Ergonomics of Endoscopy.

Optimal endoscopic operations incorporate ergonomic principles into the endoscopy environment benefiting endoscopists, endoscopy unit personnel, and patients. A high prevalence of occupational musculoskeletal injuries is well established among endoscopists and gastroenterology nurses. Ergonomics can be integrated into all facets of the endoscopy unit including scheduling, endoscopy unit design, training programs, and investment in technology. Preprocedure, intraprocedure, and postprocedure areas should aim to deliver patient safety, privacy, and comfort, while also supporting endoscopists and staff with adjustable rooms and effective work flows. Team-wide educational initiatives can improve ergonomic awareness. These strategies help mitigate risks for musculoskeletal injuries and can lead to increased productivity. The COVID-19 area brings novel challenges to endoscopy.

Balloon Tamponade Utilization for Severe Esophagitis Causing Hemorrhagic Shock.

Esophagitis causing upper gastrointestinal bleeding (UGIB) is associated with significant morbidity. We present a case report of two patients with hemorrhagic shock secondary to esophagitis. Both patients underwent esophagogastroduodenoscopy demonstrating severe bleeding pan-esophagitis complicated by hemodynamic instability. Balloon tamponade for hemostasis was performed with resultant hemodynamic improvement. Severe UGIB secondary to esophagitis is difficult to control, with a high risk of complications and limited available endoscopic therapies in extensive mucosal injury. Treatments such as angiography are ineffective due to collateralization and surgery carries high morbidity and mortality. Balloon tamponade provides a rescue option for severe, refractory UGIB secondary to esophagitis.

Poor Sleep Quality in Crohn's Disease Is Associated With Disease Activity and Risk for Hospitalization or Surgery.

BACKGROUND AND AIMS: Poor sleep quality in Crohn's disease (CD) is associated with histologic activity and clinical relapse. We sought to characterize sleep dysfunction and determine the effect of poor sleep quality on risk for hospitalization and surgery. METHODS: Clinical data were collected for CD subjects including the Pittsburgh Sleep Quality Index (PSQI) and Harvey-Bradshaw index (HBI). The PSQI score and a brief medical history were obtained for control subjects. The PSQI and HBI correlation was tested at an initial clinic visit and at follow-up. Crohn's disease subjects with and without poor sleep were compared for risk of hospitalization or surgery by Kaplan-Meier and Cox proportional hazards. RESULTS: Ninety-two CD and 82 control subjects were included. Crohn's disease and control subjects shared similar baseline characteristics and PSQI (8.3 vs 7.8, P = 0.31), and 77% of the CD population had PSQI >5. Crohn's disease subjects with PSQI >5 more often had inflammatory phenotypes and reported increased benzodiazepine and psychiatric medication use. Crohn's disease subjects with PSQI >5 also reported more night awakenings due to pain and bathroom use. The PSQI correlated with HBI (r = 0.256, P = 0.014), and ΔPSQI on follow-up correlated with ΔHBI (r = 0.47, P = 0.002). Cox proportional hazards model for hospitalization or surgery showed that PSQI >8 was predictive of surgery or hospitalization (hazards ratio 5.37; 95% confidence interval, 1.39-27.54). CONCLUSION: There is a high burden of poor sleep quality in CD, which is associated with risk for adverse outcomes. Sleep quality may identify CD patients at risk for complications and have prognostic value in CD.

Renal Safety of Intravenous Gadolinium-enhanced MRI in Patients Following Liver Transplantation.

BACKGROUND: Intravenous contrast-enhanced imaging is invaluable in diagnosing pathology following liver transplantation. Given the potential risk of contrast nephropathy associated with iodinated computed tomography contrast, alternate contrast modalities need to be examined, especially in the setting of renal insufficiency. The purpose of this study was to examine the renal safety of MRI with gadolinium following liver transplantation. METHODS: The study involved a retrospective analysis of 549 cases of abdominal MRI with low-dose gadobenate dimeglumine in liver transplant recipients at a single center. For each case, serum creatinine values before and after the MRI were compared. In addition, cases were analyzed for the development of nephrogenic systemic fibrosis. RESULTS: Pre-MRI creatinine values ranged from 0.32 to 6.57 mg/dL (median, 1.28 g/dL), with 191 cases having values ≥1.5 mg/dL (median, 1.86 g/dL). A comparison of the pre- and post-MRI creatinine values showed no significant difference, including those patients with pre-MRI values ≥1.5 mg/dL (mean change of -0.04 [95% confidence interval, -0.07 to -0.01; P = 0.004]). No cases of nephrogenic systemic fibrosis were noted. CONCLUSIONS: Our findings suggest that, irrespective of baseline renal function, MRI with gadobenate dimeglumine is a nonnephrotoxic imaging modality in liver transplant recipients. Importantly, this intravenous contrast-enhanced imaging modality can be considered in those posttransplant patients who have a contraindication to computed tomography contrast due to renal insufficiency.

Diagnosis and Treatment of Peptic Ulcer Disease.

Peptic ulcer disease continues to be a source of significant morbidity and mortality worldwide. Approximately two-thirds of patients found to have peptic ulcer disease are asymptomatic. In symptomatic patients, the most common presenting symptom of peptic ulcer disease is epigastric pain, which may be associated with dyspepsia, bloating, abdominal fullness, nausea, or early satiety. Most cases of peptic ulcer disease are associated with Helicobacter pylori infection or the use of nonsteroidal anti-inflammatory drugs (NSAIDs), or both. In this review, we discuss the role of proton pump inhibitors in the management of peptic ulcer disease, highlight the latest guidelines about the diagnosis and management of H. pylori, and discuss the latest evidence in the management of complications related to peptic ulcer disease, including endoscopic intervention for peptic ulcer-related bleeding. Timely diagnosis and treatment of peptic ulcer disease and its sequelae are crucial in order to minimize associated morbidity and mortality, as is prevention of peptic ulcer disease among patients at high risk, including those infected with H. pylori and users of NSAIDs.

Current Diagnostic and Treatment Strategies for Eosinophilic Esophagitis.

Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder of the esophagus diagnosed by the presence of esophageal symptoms accompanied by an esophageal eosinophilic infiltrate. EoE has an increasing worldwide prevalence and can be a cause of dysphagia and food impactions. There is an important role for the use of proton pump inhibitors in the diagnostic pathway of EoE. Treatment paradigms for EoE aim to minimize esophageal inflammation and improve symptom control. Dietary therapy targets dietary allergens and encompasses the elemental diet, the allergy testing-directed elimination diet, and the empiric elimination diet. Pharmacologic options include topical corticosteroids as the standard first-line treatment. Multiple other pharmacologic interventions are currently under investigation and are not recommended in the most recent guidelines. Endoscopic dilation is usually reserved for patients who relapse on pharmacologic or dietary regimens or who have symptomatic stricturing disease. This article provides a comprehensive discussion of existing diagnostic and management strategies for EoE.

Actinomycosis of the pharynx.

Few cases of pharyngeal actinomycosis have been documented in the literature. We describe the case of a 67-year-old white man who presented with symptoms of dysphagia. Laryngoscopy revealed a pedunculated mass in the left posterior pharyngeal wall; an excisional biopsy confirmed the diagnosis. Postoperatively, the patient underwent 10 weeks of intravenous penicillin therapy followed by 4 months of oral antibiotics, and his condition resolved. We discuss the diagnosis, management, and complications of this rare infection.

Assessing bolus retention in achalasia using high-resolution manometry with impedance: a comparator study with timed barium esophagram.

OBJECTIVES: The aim of this study was to assess whether high-resolution impedance manometry (HRIM) could be used to assess bolus retention similar to the timed barium esophagram (TBE). METHODS: Twenty achalasia patients (10 males, aged 21-79 years) were prospectively evaluated with HRIM and TBE to determine the correlation between barium column height and the impedance bolus height (IBH). The TBE protocol used a 200-ml barium challenge and the HRIM protocol used a 200-ml saline challenge protocol. Both protocols were performed in an upright position and the heights of the barium and impedance columns were measured at 1 and 5 min. Analysis of IBH was performed with a topographic technique and a spatial impedance variation plot. RESULTS: There was no significant difference between the median IBH and barium column at 1 min (IBH: 12.0 cm (interquartile range (IQR), 8.0-18.0); TBE: 12.0 cm (IQR, 7.0-19.0); P=0.90) or at 5 min (IBH: 11.0 cm (IQR, 1.0-17.0); TBE: 9.0 cm (IQR, 4.0-12.0); P=0.47). In addition, the correlation between the two measurements at 1 and 5 min was 0.60 and 0.86, respectively. Using a barium column or impedance height of >5.0 as a definition of bolus retention was associated with 75% concordance at 1 min and 95% concordance at 5 min. CONCLUSIONS: There was excellent agreement between TBE and high-resolution impedance manometry (HRIM) for assessing bolus retention at 5 min. Thus, HRM with impedance may be used as a single test to assess bolus retention and motor function in the management of achalasia.