Black esophagus: new insights and multicenter international experience in 2014.

BACKGROUND: Black esophagus or acute esophageal necrosis (AEN) is a striking medical condition characterized by circumferential black appearing esophageal mucosa affecting various lengths of the organ with nearly universal involvement of the distal esophagus and abrupt transition at the gastroesophageal junction. This syndrome is gaining acceptance as an important cause of upper gastrointestinal hemorrhage in hospitalized patients. AIMS: To better describe clinical features, risk factors, associated conditions, etiology, treatment, complications, and outcome in patients with AEN at various medical centers across the globe. METHODS: We analyze this syndrome as a first international multicenter series of eight patients who presented with AEN. Clinical characteristics were recorded for each case by treating physicians, and data were retrospectively analyzed and compared. RESULTS: AEN is more common in geriatric males and characteristically (88 %) presents with signs of upper gastrointestinal hemorrhage. Risk factors include alcohol abuse, hypertension, diabetes mellitus, dyslipidemia, chronic kidney disease, malnourishment, and vascular disease. Hypoalbuminemia was universal, while anemia, renal insufficiency, and hyperglycemia were seen in nearly 90 % of the patients. Endoscopically, distal esophageal involvement with various proximal extension and sharp demarcation at the GE junction was seen in all patients. Duodenal pathology was seen in 50 % of the cases. Causes of AEN were largely multifactorial with all patients affected by a combination of ischemic insult, compromised mucosal defenses, and corrosive reflux injury of gastric contents. Treatment with acid suppression and correction of underlying medical conditions was implemented in all patients. Esophageal stricture formation was seen in 25 % of the patients and was associated with concurrent duodenal pathology. Mortality was 12.5 % and unrelated to AEN. CONCLUSION: Black esophagus or AEN syndrome is an important cause of upper gastrointestinal hemorrhage with striking endoscopic presentation in a clinically compromised individual with multiple co-morbidities. Structured conservative management with correction of underlying etiology and acid suppression is essential to improved prognosis. Associated duodenal pathology on endoscopy is a reflection of the degree of initial insult and a clinical predictor for potential stricture development. Proximal extension of the black esophagus may be related to the degree of hyperglycemia. Increased awareness of AEN syndrome will lead to early recognition and proper treatment.

Effects of triple-drug therapy with nitazoxanide, high-dose ribavirin and peginterferon-α-2a in patients with chronic hepatitis C.

AIM: The historical standard of care for patients with chronic hepatitis C virus (HCV) was peginterferon (PEG IFN) and ribavirin combination therapy, yielding sustained virological response (SVR) rates of 38-52% in HCV genotype 1 patients. This study evaluated a novel three-drug regimen of nitazoxanide and high-dose ribavirin as lead-in therapy, followed by PEG IFN-α-2a in triple therapy. METHODS: A prospective, open-label pilot study was conducted in treatment-naive patients with HCV genotype 1. Patients received nitazoxanide 500 mg twice a day for 2 weeks, then nitazoxanide plus ribavirin 1400 mg/day for 2 weeks, then nitazoxanide plus ribavirin plus PEG IFN-α-2a 180 µg weekly for 12 weeks, followed by ribavirin plus PEG IFN-α-2a for 12 weeks (48 weeks if HCV RNA negative after week 24). Primary outcome was SVR. Other outcomes included very rapid virological response (VRVR), rapid virological response (RVR), early virological response (EVR), end-of-treatment response (ETR), and safety and tolerability. RESULTS: Thirty-three patients with a mean age of 46 years, detectable HCV RNA (64% with <600 000 IU/mL), and METAVIR fibrosis scores (F1:F2:F3) of 15%:49%:36% were enrolled. Outcomes were as follows: SVR, 67% (22/33); VRVR, 39% (13/33); RVR, 48% (16/33); EVR, 70% (23/33); and ETR, 67% (22/33). Most patients required at least one growth factor. Two patients discontinued because of adverse events. CONCLUSION: This three-drug regimen was effective in achieving SVR in patients with HCV genotype 1. No patients relapsed, and the toxicity profile was favorable. Further studies on the role of nitazoxanide in the treatment of chronic HCV are warranted.

A randomized study comparing levofloxacin, omeprazole, nitazoxanide, and doxycycline versus triple therapy for the eradication of Helicobacter pylori.

OBJECTIVES: Resistance to standard Helicobacter pylori (HP) treatment regimens has led to unsatisfactory cure rates in HP-infected patients. This study was designed to evaluate a novel four-drug regimen (three antibiotics and a proton pump inhibitor (PPI)) for eradication of HP infection in treatment-naive patients. METHODS: Patients with a diagnosis of HP gastritis or peptic ulcer disease confirmed using endoscopy and stool antigen testing were eligible for inclusion in this study. All patients underwent a washout period of 6 weeks from any prior antibiotic or PPI usage. Patients were then randomized to either levofloxacin, omeprazole, nitazoxanide, and doxycycline (LOAD) therapy for 7 days (LOAD-7) or 10 days (LOAD-10), including levofloxacin 250 mg with breakfast, omeprazole 40 mg before breakfast, nitazoxanide (Alina) 500 mg twice daily with meals and doxycycline 100 mg at dinner, or lansoprozole, amoxicillin, and clarithromycin (LAC) therapy for 10 days, which included lansoprozole 30 mg, amoxicillin 1 g with breakfast and dinner, and clarithromycin 500 mg with breakfast and dinner. HP eradication was confirmed by stool antigen testing at least 4 weeks after cessation of therapy. RESULTS: Intention-to-treat analysis revealed significant differences (P<0.05) in the respective eradication rates of the LOAD therapies (88.9% (80/90) LOAD-10, 90% (81/90) LOAD-7, 89.4% (161/180) for combined LOAD) compared with those receiving LAC, 73.3% (66/90). There were no differences in adverse effects between the groups. CONCLUSIONS: This open-label, prospective trial demonstrates that LOAD is a highly active regimen for the treatment of HP in treatment-naive patients. A large randomized controlled trial is warranted to further evaluate the efficacy of this regimen.

Filling Defect on ERCP: Biliary Cystadenoma, a Rare Tumor.

Biliary cystadenomas are rare tumors of the bile ducts most commonly presenting as large right liver lobe lesions. These are usually slow-growing and mostly benign. They commonly present with abdominal pain. On physical exam an abdominal mass can be identified occasionally. Walls of biliary cystadenomas appear thicker than simple cysts, with soft tissue nodules and enhancing septations on CT or MRI. Radiographic images can vary with the amount of protein content in the fluid on CT or MRI. Due to the risk of malignant transformation, complete surgical resection is advised. Hereby, we describe a 37-year-old lady who presented to the outpatient clinic with bloating and abdominal discomfort with intermittent elevated liver enzymes and hyperbilirubinemia. Ultrasound of the liver and bile ducts followed by CT scan and magnetic resonance cholangiopancreatography confirmed the presence of biliary cystadenoma of the intra- and extrahepatic ducts. It was seen as a filling defect of the intra- and extrahepatic ducts (common hepatic duct) on endoscopic retrograde cholangiopancreatography. Involvement of the intra- and extrahepatic bile ducts simultaneously is a rare presentation of this tumor. She later on underwent exploratory laparotomy with extrahepatic bile duct resection, left hepatic lobe resection and reconstruction with hepaticojejunostomy. Pathology confirmed the presence of biliary cystadenoma with ovarian-like stroma. She had recovered uneventfully from the surgery when seen 2 weeks later in the clinic. Biliary cystadenoma is a rare, mostly benign neoplasm of the biliary tract that should be considered in the differential diagnosis of cystic lesions of the biliary tract.

Rifaximin therapy for metronidazole-unresponsive Clostridium difficile infection: a prospective pilot trial.

BACKGROUND: Clostridium difficile infection (CDI) is a recent epidemic in the United States, particularly in the hospital setting. Oral metronidazole is standard therapy for C. difficile infection, but resistance to metronidazole is becoming a clinical challenge. METHODS: We evaluated the efficacy of the nonsystemic oral antibiotic rifaximin for the treatment of metronidazole-resistant C. difficile infection. Twenty-five patients with C. difficile infection were enrolled in the study. All had mild-to-moderate C. difficile infection (5-10 bowel movements a day without sepsis) unresponsive to metronidazole (i.e. stools positive for toxins A and B after oral metronidazole 500 mg three times daily [t.i.d.] for 5 days). After discontinuation of metronidazole, rifaximin 400 mg t.i.d. for 14 days was prescribed. Patients were followed for 56 days and stool was tested for C. difficile using polymerase chain reaction (PCR) to assess the effect of treatment. A negative PCR test result was interpreted as a favorable response to rifaximin. RESULTS: Sixteen of 22 patients (73%) were eligible for study inclusion and completed rifaximin therapy experienced eradication of infection (stool negative for C. difficile) immediately after rifaximin therapy and 56 days post-treatment. Three patients (12%) discontinued therapy because of abdominal distention. Rifaximin was generally well tolerated. CONCLUSIONS: In conclusion, rifaximin may be considered for treatment of mild-to-moderate C. difficile infection that is resistant to metronidazole. Larger randomized trials are needed to confirm these positive findings.