Association Between Helicobacter pylori and Steatosis Severity on Transient Elastography.

Background A possible association between Helicobacter pylori (HP) infection and liver diseases including steatosis is suspected. There is a lack of studies evaluating the association of HP and liver steatosis severity using transient elastography. Aim The aim of this study was to evaluate the frequency and risk factors for liver steatosis measured by transient elastography in patients with or without HP. Methods A total of 484 patients tested for liver steatosis and fibrosis using transient elastography from January 2017 to June 2018 were evaluated. Ninety-one patients who were also tested for H. pylori infection were included in the study. Transient elastography findings were compared between HP-positive patients and HP-negative patients. Demographic, clinical, and laboratory variables and the presence and severity of liver fibrosis and steatosis were analyzed. Results Patients with HP had a higher frequency of steatosis on transient elastography (86.8% vs. 60.7%, p =0.009). Patients with HP had increased steatosis severity compared to HP-negative patients (mild steatosis 15.8% vs. 7.1%, p=0.037; moderate to severe steatosis 71.1% vs. 53.6%, p=0.015, respectively). In the stepwise multivariate logistic regression analysis, HP infection remained an independent risk factor for steatosis (odds ratio: 4.36, 95% confidence interval: 1.09-14.78; p=0.037). Conclusion Patients with HP had an increased steatosis frequency, and patients with liver steatosis may warrant HP evaluation and treatment.

Weight Loss and Weight Regain in Usual Clinical Practice: Results From the TARGET-NASH Observational Cohort.

First-line treatment for nonalcoholic fatty liver disease (NAFLD) focuses on weight loss through lifestyle modifications.1,2 Weight loss ≥5% results in reduction of steatosis and weight loss ≥10% has been associated with improvement in hepatic inflammation and fibrosis.3 The incidence and sustainability of weight loss among patients with NAFLD were estimated and associating factors identified.

Esophageal Bronchial Artery Fistulaization: A Complication of an Endobronchial Ultrasound.

Bronchial artery pseudoaneurysms are an extremely rare cause of upper gastrointestinal bleeding. The presence of a bronchial artery pseudoaneurysm resulting in an esophageal fistula is an entity that, to our knowledge, has yet to be described. Successful management requires an interdisciplinary approach to guide closure of the defects. We present a novel case of an esophageal fistula and bronchial artery pseudoaneurysm resulting from an endobronchial ultrasound-guided transbronchial needle aspiration successfully managed by endoscopic therapy and coil embolization.

Barriers to treatment of chronic hepatitis C with direct acting antivirals in an urban clinic.

INTRODUCTION AND AIM: Direct-acting antiviral (DAA) agents are highly effective for treatment of chronic hepatitis C virus (HCV) yet access to treatment remains a serious challenge. The aim of this study was to identify barriers to treatment initiation with DAA-containing regimens in an urban clinic setting. MATERIALS AND METHODS: A retrospective cohort of all chronic HCV patients seen in an urban academic practice in Jacksonville, FL, USA from 1/2014 to 1/2017 was analyzed. Baseline characteristics were recorded and a review of medical records was performed to identify barriers to treatment initiation and overall success rates. RESULTS: Two-hundred and forty patients with chronic HCV were analyzed. Fifty-six percent of patients were African-American and 63% were insured through Medicaid/county programs or uninsured. Sixty-nine percent had barriers to initiating antiviral therapy categorized as psychosocial (n=112), provider (n=26), medical (n=20), and insurance-related factors (n=7). The most commonly encountered psychosocial barriers included failure to keep appointments (79/240, 33%), active substance abuse (18/240, 8%), and failure to obtain laboratory testing (11/240, 5%). Overall, only 27% of patients evaluated were initiated on DAA-containing regimens with 18% reaching SVR12 within the 36-month study period. CONCLUSION: In conclusion, only 27% of patients who presented to an urban academic practice with chronic HCV received DAA-containing regimens over a 36-month period. Psychosocial issues were the major barriers to antiviral therapy. These findings illustrate the need for an integrated approach that addresses psychosocial factors as well as comorbidities and adherence to care in order to increase rates of HCV treatment in at risk patients.

Endocrine Diseases and the Liver: An Update.

The endocrine system is a complex interconnected system of organs that control corporeal processes and function. Primary endocrine organs are involved in hormonal production and secretion but rely on a bevy of signals from the hypothalamic-pituitary axis and secondary endocrine organs, such as the liver. In turn, proper hepatic function is maintained through hormonal signaling. Thus, the endocrine system and liver are codependent, and diseases affecting either organs can lead to alterations in function within their counterparts. This article explores the hepato-endocrine relationship, including the effects on endocrine diseases on the liver.

Safety and efficacy of over-the-scope clip-assisted full thickness resection of duodenal subepithelial tumors: A case report.

BACKGROUND: Over-the-scope clip-assisted endoscopic full thickness resection (eFTR) of subepithelial tumors is a novel and promising endoscopic technique. Recently, there have been prospective studies investigating its use for colonic masses, but data regarding its use and efficacy in the duodenum are limited to a few reports. CASE SUMMARY: A 65-year-old African American female presents for evaluation of persistent gastroesophageal reflux disease not responsive to medical treatment. A 1 cm nodule was incidentally found in the duodenum and biopsies revealed a low grade well differentiated neuroendocrine tumor. The nodule was removed using over-the-scope clip-assisted eFTR and pathology revealed clear margins. We review the available literature with a discussion on the efficacy and safety of clip-assisted eFTR s of subepithelial lesions in the duodenum. CONCLUSION: Clip assisted eFTR appears to be a safe and efficacious treatment approach to duodenal subepithelial lesions. Further prospective studies are needed to investigate the long-term utility and safety of clip-assisted eFTR in the management of subepithelial duodenal lesions.

Comparison of EUS-guided versus percutaneous and transjugular approaches for the performance of liver biopsies.

BACKGROUND: Liver biopsy through endoscopic ultrasound (EUS) has become a novel approach for tissue acquisition. We aim to evaluate the adequacy of EUS-guided liver biopsies in comparison to those obtained through interventional radiology (IR) techniques. METHODS: A retrospective single-center analysis was performed of all IR (transjugular or image-guided percutaneous) and EUS-guided liver biopsies performed at an academic medical center from January 2016 to January 2018. Patient demographics, histologic characteristics, and clinical outcomes were collected. RESULTS: 152 procedures were included for analysis. 45% of liver biopsies were performed through EUS-guidance. The most common indication for liver biopsy was NASH fibrosis staging (n = 64). IR-guided biopsies contained a higher number of complete portal triads (13.6 vs. 10.8 p ≤ 0.01) while EUS-guided biopsies produced an increased total specimen length (4.6 cm vs. 3.6 cm p ≤ 0.01).47% of biopsy samples were fragmented with the majority of these (72%) occurring with EUS-guided procedures (p ≤ 0.01). IR-guided biopsies led to more complications in comparison to EUS-guided procedures (p = 0.03) CONCLUSION: Liver biopsies performed through EUS-guidance are comparable to IR-guided liver biopsies and may have an enhanced safety profile with acceptable tissue acquisition characteristics. Standardization of techniques and needles is needed for optimization of tissue sampling.

Ipilimumab and Nivolumab induced steroid-refractory colitis treated with infliximab: A case report.

BACKGROUND: A variety of immune-modulating drugs are becoming increasingly used for various cancers. Despite increasing indications and improved efficacy, they are often associated with a wide variety of immune mediated adverse events including colitis that may be refractory to conventional therapy. Although these drugs are being more commonly used by Hematologists and Oncologists, there are still many gastroenterologists who are not familiar with the incidence and natural history of gastrointestinal immune-mediated side effects, as well as the role of infliximab in the management of this condition. CASE SUMMARY: We report a case of a 63-year-old male with a history of metastatic renal cell carcinoma who presented to our hospital with severe diarrhea. The patient had received his third combination infusion of the anti-CTLA-4 monoclonal antibody Ipilimumab and the immune checkpoint inhibitor Nivolumab and developed severe watery non-bloody diarrhea the same day. He presented to the hospital where he was found to be severely dehydrated and in acute renal failure. An extensive workup was negative for infectious etiologies and he was initiated on high dose intravenous steroids. However, he continued to worsen. A colonoscopy was performed and revealed no endoscopic evidence of inflammation. Random biopsies for histology were obtained which showed mild colitis, and were negative for Cytomegalovirus and Herpes Simplex Virus. He was diagnosed with severe steroid-refractory colitis induced by Ipilimumab and Nivolumab and was initiated on Infliximab. He responded promptly to it and his diarrhea resolved the next day with progressive resolution of his renal impairment. On follow up his gastrointestinal side symptoms did not recur. CONCLUSION: Given the increasing use of immune therapy in a variety of cancers, it is important for gastroenterologists to be familiar with their gastrointestinal side effects and comfortable with their management, including prescribing infliximab.

Case Series of 10 Patients with Cirrhosis Undergoing Emergent Repair of Ruptured Umbilical Hernias: Natural History and Predictors of Outcomes.

OBJECTIVES: Ascites represents an important event in the natural history of cirrhosis, portending increased 1-year mortality. Umbilical herniation with rupture is an uncommon complication of large-volume ascites that is associated with significant morbidity and mortality. The aim of this study was to describe predictors of outcomes in patients undergoing emergent repair for spontaneous umbilical hernia rupture. MATERIALS AND METHODS: We report a case series of 10 patients with decompensated cirrhosis (mean age 66 ± 9 years, mean Model for End-Stage Liver Disease score of 21 ± 7) who presented with a ruptured umbilical hernia and had emergent repair. RESULTS: Thirty percent (3/10) of patients died or required liver transplant. Factors associated with death or transplant included the development of bacterial peritonitis (P = .03) and the presurgical 30-day Mayo Clinic Postoperative Mortality Risk in Patient with Cirrhosis Score (P = .03). CONCLUSIONS: Emergent repair after umbilical hernia rupture in patients with decompensated cirrhosis carries a poor prognosis with 30% of patients developing poor postsurgical outcomes.

Predictors of No-show Rate in the GI Endoscopy Suite at a Safety Net Academic Medical Center.

BACKGROUND/OBJECTIVES: Noncompliance with physician and procedure appointments is associated with poor disease control and worse disease outcomes. This also impacts the quality of care, decreases efficiency, and affects revenue. Studies have shown that no-show rates are higher in clinics caring for underserved populations and may contribute to poorer health outcomes in this group. METHODS: We performed a 17-month retrospective observational cohort study of patients scheduled for outpatient procedures in the Gastroenterology endoscopy suite at the University of Florida Health, Jacksonville. Multivariate logistic regression analysis was performed to evaluate associations between attendance and predictors of no-show. RESULTS: In total, 6157 patients were scheduled to undergo different GI procedures during the study period. A total of 4388 (71%) patients completed their procedure, whereas 2349 (29%) failed to attend their appointment and were considered "no-show". There was a significant relationship between the visit attendance and race, insurance, gender, and marital status. Males had a higher no-show rate compared with females (30% vs. 28%; P<0.05). African Americans had the highest no-show rate (32%; P<0.05) amongst different races. Patients scheduled for surveillance colonoscopy (ie, history of polyps, IBD, Colon cancer) were more likely to show (78%) than those obtaining initial colorectal cancer screening (74%) or other indications (71%) (P<0.05).In the logistic regression model, patients with commercial insurance are more likely to show for their appointments than those with noncommercial insurance (eg, Medicare, Medicaid, City contract etc) [odds ratio (OR), 2.6; 95% confidence interval (CI), 2.2-3.0]. The odds of showing up are 1.7 times higher for married men compared with single men (OR, 1.7; 95% CI, 1.3-2.0). Similarly, married females are more likely to show up for appointment than single females (OR, 1.1; 95% CI, 0.9-1.3). We did not find significant association between the type of GI procedure (eg, colonoscopy vs. esophagogastroduodenoscopy vs. advanced endoscopic procedures) (P>0.05). CONCLUSIONS: Predictors of no-shows for endoscopic gastrointestinal procedures included unpartnered or single patients, African American race and noncommercial insurance providers. Patients scheduled for surveillance colonoscopy had better adherence than initial screening. Further studies are required to better characterize these factors and improve adherence to the outpatient appointments based on the identified predictors.

Helicobacter pylori is Associated with Less Fistulizing, Stricturing, and Active Colitis in Crohn's Disease Patients.

Introduction A potential protective role of Helicobacter pylori (HP) infection against the development of Crohn's disease (CD) has been postulated. There is a lack of studies evaluating the association of HP with CD phenotypes. The aim of this study was to investigate the clinical features and disease activity of patients with CD who were diagnosed with HP infection. Methods The charts of 306 consecutive patients from the inflammatory bowel disease (IBD) database at the University of Florida College of Medicine, Jacksonville from January 2014 to July 2016 were reviewed. Ninety-one CD patients who were tested for HP were included, and the frequencies of strictures, fistulas, and colitis in surveillance biopsies in these patients were evaluated. Results Of the 91 CD patients tested for HP, 19 had HP infection. A total of 44 patients had fistulizing/stricturing disease, and 62 patients had active colitis. In the univariate analysis, patients with HP infection had less fistulizing/stricturing disease (21.1% vs. 55.6%, p = 0.009) and less active colitis (42.1% vs. 77.1%, p = 0.005). In the multivariate analysis, HP infection remained as a protective factor for fistulizing/stricturing disease phenotype (OR: 0.22; 95%CI: 0.06-0.97; p = 0.022) and active colitis (OR: 0.186; 95%CI: 0.05-0.65; p = 0.010). Conclusion HP infection was independently associated with less fistulizing/stricturing disease and less active colitis in CD patients. Our study suggests CD patients with a history of HP infection are less prone to complications.

Botulinum Toxin as a Treatment for Refractory Gastroparesis: a Literature Review.

PURPOSE OF REVIEW: Gastroparesis (GP) is a disorder of gastrointestinal motility which leads to delayed gastric emptying in the absence of mechanical obstruction. Treatment is limited as many patients are refractory to dietary modification and the use prokinetic medications carry significant adverse risks. These limitations necessitate more research into experimental therapies. The purpose of this article is to summarize the known information and guidelines on the diagnosis and management of GP and to review the latest literature on experimental treatments. RECENT FINDINGS: Based on the current available literature, there is conflicting data regarding the efficacy of intra-pyloric botulinum injections (IPBIs) for refractory gastroparesis. There have been many open-label trials showing good clinical response, but the only two randomized controlled trials on the matter showed no objective improvement gastric emptying studies. However, both studies were likely underpowered and changes in gastric emptying may not correlate with symptom improvement. As such, these discouraging findings should not be used to exclude botox from the armamentarium of therapies for refractory GP. More large-scale, double-blinded, multicenter randomized control trials are needed to further validate the long-term efficacy and safety of IPBI, as well as gastric peroral endoscopic myotomy (G-POEM), as compared to gastric electrical stimulation (GES) or surgical intervention (i.e., laparoscopic pylorotomy) for refractory gastroparesis.

Intestinal Spirochetosis: An Obscure Cause of Lower Gastrointestinal Bleeding.

Adherence of spirochetes to the apical membrane of the colonic epithelium has been well-described in the literature, but the exact pathogenesis leading to symptomatic clinical manifestations is poorly understood. Most cases are found incidentally on the pathological evaluation of colonic biopsies taken during diagnostic or therapeutic colonoscopies. However, whether the colonization of the intestinal mucosa can be attributed to clinical symptoms is a matter of debate. Here, we present a case of intermittent hematochezia attributed to the overwhelming invasion of the colonic mucosa by intestinal spirochetes.

A longitudinal analysis of the epidemiology and economic impact of inpatient admissions for chronic pancreatitis in the United States.

BACKGROUND: Chronic pancreatitis (CP) is a chronic, debilitating disorder associated with multiple complications, frequently necessitating hospitalization. The aim of this study was to investigate the longitudinal trends for hospitalization, mean length of stay (LOS), and cost associated with inpatient admissions for CP across the United States. METHODS: Using the Nationwide Inpatient Sample, all hospitalizations between 1997 and 2014 were analyzed. We examined annual data for rate of hospitalization, average LOS and cost for CP inpatient admissions. Trends were described over the surveillance period. RESULTS: Between 1997 and 2014, the number of hospitalizations for patients with a primary discharge diagnosis of CP decreased by 41.5% (P<0.001). While the average LOS decreased by 21.2% from 6.2 days in 1997 to 4.9 days in 2014 (P<0.001), the mean charges for CP-related hospital admissions increased by 308.5% from $12,725 in 1997 to $39,260 (adjusted for inflation) in 2014 (P<0.001). The risk of a discharge for CP significantly increased from 1997-2014 for the 1-17 year age group (relative risk 1.518, 95% confidence interval 1.516-1.520; P<0.0001), while it significantly decreased over time for all the other age groups. CONCLUSIONS: Although it is reassuring that the average LOS has reduced, the cost associated with these hospitalizations has almost tripled. We postulate that the increase in cost is likely attributable to a greater number of studies and/or interventions. In order to deliver more cost-conscious care, further investigation is required into the effect that these additional investigations and interventions have on specific endpoints, including disease-specific and all-cause morbidity and mortality.

Medical management of esophageal food impaction refractory to endoscopic interventions.

Most esophageal food impactions either pass spontaneously or are treated endoscopically. Severe food impactions can require extensive endoscopic therapy that potentially could lead to procedure-related complications. There are few alternate therapies available when endoscopy fails. Traditionally, pharmacologic therapy with glucagon has been performed with varying success. This case report and discussion will outline the management of a complete food impaction and medical therapies available when first-line endoscopic treatment fails. We present a case in which the endoscopic intervention for esophageal food bolus impaction was unsuccessful.

Intestinal Schistosomiasis: A Rare Cause of Abdominal Pain and Weight loss.

Abdominal pain is one of the most common reasons for outpatient visits. Although intestinal schistosomiasis is extremely rare in US, it should be considered in the differential diagnosis for those patients with risk factors such as international traveling history. This case report illustrates a unique case of intestinal schistosomiasis, which presented with an eight-week history of nonspecific abdominal pain and weight loss. Her colonoscopy revealed a 10 mm polyp in the colon. Endoscopic mucosal resection confirmed the diagnosis of schistosomiasis. Treatment with Praziquantel resulted in significant improvement of her symptoms.

Patients' perceptions of gastroenterologists' attire in the clinic and endoscopy suite.

Background: Studying the role of gastroenterologists' attire can provide insight into patients' perceptions and help us optimize the physician-patient relationship. In this study we assessed patients' preference concerning gastroenterologists' attire, and its influence on patients' trust, empathy and perceptions of the quality of care in the clinic and endoscopic suite. Methods: A cross-sectional survey was conducted from August 2016 to February 2017. A total of 240 consecutive patients who presented to the Gastroenterology Department at the University of Florida in Jacksonville both in the clinic and endoscopic suite were included in this study. The questionnaire applied included 8 questions concerning patients' preferences regarding gastroenterologists' attire and the impact the attire had on patients' trust, empathy and perceptions of quality of care. Results: Overall, 85% of patients preferred scrubs to formal dress clothes. The preference for scrubs was higher in the endoscopic suites (89% and 93%) compared to the outpatient office (66%, P<0.01). In addition, 82% of patients said they felt more comfortable speaking with gastroenterology doctors wearing scrubs and 85% of patients felt more confident about the skills of those gastroenterologists. Conclusions: Gastroenterologists' attire does influence patients' perception of the care they are receiving. There is an overall preference for the use of scrubs in the different settings of gastroenterology, both office and lab.

Nutritional Considerations in Liver Disease.

Malnutrition occurs in most patients with advanced liver diseases and is associated with higher rates of morbidity and mortality. In this article, the authors discuss the pathophysiology of malnutrition and methods to optimize nutrition status in liver disease and include a brief section on perioperative and postoperative nutrition.