Goals: To better understand the characteristics, treatment approaches, and outcomes of patients with esophageal lichen planus (ELP). Background: ELP is a rare, often unrecognized and misdiagnosed disorder. Data on this unique patient population are currently limited to small, single-center series. Study: A multicenter, retrospective descriptive study was conducted of adults diagnosed with ELP over a 5-year period, between January 1, 2015, and October 10, 2020, from 7 centers across the United States. Results: Seventy-eight patients (average age 65 y, 86% female, 90% Caucasian) were included. Over half had at least 1 extraesophageal manifestation. Esophageal strictures (54%) and abnormal mucosa (50%) were frequent endoscopic findings, with the proximal esophagus the most common site of stricture. Approximately 20% had normal endoscopic findings. Topical steroids (64%) and/or proton pump inhibitors (74%) dominated management; endoscopic response favored steroids (43% vs. 29% respectively). Almost half of the patients required switching treatment modalities during the study period. Adjunctive therapies varied significantly between centers. Conclusions: Given its at times subtle clinical and endoscopic signs, a high index of suspicion and biopsy will improve ELP diagnosis, especially in those with extraesophageal manifestations. Effective therapies are lacking and vary significantly. Prospective investigations into optimal treatment regimens are necessary.

INTRODUCTION:Colorectal cancer (CRC) screening is now recommended at the age of 45 years in the United States. However, information regarding the adenomas detection rate (ADR) and sessile serrated lesions (SSLs) in 45- to 49-year-old individuals is limited. In addition, the impact of lowering the screening age to 45 years on the ADR and the detection rate of SSLs is not well elucidated. This systematic review and meta-analysis aims to report the overall ADR and SSL detection rate in 45- to 49-year-old individuals undergoing colonoscopy. METHODS:We searched MEDLINE, EMBASE, SCOPUS, Web of Science, ClinicalTrials.gov , and the Cochrane database from inception through October 2022 to identify studies reporting on ADR and SSL detection rates in 45- to 49-year-old individuals undergoing colonoscopies for all indications. This approach acknowledges the possibility of including individuals undergoing diagnostic colonoscopies or those with increased risk factors for CRC. We also conducted a separate analysis examining ADR in average-risk individuals undergoing screening colonoscopy. The pooled rates with their corresponding 95% confidence intervals (CIs) were generated using the fixed-effects model. I2 was used to adjudicate heterogeneity. RESULTS:Sixteen studies met the inclusion criteria. All studies were retrospective except one; 3 had data from national/local registries. There were 41,709 adenomas detected across 150,436 colonoscopies. The pooled overall ADR was 23.1% (95% CI 19.7%-27.0%, I2 = 98.6%). The pooled ADR in individuals with average risk of CRC from 7 studies was 28.2% (95% CI 24.6%-32.0%, I2 = 96.5%). The pooled overall SSL detection rate from 6 studies was 6.3% (95% CI 3.8%-10.5%, I2 = 97%). The included studies were heterogeneous because of differences in the inclusion and exclusion criteria and patient population. DISCUSSION:In 45- to 49-year-old individuals undergoing a colonoscopy for any indication, the ADR and SSL detection rates were 23.1% and 6.3%, respectively. We conclude that these outcomes in 45- to 49-year-olds are comparable with individuals aged 50-54 years.

Variation in colorectal neoplasia detection limits the effectiveness of screening colonoscopy. By evaluating neoplasia detection rates of individual colonoscopists, we aimed to quantify the effects of pre-procedural knowledge of a positive (+) multi-target stool DNA (mt-sDNA) on colonoscopy quality metrics. We retrospectively identified physicians who performed a high volume of + mt-sDNA colonoscopies; colorectal neoplasia at post-mt-sDNA colonoscopy was recorded. These colonoscopists were stratified into quartiles based on baseline adenoma detection rates. Baseline colonoscopy adenoma detection rates and sessile serrated lesion detection rates were compared to post-mt-sDNA colonoscopy neoplasia diagnosis rates among each quartile. Withdrawal times were measured from negative exams. During the study period (2014–17) the highest quartile of physicians by volume of post-mt-sDNA colonoscopies were evaluated. Among thirty-five gastroenterologists, their median screening colonoscopy adenoma detection rate was 32

University of Minnesota, USA; Brown University, USA; University of Missouri Kansas City, USA; Emory University, USA; Saint Louis University, USA; Minneapolis VA Health Care System, USA; New York University, USA.

GOALS:To better understand the characteristics, treatment approaches, and outcomes of patients with esophageal lichen planus (ELP). BACKGROUND:ELP is a rare, often unrecognized and misdiagnosed disorder. Data on this unique patient population are currently limited to small, single-center series. STUDY:A multicenter, retrospective descriptive study was conducted of adults diagnosed with ELP over a 5-year period, between January 1, 2015, and October 10, 2020, from 7 centers across the United States. RESULTS:Seventy-eight patients (average age 65 y, 86% female, 90% Caucasian) were included. Over half had at least 1 extraesophageal manifestation. Esophageal strictures (54%) and abnormal mucosa (50%) were frequent endoscopic findings, with the proximal esophagus the most common site of stricture. Approximately 20% had normal endoscopic findings. Topical steroids (64%) and/or proton pump inhibitors (74%) dominated management; endoscopic response favored steroids (43% vs. 29% respectively). Almost half of the patients required switching treatment modalities during the study period. Adjunctive therapies varied significantly between centers. CONCLUSIONS:Given its at times subtle clinical and endoscopic signs, a high index of suspicion and biopsy will improve ELP diagnosis, especially in those with extraesophageal manifestations. Effective therapies are lacking and vary significantly. Prospective investigations into optimal treatment regimens are necessary.

BACKGROUND AND AIMS:Multitarget stool DNA (mt-sDNA) is approved for average-risk colorectal cancer screening; test performance in persons with prior radiation therapy (RT) has not been studied. RT can induce gastrointestinal bleeding and alter DNA methylation, which may affect mt-sDNA accuracy. Among patients previously treated with RT, we aimed to measure the positive predictive value (PPV) of mt-sDNA and compare these results to historical estimates of mt-sDNA PPV among average-risk patients. METHODS:After institutional review board approval, we conducted a retrospective cohort study of a multisite academic and community-based practice. Patients with RT and subsequent mt-sDNA use during the study period (2014-2016) were identified. The findings at diagnostic colonoscopy were compared with published reports among average-risk patients. Nominal P values were generated by 2-tailed Fisher's exact testing in comparisons of colorectal neoplasia (CRN) rates between groups. RESULTS:There were 220 patients who had RT before mt-sDNA testing. RT was delivered along the aerodigestive tract in 108 patients. Mt-sDNA tests were positive in 45 of 220 patients (20%), and colonoscopy findings were available for 42; 31 of 42 patients (74%) had CRN. PPV by mt-sDNA was similar when stratified by site of prior RT (along vs outside the aerodigestive tract; P = 1.00). Detection of advanced CRN (36%) was nominally higher than previously published retrospective (27%) and prospective (20%) studies. The median time from the start of RT to mt-sDNA use was 7 (interquartile range, 3-14) years. CONCLUSION:With a test positivity rate and PPV for CRN similar to reports among average-risk patients, prior RT does not appear to adversely affect mt-sDNA performance.

Diverticular disorders are frequently encountered in the primary care setting. Diverticular bleeding is the most common cause of lower gastrointestinal bleeding. Low risk patients with uncomplicated diverticulitis can be managed in the outpatient setting, in some cases without the need for antibiotics. In patients with diverticulosis and persistent abdominal pain, chronic smoldering diverticulitis, segmental colitis associated with diverticulosis (SCAD), symptomatic uncomplicated diverticular disease (SUDD), and visceral hypersensitivity should all be considered. To avoid these complications, patients should be encouraged to lead an active lifestyle, consume a healthy diet, and avoid tobacco, alcohol, and certain medications. Contrary to conventional teaching, seeds and nuts do not need to be avoided.

As the average life expectancy rises in the USA, an increasing number of elderly patients are being referred for both screening and diagnostic colonoscopy. In this article, we review recent data and propose an approach to the consideration of polypectomy in elderly patients. Current data highlight the importance of considering age, medical comorbidities, functional status, and pre-operative planning to identify patients most likely to benefit from colonoscopy and polypectomy. Cold snare polypectomy and cold endoscopic mucosal resection, in addition to the use of prophylactic hemostatic clips for large, proximal polyps, reduce post-polypectomy bleeding risk. Post-procedurally, elderly patients should be informed to monitor for specific signs and symptoms of adverse events. The decision to perform polypectomy in elderly patients should be individualized and involve clear, informed shared decision-making. Specific approaches can be taken to decrease risk of adverse events in elderly patients. Additional research is needed to establish clearer guidelines in this population.

Purpose of review Diverticulosis leads to significant morbidity and mortality and is increasing in prevalence worldwide. In this paper, we review the clinical features, diagnosis, and management of diverticular disorders, followed by a discussion of recent updates and changes in the clinical approach to diverticular disease. Recent findings Recent literature suggests that antibiotics are likely not necessary for low-risk patients with acute uncomplicated diverticulitis, and not all patients with recurrent diverticulitis require colectomy. Dietary restrictions do not prevent recurrent diverticulitis. Visceral hypersensitivity is increasingly being recognized as a cause of persistent abdominal pain after acute diverticulitis and should be considered along with chronic smoldering diverticulitis, segmental colitis associated with diverticula, and symptomatic uncomplicated diverticular disease. Summary Clinicians should be aware that traditionally held assumptions regarding the prevention and management of diverticular disorders have recently been called into question and should adjust their clinical practice accordingly.

INTRODUCTION: Significant variability between colonoscopy operators contributes to postcolonoscopy colorectal cancers (CRCs). We aimed to estimate postcolonoscopy colorectal neoplasia (CRN) detection by multi-target stool DNA (mt-sDNA), which has not previously been studied for this purpose. METHODS: In a retrospective cohort of patients with +mt-sDNA and completed follow-up colonoscopy, positive predictive value (PPV) for endpoints of any CRN, advanced adenoma, right-sided neoplasia, sessile serrated polyps (SSP), and CRC were stratified by the time since previous colonoscopy (0–9, 10, and ≥11 years). mt-sDNA PPV at ≤9 years from previous average-risk screening colonoscopy was used to estimate CRN missed at previous screening colonoscopy. RESULTS: Among the 850 studied patients with +mt-sDNA after a previous negative screening colonoscopy, any CRN was found in 535 (PPV 63%). Among 107 average-risk patients having +mt-sDNA ≤9 years after last negative colonoscopy, any CRN was found in 67 (PPV 63%), advanced neoplasia in 16 (PPV 15%), right-sided CRN in 48 (PPV 46%), and SSP in 20 (PPV 19%). These rates were similar to those in 47 additional average risk persons with previous incomplete colonoscopy and in an additional 68 persons at increased CRC risk. One CRC (stage I) was found in an average risk patient who was mt-sDNA positive 6 years after negative screening colonoscopy. DISCUSSION: The high PPV of mt-sDNA 0–9 years after a negative screening colonoscopy suggests that lesions were likely missed on previous examination or may have arisen de novo. mt-sDNA as an interval test after negative screening colonoscopy warrants further study.

After 2 screen-setting studies showing high sensitivity for colorectal cancer and advanced precancerous lesions, multitarget stool DNA testing was endorsed by the US Preventative Services Task Force as a first-line colorectal cancer screening test. Uptake has increased exponentially since approval by the US Food and Drug Administration and Centers for Medicare and Medicaid Services. Adherence to testing is approximately 70%. Patients with positive results have high diagnostic colonoscopy completion rates in single-center studies. The positive predictive value for colorectal neoplasia in postapproval studies is high. Next-generation test prototypes show promise to extend specificity gains while maintaining high sensitivity.

Rituximab, a monoclonal antibody directed against the CD20 antigen on B lymphocytes, is commonly used in the treatment of hematologic malignancies and rheumatologic disorders.1,2 It acts to rapidly deplete the B lymphocyte population through multiple mechanisms, leading to dysregulation of the immune system.3 Rituximab has been associated with numerous adverse gastrointestinal effects including diarrhea and bowel perforation, and recent reports have associated rituximab with the development of de novo inflammatory bowel disease (IBD).4,5 To our knowledge, there have been no reports of microscopic colitis (MC) associated with rituximab therapy. We aimed to identify patients with rituximab-associated colitis, and to better characterize the clinical features and disease course of these patients.

OBJECTIVES: Multitarget stool DNA (MT-sDNA) testing has grown as a noninvasive screening modality for colorectal cancer (CRC), but real-world clinical data are limited in the post-FDA approval setting. The effect of previous colonoscopy on MT-sDNA performance is not known. We aimed to evaluate findings of colorectal neoplasia (CRN) at diagnostic colonoscopy in patients with positive MT-sDNA testing, stratified by patient exposure to previous colonoscopy. METHODS: We identified consecutive patients completing MT-sDNA testing over a 39-month period and reviewed the records of those with positive tests for neoplastic findings at diagnostic colonoscopy. MT-sDNA test positivity rate, adherence to diagnostic colonoscopy, and the positive predictive value (PPV) of MT-sDNA for any CRN and neoplastic subtypes were calculated. RESULTS: Of 16,469 MT-sDNA tests completed, testing returned positive in 2,326 (14.1%) patients. After exclusion of patients at increased risk for CRC, 1,801 patients remained, 1,558 (87%) of whom underwent diagnostic colonoscopy; 918 of 1,558 (59%) of these patients had undergone previous colonoscopy, whereas 640 (41%) had not. Any CRN was found in 1,046 of 1,558 patients (PPV = 67%). More neoplastic lesions were found in patients without previous colonoscopy (73%); however, the rates remained high among those who had undergone previous colonoscopy (63%, P < 0.0001). The large majority (79%) of patients had right-sided neoplasia. DISCUSSION: MT-sDNA has a high PPV for any CRN regardless of exposure to previous colonoscopy. Right-sided CRN was found at colonoscopy in most patients with positive MT-sDNA testing, representing a potential advantage over other currently available screening modalities for CRC.

Purpose of Review Multi-target stool DNA (MT-sDNA) was approved in 2014 for use in screening average-risk patients for colorectal cancer (CRC). Here, we highlight recent literature from post-market studies to provide an update on clinical use and utility not possible from pre-approval studies. Recent Findings MT-sDNA has been included in major society guidelines as an option for colorectal cancer screening, and has seen exponentially increasing use in clinical practice. MT-sDNA appears to be attracting new patients to CRC screening, and patient adherence to diagnostic colonoscopy after a positive MT-sDNA test is high. Approximately two-thirds of these patients are found to have colorectal neoplasia (CRN), 80% of whom have at least one right-sided lesion; 1 in 3 will have advanced CRN. High yield of CRN is due not only to post-screening increase in probability but also likely improved endoscopist attention. In those with a negative high-quality colonoscopy after positive MT-sDNA test (“false positive MT-sDNA”), further interventions do not appear to be necessary. Summary MT-sDNA is a promising tool to improve rates and quality of CRC screening. Further investigation should examine MT-sDNA performance in populations at increased risk for CRC, and as an interval test after colonoscopy to detect potentially missed lesions.

A 30-year-old woman presented to the hospital with a 6-week history of intractable vomiting and postprandial abdominal distention. She experienced frequent episodes of nonbilious, nonbloody emesis containing undigested food, which would occur within 2 to 10 minutes after ingestion of any solid foods, liquids, or medications. The emesis was accompanied by a sensation of retrosternal pressure, without any preceding nausea or retching. She denied any dysphagia or odynophagia but did report a history of chronic constipation managed with over-the-counter laxatives. At the time of evaluation, she endorsed normal bowel movements and passage of flatus. Her medical history was otherwise notable for secondary adrenal insufficiency thought to be related to chronic illness for which she was treated with corticosteroid replacement, anxiety, postural orthostatic tachycardia syndrome (POTS), and endometriosis status post-numerous abdominal surgical interventions without complication by bowel obstruction. A medication reconciliation was performed.1.Which one of the following oral medications, if taken by our patient, would be the most likely to be contributing to her symptoms?a.Polyethylene glycolb.Vitamin Dc.Oral hydrocortisoned.Oxycodonee.Ibuprofen A detailed medication history is crucial in the evaluation of a patient presenting with nausea and vomiting. Our patient’s home medications were limited to over-the-counter laxatives, vitamin D, and oral hydrocortisone for adrenal insufficiency, none of which are classically associated with nausea and vomiting as side effects. Opioid analgesics, such as oxycodone, are common culprits of medication-induced nausea and vomiting, especially early in therapy, although opioids’ emetogenic effect often diminishes over time as tolerance develops.1Coluzzi F. Rocco A. Mandatori I. Mattia C. Non-analgesic effects of opioids: opioid-induced nausea and vomiting: mechanisms and strategies for their limitation.Curr Pharm Des. 2012; 18: 6043-6052Crossref PubMed Scopus (38) Google Scholar Furthermore, it is important to consider other illicit drug use, especially marijuana, in the evaluation of nausea and vomiting. Although many patients use marijuana for its antiemetic properties, prolonged use can paradoxically lead to significant nausea and vomiting that can take weeks to months to resolve after cessation of marijuana use. Our patient denied any illicit drug, alcohol, or tobacco use. Finally, although prolonged ingestion of ibuprofen can lead to ulceration of the gastrointestinal mucosa, severe intractable vomiting is generally not observed in the absence of dyspepsia or hematemesis. Further evaluation of the patient revealed stable vital signs, with blood pressure of 112/79 mm Hg and heart rate of 76 beats per minute, with body mass index of 24 kg/m2. Physical examination of the oropharynx revealed moist mucous membranes, intact gag reflex, and grossly normal swallow mechanics for both liquids and solid foods on bedside evaluation. Bowel sounds were normal, and her abdomen was soft and nontender throughout, without palpable masses and with normal tympany. The results of a complete blood count and basic metabolic panel were normal other than a mild leukocytosis to 11.1 x 109/L (normal 3.4 to 9.6 x 109/L) and hypokalemia to 3.2 mmol/L (normal 3.6 to 5.2 mmol/L). The result of a urine pregnancy test was negative. Her white blood cell count subsequently normalized without intervention.2.Which one of the following electrolyte or metabolic abnormalities discovered on further laboratory evaluation would be most likely to cause nausea and vomiting in this patient?a.Adrenal insufficiencyb.Hyperthyroidismc.Hypocalcemiad.Hypoalbuminemiae.Indirect hyperbilirubinemia It is important to evaluate adrenal function in patients presenting with nausea and vomiting, as more than half of patients with adrenal insufficiency present with nausea and vomiting.2Bancos I. Hahner S. Tomlinson J. Arlt W. Diagnosis and management of adrenal insufficiency.Lancet Diabetes Endocrinol. 2015; 3: 216-226Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar A morning cortisol level drawn at 8 AM is an appropriate screening tool in most patients, with levels below 3 μg/dL suggestive of potential adrenal insufficiency and necessitating further work-up.3Hagg E. Asplund K. Lithner F. Value of basal plasma cortisol assays in the assessment of pituitary-adrenal insufficiency.Clinical Endocrinol (Oxf). 1987; 26: 221-226Crossref PubMed Scopus (195) Google Scholar Although hypothyroidism can cause nausea caused by slowing of the intestinal transit system, hyperthyroidism is associated with increased intestinal motility and more commonly causes diarrhea. Thyroid-stimulating hormone was checked in this patient and was within normal limits at 0.7 mIU/L (0.3 to 4.2 mIU/L). Hypocalcemia classically causes tetany and, in severe cases, seizures but not nausea or vomiting. Furthermore, calcium levels were normal in this patient. Hypoalbuminemia could be an indication of poor nutritional status in a patient with chronic nausea and vomiting but would not directly cause nausea. Finally, an elevated direct bilirubin would be suggestive of biliary obstruction, which could be associated with nausea and abdominal pain. However, one would not expect these symptoms with an elevated indirect bilirubin, and liver chemistries in this patient—including alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, total bilirubin, and albumin—were all within normal limits. This patient had undergone recent cosyntropin stimulation testing prior to her hospitalization, the results of which were within normal limits, suggesting adequate hormonal replacement on her home hydrocortisone regimen. Therefore, further testing was not pursued during her hospitalization. Because of her poor tolerance for oral intake, she was treated with intravenous corticosteroids under the guidance of the endocrinology department, without significant change in her symptoms.3.Which one of the following studies would be the next best step for further work-up in this patient?a.Esophagogastroduodenoscopy (EGD)b.Right upper quadrant (RUQ) ultrasoundc.Hepatobiliary iminodiacetic acid (HIDA) scand.Computed tomography (CT) of the heade.Anorectal manometry After this patient’s unrevealing initial work-up, a functional diagnosis as the cause of her intractable vomiting was suspected. However, before considering this diagnosis, mechanical obstruction and other organic etiologies of nausea must be ruled out via EGD. A RUQ ultrasound (and, rarely, HIDA scan) would be an appropriate evaluation in patients with suspected hepatobiliary or gallbladder pathology, such as those presenting with RUQ pain or elevated liver chemistries, neither of which were present in this patient. CT of the head should be performed in patients who, unlike this patient, have suspected elevated intracranial pressure (ICP) as an etiology of their nausea or vomiting. Finally, anorectal manometry would be a reasonable next step in the evaluation of a patient with nausea, vomiting, and prominent constipation, the latter of which was not a predominant symptom in this case. However, with the observed association between functional swallowing disorders and pelvic-floor dysfunction, this could be considered after upper endoscopy.4Vijayvargiya P. Iturrino J. Camilleri M. et al.Novel association of rectal evacuation disorder and rumination syndrome: diagnosis, co-morbidities and treatment.United European Gastroenterol J. 2014; 2: 38-46Crossref PubMed Scopus (21) Google Scholar An EGD was performed in this patient and showed no evidence of mechanical obstruction, with gastric and duodenal biopsies negative for Helicobacter pylori or other pathology. A small 2-cm hiatal hernia was incidentally noted but was not thought to explain her symptoms. With the negative results of the EGD, a gastric-emptying study was considered but was not attempted, given her lack of early satiety and predisposing comorbidities for gastroparesis, as well as the likelihood that she would not tolerate the study. In light of her typical history and negative work-up, a presumptive diagnosis of rumination syndrome was made.4.Which one of the following tests could be performed next to confirm a diagnosis of rumination syndrome?a.Barium esophagramb.Esophageal manometryc.Gastric accommodation studyd.Esophageal pH monitore.Video swallow study A barium esophagram would not be necessary in this patient, as structural abnormalities had already been ruled out via endoscopy. High-resolution esophageal manometry is the most appropriate modality to confirm a diagnosis of rumination syndrome, and should be ordered using a postprandial protocol in which food is given to aid in detection of rumination events. Characteristic findings of a rumination event on manometry include reflux into the proximal esophagus following food ingestion, associated with increased gastric pressure.5Halland M. Parthasarathy G. Bharucha A.E. Katzka D.A. Diaphragmatic breathing for rumination syndrome: efficacy and mechanisms of action.Neurogastroenterol Motil. 2016; 28: 384-391Crossref PubMed Scopus (52) Google Scholar A gastric accommodation study may be considered in a patient with suspected functional dyspepsia and bloating but is not widely available and would not confirm a diagnosis of rumination syndrome. Esophageal pH monitoring can be useful in the evaluation of refractory gastroesophageal reflux symptoms but would not be confirmatory of rumination syndrome. Finally, a video swallow study would provide useful information regarding initiation and coordination of the swallow mechanism and is typically used in the evaluation of a patient experiencing oropharyngeal dysphagia. In this patient, esophageal manometry showed very high gastric pressurizations upon food bolus reception, which led to reflux events into the esophagus, confirming a diagnosis of rumination syndrome. There was no evidence of achalasia or other esophageal motility disorders to explain her symptoms.5.Which one of the following is the most appropriate treatment modality for this patient with confirmed rumination syndrome?a.Cognitive behavioral therapyb.Low-dose amitriptylinec.Diaphragmatic breathing exercisesd.Fundoplicatione.Buspirone Many functional gastrointestinal disorders are treated with cognitive behavioral therapy or a low-dose antidepressant medication such as amitriptyline. Although these approaches may be used for treatment of comorbid conditions, such as depression or anxiety, diaphragmatic breathing exercises are the treatment of choice for rumination syndrome. This technique, described in more detail in the discussion section of this article, has been shown in multiple studies to both improve subjective symptoms of vomiting as well as documented rumination events on manometry.4Vijayvargiya P. Iturrino J. Camilleri M. et al.Novel association of rectal evacuation disorder and rumination syndrome: diagnosis, co-morbidities and treatment.United European Gastroenterol J. 2014; 2: 38-46Crossref PubMed Scopus (21) Google Scholar, 6Barba E. Accarino A. Soldevilla A. Malagelada J.R. Azpiroz F. Randomized, placebo-controlled trial of biofeedback for the treatment of rumination.Am J Gastroenterol. 2016; 111: 1007-1013Crossref PubMed Scopus (31) Google Scholar, 7Barba E. Burri E. Accarino A. et al.Biofeedback-guided control of abdominothoracic muscular activity reduces regurgitation episodes in patients with rumination.Clin Gastroenterol Hepatol. 2015; 13: 100-106.e1Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar Baclofen, a gamma-aminobutyric acid (GABA) agonist, would be another treatment option in this patient. This medication has been evaluated for the treatment of rumination syndrome in 2 small clinical trials, both of which showed significant improvement in symptoms as compared with baseline.8Blondeau K. Boecxstaens V. Rommel N. et al.Baclofen improves symptoms and reduces postprandial flow events in patients with rumination and supragastric belching.Clin Gastroenterol Hepatol. 2012; 10: 379-384Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 9Pauwels A. Broers C. Van Houtte B. Rommel N. Vanuytsel T. Tack J. A Randomized double-blind, placebo-controlled, cross-over study using baclofen in the treatment of rumination syndrome.Am J Gastroenterol. 2018; 113: 97-104Crossref PubMed Scopus (35) Google Scholar However, because of the limited data available, baclofen is typically reserved for patients who are refractory to initial treatment with diaphragmatic breathing exercises. Fundoplication is a surgical or endoscopic procedure most commonly performed in patients with persistent gastroesophageal reflux despite optimal medical management, although it has rarely been used in refractory cases of severe rumination syndrome. Buspirone can be used to treat patients with gastric accommodation disorders. Although some clinicians may use buspirone in the treatment of rumination syndrome as well, there is no evidence to support its use in this context. This patient began diaphragmatic breathing exercises, with moderate improvement in her symptoms. However, because of persistent regurgitation, she was also initiated on a trial of baclofen 5 mg 3 times daily. This medication was ultimately discontinued owing to poor tolerance of adverse effects, mainly dizziness. At her most recent follow-up appointment, she described significant improvement both in frequency and severity of her symptoms with ongoing use of diaphragmatic breathing exercises. Rumination syndrome is a functional gastrointestinal disorder characterized by effortless regurgitation of ingested material within 5 to 10 minutes after oral intake.10O'Brien M.D. Bruce B.K. Camilleri M. The rumination syndrome: clinical features rather than manometric diagnosis.Gastroenterology. 1995; 108: 1024-1029Abstract Full Text PDF PubMed Scopus (120) Google Scholar The regurgitated content typically contains undigested food with a recognizable taste that patients may spit out or re-swallow. Although patients may describe their symptoms as “vomiting,” there generally is no significant retching preceding the episodes. Some patients may also complain of abdominal symptoms, such as pain or burning, prior to the onset of regurgitation, with relief thereafter. This disorder can affect both children and adults and may be more common in those with comorbid psychiatric, mood, or chronic-pain conditions. Although the underlying pathogenesis remains unclear, the regurgitation of ingested material occurs because of a combination of increased intra-abdominal pressure and negative intrathoracic pressure.11Halland M. Pandolfino J. Barba E. Diagnosis and treatment of rumination syndrome.Clin Gastroenterol Hepatol. 2018; 16: 1549-1555Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar The diagnosis of rumination syndrome should be made clinically, using the Rome IV criteria.11Halland M. Pandolfino J. Barba E. Diagnosis and treatment of rumination syndrome.Clin Gastroenterol Hepatol. 2018; 16: 1549-1555Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar The Rome IV criteria for rumination syndrome require persistent or recurrent regurgitation of recently ingested food into the mouth with subsequent spitting or remastication and swallowing and regurgitation not preceded by retching.12Stanghellini V. Chan F.K. Hasler W.L. et al.Gastroduodenal disorders.Gastroenterology. 2016; 150: 1380-1392Abstract Full Text Full Text PDF PubMed Scopus (755) Google Scholar High-resolution esophageal manometry with postprandial protocol can be used to support the diagnosis, but the lack of its widespread availability and standardized protocols limit its generalizability.11Halland M. Pandolfino J. Barba E. Diagnosis and treatment of rumination syndrome.Clin Gastroenterol Hepatol. 2018; 16: 1549-1555Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar A limited work-up to rule out mechanical obstruction should also be performed, generally with upper endoscopy. The mainstay of treatment for rumination syndrome consists of diaphragmatic breathing exercises.6Barba E. Accarino A. Soldevilla A. Malagelada J.R. Azpiroz F. Randomized, placebo-controlled trial of biofeedback for the treatment of rumination.Am J Gastroenterol. 2016; 111: 1007-1013Crossref PubMed Scopus (31) Google Scholar This technique can be taught by instructing patients to inhale through their nose while protruding the abdomen and keeping the chest stationary, which decreases postprandial intragastric pressure and increases lower esophageal sphincter pressure. By decreasing the pressure gradient between the stomach and the esophagus, rumination events decrease.11Halland M. Pandolfino J. Barba E. Diagnosis and treatment of rumination syndrome.Clin Gastroenterol Hepatol. 2018; 16: 1549-1555Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar In patients with refractory symptoms, baclofen at a dose of 5 to 10 mg 3 times daily can be considered.11Halland M. Pandolfino J. Barba E. Diagnosis and treatment of rumination syndrome.Clin Gastroenterol Hepatol. 2018; 16: 1549-1555Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar In conjunction with these therapeutic interventions, patients should also be educated about their disease process, and reassurance should be offered. In summary, clinicians should consider the possibility of rumination syndrome in patients presenting with consistent immediate postprandial regurgitation and initiate treatment with diaphragmatic breathing exercises when appropriate.

Table 1.Baseline CharacteristicsFigure 1.Kaplan-Meier survival curves for patients of each age groups.(A) Adjusted overall survival and adjusted hazard ratio of each age groups.(B) Overall survival of SD-CRC and non-SD-CRC group of each age groups, and adjusted hazard ratio of SD-CRC group.

Adenomatous polyp detection rates (ADR) are inversely correlated with the incidence of post-colonoscopy colorectal cancers. To measure colonoscopy quality, a minimum ADR of 25% and sessile serrated polyp detection rate (SDR) of 5% have been proposed as quality standards. Colonoscopy appears to have higher ADR after a positive (+) MT-sDNA among providers aware of stool test results versus those blinded in a clinical trial. The interaction between endoscopists’ baseline polyp detection rates and MT-sDNA yield in practice has not been explored.

1Department of Internal Medicine, Northeastern Health System, Tahlequah, OK; 2Department of Rural Health–Gastroenterology, Oklahoma State University College of Osteopathic Medicine Tulsa, OK. Correspondence: William G. Simpson, MD. E-mail: [email protected].