Impact of intragastric balloon on blood pressure reduction: A retrospective study in Eastern North Carolina.

BACKGROUND: Obesity has evolved into a global pandemic. The prevalence of obesity and hypertension in eastern North Carolina are comparable, if not higher, than the national prevalence. In the United States, an estimated 34% of adults have hypertension, the most modifiable risk factor for heart disease and stroke. Lifestyle and pharmacological interventions often do not provide sustained weight loss in obese patients. Bariatric surgery offers an effective weight reduction with short-and long-term health improvements; however, a higher body mass index is associated with higher surgical morbidity and mortality, longer hospitalization, and increasing rates of 30-day readmission due to co-morbidities. Intragastric balloon may bridge a critical gap in the treatment of obesity. The objective of this paper is to showcase the impact of endoscopic bariatric therapy on blood pressure reduction. AIM: To investigate the impact of intragastric balloon on blood pressure reduction. METHODS: A retrospective chart review was conducted from January 1, 2016 to January 31, 2019 of consecutive adults who received intragastric balloon therapy (IGBT) in a gastroenterology private practice in Eastern North Carolina. The balloon was introduced into the stomach under endoscopic guidance, and while in the region of the gastric body, inflation with saline was performed at increments of 50 mL until target volume between 500 to 650 mL of saline was attained depending on the patient's gastric capacity. No procedural complications were noted during endoscopic placement and removal of the balloon. A cohort study design was used for data analysis. A total of 172 patients had the Orbera® intragastric balloon placed. Of the 172 patients who had IGBT at baseline, 11 patients (6.4%) requested early balloon removal due to foreign body sensation (n = 1), and/or intolerable gastrointestinal adverse events (n = 10). The reported gastrointestinal adverse events were nausea, vomiting, abdominal pain, and diarrhea. Eventually, 6-mo follow-up data were available for only 140 patients. As a result, only the 140 available at the 6-mo follow-up were included in the analysis. Univariate, bivariate, and multivariate statistical analyses were performed. Specifically, scatterplots were created to show the relationship between weight and blood pressure, and paired two-sample t-test was carried out to determine if there was a significant reduction in weight before and after the IGBT. Multiple regressions were also performed to examine the association between participants' total body weight and blood pressure. The outcome variables for the multiple regression were systolic and diastolic blood pressure measured as continuous variables. This was followed by logistic regression analyses to determine the association between total body weight and hypertension at 6-mo post-implantation. The outcome variables for the logistic regression were systolic blood pressure-non-hypertensive (140 mmHg or less) or hypertensive (greater than 140 mmHg), and diastolic blood pressure-non-hypertensive (90 mmHg or less) or hypertensive (greater than 90 mmHg). All authors had access to the study data and reviewed and approved the final manuscript. All statistical analyses were done using STATA 14®. RESULTS: The study included 15% males and 85% females. 50% of the patients were white and just over 22% were non-white, and about 27% declined to give their race. The average baseline patients' weight prior to IGBT was 231.61 Lbs. (SD = 46.53 Lbs.). However, the average patients' weight after IGBT at the 6-mo follow-up was 203.88 Lbs. (SD = 41.04 Lbs.). Hence, on average, the percent total body weight loss at 6-mo is 11.97 after IGBT. The logistic regression performed revealed that weight (ß = 0.0140, P < 0.000) and age (ß = 0.0534, P < 0.000) are important factors in determining systolic blood pressure after IGBT. None of the other demographic characteristics or indicated comorbidities were found to be significant. CONCLUSION: IGBT can be an effective short-term weight reduction modality with a relatively little risk of adverse event. Due to its improvement on systolic blood pressure, IGBT may help reduce cardiovascular risk.

Nutritional Care for Patients with Intestinal Failure.

Intestinal failure is a debilitating, complex disorder associated with loss of portions of intestine or loss of intestinal function. Short bowel syndrome is the most common form of intestinal failure and results in inability to maintain nutritional, fluid, and electrolyte status while consuming a regular diet. Nutrition interventions to treat short bowel syndrome include enteral and parenteral nutrition, intestinal rehabilitation techniques to enhance absorptive capacity of remnant bowel, and surgical reconstruction designed to provide more surface area for absorption. These therapies are interrelated services to restore nutritional status through the safest most effective therapy consistent with patient lifestyle and wishes.

Rectal indomethacin reduces the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis in low-risk patients.

BACKGROUND: Evidence shows that rectal indomethacin (RI) reduces the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk patients. The prophylactic role of RI in low-risk patients has not yet been identified. The objective of our study was to evaluate the impact of RI in preventing PEP in low-risk patients. METHODS: A retrospective cohort study was conducted to evaluate the impact of RI in preventing PEP. RI was available starting November 2012. Patient characteristics and procedure details were collected. RESULTS: The study population included 2238 patients who underwent ERCP (1055 in the RI group and 1183 in the control group). PEP was diagnosed in 107 patients (4.8%). In a multivariate model of consecutive patients, RI reduced the incidence of PEP by 55% (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.36-0.94; P=0.03). In a multivariate model that included 1874 (84%) low-risk patients, RI reduced the incidence of PEP by 62% (OR 0.38, 95%CI 0.19-0.74; P=0.004). Propensity-matched group analysis was performed for low-risk native papilla patients. RI reduced the incidence of PEP by 61% (OR 0.39, 95%CI 0.18-0.8; P=0.009). CONCLUSION: RI reduced PEP in consecutive as well as low-risk patients. RI should be administrated in consecutive patients unless contraindicated. Larger prospective studies are needed to confirm our results.

Patients presenting for colonoscopy: A great opportunity to screen for sleep apnea.

AIM: To discover the prevalence and the feasibility of screening for obstructive sleep apnea (OSA) in patients presenting for routine colonoscopy. METHODS: Adult patients having a colonoscopy for routine indications at our outpatient endoscopy center were eligible if they did not carry a diagnosis of OSA or had not had a prior sleep study. All patients were administered the Berlin questionnaire prior to the procedure. Mallampati, neck circumference, height, weight, and BMI were obtained for each patient. Patients were observed for any drops in oxygen saturation < 92% or the presence of snoring for > 10 s. Patients were determined to be high-risk if they met at least 2 of the 3 symptom categories for the Berlin questionnaire. RESULTS: A total of 60 patients were enrolled and completed the study; mean age was 56 years (range 23-72 year). Twenty-six patients had a positive Berlin questionnaire (43.3%), 31 patients had a negative Berlin questionnaire (51.6%) and 3 patients had an equivocal result (5.0%). Patients with a positive Berlin questionnaire were more likely to be of increased weight (mean 210.5 lbs vs mean 169.8 lbs, P = 0.003), increased BMI (33.0 kg/m2vs 26.8 kg/m2, P = 0.0016), and have an increased neck circumference (38.4 cm vs 35.5 cm, P = 0.012). Patients with a positive Berlin questionnaire were more likely to have a drop in oxygen saturation < 92% (76.9% vs 36.4%, P = 0.01). Patients with snoring were more likely to have a positive Berlin questionnaire (8/9 patients vs 1/31 patients with negative Berlin questionnaire; P = 0.0045). CONCLUSION: Risk for OSA is extremely common in a population presenting for a routine colonoscopy, and screening at the time of a colonoscopy offers an excellent opportunity to identify these patients.

Airway observations during upper endoscopy predicting obstructive sleep apnea.

BACKGROUND: This pilot study examined airway characteristics during upper endoscopy to determine who is at high risk for obstructive sleep apnea. METHODS: Patients undergoing routine upper endoscopy were divided into 2 groups according to the Berlin Questionnaire (high and low risk for sleep disordered breathing). Patients underwent routine upper endoscopy using propofol sedation. The airway was then evaluated for no, partial, or complete collapse at the levels of the palate/uvula/tonsils, the tongue base, the hypopharynx, and the larynx. They were given a score of 0 for no collapse, 1 for partial collapse, and 2 for complete collapse. The score for each of these levels was added to give a total score or severity index. The larynx was also evaluated for lateral pharyngeal collapse (minimal, up to 50%, >50%, or 100%). RESULTS: We found that patients with a partial obstruction at the level of the palate/uvula/tonsils, tongue base, hypopharynx, or larynx, or complete obstruction at any level more often had a positive Berlin questionnaire. Patients with a positive Berlin questionnaire were more often of increased weight (mean 197 vs 175 lbs, P=0.19), increased body mass index (31.2 vs 27.42 kg/m2, P=0.11), increased neck circumference (36.7 vs 34.7 cm, P=0.23), and had a higher total airway score (2.61 vs 1.67, P=0.09). CONCLUSIONS: The results of our pilot study represent preliminary data regarding the use of upper endoscopy as a potential tool to evaluate patients for obstructive sleep apnea.

Adult-Onset Esophageal Crohn's Disease.

Crohn's disease (CD) is an idiopathic inflammatory bowel disease that can involve any part of the gastrointestinal tract. Esophageal involvement is rarely seen in adults, especially at the initial diagnosis of CD. Esophageal symptoms as primary manifestations of the disease are extremely rare. We report a case of a CD with esophageal involvement at the time of her initial diagnosis of CD.

Sclerosing Mesenteritis: A Rare Cause of Small Bowel Obstruction.

Sclerosing mesenteritis falls within a spectrum of primary idiopathic inflammatory and fibrotic processes that affect the mesentery. The exact etiology has not been determined, although the following associations have been noted: abdominal surgery, trauma, autoimmunity, paraneoplastic syndrome, ischemia and infection. Progression of sclerosing mesentritis can lead to bowel obstruction, a rare complication of this uncommon condition. We report a case of a 66-year-old female with abdominal pain who was noted to have a small bowel obstruction requiring laparotomy and a partial small bowel resection. The pathology of the resected tissue was consistent with sclerosing mesenteritis, a rare cause of a small bowel obstruction. Sclerosing mesenteritis has variable rates of progression, and there is no consensus regarding the optimal treatment. Physicians should consider sclerosing mesenteritis in the differential diagnosis of a small bowel obstruction.

Two Cases of Paradoxical Hidradenitis Suppurativa while on Adalimumab.

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disease characterized by recurring abscesses, nodules, and fistulas predominantly in the groin and axillae. The association between HS and Crohn's disease (CD) has been well documented. Tumor necrosis factor (TNF) inhibitors have shown to be effective in treating both HS and CD. We report 2 patients who developed HS while on TNF inhibitor treatment for CD.

Colon Cancer Screening in North Carolina.

Colorectal cancer (CRC) is the 2nd leading cause of cancer death both in North Carolina and in the United States. The goal of CRC screening is early detection and prevention. This commentary reviews the evidence for screening, discusses current screening options, and explores which options are best suited for use in North Carolina.

Review of musculoskeletal injuries and prevention in the endoscopy practitioner.

Practitioners of endoscopy often experience musculoskeletal pain and injury (most often in the back, neck, shoulders, hands, wrists, and thumbs) that are associated with the minute and repetitive strain that is placed on these areas during endoscopic procedures. This review of the current documentation of endoscopy-related pain and injuries among practitioners finds that such problems are widespread and specific in kind as well as strongly correlated with high procedure volume and procedure duration. Research on the nature and impact of cumulative trauma and overuse syndromes in other professions such as dentistry, pianists, production labor, and athletics is brought to bear on the work of the endoscopist. A more thorough understanding of the nature and prevalence of work-related pain and injury sustained by endoscopists should inform further development of ergonomic practices and equipment design. This article reviews current recommendations for ergonomic design in the endoscopy procedure space and finds that reported compliance with those recommendations is quite low. Strategies for the management of the risk of musculoskeletal injuries related to the practice of endoscopy include compliance with currently recommended ergonomic practices, education of trainees in ergonomic technique when practicing endoscopy, and research toward the modification and development of more ergonomic endoscopes and procedure spaces.

Bouveret's Syndrome with Severe Esophagitis and a Purulent Fistula.

Bouveret's syndrome is a rare variant of gallstone ileus with an overall incidence of 1-3%. It is a rare cause of gastric outlet obstruction resulting from the passage and impaction of a large gallstone through a cholecysto-duodenal fistula. A combination of diagnostic modalities is often required for a diagnosis. Management options include endoscopy and surgery. The most commonly performed procedures are enterolithotomy or gastrostomy, either alone or with cholecystectomy and fistula repair. We describe a unique variant of chronic Bouveret's syndrome with the unusual associations of severe esophagitis and a purulent fistula.

The impact of race on weight loss after Roux-en-Y gastric bypass surgery.

BACKGROUND: Gastric bypass surgery for morbid obesity has dramatically increased in volume over the past decade. Caucasian patients have been noted previously to lose more weight after bariatric surgery than African-Americans patients. Data regarding predictors of maintaining weight loss after surgery are minimal. We sought to determine predictors of long-term weight loss after bariatric surgery. METHODS: Retrospective analysis using a multivariate logistic regression model of all patients undergoing Roux-en-Y gastric bypass surgery at the Medical University of South Carolina from May 1993 to December 2004 for whom 2 years of follow-up data was available. Our dependent variable was the percentage of weight lost from baseline, dichotomized at +/-35%. Our primary independent variable was race, defined as Caucasian, African-American, or other. Relevant covariates were added to the model to control for their potential effects on outcome. RESULTS: One hundred eleven patients (17 male/94 female; 85% Caucasian, mean age 44 years (range 18-68 years). In our model, Caucasian subjects (adjusted odds ratio [OR] = 7.60, 95% confidence intervals [95%CI] = 1.83-31.5) and late post surgical complications (adjusted OR = 2.67, 95%CI = 1.05-6.80) significantly predicted weight loss at 2 years, after controlling for relevant confounders. Other covariates did not significantly impact the model. CONCLUSION: Race and late post surgical complications significantly impacted the percentage of weight loss at 2 years for patients undergoing Roux-en-Y gastric bypass surgery at our institution. Future research should be directed at determining potential genetic and/or social reasons for these differences.