Bouras, Ernest P.

Abstract Background and study aim The clinical impact of eosinophilic esophagitis (EoE) limited to the distal esophagus (Lim-EE) vs. diffuse involvement (Dif-EE) is unknown. This study compared clinical characteristics and outcomes of Lim-EE vs. Dif-EE. Patients and methods This retrospective, single-center study of patients with EoE between December 2011 and December 2019 evaluated treatment response based on repeated pathology and/or clinical improvement using comparative statistics. Results 479 patients were identified (126 Lim-EE, 353 Dif-EE). Lim-EE patients had a higher incidence of endoscopically identified esophagitis (23.0 % vs. 14.7 %; P = 0.04), were older (50.8 [SD 16.2] vs. 46.4 [SD 15.3] years; P = 0.007), and were more likely to present with iron deficiency anemia (5.6 % vs. 1.7 %; P = 0.05), dyspepsia (15.1 % vs. 8.8 %; P = 0.06) or for Barrett’s surveillance (10.3 % vs. 3.7 %; P = 0.02). Patients with Dif-EE presented more frequently with dysphagia (57.2 % vs. 45.2 %; P = 0.02). Both groups had similar proton pump inhibitor (87.2 % vs. 83.3 %; P = 0.37) and steroid (12.8 % vs. 21.4 %; P = 0.14) use. Patients with Lim-EE had a better clinicopathologic response (61.5 % vs. 44.8 %; P = 0.009). On multivariate analysis, EoE extent predicted treatment response with an odds ratio of 1.89 (95 % confidence interval 1.13–3.20; P = 0.02). However, treatment response based only on repeat biopsy results showed no statistical difference between Lim-EE (52.5 %) and Dif-EE (39.7 %; P = 0.15). Conclusions Lim-EE may represent a distinct phenotype separate from Dif-EE, with more overlap with gastroesophageal reflux disease and better treatment response.

Abstract Introduction. Commonly prescribed medications are associated with various gastrointestinal (GI) side effects but few data are available on prescription medication use and polypharmacy in a gastroenterology outpatient practice. We aimed to examine the prevalence of polypharmacy, defined as the simultaneous use of 5 or more medications. Methods. A descriptive correlational study of consecutive outpatient consultations in 988 patients referred to a tertiary gastroenterology practice. Main outcome measurements were frequency of prescription medication use and polypharmacy. Results. The most common GI symptoms were abdominal pain (72%), nausea (57%), and constipation (53%). The frequency of polypharmacy was 10%. Eighty percent of patients took at least one medication and 60% took two or more. The most frequently used medication classes were proton pump inhibitors (43%), followed by benzodiazepines (30%), selective serotonin-reuptake or norepinephrine-reuptake inhibitors (28%), non-steroidal anti-inflammatory drugs (27%), and opioids (21%). Conclusion. There was a higher use of prescription medicine including antidepressants, and a lower frequency of polypharmacy in our study cohort compared to the general population. The use of medications may have contributed to the symptoms leading to our study’s population GI consultation.

INTRODUCTION: High-resolution manometry using the Chicago Classification is standard in the evaluation of esophageal motility. When the relaxation of the esophagogastric junction is impaired and achalasia excluded, esophagogastric junction outflow obstruction (EGJ-OO) is diagnosed and the esophageal body is essentially ignored. We sought to characterize the function of the esophageal body in consecutive patients with EGJ-OO. METHODS: Retrospective review of the esophageal manometry findings in consecutive patients where there was computer recognition of EGJ-OO collected over a 2-month period. In each case, the esophageal body was reviewed manually and results reported independent of the suggested computer diagnosis. RESULTS: 116 patients underwent manometry over a 2-month period and 30 (26%) were identified as having EGJ-OO. The indications for testing included chronic cough (n = 5), GERD (n = 8), dysphagia (n = 9) and esophageal evaluation associated with severe lung disease or transplantation (n = 8). The mean IRP was 20.8 (range 16-33.6) and did not vary depending on indication ( P = 0.381). Computer interpretation was EGJ-OO in all patients without mention of the esophageal body. After review, 11 (37%) had an additional esophageal diagnosis. In effective esophageal motility (IEM) was the most prevalent among them (IEM-8, achalasia-2, jackhammer esophagus-1; P = 0.020). The frequency of an additional esophageal diagnosis was significantly different between GERD (0%) and dysphagia (66%; P = 0.004), but not between other groups (i.e. 40% in cough and 37.5% in transplant group). An esophageal body diagnosis was significantly more likely in patients with IRP > 25 (80%) compared with those with IRP < 25 (28%; P = 0.028). CONCLUSION: 1-EGJ-OO is common in patients referred for esophageal manometry. 2-An additional esophageal body diagnosis is common in those with EGJ-OO.3-Esophageal diagnoses are more common in patients with dysphagia and in those with a very high IRP. The body of the esophagus is important in cases of EGJ-OO and should be reported independent of the computer-generated interpretation of the Chicago Classification.

Objective It is unclear whether endoscopic assessment of scars after colorectal endoscopic mucosal resection (EMR) has to include biopsies, even if endoscopy is negative. Vice versa, endoscopic diagnosis of recurrent adenoma may not require biopsy before endoscopic reinterventions. We prospectively analysed various endoscopic modalities in the diagnosis of recurrence following EMR. Design We conducted a prospective study of patients undergoing colonoscopy after EMR of large (≥20 mm) colorectal neoplasia. Endoscopists predicted recurrence and confidence level with four imaging modes: high-definition white light (WL) and narrow-band imaging (NBI) with and without near focus (NF). Separately, 26 experienced endoscopists assessed offline images. Results Two hundred and thirty patients with 255 EMR scars were included. The prevalence of recurrent adenoma was 24%. Diagnostic values were high for all modes (negative predictive value (NPV) ≥97%, positive predictive value (PPV) ≥81%, sensitivity ≥90%, specificity ≥93% and accuracy ≥93%). In high-confidence cases, NBI with NF had NPV of 100% (95% CI 98% to 100%) and sensitivity of 100% (95% CI 93% to 100%). Use of clips at initial EMR increased diagnostic inaccuracy (adjusted OR=1.68(95% CI 1.01 to 2.75)). In offline assessment, specificity was high for all imaging modes (mean: ≥93% (range: 55%–100%)), while sensitivity was significantly higher for NBI-NF (82%(72%–93%)%)) compared with WL (69%(38%–86%); p<0.001), WL-NF (68%(55%–83%); p<0.001) and NBI (71%(59%–90%); p<0.001). Conclusion Our study demonstrates very high sensitivity and accuracy for all four imaging modalities, especially NBI with NF, for diagnosis of recurrent neoplasia after EMR. Our data strongly suggest that in cases of high confidence negative optical diagnosis based on NBI-NF, no biopsy is needed to confirm absence of recurrence during colorectal EMR follow-up. A high confidence positive optical diagnosis can lead to immediate resection of any suspicious area. In all cases of low confidence, biopsy is still required. Trial registration number NCT02668198 .

Abstract Background and study aims Risk factors for colorectal adenoma recurrence after endoscopic mucosal resection (EMR) have been well documented. We assessed the efficacy of the newer 190 colonoscope versus the standard 180 colonoscope for complete resection of lateral spreading lesions. Patients and methods A single-center, retrospective study of patients who underwent EMR with Olympus 180 or 190 colonoscopes from January 1, 2010 to September 30, 2016. We included patients with lesions ≥ 20 mm and surveillance colonoscopy (SC1) after index EMR. A propensity score approach with inverse probability weighting was used to control for potential confounders. A secondary aim was to identify risk factors for recurrence and assess the applicability of the Sydney EMR recurrence tool (SERT) by grading each lesion of our cohort and analyzing associations with recurrence. Results Two hundred ninety-one lesions met inclusion criteria for the study. Odds ratio (OR) for recurrence with the 190 colonoscope was 1.06 (P = .85). Adenoma size (P = .02) and use of argon plasma coagulation (APC; P < .001) were risk factors for recurrence. Lesions with SERT scores > 0 had a higher recurrence risk during follow-up (32 % vs 21 %; OR 1.71; P = .05). Lesions with SERT scores = 0 reached a plateau for recurrence at 12 and 18 months in Kaplan-Meier curves. Conclusions The use of 190 colonoscopes did not measurably affect adenoma recurrence at SC1. Recurrence was associated with adenoma size, complementary APC for resection, and SERT scores > 0. Lesions with SERT scores = 0 that remain negative for recurrence at 18 months may return to routine surveillance.

Central processing of visceral information in humans is incompletely understood. We aimed to demonstrate the feasibility of single photon emission computed tomography (SPECT) and to quantitate the changes in regional cerebral blood flow during rectal distension. Ten healthy volunteers underwent randomized sham and active rectal distensions on separate days, during which cerebral blood flow was assessed by intravenous technetium-99m ethyl cysteinate dimer (99mTc-ECD) SPECT. Three-dimensional coregistration of brain images was used to quantitate activation in four preselected cerebral foci and two control regions. Paired analysis compared blood flow during sham and active distensions. There was increased right anterior cingulate gyrus activity (6.5 ± 2.9%, P = 0.03) with active rectal distension. A 5.4 ± 2.4% reduction in blood flow in the superior parieto-occipital control region ( P = 0.04) suggested blood “redistribution” during stimulation. Marked variability in activation of the frontal cortex, thalamus/basal ganglia complex, and mesiotemporal lobe was noted. Thus rectal distension increases activity in the right anterior cingulate gyrus on average; other foci of cerebral activation are quite variable, suggesting a lack of specific cerebral projections during rectal stimulation.

ObjectiveOur aim was to identify patient and procedure characteristics that correlate with increased likelihood of bleeding during and after endoscopic mucosal resection (EMR), and thus anticipate the need for preventative therapy.MethodsThis was a retrospective, observational, descriptive study using a prospective EMR database, performed in a tertiary‐care center. A total of 935 EMR of various locations within the gastrointestinal tract were collected. The main outcome measurement was early bleeding (occurring during the procedure) and delayed bleeding (occurring after the completion of the procedure and up to 30 days after).ResultsEarly bleeding occurred in 5.3% (50/935) of the procedures. In multivariate logistic regression analysis, esophageal EMR (OR 2.5, 95% CI 1.2–5, P = 0.0009) and increase in lesion size (OR 1.24, 95% CI 1.1–1.5, P = 0.003) were both associated with higher odds of early bleeding in EMR when controlling for age, gender and non‐steroidal anti‐inflammatory drugs (NSAIDs)/clopidogrel use. Delayed bleeding occurred after 3.1% (n = 29) of the procedures. Of these, 86.2% (25/29) required hospital admission and endoscopic intervention to confirm and/or treat bleeding site. In multivariate logistic regression analysis, increased lesion size (OR 1.3, 95% CI 1.1–1.5, P = 0.004) was associated with higher incidence of delayed bleeding post‐EMR.ConclusionsIn experienced hands bleeding during and after EMR appears to be uncommon. Larger lesions are at increased risk of early and delayed bleeding.

SummaryBackgroundFunctional dyspepsia (FD), a common functional gastrointestinal disorder, is defined by the Rome III criteria as symptoms of epigastric pain or discomfort (prevalence in FD of 89–90%), postprandial fullness (75–88%), and early satiety (50–82%) within the last 3 months with symptom onset at least 6 months earlier. Patients cannot have any evidence of structural disease to explain symptoms and predominant symptoms of gastroesophageal reflux are exclusionary. Symptoms of FD are non‐specific and the pathophysiology is diverse, which explains in part why a universally effective treatment for FD remains elusive.AimTo present current management options for the treatment of FD (therapeutic gain/response rate noted when available).ResultsThe utility of Helicobacter pylori eradication for the treatment of FD is modest (6–14% therapeutic gain), while the therapeutic efficacy of proton pump inhibitors (PPI) (7–10% therapeutic gain), histamine‐type‐2‐receptor antagonists (8–35% therapeutic gain), prokinetic agents (18–45%), tricyclic antidepressants (TCA) (response rates of 64–70%), serotonin reuptake inhibitors (no better than placebo) is limited and hampered by inadequate data. This review discusses dietary interventions and analyses studies involving complementary and alternative medications, and psychological therapies.ConclusionsA reasonable treatment approach based on current evidence is to initiate therapy with a daily PPI in H. pylori‐negative FD patients. If symptoms persist, a therapeutic trial with a tricyclic antidepressant may be initiated. If symptoms continue, the clinician can possibly initiate therapy with an anti‐nociceptive agent, a prokinetic agent, or some form of complementary and alternative medications, although evidence from prospective studies to support this approach is limited.