Endoscopy for the diagnosis and treatment of gastrointestinal bleeding caused by malignancy.

BACKGROUND AND AIM: The diagnosis and treatment of gastrointestinal (GI) bleeding secondary to malignancy can be challenging. Endoscopy is the gold standard to diagnose and treat gastrointestinal bleeding but clinical characteristics and outcomes of patients with malignancy-related bleeding are not well understood. This study aims to look at clinical characteristics, endoscopic findings, safety and clinical outcomes of endoscopic interventions for GI malignancy-related bleeding. METHODS: We retrospectively reviewed outcomes of patients with confirmed GI malignancies who underwent endoscopy for GI bleeding at MD Anderson Cancer Center between 2010 and 2019. Cox hazard analysis was conducted to identify factors associated with survival. RESULTS: A total of 313 patients were included, with median age of 59 years; 74.8% were male. The stomach (30.0%) was the most common tumor location. Active bleeding was evident endoscopically in 47.3% of patients. Most patients (77.3%) did not receive endoscopic treatment. Of the patients who received endoscopic treatment, 57.7% had hemostasis. No endoscopy-related adverse events were recorded. Endoscopic treatment was associated with hemostasis (P < 0.001), but not decreased recurrent bleeding or mortality. Absence of active bleeding on endoscopy, stable hemodynamic status at presentation, lower cancer stage, and surgical intervention were associated with improved survival. CONCLUSIONS: This study indicates that endoscopy is a safe diagnostic tool in this patient population; while endoscopic treatments may help achieve hemostasis, it may not decrease the risk of recurrent bleeding or improve survival.

Making a Confident Diagnosis of Irritable Bowel Syndrome.

Irritable bowel syndrome (IBS) is among the most common diagnoses made by medical providers and its symptoms are common causes for health care consultation. IBS is characterized by abdominal pain associated with abnormal stool consistency and/or frequency and is widely considered a diagnosis of exclusion, despite abundant evidence contradicting such an approach. A positive diagnosis is achieved through application of symptom-based clinical criteria, careful history and physical examination, evaluation for alarm sign/symptoms, and judicious use of diagnostic testing. This article reviews the symptom-based criteria for IBS and utility of diagnostic tests commonly included in the evaluation of IBS symptoms.

Gastrointestinal toxic effects in patients with cancer receiving platinum-based therapy.

Background: Platinum-based therapy (PBT) can be limited by gastrointestinal adverse events, particularly PBT-related colitis and diarrhea (PCD). We studied clinical features, treatments, and outcomes of PCD. Methods: This was a retrospective study of cancer patients who received PBT and colonoscopic evaluation for PCD symptoms from 2009 to 2018. Results: Of 36,595 patients who received PBT, 86 (0.2%) met inclusion criteria. Median time from PBT initiation to PCD was 66 days. Regarding PBT type, 47% of the patients received carboplatin, 31% cisplatin, and 22% oxaliplatin. Median duration of PCD symptoms was 20 days. Colonoscopy revealed mucosal ulceration in 34% of the patients and nonulcerative inflammation in 33%. Half of the cohort needed hospitalization for PCD (49%). The majority received treatment for PCD (59%): immunosuppressive therapy in 21%, antibiotics in 27%, antimotility agents in 22%, and intravenous fluids in 51%. Eight patients (9%) were admitted to the intensive care unit for PCD management. Six patients (7%) experienced colonic perforation that required surgical intervention; two of them had gastrointestinal tumors. Physicians restarted PBT in 37 (43%) patients; 8 (22%) of them had PCD recurrence that was managed expectantly. Colonic perforation occurred more frequently with use of oxaliplatin and cisplatin than carboplatin (P=0.05). The median duration of PCD symptoms was longer in patients receiving carboplatin or cisplatin than in those receiving oxaliplatin (P=0.182). Conclusions: PCD is rare, but in a small subset of patients, it can lead to serious complications. Treatment of PCD is mainly supportive, but immunosuppressive therapy may be required.

Serum alanine aminotransferase levels and all-cause mortality.

BACKGROUND AND OBJECTIVES: Studies have examined the relationship between serum alanine aminotransferase (ALT) and mortality with inconsistent results. Our aims were to examine the association of normal range serum ALT with mortality, to explore a nonlinear relationship between ALT and mortality, and to investigate whether age modifies this relationship. STUDY: We used the continuous National Health and Nutrition Examination Survey (NHANES) from 1999 to 2010. Vital status of the participants was obtained by probabilistic matching between NHANES and the National Death Index. Cox proportional models were used to examine the relationship with and without adjustment for age, sex, race, BMI, hypertension, diabetes, alcohol use, serum triglycerides, prescription drug use, and glomerular filtration rate, and accounting for the sampling methodology of NHANES. Nonlinear relationship was examined using spline (single knot at 17 U/l) regression. Interaction terms were used to examine effect modification by age. RESULTS: Higher serum ALT was associated with lower all-cause mortality [adjusted hazard ratio (HR)/ALT increment=0.98, 95% confidence interval (CI)=0.97-0.99]; however, this relationship was nonlinear and present only until 17 U/l (adjusted HR/ALT increment=0.93, 95% CI=0.91-0.95) and not thereafter. Age modified the relationship between ALT and mortality; elderly patients (>64 years) had a 6% lower adjusted mortality risk than younger (<35 years) participants (HR/ALT increment=0.94, 95% CI=0.91-0.96; interaction P<0.001). CONCLUSION: Increase in serum ALT within the normal range is initially associated with lower mortality, but has no effect after 17 U/l. The elderly show a significantly larger decrease in mortality with an increase in ALT than younger individuals. The mechanisms underlying this relationship need further exploration.

Does unconscious thought improve complex decision making?

In a recent study, Dijksterhuis et al. (Science 311:1005, 2006) reported that participants were better at solving complex decisions after a period of unconscious thought relative to a period of conscious thought. They interpreted their results as an existence proof of powerful unconscious deliberation mechanisms. In the present report, we used a similar experimental design with an additional control, immediate condition, and we observed that participants produced as good (and even descriptively better) decisions in this condition than in the "unconscious" one, hence challenging the initial interpretation of the authors. However, we still obtained lower performances in the "conscious" relative to the "immediate" condition, suggesting that the initial result of Dijksterhuis et al. was not due to the action of powerful unconscious thought processes, but to the apparent disadvantage of further conscious processing. We provide an explanation for this observation on the basis of current models of decision making. It is finally concluded that the benefit of unconscious thought in complex decision making is still a controversial issue that should be considered cautiously.