A case of duodenal variceal bleeding treated by Doppler-guided endoscopic cyanoacrylate injection.

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High Burden of Obesity and Low Rates of Weight Loss Pharmacotherapy in Inflammatory Bowel Disease: 10-Year Trend.

Background: The prevalence of obesity and inflammatory bowel disease (IBD) has increased in the last decade. There is a paucity of data on the recent trend of obesity and the utilization of anti-obesity pharmacotherapy in IBD. We aimed to use a population-level database to analyze their trends. Methods: A retrospective analysis of population-level data from 2010 to 2019 was performed among individuals ≥18 years of age using a commercial database, IBM Explorys. The prevalence and trends of obesity, diabetes mellitus type 2 (DM2), essential hypertension, dyslipidemia and/or hyperlipidemia, sleep apnea, and anti-obesity pharmacotherapy were studied. Univariate analysis using chi-square test and trend analysis using the Cochrane Armitage test were performed. Results: Among 39 717 520 adults, 37.3% of IBD patients have a diagnosis of obesity (Crohn's disease 36.9% vs ulcerative colitis 38.5%, P < .0001). The proportion of IBD adults with obesity and metabolic comorbidities increased from 2010 to 2019: obesity (19.7%-30.1%), DM2 (8.3%-12.5%), hypertension (25.1%-33.9%), hyperlipidemia (22.1%-32.2%), and sleep apnea (4.1%-10.8%). All comparisons were statistically significant (P < .0001). Only 2.8% of eligible adults with obesity were prescribed anti-obesity pharmacotherapy in the last 10 years, with trends increasing from 1.4% to 3.6%, 2010-2019. Conclusions: With obesity being a harbinger for metabolic syndrome, the increase in obesity in IBD patients was accompanied by a concomitant increase in the diseases associated with obesity in the past decade. However, this alarming rise in obesity was accompanied by a disproportionately small increase in anti-obesity pharmacotherapy similar to general population.

Irritable bowel syndrome is strongly associated with the primary and idiopathic mast cell disorders.

BACKGROUND: Mounting evidence supports a mechanistic association between irritable bowel syndrome (IBS) symptoms and mast cell hyperactivity. Yet, association between IBS and mast cell disorders (MCDs) has not been studied. We examined this association using two large databases and verified with manual chart review. METHODS: The IBM Watson Health Explorys database (Somers, NY), an aggregate of electronic health record (EHR) data from over two dozen US healthcare systems, and Epic's SlicerDicer tool, a self-service tool containing de-identified data from the Epic EHR, were used to identify patients with IBS and MCDs. Patients with organic gastrointestinal disease or diseases associated with secondary mast cell hyperproliferation were excluded. Results were verified with manual chart review from two academic centers. KEY RESULTS: Up to 4% of IBS patients had a comorbid MCD. IBS was strongly associated with all MCDs. The strongest association was between IBS and mast cell activation syndrome (OR 16.3; 95% CI 13.1-20.3). Odds ratios for IBS+urticaria, IBS+idiopathic urticaria, IBS+non-malignant mastocytosis, and IBS+mast cell malignancy ranged from 4.5 to 9.9. Patients from each of these overlap cohorts were predominantly female, and the overlap occurred with all IBS subtypes. Thorough endoscopic evaluation and comorbid mood disorders and migraines are more common in the overlap cohorts than in IBS alone. CONCLUSIONS/INFERENCES: In a large US database encompassing >53 million patients over >20 years, patients with IBS are at least 4 times more likely to have a MCD than the general population. Further study of mast cell involvement in the pathogenesis of IBS is warranted.

10-Year Trend of Abdominal Magnetic Resonance Imaging Compared With Abdominal Computed Tomography Scans in Inflammatory Bowel Disease.

BACKGROUND: Patients with inflammatory bowel disease (IBD) frequently undergo multiple computed tomography (CT) examinations. With the widespread availability of magnetic resonance imaging (MRI), it is unclear whether the use of CTs in IBD has declined. We aimed to analyze the trends of CT and MRI use in a large cohort of IBD patients in a 10-year period. METHODS: We retrospectively analyzed adults ≥18 years of age using a de-identified database, IBM Explorys. Patients with ≥1 CT of the abdomen (± pelvis) or MRI of the abdomen (± pelvis) at least 30 days after the diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) were included. We examined the factors associated with patients undergoing multiple CTs (≥5 CTs of the abdomen) and performed a trend analysis from 2010 to 2019. RESULTS: Among 176 110 CD and 143 460 UC patients, those with ≥1 CT of the abdomen annually increased from 2010 to 2019 with mean annual percentage change of +3.6% for CD and +4.9% for UC. Similarly, annual percentage change for patients with ≥1 MRI (CD: +15.6%; UC: +22.8%) showed a rising trend. There was a 3.8% increase in CD patients receiving ≥5 CTs of the abdomen annually compared with a 2.4% increase among UC patients in the 10-year period. Age ≥50 years, men, African Americans, public insurance payors, body mass index ≥30kg/m2, and smoking history were associated with ≥5 CTs. CONCLUSIONS: There is a considerable increase in the number of CT scans performed in IBD patients. Further studies can explore factors influencing the use of CT and MRI of the abdomen in IBD patients.

The proportion of inflammatory bowel disease patients with ≥5 computed tomographies of the abdomen annually has increased by 2.4%-3.8% from 2010 to 2019. Age ≥50 years, men, African Americans, public insurance payors, body mass index ≥30kg/m2, and smoking history were associated with ≥5 computed tomographies of the abdomen annually.

Underutilization of prophylactic rectal indomethacin and pancreatic duct stent for prevention of post-ERCP Pancreatitis.

Background and study aims Incidence of Post-ERCP pancreatitis (PEP) ranges from 1 % to 10 % in unselected patients and as high as 25 % to 30 % in high-risk patients. Rectal indomethacin administered before or immediately after an ERCP and prophylactic pancreatic duct stent placement (PPS) are associated with a reduction in the incidence of PEP. We sought to investigate the utilization rate for prophylactic rectal indomethacin and PPS in average and high-risk patients undergoing ERCP between 2014 and 2019. Patients and methods We performed a retrospective analysis in the IBM Explorys database, a pooled, national de-identified clinical database of over 72 million unique patients from 26 health care networks and 300 hospitals across the United States from 2014 to 2019. Average and high-risk patients undergoing ERCP were identified using Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) diagnosis codes. PEP was defined by the presence of SNOMED CT diagnosis of acute pancreatitis and an inpatient admission within 5 days of an ERCP procedure. Results Out of 31,050 adults who had undergone ERCP from 2014 to 2019, only 10,500 individuals (33.8 %) had a PEP prophylaxis. Rectal indomethacin and PPS accounted for 82.4 % and 12.9 % respectively. Individuals with three risk factors had the highest PEP rates followed by individuals with two risk factors. Conclusions Only one-third of all patients undergoing ERCP received prophylaxis in the form of rectal indothemacin and/or PPS in this large population-based data. Increased implementation of prophylactic use is needed in patients undergoing ERCP as supported by current guidelines.

Alteration in Integrated Relaxation Pressure During Successive Swallows in Subjects With Normal Manometry Versus Those With Esophagogastric Junction Outflow Obstruction.

BACKGROUND/AIMS: Integrated relaxation pressure (IRP) is defined as the average minimum esophagogastric junction pressure for 4 seconds of relaxation (contiguous or noncontiguous) within 10 seconds of swallowing. The durability of IRP values during successive swallows in the supine position remains to be elucidated. The aim is to determine alteration in IRP values during successive swallows among subjects with normal esophageal manometry versus those with esophagogastric junction outflow obstruction (EGJOO). METHODS: Consecutive subjects, who underwent high-resolution esophageal manometry (HREM) were included in the study. Individuals had to have either normal manometry or EGJOO. A total of 10 wet swallows of 5 mL water were performed after an adaptation period of a minimum of 3 minutes. Mean IRP was analyzed for both subject groups for each individual swallow. RESULTS: Thirty-one patients with EGJOO and seventy patients with normal manometry were included. As expected, the median IRP was higher in EGJOO patients compared to those with normal HREM (mean: 23.92 vs 5.34, P < 0.001). The mean IRP of the last swallow was 40% lower than the mean IRP of the first swallow in the normal subjects (P = 0.015). In contrast, the difference in the mean IRP value in the EGJOO group between the first and the last swallow was 19% (P = 0.018). CONCLUSIONS: This study demonstrated that there is a significant decline in the mean IRP during successive swallows in subjects with normal esophageal manometry and those with EGJOO, despite adequate adaptation periods. This decline in IRP was less pronounced in EGJOO.

Colorectal Cancer, Age, and Obesity-Related Comorbidities: A Large Database Study.

BACKGROUND AND AIMS: The association between obesity and colorectal cancer (CRC) is well established in older individuals, but evidence is limited in the younger population. The study aims to analyze the relationship of obesity and its related comorbidities in early-onset CRC (E-CRC) and compare it to late-onset CRC (L-CRC). METHODS: A retrospective, cross-sectional study was performed on average-risk individuals ≥ 20 years who were active patients in the commercial database, IBM Watson Health Explorys in the last 5 years. Individuals with CRC were compared to those without CRC across different age groups (20-39, 40-49, and 50-74 years). Individuals with CRC diagnosed < 50 years (E-CRC) were compared to those with CRC between 50 and 74 years (L-CRC). Variables included sex, smoking, obese BMI, diabetes mellitus type 2 (DM2), hypertension (HTN), and hyperlipidemia (HLD). Since Explorys aggregates population-level, de-identified data, approval from institutional review board was not required. RESULTS: Among 37,483,140 individuals, 162,150 cases of sporadic CRC were identified. Compared to the general population, obesity and HLD were independent risk factors for CRC across all age groups; DM2, HTN, and smoking were independent risk factors for CRC in men of all age groups and women with L-CRC. Compared to L-CRC, individuals with E-CRC had lower percentages of obesity-related comorbidities. CONCLUSION: In E-CRC, obesity, DM2, HTN, HLD, and smoking are independent risk factors for CRC among men; obesity and HLD are independent risk factors for CRC in women. These subgroups may benefit from a personalized screening approach to detect early-onset CRC.

Pharmacotherapy for Obesity-Trends Using a Population Level National Database.

BACKGROUND: Despite the growing trend of obesity, the utilization of anti-obesity therapeutic interventions is not robust in the USA. We aimed to analyze the trends of anti-obesity pharmacotherapy using a population level database. METHODS: We used an electronic health record-derived database (Explorys, IBM Watson Health) to identify adults with obesity (body mass index ≥ 30 kg/m2), 2010-2019. Annual rates of anti-obesity pharmacotherapy were analyzed. To assess post-bariatric utilization of these medications, the trend of adults with morbid obesity (BMI ≥ 40 kg/m 2) who were newly started on anti-obesity medications after sleeve gastrectomy was also analyzed. RESULTS: Among 11,195,020 adults with obesity, 274,160 (2.4%) were prescribed anti-obesity medications during the study period with an increase from 1.1% in 2010 to 2.9% in 2019 (p < 0.0001). A total of 900 (3.5%) of those with morbid obesity were started on weight loss medications within 5 years of sleeve gastrectomy. Women [odds ratio (OR) 3.57, 95% confidence interval (CI) 3.51-3.58], individuals under 50 years (OR 1.59, CI 1.57-1.60), non-Hispanics (OR 1.12, 1.10-1.14, p < 0.0001), African Americans (OR 1.18, CI 1.16-1.19), Medicaid (OR 1.70, CI 1.67-1.73), and commercial insurance holders (OR 2.46, 2.43-2.49) were more likely to receive anti-obesity pharmacotherapy, p < 0.001 for all comparisons. CONCLUSION: There has been a modest increase in the prevalence of anti-obesity medications in the last 10 years, but they remain significantly underutilized. Further studies addressing the barriers to anti-obesity pharmacotherapy might help in increasing the utilization of these medications among adults with obesity.

Disparities in Colorectal Cancer Screening Practices in a Midwest Urban Safety-Net Healthcare System.

AIMS: Although colorectal cancer screening (CRC) using stool-based test is well-studied, evidence on fecal immunochemical test (FIT) patterns in a safety-net healthcare system utilizing opportunistic screening is limited. We studied the FIT completion rates and adenoma detection rate (ADR) of positive FIT-colonoscopy (FIT-C) in an urban safety-net system. METHODS: We performed a retrospective cross-sectional chart review on individuals ≥ 50 years who underwent CRC screening using FIT or screening colonoscopy, 09/01/2017-08/30/2018. Demographic differences in FIT completion were studied; ADR of FIT-C was compared to that of screening colonoscopy. RESULTS: Among 13,427 individuals with FIT ordered, 7248 (54%) completed the stool test and 230 (48%) followed up a positive FIT with colonoscopy. Increasing age (OR 1.01, CI 1.01-1.02), non-Hispanic Blacks (OR 0.87, CI 0.80-0.95, p = 0.002), current smokers (OR 0.84, CI 0.77-0.92, p < 0.0001), those with Medicaid (OR 0.86, CI 0.77-0.96, p = 0.006), commercial insurance (OR 0.85, CI 0.78-0.94, p = 0.002), CCI score ≥ 3 (OR 0.82, CI 0.74-0.91, p < 0.0001), orders by family medicine providers (OR 0.87, CI 0.81-0.94, p < 0.0001) were associated with lower completion of stool test. Individuals from low median household income cities had lower follow-up of positive FIT, OR 0.43, CI 0.21-0.86, p = 0.017. ADR of FIT-C was higher than that of screening colonoscopy. CONCLUSION: Adherence to CRC screening is low in safety-net systems employing opportunistic screening. Understanding demographic differences may allow providers to formulate targeted strategies in high-risk vulnerable groups.

When to use probiotics in luminal gastrointestinal disorders?

PURPOSE OF REVIEW: With the growing popularity and commercialization of probiotics, it is important to understand the implications of existing randomized controlled trials and their applicability in the clinical setting to treat luminal gastrointestinal diseases. RECENT FINDINGS: Probiotics may be useful in the prevention of antibiotic-associated diarrhea, prevention of Clostridioides difficile infection and eradication of Helicobacter pylori. Some evidence supports the use of probiotics in the treatment of ulcerative colitis, prevention and treatment of pouchitis and irritable bowel syndrome. Caution has to be exercised in immunocompromised and critically ill individuals. New society guidelines do not encourage probiotic use in gastrointestinal disorders with the exception of premature infants to prevent necrotizing enterocolitis. SUMMARY: Despite burgeoning body of literature and wide acceptance by the public, a thorough understanding of efficacy and safety of probiotics is lacking. Uniform dosage, standardized clinical end points, personalization based on host microbial profile and longer duration of follow-up on the research front may help in the future in appropriate positioning of probiotics in health and disease.

Microbiota modulation-based therapy for luminal GI disorders: current applications of probiotics and fecal microbiota transplantation.

Introduction: Alteration in the intestinal microbiota also termed as intestinal dysbiosis has been demonstrated in numerous gastrointestinal disorders linked to aberrant immune processes, acquisition of pathogenic organisms and often administration of antibiotics. Restoration of microbiota through probiotics and fecal microbiota transplantation (FMT) has gained tremendous popularity among researchers in the prevention and treatment of gastrointestinal diseases.Areas covered: In this review, studies testing the safety and efficacy of probiotics and FMT for the treatment of various infectious and inflammatory luminal gastrointestinal diseases are reviewed. Randomized control studies are given priority while important uncontrolled studies are also highlighted.Expert opinion: Probiotics have demonstrated efficacy in the prevention of antibiotic-associated diarrhea and in the eradication of Helicobacter pylori infection. Their utility in the primary and secondary prevention of Clostridioides difficile infection is debatable. The future of medicine should bring forth a personalized approach to probiotic use. FMT has revolutionized the treatment of recurrent CDI as well as severe and fulminant CDI. At the same time, it has galvanized gut microbiota research in the last decade. While FMT in ulcerative colitis appears promising, further studies on the durability and long-term safety are needed before it can be recommended in clinical practice.