BACKGROUND AND AIMS:Chronic diarrhea affects about 5% of the population overall. Altered bile acid metabolism is a common but frequently undiagnosed cause.METHODS:We performed a systematic search of publication databases for studies of assessment and management of bile acid diarrhea (BAD). The certainty (quality) of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation approach. Patient population, intervention, comparator and outcome questions were developed through an iterative process and were voted on by a group of specialists.RESULTS:The certainty of evidence was generally rated as very low. Therefore, 16 of 17 recommendations are conditional. In patients with chronic diarrhea, consideration of risk factors (terminal ileal resection, cholecystectomy or abdominal radiotherapy), but not additional symptoms, was recommended for identification of patients with possible BAD. The group suggested testing using 75selenium homocholic acid taurine (where available) or 7α-hydroxy-4-cholesten-3-one, including patients with irritable bowel syndrome with diarrhea, functional diarrhea and Crohn's disease without inflammation. Testing was suggested over empiric bile acid sequestrant therapy (BAST). Once remediable causes are managed, the group suggested cholestyramine as initial therapy, with alternate BAST when tolerability is an issue. The group suggested against BAST for patients with extensive ileal Crohn's disease or resection and suggested alternative antidiarrheal agents if BAST is not tolerated. Maintenance BAST should be given at the lowest effective dose, with a trial of intermittent, on-demand administration, concurrent medication review and reinvestigation for patients whose symptoms persist despite BAST.CONCLUSIONS:Based on a systematic review, BAD should be considered for patients with chronic diarrhea. For patients with positive results from tests for BAD, a trial of BAST, initially with cholestyramine, is suggested.

Introduction: Eosinophilic esophagitis (EoE), a known cause of dysphagia, is increasingly associated with foreign body/food impaction (FBI), requiring urgent endoscopic removal in children and adults. This study examines the prevalence of EoE in patients requiring FB removal in Calgary and its surrounding areas. Methods: A retrospective review of all emergency (ER) and urgent care FB presentations from November 2015 to September 2016 in a population of approximately 1.2 million people was performed using the regional electronic health database. Patient's age, sex, clinical impression, endoscopy, and pathology was collected in agreement with local research ethics (ARECCI) guidelines. Results: A total of 334 patients presented with symptoms of FBI. 131 patients were excluded: 100 had FB that spontaneously resolved without a GI assessment and 31 had non-GI concerns (e.g. drug overdose, allergic reaction, psychosis, and seizures). The remaining 203 patients underwent gastroscopy (EGD). Their average age was 39 ± 14 years; the majority were male (M: F ratio was 133:70). EoE was identified in 35% of all EGDs; 65% had other esophageal disorders (Figure 1). For the 72 patients in whom EoE was endoscopically evident, 22% were known cases of EoE whereas 78% underwent subsequent confirmation with biopsies. Biopsies were not performed in those with an endoscopically normal esophagus or a Schatzki's ring (Figure 1). A minority of patients (35%) with EoE features had a biopsy at the initial endoscopy (Table 1). Of the EoE cases, 9 patients (4 previously known and 5 new cases) had experienced more than one episode of FBI. The most common management in ER was to prescribe PPIs and repeat an EGD as an outpatient (90%). Those with a prior history of FBI or EoE were more likely to be prescribed budesonide plus PPI. The remaining 10% were scheduled for follow-up only.Figure: Esophageal findings in documented food bolus impaction in 203 patients.Table: Table. Patient demographics and eosinophilic esophagitis related informationConclusion: EoE is the most common cause (35%) of FBI necessitating urgent endoscopic removal in Calgary. As mucosal biopsies were not taken from all patients with FBI, the true incidence of EoE is likely underestimated. Education and better follow-up are needed for the 12.5% (9/72) of patients that frequented ER for >1 episode of FBI. Given the rate of detection in ER, obtaining biopsies at the preliminary EGD for FBI should become a standard of practice for early detection and diagnosis of EoE.

Eosinophilic oesophagitis (EoE) is an emerging disorder that manifests clinically with characteristic symptoms of oesophageal dysfunction and histologically by tissue eosinophilia. This chronic immunemediated oesophageal disease represents a response primarily to food antigens. The incidence of EoE is escalating in both adults and children. This rise stems not only from heightened recognition but also an increased frequency of allergic/atopic diseases and defective immune tolerance. In adults, EoE presents as intermittent solid-food dysphagia or food impaction, heartburn, and chest pain, typically presenting in young men with known allergies. Presentation differs in children, who experience upper gastrointestinal complaints: abdominal pain, vomiting, feeding difficulties, and/or failure to thrive. Endoscopic features include circular rings, linear furrows, white exudative plaques, strictures, and mucosal fragility. The pathologic hallmark of EoE is mucosal eosinophilia (>15 eosinophils per high-power field) isolated to the oesophagus. Such tissue eosinophilia must be distinguished from gastro-oesophageal acid reflux that responds to optimal proton pump inhibitor (PPI) treatment and from PPI-responsive oesophageal eosinophilia (PPI-ROE). Innovative modalities such as high resolution digitally-enhanced endoscopy and functional luminal impedance planimetry are emerging to better detect EoE and monitor its response to treatment. Current therapeutic strategies involve elimination and elemental diets to avoid food allergens, topical corticosteroids to counter the inflammatory response, and endoscopic dilation of fibrostenotic complications. Other treatments have employed immunosuppressants, antagonists to the leukotriene and T helper Type 2 inflammatory pathways, and biologics that target interleukins, tumour necrosis factor, or immunoglobulin E with variable success. This review highlights the current understanding of the epidemiology, pathogenesis, presentation, treatment, and natural history of EoE, and scrutinises current controversies and future directions for investigation.

Background: Tegaserod is effective in treating IBS patients with constipation, and does not alter gallbladder motility in healthy individuals or in patients with IBS. However, it is not known if tegaserod affects the biliary tract in gallstone disease, so to this end the effects of tegaserod on bile composition and hepatic secretion of Richardson ground squirrels maintained on an enriched cholesterol diet were examined. Results: Animals were fed either a control (0.03%) or enriched (1%) cholesterol diet for 28 days, and treated s.c. with tegaserod (0.1 mg/kg BID) or vehicle. Bile flow, bile acid, phospholipids and cholesterol secretion were measured with standard methods. Tegaserod treatment or enriched cholesterol diet, alone or combination, did not alter body or liver weights. The enriched cholesterol diet increased cholesterol saturation index (CSI), cholesterol concentrations in gallbladder and hepatic duct bile by ~50% and decreased bile acids in gallbladder bile by 17%. Tegaserod treatment reversed these cholesterol-induced changes. None of the treatments, drug or diet, altered fasting gallbladder volume, bile flow and bile salts or phospholipid secretion in normal diet and cholesterol-fed animals. However, tegaserod treatment prevented the decreases in bile acid pool size and cycling frequency caused by the enriched cholesterol diet, consequent to re-establishing normal bile acid to concentrations in the gall bladder. Tegaserod had no effect on these parameters with normal diet animals. Conclusion: Tegaserod treatment results in increased enterohepatic cycling and lowers cholesterol saturation in the bile of cholesterol-fed animals. These effects would decrease conditions favorable to cholesterol gallstone formation. Background Irritable bowel syndrome (IBS) is a poorly understood symptom complex with abdominal pain and altered bowel function. Its basis likely involves visceral hypersensitivity and altered intestinal motility, perhaps mediated by the serotonin (5-HT) receptors [1]. IBS is not merely a motility disorder confined to the colon, but may involve the entire gut, urinary tract and gallbladder. As to the Published: 22 June 2006 Lipids in Health and Disease 2006, 5:15 doi:10.1186/1476-511X-5-15 Received: 25 April 2006 Accepted: 22 June 2006 This article is available from: http://www.lipidworld.com/content/5/1/15 © 2006 Mathison et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gallbladder cancer, though generally considered rare, is the most common malignancy of the biliary tract, accounting for 80%-95% of biliary tract cancers. An early diagnosis is essential as this malignancy progresses silently with a late diagnosis, often proving fatal. Its carcinogenesis follows a progression through a metaplasia-dysplasia-carcinoma sequence. This comprehensive review focuses on and explores the risks, management, and outcomes for primary gallbladder carcinoma. Epidemiological studies have identified striking geographic and ethnic disparities - inordinately high occurrence in American Indians, elevated in Southeast Asia, yet quite low elsewhere in the Americas and the world. Age, female sex, congenital biliary tract anomalies, and a genetic predisposition represent important risk factors that are immutable. Environmental triggers play a critical role in eliciting cancer developing in the gallbladder, best exemplified by cholelithiasis and chronic inflammation from biliary tract and parasitic infections. Mortality rates closely follow incidence; those countries with the highest prevalence of gallstones experience the greatest mortality from gallbladder cancer. Vague symptoms often delay the diagnosis of gallbladder cancer, contributing to its overall progression and poor outcome. Surgery represents the only potential for cure. Some individuals are fortunate to be incidentally found to have gallbladder cancer at the time of cholecystectomy being performed for cholelithiasis. Such an early diagnosis is imperative as a late presentation connotes advanced staging, nodal involvement, and possible recurrence following attempted resection. Overall mean survival is a mere 6 months, while 5-year survival rate is only 5%. The dismal prognosis, in part, relates to the gallbladder lacking a serosal layer adjacent to the liver, enabling hepatic invasion and metastatic progression. Improved imaging modalities are helping to diagnose patients at an earlier stage. The last decade has witnessed improved outcomes as aggressive surgical management and preoperative adjuvant therapy has helped prolong survival in patients with gallbladder cancer. In the future, the development of potential diagnostic markers for disease will yield screening opportunities for those at risk either with ethnic susceptibility or known anatomic anomalies of the biliary tract. Meanwhile, clarification of the value of prophylactic cholecystectomy should provide an opportunity for secondary prevention. Primary prevention will arrive once the predictive biomarkers and environmental risk factors are more clearly identified.

AimEosinophilic colitis (EC) is a rare manifestation of eosinophilic gastrointestinal disorders. Due to its rarity, little information is available on its natural history.MethodFrom the single population-based pathology database of the Calgary Health Region (comprising a population of 1.28 million in 2008), cases of EC during the period 1996-2008 were identified. Medical records of all adults diagnosed with EC were identified and the pathology reviewed. The patients were then contacted for follow-up using a standardized questionnaire.ResultsSeven cases of EC (four in women) were identified, with a median follow-up of 45 (23-79) months. The median age at diagnosis was 42 (22-70) years. Symptoms at diagnosis were abdominal pain (86%), nonbloody diarrhoea (57%), bloody diarrhoea (29%) and significant (>10%) weight loss (29%). Three patients gave a history of allergic reactions to drugs and four reported allergy to cows' milk. Endoscopic findings were nonspecific, ranging from oedema to small aphthous ulceration. An eosinophilic infiltrate was identified in the lamina propria in the initial colonic biopsy in all patients. Over the longer term, three patients experienced spontaneous resolution without treatment. Two continued to have mild diarrhoea and abdominal cramps but did not require medical therapy. Two patients required medical treatment by 5-aminosalicylic acid, with one requiring prednisone and azathioprine maintenance therapy.ConclusionEosinophilic colitis is a rare mostly self-limiting disease affecting middle-aged adults. It usually has a mild clinical course and drug treatment is not usually necessary. When required, drug treatment follows the standard medication for other inflammatory bowel disease.

Single authorship was the norm eons ago. According to rabbinical tradition, Moses wrote the five books of the Jewish bible, the Torah, meaning ‘Instruction’ or ‘Law’. Christian scholars credit God with breathing out the Bible. Before the mid-20th century, landmark scientific works from giants, such as Newton, Einstein and Fermi, were single authored. Although single authors wrote the vast majority (>98%) of important medical articles a century ago, this has become a rarity; <5% are now single authored. Meanwhile, the number of multi-authored articles has escalated, many of which list individuals who made insignificant contributions (1). At times, the list of authors reaches astronomical numbers, occupying as much space as the corresponding abstract. Extreme examples include a report in the physical sciences on the Large Hadron Collider listing almost 3000 authors, and a clinical trial published in The New England Journal of Medicine listing 974 authors (2). The basis for this rise in multiple authors does not simply reside in the complexities of current medical bioscience or the need for large multicentred clinical trials. Unmerited authorship is rampant. Twenty to thirty percent of medical science authors do not contribute substantially to the eventual peer-reviewed publication, particularly in large, multi-authored articles (1,3). One facet of undeserved authorship increasingly occurs in the form of ‘honorary authorship’ (ie, named authors who do not significantly contribute), which is granted either to chairs of departments as a convention or to more senior authors to boost the paper (4). Another is ‘ghost writers’ (unnamed authors who do contribute), employed by some biotechnology companies, aiming to lever ‘key opinion leaders’ and, so, portray the publication as originating in the academic domain, unsullied by commercial interests (5). To assess original articles appropriately, scientists and clinicians must know the proper authorship and the origin and execution of the study, devoid of ghost writing or other bias. For the academic, authorship represents the means by which peers perceive their scholarly work. This establishes their reputation, productivity, grant support and opportunity for promotion. The order in which authors are listed quantitatively identifies credit. Although there are some differences among disciplines, most have the authors listed according to the magnitude of their involvement in the work, placing the principal investigator last. Because some journals, such as Gastroenterology, limit authorship lists in the references to contain a maximum of three followed by the near afterthought ‘et al’, the senior author may select the third position so as to appear in any subsequent citations. Many publications, however, allow up to six authors before ‘et al’ (eg, Canadian Journal of Gastroenterology and Hepatology, Hepatology) to be listed in the references. Thus, this practice has disappeared. To accommodate the growing number of authors per article, institutions and journals have established guidelines that seek to clarify the role, involvement and responsibility of each author. Since 1985, a voluntary, closed-membership group of select general medical editors (the International Committee of Medical Journal Editors) has provided guidance on authorship that continually evolves with time. This committee of editors provides clarification on accountability, roles and responsibilities of authors, fraud, conflict of interest and clinical trial registration. The International Committee of Medical Journal Editors “recommends that authorship be based on the following 4 criteria: substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND drafting the work or revising it critically for important intellectual content; AND final approval of the version to be published; AND agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved” (6). In its instructions to authors, the Canadian Journal of Gastroenterology and Hepatology fulfills some of these criteria: requesting a letter to indicate that all authors have participated in the research, and have reviewed and agree with the contents of the article. Few articles, however, clarify the actual contributions of the authors. Authorship assigns responsibility and attributes credit. Substantive contribution must be a primary criterion. This should include significant involvement in the three components of any scientific publication: its original conception and design; implementation of the study including data collection and analysis; and, finally, writing major sections of the manuscript while being accountable for all of its content. Such decisions about authorship and order in the publication is best identified by the research team engaging in an open conversation. This should begin with the design of the study and continue throughout its implementation and manuscript submission. Recognizing individuals whose role represents a limited contribution may best be communicated through an ‘Acknowledgement’ section. Multiple authors are necessary in this increasingly complex biomedical world. Even in biblical times, 40 different authors from three continents, writing in three different languages, created the Bible. Moses required help to complete Deuteronomy as the last portion covered a time after his death.

We assessed 6 cases acquired during routine surgical sign-out for IgG4-related disease (IRD) according to criteria from a recent consensus meeting. These cases fulfilled the morphologic criteria—that is, dense lymphoplasmacytic infiltrates, IgG4:IgG ratio greater than or equal to 0.4, and fibrosis (storiform in 4 cases—but were associated with malignancy or did not fulfill the criteria for a new site. These criteria include increased serum IgG4 (normal in the majority of IRD) and a response to glucocorticoids, which is not appropriate treatment for resectable lesions as in our cases. Until more is known about the natural history of the disease, we propose that the possibility of an early, localized, or forme fruste of IRD should be considered and that cases associated with malignancy should at least be documented. Although we acknowledge the value of the consensus criteria, their strict application may result in missed opportunities to study the disease.

Background: An association between eosinophilic esophagitis (EoE) and celiac disease (CD) has been suggested in the literature. Our aim was to confirm and quantify the association between these two diseases.Methods: All patients in a large Canadian city diagnosed with EoE or CD over a five-year period were identified. Standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) were calculated.Results: Over the five-year study EoE was diagnosed in 421 patients and CD was diagnosed in 763 patients. The incidence of EoE ranged from 2.1 to 10.7 cases per 100,000 population. The incidence of CD ranged from 10.4 to 15.7 cases per 100,000 population. Among the EoE cohort, 83 (20%) cases of EoE and 245 (32%) cases of CD were diagnosed in pediatric patients. The incidence of EoE in the pediatric subpopulation ranged from 3.7 to 6.9 cases per 100,000 population. The incidence of CD in the pediatric subpopulation ranged from 9.5 to 22.7 cases per 100,000 population. The concomitant diagnosis of both EoE and CD was made in three patients, all of whom were pediatric males. The SIR for EoE in the CD cohort was 48.4 (95% CI = 9.73, 141.41) with a SIR for CD within the paediatric EoE cohort of 75.05 (95% CI = 15.08, 219.28).Conclusions: This study confirms the association between EoE and CD. However, this association may be limited to pediatrics where the risk of each condition is increased 50 to 75-fold in patients diagnosed with the alternative condition. The concomitant diagnosis of these conditions should be considered in pediatric patients with upper gastrointestinal symptoms.

Diseases of the gallbladder are common and costly. The best epidemiological screening method to accurately determine point prevalence of gallstone disease is ultrasonography. Many risk factors for cholesterol gallstone formation are not modifiable such as ethnic background, increasing age, female gender and family history or genetics. Conversely, the modifiable risks for cholesterol gallstones are obesity, rapid weight loss and a sedentary lifestyle. The rising epidemic of obesity and the metabolic syndrome predicts an escalation of cholesterol gallstone frequency. Risk factors for biliary sludge include pregnancy, drugs like ceftiaxone, octreotide and thiazide diuretics, and total parenteral nutrition or fasting. Diseases like cirrhosis, chronic hemolysis and ileal Crohn's disease are risk factors for black pigment stones. Gallstone disease in childhood, once considered rare, has become increasingly recognized with similar risk factors as those in adults, particularly obesity. Gallbladder cancer is uncommon in developed countries. In the U.S., it accounts for only ~ 5,000 cases per year. Elsewhere, high incidence rates occur in North and South American Indians. Other than ethnicity and female gender, additional risk factors for gallbladder cancer include cholelithiasis, advancing age, chronic inflammatory conditions affecting the gallbladder, congenital biliary abnormalities, and diagnostic confusion over gallbladder polyps.

Canadians are proud of their health care system. A key quality measure is access, reputed to be universal, yet a major obstacle to obtaining care (1). This problem includes wait times in finding and obtaining an appointment with a family physician and being referred for more highly specialized investigations when needed (2). Nevertheless, 20% of Canadians experience adverse effects while awaiting general health care or a specialist’s assessment, profoundly impacting their quality of life and carrying a fiscal cost in the work-place. Gastroenterology ranks with the top clinical areas in which family physicians and patients experience frustration while awaiting a consultation (3). In response, the Canadian Association of Gastroenterology has joined the Wait Time Alliance under the auspices of the Canadian Medical Association and developed consensus guidelines for medically acceptable wait times, stratified according to acuity into four categories: 24 h, two weeks, two months and six months (4). Their most recent survey, however, suggests that wait times are actually worsening – now 30 days longer, generally, than in 2005 (5). For example, the targeted wait time for a patient with a high likelihood of experiencing severe inflammatory bowel disease is 14 days. The overall wait time is actually 126 days: 72 days before a consultation, followed by 44 days for a diagnostic endoscopy. In Calgary (Alberta), our central gastrointestinal triage servicing 23 gastroenterologists currently has wait times of two weeks, two months, 10 months and 16 months, for emergent, urgent, semi-urgent and nonurgent referrals, respectively (personal communication, Dr Kerri Novak, Division of Gastroenterology, University of Calgary). In Ontario, the median wait time to see a gastroenterologist approaches 100 days (6). From another perspective, primary care physicians vary in their threshold for initiating such referrals while many referrals do not provide sufficient information to make a valid medical decision about need or acuity. In fact, breakdowns and inefficiencies occur for all components of the specialty referral process across North America (7). The public has a growing awareness and expectation that consultations with specialists should be timely, but frequently are not. What happens after a referral is declined or the fax machine is turned off? In the current issue of the Canadian Journal of Gastroenterology, de Boer et al (8) (pages 785–790) tracked the outcome of patients who were referred to their university division’s central triage in Edmonton (Alberta) but were not accepted because their limited resources (inadequate number of gastroenterologists and endoscopy slots) precluded a timely evaluation. They assessed four referral diagnoses: abdominal pain, rectal bleeding, positive fecal occult blood tests and iron deficiency (unspecified was if all were anemic). In the 12 months following the original referral being declined, one-half (47.8% [110 of 230 patients]) were seen by a gastroenterologist or surgeon, as captured through the Edmonton region data base from electronic medical records, and diagnostic imaging and pathology reports. In 9.1% (21 of 230), a clinically relevant diagnosis was forthcoming. Five of these 12 had immediate clinical implications: Crohn disease, ulcerative colitis, celiac disease, colon cancer and small bowel obstruction from an incisional hernia. Overall, the rejected patients experienced a 15% increase in gastrointestinal x-rays alone. The authors are to be commended for initiating this important study of patient referrals that were declined. Limitations included the quality or completeness of the original referral (eg, not clearly identifying the acuity in those with significant disease, the celiac case without serology being performed), limited endoscopy documentation and no subsequent information for out-of-region patients. What is the ‘natural’ history of the other one-half (120 of 230) who were not captured by the imaging or pathology data base? One is left wondering what would have transpired had there not been an alternative group of consultants who were not part of their academic division yet were available in their region. Interventions to improve the referral process should begin with involving consultants in educational activities, communicating with family physicians and disseminating clear guidelines with structured referral sheets (9). Preconsultation criteria for appropriate and adequate management should be available to referring physicians. Where feasible, there should be a central triage with reasonable guidelines that are transparent to all stakeholders. The decision making for access should not reside with administrative assistants reviewing faxes in consultants’ offices. Ideally, the workforce should expand, increasing the number of gastroenterologists and available endoscopy slots. The latter might arise through screening endoscopies being performed outside the setting of high acuity, thus, lowering cost and yielding higher efficiencies. Alternatives to specialist referrals might come from family physicians with additional training and nurse clinicians under the supervision of gastroenterologists. A shifted outpatient model would envision specialists attending regularly scheduled clinics in the primary care setting, providing not only consultations but also an educationl opportunity (10). Finally, teleconferencing and outreach clinics are particularly attractive for rural settings. What about patients who fall off the consultative pathway, either not accepted or waiting years? For nonurgent referrals, one strategy uses follow-up letters to better identify those still requiring a consultation and directing them to specialty clinics (11). An overarching challenge in triaging remains the ethics of rejecting consultations and the attendant medical-legal implications. Conversely, accepting consultations into an excessively long wait list carries its own set of accountabilities. Ignoring or disregarding referrals, however, merely shifts the burden of responsibility back onto primary care physicians. Now for a reality check. Canada appears to have a relatively low number of gastroenterologists compared with other countries: 1.83 per 100,000 population in Canada versus 3.9 per 100,000 population in the United States (12). Burdened by rising health care costs, yet under constraints engendered by the current ‘great recession’, government agencies are unlikely to increase resources anytime soon. Access for performing endoscopy may not rise, limiting growth to mint additional gastroenterologists. More gastroenterologists performing more endoscopies, therefore, appears to be an unlikely solution. A further challenge to endoscopy access is the escalating number of procedures, many of which are not supported by contemporary guidelines (13). In addition, procedures such as screening colonoscopies, when once established, have an inherent growth rate: 15% to 25% of such screens will detect adenomas. Colonoscopy surveillance, therefore, might increase 10% each year, doubling over the next decade (14). The current state of the specialty-referral process is often flawed but contains substantial opportunities for innovation to facilitate access to gastroenterologists, reduce wait times and, ultimately, lower patient mortality and morbidity while minimizing personal and fiscal stress. A better working approach with family physicians and administrative leaders is essential. Given our limited resources, gastroenterologists must prioritize and ensure that every procedure performed is appropriate. Let us seize this opportunity to increase capacity, reduce unnecessary demand and so improve access. Wait no longer.

BACKGROUNDPrimary eosinophilic gastrointestinal disorders, a spectrum of inflammatory conditions, occurs when eosinophils selectively infiltrate the gut in the absence of known causes for such tissue eosinophilia. These may be classified into eosinophilic esophagitis, eosinophilic gastroenteritis and eosinophilic colitis (EC). This review focuses on EC: its pathogenesis, epidemiology, clinical presentation, diagnosis and current approach to treatment.SOURCES OF DATAA literature review published in English was performed using Pubmed, Ovid, Google scholar search engines with the following keywords: eosinophilic gastrointestinal disorder, EC, eosinophils, colitis and gastrointestinal.AREAS OF AGREEMENTThe basis for primary EC appears related to increased sensitivity to allergens, principally as a food allergy in infants and a T lymphocyte-mediated event in adults. Endoscopic changes are generally modest, featuring edema and patchy granularity.AREAS OF CONTROVERSYClear clinical and pathological diagnostic criteria of EC and its management strategy.GROWING POINTSIntestinal involvement of EC is primarily mucosal, presenting as a mild self-limited proctitis in infants and self-limited colitis in young adults. Therapeutic approaches based on case reports tend to use either elimination diets to avoid a presumed allergen; agents traditionally used in inflammatory disease or targeted drugs like anti-histamines or leukotriene receptor antagonists.AREAS TIMELY FOR DEVELOPING RESEARCHProspective randomized controlled trials addressing the disease natural history, possible preventive methods and effective medical approach and long-term prognosis are required.

Background: Primary eosinophilic gastrointestinal disease (EGID) is a rare spectrum of gastrointestinal disorders that primarily affects the gastrointestinal tract. EGID causes inflammation rich in eosinophilic cells in the absence of known causes for eosinophilia. Eosinophilic colitis (EC) represents the least frequent manifestation of EGID and it is unknown whether it represents an independent group of diseases. Methods: The pathology database of the Calgary Health Region was used to identify all cases of EGID and EC. The medical records of all seven patients diagnosed with EC in the Calgary Health Region from 1996-2008 were retrospectively reviewed and the diagnosis was again confirmed by an expert pathologist. Results: The median age of presentation was 42 years. Four patients (57.1%) were females and three (42.9%) were males. Abdominal pain was present in six patients (85.7%), nonbloody diarrhea in four patients (57.1%), bloody diarrhea in two (28.6%) and two patients (28.6%) had more than 10% significant weight loss. Four patients (57.1%) reported a history of drug allergies indicating a predisposition towards allergic diseases but in none of the patients a distinct allergy causing EC was identified. Two patients (28.6%) were on non steroidal anti-inflammatory drugs at diagnosis. One patient (14.3%) was found to have additional peripheral eosinophilia. On histology, all patients had eosinophilic infiltrate in the Lamina propria, two (28.6%) had additional Muscularis propria infiltrate, and four patients (57.1%) had cryptitis. Conclusion: EC is a rare medical condition with different patterns of presentations. A high index of suspicion is needed to diagnose this disease. Pathology plays a crucial rule in diagnosis and colonic biopsies are important to rule out EC for the indication diarrhea.

Gallstones are common with prevalences as high as 60% to 70% in American Indians and 10% to 15% in white adults of developed countries. Ethnic differences abound with a reduced frequency in black Americans and those from East Asia, while being rare in sub-Saharan Africa. Certain risk factors for gallstones are immutable: female gender, increasing age, and ethnicity/family (genetic traits). Others are modifiable: obesity, the metabolic syndrome, rapid weight loss, certain diseases (cirrhosis and Crohn disease), gallbladder stasis (from spinal cord injury or drugs, such as somatostatin), and lifestyle.

Pneumatosis intestinalis is a rare disorder characterized by gas-filled cysts within the subserosal and/or submucosal regions of the intestinal wall. The source of this gas and its translocation across the mucosa is incompletely understood. Most (85%) cases are associated with medical conditions, ranging from psychiatric through respiratory disorders to gastrointestinal-related diseases; the remaining 15% lack any recognizable cause or association. In this case report, pneumatosis coli (affecting the colon) occurred in a patient following abdominal surgery and was associated with pseudomembranous colitis, which was Clostridium difficile toxin negative—presumably a false negative. Supportive care and appropriate antibacterial agents sufficed to alleviate symptoms and resolve the pneumatosis. Recognizing this uncommon but important association can avoid high financial and personal costs from unnecessary testing and invasive surgical explorations. Consideration should be given to pseudomembranous colitis as the basis for pneumatosis coli developing in patients who have received antibiotics, once gut ischemia has been ruled out.

Primary eosinophilic gastrointestinal disorders (EGIDs) represent a spectrum of inflammatory gastrointestinal disorders in which eosinophils infiltrate the gut in the absence of known causes for such tissue eosinophilia. EGIDs can be subgrouped as eosinophilic esophagitis (EE), eosinophilic gastroenteritis (EG), and eosinophilic colitis (EC). The least frequent manifestation of EGIDs is EC. EC is a heterogeneous entity with a bimodal age distribution, presenting with either an acute self-limited bloody diarrhea in otherwise healthy infants or as a more chronic relapsing colitis in young adults. The pathophysiology of primary EC appears related to altered hypersensitivity, principally as a food allergy in infants and T lymphocyte-mediated (i.e. non-IgE associated) in young adults. In adults, symptoms include diarrhea, abdominal pain, and weight loss. Endoscopic changes are generally modest, featuring edema and patchy granularity. Although standardized criteria are not yet established, the diagnosis of EC depends on histopathology that identifies an excess of eosinophils. Therapeutic approaches are based on case reports and small case series, as prospective randomized controlled trials are lacking. Eosinophilic colitis in infants is a rather benign, frequently food-related entity and dietary elimination of the aggressor often resolves the disorder within days. Adolescent or older patients require more aggressive medical management including: glucocorticoids, anti-histamines, leukotriene receptors antagonists as well as novel approaches employing biologics that target interleukin-5 (IL-5) and IgE. This review article summarizes the current knowledge of EC, its epidemiology, clinical manifestations, diagnosis, and treatment.

Most asymptomatic gallstone carriers require no therapy. Laparoscopic cholecystectomy is the best definitive therapy for symptomatic gallstone disease. Selective laparoscopic cholecystectomy can provide secondary prevention of symptoms and complications in certain instances (in a complex clinical setting such as sickle cell disease or to prevent gallbladder carcinoma from developing in those at risk with large [> 3 cm] gallstones or with a calcified gallbladder). Primary prevention is unproven but focuses on early identification and risk alteration to decrease the possibility of developing gallstones. Ursodeoxycholic acid has a limited role for stone dissolution but can prevent stone development in severe obesity during rapid weight reduction with diet or after bariatric surgery. Endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy represents the therapeutic cornerstone for managing severe pancreatitis and cholangitis.

Eosinophils are important effector cells of the innate immune system. Eosinophilic infiltrative disorders of the gastrointestinal tract, though recognised for decades, have recently witnessed a resurgence of interest, particularly for oesophageal disease. A more comprehensive basis for eosinophilic infiltration and activation has identified interleukin 5 (IL5) as a key cytokine for the differentiation and proliferation of eosinophils, while eotaxins promote the recruitment of mature eosinophils to the gut. When activated, eosinophils release multiple cytotoxic agents and immunomodulatory cytokines, resulting in local inflammation and tissue damage. Although eosinophils normally convey a defence against unwanted interlopers such as parasites, in the absence of such inciting agents, their accumulation and activation can elicit the primary infiltrative disorders of the gut: eosinophilic oesophagitis, gastroenteritis and colitis. Diagnosis of these disorders is dependent on the clinical presentation, endoscopic findings (particularly for eosinophilic oesophagitis), and most importantly, histological confirmation. Dietary modifications and topical corticosteroids are first-line treatments for eosinophilic oesophagitis. Systemic corticosteroids are the mainstay of treatment for eosinophilic gastroenteritis; surgery may be required depending on the layer of mucosa involved. Eosinophilic colitis most often occurs in infants; removal of the causative allergen usually results in a complete response. Steroids may be required for older children/adolescents or adults. This review summarises current knowledge on the trafficking of eosinophils to the gastrointestinal tract and the clinical management of the primary disorders of eosinophilic oesophagitis, eosinophilic gastroenteritis and eosinophilic colitis.