Reproducibility of the AGREE II Tool for Assessing the Methodological Quality of Clinical Practice Guidelines for the Management of Antithrombotic Agents in Patients Undergoing GI Endoscopy.

BACKGROUND: Clinical practice guidelines (CPGs) exist for the management of antithrombotic agents in the periendoscopic period; however, their methodological qualities vary. The Appraisal of Guidelines for Research & Evaluation II (AGREE II) tool has been validated for the assessment of the methodological quality of CPGs; however, its reproducibility has not been assessed. The goal of this study was to assess the reproducibility of the AGREE II tool for CPGs published within the last 6 years for the management of antithrombotic agents in the periendoscopic period. STUDY: A systematic search of PubMed and Embase databases was performed to identify eligible CPGs published between January 1, 2016 and April 14, 2022. The quality of the CPG was independently assessed by 6 reviewers using the AGREE II instrument. The reproducibility was summarized as weighted κ statistic and intraclass correlation coefficient using the SPSS statistical analysis package. RESULTS: The search yielded 343 citations with 7 CPGs from Europe, Asia, and the United States included in the critical appraisal. The overall mean weighted κ score across all guidelines was 0.300 (range, 0.093 to 0.384) indicating a fair agreement. The overall intraclass correlation coefficient was 0.462 (range, 0.175 to 0.570) for single measures and 0.837 (range, 0.560 to 0.888) for average measures indicating moderate reliability. CONCLUSIONS: Our study shows only a fair overall interobserver agreement in the methodological quality of the included CPGs. The results suggest the need for education and training of CPG raters to enhance the application of the AGREE II tool to improve its reproducibility.

A systematic critical appraisal of clinical practice guidelines of antithrombotic agents in gastrointestinal endoscopy using the AGREE II tool.

BACKGROUND AND AIM: The quality of clinical practice guidelines (CPGs) for the management of antithrombotic agents in patients undergoing gastrointestinal (GI) endoscopy has not been systematically appraised. The goal of this study was to evaluate the methodological quality of CPGs for the management of antithrombotic agents in periendoscopic period published within last 6 years. METHODS: A systematic search of PubMed and Embase databases was performed to identify eligible CPGs published between January 1, 2016, and April 14, 2022, addressing the management of antithrombotic agents in the periendoscopic period. The quality of the CPG was independently assessed by six reviewers using the Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument. Domain scores were considered of sufficient quality when > 60% and of good quality when > 80%. RESULTS: The search yielded 343 citations, of which seven CPGs published by the gastroenterology associations in Asia (n = 3), Europe (n = 2), and North America (n = 2) were included for the critical appraisal. The overall median score for the AGREE II domains was 93% (interquartile range [IQR] 11%) for scope and purpose, 79% (IQR 61%) for stakeholder involvement, 79% (IQR 36%) for rigor of development, 100% (IQR 14%) for clarity of presentation, 32% (IQR 36%) for applicability, 93% (IQR 29%) for editorial independence, and 86% (IQR 29%) for overall assessment. CONCLUSIONS: The findings show that the overall methodological quality of the CPGs for the management of antithrombotic agents in the periendoscopic period varies across the domains. There is significant scope for improvement in the methodological rigor and applicability of CPGs.

Lichen planus esophagitis.

PURPOSE OF REVIEW: Dysphagia is one of the most common reasons for patients' visits to a gastroenterologist. Esophageal lichen planus (ELP) has historically been felt to be a rare disease, when in fact it is often misdiagnosed and unrecognized. Often first diagnosed as an unusual esophagitis, all gastroenterologists will see ELP in their practice, and need to be able to recognize this condition. RECENT FINDINGS: Although there is still a relative paucity of data on this condition, this article will update the typical presenting symptoms, endoscopic findings, and ways to differentiate ELP from other inflammatory mucosal diseases. There is still no standardized treatment algorithm, but we will also present the most recent treatment approaches. SUMMARY: It is critical that physicians maintain an increased awareness of ELP and have a high clinical suspicion in the appropriate patients. While management remains challenging, it is important to treat both the inflammatory and stricturing components of the disease. A multidisciplinary approach is also often required, utilizing dermatologists, gynecologists, and dentists who are familiar with managing patients with LP.

Quality of Pancreatic Cyst Clinical Practice Guidelines.

BACKGROUND: There are various published clinical practice guidelines (CPGs) for the management of pancreatic cystic lesions. However, the quality of these guidelines has not been systematically appraised. This study aimed to evaluate the quality of CPGs published in the last 5 years for the management of pancreatic cysts. METHODS: A systematic search of the PubMed database for eligible CPGs published between January 1, 2016 and November 17, 2021, using a sensitive filter. The quality of the CPGs was independently evaluated using the Appraisal of Guidelines for Research & Evaluation II instrument, with domain scores considered sufficient quality if >60% and good quality if >80%. RESULTS: The search yielded 4 eligible CPGs out of 426 citations. The scores varied for different domains for each CPG, with the overall median score being 79% for scope and purpose, 26% for stakeholder involvement, 51% for rigor of development, 69% for clarity of presentation, 14% for applicability, and 75% for editorial independence. CONCLUSIONS: The study revealed that the quality of the CPGs for pancreatic cyst management in adults remains moderate at best. Patient representatives were not involved in any of the CPG development process. There is a significant scope for improvement in methodological rigor and clarity of presentation.

Update on the Diagnosis and Treatment of Achalasia.

Achalasia is a rare disease of the esophagus with impaired relaxation of the lower esophageal sphincter and aperistalsis. The etiology is unknown but speculations include a viral or autoimmune etiology. All specialists dealing with swallowing and esophageal diseases should recognize the classic symptoms of dysphagia for solids/liquids, regurgitation, and choking, especially at night. High-resolution manometry is critical for the diagnosis with endoscopy and barium esophagram having a supportive role. The disease cannot be cured but most can return to near normal swallowing and a regular diet with appropriate therapy. Treatment includes smooth muscle relaxants, botulinum toxin injections to the lower sphincter, pneumatic dilation, Heller myotomy, and peroral endoscopic myotomy. One treatment does not fit all and a tailored approach through a multidiscipline team will give the best long-term outcomes.

Is inguinal hernia associated with an increased risk of colon cancer? A systematic review and meta-analysis.

BACKGROUND: The presence of an inguinal hernia has been associated with an increased risk of identifying colon cancer, and therefore colonoscopy is recommended prior to inguinal hernia repair. However, the evidence on the association between the presence of an inguinal hernia and colon cancer is conflicting and uncertain. We performed a systematic review and meta-analysis to synthesize all available evidence on this topic. METHODS: A comprehensive search of PubMed and EMBASE was performed. Any comparative study (case-control or cohort study) comparing the rate of colon cancer detection in patients with and without inguinal hernias who underwent screening colonoscopy or flexible sigmoidoscopy was eligible for inclusion. Data were extracted and pooled under a random effects model. RESULTS: The initial search identified 692 references, of which 4 comparative studies (1462 patients) met the inclusion criteria. The overall risk of bias in the included studies was low. Pooled results showed a statistically non-significant difference in the incidence of detection of colon cancer, with patients with inguinal hernia having a 1.26 times increased likelihood of colon cancer diagnosis compared with patients without inguinal hernia (odds ratio (OR) 1.26; 95% confidence interval (CI) 0.63-2.51; P = 0.51). Although patients with inguinal hernia were also 1.23 times more likely to be diagnosed with colon polyps compared to patients without inguinal hernia, this difference was statistically non-significant (OR 1.23; 95% CI 0.94-1.60; P = 0.12). CONCLUSION: The findings from this first systematic review and meta-analysis show that there is no difference in the incidence of either colon cancer or colon polyps in patients presenting with inguinal hernias compared to those without. Nevertheless, larger prospective studies are needed to further investigate the relationship between the risk of colon cancer or polyps and the presence of inguinal hernia.

Timed Barium Swallow: Diagnostic Role and Predictive Value in Untreated Achalasia, Esophagogastric Junction Outflow Obstruction, and Non-Achalasia Dysphagia.

OBJECTIVES: Timed barium swallow (TBS) assesses esophageal emptying in patients with achalasia and is considered the standard workup for patients with dysphagia. Our aim was to determine the usefulness of TBS in differentiating patients with achalasia (type 1-3), esophagogastric junction outflow obstruction (EGJOO), and non-achalasia dysphagia. METHODS: We performed a retrospective cohort study including consecutive patients who underwent TBS evaluation between May 2013 and September 2015. Patients were separated into untreated achalasia (n=117), EGJOO (n=46), and non-achalasia (n=146) groups. Diagnosis of achalasia/EGJOO was based on high-resolution manometry using Chicago Classification. Receiver operating characteristic (ROC) curve analysis was performed to determine the accuracy of TBS (barium height at 1 and 5 min and tablet retention) in identifying achalasia vs. EGJOO and non-achalasia. RESULTS: Barium column height of 5 cm at 1 min showed a sensitivity of 94% and specificity of 71% and barium column height of 2 cm at 5 min showed a sensitivity of 85% and specificity of 86% in differentiating untreated achalasia from EGJOO and non-achalasia. Combined liquid barium and tablet increases diagnostic yield from 79.5 to 100% in untreated achalasia patients and from 48.9 to 60% in EGJOO patients. CONCLUSIONS: TBS is a simple and useful test in differentiating untreated achalasia, EGJOO, and non-achalasia dysphagia. We propose that barium height >2 cm at 5 min be used as cutoff point for identifying achalasia. Combination of liquid barium and tablet increased the diagnostic yield of TBS in achalasia and EGJOO. Retention of barium tablet alone suggests functional/anatomic obstruction at the esophagogastric junction.

Risk of lymphoma in patients with inflammatory bowel disease treated with azathioprine and 6-mercaptopurine: a meta-analysis.

BACKGROUND & AIMS: Thiopurine therapy for inflammatory bowel disease (IBD) has been associated with increased risk for lymphoma. We estimated the relative risk of lymphoma in patients with IBD exposed to thiopurines and compared relative risk values derived from population-based studies with those from referral center-based studies. We investigated whether active use increased risk compared with past use, and whether sex, age, or duration of use affects risk of lymphoma. METHODS: We searched MEDLINE, EMBASE, and Cochrane databases, as well as conference abstracts and international publications, for the terms "6-MP and lymphoma," "6-mercaptopurine and lymphoma," "thiopurines and lymphoma," "azathioprine and cancer and IBD," "azathioprine and malignancy and IBD," "azathioprine and lymphoma," and "lymphoproliferative and thiopurines." Pooled standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were estimated. The deviance statistic from Poisson models was used to calculate heterogeneity. RESULTS: Eighteen studies (among 4383 citations) met our inclusion criteria. Overall, the SIR for lymphoma was 4.92 (95% CI, 3.10-7.78), ranging from 2.80 (95% CI, 1.82-4.32) in 8 population studies to 9.24 (95% CI, 4.69-18.2) in 10 referral studies. Population studies demonstrated an increased risk among current users (SIR = 5.71; 95% CI, 3.72-10.1) but not former users (SIR = 1.42; 95% CI, 0.86-2.34). Level of risk became significant after 1 year of exposure. Men have a greater risk than women (relative risk = 1.98; P < .05); both sexes were at increased risk for lymphoma (SIR for men = 4.50; 95% CI = 3.71-5.40 and SIR for women = 2.29; 95% CI = 1.69-3.05). Patients younger than 30 years had the highest relative risk (SIR = 6.99; 95% CI, 2.99-16.4); younger men had the highest risk. The absolute risk was highest in patients older than 50 years (1:354 cases per patient-year, with a relative risk of 4.78). CONCLUSIONS: Compared with studies from referral centers, population-based studies of IBD patients show a lower but significantly increased risk of lymphoma among patients taking thiopurines. The increased risk does not appear to persist after discontinuation of therapy. Patients over 50 have the highest absolute risk of lymphoma per year on thiopurines, while men under 35 may also be a high risk group. More study is needed to precisely understand groups highest at risk. The risks of lymphoma and potential benefits of therapy should be considered for all patients with IBD.

Treatment of ulcerative colitis.

PURPOSE OF REVIEW: Ulcerative colitis is a chronic inflammatory disease of the colon of unknown cause that is characterized by alternating intervals of active and inactive disease in 80-90% of patients. The primary goal of treatment is to induce and maintain remission using therapy tailored to the individual patient. The purpose of this review was to describe the management of ulcerative colitis with emphasis on the use of anti-tumor necrosis factor (TNF) agents. RECENT FINDINGS: Recent research has shown that new anti-TNF agents, adalimumab (ADA) and golimumab, are effective in induction of remission and maintenance of remission in patients with extensive ulcerative colitis. In a recent study, infliximab was found to have comparable efficacy to cyclosporine in treatment of acute severe refractory to corticosteroids ulcerative colitis. SUMMARY: Anti-TNF therapy should be initiated in patients with acute severe refractory to corticosteroids ulcerative colitis and in patients with moderate-to-severe ulcerative colitis who are not responsive to conventional treatment with aminosalicylates, corticosteroids and immune modulators. Alternatives to infliximab are ADA and golimumab. Future research is needed to further assess the long-term efficacy and safety of ADA and golimumab in ulcerative colitis.

The influence of anti-TNF therapy on the course of chronic hepatitis C virus infection in patients with inflammatory bowel disease.

BACKGROUND: The immunosuppressive potential of anti-tumor necrosis factor (TNF) in exacerbating chronic hepatitis C virus (HCV) infection has been a major concern. We aim to critically analyze the impact of anti-TNF on the course of chronic HCV infection in patients with concurrent inflammatory bowel disease (IBD) and HCV infection. MATERIALS AND METHODS: Patients with diagnosis of IBD and HCV were identified retrospectively through the University of Pennsylvania Health System electronic database. Data assessed included demographics, duration of IBD and HCV infection, HCV RNA levels, HCV genotype, liver histology, hepatic biochemical tests (HBT) and IBD disease activity index. RESULTS: A total of 4,274 IBD and 3,523 HCV patients were identified from 10/1998 to 05/2010. Thirty-seven patients had concurrent HCV infection and IBD, of which 23 patients were eligible (61 % CD; 39 % UC). Five patients (22 %) received anti-TNF therapy (infliximab). Two patients received pegylated interferon and ribavirin (both were non-responders). Overall, three patients had clinical remission and one patient had clinical response to infliximab. When compared to baseline, one patient had HBT improvement, three patients remained stable and one patient had HBT elevation, which was likely due to progressive liver disease in view of HIV co-infection. CONCLUSION: This represents the first critical analysis assessing the impact of anti-TNF therapy on the course of chronic HCV in IBD patients. Concurrent HCV infection in IBD patients is uncommon. Treatment of IBD with infliximab in HCV patients did not result in flares in hepatic biochemical tests while there was an improvement in the IBD disease activity score.

Impact of opioids on treatment response among idiopathic esophagogastric junction outflow obstruction patients: A retrospective cohort study.

BACKGROUND: Esophageal dysmotility has been attributed to opioid use. The goal was to assess the differences in pre- and post-treatment timed-barium esophagram (TBE) barium heights at 1 and 5 minutes and symptomatic response to treatment in esophagogastric junction outflow obstruction (EGJOO) patients according to opioid use status. METHODS: We performed a retrospective cohort study. Consecutive patients with EGJOO were eligible for inclusion. Data were collected on demographics, pre and post-treatment 1 and 5 minutes TBE barium heights and symptom outcomes. Groups were compared according to opioid use. RESULTS: Thirty-one EGJOO patients met the inclusion criteria. All patients were treated with pneumatic dilation. Of the 31 patients, 11 (35%) had opioid exposure and 20 (65%) did not. The median follow-up post-treatment was two months (range 1-47 months). There was no statistically significant difference in post-treatment outcomes for opioid exposed vs. unexposed groups. The median per cent decrease in the TBE barium height at 1 minute was 100% for the opioid exposed vs. 71% for the unexposed group (p = 0.92). The median per cent decrease in the TBE barium height at 5 minutes was zero % for the opioid exposed and unexposed groups (p = 0.67). The incidence of symptomatic improvement was 82% (9/11) for the opioid exposed group vs 95% (19/20) for the unexposed group (p = 0.28). CONCLUSIONS: Patients with EGJOO seem to respond to treatment similarly regardless of being on opioids.

A Systematic Critical Appraisal of Clinical Practice Guidelines in Heart Failure Using the AGREE II Tool.

Multiple clinical practice guidelines (CPGs) for heart failure management have been published to provide the best practices regarding the use of foundational therapies to reduce morbidity and mortality in this patient population. However, a critical appraisal of these heart failure guidelines has not been performed. This systematic review aimed to assess the methodological quality of current CPGs in the management of patients with heart failure. A comprehensive search of EMBASE and PubMed was conducted to identify CPGs published between January 1, 2021 and September 8, 2022. Any CPGs published in the last 2 years addressing the management of heart failure were eligible for inclusion. The methodological quality of the CPGs was assessed using the AGREE II (Appraisal of Guidelines for Research & Evaluate II) instrument. The initial search yielded 3,269 citations, of which, 6 CPGs were included. A total of 2 CPGs were each published by the cardiology associations in North America and Asia and 1 each in Europe and South America. The overall median score for the AGREE II domains were 100% for scope and purpose, 71% for stakeholder involvement, 71% for the rigor of development, 100% for clarity of presentation, 43% for applicability, 100% for editorial independence, and 64% for overall assessment. CPG developers would benefit from the use of a standardized approach to the development of CPGs and use the contents of the AGREE II tool to improve the methodological rigor, reporting, and applicability of CPGs.

A systematic review of factors that contribute to hepatosplenic T-cell lymphoma in patients with inflammatory bowel disease.

BACKGROUND & AIMS: Hepatosplenic T-cell lymphoma (HSTCL) is a rare and usually fatal lymphoma that primarily affects men younger than 35 years old. Treatment of patients with inflammatory bowel disease (IBD) using antibodies to tumor necrosis factor (anti-TNFs) and thiopurines has been associated with HSTCL. We investigated the medications, duration of therapy, and ages of patients associated with HSTCL. METHODS: We collected and analyzed data on the association between HSTCL, and anti-TNF and thiopurine therapies in patients with IBD from published reports and the MedWatch reporting system of the US Food and Drug Administration. RESULTS: Of 36 patients with HSTCL, 20 received therapy with infliximab and a thiopurine and 16 received a thiopurine as monotherapy for IBD. Four patients who had been treated with infliximab and a thiopurine also received adalimumab. One of these patients had been given infliximab, adalimumab, and natalizumab. Of 31 patients of known gender, only 2 were female. Twenty-seven of the 30 patients of known age were younger than 35 years old. CONCLUSIONS: Most patients with HSTCL who received long-term therapy (at least 2 y) with thiopurines for IBD were men younger than 35 years old. There were no reported cases of HSTCL in patients with IBD who received only anti-TNF therapy. Physicians should consider giving thiopurines and anti-TNF agents to young male patients with IBD only in cases in which a clear benefit is expected, such as in early stage disease in untreated patients or possibly in very severe cases.

Inflammatory bowel disease therapy: current state-of-the-art.

PURPOSE OF REVIEW: The aim of this article is to review current evidence-based approaches to treatment of ulcerative colitis and Crohn's disease. RECENT FINDINGS: The primary goal of treatment is to induce and to maintain remission in a safe and efficacious fashion. The 5-aminosalicylic acid (5-ASA) agents and oral steroids remain the first-line approach for the treatment of ulcerative colitis and Crohn's disease. The 'step-up' approach includes the use of immunomodulators [azathioprine (AZA), or 6-mercaptopurine (6-MP)] and newer biologic agents (infliximab, adalimumab, and natalizumab). The 'step-down' approach can also be considered individually on the basis of the severity of Crohn's disease. SUMMARY: Current treatment regimens still involve medications with well known efficacy and safety profiles and progress to more potent treatments such as immunomodulators and biologic agents. Adverse events of potent treatment with biologics and immunomodulators have been recognized. In some cases, aggressive approaches with the use of more potent agents as first-line therapy has been proposed, but they are still not considered a routine approach.

Update on the management of Crohn's disease.

Crohn's disease (CD) is a chronic inflammatory disorder characterized by focal, asymmetric, transmural inflammation of any part of the luminal gastrointestinal tract of uncertain etiology and an unpredictable course. The available treatment options include aminosalicylates, budesonide and systemic corticosteroids, antibiotics, immunomodulators,methotrexate and anti-TNF agents. This review discusses recent developments in the treatment of CD and provides a comprehensive update on management of patients with CD based on the data from randomized controlled trials.

Timed barium swallow for assessing long-term treatment response in patients with achalasia: Absolute cutoff versus percent change - A cross-sectional analytic study.

BACKGROUND: Timed barium swallow (TBS) assesses esophageal emptying before and after therapy in patients with achalasia. Our aim was to compare the accuracy of percent change in barium height with traditional absolute cutoff of <5 cm on post-treatment TBS. MATERIALS AND METHODS: Consecutive patients with treatment naïve achalasia treated with either PD, HM, or POEM between 1/2012 and 7/2017 were eligible for inclusion. The accuracy of percent change in pre- and post-treatment barium height at 5 minutes versus an absolute <5 cm cutoff for assessing treatment response was assessed using the receiver operating curve analysis (ROC). RESULTS: Eighty-one patients met the inclusion criteria. The median percent change in barium heights at five minutes in patients who did not improve was 6 percent increase (n = 10; mean 10.6) versus 78 percent decrease (n = 71; mean 64) in patients who improved (P = 0.0001). The AUC for percent change in TBS 5 minutes height was 76% (95% CI 48% to 90%), and a 3% decrease from baseline as a cutoff had a sensitivity of 60% and specificity of 99%. The AUC for post-treatment TBS 5 minutes height was 79% (95% CI 53% to 91%), and the 5 cm cutoff had a sensitivity of 70% and specificity of 75%. CONCLUSIONS: The results show that 3% percent improvement in pre- and post-treatment barium height at 5 minutes rather than absolute cutoff value of <5 cm on post-treatment TBS is a better indicator of treatment success in achalasia patients. These findings indicate the need for reassessment of tools to identify treatment response.

Comparison of reflux frequency during prolonged multichannel intraluminal impedance and pH monitoring on and off acid suppression therapy.

BACKGROUND: The aim of this study was to assess and compare reflux frequency during prolonged multichannel intraluminal impedance and pH monitoring with special attention to the 2-hour postprandial interval after the major meal in patients on or off proton pump inhibitor (PPI) therapy. MATERIALS AND METHODS: We retrospectively analyzed multichannel intraluminal impedance and pH studies performed in 110 patients monitored on (n=70) or off PPI (n=40) to assess number of acid and nonacid reflux episodes per hour (RE/h). RESULTS: Patients on PPI had significantly higher mean number of nonacid than acid RE/h during the total monitoring and 2-hour postprandially (pp). The mean number of nonacid RE/h was significantly higher during 2-hour pp than the total monitoring period (4.5 vs. 1.7). Patients off PPI had significantly higher mean number of acid than nonacid RE/h only during the total monitoring. The total number of RE/h was significantly higher during 2-hour pp than the total monitoring (5.1 vs. 2.3). Patients on PPI had significantly higher mean number of nonacid RE/h whereas patients off PPI had significantly higher mean number of acid RE/h throughout total monitoring and 2-hour pp. Number of RE/h was numerically (2.3 vs. 1.7) but not statistically greater off PPI than on PPI during total monitoring. CONCLUSIONS: The total number of reflux episodes increases during the postprandial period irrespective of PPI therapy. Maximal rate of reflux episodes occurs during the postprandial period and is the same whether taking PPI or not.

The effect of oral buspirone, pyridostigmine, and bethanechol on esophageal function evaluated with combined multichannel esophageal impedance-manometry in healthy volunteers.

BACKGROUND: There is limited information on medications with promotility effects on the esophagus. Studies in healthy volunteers have shown the potential role of the direct cholinergic agonist bethanechol and the serotonin receptor agonist buspirone in improving esophageal motility. It has been also shown that an acetylcholinesterase inhibitor, the short-acting drug edrophonium administered intravenously caused a greater increase in the esophageal contraction amplitude and duration than bethanechol. Edrophonium cannot be used as a promotility therapy owing to short duration of action and lack of oral administration. The use of another acetylcholinesterase inhibitor pyridostygmine with longer duration of action has not been studied. The aim of the study was to evaluate the effect of oral pyridostygmine (60 mg), buspirone (20 mg), and bethanechol (25 mg) on esophageal function assessed by combined multichannel intraluminal impedance-esophageal manometry. MATERIALS AND METHODS: Ten healthy volunteers were enrolled in a double blind randomized 3-period crossover study. Multichannel intraluminal impedance-esophageal manometry recorded esophageal pressures and bolus transit data during 6 liquid and 6 viscous swallows at baseline and 20, 40, and 60 minutes after the randomized oral administration of each drug. RESULTS: Blinded analysis found significant increases in mean distal esophageal amplitude for liquid swallows from baseline to 60 minutes postdosing after pyridostygmine (87.6 vs. 118.0 mm Hg, P<0.001), buspirone (85.1 vs. 101.9 mm Hg, P<0.05), and bethanechol (87.6 vs. 118.8 mm Hg, P<0.01). Only pyridostygmine showed a significant decrease in mean distal onset velocity for liquid swallows at 60 minutes postdosing (3.4 vs. 2.3 cm/s, P<0.01) and increase in total bolus transit time at 60 minutes postdosing (7.9 vs. 9.3 s, P<0.05). All 3 agents significantly increased mean lower esophageal sphincter residual pressure for liquid swallows at 20, 40, and 60 minutes postdosing. Increased lower esophageal sphincter resting pressure was not significant. Similar results were found with viscous swallows. CONCLUSIONS: Oral pyridostygmine, buspirone, and bethanechol enhance esophageal motility with pyridostygmine appearing to have the greatest effect. A potential effect on improving esophageal function and symptoms in patients requires further study.

Pneumatic dilation improves esophageal emptying and symptoms in patients with idiopathic esophago-gastric junction outflow obstruction.

BACKGROUND AND AIMS: Idiopathic Esophago-gastric outflow obstruction (EGJOO) is a new clinical entity resulting in delayed esophageal emptying secondary to a poorly relaxing lower esophageal sphincter. Little is known about treatment outcomes of idiopathic EGJOO patients. The aim of this study was to investigate the clinical response of pneumatic dilation (PD) in idiopathic EGJOO patients with a standing barium column and/or with pill arrest on timed barium esophagram (TBE) before and after undergoing PD. METHODS: Idiopathic EGJOO patients with retained liquid barium on TBE at 1 minute and/or with pill arrest in esophagus at 5 minutes were included. Patients were treated with PD and evaluated with post-procedural TBE. RESULTS: A total of 33 patients with Idiopathic EGJOO and poor esophageal emptying on TBE were treated with PD. 67% of Idiopathic EGJOO patients reported subjective symptom relief, 18% improved and symptoms later recurred, 6% were lost to follow up, and 9% reported no change. TBE results of pre-PD showed 1 minute average barium column height of 11.0 cm and 1 minute barium column width of 1.7 cm. There was significant decrease in 1 minute liquid barium column height and width (P < 0.001 and <0.001, respectively) as well as significant improvement in pill passing (P < 0.006) after undergoing PD. No complications occurred after PD. CONCLUSION: PD is an effective initial treatment for Idiopathic EGJOO patients with abnormal TBE. Pneumatic dilation relieved symptoms and improved esophageal emptying in Idiopathic EGJOO patients on TBE.

Hepatitis C virus infection and hepatocellular carcinoma.

Primary liver cancer is the sixth most common cancer in the world and the third most common cause of death attributable to cancer. Most primary liver cancers are hepatocellular carcinoma (HCC), accounting for 85% to 90% of cases. There is a trend of growing incidence of HCC in the United States. One of the most important risk factors for developing HCC is chronic hepatitis C virus (HCV) infection. Although several studies suggested the preventive effect of interferon from developing HCC in HCV-infected individuals, these findings need to be validated in large prospective and randomized trials.