Utility of the CANUKA Scoring System in the Risk Assessment of Upper GI Bleeding.

BACKGROUND: The Canada-United Kingdom-Adelaide (CANUKA) score was developed to stratify patients who experience upper gastrointestinal bleeding (UGIB) to predict who could be discharged from the emergency department. Our aim was to determine if the CANUKA score could be utilized for UGIB in-patients undergoing endoscopy in predicting adverse outcomes. We additionally sought to establish a CANUKA score cut point to predict adverse outcomes and in-hospital mortality and compare this to established scoring systems. METHODS: Between January 1, 2018 to June 30, 2019 all patients who underwent upper endoscopy after admission for UGIB were identified. We assigned a CANUKA score and compared the area under the receiver operating curve to established scoring systems. RESULTS: Our data set included 641 patients, with a mean age of 59.5±14.5 years. A CANUKA score ≥10 was associated with an adverse outcome [unadjusted odds ratio, 3.08 (1.79, 5.27)]. No patients experienced an adverse outcome with a CANUKA score <4. No patients died with a CANUKA score <6. Those with a CANUKA score of <10 had an in-hospital mortality of 2.1% compared with 6.8% for those with a score ≥10 ( P =0.008). AIMS65 had the best area under the receiver operating characteristic curve (0.809) for predicting mortality. CONCLUSIONS: The CANUKA score may serve utility as a predictor of adverse outcomes and mortality in patients admitted with UGIB undergoing endoscopy. Future studies, ideally prospective and multicenter, will be needed to validate its clinical utility.

Is the Medium Still the Message? Culture-Independent Diagnosis of Gastrointestinal Infections.

Infectious diarrhea is caused by a variety of pathogens, including viruses, bacteria, and parasitic organisms. Though the causative agent of diarrhea has historically been evaluated via stool cultures, recently, culture-independent diagnostic tests (CIDT) have been developed and utilized with increasing frequency. Current practice guidelines recommend their use as adjuncts to stool cultures for diagnosing acute and chronic diarrhea. The three principal CIDT are microscopy, enzyme-based immunoassays (EIAs), and molecular based polymerase chain reaction (PCR). This review explores the common causes of infectious diarrhea, the basics of stool culture, the diagnostic utility of these three culture-independent modalities, and the strengths and weaknesses of all currently available clinical techniques. It also outlines considerations for specific populations including returning travelers and those with inflammatory bowel disease.

Current Status of Medical Therapy for Inflammatory Bowel Disease: The Wealth of Medications.

Previously, the natural history of Crohn's disease and ulcerative colitis included significant morbidity due to limited treatment options that were not without serious side effects. Early treatment options included corticosteroids as well as mesalamine, thiopurines, and methotrexate. In 1998, monoclonal antibodies to a key inflammatory cytokine, TNFα, became available. Over the next 22 years, the field of gastroenterology has seen multiple new treatments emerging for inflammatory bowel disease (IBD) that target different aspects of the inflammatory cascade, significantly changing the therapeutic landscape. Additional monoclonal antibodies are available that target the integrins, which are adhesion proteins that traffic inflammatory leukocytes. Small molecule inhibitors block the inflammatory signals of several cytokines. New therapies that modulate lymphocyte escape from lymphoid tissue are promising. Lastly, stem cell technology has emerged as a platform to successfully treat perianal fistulizing disease. Our aim is to summarize the currently available therapies for IBD beyond steroids, mesalamine, and immune modulators. We highlight the most important clinical trials that have brought these treatments to clinical practice, and we discuss the ongoing clinical trials of novel therapies that have a high probability of eventual regulatory approval.

Nationwide estimate of emergency department visits in the United States related to caustic ingestion.

INTRODUCTION: Caustic ingestion, whether intentional or unintentional, may result in significant morbidity. Our aim was to provide an estimate of the incidence and outcomes of caustic ingestion among emergency department (ED) visits across the United States. METHODS: The Nationwide Emergency Department Sample (NEDS) is part of the family of databases developed for the Healthcare Cost and Utilization Project. We analyzed NEDS for the period 2010-2014. Adults (≥18 years of age) with a diagnosis of caustic ingestion were identified by ICD-9 codes. The weighted frequencies and proportions of caustic ingestion-related ED visits by demographic characteristics and disposition status were examined. A weighted multivariable logistic regression model was performed to examine factors associated with inpatient admission for caustic ingestion-related visits. RESULTS: From 2010 to 2014, there were 40,844 weighted adult ED visits related to caustic ingestion among 533.8 million visits (7.65/100,000, 95% CI 7.58/100,000-7.73/100,000), resulting in over $47 million in annual cost. Among ED visits related to caustic ingestion, 28% had comorbid mental and substance use disorders. Local and systemic complications were rare. There was significant regional, gender, and insurance variability in the decision as to perform endoscopy. Males, insured patients, patients domiciled in the Southeast region of the United States, and patients with mental or substance use disorders had significantly higher percentages of receiving endoscopic procedures. Overall, 6,664 (16.27%) visits resulted in admission to the same hospital and 1,063 (2.60%) visits resulted in transfer to another hospital or facility. The risk factors for admission were increasing in age, male gender, local or systemic complications related to caustic ingestion, and comorbid mental and substance use disorders. A total of 161 (0.39%) patients died related to caustic ingestion. CONCLUSION: Our results from NEDS provide national estimates on the incidence of caustic ingestions involving adults seen in US EDs. Further studies are needed to examine the standard management of caustic ingestion and investigate the factors causing variability of esophagogastroduodenoscopy performance and caustic ingestion care.

Incidence and risk factors of dysphagia after variceal band ligation.

BACKGROUND AND AIM: There is a lack of data on long-term morbidity, particularly dysphagia, following endoscopic variceal band ligation (EVL). The aim of this study are to assess the incidence of dysphagia and variables associated with this complication after EVL. METHODS: We identified individuals who completed at least one session of EVL as their sole treatment for varices from August 2012 to December 2017. Included patients achieved "complete eradication" of varices not requiring further therapy. Patients ≥90 days from their last EVL session completed a modified version of the Mayo Clinic Dysphagia Questionnaire. Individuals with dysphagia were invited to undergo a barium esophagram. Patients with pre-EVL dysphagia were excluded. RESULTS: Of the patients, 68 possessed inclusion criteria, nine (13.2%) died and 20 (29.4%) were lost to follow up. For the remaining 39 (57.4%) patients, 23 were males, mean age of 61.7±8.6 years. The most common etiology of liver disease was hepatitis C virus (n=18; 46.2%). The median number of banding sessions was 2.0 (interquartile range [IQR], 1.0-4.0) with a median of 9.0 bands placed (IQR, 3.0-14.0). Twelve patients (30.8%) developed new-onset dysphagia post-EVL. In univariate analysis, pre-EVL MELD score and non-emergent initial banding were associated with long-term dysphagia. In a regression model adjusted for age, sex, number of bands, and use of acid suppression after EVL, no factor was independently associated with dysphagia (all P>0.05). No strictures were identified on subsequent esophageal evaluation. CONCLUSION: Approximately 30% of patients developed new-onset, chronic dysphagia post-EVL. Incident dysphagia was associated with a non-emergent initial banding session. The mechanism for dysphagia remains unknown.

Recent use of NSAID and NOAC medications are associated with a positive CT arteriogram.

BACKGROUND: Computed tomography angiography (CTA) is a diagnostic modality utilized in patients with suspected active lower gastrointestinal (GI) bleeding. CTA use in clinical practice is limited by the risk of contrast-induced nephropathy, and the loss of patients from direct physician observation while undergoing the test. Identifying clinical predictors of a positive result would be useful in guiding physician utilization of CTA studies. METHODS: We performed a single-center retrospective study to determine which clinical predictors are associated with a positive CTA. Binary logistical regression modeling was used to identify the independent predictors and the results were expressed as adjusted odds ratios with corresponding 95% CI . RESULTS: 262 patients met inclusion criteria and there were 61 (23.3%) positive CTA exams. In unadjusted analysis those who were CTA positive were more likely to require management in the intensive care unit (85.2% vs. 14.8%, p < 0.01) and being CTA positive was associated with a significantly increased in-hospital mortality (14.8% vs. 4.5%, p < 0.01). The use of a novel oral anticoagulant (NOAC) in the week prior to presentation was associated with a positive CTA after adjustment for confounders (adjusted odds ratio = 3.89; 95% CI 1.05-14.43). Similarly, the use of a non-steroidal anti-inflammatory drug (NSAID) was associated with a positive CTA (OR 2.36; 1.03-5.41). Only 8% of patients experienced contrast-induced nephropathy. CONCLUSION: Use of either NOACs or NSAIDs in the previous week is independently associated with a positive CTA in the setting of acute lower GI bleeding. CTA exams appear to confer a low risk of contrast-induced nephropathy.

Multiple Rapid Swallows (MRS) Complements Single-Swallow (SS) Analysis for High-Resolution Esophageal Manometry (HREM).

BACKGROUND: Multiple rapid swallows (MRS) during HREM assess post-deglutitive inhibition, LES relaxation, and subsequent esophageal contraction. AIMS: (1) To determine the relationship between MRS and single-swallow (SS) responses and (2) to determine if MRS provides information for symptomatic patients. METHODS: Healthy volunteers (HVs) and patients underwent HREM [30-s landmark, ten 5-mL SS, MRS (5 consecutive 2-mL swallows every 2-3 s)] and were analyzed with ManoView software version 3 with CC version 3.0. RESULTS: In 20 HVs, MRS response consisted of: (1) reduction in GEJ pressure; (2) absence of esophageal contractile activity during MRS; and (3) post-MRS peristaltic contraction greater than SS contractions. In 20 HVs and 403 patients, MRS IRP correlated with SS IRP (r = 0.65; p < 0.0001) and post-MRS contraction DCI correlated with SS DCI (r = 0.76; p < 0.0001). Abnormally elevated MRS IRP was seen in 68% type 2 achalasia, 50% type 3 achalasia, 47% EGJOO, and 9% jackhammer. Increased MRS DCI was seen in 53% type 2 achalasia, 92% type 3 achalasia, 10% EGJOO, 22% jackhammer, and 18% DES. Increased DCI post-MRS was seen in 38% patients with jackhammer, 8% type 3 achalasia, 12% EGJOO, and 9% DES. 14 out of 143 (10%) patients with normal or indeterminate results on SS analysis had at least one abnormality on MRS. CONCLUSIONS: MRS IRP correlated with SS IRP, and post-MRS DCI correlated with SS DCI. Patients with defined CC disorders have abnormalities on MRS. There were MRS abnormalities in some patients with normal SS studies, most notably suggesting impaired LES relaxation and/or spastic esophageal motility. MRS may complement the baseline SS study analysis.

Utility of Esophageal High-Resolution Manometry in Clinical Practice: First, Do HRM.

Esophageal high-resolution manometry (HRM) has advanced the understanding of esophageal motor function and the ability to diagnose and manage disorders of esophageal motility. In this review, we describe the indications for and the technical performance of HRM. The Chicago classification of esophageal motor function, now in its third iteration, streamlines and standardizes the nomenclature and basic interpretation of HRM data depicted as Clouse topographic plots. In clinical practice, HRM is an important diagnostic test for patients with dysphagia as well as patients with suspected gastroesophageal reflux disease (GERD), particularly in those patients with a suboptimal symptomatic response to antisecretory therapy. HRM can support diagnoses such as achalasia, as well as provide evidence for behavioral disorders such as rumination syndrome or supragastric belching with the assistance of postprandial HRM with impedance. Further, the GERD classification of motor function introduces a three-part hierarchical evaluation of esophageal motor function in GERD, highlighting the value of assessment of esophageal contractile reserve through provocative maneuvers during HRM such as multiple rapid swallows.

Chemoprevention of colorectal cancer in inflammatory bowel disease.

INTRODUCTION: Patients with inflammatory bowel disease are at an increased risk of colorectal cancer when compared to the general population. Chronic inflammation is thought to be the underlying cause, and medications that reduce inflammation have the potential to reduce the risk of colorectal cancer. Areas covered: After conducting a PubMed search for relevant literature, we examined several classes of medications that have been studied as potential chemopreventive agents. These include 5-aminosalicylates, thiopurines, tumor necrosis factor antagonists, ursodeoxycholic acid, NSAIDs, and statins. Expert commentary: While each class of medications has some data to support its use in chemoprevention, the majority of the evidence in each case argues against the routine use of these medications solely for a chemopreventive benefit.

Chronic Abdominal Wall Pain: An Under-Recognized Diagnosis Leading to Unnecessary Testing.

Chronic abdominal wall pain (CAWP) refers to a condition wherein pain originates from the abdominal wall itself rather than the underlying viscera. According to various estimates, 10% to 30% of patients with chronic abdominal pain are eventually diagnosed with CAWP, usually after expensive testing has failed to uncover another etiology. The most common cause of CAWP is anterior cutaneous nerve entrapment syndrome. The diagnosis of CAWP is made using an oft-forgotten physical examination finding known as Carnett's sign, where focal abdominal tenderness is either the same or worsened during contraction of the abdominal musculature. CAWP can be confirmed by response to trigger point injection of local anesthetic. Once diagnosis is made, treatment ranges from conservative management to trigger point injection and in refractory cases, even surgery. This review provides an overview of CAWP, discusses the cost and implications of a missed diagnosis, compares somatic versus visceral innervation, describes the pathophysiology of nerve entrapment, and reviews the evidence behind available treatment modalities.

Measurement of Fractional Exhaled Nitric Oxide as a Marker of Disease Activity in Inflammatory Bowel Disease.

BACKGROUND AND AIMS: Definitive diagnosis of IBD requires endoscopic and pathologic confirmation. These tools are also used to classify disease activity. Our aim was to determine if the fractional exhaled nitric oxide (FeNO) could be utilized to screen for IBD and assess for disease activity. METHODS: We matched weighted IBD cases and controls from the 2009-2010 NHANES dataset. All subjects underwent measurement of FeNO using standardized techniques. We assessed for potential confounders for FeNO measurement including age, height, and asthma. For IBD subjects, we used the presence of diarrhea, fatigue, and weight loss as a proxy for IBD activity. Laboratory parameters examined to estimate disease activity included anemia (≤ 10 g/dl), iron deficiency (ferritin ≤ 20 ng/ml), hypoalbuminemia (≤ 3.2 g/dl), and CRP (≥ 1.1 mg/dl). RESULTS: The weighted sample represented 199,414,901 subjects. The weighted prevalence of IBD was 2,084,895 (1.0%). IBD subjects had nearly the same FeNO level as those without IBD (17.0 ± 16.2 vs. 16.7 ± 14.5 ppb). The odds of a FeNO > 25 ppb was half (OR=0.501; 95% CI 0.497-0.504) for subjects with IBD compared to those without IBD after controlling for confounders. The AUROC curve for FeNO was 0.47 (0.35-0.59). FeNO levels were not higher in patients with laboratory values suggestive of active disease. FeNO levels were higher in IBD patients with diarrhea, rectal urgency, and fatigue but were lower in those with unintentional weight loss. CONCLUSION: Measurement of FeNO does not appear to be useful to screen for IBD or assess disease activity.

Patterns of cannabis use in patients with Inflammatory Bowel Disease: A population based analysis.

BACKGROUND: Tobacco use patterns and effects in patients with Inflammatory Bowel Disease have been extensively studied, however the role and patterns of cannabis use remains poorly defined. Our aim was to evaluate patterns of marijuana use in a large population based survey. METHODS: Cases were identified from the NHANES database from the National Center for Health Statistics for the time period from January, 2009 through December, 2010 as having ulcerative colitis or Crohn's disease, and exact matched with controls using the Propensity Score Module of SPSS, based on age, gender, and sample weighted using the nearest neighbor method. RESULTS: After weighting, 2084,895 subjects with IBD and 2013,901 control subjects were identified with no significant differences in demographic characteristics. Subjects with IBD had a higher incidence of ever having used marijuana/hashish (M/H) (67.3% vs. 60.0%) and an earlier age of onset of M/H use (15.7 years vs. 19.6 years). Patients with IBD were less likely to have used M/H every month for a year, but more likely to use a heavier amount per day (64.9% subjects with IBD used three or more joints per day vs. 80.5% of subjects without IBD used two or fewer joints per day). In multivariable logistic regression, presence of IBD, male gender, and age over 40 years predicted M/H use. CONCLUSION: Our study is the first to evaluate marijuana patterns in a large-scale population based survey. Older, male IBD patients have the highest odds of marijuana use.

Vancomycin Enemas as Adjunctive Therapy for Clostridium difficile Infection.

BACKGROUND: For severe, complicated Clostridium difficile infection (CDI), concomitant treatment with IV metronidazole and oral vancomycin is usually prescribed. Sometimes vancomycin per rectum (VPR) is added to increase colonic drug delivery. Our purpose was to examine clinical outcomes of patients with CDI treated with VPR and compare results to a matched control group. METHODS: This was a retrospective case-control study in a setting of tertiary-care ICU on diarrhea patients with a positive toxin test for C. difficile. We identified all ICU patients prescribed VPR from January 2003 to December 2013. The dose of VPR mixed in 100 cc of tap water ranged from 125 to 250 mg Q 6 - 8 hours. All patients had diarrhea and a positive test for C. difficile toxin. Included patients received ≥ 4 doses of VPR. The primary outcome was the combined endpoint of colon surgery or death. We matched VPR cases 1:2 with CDI controls that had identical APACHE II scores. RESULTS: We identified 24 CDI patients who received VPR and met inclusion criteria: 11 male, mean age 61.8 ± 15.9 years. All patients received concomitant CDI therapy. Four patients (16.7%) required colectomy, and overall mortality was 45.8%. For the 48 controls, need for surgery was identical (16.7%; P = 1.00). The mortality rate also did not differ (41.7%; P = 0.74). For the combined outcome of surgery or death, the rate was 45.8% for the controls and 50.0% for the VPR group (P = 0.73). CONCLUSION: In a case-control study, the use of VPR was not demonstrated to reduce the need for colectomy or decrease mortality. Based on our modest sample size and failure to show efficacy, we cannot strongly advocate for the use of VPR.

Administrative Database Research Overestimates the Rate of Interval Colon Cancer.

GOALS: Our study reexamines the prevalence of interval colorectal cancer (I-CRC) by manually reviewing CRC cases at a single institution. BACKGROUND: In 2% to 8% of patients with CRC, diagnosis occurs during the interval 6 to 36 months after a cancer-free colonoscopy. Rates are often determined by linking the date of colonoscopy with cancer registry information. STUDY: We examined all colonoscopies from 1993 to 2011. These examinations were linked with Pennsylvania Cancer Registry data. Matched charts were manually reviewed. We determined whether the CRC was "prevalent" or, for patients with a previous colonoscopy, whether they were interval or noninterval based on time from last colonoscopy. For interval cases, we identified "administrative errors" that could falsely increase the number of reported I-CRC. RESULTS: Over the study period, 43,661 colonoscopies were performed, with 1147 (2.6%) positive for CRC after excluding cases (n=52) in which patients had IBD, previous surgery, or nonadenocarcinoma malignancy. Prevalent CRCs totaled 1062 (92.6%). Noninterval CRCs (diagnosed over 36 mo from index colonoscopy) were present in 40 (3.5%). There remained 45 (3.9%) potential I-CRC cases. However, after manual review, 21 cases were found to be administrative errors. Therefore, the accurate proportion of colonoscopies that found an I-CRC was 2.1% (95% confidence interval, 1.5%-3.2%). CONCLUSIONS: The prevalence of I-CRC at our institution before adjustment was comparable with previously reported rates. This proportion was 47% lower after adjusting for administrative errors placing our figure at the lower end of reported I-CRC incidence. Reported rates of I-CRC may be falsely elevated due to errors unique to merging administrative databases.

Post-traumatic Stress Disorder Is Associated With Irritable Bowel Syndrome in African Americans.

BACKGROUND/AIMS: Psychosocial stressors likely play an important role in irritable bowel syndrome (IBS). The association between IBS and post-trau-matic stress disorder (PTSD) in non-minorities has been described. Our aim was to investigate the potential association between IBS and PTSD in an urban African American population. METHODS: Our institution maintains a longitudinal population-based survey of African Americans (AA). The survey utilizes a complex, stratified sampling design. The study group consisted of adult AA meeting Rome III criteria for IBS of any subtype. The 4-item Primary Care PTSD screener was administered; score of≥ 3 (range, 0-4) was considered positive for PTSD. Depression (Public Health Questionnaire-9 depression) and anxiety (generalized anxiety disorder-7) levels were measured using standardized scales. To assess quality of life, norm-based physical and mental component summary scores from the short-form 36 health survey ver-sion 2 were obtained. Descriptive and inferential statistics were calculated using Complex Sample Module of SPSS after weight-ing of the study sample. RESULTS: Four hundred nineteen subjects included corresponded to a weighted 21,264 (95% CI, 19,777-22,751) individuals. The preva-lence of IBS in our sample of urban AA was 8.2%. In multivariate regression analysis, female gender, age > 40, higher educa-tional attainment and divorce were independently associated with IBS. Those with IBS were considerably more likely to suffer from PTSD (OR, 4.54; 95% CI, 4.07-5.06). PTSD was independently associated with depression, anxiety, harmful drinking and substance abuse. CONCLUSIONS: In AA, PTSD is independently associated with IBS. PTSD has a significantly negative impact on physical and mental self-assess-ment of quality of life. Evaluation of minorities presenting with functional gastrointestinal disorders should include screening for PTSD.(J Neurogastroenterol Motil 2014;20:523-530).

Double balloon enteroscopy: effective and minimally invasive method for removal of retained video capsules.

BACKGROUND AND AIM: Prior case series document removal of retained video capsules predominantly via surgical intervention. Data on endoscopic removal of retained capsules are limited. Our aim was to describe an endoscopic method of retrieval using double balloon enteroscopy (DBE). METHODS: A retrospective case series examination found 10 patients who underwent DBE for retrieval of a retained video capsule at two large tertiary referral academic centers from May 2007 to June 2013. RESULTS: Mean age of patients was 64.9 ± 18.1 years (four females, six males). Five patients failed to pass the capsule as a result of an ileal or jejunal stricture (one patient with ulcerative colitis; four patients with Crohn's disease); two patients had a small bowel stricture as a result of non-steroidal anti-inflammatory drug enteropathy; one patient had intermittent partial small bowel obstruction without evidence of a stricture; one patient had an obstructing malignant jejunal mass and one patient had a small bowel stricture as a result of radiation enteritis. Endoscopic removal via DBE was successful in eight of 10 patients (80%). The remaining two patients underwent surgical removal of the retained capsule. The two failed cases of capsule retrieval were both patients with suspected ileal disease. CONCLUSIONS: The most common cause of capsule retention was underlying Crohn's disease. DBE is an effective and minimally invasive method of capsule retrieval, including those patients with ileal disease, which has not been previously described. DBE can prevent unnecessary surgery while providing endoscopic therapy of inflammatory strictures by dilation.

Obesity and GERD.

Epidemiologic data have demonstrated that obesity is an important risk factor for the development of gastroesophageal reflux disease (GERD). There is also accumulating data that obesity is associated with complications related to longstanding reflux such as erosive esophagitis, Barrett esophagus, and esophageal adenocarcinoma. Central obesity, rather than body mass index, appears to be more closely associated with these complications. Surgical data are confounded by the concomitant repair of prevalent hiatal hernias in many patients.