High-risk smoking in the United States: Nicotine staining predicts increased colonic adenomas and advanced adenomas on colonoscopy.

BACKGROUND: Smoking is linked with numerous adverse health effects. Nicotine staining on fingers or teeth is thought to suggest active or heavy smoking. The significance of nicotine staining within gastroenterology remains unclear. AIM: We set out to establish the predictive value of nicotine staining for adenomas and advanced adenomas. METHODS: This was a cross-section study of patients who underwent colonoscopy at the Oklahoma City Veterans Affairs Medical Center from November 2019 to November 2020. Pre-procedure patient survey ascertained current smoking status. Endoscopist performed a nicotine staining survey upon completion of the respective colonoscopy. Chart review allowed determination of patient demographics, comorbidities, and colonoscopy findings. Patients without smoking history were assigned to a control cohort. We applied one-way analysis of variance when comparing the mean of continuous variables and the Chi-square test when comparing categorical variables. Lastly, we used stepwise logistic regression to estimate adjusted odds ratio. A p-value <0.05 was considered statistically significant. RESULTS: Compared to those without smoking history or evidence of nicotine staining, patients with positive nicotine staining were older (P = 0.03), leaner (P < 0.0001), and more likely to have chronic obstructive pulmonary disease (P < 0.0001) or history of alcohol abuse (P < 0.0001). Furthermore, presence of nicotine staining independently predicted increased likelihood of multiple adenomas (OR 1.5, 95% CI [1.2-1.9]) and advanced adenomas (OR 1.6, 95% CI [1.2-2.2]). CONCLUSION: This marks the first investigation of nicotine staining within gastroenterology. We have demonstrated that the presence of nicotine staining independently predicts numerous adenomas and advanced adenomas.

Potential Cost Savings in Medicare Part D Across Gastroenterology: An Assessment of Alternative Drug Sourcing.

INTRODUCTION: Until recently, the Centers of Medicare and Medicaid were restricted from negotiating drug cost. We assessed the potential impact of alternative drug sourcing models on Medicare Part D spending. METHODS: Twenty-seven drugs were extracted from 2021 Medicare Part D claims. Drug-specific/total spending was compared against cost at Mark Cuban Cost Plus Drugs Company, Costco Member Prescription Program, and Veterans Health Administration price point. RESULTS: Potential Part D savings were $798.99 million, $573.84 million, and $1.02 billion (Mark Cuban Cost Plus Drugs Company, Costco Member Prescription Program, and Veterans Health Administration, respectively). DISCUSSION: Disproportionate Part D spending likely reflects less competitive acquisition cost. Provider awareness of medications with advantaged price may promote targeted prescribing with potentially tremendous health care savings.

Factors Associated with Difficulty Maintaining Insufflation of the Colon During Endoscopy.

BACKGROUND: Insufflation of the colon allows for adequate visualization of the mucosal tissue and advancement of the endoscope during colonoscopy. Most colonoscopies are performed with sedation to mitigate discomfort and enhance the colonoscopy experience for both the patient and the endoscopist. AIM: We aimed to evaluate factors associated with difficulty maintaining insufflation. METHODS: A cross-sectional study of individuals undergoing colonoscopy at the Oklahoma City Veterans Affairs Medical Center was performed. Experiencing difficulty maintaining air insufflation during colonoscopy was assessed with a questionnaire completed by the performing endoscopist at the end of procedure. Information regarding procedure times, sedation used, demographics, comorbidities, surgical history, and medications used was extracted from the medical record. A multivariate regression analysis was performed to identify factors associated with difficulty maintaining air insufflation. A P value < 0.05 was considered significant. RESULTS: 996 Patients were included for the analysis. Difficulty with insufflation was reported in 240 (24%) colonoscopies; mean age of 63.8 ± 10.4 years old and 13% were female. Fellow trainees were involved in 669 (67%) colonoscopies. Older age (OR 1.02, P 0.03, CI [1.00-1.04]), diabetes (OR 1.5, 95% CI [1.03, 2.05]), fellow's involvement (OR 2.6. (95% CI [1.68, 4.09]), total procedure time (OR 1.02, 95% CI [1.00, 1.03]), mean number of adenomas (OR 1.05, 95% CI [1.00, 1.09]), and MAC use (OR 2.6, 95% CI [1.80, 3.85]) were independent predictors for difficulty in maintaining air insufflation. CONCLUSION: Our findings suggest that endoscopists should be cognizant of colon insufflation issues in older, diabetic patients undergoing colonoscopies under deep sedation, particularly if prolonged procedure is anticipated or encountered.

Empirical Dilation of Non-obstructive Dysphagia: Current Understanding and Future Directions.

Non-obstructive dysphagia (NOD) is defined as symptomatic dysphagia in patients with negative endoscopic and radiographic workup. The management of NOD remains controversial as there is a discrepancy between different guidelines and clinical practice. Despite the lack of high-quality studies, empiric dilation for NOD is a common clinical practice among endoscopists and the approach varies between different clinical centers. In this review, we summarize the published literature on empiric dilation for NOD and propose a management algorithm for offering empiric dilation to patients presenting with dysphagia.

Oral sulfate solution versus low-volume polyethylene glycol for bowel preparation: Meta-analysis of randomized controlled trials.

BACKGROUND AND AIMS: Oral sodium sulfate (OSS) solution and low-volume polyethylene glycol-based solutions are two of the more common low-volume purgatives used as colonoscopy preparations. Data on how these different low-volume solutions compare are mixed. Our aim was to conduct a meta-analysis of randomized controlled trials (RCTs) to compare OSS with low-volume polyethylene glycol solutions (PEG) plus ascorbic acid (PEG + Asc) solution with respect to (i) satisfactory bowel preparation, (ii) excellent bowel preparation, and (iii) tolerability. METHODS: Studies were identified by searching 10 medical databases for reports published from 1974 until 2019. Only fully published RCTs comparing OSS and low-volume PEG-based products with regard to overall satisfactory bowel preparation were included. Pooling was conducted by both fixed-effects and random effects models; results are presented from the random effects model when heterogeneity was significant. RESULTS: Seven studies (involving 2049 subjects) met the inclusion criteria. There was no difference between OSS and PEG + Asc with respect to adequate bowel preparation (risk ratio [RR] 1.02 [0.99-1.06]; P = 0.16). OSS did result in a higher chance of excellent bowel preparation (RR 1.18 [1.06-1.31]; P = 0.03). OSS was associated with a 30% increased risk of nausea (RR 1.35 [1.03-1.77]; P = 0.03) and more than double the risk of vomiting (RR 2.30 [1.63-2.23]; P < 0.05) compared with PEG + Asc. Begg's funnel plot indicated low probability of publication bias. CONCLUSIONS: Individuals at low risk of inadequate bowel preparation who use OSS for bowel preparation are more likely to achieve excellent bowel preparation, but are more likely to experience nausea and vomiting than are individuals using low-volume PEG-based solutions.

The Mystery of Episodic Recurrent Jaundice in a Young Male: Cholestasis With a Normal Gamma-Glutamyl Transferase.

Benign recurrent intrahepatic cholestasis (BRIC) is a very rare autosomal recessive genetic disorder which presents with recurrent jaundice. We report the case of a young male with a history of methamphetamine use who presented with recurrent episodes of right upper quadrant abdominal pain, vomiting, dark urine, and pale stools. These symptoms always resolved within four weeks of presentation. During these episodes, the patient had a cholestatic pattern derangement of liver function tests with a normal gamma-glutamyl transferase (GGT). Workup for abnormal transaminases was unremarkable. A percutaneous liver biopsy obtained on the third visit was notable for a parenchymal lobule that exhibited slight Kupffer cell hyperplasia and subtle evidence of canalicular cholestasis. There was no evidence of cirrhosis, steatosis, hepatitis, or malignancy. Thus, a diagnosis of BRIC was made, and the patient was managed conservatively. Recognition of this rare entity is critical since its benign natural history is reassuring for the patient, and physicians can refrain from repetitive expansive and costly workups.

Straight leg raise metrics on high-resolution manometry associate with esophageal reflux burden.

BACKGROUND: Straight leg raise (SLR) is a provocative maneuver that assesses esophagogastric junction (EGJ) barrier function during high-resolution manometry (HRM). We evaluated the value of SLR in symptomatic reflux patients undergoing ambulatory reflux monitoring. METHODS: Adult patients being evaluated for reflux symptoms with esophageal physiologic testing off antisecretory therapy over a 12 month period were studied. Demographics, clinical presentation, HRM studies, and reflux monitoring studies were analyzed. Intra-abdominal and intra-esophageal pressures were extracted at baseline and during SLR from HRM studies. Acid exposure time (AET) was derived from reflux monitoring studies, and EGJ morphology and tone from HRM studies. SLR pressure metrics predicting abnormal AET were evaluated. KEY RESULTS: Of 122 patients, 70 (57.4%) had ≥50% peak intra-abdominal pressure increase during SLR (58.0 ± 1.4 years, 75.7% female). Peak intra-esophageal pressure gradient between baseline and SLR predicted pathologic AET when ≥100% (AUC 0.78, sensitivity 71%, specificity 75%, P < .001), seen in 60.7% with AET > 6%, but only 23.7% with AET < 4% (P = .01). Peak intra-esophageal pressure gradient ≥100% was most discriminative in identifying abnormal acid burden in type 1 EGJ morphology (P = .005) but trended toward significance in type 2 and type 3 morphology (P = .1). Normal and abnormal EGJ contractile integral did not associate with peak intra-esophageal pressure gradient either collectively or when subdivided by EGJ morphology (P ≥ .2). CONCLUSIONS & INFERENCES: Analysis of intra-esophageal pressure gradients during SLR, a simple HRM maneuver, may augment evaluation of symptomatic GERD, and provide adjunctive evidence supporting GERD.

Smart Phone/Device Application to Improve Delivery of Enteral Nutrition in Adult Patients Admitted to the Medical Intensive Care Unit.

BACKGROUND: Resident physicians are frequently uncomfortable ordering enteral nutrition (EN) and are unaware of the variety of formulas and supplements available for different disease processes. Many depend on a clinical dietician to assist with recommending EN formulas and patient energy requirements that may not be readily available on patient admission. This creates a barrier to early initiation of EN and non-compliance with Society of Critical Care Medicine and American Society of Parenteral and Enteral Nutrition clinical guidelines. OBJECTIVE: Internal medicine resident physicians were provided an iPod with a smart phone/device application (EN application) to assist them in choosing EN formulas for patients during their intensive care unit (ICU) rotation. The primary outcome was improved initiation of EN within 24 hours of admission. Secondary outcomes included the following: time to initiate EN, goal calories reached, infections rates, length of stay, mortality, and concordance with clinical guidelines. DESIGN: The study is a quasi-experimental design to improve delivery of EN at an academic medical center in the medical ICU. Data were collected from a retrospective chart review to evaluate the impact of an EN application to assist resident physicians when ordering EN. RESULTS: Use of the EN application reduced the percent of patients with delayed initiation of EN from 61.2% prior to 37.5% (P < .01). The mean time to initiate EN also improved 44.5 vs 31.9 hours (P < .01). Patients were also more likely to achieve their daily caloric goal (P < .01). CONCLUSION: The use of an EN application to assist internal medicine residents when ordering EN reduced delays in initiation of EN and improved overall delivery of EN to medical ICU patients.

Hepatocellular Carcinoma Occurrence and Recurrence in Hepatitis C-infected Patients Treated with Direct-acting Antivirals.

Introduction Multiple studies have shown the efficacy of the new direct-acting antivirals (DAAs) with a cure rate of over 90% in hepatitis C virus (HCV)-infected patients. Some recently published studies have suggested an increased incidence of de novo and recurrent hepatocellular carcinoma (HCC) in cirrhotic patients in sustained virological response (SVR) after completing therapy. A possible mechanism is the breakdown of immune surveillance after starting DAAs. We report a retrospective analysis on a population of chronic HCV infected patients, with and without a prior history of HCC, who developed HCC after receiving DAAs in the hope of adding to existing literature and in pursuit of greater clarity into this emerging concern with DAAs. Methods We analyzed 497 HCV-infected patients who were treated with DAAs, or a combination of DAA with interferon, from January 2014 to April 2017 at the Veterans Medical Center, Oklahoma City. Descriptive analysis, including the mean and standard deviation for different variables, was used. The cohort was divided into two groups: cirrhotic and non-cirrhotic. The analysis was run in the cirrhotic group between the subgroups who developed HCC and who did not. Results Data from a total of 233 cirrhotic patients were analyzed. We further subdivided these patients into those who eventually were diagnosed with HCC (group 1) and those who were not (group 2). These subgroups were comparable in regards to race, gender, baseline serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), platelets, sodium, HCV genotypes, and pretreatment viral load. All patients completed therapy. The rate of SVR was much lower in group 1 compared to group 2 (62.5% vs 88.94%, p = 0.002), respectively. Model End-stage Liver Disease (MELD) score, Child-Turcotte-Pugh (CTP) score, and Fibrosis-4 (FIB-4) score were higher in the group that developed HCC. The average time period (weeks) from DAA therapy to HCC diagnosis was 48.2 weeks. The remaining 264 non-cirrhotic patients had no reported cases of HCC. Conclusion From a total of 497 treated HCV-infected patients, 233 (46.88 %) had cirrhosis, out of which 16 (6.86%) were reported to develop HCC during or after DAA therapy was initiated. The remaining 217 (93.1%) cirrhotic patients did not develop HCC. As per our comparison, achieving SVR in cirrhotic patients should not preclude HCC screening, and more studies are needed to assess the risk of HCC in patients who achieve SVR but have a high FIB-4 score. In fact, patients who do not achieve SVR may be at a higher risk of eventually developing HCC and may be candidates for closer surveillance.

Immunization Against Hepatitis A Virus and Hepatitis B Virus in Patients with Chronic Liver Disease: Are We Doing a Good Job?

INTRODUCTION: In the era of highly effective vaccines for Hepatitis A Virus (HAV) and Hepatitis B Virus (HBV), acute viral hepatitis in patients with a chronic liver disease remains a public health concern. Vaccination for HAV and HBV is endorsed by all liver society guidelines. The aim of our study was to determine the rates of immunization in an internal medicine resident clinic. METHODS: We identified patients with a chronic liver disease seen at the University of Oklahoma Internal Medicine resident clinic between June 2014 and May 2015. ICD-9 code 571 was used to identify patients with a chronic liver disease. Vaccination records and patient data were reviewed. RESULTS: A total of 141 patients with a chronic liver disease (mean age 54.1 years, 56% males) were identified. Almost half of the patients (47.5%) were also being seen in the gastroenterology clinic. During the internal medicine resident clinic visit, vaccination against HAV and HBV was addressed for 50% and 46% of the patients, respectively. Patients being seen by senior residents were more likely to be immunized against HAV (OR 2.7, p=0.009) and HBV (OR 2.1, p=0.03). Patients followed in the GI clinic were more likely to be immunized against HAV (OR 2.1, p= 0.02) and HBV (OR 2.0, p=0.02). The gender of the treating physician and etiology had no impact on vaccination rates. DISCUSSION: Immunization rates for HAV and HBV remain subpar despite clear guidelines for patients with a chronic liver disease. This provides an important avenue for improvement. Different strategies, including resident education, developing vaccination protocols, and referral to the gastroenterology clinic, are likely to improve vaccination status for patients with chronic liver diseases.

Strongyloides Hyperinfection in a Renal Transplant Patient: Always Be on the Lookout.

We present a case of a 71-year-old Vietnamese man with chronic kidney disease secondary to adult polycystic kidney disease. He had been a prisoner of war before undergoing a successful cadaveric renal transplant in the United States. He presented to clinic one year after the transplant with gross hematuria, productive cough, intermittent chills, and weight loss. Long standing peripheral eosinophilia of 600-1200/µL triggered further evaluation. A wet mount of stool revealed Strongyloides stercoralis larvae. A computed tomography (CT) of chest showed findings suggestive of extension of the infection to the lungs. The patient was treated with a three-week course of ivermectin with complete resolution of signs, symptoms, peripheral eosinophilia, and the positive IgG serology. Strongyloides infection in renal transplant patient is very rare and often presents with hyperinfection, associated with high mortality rates. The American Transplant Society recommends pretransplant screening with stool examination and Strongyloides stercoralis antibody in recipients and donors from endemic areas or with eosinophilia. It is imperative that healthcare professionals involved in the care of these individuals be cognizant of these recommendations as it is a very preventable and treatable entity.

Mystery of hepatitis e virus: recent advances in its diagnosis and management.

Mysterious aspects of the long presumed to be well-known hepatitis E virus (HEV) have recently surfaced that distinguish it from other hepatotropic viruses. It is a cause of chronic hepatitis in immunosuppressed patients. It has human to human transmission through blood and mantains high seroprevalence in blood donors. HEV has also been found to occur more frequently in the West in those without a history of travel to endemic countries. It has varied extrahepatic manifestations and has multiple non-human reservoirs including pigs and rats. Considering these recent discoveries, it appears odd that HEV is not sought more frequently when working up acute and chronic hepatitis patients. The disease is particularly severe among pregnant women and has a high attack rate in young adults. What adds to its ambiguity is the absence of a well-established diagnostic criteria for its detection and that there is no specific antiviral drug for hepatitis E, except for isolated cases where ribavirin or pegylated interferon alpha has been used with occasional success. This review paper discusses the recent advances in the knowledge of the virus itself, its epidemiology, diagnostic approach and prevention, and the treatment options available.

Posterior reversible leukoencephalopathy syndrome secondary to hepatic transarterial chemoembolization with doxorubicin drug eluting beads.

Posterior reversible encephalopathy syndrome (PRES) is a rare complication of transarterial chemoembolization (TACE) used to treat liver metastases and has never been reported in a patient with metastatic uveal melanoma (UM) to the liver. We report the first case of PRES secondary to TACE with drug eluting beads (DEBs) loaded with doxorubicin in a 56-year-old woman with metastatic UM to the liver.

Intramural Duodenal Hematoma with Acute Pancreatitis in a Patient With an Overt Pancreatic Malignancy.

Intramural hematomas have rarely been associated with pancreatitis, and to date there is only 1 case report of an intramural hematoma occurring with pancreatic adenocarcinoma. We describe a patient who presented with gastric outlet obstruction secondary to a spontaneous intramural duodenal hematoma and was found to have a pancreatic adenocarcinoma on endoscopic ultrasound (EUS) after it was not visualized by computed tomography (CT).