Chronic Hepatitis C: Treatment, Complications, and Long-term Outcomes in a Population of Latino Veterans.

OBJECTIVE: Chronic hepatitis C (CHC) is a major public health problem in Puerto Rico. It is the most common cause of chronic liver disease and the most frequent indication for liver transplantation in the United States. Our main objectives were to estimate the seroprevalence of CHC infection, to describe the demographic and histological parameters of the infection in our sample population, and to evaluate the treatment outcomes in Puerto Rican veterans. METHODS: To determine overall seroprevalence, we reviewed all the hepatitis C cases (encompassing from January 1, 2002, to December 31, 2009) of the VA Caribbean Healthcare System, Department of Veterans Affairs. The records of only those individuals who received treatment with pegylated interferon and ribavirin were reviewed to determine risks factors for infection, response rates, adverse events, and outcomes. RESULTS: During the study period, there were a total of 1,496 patients identified as being infected with HCV, for an estimated seroprevalence of 2.3%. Of these, approximately 10% (137) were treated with combination therapy and were included in this study. The mean age was 58 (±6.4); 96.4% were men. The most common genotype was type 1. The responses to treatment were generally poor, with only 48.4% of the patients achieving sustained virological response. DISCUSSION: Though the seroprevalence of chronic hepatitis C in the Latino veteran population of Puerto Rico is high, relatively few patients have received treatment, most probably because of the contraindications of the medications used. Combination therapy with pegylated interferon plus weight-based ribavirin was inefficient and plagued with side effects; as a whole, this therapy was not found to be overly beneficial to our patients. New emerging and approved therapies will change this paradigm, allowing the treatment of a larger population without the side effects of the studied therapy.

Diagnostic Yield of Video Capsule Endoscopy for Small Bowel Bleeding: Eight Consecutive Years of Experience at the VA Caribbean Healthcare System.

OBJECTIVE: To evaluate the diagnostic yield of video capsule endoscopy (VCE) in patients with small bowel gastrointestinal bleeding and examine the impact of this diagnostic technology on the clinical management of this complaint. METHODS: This was a retrospective study in which all patients who underwent VCE (May 7, 2003 - December 31, 2011) were included. Records were reviewed for the type of bleeding (overt vs. occult; when present), demographic data, lab results, and capsule endoscopy findings. Information regarding medical treatment (i.e., endoscopic intervention, surgical therapy, or both) was also recorded. RESULTS: A total of 229 subjects were included in the study. Most were men; the mean age of all the subjects was 69.8 years. Of the 229 VCEs, 154 (67.3%) were done because of occult bleeding and 75 (32%) because of overt bleeding. VCEs were normal in 34 (14.9%) cases and non-diagnostic in 15 (6.6%). Angiodysplasia, erosions, and ulcers were the most common findings (48.5%, 24.5%, and 10.92% respectively). Active bleeding was reported in 7 cases (3%). Nearly 20% of the 229 cases required either endoscopic or surgical intervention. CONCLUSION: In our study, VCE achieved a diagnostic yield of 78.6%. In 1 of every 5 subjects, video capsule endoscopy led to the identification of small bowel lesions that required either endoscopic or surgical resection, rather than conservative treatment with iron replacement. VCE proved to be a very useful investigative tool, not only for establishing the source of bleeding but also, most importantly, for directing the appropriate therapy for lesions that would otherwise have been missed by conventional studies.

Neither 10- nor 14-Day Sequential Treatment is better than Standard Triple Therapy for Helicobacter Pylori Eradication.

OBJECTIVE: Helicobacter pylori is a bacterial pathogen associated with chronic gastritis, peptic ulcer disease, gastric adenocarcinoma, and gastric mucosa associated lymphoid tissue lymphoma. Current treatment guidelines support a 7- to 14-day, triple-drug protocol consisting of a proton-pump inhibitor (PPI), clarithromycin, and either amoxicillin or an imidazole. The initial eradication rates for this regimen were 80 to 90%. Nevertheless its effectiveness has declined as the antibiotic resistance to clarithromycin and metronidazole has emerged. In Puerto Rico the reported resistance of H. pylori to clarithromycin is 16% and to metronidazole, 3.7%. Sequential therapy for H. pylori eradication, 5 days of treatment with a PPI and amoxicillin followed by 5 days of treatment with the PPI and 2 other antibiotics (clarithromycin and an imidazole), was introduced as an effective alternate regimen. This is a prospective clinical trial intended to compare the efficacy of first-line, standard 10-day tripledrug therapy with those of both 10- and 14-day sequential therapy in eradicating H. pylori at the San Juan Veterans Affairs Hospital in a population that is naïve to previous treatment. METHODS: This was a prospective, open-label, randomized clinical trial. RESULTS: Based on the intention-to-treat analysis, the eradication rate was 83.7% (72 of 86 patients) in the standard triple-therapy group, 80.0% (68/85) in the 10- day sequential-therapy group, and 79.1% (68/86) in the 14-day sequential-therapy group. There were no significant statistical differences between the eradication rates among therapies. CONCLUSION: Sequential-therapy treatment regimens are not better than standard triple therapy for the eradication of H. pylori infection, regardless of the treatment duration.

The Perils of Diagnosing and Treating Overlap Syndrome.

Autoimmune hepatitis (AIH) may present with clinical, laboratory abnormalities and histological features suggestive of primary biliary cirrhosis (PBC) or primary sclerosing cholangitis (PSC). These variants of AIH are known as overlap syndromes. We present a case of a 62 year-old-male who presented with altered liver function tests, anemia and unintentional weight loss. Initial laboratories revealed anemia and a cholestatic pattern. Diagnostic work-up was remarkable for a positive antinuclear antibodies (ANA) test and a liver biopsy suggestive of an AIH-PBC overlap syndrome. This case illustrates the complexity of establishing the diagnosis and effective therapy in this condition.

Primary Enteropathy-Associated T-Cell Lymphoma Type 2: An Emerging Entity?

Intestinal T-cell lymphoma is a rare hematological malignancy that can present as primary intestinal lymphoma or as a manifestation of systemic disease. Primary involvement accounts for approximately 0.1% to 0.5% of all colorectal neoplasms. It is an aggressive disease with a poor prognosis and low survival rate. Inflammatory bowel disease, celiac disease, immunosuppression, and infectious etiologies, such as Epstein-Barr and human T-lymphotropic viruses, have been reported as risk factors, but no direct causal link has been established. Herein, we examine the case of a Hispanic man 69 years of age diagnosed with positive CD3, CD7, CD8, CD43, and Bcl-2 diffuse primary colorectal T-cell lymphoma. The patient did not exhibit a concomitant autoimmune or genetic disease. Because of the patient's history of polyps, surveillance colonoscopy was performed and the diagnosis was confirmed.

A Comparison of Brunt's Criteria, the Non-Alcoholic Fatty Liver Disease Activity Score (NAS), and a Proposed NAS Scoring that Includes Fibrosis in Non-Alcoholic Fatty Liver Disease Staging.

OBJECTIVE: The aim of this study was to determine the prevalence of NASH in veterans with metabolic syndrome and compare histologic grading using the Brunt criteria, the NAFLD activity score (NAS), and a proposed NAS scoring system that has been modified to include fibrosis staging. METHODS: Veterans with metabolic syndrome, hepatic steatosis, and elevated ALT and AST levels and who underwent liver biopsies from 2004 through 2010 were included in this study. Biopsies were evaluated by a single hepatopathologist. Each biopsy was analyzed using the Brunt criteria, the NAS system, and the NAS system plus fibrosis staging. RESULTS: Sixty patients having a mean age of 50.4 (±12.8 years) were included in the study; 88.3% were men. Fifty percent met criteria according to the Brunt system. When biopsies were classified using the NAS system, only 30.0% (18/60) were found to have a score of 5 or more, while, when adding fibrosis staging, the number of patients with a score of 5 or more increased to 33 (55.0%). Upon evaluating the predictive ability of the NAS scoring system, we found that when including fibrosis staging we obtained a higher sensitivity (86.7% vs. 40.0%) and a lower specificity (76.7% vs. 80.0%). CONCLUSION: In our population of patients with metabolic syndrome about 50 to 55% had steatohepatitis. There were significant differences between the scoring systems. When our NAS plus fibrosis system was used, more patients were recognized and the sensitivity increased. Further validation studies are required to evaluate this proposed modified NAS scoring system.

Epiploic Appendagitis, an Uncommon Cause of Abdominal Pain: A Case Series and Review of the Literature.

OBJECTIVE: Epiploic appendagitis (EA) is a rare entity caused by the inflammation of the appendix epiploica. It is a benign and self-limited condition presenting as acute onset abdominal pain. The inaccurate diagnosis of EA can lead to unnecessary hospitalization, antibiotic therapy, and surgery. Our aim is to describe the common clinical features of patients who were diagnosed with EA over a 2-year period at the San Juan Veterans Administration Hospital. METHODS: A retrospective descriptive review of the records of all patients diagnosed with EA from 2007 to 2009. The clinical data was obtained through record review. Diagnoses were confirmed by 2 radiologists reviewing imaging studies. RESULTS: Eight patients were included in the study. All were male with a mean age of 58 years. Seven patients were overweight as per body mass index (BMI) scale. All had localized focal, non-migratory abdominal pain, most (75%) in the left lower quadrant. Nausea (37.5%), anorexia (12.5%), constipation (12.5%), and diarrhea (25%) were documented as well. Only 2 patients demonstrated mild elevations in WBC, but none of the 8 had a fever. During the study period, all the patients' symptoms resolved without documented recurrence. CONCLUSION: In our small case series, overweight was a common finding, supporting the described association between EA and obesity. History and physical exam should prompt the clinician to consider EA in the differential diagnosis of acute abdominal pain, particularly in those who are obese and who have pain localized to the left lower quadrant.

Helicobacter Pylori and Gastric Cancer: An Update in the Literature.

Of the chronic bacterial infections that affect humans, Helicobacter pylori (H. pylori) infection is one of the most common. It inhabits the stomachs of half of the adult human population. In Puerto Rico, a US territory, it has an overall prevalence of 33%, similar to the prevalence reported in the population of the US as a whole. Helicobacter pylori infection is responsible for mucosal inflammation that may lead to chronic gastritis, most peptic ulcers, gastric adenocarcinoma, and mucosa-associated lymphoid tissue lymphoma. The International Agency for Research on Cancer identified H. pylori as a definite carcinogen in 1994, the only bacterium to be given such a classification. Its oncogenic effect has been postulated to be caused by different mechanisms, including bacterial characteristics and host factors. Epidemiologic studies have shown that gastric cancer risk differs among regions. One of the top 10 causes of cancer death in Puerto Rico is gastric cancer. Although the eradication of H. pylori has well-known benefits, there are some concerns when considering mass screening and treatment of infected patients. These include the fact that such eradication could provoke an increase in antibiotic resistance rates, the disturbance of the gut microbiota, an increase in body weight, and the aggravation of existing gastroesophageal reflux symptoms. Gastric cancer is a major health concern, and we should understand the role of H. pylori eradication in its prevention. This article is geared to summarize current knowledge and controversies.

Small cell neuroendocrine carcinoma of rectum with associated paraneoplastic syndrome: a case report.

Neuroendocrine carcinomas of the colon and rectum comprise fewer than 1% of all colorectal cancers. These aggressive tumors generally have a poor prognosis compared to that associated with colorectal adenocarcinoma. We describe herein the case of a 68-year-old female presenting with a bleeding rectal mass involving the anal canal, which case was associated with hyponatremia due to inappropriate serum levels of antidiuretic hormone. The histopathological examination was consistent with a small-cell neuroendocrine tumor. She was treated with combination chemotherapy and radiation therapy. The Syndrome of Inappropriate Antidiuretic Hormone (SIADH) was managed with vasopressin antagonists. After the completion of therapy, endoscopic ultrasound revealed evidence of residual disease, for which she underwent an abdominoperineal resection (APR). The patient died 4 months later of disease progression. To our knowledge, this is the first report of a small-cell neuroendocrine tumor involving the rectum and anal canal that presented with the paraneoplastic syndrome, SIADH.

Acute Liver Infarct with a Superimposed Liver Abscess as a Consequence of Hypercoagulable State in a Patient with COVID-19 without Respiratory Manifestations.

COVID-19 infection has been associated, particularly in severely ill patients requiring hospitalization, with a hypercoagulable state. The case presented herein was a 66-year-old man with SARS-CoV-2 infection who did not have any respiratory symptoms. He presented with the following clinical manifestations: portal vein and hepatic artery thrombosis, liver infarction, and a superimposed abscess of the liver. In this case, early detection and the administration of anticoagulants and antibiotics led to a significant improvement within weeks of the diagnosis. We encourage physicians to be aware of COVID-19-associated hypercoagulable state and its potential complications, regardless of the acuity of the presentation or the absence of respiratory symptoms.

Increased Prevalence of Advanced Histologic Features in Small and Diminutive Polyps in Patients Undergoing Surveillance and Diagnostic Colonoscopy.

OBJECTIVE: Studies addressing small and diminutive polyps and their potential of harboring advanced histologic features (AH) are scarce in Hispanics. We aimed to determine the prevalence of AH in a cohort of Hispanics. METHODS: A retrospective review of medical records of patients who had a colonoscopy from 2005 through 2010. The data collected included demographics, indications, history (personal/family) of colon cancer and/or polyps, and polyp histology. Polyps with high-grade dysplasia, prominent villous component, adenocarcinoma or serrated were classified as having AH. RESULTS: The population comprised 1884 patients, and 3835 polyps were evaluated; 63.3% were diminutive (1-5 mm), 22.7% small (6-9 mm), and 13.9% large (≥10 mm). The prevalence of AH for small and diminutive polyps were 4.9% and 1.1%, respectively. Of the polyps with AH, 11.9% were diminutive and 19.6% small. Small polyps were 5.04 times more likely to harbor AH than were diminutive polyps. Distal rather than proximal polyps were more likely to harbor AH. Furthermore, AH was >7 times more common in small (6-9 mm) polyps identified during diagnostic or surveillance colonoscopies compared to screening colonoscopies. CONCLUSION: The prevalence of AH was significantly associated with size, location (distal), and procedure indication. Although diminutive polyps (<6 mm) were less likely to harbor AH, the risk for non-Hispanics was higher than previously reported. The "resect and discard" strategy for polyps ≤ 1 cm should be used with caution in ethnically diverse cohorts, as the risk for AH may be higher in Hispanics than in non-Hispanic Whites.

Molecular and Sociodemographic Colorectal Cancer Disparities in Latinos Living in Puerto Rico.

BACKGROUND: The incidence of sporadic colorectal cancer (CRC) among individuals <50 years (early-onset CRC) has been increasing in the United States (U.S.) and Puerto Rico. CRC is currently the leading cause of cancer death among Hispanic men and women living in Puerto Rico (PRH). The objective of this study was to characterize the molecular markers and clinicopathologic features of colorectal tumors from PRH to better understand the molecular pathways leading to CRC in this Hispanic subpopulation. METHODS: Microsatellite instability (MSI), CpG island methylator phenotype (CIMP), and KRAS and BRAF mutation status were analyzed. Sociodemographic and clinicopathological characteristics were evaluated using Chi-squared and Fisher's exact tests. RESULTS: Of the 718 tumors analyzed, 34.2% (n = 245) were early-onset CRC, and 51.7% were males. Among the tumors with molecular data available (n = 192), 3.2% had MSI, 9.7% had BRAF, and 31.9% had KRAS mutations. The most common KRAS mutations observed were G12D (26.6%) and G13D (20.0%); G12C was present in 4.4% of tumors. A higher percentage of Amerindian admixture was significantly associated with early-onset CRC. CONCLUSIONS: The differences observed in the prevalence of the molecular markers among PRH tumors compared to other racial/ethnic groups suggest a distinct molecular carcinogenic pathway among Hispanics. Additional studies are warranted.

Effectiveness of Multiple Consecutive Fecal Immunohistochemical Testing for Colorectal Cancer Screening.

OBJECTIVE: The fecal immunohistochemical test (FIT) is a simple colorectal-cancer screening test. There are no recent studies evaluating the benefits of doing more than one a year. Our study aimed to evaluate the effectiveness of performing the test for 3 consecutive days in terms of detecting cancer and advanced adenomas. METHODS: This was a single-center retrospective review of records of patients who had daily tests for 3 consecutive days and had at least one positive during the period from 2009-2011. RESULTS: A total of 456 records were reviewed, 410 met the inclusion criteria. Most of the participants were men (95.9%), with the mean age of all the participants being 64.3 (±7.8) years. Regarding the FIT results, 18.8% had positive results on all 3 tests, 20.2% had 2 positive tests, and 61.0% had 1 positive FIT. There were 16 (3.9%) patients in the studied sample that had colon cancer. Their lesions were located predominantly in the distal colon (ratio of distal to proximal: 2:1). The patients with 3 positive FITs had a higher prevalence of advanced adenomas (33.3% vs. 13.4%, respectively; P < .05). DISCUSSION: Our study showed a low concordance between daily consecutive tests results. those patients with more than 1 positive FIT had a higher prevalence of advanced adenoma or adenocarcinoma than patients who had only one. Fewer than 4% of the patients in our study had colon cancer. Prospective studies would be needed to determine the effectiveness of more than 1 annual FIT in colon cancer prevention.

The Impact of a Sustained Virologic Response to Hepatitis C Virus Treatment on Liver Stiffness in the Puerto Rico Veterans Attending Liver Clinics in the Veterans Affairs Caribbean Healthcare System.

OBJECTIVE: To evaluate the impact of sustained virologic response (SVR) on liver stiffness, as measured by transient elastography (TE), in Hispanic patients treated with direct-acting antivirals (DAAs) in the outpatient clinics in the Veterans Affairs Caribbean Healthcare System. METHODS: We included hepatitis C virus (HCV) patients treated with DAA regimens from 11/2017 through 06/2019. Patient demographics and variables such as body mass index, HCV genotype, and treatment regimen were collected. The patients had a TE measurement before treatment initiation, and a repeat study 6 to 9 months after the achievement of SVR. A comparison between pre and post-treatment TE scores was performed via a paired t test. RESULTS: Forty-three subjects met all the inclusion criteria and completed a posttreatment TE. Most of the subjects were infected with genotypes 1a or 1b. Six to 9 months post SVR, we measured liver stiffness and found a statistically significant reduction in TE score (P value = .0003). The pretreatment median TE score was 10.2 kPa. On a repeat TE study at 6 to 9 months post-treatment, our subjects had a median score of 7.2 kPa. CONCLUSION: The eradication of HCV infection with DAAs is associated with improved TE scores. Fibrosis-stage reduction was more frequent in those who had stage 4 fibrosis prior to treatment. These results suggest that achieving SVR may spare patients from future clinical decompensation and complications. Adequate screening of this potentially deadly chronic infection can lead to early therapy with DAAs and the significant regression of fibrosis in this kind of patient.

Presence of hemochromatosis-associated mutations in Hispanic patients with iron overload.

OBJECTIVE: To determine the characteristics of the Puerto Rico Veteran population with iron overload in terms of demographic features, clinical manifestations, and the presence of hereditary hemochromatosis (HH) mutations, and to compare such characteristics in patients with and without HH mutations. METHODS: A retrospective study was conducted in patients with iron overload (transferrin saturation > or = 45%) who were tested for HH mutations from January 2003 to June 2007. Data collected included age, gender, body mass index, hemoglobin level, platelet count, ferritin level, transferrin saturation, ceruloplasmin, alfa-1 antitrypsin, anti-nuclear antibodies, aspartate aminotransferase, alanine aminotransferase, alfa-fetoprotein, viral hepatitis profile, imaging studies, and comorbid conditions. Patients were grouped according to the results of the commercially available HH DNA mutation analysis as homozygote, heterozygote, compound heterozygote, or negative. RESULTS: 94 patients were studied. Most patients were male (90/94); the mean age was 60 years. Of the study group, 36% (34/94) was found positive for HH mutations. The most common mutation was H63D, which was found in 85% (29/34) of patients; 4 homozygotes and 25 heterozygotes. C282Y mutation was identified in only 12% (4/34) of patients, of which one was homozygote. A compound heterozygote (C282Y/ H63D) was also identified. After analyzing the data for confounding factors, 6 of 29 heterozygotes had no other risk factors for liver disease other than the H63D mutation. CONCLUSION: The predominance of H63D mutations in our population deserves further investigation since it considerably differs from other studied populations with iron overload in which C282Y is the most common mutation.

Relationship between sporadic hyperplastic polyps and colorectal neoplasia in Hispanic veterans.

OBJECTIVE: Hyperplastic polyps (HP) traditionally have been regarded as having no malignant potential. Some studies have suggested that HP in the distal colon may predict presence of adenomatous polyps in the proximal colon. Other studies have failed to show this relationship. The purpose of this study was to evaluate for the first time in our Hispanic veterans population if there was a relationship between the presence of sporadic HP and colorectal neoplasia (CRN) and to evaluate if proposed risk factors for CRN are also risk factors for sporadic HP. METHODS: The study consisted of a retrospective review of all the medical records of patients who underwent a colonoscopy for the first time during the calendar year 2005 and had a pathologic diagnosis of HP, tubular adenoma (TA), tubulovillous adenoma (TVA), villous adenoma (VA) and/or colon adenocarcinoma at the VA Caribbean Healthcare System. Patient's age, BMI, smoking and alcohol use history, presence of DM, cholesterol and triglyceride levels, use of aspirin and the size and location of the lesions were recorded. Records with incomplete data and patients with a prior colonoscopy were excluded. RESULTS: 861 patient records were reviewed of which 405 met the inclusion criteria. Most patients (99%) of the patients were males, mean age 67.5 (range 36-87). The total number of colonic lesions was 1,065 (240 hyperplastic, 825 CRN). Histologic evaluation of lesions revealed: 121 patients who had HP, 331 with TA, 33 with TVA, 12 with VA, 13 with serrated adenomas and 61 patients had adenocarcinoma. Univariate analysis revealed that patients with HP appeared to have a lower likelihood of having TA (p < 0.001), adenocarcinoma (p = 0.002), and CRN in general (P < 0.001) as compared to patients without HP. Multivariate analysis with logistic regression revealed that patients with HP had a significantly lower likelihood of having TA (adjusted OR = 0.21; 95% CI 0.12-0.37), and adenocarcinoma (adjusted OR = 0.33; 95% CI 0.15-0.73) compared to patients without HP. No correlation was found between DM, use of alcohol, smoking, or aspirin use and the presence of sporadic HP. CONCLUSION: The present study suggests that the presence of HP is not associated with CRN in our veteran population. None of the risk factors proposed for CRN appear to be also risk factors for developing HP. The results of this study support current colon cancer guidelines in which surveillance for HP is not recommended.

Sustained virologic response among Latino veterans; does it represent the cure of chronic hepatitis C infection?

OBJECTIVE: Short-term benefits of achieving sustained virologic response (SVR) to treatment for hepatitis C virus infection (HCV) have been well established. However long-term data on benefits of achieving SVR has just begun to emerge. The purpose of this study was to determine whether SVR truly represents long- term viral eradication in a Latino veteran population and document clinical and biochemical outcomes in this group. METHODS: This was a two-phase study, which consisted of a single center retrospective study followed by a cross-sectional analysis which includes a single clinic visit. The first phase of the study consisted of a retrospective record review of all HCV patients treated at the VA Caribbean Healthcare System from 1990 to 2006. Records were reviewed to identify patients who had completed therapy, had documented SVR and at least 12 months of time elapsed since end of therapy. The second phase of the study entailed a single appointment to the gastroenterology research clinics, for blood testing and a short risk factor questionnaire. RESULTS: Sixty four patients were enrolled; mostly males with a mean age at time of enrollment of 54.3 years (range 37-72). One hundred percent of subjects self reported their ethnicity as Hispanic, born in Puerto Rico. Most of our population had HCV genotype 1. Forty seven of 64 (73.4%) patients were naive to therapy while 4 (6.3%) were previously treated. In 13 (20.3%) patients, the prior treatment status could not be clearly established. Regarding therapy used to achieve SVR, 32 (50.0%) patients received interferon (IFN) and ribavarin, 28 (43.8%) peginterferon (PEG) and ribavarin and 4 (6.3%) IFN monotherapy. There was no statistical difference in long-term SVR among these 3 three treatment alternatives. A pre-treatment biopsy specimen was available on 37/64 (57.8%) of our subjects. Marked fibrosis and/or cirrhosis was present in 14/37 (37.8%) subjects who had a pre-treatment biopsy. At the time of the study visit mild elevation of aspartate aminotransferase (AST) was identified only in 5 (7.8%) patients. Alanine aminotransferase (ALT) and bilirubin were normal. Only 3/64 (4.7%) had elevations in alkaline phosphatase. None (0/58) of the patients who presented with normal enzymes had detectable viral load, whereas 20% (1/5) of those with elevated liver function tests had evidence of viremia (p < 0.001). Overall, only 1 (1.6%) patient of our study group had evidence of virological relapse after having achieved SVR, which was documented 30 months after the end of therapy. No identifiable risk factors for re-infection were identified. CONCLUSION: In conclusion, in this Latino veteran population, achievement of (SVR) is a good predictor of clinical outcomes and long-term (HCV) eradication. Altered liver function tests seems to be the best predictor of relapse and should prompt the clinician to investigate for recurrence. For those that after achieving SVR maintain normal liver enzymes, routine follow up viral load demonstrates to have a very low yield and may not be required.

Duodenal adenomas in nonpolyposis syndrome patients are not associated to colorectal neoplasia.

BACKGROUND: Duodenal adenomas are extremely common in patients with familial adenomatous polyposis. In the general population, sporadic duodenal adenomas are an uncommon finding. Among individuals with duodenal adenomas, the development of concurrent colonic adenomas has been proposed, suggesting a diffuse gastrointestinal mucosa proliferative process and thus surveillance with colonoscopy. METHODS: A total of 10,666 upper endoscopies were performed from January 1997 to July 2007. Four controls without duodenal adenomas were selected for each case. Association of duodenal polyposis with colonic adenomas was calculated using two sample proportions and chi square using SPSS. RESULTS: In the 10-year period, 21 patients met inclusion criteria. All the patients were male with a mean age of 67 years (range: 45-86 years). Among cases, the most common indication for upper gastrointestinal endoscopy (EGD) was an abnormal imaging (47.6%). For controls, the most common indication for EGD was gastrointestinal bleeding (29.8%). Most adenomas were located in the second portion of the duodenum (63%). Mean size for duodenal adenomas was 5mm (range 1-21mm). High grade dysplasia was reported in 4 (18%) adenomas. The prevalence of sporadic duodenal adenomas was 0.2%. Nine of 21(42.8%) duodenal adenoma cases were found with concurrent colonic adenomas. In the control group, 38 of 84 (45%) patients were found with colon adenomas (p = 0.21). There was no significant statistical association between duodenal polyposis and anemia, smoking, alcohol, medical history of diabetes mellitus or BMI. CONCLUSION: Prevalence of duodenal polyposis was low, although a high number of polyps exhibited high grade dysplasia. There was no statistically significant association between nonfamilial duodenal polyposis and colorectal adenomas. Our observations do not support early colonoscopy surveillance for patients with duodenal polyposis.

A Descriptive Study on the Population of Patients with Inflammatory Bowel Disease at the Veterans Affairs Caribbean Healthcare System in San Juan.

OBJECTIVE: Inflammatory bowel disease (IBD) comprises a group of related conditions characterized by idiopathic inflammation of the gastrointestinal (GI) tract. Several studies have described the epidemiology of IBD in Puerto Rico (PR) but none have included the US military and Veteran population. The goal of this study was to describe the prevalence of IBD in this population as well as to describe patients' characteristics. METHODS: We conducted a retrospective analysis of 163 patients using data gathered from electronic medical records of Veterans who received care at the VA Caribbean Healthcare System (VACHS) and the diagnosis of IBD between October 1, 2010 and September 30, 2015. The prevalence out of 100,000 in our study was calculated for each Fiscal Year. RESULTS: Overall, the prevalence of IBD markedly increased among VA patients. Among 163 patients who met inclusion criteria, 7 (4.3%) patients had a diagnosis of undetermined IBD, 45 (27.6%) had Crohn's disease (CD) and 111 (68.0%) had ulcerative colitis (UC). This information was used to compare the epidemiologic data of IBD in the population receiving care at the VACHS with the epidemiologic data of IBD in the general population in PR. CONCLUSION: This is the first study to describe the prevalence of IBD and to describe additional characteristics of patients with IBD receiving care at the VACHS.