Social determinants of health influencing the adherence to post-endoscopic mucosal resection surveillance

BACKGROUND AND AIMS

Colorectal cancer (CRC) is a global health challenge, particularly in Alabama, where the incidence rates exceed national averages. This study investigated the factors influencing adherence to post-endoscopic mucosal resection (EMR) colonoscopies, focusing on travel distance and socioeconomic status. This study aimed to provide evidence-based insights to improve patient care in CRC management.

METHODS

This retrospective study in a tertiary care referral center analyzed 465 patients who underwent EMR. The data included demographics, clinical details, and travel-related variables. Descriptive statistics, logistic regression, and spatial analysis were used to assess the factors affecting adherence.

RESULTS

Of 465 patients, 36.6 % had adequate follow-up, 21.8 % had inadequate follow-up, and 41.6 % were lost to follow-up. Noteworthy demographic variations were observed, with median ages differing across adherence groups. Traveled distances showcased compelling insights, indicating a median distance of 22.2 miles for adequate follow-up, 15.7 miles for inadequate follow-up, and 31.6 miles for the lost-to-follow-up group (p<0.001). Longer travel distances were associated with better adherence. Longer travel distances from the hospital were associated with significantly lower odds of inadequate follow-up: 10-25 miles OR:0.29, 25-85 miles OR:0.35, and >80 miles OR:0.24 compared to the first quartile (<10 miles). Socioeconomic factors, particularly educational attainment, significantly influenced the follow-up rates.

CONCLUSIONS

This study revealed suboptimal post-EMR follow-up rates and underscored the impact of travel distance and socioeconomic factors. Targeted interventions addressing distance-related barriers can enhance treatment adherence and ensure timely CRC surveillance after EMR. Further research is needed in diverse healthcare settings.

Targeting of oncogenic AAA-ATPase TRIP13 reduces progression of pancreatic ductal adenocarcinoma

Thyroid hormone receptor-interacting protein 13 (TRIP13) is involved in cancer progression, but its role in pancreatic ductal adenocarcinoma (PDAC) is unknown. Thus, we assessed the expression, functional role, and mechanism of action of TRIP13 in PDAC. We further examined the efficacy of TRIP13 inhibitor, DCZ0415, alone or in combination with gemcitabine on malignant phenotypes, tumor progression, and immune response. We found that TRIP13 was overexpressed in human PDACs relative to corresponding normal pancreatic tissues. TRIP13 knockdown or treatment of PDAC cells with DCZ0415 reduced proliferation and colony formation, and induced G2/M cell cycle arrest and apoptosis. Additionally, TRIP13 knockdown or targeting with DCZ0415 reduced the migration and invasion of PDAC cells by increasing E-cadherin and decreasing N-cadherin and vimentin. Pharmacologic targeting or silencing of TRIP13 also resulted in reduce expression of FGFR4 and STAT3 phosphorylation, and downregulation of the Wnt/β-catenin pathway. In immunocompromised mouse models of PDAC, knockdown of TRIP13 or treatment with DCZ0415 reduced tumor growth and metastasis. In an immunocompetent syngeneic PDAC model, DCZ0415 treatment enhanced the immune response by lowering expression of PD1/PDL1, increasing granzyme B/perforin expression, and facilitating infiltration of CD3/CD4 T-cells. Further, DCZ0415 potentiated the anti-metastatic and anti-tumorigenic activities of gemcitabine by reducing proliferation and angiogenesis and by inducing apoptosis and the immune response. These preclinical findings show that TRIP13 is involved in PDAC progression and targeting of TRIP13 augments the anticancer effect of gemcitabine.

Safety and efficacy of direct percutaneous endoscopic jejunostomy tube placement compared with surgical jejunostomy: a tertiary care analysis

BACKGROUND AND AIMS

Jejunostomy tube placements provides enteral access for feeding in eligible patients who cannot meet their nutritional needs by mouth. They can be surgically placed laparoscopically (lap-J) or with the use of a conventional open laparotomy approach (open-J). Recently, direct percutaneous endoscopic jejunostomy (DPEJ) has emerged as an alternative owing to its low cost and shorter recovery times. We sought to retrospectively compare the procedural success rates and adverse events of these methods.

METHODS

Patients were identified by querying our health system patient database and the departmental database of patients who underwent DPEJ. The patients were divided into 3 cohorts based on the procedure: DPEJ, lap-J, or open-J. Patient age and body mass index, procedural success rate, and adverse event rate were compared among the 3 groups.

RESULTS

A total of 201 patients met inclusion criteria (65 DPEJ, 111 lap-J, and 25 open-J). Procedural success rates were similar among the 3 groups (DPEJ 96.9%, lap-J 99.1%, open-J 100%; P = .702). Rates of infection and bleeding were also similar among the 3 groups. There were no cases of GI perforation. Tube dysfunction for any reason that required complete removal or replacement within 90 days occurred more often in the surgical groups than in the DPEJ group (DPEJ 0%, lap-J 35.1%, open-J 40.0%; P < .001). This was driven largely by increased rates of tube clogging and tube dislodgement in the surgical groups.

CONCLUSIONS

DPEJ is a safe and effective alternative to surgical jejunostomy in eligible patients and may be associated with decreased adverse event rates at 90 days.

Feasibility and Utility of Routine Point-of-Care Gastric Ultrasonography in Patients Undergoing Upper Gastrointestinal Endoscopy Procedures: A Prospective Cohort Study

OBJECTIVES

Previous studies have indicated that point-of-care ultrasonography (POCUS) of the gastric antrum can predict the adequacy of fasting before surgery and anesthesia. The aim of this study was to evaluate the utility of gastric POCUS in patients undergoing upper gastrointestinal (GI) endoscopy procedures.

METHODS

We performed a single-center cohort study in patients undergoing upper GI endoscopy. Consenting patient's gastric antrum was scanned before anesthetic care for endoscopy to determine the cross-sectional area (CSA) and qualitatively determine safe and unsafe contents. Further, an estimate of residual gastric volume was determined using the formula and the nomogram methods. Subsequently, gastric secretions aspirated during endoscopy were quantified and further correlated with nomogram and formula-based assessments. No patient required a change in the primary anesthetic plan except for using rapid sequence induction in those with unsafe contents on POCUS scans.

RESULTS

Qualitative ultrasound measurements consistently determined safe and unsafe gastric residual contents in 83 patients enrolled in the study. Unsafe contents were determined by qualitative scans in 4 out of 83 cases (5%) despite adequate fasting status. Quantitatively, only a moderate correlation was demonstrated between measured gastric volumes and nomogram (r = .40, 95% CI: 0.20, 0.57; P = .0002) or formula-based (r = .38, 95% CI: 0.17, 0.55; P = .0004) determinations of residual gastric volumes.

CONCLUSION

In daily clinical practice, qualitative POCUS determination of residual gastric content is a feasible and useful technique to identify patients at risk of aspiration before upper GI endoscopy procedures.

Gastrointestinal bleeding and pro-angiogenic shift in the angiopoietin axis with continuous flow left ventricular assist device implantation

BACKGROUND

Gastrointestinal bleeding (GIB) affects up to 40% of continuous-flow left ventricular assist device (CF-LVAD) recipients. A higher risk of GIB is seen in CF-LVAD recipients with lower device pulsatility without a known mechanism. One hypothesis is that the novel hemodynamics in CF-LVAD recipients affect angiogenesis signaling. We aimed to (1) measure serum levels of angiopoietin (Ang)-1, Ang-2, and VEGF-A in CF-LVAD recipients with and without GIB and in healthy controls and (2) evaluate correlations of those levels with hemodynamics.

METHODS

We recruited 12 patients with CF-LVADs (six who developed GIB after device implantation) along with 12 age-matched controls without heart failure or GIB and measured Ang-1, Ang-2, and VEGF-A levels in serum samples from each patient.

RESULTS

CF-LVAD recipients had significantly higher Ang-2 and lower Ang-1 levels compared to controls with no difference in VEGF-A levels. CF-LVAD recipients with GIB had lower Ang-1 levels than those without GIB. There were trends for pulse pressure to be positively correlated with Ang-1 levels and negatively correlated with Ang-2 levels in CF-LVAD recipients with no correlation observed in healthy controls.

CONCLUSION

CF-LVAD recipients demonstrated a shift toward a pro-angiogenic phenotype in the angiopoietin axis that is significantly associated with GIB and may be linked to low pulse pressure.

Clinical approach to indeterminate biliary strictures: Clinical presentation, diagnosis, and workup

Despite advances in cross-sectional imaging and endoscopic technology, bile duct strictures remain a challenging clinical entity. It is crucial to make an early determination of benign or malignant nature of biliary strictures. Early diagnosis not only helps with further management but also minimizes mortality and morbidity associated with delayed diagnosis. Conventional imaging and endoscopic techniques, particularly endoscopic retrograde cholangiopancreatography (ERCP) and tissue sampling techniques play a key in establishing a diagnosis. Indeterminate biliary strictures (IDBSs) have no definite mass on imaging or absolute histopathological diagnosis and often warrant utilization of multiple diagnostics to ascertain an etiology. In this review, we discuss possible etiologies, clinical presentation, diagnosis, and management of IDBSs. Based on available data and expert opinion, we depict an evidence based diagnostic algorithm for management of IDBSs. Areas of focus include use of traditional tissue sampling techniques such as ERCP with brush cytology, intraductal biopsies, fluorescence in situ hybridization and flow cytometry. We also describe the role of endoscopic ultrasound (EUS)-guided fine needle aspiration and biopsies, cholangioscopy, confocal laser endomicroscopy, and intraductal EUS in management of IDBSs.

BZW2 Inhibition Reduces Colorectal Cancer Growth and Metastasis

Because survival of patients with metastatic colorectal cancer remain poor, there is an urgent need to identify potential novel druggable targets that are associated with colorectal cancer progression. One such target, basic leucine zipper and W2 domains 2 (BZW2), is involved in regulation of protein translation, and its overexpression is associated with human malignancy. Thus, we investigated the expression and regulation of BZW2, assessed its role in activation of WNT/β-catenin signaling, identified its downstream molecules, and demonstrated its involvement in metastasis of colorectal cancer. In human colorectal cancers, high mRNA and protein expression levels of BZW2 were associated with tumor progression. BZW2-knockdown reduced malignant phenotypes, including cell proliferation, invasion, and spheroid and colony formation. BZW2-knockdown also reduced tumor growth and metastasis; conversely, transfection of BZW2 into BZW2 low-expressing colorectal cancer cells promoted malignant features, including tumor growth and metastasis. BZW2 expression was coordinately regulated by microRNA-98, c-Myc, and histone methyltransferase enhancer of zeste homolog 2 (EZH2). RNA sequencing analyses of colorectal cancer cells modulated for BZW2 identified P4HA1 and the long noncoding RNAs, MALAT1 and NEAT1, as its downstream targets. Further, BZW2 activated the Wnt/β-catenin signaling pathway in colorectal cancers expressing wild-type β-catenin. In sum, our study suggests the possibility of targeting BZW2 expression by inhibiting EZH2 and/or c-Myc.

IMPLICATIONS

FDA-approved small-molecule inhibitors of EZH2 can indirectly target BZW2 and because BZW2 functions as an oncogene, these inhibitors could serve as therapeutic agents for colorectal cancer.

Early intervention with double balloon enteroscopy for higher yield for inpatient overt obscure gastrointestinal bleeding: A propensity matched analysis

Background and Aim

Overt obscure gastrointestinal bleeding (OOGIB) is defined as continued bleeding with unknown source despite esophagogastroduodenoscopy (EGD) and colonoscopy evaluation. Small bowel evaluation through video capsule endoscopy (VCE) or double balloon enteroscopy (DBE) is often warranted. We studied the timing of DBE in hospitalized OOGIB patients regarding diagnostic yield, therapeutic yield, and GI rebleeding.

Methods

We performed a retrospective review of DBEs performed at a tertiary medical center between November 2012 and December 2020. The inclusion criterion was first admission for OOGIB undergoing DBE. Those without previous EGD or colonoscopy were excluded. Patients were stratified into two groups: DBE performed within 72 h of OOGIB (emergent) and beyond 72 h of OOGIB (nonemergent). Propensity score matching was used to adjust for the difference in patients in the two groups. Logistic regression analysis was used to assess factors associated with diagnostic and therapeutic yield. Kaplan-Meir survival curve showed GI bleed-free survival following initial bleed and was compared using the log rank test.

Results

A total of 154 patients met the inclusion criterion, of which 62 had emergent DBE and 92 had nonemergent DBE. The propensity-score-matched sample consisted of 112 patients, with 56 patients each in the emergent and nonemergent groups. Univariate and multivariable logistic regression analysis showed a significant association between VCE and emergent DBE and diagnostic and therapeutic yield (P < 0.05). Emergent DBE patients had increased GI bleed-free survival compared to those in the nonemergent group (P = 0.009).

Conclusion

Our data demonstrate that emergent DBE during inpatient OOGIB can impact the overall diagnostic yield, therapeutic yield, and GI rebleeding post DBE.

Gastrointestinal Bleeding in Patients Supported with Left Ventricular Assist Devices: The Journey from Bridging to Destination

End-stage heart failure is a prevalent and fatal cardiovascular disease. Almost 1 in 4 cases of mortality in the United States is attributed to heart failure. Left ventricular assist devices (LVADs) have emerged as a safe destination therapy or bridge to transplant. Despite remarkable results, LVAD is associated with significant adverse events, such as gastrointestinal bleeding (GIB). In this review, we aimed to understand the incidence and prevalence, pathophysiologic mechanisms, predictors, diagnostic mechanisms, management, and preventative measures of GIB in patients with an LVAD. GIB is a common adverse event in patients with an LVAD with an incidence of 15% to 25%. The exact pathogenesis of GIB is poorly understood. However, different mechanisms of bleeding have been described, such as arteriovenous malformations, acquired von Willebrand syndrome, coagulopathy, and treatment with antithrombotic therapy. Upper GIB is the most common site of GIB in patients with an LVAD. The management of GIB in patients with LVAD includes ensuring hemodynamic stability, holding or reversing antithrombotic therapy, and investigating and controlling the source of GIB through diagnostic and interventional endoscopic and radiologic means. Prophylactic medication use (e.g., danazol, octreotide, and bevacizumab) can decrease the risk of GIB in patients with an LVAD by decreasing arteriovenous malformations. Despite that the overall risk of GIB has decreased with new advancements in LVAD technology, further studies are needed regarding predictors, risk stratification, and optimal antithrombotic therapy to minimize the morbidity and mortality in patients with an LVAD. In conclusion, prompt diagnosis and management in a multidisciplinary team approach are crucial and lifesaving in such a life-threatening condition.

Duodenal stenting as a palliative approach to a malignant duodenocolonic fistula

Video 1Duodenocolonic stenting video.

Direct percutaneous endoscopic jejunostomy tube placement in patients post Roux-en-Y gastric bypass, a single tertiary care center experience

Background and study aims Obesity prevalence continues to rise in the United States with Roux-en-Y gastric bypass (RYGB) surgery being one of the most common bariatric procedures. With this trend, more patients with altered upper gastrointestinal (UGI) anatomy have required endoscopic intervention including direct percutaneous endoscopic jejunostomy (DPEJ) placement. We aimed to assess the safety and success rates of DPEJ in RYGB patients. Patients and methods All patients at a tertiary care referral center who underwent DPEJ during an 8-year period were queried from a prospectively maintained registry of all enteroscopy procedures. Duplicate cases and altered upper UGI anatomy subtypes other than RYGB were excluded. The final cohort consisted of two groups: RYGB vs native anatomy (NA). Demographic, procedural, readmission, follow-up, and complication data were recorded. Comparative analysis was performed. Results Seventy-two patients were included where 28 had RYGB and 44 had NA. Both groups had similar baseline and pre-procedure data. Procedure success rate was 89 % in RYGB patients and 98 % in NA patients ( P  = 0.13). There were no intraprocedural complications. Early and late postprocedural complication rates were similar between the groups (both 4 % vs 7 %). Average follow-up times in the RYGB and NA groups were 12.97 ± 9.35 and 13.44 ± 9.21 months, respectively. Although readmission rates at 1 and 6 months were higher in the NA versus the RYGB group (21 % vs 7 % and 25 % vs 15 %), these differences were not significant. Conclusions DPEJ can be successful and safely placed in RYGB patients with no significant difference in procedure success, complication, or readmission rates when compared to control.

Bedside Live-View Capsule Endoscopy in Evaluation of Overt Obscure Gastrointestinal Bleeding -A Pilot Point of Care Study

BACKGROUND

Capsule endoscopy (CE) is an emerging tool in the diagnosis and management of occult bleeding and overt obscure gastrointestinal bleeding (OOGIB). Maximizing efficiency of CE can lead to rapid bleeding localization and shorter time to therapy. We investigated whether a trained registered nurse (RN) can accurately interpret bleeding by CE in real time by measuring inter-observer agreement between RN and physician interpretation.

METHODS

We conducted a prospective study of patients admitted for OOGIB who underwent live-view capsule endoscopy (LVCE) between 12/2016 and 11/2017. A match control group who underwent standard CE was obtained through retrospective review. An RN received a 2-day training program for CE interpretation. RN bedside interpretation for bleeding was followed by interpretation by 2 GI physicians blinded to LVCE findings. Outcomes were compared between groups using t-tests and chi-square tests. Cohen's kappa measured agreement between physician and RN.

RESULTS

Ten subjects were in the LVCE group, and 12 subjects were in the standard of care group. The agreement between the physicians and RNs was 9/10 (90%) with a kappa of 0.73 (95% CI: 0.26-1.00; p=0.016). Patients in the LVCE group had shorter duration to physician interpretation (0.6 vs 0.7 days (p=0.50), duration to endoscopy (1.8 days vs 3 days (p=0.240) and length of stay (8.1 vs. 11.4 days (p=0.26) compared to the standard of care group.

CONCLUSION

This study utilizing an RN for LVCE interpretation found interobserver agreement between RN and physician findings. Larger studies are needed to assess whether this RN-physician team approach can translate to improved outcomes.

Role of balloon enteroscopy for obscure gastrointestinal bleeding in those with surgically altered anatomy: A systematic review

BACKGROUND

Obscure gastrointestinal (GI) bleeding is defined as persistent bleeding despite negative evaluation with both esophagogastroduodenoscopy and colonoscopy and can be secondary to small intestinal pathology. Standard endoscopy as well as push endoscopy can be a challenge in those with altered anatomy given inaccessible areas as well as perforation risk. Single and double balloon enteroscopy can be warranted in this patient population in instances of obscure GI bleed.

AIM

To assess the safety and diagnostic efficacy of balloon enteroscopy for obscure GI bleeding in patients with surgically altered anatomy.

METHODS

A search was conducted through PubMed, MEDLINE, Google Scholar, Scopus, and Embase with the key words “enteroscopy,” “obscure bleeding,” and “altered anatomy,” to identify relevant articles in English with no restricted time frame. A search within the Reference Citation Analysis database was conducted to ensure inclusion of the latest high impact articles. Study types included in the review were prospective and retrospective reviews, case series, and case reports. The reference lists of these papers were also reviewed to find further papers that were applicable. The authors extracted the data from the studies that fit inclusion criteria. Data of interest included type of study, type of procedure, and type of altered anatomy, as well as the number of patients with any diagnostic or therapeutic intervention. Data was also recorded on procedure tolerance and complications. The data was analyzed with descriptive statistics.

RESULTS

Our literature search yielded 14 studies that were included. There were 68 procedures performed with 61 unique patients subjected to these procedures. Forty-four (65%) of the procedures were double balloon, 21 (31%) were single balloon, and 3 (4%) were classified as through the scope balloon assisted. The most common altered anatomy types included Gastric Bypass Roux-en-Y, Pylorus Sparing Whipple, Orthotopic Liver Transplantation with Roux-en-Y, and Gastrojejunostomy Roux-en-Y. The procedures were successfully performed in each patient. There were 5 (7%) procedures that were complicated by perforation. Amongst the available data, the diagnostic yield was 48/59 (81%) and a therapeutic yield of 39/59 (66%). One patient was recommended surgical revision of their altered anatomy following enteroscopy.

CONCLUSION

Balloon enteroscopy is a useful diagnostic modality in investigating obscure GI bleeding within those with surgically altered anatomy; however, precautions must be taken as this population may have increased perforation risk.

The misclassification of gastric antral vascular ectasia

BACKGROUND

Gastric antral vascular ectasia (GAVE) is characterized by angiodysplastic lesions and is a rare form of gastrointestinal bleeding. Given the multiple patterns, GAVE can be misclassified.

AIM

We analyzed the misclassification of GAVE among patients undergoing esophagogastroduodenoscopy (EGD).

METHODS

We performed a retrospective review of 941 EGDs between 2017 and 2019. Inclusion criteria included findings of GAVE on EGD±biopsy. Correct classification was based on visual EGD findings. Outcome variables included misclassification rate, endoscopist's background, and concordance between EGD and pathology. Cohen's Kappa test was used for concordance analysis.

RESULTS

A total of 110 patients had EGD findings of GAVE with a corresponding 184 EGDs. The misclassification rate among EGDs was 74/184 (40%). Furthermore, 81/110 patients were correctly classified with their first workup, whereas 29/110 patients needed repeat testing. In cases of misclassification, GAVE was mostly referred to as erythema (43%), with ulceration, gastritis, or polyps. Sixty-six (60%) patients had biopsies with a concordance of 76% between EGD and biopsy (κ=0.35).

CONCLUSIONS

Our findings indicate GAVE was misclassified up to 40% on EGDs with hepatologists and gastroenterologists having similar misclassification rates. Proper identification is crucial given susceptibility to upper gastrointestinal bleeding.

RELEVANCE FOR PATIENTS

This study emphasizes the importance of accurate classification of GAVE to ensure proper treatment of these lesions which can improve clinical outcomes.

Videoconference microscopy is a reliable alternative to conventional microscopy in the evaluation of Barrett's esophagus: Zooming into a new era

Telepathology, practicing pathology from a distance, allows experts to review cases without the need to transfer glass slides. Due to significant intra- and inter-observer variabilities in the histological evaluation of Barrett's esophagus (BE), current guidelines recommend expert consultation in cases of dysplasia. We aimed to determine whether telepathology using microscope videoconferencing can be reliably used for evaluation of BE. Biopsies from 62 patients with endoscopic findings of salmon colored mucosa extending ≥1 cm proximal to the gastroesophageal junction were randomly selected to represent benign esophagus, non-dysplastic BE, low-grade dysplasia, high-grade dysplasia, and adenocarcinoma. Three gastrointestinal-trained pathologists reviewed the cases via videoconference microscopy followed by conventional microscopy. Intra-observer and pairwise inter-observer agreements between the conventional microscopy and videoconference methodologies were calculated for each of the three pathologists using Fleiss-Cohen weighted kappa (K) analysis. The intra-observer agreement for each pathologist's assessment of videoconference microscopy and glass slide readings showed very good reliability (K = 0.94, 95% confidence interval = 0.89-0.99; 0.88, 95% confidence interval = 0.79-0.98; 0.93, 95% confidence interval = 0.90-0.97). Mean pairwise inter-observer agreement was 0.90 for videoconference and 0.91 for conventional microscopy. Diagnosis and grading of BE using videoconference microscopy show similar reliability as conventional microscopy. Based on our findings, we propose that videoconferencing pathology is a valid instrument for evaluating BE.

Validation of the Orlando Protocol for endoscopic management of pancreatic fluid collections in the era of lumen-apposing metal stents

OBJECTIVES

Although lumen-apposing metal stents (LAMS) are being increasingly used in lieu of plastic stents, the clinical approach to endoscopic management of pancreatic fluid collections (PFCs) is poorly standardized. We compared outcomes of approaches over two time intervals, initially using plastic stents and later integrating LAMS.

METHODS

This was a retrospective, observational, before-after study of prospectively collected data on consecutive patients with symptomatic PFCs managed over two time periods. In the initial period (January 2010-January 2015) endoscopic treatment was undertaken with plastic stents and in the later period (February 2015-August 2020) by integration of LAMS with selective use of plastic stents. The treatment strategy in both periods were tailored to size, extent, type of PFC and stepwise response to intervention. The main outcome was treatment success, defined as resolution of PFC and presenting symptoms at 6-month follow-up.

RESULTS

A total of 160 patients were treated with plastic stents and 227 patients were treated using an integrated LAMS approach. Treatment success was significantly higher for the integrated approach compared to using only plastic stents (95.6 vs. 89.4%; P = 0.018), which was confirmed to be predictive of treatment success on multivariable logistic regression analysis (odds ratio 2.7, 95% confidence interval 1.1-6.4; P = 0.028).

CONCLUSIONS

A structured approach integrating LAMS with selective use of plastic stents improved treatment success in patients with PFCs compared to an approach using only plastic stents.

Gastrointestinal Manifestations of COVID-19 Infection: Clinicopathologic Findings in Intestinal Resections Performed at Single Institution

It is now known that COVID-19 not only involves the lungs, but other organs as well including the gastrointestinal tract. Although clinic-pathological features are well-described in lungs, the histopathologic features of gastrointestinal involvement in resection specimens are not well characterized. Herein, we describe in detail the clinicopathologic features of intestinal resection specimens in four patients with COVID-19 infection. COVID-19 viral particles by in situ hybridization and immunofluorescence studies are also demonstrated. All four patients were males, aged 28–46 years, with comorbidities. They initially presented with a severe form of pulmonary COVID-19 and showed gastrointestinal symptoms, requiring surgical intervention. Histopathologic examination of resected GI specimens, mostly right colectomies, revealed a spectrum of disease, from superficial mucosal ischemic colitis to frank transmural ischemic colitis and associated changes consistent with pneumatosis cystoides intestinalis. Three patients were African American (75%), and one was Caucasian (25%); three patients died due to complications of their COVID-19 infection (75%), while one ultimately recovered from their GI complications (25%), but experienced prolonged sequela of COVID-19 infection including erectile dysfunction. In conclusion, COVID-19 infection, directly or indirectly, can cause ischemic gastrointestinal complications, with predilection for the right colon.

Prevalence of metabolic syndrome in cirrhotics with gastric antral vascular ectasia

BACKGROUND AND AIMS

Gastric antral vascular ectasia (GAVE) is characterized by angliodysplastic lesions that can cause upper gastrointestinal bleeding (UGIB). The mechanism behind GAVE and its association with other diseases remains unknown. We investigated the association of metabolic syndrome in cirrhotic GAVE patients when compared to esophageal variceal hemorrhage (EVH) patients.

METHODS

We performed a retrospective review of 941 consecutive esophagogastroduodenoscopies (EGDs) for UGIB at a medical center between 2017 and 2019. The GAVE group consisted of EGD or biopsy diagnosed cirrhotic GAVE patients, and the EVH group consisted of EVH patients with active bleeding or stigmata of recent hemorrhage on EGD. Baseline variables including co-morbidities and cirrhotic etiology were recorded. Continuous variables were compared using Wilcoxon test and categorical variables were compared using Chi-square or Fisher's exact test. Multiple logistic regression analysis evaluated the association between GAVE and covariates.

RESULTS

The final cohort had 96 GAVE and 104 EVH patients. Mean BMI was significantly higher in the GAVE cohort (32.6 vs 27.9, p < 0.0001) in addition to diabetes, hypertension, and hyperlipidemia (53.1% vs 37.5%; 76% vs 47.1%; 38.5% vs 14.4%; respectively, all p < 0.05). Non-alcoholic steatohepatitis (NASH) cirrhosis was more prevalent in GAVE than EVH patients (50% vs 24%, p = 0.0001). Multiple logistics regression revealed female sex, increased BMI, hypertension, and hyperlipidemia all having significantly higher risk of GAVE (all p < 0.05).

CONCLUSION

Our data indicates that when compared to cirrhotics patients with EVH, cirrhotics with GAVE have increased risk of metabolic syndrome. This may play a role in the underlying pathophysiology of GAVE.

The role of ablation in the treatment of dysplastic Barrett's esophagus

Endoscopic eradication therapy for Barrett's esophagus has been established as an effective management strategy for patients with Barrett's esophagus with dysplasia and early esophageal cancer. Among the endoscopic therapies, ablation techniques such as radiofrequency ablation and cryoablation are effective primary treatment interventions with acceptable low complication rates forming the spectrum of a multimodal approach. Appropriate selection of patients, high-definition endoscopic evaluation, and dedicated histological assessment are important cornerstones to help navigate to the best effective treatment method. Carefully structured surveillance programs and preventive measures will be needed to provide long-term durability for maintaining complete remission.

Single-use duodenoscopes: where are we and where are we going?

PURPOSE OF REVIEW

Given the growing concerns about infection transmission from use of contaminated reusable duodenoscopes, technological advancements have been made that vary from modifications of existing designs to development of single-use devices.

RECENT FINDINGS

To circumvent mechanical limitations that preclude access to critical areas of a duodenoscope to perform thorough cleaning and disinfection, single-use disposable duodenoscopes have been developed. A thorough assessment of this technology is limited by the minimal published data that is currently available. This opinion assesses the current technical functionality of these devices, potential for further improvements, implications for healthcare economics and the future of gastrointestinal endoscopy.

SUMMARY

Currently available data suggest that majority of endoscopic retrograde cholangiopancreatography procedures can be safely performed using single-use duodenoscopes. The ability to improve technical functionality, incorporate futuristic technology and secure financial reimbursement from insurance carriers will largely define the future prospects of this recent innovation.

Endoscopic spectrum and practical classification of small bowel gastrointestinal stromal tumors (GISTs) detected during double-balloon enteroscopy

Background and study aims  Information about the endoscopic characterization of small bowel gastrointestinal tumors (GISTs) is limited. The aim of this case study was to describe the endoscopic spectrum of small bowel GISTs and to present a practical classification. Patients and methods  Observational, retrospective, consecutive case series of patients with small bowel GIST. Results  A total of 10 small bowel GISTs were found in patients (6 male, 4 female, mean age 52 years, range 28 to 68).). All patients presented with obscure gastrointestinal bleeding (overt, n = 8, occult, n = 2). Most GISTs were present in the proximal or middle small bowel (n = 7). The endoscopic tumor characteristics could be categorized as follows: submucosal round (n = 4), submucosal sessile (n = 2), and invasive/penetrating) (n = 4). The mucosa overlying the tumor was normal (n = 4), grooved (n = 3) or frankly ulcerated (n = 3). Tumor size ranged from 8 mm to 50 mm. Biopsy was negative in all patients with normal mucosa but showed tumor in all patients with ulcerations. Regardless of biopsy results, all patients were sent for surgery. Nine resections were carried out. One patient refused surgery. There were no complications of endoscopy in this cohort. Conclusion  Our series shows that GISTs have a wider spectrum of endoscopic characteristics than previously described. The round type with normal overlying mucosa was equally prevalent as the grooved or ulcerated variant. Endoscopists should be aware of this wide spectrum of presentation of small bowel GIST.

NCCN Guidelines Insights: Colorectal Cancer Screening, Version 2.2020

The NCCN Guidelines for Colorectal Cancer (CRC) Screening describe various colorectal screening modalities as well as recommended screening schedules for patients at average or increased risk of developing sporadic CRC. They are intended to aid physicians with clinical decision-making regarding CRC screening for patients without defined genetic syndromes. These NCCN Guidelines Insights focus on select recent updates to the NCCN Guidelines, including a section on primary and secondary CRC prevention, and provide context for the panel's recommendations regarding the age to initiate screening in average risk individuals and follow-up for low-risk adenomas.

NCCN Guidelines Insights: Genetic/Familial High-Risk Assessment: Colorectal, Version 2.2019

Identifying individuals with hereditary syndromes allows for improved cancer surveillance, risk reduction, and optimized management. Establishing criteria for assessment allows for the identification of individuals who are carriers of pathogenic genetic variants. The NCCN Guidelines for Genetic/Familial High-Risk Assessment: Colorectal provide recommendations for the assessment and management of patients with high-risk colorectal cancer syndromes. These NCCN Guidelines Insights focus on criteria for the evaluation of Lynch syndrome and considerations for use of multigene testing in the assessment of hereditary colorectal cancer syndromes.

Evolving screening and surveillance techniques for Barrett's esophagus

Barrett’s esophagus (BE) is a change in the esophageal lining and is known to be the major precursor lesion for most cases of esophageal adenocarcinoma (EAC). Despite an understanding of its association with BE for many years and the falling incidence rates of squamous cell carcinoma of the esophagus, the incidence for EAC continues to rise exponentially. In association with this rising incidence, if the delay in diagnosis of EAC occurs after the onset of symptoms, then the mortality at 5 years is greater than 80%. Appropriate diagnosis and surveillance strategies are therefore vital for BE. Multiple novel optical technologies and other advanced approaches are being utilized to assist in making screening and surveillance more cost effective. We review the current guidelines and evolving techniques that are currently being evaluated.

Outcomes of use of electromagnetic guidance with responsive insertion technology (RIT) during colonoscopy: a prospective randomized controlled trial

Background and study aims  Colonoscopy can be technically challenging and cause discomfort in patients. The integrated Scope Guide assist is built in to show that with its use outcomes are improved during colonoscopy. We aimed to test the usefulness of the Magnetic Scope Guide Assist (ScopeGuide ) with respect to cecal intubation time, and other procedural quality outcomes. Patients and methods  We conducted a prospective study of outpatients undergoing elective colonoscopy at the endoscopic units of the University of Alabama at Birmingham (UAB) from March 2016 to July 2016. Patients were randomly assigned in a 1:1 block design to groups that either had standard colonoscopy or Scope-guided colonoscopy. The primary outcome measure was cecal intubation time (CIT). Secondary outcome measures included use of manual pressure, position changes for cecal intubation and sedation requirements. Results  Three hundred patients were randomized to either group; standard (n = 150) vs. Scope-guided (n = 150). The mean CIT was not statistically different for the standard and the Scope-guided groups (4.6 vs. 4.3 minutes; P  = 0.46). There were also no statistical differences in frequency of manual pressure applied (16.7 % for Scope-guided vs. 19.1 % for standard; P  = 0.65) or position changes (11.4 % for scope guided vs. 8.8 % standard; P  = 0.56). Sedation requirements showed lesser use of midazolam (3.9 mg vs. 4.7 mg, P  = 0.003) in the Scope-guide group, while there was no significant difference in use of fentanyl (fentanyl - 62.1 mg vs. 68.9 mg, P  = 0.09 similar between groups, for Scope-guided vs. standard groups, respectively). Adverse events were similar in both groups. Conclusions  In patients undergoing routine elective colonoscopy, use of ScopeGuide by experienced colonoscopists did not improve CIT or affect the frequency of ancillary maneuvers. The benefit of this device during training of endoscopists could be considered for further studies.

Predictors for outcomes and readmission rates following double balloon enteroscopy: a tertiary care experience

AIM

 The objectives of this study are to examine clinical characteristics of patients undergoing anterograde and retrograde double balloon enteroscopy (DBE) and to assess factors predicting positive diagnostic yield, therapeutic yield, and readmission.

METHODS

 We conducted a retrospective cohort study of patients (n = 420) who underwent DBE at a tertiary care center between 2012 and 2016 at a tertiary referral center. Measures of central tendency and frequency distributions were used for univariate analysis. Chi-square and t-test analyses were used to compare patient characteristics. Logistic regression was used to predict outcomes of interest.

RESULTS

 Of patients included in the study, 59 % were male with a mean age of 61.49 (SD = 15.15) Altered anatomy was noted in 14 %, while 5 % and 13 % of patients had end stage renal disease (ESRD) and current use of anticoagulation, respectively. The most common indication for DBE was obscure gastrointestinal bleed (OGIB) (33 %). Forty-nine patients had obscure and overt gastrointestinal bleeding (GIB) and 22 % had occult GIB with iron deficiency. The cohort's rate of positive diagnostic yield was 73 % and 35 % for therapeutic yield. The 30-day and 6-month readmission rates were both 11 %. A higher proportion of those readmitted were male (75 % vs 57 %, P  = 0.027) and had longer procedural time (38.68 vs 46.57, P  = 0.011). Likewise, occult GIB with iron deficiency anemia and iron deficiency alone (OR = 2.45, CI: 1.233 - 4.859, P  = 0.011), inpatient status (OR 2.42, CI 1.344 - 4.346, P  = 0.003), and longer procedural time (OR = 1.02, CI: 1.004 - 1.029, P  = 0.008) were associated positively with readmission.

CONCLUSION

 DBE procedures have relevant efficacy for both diagnostic and therapeutic yield while evaluating small bowel disease. Readmission rates are low and more in those with GI bleed and iron deficiency with longer index procedural times.

Length of Barrett's segment predicts failure of eradication in radiofrequency ablation for Barrett's esophagus: a retrospective cohort study

Background

We aim to investigate factors that may contribute to failure of eradication of dysplastic Barrett’s Esophagus among patients undergoing radiofrequency ablation treatment.

Methods

A retrospective review of patients undergoing radiofrequency ablation for treatment of Barrett’s Esophagus was performed. Data analyzed included patient demographics, medical history, length of Barrett’s Esophagus, number of radiofrequency ablation sessions, and histopathology. Subsets of patients achieving complete eradication were compared with those not achieving complete eradication.

Results

A total of 107 patients underwent radiofrequency ablation for Barrett’s Esophagus, the majority white, overweight, and male. Before treatment, 63 patients had low-grade dysplasia, and 44 patients had high-grade dysplasia or carcinoma. Complete eradication was achieved in a majority of patients (57% for metaplasia, and 76.6% for dysplasia). Failure of eradication occurred in 15.7% of patients. The median number of radiofrequency ablation treatments in patients achieving complete eradication was 3 sessions, compared to 4 sessions for failure of eradication (p = 0.06). Barrett’s esophagus length of more than 5 cm was predictive of failure of eradication (p < 0.001).

Conclusions

Radiofrequency ablation for dysplastic Barrett’s Esophagus is a proven and effective treatment modality, associated with a high rate of complete eradication. Our rates of eradication from a center starting an ablation program are comparable to previously published studies. Length of Barrett’s segment > 5 cm was found to be predictive of failure of eradication in patients undergoing radiofrequency ablation.

Clinical Predictors for Repeat Hospitalizations in Left Ventricular Assist Device (LVAD) Patients With Gastrointestinal Bleeding

Background

Patients implanted with left ventricular assist devices (LVAD) carry an increased risk of gastrointestinal bleeding (GIB), estimated at 25% in most studies. Significant efforts are employed in localizing and stopping the source of bleeding, but the rates of repeat hospitalization for GIB remain surprisingly high. Given the increasing incidence of LVAD-dependent end-stage heart failure and the excessive costs associated with repetitive endoscopic investigations, risk factors associated with re-bleeding need to be determined. The aim of our study was to investigate clinical predictors associated with repeat hospitalizations for GIB in patients implanted with a LVAD.

Methods

We conducted a retrospective cohort using the prospectively assembled ventricular assist device database at the University of Alabama at Birmingham. We identified all end-stage heart failure patients who were implanted with a continuous-flow (CF) LVAD between Jan 1, 2009 and Dec 31, 2013. We excluded pulsatile devices, biventricular assist devices (BiVADs), right ventricular assist devices (RVADs), and patients under 19 years of age.

Results

There were 102 patients implanted with a CF-LVAD within the specified time period. With an average follow-up of 127 weeks, 32 (31.4%) patients developed GIB requiring 79 separate hospitalizations. Average time from LVAD implantation to first bleed was 343 days. The re-bleeding rate requiring readmission was 56.3% in those admitted with GIB, with eight (25%) of the patients necessitating multiple readmissions. The average hospital stay for a primary diagnosis of GIB was 9.45 days. Totally, 68 (86%) patients required endoscopic evaluation during their hospitalization, with 35 (44%) necessitating multiple procedures during the same admission. The average time to first endoscopy was 2.5 days with a median of 2 days. Patients receiving early endoscopy (< 48 h from admission) were 57% less likely to require future readmission for GIB compared to patients undergoing late endoscopy (> 48 h) (OR: 0.43, CI: 0.19 - 0.9). Other factors associated with repeat admissions for GIB included indication for LVAD (bridge to transplant had OR: 0.07, CI: 0.02 - 0.27), male gender (OR: 10.4, CI: 1.8 - 59), length of initial hospital stay (OR: 0.83, CI: 0.71 - 0.97), and INR on admission (OR: 3.6, CI: 1.46 - 8.8). Although not statistically significant, patients undergoing subsequent endoscopies during a single admission were 84% less likely to develop re-bleeding in the future (OR: 0.158, CI: 0.025 - 1.02).

Conclusions

GIB in LVAD patients is a significant problem with high rates of readmission despite extensive endoscopic investigations and anticoagulant adjustments. Our experience revealed that early endoscopy, longer initial hospital stay, and better INR control were all associated with decreased rates of readmission for GIB in this population. These modifiable factors should be emphasized and addressed in the future to reduce the burdens associated with repeated hospitalizations.

Case series on multimodal endoscopic therapy for gastric antral vascular ectasia, a tertiary center experience

AIM

To study and describe patients who underwent treatment for gastric antral vascular ectasia (GAVE) with different endoscopic treatment modalities.

METHODS

We reviewed patients with GAVE who underwent treatment at University of Alabama at Birmingham between March 1, 2012 and December 31, 2016. Included patients had an endoscopic diagnosis of GAVE with associated upper gastrointestinal bleeding or iron deficiency anemia.

RESULTS

Seven out of 15 patients had classic watermelon description for GAVE, 1/15 with diffuse/honeycomb pattern and 6/15 with nodular GAVE per EGD description. Seven out of 15 patients required multimodal treatment. Four out of six of patients with endoscopically nodular GAVE required multimodal therapy. Overall, mean pre- and post-treatment hemoglobin (Hb) values were 8.2 ± 0.8 g/dL and 9.7 ± 1.6 g/dL, respectively (P ≤ 0.05). Mean number of packed red blood cells transfusions before and after treatment was 3.8 ± 4.3 and 1.2 ± 1.7 (P ≤ 0.05), respectively.

CONCLUSION

Patients with nodular variant GAVE required multimodal approach more frequently than non-nodular variants. Patients responded well to multimodal therapy and saw decrease in transfusion rates and increase in Hb concentrations. Our findings suggest a multimodal approach may be beneficial in nodular variant GAVE.

In vitro susceptibility to 19 agents other than β-lactams among third-generation cephalosporin-resistant Enterobacteriaceae recovered on hospital admission

Objectives

As part of the multicentre Antibiotic Therapy Optimisation Study, MIC values of 19 non-β-lactam agents were determined for third-generation cephalosporin-resistant Escherichia coli , Klebsiella species and Enterobacter species (3GCREB) isolates collected in German hospitals.

Methods

A total of 328 E. coli , 35 Klebsiella spp. (1 Klebsiella oxytoca and 34 Klebsiella pneumoniae ) and 16 Enterobacter spp. (1 Enterobacter aerogenes and 15 Enterobacter cloacae ) isolates were submitted to broth microdilution antimicrobial susceptibility testing with the MICRONAUT system. MICs of fluoroquinolones (levofloxacin and moxifloxacin), aminoglycosides (gentamicin, tobramycin, amikacin, streptomycin, neomycin and paromomycin), tetracyclines (tetracycline, minocycline and tigecycline), macrolides (erythromycin, clarithromycin and azithromycin) and miscellaneous agents [trimethoprim/sulfamethoxazole, chloramphenicol, nitrofurantoin, colistin and fosfomycin intravenous (iv)] were determined and reviewed against 2016 EUCAST breakpoints.

Results

The MIC of levofloxacin was >2 mg/L for 128 of 328 E. coli and 8 of 35 Klebsiella spp., but only 1 of 16 Enterobacter spp. Rates of resistance to trimethoprim/sulfamethoxazole were high (>70%), except for Enterobacter spp. Rates of resistance to colistin and fosfomycin iv were still low. About 20% of the tested isolates were resistant to chloramphenicol. Only 1 (of 328) E. coli isolate had an MIC of amikacin >16 mg/L and only 33 of 328 E. coli and 1 of 35 Klebsiella spp. had an MIC of tobramycin >4 mg/L, whereas average gentamicin MICs were in general more elevated. A tigecycline MIC >2 mg/L was only found for 1 of 16 Enterobacter spp., but in none of the E. coli or Klebsiella spp. isolates.

Conclusions

Our study gives insight into previously unreported non-β-lactam MIC distributions of 3GCREB isolates.

Home-based vs inpatient education for children newly diagnosed with type 1 diabetes

BACKGROUND

Initial management of children diagnosed with type 1 diabetes (T1D) varies worldwide with sparse high quality evidence regarding the impact of different models of care.

AIM

To compare the inpatient model of care with a hybrid home-based alternative, examining metabolic and psychosocial outcomes, diabetes knowledge, length of stay, and patient satisfaction.

SUBJECTS AND METHODS

The study design was a randomized-controlled trial. Inclusion criteria were: newly diagnosed T1D, aged 3 to 16 years, living within approximately 1 hour of the hospital, English-speaking, access to transport, absence of significant medical or psychosocial comorbidity. Patients were randomized to standard care with a 5 to 6 day initial inpatient stay or discharge after 2 days for home-based management. All patients received practical skills training in the first 48 hours. The intervention group was visited twice/day by a nurse for 2 days to assist with injections, then a multi-disciplinary team made 3 home visits over 2 weeks to complete education. Patients were followed up for 12 months. Clinical outcomes included HbA1c, hypoglycemia, and diabetes-related readmissions. Surveys measured patient satisfaction, diabetes knowledge, family impact, and quality of life.

RESULTS

Fifty patients were recruited, 25 to each group. There were no differences in medical or psychosocial outcomes or diabetes knowledge. Average length of admission was 1.9 days shorter for the intervention group. Families indicated that with hindsight, most would choose home- over hospital-based management.

CONCLUSIONS

With adequate support, children newly diagnosed with T1D can be safely managed at home following practical skills training.

Orthotopic liver transplantation changes the course of gastric antral vascular ectasia: a case series from a transplant center

BACKGROUND AND AIM

Gastric antral vascular ectasia (GAVE) is an important cause of upper gastrointestinal bleeding and anemia in patients with cirrhosis. The aim of our study was to evaluate the effect of orthotopic liver transplantation (OLT) on GAVE and associated anemia.

PATIENTS AND METHODS

We performed a chart review and identified all cirrhotic patients with GAVE who underwent OLT at the University Of Alabama at Birmingham between 2005 and 2013. Population's demographics, etiology of cirrhosis, comorbidities, presentation and treatment modalities of GAVE, endoscopic and histopathologic reports, hemoglobin values before and after transplant, and immunosuppressive regimens were collected.

RESULTS

Twelve patients were identified, mean age 52.4±4.4 years; seven were men (58.3%); 11 (91.7%) were White; and 6 of 12 patients had biopsy-proven GAVE. The most common etiology of cirrhosis in the cohort was chronic hepatitis C and obesity was the most common chronic condition in 50 and 83.3%, respectively. Anemia resolution was observed in 9/12 (75%) patients who underwent OLT with an increase in hemoglobin from 8.1±2.4 (5.7-13.1) before transplant to 12.0±1.4 (10-15) after transplant (P<0.0001). Esophagogastroduodenoscopy after transplant was performed in all 12 (100%) patients. The mean time between transplant and post-OLT esophagogastroduodenoscopy was 13.8±18.28 (2-57) months; complete resolution of GAVE was observed in 10 (83.3%) patients, with resolving GAVE in one (8.3%) patient.

CONCLUSION

GAVE is an important cause of anemia and upper gastrointestinal bleeding in patients with liver cirrhosis. Our findings show that liver transplantation can resolve GAVE and related anemia.