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1.
Dis Esophagus ; 36(3)2023 Feb 24.
Artículo en Inglés | MEDLINE | ID: mdl-35938855

RESUMEN

Many patients who experience esophageal food impaction (EFI) will have non-endoscopic resolution (NER) of their EFI, but this population is poorly defined. The purpose of this study is to describe the outcomes of patients with NER of EFI. A retrospective chart review from 2007 to 2017 was performed at a single tertiary care center. There were 593 patients who presented to the emergency department with EFI, defined as recent soft food ingestion and inability to tolerate oral secretions. Adequate follow-up was defined as a gastroenterology clinic visit or EGD within 6 months of EFI. Out of these, 149 patients (25.1%) had NER of their EFI. Patients with NER were less likely to have adequate follow-up than those with ER (45.0% vs. 59.5%, P = 0.003). Of those without established esophageal disease and NER, 92.5% had significant esophageal pathology on endoscopy, including stricture (34.0%), features of eosinophilic esophagitis (30.2%), and esophagitis (22.6%). Recurrent EFI occurred at a similar rate between patients with NER and ER (9.4% vs. 14.6%, P = 0.14). Patients with established esophageal disease (odds ratio [OR]: 1.51, P = 0.04) and recommendation to follow-up at time of EFI (OR: 6.06, P < 0.001) were most likely to follow up after EFI. Approximately, a quarter of patients with EFI will experience NER of their EFI. Virtually, all patients (92.5%) were found to have esophageal disease warranting longitudinal care. Importantly, follow-up rates are significantly lower in those with NER than their counterparts requiring EGD. Our study highlights the need to develop standardized protocols that improve follow-up for patients after NER of EFI.


Asunto(s)
Trastornos de Deglución , Esofagitis Eosinofílica , Humanos , Trastornos de Deglución/epidemiología , Estudios Retrospectivos , Estudios de Seguimiento , Endoscopía , Esofagitis Eosinofílica/epidemiología , Alimentos
2.
Dis Esophagus ; 34(11)2021 Nov 11.
Artículo en Inglés | MEDLINE | ID: mdl-33987650

RESUMEN

Esophageal food impaction (EFI) is often the first presentation for patients with eosinophilic esophagitis (EoE); however, there is significant heterogeneity in the management of EFI. We aimed to study the impact of EFI management, particularly post-EFI medication prescriptions on EoE diagnosis, follow-up, and recurrence in patients with endoscopic features of EoE. In our retrospective study, adults presenting between 2007 and 2017 with EFI requiring endoscopic dis-impaction with endoscopic features of EoE (furrows, rings, and/or exudates) were included. We examined the impact of demographics and EFI management on EoE diagnosis, follow-up (esophagogastroduodenoscopy [EGD] or clinic visit within 6 months), and recurrence. We identified 164 cases of EFI due to suspected EoE. Biopsy was performed in 68 patients (41.5%), and 144 patients (87.8%) were placed on proton pump inhibitor (PPI) and/or swallow corticosteroids after EFI, including 88.5% of those not biopsied. PPI use at time of biopsy was negatively associated with EoE diagnosis (odds ratio: 0.39, confidence interval: 0.17-0.85). Sixty-one (37.4%) patients were lost to follow-up at 6 months. Recurrent EFI at 1 year occurred in 3.7% of patients. Medications, most commonly PPI, are frequently prescribed after EFI when the endoscopic features of EoE are present, which may mask the diagnosis of EoE on follow-up EGD. We estimated that for every five patients biopsied on PPI, one case of EoE is masked. As recurrent EFI within 1 year is uncommon, empiric therapy should be avoided until diagnostic biopsies are obtained. Further efforts to reduce loss to follow-up after EFI are also needed.


Asunto(s)
Trastornos de Deglución , Esofagitis Eosinofílica , Adulto , Trastornos de Deglución/etiología , Esofagitis Eosinofílica/complicaciones , Esofagitis Eosinofílica/diagnóstico , Esofagitis Eosinofílica/tratamiento farmacológico , Estudios de Seguimiento , Humanos , Inhibidores de la Bomba de Protones/uso terapéutico , Estudios Retrospectivos
3.
Clin Gastroenterol Hepatol ; 18(3): 736-738, 2020 03.
Artículo en Inglés | MEDLINE | ID: mdl-31077832

RESUMEN

Cytomegalovirus (CMV) can infect multiple areas of the gastrointestinal tract, most commonly the esophagus and colon.1 CMV esophagitis is the third leading cause of infectious esophagitis, after Candida and herpes simplex virus.2 It occurs predominantly in immunocompromised hosts such as patients with human immunodeficiency virus (HIV) and is considered an acquired immunodeficiency syndrome (AIDS) defining illness.1 However, more recent case reports suggest that this disease may also affect the non-HIV immunosuppressed patient population.3 The aim of this study was to reevaluate predictors for development of CMV esophagitis in the post highly active antiretroviral therapy era and describe clinical and endoscopic features of CMV esophagitis as well as patient outcomes from a large tertiary care center.


Asunto(s)
Síndrome de Inmunodeficiencia Adquirida , Infecciones por Citomegalovirus , Esofagitis , Citomegalovirus , Infecciones por Citomegalovirus/epidemiología , Esofagitis/epidemiología , Humanos , Factores de Riesgo
4.
Clin Gastroenterol Hepatol ; 17(1): 200-202.e1, 2019 01.
Artículo en Inglés | MEDLINE | ID: mdl-29702297

RESUMEN

Candida infection in the gastrointestinal tract is most studied in immunocompromised patients. Patients without systemic immunodeficiency, however, may have esophageal candidiasis associated with antibiotic or steroid medication use, alcoholic consumption, diabetes mellitus, and esophageal stasis disorders such achalasia or scleroderma esophagus.1-5 This population has not been well studied. We aim to describe demographics, risk factors, and relevant clinical outcomes for patients with Candida esophagitis with an emphasis in systemically immunocompetent patients.


Asunto(s)
Antifúngicos/uso terapéutico , Candidiasis/tratamiento farmacológico , Candidiasis/patología , Esofagitis/tratamiento farmacológico , Esofagitis/patología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Animales , Candidiasis/epidemiología , Demografía , Esofagitis/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Resultado del Tratamiento , Adulto Joven
5.
Dig Dis Sci ; 64(7): 1893-1900, 2019 07.
Artículo en Inglés | MEDLINE | ID: mdl-30725296

RESUMEN

BACKGROUND AND AIMS: Herpes simplex esophagitis (HSE) is the second most common cause of infectious esophagitis and occurs in both immunocompetent and immunocompromised patients. The aim of this study was to reappraise the clinical course of HSE in different patient populations based on degree of immunocompetence and the presence or absence of underlying esophageal disease. METHODS: Patients with histopathologically confirmed HSE identified from the Mayo Clinic pathology database from 2006 to 2016 were included in this study. Relevant demographic, clinical, and endoscopic data were retrospectively reviewed and compared between two cohorts: (a) immunocompromised and immunocompetent patients and (b) patients with and without underlying esophageal disorders. RESULTS: Forty-six patients were included in the study. The most common presenting symptoms were odynophagia (34.8%) and dysphagia (30.4%). Thirty-three (71.7%) patients were immunocompromised, and these patients who experienced longer duration of symptoms (25.5 ± 23.4 days vs. 7.0 ± 5.5 days, p = 0.04) were more likely to require an extension of treatment course (38.1% vs. 8.3%, p = 0.05) compared to their immunocompetent counterparts. Seventeen (37%) patients had underlying esophageal disease, and these patients were more likely to have concomitant esophageal candidiasis (41.2% vs. 10.3%, respectively; p = 0.01). CONCLUSION: Herpes simplex virus causes esophagitis in both immunocompetent and immunocompromised patients. While the disease course appears to be self-limited for all patient populations, clinical and endoscopic differences in the disease presentation and clinical course based on immune status and the presence or absence of underlying esophageal disease exist.


Asunto(s)
Trastornos de Deglución/inmunología , Esofagitis/inmunología , Esófago/inmunología , Herpes Simple/inmunología , Inmunocompetencia , Huésped Inmunocomprometido , Infecciones Oportunistas/inmunología , Adulto , Anciano , Antivirales/uso terapéutico , Biopsia , Candidiasis/inmunología , Bases de Datos Factuales , Deglución , Trastornos de Deglución/diagnóstico , Trastornos de Deglución/fisiopatología , Trastornos de Deglución/virología , Esofagitis/diagnóstico , Esofagitis/fisiopatología , Esofagitis/virología , Esofagoscopía , Esófago/patología , Esófago/fisiopatología , Esófago/virología , Femenino , Herpes Simple/diagnóstico , Herpes Simple/fisiopatología , Herpes Simple/virología , Humanos , Masculino , Persona de Mediana Edad , Infecciones Oportunistas/diagnóstico , Infecciones Oportunistas/fisiopatología , Infecciones Oportunistas/virología , Pronóstico , Estudios Retrospectivos , Factores de Riesgo
6.
J Urol ; 195(4 Pt 1): 1009-13, 2016 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-26498055

RESUMEN

PURPOSE: Cerebral palsy is characterized by motor impairment following injury to the developing brain. Neurogenic lower urinary tract dysfunction is estimated to affect at least a third of children with cerebral palsy. However there are limited data as patients transition to adulthood. We sought to describe the symptoms, sequelae and management of neurogenic lower urinary tract dysfunction in adults with cerebral palsy. MATERIALS AND METHODS: We retrospectively reviewed the charts of adult patients with cerebral palsy between 2011 and 2014. Patients with prior bladder reconstruction or catheterization based bladder drainage were excluded from study. Cerebral palsy severity was determined using GMFCS (Gross Motor Function Classification System). A conservative evaluation and treatment paradigm was used. Noninvasive treatments were encouraged. Specifically clean intermittent catheterization, which is often not feasible, is avoided unless urinary retention, hydronephrosis or refractory lower urinary tract symptoms develop. RESULTS: There were 121 patients included in final analysis. Median age was 25 and 61 patients (50%) had GMFCS level V. Noninvasive management failed in 28 of 121 patients (23%) as defined by hydronephrosis in 9, persistent urinary retention in 10 and refractory lower urinary tract symptoms/incontinence in 9. Urethral clean intermittent catheterization was poorly tolerated. Of all patients 25% showed evidence of urolithiasis during the study period. Surgical intervention was rare and associated with significant morbidity. CONCLUSIONS: Adults with cerebral palsy may present with variable signs and symptoms of neurogenic lower urinary tract dysfunction. Conservative treatment was successful in more than 75% of patients. Clean intermittent catheterization was poorly tolerated in patients in whom conservative treatment failed. Surgical intervention was rarely indicated and it should be reserved for select individuals.


Asunto(s)
Parálisis Cerebral/complicaciones , Tratamiento Conservador , Síntomas del Sistema Urinario Inferior/etiología , Síntomas del Sistema Urinario Inferior/terapia , Vejiga Urinaria Neurogénica/etiología , Vejiga Urinaria Neurogénica/terapia , Adulto , Femenino , Humanos , Masculino , Estudios Retrospectivos , Resultado del Tratamiento
10.
Mayo Clin Proc ; 94(4): 697-703, 2019 04.
Artículo en Inglés | MEDLINE | ID: mdl-30947833

RESUMEN

Upper gastrointestinal bleeding is a medical condition routinely encountered in clinical practice. Overt upper gastrointestinal bleeding usually presents as melena or hematemesis but can also present as hematochezia in cases of brisk bleeding. The initial evaluation of a patient with suspected upper gastrointestinal bleeding begins with assessment of hemodynamic status, identification of potential risk factors, and appropriate triage of level of care. After resuscitation measures, endoscopic evaluation can be performed to diagnose and potentially treat the source of bleeding. Risk factors that increase the propensity for recurrent bleeding should be identified and addressed.


Asunto(s)
Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/terapia , Hemostasis Endoscópica/métodos , Manejo de la Enfermedad , Endoscopía Gastrointestinal/métodos , Hemorragia Gastrointestinal/complicaciones , Hematemesis/etiología , Humanos , Melena/etiología , Factores de Riesgo
11.
Mayo Clin Proc ; 94(1): 139-144, 2019 01.
Artículo en Inglés | MEDLINE | ID: mdl-30611441

RESUMEN

Chronic abdominal wall pain is a common, yet often overlooked, cause of chronic abdominal pain in both the outpatient and inpatient settings. This disorder most commonly affects middle-aged adults and is more prevalent in women than in men. In chronic abdominal wall pain, the pain occurs due to entrapment of the cutaneous branches of the sensory nerves that supply the abdominal wall. Although the diagnosis of chronic abdominal wall pain can be made using patient history, physical examination, and response to a trigger point injection, patients often undergo extensive and exhaustive laboratory, imaging, and procedural work-up before being diagnosed with this condition, given it is often overlooked. Carnett's sign is a specialized physical examination technique that can help support the fact that the abdominal pain originates from the abdominal wall rather than from the abdominal viscera. The mainstay of treatment consists of reassurance, activity modification, over-the-counter analgesic agent, and trigger point injection. In rare cases, treatment with chemical neurolysis or surgical neurectomy may be required.


Asunto(s)
Dolor Abdominal/etiología , Dolor Crónico/etiología , Síndromes de Compresión Nerviosa/complicaciones , Dolor Abdominal/diagnóstico , Pared Abdominal , Dolor Crónico/diagnóstico , Diagnóstico Diferencial , Humanos , Síndromes de Compresión Nerviosa/diagnóstico , Dimensión del Dolor
12.
Inflamm Bowel Dis ; 25(4): 767-774, 2019 03 14.
Artículo en Inglés | MEDLINE | ID: mdl-30295784

RESUMEN

BACKGROUND: Crohn's disease (CD) of the pouch and chronic pouchitis occur in approximately 10% of patients after ileal pouch-anal anastomosis (IPAA) for refractory ulcerative colitis (UC) or UC-related dysplasia. The efficacy of anti-tumor necrosis factor (anti-TNF) agents and vedolizumab have been reported for the treatment of CD of the pouch and chronic pouchitis, but little is known regarding the use of ustekinumab in these settings. Our primary aim was to evaluate the efficacy of ustekinumab for these conditions. METHODS: This is a retrospective, multicenter cohort study evaluating the efficacy of ustekinumab in patients with CD of the pouch and chronic pouchitis. Clinical response or remission was judged by the treating physician's assessment at 6 months. RESULTS: Fifty-six patients (47 with CD of the pouch and 9 with chronic pouchitis) were included the study. Of these, 73% had previously been treated with either anti-TNF therapy, vedolizumab, or both after IPAA. Among patients with CD of the pouch and chronic pouchitis, 83% demonstrated clinical response 6 months after induction with ustekinumab. Responders demonstrated significantly less pouch inflammation on endoscopy when compared with nonresponders (29% vs 100%; P = 0.023). Higher mean body mass index at induction (26.3 vs 23.7; P = 0.033) and male sex (83% vs 30%; P = 0.014) were significant predictors of nonresponse to ustekinumab in those with CD of the pouch. CONCLUSION: In this refractory patient population, ustekinumab appears to be a safe and effective treatment for chronic pouchitis and CD of the pouch in biologic-naïve patients and those with prior anti-TNF or vedolizumab therapy failure. 10.1093/ibd/izx005_video1 izy302.video1 5844889626001.


Asunto(s)
Enfermedad de Crohn/tratamiento farmacológico , Fármacos Dermatológicos/uso terapéutico , Reservoritis/complicaciones , Ustekinumab/uso terapéutico , Adulto , Enfermedad de Crohn/etiología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Pronóstico , Estudios Retrospectivos
13.
Inflamm Bowel Dis ; 25(9): 1569-1576, 2019 08 20.
Artículo en Inglés | MEDLINE | ID: mdl-30810748

RESUMEN

BACKGROUND AND AIMS: Inflammation of the pouch after ileal pouch-anal anastomosis (IPAA) can significantly impact quality of life and be difficult to treat. We assessed the effectiveness and safety of vedolizumab in Crohn's disease (CD) of the pouch and chronic antibiotic-dependent or antibiotic-refractory pouchitis. METHODS: This was a retrospective, multicenter cohort study at 5 academic referral centers in the United States. Adult patients with endoscopic inflammation of the pouch who received vedolizumab were included. The primary outcome was clinical response at any time point. Secondary outcomes included clinical remission, endoscopic response, and remission. Univariate analysis and multivariate analysis were performed for the effect of the following variables on clinical response: fistula, onset of pouchitis less than 1 year after IPAA, younger than 35 years old, gender, previous tumor necrosis factor inhibitor-alpha use, and BMI >30. RESULTS: Eighty-three patients were treated with vedolizumab for inflammation of the pouch between January 2014 and October 2017. Median follow-up was 1.3 years (interquartile range 0.7-2.1). The proportion of patients that achieved at least a clinical response was 71.1%, with 19.3% achieving clinical remission. Of the 74 patients with a follow-up pouchoscopy, the proportion of patients with endoscopic response and mucosal healing was 54.1% and 17.6%, respectively. Patients who developed pouchitis symptoms less than 1 year after undergoing IPAA were less likely to respond to vedolizumab, even after controlling for other risk factors. CONCLUSIONS: Vedolizumab is safe and effective in the management of CD of the pouch and chronic pouchitis. Further studies are needed to compare vedolizumab with other biologic therapies for pouchitis and CD of the pouch.


Asunto(s)
Anticuerpos Monoclonales Humanizados/uso terapéutico , Enfermedad de Crohn/cirugía , Resistencia a Medicamentos/efectos de los fármacos , Reservoritis/tratamiento farmacológico , Proctocolectomía Restauradora/efectos adversos , Adulto , Femenino , Estudios de Seguimiento , Fármacos Gastrointestinales/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Reservoritis/etiología , Pronóstico , Estudios Retrospectivos , Estados Unidos
14.
BMJ Case Rep ; 20182018 Apr 17.
Artículo en Inglés | MEDLINE | ID: mdl-29666092

RESUMEN

A 33-year-old man presented with new-onset, asymmetric, migratory oligoarthritis in the setting of several weeks of nausea and vomiting, diarrhoea, fevers and dysuria. He was initially treated in the inpatient setting with broad-spectrum antibiotics due to concern for an evolving sepsis presentation. Arthrocentesis of a large right knee effusion revealed inflammatory synovial fluid without findings suggestive of septic arthritis. Human leucocyte antigen B27 was positive and, taken together with the antecedent history of gastroenteritis, dysuria and inflammatory oligoarthritis, the clinical diagnosis was most consistent with reactive arthritis. Antibiotics were discontinued. His treatment course proved refractory to non-steroidal anti-inflammatory drugs and intra-articular and systemic glucocorticoid therapy with concurrent use of sulfasalazine and ultimately necessitated treatment with a tumour necrosis factor alpha inhibitor.


Asunto(s)
Antiinflamatorios no Esteroideos/uso terapéutico , Artritis Reactiva/diagnóstico , Enfermedades Gastrointestinales/microbiología , Articulación de la Rodilla/patología , Sepsis/diagnóstico , Líquido Sinovial/microbiología , Adulto , Artritis Reactiva/tratamiento farmacológico , Artritis Reactiva/fisiopatología , Diarrea , Disuria , Fiebre , Enfermedades Gastrointestinales/complicaciones , Glucocorticoides/uso terapéutico , Humanos , Articulación de la Rodilla/microbiología , Masculino , Enfermedades Raras , Sepsis/tratamiento farmacológico , Sepsis/fisiopatología , Sulfasalazina/uso terapéutico , Resultado del Tratamiento , Vómitos
15.
Endosc Int Open ; 6(1): E73-E77, 2018 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-29344563

RESUMEN

BACKGROUND AND STUDY AIMS: Management of post-sphincterotomy perforations is variable, with some patients managed conservatively and other requiring surgery. Fully-covered self-expanding metal stents (FCSEMs) have been used in the past, but data is limited. The aim of this study was to report the clinical characteristics and outcomes following placement of anchored FCSEMSs for the immediate management of post-sphincterotomy perforation. PATIENTS AND METHODS: All patients undergoing an ERCP procedure between June 2011 and December 2015 at our institution were reviewed for post-sphincterotomy perforation. All intra-procedurally recognized perforations underwent placement of FCSEMs with flexible anchoring fins and were included in this study. Data extracted included patient demographics, indication, peri-procedural details, clinical course and long-term outcome following anchored FCSEMS placement. RESULTS: A total of 15 patients (12 females, median age-66 years) with post-sphincterotomy perforation were included. Major indications included choledocholithiasis in 9 (60 %), and 5 (33.3 %) patients had intra-ampullary or periampullary diverticula. All patients underwent placement of FCSEMS without any complication and had immediate resolution of perforation as evidenced by decrease in fluoroscopic gas and lack of contrast extravasation. None of the patients became symptomatic or needed surgery with a median 2 days of hospitalization following the procedure. Stents were removed after a median of 30.5 days and no complications were noted during follow-up after stent removal. CONCLUSIONS: Anchored FCSEMs are safe and effective for management of intra-procedurally recognized post-sphincterotomy perforations and obviates need for surgery.

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