Gastroduodenal tuberculosis is infrequently seen in day-to-day clinical practice with few cases reported in the literature. It is usually associated with features of gastric outlet obstruction. This is a case series of 4 patients with 2 of them having associated lower gastrointestinal involvement. One of them resembled a growth in the cardia of the stomach which responded to antitubercular drugs. Another had duodenal erosions with portal lymph node enlargement which responded to antitubercular drug treatment. None of the patients required surgical management. Gastroduodenal tuberculosis should be considered with a high degree of suspicion when patients present with gastric outlet obstruction or with endoscopic evidence of ulceronodular disease in areas endemic for tuberculosis.
Background: Three device-assisted deep endoscopic platforms presently exist and are available for clinical use: double-balloon enteroscopy, single-balloon enteroscopy (SBE), and spiral enteroscopy (SE). In a retrospective study, SE was associated with a greater depth of maximal insertion (DMI) with similar diagnostic yields and procedure time as compared with SBE. Aims: This was a prospective, randomized comparison of SE and SBE with respect to DMI, diagnostic yield, procedure time, and rate of adverse events. Methods: Patients were prospectively randomized to undergo either anterograde SE or SBE. Patient demographics, indication for procedure, DMI, procedure time, therapeutic procedure time, adverse event, diagnostic findings, and therapeutic interventions were prospectively recorded. The primary outcome was DMI. Secondary outcomes included: procedure time; diagnostic yield; therapeutic yield and adverse event rates. Results: During the study period, 30 patients underwent deep enteroscopy (SE 13, SBE 17). The most common indication was gastrointestinal bleeding in both groups. There was no significant difference in the DMI between SE and SBE (330.0 ± 88.2 cm vs 285.3 ± 80.8 cm, P = .16). There was no difference between SE and SBE in procedure time (37.0 ± 10.5 vs 38.3 ± 12.4, P = .76), diagnostic yield (SE = 9 [69%] vs SBE = 7 [41%], P = .16), or therapeutic yield (SE = 6 [46%] vs SBE = 4 [24%], P = .26). There were no major adverse events in either group. Conclusions: Spiral enteroscopy and SBE are similar with respect to DMI, diagnostic yield, therapeutic yield, procedure time, and rate of adverse events. Small numbers prevent giving a definitive judgment and future adequately powered prospective study is required to confirm these findings.
For more than a decade, the therapeutic focus for Crohn’s disease has remained fixed at temporary arrestment of symptomology. The Centers for Disease Control and Prevention (CDC) lists Crohn’s disease as a disease entity without current cure. Biologics in combination with antibiotics can frequently achieve remissions. Without ongoing drug administration, these remissions tend to be of limited duration. Conceptual advancements in understanding the pathogenesis of Crohn’s disease have identified treatment approaches, the focus of which goes beyond temporary remission. Concepts derived from Infectious Diseases Inc.’s 17 years of research with Mycobacterium avium subspecies paratuberculosis delineate how new knowledge can be integrated to achieve more sustained remissions.
Peptic oesophageal stricture can be considered as the end result of prolonged gastro-oesophageal reflux. The 'gold standard' treatment for peptic stricture is endoscopic dilatation with balloon or bougie. It is predicted that up to 40% of patients remain symptomatic with dysphagia due to refractory (resistant to treatment) or recurrent strictures, needing frequent interventions at short intervals. Such patients have poor nutritional status due to the primary disease and are susceptible to complications related to repeated endoscopic dilatation such as bleeding and perforation. This general review aims to analyse existing published evidence and address the role of biodegradable stents in resistant peptic strictures as an alternative treatment to provide long-term dysphagia-free intervals.
Background: Nonalcoholic fatty liver disease (NAFLD) is a common complication in patients with metabolic syndrome. The role of statin therapy specifically for the treatment of NAFLD remains unknown. The aim of this review is to discuss outcomes of recent articles analyzing statin therapy in patients with NAFLD. Findings: A total of 12 trials met the inclusion criteria. Statins were not found to increase the prevalence of NAFLD once confounding variables were considered. Statins were also found to be beneficial in treating dyslipidemia and improving liver function. Histological liver outcomes in patients with NAFLD were controversial. One trial found a reduction in the incidence of hepatocellular carcinoma associated with the use of statins. Conclusions: Overall, therapy with statins appears to be safe for use in patients with NAFLD. Several trials have validated the use of statins for the treatment of dyslipidemia; however, it remains unknown as to whether statins should be used to specifically treat NAFLD.
Several properties of the probiotic medicinal yeast Saccharomyces boulardii CNCM I-745 contribute to its efficacy to prevent or treat diarrhoea. Besides immunologic effects, pathogen-binding and anti-toxin effects, as well as positive effects on the microbiota, S boulardii CNCM I-745 also has pronounced effects on digestive enzymes of the brush border membrane, known as trophic effects. The latter are the focus of this review. Literature has been reviewed after searching Medline and PMC databases. All relevant non-clinical and clinical studies are summarized. S. boulardii CNCM I-745 synthesizes and secretes polyamines, which have a role in cell proliferation and differentiation. The administration of polyamines or S. boulardii CNCM I-745 enhances the expression of intestinal digestive enzymes as well as nutrient uptake transporters. The signalling mechanisms leading to enzyme activation are not fully understood. However, polyamines have direct nucleic acid–binding capacity with regulatory impact. S. boulardii CNCM I-745 induces signalling via the mitogen-activated protein kinase pathway. In addition, effects on the phosphatidylinositol-3 kinase (PI3K) pathway have been reported. As an additional direct effect, S. boulardii CNCM I-745 secretes certain enzymes, which enhance nutrient acquisition for the yeast and the host. The increased availability of digestive enzymes seems to be one of the mechanisms by which S. boulardii CNCM I-745 counteracts diarrhoea; however, also people with certain enzyme deficiencies may profit from its administration. More studies are needed to fully understand the mechanisms of trophic activation by the probiotic yeast.
BACKGROUND: Melanosis coli, a brown discoloration of colonic mucosa, is considered as a benign condition mainly observed in patients under chronic anthranoid laxatives. Recent data link this condition with an increased adenoma detection rate. Moreover, its tumorigenic potential and possible association with the development of colorectal cancer remains uncertain. We conducted this study to compare the polyp detection rate and colorectal cancer diagnosis in patients with melanosis against matched control group without melanosis. PATIENTS AND METHODS: A retrospective single-center study. Patients diagnosed with melanosis coli on colonoscopy over a 15-year period were included. Each melanosis coli patient was matched with three controls by age, gender, setting (inpatient/outpatient), and procedure's indication. Polyp detection rate and diagnosis of colorectal cancer were recorded and compared between the groups before and after adjustment for bowel preparation. RESULTS: A cohort of 718 patients with melanosis and 2154 controls were included. The polyp detection rates were 33.4% and 21.8% of melanosis and control groups, respectively (P < .001). Melanosis coli, however, was associated with less diagnosis of colorectal cancer than controls (0.3% vs 3.9%; P < .001). In multivariate analysis, melanosis diagnosis on endoscopy was significantly associated with higher polyp detection rate (odds ratio [OR] = 1.986, 95% confidence interval [CI]: 1.626-2.425; P value < .01). CONCLUSIONS: Melanosis coli is not associated with increased diagnosis of colorectal cancer. It is associated, however, with enhanced polyp detection likely due to chromo-endoscopy-like effect.
Cirrhosis causes systemic and metabolic changes that culminate in various complications, such as compromised pulmonary function, ascites, hepatic encephalopathy, weight loss, and muscle weakness with significant physical function limitations. Our aim is to evaluate the effects of training with neuromuscular electrical stimulation (NMES) on the muscular and functional capacity of patients with cirrhosis classified as Child-Pugh B and C. A total of 72 patients diagnosed with cirrhosis will be recruited and randomized to perform an NMES protocol for 50 minutes, 3 times a week, for 4 weeks. The evaluations will be performed at the beginning and after 12 sessions, and patients will be submitted to a pulmonary function test, an ultrasound evaluation of the rectus femoris, an evaluation of peripheral muscle strength, a submaximal exercise capacity test associated with an evaluation of peripheral tissue oxygenation, a quality of life evaluation, and orientation about monitoring daily physical activities. The evaluators and patients will be blinded to the allocation of the groups. Training Group will be treated with the following parameters: frequency of 50 Hz, pulse width of 400 μs, rise and fall times of 2 s, and on:off 1:1; Sham Group: 5 Hz, 100 μs, on:off 1:3. The data will be analyzed using the principles of the intention to treat. This study provides health professionals with information on the benefits of this intervention. In this way, we believe that the results of this study could stimulate the use of NMES as a way of rehabilitating patients with more severe cirrhosis, with the objective of improving these patients’ functional independence.
Aim: To investigate the effect of video aid on quality of bowel preparation. Study: A retrospective study was done on patients undergoing outpatient screening colonoscopy. All subjects received educational video prior to colonoscopy in addition to the standard counseling. Patient charts were reviewed to collect data regarding quality of bowel preparation (adequate or inadequate). The study population was stratified into four groups according to viewing status: Group I 0% (control group), Group II <50%, Group III >50% to <75%, and Group IV watched ⩾75% of the video. Results: A total of 338 patients with an average age of 59.1 years and 60.3% females were included in the final study cohort. Of the patients in Groups I, II, III, and IV, 94.3%, 90.9%, 100%, and 91.7%, respectively, had adequate preparation ( P value = .827). Adenoma detection rate (ADR) for Groups I, II, III, and IV was 28.8%, 50%, 50%, and 22.6%, respectively ( P value = .305). The mean cecal intubation time was 20.7, 16.4, 16.57, and 17 minutes for Groups I, II, III, and IV, respectively ( P value = .041). Conclusions: Video aid use for patients undergoing screening colonoscopy lacked a statistically significant impact on the quality of bowel preparation, ADR, and advanced adenoma detection rate when compared with standard practice.
Extramedullary plasmacytomas (EMP) are a subcategory of plasma cell neoplasm that involves organs outside the bone marrow. Involvement of the pancreas is relatively rare, reported in only 2.3% of autopsies. Radiologic findings in plasmacytoma are nonspecific, but endoscopic ultrasound fine-needle aspiration is a fast and reliable technique to acquire a histologic sample for initial diagnosis. Recently, the use of fluorine-18 fluorodeoxyglucose PET/CT has been recommended in patients with active multiple myeloma and solitary plasmacytoma. We present an interesting case of primary EMP in the pancreatic body encasing the portal vein as well as the celiac artery, which was detected before the patient was diagnosed of multiple myeloma.
We aimed to clarify the relationship between plasma-free amino acid (PFAA) profiles and the Crohn's disease (CD) activity index (CDAI) in patients with CD.METHODS:We measured fasting PFAA concentrations in 29 patients with CD and their correlation with disease activity.RESULTS:In all patients, significant correlations were noted between CDAI and concentrations of valine, methionine, leucine, histidine, tryptophan, alanine, tyrosine, total amino acids (TAAs), nonessential amino acids (NEAAs), essential amino acids (EAAs), and branched-chain amino acids (BCAAs). In patients with the ileo-colonic type of CD, significant correlations were noted between CDAI and valine, histidine, tryptophan, glutamine, TAA, NEAA, EAA, and BCAA. In ileal type, significant correlations were observed between CDAI and threonine, valine, histidine, serine, and glycine. In colonic type, significant correlations were noted between CDAI and valine, histidine, tryptophan, TAA, NEAA, EAA, and BCAA.CONCLUSIONS:In patients with CD, plasma amino acids appear to be associated with disease activity.
OBJECTIVE:The incidence of esophageal adenocarcinoma, one of the most lethal gastroenterological diseases, has been increasing since the 1960s. Prevention of esophageal adenocarcinoma is important because no early detection screening programs have been shown to reduce mortality. Obesity, gastroesophageal reflux disease, and tobacco smoking are risk factors for esophageal adenocarcinoma. Due to the high prevalence in Ohio of obesity (32.6%) and cigarette smoking (21.0%), this study sought to identify trends and patterns of these risk factors and esophageal adenocarcinoma in Ohio as compared with the United States.METHODS:Data from the Ohio Cancer Incidence Surveillance System, Surveillance Epidemiology and End Results Program (SEER), and Behavioral Risk Factor Surveillance System were used. Incidence rates overall, by demographics and by county, as well as trends in incidence of esophageal adenocarcinoma and the percent of esophageal adenocarcinoma among esophageal cancers were examined. Trends in obesity and cigarette smoking in Ohio, and the prevalence of each by county, were reported.RESULTS:There was an increasing trend in esophageal adenocarcinoma incidence in Ohio. Ohio's average annual esophageal adenocarcinoma incidence rate was higher than the SEER rate overall and for each sex, race, and age group in 2009 to 2013. There was also an increasing prevalence of obesity in Ohio. Although the prevalence of cigarette smoking has been stable, it was high in Ohio compared with the United States.CONCLUSIONS:Health care providers and researchers should be aware of the esophageal adenocarcinoma incidence rates and risk factor patterns and tailor interventions for areas and populations at higher risk.
Consumption of herbal and dietary supplements (HDS) has increased worldwide as potential treatment for weight reduction and metabolic enhancement However, it has been reported that HDS can cause liver injury which accounts for 20% of hepatotoxicity in the United States Prevention of HDS induced liver injury remains a challenge due to difficulties in identifying the hepatotoxins in these preparations and lack of federal regulations for dietary supplements We report a case of acute severe hepatic necrosis presumably due to consumption of nutritional supplement advertised to boost vitality and stem cells in human body.
Aims: The reflux of duodeno-gastric contents into the remnant esophagus (gastric tube-esophageal reflux: GTER) is a significant issues in long-term esophageal cancer survivors after radical esophagectomy. We attempted endoscopic valve (funnel) creation for prevention for GTER using OverStitch endoscopic suturing system. Methods: The OverStitch was mounted onto a standard double-channel endoscope. Under general anesthesia, the funnel creation was attempted by placing semi-full thickness sutures on the gastric wall, at 3 cm distal to the primary esophago-gastric anastomosis. The postoperative outcomes were also evaluated. Results : In total, 4 sutures were needed and the operating time was 62 minutes without complication. The endoscopic and swallowing studies, as well as pH profile, were all improved postoperatively. The patient's quality of life was dramatically improved with complete disappearance of night-time reflux in spine position. Conclusions: Endoscopic antireflux funnel creation was feasible and safe. This procedure may become a useful treatment for patients with severe GTER after esophagectomy.
INTRODUCTION: The perioperative mortality is significantly higher in patients with cirrhosis undergoing certain surgical procedures. In this study, we examined the inpatient perioperative mortality and morbidities in cirrhotic people who underwent laparoscopic appendectomy. METHODS: We performed a retrospective analysis using the National Inpatient Sample database for 2010. Inclusion criteria were all race and sex who are 18 years or older. Those who have laparoscopic appendectomy and have a history of liver cirrhosis were assigned to case group. An equal random number of appendectomy-related admissions and those who have no history of liver cirrhosis were selected and placed in the control group. A binary logistic regression statistical test was used to examine the odds ratio for the mortality difference and postoperative complication including pneumonia, urinary tract infection (UTI), surgical site infection, postoperative bleeding. IBM SPSS statistics was used to execute the analysis. A confidence interval of 95% and P value less than .05 were determined to define the statistical significance. RESULT: A total of 754 appendectomy-related admissions were identified-376 appendectomy-related admissions and history of cirrhosis and 378 admissions with appendectomy and no history of cirrhosis. Control group was not found to be statistically different from the case group when it comes to age, race, and sex. Of 754, 520 were white (73.5%), 334 (44.3%) were men. The mean age was 43.75 years for the case group and 46.68 years for the control group. Comparing cirrhotic with noncirrhotic group, the mean length of stay was 1.1 vs 1.52 days, inpatient mortality was 2 (0.5%) vs 1 (0.3%) (P=.56), pneumonia 8 (2.1%) vs 3 (0.8%) (P=.142), surgical site infection 3 (0.8%) vs 2 (0.5%) (P=.652), UTI 18 (4.8%) vs 12 (3.2%) (P=.26), and postoperative bleeding 3 (0.8%) vs 2 (0.5%) (P=.65). CONCLUSIONS: Appendectomy-related morbidity and mortality in cirrhotic patients are not different from noncirrhotic patients.
Orbital inflammatory disease is a rare ophthalmic manifestation of Crohn’s disease. Inflammation is characteristically nonspecific, involving one or multiple structures of the orbit. Mechanisms of disease and optimal methods of treatment are poorly understood. The aim of this report is to present 3 cases of orbital involvement in Crohn’s disease. A retrospective case note review of patients with orbital inflammatory disease and Crohn’s disease was performed at our academic center to determine the clinical, imaging, and histopathologic features of this condition and its relationship to intestinal Crohn’s disease. Three patients were identified with orbital inflammatory manifestations complicating Crohn’s disease. All patients described were women with active intestinal disease and had a history of treatment with immunosuppressive therapies. Similarities were observed in clinical presentations with variance noted in radiologic and histopathologic findings. In all cases, symptoms improved with oral corticosteroids or nonsteroidal drugs in combination with anti-tumor necrosis factor agents. Inflammatory bowel disease–related orbital complications are rare but potentially vision-threatening. It is important to consider mimics of orbital inflammatory disease such as systemic inflammatory disease, malignancy, congenital malformations, infection, and trauma when formulating a comprehensive differential diagnosis. Therapeutic intervention is directed toward preservation of vision and orbital function and reducing the acute inflammatory process. Corticosteroids are typically the initial treatment of choice for moderate-to-severe disease, although several classes of immunomodulatory agents have been variably useful in treating this condition. Heightened awareness and close cooperation between gastroenterologists and ophthalmologists are mandatory.
BACKGROUND:Iron deficiency anemia (IDA) is a frequent disorder that is associated with many serious diseases. However, the findings of an evaluation of IDA-associated gastrointestinal disorders are lacking among African American patients.AIM:To determine the most prevalent gastrointestinal lesions among African American patients with IDA especially in young men.METHODS:We reviewed medical records (n = 422) of patients referred for evaluation of IDA from 2008 to 2012. Iron deficiency anemia was diagnosed using clinical laboratory tests. The results of esophagogastroduodenoscopy, colonoscopy, and pathology specimens along with demographic data were abstracted and analyzed using Stata.RESULTS:The mean age was 61.9 years, and 50.5% were women. In total, 189 patients (45%) had gross gastrointestinal (GI) bleeding. The most frequent diagnoses were gastritis (40%), benign colonic lesions (13%), esophagitis (9%), gastric ulcer (6%), and duodenitis (6%). GI bleeding was significantly more frequent in men (P = 0.001). Benign and malignant colonic lesions were significantly more present among older patients: 16% vs 6% (P = .005) and 5% vs 0% (P = .008), respectively. Colitis was more prevalent in younger patients (⩽50): 11% vs 2% (P = .001). In patients with gross lower GI bleeding, the top diagnoses were gastritis (25%), benign colon tumors (10%), and duodenitis (6%). Colon cancer was diagnosed among 15 patients, and all these patients were older than 50 years of age.CONCLUSIONS:Gastritis and colonic lesions are most common associated lesions with IDA among African Americans. So bidirectional endoscopy is required for unrevealing of the cause of IDA in asymptomatic patients.
Celiac disease (CD) is an autoimmune disorder characterized by the permanent inflammation of the small bowel, triggered by the ingestion of gluten. It is associated with a number of symptoms, the most common being gastrointestinal. The prevalence of this illness worldwide is 1%. One of the main problems of CD is its difficulty to be diagnosed due to the various presentations of the disease. Besides, in many cases, CD is asymptomatic. Celiac disease is a multifactorial disease, HLA-DQ2 and HLA-DQ8 haplotypes are predisposition factors. Nowadays, molecular markers are being studied as diagnostic tools. In this review, we explore CD from its basic concept, manifestations, types, current and future methods of diagnosis, and associated disorders. Before addressing the therapeutic approaches, we also provide a brief overview of CD genetics and treatment.
AIM:To compare the efficacy and safety of omeprazole-domperidone combination vs omeprazole monotherapy in gastroesophageal reflux disease (GERD).METHODS:In a comparative, randomized controlled, phase 4 study, outpatients with GERD were randomly allocated to either group 1 (omeprazole 20 mg + domperidone 30 mg) or group 2 (omeprazole 20 mg) in an equal ratio; 2 capsules daily in the morning were administered for 8 weeks.RESULTS:Sixty patients were enrolled. Esophagitis reversal was observed in 92% patients in group 1 vs 65.2% in group 2. Approximately, 83.3% patients in group 1 vs 43.3% patients in group 2 demonstrated full cupping of reflux symptoms at 8 weeks. Combined therapy resulted in significantly longer period of heartburn-free days (23 vs 12 days on omeprazole). There were no safety concerns.CONCLUSIONS:Omeprazole-domperidone combination was more effective than omeprazole alone in providing complete cupping of reflux symptoms and healing of esophagitis in patients with GERD. Both the treatments were well tolerated with few reports of adverse events.TRIAL REGISTRATION:This trial is registered with http://clinicaltrials.gov, number NCT02140073.
Availability of normative patient outcome data may assist in designing experiments and estimating sample sizes. The purpose of this review was to determine normative ranges for colonic transit time (CTT), Patient Assessment of Constipation-Symptoms (PAC-SYM), and Patient Assessment of Constipation-Quality of Life (PAC-QOL) in adults diagnosed with functional constipation per Rome III guidelines. Pooled estimates were derived from random-effects meta-analysis. Meta-regression was used to explore sources of heterogeneity among studies. A total of 24 studies (3786 patients) were included in the review. In 10 studies with 1119 patients, pooled CTT was 58 hours (95% confidence interval [CI]: 50-65 hours). Publication bias was not evident (Egger P = .51); heterogeneity was high (I-2 = 92%, P < .001). In meta-regression, geographical location explained 57% of the between-study variance, with CTT significantly longer in studies conducted in Europe (71 hours) compared with Asia (49 hours) or the Americas (44 hours). In 9 studies with 2061 patients, pooled PAC-SYM was 1.70 (95% CI: 1.58-1.83). Publication bias was not evident (Egger P = .44). Heterogeneity was high (I-2 = 90%, P < .001); however, no study or patient factor influenced PAC-SYM in meta-regression. In 12 studies with 1805 patients, pooled PAC-QOL was 1.97 (95% CI: 1.70-2.24). Publication bias was not evident (Egger P = .28); heterogeneity was high (I-2 = 98%, P < .001). In meta-regression, age explained 52% of the between-study variance, with older age associated with lower PAC-QOL scores. Overall, in adults diagnosed with functional constipation per Rome III criteria, significant heterogeneity in CTT, PAC-SYM, and PAC-QOL exists among studies. Variability among studies may be explained by geography and patient factors.
