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Direct percutaneous endoscopic jejunostomy (DPEJ) provides post-pyloric enteral access in patients unable to meet long-term nutritional needs per os in situations where gastric feeding is neither tolerated nor feasible. Specific conditions associated with feeding intolerance due to due to nausea, vomiting, or ileus include gastric outlet obstruction, gastroparesis, or complications of acute or chronic pancreatitis; infeasibility may be due to high aspiration risk or prior gastric surgery. Since performing DPEJ is not an ACGME requirement for GI fellows or early career gastroenterologists, not all trainees are taught this technique. Hence, provider expertise for teaching and performing this technique varies widely across centers. In this article, we provide top tips for successful performance of DPEJ. [ABSTRACT FROM AUTHOR]

The benefits of large-scale genetic studies for healthcare of the populations studied are well documented, but these genetic studies have traditionally ignored people from some parts of the world, such as South Asia. Here we describe whole genome sequence (WGS) data from 4806 individuals recruited from the healthcare delivery systems of Pakistan, India and Bangladesh, combined with WGS from 927 individuals from isolated South Asian populations. We characterize population structure in South Asia and describe a genotyping array (SARGAM) and imputation reference panel that are optimized for South Asian genomes. We find evidence for high rates of reproductive isolation, endogamy and consanguinity that vary across the subcontinent and that lead to levels of rare homozygotes that reach 100 times that seen in outbred populations. Founder effects increase the power to associate functional variants with disease processes and make South Asia a uniquely powerful place for population-scale genetic studies. South Asia is home to almost 2 billion people but is extremely underrepresented in human genetics. This study uses genomes from ~5,000 South Asians to characterize genetic variation and help facilitate future South Asian genetic studies. [ABSTRACT FROM AUTHOR]

Targeted high-throughput DNA sequencing is a primary approach for genomics and molecular diagnostics, and more recently as a readout for DNA information storage. Oligonucleotide probes used to enrich gene loci of interest have different hybridization kinetics, resulting in non-uniform coverage that increases sequencing costs and decreases sequencing sensitivities. Here, we present a deep learning model (DLM) for predicting Next-Generation Sequencing (NGS) depth from DNA probe sequences. Our DLM includes a bidirectional recurrent neural network that takes as input both DNA nucleotide identities as well as the calculated probability of the nucleotide being unpaired. We apply our DLM to three different NGS panels: a 39,145-plex panel for human single nucleotide polymorphisms (SNP), a 2000-plex panel for human long non-coding RNA (lncRNA), and a 7373-plex panel targeting non-human sequences for DNA information storage. In cross-validation, our DLM predicts sequencing depth to within a factor of 3 with 93% accuracy for the SNP panel, and 99% accuracy for the non-human panel. In independent testing, the DLM predicts the lncRNA panel with 89% accuracy when trained on the SNP panel. The same model is also effective at predicting the measured single-plex kinetic rate constants of DNA hybridization and strand displacement. DNA probes used in next generation sequencing (NGS) have variable hybridisation kinetics, resulting in non-uniform coverage. Here, the authors develop a deep learning model to predict NGS depth using DNA probe sequences and apply to human and non-human sequencing panels. [ABSTRACT FROM AUTHOR]

The aim of this study was to test the effects of CPAP on moderately sedated patients undergoing colonoscopy. Our hypothesis was that CPAP can reduce the incidence and duration of obstructive apnea and hemoglobin oxygen desaturation in patients undergoing procedural sedation for colonoscopy. Two groups of consenting adult patients scheduled to undergo routine colonoscopy procedures and sedated with propofol and fentanyl were monitored in this study: control and intervention. Patients in the intervention group were connected via a facemask to a ventilator that delivered supplemental oxygen (100%) through a standard air-cushion mask. The mask had a built-in leak to facilitate CO2 clearance during CPAP. Patients in the control group received 2-10 L/min of oxygen via nasal cannula or non-rebreather mask. Subjects in the control group were collected in a prior study and used as historical controls. The primary outcome measures were the number of apneic events and the cumulative duration of apneic events. An apneic event was defined as a period longer than 10 s without respiration. The secondary outcome was the area under the curve (AUC) for the arterial oxygen saturation less than 90% versus time during sedative and analgesic administration (time (s) below threshold multiplied by percent below threshold). A desaturation event was defined as a period of time during which arterial oxygen saturation was less than 90%. 29 patients were enrolled in the intervention group and 156 patients were previously enrolled in the control group as part of an earlier study. The median number of apneic events in the control group was 7 compared to 0 in the intervention group. The intervention group experienced apnea less than 1% of the total procedure time compared to 17% in the control group (p < 0.001). There were no desaturation events observed in the 29 patients in the intervention group. In contrast, 27 out of 156 patients in the control group experienced a desaturation event. Average AUC of patients in the control group was 70%-s (time (s) * oxygen saturation below < 90%) (95% CI 32.34-108.60%) whereas the average AUC in intervention group patients was 0%-s (% time (s) * oxygen saturation < 90%) (95% CI 0-0%), p = 0.01. This preliminary study found that CPAP via a tight-fitting mask may be an effective tool to reduce the incidence and duration of obstructive apneic events as well as hemoglobin oxygen desaturation during lower endoscopy procedures that use propofol and fentanyl for sedation.Clinical Trial Registration ClinicalTrials.gov ID: NCT02623270. https://clinicaltrials.gov/ct2/show/NCT02623270 . [ABSTRACT FROM AUTHOR]

Background: Inadequate bowel preparation is the most common cause of failed colonoscopy, and repeat failure occurs in more than 20 % of follow-up attempts. Limited data suggest that next-day follow-up may reduce the risk for repeat inadequate preparation.Objective: Evaluate differences in prep quality with next-day follow-up after initial inadequate preparation.Design: Retrospective study.Setting: Academic center.Patients: Outpatient screening and surveillance colonoscopies between 7/2002 and 6/2007.Intervention: Comparison of next-day versus any other day ("non-next-day") repeat colonoscopy outcomes.Main Outcome Measurements: Aronchick scale, polyp and adenoma detection rates.Results: Of 20,798 initial colonoscopies, 857 (4.1 %) had inadequate preparation. 460 (54 %) were lost to follow-up. One hundred and fourteen (13 %) had next-day and 283 (33 %) had non-next-day colonoscopy with mean follow-up of 8.8 months. On follow-up examination, 29.8 % of next-day and 23.3 % of non-next-day colonoscopies had inadequate bowel preparation (p = 0.48). The adenoma detection rate for the next-day group improved from 3.5 to 38.6 % on follow-up, compared to 20.5 and 36.8 % in the non-next-day group. There was no significant difference between groups in detection of total adenoma (p = 0.73) or advanced adenomas (p = 0.20) on follow-up examinations.Limitations: Retrospective design, differences in baseline colonoscopy characteristics.Conclusion: The results confirm the need for repeat examination after a colonoscopy with inadequate bowel prep, as there was substantial increase in adenoma detection on follow-up. There were no differences in outcomes between next-day versus non-next-day colonoscopy. These data support repeating after inadequate colonoscopy within 1 year as convenient for patient and physician. [ABSTRACT FROM AUTHOR]

Background: Esophagogastroduodenoscopy (EGD) procedures are performed frequently to evaluate gastrointestinal disease and symptoms.Aim: To determine regional practice variability of repeat EGDs in a national population.Methods: The study sample included US Veterans with an outpatient index EGD from 1/1/2008 to 12/2010. We determined risk of repeat endoscopy from 1/2008 to 10/1/2014. A logistic regression model was used to assess the association between the odds of repeated EGD and patient demographics, ICD diagnostic codes, and geographic region. Multivariable logistic regression was performed to obtain the adjusted odds ratio and predicted probabilities of repeat EGDs by region.Results: A total of 202,086 patients had an index endoscopy from 1/2008 to 12/2010. Unique patients with an index endoscopy were predominantly male (93.2%), white (72.8%), and on average 61 years. A total of 58,469 patients (28.9%) had one or more repeat EGDs, accounting for 103,253 repeat procedures through 10/2014. ICD-9-CM codes associated with increased risk of repeat procedures were Barrett's esophagus (OR 3.6, 95% CI 3.5-3.7), dysphagia (OR 1.3, 95% CI 1.2-1.3), ulcer (OR 1.3, 95% CI 2.2-2.4), stricture (OR 1.8, 95% CI 1.7-1.9), and esophageal varices (OR 2.8, 95% CI 2.7-3.0). There was a significant difference in the probability of repeat EGD by VA region, with the Midwest region having the highest probability (31.2%) and Southeast the lowest probability (27.3%). This difference would account for 400 more EGD procedures per 10,000 Veterans, after adjusting for patient demographics and diagnosis codes.Conclusions: Regional practice variability accounts for a substantial volume of repeat EGD procedures, regardless of patient characteristics and associated diagnoses. [ABSTRACT FROM AUTHOR]

Endoscopic bariatric therapies are predicted to become much more widely used in North America for obese patients who are not candidates for bariatric surgery. Of all the endoscopic bariatric therapies, intragastric balloons (IGBs) have the greatest amount of clinical experience and published data supporting their use. Three IGBs are FDA approved and are now commercially available in the USA (Orbera, ReShape Duo, and Obalon) with others likely soon to follow. They are generally indicated for patients whose BMI ranges from 30 to 40 mg/kg2 and who have failed to lose weight with diet and exercise. IGBs have been shown to be safe, effective, and relatively straightforward to place and remove. Accommodative symptoms commonly occur within the initial weeks post-placement; however, major complications are rare. Gastric ulceration can occur in up to 10% of patients, while balloon deflation with migration and bowel obstruction occurs in <1% of patients. The effectiveness of the Orbera and ReShape Duo IGBs ranges from 25 to 50% EWL (excess weight loss) after 6 months of therapy. The use of IGBs is likely to grow dramatically in the USA, and gastroenterologists and endoscopists should be familiar with their indications/contraindications, efficacy, placement/removal, and complications. [ABSTRACT FROM AUTHOR]

Background: Non-anesthesia administered propofol (NAAP) has been shown to be a safe and effective method of sedation for patients undergoing gastrointestinal endoscopy. Bariatric surgery patients are potentially at a higher risk for sedation-related complications due to co-morbidities including obstructive sleep apnea. The outcomes of NAAP in bariatric patients have not been previously reported. Methods: In this retrospective cohort study, severely obese patients undergoing pre-surgical outpatient esophagogastroduodenoscopy (EGD) were compared to non-obese control patients (BMI ≤ 25 kg/m) undergoing diagnostic EGD at our institution from March 2011-September 2015 using our endoscopy database. Patients' demographics and procedural and recovery data, including any airway interventions, were statistically analyzed. Results: We included 130 consecutive pre-operative bariatric surgical patients with average BMI 45.8 kg/m (range 34-80) and 265 control patients with average BMI 21.9 kg/m (range 14-25). The severely obese group had a higher prevalence of sleep apnea (62 vs 8%; p < 0.001), experienced more oxygen desaturations (22 vs 7%; p < 0.001), and received more chin lift maneuvers (20 vs 6%; p < 0.001). Advanced airway interventions were rarely required in either group and were not more frequent in the bariatric group. Conclusions: With appropriate training of endoscopy personnel, NAAP is a safe method of sedation in severely obese patients undergoing outpatient upper endoscopy. [ABSTRACT FROM AUTHOR]

Background: Eosinophilic esophagitis (EoE) remains difficult to classify because of varying presentations. Not uncommonly, patients present with symptoms of esophageal dysfunction and have esophageal changes on endoscopy resembling EoE but without >15 eosinophils/HPF. Patients with low numbers of eosinophils in esophageal biopsy specimens may have esophageal changes and symptomatic disease brought about by eosinophil granule protein deposition without recognizable intact cells. Aim: To determine whether extracellular eosinophil granule protein deposition is present in the esophagi of patients with low eosinophil numbers who have clinical symptoms and characteristic endoscopic esophageal changes of EoE including ringed esophagus (RE). Methods: Esophageal biopsy specimens were studied from eight EoE patients with >15 eosinophils per high power field (HPF) and nine patients with RE (<15 eosinophils/HPF). The specimens were analyzed for eosinophil granule proteins, major basic protein 1 (eMBP1) and eosinophil-derived neurotoxin (EDN), by indirect immunofluorescence. Results: Both EoE and RE showed positive EDN and eMBP1 extracellular deposition; control esophagus showed minimal or none. Comparing EoE and RE, extracellular EDN and eMBP1 were similar except that EDN in EoE was greater in the distal esophagus. Conclusions: This study highlights the importance of assessing eosinophil granule protein deposition in esophageal disease with potential eosinophil involvement. Persistent/progressive esophageal changes may be brought about by eosinophil granule proteins despite low numbers of intact cells. The meaning of 'resolution' in EoE may need to be redefined based on numbers of esophageal eosinophils, extracellular eosinophil granule protein deposition, and subsequent clinical course of patients. [ABSTRACT FROM AUTHOR]

Background and Aim: Obstructive jaundice caused by distal biliary obstruction can present in up to 70 % of patients with localized cancer of the head of the pancreas. The aim of this study was to report our experience in using self-expanding metal stents (SEMS) for preoperative biliary decompression in patients with resectable and borderline resectable carcinoma of the pancreatic head. Methods: We performed a retrospective study evaluating patients from two tertiary referral centers. Two-hundred and forty-one patients with resectable and borderline resectable pancreatic carcinoma underwent ERCP with metal biliary stent placement between September 2006 and August 2011. We assessed the effectiveness of SEMS to adequately decompress the biliary tree, procedural success, patient survival, stent patency, and stent-related complications. Results: Two-hundred and forty-one patients were evaluated [123 male, mean age (±SD) 67.4 ± 9.8 years; resectable 174, borderline resectable 67]. Patients with borderline-resectable cancer underwent neoadjuvant therapy and restaging before possible curative surgery. Successful placement of a metal biliary stent was achieved in all patients and improved jaundice. Patients were followed for mean duration of 6.3 months. The overall survival was 49 % at 27 months. Fourteen (5.8 %) patients experienced stent occlusion; the mean time to stent occlusion was 6.6 (range 1-20) months. Immediate complications included: post-ERCP pancreatitis ( n = 14), stent migration ( n = 3), and duodenal perforation ( n = 3). Long-term complications included stent migration ( n = 9) and hepatic abscess ( n = 1). A total of 144/174 patients deemed to have resectable cancer at time of diagnosis underwent curative surgery. Due to disease progression or the discovery of metastasis after neoadjuvant therapy, only 22/67 patients with borderline-resectable cancer underwent curative surgery. Conclusions: SEMS should be considered for patients with obstructive jaundice and resectable or borderline resectable pancreatic cancer, especially if surgery is not planned immediately as a result of preoperative chemoradiation. These stents appear to be safe and effective. [ABSTRACT FROM AUTHOR]

OBJECTIVES:Elemental diets have not been studied in adults with eosinophilic esophagitis (EoE). The goal of this trial was to assess the efficacy of an elemental diet in adults with EoE.METHODS:A total of 18 adults with EoE were given an elemental diet for 4 weeks, or just 2 weeks if their response was complete. Symptoms and histologic findings, based on biweekly biopsies, were monitored. Six subjects were rebiopsied 2-7 days after resuming a normal diet.RESULTS:After therapy, esophageal tissue eosinophil content decreased from 54 to 10 per maximal high power field (P=0.0006). There was complete or nearly complete response (≤10 eosinophils) in 72% of subjects. Mast cell content, parabasal layer thickness, and endoscopic furrows and exudates also significantly decreased. Of the 29 qualified subjects, 11 (38%) failed to adhere to the diet. Several subjects had significant weight loss. Symptoms and endoscopic fixed strictures did not improve. After the subjects resumed a normal diet, the eosinophil content increased substantially in 3-7 days.CONCLUSIONS:While symptoms did not improve and dietary compliance was problematic, there was substantial histologic improvement after 4 weeks on the elemental diet. EoE in adults is substantially triggered by foods. [ABSTRACT FROM AUTHOR]

Background: The overwhelming majority of reported duodenal and colonic SEMS placements in the literature have used the 0.035″ guidewire almost to the exclusion of guidewires of other diameters.Aims: The purpose of this study was to compare technical and clinical outcomes in patients undergoing duodenal or colonic SEMS placement with 0.025″ or 0.035″ guidewires.Methods: This was a retrospective study to compare technical and clinical outcomes and complications of patients receiving duodenal or colonic SEMS placement with a 0.035″ guidewire to those undergoing placement with a 0.025″ guidewire.Results: A total of 34 duodenal and 30 colonic stent placement procedures were performed in 59 patients. Technical success was achieved in all duodenal stent placement procedures. The difference in mean GOOSS score increase after stent placement was not statistically significant between the 0.035″ and 0.025″ guidewire groups (P = 0.49). Complications were not statistically significantly different between the two groups undergoing gastroduodenal stenting. Technical and clinical success was achieved in all colonic stent placement procedures. There were no statistically significant differences in complication rates between the two groups undergoing colonic stenting. Procedure times were not significantly different using either wire type.Conclusions: Our study shows that both 0.035″ and 0.025″ guidewires were equally effective with regards to technical success, clinical success, and with regards to the development of complications. [ABSTRACT FROM AUTHOR]

Dysphagia is a common problem and an indication for upper endoscopy. There is no data on the frequency of the different endoscopic findings and whether they change according to demographics or by single versus repeat endoscopy. To determine the prevalence of endoscopic findings in patients with dysphagia and whether findings differ in regard to age, gender, ethnicity, and repeat procedure. This was a retrospective study using a national endoscopic database (CORI). A total of 30,377 patients underwent esophagogastroduodenoscopy (EGD) for dysphagia of which 4,202 patients were repeat endoscopies. Overall frequency of endoscopic findings was determined by gender, age, ethnicity, and single vs. repeat procedures. Esophageal stricture was the most common finding followed by normal, esophagitis/ulcer (EU), Schatzki ring (SR), esophageal food impaction (EFI), and suspected malignancy. Males were more likely to undergo repeat endoscopies and more likely to have stricture, EU, EFI, and suspected malignancy ( P = 0.001). Patients 60 years or older had a higher prevalence of stricture, EU, SR, and suspected malignancy ( P < 0.0001). Esophageal stricture was most common in white non-Hispanic patients compared to other ethnic groups. In patients undergoing repeat EGD, stricture, SR, EFI, and suspected malignancy were more common ( P < 0.0001). The prevalence of endoscopic findings differs significantly by gender, age, and repeat procedure. The most common findings in descending order were stricture, normal, EU, SR, EFI, and suspected malignancy. For patients undergoing a repeat procedure, normal and EU were less common and all other abnormal findings were significantly more common. [ABSTRACT FROM AUTHOR]

Background: Radiofrequency atrial fibrillation ablation (AFA) is commonly performed in patients with atrial fibrillation. It is imperative to develop a strategy for the early detection of esophageal lesions secondary to AFA. The current protocol is to obtain cross-sectional imaging before and immediately after the procedure. If patients have evidence of esophageal inflammation, they undergo esophagogastroduodenoscopy (EGD). We hypothesized that esophageal abnormalities seen on imaging immediately post-ablation are a poor predictor of the damage seen during EGD.Methods: Patients referred for EGD following AFA from 1/2009 to 11/2010 were included. Two endoscopists reviewed and scored the EGD images. Two radiologists reviewed the post-AFA imaging studies. For computed tomography (CT) scans, esophageal inflammation was scored from 0 to 2. For T2 and delayed magnetic resonance imaging (MRI) pictures, esophageal enhancement was scored from 0 to 2, with the circumference involved as 0, <50%, or >50%, and the length of esophageal enhancement in mm.Results: In total, 76 patients were included; 22 patients had only endoscopic images and 54 had both endoscopic and radiologic images for review. Of the post-AFA imaging studies, 16 were CTs and 60 were MRIs. The kappa score for the inter-rater agreement of esophageal inflammation on EGD was 0.4584 (moderate). For MRIs, the kappa scores for T2 images were 0.1980 and 0.2857 for edema and circumference, respectively. For delayed images, the kappa scores were 0.2687 and 0.3101 for edema and circumference, respectively. The kappa scores were negative between EGD score by T2 edema (-0.2104) and circumference (-0.2212), and between EGD score and delayed edema (-0.0588) and circumference (-0.0446). When measures were treated as dichotomous, the overall agreement between CT measures and EGD scores was kappa = 0, for T2 measures and EGD kappa = -0.2963, 95% confidence interval (CI) (-0.5643, -0.0282), and between delayed measures kappa = -0.0244, 95% CI (-0.1420, -0.0932).Conclusions: There was no agreement between immediate imaging and the endoscopic findings of esophageal inflammation after AFA. A longer period of time between AFA and obtaining an imaging study may be useful in detecting patients with significant esophageal injury who should undergo EGD to assess for complications of AFA. Further studies are needed in order to determine the best modalities and optimal timing to detect post-AFA esophageal damage in an attempt to prevent the formation of atrial-esophageal fistulas. [ABSTRACT FROM AUTHOR]

Background: Nurse-administered propofol sedation (NAPS) is now in widespread use. The safety profile of NAPS for routine endoscopic procedures in patients with obstructive sleep apnea (OSA) is unknown.Aims: To compare outcomes of patients with and without OSA undergoing routine endoscopic procedures with NAPS and standard conscious sedation (CS) with benzodiazepines and narcotics.Methods: Retrospective cohort study.Results: A total of 215 patients were placed in one of four groups: OSA patients undergoing endoscopy with NAPS, OSA patients undergoing endoscopy with standard CS, non-OSA patients undergoing endoscopy with NAPS, and non-OSA patients undergoing endoscopy with standard CS. Procedures were generally accomplished faster with NAPS. There was no statistically significant difference in complication rates or overall outcomes in patients with OSA when compared to non-OSA patients when either NAPS or CS was utilized.Conclusions: Routine endoscopic procedures using NAPS are safe in patients with documented OSA, with complication rates comparable to when using CS. NAPS helped to decrease procedure times in general. [ABSTRACT FROM AUTHOR]

Expertise in enteral nutrition (EN) is an important aspect of the skill set of the clinical gastroenterologist. Delivery of adequate EN in critically ill patients is an active therapy that attenuates the metabolic response to stress and favorably modulates the immune system. EN is less expensive than parenteral nutrition and is favored in most cases because of improvement in patient outcomes, including infections and length of stay. Newer endoscopic techniques for placing nasoenteric feeding tubes have been developed, which improve placement success and efficiency. It appears that there is an ideal window period of 24-48 h when enteral feeding should be started in critically ill patients. Most patients can be fed into the stomach, but certain groups may benefit from small bowel feeding. Protocols on how to start and monitor enteral feeding have been developed. Immune-modulating feeding formulations also appear to be beneficial in specific patient populations. The gastroenterologist is a crucial member of the multidisciplinary team for nutritional support in the intensive care unit patient, with his knowledge of gastrointestinal pathophysiology, nutrition, and endoscopic feeding-tube placement. [ABSTRACT FROM AUTHOR]

OBJECTIVES:We conducted a nationwide survey of US gastroenterology fellows to identify key demographic and job-related factors relevant to the decision between an academic and a non-academic career.METHODS:A survey was e-mailed to all US GI fellowship program directors and distributed at fellows’ endoscopy courses. Data were evaluated via univariate and multivariate analysis.RESULTS:One hundred eighty-four fellows completed surveys. Univariate analysis identified one factor that predisposed fellows to pursue non-academic practice: the perception that a non-academic salary would meet their financial needs. Four factors were identified that predisposed fellows to pursue academic practice: age >35 years, prior attainment of a master’s or a PhD degree, and advanced fellowship. All factors were significant on multivariate analysis. If salaries were equal, 60% of respondents would choose academic over non-academic practice. Fellows selecting academic practice were motivated to publish and conduct research. Level of debt and a positive relationship with a mentor were not significant factors.CONCLUSIONS:Fellows desiring more money strongly favor non-academic practice. Fellows choosing academic practice tend to be older, plan to pursue advanced training, desire fewer work hours per week, and have a higher rate of prior graduate study. If salaries were equal in academic medicine and non-academic practice, the majority of fellows would choose academic medicine. [ABSTRACT FROM AUTHOR]

Background: Both gastroesophageal reflux disease and allergy/atopy have been implicated in the pathogenesis of eosinophilic esophagitis (EoE). There are no prospective studies comparing treatment of EoE with acid suppression versus topical corticosteroids.Objective: To determine the outcome of adult eosinophilic esophagitis patients treated with esomeprazole versus topical fluticasone.Design: Prospective randomized controlled trial.Setting: Academic medical center.Participants: Adults (18-80) diagnosed with EoE by symptoms of dysphagia and esophageal biopsies with >or=15 eosinophils/hpf.Interventions: Subjects were randomized to esomeprazole (40 mg by mouth every morning) or aerosolized, swallowed fluticasone (440 mcg by mouth twice a day) for 8 weeks.Main Outcome Measurements: Improvement in dysphagia (8-point scale), esophageal eosinophil infiltration before and after treatment, prevalence of GERD measured by validated questionnaire and baseline pH study.Results: About 56% (14/25) had acid reflux by pH study. There was no difference between treatment groups in improvement in dysphagia scores [3/12 (25%) of the esomeprazole group versus 6/12 (50%) in the fluticasone group, P = 0.40]. Eosinophil infiltration decreased with treatment in both groups, and there was no difference in the amount of decrease between groups (P = 0.70).Limitations: Small sample size, unexpectedly high drop-out rate.Conclusions: Gastroesophageal reflux disease is common in adult eosinophilic esophagitis patients. Dysphagia improves and esophageal eosinophilic infiltration decreases with either treatment. There was no difference in degree of improvement in dysphagia or eosinophil infiltration in patients treated with either topical fluticasone or oral esomeprazole. GERD may be important in the pathogenesis of adult EoE. [ABSTRACT FROM AUTHOR]

Background: Exercise-triggered asthma (ETA) develops when physical activity triggers asthma symptoms during or directly after exercise. In patients prone to symptoms of supra-esophageal reflux, exercise may trigger gastroesophageal reflux (GER), resulting in such symptoms.Aims: To determine the prevalence of abnormal pH in patients with ETA and to determine whether acid suppression improves symptoms in ETA patients.Methods: We performed a randomized double-blind trial of rabeprazole versus placebo in the treatment of patients with ETA. Patients underwent treadmill protocol to determine their VO(2 max). Next, pH testing was initiated while undergoing a 30-min treadmill program exercising them at 65% of their VO(2 max). They were subsequently randomized to rabeprazole or placebo for 10 weeks. At the end of 10 weeks, exercise testing was repeated.Results: A total of 31 patients completed the study (20 asthmatics, 11 non-asthmatics). Twenty-two out of 30 (73%) subjects had abnormal pH studies. For all subjects, rabeprazole improved symptoms more than placebo (P = 0.03). The association was stronger in the pH-positive group (P = 0.009).Conclusion: Acid reflux is common in ETA patients. Many patients with exercise-related respiratory symptoms are misdiagnosed as chronic asthmatics. Exercise-related symptoms improve with the use of acid suppression. This study suggests that ETA patients may benefit from acid suppression. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Most colorectal cancers (CRCs) arise from adenomatous polyps, but the effects of CRC family history on adenoma risk are not well known. This issue is clinically relevant since several medical societies currently recommend earlier and more rigorous colorectal screening for individuals with a strong family history of CRC. METHODS: Colonoscopies were performed in 236 first-, second-, and third-degree relatives of 40 index CRC cases from six large kindreds selected from a large population database. The kindreds were selected for significantly greater risk of CRCs compared with the overall population. Known hereditary colon cancer syndromes were clinically and genetically excluded. RESULTS: Thirty-seven percent of relatives were found to have adenomas on colonoscopy. The average age of diagnosis for colon cancer was 63 yr and advanced adenomas 56 yr. Independent predictors of adenomatous polyps in the relatives were advancing age ( P < 0.0001), male gender ( P < 0.001), and greater degree of relation to CRC cases ( P < 0.01). There was no significant predilection of colorectal tumors for the right or left colon. A higher degree of relationship to CRC cases was a significant predictor of having simple and advanced adenomas, but not hyperplastic polyps after adjustment for age and gender. CONCLUSIONS: These data support the current recommendations for colonoscopy starting before the age of 50 yr in individuals with a strong family history of CRC. [ABSTRACT FROM AUTHOR]

Clinical gastrointestinal manometry studies are currently performed with multilumen water-perfused polyvinyl or strain gauge sensor solid-state catheters. A disposable catheter incorporating air-filled balloons has been developed with performance characteristics suitable for esophageal and anorectal manometry studies. Our aim was to compare esophageal and anorectal pressure measurements using this newly developed catheter with measurements obtained using standard solid-state or water-perfused catheters. Measurements of resting LES pressure, esophageal contraction amplitudes, and anorectal rest and squeeze pressures were obtained in 10 healthy volunteers using a solid-state esophageal catheter, a water-perfused anorectal catheter, and air-filled balloon esophageal and anorectal catheters. Correlation coefficient analysis demonstrated that LES pressures, esophageal contraction amplitudes, and anorectal resting and squeeze pressures were not significantly among between the different catheters. We conclude that recently developed air-filled balloon esophageal and anorectal manometry catheters provide very similar measurements of LES, esophageal body, and anorectal sphincter pressures compared to presently used manometry catheters. [ABSTRACT FROM AUTHOR]

Most patients with acute pancreatitis have mild to moderate disease and require no specialized nutritional support. Twenty percent to 30% have severe cases, resulting in a catabolic hypermetabolic state, and these patients may require early aggressive nutritional support. Traditionally, this support has been in the form of total parenteral nutrition. However, recent data suggest that enteral nutrition infused into the jejunum is feasible, well tolerated, associated with fewer complications, and significantly less expensive than parenteral nutrition. The pathophysiology of gut function in acute pancreatitis and the rationale and evidence for parenteral and enteral nutritional support are reviewed herein. An algorithm on the nutritional management of acute pancreatitis is suggested. [ABSTRACT FROM AUTHOR]

Approximately 30% of coronary angiograms performed in this country are negative for significant coronary artery disease. These patients are classified as having noncardiac or unexplained chest pain (UCP). Despite the good overall prognosis, this condition has significant morbidity and costs. The pathophysiology of this condition is likely caused by overlapping cardiac, esophageal, and psychiatric abnormalities with visceral hyperalgesia playing a central role. Gastroenterologists are often consulted in the evaluation of these patients because esophageal disorders are among the most common conditions associated with UCP. However, clinical symptoms are unreliable in differentiating between esophageal and cardiac causes of UCP. Gastroesophageal reflux disease, not esophageal motility disorders, is the most common esophageal disorder present in patients with UCP. The most useful diagnostic test in the evaluation of UCP is 24-h pH monitoring. An initial empiric trial of high-dose acid suppression is the most cost-effective intervention in the management of these patients. A clinical algorithm is suggested for the evaluation and treatment of UCP. [ABSTRACT FROM AUTHOR]

A prospective, randomized study was conducted to determine whether preoperative esophageal dysmotility affects clinical outcome of gastroesophageal reflux disease (GERD) after laparoscopic fundoplication and whether esophageal motor function changes postoperatively. Two hundred patients with chronic GERD referred for laparoscopic fundoplication underwent clinical assessment, esophagogastroduodenoscopy, esophageal manometry, and 24-h pH monitoring. Patients were stratified according to presence or absence of esophageal dysmotility (100 in each group) and randomized to either a 360° (Nissen) or a 270° (Toupet) fundoplication. This resulted in 50 patients with normal motility and 50 patients with dysmotility undergoing Nissen fundoplications and Toupet fundoplications, respectively. Esophageal dysmotility was defined as primary peristalsis of ≤40% and/or mean distal esophageal pressure of <40 mm Hg. All preoperative tests were repeated 4 months postoperatively.Pre-operative dysmotility was associated with more severe and medically refractory GERD with lower resting LES pressures than normal motility. Postoperative clinical outcome and reflux recurrence were similar and independent of preoperative motility. Reflux recurred in 14% of normal motility patients (four Toupet, 10 Nissen) and 21% of dysmotility patients (11 Toupet, 10 Nissen). Postoperative dysphagia was unrelated to preoperative esophageal motor function (30 normal motility, 31 dysmotility) but dependent on the type of fundoplication (44 Nissen and 17 Toupet patients developed dysphagia). Esophageal motility changed from pathological to normal in 10% and normal to pathological in 5%, with the remaining 85% unchanged. The authors concluded that esophageal dysmotility reflects more severe disease, does not affect postoperative clinical outcome, is not corrected by fundoplication, and requires no tailoring of the surgical procedure. [Copyright &y& Elsevier]

A response by Douglas G. Adler, Kristen Hilden, and John Fang to a letter to the editor about their article "What drives U.S. gastroenterology fellows to pursue academic vs. non-academic careers?: results of a national survey" in the 2010 issue is presented.

The purpose of the study was to estimate the cost-effectiveness of gastric bypass in the treatment of severe obesity (body mass index > 40). A deterministic decision analysis that compared the lifetime expected costs and outcomes between open gastric bypass and no treatment of severe obesity from the payer perspective was performed. Men and women between the ages of 35 and 55 yr, with body mass index between 40 and 50 kg/m2, who did not have cardiac disease and who failed conservative treatment, including pharmacotherapy, were included. Cost-effectiveness ratio of the base case conditions was made with parameter estimates from the literature and expert discussion and expressed as cost per quality-adjusted life-years (QALY). One- and two-way sensitivity analyses were performed on selected variables.Gastric bypass was not cost-saving, because the reduction in lifetime medical costs was less than the cost of treatment in any subgroup. The base case cost-effectiveness ratios ranged from $5,400 to $16,100 for women and from $10,700 to $35,600 per QALY for men. Sensitivity analysis demonstrated that in older, less obese men, the cost effectiveness ratio was responsive to the amount of weight lost, obesity-related quality of life, and complication rates. Parameter variation did not significantly affect cost-effectiveness ratios in the remaining patients. The authors concluded that gastric bypass is a cost-effective alternative to no treatment in the severely obese, at less than $50,000 per QALY. [Copyright &y& Elsevier]

Colonoscopy using standard adult colonoscopes can be difficult in patients with fixed, angulated sigmoid colons. An earlier study from the same center suggested that in women who have had hysterectomy, successful colonoscopy occurred with greater frequency when initiated with a pediatric colonoscope versus an adult colonoscope. This follow-up study was a nonblinded clinical trial comparing the use of a pediatric colonoscope with an adult colonoscope for routine colonoscopy in women with previous hysterectomy. A total of 100 female patients presenting for an outpatient colonoscopy were randomized to use the pediatric (Olympus PCF-100) or adult (Olympus CF-100L or CF-Q140L) colonoscope.The primary outcome was the comparative rate of cecal intubation. Secondary outcomes included total procedure time, cecal insertion time, sedative administration, procedural difficulty, and patients’ experience. Endoscopists encountering difficult insertion had the opportunity to use the alternate scope. The cecum was reached in 49 of 51 (96.1%) women when using the pediatric colonoscope versus 35 of 49 (71.4%) women when using the adult colonoscope. Of the 14 incomplete examinations initiated with an adult colonoscope, the pediatric colonoscope was used 12 times, and the cecum was reached in nine, adjusting the rate of successful colonoscopy to 44 of 49 (89.8%). There was no statistical difference in total procedure time, cecal insertion time, sedative drug dosages, procedural difficulty, or patient comfort using either scope.When performing routine colonoscopy in women with previous hysterectomy, the authors recommend either starting with a pediatric colonoscope or having one available in the advent of a fixed, angulated sigmoid colon. [Copyright &y& Elsevier]

A retrospective study was performed to determine the frequency of acid-related esophageal dysfunction in an unselected group of patients with nutcracker esophagus (NE). Five hundred seventy-two consecutive patients who underwent esophageal manometry and pH testing at one institution were evaluated. Forty-one percent were referred for evaluation of chest pain, 39% for reflux symptoms, and 20% for dysphagia, nausea, or epigastric pain. Esophageal manometry and 24-h pH monitoring were performed using standard methods. NE was defined as amplitude of phasic contractions of ≥180 mm Hg in any manometric tracing at any level of the esophagus. Abnormal total reflux was defined as >4% of the time with the esophageal pH < 4. A positive symptom index was defined as >50% of periods with pH < 4 coinciding with symptoms of chest pain or heartburn. Esophagitis was defined as an unequivocal mucosal defect if esophagogastroduodenoscopy was performed.Forty-five patients met criteria for NE, with acid-related abnormalities found in 77%. Forty-nine percent had abnormal acid exposure time, 16% had positive symptom indexes with normal acid exposure, and 5% had endoscopic esophagitis. An additional 7% had only an increased number of reflux episodes with normal acid exposure and symptom indexes. The prevalence of NE was significantly higher in patients referred for chest pain than for typical reflux symptoms (14.3% vs 4.5%). Seventy-four percent of the patients with NE and chest pain did not have classic reflux symptoms. Seventy-six percent of 34 evaluable subjects who had been started on acid suppression were either improved or symptom free at an average of 10.7 months of follow-up. [Copyright &y& Elsevier]

An abstract of the article "Capsule Endoscopy in Patients with Continent Ileostomy" by Ashok K. Tuteja, John C. Fang, and DiSario A. James is presented.