Subject(s)
Anemia, Iron-Deficiency/diagnosis , Endoscopy, Gastrointestinal/standards , Evidence-Based Medicine/standards , Gastrointestinal Diseases/diagnosis , Iron/blood , Anemia, Iron-Deficiency/blood , Anemia, Iron-Deficiency/etiology , Biopsy/standards , Female , Gastric Mucosa/diagnostic imaging , Gastric Mucosa/metabolism , Gastric Mucosa/pathology , Gastroenterology/standards , Gastrointestinal Diseases/blood , Gastrointestinal Diseases/complications , Gastrointestinal Diseases/pathology , Hemoglobins/analysis , Humans , Intestinal Mucosa/diagnostic imaging , Intestinal Mucosa/metabolism , Intestinal Mucosa/pathology , Iron/metabolism , Male , Postmenopause , Premenopause , Reference Values , Referral and Consultation/standards , Sex Factors , Societies, Medical/standards , United StatesSubject(s)
Anemia, Iron-Deficiency/diagnosis , Evidence-Based Medicine/standards , Gastroenterology/standards , Gastrointestinal Diseases/diagnosis , Iron/blood , Adolescent , Adult , Age Factors , Anemia, Iron-Deficiency/blood , Anemia, Iron-Deficiency/etiology , Biopsy , Child , Endoscopy, Gastrointestinal/standards , Female , Gastric Mucosa/diagnostic imaging , Gastric Mucosa/metabolism , Gastric Mucosa/pathology , Gastrointestinal Diseases/blood , Gastrointestinal Diseases/complications , Gastrointestinal Diseases/pathology , Hemoglobins/analysis , Humans , Intestinal Mucosa/diagnostic imaging , Intestinal Mucosa/metabolism , Intestinal Mucosa/pathology , Iron/metabolism , Male , Middle Aged , Prevalence , Reference Values , Sex Factors , Societies, Medical/standards , United States , Young AdultSubject(s)
Heart Arrest/mortality , Liver Cirrhosis/complications , Adult , Aged , Aged, 80 and over , Hospitals , Humans , Middle Aged , Retrospective Studies , Risk Assessment , Survival AnalysisABSTRACT
AIM: To determine the overall and comparative risk of procedure related perforation of balloon assisted enteroscopy (BAE) in Crohn's disease (CD). METHODS: Systematic review (PROSPERO #CRD42015016381) of studies reporting on CD patients undergoing BAE. Seventy-three studies reporting on 1812 patients undergoing 2340 BAEs were included. Primary outcome of interest was the overall and comparative risk of procedure related perforation of diagnostic BAE in CD. Secondary outcomes of interest were risk of procedure related perforation of diagnostic double balloon enteroscopy (DBE), risk of procedure related perforation of therapeutic BAE, efficacy of stricture dilation, and clinical utility of endoscopically assessing small bowel disease activity. RESULTS: Per procedure perforation rate of diagnostic BAE in CD was 0.15% (95%CI: 0.05-0.45), which was similar to diagnostic BAE for all indications (0.11%; IRR = 1.41, 95%CI: 0.28-4.50). Per procedure perforation rate of diagnostic DBE in CD was 0.12% (95%CI: 0.03-0.44), which was similar to diagnostic DBE for all indications (0.22%; IRR = 0.54, 95%CI: 0.06-0.24). Per procedure perforation rate of therapeutic BAE in CD was 1.74% (95%CI: 0.85-3.55). Eighty-six percent of therapeutic perforations were secondary to stricture dilation. Dilation was attempted in 207 patients and 30% required surgery during median follow-up of 18 months. When diagnostic BAE assessed small bowel disease activity, changes in medical therapy resulted in endoscopic improvement in 77% of patients. CONCLUSION: Diagnostic BAE in CD has a similar rate of perforation as diagnostic BAE for all indications and can be safely performed in assessment of mucosal healing.
Subject(s)
Balloon Enteroscopy/adverse effects , Crohn Disease/diagnosis , HumansABSTRACT
AIM: To determine the yield of biopsying normal duodenal mucosa for investigation of abdominal pain. METHODS: This is a retrospective chart review of consecutive patients who underwent esophagogastroduodenoscopy (EGD) with duodenal biopsies of normal appearing duodenal mucosa for an indication that included abdominal pain. All the patients in this study were identified from an electronic endoscopy database at a single academic medical center and had an EGD with duodenal biopsies performed over a 4-year period. New diagnoses that were made as a direct result of duodenal biopsies were identified. All duodenal pathology reports and endoscopy records were reviewed for indications to perform the examination as well as the findings; all the medical records were reviewed. Exclusion criteria included age less than 18 years, duodenal mass, nodule, or polyp, endoscopic duodenitis, duodenal scalloping, known celiac disease, positive celiac serology, Crohns disease, or history of bone marrow transplant. Information was collected in a de-identified database with pertinent demographic information including human immunodeficiency virus (HIV) status, and descriptive statistics were performed. RESULTS: About 300 patients underwent EGD with biopsies of benign appearing or normal appearing duodenal mucosa. The mean age of patients was 44.1 ± 16.8 years; 189 of 300 (63%) were female. A mean of 4.3 duodenal biopsies were performed in each patient. In the subgroup of patients with abdominal pain without anemia, diarrhea, or weight loss the mean age was 43.4 ± 16.3 years. Duodenal biopsies performed for an indication that included abdominal pain resulting in 4 new diagnoses (3 celiac disease and 1 giardiasis) for an overall yield of 1.3%. 183 patients with abdominal pain without anemia, diarrhea, or weight loss (out of the total 300 patients) underwent duodenal biopsy of duodenal mucosa resulting in three new diagnoses (two cases of celiac disease and one giardiasis) for a yield of 1.6%. Duodenal biopsies of 19 HIV patients presenting for evaluation of abdominal pain did not reveal any new diagnoses. Information pertaining to new diagnoses is provided. CONCLUSION: Routine biopsy of normal appearing duodena in patients with abdominal pain should be reserved for those with a high pre-test probability given its low diagnostic yield.
Subject(s)
Abdominal Pain/etiology , Duodenal Diseases/complications , Duodenal Diseases/pathology , Duodenum/pathology , Adult , Aged , Biopsy , Databases, Factual , Endoscopy, Gastrointestinal , Female , Humans , Intestinal Mucosa/pathology , Male , Middle Aged , Patient Selection , Predictive Value of Tests , Retrospective Studies , Risk FactorsABSTRACT
BACKGROUND: Chronic abdominal pain (CAP) is a common indication for gastroenterology referrals. More insidious causes of CAP isolated to the small bowel, such as malignancies and Crohn's disease, are rising in incidence and causing more gastroenterologists to evaluate their patients with video capsule endoscopy (VCE). However, the role of VCE in patients with CAP is still unclear. AIMS: We assessed the efficacy of VCE in patients with CAP and whether it led to findings that contributed to disease management and meaningful interventions. METHODS: This retrospective study evaluated 607 capsule endoscopy studies at an open referral endoscopy unit. Ninety of the studies were for CAP. These studies were compared to those performed for other indications to compare diagnostic yield. In addition, we investigated whether VCE led to an intervention that improved clinical outcomes. RESULTS: Overall, the number of abnormal findings in CAP patients was significantly lower than VCE performed for other indications (24.4% vs 39.0%, respectively p = 0.009). When patients with CAP presented with other pertinent clinical findings (e.g. nausea, weight loss, anemia, history of in inflammatory bowel disease, etc.), the likelihood of an abnormal finding increased to a level that was not different from those who received VCE for other indications (27.1%, p = 0.10). The findings from VCE lead to changed management and improved outcomes in 16.2% of CAP patients with associated symptoms. However, the subgroup that benefited the most were those who had a prior history of Crohn's disease. Patients with CAP who did not have any associated symptoms continued to have a significantly lower abnormal finding rate compared to those who received VCE for other indications (19.4%, p = 0.03) and VCE rarely led to a change in management that would improve outcomes (5.6%). CONCLUSIONS: VCE for CAP has a lower rate of abnormal findings than other indications. However, VCE is a useful diagnostic tool that can help provide a possible etiology of CAP in patients with associated symptoms. However, a change in management from VCE is likely to be limited to those with a history of Crohn's disease.
Subject(s)
Abdominal Pain/diagnosis , Capsule Endoscopy , Abdominal Pain/therapy , Adult , Aged , Chronic Disease/therapy , Cohort Studies , Community Health Centers , Female , Humans , Male , Middle Aged , Referral and Consultation , Retrospective Studies , Tertiary Care CentersABSTRACT
Patients with a left ventricular assist device (LVAD) have increased risk of gastrointestinal (GI) bleeding. They are prone to develop angiodysplasia of the small intestine, and have a higher risk of bleeding as these patients are all required to be on permanent therapeutic anticoagulation. Here we report a case of a critically ill 55-year-old male on pressors and inotropes with an LVAD, who successfully underwent an antegrade double balloon enteroscopy (DBE).
ABSTRACT
AIM: To determine if esophageal capsule endoscopy (ECE) is an adequate diagnostic alternative to esophagogastroduodenoscopy (EGD) in pre-bariatric surgery patients. METHODS: We conducted a prospective pilot study to assess the diagnostic accuracy of ECE (PillCam ESO2, Given Imaging) vs conventional EGD in pre-bariatric surgery patients. Patients who were scheduled for bariatric surgery and referred for pre-operative EGD were prospectively enrolled. All patients underwent ECE followed by standard EGD. Two experienced gastroenterologists blinded to the patient's history and the findings of the EGD reviewed the ECE and documented their findings. The gold standard was the findings on EGD. RESULTS: Ten patients with an average body mass index of 50 kg/m(2) were enrolled and completed the study. ECE identified 11 of 14 (79%) positive esophageal/gastroesophageal junction (GEJ) findings and 14 of 17 (82%) combined esophageal and gastric findings identified on EGD. Fisher's exact test was used to compare the findings and no significant difference was found between ECE and EGD (P = 0.64 for esophageal/GEJ and P = 0.66 for combined esophageal and gastric findings respectively). Of the positive esophageal/GEJ findings, ECE failed to identify the following: hiatal hernia in two patients, mild esophagitis in two patients, and mild Schatzki ring in two patients. ECE was able to identify the entire esophagus in 100%, gastric cardia in 0%, gastric body in 100%, gastric antrum in 70%, pylorus in 60%, and duodenum in 0%. CONCLUSION: There were no significant differences in the likelihood of identifying a positive finding using ECE compared with EGD in preoperative evaluation of bariatric patients.
Subject(s)
Bariatric Surgery , Capsule Endoscopy , Esophageal Diseases/diagnosis , Esophagoscopy , Obesity/surgery , Adult , Esophageal Diseases/complications , Female , Humans , Male , Middle Aged , Obesity/complications , Obesity/diagnosis , Pilot Projects , Predictive Value of Tests , Preoperative Period , Prospective StudiesABSTRACT
BACKGROUND: Studies suggest that endoscopist-related factors such as colonoscopy withdrawal time are important in determining the adenoma detection rate (ADR). OBJECTIVE: To determine the importance of withdrawal technique in differentiating among endoscopists with varying ADRs. DESIGN: Prospective, multicenter study. SETTING: Five academic tertiary-care medical centers. PARTICIPANTS: This study involved 11 gastroenterology faculty endoscopists. INTERVENTION: A retrospective review of screening colonoscopies was performed to categorize endoscopists into low, moderate, and high ADR groups. Video recordings were randomly obtained for each endoscopist on 20 (10 real, 10 sham) withdrawals during colonoscopies performed for average-risk colorectal cancer screening. Three blinded reviewers assigned withdrawal technique scores (total of 75 points) on 110 video recordings. A separate reviewer recorded withdrawal times. MAIN OUTCOME MEASUREMENTS: Withdrawal technique scores and withdrawal times. RESULTS: Mean (± standard deviation [SD]) withdrawal technique scores were higher in the moderate (62 ± 2.5) and high (59.5 ± 3) ADR groups compared with the low (40.8±3) ADR group (P = .002). Mean (± SD) withdrawal times were 6.3 ± 1.8 minutes (low ADR), 10.2 ± 1.5 minutes (moderate ADR), and 8.2 ± 1.8 minutes (high ADR) (P = .29). A comparison of the withdrawal times and technique scores of the two individual endoscopists with the lowest and highest ADRs did not find a significant difference in withdrawal times (6.6 ± 1.7 vs 7.4 ± 1.7 minutes) (P = .36) but did find a nearly 2-fold difference in technique scores (36.2 ± 9 vs 62.8 ± 9.9) (P = .0001). LIMITATIONS: Not adequately powered to detect small differences in withdrawal times. CONCLUSION: Withdrawal technique is an important indicator that differentiates between endoscopists with varying ADRs. It is possible that withdrawal technique is equal to, if not more important than, withdrawal time in determining ADRs.
Subject(s)
Adenoma/diagnosis , Colonoscopy/standards , Colorectal Neoplasms/diagnosis , Adult , Aged , Colonoscopy/methods , Female , Humans , Male , Middle Aged , Retrospective Studies , Time FactorsABSTRACT
BACKGROUND: Most screening colonoscopies require patients to miss work on the day of the procedure. Little is known about whether patients are taking additional time off from work, and the reasons for doing so. AIMS: The purpose of this study was to assess the patterns and reasons for missed work related to screening colonoscopies. METHODS: All outpatient screening colonoscopy procedures performed at an academic medical center over 6 months were reviewed. Exclusions included procedures performed for other indications, patients age 65 or older, procedures performed on Monday or Friday, and patients who were not working. Patients were interviewed by telephone regarding missed work time and the reasons for doing so. RESULTS: Sixty-eight patients met all inclusion criteria. Thirty-four percent missed work on more than the day of the procedure. Thirty-two percent took the day prior off, 10% took the day after off, and 9% took both days off. The reason for taking the day before the procedure off was uniformly anticipation of the bowel preparation. Of those who took the day after off, 57% did so as a precautionary measure after moderate sedation, while 43% had symptoms. CONCLUSIONS: One third of working patients who undergo mid-week screening colonoscopies miss work on additional days to the procedure day. Unanticipated time missed from work could increase the indirect costs of screening colonoscopy.
Subject(s)
Absenteeism , Colonoscopy/economics , Early Detection of Cancer/economics , Adult , Anxiety/chemically induced , Colonoscopy/psychology , Early Detection of Cancer/psychology , Female , Humans , Hypnotics and Sedatives/adverse effects , Male , Middle Aged , Retrospective StudiesABSTRACT
Glutamate-cysteine ligase catalytic subunit (GCLC) is regulated transcriptionally by Nrf1 and Nrf2. tert-Butylhydroquinone (TBH) induces human GCLC via Nrf2-mediated trans activation of the antioxidant-responsive element (ARE). Interestingly, TBH also induces rat GCLC, but the rat GCLC promoter lacks ARE. This study examined the role of Nrf1 and Nrf2 in the transcriptional regulation of rat GCLC. The baseline and TBH-mediated increase in GCLC mRNA levels and rat GCLC promoter activity were lower in Nrf1 and Nrf2 null (F1 and F2) fibroblasts than in wild-type cells. The basal protein and mRNA levels and nuclear binding activities of c-Jun, c-Fos, p50, and p65 were lower in F1 and F2 cells and exhibited a blunted response to TBH. Lower c-Jun and p65 expression also occurs in Nrf2 null livers. Levels of other AP-1 and NF-kappaB family members were either unaffected (i.e., JunB) or increased (i.e., Fra-1). Overexpression of Nrf1 and Nrf2 in respective cells restored the rat GCLC promoter activity and response to TBH but not if the AP-1 and NF-kappaB binding sites were mutated. Fra-1 overexpression lowered endogenous GCLC expression and rat GCLC promoter activity, while Fra-1 antisense had the opposite effects. In conclusion, Nrf1 and Nrf2 regulate rat GCLC promoter by modulating the expression of key AP-1 and NF-kappaB family members.
Subject(s)
DNA-Binding Proteins/physiology , Gene Expression Regulation , Glutamate-Cysteine Ligase/genetics , NF-kappa B/metabolism , Trans-Activators/physiology , Transcription Factor AP-1/metabolism , Animals , Binding Sites , Catalytic Domain/genetics , Cells, Cultured , DNA-Binding Proteins/genetics , Hydroquinones/pharmacology , Liver/metabolism , Mice , Mice, Knockout , NF-E2-Related Factor 1 , NF-E2-Related Factor 2 , NF-kappa B/genetics , Nuclear Respiratory Factor 1 , Nuclear Respiratory Factors , Promoter Regions, Genetic , Proto-Oncogene Proteins c-fos/metabolism , RNA, Messenger/analysis , RNA, Messenger/metabolism , Rats , Trans-Activators/genetics , Transcription Factor AP-1/genetics , Transcription, GeneticABSTRACT
Interferon alfa has been increasingly used against recurrent hepatitis C (HCV) disease in post-liver transplant (LT) recipients. A serious potential adverse effect is acute rejection. We reviewed our experience using interferon-based therapy (interferon or pegylated interferon with or without ribavirin) for treating recurrent HCV in LT recipients. Forty-four LT recipients were treated with interferon for recurrent HCV. Five of the 44 patients developed acute rejection during interferon-based therapy. These 5 patients started treatment of 42.4 +/- 33.89 months (mean +/- SD) after LT. Mean (+/- SD) histological activity index and fibrosis scores before initiating antiviral therapy were 8.8 (+/- 1.92) and 2.6 (+/- 0.55), respectively. Patients were treated for 3.3 +/- 2.28 months (mean +/- SD) prior to rejection. At the time of rejection, HCV load was not detectable in 4 of the 5 recipients. All 5 patients had tolerated interferon therapy, and none had stopped therapy because of adverse effects. The rejection was successfully treated in 3 patients. In 2 of those 3 patients, cirrhosis eventually developed. In the 2 patients who did not respond to rejection treatment, immediate graft failure occurred, leading to re-LT in 1 patient and death from sepsis in the other. In conclusion, the results indicate that further studies are needed to assess the safety of interferon in LT recipients. Interferon-based therapy may lead to acute rejection and subsequent graft loss and should therefore be used with caution. Treated recipients may also develop progressive cirrhosis despite achieving a sustained virological response.