Kaolin Clay Anemia.

Iron deficiency anemia is a common diagnosis encountered in the nutrition, primary care, and gastroenterology fields. Iron deficiency anemia most often leads to evaluation for various malabsorption disorders and colonoscopy to exclude colon cancer as an etiology. We present a case of iron deficiency anemia that was caused by geophagia. After the culprit dietary habit was stopped, the patient's iron deficiency anemia subsequently resolved.

Initial Evaluation and Care of the Patient with New-Onset Intestinal Failure.

A total parenteral nutrition (TPN) formula needs to be correctly compounded with the help of a pharmacist and patients cycled to ensure they are tolerating the TPN volume. Selection of and close working relationship with a home infusion company needs to be arranged prior to hospital discharge and can be coordinated with the help of a hospital case manager. For Medicare patients, a certificate of medical necessity must be completed and signed prior to hospital discharge. Patients should undergo education regarding catheter care, infusion pump programming, and preparation of the TPN solution with additives, such as multivitamins and trace elements.

Barriers to treatment of chronic hepatitis C with direct acting antivirals in an urban clinic.

INTRODUCTION AND AIM: Direct-acting antiviral (DAA) agents are highly effective for treatment of chronic hepatitis C virus (HCV) yet access to treatment remains a serious challenge. The aim of this study was to identify barriers to treatment initiation with DAA-containing regimens in an urban clinic setting. MATERIALS AND METHODS: A retrospective cohort of all chronic HCV patients seen in an urban academic practice in Jacksonville, FL, USA from 1/2014 to 1/2017 was analyzed. Baseline characteristics were recorded and a review of medical records was performed to identify barriers to treatment initiation and overall success rates. RESULTS: Two-hundred and forty patients with chronic HCV were analyzed. Fifty-six percent of patients were African-American and 63% were insured through Medicaid/county programs or uninsured. Sixty-nine percent had barriers to initiating antiviral therapy categorized as psychosocial (n=112), provider (n=26), medical (n=20), and insurance-related factors (n=7). The most commonly encountered psychosocial barriers included failure to keep appointments (79/240, 33%), active substance abuse (18/240, 8%), and failure to obtain laboratory testing (11/240, 5%). Overall, only 27% of patients evaluated were initiated on DAA-containing regimens with 18% reaching SVR12 within the 36-month study period. CONCLUSION: In conclusion, only 27% of patients who presented to an urban academic practice with chronic HCV received DAA-containing regimens over a 36-month period. Psychosocial issues were the major barriers to antiviral therapy. These findings illustrate the need for an integrated approach that addresses psychosocial factors as well as comorbidities and adherence to care in order to increase rates of HCV treatment in at risk patients.

Safety and efficacy of over-the-scope clip-assisted full thickness resection of duodenal subepithelial tumors: A case report.

BACKGROUND: Over-the-scope clip-assisted endoscopic full thickness resection (eFTR) of subepithelial tumors is a novel and promising endoscopic technique. Recently, there have been prospective studies investigating its use for colonic masses, but data regarding its use and efficacy in the duodenum are limited to a few reports. CASE SUMMARY: A 65-year-old African American female presents for evaluation of persistent gastroesophageal reflux disease not responsive to medical treatment. A 1 cm nodule was incidentally found in the duodenum and biopsies revealed a low grade well differentiated neuroendocrine tumor. The nodule was removed using over-the-scope clip-assisted eFTR and pathology revealed clear margins. We review the available literature with a discussion on the efficacy and safety of clip-assisted eFTR s of subepithelial lesions in the duodenum. CONCLUSION: Clip assisted eFTR appears to be a safe and efficacious treatment approach to duodenal subepithelial lesions. Further prospective studies are needed to investigate the long-term utility and safety of clip-assisted eFTR in the management of subepithelial duodenal lesions.

Ipilimumab and Nivolumab induced steroid-refractory colitis treated with infliximab: A case report.

BACKGROUND: A variety of immune-modulating drugs are becoming increasingly used for various cancers. Despite increasing indications and improved efficacy, they are often associated with a wide variety of immune mediated adverse events including colitis that may be refractory to conventional therapy. Although these drugs are being more commonly used by Hematologists and Oncologists, there are still many gastroenterologists who are not familiar with the incidence and natural history of gastrointestinal immune-mediated side effects, as well as the role of infliximab in the management of this condition. CASE SUMMARY: We report a case of a 63-year-old male with a history of metastatic renal cell carcinoma who presented to our hospital with severe diarrhea. The patient had received his third combination infusion of the anti-CTLA-4 monoclonal antibody Ipilimumab and the immune checkpoint inhibitor Nivolumab and developed severe watery non-bloody diarrhea the same day. He presented to the hospital where he was found to be severely dehydrated and in acute renal failure. An extensive workup was negative for infectious etiologies and he was initiated on high dose intravenous steroids. However, he continued to worsen. A colonoscopy was performed and revealed no endoscopic evidence of inflammation. Random biopsies for histology were obtained which showed mild colitis, and were negative for Cytomegalovirus and Herpes Simplex Virus. He was diagnosed with severe steroid-refractory colitis induced by Ipilimumab and Nivolumab and was initiated on Infliximab. He responded promptly to it and his diarrhea resolved the next day with progressive resolution of his renal impairment. On follow up his gastrointestinal side symptoms did not recur. CONCLUSION: Given the increasing use of immune therapy in a variety of cancers, it is important for gastroenterologists to be familiar with their gastrointestinal side effects and comfortable with their management, including prescribing infliximab.

Medical management of esophageal food impaction refractory to endoscopic interventions.

Most esophageal food impactions either pass spontaneously or are treated endoscopically. Severe food impactions can require extensive endoscopic therapy that potentially could lead to procedure-related complications. There are few alternate therapies available when endoscopy fails. Traditionally, pharmacologic therapy with glucagon has been performed with varying success. This case report and discussion will outline the management of a complete food impaction and medical therapies available when first-line endoscopic treatment fails. We present a case in which the endoscopic intervention for esophageal food bolus impaction was unsuccessful.

Proton radiotherapy dose perturbations caused by esophageal stents of varying material composition are negligible in an experimental model.

BACKGROUND: Self-expanding metal and plastic esophageal stents (SEMS and SEPS, respectively) are used in conjunction with chemoradiation for palliation of malignant dysphagia. To date, the dosimetric effects of stents undergoing proton radiotherapy are not known. STUDY AIM: To investigate the proton radiotherapy dose perturbations caused by esophageal stents of varying designs and materials undergoing external beam treatment for esophageal cancer. PATIENTS AND METHODS: Simulated clinical protocol. Solid acrylic phantom was used to mimic the esophageal tissue environment. Stents made of nitinol, stainless steel and polyester were tested. Proton beam dose of 2 Gy-E was delivered to each stent in a single anterior to posterior field. Film and image based evidence of dose perturbation were main outcomes measured. RESULTS: Only the stainless steel and plastic stents demonstrated slight overall dose attenuations (- 0.5 % and - 0.4 %, respectively). All the nitinol-based stents demonstrated minimal overall dose perturbations ranging from 0.0 % to 1.2 %. Negligible dose perturbations were observed on each of the stent surfaces proximal to the radiation source, ranging from - 0.8 % (stainless steel stent) to 1.0 % (nitinol stent). Negligible dose effects were also observed on the distal surfaces of each stent ranging from - 0.5 % (plastic and stainless steel stents) to 1.0 % (nitinol stent). CONCLUSION: Proton radiotherapy dose perturbations caused by stents of varying designs and material composition are negligible. Negligible dose perturbation is in keeping with the inherent advantage of proton therapy over traditional radiotherapy composed of photons - given its relative large mass, protons have little side scatter.

Gastrointestinal manifestations, diagnosis, and management of hereditary angioedema.

Abdominal pain is one of the most common conditions in clinical practice and yet a challenging complaint to accurately diagnose due to the vast number of possible etiologies. When other health care providers cannot identify the cause of abdominal pain, gastroenterologists are often looked upon to help solve the diagnostic dilemma. Consequently, it is incumbent upon gastroenterologists to be well versed in the diagnosis and management of not only common but also rare causes of abdominal pain. One such uncommon but well-described cause of abdominal pain is angioedema of the intestinal tract due to hereditary angioedema. Acute onset, recurrent abdominal pain of varying severity is its most common presenting symptom, and misdiagnosis can not only lead to unnecessary surgical procedures but also death. The purpose of this review is to raise awareness among gastroenterologists about hereditary angioedema as a potential cause of recurrent, unexplained abdominal pain.

A low pretransplant peripheral blood mononuclear cell complex I activity predicts metabolic disturbances and inability to regain fat free mass in cirrhotic patients undergoing liver transplantation.

Liver cirrhosis is associated with malnutrition and often, after liver transplantation, with the development of obesity and the inability to gain lean body mass. We have previously shown that peripheral blood mononuclear cell (PBMNC) complex I activity could be an appropriate marker for nutritional assessment. In this context, we hypothesized that a low pretransplant PBMNC complex I activity may predict a poor nutritional status in cirrhotic patients undergoing liver transplantation. Fifteen cirrhotic patients (CP) (8 men and 7 women) were recruited and investigated before and 4 months after liver transplantation. Body weight, body composition by DEXA, anthropometric measures (triceps skinfold thickness and midarm muscle circumference), resting energy expenditure, respiratory quotient and PBMNC complex I activity were measured on both time points. Patients were divided into 2 groups depending on their pretransplant PBMNC complex I activity (low vs high complex I activity [CP(low CI) vs CP(high CI)]), using as an arbitrary cutoff value-the mean complex I activity observed in age-matched healthy controls. Before transplantation, the CP(low CI) group who showed a lower complex I activity (2.11 +/- 0.53 vs 4.54 +/- 0.98 nmol/min per milligram of protein, P < .01) was significantly younger (44 +/- 9 vs 62 +/- 8 years old, P < .01); no differences were observed for any other nutritional parameters when compared to the CP(high CI) group. After transplantation, only the CP(low CI) group demonstrated a significant increase of complex I activity (+77%, P < .01), respiratory quotient (+10.5%, P < .02), triceps skinfold thickness (+126%, P < .005), and a significant decrease of fat-free mass (-8%, P < .01). In summary, our findings indicate that a low pretransplant PBMNC complex I activity in cirrhotic patients could be a useful marker of poor nutritional status despite the lack of traditional indicators of malnutrition by predicting metabolic disturbances and an inability to regain fat-free mass after liver transplantation.

Advances and controversies in clinical nutrition: the education outcome of a live continuing medical education course.

BACKGROUND: The aim of this study was to assess participants' nutrition knowledge and practice behavior before and after completing a live continuing medical education (CME) nutrition course designed for practicing nutrition clinicians. METHODS: Electronic surveys were sent to the first 100 registered participants before and after attending the course. The curriculum consisted of 16.75 hours of live education. The curriculum was revised when the precourse surveys identified a gap in medical knowledge or practice behavior. Knowledge change was assessed by a 15-question survey given before and 1 week after the course. Change in practice behavior was accessed by a 10-question survey administered 2 months after the course. RESULTS: Dietitians were the predominant discipline group attending the course. Sixty-three percent of those surveyed practiced hospital nutrition, 19% outpatient nutrition, and 18% an equal mix. Forty-eight percent indicated that they write parenteral nutrition (PN) orders and 51% write enteral nutrition (EN) orders; of these, 62% indicated they are comfortable writing PN orders and 81% are comfortable writing EN orders. Twenty-three percent indicated that they manage home PN and EN patients. Twenty-six percent stated they were certified in nutrition support. Seventy-eight percent of the participants responded to survey 2; the median correct response rates were 51% pre- and 76% postcourse. Seventy percent responded to survey 3; the median positive clinical practice behavior change was 69%. CONCLUSION: This live CME course improved knowledge, and a majority of attendants reported changing their nutrition practice after this course.

Education of gastroenterology trainees: first annual fellows' nutrition course.

BACKGROUND AND AIMS: The degree of nutrition training in gastrointestinal (GI) fellowship programs has not been reported previously, but it is thought to be inadequate. The aim of this study was to determine GI fellows' exposure to nutrition and to assess nutrition knowledge and practice behaviors before and after completing a live nutrition course. METHODS: This course was geared specifically for GI fellows. Nineteen faculty members from the United States and Canada participated. Electronic surveys were sent to each fellow before and after the course. The curriculum consisted of 20 hours of live education. Curriculum was revised when the precourse survey identified a gap in medical knowledge or practice behavior. Knowledge change was assessed by a 20-question survey before and after the course. RESULTS: Fifty-three fellows participated. Seventy percent reported no inpatient nutrition rotation. Seventy percent had never written a total parenteral nutrition or total enteral nutrition orders, and 12% had treated a home enteral or parenteral patient. Ninety percent had no outpatient nutrition or obesity rotation experience, and 59% had no core nutrition lecture series at their program. Eighty-seven percent had never been assessed for competency in nutrition, and 9% had completed a nutrition research project. Too few mentors, poor exposure, and a predominant focus on endoscopy were reasons cited for not pursing nutrition training. Knowledge change after the course was assessed; the mean correct response rates were 58% before and 88% postcourse. CONCLUSION: There is a considerable deficiency in nutrition training in GI programs. The established American Gastroenterological Association nutrition curriculum guidelines and core competencies are not being fulfilled in most programs. The curriculum of this course resulted in increased knowledge and improved nutrition practice behavior. There is a need for more nutrition training for our GI fellows.

Continuing medical education questions.

If you wish to receive credit for this activity, please refer to the Web site: http://www.acg.gi.org/journalcme/. Article Title: Drug Interactions in Inflammatory Bowel Disease.

Decreasing aspiration risk with enteral feeding.

Aspiration is a clinical concern in patients receiving enteral tube feeding. Aspiration can result in pneumonia leading to increases in the use of antibiotics, length of hospital stay, and the risk of mortality. Pneumonia caused by aspiration of gastric contents is of particular concern in patients who require mechanical ventilation and feeding by nasogastric tube. This article summarizes factors that might influence the development of aspiration pneumonia and minimize risk, such as the position of the patient's body, method of feeding, and size of the feeding tube.

Continued medical education provided by medical journals: the "red journal's" experience.

BACKGROUND AND AIMS: A mailed survey to our readership expressed an interest in providing journal CME. In January 2006, following an assessment of the readership's educational needs and the development of educational objectives to span a 12-month program, two articles per issue were provided to participants to gain category 1 credit free of charge. METHODS: Participants completed a mandatory electronic evaluation after each CME activity that they had completed. These prospective data were collected to determine participant demographics, satisfaction, and outcome results. RESULTS: A total of 1,329 CME credits were provided during the 2006 volume year. Ninety-one percent of these participants were in private practice, 98% of the participants indicated a good to excellent overall satisfaction with the CME activity, 97% indicated their experience was good to excellent compared to other journals that they had participated for CME credit, and 97% of the participants indicated that they thought the CME activity increased their knowledge and/or skills related to patient care. CONCLUSION: The results of our 1-yr outcome analysis indicate that there is a need for continued journal-based CME and that our participants are very satisfied with the process. This CME activity format also appears to have improved the participants' knowledge and their delivery of patient care.

Gastrointestinal and nutritional complications after bariatric surgery.

The prevalence of obesity has increased to epidemic proportions, making obesity and its comorbid conditions a major public health concern. Bariatric surgery is the most effective treatment, but it carries substantial morbidity. The subsequent gastrointestinal and nutritional complications are often not recognized or properly managed. As part of the multidisciplinary team taking care of obese patients, gastroenterologists should be familiar with the types of bariatric surgery and their associated complications. We review the most common gastrointestinal and nutritional complications after bariatric procedures and examine how gastroenterologists may best prevent, investigate, and treat them.

Pancreatic enzyme pharmacotherapy.

Supplemental pancreatic enzyme preparations are provided to patients with conditions of pancreatic exocrine deficiency such as chronic pancreatitis and cystic fibrosis. These patients frequently experience steatorrhea, which occurs from inadequate fat absorption. The delivery of sufficient enzyme concentrations into the duodenal lumen simultaneously with meals can reduce nutrient malabsorption, improve the symptoms of steatorrhea, and in some cases alleviate the pain associated with chronic pancreatitis. Current clinical practices dictate administration of lipase 25,000-40,000 units/meal by using pH-sensitive pancrelipase microspheres, along with dosage increases, compliance checks, and differential diagnosis in cases of treatment failure. Despite the large number of specialty enzyme replacements available commercially, many patients remain dissatisfied with standard therapy, and future developments are needed to optimize treatment in these individuals.

Home parenteral and enteral nutrition.

Home parenteral and enteral nutrition (HPEN) has evolved to become a very successful, lifesaving treatment in the management of patients with intestinal and oral failure, respectively. Nevertheless, the provision of HPEN remains intrusive, expensive, and continues to be associated with significant morbidity. The management of HPEN by a nutrition support team that optimally includes an experienced clinician, nurse specialist, dietitian, and pharmacist reduces HPEN-related morbidity and may reduce costs associated with its use. Because clinical expertise in the management of patients receiving HPEN is not widely available, the referral of these patients to experienced centers for periodic assessment should be encouraged.

Glucagon for the relief of esophageal food impaction does it really work?

We sought to evaluate our experience with glucagon used in the emergency department setting to relieve esophageal food impaction (EFI). We reviewed the records of patients with food impaction who received glucagon between January 1998 and May 2003 and recorded patient demographics, medical history, symptoms following glucagon administration, and endoscopic findings. There were 92 episodes of food impaction in 85 patients. Thirty-three percent of the episodes resulted in resolution of symptoms following a dose of glucagon. Sixty-seven percent had symptoms of food impaction after glucagon and underwent upper endoscopy in the emergency room. Only previous solid food dysphagia was positively associated with response to glucagon. Patients who received glucagon plus a benzodiazepine were more likely to have resolution of the EFI. In our experience, glucagon appears to relieve food impaction in one third of patients treated. This result is comparable to previously published data examining glucagon and placebo. The lack of advantage over placebo questions the practice of glucagon administration for EFI.