Small intestinal bacterial overgrowth: current update.

PURPOSE OF REVIEW: This article aims to provide an up-to-date review of small intestinal bacterial overgrowth (SIBO), including etiology and risk factors, clinical manifestations, diagnostic evaluation for suspected SIBO, and therapeutic options. RECENT FINDINGS: Recent advances in breath testing, capsule and urine-based testing have opened new avenues and improved diagnostic yield of SIBO. Nonantibiotic-based treatment strategies have shown promising results in initial trials. SUMMARY: Small intestinal bacterial overgrowth (SIBO) is a condition defined by the excess bacteria or changes in bacterial composition of the small intestine. These are associated with various gastrointestinal (GI) symptoms such as bloating, abdominal distension, diarrhea, nutrient deficiencies, and even frank weight loss. Small bowel jejunal aspirate of >10 5 CFU/ml has traditionally been considered the gold standard for diagnosis. Glucose and lactulose breath testing have become more common in clinical practice as they are noninvasive, easily accessible, and have lower cost. Treatment focuses on the eradication of excess bacteria in the small bowel and is traditionally done with the use of oral antibiotics. Other emerging therapies may include probiotics, diet manipulation, and prokinetic agents.

Response to botulinum toxin may predict response to peroral pyloromyotomy in patients with gastroparesis.

BACKGROUND : Patients with gastroparesis who have undergone prior intrapyloric botulinum toxin injection (BTI) may seek an opinion regarding peroral pyloromyotomy (POP). There are only two small reports assessing the role of BTI as a predictor for successful treatment with POP. METHODS: We performed a retrospective cohort study to assess whether symptomatic improvement after BTI predicts a response to POP. We included 119 patients who had undergone both BTI and POP at Cleveland Clinic Ohio or Cleveland Clinic Florida from January 2016 to September 2019. RESULTS: 65.5 % of patients had symptomatic improvement after BTI. Gastroparesis Cardinal Symptom Index (GCSI) scores were available for 74 patients, with 64 % achieving a response to POP, defined as a decrease in mean GCSI ≥ 1. In multivariable analysis, response to BTI (odds ratio [OR] 7.7 [95 %CI 2.2-26.1]) and higher pre-POP GCSI score (OR 2.3 [95 %CI 1.2-4.6]) were independent predictors of response to POP. CONCLUSIONS: Clinical improvement after BTI is a predictor of response to POP in patients with gastroparesis. This information may aid in improving patient selection for POP.

Isolated Jejunal Crohn's Disease Masquerading as Gastroparesis.

Isolated jejunal Crohn's disease (IJCD) is a rare manifestation of small bowel inflammatory disease described in a few case reports. Due to challenges in diagnosis, this condition is overlooked or misdiagnosed in many instances. We present a case that was initially diagnosed as gastroparesis due to a gastric emptying study (GES) revealing delayed stomach clearance, with additional normal imaging and endoscopic examinations. After several imaging studies and a double-balloon enteroscopy (DBE), isolated Crohn's disease was diagnosed and managed with surgical intervention. Isolated Crohn's disease should be considered as a diagnosis in patients with gastroparesis to avoid delays in appropriate treatment and improve prognosis.

Medical and surgical management of gastroparesis: a systematic review.

BACKGROUND: Gastroparesis (GPS) is a rare disease with multiple etiologies that results in delayed gastric emptying. Diagnosis of GPS can be challenging due to its rather complex clinical presentation. Pharmacologic refractory cases require surgical interventions, all of which have yet to be standardized and characterized. OBJECTIVES: We present a review of the literature and provide an update of current therapies for patients with GPS. SETTING: Department of General Surgery, Academic Hospital, United States. METHODS: We conducted a comprehensive search in PubMed, Google Scholar, and Embase of English-written articles published in the last 38 years, with an advance title search of "gastroparesis management." Other keywords included: "surgical management" and "refractory gastroparesis." Further references were obtained through cross-reference. RESULTS: A total of 12,250 articles were selected after eliminating duplicates. Following thorough screening of selection criteria, 68 full-text articles were included for review. CONCLUSION: GPS is a challenging disease to manage. Nutritional support must remain the primary approach, followed by either medical or surgical treatment modalities if necessary. In patients with refractory gastroparesis, adjunctive therapies have been proposed as promising long-term options.

Prevalence and Predictors of Gastrointestinal Dysmotility in Patients with Hypermobile Ehlers-Danlos Syndrome: A Tertiary Care Center Experience.

Introduction Ehlers-Danlos syndrome (EDS), specifically the hypermobility type (hEDS), is associated with a variety of gastrointestinal (GI) conditions. This study aims to evaluate the prevalence of and factors associated with gut dysmotility in patients with hEDS. Methods This is a retrospective study of hEDS patients conducted at the Cleveland Clinic's Center for Personalized Genetic Healthcare between January 2007 and December 2017. Demographics, GI motility testing, endoscopic, and imaging data were extracted from the patients' charts. Results A total of 218 patients with hEDS were identified. Among them, 136 (62.3%) patients had at least one GI symptom at the time of EDS diagnosis. Motility testing was performed and reported in 42 (19.2%) patients. Out of them, five (11.9%) had esophageal dysmotility, 18 (42.8%) had gastroparesis, five (11.9%) had small bowel/colon altered transit time, and four (9.5%) had global dysmotility. In univariable analysis, patients with postural orthostatic tachycardia syndrome (POTS) [odds ratio (OR): 8.88, 95% CI: 3.69-24.9, p<0.0001], fibromyalgia (OR: 4.43, 95% CI: 2.04-10.1, p=0.0002), history of irritable bowel syndrome (OR: 5.01, 95% CI: 2.31-11.2, p<0.0001), and gastroesophageal reflux disease (OR: 3.33, 95% CI: 1.55-7.44, p=0.002) were more likely to be diagnosed with GI dysmotility. On multivariable analysis, only POTS (OR: 5.74, 95% CI: 2.25-16.7, p=0.0005) was significantly associated with an increased likelihood of GI dysmotility. Conclusions This study suggests that GI symptoms are relatively common among patients with hEDS. Of the patients tested for dysmotility, 76.2% were found to have some form of dysmotility. POTS was found to be an independent predictive factor for GI dysmotility.

Pancreatic Head Mass: A Rare Manifestation of Granulomatosis With Polyangiitis.

Granulomatosis with polyangiitis may rarely present as an inflammatory pancreatic mass and mimic pancreatic cancer. We report a 73-year-old man who presented with fever and weight loss. Computed tomography imaging demonstrated a mass in the pancreatic head along with multiple cavitary pulmonary nodules. Our differential included metastatic pancreatic cancer vs an autoimmune process. Positive cytoplasmic antineutrophil cytoplasmic antibodies coupled with the lung biopsy findings established the diagnosis of granulomatosis with polyangiitis, a very rare cause of pancreatic masses. After completion of immunosuppressive therapy, magnetic resonance imaging demonstrated no evidence of a pancreatic mass. More studies are required to establish the management of these masses.

Impact of preoperative wireless pH monitoring in the evaluation of esophageal conditions prior to bariatric surgery in a severely obese patient population.

BACKGROUND: Sleeve gastrectomy (SG) is currently the most commonly performed bariatric procedure in the United States; however, it can be associated with development of de novo gastroesophageal reflux (GERD) or worsening of existing GERD. Preoperative esophagogastroduodenoscopy (EGD) and findings of esophagitis are commonly used as screening tool, but the alternative use of preoperative objective measurement of acid reflux has not been studied. OBJECTIVE: The aim of this study was to evaluate if preoperative objective measurement of acid reflux by using wireless pH monitoring (WPHM) could have an impact on surgical planning and outcomes. SETTING: Academic Center of Excellence. METHODS: Retrospective review of a prospectively collected database of 43 adult obese patients with reflux symptoms who underwent outpatient EGD and WPHM between September 2011 and September 2017. RESULTS: Change in planned surgical management from SG to Roux-en-Y-gastric bypass with the use of WPHM occurred in 21.0% (n = 9) of patients. Only 2.3% (n = 1) developed de novo GERD after SG. Nonerosive reflux disease was the most common esophageal condition on preoperative EGD. EGD, as a single diagnostic tool, appeared insufficient to diagnose acid reflux and help with the decision planning in this patient population. CONCLUSIONS: Based on objective data obtained by measurement of GERD, using preoperative WPHM compared with preoperative EGD alone aids in a better patient selection for either SG or Roux-en-Y-gastric bypass. Our cohort with preoperative WPHM required no surgical conversions or revisions.

Safety of Large-Volume, Same-Day Oral Bowel Preparations During Deep Sedation: A Prospective Observational Study.

BACKGROUND: Colonoscopy quality is directly related to the bowel preparation. It is well established that bowel preparations are improved when at least part of the laxative is ingested on the day of the procedure. However, there is concern that this can result in higher gastric residual volumes (GRV) and increase the risk of pulmonary aspiration. The aim of this study is to evaluate GRV and gastric pH in patients who received day-before bowel preparation versus those ingesting their laxative on the day of colonoscopy under anesthesiologist-directed propofol deep sedation. METHODS: This is a prospective observational study for patients undergoing same-day upper endoscopy and colonoscopy. All included patients had large-volume polyethylene glycol lavage preparation and received propofol sedation. Gastric fluid was collected during the upper endoscopy for volume and pH measurement. RESULTS: The study included 428 patients with 56% receiving same-day laxative preparation and the remainder evening-before preparation. Mean ± SD GRV was 18.1 ± 10.2 mL, 16.3 ± 16.5 mL in each of these preparation groups, respectively (P = .69). GRV ≥ 25 mL or higher than expected GRV adjusted by weight (0.4 mL/kg) were also not different among the study groups (P = .90 and P = .87, respectively). Evaluating GRV based on time since last ingestion of preparation (3-5, 5-7, >7 hours) did not result in any differences (P = .56). Gastric pH was also similar between the bowel preparation groups (P = .23), with mean ± SD of 2.5 ± 1.4 for evening-before and 2.5 ± 1.3 for the same-day preparation. There were more inadequate bowel preparations in day before bowel preparations (P = .001). CONCLUSIONS: A large-volume bowel preparation regimen finished on the day of colonoscopy as close as 3 hours before the procedure results in no increase in GRV or decrease in gastric pH.

The safety of same-day CT colonography following incomplete colonoscopy with polypectomy.

BACKGROUND: Concerns about the risk of bowel perforation for same-day computed tomography colonography (CTC) following an incomplete colonoscopy with polypectomy may lead to unnecessarily postponing the CTC. OBJECTIVE: The objective of this article is to describe the complications including colon perforations associated with same-day CTC in a cohort who had polypectomies but an incomplete colonoscopy. DESIGN: We conducted a retrospective study. SETTING: Our study took place in a single, tertiary referral center. PATIENTS: We studied consecutive patients who had CTC the same day as an incomplete colonoscopy with polypectomy. INTERVENTIONS: Interventions included optical colonoscopy (OC), endoscopic polypectomies, and same-day CTC. MAIN OUTCOME MEASUREMENTS: Our main outcome measurements included perforation rate with long-term follow-up. RESULTS: A total of 3% of patients undergoing colonoscopy from January 2008 to December 2012 had same-day CTC following incomplete OC, and 72 polypectomies were performed in 34 (or 17%) of these patients. Incomplete colonoscopies were due to colon tortuosity and looping (25), severe angulations (five), colon mass (two), colon stenosis (one), bradycardia (one). Fifty-three percent of the OCs were screening for colon neoplasia, 29% diagnostic and 18% were surveillance of colon polyps. Most polyps were ≤ 5 mm, and found in the left colon. There were no reported complications or perforations associated with same-day CTCs during short- and long-term follow-up. LIMITATIONS: Limitations of our analysis included retrospective single-center design, small number of patients for the occurrence, referral to same-day CTC was not standardized, inability to establish safety of CTC for specific scenarios such as after complex polypectomies, strictures, or advanced IBD. CONCLUSIONS: Radiologists' apprehension to perform a CTC the same day as an incomplete colonoscopy following polypectomies because of perceived risk of perforation may be unfounded. More data are needed to determine the safety of same-day CTC in patients with high-risk findings during colonoscopy such as a stricture, severe IBD, and after complex polypectomies.

Circadian and Circannual Rhythms in Thyroid Hormones: Determining the TSH and Free T4 Reference Intervals Based Upon Time of Day, Age, and Sex.

BACKGROUND: Establishing the reference interval for thyrotropin (TSH) and free thyroxine (T4) is clinically important because a number of disease states have been linked to alterations in TSH and free T4 concentrations that are within the 95% confidence interval for normal thyroid hormone values. Age, sex, time of day, and ethnicity are known to affect circulating levels of TSH and free T4 but have not been used to establish reference intervals. The purpose of this study was to define the reference interval for TSH and free T4 taking into account age, sex, ethnicity, and circadian and circannual variability. METHODS: We performed a retrospective analysis of 465,593 TSH and 112,994 free T4 measurements from subjects ages 1-104 years with no thyroid disease using a single TSH and free T4 immunoassay method. Boundaries for the central 95% of patient values, taking into account hour of day, day of year, sex, and age were calculated. RESULTS: Females had significantly higher TSH and free T4 levels than males; the magnitude of these differences did not exceed 0.1 mIU/L or 0.1 ng/dL respectively. Although the 2.5% TSH reference interval remains constant through the day, date, and age ranges, the upper limit (97.5%) of the TSH reference interval increases from 6.45 to 7.55 mIU/L with age, due primarily to a progressive increase in the amplitude of the nocturnal TSH surge. Additionally, significant ethnic differences in TSH circadian periodicity occur between African American, Pacific Island, and Caucasian populations. CONCLUSIONS: The reference interval for TSH varies significantly by age, sex, hour of day, and ethnicity. Time of year does not affect the TSH reference interval, and age, sex, hour of day and time of year do not affect the free T4 reference interval.

Efficacy of morning-only 4 liter sulfa free polyethylene glycol vs 2 liter polyethylene glycol with ascorbic acid for afternoon colonoscopy.

AIM: To compare the bowel cleansing efficacy of same day ingestion of 4-L sulfa-free polyethylene glycol (4-L SF-PEG) vs 2-L polyethylene glycol solution with ascorbic acid (2-L PEG + Asc) in patients undergoing afternoon colonoscopy. METHODS: 206 patients (mean age 56.7 years, 61% male) undergoing outpatient screening or surveillance colonoscopies were prospectively randomized to receive either 4-L SF-PEG (n = 104) or 2-L PEG + Asc solution (n = 102). Colonoscopies were performed by two blinded endoscopists. Bowel preparation was graded using the Ottawa scale. Each participant completed a satisfaction and side effect survey. RESULTS: There was no difference in patient demographics amongst groups. 4-L SF-PEG resulted in better Ottawa scores compared to 2-L PEG + Asc, 4.2 vs 4.9 (P = 0.0186); left colon: 1.33 vs 1.57 respectively (P = 0.0224), right colon: 1.38 vs 1.63 respectively (P = 0.0097). No difference in Ottawa scores was found for the mid colon or amount of fluid. Patient satisfaction was similar for both arms but those assigned to 4-L SF-PEG reported less bloating: 23.1% vs 11.5% (P = 0.0235). Overall polyp detection, adenomatous polyp and advanced adenoma detection rates were similar between the two groups. CONCLUSION: Morning only 4-L SF-PEG provided superior cleansing with less bloating as compared to 2-L PEG + Asc bowel preparation for afternoon colonoscopy. Thus, future studies evaluating efficacy of morning only preparation for afternoon colonoscopy should use 4-L SF-PEG as the standard comparator.

Risk of Clostridium difficile infection in hospitalized patients receiving metronidazole for a non-C difficile infection.

BACKGROUND & AIMS: Antibiotics often are given to prevent infections but also constitute a risk factor for Clostridium difficile infection (CDI). Metronidazole is an effective treatment for CDI. We investigated whether prophylactic administration of metronidazole to patients before they receive other antibiotics reduces the risk of CDI. METHODS: We performed a retrospective cohort analysis of data collected from 12,026 high-risk patients admitted to Cleveland Clinic Foundation Hospitals from 2008 through 2012. High-risk patients were defined as age 55 or older who received a broad-spectrum antibiotic (piperacillin-tazobactam or ciprofloxacin) and a gastric acid suppressant (a proton pump inhibitor or a histamine-2 receptor blocker) during their hospitalization. Development of CDI was compared between patients who received metronidazole for non-CDI indications before broad-spectrum antibiotics (n = 811) and those who did not (n = 11,215). Logistic regression was used to control for patient demographics and comorbidities. RESULTS: The rate of CDI was 1.4% (n = 11) among the patients who received metronidazole for non-CDI indications and 6.5% (n = 728) among those who did not. This was observed to be an 80% reduction in CDI among patients who received metronidazole (odds ratio, 0.21; 95% confidence interval, 0.11-0.38; P < .001), adjusted for age, sex, and comorbidities. CONCLUSIONS: Based on a retrospective analysis, metronidazole might be used to prevent CDI in certain high-risk patients. Prospective controlled trials are necessary before making further recommendations.

Kaposi's Sarcoma: An Unusual Cause of Gastric Outlet Obstruction.

Kaposi's sarcoma (KS) is the most common AIDS-related neoplasm and is one of the AIDS-defining illnesses. It most frequently presents with cutaneous lesions, but may also involve organ systems. Most cases of gastrointestinal (GI) involvement are clinically silent and found incidentally on imaging studies or endoscopy. Sole involvement of the GI tract can be seen with or without cutaneous disease; however, the latter has been reported as rare by some investigators. We report a case of a 25-year-old man with HIV who presented with gastric outlet obstruction (GOO) and disseminated GI involvement by KS.

Issues related to colorectal cancer and colorectal cancer screening practices in women.

Studies have shown that colorectal cancer (CRC) incidence is equal between men and women. However, several studies have demonstrated lower adenoma detection rates in women than in men. Many questions arise about differences in adenomas, CRC, and screening practices between men and women: should screening be the same for both sexes, are there differences in risk factors in the formation of colon cancer, should special groups of women be screened differently from the general population, are colonoscopies tolerated differently in women and why, and what determines if a woman will undergo colonoscopy? This article reviews these issues.

Preferences for ethnicity and sex of endoscopists in a Hispanic population in the United States.

BACKGROUND: Preferences toward endoscopists have been shown to be a barrier to colorectal cancer screening in certain patient populations. OBJECTIVE: To evaluate sex and ethnicity preferences for endoscopists in a largely Hispanic population. METHODS: This was a prospective cross-sectional study. Patients were given an anonymous questionnaire in which information on demographics and sex/ethnic preferences for endoscopists was determined. Bivariate and multivariate models were used to assess factors that affected outcome variables. RESULTS: A total of 438 patients were included (213 men, 225 women; mean age 62 years). Predominant ethnicities were white (44%) and Hispanic (45%). Twenty-six percent and 17% of patients expressed sex and ethnicity preferences, respectively. Women (30.8%), particularly Hispanic women (35%), had a sex preference more often than men (20.4%; P < .05). Hispanics had an ethnicity preference more often than white patients (P < .01). Lower education level, being a first-generation immigrant, family history of colorectal cancer, having a concurrent preference for obstetrician/gynecologist, and ethnicity preference for endoscopist were associated with the presence of a sex preference for the endoscopist (P < .05). Being a first-generation immigrant and having an ethnicity preference for a primary care provider or the sex of the endoscopist were significantly associated with a preference for the ethnicity of the endoscopist (P < .05). LIMITATIONS: Results are based on self-report. Limited study factors were also assessed. CONCLUSIONS: Among a predominant Hispanic population, sex and ethnicity preferences for endoscopists are often seen. They may coexist, increase the likelihood of the presence of one when the other is present, and likely influence compliance with colorectal cancer screening.

Overestimation of ulcerative colitis due to melanosis coli.

Melanosis coli is a benign pigment deposition in the colonic mucosa that can be seen at the time of colonoscopy especially in patients with history of laxative use. In conditions in which the endoscopic findings influence therapeutic decisions, melanosis coli can lead to overestimation of disease aggressiveness and unnecessary therapy. We describe a case in which the finding of melanosis coli affected the treatment of a patient with mild ulcerative colitis exacerbation.

Importance of gender, socioeconomic status, and history of abuse on patient preference for endoscopist.

OBJECTIVES: Patients have previously expressed preference for the gender of their endoscopist. Most of these patients were Caucasian women of predominantly high socioeconomic status. No study has evaluated the gender preferences of both women and men from a diverse but predominantly low socioeconomic background. The aim of this study was to evaluate gender preferences for endoscopists within an inner-city, tertiary care population. METHODS: Consecutive patients scheduled for elective outpatient upper or lower endoscopy were prospectively asked to complete a questionnaire. Data included patient demographics, income level, education level, medical history, social history, abuse history, and gender preferences toward various health-care professionals. RESULTS: A total of 500 patients completed the study (286 women, 214 men). Overall, 33% of patients surveyed had a preference for the gender of their endoscopist (165/500; CI: 29-37%). Women were significantly more likely to have a gender preference vs. men (42.3 vs. 21%; P<0.001). Female gender, lower income level, and history of physical/emotional abuse were significant factors for gender preference, as shown by multivariate analysis. Of our patients, 88 (18%) reported a history of abuse. A history of abuse significantly increased the percentage of patients with a gender preference for endoscopist (P<0.001). CONCLUSIONS: Women in our inner-city tertiary care center expressed gender preference for their endoscopist at rates similar to those seen in previous studies. A higher percentage of men had a gender preference than previously reported. Both men and women with a history of abuse are significantly more likely to prefer a woman endoscopist. Physicians should be aware of these high preference rates to increase compliance and optimize patient care.

Autoimmune disorders: gastrointestinal manifestations and endoscopic findings.

The gastrointestinal tract can be involved in many autoimmune disorders, and women are affected more than men in most of the disease processes discussed. As this article outlines, gastrointestinal manifestations can be either part of the clinical presentation or complications of treatment. Depending on the disease process and the severity of symptoms, gastrointestinal evaluation and treatment can have an important role in the management of these diseases.