The Association Between Helicobacter pylori Infection and Nonalcoholic Fatty Liver Disease.

PURPOSE OF REVIEW: Helicobacter pylori (HP) infection is known to be a significant risk factor in the development of certain gastric conditions, such as ulcers, gastritis, and malignancy. Recently, however, the systemic effect of HP infection on other organ systems has come to be appreciated. In this review, we will explore the association between HP infection and nonalcoholic fatty liver disease (NAFLD), the hepatic component of metabolic syndrome. RECENT FINDINGS: The possible association between HP infection and NAFLD initially stemmed from the isolation of HP bacteria in the livers of patients with NAFLD. Although there have been conflicting results, several subsequent clinical trials have demonstrated a higher rate of fatty liver and NASH in HP-positive patients compared to HP-negative patients; in addition, small trials examining the effect of HP eradication have shown improvement in markers of NAFLD activity, further supporting a link between these two conditions. The pathophysiology behind the possible association between HP infection and NAFLD has yet to be fully elucidated; several possible mechanisms include induction of a pro-inflammatory state that shifts the body toward a more lipogenic profile, and a hormonal shift that favors progression toward insulin resistance and fibrosis. The association between HP infection and NAFLD has been demonstrated in several clinical trials, including small trials evaluating the effect of HP eradication on NAFLD. Future studies examining the pathophysiology behind this association are the next step in characterizing the relationship between these two conditions.

Pseudomembranous colitis: Not always Clostridium difficile.

Although Clostridium difficile infection is the cause of most cases of pseudomembranous colitis, clinicians should consider less common causes, especially if pseudomembranes are seen on endoscopy but testing remains negative for C difficile or if presumed C difficile infection does not respond to treatment. Histologic review of colonic mucosal biopsy specimens can provide clues to the underlying cause.

Prospective evaluation and treatment of familial carcinoid small intestine neuroendocrine tumors (SI-NETs).

BACKGROUND: The aim of this study was to prospectively screen patients with a positive family history of carcinoid small intestine neuroendocrine tumors (SI-NETs) to elucidate the benefits of early detection and operative intervention. METHODS: A single-center, prospective trial was conducted from 2008 to 2014 that evaluated patients with 2 or more blood relatives with carcinoid SI-NETs. All eligible patients were screened with urine/serum biochemistries and various imaging modalities. Operative intervention was elected in patients found to have at least 1 positive diagnostic study. RESULTS: Twenty-nine patients from 13 families had occult carcinoid SI-NETs (15 female, 14 male). Twenty-four of the 29 patients (83%) had multifocal disease found in either the distal jejunum or ileum. On average, 75.9 cm (range, 13-195) of bowel was resected in 1 segment. Three patients were found to have stage IV disease at operation. All stage I-IIIB patients who had R0 resections have remained disease-free, with a median follow-up of 35 months. CONCLUSION: Familial carcinoid SI-NETs often are asymptomatic and can be diagnosed with aggressive screening. With early detection, there may be a window of opportunity for operative resection to change the natural history of this disease and even prove to be curative.

Acute Hepatocellular Drug-Induced Liver Injury From Bupropion and Doxycycline.

The management and diagnosis of drug-induced liver injury (DILI) is often challenging, particularly when patients are taking multiple medications. We present a 29-year-old African American man who presented with jaundice and malaise after starting bupropion and doxycycline 2 weeks prior. He was found to have acute hepatocellular drug-induced liver injury with autoimmune features, and made a complete recovery with prednisone. Although bupropion and doxycycline are both known to cause liver toxicity, a closer inspection of the signature of liver injury and a review of prior related DILI cases assigns causality more to bupropion than doxycycline.

Pseudomembranous Colitis: Not Always Caused by Clostridium difficile.

Although classically pseudomembranous colitis is caused by Clostridium difficile, it can result from several etiologies. Certain medications, chemical injury, collagenous colitis, inflammatory bowel disease, ischemia, and other infectious pathogens can reportedly cause mucosal injury and subsequent pseudomembrane formation. We present the case of a middle-aged woman with vascular disease who was incorrectly diagnosed with refractory C. difficile infection due to the presence of pseudomembranes. Further imaging, endoscopy, and careful histopathology review revealed chronic ischemia as the cause of her pseudomembranous colitis and diarrhea. This case highlights the need for gastroenterologists to consider non-C. difficile etiologies when diagnosing pseudomembranous colitis.

Anti-hypertensive therapy and risk factors associated with hypotension during colonoscopy under conscious sedation.

BACKGROUND AND AIMS: Pre-operative use of select anti-hypertensive therapy has been associated with peri-operative hypotension in the surgical setting. Our aim was to determine the effect of anti-hypertensive medications on blood pressure (BP) and procedural outcomes in gastrointestinal endoscopy. METHODS: Our study was a prospective, cross-sectional survey of outpatients undergoing colonoscopy with conscious sedation. We enrolled patients with hypertension that took anti-hypertensive medications within 24 hours of the procedure and patients without hypertension that were not on BP-lowering agents. We recorded mean BP prior to, during, and after the procedure. RESULTS: 626 patients (338 males; mean age 56.0 +/- 10.4 years) were enrolled, and 158 patients were on anti-hypertensive therapy. There were 57 patients who developed hypotension, defined as systolic BP <90 mmHg and/or diastolic BP <60 mmHg, during the colonoscopy. Taking a BP medication, regardless of class, was not associated with an increased risk of procedural hypotension (all p >0.05). Age, body mass index, gender, duration, fentanyl dose, midazolam dose, and co-morbidities (asthma, chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease) were also not associated (all p >0.05). Instead, a lower pre-procedure systolic BP (OR=0.97, 95% CI=0.95-0.99; p=0.004) and diastolic BP (OR=0.95, 95% CI=0.92-0.97; p<0.001) were identified as the only risk factors. CONCLUSION: Patients should continue their anti-hypertensive therapy leading up to endoscopy. A lower pre-procedure BP is the main risk factor for procedural hypotension in patients undergoing colonoscopy with conscious sedation. Future studies should explore other factors, such as bowel preparation, that can affect pre-procedure BP.

Predictive value of body mass index at age 18 on adulthood obesity: results of a prospective survey of an urban population.

INTRODUCTION: Overweight children often become obese adults. The main purpose of this study was to define the risk of teenage obesity as a predictor of adulthood obesity in an under-studied and urban population. A secondary aim was to determine whether gender had an effect on the predictive value of teenage obesity. The final goal was to examine the influence of dietary habits on obesity. METHODS: This cross-sectional survey was conducted using convenience sampling of an urban, primarily African American, community. Demographic questions were supplemented by a dietary history and measurement of body anthropometrics. RESULTS: Five hundred three subjects were interviewed; 86% were African American, and the mean age was 43 years. Body mass index (BMI) at age 18 was the strongest factor associated with current obesity status in univariate and multivariate analyses. Sixty-nine (13.7%) subjects were overweight at age 18, and 28 (5.6%) were obese. Of the 28 obese teenagers, 22 (78.6%) went on to become obese as adults. Only 2.1% of nonobese adults were obese as teenagers. For women, BMI at age 18 was more predictive of adult BMI than for men. Gain of ≥ 5 BMI units after age 18 was linked to a higher prevalence of diabetes and hypertension. No dietary differences were found between obese and nonobese adults. CONCLUSIONS: The results of this study provide evidence that high BMI at age 18 is strongly correlated with adulthood obesity, much more so with women than men. Eating habits did not have an impact, suggesting that obesity may be the result of a combination of factors yet to be clearly defined.

Gastroparesis: approach, diagnostic evaluation, and management.

Gastroparesis is a chronic motility disorder of the stomach that involves delayed emptying of solids and liquids, without evidence of mechanical obstruction. Although no cause can be determined for the majority of cases, the disease often develops as a complication of abdominal surgeries or because of other underlying disorders, such as diabetes mellitus or scleroderma. The pathophysiology behind delayed gastric emptying is still not well-understood, but encompasses abnormalities at 3 levels--autonomic nervous system, smooth muscle cells, and enteric neurons. Patients will often cite nausea, vomiting, postprandial fullness, and early satiety as their most bothersome symptoms on history and physical examination. Those that present with severe disease may already have developed complications, such as the formation of bezoars or masses of undigested food. In patients suspected of gastroparesis, diagnostic evaluation requires an initial upper endoscopy to rule out mechanical causes, followed by a gastric-emptying scintigraphy for diagnosis. Other diagnostic alternatives would be wireless capsule motility, antroduodenal manometry, and breath testing. Once gastroparesis is diagnosed, dietary modifications, such as the recommendation of more frequent and more liquid-based meals, are encouraged. Promotility medications like erythromycin and antiemetics like prochlorperazine are offered for symptomatic relief. These agents may be frequently changed, as the right combination of effective medications will vary with each individual. In patients who are refractory to pharmacologic treatment, more invasive options, such as intrapyloric botulinum toxin injections, placement of a jejunostomy tube, or implantation of a gastric stimulator, are considered. Future areas of research are based on current findings from clinical studies. New medications, such as hemin therapy, are emerging because of a better understanding of the pathophysiology behind gastroparesis, and present treatment options, such as gastric electric stimulation, are evolving to be more effective. Regenerative medicine and stem cell-based therapies also hold promise for gastroparesis in the near future.

A review of telavancin in the treatment of complicated skin and skin structure infections (cSSSI).

Telavancin is a novel antibiotic being investigated for the treatment of serious infections caused by Gram-positive bacteria, including complicated skin and skin structure infections (cSSSI) and pneumonia. This once-daily intravenous lipoglycopeptide exerts rapid bactericidal activity via a dual mechanism of action. It is intended for use to combat infections caused by Staphylococcus aureus and other Gram-positive bacteria, including methicillin-resistant and vancomycin-intermediate strains of S. aureus (MRSA and VISA, respectively). Vancomycin is the current gold standard in treating serious infections caused by Gram-positive bacteria, especially MRSA. In recent clinical trials, telavancin has shown excellent efficacy in phase II and III multinational, randomized, double-blinded studies of cSSSI. In the phase II FAST 2 study, which compared telavancin 10 mg/kg intravenously q 24 h vs standard therapy (an antistaphylococcal penicillin at 2 g IV q 6 h or vancomycin 1 gm IV q 12 h), the clinical success rate in the telavancin-treated group was 96% vs 94% in the standard therapy group. In two identical phase III trials comparing telavancin versus vancomycin at the doses of the FAST 2 study for cSSSI, the clinical cure rates were 88.3% and 87.1%, respectively. Two additional phase III clinical trials investigating telavancin for use in hospital-acquired pneumonia, caused by Gram-positive bacteria are currently ongoing. Telavancin is currently under regulatory review in both the United States and Europe for the indication of treatment of cSSSI.