Tokyo Guidelines (TG18) for Acute Cholangitis Provide Improved Specificity and Accuracy Compared to Fellow Assessment.

Background Acute cholangitis results in significant mortality unless treated promptly. The diagnostic grading criteria of the 2018 Tokyo Guidelines (TG18) are used worldwide as the standard for acute cholangitis (AC) management but validation in clinical practice is required. Aim Use of the Tokyo 2018 (TG18) guidelines in improving the diagnostic accuracy and early detection of AC compared to fellow clinical assessment. Methods A retrospective review of patient records from 1/2010-9/2019 seen at Augusta University - Medical College of Georgia with the International Classification of Diseases, Ninth Revision (ICD-9) code "cholangitis" and/or ICD-10 codes "acute cholangitis, other cholangitis, and calculus of bile duct with cholangitis" was performed. Inclusion criteria were gastroenterology inpatient consult fellow evaluation and clinical diagnosis of AC. A definitive diagnosis of AC was determined following endoscopic retrograde cholangiopancreatography (ERCP). TG18 scoring for AC was then performed, categorized as either diagnostic/non-diagnostic, and compared to fellow clinical assessments following definitive diagnosis post-ERCP. Data were analyzed with chi-square testing. Results Two hundred six patients were identified using ICD codes. Ninety-one met inclusion criteria and were analyzed. The mean patient age of the overall group was 67 years old (standard deviation of 13.3 years) with males comprising 69% and non-Hispanic white 56% of the study group. TG18 criteria assessment had a sensitivity of 86% and specificity of 63% for patients with AC post ERCP (p <0.05). TG18 accuracy was 81%. In comparison, fellow clinical suspicion had a sensitivity of 90.3% and specificity of 0% (NS). Fellow accuracy was 71%. No difference in fellows' diagnosis of suspected AC was noted based on the training year. Conclusion Application of the TG18 criteria for AC reduces the false positive rate and improves diagnostic accuracy, thus decreasing costs along with avoiding unnecessary ERCPs with associated complications.

An Unusual Long-Term Complication of Bariatric Surgery.

Roux-en-Y gastric bypass (RNYGB) has become the standard of care in treating obesity, a global health concern with associated comorbidities contributing to rising health care costs [1]. The positive outcomes of RNYGB have been well documented along with adverse effects such as nutrient deficiencies, hernia, postprandial dumping syndrome, chronic kidney disease and hypoglycemia. A lesser-known long term complication of RNYGB is liver failure. Here, we present a case where RNYGB performed 10 years prior contributed to acute liver failure.

Characteristics of Serrated Adenomas in Non-Hispanic Whites and African Americans Undergoing Screening Colonoscopy.

Background and aim Adenomatous polyps are precursor lesions for colorectal cancer (CRC). Serrated adenomas/polyps are considered a risk factor for the development of proximal and interval CRC. African-Americans are at higher risk for right-sided CRC. Minimal data evaluating serrated adenoma characteristics by race/ethnicity on initial screening colonoscopy (SC) exist. The aim of this investigation was to compare the characteristics of serrated adenomas found in non-Hispanic whites (nHw) and African-Americans (AA) undergoing initial SC. Methods The University of Florida-Jacksonville endoscopy database was searched for all SC performed between January 2000 and December 2014. Inclusion criteria were nHw or AA race/ethnicity and histologically proven serrated adenoma found at SC. Data were collected for all included age at SC, sex, number, location, and size of serrated adenomas found. Results A total of 8693 individuals (nHw - 4199 and AA - 4494) underwent SC between January 2000 and December 2014. Serrated adenomas were found in 479 individuals (nHw, n=294; AA, n=185), and AA were significantly less likely than nHw to have serrated adenomas on SC (AA 4.1% vs nHw 7%; p< 0.0001). No difference was observed in mean age, location, or size between nHw and AA with serrated adenomas. Conclusions Serrated adenomas are more frequent in nHw compared to AA at initial SC. No difference was seen in size or location of serrated adenomas, as well as patient age, between AA and nHw. A study of genetic factors predisposing to serrated adenoma formation and the impact of socioeconomic disparities should be performed across ethnic groups to understand this difference.

How to approach esophagogastric junction outflow obstruction?

The diagnosis of esophagogastric junction outflow obstruction (EGJOO) is currently based on high-resolution esophageal manometry and is characterized by impaired EGJ relaxation with preserved esophageal peristalsis. This condition has been defined by the Chicago Classification as a major esophageal motility disorder, although its clinical significance is controversial since heterogeneous and irrelevant presentations have been reported. EGJOO commonly has a benign clinical course, with spontaneous resolution, but it can also be associated with opioid usage, early achalasia, and mechanical obstruction. A careful medical, surgical, and medication history coupled with a careful manometry interpretation focused on the factors that might affect the integrated relaxation pressure are the keys for an accurate diagnosis. The advance of esophageal physiological tests can evaluate the clearance of the esophageal contents across the EGJ. The manometry technique, including testing in an upright position and provocative tests, can also complement those tests and demonstrate the evidence of EGJ obstruction. After making a diagnosis, endoscopy should be an initial step to exclude anatomical causes if it has not yet been done. Imaging studies can identify infiltrative lesions, but the reported diagnostic yield is relatively low. Management of EGJOO depends on the underlying etiology. Functional EGJOO patients with persistent dysphagia associated with the presence of outflow obstruction may require EGJ disruption therapy.

Protective Propensity of Race or Environmental Features in the Development of Barrett's Esophagus in African Americans - A Single Center Pilot Study.

BACKGROUND AND STUDY AIMS: Barrett's Esophagus (BE) is a well-recognized pre-malignant condition. Previous data indicate histologically confirmed BE frequency varies by ethnicity in the United States. However, clinical factor assessment to explain this has only occurred in a veteran population to date. The study aim was to determine which clinical factors may be associated with the ethnic variation seen in histologically confirmed BE among a general population. PATIENTS AND METHODS: The University of Florida-Jacksonville endoscopy database was searched for all cases of endoscopic BE from September 2002 to October 2012. Histologic BE was diagnosed only if salmon colored, columnar-appearing esophageal mucosa was seen at endoscopy and biopsy revealed intestinal metaplasia with Alcian blue-stained goblet cells. Data collected included: age/BMI at diagnosis, ethnicity, sex, GERD history, atypical manifestations, endoscopic BE length, presence of esophageal stricture/ulcer/hiatal hernia, presence/absence of dysplasia and medication use (aspirin/NSAIDs/statin/PPI). RESULTS: Salmon colored esophageal mucosa was observed in 1105 of 15,564 patients (7.1%) with BE histologically confirmed in 249 of 1105 patients (23%). Ethnic distribution of histologic BE patients: 83% non-Hispanic white (nHw), 13% African American (AA) and 4% other. No difference was seen between groups with regard to BMI, GERD symptom/complications, BE length, and cigarette, alcohol or medication use. CONCLUSION: BE occurs primarily in nHw in north Florida. This occurs despite similarities in GERD history, cigarette/alcohol use, medications prescribed and BMI. Molecular level investigation is necessary to explain this observed disparity between nHw and AA.

Risk of histologic Barrett's esophagus between African Americans and non-Hispanic whites: A meta-analysis.

BACKGROUND: Barrett's esophagus (BE) is rare in African Americans (AA). However, the risk difference magnitude in histologic BE prevalence between AA and non-Hispanic whites (nHw) has not been quantified to date. OBJECTIVE: The objective of this article is to determine the degree of histologic BE risk difference between AA and nHw. METHODS: PubMed, Web of Science and EMBASE were searched for studies reporting histologic BE in AA/nHw for inclusion. Pooled odds ratios (ORs) with risk estimates of histologic BE occurrence between AA/nHw were calculated along with 95% confidence intervals (CIs). Forest plots were used to quantify heterogeneity. Funnel plots and the Cochrane Collaboration Risk of Bias tool were used to assess bias risk. RESULTS: Eight studies reported BE histologic confirmation in AA/nHw. Analysis demonstrated a nearly 400% increased histologic BE risk in nHw patients compared to AA (OR 3.949, 95% CI 3.069-5.082). In the model without the case-control study, histologic BE risk remained elevated at approximately 360% in nHw compared to AA (OR 3.618, 95% CI 2.769-4.726). Heterogeneity was not present in either model. Risk of bias was significant. CONCLUSIONS: Histologic BE risk is elevated in nHw by 3.6-4 times compared to AA. Investigation into understanding any clinical, molecular or genetic mechanisms underlying this risk disparity is warranted.

Stent type used does not impact complication rate or placement time but can decrease treatment cost for benign and malignant esophageal lesions.

AIM: To evaluate if differences exist between self-expanding esophageal metal stents (SEMS) and self-expanding esophageal plastic stents (SEPS) when used for benign or malignant esophageal disorders with regard to safety, efficacy, clinical outcomes, placement ease and cost. METHODS: A retrospective analysis was performed to evaluate outcome in patients having SEPS/SEMS placed for malignant or benign esophageal conditions from January 2005 to April 2012. Inclusion criteria was completed SEMS/SEPS placement. Outcomes assessed included technical success of and time required for stent placement, procedure-related complications, need for repeat intervention, hospital stay, mortality and costs. RESULTS: Forty-three patients underwent stent placement for either benign/malignant esophageal disease during the study period. Thirty patients had SEMS (25 male, mean age 59.6 years old) and 13 patients had SEPS (10 male, mean age 61.7 years old). Placement outcome as well as complication rate (SEPS 23.1%, SEMS 25.2%) and in-hospital mortality (SEPS 7.7%, SEMS 6.7%) after placement did not differ between stent types. Migration was the most frequent complication reported occurring equally between types (SEPS 66.7%, SEMS 57.1%). SEPS was less costly than SEMS, decreasing institutional cost by $255/stent. CONCLUSION: SEPS and SEMS have similar outcomes when used for benign or malignant esophageal conditions. However, SEPS use results in decreased costs without impacting care.

African American ethnicity is not associated with development of Barrett's oesophagus after erosive oesophagitis.

BACKGROUND: Barrett's oesophagus is the primary risk factor for oesophageal adenocarcinoma; erosive oesophagitis is considered an intermediate step with Barrett's oesophagus development potential upon healing. Barrett's oesophagus occurs in 9-19% following erosive oesophagitis but minimal data exists in African Americans. The study aim was to determine if ethnicity is associated with Barrett's oesophagus formation following erosive oesophagitis. METHODS: Retrospective review of endoscopies from September 2007 to December 2012 was performed. Inclusion criteria were erosive oesophagitis on index endoscopy, repeat endoscopy ≥6 weeks later and non-Hispanic white or African American ethnicity. Barrett's oesophagus frequency following erosive oesophagitis by ethnicity was compared. RESULTS: A total of 14,303 patients underwent endoscopy during the study period; 1636 had erosive oesophagitis. Repeat endoscopy was performed on 125 non-Hispanic white or African American patients ≥6 weeks from the index procedure. Barrett's oesophagus occurred in 8% of non-Hispanic whites while no African American developed it on repeat endoscopy following erosive oesophagitis (p=0.029). No significant difference was seen between ethnic groups in any clinical parameter assessed. CONCLUSIONS: African American ethnicity appears to result in decreased Barrett's oesophagus formation following erosive oesophagitis. Further investigation to demonstrate factors resulting in decreased Barrett's oesophagus formation among African Americans should be performed.

Effect of PAH specific therapy on pulmonary hemodynamics and six-minute walk distance in portopulmonary hypertension: a systematic review and meta-analysis.

BACKGROUND: Little is known about the effect of pulmonary arterial hypertension (PAH) specific therapy on pulmonary hemodynamics and exercise capacity in patients with portopulmonary hypertension (PoPH) because such patients are usually excluded from randomized clinical trials (RCT) of such therapy. METHODS: We searched PUBMED using the terms "(Therapy/Broad (filter)) AND (portopulmonary hypertension)." We included studies that met the following criteria: ≥5 patients, AND PoPH confirmed by right heart catheterization (RHC), AND follow-up RHC data, AND/OR baseline and follow-up 6MWD available. RESULTS: 12 studies met our inclusion criteria. None was a RCT. The baseline mPAP was 48.6 ± 4.4 mmHg, cardiac output (CO) 5.6 ± 0.9 L/min, and pulmonary vascular resistance (PVR) 668.6 ± 219.1 dynes.sec/cm(5). The baseline 6MWD was 348.2 ± 35.6 meters. The use of PAH specific therapy improved mPAP by 7.54 mmHg (95% CI 10.2 to 4.9), CO by 1.77 L/min (95% CI 1.1 to 2.4), and PVR by 253 dynes.sec/cm(5) (95% CI 291.4 to 214.6) (n = 135) and 6MWD by 61.8 meters (95% CI 47.5 to 76) (n = 122). CONCLUSIONS: The use of PAH specific therapy in PoPH results in significant improvement in both pulmonary hemodynamics and 6MWD.

An unusual case of cirrhosis.

49-year-old white female with remote h/o sarcoidosis was referred to GI when her liver was noted to be nodular. Physical examination revealed normal vital signs and no icterus, spider nevi, clubbing, ascites, hepatosplenomegaly, or ankle edema. LFTs, hepatitis serologies, ANA, AMA, ASMA, Ferritin, Ceruloplasmin, and α 1-AT, level were unremarkable. Liver biopsy showed cirrhosis. She developed worsening of baseline SOB and was hospitalized. She was eventually diagnosed with constrictive pericarditis. A diagnosis of cardiac cirrhosis was made.

Does Gastrointestinal Dysmotility Predispose to Recurrent or Severe Forms of Clostridium difficile Infections?

Clostridium difficile infection (CDI) is the most common cause of hospital-acquired diarrhea. A limited number of studies have looked at the risk factors for recurrent CDI. Mitochondrial NeuroGastroIntestinal Encephalopathy (MNGIE) is a rare multisystemic disorder that causes gastrointestinal dysmotility. Herein we present a patient with MNGIE who suffered recurrent and severe C. difficile infection despite appropriate treatment. We aim to bring the gastroenterologist's attention to gastrointestinal dysmotility as a possible risk factor for the development of recurrent or severe forms of C. difficile infections.