Response to botulinum toxin may predict response to peroral pyloromyotomy in patients with gastroparesis.

BACKGROUND : Patients with gastroparesis who have undergone prior intrapyloric botulinum toxin injection (BTI) may seek an opinion regarding peroral pyloromyotomy (POP). There are only two small reports assessing the role of BTI as a predictor for successful treatment with POP. METHODS: We performed a retrospective cohort study to assess whether symptomatic improvement after BTI predicts a response to POP. We included 119 patients who had undergone both BTI and POP at Cleveland Clinic Ohio or Cleveland Clinic Florida from January 2016 to September 2019. RESULTS: 65.5 % of patients had symptomatic improvement after BTI. Gastroparesis Cardinal Symptom Index (GCSI) scores were available for 74 patients, with 64 % achieving a response to POP, defined as a decrease in mean GCSI ≥ 1. In multivariable analysis, response to BTI (odds ratio [OR] 7.7 [95 %CI 2.2-26.1]) and higher pre-POP GCSI score (OR 2.3 [95 %CI 1.2-4.6]) were independent predictors of response to POP. CONCLUSIONS: Clinical improvement after BTI is a predictor of response to POP in patients with gastroparesis. This information may aid in improving patient selection for POP.

Ustekinumab does not increase risk of new or recurrent cancer in inflammatory bowel disease patients with prior malignancy.

BACKGROUND AND AIM: There is limited data on the rate of new or recurrent cancer in patients with inflammatory bowel disease (IBD) and a history of prior or current malignancy who are initiated on biologic therapies. Furthermore, there is no data on this topic in patients using ustekinumab. METHODS: The retrospective study included 341 patients with IBD and a history of cancer who were subsequently treated with vedolizumab (VDZ; n = 34), ustekinumab (USK; n = 27), tumor necrosis factor α antagonists (anti-TNF; n = 99), or had no immunosuppressive therapy (control; n = 181). Cox proportional hazard models were developed to determine the independent effect of post-cancer immunosuppressive treatment on the occurrence of incident cancer. RESULTS: Over a median of 5.2 person-years of follow up, cancer recurrence occurred in only one patient on anti-TNF, while new cancers developed in one patient on VDZ, three patients on USK, and six patients on anti-TNF, corresponding to cancer rates of 0.4, 1.8, and 0.7 per 100 person-years, respectively. The rate of incident cancer in control patients was 2.4 per 100 person-years and included 18 new and 9 recurrent cancers. Compared with controls, a stepwise Cox proportional hazards model adjusting for significant covariates found no increased risk of incident cancer in patients receiving post-malignancy treatment with USK (hazard ratio [HR] 0.88; 95% confidence interval [CI] 0.25-3.03), VDZ (HR 0.18; 95% CI 0.03-1.35), or anti-TNF (HR 0.47; 95% CI 0.20-1.12). CONCLUSION: Use of biologic therapy in IBD patients with a previous history of malignancy was not associated with an increased risk of new or recurrent cancer.

Kimura-Takemoto Classification: A Tool to Predict Gastric Intestinal Metaplasia Progression to Advanced Gastric Neoplasia.

BACKGROUND AND AIMS: Gastric cancer is a leading cause of morbidity and mortality worldwide. Gastric intestinal metaplasia (GIM) has been described as a key histologic step in the development of gastric adenocarcinoma. However, not all people with GIM develop malignancy. We studied the factors associated with progression to dysplasia and advanced gastric neoplasia (aGN) in patients with baseline GIM. METHODS: Retrospective cohort analysis of patients with baseline GIM and subsequent endoscopic evaluation at Cleveland Clinic Florida and Ohio Main Campus between 2005 and 2017. Demographic and exposure risk factors, as well as Kimura-Takemoto classification (KTc), were used as variables for hazards ratio (HR) and Kaplan-Meier survival-free analysis for aGN and any form of dysplasia progression. RESULTS: There were 708 patients identified with GIM; 29 patients (4.1%) progressed to any degree of dysplasia. From these, LGD was present in 12 cases (1.7%), HGD in 4 cases (0.6%), and gastric cancer in 13 cases (1.8%), for a total of 17 aGN cases. KTc was associated with dysplasia and aGN progression (p < 0.001), and no cases progressed if KTc findings were absent. Open-type KTc was associated with aGN (HR 6.36, p < 0.001) and any dysplasia progression (HR 13.34, p < 0.001) compared to closed-type or absent KTc features. No other factors were associated with aGN or dysplasia progression. Open-type KTc was also associated with shorter cancer survival-free progression. CONCLUSION: Patients with baseline GIM present a higher progression risk to aGN, dysplasia, or cancer if concomitant KTc findings are present, particularly an open-type KTc pattern.

Risk Factors Associated With Postendoscopic Mucosal Resection Bleeding in Patients With Cirrhosis: A Retrospective Multicenter Cohort Study.

BACKGROUND AND AIM: There is limited data regarding the safety of endoscopic mucosal resection (EMR) in the cirrhotic population. Our study aimed to evaluate the safety of colonoscopic EMR in cirrhosis. MATERIALS AND METHODS: This was a retrospective review of cirrhotics who underwent colonic EMR at 8 Cleveland Clinic Centers between January 1, 2006, and December 31, 2018. Patient data including polyp details and complications occurring within 30 days of the procedure were noted. Univariable and multivariable logistic regression analyses were conducted to find risk factors for post-EMR bleeding. RESULTS: A total of 238 patients who underwent EMR were included. There were 145 males (60.9%) and the mean age was 61.9±8.6 years. Immediate and delayed bleeding, and postpolypectomy syndrome rates were 9.2%, 5.8%, and 1.3%, respectively. Significant risk factors for postpolypectomy bleeding were: increased age (P=0.001), procedure duration >37 minutes (P=0.001), antiplatelet use within 5 days (P=0.023), and lesion diameter >15 mm (P=0.004). Multivariable analysis revealed independent predictors of procedure-related bleeding: age above 65 years [odds ratio (OR) 2.14, P=0.044], antiplatelet use within 5 days (OR 2.42, P=0.047), right colon polyp (OR 3.51, P=0.001), and lesion diameter >15 mm (OR 3.22, P=0.003). CONCLUSIONS: EMR in cirrhotics has an acceptable bleeding risk. Age above 65 years, right colon polyp, polyp size >15 mm, and use of antiplatelets within 5 days are independent risk factors for bleeding.

Afro-Caribbeans Have a Lower Prevalence of Advanced Colon Neoplasia than African-Americans.

BACKGROUND/AIMS: The black population in the USA is a heterogeneous group composed of smaller subgroups from different origins. The definition of black in many colorectal cancer (CRC) risk studies is vague, and differences in CRC risk comparing black subpopulations have not been evaluated. The aim of the study is to compare advanced colorectal neoplasia (ACN) between two subgroups of black populations: African-American (AA) and Afro-Caribbean (AC). A secondary aim was to determine whether there are differences in prevalence of adenomas. METHODS: This was a retrospective study of 3797 AA and AC patients undergoing first time screening colonoscopy in two different institutions in the USA. RESULTS: Overall adenoma prevalence was 29.3% for the entire population with 29.5% in AAs and 29.0% in AC with no statistically significant difference between the study groups (AOR: 1.02; 95% CI 0.88-1.18, P = 0.751). However, ACN was significantly higher in the AA group (11.8%) compared to AC (9.0%) (AOR: 1.30, 95% CI 1.02-1.66, P = 0.034). It was observed that AAs had ACN at a higher BMI than AC. After adjusting for BMI/ethnicity interactions, the difference in ACN between both groups became more significant (AOR: 1.93, 95% CI 1.16-3.23, P = 0.012). CONCLUSIONS: AAs have a higher risk of ACN than AC. Current recommendations to start screening in average-risk AAs at an earlier age may not apply to other black subgroups.

Randomized Controlled Trial: Split-dose and Same-day Large Volume Bowel Preparation for Afternoon Colonoscopy Have Similar Quality of Preparation.

GOALS: We compare bowel cleanliness in patients taking same-day versus split-dose 4-L polyethylene glycol laxative for afternoon colonoscopy. Secondary objectives included patient satisfaction, adverse effects and patient tolerability. BACKGROUND: Afternoon colonoscopies have been associated with inadequate bowel preparation and lower adenoma detection rates. Same-day (morning) or split-dosing of the laxative have improved preparation quality but differences between these options are unclear. MATERIALS AND METHODS: Single-center prospective randomized endoscopist blinded trial. Patients aged 18 years and above prescribed 4-L polyethylene glycol for colonoscopy were randomized into same-day or split-dose preparation. Preparation quality was assessed using the Ottawa Bowel Preparation Scale. Patient satisfaction and side effects was collected using a questionnaire. Intention-to-treat and per-protocol analysis were performed. RESULTS: A total of 300 patients (158 split-dose, 142 same-day) were evaluated. No statistically significant difference was seen on total Ottawa score among the groups (P=0.47) or by individual colonic segments in intent-to-treat and per-protocol analysis. Patients in split-dose group were more likely to complete the entire preparation (P=0.01) but reported more sleep loss (P=0.001). The same-day preparation group reported higher incidence of vomiting (P=0.036). Patients ingesting bowel preparation ≥7 hours before colonoscopy had higher total Ottawa scores (P=0.001). CONCLUSIONS: There were no differences in quality of preparation in patients taking same-day versus split-dose preparation for afternoon colonoscopy. Those receiving same-day preparation were less likely to lose sleep but more likely to have emesis. These differences should be considered when selecting a bowel preparation regimen.

Open Access Colonoscopy for Colorectal Cancer Prevention: An Evaluation of Appropriateness and Quality.

BACKGROUND: Open access colonoscopy (OAC) has gained widespread acceptance and has the potential to increase colorectal cancer (CRC) screening. However, there is little data evaluating its appropriateness for CRC prevention. AIMS: The aim of this study is to evaluate the appropriateness of OAC in CRC screening and polyp surveillance by comparing to procedures ordered by gastroenterologists (NOAC). As secondary outcomes, we compared the quality of bowel preparation and adenoma detection rate (ADR) between OAC and NOAC. METHODS: It is retrospective single-center study. Inclusion criteria included patients > 50 years of age undergoing a colonoscopy for CRC screening and surveillance. Appropriateness was defined as those colonoscopies performed within 12 months of the recommended 2012 consensus guidelines. Secondary outcomes included the quality of bowel preparation and ADR. RESULTS: 5211 colonoscopies met inclusion criteria, and 64.9% were OAC. Screening OAC was appropriately 91.6% and NOAC 92.9% of the time (p = 0.179). Surveillance NOAC were inappropriate in 26.4% of cases, and surveillance OAC was 32.6% (p = 0.008). Multivariate analysis demonstrated that OAC did not influence ADR (OR for NOAC 0.97; 95% CI 0.86-1.1; p = 0.644) or an adequate bowel preparation (OR for NOAC 1.11; 95% CI 0.91-1.36; p = 0.306). CONCLUSION: OAC performed similarly to NOAC for screening indications, quality of bowel preparation, and ADR. However, more surveillance procedures were inappropriate in the OAC group although both groups had a high number of inappropriate indications. Although OAC can be efficiently performed for screening indications, measures to decrease inappropriate surveillance colonoscopies are needed.

Differences in Prevalence of Large Polyps Between Hispanic Americans from Mexican- and Non-Mexican-Predominant States.

BACKGROUND: There have been conflicting reports comparing the prevalence of large polyps (>9 mm) between Hispanics and non-Hispanic whites (NHW). Differences between Hispanic subpopulations may account for these variations. AIMS: We aimed to assess the prevalence of large polyps (>9 mm) in Hispanics from Mexican- and non-Mexican-predominant states compared with NHW. As secondary outcome, we evaluated results by polyp location. METHODS: The 2010 U.S. Census Bureau was used to identify states with a predominantly Mexican Hispanic (West) versus non-Mexican Hispanic (East) populations. Average-risk colonoscopies in those states from 2001 to 2014 were accessed using the Clinical Outcomes Research Initiative database. Military and Veteran's Administration sites were excluded. Hispanics were compared with NHW in each geographical location using hierarchical logistic regression analysis. RESULTS: A total of 65,138 procedures were included with 33,425 procedures in the West (14.5% Hispanics) and 31,713 procedures in the East (44.0% Hispanics,). East Hispanics had significantly less odds of large polyps, OR 0.74, CI 0.58-0.94, p = 0.02, while West Hispanics exhibited no difference, OR 0.91, CI 0.76-1.10, p = 0.33, compared with NHW. Eastern Hispanics had less odds of large distal polyps, OR 0.69, CI 0.52-0.91, p = 0.01, and no difference in proximal polyps compared with NHW. Among Western Hispanics, no differences were seen in proximal, OR 1.06, CI 0.83-1.35, p = 0.66, or distal polyps, OR 0.83, CI 0.68-1.02, p = 0.08, compared with NHW. CONCLUSION: Using NHW as a reference, Hispanics from Mexican-predominant states have a similar prevalence of large polyps, while Hispanics from non-Mexican-predominant states have a lower prevalence. Differences in Hispanic subpopulations likely explain previous conflicting reports on the prevalence of large polyps in Hispanics and NHW.

Bowel Preparations Administered the Morning of Colonoscopy Provide Similar Efficacy to a Split Dose Regimen: A Meta Analysis.

BACKGROUND: Comparative efficacy of same-day bowel preparations for colonoscopy remains unclear. AIMS: A meta-analysis of randomized controlled trials comparing the efficacy of same-day versus split dose bowel preparations for colonoscopy. METHODS: A systematic search was conducted in MEDLINE, clinicaltrials.gov, Cochrane Registry, EMBASE, SCOPUS, Web of Science and CINAHL. Studies were gathered using keywords: "morning preparation", "morning bowel preparation", "same day bowel preparation", and "colonoscopy." Pooled estimates of bowel preparation quality were analyzed among studies with categorical and continuous outcomes according to relative risk (RR) or mean difference (MD). A random effects model was chosen a priori for all analyses. RESULTS: A total of 1216 studies were retrieved with 15 trials meeting inclusion criteria. The categorical outcome of high quality bowel preparation for any same-day bowel preparation versus any split preparation was no different with a RR 0.95 [0.90;1.00] (P=0.62). Adenoma detection rate (ADR) was not different between groups, RR 0.97 [0.79;1.20] (P=0.81). Willingness to repeat and tolerability did not differ (RR 1.14 [0.96,1.36] (P=0.14) and RR 1.00 [0.96;1.04] (P=0.98), respectively. Adverse events were similar except for bloating, which was less frequent among the same-day preparation group, RR 0.68 [0.40;0.94] (P=0.02). CONCLUSION: No clinically significant differences were noted among recipients of same day or split dose regimens. Adenoma detection rate, willingness to repeat and tolerability were similar, but bloating and interference with sleep favored the same-day preparations. Given lack of clinical differences, patient preference should dictate timing of colonoscopy preparation.

Can polyp detection rate be used prospectively as a marker of adenoma detection rate?

BACKGROUND: Adenoma detection rate (ADR) is a quality indicator for screening colonoscopy, but its calculation is time-consuming. Polyp detection rate (PDR) has been found to correlate with ADR; however, its use as a quality indicator has been criticized out of concern for endoscopists artificially inflating the PDR. We aim to evaluate whether active monitoring affects PDR. METHODS: In March 2015, 14 endoscopists were made aware that their personal PDRs would be tracked monthly as a quality improvement project. Endoscopists received a report of their individual monthly and cumulative PDR, departmental averages, and a benchmark PDR. Following the intervention, data were collected for consecutive patients undergoing average risk screening colonoscopy for six months. PDR, ADR, and adenoma to polyp detection ratio quotient (APDRQ) were compared to a six-month pre-intervention period. RESULTS: 2203 patients were included in the study. There was no statistically significant difference in PDR when comparing pre- and post-intervention (44 vs. 45%, OR 1.04; 95% CI 0.77-1.36). No statistically significant difference in ADR was observed when comparing pre- and post-intervention (29 vs. 30%, OR 1.03; 95% CI 0.64-1.52). There was no statistically significant difference in APDRQ when comparing pre- and post-intervention (0.67 vs. 0.66, OR 0.99; 95% CI 0.69-1.33). CONCLUSIONS: Monthly report cards did not result in a change in PDR or APDRQ. In some environments, PDR can be used as a surrogate marker of ADR, despite endoscopist awareness that PDR is being measured.

A New Scoring System to Predict the Risk for High-risk Adenoma and Comparison of Existing Risk Calculators.

BACKGROUND: Colorectal cancer (CRC) screening guidelines likely over-generalizes CRC risk, 35% of Americans are not up to date with screening, and there is growing incidence of CRC in younger patients. GOALS: We developed a practical prediction model for high-risk colon adenomas in an average-risk population, including an expanded definition of high-risk polyps (≥3 nonadvanced adenomas), exposing higher than average-risk patients. We also compared results with previously created calculators. STUDY: Patients aged 40 to 59 years, undergoing first-time average-risk screening or diagnostic colonoscopies were evaluated. Risk calculators for advanced adenomas and high-risk adenomas were created based on age, body mass index, sex, race, and smoking history. Previously established calculators with similar risk factors were selected for comparison of concordance statistic (c-statistic) and external validation. RESULTS: A total of 5063 patients were included. Advanced adenomas, and high-risk adenomas were seen in 5.7% and 7.4% of the patient population, respectively. The c-statistic for our calculator was 0.639 for the prediction of advanced adenomas, and 0.650 for high-risk adenomas. When applied to our population, all previous models had lower c-statistic results although one performed similarly. CONCLUSIONS: Our model compares favorably to previously established prediction models. Age and body mass index were used as continuous variables, likely improving the c-statistic. It also reports absolute predictive probabilities of advanced and high-risk polyps, allowing for more individualized risk assessment of CRC.

Effect of Diet Liberalization on Bowel Preparation.

OBJECTIVES: Precolonoscopy dietary regimens often are restricted to clear liquids; however, the superiority of a clear liquid diet (CLD) for bowel preparation quality is ambiguous. We performed a meta-analysis of randomized trials comparing bowel preparation outcomes between a low-residue diet (LRD) or regular diet (RD) compared with a CLD. METHODS: MEDLINE, clinicaltrials.gov, Cochrane Central Register, Scopus, Embase, Cumulative Index to Nursing and Allied Health Literature, and the Web of Science databases were used to conduct a search for randomized controlled trials from 1976 to March 2015. Of 122 relevant references, 12 studies met our inclusion criteria, 7 studies of which were classified as being of high quality. Pooled estimates of bowel preparation quality were defined as adequate versus inadequate. Secondary outcomes included tolerability, willingness to repeat bowel preparation, adverse events, and adenoma detection rate. Pooled estimates of relative risk (RR) were used for dichotomous variables and standardized mean difference for continuous variables. RESULTS: In the high-quality studies, there were no differences in bowel preparation quality among the LRD/RD and CLD groups (RR 0.98; 95% confidence interval [CI] 0.93-1.04). Analysis of secondary outcomes included all of the studies. Tolerability (RR 1.04, 95% CI 1.01-1.08) and willingness to repeat favored the liberalized diet arm (RR 1.08, 95% CI 1.01-1.16). There was no significant difference in the adenoma detection rate, whereas hunger was more common in the CLD group. CONCLUSIONS: An LRD/RD provided no difference in bowel preparation quality as compared with a CLD. As such, it may be reasonable for patients without risk factors for poor preparation to undergo an LRD until lunch the day before their colonoscopy given that bowel preparation tolerability and willingness to repeat were greater among groups with a liberalized diet.

Comparison of Adenoma Detection Rates in Afro-Caribbeans and Non-Hispanic Whites Undergoing First Screening Colonoscopy.

OBJECTIVES: The African American population has a higher prevalence of advanced colon adenomas when compared with non-Hispanic whites and Hispanics, but the risk in other black populations has not been evaluated. Although the Afro-Caribbean population is a significant demographic segment in some regions of the United States, the data are limited on the prevalence of colon adenomas in this group and there is no comparison with a non-Hispanic white population. The objective of our study was to compare the prevalence of adenomas in Afro-Caribbean versus non-Hispanic white populations. METHODS: A total of 880 Afro-Caribbean patients and 1828 non-Hispanic white patients undergoing their first screening colonoscopy between January 2008 and August 2014 was included in the study. RESULTS: A total of 2708 patients met entry criteria for the study. The adenoma detection rate among Afro-Caribbeans was 29% and 31% among non-Hispanic whites. There was no statistically significant difference in the prevalence of adenomas in the two groups (P = 0.28), and the rate of advanced adenomas also was similar in both groups (8.6% in Afro-Caribbeans, 9.2% in non-Hispanic whites; P = 0.60). A multivariate analysis also found no difference in the occurrence of adenomas (P = 0.60) or advanced adenomas (P = 0.99) between Afro-Caribbeans and non-Hispanic whites. CONCLUSIONS: We found a similar adenoma detection rate and advanced adenoma prevalence among Afro-Caribbeans and non-Hispanic whites undergoing their first screening colonoscopy. As such, the Afro-Caribbean population may not have the same risk of colorectal neoplasia as what has been described for African Americans. Based on these results, it is appropriate to initiate colorectal cancer screening for Afro-Caribbeans at age 50 as recommended for non-Hispanic whites.

The day of the week does not affect the adenoma detection rate.

BACKGROUND: The role of operator fatigue on adenoma detection rate (ADR) is still controversial. AIMS: The purpose of this study was to determine if fatigue towards the end of the week affects the ADR. METHODS: A retrospective chart review of consecutive colonoscopies was done at a tertiary care teaching institution. Patients 45 years of age or older undergoing screening or surveillance colonoscopy from June 2007 to August 2010 were included in the study. RESULTS: A total of 3,085 patients were included in the study, with an overall 31 % ADR. ADR was between 31 and 32 % throughout the week, with no statistically significant variation (p = 0.8697). The total number of adenomas and advanced adenomas was also similar throughout the week (p = 0.8, p = 0.59, respectively). CONCLUSIONS: ADR is not influenced by the day of the week in which a colonoscopy is performed.

Gastric intestinal metaplasia and gastric cancer prevention: Watchful waiting.

Gastric intestinal metaplasia (GIM), a common histologic finding, is associated with increased risk of gastric cancer, and GIM associated with Helicobacter pylori infection is classified as an environmental metaplastic atrophic gastritis. Patients may be asymptomatic or present with various dyspeptic symptoms. Autoimmune metaplastic atrophic gastritis is a less common but important cause of chronic gastritis. The Correa cascade describes the evolution of precancerous mucosal changes that lead to development of GIM, with differentiation of 2 histologic types of GIM (complete and incomplete) and the consequences of each type. The risk of progression to malignancy is higher with incomplete GIM. It is also higher for those who immigrate from regions with a high incidence of H pylori infection to areas where the incidence is low. Guidelines regarding endoscopic management of GIM vary by geographic region.

Impact of octreotide on sodium level in cirrhotic inpatients with hyponatremia: a retrospective study.

OBJECTIVE: Octreotide could increase serum sodium in cirrhotics with hyponatremia by counteracting splanchnic vasodilation. Current supporting data is limited to case reports and series. The aim of the study is to assess the effect of octreotide on serum sodium in cirrhotic inpatients with hyponatremia compared with controls. METHODS: This is a retrospective study including adult inpatients with cirrhosis, admitted for ≥5 days with Na <133 at baseline. We excluded those receiving other vasoconstrictor infusions, hypertonic saline, tolvaptan or dialysis. Controls represented an equal number of inpatients with cirrhosis not receiving octreotide. Sodium changes on days 5, 7 and 10 were evaluated with multivariable adjustment. RESULTS: Each group consisted of 156 patients. The octreotide subjects had more cirrhosis complications. Baseline sodium was lower in the octreotide group, and their change in sodium at day 5 was higher (6.6 ± 5.6 vs. 3.5 ± 5.3; P < 0.001). Significant differences were also noted on days 7 and 10 (7.84 ± 6.76 vs. 4.33 ± 6.2 and 7.99 ± 6.72 vs. 5.2 ± 6.56, respectively). The impact of octreotide was lessened but remained significant ( P = 0.019) in a mixed model adjusting for baseline sodium, creatinine, requirement of paracentesis, midodrine, albumin and fresh frozen plasma. More octreotide patients achieved hyponatremia resolution (55.1% vs. 42.3%; P = 0.031), but significance was not preserved in multivariate logistic regression. CONCLUSION: Octreotide administration is associated with an increase in serum sodium among inpatient cirrhotics with hyponatremia, even after accounting for confounders. Prospective randomized controlled trials are warranted.

Comparison between metabolic-associated fatty liver disease and nonalcoholic fatty liver disease: From nomenclature to clinical outcomes.

As a result of the obesity epidemic, Nonalcoholic fatty liver disease (NAFLD) and its complications have increased among millions of people. Consequently, a group of experts recommended changing the term NAFLD to an inclusive terminology more reflective of the underlying pathogenesis; metabolic-associated fatty liver disease (MAFLD). This new term of MAFLD has its own disease epidemiology and clinical outcomes prompting efforts in studying its differences from NAFLD. This article discusses the rationale behind the nomenclature change, the main differences, and its clinical implications.

Rebleeding after hemoclip versus argon plasma coagulation for gastrointestinal angiodysplasias: a retrospective multicenter study.

BACKGROUND: Hemoclips are utilized for treating bleeding gastrointestinal angiodysplastic lesions (GIADs); however, the supporting evidence is limited. AIMS: Our aim is to evaluate the efficacy of hemoclips in preventing bleeding secondary to GIADs compared to argon plasma coagulation (APC). METHODS: This retrospective study included patients with bleeding gastric, small bowel or colonic GIADs that were endoscopically treated between January 2009 and November 2016. Patients that received hemoclips as monotherapy or in combination were compared to a randomly selected similar number of patients treated with APC. RESULTS: We included 157 patients that underwent APC and 141 who received hemoclips. During a median follow-up of 17 months, those with hemoclips had a 32.6% rebleeding vs. 46.5% in the APC group (P = 0.017). On multivariate regression analysis, use of hemoclips was not a significant predictor of rebleeding when compared to APC; hemoclips monotherapy (HR, 0.92; 95% CI, 0.54-1.59) and hemoclips combination (HR, 0.65; 95% CI, 0.41-1.01). When the multivariate analysis was restricted to subjects that resumed antithrombotics after endoscopy, rebleeding risk was lower when hemoclips were used in combination (HR, 0.46; 95% CI, 0.25-0.84) compared to APC. We noted a similar effect in the antithrombotic subgroup even after propensity score matching (HR, 0.51; 95% CI, 0.27-0.95). CONCLUSION: Treatment modality was not a significant predictor of rebleeding when studied for the entire population. However, the risk of rebleeding was lower with hemoclips combination therapy compared to APC in patients that resumed antithrombotic therapy, suggesting a potential role for a combined approach in this subgroup of patients.

Endoscopic and Surgical Management of Blue Rubber Bleb Nevus Syndrome.

Blue rubber bleb nevus syndrome is a rare congenital sporadic disorder characterized by multiple venous malformations localized in the skin, gastrointestinal tract, and internal organs. Gastrointestinal lesions tend to lead to massive or occult bleeding and iron deficiency anemia. The treatment of symptomatic gastrointestinal venous malformations remains a challenge, especially in the setting of recurrent blood loss anemia. An endoscopic approach may be required for refractory cases. We present a case of a 20-year-old patient with blue rubber bleb nevus syndrome with multiple lesions in the stomach, duodenal bulb, small bowel, sigmoid, and descending colon who underwent successful endoscopic mucosal resection, hybrid endoscopic submucosal dissection, and surgical transmural resection of vascular lesions for recurrent bleeding.

Clinical and Endoscopic Predictors of Hydrostatic Balloon Dilation Failure for Post-Bariatric Anastomotic Stricture Treatment.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) patients can develop anastomotic strictures. The initial management relies on endoscopic hydrostatic balloon dilation, but in a subset of patients, it may be unsuccessful despite several dilations, requiring a different treatment modality. We evaluated the factors associated with balloon dilation failure and need for revision surgery. METHODS: Retrospective analysis from patients presenting with a post-RYGB anastomotic stricture who underwent balloon dilation from 2005 to 2018 at Cleveland Clinic Florida and Cleveland Clinic Main Campus. Demographic, clinical, surgical, endoscopic, and post-procedural variables were collected. Univariate and multivariate analysis with odds ratio (OR) and 95% confidence interval (95% CI) calculation for factors associated to dilation failure was performed. RESULTS: Eighty-nine patients were included in the analysis. Population was predominantly white (85.4%) and female (87.6%), with mean age 46.4 years and followed for a mean of 97.4 months. All patients presented dysphagia, with mean stricture diameter of 7.7 mm and associated marginal ulcer in 69%. Successful dilation was achieved in 65 patients, while 24 patients had dilation failure and underwent revisional surgery. Multivariate analysis showed a higher risk of dilation failure if time from RYGB to first dilation was >3 months (OR 4.95, 1.29-19.04; p = 0.02), and if nausea/vomiting were present before first dilation (OR 4.37, 1.11-17.16; p = 0.03). One patient had a perforation after dilation and was treated surgically. CONCLUSIONS: Post-RYGB anastomotic strictures can be successfully treated with hydrostatic balloon dilation. However, patients with dilations performed > 3 months after initial RYGB and nausea/vomiting have an increased risk of dilation failure and need for further interventions.