The Association Between Acidification Time on Wireless Motility Capsule and Gastroesophageal Reflux Disease

BACKGROUND AND AIMS

Gastric physiological characteristics such as fundus accommodation, gastric distention, emptying/transit time, and basal acid output may contribute to the pathogenesis of gastroesophageal reflux disease (GERD). Wireless motility capsule (WMC) uses pH data to determine gastric transit time but has not been used in the evaluation of GERD. Certain metrics such as acidification time, nadir pH, and gastric transit time may provide insight into the mechanisms of GERD related to gastric physiology, allowing WMC to be a complementary tool in the diagnosis of GERD. We aimed to determine whether pH data and transit time on WMC tests correlated with the presence of GERD on ambulatory reflux testing.

STUDY

This was a retrospective study of 28 patients who had undergone both WMC and reflux testing via wireless pH or pH/impedance. Acidification time (time from capsule ingestion to pH<2), nadir postprandial pH, and gastric transit time were manually determined from the WMC capsule proprietary software. Spearman correlation was used to compare these metrics with gastric transit time, percent esophageal acid exposure, and DeMeester score.

RESULTS

Acidification time moderately correlated with gastric transit time, R : 0.44, P =0.02, but not nadir pH, percent esophageal acid exposure, or DeMeester score. Patients with an abnormal reflux test had a significantly longer median acidification time (135.5 vs. 78.5 min, P =0.021). After stratifying by patients with normal versus prolonged gastric transit time, there was a trend toward longer acidification time in patients with positive reflux testing in both groups, but this was not statistically significant. Patients with prolonged gastric transit time >300 minutes were not more likely to have a positive reflux test (38% vs. 35%, P =1).

CONCLUSIONS

The acidification time on WMC was significantly longer in patients with proven GERD and acidification time positively correlated with gastric transit time. Larger studies are needed to determine whether WMC could be used as a complementary tool in investigating patients with GERD symptoms.

Comparison of Anorectal Manometry, Rectal Balloon Expulsion Test, and Defecography for Diagnosing Defecatory Disorders

BACKGROUND & AIMS

The utility of high-resolution anorectal manometry (HR-ARM) for diagnosing defecatory disorders (DDs) is unclear because healthy people may have features of dyssynergia. We aimed to identify objective diagnostic criteria for DD and to ascertain the utility of HR-ARM for diagnosing DD.

METHODS

Constipated patients were assessed with HR-ARM and rectal balloon expulsion time (BET), and a subset underwent defecography. Normal values were established by assessing 184 sex-matched healthy individuals. Logistic regression models evaluated the association of abnormal HR-ARM findings with prolonged BET and reduced rectal evacuation (determined by defecography).

RESULTS

A total of 474 constipated individuals (420 women) underwent HR-ARM and BET, and 158 underwent defecography. BET was prolonged, suggesting a DD, for 152 patients (32%). Rectal evacuation was lower for patients with prolonged vs normal BET. A lower rectoanal gradient during evacuation, reduced anal squeeze increment, and reduced rectal sensation were independently associated with abnormal BETs; the rectoanal gradient was 36% sensitive and 85% specific for prolonged BET. A lower rectoanal gradient and prolonged BET were independently associated with reduced evacuation. Among constipated patients, the probability of reduced rectal evacuation was 14% when the gradient and BET were both normal, 45% when either was abnormal, and 75% when both variables were abnormal.

CONCLUSIONS

HR-ARM, BET, and defecography findings were concordant for constipated patients, and reduced rectoanal gradient was the best HR-ARM predictor of prolonged BET or reduced rectal evacuation. Prolonged BET, reduced gradient, and reduced evacuation each independently supported a diagnosis of DD in constipated patients. We propose the terms probable DD for patients with an isolated abnormal gradient or BET and definite DD for patients with abnormal results from both tests.

Decreased Gut Microbiome Tryptophan Metabolism and Serotonergic Signaling in Patients With Persistent Mental Health and Gastrointestinal Symptoms After COVID-19

INTRODUCTION

An estimated 15%-29% of patients report new gastrointestinal (GI) symptoms after coronavirus-19 disease (COVID-19) while 4%-31% report new depressive symptoms. These symptoms may be secondary to gut microbiome tryptophan metabolism and 5-hydroxytryptamine (5-HT)-based signaling.

METHODS

This study used specimens from 2 patient cohorts: (i) fecal samples from patients with acute COVID-19 who participated in a randomized controlled trial testing prebiotic fiber and (ii) blood samples from patients with acute COVID-19. Six months after recovering from COVID-19, both cohorts answered questions related to GI symptoms and anxiety or depression. Microbiome composition and function, focusing on tryptophan metabolism-associated pathways, and plasma 5-HT were assessed.

RESULTS

In the first cohort (n = 13), gut microbiome L-tryptophan biosynthesis during acute COVID-19 was decreased among those who developed more severe GI symptoms (2.0-fold lower log activity comparing those with the most severe GI symptoms vs those with no symptoms, P = 0.06). All tryptophan pathways showed decreased activity among those with more GI symptoms. The same pathways were also decreased in those with the most severe mental health symptoms after COVID-19. In an untargeted analysis, 5 additional metabolic pathways significantly differed based on subsequent development of GI symptoms. In the second cohort (n = 39), plasma 5-HT concentration at the time of COVID-19 was increased 5.1-fold in those with GI symptoms alone compared with those with mental health symptoms alone ( P = 0.02).

DISCUSSION

Acute gut microbiome-mediated reduction in 5-HT signaling may contribute to long-term GI and mental health symptoms after COVID-19. Future studies should explore modification of 5-HT signaling to reduce post-COVID symptoms.

Risk Factors and Outcomes for Gastroparesis After Lung Transplantation

BACKGROUND

Gastroparesis is common after lung transplantation and is associated with worse transplant outcomes, including the development of chronic lung allograft dysfunction (CLAD). This study sought to identify the prevalence, risk factors, and outcomes associated with a new diagnosis of gastroparesis after lung transplantation.

METHODS

This was a single-center retrospective study of patients who underwent lung transplantation in 2008-2018. The primary outcome was a new diagnosis of gastroparesis within 3 years of transplant. Secondary outcomes included a new diagnosis of gastroesophageal reflux and the association between gastroparesis and both post-transplant survival and CLAD-free survival. Multivariable logistic regression was used to compare diagnosis of gastroparesis and gastroesophageal reflux, while multivariable Cox proportional hazards models were used to analyze gastroparesis and post-transplant outcomes.

RESULTS

Of 616 patients with no prior history of gastroparesis, 107 (17.4%) were diagnosed with delayed gastric emptying within 3 years of transplant. On multivariable logistic regression, black race (OR 2.16, 95% CI 1.18-3.98, p = 0.013) was significantly associated with a new diagnosis of gastroparesis. Age, sex, history of diabetes, connective tissue disease, type of transplant, diagnosis group, renal function, and body mass index were not predictive of gastroparesis post-transplant. Gastroparesis was significantly associated with CLAD (HR 1.76, 95% CI 1.20-2.59, p = 0.004), but not with overall mortality (HR 1.16, p = 0.43).

CONCLUSION

While gastroparesis is common after lung transplantation, it remains difficult to predict which patients will develop these complications post-transplant. Black patients were more likely to be diagnosed with gastroparesis after adjusting for relevant confounders. Gastroparesis is associated with increased risk of CLAD, and further studies are needed to assess whether early detection and treatment can reduce the incidence of CLAD.

Prevalence and risk factors for gastrointestinal symptoms after recovery from COVID-19

BACKGROUND

COVID-19 frequently presents with acute gastrointestinal (GI) symptoms, but it is unclear how common these symptoms are after recovery. The purpose of this study was to estimate the prevalence and characteristics of GI symptoms after COVID-19.

METHODS

The medical records of patients hospitalized with COVID-19 between March 1 and June 30, 2020, were reviewed for the presence of GI symptoms at primary care follow-up 1 to 6 months later. The prevalence of new GI symptoms was estimated, and risk factors were assessed. Additionally, an anonymous survey was used to determine the prevalence of new GI symptoms among online support groups for COVID-19 survivors.

KEY RESULTS

Among 147 patients without pre-existing GI conditions, the most common GI symptoms at the time of hospitalization for COVID-19 were diarrhea (23%), nausea/vomiting (21%), and abdominal pain (6.1%), and at a median follow-up time of 106 days, the most common GI symptoms were abdominal pain (7.5%), constipation (6.8%), diarrhea (4.1%), and vomiting (4.1%), with 16% reporting at least one GI symptom at follow-up (95% confidence interval 11 to 23%). Among 285 respondents to an online survey for self-identified COVID-19 survivors without pre-existing GI symptoms, 113 (40%) reported new GI symptoms after COVID-19 (95% CI 33.9 to 45.6%).

CONCLUSION AND INFERENCES

At a median of 106 days after discharge following hospitalization for COVID-19, 16% of unselected patients reported new GI symptoms at follow-up. 40% of patients from COVID survivor groups reported new GI symptoms. The ongoing GI effects of COVID-19 after recovery require further study.

Oral Microbiome Alterations and SARS-CoV-2 Saliva Viral Load in Patients with COVID-19

Bacterial-viral interactions in saliva have been associated with morbidity and mortality for respiratory viruses such as influenza and SARS-CoV. However, such transkingdom relationships during SARS-CoV-2 infection are currently unknown. Here, we aimed to elucidate the relationship between saliva microbiota and SARS-CoV-2 in a cohort of newly hospitalized COVID-19 patients and controls. We used 16S rRNA sequencing to compare microbiome diversity and taxonomic composition between COVID-19 patients (n = 53) and controls (n = 59) and based on saliva SARS-CoV-2 viral load as measured using reverse transcription PCR (RT-PCR). The saliva microbiome did not differ markedly between COVID-19 patients and controls. However, we identified significant differential abundance of numerous taxa based on saliva SARS-CoV-2 viral load, including multiple species within Streptococcus and Prevotella. IMPORTANCE Alterations to the saliva microbiome based on SARS-CoV-2 viral load indicate potential biologically relevant bacterial-viral relationships which may affect clinical outcomes in COVID-19 disease.

Prevalence and Risk Factors for Inappropriate Continuation of Proton Pump Inhibitors After Discharge From the Intensive Care Unit

OBJECTIVE

To determine the prevalence and risk factors for inappropriate discharge on proton pump inhibitor (PPI) therapy started in the intensive care unit (ICU) for stress ulcer prophylaxis.

PATIENTS AND METHODS

This was a retrospective cohort study of adults initiated on treatment with a PPI in any of 9 affiliated ICUs from January 1, 2014, to December 31, 2018. Patients were excluded if they had an appropriate long-term PPI indication. Logistic regression modeling was used to identify characteristics associated with discharge on treatment with an inappropriate PPI.

RESULTS

Of 24,751 patients admitted to an ICU, 4127 were initiated on treatment with a new PPI, with 2467 (60%) lacking a long-term PPI indication. Of these 2467, a total of 1122 (45%) were continued on PPI therapy after transfer to the floor and 668 (27%) were discharged on PPI therapy. On multivariable analysis, risk factors for inappropriate discharge on PPI therapy included having an upper endoscopy (adjusted odds ratio [aOR], 1.70; 95% CI, 1.08-2.66), admission to the surgical compared with medical ICU (aOR, 2.03; 95% CI, 1.32-3.10), and discharge to a nursing home or rehabilitation facility (aOR, 1.43; 95% CI, 1.04-1.96; and aOR, 2.29; 95% CI, 1.62-3.24, respectively).

CONCLUSION

Among patients started on treatment with a PPI in the ICU without an indication for outpatient PPI use, 27% (668 of 2467) were nonetheless discharged on PPI therapy. Medically complex and surgical ICU patients are at increased risk for receiving PPIs without appropriate documented indications, and careful review of medication lists at discharge should occur in these high-risk groups.

Probiotic Use in Celiac Disease: Results from a National Survey

BACKGROUND AND AIMS

Patients with celiac disease (CD) commonly use supplements for perceived health benefits despite scant evidence. We aimed to characterize the prevalence and predictors of probiotic use among CD patients.

METHODS

We analyzed data from iCureCeliac®; a patient-powered research network questionnaire distributed by the Celiac Disease Foundation. We included adults with self-reported CD who answered questions regarding demographics, diagnosis, symptoms, and treatment. We compared probiotic users versus probiotic non-users and subsequently performed multivariable logistic regression, assessing for independent predictors of probiotic use.

RESULTS

4,909 patients met the criteria for inclusion in the study. Of these, 1,160 (23.6%) responded to a question regarding probiotic use. The mean age of participants was 38.8 years and 82% were female. 381 patients (33%) reported using probiotics. More probiotic users sought nutritional counseling at time of diagnosis (36% vs. 30%, p=0.05) and remained symptomatic despite a gluten-free diet (40% vs. 25%, p <0.001). Probiotic users had lower scores on the pain subscale of the SF36 (63.7±21.6 vs. 69.5±22.1, p=0.006). On multivariable analysis, patients diagnosed after age 50 (OR=2.04, 95%CI: 1.37-3.04), and those with persistent symptoms despite a gluten-free diet (OR=1.94, 95%CI: 1.44-2.63) were more likely to use probiotics.

CONCLUSION

In this large study of a national CD registry, roughly one-third of CD patients reported using probiotics. Patients diagnosed later in life were more likely to use probiotics and those who remained symptomatic despite a gluten-free diet were twice as likely to take probiotics. Patients may be seeking additional means of treatment for persistent symptoms.

Identification of Lung Transplant Recipients with a Survival Benefit after Fundoplication

BACKGROUND

Gastroesophageal reflux disease (GERD) and aspiration of enteric contents is associated with worse outcomes after lung transplant. The purpose of this study is to elucidate populations that benefit the most from fundoplication after lung transplant.

METHODS

Lung transplants from 2001-2019 (n=971) were retrospectively reviewed and stratified by a fundoplication before (n=128) or after (n=24) chronic lung allograft dysfunction (CLAD) development vs those who didn't. Patients with a fundoplication prior to CLAD were propensity-matched to those without a fundoplication. The primary outcome of interest was post-transplant survival. Time-to-event rates were calculated using a multivariable Cox proportional hazards model and Kaplan-Meier functions.

RESULTS

A fundoplication prior to CLAD improved post-transplant survival before and after propensity-matching, and remained a significant predictor after adjusting for baseline characteristics (HR:0.57, 95% CI:0.4-0.8, P=0.001). Recipients with a restrictive disorder (HR: 0.46, 95% CI:0.3-0.73, P=0.001), age <65 (HR:0.48, 95% CI:0.32-0.71, P<0.001), and both single (HR:0.47, 95% CI:0.28-0.79, P=0.005) or double (HR:0.55, 95% CI:0.32-0.93, P=0.027) lung transplants had a significant decrease in mortality after fundoplication. The effect was present after excluding early deaths and/or CLAD diagnoses. GERD diagnosed by pH, impedance or EGD was not associated with worse outcomes. Among patients with CLAD, a fundoplication was an independent predictor of post-CLAD survival (HR:0.27, 95% CI:0.12-0.61, P=0.002).

CONCLUSIONS

A fundoplication before or after CLAD development is an independent predictor of survival. Younger patients with restrictive disease, independent of the type of transplant, have a survival benefit. GERD diagnosed by conventional methods was not associated with worse survival.

Characteristics and Outcomes of Endoscopies before and during the COVID-19 Pandemic in New York

INTRODUCTION

The COVID-19 pandemic drastically changed hospital workflows. This study aimed to characterize differences in gastrointestinal endoscopies in the New York metropolitan region before, during, and after the first wave of the pandemic.

METHODS

Across 3 hospitals, we compared demographics, indications, and yield of endoscopies before and after March 16, 2020, the date on which elective procedures were canceled, as well as a recovery period for 5 months after they were resumed.

RESULTS

A total of 9,401 procedures before and 332 procedures during the first wave were performed. Females comprised 57 and 44% of patients (p < 0.01), respectively. There was a decline in the proportion of Black (15 vs. 7%, p < 0.02) and Hispanic patients (29 vs. 16%, p < 0.02) undergoing outpatient procedures. There was a significant rise in urgent indications such as bleeding and jaundice. There was an increase in the diagnostic yield of all esophagogastroduodenoscopies for bleeding (p < 0.01) and of outpatient endoscopic ultrasounds for malignancy (p = 0.01), but no increase in yield of inpatient colonoscopy for bleeding. A review of 7,475 procedures during the recovery period showed a return to many nonurgent indications, but still showed decreased proportions of Hispanic and male patients compared to the prepandemic period.

DISCUSSION/CONCLUSION

Lower proportions of Black and Hispanic patients underwent outpatient endoscopies during and after the first wave. The proportion of procedures done for emergent indications and their diagnostic yield increased during the pandemic, suggesting a higher threshold to perform endoscopy. In resource-sparing conditions, clinicians should pay attention to thresholds to perform colonoscopy for bleeding and to racial disparities in outpatient healthcare access.

Characteristics and Maternal-Fetal Outcomes of Pregnant Women Without Celiac Disease Who Avoid Gluten

BACKGROUND

Gluten avoidance among patients without celiac disease has become increasingly popular, especially among young and female demographics; however, no research has explored gluten avoidance during pregnancy, when nutrition is particularly important.

AIMS

To determine whether avoiding gluten in pregnancy is associated with any medical, obstetric, or neonatal characteristics.

METHODS

In this single-center retrospective cohort study, we identified women with singleton pregnancies who avoid gluten based on antenatal intake questionnaire responses and inpatient dietary orders, excluding those with celiac disease. Certain demographic, medical, obstetric, and neonatal characteristics were compared to matched controls who do not avoid gluten.

RESULTS

From July 1, 2011 to July 1, 2019, 138 pregnant women who avoid gluten were admitted for delivery of singleton gestations. Compared to controls, gluten-avoidant women had fewer prior pregnancies (p = 0.005), deliveries (p < 0.0005), and living children (p < 0.0005), higher rates of hypothyroidism (OR = 3.22; p = 0.001) and irritable bowel syndrome (OR = 6.00; p = 0.019), higher second trimester hemoglobin (p = 0.018), and lower body mass index at delivery (p = 0.045). Groups did not differ in any obstetric or fetal characteristics.

CONCLUSIONS

Gluten avoidance in pregnancy is common and, in women without celiac disease, is associated with higher rates of hypothyroidism and irritable bowel syndrome, fewer pregnancies, term births, and living children, and lower peripartum BMI, but is not associated with any obstetric or neonatal comorbidities. Avoiding gluten does not appear to adversely affect maternal or fetal health, but reasons for gluten avoidance, as well as long-term maternal and pediatric outcomes after gluten avoidance in pregnancy, warrant further study.

Minor Hematochezia Decreases Use of Venous Thromboembolism Prophylaxis in Patients with Inflammatory Bowel Disease

BACKGROUND

Despite increased risk of venous thromboembolism (VTE) among hospitalized patients with inflammatory bowel disease (IBD), pharmacologic prophylaxis rates remain low. We sought to understand the reasons for this by assessing factors associated with VTE prophylaxis in patients with IBD and the safety of its use.

METHODS

This was a retrospective cohort study conducted among patients hospitalized between January 2013 and August 2018. The primary outcome was VTE prophylaxis, and exposures of interest included acute and chronic bleeding. Medical records were parsed electronically for covariables, and logistic regression was used to assess factors associated with VTE prophylaxis.

RESULTS

There were 22,499 patients studied, including 474 (2%) with IBD. Patients with IBD were less likely to be placed on VTE prophylaxis (79% with IBD, 87% without IBD), particularly if hematochezia was present (57% with hematochezia, 86% without hematochezia). Among patients with IBD, admission to a medical service and hematochezia (adjusted odds ratio 0.27; 95% CI, 0.16-0.46) were among the strongest independent predictors of decreased VTE prophylaxis use. Neither hematochezia nor VTE prophylaxis was associated with increased blood transfusion rates or with a clinically significant decline in hemoglobin level during hospitalization.

CONCLUSION

Hospitalized patients are less likely to be placed on VTE prophylaxis if they have IBD, and hematochezia may drive this. Hematochezia appeared to be minor and was unaffected by VTE prophylaxis. Education related to the safety of VTE prophylaxis in the setting of minor hematochezia may be a high-yield way to increase VTE prophylaxis rates in patients with IBD.

Strategies for Effective Discontinuation of Proton Pump Inhibitors

PURPOSE OF REVIEW

Proton pump inhibitors (PPIs) are effective for many conditions but are often overprescribed. Recent concerns about long-term risks have made patients re-evaluate their need to take PPIs chronically, though these population-based studies have methodological weaknesses. The goal of this review is to provide evidenced-based strategies for discontinuation of PPI therapy.

RECENT FINDINGS

Given that some patients experience rebound symptoms when abruptly stopping continuous PPI therapy due to its effect on hypergastrinemia, strategies focus on avoiding rebound. Tapering the PPI and then initiating a "step-down" approach with the use of alternative medications may be effective. "On-demand therapy" provides patients with the option to take intermittent PPI courses, reducing overall use and cost while preserving patient satisfaction. It is important for providers to consider ambulatory pH or pH/impedance testing to rule out diagnoses that may require alternative medications like neuromodulators. A number of studies reviewed here can provide guidance in counseling patients on PPI discontinuation. It is important for the provider to obtain a baseline needs assessment for PPI therapy and to elucidate predictors of difficulty in discontinuation prior to initiating a strategy.