention of colorectal cancer (CRC). Split dose results in higher-quality preparation, but understanding instructions might be more difficult. Lower education levels may negatively influence BP quality. The confounding role of education level on BP quality was investigated. METHODS: This was a cross-sectional study of 60 patients given split-dose BP. Patients consented and were asked three Likert scale questions based on BP instructions before the procedure. Compliance was self-reported. BP adequacy and the number of adenomas were recorded. BP was characterized as adequate (excellent, good) or inadequate (fair, poor). Data was analyzed with chi-square, odds ratio, Mann-Whitney, and regression analysis. RESULTS: Thirty-one (52%) patients were high school graduates, 21 (38%) completed some college, and 6 (10%) were college graduates. College-educated patients had adequate BP (72%) more often than high school graduates (51%) (p = 0.02). Adenoma findings were not significantly different. The Likert scale mean ranks for patient understanding and reviewing of instructions were comparable between the two groups. Patient rating of scheduler explanations of the importance of following instructions was significantly better in the college group (mean ranks 2.59 and 1.83, respectively; p = 0.018). DISCUSSION: Patient education level significantly affected the success of BP. Split BP can be more complex to comprehend, and instructions should consider patient education level. Specific intervention programs should be implemented to advise patients with less education that poor preparation may result in missed advanced neoplasias and subsequent procedures.

Advancing high-resolution manometry: evaluating the use of multiple rapid swallows versus apple viscous swallows in clinical practice.

BACKGROUND: High-Resolution Manometry (HRM) with provocative maneuvers, such as Multiple Rapid Swallows (MRS) and Apple Viscous Swallows (AVS), is commonly utilized to diagnose esophageal disorders. Increasing standardization in HRM protocol can help save time and reduce patient discomfort. This study assesses AVS and MRS to determine their respective benefits and limitations. METHODS: Retrospective reviews were performed on 100 patients to analyze their AVS and/or MRS results. Parameters included abnormal motility patterns, tolerance, and DCI. Diagnostic benefits from MRS and AVS were assessed. Based on the previous studies, additional benefit from MRS was defined as detection of good peristaltic reserve, weak peristaltic reserve, or an abnormal motility/pressurization pattern. Additional benefit from AVS was defined as detection of IEM features or abnormal motility/pressurization pattern. RESULTS: When patients completed both MRS and AVS (n = 70), MRS provided additional benefit in assessing 36% of patients, while AVS provided additional benefit in 19% of patients (p < 0.0001). Furthermore, MRS detected significantly more abnormal motility/pressurization patterns than AVS (27% MRS; 8% AVS; p = 0.0005). Two unique strengths of AVS were higher tolerance for test completion (p = 0.009) and better detection of severe hypokinetic disorders in 4% of patients, which were missed by MRS. CONCLUSIONS: MRS may uniquely identify abnormal motility/pressurization patterns, such as paradoxical LES response, distal pressurization, hypercontractile, and spasm patterns. These findings argue for a tailored approach when selecting provocative testing. MRS may be more useful for patients with abnormal pathophysiology, while AVS may help to supplement MRS in detecting severe hypokinetic disorders in preoperative management.

The Challenges of Esaphagogastric Junction Outflow Obstruction, Is It Really a Diagnosis? Creating a Systematic Clinical Approach for EGJOO.

Esophagogastric junction outflow obstruction (EGJOO) is currently diagnosed according to the Chicago Classification V3 by an elevated median integrated relaxation pressure on high resolution manometry. However, EGJOO may not be an accurate diagnosis, as it may be based on abnormal IRP from an artifact, affected by narcotics, an achalasia variant, or a mechanical cause of obstruction. This heterogenous diagnosis can often lead to unnecessary testing and treatment. The purpose of this study is to develop a stepwise clinical management protocol on how to evaluate EGJOO. Motility studies were reviewed for the last 2 years and 39 patients were diagnosed with EGJOO. Clinical information was reviewed, and patients were classified into six stepwise categories to explain an elevated IRP resulting in EGJOO diagnosis: (1) underlying catheter artifact (2) opioid use (3) achalasia variant (4) jackhammer esophagus with obstruction (5) missed esophageal lesion (ex. Schatzki ring, EOE) and (6) extrinsic compression. 40% (n = 14) of patients with elevated IRP were due to an underlying catheter artifact. 8.6% (n = 3) were due to opioid use. 8.6% (n = 3) were due to achalasia variant. 31.4% (n = 11) were due to jackhammer esophagus with obstruction. 5.7% (n = 2) were due to missed esophageal lesion. 5.7% (n = 2) were due to external compression by cardiomegaly and aortic aneurism. EGJOO is not a diagnostic end point, but a heterogenous category with multiple underlying etiologies. We believe the use of a stepwise approach to these patients can help avoid further unnecessary testing.

Patterns of esophageal dysmotility elicited by multiple rapid swallows.

BACKGROUND: High-resolution manometry (HRM) is a gastrointestinal motility diagnostic system that measures intraluminal pressures using closely aligned sensors. Multiple rapid swallows (MRS) are used in conjunction with HRM to assess esophageal physiology prior to anti-reflux and hiatal hernia procedures. METHODS: A retrospective, qualitative study was conducted on 90 patients who underwent HRM with MRS in a single community clinic. 80 patients met the inclusion criteria. MRS testing consisted of rapid 2 mL swallows in 2-3 s intervals with patients in a seated, upright position. Clinical information was reviewed including indications for HRM, prior diagnostic workup, manometry, distal contractile integral (DCI), and integrated residual pressure (IRP). HRM studies were visualized using Manoview Analysis Software v3.0 (Medtronic). RESULTS: Certain esophageal dysmotility and pressurization manometry patterns were previously undetected on HRM alone. In our study, the addition of MRS was clinically helpful in (1) assessing contraction reserve, (2) highlighting features of jackhammer, (3) stimulating esophageal spasm, and (4) visualizing distal esophageal pressurization pattern with mechanical obstruction. Additionally, abnormal pathophysiology such as (5) paradoxical LES contraction (achalasia) and (6) loss of deglutition inhibition were identified. MRS had a diagnostic utility of 21.25% (n = 17) among the 80 patients. An intolerance rate of 7.7% (n = 7) was observed in patients unable to complete the protocol. CONCLUSIONS: Augmentation of HRM with MRS produces unique manometric features that have clinical utility in uncovering esophageal disorders. MRS provocation testing is a practical, inexpensive, well-tolerated addition to HRM that may yield useful clinical information to guide complicated diagnoses and medical management.

Obesity reduces the requirement for subsequent esophageal stricture dilation in adults with eosinophilic esophagitis.

BACKGROUND: Eosinophilic esophagitis (EoE) causes esophageal narrowing and strictures, but factors that modify the severity of strictures and requirement for subsequent dilation are not well described. The aim of this study was to identify characteristics that impact the need for repeat (> 1) esophageal dilations in EoE patients. METHODS: This was a single center retrospective cohort study over a 12-year period (September 2005-October 2017). Patients were identified using ICD9, ICD10, and CPT codes for esophageal dilation, eosinophilic esophagitis, and esophageal obstruction. Data for EoE clinical characteristics, treatments, and BMI were extracted and correlated to the number of esophageal dilations and time elapsed between dilations. RESULTS: Of the 21 patients who met inclusion criteria, 11 (52%) had at least two dilations and 9 (43%) had three dilations. There was no differences baseline demographics between patients who needed ≥ 2 vs. those who needed one dilation. However, patients with a BMI > 30 had a significantly longer median time to second dilation compared to non-obese patients (4.9 years vs. 1.8 years; p = 0.027). Stratification by either high dose PPI or inhaled steroid use did not change this result. CONCLUSIONS: EoE patients with strictures who are obese have a reduced requirement for subsequent esophageal dilation. While the mechanism for this is not clear, increased attention of non-obese patients with fibrostenotic EoE is indicated as they are at higher risk for recurrent strictures.

Second harmonic generation imaging distinguishes both high-grade dysplasia and cancer from normal colonic mucosa.

BACKGROUND AND AIM: Second harmonic generation (SHG) is a novel imaging technology that could provide optical biopsy during endoscopy with advantages over current technology. SHG has the unique ability to evaluate the amount of extracellular matrix collagen protein and its alignment. METHODS: Hematoxylin- and eosin-stained slides from colon biopsies (normal, low-grade dysplasia (LGD), high-grade dysplasia (HGD), and cancer) were examined with SHG imaging. Both signal intensity and collagen fiber alignment were measured. Average intensity per pixel (AIPP) was obtained, and an analyzing polarizer was used to calculate ß, an alignment parameter. RESULTS: The mean AIPP for normal mucosa was 48, LGD was 38, HGD was 42, and malignancy was 123 (p < 0.01). The AIPP ROC curve between malignant versus non-malignant tissue was 0.96 (0.93-0.99). An AIPP value of 60 can differentiate malignancy with 87 % sensitivity and 90 % specificity. The mean ß for normal tissue was 0.490, LGD was 0.379, HGD was 0.345, and cancer was 0.453 (p = 0.013), with a normal tissue mean rank of 6.5 compared to 2.5 for HGD (p = 0.029). CONCLUSIONS: SHG signal intensity can differentiate malignant from non-malignant colonic polyp tissue with high sensitivity and specificity. Anisotropic polarization can discern HGD from normal colonic polyp tissue. SHG can thus distinguish both HGD and malignant lesions in an objective numeric fashion, without contrast agents or interpretation skills. SHG could be incorporated into endoscopy equipment to enhance white light endoscopy.

Should gastroenterologists prescribe cannabis? The highs, the lows and the unknowns.

Cannabis, commonly known as marijuana, is a drug extracted from the Cannabis plant known for its psychotropic and medicinal properties. It has been used for healing purposes during ancient times, although its psychoactive components led to its restricted use in medicine. Nonetheless, cannabis is found to have modulatory effects on the endocannabinoid system exhibiting its medicinal role in the gastrointestinal (GI) system. Emerging animal and human studies demonstrate the influential effects of cannabis on a variety of GI diseases including inflammatory bowel disease, motility disorders and GI malignancies. It also has a regulatory role in GI symptoms including nausea and vomiting, anorexia, weight gain, abdominal pain, among others. However, both its acute and chronic use can lead to undesirable side effects such as dependency and addiction, cognitive impairment and cannabinoid hyperemesis syndrome. We will discuss the role of cannabis in the GI system as well as dosing strategies to help guide gastroenterologists to assess its efficacy and provide patient counseling before prescription of medical marijuana.

Cautious optimism in anticipation of hepatitis B curative therapies.

Despite relative effectiveness of current hepatitis B therapies, there is still no curative agents available. The new emerging approaches hold promise to achieve cure and loss of hepatitis B surface antigen. Studies or clinical trials investigating new therapies remain small and either focus on patients with low viral load and without hepatotoxic injury or patients with hepatitis D co-infection, which makes it challenging to assess their effectiveness and side effect profile in hepatitis B population.

Lessons learned: Preventable misses and near-misses of endoscopic procedures.

Endoscopy is a complex procedure that requires advanced training and a highly skilled practitioner. The advances in the field of endoscopy have made it an invaluable diagnostic tool, but the procedure remains provider dependent. The quality of endoscopy may vary from provider to provider and, as a result, is not perfect. Consequently, 11.3% of upper gastrointestinal neoplasms are missed on the initial upper endoscopy and 2.1%-5.9% of colorectal polyps or cancers are missed on colonoscopy. Pathology is overlooked if endoscopic exam is not done carefully, bypassing proper visualization of the scope's entry and exit points or, if exam is not taken to completion, not visualizing the most distal bowel segments. We hope to shed light on this issue, establish areas of weakness, and propose possible solutions and preventative measures.

Bilateral Pulmonary Embolism in a Hospitalized Ulcerative Colitis Patient.

Patients with inflammatory bowel disease (IBD) are at higher risk of venous thromboembolism (VTE), though physicians may be unaware of this risk or hesitant to start pharmacologic VTE prophylaxis in the presence of active gastrointestinal bleeding. We report a case of a 38-year-old patient hospitalized with acute severe ulcerative colitis (UC) who was not placed on pharmacologic VTE prophylaxis and developed bilateral pulmonary embolism (PE). The patient's UC did not respond to medical therapy. Due to his PE, the patient's total proctocolectomy was delayed six months. He also developed a large pelvic hematoma after colectomy requiring further surgical intervention. Hospitalized inflammatory bowel disease (IBD) patients require pharmacologic VTE prophylaxis unless they have life-threatening bleeding.

The Supportive Role of Provocative Maneuvers and Impedance Clearance in Detecting Ineffective Esophageal Motility.

Background: Ineffective esophageal motility (IEM) is one of the most common esophageal motility disorders. However, the definition of IEM has evolved. Chicago classification version 4.0 (CCv4.0) made IEM parameters more stringent with greater than 70% of ineffective wet swallows (WS) necessary to diagnose conclusive IEM. Of the ineffective swallows, 50-70% are deemed "inconclusive cases". This study sought to determine whether provocative maneuvers, including multiple rapid swallows (MRS) and apple viscous swallows (AVS), and impedance clearance can provide supportive information for inconclusive IEM disorders based on CCv4.0. Methods: Esophageal motility data on 100 patients were analyzed. All patients completed WS and at least one additional swallow test (MRS and/or AVS). Patients were classified as having conclusive IEM, inconclusive IEM, or normal motility. IEM features detected on MRS/AVS and incomplete bolus clearance were recorded. Percentage of agreement between IEM features and incomplete bolus clearance was calculated for each motility group. Results: Ten patients had conclusive IEM, nine had inconclusive IEM, and 32 had normal motility. There was 70% agreement between IEM features and incomplete bolus clearance with conclusive IEM, 33% agreement with inconclusive IEM, and 9% agreement with normal motility. There was significantly more agreement in the conclusive and inconclusive IEM groups than in the normal motility group (P = 0.0003). Conclusions: Combinational follow-up testing with provocative maneuvers and impedance clearance may assist with risk stratification of IEM patients and assist in further management of inconclusive IEM. MRS and AVS can detect unique IEM features that may help with preoperative management of inconclusive IEM.

Rebuilding trust in proton pump inhibitor therapy.

Introduction of proton pump inhibitor (PPI) therapy into clinical practice has revolutionized treatment approach to acid-related diseases. With its clinical success came a widespread use of PPI therapy. Subsequently, several studies found that PPIs were oftentimes overprescribed in primary care and emergency setting, likely attributed to seemingly low side-effect profile and physicians having low threshold to initiate therapy. However, now there is a growing concern over PPI side-effect profile among both patients and providers. We would like to bring more awareness to the currently available guidelines on PPI use, discuss clinical indications for PPIs and the evidence behind the reported side-effects. We hope that increased awareness of proper PPI use will make the initiation or continuation of therapy a well informed and an evidence-based decision between patient and physician. We also hope that discussing evidence behind the reported side-effect profile will help clarify the growing concerns over PPI therapy.

The Unusual Suspect: An Acute Gastric Dilation With Volvulus in a Scleroderma Patient.

Systemic scleroderma (SSc) is a chronic autoimmune disorder that can affect various organ systems. About 90% of patients with SSc have gastrointestinal (GI) manifestations, with esophageal dysmotility being the most frequently reported. While esophageal involvement is the most common, other segments of the upper GI tract can be affected as well, such as the stomach or small bowel. Some of the examples of gastric involvement include gastric antral vascular ectasia (GAVE) and gastroparesis. Small bowel involvement can present with reduced contractility, pseudo-obstruction, small intestinal bacterial overgrowth (SIBO), and atrophy. Although many of these manifestations bear little clinical urgency, acute gastric dilation or pseudo-obstruction constitute a medical emergency and require prompt intervention. We are presenting a case of acute gastric dilation with gastric volvulus in the setting of SSc, which is not well reported in the medical literature. We hope to increase providers' awareness of this rare manifestation of SSc to facilitate prompt diagnosis and intervention. Furthermore, we hope to prompt more research to be done to better understand its pathophysiology and determine whether this manifestation of SSc is preventable.