Does preoperative enteral or parenteral nutrition reduce postoperative complications in Crohn's disease patients: a meta-analysis.

OBJECTIVES: Crohn's disease (CD) patients frequently develop complications that require surgery for management. The high prevalence of malnutrition in CD patients presents a challenge because poor preoperative nutritional status has been shown to increase postoperative complications. In this study, we assessed whether preoperative enteral nutrition (EN) or total parenteral nutrition (TPN) decreases postoperative complications in CD patients. MATERIALS AND METHODS: A three-point systematic and comprehensive literature search was carried out on multiple databases followed by a meta-analysis with results presented as odds ratio (OR) using two models, the Mantel-Haenszel model and the DerSimonian and Laird model. The I measure of inconsistency was utilized to assess heterogeneity. If statistically significant heterogeneity was identified, the results underwent a separate sensitivity analysis. RESULTS: Five studies met inclusion criteria totaling 1111 CD patients. The rate of postoperative complications in the group receiving preoperative nutrition (EN or TPN) support was 20.0% compared with 61.3% in the group who had standard care without nutrition support [OR=0.26, 95% confidence interval (CI): 0.07-0.99, P<0.001]. Postoperative complications occurred in 15.0% of patients in the group who received preoperative TPN compared with 24.4% in the group who did not (OR=0.65, 95% CI: 0.23-1.88, P=0.43). Postoperative complications occurred in 21.9% in the group who received preoperative EN compared with 73.2% in the group that did not received preoperative EN (OR=0.09, 95% CI: 0.06-0.13, P<0.001). CONCLUSION: Preoperative nutrition supplementation reduces postoperative complications in CD patients. In particular, EN in CD patients before undergoing surgery is superior to standard of care without nutrition support with a number needed to treat of 2. There is a trend toward TPN being superior to standard of care without nutrition support, but this trend did not reach statistical significance. Further studies are necessary to evaluate specific components in EN or TPN that may be most beneficial for CD patients requiring surgical intervention.

Females without reflux symptoms or gastroesophageal reflux disease have less distal esophageal acid exposure than males without reflux symptoms or gastroesophageal reflux disease.

Ambulatory 24-hour esophageal pH monitoring is the gold standard examination to assess esophageal acid exposure. Gender-related variation is a well-recognized physiologic phenomenon in health and disease. To date, limited gender-specific 24-hour esophageal pH monitoring data are available. The aim of this study was to obtain values of esophageal pH monitoring in males and females without reflux symptoms or gastroesophageal reflux disease (GERD) to determine if gender variation exists in esophageal acid exposure among individuals without these factors. Twenty-four-hour dual esophageal pH monitoring was performed in male and female volunteers without reflux symptoms or GERD. Values for total number of reflux episodes, episodes longer than 5 minutes, total reflux time in minutes, % time with pH below 4, and longest reflux episode in the proximal/distal esophagus were obtained and recorded for both groups. The distal channel was placed 5 cm and proximal channel 15 cm above the manometrically determined lower esophageal sphincter. Means were compared using an independent sample t-test. Sixty-seven males and 69 females were enrolled. All subjects completed esophageal 24-hour pH monitoring without difficulty. There was no age or body mass difference between groups. Females had significantly fewer reflux episodes at both esophageal measuring sites and, significantly less total reflux time and % time with pH below 4 in the distal esophagus than males. All other parameters were similar. Significant gender-related differences exist in esophageal acid exposure, especially in the distal esophagus in individuals without reflux symptoms or GERD. These differences underscore the need for gender-specific reference values for 24-hour pH monitoring, allowing for an accurate evaluation of esophageal acid exposure in symptomatic patients.

Decreased acid suppression therapy overuse after education and medication reconciliation.

BACKGROUND: Acid suppression therapy (AST) is commonly overprescribed in hospitalised patients. This indiscriminate use increases cost and drug-related side effects. Minimal data is available on interventions aimed at reducing the burden of overprescription. The aim of our study was to evaluate the impact of education and medication reconciliation forms use on admission as well as discharge, on AST overuse in hospitalised patients. METHODS: A retrospective chart review of randomly selected patients admitted to the general medicine service at University of Florida Health Science Center/Jacksonville was performed prior to and after the introduction of interventions (education/medication reconciliation) aimed at reducing AST overuse. The percentage of patients started on inappropriate AST, the admitting diagnosis, indications for starting AST and discharge on these medications was compared in the pre and postintervention groups. RESULTS: Acid suppression therapy use declined from 70% (279/400) in the preintervention period to 37% (100/270) postintervention (p < 0.001). There was a reduction in inappropriate prescriptions from 51% (204/400) pre to 22% (60/270) postintervention (p < 0.02). Stress ulcer prophylaxis in low-risk patients or the concomitant use of ulcerogenic drugs continued to motivate inappropriate AST therapy in most patients. Postintervention, only 20% (12/60) of patients were discharged on unneeded AST compared with 69% (140/204) in the preintervention group (p < 0.001). CONCLUSION: Interventions consisting of education and use of medication reconciliation forms decreased inappropriate prescription of AST on admission and discharge. This can significantly decrease cost to the healthcare system and the risk of drug interactions.

Reflux episodes are similar in healthy African Americans and non-Hispanic whites.

Ambulatory esophageal pH monitoring is the current gold standard diagnostic exam for gastroesphageal reflux disease. Presently, no data are available for normal 24-hour esophageal pH monitoring among any US ethnic group. The aim of the present study was to obtain normal values of 24-hour esophageal pH monitoring in healthy adult African American (AA) volunteers and compare these with values obtained in healthy non-Hispanic white (nHw) volunteers to determine if ethnic variation exists in 24-hour esophageal pH testing. Twenty-four-hour dual esophageal pH monitoring was performed in healthy AA and nHw. Values for total number of reflux episodes, episodes longer than 5 min, total reflux time in minutes, and longest reflux episode in the proximal and distal esophagus were obtained for both ethnic groups. Differences between groups were considered significant if P < 0.05. Eighty subjects volunteered for the study and completed 24-hour pH testing. Forty-one were AAs and 39 were nHws, with males making up 49% of each group. The AAs were older and had higher body mass index than the nHws. No difference was observed between the AA and the nHw subjects for any measured pH parameter in either the proximal or distal esophagus. There is no difference in values obtained during esophageal pH monitoring in healthy African Americans and non-Hispanic whites. This indicates that the currently accepted normal values of ambulatory esophageal pH monitoring are readily applicable to African Americans and can be used without compromising diagnostic accuracy in this ethnic group.

Ethnic variation in lower oesophageal sphincter pressure and length.

BACKGROUND: Oesophageal manometry (OM) is used to diagnose oesophageal motor disorders. Normal values of OM among United States ethnic groups are only available for Hispanic Americans (HA). AIM: To obtain normal values of OM in adult African American (AA) volunteers, compare these with those obtained in HA and non-Hispanic white (nHw) volunteers to determine if ethnic variation in normal oesophageal motor function exists. METHODS: Healthy AA, HA and nHw were recruited from the Jacksonville metropolitan area. Ethnicity was self-reported. Exclusion criteria were symptoms suggestive of oesophageal disease, medication use or concurrent illness affecting OM. All underwent OM using a solid-state system with wet swallows. Resting lower oesophageal sphincter (LOS) pressure and LOS length were measured at mid-expiration, while per cent peristaltic contractions, distal oesophageal contraction velocity, amplitude and duration were measured after 5 cc water swallows. RESULTS: Fifty-six AA, 20 HA and 48 nHw were enrolled. All completed OM. AA had significantly higher resting LOS pressure, LOS length and distal oesophageal contraction duration than nHw (P < 0.05). CONCLUSIONS: Significant ethnic exist in OM findings between AA and nHw. These underscore the need for ethnic specific reference values for OM to allow for correct diagnosis of oesophageal motor disorders in AA.

Significant increase in the prevalence of non-rheumatic aortic valve disease in patients with type 2 diabetes mellitus.

BACKGROUND: Diabetes mellitus (DM) is a major risk for coronary artery disease and hyperlipidemia. The role of Diabetes as an independent risk factor for aortic stenosis or regurgitation has been controversial. The goal of this study was to evaluate any association between DM and non-rheumatic aortic valve disease using a very large database. METHOD: We used PTF documents containing discharge diagnosis using ICD-9 codes of inpatient treatment from all Veterans Health Administration Hospitals (VA). The data were stratified using ICD-9 code for DM (n=293,124), a control group with hypertension (HTN) but no DM (n=552,623). The occurrence of non-rheumatic aortic valve disease in DM patients was studied in comparison with the control. We performed multivariate analysis adjusting for coronary artery disease (CAD), congestive heart failure (CHF) , smoking, renal failure, and hyperlipidemia. RESULTS: Non-rheumatic aortic valve disease diagnosis was present in 7,322 (2.5%) of DM patients vs. 10,906 (2.0%) in the control group. (25% relative increase) Using multivariate analysis, DM remained strongly associated with non-rheumatic aortic valve disease: (odds ratio (OR): 2.23, 95%; confidential interval (CI): 2.16 to 2.30 p<0. 0001). CONCLUSION: Type II diabetes mellitus is independently associated with non-rheumatic aortic valve disease. Since women were underrepresented in our study, our results apply only to diabetic men. The cause of this association is not known. CONDENSE ABSTRACT:The role of Diabetes as an independent risk factor for aortic stenosis or regurgitation has been controversial. We used PTF documents containing discharge diagnosis using ICD-9 codes of inpatient treatment from Veterans Health Administration Hospitals (VA) were analysed.( DM (n=293,124), a control group with hypertension (HTN) but no DM (n=552,623)). The occurrence of non-rheumatic aortic valve disease in DM patients was studied in comparison with the control. Non-rheumatic aortic valve disease diagnosis was present in 7,322 (2.5%) of DM patients vs. 10,906 (2.0%) in the control group. Using multivariate analysis, DM remained strongly associated with non-rheumatic aortic valve disease: (odds ratio (OR): 2.23, 95%; confidential interval (CI): 2.16 to 2.30 p<0. 0001). Since women were underrepresented in our study, our results apply only to diabetic men.

Rare complications of endoscopic retrograde cholangiopancreatography: two case reports.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic procedure with several known risks. We present two rarely reported complications of ERCP and sphincterotomy: transverse mesocolon disruption with ischemic colitis and splenic rupture. RESULTS: The first patient, a 54-year-old female, presented one day following ERCP and stent revision for pancreas divisum. She presented with hypotension and abdominal distention. An abdominal computed tomography (CT) showed a ruptured spleen, which was confirmed on laparotomy. She had a complicated postoperative course and died of multiple organ failure. The second patient is a 56-year-old female who presented five days after ERCP and sphincterotomy with abdominal pain, abdominal wall ecchymosis, and decreasing hematocrit. Her evaluation included hospital admission and abdominal CT scan, which showed free fluid and a large hematoma in the transverse mesocolon. These findings were confirmed on laparotomy and a devascularized segment of bowel was resected. CONCLUSION: Only 6 cases of ERCP-related splenic injury have been reported in the literature. One additional report is available of a fatal splenic artery injury. No previous reports exist of a mesenteric hematoma resulting in bowel devascularization. Prompt evaluation and awareness of potential complications should help capture potentially life-threatening sequelae of ERCP.

Changing pattern of esophageal cancer incidence in New Mexico.

OBJECTIVE: Multiple reports indicate that esophageal adenocarcinoma incidence has increased during the past 20 yr, especially in non-Hispanic white men. We retrospectively reviewed adenocarcinoma and squamous cell carcinoma cases in our heterogeneous state population to determine the effect of ethnicity on histology. METHODS: We searched the New Mexico Tumor Registry for all cases of esophageal cancer from 1973 to 1997. Inclusion criteria included histological diagnosis of adenocarcinoma or squamous cell carcinoma, self-reported ethnicity, and gender. Age-adjusted incidence rates for both adenocarcinoma or squamous cell carcinoma were compared among ethnic groups in 5-yr intervals. RESULTS: Six hundred fifteen patients met inclusion criteria. Esophageal adenocarcinoma age-adjusted incidence rates/100,000 increased significantly during the 25-yr period: 1973-1977, 0.25 cases; 1978-1982, 0.33 cases; 1983-1987, 0.45 cases; 1988-1992, 0.85 cases; and 1993-1997, 1.19 cases; p < 0.001. In comparison, squamous cell carcinoma age-adjusted incidence rates did not increase significantly during the study period. In non-Hispanic whites, the histological age-adjusted incidence rate changed during the 1993-1997 period compared to other periods: 1993-1997, squamous cell carcinoma 1.01 and adenocarcinoma 1.42, p < 0.001. In Hispanics, the age-adjusted incidence rate of adenocarcinoma increased significantly in the fifth period compared to other periods, p < 0.001. In all minority groups, squamous cell carcinoma remained the predominant type. CONCLUSIONS: Esophageal adenocarcinoma age-adjusted incidence increased in New Mexico from 1973 to 1997. This increase was found in non-Hispanic whites and Hispanics and became predominant in non-Hispanic whites. Squamous cell carcinoma remains the primary type in minorities. This study suggests that ethnicity may influence esophageal cancer histology or ethnic background may place an individual at increased risk for certain types of esophageal cancer.

Clinical features of hepatitis C-infected patients with persistently normal alanine transaminase levels in the Southwestern United States.

Approximately one third of patients with chronic hepatitis C virus (HCV) infection have normal alanine transaminase (ALT) levels. We studied the clinical, biochemical, virological, and histological features in patients with persistently normal ALT. A case-control study was conducted on 275 patients with chronic HCV infection, including 75 patients with persistently normal ALT and 200 patients with abnormal ALT. Persistently normal ALT was defined as 4 consecutive ALT values in each patient within a period of 12 months. The average age of the patients was 44 years (range 18 to 69 years). More non-Hispanic whites had persistently normal ALT. The mean serum ferritin level was significantly lower in patients with persistently normal ALT as compared with abnormal ALT (128 +/- 92 ng/mL and 224 +/- 128 ng/mL), respectively (P =.017). The mean HCV-RNA level was significantly lower in patients with persistently normal ALT as compared with abnormal ALT (12 x 10(5) +/- 2.8 x 10(6) copies/mL and 33 x 10(5) +/- 8.0 x 10(6)), respectively (P =.02). Histologically, patients with persistently normal ALT had less severe portal inflammation (P <.05), lobular inflammation (P =.003), piecemeal necrosis (P =.002), fibrosis (P <.05), lower prevalence of cirrhosis (P =.007), as well as a slower fibrosis progression rate (P <.001). Chronic hepatitis C patients with persistently normal ALT have low-activity grade and stage on liver biopsy. In these patients the hepatitis C RNA level was lower compared with abnormal ALT patients, which may explain the slower fibrosis progression rate.

Corpus gastritis is protective against reflux oesophagitis.

BACKGROUND: Gastric acid is important in the pathogenesis of reflux oesophagitis. Acid production by the gastric corpus is reduced in corpus gastritis. AIMS: To determine whether corpus gastritis protects against reflux oesophagitis. METHODS: Patients presenting for elective oesophagogastroduodenoscopy were studied. Two biopsy specimens were taken from the antrum, corpus, and cardia and stained with haematoxylin/eosin and Diff-Quick II stains. The presence and severity of gastritis were graded according to a modified updated Sydney classification. RESULTS: Of 302 patients, 154 had endoscopic signs of reflux oesophagitis. There was no difference between patients with and controls without oesophagitis in the overall infection rates with Helicobacter pylori. Acute or chronic corpus gastritis occurred less often in patients with than those without reflux oesophagitis. Compared with controls, corpus gastritis was less severe in patients with reflux oesophagitis. The presence of acute or chronic gastritis in the corpus was significantly correlated with either type of gastritis in other areas of the stomach. In a multivariate logistic regression, age, sex, smoking status, and the presence of chronic corpus gastritis all exerted a significant influence on the presence of reflux oesophagitis. Chronic corpus gastritis was associated with a 54% reduced risk for reflux oesophagitis. CONCLUSIONS: While infection with H pylori alone may not affect the occurrence of reflux oesophagitis, the development of chronic corpus gastritis seems to be protective.

A case-control study of risk factors for sporadic hepatitis C virus infection in the southwestern United States.

OBJECTIVE: We performed a case-control study to evaluate risk factors and possible modes of transmission for hepatitis C virus (HCV) infection in patients with no history of blood transfusion or injection drug use. METHODS: Study subjects were selected from among patients seen in gastroenterology outpatient clinics at a university medical center in the southwestern United States. The study group consisted of 58 patients (12%) with chronic HCV infection who reported no history of transfusion or injection drug use, among a total of 477 patients evaluated for a positive HCV antibody test. These 58 patients were matched by age, ethnicity, and gender with 58 control patients diagnosed with gastroesophageal reflux attending the same clinics. Patients and controls were subjected to structured interviews and review of medical records. RESULTS: A variety of variables were significantly associated with increased risk of sporadic HCV infection, including a history of tattoos, needlestick exposure, a history of sexually transmitted disease, intercourse with an injection drug user, five or more lifetime sexual partners, intercourse during menses (for women), lower income, and heavy alcohol intake (>60 g/day). Multivariate analysis identified a history of sexually transmitted disease, heavy alcohol intake, and the presence of a tattoo as independent risk factors for sporadic HCV. In addition, six cases and one control had a history of needlestick exposure. Of the cases, 88% had at least one of these four risk factors, as compared with 26% of controls (odds ratio = 16.5; 95% confidence interval = 4.0-68.8). CONCLUSIONS: A history of sexually transmitted disease, heavy alcohol intake, the presence of tattoos, and a history of needlestick exposure were identified as risk factors for sporadic hepatitis C in this case-control study. If we include all patients with a history of blood transfusion or injection drug use, only 2% of the total 477 HCV patients had no identified risk factors.

Characteristics of intestinal metaplasia in the gastric cardia.

OBJECTIVE: Intestinal metaplasia of the gastroesophageal junction is frequently grouped together with Barrett's esophagus. The area of the gastroesophageal junction is comprised of the distal esophagus and the gastric cardia. The aim of the present study was to assess whether intestinal metaplasia in the distal esophagus and gastric cardia represent two different entities with a different set of risk factors. METHODS: Patients presenting for elective upper endoscopy were enrolled into a prospective study. The presence of gastritis and intestinal metaplasia was evaluated in gastric biopsies taken from the antrum, corpus, and cardia. Barrett's esophagus was defined by the presence of any length of columnar mucosa above the gastroesophageal junction. RESULTS: Of 302 patients, 50 patients had intestinal metaplasia of the gastric cardia, 73 Barrett's esophagus, and 116 erosive esophagitis. Men were more prone than women to develop Barrett's esophagus or erosive esophagitis. Both conditions were also more common among whites than nonwhites. Smoking was particularly common among patients with Barrett's esophagus. Patients with cardiac intestinal metaplasia did not share these demographic characteristics. The prevalence of daily reflux symptoms, erosive esophagitis, and Barrett's esophagus was similar among patients both with and without cardiac intestinal metaplasia. However, atrophy and intestinal metaplasia of the gastric antrum and corpus were found more frequently among patients with than without cardiac intestinal metaplasia. CONCLUSIONS: Intestinal metaplasia of the gastric cardia is different from Barrett's esophagus. Although cardiac intestinal metaplasia is closely associated with signs of gastritis in other parts of the stomach, gastroesophageal reflux disease does not seem to be a risk factor. A diagnosis of Barrett's esophagus should not be made based on the presence of intestinal metaplasia within the cardiac portion of the gastroesophageal junction.

A case-control study of the factors associated with spontaneous resolution of hepatitis C viremia.

OBJECTIVE: Infection with the hepatitis C virus (HCV) becomes chronic in 85% of the infected individuals. We studied risk factors that may predict clearance of HCV. METHODS: A case-control study compared the association between risk factors and viral clearance. Viral clearance was defined as presence of a positive HCV antibody test plus negative HCV test by polymerase chain reaction (PCR). Forty-four cases and 214 controls with persistent viremia were identified in a database of patients evaluated at the Gastroenterology Clinic of the University of New Mexico. RESULTS: Of all 258 HCV-antibody-positive patients, 17% had a negative test by PCR. The multivariate logistic regression revealed that a history of parenteral exposure and a long time interval since the most recent exposure were both associated with an increased likelihood of persistent viremia, whereas subjects who had been monogamous for longer time periods were more likely to have cleared HCV from their serum. A low serum level of ferritin also conferred protection against persistent viremia. Case and control subjects did not differ with respect to their demographic characteristics, occurrence of comorbid disease, previous medical history, occurrence of sexually transmitted diseases, blood group, and risky health or sexual practices. CONCLUSIONS: These data suggest that route of exposure and time when exposure occurred are important in the development of persistent HCV infection.

Gastric outlet obstruction with benign endoscopic biopsy should be further explored for malignancy.

BACKGROUND: Gastric outlet obstruction is commonly considered a complication of peptic ulcer disease. Malignancy accounts for up to 39% of gastric outlet obstruction. The object of this study was to evaluate the reliability of endoscopic biopsies in excluding malignancy as the cause of gastric outlet obstruction. METHODS: A retrospective study of 40 consecutive patients admitted with gastric outlet obstruction was conducted. Patient demographics, their use of H2-receptor antagonists or nonsteroidal anti-inflammatory drugs, and history of peptic ulcer disease were recorded. Histopathologic results of the endoscopic biopsy and surgical specimen were reviewed. The diagnosis based on the surgical specimen was considered the gold standard. RESULTS: Sixteen patients (40%) had malignant gastric outlet obstruction. Seven patients had gastric adenocarcinoma and nine had extragastric tumors. The patients with malignant obstruction were significantly older (> 55 years) (p = 0.03; odds ratio: 95% CI: 5.21 [1.05-23.49]). Gastric cancer patients had less frequently a history of peptic ulcer disease when compared with patients with benign gastric outlet obstruction (p = 0.04; odds ratio: 95% CI: 5 [1.04-38.13]). Endoscopic biopsy to detect malignant obstruction had poor sensitivity (i.e., 37%) when compared with biopsies of the surgical specimen. In three of seven patients with gastric cancer (40%), repeated jumbo biopsies were negative for malignancy. CONCLUSION: Patients with gastric outlet obstruction who had endoscopic biopsies negative for cancer should be explored surgically before embarking on medical therapy. The surgical exploration is especially important in gastric outlet obstruction patients who are considered at high risk for malignancy, that is, those who are older and have no history of peptic ulcer disease.

Sarcoidosis presenting as acute myositis. Report and review of the literature.

A patient with sarcoidosis who presented with acute inflammatory myopathy is described. The patient had no symptoms other than those of the muscle involvement, with elevated serum levels of creatine kinase. Muscle biopsies revealed epithelioid granulomas, consistent with sarcoidosis. There was a dramatic response to a moderate dose of corticosteroids, but relapse occurred after the dose was tapered. We suggest that sarcoidosis be considered in the differential diagnosis of inflammatory myopathy, and that patients with acute sarcoid myositis be maintained with at least a moderate dose of corticosteroids for at least 6 months.