The Effect of Obesity on the Quality of Bowel Preparation for Colonoscopy: Results From a Large Observational Study.

BACKGROUND: Obesity has been linked to suboptimal bowel preparation but this association has not been conclusively investigated in prospective studies. GOALS: Our objective was to determine whether any relationship exists between obesity as measured by body mass index (BMI) and quality of bowel preparation. STUDY: Adult patients who presented for outpatient colonoscopy at a single urban ambulatory surgery center within a 6-month period and fulfilled inclusion criteria were prospectively enrolled for the study. Patients were divided by BMI into subcategories based on the World Health Organization international classification of obesity. The Modified Aronchick scale was used to assess bowel preparation for colonoscopy. A univariate and multivariate analysis was used to determine a possible association between BMI and poor preparation. RESULTS: A total of 1429 patients were evaluated. On the basis of inclusion criteria, 1314 subjects were analyzed, out of which 73% were overweight or obese. Inadequate bowel preparation was noted in 21.1% of patients. There was no correlation between obesity and the quality of the bowel preparation. Male gender (P=0.002), diabetes mellitus (P<0.0001), liver cirrhosis (P=0.001), coronary artery disease (P=0.003), refractory constipation (P<0.0001), and current smoking (P=0.01) were found to be independently predictive of poor bowel preparation. CONCLUSIONS: Increased BMI is not predictive of suboptimal bowel preparation for colonoscopy. The results of our study are pivotal given the increased risk of colorectal cancer in obese patients and their known lower rate of colorectal cancer screening in certain populations. It is important to avoid subjecting these patients to an intensive bowel preparation that may further discourage screening in a patient population that requires it.

Percutaneous endoscopic sigmoidopexy using T-fasteners for management of sigmoid volvulus.

BACKGROUND: Sigmoid volvulus (SV) is the third leading cause of large bowel obstruction after colonic neoplasms and diverticular disease. SV has traditionally been managed via endoscopic detorsion and decompression followed by non-emergent surgical resection owing to the high risk of recurrence. Most cases of SV occur in elderly debilitated patients with multiple comorbidities and may not be candidates for surgical resection. Endoscopic sigmoidopexy has been described as an alternative to surgical resection. Here, we describe our experience with endoscopic sigmoidopexy using T-fasteners. METHODS: Three patients with recurrent SV that were identified as poor surgical candidates by our colorectal surgery team underwent endoscopic sigmoidopexy. The patients received preoperative bowel preparation. A colonoscope was inserted and the site of the volvulus was visualized and assessed for adequate decompression. Subsequently, four points of fixation were identified and T-fasteners were deployed. RESULTS: Two patients underwent successful sigmoidopexy without any complications or recurrence on follow-up. One patient developed post procedure pneumoperitoneum that was successfully treated conservatively; however, he passed away from their underlying comorbidities. CONCLUSION: Overall, preliminary results for sigmoidopexy using T-fasteners have been promising, offering a potential option to prevent recurrence in high risk patients unsuitable for surgical intervention.

Fish Bone-Induced Pancreatitis.

Fish bone-induced pancreatitis is an uncommon cause of pancreatitis, with only a few reported cases in the literature. The patients with the highest risk for fish bone-induced pancreatitis include those from cultures where unfilleted fish is a culinary delicacy. The etiology of foreign body-induced pancreatitis is very common, secondary to inflammation of the duodenal papilla or bile duct obstruction. CT imaging is key for visualization of the fish bone, as radiography rarely detects fish bones. Complications of fish bone-induced pancreatitis include thrombosis of the superior mesenteric vein, bacteremia (with Peptostreptococcus), pancreatic granuloma, and gastrointestinal perforation. Management of fish bone-induced pancreatitis includes either endoscopic resection or exploratory laparotomy, followed by supportive care until pancreatitis resolves. Here, we present a case of pancreatitis secondary to accidental fish bone ingestion, identified during upper gastrointestinal endoscopy and managed by bone removal and supportive care.

Impact of COVID-19 on gastroenterology fellowship training: a multicenter analysis of endoscopy volumes.

Background and study aims The COVID-19 pandemic has had a profound impact on gastroenterology training programs. We aimed to objectively evaluate procedural training volume and impact of COVID-19 on gastroenterology fellowship programs in the United States. Methods This was a retrospective, multicenter study. Procedure volume data on upper and lower endoscopies performed by gastroenterology fellows was abstracted directly from the electronic medical record. The study period was stratified into 2 time periods: Study Period 1, SP1 (03/15/2020 to 06/30/2020) and Study Period 2, SP2 (07/01/2020 to 12/15/2020). Procedure volumes during SP1 and SP2 were compared to Historic Period 1 (HP1) (03/15/2019 to 06/30/2019) and Historic Period 2 (HP2) (07/01/2019 to 12/15/2019) as historical reference. Results Data from 23 gastroenterology fellowship programs (total procedures = 127,958) with a median of 284 fellows (range 273-289; representing 17.8 % of all trainees in the United States) were collected. Compared to HP1, fellows performed 53.6 % less procedures in SP1 (total volume: 28,808 vs 13,378; mean 105.52 ±â€Š71.94 vs 47.61 ±â€Š41.43 per fellow; P  < 0.0001). This reduction was significant across all three training years and for both lower and upper endoscopies ( P  < 0.0001). However, the reduction in volume was more pronounced for lower endoscopy compared to upper endoscopy [59.03 % (95 % CI: 58.2-59.86) vs 48.75 % (95 % CI: 47.96-49.54); P  < 0.0001]. The procedure volume in SP2 returned to near baseline of HP2 (total volume: 42,497 vs 43,275; mean 147.05 ±â€Š96.36 vs 150.78 ±â€Š99.67; P  = 0.65). Conclusions Although there was a significant reduction in fellows' endoscopy volume in the initial stages of the pandemic, adaptive mechanisms have resulted in a return of procedure volume to near baseline without ongoing impact on endoscopy training.

Endoscopic Retrograde Cholangiopancreatography in Nonagenarian Patients: Is It Really Safe?

BACKGROUND/AIMS: Literature on the safety of endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients is divided. Based on this we decided to examine the safety of ERCP in nonagenarian patients. METHODS: A total of 1,389 patients, with a mean age of 63.94±19.62 years, underwent ERCP during the study period. There were 74 patients aged 90 years or older with a mean age of 92.07±1.8. Logistic regression showed that nonagenarian patients had a significantly increased odds of in-patient mortality (adjusted odds ratio [AOR]=9.6; 95% confidence interval [CI]=4, 23; p≤0.001). Charlson Comorbidity Index (CCI) ≥2 was also an independent predictor of in-patient mortality (AOR=2.4; 95% CI=1.2, 5.2; p=0.021). Age ≥90 was not associated with increased adverse events; however emergency procedures (AOR=2.4; 95% CI=1.5, 4; p<0.001) and CCI ≥2 (AOR=2.6; 95% CI=1.7, 4.0; p<0.001) were more likely to have adverse events. CONCLUSIONS: Age ≥90 and CCI ≥2 are independently associated with increased odds of in-patient mortality in patients undergoing ERCP, whereas emergency procedures and CCI ≥2 are associated with an increased adverse event rate. Caution must be exercised when considering ERCP in patients aged ≥90 years and those with a CCI ≥2.

Safety of Percutaneous Endoscopic Gastrostomy Tubes in Centenarian Patients.

BACKGROUND/AIMS: Percutaneous endoscopic gastrostomy (PEG) is a relatively safe procedure; however, no study has evaluated the safety of PEG tube placement in patients over the age of 100 years. METHODS: We conducted a retrospective review of patient records for patients who underwent PEG tube placement. Thirty patients aged 100 years and older were identified and a random sample of 275 patients was selected for comparison. RESULTS: The mean age of the patients was 80.6±16.2 years. No procedure-related deaths or major complications were identified; the overall inpatient mortality rate was 7.6%. Minor complications were noted in 4% (n=12) of the patients. Centenarian patients were predominantly female (80% [n=24] vs. 54% [n=147], p=0.006), with a mean age of 100.5±0.9 years. There was no significant difference in procedural success rates (93.3% vs. 97.4%, p=0.222) or inpatient mortality (6.7% [n=2] vs. 7.7% [n=21], p=1.000) between the two groups. However, a higher minor complication rate was noted in the older patients (13.3% [n=4] vs. 2.9% [n=8], p=0.022). CONCLUSIONS: Success rates, major complications and inpatient mortality associated with PEG tubes in patients aged over 100 years are comparable to those observed in relatively younger patients at our center; however minor complication rates are relatively higher. These findings lead us to believe that PEG tubes may be safely attempted in carefully selected patients in this subset of the population.

Endoscopic ultrasound-fine needle aspiration: A novel way to diagnose a solitary extramedullary plasmacytoma of the liver.

Plasmacytoma is a neoplastic production of a single line of plasma cells, usually forming monoclonal immunoglobulin. It most often occurs in the bone marrow; however, in 3% of the cases, solitary extramedullary plasmacytoma arises, which is a proliferation in the soft tissue, outside the bone marrow. In only 10% of the cases is the gastrointestinal tract involved. A 77-year-old female presented with lethargy, abdominal fullness, bilious vomiting, and clay-colored stools. The patient was anemic with initial laboratory results showing increased total and direct bilirubin with elevated transaminases. Despite conservative management, liver function tests (LFTs) continued to increase. On endoscopic ultrasound (EUS), there was mild diffuse mucosal thickening consistent with possible infiltrative disease of the gastric body without any obvious focal lesions. There was a 1.7 cm × 1.8 cm hypoechoic heterogeneous lesion noted in the porta hepatis and fine needle aspiration (FNA) was performed. Cytology showed infiltrative plasma cells. The patient was then taken for computed tomography (CT)-guided biopsy of the liver. Pathology showed liver involvement by atypical plasma cells in a nodular and sinusoidal pattern. Immunohistochemical staining appropriately identified the solitary extramedullary plasmacytoma. Plasma cell neoplasm is essentially a clonal disease of differentiated B-cells that can encompass a broad spectrum and present as asymptomatic monoclonal gammopathy of undetermined significance to plasma cell neoplasms or multiple myeloma. Five percent of patients with multiple myelomas are diagnosed with extramedullary plasmacytomas, and even less than that are diagnosed as a primary lesion. When the liver is affected, either as a direct diffuse neoplastic plasma cell infiltration, or as a single or multiple space occupying lesion as plasmacytomas, symptomatic features include extrahepatic biliary obstruction, jaundice, or ascites. In our case, the patient was diagnosed via EUS-guided FNA (EUS-FNA) bringing to light an alternative method to its diagnosis.

Severe Hypercholesterolemia: A Unique Presentation of Non-Hodgkin's Lymphoma in a Patient with Neurofibromatosis Type 1.

We report a case of non-Hodgkin's lymphoma (NHL) with an unusual initial manifestation as severe hypercholesterolemia and obstructive jaundice in a patient with neurofibromatosis type 1 (NF 1). NHL should be considered in the evaluation of obstructive jaundice alone or in combination with severe hypercholesterolemia. Relief of biliary obstruction led to the resolution of hypercholesterolemia in our 59-year-old male patient, followed by doxorubicin-based chemotherapy for the underlying lymphoma. NF 1 is a genetic condition that results from a defect in a tumor-suppressor gene and it is likely that this led to the development of NHL in our patient. It is important that clinicians are familiar with the gastrointestinal manifestations of NF 1, especially its association with intra-abdominal malignancies, when treating patients with a personal or family history. To the best of our knowledge, this is the first case of NHL presenting initially as severe hypercholesterolemia and it is also one of the few instances where NHL has been reported in association with NF 1.

Early intensive resuscitation of patients with upper gastrointestinal bleeding decreases mortality.

OBJECTIVE: Despite advances in diagnostic and therapeutic endoscopy, the mortality of patients with upper gastrointestinal bleeding (UGIB) has remained relatively constant. Inadequate early resuscitation is believed to be a major factor in the persistently high mortality rate in patients with UGIB. In order to evaluate the role of intensive resuscitation in the outcome of patients with UGIB, we conducted the following prospective study. METHODS: A consecutive series of patients with UGIB complicated by hemodynamic instability related to bleeding were enrolled in the study. An initial cohort of patients (Observation Group) was followed by a team of physicians to collect data. After recording demographic information, the time interval between presentation with UGIB and the correction of hemodynamic instability, hematocrit (HCT), and coagulopathy was prospectively recorded. Medical treatment, endoscopic intervention, and subsequent outcome were also prospectively recorded. A subsequent cohort of patients (Intensive Resuscitation Group) was then prospectively followed and similar demographic and outcome data were collected. However, in this cohort, the physicians involved in collecting the data also provided guidance to the health care team managing the patients. The goal for this group of patients was to allow a more rapid correction of hemodynamic instability, HCT, coagulopathy, and medical/endoscopic intervention. RESULTS: Seventy-two patients were included in the study, 36 males, 36 females, mean age 70 yr (range 21-94). Thirty-six patients were followed in the Observational Group, and 36 in the Intensive Resuscitation Group. There were no significant differences with regard to age, gender, number and type of comorbid diseases, history of prior gastrointestinal bleeding, or etiology of bleeding between the two groups. Patients treated in the Intensive Resuscitation Group had a significant decrease in the time interval from admission to the stabilization of hemodynamics and the correction of HCT. There were no significant differences in the time interval from admission to endoscopic intervention, length-of-stay (LOS), or the number of units of blood given. Fewer patients in the Intensive Resuscitation Group suffered myocardial infarction (p= 0.04). Mortality was lower in the Intensive Resuscitation Group (one death) compared to the Observational Group (four deaths), (p= 0.04). CONCLUSION: Early intensive resuscitation of patients with upper gastrointestinal bleeding significantly decreases mortality. Physicians involved in the care of patients with UGIB should focus on early and rapid correction of hemodynamics, HCT, and underlying coagulopathy.