2021 National Survey on Prior Authorization Burden and Its Impact on Gastroenterology Practice.

INTRODUCTION: Prior authorizations (PAs) are intended to control prescription drug expenditures. METHODS: One hundred fifty-six physician and advanced practice provider members of the American College of Gastroenterology completed a national survey to assess PA burden and impact. RESULTS: One-half of PA requests relate to prescription refills. Greater than 50% of the respondents choose inferior treatments at least weekly because of perceived PA burden for preferred agents. One-half of the respondents reported a patient who experienced serious adverse events due to PA-related care delays. DISCUSSION: PA is an administrative burden that exhausts practice resources and may have a negative impact on patient care.

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.

Optimal sequences of same-visit bidirectional endoscopy: Systematic review and meta-analysis.

BACKGROUND AND AIM: Same-visit colonoscopy and esophagogastroduodenoscopy (EGD) have become common. Recent studies showed conflicting results regarding the performance, safety, and efficacy of different sequences. We conducted this meta-analysis to determine the most favorable performance and discomfort between an EGD followed by colonoscopy (E-C) and colonoscopy followed by EGD (C-E). METHODS: The authors searched the databases of MEDLINE and EMBASE. Outcomes of interest were performance (including cecal intubation time, adenoma detection rate, and polyp detection rate), discomfort score (patients and endoscopists; Likert scale), and sedation uses. Pooled mean differences (MD) or odds ratios (OR) were calculated with 95% confidence intervals (CI). RESULTS: Six randomized controlled trials were included in the meta-analysis. The authors found that there was significantly lower sedative use including fentanyl (14.70; 95% Cl: 8.20-21.20) and propofol (15.58; 95% Cl: 3.27-27.89) in the E-C group compared with the C-E group. There was a significantly better discomfort score in patients and endoscopists after both procedures in the E-C group than in the C-E group with pooled MD of 0.64 points (95% Cl: 0.09-1.20) and 0.47 (95% Cl: 0.05-0.90), respectively. There were no differences in cecal intubation time, adenoma detection rate, or polyp detection rate between the two groups. CONCLUSION: The present study found that the discomfort score was better in the E-C group. However, there was no difference in polyp and adenoma detection. Therefore, the E-C group is the optimal sequence.

Real-World Safety and Efficacy of Fluid-Filled Dual Intragastric Balloon for Weight Loss.

BACKGROUND & AIMS: Reshape Duo is a saline-filled dual, integrated intragastric balloon (IGB) approved by the Food and Drug Administration for weight loss in patients with obesity. In a prospective, randomized trial, obese patients who received the balloon had significantly greater percent excess weight loss (%EWL) compared with patients treated with diet and exercise alone. However, there are limited data on the real-world efficacy of the Reshape balloon. METHODS: We performed a retrospective study of data collected from 2 academic centers and 5 private practices in which all patients paid for the IGB and follow-up visits out of pocket. The IGB was removed after 6 months. We collected data (demographic, medical, and laboratory) from 202 adults (mean age 47.8 ± 10.8 years; 83% female) with a baseline mean body mass index of 36.8 + 8.4 kg/m2 who had IGB insertion for weight loss therapy, along with counselling on lifestyle modifications focused on diet and exercise. Primary outcomes were percent total body weight loss (%TBWL) and %EWL at 1, 3, 6, 9, and 12 months after the procedure. RESULTS: Mean %TBWL at 1, 3, 6, 9 and 12 months was 4.8 ± 2.4%, 8.8 ± 4.3%, 11.4 ± 6.7%, 13.3 ± 7.8%, and 14.7 ± 11.8%, respectively. Data were available from 101 patients at 6 months and 12 patients at 12 months; 60.4% of patients achieved more than 10% TBWL and 55.4% had more than 25% EWL. Seventeen patients (8.4%) had esophageal tears during balloon insertion, with no intervention required. Thirteen patients (6.4%) had their IGB removed before the end of the 6-month treatment period. Nausea, vomiting, and abdominal pain were the most common adverse effects, occurring in 149 (73.8%), 99 (49%), and 51 (25.2%) patients. In one patient, the IGB migrated distally leading to small intestinal obstruction requiring surgical removal. CONCLUSION: In a retrospective analysis of real-world patients who received the Reshape Duo IGB, we found it to be a safe and efficacious endoscopic method for producing weight loss, with most patients achieving greater than 10% TBWL at 6 months.

Retrograde cricopharyngeus dysfunction: How does the inability to burp affect daily life?

BACKGROUND: Retrograde cricopharyngeus dysfunction (R-CPD), a condition first detailed in 1987 and termed in 2019, refers to the cricopharyngeal muscle's inability to relax to allow the retrograde passage of gas. Limited research exists on the fundamental characteristics of this condition, including its impact on one's life. The purpose of this study is to characterize R-CPD and how the inability to burp affects the social lives of people who suffer from it. METHODS: A Qualtrics survey was distributed on the subreddit "r/noburp," a community of 26,000 individuals sharing information about R-CPD. Adults aged 18-89 experiencing R-CPD symptoms were invited to participate. Participants reported on their experiences with R-CPD and its effects on social life on a 4-point Likert scale (1 = strongly disagree to 4 = strongly agree). Data was analyzed using descriptive statistics. KEY RESULTS: Among the 199 respondents, the mean age was 30.9, and gender identity was 74%/25% female/male. 99% reported inability to burp, 98% reported abdominal bloating, 93% reported socially awkward gurgling noises, 89% reported excessive flatulence, and 55% reported difficulty vomiting. Only half discussed their symptoms with their primary care provider (PCP), and 90% disagreed with receiving adequate help. Average Likert scores indicated embarrassment (3.4), anxiety/depression (3.1), negative impact on relationships (2.6), and work disruption (2.7) due to R-CPD. CONCLUSIONS & INFERENCES: R-CPD is unfamiliar to many healthcare providers, leaving patients underserved. It not only affects daily life but also personal and professional relationships. Raising awareness by understanding disease basic features may increase diagnosis and treatment rates, improving quality of life.

The use of DNA fingerprinting to resolve conflicting results in patients with suspected gastrointestinal malignancy.

GOALS: To underscore the utility of DNA fingerprinting for clarifying disparate results from endoscopic pathologic specimens. BACKGROUND: Occasionally, serially obtained gastrointestinal biopsies may yield inconsistent results. These discrepancies pose a dilemma for gastroenterologists and their patients, especially when malignancy is a consideration. STUDY: Patients referred to our tertiary care center from outside institutions had undergone endoscopically obtained esophageal biopsies showing malignancy, verified by pathologists at both our site and from the referring center. Repeat endoscopic biopsies at our center did not show malignancy. To verify that different sets of biopsies came from the same patient, we performed a polymerase chain reaction-based analysis comparing the 2 specimens. This analysis, called DNA fingerprinting, can show a high degree of certainty whether 2 specimens came from the same patient. RESULTS: In each case, DNA fingerprinting verified a match, laying the groundwork for intervention. One patient underwent endoscopic radiofrequency ablation to the esophageal mucosa involved. Another underwent esophagectomy with partial gastrectomy. Both are doing well clinically and remain cancer-free on follow-up. CONCLUSIONS: DNA fingerprinting is a powerful and a relatively inexpensive tool. Usually, only small amounts of tissue are required, and even degraded or archival tissue is adequate. DNA fingerprinting can be an important tool in the gastroenterologist's arsenal to help clarify conflicting results, allowing the patient and physician to move forward with the management.

Prolapsed anorectal malignant melanoma presenting as hemorrhoids.

Rectal bleeding in a patient with a history of hemorrhoids should not be ignored. It is often benign and resolves spontaneously without treatment. Here we present a case of anorectal malignant melanoma that presented with rectal bleeding and a prolapsed rectal mass.

Chronic diarrhea as a presentation of Behçet's disease.

Key Clinical Messages: Behçet's disease (BD) or syndrome is a chronic, recurrent, multisystem, inflammatory vasculitis disorder with findings of oral aphthous ulcers, genital ulcers, and uveitis. Gastrointestinal (GI) involvement can be the initial presentation as presented in this case. Abstract: Behçet's disease (BD) or syndrome is a chronic, recurrent, multisystem, inflammatory vasculitis disorder of unknown etiology with classical findings of oral aphthous ulcers, genital ulcers, and ocular involvements including chronic anterior, intermediate, posterior, and even panuveitis. Gastrointestinal involvement in BD usually presents with chronic diarrhea, hematochezia as the disease affects ileocecal area which might be similar to presentation of inflammatory bowel diseases. Here, we report a case of undiagnosed BD who presented with chronic diarrhea for 4 months, leading to the diagnosis of BD and responded well to corticosteroid therapy.

Increasing inpatient mortality of nonvariceal upper gastrointestinal bleeding during the COVID-19 pandemic: a nationwide retrospective cohort study.

Upper gastrointestinal bleeding results in significant morbidity, mortality, and healthcare burden. This study aimed to evaluate inpatient outcomes of nonvariceal upper gastrointestinal bleeding (NVUGIB) during the year 2020 of the COVID-19 pandemic. The National Inpatient Sample databases were used to identify NVUGIB-related hospitalizations. Outcomes of interest for the year 2019 were compared to 2020 and included inpatient mortality, length of stay, mean inpatient cost, odds of getting esophagogastroduodenoscopy (EGD), mean time to EGD, early EGD (within 1 day of hospitalization), endoscopic intervention for hemostasis, and the odds of developing complications. NVUGIB-related hospitalizations increased by 8.1% in 2020. NVUGIB-related hospitalizations in 2020 were also associated with an 11.1% higher mortality (adjusted odds ratio [aOR] = 1.11, confidence interval [CI] = 1.06-1.17, P < 0.01), 0.15-day longer mean time to EGD (aOR = 0.15, CI = 0.08-0.24, P < 0.01), 4% lower odds of getting an EGD (aOR = 0.96, CI = 0.93-0.99, P = 0.02), 8% lower odds of getting an early EGD (aOR = 0.92, CI = 0.89-0.96, P < 0.01), and $6340 higher mean inpatient cost (aOR = 6340, CI = 1762-10919, P = 0.01) compared to 2019. We conclude that there was an increase in NVUGIB-related hospitalizations and mortality in 2020 when the COVID-19 pandemic started.

Antiplatelet therapy associated with lower prevalence of advanced liver fibrosis in non-alcoholic fatty liver disease: A systematic review and meta-analysis.

Despite the growing disease burden of non-alcoholic fatty liver disease (NAFLD), approved medical treatments to improve or prevent liver fibrosis are effective only in a small number of patients. Recent studies have found the new use of antiplatelet agents for antifibrotic benefits in NAFLD, but human studies are still limited. The goal of this meta-analysis was to combine the findings of existing relevant studies to investigate the effects of antiplatelet therapy in reducing or preventing advanced liver fibrosis in patients with NAFLD. We conducted a systematic literature search in PubMed, EMBASE, and Web of Science databases from inception to January 2021 to identify all original studies that investigated the use of antiplatelet agents in patients with NAFLD. We used the National Institutes of Health's quality assessment tool for observational cohort and cross-sectional studies to assess study quality and risk of bias. The primary outcome was the prevalence of advanced liver fibrosis stage 3-4. Data from each study was combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate pooled odds ratio (OR) and 95% confidence intervals (CIs). Of the 2,498 studies identified, 4 studies involving 2,593 patients with NAFLD were included in this study (949 antiplatelet agent users and 1,644 non-antiplatelet agent users). The use of aspirin and/or P2Y12 receptor inhibitors was associated with a lower pooled OR of advanced liver fibrosis in patients with NAFLD (pooled OR = 0.66; 95% CI: 0.53-0.81, I2 = 0.0%; p < 0.001). This study focuses on the outcome of advanced liver fibrosis in patients with NAFLD. Our study is limited by the small number of studies that were included. Preliminary evidence from this meta-analysis suggests a protective association between antiplatelet therapy and the prevalence of advanced liver fibrosis in patients with NAFLD. Our findings support future research into repositioning an antiplatelet agent as a novel NAFLD treatment.

Vomiting and profound weight loss as a clue to the diagnosis of malignant coloduodenal fistula.

Colon cancer generally presents with lower gastrointestinal symptoms, such as diarrhea, constipation, and general abdominal discomfort; it is rare for the primary presentation to have upper gastrointestinal symptoms. We report a patient with coloduodenal fistula secondary to colon malignancy who presented with incessant vomiting and dramatic weight loss as the chief complaint. It is important to consider colon cancer as part of the differential in patients with atypical presentations of upper gastrointestinal symptoms who have known colon cancer risk factors.

Heyde's syndrome: A critical review of the literature.

Heyde's syndrome is an uncommon association between aortic stenosis and gastrointestinal bleeding. Although initially described during the late 1950s, with subsequent reports of a possible link between these disorders, controversy persists regarding the incidence, pathogenesis, and treatment of this syndrome. The main disagreements center on the actual association of aortic stenosis and angiodysplasia, though other controversies include the pathogenesis of Heyde's syndrome, ranging from von Willebrand factor deficiency and age-related degeneration to mucosal ischemia and cholesterol embolization. A variety of treatment modalities of the syndrome has been applied, including medical management, endoscopic therapy, embolization, and aortic valve replacement. Here, the controversies surrounding Heyde's syndrome, which focus on pathogenesis and treatment, are reviewed with the aim of providing a clearer understanding of the syndrome and the implications for patient care.

Upper gastrointestinal bleeding as the initial manifestation of gastroenteropancreatic neuroendocrine tumors.

A 78-year-old man presented with upper gastrointestinal bleeding, which was biopsy proven to be from a gastric neuroendocrine tumor. By the time of diagnosis, he developed liver metastasis and died 2 months later. Upper gastrointestinal bleeding is an uncommon feature in gastroenteropancreatic neuroendocrine tumor.

Primary Pancreatic Large B-Cell Lymphoma Presenting as Acute Pancreatitis.

Primary pancreatic lymphoma (PPL) is an extremely rare form of extranodal malignant lymphoma. The most common histological subtype of PPL is diffuse large B-cell lymphoma (DLBCL). Clinical and imaging features of PPL may often overlap with pancreatic adenocarcinoma. Therefore, it is very important to obtain a preoperative cytohistology diagnosis of pancreatic tumors to avoid unnecessary surgeries in cases with a diagnosis of PPL. Herein, we report a 71-year-old male who was admitted to our hospital with a diagnosis of acute pancreatitis after he presented with complaints of nausea, vomiting, and epigastric abdominal pain. MRI of the abdomen revealed a pancreatic head mass, and histopathology and immunohistochemical assessment of the pancreatic lesion established the diagnosis of DLBCL. The patient achieved remission after six cycles of rituximab-cyclophosphamide, doxorubicin (hydroxydaunomycin), vincristine (oncovin), prednisolone (R-CHOP) chemotherapy.

Marijuana use-induced spontaneous pneumomediastinum.

The presence of air in the mediastinum is a rare finding called pneumomediastinum. Spontaneous pneumomediastinum is typically benign. Marijuana use has been rarely reported to cause pneumomediastinum. Our case series presents two young men with no significant past medical history who had a history of marijuana use and developed pneumomediastinum after multiple episodes of intractable vomiting. The pathophysiology of spontaneous pneumomediastinum in marijuana users includes cyclic vomiting or microperforation of the esophagus or barotrauma during breathing maneuvers. Most cases can be managed conservatively.

Usefulness of the ReShape intragastric balloon for obesity.

Intragastric balloon (IGB) is approved for weight reduction in obesity patients who have a body mass index (BMI) of 30 to 40 kg/m2. The effectiveness of IGB in various degrees of obesity is not well established. We aimed to study the effect and safety of IGB in different groups of obese patients. A retrospective study was performed. All patients who underwent placement of the ReShape™ gastric balloon and completed a 6-month follow-up were included. There were 35 gastric balloons in 34 patients who had a baseline body weight of 106.5 ± 23.5 kg and a BMI of 37.1 ± 5.5 kg/m2. After IGB removal, total body weight was reduced 6.8 ± 7.3% (P < 0.001) and the BMI reduction was 2.7 ± 2.9 kg/m2 (P < 0.001). Subgroup analysis showed that patients with BMI >40 kg/m2 also had significant reduction of total body weight and BMI. The diastolic blood pressure was reduced by 4.7 ± 12.3 mm Hg (P = 0.03) after balloon removal. The most common complication was nausea in 22.9%. One patient had balloon migration leading to small bowel obstruction. One patient had a bleeding gastric ulcer. In summary, IGBs are an effective method to assist in weight loss in patients with various degrees of obesity, even with a BMI >40 kg/m2, with minor adverse effects.

Isolated Asymptomatic Metastatic Melanoma to the Colon: A Case Report.

Metastatic melanoma is generally rare, and the colon is a very rare metastatic site. We report a case of asymptomatic, isolated metastatic melanoma to the colon. Asymptomatic patients are usually not expected to have metastatic lesions in the colon. Ninety-five percent of large bowel metastases are identified during a postmortem examination. Our patient was found to have metastatic melanoma to the colon during a follow-up colonoscopy done for the surveillance of colon polyps. An awareness that patients with melanoma may possibly develop colon metastases is needed.

Anesthesia and congestive heart failure: pathology, medical, and surgical management.

Congestive heart failure (CHF) is increasingly being recognized as a health problem in the United States. It is estimated that the lifetime risk for CHF is 1 in 5. The clinical anesthesiologist can expect to see several cases involving patients suffering from CHF. Because of the danger associated with surgery in a patient with CHF, a thorough knowledge of the disorder and the potential effects on the delivery of anesthetics must be considered. In addition, knowledge of the disease process and its manifestations is required for smooth guidance of the patient through the perioperative period. The understanding of current pharmacotherapies, surgical procedures and their implications related to interactions with anesthetics are all discussed.

A Systematic Review of Extramural Presentations and Publications from Pharmacy Student Research Programs.

Objective. To conduct a systematic review of reports of pharmacy student research programs that describes the programs and resulting publications or presentations. Methods. To be eligible for the review, reports had to be in English and indicate that students were required to collect, analyze data, and report or present findings. The outcome variables were extramural posters/presentations and publications. Results. Database searches resulted in identification of 13 reports for 12 programs. Two-thirds were reports of projects required for a course or for graduation, and the remaining third were elective (participation was optional). Extramural posters resulted from 75% of the programs and publications from 67%. Conclusion. Although reporting on the outcomes of student research programs is limited, three-quarters of the programs indicated that extramural presentations, publications, or both resulted from student research. Additional research is needed to identify relevant outcomes of student research programs in pharmacy.