The Yield of Colonoscopy in the Evaluation of Constipation: An Age-Based Analysis of Outcome.

Background: Chronic constipation, a prevalent gastrointestinal complaint, exhibits rising incidence and diverse clinical implications, especially among the aging population. This study aims to assess colonoscopy performance in chronic constipation across age groups, comprehensively evaluating diagnostic yield and comparing results with average-risk controls. Methods: A retrospective analysis was conducted on 50,578 colonoscopy procedures performed over 12 years, including 5478 constipated patients. An average-risk control group (n = 4100) was included. Data extracted from electronic medical records covered demographics, operational aspects, and colonoscopy findings. The primary outcome measures included the diagnosis rate of colorectal cancer (CRC), polyp detection rate (PDR), and inflammatory bowel disease (IBD) diagnoses in constipated patients versus controls, with age-based and multivariate analyses. Results: Constipated patients exhibiting lower rates of adequate bowel preparation (92.7% vs. 85.3%; p < 0.001) and a lower cecal intubation rate. No significant variances between CRC and PDR were observed between constipated and controls, except for a potential of a slightly elevated CRC risk in constipated patients older than 80 (2.50% vs. 0% in controls; p = 0.07). Multivariate analysis demonstrated, across all age groups, that constipation did not confer an increased risk for CRC or polyp detection. Younger constipated patients exhibited a higher rate of IBD diagnoses (1.7% vs. 0.1% in controls; p < 0.001). Conclusions: Constipation did not confer an increased risk for CRC or polyps, among any age groups, except for a potential signal of elevated CRC risk in patients older than 80; additionally, it was associated with higher rates of IBD in younger patients.

Hepatitis B virus infection and risk of colorectal cancer: a large, population-based cohort study from Israel.

BACKGROUND: Recent population-based studies have suggested a possible link between hepatitis B (HBV) infection and extra-hepatic malignancies. We aimed to evaluate the association between HBV and colorectal cancer (CRC) using a large, population-based cohort study utilizing data from a large health maintenance organization (HMO). METHODS: The study included patients with non-cirrhotic HBV based on relevant ICD-9-CM codes and supportive serology identified from the HMO's database. Age-, sex-, ethnicity-, and BMI-matched non-HBV patients in a 1:10 ratio were included in the control group. We assessed the overall diagnosis rate of CRC and hepatocellular carcinoma (HCC) during the study period and calculated the diagnosis rate of CRC in each age category (≤50, 51-70, and ≥70) in both groups. RESULTS: A total of 3430 HBV patients and 34,300 controls were included in the study. The mean age, sex, BMI, and ethnic composition were similar, and the rates of family history of CRC did not differ between both groups. The overall follow-up period was 134±16 months. The diagnosis rate of HCC (1.6% vs. 0.1%; P<0.0001) was significantly higher in the HBV patients. However, the proportion of CRC was comparable for both groups (0.6% vs. 0.8%, P=0.404), which was evident in all age subgroups. CONCLUSIONS: Our findings suggest that HBV infection is associated with an increased risk of HCC diagnosis but is not linked to an elevated risk of CRC. These findings may inform future clinical practice and research regarding the relationship between HBV and extrahepatic malignancies.

Colorectal Cancer Screening in the Elderly: Does Increased Prevalence Necessitate Tighter Surveillance.

BACKGROUND: With age, colorectal cancer (CRC) prevalence rises. The elderly (> 75 years), and the very elderly (> 85 years) are especially vulnerable. The advantages of screening must be assessed in the context of diminished life span and co-morbidities. OBJECTIVES: To compare CRC findings in colonoscopies that were performed following a positive fecal occult blood test/fecal immunochemical test (FOBT/FIT) in both elderly and very elderly age groups with those of younger patients. METHODS: We identified colonoscopies conducted between 1998 and 2019 following a positive stool test for occult blood in asymptomatic individuals. A finding of malignancy was compared between the two patient age groups. Furthermore, a sub-analysis was performed for positive malignancy findings in FOBT/FIT among patients > 85 years compared to younger than < 75 years. RESULTS: We compared the colonoscopy findings in 10,472 patients: 40-75 years old (n=10,146) vs. 76-110 years old (n=326). There was no significant difference in prevalence of CRC detection rate between the groups following positive FOBT/FIT (2.1% vs. 2.7%, P = 0.47). Similar results for non-significant differences were obtained in the sub-analysis compared to malignancy detection rates in the very elderly 0% (n=0) vs. 2.1% for < 75 years old (n=18), P = 0.59. CONCLUSIONS: Although the prevalence of CRC increases with age, no significant increase in the detection rate of CRC by FOBT was found in either the elderly or very elderly age groups. Screening colonoscopies in elderly patients should be performed only after careful consideration of potential benefits, risks, and patient preferences.

Screening and Colonoscopy Quality Measures: Ethnic Disparities and Impact on Patients' Outcome.

Background: Recent reports have confirmed the improving trends in colorectal cancer (CRC) incidence and outcomes. Still, disparities in incidence and mortality in CRC continue to persist between major ethnic groups despite the provision of widespread screening and improved care. We aimed to outline, from an endoscopic point of view, ethnic disparities in major endoscopic measures concerned with CRC screening and detection and track their impact on patients' outcomes. Methods: We reviewed electronic reports of patients referred for colonoscopy procedures over 20 years. We compared demographic, clinical, and endoscopic findings between major ethnic population groups in Israel. In addition, trends of screening utilization, bowel preparation, and polyp detection rates were tracked, and the incidence of CRC diagnosis was followed. Results: A total of 51307 patients had undergone colonoscopies, of whom 16% were Arabs, and 84% were Jewish. The procedures performed for CRC screening throughout the study period were significantly lower in Arabs (5% vs. 13.1%; P < 0.0001). In parallel, for most of the follow-up period, the Arab patients had higher rates of inadequate bowel preparation (overall: 19.9% vs. 12%; P < 0.001) and a lower polyp detection rate (16.7% vs. 22.5%; P < 0.0001). Expectedly, the incidence of CRC has steadily decreased in the Jewish group, while an adverse pattern of increasing incidence was documented in the Arab patient during the follow-up period. Conclusion: Characterized by lower screening utilization and poor bowel preparation, the incidence of CRC development in Arab patients is increasing, while improving trends of CRC were observed in their Jewish counterparts.

Colonoscopy in the young: An indication-based analysis of outcome.

BACKGROUND: Data on colonoscopy's diagnostic yield in young adults with lower gastrointestinal symptoms are scarce. We evaluated this yield in young patients by performing an indication-based analysis of outcomes. METHODS: We reviewed diagnostic colonoscopies performed in young adults (age <50 years) over 10 years. We created two groups of young adults (18-39 years, n = 4941) and quadragenarians (40-49 years; n = 6605), included a control group of average-risk patients referred for screening colonoscopies during the same period (50-60 years, n = 1453). We evaluated clinical indications for colonoscopies among the young and performed an indication-based analysis of patients' outcomes. RESULTS: Chronic diarrhea and abdominal pain (42.4 and 36.2%), rectal bleeding (19.8 and 18.4%), and constipation were major indications for colonoscopy performance in quadragenarian and younger patients, respectively. Overall, diverticulosis (8.7 vs 1.3 and 3.9%; p1,2 < 0.000) and polyp detection rates (PDR) (19.6 vs 6.1 and 12.1; p1,2 < 0.000) were significantly higher in the control group, while inflammatory bowel disease (10.9 and 3.6% vs 0.1%; p1,2 < 0.000) was more prevalent in both young patients' groups. Indication-based analysis revealed that rectal bleeding was linked with increased PDR and significantly and independently associated with colorectal cancer (CRC) development (odds ratio = 10.160. p < 0.001 and 95% confidence interval = 6.201-16.647), even in the younger patients. In contrast, performing a colonoscopy for the evaluation of constipation was associated with the lowest yield. CONCLUSION: We outlined the expected diagnostic yields of colonoscopy performed in young patients for multiple indications, showing that rectal bleeding was consistently associated with CRC and polyp detection.

Performance of serum-based biomarkers in fibrosis prediction of chronic hepatitis B patients in real life practice.

BACKGROUND: Few studies have addressed the performance and diagnostic accuracy of laboratory-based markers for fibrosis prediction in chronic hepatitis B (CHB) patients yielding heterogeneous results. We aimed to study the performance of the FIB-4 and neutrophil-to-lymphocyte ratio (NLR) markers for the differentiation between significant and non-significant hepatic fibrosis in real-life practice. METHODS: We prospectively recruited CHB patients attending the hepatology clinic to undergo shear wave elastography (SWE) and blood tests. The predictive accuracy of FIB-4 and NLR for liver fibrosis was assessed by receiver operating characteristics (ROC) analysis. RESULTS: Overall, 174 fully characterized CHB patients with an average age of 50.2±11.2 (29-86 years) and a male predominance (65.2%) were included. Of these, 23% had significant fibrosis (≥F2) per SWE (>7.1KPA). A significant and linear correlation was found between the SWE score and FIB-4 values (r=0.572; P<0.001). A lower cut-off of 1.43 has yielded an AUROC of 0.76, with a sensitivity of 68.8%, specificity of 79.8%, diagnostic accuracy of 78.5%, and NPV of 96%. On the contrary, NLR values were similar between significant and minimal fibrosis and were not found to be correlated with significant fibrosis (r=0.54, P=0.39). CONCLUSIONS: FIB4 has a moderate performance and may have a valuable role in excluding significant fibrosis in CHB patients in daily practice.

Obstructive Esophageal Cancers at Endoscopy Are Associated with Reduced Survival and Poor Outcome.

BACKGROUND: Esophageal cancer is comprised of adenocarcinoma and squamous cell carcinoma and is the sixth leading cause of cancer-related mortality worldwide. Upper endoscopy may reveal a partially or completely lumen-occluding mass at diagnosis, yet the prognostic significance of such a presentation is not clear. OBJECTIVES: To investigate whether endoscopic obstructing lesions have a meaning regarding patient prognosis. METHODS: We reviewed upper gastrointestinal endoscopic studies performed over a 20-year period (2000-2020). We compared overall survival, disease stage, histologic criteria, and anatomic location of the lesions in esophagus lumen-obstructing and non-obstructing tumors. Differences between the two groups were statistically evaluated. RESULTS: Sixty-nine patients were diagnosed with histologically confirmed esophageal cancer. As assessed through endoscopy, 32/69 (46%) patients had obstructive and 37/69 (54%) had non-obstructive cancers. Median survival was significantly shorter in the lumen-obstructing lesions compared with the non-obstructing lesions (3.5 months vs. 10 months, P = 0.001). Female median survival displayed a trend toward shorter survival compared to males (3.5 months vs. 10 months, P = 0.059). There was no statistically significant difference in the percentages of advanced, stage IV disease in the obstructive group and the non-obstructive group (11/32 [34.3%] and 14/37 [37.8%], respectively P = 0.80). CONCLUSIONS: Obstructive esophageal cancers predict shorter median overall survival compared with non-obstructive cancers, without any correlation between obstruction of the lesion and tumor metastatic stage.

Chronic hepatitis B infection and diabetes mellitus: a double liver trouble?

BACKGROUND: Concomitant Diabetes mellitus (DM) is commonly recognized in patients with chronic hepatitis B (CHB) infection, although its impact on liver-related outcomes remains controversial. We aimed to evaluate the effect of DM on the course, management and outcome of patients with CHB. METHODS: We performed a large retrospective cohort study utilizing the Leumit-Health-Service (LHS) database. We reviewed electronic reports of 692106 LHS members from different ethnicities and districts in Israel from 2000-2019 and included patients with CHB diagnosis based on ICD-9-CM codes and supportive serology results. These were divided into two cohorts of patients with CHB and DM (CHD-DM) (N.=252) and those with CHB without DM (N.=964). Clinical parameters, treatment figures and patients' outcomes were compared and multiple regression models and Cox regression analysis were performed to investigate the association between DM and cirrhosis/HCC risk in CHB patients. RESULTS: CHD-DM patients were significantly older (49.2±10.9 vs. 37.9±14, P<0.001), and had higher rates of obesity (BMI>30) and NAFLD (47.2% vs. 23.1%, and 27% vs. 12.6%, P<0.001, respectively). Both groups had a predominance of inactive carrier (HBeAg negative infection) state, but the HBeAg seroconversion rate was significantly lower in the CHB-DM group (25% vs. 45.7%; P<0.01). Multivariable Cox regression analysis showed that DM was independently associated with increased cirrhosis risk (HR 2.63; P=0.002). Older age, advanced fibrosis and DM were associated with HCC, but DM did not reach significance (HR 1.4; P=0.12) possibly due to the small number of HCC cases. CONCLUSIONS: Concomitant DM in CHB patients was significantly and independently associated with cirrhosis and possibly with increased risk of HCC.

Effect of Doctor's and Assisting Nurse's Years of Experience on Polyp Detection Rate: A Retrospective Cohort.

BACKGROUND: Polyp detection rate (PDR) is a convenient quality measure indicator. Many factors influence PDR, including the patient's background, age, referral (ambulatory or hospitalized), and bowel cleansing. OBJECTIVES: To evaluate whether years of professional experience have any effect on PDR. METHODS: A multivariate analysis of a retrospective cohort was performed, where both patient- and examiner-related variables, including the experience of doctors and nurses, were evaluated. PDR, as the dependent variable was calculated separately for all (APDR), proximal (PPDR), and small (SPDR) polyps. RESULTS: Between 1998 and 2019, 20,996 patients underwent colonoscopy at a single center. After controlling for covariates, the experience of both doctors and nurses was not found to be associated with APDR (odds ratio [OR] 0.99, 95% confidence interval [95%CI] 0.98-1.00, P = 0.15 and OR 1.03, 95%CI 1.02-1.04, P < 0.0001, respectively). However, after 2.4 years of colonoscopy experience for doctors, and 9.5 years of experience for nurses, a significant increase in APDR was observed. Furthermore, results revealed no association for PPDR and SPDR, as well. CONCLUSIONS: Years of colonoscopy experience for both doctors and assisting nurses were not associated with APDR, PPDR, and SPDR. In doctors with 2.4 years of experience and nurses with 9.5 years of experience, a significant increase in APDR was observed.

The impact of ethnicity on chronic hepatitis B infection course and outcome: big data analysis from Israel.

OBJECTIVES: The effect of ethnicity on chronic hepatitis B virus (CHB) infection's course and outcome has attracted little research. We aimed to compare different aspects of ethnic disparities in CHB patients, including prevalence, phenotypes, management, and outcome between two major ethnic groups in Israel. DESIGN: We conducted a large retrospective cohort study utilizing the Leumit-Health-Service database. Electronic reports of almost 700,000 members from different ethnicities and districts throughout Israel from 2000 to 2019 were reviewed. Patients' ethnicity was categorized based on the classification of the Israeli Central Bureau of Statistics into two main groups, Arabs and Jews. CHB diagnosis was based on ICD-9-CM codes and supportive serology results. Prevalence, clinical backgrounds, disease course, and patients' outcomes were compared between both groups. RESULTS: The prevalence of CHB in the Arab minority group was almost twice and a half-higher when compared to their Jewish counterparts (4.3% vs. 1.8%), but they had a lower rate of referral for HBsAg testing (7% vs. 7.9%). The Arab CHB patients were significantly younger at the time of diagnosis (37.6± 13.5 vs. 45.3± 15; P < 0.001). Male predominance was noted in both groups. The Arab patients had a higher rate of active hepatitis (HBeAg-positive and/or negative hepatitis) phase (36.4% vs. 29.8%; P = 0.01), as well as a significantly higher rate of HBeAg seroconversion (45.2% vs. 35.4%; P = 0.033). Nucleos/tide analogue treatment figures were similar, with most patients in both groups receiving a high barrier to resistance treatment. Patients' outcome was similar in both groups as the rate of hepatocellular carcinoma, cirrhosis, and advanced fibrosis (after stratification analysis) were comparable between both groups. CONCLUSION: Marked by a prominently higher prevalence of HBV infection, patients in the Arab ethnic group had a lower rate of referral for HBsAg testing but received comparable management and had a similar outcome compared to their Jewish counterparts.

Real-world hepatitis B antiviral treatment trends and adherence to practice guidelines: a large cohort study.

BACKGROUND: Epidemiologic data regarding chronic hepatitis B virus infections in Israel is limited as extensive population-based studies have not been performed. OBJECTIVE: This work aimed to evaluate the current characteristics of hepatitis B infection among Israeli adults and evaluate adherence to the European Association for the Study of the Liver practice guidelines for antiviral treatment. METHODS: Clinical and demographic data of HBsAg-positive patients registered in the Leumit-Health-Service database (one of the four major health maintenance organizations in Israel) between 2000 and 2019 were retrieved. Patients were compared according to eligibility to antiviral treatment and type of nucleos(t)ide analogue (NA) treatment. RESULTS: In total, 1216 patients had documented HBsAg positivity (males 58.6%, mean age 40.2 ± 14.2 years), 90.6% of whom were HBeAg negative. Antiviral therapy eligibility was met by 37% of patients, among whom 89% received antiviral therapy. Antiviral therapies include NA with a high barrier to resistance (HBR) (64.5%) and NA with a low barrier to resistance (LBR) (35.5%). Compared to patients who received LBR NA, patients receiving HBR NA had shorter treatment (68.7 ± 50 vs. 161.5 ± 42.6 months, p < .001) and follow-up duration (125 ± 68 vs. 188 ± 48 months, p < .001); at the end of follow-up, ALT levels and APRI score were higher among patients on LBR NA compared to patients on HBR NA. CONCLUSION: Most patients received antiviral treatment according to the international practice guidelines. However, one-third of them were treated with a less potent NA, probably due to their lower cost. These findings should encourage the optimization of HBV care and full compliance with the professional practice guideline recommendations.

Clinical and endoscopic predictors of gastric precancerous conditions: a large population case control study.

BACKGROUND: Atrophic gastritis (AG) and gastric intestinal metaplasia (GIM) are well defined intermediate precancerous conditions (PCCs) in the gastric cancer cascade. The diagnosis of PCCs may be suspected based on endoscopic findings but is established by histology. Estimates of the global prevalence of PCCs vary widely but simple clinical or endoscopic predictors of their diagnosis are ill defined. We aimed to evaluate the prevalence of gastric PCCs in our practice and to identify predictors for its diagnosis. METHODS: We analyzed electronic reports of patients referred for gastroscopy procedures over a 5-year period and included those for whom gastric biopsies were performed. We investigated demographic, clinical, and endoscopic findings to identify possible association with histologic detection of gastric PCCs and performed multivariate analysis to identify predictors of its diagnosis. RESULTS: A total of 4930 patients with full endoscopic and histologic data were included for the final analysis. Of these, 806 (16.3%) patients had a histologic diagnosis of gastric PCCs. Demographic and clinical variables including male sex (51.4% vs. 45.7%; P=0.003), age over 60 (69.8% vs. 45.2%; P<0.001), and anemia indication for gastroscopy (17.6% vs. 14.8%; P=0.04) were significantly associated with gastric PCCs diagnosis. Likewise, endoscopic findings of Barret's esophagus (2.6% vs. 1.3%; P=0.006), atrophic gastritis according to endoscopist's judgment (12.9% vs. 3.5%; P<0.01) and corpus predominant gastritis (22.5% vs. 14.7%; P=0.02) were significantly associated with gastric PCCs. In multivariate analysis, age>60 (please explain all acronyms HR 2.51, 95% CI 2.12-2.96), male sex (HR 1.235, 95% CI 1.05-1.44), corpus predominant (HR 1.284, 95% CI 1.04-1.57), and atrophic gastritis (HR 4, 95% CI 3.07-5.21) were independent predictors for PCCs diagnosis. CONCLUSIONS: Not uncommonly encountered in our practice, a judicious performance of gastric biopsies to detect gastric PCCs should be adopted especially in older, male patients with endoscopic findings of corpus predominant and/or gastric atrophy.

Pulmonary embolism risk in hospitalized patients with nonalcoholic fatty liver disease: A case-control study.

Abundant research has associated nonalcoholic fatty liver disease (NAFLD) with atherosclerosis, but very few reports have evaluated the association between NAFLD and venous thromboembolism. We aimed to investigate the association between NAFLD and pulmonary embolism (PE) in hospitalized patients. In this retrospective case-control study, we included consecutive patients from 2 university-affiliated hospitals who were referred for CT pulmonary angiograms for a suspected PE. Patients with a history of excessive alcohol consumption, chronic liver diseases or cirrhosis were excluded. The imaging studies of the entire cohort were reviewed by 2 expert radiologists who confirmed the diagnosis of PE and examined the liver to detect and grade hepatic steatosis. Accordingly, patients were categorized into NAFLD patients and non-NAFLD controls. Patient demographics, medical history, hospitalization details as well as patients' outcomes were documented. Multivariate analysis was performed to identify predictors for developing PE and hazard ratios with corresponding 95% confidence intervals were estimated. A total of 377 patients (101 with NAFLD and 276 controls) were included. NAFLD patients had significantly higher BMI values (33.16 ±â€…6.78 vs 26.81 ±â€…5.6; P < .001) and prevalence of diabetes (41 (40%) vs 85 (30.8%); P = .03). The prevalence of PE was significantly higher in the NAFLD group (80 (79.2%) vs 147 (53.3%), P < .001). In a multivariate analysis, older age, recent surgery or trauma, active malignancy, smoking, and NAFLD (HR ratio = 4.339, P < .0001 and 95% CI = 2.196-8.572) were independently associated with PE development. Patients with NAFLD were associated with an increased risk of developing PE independent of other classical risk factors for PE.

The yield of solid swallows in high resolution esophageal manometry among patients with dysphagia and gastro-esophageal reflux symptoms.

BACKGROUND: Swallowing disorders are frequently reported esophageal symptoms and represent a common cause for referrals to gastroenterology consultations. Esophageal high-resolution manometry (HRM) is considered the gold standard modality for the evaluation of esophageal peristalsis and esophageal sphincter. The standard protocol of HRM includes water swallows only, that may not assess appropriately esophageal function and symptoms. Hence, we investigated the diagnostic yield of combining solid food swallows (SFS) to standard HRM. METHODS: We conducted a retrospective study at the Gastroenterology unit of EMMS Nazareth Hospital, Israel. Patients who underwent manometry mainly due to dysphagia or reflux symptoms between November 2019 and November 2020 were enrolled. All patients underwent routine HRM and completed ten 5 ml water swallows and 5 bread swallows. Analysis and reports were done by an expert gastroenterologist, based on the Chicago Classification version 3. RESULTS: Overall, 99 patients (45.5% men, mean age 52.1±16 years) who underwent HRM were included. The addition of solid swallows to the test changed manometry results in 43 patients (43.4%) (P<0.005). Furthermore, SFS improved the contractility in 26/42 cases of ineffective and/or absent motility (61%) (P< 0.005). Finally, SFS aggravated symptoms in 44 patients (44.6% more aggravation than in liquid only) (P<0.005). CONCLUSIONS: Combining SFS to HRM can improve the diagnostic yield of the study. Adding solid swallows is of special value in cases of ineffective esophageal motility but induces a high rate of symptoms aggravation.

HBV-RNA, Quantitative HBsAg, Levels of HBV in Peripheral Lymphocytes and HBV Mutation Profiles in Chronic Hepatitis B.

A comprehensive characterization of chronic HBV (CHB) patients is required to guide therapeutic decisions. The cumulative impact of classical and novel biomarkers on the clinical categorization of these patients has not been rigorously assessed. We determined plasma HBV-RNA and HBsAg levels, HBV in peripheral lymphocytes (PBMCs) and HBV mutation profiles in CHB patients. Patient demographics (n = 139) and classical HBV biomarkers were determined during a clinical routine. HBV-RNA in plasma and HBV-DNA in PBMCs were determined by RT-PCR. HBsAg levels were determined using Architect. In samples with HBV-DNA viral load >1000 IU/mL, genotype mutations in precore (PC), basal core promoter (BCP), HBsAg and Pol regions were determined by sequencing. Most patients (n = 126) were HBeAg-negative (HBeAgNeg) with significantly lower levels of HBV-RNA, HBV-DNA and HBsAg compared to HBeAg-positive (HBeAgPos) patients (p < 0.05). HBV genotype D prevailed (61/68), and >95% had BCP/PC mutations. Escape mutations were identified in 22.6% (13/63). HBeAgNeg patients with low levels of HBsAg (log IU ≤ 3) were older and were characterized by undetectable plasma HBV-DNA and undetectable HBV-RNA but not undetectable HBV-DNA in PBMCs compared to those with high HBsAg levels. In >50% of the studied HBeAgNeg patients (66/126), the quantitation of HBsAg and HBV-RNA may impact clinical decisions. In conclusion, the combined assessment of classical and novel serum biomarkers, especially in HBeAgNeg patients, which is the largest group of CHB patients in many regions, may assist in clinical decisions. Prospective studies are required to determine the real-time additive clinical advantage of these biomarkers.

The Yield of Endoscopy and Histology in the Evaluation of Esophageal Dysphagia: Two Referral Centers' Experiences.

Background and Objectives: The initial diagnostic test required to evaluate esophageal dysphagia is upper endoscopy (EGD) to assess the structure of the esophagus and the esophageo-gastric junction (EGJ). Taking biopsies during EGD has become a common practice in patients with dysphagia to rule out eosinophilic esophagitis (EoE). The aims of this study were to evaluate the endoscopic findings of patients who underwent EGD for esophageal dysphagia, to assess the rate of biopsy taking from the esophagus to diagnose/exclude EoE, and to report histology outcomes of these biopsies. Materials and Methods: This was a retrospective multicenter study that included individuals ≥18 years who underwent EGD due to esophageal dysphagia between the years 2015 and2020, (with no other alarm signs, such as weight loss, new iron deficiency anemia, and lymphadenopathy). We obtained data from patients' electronic files. The endoscopy and histology findings were obtained from endoscopy reports saved in our electronic files. Results: A total of 209 patients were included in the study. The average age was 57.1 ± 17.1 years. The most common endoscopic findings were normal endoscopy in 76 patients (36.4%) and erosive esophagitis in 75 patients (35.9%). Barrett's esophagus and esophageal malignancy were encountered in 11 patients (5.3%) and 2 patients (0.95%), respectively. Esophageal biopsies were taken in 50.2% of patients, and one patient had histological evidence of EoE (0.5%). On univariate analysis, there was a trend for association between proton pump inhibitors (PPIs) use and a normal EGD, but it was not statistically significant (OR 0.28, 95% CI 0.07-1.11, p = 0.07). Conclusions: Endoscopic findings were prevalent in dysphagia patients even when no other alarm symptoms exist. Neoplastic lesions and EOE were rare in our study.

Genetic analysis of four consanguineous multiplex families with inflammatory bowel disease.

BACKGROUND: Family studies support a genetic predisposition to inflammatory bowel diseases (IBD), but known genetic variants only partially explain the disease heritability. Families with multiple affected individuals potentially harbour rare and high-impact causal variants. Long regions of homozygosity due to recent inbreeding may increase the risk of individuals bearing homozygous loss-of-function variants. This study aimed to identify rare and homozygous genetic variants contributing to IBD. METHODS: Four families with known consanguinity and multiple cases of IBD were recruited. In a family-specific analysis, we utilised homozygosity mapping complemented by whole-exome sequencing. RESULTS: We detected a single region of homozygosity shared by Crohn's disease cases from a family of Druze ancestry, spanning 2.6 Mb containing the NOD2 gene. Whole-exome sequencing did not identify any potentially damaging variants within the region, suggesting that non-coding variation may be involved. In addition, affected individuals in the families harboured several rare and potentially damaging homozygous variants in genes with a role in autophagy and innate immunity including LRRK1, WHAMM, DENND3, and C5. CONCLUSION: This study examined the potential contribution of rare, high-impact homozygous variants in consanguineous families with IBD. While the analysis was not designed to achieve statistical significance, our findings highlight genes or loci that warrant further research. Non-coding variants affecting NOD2 may be of importance in Druze patients with Crohn's disease.

Predictors of Clinical Course and Outcomes of Acute Diverticulitis: The Role of Age and Ethnicity.

Background and Objectives: Acute diverticulitis (AD) is the leading and most burdensome complication of colonic diverticulosis. However, risk factors for its development and predictors of its course are still poorly defined. In this regard, the association of a young age with a complicated course and worse outcome are still controversial. Moreover, little research has addressed the effect of ethnicity on the course of AD. The current study aimed to evaluate the impact of these variables on AD's course and outcome in the diverse and unique ethnic landscape of Israel. Materials and Methods: We performed a retrospective review of the charts of patients with a radiologically confirmed diagnosis of AD. Patients' outcomes and disease course, including hospitalization duration, complications, and recurrent episodes, were documented and compared among different age and ethnic groups. Multivariate analysis was performed to identify predictors of complicated AD. Results: Overall, 637 patients with AD were included, the majority (95%) had distal colon AD, and almost one quarter of them were aged less than 50 years. The majority of patients in the young age (<50) group were males (69.7%). Nonetheless, the rate of recurrent episodes (35.3% vs. 37.3%, p = 0.19), hospitalization duration (5 ± 4.7 vs. 6 ± 3.2, p = 0.09) and complications rate (17.3% vs. 13.7%; p = 0.16) were similar for both age groups. In the ethnicity group analysis, Arab minority patients had a first episode of AD at a significantly younger age compared to their Jewish counterparts (51.8 vs. 59.4 years, p < 0.001). However, factors such as a complicated course (16% vs. 15%; p = 0.08) and relapsing episode rates (33% vs. 38%; p = 0.36) did not differ significantly between groups. None of the variables, including young age and ethnic group, were predictors of complicated AD course in the multivariate analysis. Conclusion: AD is increasingly encountered in young patients, especially in ethnic minority groups, but neither ethnicity nor young age was associated with worse outcomes.

Diagnosis and Management of Achalasia: Updates of the Last Two Years.

Achalasia is a rare neurodegenerative disorder causing dysphagia and is characterized by abnormal esophageal motor function as well as the loss of lower esophageal sphincter (LES) relaxation. The assessment and management of achalasia has significantly progressed in recent years due to the advances in high-resolution manometry (HRM) technology along with the improvements and innovations of therapeutic endoscopy procedures. The recent evolution of HRM technology with the inclusion of an adjunctive test, fluoroscopy, and EndoFLIP has enabled more precise diagnoses of achalasia to be made and the subgrouping into therapeutically meaningful subtypes. Current management possibilities include endoscopic treatments such as Botulinum toxin injected to the LES and pneumatic balloon dilation. Surgical treatment includes laparoscopic Heller myotomy and esophagectomy. Furthermore, in recent years, per oral endoscopic myotomy (POEM) has established itself as a principal endoscopic therapeutic alternative to the traditional laparoscopic Heller myotomy. The latest randomized trials report that POEM, pneumatic balloon dilatation, and laparoscopic Heller's myotomy have comparable effectiveness and complications rates. The aim of the current review is to provide a practical clinical approach to dysphagia and to shed light on the most recent improvements in diagnostics and treatment of achalasia over the last two years.

The Impact of Ramadan Fasting on Fatty Liver Disease Severity: A Retrospective Case Control Study from Israel.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is emerging as an important public health condition. The effect of Ramadan fasting on several metabolic conditions has been previously assessed. OBJECTIVES: To assess the impact of Ramadan fasting on non-alcoholic steatohepatitis (NASH) severity scores. METHODS: A retrospective, case control study was conducted in Nazareth Hospital between 2017 and 2019. We included NAFLD patients who had been diagnosed by abdominal ultrasonography. The study population was divided in two matched groups: NASH subjects who fasted all of Ramadan and NAFLD/NASH subjects who did not fast (control). Metabolic/NASH severity scores, homeostatic model assessment of ß-cell function and insulin resistance (HOMA-IR), NAFLD Fibrosis Score (NFS), BARD scores, and fibrosis-4 (FIB4) scores were assessed in both groups before and after the Ramadan month. RESULTS: The study included 155 NASH subjects, 74 who fasted and 81 who did not. Among the fasting group, body mass index decreased from 36.7 ± 7.1 to 34.5 ± 6.8 after fasting (P < 0.003), NFS declined from 0.45 ± 0.25 to 0.23 ± 0.21 (P < 0.005), BARD scores declined from 2.3 ± 0.98 to 1.6 ± 1.01 (P < 0.005), and FIB4 scores declined from 1.93 ± 0.76 to 1.34 ± 0.871 (P < 0.005). C-reactive protein decreased from 14.2 ± 7.1 to 7.18 ± 6.45 (P < 0.005). Moreover, HOMA-IR improved from 2.92 ± 1.22 to 2.15 ± 1.13 (P < 0.005). CONCLUSIONS: Ramadan fasting improved on inflammatory markers, insulin sensitivity, and noninvasive measures for NASH severity assessment.