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Endoscopy is the mainstay treatment option for acute variceal bleeding (AVB) in liver cirrhosis. However, the optimal timing of endoscopy in such patients remains unclear.PubMed, EMBASE and Cochrane Library databases were searched. We compared the mortality, incidence of rebleeding, length of stay, endoscopic hemostasis, need for salvage and units of transfusion between cirrhotic patients with AVB who underwent early and delayed endoscopy. Meta-analyses were performed by using a random-effect model. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Subgroup analysis was performed in studies where early endoscopy was defined as12 h.Nine retrospective studies involving 2824 patients were included. The early endoscopy group had a significantly lower overall mortality than the delayed endoscopy group in overall analysis (OR = 0.56, 95% CI, 0.33-0.95, P = 0.03), but the difference between them was NS in subgroup analysis (OR = 0.72, 95% CI, 0.38-1.38, P = 0.33). In-hospital (OR = 0.77, 95% CI, 0.26-2.32, P = 0.65) and 6-week (OR = 0.78, 95% CI, 0.42-1.47, P = 0.45) mortality were not significantly different between them. Overall rebleeding was not significantly different between early and delayed endoscopy groups in both overall (OR = 0.88, 95% CI, 0.51-1.51, P = 0.63) and subgroup (OR = 1.04, 95% CI, 0.55-1.95, P = 0.90) analyses. In-hospital (OR = 1.41, 95% CI, 0.67-2.96, P = 0.37) and 6-week (OR = 0.93, 95% CI, 0.40-2.17, P = 0.86) rebleeding remained not significantly different between them. Additionally, the length of stay, endoscopic hemostasis, need for salvage and units of transfusion were not significantly different between them.Early endoscopy may improve the survival of cirrhotic patients with AVB, but has no remarkable benefit on the prevention of rebleeding. These findings should be further validated by high-quality studies.

Endoscopic management of early gastric cancer is limited by the risk of lymph node metastasis. We aimed to examine the incidence and predictors of nodal metastasis in early gastric adenocarcinoma in a large national US cohort. Cases were abstracted from the National Cancer Database from 2004 to 2016. The incidence and predictors of lymph node involvement for patients with Tis, T1a, and T1b tumors were examined. A total of 202,216 cases of gastric adenocarcinoma were identified in the NCDB. Cases with unknown patient or tumor characteristics, presence of other cancers, and prior neoadjuvant chemotherapy or radiotherapy were excluded. 1839 cases of Tis, T1a, and T1b tumors were identified. Lymph node metastases were present in 18.1% of patients. Lymphovascular invasion (LVI), high-grade histology, stage T1b, and larger size (> 3 cm) were independently associated with an increased risk of nodal metastasis on multivariate analysis (P

Goals and background Stress ulcer prophylaxis has been shown to lower gastrointestinal bleeding (GIB) rates. Various agents have been studied, and the optimal strategy continues to be contested. This study evaluates the efficacy between proton pump inhibitors (PPIs) and histamine-2-receptor antagonists. Small sample sizes and methodology flaws limited prior studies. Study A systematic search of MEDLINE, EMBASE, CENTRAL, Web of Science, and ClinicalTrials.gov for randomized controlled trials reporting the use of PPI and histamine-2-receptor antagonist reporting rates of GIB and standardized intensive care outcomes. Risk ratios (RR) and standardized mean difference (SMD) with 95% confidence intervals (CIs). A trial sequential analysis was performed to guard against errors. Results A total of 14 randomized controlled trials of 28,526 patients with a mean age of 57.83±17.35 years and 30.82% females. In our pooled analysis, PPI outperformed its comparator (RR: 0.68; 95% CI: 0.57-0.82) in clinically significant GIB. PPI re-demonstrated significant reduction in overt GIB (RR: 0.61; 95% CI: 0.39-0.97). No differences between groups was noted toward all-cause mortality (RR: 1.05; 95% CI: 1.00-1.10) or incidence of pneumonia (RR: 1.11; 95% CI: 0.82-1.51). Duration of stay (SMD: 0.07; 95% CI: -0.04-0.17) and ventilator days (SMD: 0.01; 95% CI: -0.01-0.04) were indifferent between the groups. Conclusions Among critically ill patients, PPI was associated with reduced clinically significant or overt GIB. No differences in pneumonia were seen with the use of either agent. Trial sequential analysis for clinically significant GIB ruled out the risk for false-positive results, and thereby it is unlikely that future trials will affect our conclusions.

African-Americans rank last among all racial groups for age-adjusted colorectal cancer mortality, 5-year survival rates, and rates of screening. Access to care does not fully explain racial disparities in rates of CRC and mortality. Sociocultural attitudes can predict probabilities of CRC screening. The objective of this study is to identify factors that influence colorectal cancer screening behavior in African-American men. Semi-structured interviews were conducted among 32 African-American men. Transcripts were analyzed using MAXQDA software. We then conducted a cross-sectional survey of 103 African-American men, using previously validated scales related to colorectal cancer screening and determinants. Data were analyzed with SPSS. In the interview phase, beliefs relating to masculinity emerged as factors that hindered participation in screening. Overwhelmingly, participants felt that having an in-depth discussion about colorectal cancer with their provider was critical to enabling them to get screened. The survey phase demonstrated that most participants had poor colorectal cancer knowledge, as only 16% passed the knowledge test. Forty-eight percentage agreed that their provider did not recommend getting screened. Those who had been previously screened for colorectal cancer scored higher in total and on all subsets of the masculinity index than those who had not (p

Objectives Recent studies have shown a decrease in gallstone-related complications if same-admission cholecystectomy (SAC) is performed in mild gallstone pancreatitis (GSP); however, SAC often is not performed in resource-limited settings such as safety net hospitals. The aims of this study were to evaluate the rate of SAC and compare a composite endpoint of recurrent biliary events in patients undergoing SAC with patients in the delayed cholecystectomy (DC) group. Secondary aims included evaluating the rate of recurrent pancreatitis in patients in the DC group, identifying the predictors for DC and the reasons for not undergoing SAC. Methods We reviewed 310 patients admitted in the past 5 years with the diagnosis of acute pancreatitis. Eighty patients were admitted for gallstone pancreatitis; 75% were African American, 18% were white, and the average age was 44 years with a mean body mass index of 30. Forty patients did not receive cholecystectomy before discharge. The DC and SAC groups were similar in body mass index, ethnicity, severity of pancreatitis, and complications. Results The DC group was significantly more likely to be older and with higher comorbidity indexes compared with the SAC group. Bedside Index of Severity in Acute Pancreatitis scores and revised Atlanta classification definitions were used to define severe acute pancreatitis; 10% (4) of patients had organ failure at 48 hours, whereas 17.5% (7) had a Bedside Index of Severity in Acute Pancreatitis scores ≥3. A total of 14 recurrent biliary events occurred in the DC group (14 of 40), which was 35% compared with 2 of 40 (5%) in the SAC group (P 2 was the only significant predictor of DC. The most common reason for DC was no surgical consultation during the inpatient stay (22%). Conclusions Our findings support existing evidence that DC is associated with a significantly increased risk of recurrent biliary events and pancreatitis. Furthermore, we report a 56% adherence to the current guidelines for SAC and report that the most common reason for not undergoing SAC was the absence of surgical consultation. We conclude that ensuring SAC in eligible patients should be a priority for safety net hospitals because it may help decrease hospital costs in the long term, and active efforts should be made to identify patients who may be less likely to receive SAC.

Objectives The exact prevalence for intraductal papillary mucinous neoplasm (IPMN) in patients with chronic kidney disease (CKD) remains unknown. In this single-center case-control study, we aimed to study the prevalence and risk factors for IPMN in patients with CKD. Methods We performed a retrospective case-control study comparing patients with and without CKD who had magnetic resonance imaging of the abdomen performed between January 2018 and December 2018. Patient demographic, clinical, and imaging metrics were extracted from chart review. The prevalence of IPMN was compared between the 2 groups. Results A total of 800 patient charts were reviewed. There were 400 patients with CKD compared with an age-matched control group of 400 patients without CKD. The total prevalence of IPMN in patients with CKD was 13.7% (55/400) compared with 7.8% (29/400; P = 0.002) in non-CKD patients. The prevalence of diabetes mellitus was significantly higher in the CKD group (41% vs 14%, P = 0.0001). The percentage of patients consuming alcohol was significantly higher in the non-CKD group (23% vs 35%, P = 0.002). Conclusions Patients with CKD have a significantly higher prevalence of IPMN compared with non-CKD patients. Larger population-based studies are needed to confirm these findings.

Kidney failure is common in patients with Coronavirus Disease-19 (COVID-19) resulting in increased morbidity and mortality. In an international collaboration, 284 kidney biopsies were evaluated to improve understanding of kidney disease in COVID-19. Diagnoses were compared to five years of 63,575 native biopsies prior to the pandemic and 13,955 allograft biopsies to identify diseases increased in patients with COVID-19. Genotyping for APOL1 G1 and G2 alleles was performed in 107 African American and Hispanic patients. Immunohistochemistry for SARS-CoV-2 was utilized to assess direct viral infection in 273 cases along with clinical information at the time of biopsy. The leading indication for native biopsy was acute kidney injury (45.4%), followed by proteinuria with or without concurrent acute kidney injury (42.6%). There were more African American patients (44.6%) than patients of other ethnicities. The most common diagnosis in native biopsies was collapsing glomerulopathy (25.8%) which associated with high-risk APOL1 genotypes in 91.7% of cases. Compared to the five-year biopsy database, the frequency of myoglobin cast nephropathy and proliferative glomerulonephritis with monoclonal IgG deposits was also increased in patients with COVID-19 (3.3% and 1.7%, respectively), while there was a reduced frequency of chronic conditions (including diabetes mellitus, IgA nephropathy, and arterionephrosclerosis) as the primary diagnosis. In transplants, the leading indication was acute kidney injury (86.4%), for which rejection was the predominant diagnosis (61.4%). Direct SARS-CoV-2 viral infection was not identified. Thus, our multi-center large case series identified kidney diseases that disproportionately affect patients with COVID-19, demonstrated a high frequency of APOL1 high-risk genotypes within this group, with no evidence of direct viral infection within the kidney., Graphical abstract

BACKGROUND Sickle cell disease (SCD) is a disorder that results in increased hospitalizations and higher mortality. Advances in management have resulted in increases in life expectancy and led to increasing awareness of sickle cell hepatopathy (SCH). However, its impact in patients on the natural history and outcomes of SCD is not known. Our study aims to describe the prevalence of extreme hyperbilirubinemia (EH), one form of SCH, its effect on morbidity and mortality, and correlations between sickle cell genotype and SCH type. We hypothesize that EH is associated with higher morbidity and mortality. AIM To investigate the effects of EH on morbidity and mortality among patients with SCD. METHODS This retrospective cohort study was performed using a database of patients with SCD treated at Grady Memorial Hospital between May 2004 and January 2017. Patients with EH (defined as total bilirubin above 13.0 mg/dL) were identified. A control group was identified from the same database with patients with total serum bilirubin ≤ 5.0 mg/dL. Electronic medical records were used to extract demographic information, laboratory values, radiology results, current medications, need for transfusions and mortality data. Two samples T-test, chi-squared test and Fisher’s exact test were then used to compare the parameters between the two groups. RESULTS Out of the database, fifty-seven charts were found of patients with bilirubin > 13 mg/dL. Prevalence of severe SCH as defined by EH was 4.8% (57/1172). There were no demographic differences between patients with and without EH. Significant genotypic differences existed between the two groups, with hemoglobin SS SCD being much higher in the EH group (P < 0.001). Patients with severe EH had a significant elevations in alanine aminotransferase (157.0 ± 266.2 IU/L vs 19.8 ± 21.3 IU/L, P < 0.001), aspartate aminotransferase (256.5 ± 485.9 U/L vs 28.2 ± 14.7 U/L, P < 0.001) and alkaline phosphatase (218.0 ± 176.2 IU/L vs 85.9 ± 68.4 IU/L, P < 0.001). Patients with EH had significantly higher degree of end organ failure measured with quick Sequential Organ Failure Assessment scores (0.42 ± 0.68 vs 0.01 ± 0.12, P < 0.001), increased need for blood products (63% vs 5%, P < 0.001), and exchange transfusions (10.5% vs 1.3%, P = 0.022). CONCLUSION Among patients with SCD, elevated levels of total bilirubin are rare, but indicative of elevated morbidity, mortality, and need for blood transfusions. Large differences in sickle cell genotype also exist, but the significance of this is unknown.

BACKGROUND The three-delays model describes delays in seeking, reaching, and receiving care for vulnerable populations needing treatment. The dominant delay for patients with gastric adenocarcinoma (GAC) is unknown. We aimed to define patients with GAC who reached and received care at our regional safety-net hospital (Grady Memorial Hospital [GMH]) and our neighboring quaternary referral hospital (Emory University Hospital [EUH]). METHODS Clinicopathologic data from National Cancer Database (NCDB) participating academic centers were compared with GMH from 2004 to 2014. Outcomes of patients undergoing surgery at GMH were compared to those at EUH. RESULTS At presentation, compared to NCDB centers (n = 69 662), GMH patients (n = 154) were more often black (85.1 vs 17.2%; P

Liver cirrhosis is the final stage of any chronic liver disease, independent of etiology, and is characterized by fibrosis and transition of normal architecture into structurally abnormal nodules. Portal hypertension is a consequence of these changes which may ultimately lead to the formation of varices. Esophageal varices are present in approximately 40% of patients with cirrhosis and as many as 60% of patients with cirrhosis and ascites. Approximately 25% of patients with portal hypertension have gastric varices, most commonly gastroesophageal varices (extending 2–5 cm below gastroesophageal junction and are in continuity with esophageal varices). The most life-threatening complication of liver cirrhosis is acute variceal hemorrhage which is associated with increased mortality cited to be around 20% at 6 weeks. The current mainstay treatments include administration of vasoactive medications, prophylactic antibiotics against spontaneous bacterial peritonitis and bacteremia, as well as endoscopic banding to prevent or treat bleeding varices. This chapter reviews promising new modalities for the management of variceal bleeding. These include endoscopic therapies like self-expandable metallic stents or temporizing modalities, such as hemostatic powder, and endosonographic techniques like endoscopic ultrasound guided angiotherapy. Other non-endoscopic therapies include balloon-occluded retrograde transvenous obliteration and the changing role of transjugular intrahepatic portosystemic shunting is also discussed.

Tobacco exposure is an established risk factor for pancreatic cancer and chronic pancreatitis; however, its role in pancreatic insufficiency is not clear.This controlled, cross-sectional study examined smokers and nonsmokers with no history of pancreatic disease. Histories and validated inventories of alcohol and tobacco use were obtained, and pancreatic insufficiency was assessed using the fecal elastase-1 assay.Of 7854 patients approached, 226 were interviewed and 200 enrolled. The rates of pancreatic insufficiency [18% (18/100)] and severe pancreatic insufficiency [10% (10/100)] were significantly higher in smokers than in controls [6% (6/100), P = 0.009 and 1% (1/100), P = 0.010, respectively]. On multivariate logistic regression, the risk of pancreatic insufficiency in smokers was significantly increased [odds ratio, 4.34 (1.37-13.75); P = 0.012], controlling for alcohol use and relevant covariates. Tobacco exposure was associated with the highest odds ratio for pancreatic insufficiency. Alcohol consumption was strongly associated with tobacco exposure (P0.001), but not with pancreatic insufficiency by multivariate analysis (P = 0.792).This study suggests that tobacco exposure is independently associated with pancreatic exocrine insufficiency in patients without a prior diagnosis of pancreatic disease. Tobacco exposure seems to have greater detrimental effects on pancreatic function than alcohol in this population.

Pancreatic ductal adenocarcinoma is associated with a poor prognosis and a high case-fatality rate. The reasons for poor prognosis are low rates of curative resection due to local infiltration and distant metastasis. To increase survival rates of patients with pancreatic cancer, early detection through surveillance and screening is important. However, screening could only be cost-effective in high-risk populations. Identification of significant risk factors therefore assumes significance. Risk factors could be non-modifiable or modifiable. Non-modifiable risk factors include increasing age, familial cancer syndromes, Afro-American race, hereditary and other forms of chronic pancreatitis, diabetes, and non-O blood group. Important modifiable risk factors include smoking, obesity, dietary factors such as non-vegetarian diet, and toxins. Preventive strategies at the population level and an effective screening program targeted at high-risk people may help in prevention and early detection of pancreatic ductal adenocarcinoma.

Background Esophageal variceal bleeding remains the leading cause of acute mortality in patients with cirrhosis. Platelet count to spleen diameter (PC/SD) ratio less than 909 is one of several parameters proposed for the noninvasive prediction of esophageal varices. The aim of this study is to systematically review the evidence on the diagnostic accuracy of the 909 ratio. Methods We identified relevant studies from a MEDLINE search and performed a meta-analysis to estimate the pooled sensitivity, specificity, and positive and negative likelihood ratios (LRs) using Meta-Disc software. Results Eight studies met the inclusion criteria and included a total of 1275 patients. Meta-analysis yielded a pooled sensitivity of 89% [95% confidence interval (CI) 87-92%; I2 statistic 92.9%] and a pooled specificity of 74% (95% CI 70-78%; I2 statistic 94.5%). The pooled positive LR was 3.5 (95% CI 1.92-6.25; I2 statistic 94.0%) and the pooled negative LR was 0.12 (95% CI 0.05-0.32; I2 statistic 90.8%). The quality of the evidence as assessed by the GRADE methodology was low. Conclusion In its present form, the test characteristics of PC/SD ratio of 909 may not be adequate to completely replace esophagogastroduodenoscopy as a noninvasive screening tool for esophageal varices, given the low grade of evidence. However, it may be potentially useful as part of a prediction rule incorporating other clinical characteristics or varying PC/SD cutoffs. When compared with other noninvasive predictor tools, the PC/SD ratio is elegant, simple, and inexpensive. With some minor modifications, it may become a helpful tool to limit the number of endoscopies in primary prophylaxis to be performed in patients with portal hypertension.

The common bile duct (CBD) diameter is one factor that clinicians use when deciding on invasive evaluation for intra-ductal pathology, e.g., endoscopic retrograde cholangiopancreatography. Previous studies and gastrointestinal and radiological textbook authors report disparate interpretations. These inconsistent interpretations likely result from methodological limitations in prior studies. The purpose of this work is to primarily compare the CBD diameter among patients with and without prior cholecystectomy and secondarily to compare proximal and distal CBD measurements. Among 40 matched pairs, post-cholecystectomy patients had larger mean CBD diameters at proximal (7.0 vs. 5.4 mm; P < 0.001) and distal (5.9 vs. 4.6 mm; P < 0.001) sites. Post-cholecystectomy patients were also more likely to exceed the 6-mm cut point for proximal (80 vs. 28%; P < 0.001) or distal (58 vs. 20%; P = 0.003) measurements. Incidental radiographic detection of enlarged CBDs among post-cholecystectomy patients is common; therefore, clinicians should use clinical determinants to guide decisions about additional costly or potentially harmful evaluation for intraductal pathology.