Drug-Induced Liver Injury in GI Practice.

Although drug-induced liver injury (DILI) is a rare clinical event, it carries significant morbidity and mortality, leaving it as the leading cause of acute liver failure in the United States. It is one of the most challenging diagnoses encountered by gastroenterologists. The development of various drug injury networks has played a vital role in expanding our knowledge regarding drug-related and herbal and dietary supplement-related liver injury. In this review, we discuss what defines liver injury, epidemiology of DILI, its biochemical and pathologic patterns, and management.

Drug-induced Liver Injury Secondary to Herbal and Dietary Supplements.

The use of herbal and dietary supplements (HDS) is increasing in the United States and worldwide. Its significant association with liver injury has become a concern, particularly because rates of hepatotoxicity caused by HDS are increasing. There are variety of HDS available, ranging from multi-ingredient substances, to anabolic steroids for bodybuilding purposes, to individual ingredients for purposes of supplementing a diet. This article reviews the impact of liver injury cause by HDS and explores the hepatotoxic potential of such products and their individual ingredients.

Plummer-Vinson syndrome: improving outcomes with a multidisciplinary approach.

Plummer-Vinson syndrome is a rare condition associated with dysphagia, iron deficiency, and esophageal webs. Data regarding this condition is limited to mostly case reports and a few small cohort studies. Although most cases have a benign and indolent course, the risk of malignancy warrants long-term surveillance. A multidisciplinary approach among healthcare providers is of the utmost importance in the management of this condition.

Jackhammer Esophagus: Symptom Presentation, Associated Distal Contractile Integral, and Assessment of Bolus Transit.

GOALS: The aim of our study was to characterize jackhammer esophagus symptoms and their relationship with the distal contractile integral (DCI) and bolus transit. BACKGROUND: Jackhammer esophagus is defined by the Chicago Classification version 3.0. This diagnosis is relatively new, with the most current definition being established in 2014. The forerunners of this diagnosis, nutcracker (or hypercontractile) esophagus, have been associated with noncardiac chest pain (NCCP). STUDY: A retrospective chart review was performed of motility studies from 2011 to 2016. Studies with a diagnosis of jackhammer esophagus, hypercontractile esophagus, nutcracker, esophagogastric junction outflow obstruction, or hypertensive lower esophageal sphincter were reread using Chicago Classification version 3.0, and were included if they met criteria for jackhammer esophagus. Unpaired t-tests were used for analysis (P≤0.05). RESULTS: In total, 142 studies were identified with the above diagnoses. After excluding 84 studies, 58 remained for analysis and 17 were found to have jackhammer esophagus (29%). The mean age was 54 (28 to 75), 5 (29%) were males and 12 (71%) were females. The primary indications were NCCP (5), dysphagia (8), and other causes (4) (cough, heartburn, or regurgitation). The mean DCIs were 17,245 mm Hg×s×cm (NCCP), 14,669 mm Hg×s×cm (dysphagia), and 11,264 mm Hg×s×cm (other causes). The mean DCIs were compared: NCCP versus dysphagia (P=0.41), and NCCP versus other causes (P=0.05). Fifteen (88%) had normal bolus transit for both liquid and viscous swallows. CONCLUSIONS: In our small sample size, dysphagia was frequently the presenting symptom followed by NCCP. Those with NCCP have a trend toward a higher DCI. Bolus transit appeared to be normal in this patient population. More data are needed to further elucidate the genesis of symptoms and how they relate to the degree of contractility.

Endoscopic electrocautery incision therapy for benign lower gastrointestinal tract anastomotic strictures.

Benign anastomotic strictures can occur in up to 22% of patients who undergo colonic or rectal resection. Traditionally, surgery was the preferred method of treatment, but, over time, endoscopic techniques, such as balloon dilation, have become the preferred modality. However, a high stricture recurrence rate of up to 18-20% and the increased risk of perforation due to uncontrolled stretching are its major drawbacks. Endoscopic electrocautery incision (EECI) allows for controlled mucosal incision in predetermined locations of stricture. In this meta-analysis, we have summarized case reports, case series, retrospective studies and prospective studies describing the different endoscopic EECI techniques used for benign lower gastrointestinal tract anastomotic strictures. Our analysis showed that EECI, either alone or in combination with other modalities (e.g. balloon dilation, steroid injection or argon plasma coagulation) is an effective treatment option for both treatment-naïve and refractory short non-inflammatory strictures. The overall success rate for EECI-based therapy for benign colorectal stricture was 98.4%, with a stricture recurrence rate of 6.0%. No major adverse event (bleeding, infection or perforation) was reported. Only minor adverse events (abdominal pain) were reported in 3.8% of the population.

New Developments in Mechanical Enhancement of Colonoscopy: Cuffs, Caps and Rings.

BACKGROUND: Colorectal cancer (CRC) is a common cause of cancer-related deaths. Early detection of precursor lesions in the adenoma-carcinoma sequence via colonoscopy can decrease mortality from CRC. SUMMARY: In this review article, we have summarized retrospective studies, prospective single center, multicenter studies and randomized controlled trials describing the efficacy of endocuff colonoscopy (EC), cap-assisted colonoscopy (CAC) and endorings colonoscopy (ERC). Indications, techniques, outcomes, limitations and complications reported are discussed. KEY MESSAGE: Use of colonoscope with cap, cuff or rings attached to its distal tip has been shown to increase the polyp detection rate and adenoma detection rate, predominantly for the small polyps (<1 cm) and proximal colon location. Evidence is uniform for EC and ERC but not for CAC. Benefits of shorter cecum intubation time, improved cecum intubation rates and decreased pain scores during colonoscopy done with assistance of cuff or cap has potential to decrease the number of incomplete colonoscopy and increase overall patient satisfaction, thus improving follow-up. In the absence of any additional adverse events, EC, CAC and ERC have potential to enhance the benefits of colonoscopy.

Proton Pump Inhibitor-Induced Remission of Lymphocytic Esophagitis.

Lymphocytic esophagitis is a chronic condition that has been described in the literature; however, there is little information describing its characteristics and treatment. We present a case of lymphocytic esophagitis that was identified following food impaction. Repeat esophagogastroduodenoscopy (EGD) with biopsy showed a marked decrease in lymphocytic infiltration after a 6-week course of twice-daily high-dose proton pump inhibitor (PPI). After initiation of the high-dose PPI regimen, the patient had no further episodes of dysphagia or food impaction. We propose that treating lymphocytic esophagitis with twice-daily PPI can improve symptoms and show histologic evidence of improvement.