Abdominal diameter index is a stronger predictor of prevalent Barrett's esophagus than BMI or waist-to-hip ratio.

Abdominal obesity is associated with gastroesophageal reflux disease (GERD) and Barrett's esophagus (BE). Increased body mass index (BMI) and waist-to-hip ratio (WHR) have been associated with BE. Abdominal diameter index (ADI, sagittal abdominal diameter divided by thigh circumference) was previously shown to be a more accurate predictor of incident cardiovascular disease compared to other measurements. Our aim is to examine whether abdominal diameter index was a more accurate predictor of prevalent BE compared to other anthropometric measurements. We conducted a case-control study of patients presenting to our institution. Our study population was consecutive Caucasian men with a known history of BE, and we recruited control patients who had GERD without BE. Both groups completed a questionnaire about demographics, smoking, and medications and underwent a series of anthropometric body measurements using standardized measuring tools. BMI, waist-to-hip ratio, and abdominal diameter index were calculated. Thirty-one BE patients and 27 control patients were recruited. The BE cohort were older and had a higher rate of hiatal hernia. The mean abdominal diameter index for patients with BE was 0.65 ± 0.07 and without BE was 0.60 ± 0.07 (p = 0.01). The predictive value of abdominal diameter index was analyzed using a receiver-operator characteristic (ROC) curve and was a more powerful predictor of BE than waist-to-hip ratio or BMI (AUROC = 0.70 vs. 0.60 vs. 0.52, respectively). Using a cut-point abdominal diameter index value of 0.60, abdominal diameter index had a sensitivity of 77.4% and a specificity of 63.0% for the presence of BE. When controlling for age, smoking status, and BMI, an abdominal diameter index ≥0.60 was a significant independent risk factor for BE (OR = 5.7, 95% CI = 1.29-25.4). In this pilot study, the abdominal diameter index appears to be a more powerful predictor of the presence of BE than BMI and waist-to-hip ratio and remained the only significant predictor of BE in multivariate analysis. We propose further validation of abdominal diameter index before inclusion in future prediction tools for BE.

Diabetes mellitus is an independent risk for gastroesophageal reflux disease among urban African Americans.

An association between gastroesophageal reflux disease (GERD) and diabetes mellitus (DM) has been reported. Studies have not been population-based and have failed to include a representative sample of African American subjects. The aim of the study was to determine if DM is independently associated with GERD among urban African Americans. Single-center, population-based survey utilizing a complex, stratified sampling design. To obtain a simple random sample of the entire African American community, targeted survey zones and hand-delivered invitations were identified. Participating subjects had to be self-described African American, age ≥18. Surveys were completed at a computer terminal assisted by a research coordinator. Four hundred nineteen subjects (weighted sample size of 21 264 [20 888-23 930]). GERD prevalence was 23.7% (95% confidence interval [CI] 23.2-23.9). GERD prevalence was 41.5 % in those with DM versus 20.6 % for those without (P < 0.001). Those with GERD had DM longer but had lower glycohemoglobin levels. The prevalence of ≥2 DM comorbidities was higher in those with GERD (odds ratio [OR] = 2.06; 95% CI 1.71-2.48). In the final model, age >40, DM, increasing body mass index, harmful drinking, and increasing smoking dependence were independently associated with GERD. For DM, there was significant effect modification by gender. In males, the risk was (OR = 4.63; 95% CI 3.96-5.40), while in females, the risk was markedly attenuated (OR = 1.79; 95% CI 1.61-2.00). Among urban African Americans, there is an independent association between DM and GERD that appears to be stronger in men. More information is needed to understand this association.

Review article: the biology, diagnosis and management of gastrointestinal stromal tumours.

BACKGROUND: Gastrointestinal stromal tumours (GIST) are the most common mesenchymal tumours of the gastrointestinal tract with an increasing incidence. AIMS: To review the biology, diagnosis and treatment of gastrointestinal stromal tumours. METHODS: A PubMed search using the phrases 'Gastrointestinal stromal tumor', 'imatinib', 'c-kit'. RESULTS: The diagnosis of GIST is established by histology supplemented by the immunohistochemical marker CD117, which is positive in 95% of cases. The most common site of the tumour is the stomach. Most GIST are benign with 20-30% malignant. Five-year survival for malignant GIST ranges between 35% and 65% and depends primarily on tumour size, mitotic index and location. The malignant behaviour of GIST is best assessed by invasion of adjacent structures and distant metastases. The gold standard for treatment is surgical resection. Imatinib, a tyrosine kinase inhibitor, is the primary therapy for unresectable, recurrent or metastatic disease. CONCLUSIONS: Gastrointestinal stromal tumours are rare tumours of the gastrointestinal tract and they vary in presentation. When surgical resection is not achievable, imatinib is the treatment of choice.

Pathogenesis and outcomes of traumatic injuries of the esophagus.

Traumatic injury of the esophagus is extremely uncommon. The aims of this study were to use the Pennsylvania Trauma Outcome Study (PTOS) database to identify clinical factors predictive of esophageal trauma, and to report the morbidity and mortality of this injury. A cross-sectional review of patients presenting to 20 Level I trauma centers in Pennsylvania from 2004 to 2010 was performed. We compared clinical and demographic variables between patients with and without esophageal trauma both prior to and after arrival in the emergency room (ER). Primary mechanism of injury and clinical outcomes were analyzed. There were 231 694 patients and 327 (0.14%) had esophageal trauma. Patients with esophageal trauma were considerably younger than those without this injury. The risk of esophageal trauma was markedly increased in males (odds ratio [OR] = 2.62 [CI 1.98-3.47]). The risk was also increased in African Americans (OR = 4.61 [CI 3.65-5.82]). Most cases were from penetrating gunshot and stab wounds. Only 34 (10.4%) of esophageal trauma patients underwent an upper endoscopy; diagnosis was usually made by CT, surgery, or autopsy. Esophageal trauma patients were more likely to require surgery (35.8% vs. 12.5%; P < 0.001). Patients with esophageal trauma had a substantially higher mortality than those without the injury (20.5% vs. 1.4%; P < 0.005). In logistic regression modeling, traumatic injury of the esophagus (OR = 3.43 [2.50-4.71]) and male gender (OR = 1.52 [1.46-1.59]) were independently associated with mortality. For those patients with esophageal trauma, there was an association between trauma severity and mortality (OR = 1.10 [1.07-1.12]) but not for undergoing surgery within the first 24 hours of hospitalization (OR = 0.84; 0.39-1.83). Our study on traumatic injury of the esophagus is in concordance with previous studies demonstrating that this injury is rare but carries considerable morbidity (∼46%) and mortality (∼20%). The injury has a higher morbidity and mortality when the thoracic esophagus is involved compared to the cervical esophagus alone. The injury most commonly occurs in younger, Black males suffering gunshot wounds. Efforts to control gun violence in Pennsylvania are of paramount importance.

Population-based assessment of heartburn in urban Black Americans.

Prevalence data for heartburn in the urban Black American community is lacking. In order to estimate prevalence for this community, we analyzed data from an ongoing cohort study in progress at our hospital. Comprehensive interviews allowed for exploration of factors associated with heartburn. Complex, stratified sampling design was the method used. Survey invitations are hand-delivered to random blocks in a single zip code tabulation area. One member per eligible household is invited to complete a computer-based survey. Heartburn was defined as ≥ 3 days/week of symptoms as defined by the Montreal Definition and Classification of gastroesophageal reflux disease. Scaling and weighting factors were utilized to estimate population level prevalence. Multivariate logistic regression was used to identify independent predictor variables for heartburn. Enrolled 379 participants corresponding to a weighted sample size of 22,409 (20,888-23,930) citizens. Demographic characteristics of the sample closely matched those of the entire targeted population. Overall, the weighted prevalence of heartburn ≥ 3 times per week was 17.6% (16.4-18.8%). Variables independently associated with heartburn were body mass index, daily caloric and fat intake, diabetes mellitus (odds ratio = 2.95; 2.59-3.36), cigarette smoking, and alcohol consumption (odds ratio = 2.55; 2.25-2.89). Factors inversely associated included illicit drug use and increased physical activity. Waist : hip ratio showed no relationship. The prevalence of heartburn ≥ 3 times per week is high in the Black American community. Adverse lifestyle behaviors showed particularly important associations. Our study needs to be replicated in other communities with similar demographics.

A comprehensive review of gastroesophageal reflux disease and obesity.

Obesity has been implicated as an important risk factor for the development of gastroesophageal reflux disease (GERD). A variety of physiological abnormalities have been described which likely contribute to the association of GERD and obesity. These abnormalities involve the oesophageal body, lower oesophageal sphincter and stomach. For obese patients with GERD, weight loss in conjunction with anti-secretory medications is first-line therapy. For those with severe obesity who fail medical weight loss treatment, bariatric surgery has been shown to be beneficial. On balance, Roux-en-Y gastric bypass is probably the most efficacious surgery for patients with morbid obesity suffering from concomitant GERD.

The impact of diabetes and obesity on liver histology in patients with hepatitis C.

AIM: An association between diabetes mellitus and HCV has been recognized previously. No study has examined whether there is an independent association between the degree of hepatic fibrosis and the incidence of diabetes in HCV patients when controlling for other risk factors. METHODS: We reviewed the charts of 264 consecutive patients with chronic HCV infection at a referral liver centre from January 1991 to December 1999. Demographic background, medical history, laboratory and liver biopsy results were retrieved. RESULTS: The prevalence of diabetes was 16.3%. Gender, intravenous drug use, steatosis scores, aminotransferase levels and iron studies were similarly distributed in patients with and without diabetes (all p > 0.05). In contrast, mean age was greater in the diabetic group (49.8 vs. 44.3, p = 0.003). The prevalence of diabetes was substantially higher in African-Americans (p = 0.001) and those with BMI > 30 (p = 0.015). Although the fibrosis score was higher in diabetics (rho = 0.14, p = 0.03), that association did not remain significant when controlling for diabetes risk factors (p > 0.3). The degree of steatosis and fibrosis both tended to increase with increasing BMI (rho = 0.47, p < 0.001 and rho = 0.13, p = 0.03, respectively). Even after controlling for diabetes, age, gender, race, and current alcohol use, those associations remained (both p < 0.001). CONCLUSIONS: The prevalence of diabetes in our group of HCV patients was high, consistent with other studies. Diabetes is not an independent predictor of degree of fibrosis. Body mass index is an independent predictor of both fibrosis and steatosis in HCV patients.

Hepatic Cysts.

Treatment of hepatic cysts should be considered only for those patients who are symptomatic. For simple cysts, percutaneous aspiration invariably leads to recurrence; laparoscopic deroofing is usually curative. Open deroofing (fenestration) should be reserved for cysts inaccessible by laparoscopy. Percutaneous instillation of sclerosing agents (ethanol, iophendylate, minocycline) into nonbiliary and nonparasitic cysts is an alternative therapeutic option in certain cases. Due to increased morbidity, hepatic resection should be reserved for polycystic liver disease, diffuse hepatic involvement, or recurrence after a deroofing procedure. Patients with congenital fibropolycystic disorders (eg, congenital hepatic fibrosis) with evidence of hepatic decompensation, should be considered for liver transplantation. For hepatic hydatid cysts, simple cystectomy or the PAIR (puncture, aspirate, inject, and reaspirate) technique with albendazole treatment have been shown to be equally successful. In the case of alveolar echinococcosis, hepatic resection and liver transplantation are the only effective modalities for localized and extensive hepatic disease, respectively.

Jejunal telangiectasias as a cause of massive bleeding in a patient with scleroderma.

Telengiectasias (arteriovenous malformations) can be seen in scleroderma throughout the gastrointestinal tract, including the stomach, small bowel and colon. Massive gastrointestinal bleeding rarely results from these malformations in scleroderma. The case of a patient presenting with severe jejunal bleeding secondary to telangiectasias with special regard to the management is discussed. This case emphasizes the importance of endoscopic examination combined with mesenteric angiography in patients with scleroderma who present with a high index of suspicion of telangiectasias as a source of bleeding.

Accuracy and clinical utility of the mini-dose 14C-urea breath test in the evaluation of Helicobacter pylori infection.

The aim of this study was to evaluate the accuracy of the 14C-urea breath test by comparing the results to those obtained by endoscopy with mucosal biopsy. We also examined the value of the breath test result obtained prior to endoscopy in predicting peptic ulcer disease. Forty-two individuals underwent the 14C-urea breath test. Collections of expired C02 were analysed using a liquid scintillation counter. All individuals then underwent endoscopy with biopsy. Biopsy material was evaluated by the rapid urease method and by histology for the presence of H. pylori. Our results demonstrated that the 14C-urea breath test was 100% sensitive and specific when compared to the rapid urease test as the 'gold standard' for the detection of H. pylori. In comparison to pathology, the sensitivity remained 100% and the specificity was 89%. The results of the 14C-urea breath test had a poor predictive value for the determination of peptic ulcer disease. We conclude that the 14C-urea breath test can be easily performed at any medical facility equipped with a liquid scintillation counter and can accurately detect H. pylori. A negative breath test result could not exclude the presence of peptic ulcer disease.

Serum albumin is predictive of 30-day survival after percutaneous endoscopic gastrostomy.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) tubes have been used since 1980 in patients who require prolonged enteral feeding. PURPOSE: To identify factors associated with poor survival (defined as survival < 30 days) post-PEG. METHODS: We assessed a cohort of 64 patients consecutively referred for a percutaneous endoscopic gastrostomy tube in a single, tertiary care hospital. Prior to PEG tube placement, we evaluated relevant clinical variables in each patient to determine their effect on 30-day mortality. RESULTS: Of the cohort, 43 of 64 (67.2%) survived at least 30 days after tube placement. One death was attributable to tube placement. Bivariate analyses showed that 30-day survival correlated directly with serum albumin (r = .253; p = .049) and inversely with creatinine (r = -0.255; p = .042). Using multivariable logistic regression analysis, only albumin was identified as an independent predictor of 30-day survival (p = .044). Eighty-three percent of patients with a serum albumin > or = 3.0 g/dL survived 30 days compared with 58% with an albumin < 3.0, a difference of 25% (95% CI, -2% to 54%; p = .07). CONCLUSIONS: In conclusion, serum albumin appears to be a predictor of early survival in individuals undergoing percutaneous endoscopic gastrostomy tube placement.