Novel non-injection non-tunnel technique for peroral endoscopic myotomy of Zenker's diverticulum.

Video 1.

Symptoms associated with healthcare resource utilization in the setting of inflammatory bowel disease.

Several symptoms have been connected to increased healthcare resource utilization (HRU) in the context of inflammatory bowel disease (IBD), including both Crohn's disease (CD) and ulcerative colitis (UC). This study was designed to investigate the prevalence of IBD-associated symptoms and to determine whether any are independently associated with HRU. We undertook a retrospective analysis of data related to consecutive IBD patient encounters from a tertiary care referral center between 1/1/2015 and 8/31/2019. Demographics, clinical activity, endoscopic severity, IBD-related symptom scores, anxiety and depression scores, and other key clinical data were abstracted. Four hundred sixty-seven IBD patients [247f.: 220 m; 315 CD, 142 UC and 11 indeterminate colitis] were included in this study. The most common symptoms were fatigue (83.6%), fecal urgency (68.2%) and abdominal pain (63.5%). Fatigue, abdominal pain, anxiety or depression, corticosteroids, and opioids were each positively associated with HRU, while NSAID and mesalamine use were inversely associated on bivariate analysis. The only factor that demonstrated a statistically significant association with HRU in the whole cohort on multivariable analysis was abdominal pain. Abdominal pain is independently associated with HRU and should be specifically screened for in IBD patients to identify individuals at risk of undergoing expensive interventions. This study also reinforces the importance of optimizing diagnostic and therapeutic management of abdominal pain in IBD.

Colonic Intussusception Secondary to Hereditary Angioedema.

Hereditary angioedema (HAE) is a rare genetic disease with numerous gastrointestinal manifestations. Intussusception, although rare, has been a reported complication with documentation of bowel wall edema on endoscopy during an acute flare. With the advent of synthetic C1 esterase inhibitors, this disease has become more effectively treatable. This case report shows a HAE flare complicated by colonic intussusception, treated with C1 esterase inhibitor, with complete endoscopic resolution seen on hospital day 5. This case provides evidence that with proper medical treatment, an HAE flare with intussusception has the potential to resolve without any further need for surgical or endoscopic intervention.

Abdominal pain in quiescent inflammatory bowel disease.

OBJECTIVES: Inflammation is an important driver of abdominal pain in inflammatory bowel disease (IBD). However, some patients in remission still experience pain. We aimed to identify risk factors associated with abdominal pain in quiescent IBD (QP-IBD) and to characterize differences from patients with active disease experiencing pain (AP-IBD). METHODS: We performed a retrospective analysis utilizing data from our institution's IBD Natural History Registry (January 1, 2015-August 31, 2018). Endoscopic evaluation, concurrent laboratory studies, and validated surveys were completed by participants. Demographic and clinical data were also abstracted. RESULTS: We recruited 122 patients with quiescent disease (65f:57 m; 93CD:26UC:3Indeterminate) for participation in this study, 74 (60.7%) had QP-IBD. QP-IBD patients were more likely to have anxiety/depression (71.6% vs. 25.0%, p < 0.001) or to use antidepressants (47.3% vs. 22.9%, p < 0.010), opiates (18.9% vs. 2.1%, p < 0.010), other pain medications (50.0% vs. 18.8%, p < 0.010), or corticosteroids (18.9% vs. 2.1%, p < 0.010). On logistic regression analysis, corticosteroid use, anxious/depressed state, and female gender were each independently associated with QP-IBD (p < 0.050 or less). Compared with AP-IBD patients (n = 110, 59f:51 m; 69CD:38UC:3Indeterminate), QP-IBD patients were more likely to use antidepressants (45.6% vs. 26.4%, p < 0.010). Platelet, white blood cell, C-reactive protein, and sedimentation rate levels were all less likely to be elevated in QP-IBD (all p < 0.050), though 44% exhibited pathological elevation in at least one. DISCUSSION: QP-IBD was independently associated with corticosteroid use, anxiety/depression, and female gender. Compared with AP-IBD, QP-IBD patients were more likely to use antidepressants and less likely to exhibit elevated inflammatory markers. However, many QP-IBD patients still demonstrated pathological elevation of these tests, demonstrating the need to develop new noninvasive screening methods for this condition.

Dysplasia detection is similar between chromoendoscopy and high-definition white-light colonoscopy in inflammatory bowel disease patients: a US-matched case-control study.

INTRODUCTION: Inflammatory bowel disease (IBD) patients are at greater risk of developing colorectal cancer (CRC). Detection of precursor dysplasia is important for cancer prevention. Recent guidelines recommend dye chromoendoscopy (DCE) as the preferred method for dysplasia detection. Universal adoption of DCE is time-consuming and may limit endoscopy access. The benefit of universal application of the guidelines is unclear. We compared high-definition white-light colonoscopy (HD-WLC) with DCE for dysplasia detection in IBD patients. METHODS: We conducted a retrospective case-control study of adult IBD patients undergoing dysplasia surveillance between September 1, 2015, and February 1, 2020. DCE cases were matched to HD-WLC in a 1:1 ratio for gender, IBD diagnosis, and age. DCE patients were considered high risk for colorectal cancer by the referring provider. RESULTS: A total of 187 subjects were enrolled. Majority were males, were Caucasian, and had longstanding IBD (primarily ulcerative colitis). Baseline characteristics were similar between the two groups, except for history of surgery, duration of IBD, and history of dysplasia. There was no significant difference in dysplasia detection between DCE and HD-WLC (10.2% vs 6.7%, p = 0.39). More polyps were detected in the DCE arm compared with the HD-WLC group (1.35 vs 0.80, p = 0.018), but adenoma detection rate was not statistically different between the two groups (10.2% vs 9.0%, p = 0.31). Mean withdrawal time was longer in the DCE group (24.6 min vs 15.4, p < 0.001). CONCLUSIONS: There were no differences in dysplasia detection using DCE compared with HD-WLC, although withdrawal times were longer with DCE.

Abdominal Pain and Anxious or Depressed State Are Independently Associated With Weight Loss in Inflammatory Bowel Disease.

BACKGROUND: Many factors impact nutritional status in inflammatory bowel disease (IBD). We undertook this study to evaluate the potential role that abdominal pain has on weight loss and dietary behavior in IBD. METHODS: This is a retrospective cohort study utilizing data from an IBD registry at our institution between January 1, 2015 and August 31, 2018. Pain scores and nutritional outcomes were derived from validated questionnaires while key associated clinical data were derived from the medical record. RESULTS: Three hundred and three patients (154 females; 206 Crohn's disease) were included in this study. Ninety-six patients (31.7%) had experienced a 6-lb or greater weight loss in the prior month. On multivariate analysis, abdominal pain and anxious/depressed state were independently associated with weight loss, while female gender and NSAID use were inversely associated with weight loss (P < 0.05). IBD patients with abdominal pain also reported significantly poorer dietary behavior than those without this symptom. CONCLUSIONS: Abdominal pain is more likely to result in negative dietary outcomes and independently associated with weight loss in IBD. IBD providers should screen for malnutrition when patients report abdominal pain.

Efficacy and safety of over-the-scope clips for gastrointestinal bleeding: a systematic review and meta-analysis.

BACKGROUND: The over-the-scope clip (OTSC) has been increasingly utilized for the management of gastrointestinal (GI) bleeding. Limited efficacy data are currently available from large-scale studies. METHODS: An electronic database search was conducted for eligible articles using OTSCs for hemostasis in GI bleeding. The primary outcome was the rate of definitive hemostasis after primary hemostasis and without rebleeding at follow-up. Secondary outcomes were: primary technical success, primary clinical success, rebleeding, and failure rates. Pooled rates were expressed as proportions of patients with events over total patients, 95 % confidence limits (CI) with heterogeneity, and P values of < 0.05 for significance. RESULTS: A total of 21 studies (n = 851) were analyzed (62.2 % males), with a median patient age of 69.7 years. The definitive hemostasis rate was 87.8 % (95 %CI 83.7 % - 92 %) after a median follow-up of 56 days. The OTSC was successfully deployed in 97.8 % of patients (95 %CI 96.7 % - 98.9 %) and the primary clinical success rate was 96.6 % (95 %CI 95.1 % - 98.2 %). Rebleeding was seen in 10.3 % of patients (95 %CI 6.5 % - 14.1 %). The failure rate of OTSCs was 9 % (95 %CI 5.2 % - 12.8 %) when used as first-line treatment and 26 % (95 %CI 16.1 % - 36.0 %) when used as second-line treatment. CONCLUSION: This systematic review showed high rates of definitive hemostasis, technical success, and clinical success, along with low rebleeding rates when OTSCs were used for the treatment of GI bleeding. The lack of randomized controlled trials of OTSC vs. other therapies makes comparison with conventional treatment difficult.

Hot snare vs. cold snare polypectomy for endoscopic removal of 4 - 10 mm colorectal polyps during colonoscopy: a systematic review and meta-analysis of randomized controlled studies.

Introduction In recent years, cold snare polypectomy (CSP) has increasingly been used over hot snare polypectomy (HSP) for the removal of colorectal polyps (4 - 10 mm in size). However, the optimal technique (CSP vs. HSP), in terms of complete polyp resection and complications, is uncertain. Our aim was to compare incomplete resection rate (IRR) of polyps and complications using CSP vs. HSP. Methods Randomized controlled studies (RCTs) comparing CSP and HSP for removal of 4 - 10 mm colorectal polyps were considered. Studies were included in the analysis if they obtained biopsy specimens from the resection margin to confirm the absence of residual tissue and reported complications. IRR and complication rate were the outcome measures. Pooled rates were reported as Odds Ratios (OR) or risk difference with 95 % Confidence Interval (CI). Results In total, three RCTs were included in the final analysis. A total of 1051 patients with 1485 polyps were randomized to either HSP group (n = 741 polyps) or CSP group (n = 744 polyps). The overall IRR did not differ between the two groups (HSP vs. CSP: 2.4 % vs. 4.7 %; OR 0.51, 95 %CI 0.13 - 1.99, P  = 0.33, I 2  = 73 %). The HSP group had a lower rate of overall complications compared to the CSP group (3.7 % vs. 6.6 %; OR 0.53, 95 % CI 0.3 - 0.94, P  = 0.03, I 2  = 0 %). Polyp retrieval rates were not different between the two groups (99 % vs. 98.1 %). Conclusion Our results suggest that HSP and CSP techniques can be effectively used for the complete removal of 4 - 10 mm colorectal polyps; however, HSP has a lower incidence of overall complications.

Significantly lower annual rates of neoplastic progression in short- compared to long-segment non-dysplastic Barrett's esophagus: a systematic review and meta-analysis.

BACKGROUND: Although shorter lengths of Barrett's esophagus (BE) have been associated with a lower risk of neoplastic progression, precise estimates have varied, especially for non-dysplastic BE (NDBE) only. Therefore, current US guidelines do not provide specific recommendations on surveillance intervals based on BE length. We performed a systematic review and meta-analysis of the published literature to examine neoplastic progression rates of NDBE based on BE length. METHODS: PubMed, Cochrane, Google Scholar, and Embase were comprehensively searched. Studies reporting progression rates in patients with NDBE and > 1 year of follow-up were included. The number of patients progressing to esophageal adenocarcinoma (EAC) and high grade dysplasia (HGD)/EAC in individual studies and the mean follow-up were recorded to derive person-years of follow-up. Pooled rates of progression to EAC and HGD/EAC based on BE length (< 3 cm vs. ≥ 3 cm) were calculated. RESULTS: Of the 486 initial studies identified, 10 met the inclusion/exclusion criteria. These included a total of 4097 NDBE patients; 1979 with short-segment BE (SSBE; 10 773 person-years of follow-up) and 2118 with long-segment BE (LSBE; 12 868 person-years). The annual rates of progression to EAC were significantly lower for SSBE compared with LSBE: 0.06 % (95 % confidence interval 0.01 % - 0.10 %) vs. 0.31 % (0.21 % - 0.40 %), respectively; odds ratio (OR) 0.25 (0.11 - 0.56); P < 0.001, as were the rates for the combined endpoint (HGD/EAC): 0.24 % (0.09 % - 0.32 %) vs. 0.76 % (0.43 % - 0.89 %), respectively; OR 0.35 (0.21 - 0.58); P < 0.001. There was no significant heterogeneity among studies. CONCLUSION: The results demonstrate significantly lower rates of neoplastic progression in NDBE patients with SSBE compared with LSBE. BE length can easily be used for risk stratification purposes for NDBE patients undergoing surveillance endoscopy and consideration should be given to tailoring surveillance intervals based on BE length in future US guidelines.

Increasing adenoma detection rates in the right side of the colon comparing retroflexion with a second forward view: a systematic review.

BACKGROUND AND AIMS: Right-sided lesions are often missed during standard colonoscopy (SC). A second forward-view examination or retroflexion in the right side of the colon have both been proposed as techniques to improve adenoma detection rate (ADR) in the right side of the colon. Comparative data on examining the right side of the colon with a second forward view or retroflexion is not known in a pooled analysis. We performed a systematic review of the literature to assess the yield of a second forward view compared with retroflexion examination for the detection of right-sided adenomas. METHODS: A systematic literature search was performed using the following databases: PubMed, Embase, Web of Science, and Cochrane. Only full-length published articles that provided information on adenoma detection and miss rates during either a second forward view or retroflexed view of the right side of the colon after the initial standard forward withdrawal (SC) were included. The following outcomes were assessed: comparison of adenoma miss rate (AMR) for second forward view versus retroflexion after SC, AMR of SC compared with second forward view, AMR of SC compared with retroflexion, and right-sided adenoma detection with second forward view and retroflexion. Pooled rates were reported as risk difference or odds ratios (OR) with 95% confidence intervals (CI) with a P value <.05 indicating statistical significance. Statistical analysis was performed with Review Manager v5.3. RESULTS: We identified 4 studies with 1882 patients who underwent a second forward view of the right side of the colon after an initial SC. The average age of the patients was 58.3 years. Data on right-sided ADR were available from all 4 studies for the second forward view; however, only 2 of the studies provided information on right-sided ADR with retroflexion. The pooled estimate of AMR of a single SC was 13.3% (95% CI, 6.6%-20%) compared with a second forward-view examination (n = 4), whereas it was 8.1% (3.7%-12.5%) compared with a retroflexion examination (n = 3). However, when the second forward view was compared with retroflexion in terms of AMR from an analysis of 3 eligible studies, there was no statistically significant difference (7.3% vs 6.3%; pooled OR, 1.2; 95% CI, 0.9-1.61; P = .21). Second forward view of the right side of the colon increased the right-sided ADR by 10% (n = 4; second forward view vs SC, 33.6% vs 26.7%) with a pooled risk difference of 0.09 (95% CI, 0.03-0.15; P < .01). Retroflexion increased the right-sided ADR by 6% (n = 3; retroflexion vs SC, 28.4% vs 22.7%) with a pooled risk difference of 0.06 (95% CI, 0.03-0.09; P < 01). CONCLUSION: After SC withdrawal, a second forward view and retroflexed view of the right side of the colon are both associated with improvement in ADR. One of these techniques should be considered during SC to increase ADR and to improve the quality of colonoscopy.

Anxiety, depression, and inflammation after restorative proctocolectomy.

PURPOSE: Anxiety and depression (A&D) are more common in inflammatory bowel disease (IBD) and in IBD patients who undergo proctocolectomy with ileal pouch-anal anastomosis (IPAA). Our aim was to test the hypothesis that chronic inflammatory conditions in IPAA are associated with increased incidence of A&D. METHODS: Retrospective cohort study at a single tertiary care referral center using a consented IBD and colon cancer natural history registry. Demographic and clinical factors, including surgical and psychiatric history, were abstracted. RESULTS: We compared A&D rate in three cohorts: (1) ulcerative proctocolitis with IPAA (UC) (n = 353), (2) Crohn's disease/indeterminate proctocolitis with IPAA (CDIC) (n = 49), and (3) familial adenomatous polyposis with IPAA (FAP) (n = 33). Forty-six CDIC patients (93.9%) demonstrated pouch-related inflammation, while 126 UC patients (35.7%) and 2 FAP patients (6.1%) developed pouchitis. CDIC had a higher rate of A&D co-diagnosis compared to UC and FAP (20.4 vs.12.7 vs.12.1% respectively; p < 0.05). UC patients with pouchitis also exhibited a higher rate of A&D than UC without pouchitis (19.8 vs.8.8%; p < 0.05). Multivariable analysis demonstrated that pre-operative corticosteroid use (OR = 4.46, CI = 1.34-14.87, p < 0.05), female gender (OR = 2.19, CI = 1.22-3.95, p < 0.01), tobacco use (OR = 2.92, CI = 1.57 = 5.41, p < 0.001), and pouch inflammation (OR = 2.37, CI = 1.28-4.39, p < 0.05) were each independently associated with A&D in these patients. CONCLUSIONS: Anxiety and depression were more common in patients experiencing inflammatory conditions of the pouch. UC without pouchitis and FAP patients demonstrated lower rates of A&D (that were comparable to the general population), implying that having an IPAA alone was not enough to increase risk for A&D. Factors independently associated with A&D in IPAA included an inflamed pouch, corticosteroid use, smoking, and female gender.

Smoking and the Risk of Pouchitis in Ulcerative Colitis Patients With Ileal Pouch-Anal Anastomosis.

BACKGROUND: Ulcerative colitis (UC) patients who undergo proctocolectomy with ileal pouch-anal anastomosis (IPAA) may develop pouchitis, a poorly understood inflammatory condition. There is controversy over whether tobacco use can protect against pouchitis. We undertook this investigation to further evaluate whether smoking reduces the risk of developing pouchitis and to determine whether other previously associated clinical factors change the risk for pouchitis. METHODS: We performed a retrospective analysis using a consented inflammatory bowel disease (IBD) natural history registry between the years 1995-2015 from a single tertiary care referral center. Demographic data, medical history, surgical information, medication use, laboratory data, and smoking history were abstracted. Former smokers had quit for at least 1 year. The primary end point was development of pouchitis. RESULTS: Of the 353 UC patients with IPAA in this study, 126 (35.6%) developed pouchitis. Prior tobacco use (P < 0.0001) was more common in patients who developed pouchitis. Former and active smokers were more likely to develop pouchitis compared with those without a history of tobacco use (63.4% vs 27.3% respectively, P < 0.001). There was no significant difference in active smoking rate between those without pouchitis and the group that did develop pouchitis. Multivariate analysis demonstrated that the only independent risk factor associated with pouchitis was a history of tobacco use. CONCLUSIONS: These results suggest that smoking cessation may increase the likelihood of developing pouchitis in tobacco users with UC and IPAA, but active smoking does not seem to be more effective in preventing this condition.

Influences and Impact of Anxiety and Depression in the Setting of Inflammatory Bowel Disease.

Background: Individuals with inflammatory bowel disease (IBD) are at increased risk of developing anxiety or depression (A&D). Crohn's disease (CD) and ulcerative colitis (UC) with comorbid A&D are both more challenging to manage. IBD providers need to better understand the causes and impact of A&D in order to improve care for IBD patients. We sought to identify clinical factors that influence development of A&D and healthcare utilization in IBD. Methods: This is a retrospective analysis using an IBD natural history registry from a single tertiary care referral center. Presence of A&D was determined based upon responses to the Hospital Anxiety and Depression Scale. Demographic and clinical factors were abstracted to evaluate for significant associations. Results: Four hundred thirty-two IBD patients (132 UC, 256 CD, and 44 indeterminate colitis) were included in this study. One hundred ninety-two (44.4%) had anxiety or depression or both, and most were female (59.4%, P < 0.05). History of surgery (P < 0.05), female gender (P < 0.05), smoking (P < 0.05), and extra-intestinal manifestations (P < 0.01) were each independently predictive of A&D. Inflammatory bowel disease patients with A&D more often underwent imaging studies (53.6% vs 36.7%, P < 0.05), visited the ED (30.7% vs 20.8%, P < 0.05), or were hospitalized (31.7% vs 21.7%, P < 0.05). They were also more frequently prescribed corticosteroids (50.5% vs 36.7%, P < 0.01) and biologic medications (62.5% vs 51.3%, P < 0.05). Finally, they were more likely to have had at least 1 "no-show" (29.2% vs 16.7%, P < 0.01) and had a higher mean number of "no-shows" (0.69 +/- 0.1 vs 0.30 +/- 0.1, P < 0.01) over the study period. Discussion: Anxiety and depression are common in the setting of IBD and are strongly associated with surgical history, disease complications (including extra-intestinal manifestations), smoking, and female gender. Inflammatory bowel disease patients with A&D are also more likely to require therapy and to utilize healthcare resources. This study refines our understanding of A&D development and its impact in IBD and provides additional considerations for management in this setting.

Neoterminal Ileal Polyposis and Ulceration after Restorative Proctocolectomy with a Current Review of the Literature.

After ileal pouch anal anastomosis, one of the frequently encountered complications is polyposis of the pouch. We describe a case of proximal neoterminal ileal polyposis associated with deep ulceration suggestive of Crohn's disease and review the available literature. A 36-year-old male presented with resistant pouchitis 11 years after surgery for ulcerative colitis. With all-negative initial workup, pouchoscopy showed multiple deep ulcers in the proximal ileum with some polyps. Biopsy of polyps showed inflammatory polyps with negative immunohistological staining for IgG pouchitis. With no treatable etiology for pouchitis and the presence of inflammatory polyps, there are no guidelines for surveillance of this condition. Definitive diagnosis is challenging and there is no consensus or recommended guidelines on the management.

How Should We Report Endoscopic Results in Patient's with Barrett's Esophagus?

Barrett's esophagus is the only known pre-cancerous lesion for esophageal adenocarcinoma and is diagnosed by high-definition white light endoscopy demonstrating a columnar-lined esophagus along with biopsy evidence of intestinal metaplasia. With accurate performance and reporting of the endoscopic procedure, an evidence-based management strategy can be developed for treatment of Barrett's dysplasia. However, cross-sectional data demonstrate that there is still inconsistency among gastroenterologists in performance and reporting of endoscopic findings in patients with Barrett's esophagus. Here, we present an evidence-based review of how to report endoscopic findings in Barrett's esophagus.

Corrigendum to 'A rare case of fibrostenotic endobronchial tuberculosis of trachea' [Ann. Med. Surg. 4 (2015) 479-482].

[This corrects the article DOI: 10.1016/j.amsu.2015.10.007.].

High Total Bilirubin as a Protective Factor for Diabetes Mellitus: An Analysis of NHANES Data From 1999 - 2006.

BACKGROUND: Diabetes Mellitus (DM) is a rampantly growing epidemic in the United States, affecting nearly 10% of the adult population. Studies have shown that higher levels of Total Bilirubin (TBili) convey a protective effect with regard to cardiovascular risk. In this study, we will examine the relationship between TBili level and prevalence of DM to discern whether a similar relationship exists. METHODS: The National Health and Nutrition Examination Survey (NHANES) is a comprehensive survey performed regularly to evaluate the overall health and nutrition status of the United States population. For the purpose of this study, we combined NHANES data collected between 1999 and 2006. Totally 15,876 eligible participants were selected after excluding all patients younger than twenty years, those with a history of abnormal liver function tests, or those who disclosed a history of liver disease. The data collected on these individuals was adjusted for demographic characteristics, as well as risk factors for DM, and was analyzed via multivariate logistic regression, using SAS proc survey methodology. RESULTS: After age adjustment, increased TBili was associated with 26% reduction in diabetes risk (OR 0.74, 95% CI 0.64 - 0.88). Multivariate analysis, adjusting for all diabetes risk factors assessed, confirmed this association (OR 0.80, 95% CI 0.67 - 0.95). CONCLUSIONS: Our results show that a higher level of serum TBili is associated with odds of having a lower incidence of DM. This finding supports the hypothesis that the antioxidant nature of TBili, demonstrating a protective effect with regard to the risk of stroke, atherosclerosis, and vasculitis in prior research, also extends to DM risk. Furthermore, research has shown that higher levels of TBili increase glucose mobilization into the cells, leading to more efficient, biologic glucose utilization. There is no doubt that the beneficial effect of TBili is multifactorial; thus further investigation is warranted. KEYWORDS: Bilirubin; Diabetes; Antioxidant; Protective.