Progression of gastrointestinal symptoms over time in patients with systemic sclerosis.

Up to 90% of patients with systemic sclerosis (SSc) develop gastrointestinal (GI) symptoms. To evaluate whether GI symptoms and quality of life in patients with SSc demonstrate longitudinal stability. Consecutive patients with SSc (n = 100) completed the validated university of California at Los Angeles scleroderma clinical trial consortium gastrointestinal tract 2.0 (GIT) instrument and completed the same instrument approximately 5 years later. Comparison was made between patients with diffuse (dcSSc) and limited (lcSSc) subtypes and duration of disease of less than or greater than 5 years. GIT scores were calculated and analyzed for differences. 37 patients with dcSSc and 63 patients with lcSSc were included. Social functioning score significantly improved over time [0.44 (0.59)-0.31 (0.47); P = 0.003]. Total GIT scores were lower in patients with diffuse [0.51 (0.41)] compared with limited [(0.72 (0.53); P = 0.029] disease at both baseline and follow-up. Social functioning improved similarly in both dcSSc and lcSSc over time (P = 0.004). GIT Total scores increased in 27% (27/100) of patients and did not change or improved in 73% (73/100). Patients with worsening GI status had significantly increased scores on all GIT subscales. A lower body-mass index at baseline was significantly associated with worsening GIT Total score (OR 1.22; 95% CI 1.07-1.39; P < 0.001). Patients with SSc generally demonstrate longitudinal stability or improvement in their GI symptoms, but a subset of patients experience worsening of GI symptoms and negative impacts on GI-related quality of life.

Effect of bowel preparation volume in inpatient colonoscopy. Results of a prospective, randomized, comparative pilot study.

BACKGROUND: Inpatient status has been shown to be a predictor of poor bowel preparation for colonoscopy; however, the optimal bowel preparation regimen for hospitalized patients is unknown. Our aim was to compare the efficacy of bowel preparation volume size in hospitalized patients undergoing inpatient colonoscopy. METHODS: This prospective, single blinded (endoscopist), randomized controlled trial was conducted as a pilot study at a tertiary referral medical center. Hospitalized patients undergoing inpatient colonoscopy were assigned randomly to receive a high, medium, or low-volume preparation. Data collection included colon preparation quality, based on the Boston Bowel Preparation Scale, and a questionnaire given to all subjects evaluating the ability to completely finish bowel preparation and adverse effects (unpleasant taste, nausea, and vomiting). RESULTS: Twenty-five colonoscopies were performed in 25 subjects. Patients who received low-volume preparation averaged a higher mean total BBPS (7.4, SD 1.62), in comparison to patients who received high-volume (7.0, SD 1.41) and medium-volume prep (6.9, SD 1.55), P = 0.77. When evaluating taste a higher score meant worse taste. The low-volume group scored unpleasant taste as 0.6 (0.74), while the high-volume group gave unpleasant taste a score of 2.2 (0.97) and the medium-volume group gave a score of 2.1 (1.36), P < 0.01. CONCLUSION: In this pilot study we found that low-volume colon preparation may be preferred in the inpatient setting due its better rate of tolerability and comparable bowel cleanliness when compared to larger volume preparation, although we cannot overreach any definitive conclusion. Further more robust studies are required to confirm these findings. TRIAL REGISTRATION: The Affect of Low-Volume Bowel Preparation for Hospitalized Patients Colonoscopies. TRIAL REGISTRATION: NCT01978509 (terminated). Retrospectively registered on November 07, 2013.

Impact of feedback on adenoma detection rates: Outcomes of quality improvement program.

BACKGROUND AND AIM: Feedback has been shown to improve performance in colonoscopy including adenoma detection rate (ADR). The frequency at which feedback should be given is unknown. As part of a quality improvement program, we sought to measure the outcome of providing quarterly and monthly feedback on colonoscopy quality measures. METHODS: All screening colonoscopies performed at endoscopy unit at Mayo Clinic Arizona by gastroenterologists between October 2010 and December 2012 were reviewed. Quality indicators, including ADR, were extracted for each individual endoscopist, and feedback was provided. The study period was divided into four distinct groups: pre-intervention that served as baseline, quarterly feedback, monthly feedback, and post-intervention. Based on ADR, endoscopists were grouped into "low detectors" (≤ 25%), "average detectors" (26-35%), and "high detectors" (> 35%). RESULTS: A total of 3420 screening colonoscopies were performed during the study period (555 patients during pre-intervention, 1209 patients during quarterly feedback, 599 during monthly feedback, and 1057 during the post-intervention period) by 16 gastroenterologists. The overall ADR for the group improved from 30.5% to 37.7% (P = 0.003). Compared with the pre-interventional period, all quality indicators measured significantly improved during the monthly feedback and post-intervention periods but not in the quarterly feedback period. CONCLUSIONS: In our quality improvement program, monthly feedback significantly improved colonoscopy quality measures, including ADR, while quarterly feedback did not. The impact of the intervention was most prominent in the "low detectors" group. Results were durable up to 6 months following the intervention.

Esophageal Motor Abnormalities in Patients With Scleroderma: Heterogeneity, Risk Factors, and Effects on Quality of Life.

BACKGROUND & AIMS: Systemic scleroderma (SSc) is associated with esophageal aperistalsis and hypotensive esophagogastric junction pressure, although there could be a gradation in esophageal motor dysfunction. We characterized esophageal motor function by high-resolution esophageal manometry (HRM) and assessed associations between SSc severity, health-related quality of life (HRQOL), and HRM findings in patients. METHODS: We performed a prospective study of 200 patients with SSc and 102 patients without SSc (controls) who underwent HRM at Mayo Clinic Arizona from May 2006 through January 2015. We used data on integrated relaxation pressure, distal contractile integral, and distal latency to classify esophageal motility disorders according to the Chicago Classification v 3.0. A subset of subjects (n = 122) completed SSc-specific gastrointestinal symptom and HRQOL questionnaires. HRM findings, symptoms, and HRQOL data were compared among diffuse SSc, limited SSc, and control subjects. Categorical variables were compared by using the χ2 or Fisher exact test; continuous variables were compared by using Mann-Whitney or Kruskal-Wallis test. Multivariable logistic regression was used to assess the association between severity of esophageal dysmotility and baseline clinical factors. RESULTS: Among patients with SSc, 83 had diffuse SSc (42%), and 117 had limited SSc (58%). Absent contractility was more frequent in patients with SSc than in controls (56% vs 13%; P < .001). HRM findings varied among the patients; absent contractility (56%) was the most frequent diagnosis, followed by normal motility (26%) and ineffective esophageal motility (10%). Classic scleroderma esophagus (esophagogastric junction pressure with absent contractility) was only observed in 33% of patients (34% with diffuse SSc vs 32% limited SSc) (P = .880). Severe esophageal dysmotility was associated with disease duration, interstitial lung disease, and higher gastrointestinal symptom scores (P < .001). HRQOL was decreased in patients with SSc and severe esophageal dysmotility. CONCLUSIONS: Although severe dysmotility is more common in patients with SSc than in controls, we observed the so-called scleroderma esophagus in only one-third of patients with SSc. Esophageal motor function appears to be heterogeneous in SSc. Esophageal dysmotility reduces HRQOL in patients with SSc.

The Impact of Pelvic Floor and Lower Gastrointestinal Symptoms on Quality of Life in Women With Systemic Sclerosis.

BACKGROUND: Systemic sclerosis (SSc) patients with gastrointestinal (GI) involvement have a lower quality of life (QoL) and while the impact of upper GI symptoms on QoL in SSc patients has been described few data exist on the presence and impact of lower gastrointestinal (LGI) and pelvic floor symptoms in SSc. Our goal was to assess the prevalence of these symptoms in women with SSc and evaluate their impact on QoL. A secondary hypothesis was that the impact of LGI symptoms on QoL is mediated by depression. STUDY: Women with SSc (n=175) attending an outpatient scleroderma clinic completed multiple validated questionnaires. Pelvic floor and LGI symptoms included fecal incontinence (FI), urinary incontinence (UI), dual incontinence (DI), chronic constipation, diarrhea, and pelvic pain. The Student t tests adjusted for multiple comparisons were used to evaluate group differences at the 0.05 level. RESULTS: Complete data were available for 160 women. FI was reported by 65, UI by 64, DI by 40, chronic constipation by 94, diarrhea by 82, and pelvic pain by 35 of SSc patients. Overall QoL was reduced in SSc patients with FI (0.96 vs. 0.63; P=0.007), UI (0.96 vs. 0.65; P=0.01), DI (1.11 vs. 0.67; P=0.002), and pelvic pain (1.01 vs. 0.70; P=0.04). Antidepressant use was reported by 26%. The negative impact on QoL in patients with pelvic floor symptoms was partially mediated by depression. CONCLUSIONS: Women with SSc suffer from an increased prevalence of LGI and pelvic floor symptoms including FI, UI, diarrhea, constipation, and pelvic pain and this effect seems to be partially mediated by depression.

Multi-Dimensional Gastrointestinal Symptom Severity Index: Validation of a Brief GI Symptom Assessment Tool.

UNLABELLED: Few instruments have been developed and validated for the evaluation of multi-dimensional GI symptoms. The Gastrointestinal Symptoms Severity Index (GISSI), a multi-dimensional, self-report instrument, was designed as a brief measure of the frequency, severity, and bothersomeness of individual GI and pelvic floor/urogynecologic symptoms. AIM: To report the psychometric properties of the GISSI subscales, including factorial structure, validity, and internal consistency. METHODS: The GISSI included 32 items that assessed upper and lower GI symptoms and seven items related to pelvic floor/urogynecologic symptoms. A total of 934 patients presenting for upper and lower GI complaints completed the questionnaire between January 2013 and December 2013. The sample was randomly split into derivation (n = 466) and validation datasets (n = 468). A non-patient sample of 200 was collected separately. RESULTS: Exploratory factor analysis supported a six-factor model for the derivation sample that accounted for 69.3 % of the total variance. The six GI symptom clusters were labeled as constipation/difficult defecation (five items), abdominal pain/discomfort (four items), dyspepsia (four items), diarrhea/anal incontinence (four items), GERD/chest symptoms (four items), and nausea/vomiting (two items). Inclusion of additional items related to female pelvic floor/urogynecologic symptoms resulted in a separate factor. Confirmatory factor analysis of the validation dataset supported the a priori hypothesized six-factor measurement model (Χ (2)(428) = 1462.98; P < 0.001; GFI = .88; RMSEA = .051). CONCLUSION: The GISSI demonstrated good to excellent psychometric properties and provided multi-dimensional scaling of prominent GI symptom clusters. Further validation may provide an efficient, valid, and reliable measure of patient-reported clinical outcomes.

Esophageal peristaltic defects in adults with functional dysphagia.

Functional dysphagia (FD) is characterized by the presence of dysphagia without evidence of mechanical esophageal obstruction, GERD, and histopathology-based esophageal motor disorders. Dysphagia is common in older patients; however, there is a paucity of information regarding the type and frequency of peristaltic abnormalities compared to younger patients. Based on recently validated criteria for classification of weak peristalsis using high-resolution manometry (HRM), we hypothesized that older patients with FD would have more peristaltic defects detected by HRM compared to younger FD patients. A retrospective review of our motility database yielded 65 patients that met inclusion criteria. Patients were divided into two groups based on age (younger: <70 years; older: ≥70 years). Patients were interviewed, completed a quality-of-life questionnaire, and underwent solid-state HRM. The two groups differed in age but in no other demographic characteristics, severity of dysphagia, or quality of life. Dyspeptic symptoms, including nausea (p < 0.001), early satiety (p = 0.01), bloating (p = 0.02), and belching (p = 0.01), were also more prevalent in younger FD patients. Older age was associated with weak peristalsis involving frequent failed peristalsis, small proximal peristaltic defects (2-5 cm), and large proximal peristaltic defects (>5 cm) (p < 0.001). The mean contraction amplitude was also lower in the older group (p < 0.05). These data support the hypothesis that older patients with FD have a higher frequency of peristaltic abnormalities on HRM compared to younger patients. Older age was associated with increased frequency of weak peristalsis with small and large peristaltic defects.

Proton pump inhibitor therapy use does not predispose to small intestinal bacterial overgrowth.

OBJECTIVES: Small intestinal bacterial overgrowth (SIBO) occurs due to alteration of the microbiota within the upper gastrointestinal tract. Proton pump inhibitor (PPI) therapy has been suggested as a risk factor for SIBO; however, the published reports have yielded conflicting results on the association between PPI therapy and risk of developing SIBO. The aim of this study was to compare the prevalence of SIBO as measured by glucose hydrogen breath testing (GHBT) in patients on PPI therapy compared with those not on PPI therapy. METHODS: A retrospective chart review was completed for all patients who underwent GHBT testing from 2004 to 2010. Breath samples for hydrogen (H2) and methane (CH4) were collected before and every 20 min for 120 min following ingestion of a 50-g oral glucose load. We used the following criteria to define a positive GHBT (a) increase in H2 > 20 parts per million (p.p.m.) over baseline, (b) sustained rise H2 > 10 p.p.m. over baseline, (c) CH4 > 15 p.p.m. over baseline, and (d) either rise H2 > 20 p.p.m. over baseline or CH4 > 15 p.p.m. RESULTS: A total of 1,191 patients (70% female) were included, of whom 566 (48%) were on PPI therapy. GHBT positivity did not differ significantly between PPI users and nonusers by any of the diagnostic criteria used and PPI use was not significantly associated with GHBT positivity using any of these criteria. GHBT positivity was associated with older age (odds ratio (OR) 1.03, 95% confidence interval (CI) 1.01-1.04) and antidiarrheal use (OR 1.99, 95% CI 1.15-3.44) using H2 > 20, older age (OR 1.01, 95% CI 1.00-1.02) and diarrhea (OR 1.53, 95% CI 1.13-2.09) using H2 > 10, and older age (OR 1.01, 95% CI 1.00-1.02) using either H2 > 20 or CH4 > 15. PPI use was not significantly associated with GHBT positivity using any of these criteria. CONCLUSIONS: In this large, adequately powered equivalence study, PPI use was not found to be significantly associated with the presence of SIBO as determined by the GHBT.

Personality traits and impaired health-related quality of life in patients with functional gastrointestinal disorders.

BACKGROUND & AIMS: Negative affectivity and social isolation (Type D personality) are personality traits associated with poor health-related quality of life (HRQoL). We hypothesized these traits would be associated with impaired HRQoL and increased gastrointestinal symptom severity in functional gastrointestinal disorders. METHODS: Data were collected from patients undergoing breath testing. Patients completed the Type D Scale-14, Gastrointestinal Symptoms Severity Index and Short-Form Health Survey 12. RESULTS: Of 230 patients evaluated, 37% met criteria for Type D personality. Type D was associated with a decreased Mental Component score on the Short-Form Health Survey 12 (mean difference = -8.29; 95% confidence interval, 5.2-11.4; P < .001). On the Gastrointestinal Symptoms Severity Index, severity of symptoms was significantly higher in Type D patients compared with non Type D patients (P < .001). CONCLUSIONS: Type D personality was associated with decreased perceived HRQoL and reporting of more severe gastrointestinal symptoms. Type D personality construct may be an important consideration when assessing HRQoL outcomes. Consideration of personality traits could improve risk stratification in research and clinical practice in this patient group.

Protein-losing enteropathy: case illustrations and clinical review.

Protein-losing enteropathy (PLE) is a rare syndrome of gastrointestinal protein loss that may complicate a variety of diseases. The primary causes can be divided into erosive gastrointestinal disorders, nonerosive gastrointestinal disorders, and disorders involving increased central venous pressure or mesenteric lymphatic obstruction. The diagnosis of PLE should be considered in patients with hypoproteinemia after other causes, such as malnutrition, proteinuria, and impaired protein synthesis due to cirrhosis, have been excluded. The diagnosis of PLE is most commonly based on the determination of fecal alpha-1 antitrypsin clearance. Treatment of PLE targets the underlying disease but also includes dietary modification, supportive care, and maintenance of nutritional status. In this article, cases illustrating a variety of clinical presentations and etiologies of PLE are presented, and its diagnostic approach and treatment are reviewed.

Individuals With Scleroderma May Have Increased Risk of Sleep-Disordered Breathing.

STUDY OBJECTIVES: Scleroderma is associated with abnormal skin thickening, interstitial lung disease, pulmonary hypertension, and abnormalities of the upper airway. These changes can cause cardiopulmonary complications, potentially including sleep-disordered breathing. The objective of this study is to examine the risk of sleep-disordered breathing in patients with scleroderma. METHODS: We retrospectively identified patients with documented scleroderma. We abstracted data from their electronic health records, including findings from antibody tests, serial pulmonary function tests, transthoracic echocardiography, high-resolution computed tomography, and overnight forehead oximetry. RESULTS: We identified 171 patients with scleroderma. Mean age at the time of initial consult was 56.5 years (range, 18-96 years), and 150 (86.7%) were women. Scleroderma was categorized as limited disease for 108 (62.4%), diffuse disease for 59 (34.1%), and mixed connective tissue disease for 6 (3.5%). Fifty-four patients (31.2%) had abnormal overnight forehead oximetry results, defined as an oxygen desaturation index greater than 5 or a baseline mean arterial oxygen saturation level less than 90%. CONCLUSIONS: Cardiopulmonary complications are common in patients with scleroderma, one of which may be sleep-disordered breathing. In our cohort, approximately one-third of individuals with scleroderma had evidence of sleep-disordered breathing. Moreover, the rate of sleep-disordered breathing in our population of scleroderma patients was twice the rate of pulmonary hypertension and was approximately the same as the rate of interstitial lung disease. Future prospective studies are needed to further assess the role of sleep-disordered breathing in scleroderma clinical outcomes.

Is the level of cleanliness using segmental Boston bowel preparation scale associated with a higher adenoma detection rate?

BACKGROUND: The impact of Boston bowel preparation scale (BBPS) scores on the adenoma detection rate (ADR) in each segment has not been adequately addressed. The aim of this study was to determine the association between segmental or overall ADR and serrated polyp detection rate (SDR) with segmental and total BBPS scores. METHODS: All outpatient screening colonoscopies with documented BBPS scores were retrospectively reviewed at a tertiary institution from January to December 2013. Chi-square tests and logistic regression were used to analyze the detection rates of adenomas and serrated polyps with bowel prep scores. Odds ratios were calculated using logistic regression that controlled for withdrawal time, age, body mass index, diabetes status and sex. RESULTS: We analyzed 1991 colonoscopies. The overall ADR was 37.5% (95% confidence interval [CI], 35.3-39.6). There was a significant difference in the overall ADR, and in SDR across all bowel category groups, with total BBPS scores of 8 and 9 having lower detection rates than scores of 5, 6 and 7. As the quality of bowel preparation increased, there was a statistical decrease in the ADR (odds ratio [OR] 0.79 [CI 0.66-0.94], P=0.04) of the right colon, while in the left colon, there was a statistical decrease in SDR (OR 0.78, [CI 0.65-0.92] P=0.019). CONCLUSION: Segmental ADR and SDR both decreased as prep scores increased, decreasing notably in patients with excellent prep scores of 8 and 9. A possible explanation for this unexpected discrepancy may be related to longer and better visualization of the mucosa when cleansing and suctioning is necessary.