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Neshatian L, Grant G, Fernandez-Becker N, Yuan Y, Garcia P, Becker L, Gurland B, Triadafilopoulos G. The association between vitamin-D deficiency and fecal incontinence. Neurogastroenterol Motil 2024; 36:e14753. [PMID: 38316640 DOI: 10.1111/nmo.14753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 01/08/2024] [Accepted: 01/18/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Vitamin-D is essential for musculoskeletal health. We aimed to determine whether patients with fecal incontinence (FI): (1) are more likely to have vitamin-D deficiency and, (2) have higher rates of comorbid medical conditions. METHODS We examined 18- to 90-year-old subjects who had 25-hydroxy vitamin-D levels, and no vitamin-D supplementation within 3 months of testing, in a large, single-institutional electronic health records dataset, between 2017 and 2022. Cox proportional hazards survival analysis was used to assess association of vitamin-D deficiency on FI. KEY RESULTS Of 100,111 unique individuals tested for serum 25-hydroxy vitamin-D, 1205 (1.2%) had an established diagnosis of FI. Most patients with FI were female (75.9% vs. 68.7%, p = 0.0255), Caucasian (66.3% vs. 52%, p = 0.0001), and older (64.2 vs. 53.8, p < 0.0001). Smoking (6.56% vs. 2.64%, p = 0.0001) and GI comorbidities, including constipation (44.9% vs. 9.17%, p = 0.0001), irritable bowel syndrome (20.91% vs. 3.72%, p = 0.0001), and diarrhea (28.55% vs. 5.2%, p = 0.0001) were more common among FI patients. Charlson Comorbidity Index score was significantly higher in patients with FI (5.5 vs. 2.7, p < 0.0001). Significantly higher proportions of patients with FI had vitamin-D deficiency (7.14% vs. 4.45%, p < 0.0001). Moreover, after propensity-score matching, rate of new FI diagnosis was higher in patients with vitamin-D deficiency; HR 1.9 (95% CI [1.14-3.15]), p = 0.0131. CONCLUSION & INFERENCES Patients with FI had higher rates of vitamin-D deficiency along with increased overall morbidity. Future research is needed to determine whether increased rate of FI in patients with vitamin-D deficiency is related to frailty associated with increased medical morbidities.
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Affiliation(s)
- Leila Neshatian
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Gabrielle Grant
- Clinical Observation and Medical Transcription Program, Stanford University School of Medicine, Stanford, California, USA
| | - Nielsen Fernandez-Becker
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Ye Yuan
- Atropos Health, New York, New York, USA
| | - Patricia Garcia
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Laren Becker
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Brooke Gurland
- Department of Surgery, Stanford University, Stanford, California, USA
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
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Triadafilopoulos G. Endoscopic Non-ablative Radiofrequency Treatment (Stretta) for Gastroesophageal Reflux Disease (GERD). Curr Gastroenterol Rep 2024; 26:93-98. [PMID: 38393432 DOI: 10.1007/s11894-024-00917-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2024] [Indexed: 02/25/2024]
Abstract
PURPOSE OF REVIEW Gastroesophageal reflux disease (GERD) is very common in the general population and poses a large societal socio-economic burden. In this article, we review the evidence supporting non-ablative radiofrequency treatment (Stretta) for the endoscopic management of GERD and we compare it to pharmacologic and other minimally invasive and surgical interventions. RECENT FINDINGS Proton pump inhibitors (PPI) are a key therapy for GERD. For patients without associated significant sliding hiatal hernia, who have inadequate relief of their reflux symptoms, Stretta and other endoscopic therapies, such as transoral fundoplication (TIF), may improve symptoms and GERD-related quality of life. Unfortunately, there are no recent large randomized controlled trials, and most of the evidence is based on meta-analyses and small scale, prospective and retrospective single center efforts. Comparisons of Stretta efficacy to other anti-reflux endoscopic modalities and anti-reflux surgery (ARS) are also presented. There are several endoscopic and minimally invasive modalities to manage PPI-refractory GERD acting through various mechanisms that have been found effective in managing GERD symptoms and quality of life. Among them, Stretta has the longest track record of efficacy and safety. Larger-scale and longer-term comparative efficacy trials in selected populations of patients with acid reflux with and without hiatal hernia will be needed.
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Affiliation(s)
- George Triadafilopoulos
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, 100 Fellowship Drive, Conroe, TX, 77384, USA.
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Ramrakhiani H, Triadafilopoulos G. Banding on the Run: Use of Over-the-Scope Clips (OTSC) for Treatment of Post Banding Ulcer Bleeding (PBUB). Dig Dis Sci 2024; 69:1098-1101. [PMID: 38446310 DOI: 10.1007/s10620-024-08331-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 03/07/2024]
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Triadafilopoulos G, Gardner JD. Relationship of Age and Gender to Motility Test Results and Symptoms in Patients with Chronic Constipation. Dig Dis Sci 2024; 69:1302-1317. [PMID: 38430328 DOI: 10.1007/s10620-024-08314-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 01/23/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND/AIMS Patients with chronic constipation (CC) exhibit symptoms and functional abnormalities upon testing, but their relationship to age and gender is unclear. We assessed age- and gender-related differences in symptoms, colon transit time, and anorectal motility, sensation, and expulsion. PATIENTS AND METHODS Retrospective, post hoc data analysis of patients with CC, who underwent Wireless Motility Capsule (WMC), High-Resolution Anorectal Manometry (HR-ARM), Balloon Expulsion Test (BET) and Rectal Sensory Testing (RST). Clinical assessment was made by questionnaires. Standard WMC criteria for colonic transit time (CTT) and the London classification was used for HR-ARM analyses, and regression plots between age, gender, CTT, HR-HRM, RST and BET were calculated. RESULTS We studied 75 women and 91 men. Abdominal pain, infrequent defecation, incomplete evacuation, defecatory straining, and multiple motility and anorectal function abnormalities were common. Abdominal pain was least frequently, and straining was most frequently associated with a motility abnormality. For each symptom, the highest prevalence was associated with failed BET. There was a significant increase in CTT with age only in men (p = 0.0006). In men, for each year of age there was a CTT increase of 1.02 h. The prevalence of abdominal pain and incomplete evacuation for females was significantly higher than that for males (both P < 0.05). The prevalence of low anal squeeze pressure for females was significantly higher than that for males, and the prevalence of poor rectal sensation for males was significantly higher than that for females (both P < 0.05). A significant decrease in basal anal and squeeze pressures with age occurred in women (p < 0.0001); an increase in age of one year was associated with a decrease in anal base pressure of 1.2 mmHg. Abnormal CTT and HR-ARM tests were associated with increased symptom frequency, but not severity. CONCLUSIONS There are significant age- and gender-related differences in symptoms, CTT, and HR-HRM parameters, rectal sensation, and expulsion, that may influence the multifaceted management of constipation.
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Affiliation(s)
- George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 420 Broadway Street, Pavilion D, 2nd Floor, Redwood City, CA, 94063, USA.
- Silicon Valley Neuro-Gastroenterology and Motility Center, 2490 Hospital Drive, Suite 211, Mountain View, CA, 94040, USA.
| | - Jerry D Gardner
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 420 Broadway Street, Pavilion D, 2nd Floor, Redwood City, CA, 94063, USA
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Neshatian L, Triadafilopoulos G, Wallace S, Jawahar A, Sheth V, Shen S, Gurland B. Increased Grades of Rectal Intussusception: Role of Decline in Pelvic Floor Integrity and Association With Dyssynergic Defecation. Am J Gastroenterol 2024:00000434-990000000-00937. [PMID: 37975595 DOI: 10.14309/ajg.0000000000002605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 11/14/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION The natural history of rectal intussusception (RI) is poorly understood. We hypothesized that decline in pelvic floor integrity and function leads to increasing RI grades. METHODS Retrospective analysis of a registry of patients with defecatory disorders with high-resolution anorectal manometry and magnetic resonance defecography was performed. Association of risk factors on increasing RI grades was assessed using logistic regression. RESULTS Analysis included a total of 238 women: 90 had no RI, 43 Oxford 1-2, 49 Oxford 3, and 56 Oxford 4-5. Age ( P = 0.017), vaginal delivery ( P = 0.008), and prior pelvic surgery ( P = 0.032) were associated with increased Oxford grades. Obstructive defecation symptoms and dyssynergic defecation were observed at relatively high rates across groups. Increased RI grades were associated with less anal relaxation at simulated defecation yet, higher rates of normal balloon expulsion ( P < 0.05), linked to diminished anal sphincter. Indeed, increased RI grades were associated with worsening fecal incontinence severity, attributed to higher rates of anal hypotension. Levator ani laxity, defined by increased levator hiatus length and its excessive descent at straining, was associated with increasing RI grades, independent of age, history of vaginal delivery, and pelvic surgeries and could independently predict increased RI grades. Concurrent anterior and posterior compartments, and visceral prolapse were associated with higher Oxford grades. DISCUSSION Our data suggest that decline in pelvic floor integrity with abnormal levator ani laxity is associated with increased RI grades, a process that is independent of age, history of vaginal deliveries, and/or pelvic surgeries, and perhaps related to dyssynergic defecation.
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Affiliation(s)
- Leila Neshatian
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Shannon Wallace
- Women's Health Institute, Division of Urogynecology and Pelvic Floor Disorders, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Anugayathri Jawahar
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Vipul Sheth
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Sa Shen
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California, USA
| | - Brooke Gurland
- Division of Colorectal Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
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Kamal AN, Wang CHJ, Triadafilopoulos G, Diehl DL, DuCoin C, Dunst CM, Falk G, Iyer PG, Katzka DA, Konda VJA, Muthusamy R, Otaki F, Pleskow D, Rubenstein JH, Shaheen NJ, Sharma P, Smith MS, Sujka J, Swanstrom LL, Tatum RP, Trindade AJ, Ujiki M, Wani S, Clarke JO. A Delphi Method for Development of a Barrett's Esophagus Question Prompt List as a Communication Tool for Optimal Patient-physician Communication. J Clin Gastroenterol 2024; 58:131-135. [PMID: 36753462 DOI: 10.1097/mcg.0000000000001832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 01/02/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND METHODS The question prompt list content was derived through a modified Delphi process consisting of 3 rounds. In round 1, experts provided 5 answers to the prompts "What general questions should patients ask when given a new diagnosis of Barrett's esophagus" and "What questions do I not hear patients asking, but given my expertise, I believe they should be asking?" Questions were reviewed and categorized into themes. In round 2, experts rated questions on a 5-point Likert scale. In round 3, experts rerated questions modified or reduced after the previous rounds. Only questions rated as "essential" or "important" were included in Barrett's esophagus question prompt list (BE-QPL). To improve usability, questions were reduced to minimize redundancy and simplified to use language at an eighth-grade level (Fig. 1). RESULTS Twenty-one esophageal medical and surgical experts participated in both rounds (91% males; median age 52 years). The expert panel comprised of 33% esophagologists, 24% foregut surgeons, and 24% advanced endoscopists, with a median of 15 years in clinical practice. Most (81%), worked in an academic tertiary referral hospital. In this 3-round Delphi technique, 220 questions were proposed in round 1, 122 (55.5%) were accepted into the BE-QPL and reduced down to 76 questions (round 2), and 67 questions (round 3). These 67 questions reached a Flesch Reading Ease of 68.8, interpreted as easily understood by 13 to 15 years olds. CONCLUSIONS With multidisciplinary input, we have developed a physician-derived BE-QPL to optimize patient-physician communication. Future directions will seek patient feedback to distill the questions further to a smaller number and then assess their usability.
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Affiliation(s)
- Afrin N Kamal
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City
| | - Chih-Hung Jason Wang
- Department of Pediatrics and Department of Health Policy, Stanford University School of Medicine, Stanford
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City
| | - David L Diehl
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Geisinger Commonwealth School of Medicine, Danville
| | - Christopher DuCoin
- Department of Surgery, USF Morsani College of Medicine, University of South Florida
| | - Christy M Dunst
- Division of Gastrointestinal and Minimally Invasive Surgery, The Oregon Clinic Center for Advanced Surgery
| | - Gary Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic Minnesota, Rochester, MN
| | | | - Vani J A Konda
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor University Medical Center, Dallas, TX
| | - Raman Muthusamy
- Division of Digestive Diseases, Vatche and Tamar Manoukian David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Fouad Otaki
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, OR
| | - Douglas Pleskow
- Division of Gastroenterology Beth Israel Deaconess Medical Center, Boston, MN
| | - Joel H Rubenstein
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan; Barrett's Esophagus Program, University of Michigan, Ann Arbor, MI
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina, Chapel Hill, NC
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, University of Kansas School of Medicine, Veterans Affairs Medical Center, Kansas City, MS
| | - Michael S Smith
- Division of Gastroenterology and Hepatology, Department of Medicine, Mount Sinai West and Mount Sinai Morningside Hospitals, Icahn School of Medicine at Mount Sinai, New York
| | - Joseph Sujka
- Department of Surgery, Tampa General Hospital, Tampa, FL
| | - Lee L Swanstrom
- Insitute of Image-Guided Surgery, IHU-Strasbourg (Institut Hospitalo-Universitaire), Strasbourg, FR
| | - Roger P Tatum
- Department of Surgery, University of Washington School of Medicine and VA Puget Sound Health Care System, Seattle, WA
| | - Arvind J Trindade
- Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, NY
| | - Michael Ujiki
- Department of Surgery, University of Chicago, Pritzker School of Medicine, Chicago, IL
| | - Sachin Wani
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City
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Triadafilopoulos G, Lee M, Neshatian L. High Prevalence of Anorectal Dysfunction in Ambulatory Patients with Chronic Constipation, Regardless of Colon Transit Time. Dig Dis Sci 2024; 69:180-188. [PMID: 37555883 DOI: 10.1007/s10620-023-08072-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/31/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Classification of chronic constipation (CC) into its three subtypes of slow transit constipation, defecation disorder and normal transit constipation, may improve its multifaceted management. We assessed the merits of the London classification in patients with CC, who were studied by both wireless motility capsule (WMC) and high-resolution anorectal manometry (HR-ARM), examining their relative utilities in decision-making.s PATIENTS AND METHODS: Retrospective, community-based study of prospectively collected data on patients with CC by Rome IV criteria, who underwent WMC and HR-ARM, Balloon Expulsion Test, and Rectal Sensory Testing. Clinical assessment was made by standard questionnaires. On WMC, standard criteria for colonic transit time (CTT) were used (normal CTT < 59 h). The hierarchical London classification was used for HR-ARM analyses. RESULTS Of 1261 patients with CC, 166 (91 M; ages 22-86) received technically satisfactory WMC and HR-ARM, formed the analyzed study cohort, of whom 84 had normal CTT and 82 had prolonged CTT (> 59 h). Patients with slow CTT were significantly older and had longer duration and more severe disease. Using the London classification criteria for disorders of anorectal function, we noted a high prevalence of anorectal dysfunction, regardless of CTT. Except for lower rate of anal hypertonicity in patients with slow CTT, disorders of recto-anal coordination, and rectal sensation were seen at a comparable rate in patients with CC, regardless of CTT. CONCLUSION There is a significant overlap of anorectal disorders in patients with slow CTT. There is questionable specificity and utility of WMC and HR-ARM in assessing patients with CC. More work is needed to demonstrate the value of these studies as surrogate markers of the disease and its response to multifaceted therapy.
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Affiliation(s)
- George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 420 Broadway Street, Pavilion D, 2nd Floor, Redwood City, CA, 94063, USA.
- Silicon Valley Neuro-Gastroenterology and Motility Center, 2490 Hospital Drive, Suite 211, Mountain View, CA, 94040, USA.
| | - Megan Lee
- Silicon Valley Neuro-Gastroenterology and Motility Center, 2490 Hospital Drive, Suite 211, Mountain View, CA, 94040, USA
| | - Leila Neshatian
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 420 Broadway Street, Pavilion D, 2nd Floor, Redwood City, CA, 94063, USA
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Zhou MJ, Ladabaum U, Triadafilopoulos G, Clarke JO. Impact of race/ethnicity and socioeconomic status on incident and prevalent esophageal cancer in patients with Barrett's esophagus. Dis Esophagus 2023; 36:doad044. [PMID: 37431107 DOI: 10.1093/dote/doad044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 06/02/2023] [Indexed: 07/12/2023]
Abstract
The impact of race/ethnicity (RE) or socioeconomic status (SES) on progression from Barrett's esophagus (BE) to esophageal cancer (EC) is not well established. We aimed to evaluate the association between demographic factors and SES on EC diagnosis in an ethnically diverse BE cohort. Patients aged 18-63 with incident BE diagnosed in October 2015-March 2020 were identified in the Optum Clinformatics DataMart Database. Patients were followed until the diagnosis of prevalent EC <1 year or incident EC ≥1 year from BE diagnosis, or until the end of their continuous enrollment period. Cox proportional hazards analysis was used to determine associations between demographics, SES factors, BE risk factors, and EC. Demographics of the 12,693 patients included mean age of BE diagnosis 53.0 (SD 8.5) years, 56.4% male, 78.3% White/10.0% Hispanic/6.4% Black/3.0% Asian. The median follow-up was 26.8 (IQR 19.0-42.0) months. In total, 75 patients (0.59%) were diagnosed with EC (46 [0.36%] prevalent EC; 29 [0.23%] incident EC), and 74 patients (0.58%) developed high-grade dysplasia (HGD) (46 [0.36%] prevalent HGD; 28 [0.22%] incident HGD). Adjusted HR (95% CI) for prevalent EC comparing household net worth ≥$150,000 vs. <$150,000 was 0.57 (0.33-0.98). Adjusted HRs (95% CI) for prevalent and incident EC comparing non-White vs. White patients were 0.93 (0.47-1.85) and 0.97 (0.21-3.47), respectively. In summary, a lower SES, captured by the household net worth, was associated with prevalent EC. There was no significant difference in prevalent or incident EC among White vs. non-White patients. EC progression in BE may be similar among racial/ethnic groups, but SES disparities may impact BE outcomes.
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Affiliation(s)
- Margaret J Zhou
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Jiang Y, Sonu I, Garcia P, Fernandez-Becker NQ, Kamal AN, Zikos TA, Singh S, Neshatian L, Triadafilopoulos G, Goodman SN, Clarke JO. The Impact of Intermittent Fasting on Patients With Suspected Gastroesophageal Reflux Disease. J Clin Gastroenterol 2023; 57:1001-1006. [PMID: 36730832 DOI: 10.1097/mcg.0000000000001788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/27/2022] [Indexed: 02/04/2023]
Abstract
GOAL The aim was to investigate the short-term impact of time restricted feeding on patients with suspected gastroesophageal reflux disease (GERD). BACKGROUND Lifestyle modifications are often suggested, but the role of diet in GERD is unclear. Intermittent fasting is popular in the media and has demonstrated potential benefits with weight loss and inflammatory conditions as well as alterations in gastrointestinal hormones. STUDY Patients who were referred for 96-hour ambulatory wireless pH monitoring off proton pump inhibitor to investigate GERD symptoms were screened for eligibility. Patients were instructed to maintain their baseline diet for the first 2 days of pH monitoring and switch to an intermittent fasting regimen (16 consecutive hour fast and 8 h eating window) for the second 2 days. Objective measures of reflux and GERD symptom severity were collected and analyzed. RESULTS A total of 25 participants were analyzed. 9/25 (36%) fully adhered to the intermittent fasting regimen, with 21/25 (84%) demonstrating at least partial compliance. Mean acid exposure time on fasting days was 3.5% versus 4.3% on nonfasting days. Intermittent fasting was associated with a 0.64 reduction in acid exposure time (95% CI: -2.32, 1.05). There was a reduction in GERD symptom scores of heartburn and regurgitation during periods of intermittent fasting (14.3 vs. 9.9; difference of -4.46, 95% CI: -7.6,-1.32). CONCLUSIONS Initial adherence to time restricted eating may be difficult for patients. There is weak statistical evidence to suggest that intermittent fasting mildly reduces acid exposure. Our data show that short-term intermittent fasting improves symptoms of both regurgitation and heartburn.
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Affiliation(s)
- Yan Jiang
- Division of Gastrointestinal and Liver Diseases, Keck Medicine of University of Southern California, Los Angeles
| | - Irene Sonu
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City
| | - Patricia Garcia
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City
| | | | - Afrin N Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City
| | - Thomas A Zikos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City
| | - Sundeep Singh
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City
| | - Leila Neshatian
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City
| | - Steven N Goodman
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City
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Braghetto I, Triadafilopoulos G, de Paula GA, Hevia M, Lanzarini E, Figueredo E, Durand L, Korn O. If Pills Don't Work, Try Staples: Surgery for Barrett's Esophagus Complicating Progressive Systemic Sclerosis. Dig Dis Sci 2023; 68:3879-3885. [PMID: 37634186 DOI: 10.1007/s10620-023-08064-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/29/2023]
Affiliation(s)
- Italo Braghetto
- Department of Surgery, University of Chile, Santos Dumont 999, Santiago, Chile.
| | | | | | - Macarena Hevia
- Gastroenterology Division, University of Chile, Santiago, Chile
| | - Enrique Lanzarini
- Department of Surgery, University of Chile, Santos Dumont 999, Santiago, Chile
| | | | - Luis Durand
- Department of Surgery, University of Buenos Aires, Buenos Aires, Argentina
| | - Owen Korn
- Department of Surgery, University of Chile, Santos Dumont 999, Santiago, Chile
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Fass OZ, Regalia KA, Sweatt AJ, Nandwani MC, Zikos TA, Fernandez-Becker NQ, Nguyen LA, Sonu IS, Triadafilopoulos G, Clarke JO. The integrated relaxation pressure may not be an appropriate gold standard for deglutitive relaxation due to reliance on a single intragastric reference sensor. Neurogastroenterol Motil 2023; 35:e14635. [PMID: 37357376 PMCID: PMC10906680 DOI: 10.1111/nmo.14635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 06/09/2023] [Accepted: 06/16/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Integrated relaxation pressure (IRP) calculation depends on the selection of a single gastric reference sensor. Variable gastric pressure readings due to sensor selection can lead to diagnostic uncertainty. This study aimed to examine the effect of gastric reference sensor selection on IRP measurement and diagnosis. METHODS We identified high-resolution manometry (HRM) conducted between January and November 2017 with at least six intragastric reference sensors. IRP measurements and Chicago Classification 3.0 (CCv3) diagnoses were obtained for each of six gastric reference sensors. Studies were categorized as "stable" (no change in diagnosis) or "variable" (change in diagnosis with gastric reference selection). Variable diagnoses were further divided into "variable normal/dysmotility" (≥1 normal IRP measurement and ≥1 CCv3 diagnosis), or "variable dysmotility" (≥1 CCv3 diagnosis, only elevated IRP measurements). Bland-Altman plots were used to compare IRP measurements within HRM studies. KEY RESULTS The analysis included 100 HRM studies, among which 18% had variable normal/dysmotility, and 10% had variable dysmotility. The average IRP difference between reference sensors was 6.7 mmHg for variable normal/dysmotility and 5.9 mmHg for variable dysmotility. The average difference between the proximal-most and distal-most sensors was -1.52 mmHg (lower limit of agreement -10.03 mmHg, upper limit of agreement 7.00 mmHg). CONCLUSIONS & INFERENCES IRP values can vary greatly depending on the reference sensor used, leading to inconsistent diagnoses in 28% of HRM studies. Choosing the correct gastric reference sensor is crucial for accurate test results and avoiding misdiagnosis. Standardization of reference sensor selection or supportive testing for uncertain results should be considered.
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Affiliation(s)
- Ofer Z. Fass
- Division of Gastroenterology, Stanford University School of Medicine, Redwood City, California, USA
| | | | - Andrew J. Sweatt
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Monica C. Nandwani
- Division of Gastroenterology, Stanford University School of Medicine, Redwood City, California, USA
| | - Thomas A. Zikos
- West Los Angeles Medical Center, Kaiser Permanente, Los Angeles, California, USA
| | | | - Linda A. Nguyen
- Division of Gastroenterology, Stanford University School of Medicine, Redwood City, California, USA
| | - Irene S. Sonu
- Division of Gastroenterology, Stanford University School of Medicine, Redwood City, California, USA
| | - George Triadafilopoulos
- Division of Gastroenterology, Stanford University School of Medicine, Redwood City, California, USA
| | - John O. Clarke
- Division of Gastroenterology, Stanford University School of Medicine, Redwood City, California, USA
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Triadafilopoulos G, Mashimo H, Tatum R, O'Clarke J, Hawn M. Mixed Esophageal Disease (MED): A New Concept. Dig Dis Sci 2023; 68:3542-3554. [PMID: 37470896 DOI: 10.1007/s10620-023-08008-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 06/15/2023] [Indexed: 07/21/2023]
Abstract
We define mixed esophageal disease (MED) as a disorder of esophageal structure and/or function that produces variable signs or symptoms, simulating-fully or in part other well-defined esophageal conditions, such as gastroesophageal reflux disease, esophageal motility disorders, or even neoplasia. The central premise of the MED concept is that of an overlap syndrome that incorporates selected clinical, endoscopic, imaging, and functional features that alter the patient's quality of life and affect natural history, prognosis, and management. In this article, we highlight MED scenarios frequently encountered in medico-surgical practices worldwide, posing new diagnostic and therapeutic challenges. These, in turn, emphasize the need for better understanding and management, aiming towards improved outcomes and prognosis. Since MED has variable and sometimes time-evolving clinical phenotypes, it deserves proper recognition, definition, and collaborative, multidisciplinary approach, be it pharmacologic, endoscopic, or surgical, to optimize therapeutic outcomes, while minimizing iatrogenic complications. In this regard, it is best to define MED early in the process, preferably by teams of clinicians with expertise in managing esophageal diseases. MED is complex enough that is increasingly becoming the subject of virtual, multi-disciplinary, multi-institutional meetings.
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Affiliation(s)
- George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305, USA.
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway Street 3rd floor, MC6341, Redwood City, CA, 94063, USA.
| | - Hiroshi Mashimo
- Section of Gastroenterology, Harvard Medical School, VA Boston Healthcare - Roxbury, 1400 VFW Pkwy, West Roxbury, MA, 02132, USA
| | - Roger Tatum
- Department of General Surgery, University of Washington, 1660 S. Columbian Way, Seattle, WA, 98108, USA
| | - John O'Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Mary Hawn
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, 94305, USA
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13
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Yeoh A, Kulkarni C, Ryan E, Berry G, Triadafilopoulos G. Severe Diarrhea and Weight Loss Due to Protein-Losing Enteropathy: Don't Pass Up the PAS Stain. Dig Dis Sci 2023; 68:3249-3253. [PMID: 37231192 DOI: 10.1007/s10620-023-07982-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 05/27/2023]
Affiliation(s)
- Aaron Yeoh
- Division of Gastroenterology & Hepatology, Stanford Hospital & Clinics, Stanford, CA, USA.
| | - Chiraag Kulkarni
- Division of Gastroenterology & Hepatology, Stanford Hospital & Clinics, Stanford, CA, USA
| | - Emily Ryan
- Department of Pathology, Stanford Hospital & Clinics, Stanford, CA, USA
| | - Gerald Berry
- Department of Pathology, Stanford Hospital & Clinics, Stanford, CA, USA
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14
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Zhou W, Triadafilopoulos G, Gurland B, Halawi H, Becker L, Garcia P, Nguyen L, Miglis M, Muppidi S, Sinn D, Jaradeh S, Neshatian L. Differential Findings on Anorectal Manometry in Patients with Parkinson's Disease and Defecatory Dysfunction. Mov Disord Clin Pract 2023; 10:1074-1081. [PMID: 37476327 PMCID: PMC10354598 DOI: 10.1002/mdc3.13755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/22/2023] [Accepted: 04/15/2023] [Indexed: 07/22/2023] Open
Abstract
Introduction Gastrointestinal dysfunction, particularly constipation, is among the most common non-motor manifestations in Parkinson's Disease (PD). We aimed to identify high-resolution anorectal manometry (HR-ARM) abnormalities in patients with PD using the London Classification. Methods We conducted a retrospective review of all PD patients at our institution who underwent HR-ARM and balloon expulsion test (BET) for evaluation of constipation between 2015 and 2021. Using age and sex-specific normal values, HR-ARM recordings were re-analyzed and abnormalities were reported using the London Classification. A combination of Wilcoxon rank sum and Fisher's exact test were used. Results 36 patients (19 women) with median age 71 (interquartile range [IQR]: 69-74) years, were included. Using the London Classification, 7 (19%) patients had anal hypotension, 17 (47%) had anal hypocontractility, and 3 women had combined hypotension and hypocontractility. Anal hypocontractility was significantly more common in women compared to men. Abnormal BET and dyssynergia were noted in 22 (61%) patients, while abnormal BET and poor propulsion were only seen in 2 (5%). Men had significantly more paradoxical anal contraction and higher residual anal pressures during simulated defecation, resulting in more negative recto-anal pressure gradients. Rectal hyposensitivity was seen in nearly one third of PD patients and comparable among men and women. Conclusion Our data affirms the high prevalence of anorectal disorders in PD. Using the London Classification, abnormal expulsion and dyssynergia and anal hypocontractility were the most common findings in PD. Whether the high prevalence of anal hypocontractility in females is directly related to PD or other confounding factors will require further research.
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Affiliation(s)
- Wendy Zhou
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - George Triadafilopoulos
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Brooke Gurland
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Houssam Halawi
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Laren Becker
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Patricia Garcia
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Linda Nguyen
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Mitchell Miglis
- Stanford University, Department of Neurology and Autonomic DisordersStanford Neuroscience Health CenterStanfordCAUSA
| | - Srikanth Muppidi
- Stanford University, Department of Neurology and Autonomic DisordersStanford Neuroscience Health CenterStanfordCAUSA
| | - Dong‐In Sinn
- Stanford University, Department of Neurology and Autonomic DisordersStanford Neuroscience Health CenterStanfordCAUSA
| | - Safwan Jaradeh
- Stanford University, Department of Neurology and Autonomic DisordersStanford Neuroscience Health CenterStanfordCAUSA
| | - Leila Neshatian
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
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15
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Folz J, Culver RN, Morales JM, Grembi J, Triadafilopoulos G, Relman DA, Huang KC, Shalon D, Fiehn O. Human metabolome variation along the upper intestinal tract. Nat Metab 2023; 5:777-788. [PMID: 37165176 PMCID: PMC10229427 DOI: 10.1038/s42255-023-00777-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 03/03/2023] [Indexed: 05/12/2023]
Abstract
Most processing of the human diet occurs in the small intestine. Metabolites in the small intestine originate from host secretions, plus the ingested exposome1 and microbial transformations. Here we probe the spatiotemporal variation of upper intestinal luminal contents during routine daily digestion in 15 healthy male and female participants. For this, we use a non-invasive, ingestible sampling device to collect and analyse 274 intestinal samples and 60 corresponding stool homogenates by combining five mass spectrometry assays2,3 and 16S rRNA sequencing. We identify 1,909 metabolites, including sulfonolipids and fatty acid esters of hydroxy fatty acids (FAHFA) lipids. We observe that stool and intestinal metabolomes differ dramatically. Food metabolites display trends in dietary biomarkers, unexpected increases in dicarboxylic acids along the intestinal tract and a positive association between luminal keto acids and fruit intake. Diet-derived and microbially linked metabolites account for the largest inter-individual differences. Notably, two individuals who had taken antibiotics within 6 months before sampling show large variation in levels of bioactive FAHFAs and sulfonolipids and other microbially related metabolites. From inter-individual variation, we identify Blautia species as a candidate to be involved in FAHFA metabolism. In conclusion, non-invasive, in vivo sampling of the human small intestine and ascending colon under physiological conditions reveals links between diet, host and microbial metabolism.
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Affiliation(s)
- Jacob Folz
- West Coast Metabolomics Center, University of California, Davis, CA, USA
| | - Rebecca Neal Culver
- Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Jessica Grembi
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - David A Relman
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
- Infectious Diseases Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Kerwyn Casey Huang
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | | | - Oliver Fiehn
- West Coast Metabolomics Center, University of California, Davis, CA, USA.
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16
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Shalon D, Culver RN, Grembi JA, Folz J, Treit PV, Shi H, Rosenberger FA, Dethlefsen L, Meng X, Yaffe E, Aranda-Díaz A, Geyer PE, Mueller-Reif JB, Spencer S, Patterson AD, Triadafilopoulos G, Holmes SP, Mann M, Fiehn O, Relman DA, Huang KC. Profiling the human intestinal environment under physiological conditions. Nature 2023; 617:581-591. [PMID: 37165188 PMCID: PMC10191855 DOI: 10.1038/s41586-023-05989-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/21/2023] [Indexed: 05/12/2023]
Abstract
The spatiotemporal structure of the human microbiome1,2, proteome3 and metabolome4,5 reflects and determines regional intestinal physiology and may have implications for disease6. Yet, little is known about the distribution of microorganisms, their environment and their biochemical activity in the gut because of reliance on stool samples and limited access to only some regions of the gut using endoscopy in fasting or sedated individuals7. To address these deficiencies, we developed an ingestible device that collects samples from multiple regions of the human intestinal tract during normal digestion. Collection of 240 intestinal samples from 15 healthy individuals using the device and subsequent multi-omics analyses identified significant differences between bacteria, phages, host proteins and metabolites in the intestines versus stool. Certain microbial taxa were differentially enriched and prophage induction was more prevalent in the intestines than in stool. The host proteome and bile acid profiles varied along the intestines and were highly distinct from those of stool. Correlations between gradients in bile acid concentrations and microbial abundance predicted species that altered the bile acid pool through deconjugation. Furthermore, microbially conjugated bile acid concentrations exhibited amino acid-dependent trends that were not apparent in stool. Overall, non-invasive, longitudinal profiling of microorganisms, proteins and bile acids along the intestinal tract under physiological conditions can help elucidate the roles of the gut microbiome and metabolome in human physiology and disease.
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Affiliation(s)
| | - Rebecca Neal Culver
- Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA.
| | - Jessica A Grembi
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jacob Folz
- West Coast Metabolomics Center, University of California, Davis, Davis, CA, USA
| | - Peter V Treit
- Department of Proteomics and Signal Transduction, Max-Planck Institute of Biochemistry, Martinsried, Germany
| | - Handuo Shi
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Florian A Rosenberger
- Department of Proteomics and Signal Transduction, Max-Planck Institute of Biochemistry, Martinsried, Germany
| | - Les Dethlefsen
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Eitan Yaffe
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Philipp E Geyer
- Department of Proteomics and Signal Transduction, Max-Planck Institute of Biochemistry, Martinsried, Germany
| | - Johannes B Mueller-Reif
- Department of Proteomics and Signal Transduction, Max-Planck Institute of Biochemistry, Martinsried, Germany
| | - Sean Spencer
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrew D Patterson
- Department of Veterinary and Biomedical Sciences, Pennsylvania State University, University Park, PA, USA
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
- Silicon Valley Neurogastroenterology and Motility Center, Mountain View, CA, USA
| | - Susan P Holmes
- Department of Statistics, Stanford University, Stanford, CA, USA
| | - Matthias Mann
- Department of Proteomics and Signal Transduction, Max-Planck Institute of Biochemistry, Martinsried, Germany
| | - Oliver Fiehn
- West Coast Metabolomics Center, University of California, Davis, Davis, CA, USA.
- Department of Food Science and Technology, University of California, Davis, Davis, CA, USA.
| | - David A Relman
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA.
- Chan Zuckerberg Biohub, San Francisco, CA, USA.
- Infectious Diseases Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
| | - Kerwyn Casey Huang
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Bioengineering, Stanford University, Stanford, CA, USA.
- Chan Zuckerberg Biohub, San Francisco, CA, USA.
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17
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Triadafilopoulos G, Kamal A, Clarke JO. Value of 96-hour ambulatory esophageal pH monitoring in the assessment of patients with refractory acid reflux symptoms and their response to anti-reflux diet. Dis Esophagus 2022:6960692. [PMID: 36567531 DOI: 10.1093/dote/doac102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 11/01/2022] [Accepted: 11/13/2022] [Indexed: 12/27/2022]
Abstract
Ambulatory esophageal pH monitoring is a diagnostic tool in patients with heartburn and regurgitation. The aim of this study is to evaluate 96-hour esophageal pH monitoring in patients with gastroesophageal reflux disease (GERD), at baseline and under diet that impedes GER. We hypothesized that diet would potentially reduce pathologic acid exposure time (AET). Retrospective series of 88 patients with GERD undergoing wireless 96-hour pH monitoring. Two-day (48 hours) tandem periods, one on liberal, followed by another on restricted diet assessed esophageal AET. Primary end point was >30% reduction in AET while on anti-GER diet. Of the 88 patients, 16 were excluded because of probe migration. Endoscopy and biopsies assessed erosive esophagitis (EE) and Barrett's esophagus (BE), or normal esophagus. Abnormal AET (% pH < 4.0 ≥ 6) further defined nonerosive reflux disease (NERD), whereas normal AET (% pH < 4.0 < 6) with normal endoscopy defined patients as functional heartburn (FH). There were 6 patients with EE (n = 5) and BE (n = 1), 23 with NERD and 43 with FH. Anti-GER diet led to >30% reduction in AET in EE and NERD patients, but not in those with FH. Most patients (n = 43/72; 60%) had FH and could have avoided acid suppression. Furthermore, (14/23; 61%) of patients with NERD completely normalized AET with diet, potentially negating acid suppression. Ninety-six-hour esophageal pH distinguishes GERD patients from those with FH. Fifty percent of EE/BE patients and 61% of those with NERD completely normalize AET with diet. If pathologic AET occurs despite diet, acid suppression is indicated.
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Affiliation(s)
- George Triadafilopoulos
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Afrin Kamal
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - John O Clarke
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
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18
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Zhou W, Triadafilopoulos G, Fernandez-Becker N. Hiding in Planus Sight: Localized Ulcerative Jejunitis in a Patient with Celiac Disease. Dig Dis Sci 2022; 67:5434-5438. [PMID: 36125592 DOI: 10.1007/s10620-022-07693-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/18/2022] [Indexed: 01/05/2023]
Affiliation(s)
- Wendy Zhou
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Nielsen Fernandez-Becker
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
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19
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Triadafilopoulos G, Clarke JO, Kamal A, Neshatian L. Intra-subject Variability in High Resolution Anorectal Manometry Using the London Classification: Diagnostic and Therapeutic Implications. Dig Dis Sci 2022; 67:5014-5018. [PMID: 35194706 DOI: 10.1007/s10620-021-07373-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/20/2021] [Indexed: 01/05/2023]
Abstract
This retrospective pilot study conducted on a community-based cohort of both men and women of various ages and underlying clinical presentations examined the durability and reproducibility of HR-ARM findings influencing their potential impact on clinical decision-making at the point of care (Jameson et al. in Br J Surg 81:1689-1692, 1994). The key finding of our study was that only a minority of patients who underwent repeat anorectal manometry as analyzed by the London Classification had stable manometric findings, raising questions regarding the validity of a single manometric measurement, as currently analyzed, for clinical decision-making.
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Affiliation(s)
| | - John O Clarke
- Stanford University School of Medicine, Stanford, USA
| | - Afrin Kamal
- Stanford University School of Medicine, Stanford, USA
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20
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Ramrakhiani H, Triadafilopoulos G. Erasing Giant Folds: Ménétrier's Disease Treated with Cetuximab. Dig Dis Sci 2022; 67:5006-5009. [PMID: 36125594 DOI: 10.1007/s10620-022-07692-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 01/05/2023]
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21
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22
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Kamal AN, Triadafilopoulos G, Gyawali CP, Nguyen L, Sayuk GS, Azagury DE, Tatum RP, Clarke JO. Model for multi-disciplinary, multi-institutional virtual learning: The Stanford Esophageal Virtual Collaborative Conference on benign esophageal diseases. Neurogastroenterol Motil 2022; 34:e14369. [PMID: 35340088 DOI: 10.1111/nmo.14369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/15/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Afrin N Kamal
- Division of Gastroenterology, Department of Medicine, Stanford University, Stanford, California, USA
| | - George Triadafilopoulos
- Division of Gastroenterology, Department of Medicine, Stanford University, Stanford, California, USA
| | - Chandra Prakash Gyawali
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Linda Nguyen
- Division of Gastroenterology, Department of Medicine, Stanford University, Stanford, California, USA
| | - Gregory S Sayuk
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Dan E Azagury
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Roger P Tatum
- Department of Surgery, University of Washington, and VA Puget Sound Healthcare System, Seattle, Washington, USA
| | - John O Clarke
- Division of Gastroenterology, Department of Medicine, Stanford University, Stanford, California, USA
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Zhou W, Frye J, Soroudi C, Triadafilopoulos G, Berry R. From ICI to ICU: Ipilimumab and Nivolumab-Induced Immune Checkpoint Inhibitor Colitis. Dig Dis Sci 2022; 67:800-803. [PMID: 34159488 DOI: 10.1007/s10620-021-07100-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Wendy Zhou
- Department of Medicine, Santa Clara Valley Medical Center, San Jose, CA, USA.
| | - Joseph Frye
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Camille Soroudi
- Department of Medicine, University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - George Triadafilopoulos
- Department of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Rani Berry
- Department of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
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24
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Li AA, Raghu P, Chen A, Triadafilopoulos G, Park W. Sticky Situation: Bleeding Duodenal Lymphangiectasias Treated with Lymphatic Glue Embolization. Dig Dis Sci 2022; 67:71-74. [PMID: 33638090 DOI: 10.1007/s10620-021-06898-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 12/09/2022]
Affiliation(s)
- Andrew A Li
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Preethi Raghu
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Anne Chen
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Walter Park
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
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25
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Zhou W, Zikos TA, Clarke JO, Nguyen LA, Triadafilopoulos G, Neshatian L. Regional Gastrointestinal Transit and Contractility Patterns Vary in Postural Orthostatic Tachycardia Syndrome (POTS). Dig Dis Sci 2021; 66:4406-4413. [PMID: 33428036 DOI: 10.1007/s10620-020-06808-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 12/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postural orthostatic tachycardia syndrome (POTS) is an autonomic disorder that affects multiple organs, including the gastrointestinal system. These patients often have multiple GI complaints with a severe impact on their quality of life. GI dysmotility patterns in POTS remains poorly understood and difficult to manage. AIMS The aim of this study was to investigate the diagnostic yield of wireless motility capsule in patients with gastrointestinal symptoms and POTS, with use of a symptomatic control group without POTS as a reference. METHODS We retrospectively reviewed the charts of patients who had both autonomic testing and wireless motility capsule between 2016 and 2020. The two groups were divided into those with POTS and those without POTS (controls) as diagnosed through autonomic testing. We compared the regional transit times and motility patterns between the two groups using the data collected from wireless motility capsule. RESULTS A total of 25% of POTS patients had delayed small bowel transit compared to 0% of non-POTS patients (p = 0.047). POTS patients exhibited hypo-contractility patterns within the small bowel, including decreased contractions/min (2.95 vs. 4.22, p = 0.011) and decreased motility index (101.36 vs. 182.11, p = 0.021). In multivariable linear regression analysis, migraine predicted faster small bowel transit (p = 0.007) and presence of POTS predicted slower small bowel transit (p = 0.044). CONCLUSIONS Motility abnormalities among POTS patients seem to affect mostly the small bowel and exhibit a general hypo-contractility pattern. Wireless motility capsule can be a helpful tool in patients with POTS and GI symptoms as it can potentially help guide treatment.
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Affiliation(s)
- Wendy Zhou
- Department of Medicine, Santa Clara Valley Medical Center, San Jose, USA
| | - Thomas A Zikos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St, Pav C 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St, Pav C 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - Linda A Nguyen
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St, Pav C 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St, Pav C 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - Leila Neshatian
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St, Pav C 3rd Floor, GI Suite, Redwood City, CA, 94063, USA.
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Kamal AN, Kathpalia P, Otaki F, Bredenoord AJ, Castell DO, Clarke JO, Falk GW, Fass R, Gyawali CP, Kahrilas PJ, Katz PO, Katzka DA, Pandolfino JE, Penagini R, Richter JE, Roman S, Savarino E, Triadafilopoulos G, Vaezi MF, Vela MF, Leiman DA. Development of quality indicators for the diagnosis and management of achalasia. Neurogastroenterol Motil 2021; 33:e14118. [PMID: 33720448 PMCID: PMC9380030 DOI: 10.1111/nmo.14118] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/21/2021] [Accepted: 02/14/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND The management of achalasia has improved due to diagnostic and therapeutic innovations. However, variability in care delivery remains and no established measures defining quality of care for this population exist. We aimed to use formal methodology to establish quality indicators for achalasia patients. METHODS Quality indicator concepts were identified from the literature, consensus guidelines and clinical experts. Using RAND/University of California, Los Angeles (UCLA) Appropriateness Method, experts in achalasia independently ranked proposed concepts in a two-round modified Delphi process based on 1) importance, 2) scientific acceptability, 3) usability, and 4) feasibility. Highly valid measures required strict agreement (≧ 80% of panelists) in the range of 7-9 for across all four categories. KEY RESULTS There were 17 experts who rated 26 proposed quality indicator topics. In round one, 2 (8%) quality measures were rated valid. In round two, 19 measures were modified based on panel suggestions, and experts rated 10 (53%) of these measures as valid, resulting in a total of 12 quality indicators. Two measures pertained to patient education and five to diagnosis, including discussing treatment options with risk and benefits and using the most recent version of the Chicago Classification to define achalasia phenotypes, respectively. Other indicators pertained to treatment options, such as the use of botulinum toxin for those not considered surgical candidates and management of reflux following achalasia treatment. CONCLUSIONS & INFERENCES Using a robust methodology, achalasia quality indicators were identified, which can form the basis for establishing quality gaps and generating fully specified quality measures.
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Affiliation(s)
- Afrin N. Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Priya Kathpalia
- Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, California, USA
| | - Fouad Otaki
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon, USA
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Donald O. Castell
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - John O. Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Gary W. Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania, USA
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, Department of Medicine, The MetroHealth Medical Center and Case Western Reserve, Cleveland, Ohio, USA
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Peter J Kahrilas
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Philip O. Katz
- Division of Gastroenterology, Weill Cornell School of Medicine, New York, NY, USA
| | - David A. Katzka
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - John E. Pandolfino
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Roberto Penagini
- Department of Pathophysiology and Transplantation, Università degli Studi of Milan, Milan, Italy,Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Joel E. Richter
- Division of Digestive Diseases & Nutrition, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Sabine Roman
- Digestive Physiology, Hospices Civils de Lyon, Hospital E Herriot and Lyon I University, Lyon, France
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Michael F. Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marcelo F. Vela
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - David A. Leiman
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
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Axelrod L, Axelrod S, Navalgund A, Triadafilopoulos G. Pilot Validation of a New Wireless Patch System as an Ambulatory, Noninvasive Tool That Measures Gut Myoelectrical Signals: Physiologic and Disease Correlations. Dig Dis Sci 2021; 66:3505-3515. [PMID: 33063188 DOI: 10.1007/s10620-020-06663-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 10/06/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Limited means exist to assess gastrointestinal activity in a noninvasive, objective way that is highly predictive of underlying motility disorders. The aim of this paper is to demonstrate the feasibility of recording myoelectric gastrointestinal activity by cutaneous patches and to correlate myoelectric signals with gastrointestinal function in various clinical settings. METHODS A novel wireless patch system (WPS) (G-Tech Medical) that acquires gastrointestinal myoelectrical signals was placed on the patients' anterior abdomens. Data were transmitted wirelessly to a mobile device with a user interface and forwarded to a cloud server where processing algorithms identified episodes of motor activity, quantified their parameters, and nominally assigned them to specific gastrointestinal organs based on their frequencies. RESULTS The inherent reproducibility of the WPS measurement technique itself and from the underlying gut activity, coupled with source validation and sensitivity to changes in gut activity in several physiologic and pathologic states, demonstrates its feasibility, safety, and performance in clinical settings. CONCLUSIONS The novel WPS technology, measuring myoelectric intestinal activity noninvasively and continuously over multiple days, is feasible in a wide range of clinical settings, highlighting its promise in the diagnosis and management of motility disorders. Further research is required for more extensive validation and to determine how best to employ this information to optimize patient care.
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Affiliation(s)
- Lindsay Axelrod
- G-Tech Medical, Fogarty Institute for Innovation, 2495 Hospital Drive, Suite 300, Mountain View, CA, 94040, USA
| | - Steve Axelrod
- G-Tech Medical, Fogarty Institute for Innovation, 2495 Hospital Drive, Suite 300, Mountain View, CA, 94040, USA
| | - Anand Navalgund
- G-Tech Medical, Fogarty Institute for Innovation, 2495 Hospital Drive, Suite 300, Mountain View, CA, 94040, USA
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA.
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28
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Ramrakhiani H, Thaker AK, Pisani A, Sangoi A, Triadafilopoulos G. Magnifying Power: New Endoscopic Tools for the Diagnosis of Krukenberg Tumor. Dig Dis Sci 2021; 66:3296-3299. [PMID: 33433803 DOI: 10.1007/s10620-020-06799-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2020] [Indexed: 12/09/2022]
Affiliation(s)
| | | | - Albert Pisani
- Palo Alto Medical Foundation, Mountain View, CA, USA
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29
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Soetikno R, Chiu HM, Asokkumar R, Sanduleanu S, Tanaka S, Rastogi A, Uedo N, Hammad H, Triadafilopoulos G. Use of the ACES (Appearance, Classification, Enhanced endoscopy, and Safe resection) algorithm for the recognition and management of malignant polyps-a letter in response to the Multi-Society Task Force on Colorectal Cancer recommendations. Gastrointest Endosc 2021; 93:1194-1198. [PMID: 33875147 DOI: 10.1016/j.gie.2020.12.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 12/20/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Roy Soetikno
- Academy of Endoscopy, Woodside, California, USA; Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Han Mo Chiu
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taiwan; Health Management Center, National Taiwan University Hospital, Taiwan
| | - Ravishankar Asokkumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | | | - Shinji Tanaka
- Department of Endoscopy and Medicine, Hiroshima University, Hiroshima, Japan
| | - Amit Rastogi
- Department of Gastroenterology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Hazem Hammad
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, California, USA
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30
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Soetikno R, Chiu HM, Asokkumar R, Sanduleanu S, Tanaka S, Rastogi A, Uedo N, Hammad H, Triadafilopoulos G. Letter to the Editor in Response to "Endoscopic Recognition and Management Strategies for Malignant Colorectal Polyps: Recommendations of the US Multi-Society Task Force on Colorectal Cancer". Gastroenterology 2021; 160:2216-2220. [PMID: 33387527 DOI: 10.1053/j.gastro.2020.12.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 12/24/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Roy Soetikno
- Academy of Endoscopy, Woodside, California and, Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Han Mo Chiu
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan and, Department of Internal Medicine and, Health Management Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Ravishankar Asokkumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | | | - Shinji Tanaka
- Department of Endoscopy and Medicine, Hiroshima University, Hiroshima, Japan
| | - Amit Rastogi
- Department of Gastroenterology, University of Kansas Medical Center, Kansas City, Kansas
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Hazem Hammad
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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31
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Wei MT, Triadafilopoulos G, Friedland S. The Mettle to Use the Petals: Using Over-the-Scope Rings to Optimize Endoscopic Submucosal Dissection. Dig Dis Sci 2021; 66:989-993. [PMID: 32909123 DOI: 10.1007/s10620-020-06596-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/28/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Mike T Wei
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, 300 Pasteur Drive, Palo Alto, CA, 94305, USA. .,Veterans Affairs Palo Alto, Palo Alto, CA, USA.
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, 300 Pasteur Drive, Palo Alto, CA, 94305, USA
| | - Shai Friedland
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, 300 Pasteur Drive, Palo Alto, CA, 94305, USA.,Veterans Affairs Palo Alto, Palo Alto, CA, USA
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32
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Weingarden AR, Villescas V, Clarke J, Triadafilopoulos G. Occam's Razor: An Unusual Shoulder Mass in a Patient with Achalasia. Dig Dis Sci 2021; 66:724-727. [PMID: 32833155 DOI: 10.1007/s10620-020-06558-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Alexa R Weingarden
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA, USA.
| | | | - John Clarke
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA, USA
| | - George Triadafilopoulos
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA, USA
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33
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Akiyama J, Sumida J, Nakagawa K, Masamune A, Issariyakulkarn N, Patcharatrakul T, Shetler K, Kuribayashi S, Uraoka T, Triadafilopoulos G. New developments in esophageal function testing and esophageal manifestations of connective tissue disorders. Ann N Y Acad Sci 2020; 1481:170-181. [DOI: 10.1111/nyas.14424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/25/2020] [Accepted: 06/09/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Junichi Akiyama
- Division of Gastroenterology and Hepatology National Center for Global Health and Medicine Tokyo Japan
| | - Junko Sumida
- Division of Gastroenterology and Hepatology National Center for Global Health and Medicine Tokyo Japan
| | - Kenichiro Nakagawa
- Division of Gastroenterology Tohoku University Graduate School of Medicine Sendai Japan
| | - Atsushi Masamune
- Division of Gastroenterology Tohoku University Graduate School of Medicine Sendai Japan
| | - Navapan Issariyakulkarn
- Division of Gastroenterology King Chulalongkorn Memorial Hospital Thai Red Cross Society Bangkok Thailand
| | - Tanisa Patcharatrakul
- Division of Gastroenterology King Chulalongkorn Memorial Hospital Thai Red Cross Society Bangkok Thailand
- Center of Excellence in Neurogastroenterology and Motility, Department of Medicine, Faculty of Medicine Chulalongkorn University Bangkok Thailand
| | - Katerina Shetler
- Department of Gastroenterology Palo Alto Medical Foundation Mountain View California
| | - Shiko Kuribayashi
- Department of Gastroenterology and Hepatology Gunma University Graduate School of Medicine Maebashi Japan
| | - Toshio Uraoka
- Department of Gastroenterology and Hepatology Gunma University Graduate School of Medicine Maebashi Japan
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology Stanford University School of Medicine Stanford California
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Zikos TA, Nguyen L, Kamal A, Fernandez-Becker N, Regalia K, Nandwani M, Sonu I, Garcia M, Okafor P, Neshatian L, Grewal D, Garcia P, Triadafilopoulos G, Clarke JO. Marijuana, Ondansetron, and Promethazine Are Perceived as Most Effective Treatments for Gastrointestinal Nausea. Dig Dis Sci 2020; 65:3280-3286. [PMID: 32185665 DOI: 10.1007/s10620-020-06195-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 03/05/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Many anti-nausea treatments are available for chronic gastrointestinal syndromes, but data on efficacy and comparative effectiveness are sparse. AIMS To conduct a sectional survey study of patients with chronic nausea to assess comparative effectiveness of commonly used anti-nausea treatments. METHODS Outpatients at a single center presenting for gastroenterology evaluation were asked to rate anti-nausea efficacy on a scale of 0 (no efficacy) to 5 (very effective) of 29 commonly used anti-nausea treatments and provide other information about their symptoms. Additional information was collected from the patients' chart. The primary outcome was to determine which treatments were better or worse than average using a t test. The secondary outcome was to assess differential response by individual patient characteristics using multiple linear regression. RESULTS One hundred and fifty-three patients completed the survey. The mean efficacy score of all anti-nausea treatments evaluated was 1.73. After adjustment, three treatments had scores statically higher than the mean, including marijuana (2.75, p < 0.0001), ondansetron (2.64, p < 0.0001), and promethazine (2.46, p < 0.0001). Several treatments, including many neuromodulators, complementary and alternative treatments, erythromycin, and diphenhydramine had scores statistically below average. Patients with more severe nausea responded better to marijuana (p = 0.036) and diphenhydramine (p < 0.001) and less so to metoclopramide (p = 0.020). There was otherwise no significant differential response by age, gender, nausea localization, underlying gastrointestinal cause of nausea, and GCSI. CONCLUSIONS When treating nausea in patients with chronic gastrointestinal syndromes, clinicians may consider trying higher performing treatments first, and forgoing lower performing treatments. Further prospective research is needed, particularly with respect to highly effective treatments.
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Affiliation(s)
- Thomas A Zikos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA.
| | - Linda Nguyen
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - Afrin Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - Nielsen Fernandez-Becker
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - Kirsten Regalia
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - Monica Nandwani
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - Irene Sonu
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - Mildred Garcia
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - Philip Okafor
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - Leila Neshatian
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - Damanpreet Grewal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - Patricia Garcia
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
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35
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Weingarden AR, Smith P, Streett S, Triadafilopoulos G. A Failure to Communicate: Disentangling the Causes of Perianal Fistulæ in Crohn's Disease and Anal Squamous Cell Cancer. Dig Dis Sci 2020; 65:2806-2809. [PMID: 32037474 DOI: 10.1007/s10620-020-06130-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Alexa R Weingarden
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA, USA.
| | - Philip Smith
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - Sarah Streett
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA, USA
| | - George Triadafilopoulos
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA, USA
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36
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Zikos TA, Triadafilopoulos G, Kamal A, Podboy A, Sonu IS, Regalia KA, Nandwani MC, Nguyen LA, Fernandez-Becker NQ, Clarke JO. Baseline impedance via manometry and ambulatory reflux testing are not equivalent when utilized in the evaluation of potential extra-esophageal gastroesophageal reflux disease. J Thorac Dis 2020; 12:5628-5638. [PMID: 33209395 PMCID: PMC7656325 DOI: 10.21037/jtd-20-1623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Esophageal baseline impedance (BI) shows promise for the diagnosis of gastroesophageal reflux disease (GERD), but means of acquisition and relevance to extra-esophageal manifestations of GERD (EE-GERD) remain unclear. In this study we aim to (I) evaluate concordance between BI as measured by 24-hour pH-impedance (pH-MII) and high-resolution impedance manometry (HRIM), and (II) assess relationship to potential EE-GERD symptoms. Methods In this prospective open cohort study, patients presenting for outpatient HRIM and pH-MII studies were prospectively enrolled. All patients completed the GERD-HRQL, NOSE, and respiratory symptom index questionnaire (RSI), plus questions regarding wheezing and dental procedures. HRIM and pH-MII were evaluated with calculation of BI. Correlations were assessed using either Pearson’s correlation or Spearman’s rank coefficients. Results 70 HRIM patients were enrolled, 35 of whom underwent pH-MII. There was no correlation between BI measurements as assessed by HRIM and pH-MII proximally, but there was moderate-weak correlation distally (r=0.34 to 0.5). Distal acid exposure time correlated with distal BI only for measurements by pH-MII (rho= −0.5 to −0.65), and not by HRIM. There was no relationship between proximal acid exposure time and proximal BI. There were no correlations when comparing proximal or distal BI measurements, acid exposure times, and impedance events to symptoms. Conclusions Concordance between BI as measured by HRIM and pH-MII is poor, especially proximally, suggesting that these two methods are not interchangeable. There is no correlation between BI both distally/proximally and symptoms of either GERD/EE-GERD, suggesting that many symptoms are unrelated to acid or that BI is not an adequate marker to assess EE-GERD symptoms.
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Affiliation(s)
- Thomas A Zikos
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - George Triadafilopoulos
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Afrin Kamal
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Alexander Podboy
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Irene S Sonu
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Kirsten A Regalia
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Monica C Nandwani
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Linda A Nguyen
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Nielsen Q Fernandez-Becker
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - John O Clarke
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
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Ramrakhiani H, Simpson N, Strichartz SD, Shetler K, Triadafilopoulos G. Like a "Rolling" Gallstone: Cholecystoduodenal Fistula as Evidence of Gallstone Ileus. Dig Dis Sci 2020; 65:2518-2520. [PMID: 31989397 DOI: 10.1007/s10620-020-06088-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Wei MT, Scapa J, Bingham D, Triadafilopoulos G. Gut Dysthymia: Paraneoplastic Chronic Watery Diarrhea. Dig Dis Sci 2020; 65:2217-2220. [PMID: 31965390 DOI: 10.1007/s10620-020-06058-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Mike Tzuhen Wei
- Department of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Jason Scapa
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - David Bingham
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - George Triadafilopoulos
- Department of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
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Triadafilopoulos G, Korzilius JW, Zikos T, Sonu I, Fernandez-Becker NQ, Nguyen L, Clarke JO. Ninety-Six Hour Wireless Esophageal pH Study in Patients with GERD Shows that Restrictive Diet Reduces Esophageal Acid Exposure. Dig Dis Sci 2020; 65:2331-2344. [PMID: 31734874 DOI: 10.1007/s10620-019-05940-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/05/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Prolonged (96 h) pH monitoring may explore the effect of diet on pH and symptoms in patients with GERD. AIMS To assess the usefulness of a 96 h esophageal pH study in patients with GER symptoms under different diets (pro- and anti-GER). METHODS Prospective study of 66 patients with GERD undergoing wireless 96 h pH monitoring. Two-day periods, one on liberal (pro-reflux) and another on restricted (anti-reflux) diet assessed esophageal acid exposure and symptoms. The primary end point was normalization of acid exposure time while on restricted diet. Secondary end point was a > 50% reduction in symptoms with restricted diet. RESULTS Normal (pH time < 4 of < 6%) was found in 34 patients (51.5%) while on the initial 48 h (liberal) diet [median % time < 4: 3.2 (95% CI, 1.9, 4.0)] and remained normal while on restricted diet [median % time < 4: 2.6 (95% CI, 0.8, 3.4)]. Abnormal acid exposure (% pH time < 4: > 6%) was found in 32 patients (48.5%) while on initial 48 h liberal diet [median % time < 4: 10.5, (95% CI 8.9, 12.6)], and decreased significantly with restricted diet [median % time < 4: 4.5 (95% CI 3.1, 7.3)] (p = 0.001), and normalized with anti-GERD diet in 21 patients (65.6%). Only 11/66 patients were candidates for proton pump inhibitor (PPI) use; 34 had either normal pH studies or normalized them with restricted diet (n = 21). Symptoms did not improve with restricted diet. CONCLUSIONS The 96-h esophageal pH study tests for GERD under pro- and anti-GER diets and allows minimization of PPI therapy to only 16.6% of patients.
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Affiliation(s)
- George Triadafilopoulos
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305, USA. .,Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway Street 3rd Floor, MC6341, Redwood City, CA, 94063, USA.
| | - Julia Wilhelmina Korzilius
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Thomas Zikos
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Irene Sonu
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Nielsen Q Fernandez-Becker
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Linda Nguyen
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - John O Clarke
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305, USA
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Gawron AJ, Bell R, Dayyeh BKA, Buckley FP, Chang K, Dunst CM, Edmundowicz SA, Jobe B, Lipham JC, Lister D, Canto MI, Smith MS, Starpoli AA, Triadafilopoulos G, Watson TJ, Wilson E, Pandolfino JE, Kaizer A, Van De Voorde Z, Yadlapati R. Surgical and endoscopic management options for patients with GERD based on proton pump inhibitor symptom response: recommendations from an expert U.S. panel. Gastrointest Endosc 2020; 92:78-87.e2. [PMID: 32007519 PMCID: PMC7321870 DOI: 10.1016/j.gie.2020.01.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/22/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The objective of this study was to examine expert opinion and agreement on the treatment of distinct GERD profiles from surgical and therapeutic endoscopy perspectives. METHODS We used the RAND/University of California, Los Angeles Appropriateness Method over 6 months (July 2018 to January 2019) to assess the appropriateness of antireflux interventions among foregut surgeons and therapeutic gastroenterologists. Patients with primary atypical or extraesophageal symptoms were not considered. Patient scenarios were grouped according to their symptom response to proton pump inhibitor (PPI) therapy. The primary outcome was appropriateness of an intervention. RESULTS Antireflux surgery with laparoscopic fundoplication (LF) and magnetic sphincter augmentation (MSA) were ranked as appropriate for all complete and partial PPI responder scenarios. Transoral incisionless fundoplication was ranked as appropriate in complete and partial PPI responders without a hiatal hernia. Radiofrequency energy was not ranked as appropriate for complete or partial responders. There was lack of agreement between surgery and interventional gastroenterology groups on the appropriateness of LF and MSA for PPI nonresponders. Rankings for PPI nonresponders were similar when results from impedance-pH testing on PPI therapy were available, except that LF and MSA were not ranked as appropriate for PPI nonresponders if the impedance-pH study was negative. CONCLUSIONS This work highlights areas of agreement for invasive therapeutic approaches for GERD and provides impetus for further interdisciplinary collaboration and trials to compare and generate novel and effective treatment approaches and care pathways, including the role of impedance-pH testing in PPI nonresponders.
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Affiliation(s)
- Andrew J. Gawron
- University of Utah, Salt Lake City UT, Salt Lake City VA Medical
Center
| | - Reginald Bell
- Institute of Esophageal and Reflux Surgery, Denver CO
| | | | | | | | | | | | | | | | - Dan Lister
- Arkansas Heartburn Treatment Center, Heber Springs, AR
| | | | - Michael S. Smith
- Mount Sinai West & Mount Sinai St. Luke’s Hospitals,
New York, NY New York, NY
| | | | | | | | - Erik Wilson
- University of Texas McGovern Medical School, Houston, TX
| | | | | | | | - Rena Yadlapati
- University of Colorado, Aurora, CO; University of California San
Diego, San Diego, CA
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41
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Zikos TA, Hendler S, Clarke JO, Triadafilopoulos G, Nguyen L, Limketkai BN. Reduction in Hospitalizations for Esophageal Reflux in a Decade with Minimal Increases in Other Functional and Motor Disorders. Dig Dis Sci 2020; 65:1661-1668. [PMID: 31620929 DOI: 10.1007/s10620-019-05895-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/03/2019] [Indexed: 12/09/2022]
Abstract
BACKGROUND Functional and motility disorders (FMDs) are common conditions that cause significant morbidity and economic loss. A comprehensive analysis of these disorders and their impact has not been done in an inpatient setting. AIMS We seek to evaluate adult hospitalization trends for FMDs in the USA. METHODS The National Inpatient Sample between 2005 and 2014 was analyzed. Poisson regression was used to assess hospitalization trends for FMDs referenced to non-FMD hospitalizations. Linear regression was used to assess cost per hospitalization and length of stay (LOS). All models were adjusted for age, sex, primary insurance, and Charlson comorbidity index. RESULTS Hospitalizations with FMDs as the primary diagnosis fell by an adjusted 2.46%/year over the study period (p < 0.001). The entirety of this reduction was explained by falling admissions for gastroesophageal reflux (adjusted reduction of 7.04%/year, p < 0.001). The hospitalization rate for all other FMDs (excluding gastroesophageal reflux) minimally increased by 0.75%/year (p = 0.001). Total cost of care for FMD hospitalizations remained relatively stable ($3.17 billion in 2014), while increasing for all other hospitalizations. Mean LOS for FMD hospitalization increased by an adjusted 0.025 days/year, but decreased by 0.038 days/year for all other hospitalizations (p < 0.001). CONCLUSIONS The hospitalization rate for gastroesophageal reflux fell between 2005 and 2014, but remained relatively stable to increase for all other FMDs. These trends may be due to increased proton pump inhibitor use, better patient/provider education, emphasis on outpatient management, and/or coding bias.
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Affiliation(s)
- Thomas A Zikos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA.
| | - Steven Hendler
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - Linda Nguyen
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
| | - Berkeley N Limketkai
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway St., Pavilion C, 3rd Floor, GI Suite, Redwood City, CA, 94063, USA
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Gubatan J, Triadafilopoulos G, Fernandez-Becker NQ. Double Threat: Interplay of Celiac Disease with Inflammatory Bowel Disease. Dig Dis Sci 2020; 65:952-956. [PMID: 31828460 DOI: 10.1007/s10620-019-05994-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- John Gubatan
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA.
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
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Triadafilopoulos G, Kamal A, Zikos T, Nguyen L, Clarke JO. Changes in high-resolution manometric diagnosis over time: implications for clinical decision-making. Dis Esophagus 2020; 33:5697879. [PMID: 31909786 DOI: 10.1093/dote/doz094] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/25/2019] [Accepted: 10/22/2019] [Indexed: 12/11/2022]
Abstract
Although High resolution esophageal manometry (HRM) is the gold standard to assess esophageal motility, little is known about the stability of the manometric diagnosis over time and its implications for management. To assess the stability and usefulness of repeat HRM in patients presenting with esophageal symptoms over time we performed this retrospective study of patients with esophageal symptoms. Medical records, questionnaires, and HRM tracing were independently reviewed using the Chicago classification. The primary objective was to assess the stability of the manometric diagnosis over time; secondary objective was its change (positive or negative). At least one repeat study was performed in 86 patients (36% women, ages 20-86, with mild to moderate symptoms), while 26 had a third procedure. Mean intervals between studies were 15 ± 1.6 months (for baseline v. first study) and 13 ± 0.8 months (for second to third study). Of the 27 patients initially with a normal study, 11 changed (five had esophago-gastric junction outflow obstruction [EGJOO], two diffuse esophageal spasm [DES], one jackhammer esophagus [JE], and three ineffective esophageal motility [IEM] [41% change]). Of the 24 patients with initial EGJOO, only nine retained it (65.2% change). Of nine patients with initial DES, four changed (44.4% change). Similarly, different diagnosis was seen in 7 of 24 initial IEM patients (22.7% change). Only one patient had achalasia initially and this remained stable. Additional changes were noted on a third HRM. Fluidity in the HRM diagnosis over time questions its validity at any timepoint and raises doubts about the need for intervention.
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Affiliation(s)
- George Triadafilopoulos
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Afrin Kamal
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Thomas Zikos
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Linda Nguyen
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - John O Clarke
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA
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44
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Podboy AJ, Hwang JH, Rivas H, Azagury D, Hawn M, Lau J, Kamal A, Friedland S, Triadafilopoulos G, Zikos T, Clarke JO. Long-term outcomes of per-oral endoscopic myotomy compared to laparoscopic Heller myotomy for achalasia: a single-center experience. Surg Endosc 2020; 35:792-801. [DOI: 10.1007/s00464-020-07450-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 02/11/2020] [Indexed: 02/07/2023]
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Abstract
PURPOSE OF REVIEW We summarize the current epidemiology, presentation, diagnostic workup, and treatment of esophagogastric junction outflow obstruction (EGJOO). We also propose a treatment algorithm based upon the literature and our personal clinical experience. RECENT FINDINGS EGJOO can be caused by functional obstruction (akin to achalasia), mechanical obstruction, medications, or artifact. High-resolution esophageal manometry is currently the gold standard of diagnosis. Recent research on FLIP (functional lumen imaging probe) and timed barium support use as adjunctive testing. The diagnostic yield of cross-sectional imaging is low. Current diagnostic testing and treatment should be targeted to the suspected underlying etiology and clinical presentation of EGJOO. If functional obstruction is present with significant and persistent dysphagia, and either an abnormal FLIP or timed barium swallow, we consider therapy aimed at LES disruption (similar to achalasia). Pharmacologic therapy has a limited role. More research is needed on diagnostic and treatment modalities.
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Affiliation(s)
- Thomas A Zikos
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway Street, Pavilion C, 3rd Floor, GI suite, Redwood City, CA, 94063, USA
| | - George Triadafilopoulos
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway Street, Pavilion C, 3rd Floor, GI suite, Redwood City, CA, 94063, USA
| | - John O Clarke
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway Street, Pavilion C, 3rd Floor, GI suite, Redwood City, CA, 94063, USA.
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46
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Gyawali CP, Sifrim D, Carlson DA, Hawn M, Katzka DA, Pandolfino JE, Penagini R, Roman S, Savarino E, Tatum R, Vaezi M, Clarke JO, Triadafilopoulos G. Ineffective esophageal motility: Concepts, future directions, and conclusions from the Stanford 2018 symposium. Neurogastroenterol Motil 2019; 31:e13584. [PMID: 30974032 PMCID: PMC9380027 DOI: 10.1111/nmo.13584] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/11/2019] [Accepted: 03/05/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ineffective esophageal motility (IEM) is a heterogenous minor motility disorder diagnosed when ≥50% ineffective peristaltic sequences (distal contractile integral <450 mm Hg cm s) coexist with normal lower esophageal sphincter relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high-resolution manometry (HRM). Ineffective esophageal motility is not consistently related to disease states or symptoms and may be seen in asymptomatic healthy individuals. PURPOSE A 1-day symposium of esophageal experts reviewed existing literature on IEM, and this review represents the conclusions from the symposium. Severe IEM (>70% ineffective sequences) is associated with higher esophageal reflux burden, particularly while supine, but milder variants do not progress over time or consistently impact quality of life. Ineffective esophageal motility can be further characterized using provocative maneuvers during HRM, especially multiple rapid swallows, where augmentation of smooth muscle contraction defines contraction reserve. The presence of contraction reserve may predict better prognosis, lesser reflux burden and confidence in a standard fundoplication for surgical management of reflux. Other provocative maneuvers (solid swallows, standardized test meal, rapid drink challenge) are useful to characterize bolus transit in IEM. No effective pharmacotherapy exists, and current managements target symptoms and concurrent reflux. Novel testing modalities (baseline and mucosal impedance, functional lumen imaging probe) show promise in elucidating pathophysiology and stratifying IEM phenotypes. Specific prokinetic agents targeting esophageal smooth muscle need to be developed for precision management.
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Affiliation(s)
- C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry Queen Mary, University of London, London, UK
| | - Dustin A. Carlson
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Mary Hawn
- Department of Surgery, Stanford University, Stanford, California
| | - David A. Katzka
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - John E. Pandolfino
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Roberto Penagini
- Università degli Studi di Milano, Milan, Italy,Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sabine Roman
- Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France,Digestive Physiology, Lyon I University, Université de Lyon, Lyon, France,Université de Lyon, Inserm U1032, LabTAU, Université de Lyon, Lyon, France
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Roger Tatum
- Department of Surgery, University of Washington, Seattle, Washington
| | - Michel Vaezi
- Division of Gastroenterology, Vanderbilt University, Nashville, Tennessee
| | - John O. Clarke
- Division of Gastroenterology, Stanford University, Stanford, California
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47
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Podboy A, Hwang JH, Nguyen LA, Garcia P, Zikos TA, Kamal A, Triadafilopoulos G, Clarke JO. Gastric per-oral endoscopic myotomy: Current status and future directions. World J Gastroenterol 2019; 25:2581-2590. [PMID: 31210711 PMCID: PMC6558440 DOI: 10.3748/wjg.v25.i21.2581] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/25/2019] [Accepted: 04/29/2019] [Indexed: 02/06/2023] Open
Abstract
Gastroparesis, or symptomatic delayed gastric emptying in the absence of mechanical obstruction, is a challenging and increasingly identified syndrome. Medical options are limited and the only medication approved by the Food and Drug Administration for treatment of gastroparesis is metoclopramide, although other agents are frequently used off label. With this caveat, first-line treatments for gastroparesis include dietary modifications, antiemetics and promotility agents, although these therapies are limited by suboptimal efficacy and significant medication side effects. Treatment of patients that fail first-line treatments represents a significant therapeutic challenge. Recent advances in endoscopic techniques have led to the development of a promising novel endoscopic therapy for gastroparesis via endoscopic pyloromyotomy, also referred to as gastric per-oral endoscopic myotomy or per-oral endoscopic pyloromyotomy. The aim of this article is to review the technical aspects of the per-oral endoscopic myotomy procedure for the treatment of gastroparesis, provide an overview of the currently published literature, and outline potential next directions for the field.
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Affiliation(s)
- Alexander Podboy
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - Linda A Nguyen
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - Patricia Garcia
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - Thomas A Zikos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - Afrin Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
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48
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Jensen CW, Worhunsky DJ, Triadafilopoulos G, Bingham DB, Visser BC. Ruptured Oncocytic Intraductal Papillary Neoplasm: Think Beyond the Pancreas. Dig Dis Sci 2019; 64:1436-1438. [PMID: 30607688 DOI: 10.1007/s10620-018-5444-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
MESH Headings
- Aged
- Bile Duct Neoplasms/diagnostic imaging
- Bile Duct Neoplasms/pathology
- Bile Duct Neoplasms/surgery
- Bile Ducts, Intrahepatic/diagnostic imaging
- Bile Ducts, Intrahepatic/pathology
- Bile Ducts, Intrahepatic/surgery
- Female
- Hepatectomy
- Humans
- Liver Neoplasms/diagnostic imaging
- Liver Neoplasms/pathology
- Liver Neoplasms/surgery
- Neoplasms, Cystic, Mucinous, and Serous/diagnostic imaging
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neoplasms, Cystic, Mucinous, and Serous/surgery
- Precancerous Conditions/diagnostic imaging
- Precancerous Conditions/pathology
- Precancerous Conditions/surgery
- Rupture, Spontaneous
- Treatment Outcome
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Affiliation(s)
| | - David J Worhunsky
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - George Triadafilopoulos
- Department of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - David B Bingham
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Brendan C Visser
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
- Stanford Cancer Center, Stanford University Medical Center, 875 Blake Wilbur Drive, MC 5826, Stanford, CA, 94305, USA.
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49
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Zikos TA, Kamal AN, Neshatian L, Triadafilopoulos G, Clarke JO, Nandwani M, Nguyen LA. High Prevalence of Slow Transit Constipation in Patients With Gastroparesis. J Neurogastroenterol Motil 2019; 25:267-275. [PMID: 30870880 PMCID: PMC6474696 DOI: 10.5056/jnm18206] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 01/09/2019] [Accepted: 01/21/2019] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Current evidence suggests the presence of motility or functional abnormalities in one area of the gastrointestinal tract increases the likelihood of abnormalities in others. However, the relationship of gastroparesis to chronic constipation (slow transit constipation and dyssynergic defecation) has been incompletely evaluated. Methods We retrospectively reviewed the records of all patients with chronic dyspeptic symptoms and constipation who underwent both a solid gastric emptying scintigraphy and a high-resolution anorectal manometry at our institution since January 2012. When available, X-ray defecography and radiopaque marker colonic transit studies were also reviewed. Based on the gastric emptying results, patients were classified as gastroparesis or dyspepsia with normal gastric emptying (control group). Differences in anorectal and colonic findings were then compared between groups. Results Two hundred and six patients met the inclusion criteria. Patients with gastroparesis had higher prevalence of slow transit constipation by radiopaque marker study compared to those with normal emptying (64.7% vs 28.1%, P = 0.013). Additionally, patients with gastroparesis had higher rates of rectocele (88.9% vs 60.0%, P = 0.008) and intussusception (44.4% vs 12.0%, P = 0.001) compared to patients with normal emptying. There was no difference in the rate of dyssynergic defecation between those with gastroparesis vs normal emptying (41.1% vs 42.1%, P = 0.880), and no differences in anorectal manometry findings. Conclusions Patients with gastroparesis had a higher rate of slow transit constipation, but equal rates of dyssynergic defecation compared to patients with normal gastric emptying. These findings argue for investigation of possible delayed colonic transit in patients with gastroparesis and vice versa.
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Affiliation(s)
- Thomas A Zikos
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City, CA, USA
| | - Afrin N Kamal
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City, CA, USA
| | - Leila Neshatian
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City, CA, USA
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City, CA, USA
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City, CA, USA
| | - Monica Nandwani
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City, CA, USA
| | - Linda A Nguyen
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Redwood City, CA, USA
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Ramrakhiani NS, Triadafilopoulos G. The Turn of the Screw: A Tale of Dysphagia. Dig Dis Sci 2019; 64:678-680. [PMID: 30155837 DOI: 10.1007/s10620-018-5266-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Nathan S Ramrakhiani
- Department of Gastroenterology, Palo Alto Medical Foundation, Mountain View, CA, USA.
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