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Background Gastric antral vascular ectasia is an infrequent cause of gastrointestinal‐related blood loss manifesting as iron‐deficiency anemia or overt gastrointestinal bleeding, and is associated with increased healthcare burdens. Endoscopic therapy of gastric antral vascular ectasia most commonly involves endoscopic thermal therapy. Endoscopic band ligation has been studied as an alternative therapy with promising results in gastric antral vascular ectasia. Aims The primary aim was to compare the efficacy of endoscopic band ligation and endoscopic thermal therapy by argon plasma coagulation for the management of bleeding gastric antral vascular ectasia in terms of the mean post‐procedural transfusion requirements and the mean hemoglobin level change. Secondary outcomes included a comparison of the number of sessions needed for cessation of bleeding, the change in transfusion requirements, and the adverse events rate. Methods PubMed, Medline, SCOPUS, Google Scholar, and the Cochrane Controlled Trials Register were reviewed. Randomized controlled clinical trials and retrospective studies comparing endoscopic band ligation and endoscopic thermal therapy in bleeding gastric antral vascular ectasia, with a follow‐up period of at least 6 months, were included. Statistical analysis was done using Review Manager. Results Our search yielded 516 papers. After removing duplicates and studies not fitting the criteria of selection, five studies including 207 patients were selected for analysis. Over a follow‐up period of at least 6 months, patients treated with endoscopic band ligation had significantly lower post‐procedural transfusion requirements (MD −2.10; 95% confidence interval (−2.42 to −1.77)) and a significantly higher change in the mean hemoglobin with endoscopic band ligation versus endoscopic thermal therapy (MD 0.92; 95% confidence interval [0.39–1.45]). Endoscopic band ligation led to a fewer number of required sessions (MD −1.15; 95% confidence interval [−2.30 to −0.01]) and a more pronounced change in transfusion requirements (MD −3.26; 95% confidence interval [−4.84 to −1.68]). There was no difference in adverse events. Conclusion Results should be interpreted cautiously due to the limited literature concerning the management of gastric antral vascular ectasia. Compared to endoscopic thermal therapy, endoscopic band ligation for the management of bleeding gastric antral vascular ectasia led to significantly lower transfusion requirements, showed a trend toward more remarkable post‐procedural hemoglobin elevation, and a fewer number of procedures. Endoscopic band ligation may improve outcomes and lead to decreased healthcare burden and costs.

The introduction of Direct Oral Anticoagulants (DOACs) to the pharmaceutical market provided patients and clinicians with novel convenient and safe options of anticoagulation. The use of this class of medications is currently limited to venous thromboembolic therapy and prophylaxis, in addition to stroke prophylaxis in patients with nonvalvular atrial fibrillation. Despite their altered hemostasis, patients with cirrhosis are thought to be in a procoagulant state and thus prone to thrombus formation. Patients with cirrhosis might benefit from the convenience of DOACs; however, the medical literature includes limited data on the efficacy and safety of DOACs in this special patient population. The aim of this review is to summarize the current evidence for anticoagulation options in patients with cirrhosis and their safety profile.

The incidence of pancreatic cancer is on the rise, and as a result, screening for pancreatic cancer is, ipso facto, a matter of increased discussion in the medical literature. Consequently, with the increasing amount of research targeting the natural history of pancreatic cancer, we are getting closer, but are still relatively far from confidently answering the questions of who and when to screen for pancreatic cancer. In this chapter, we will discuss the current evidence for pancreatic cancer screening in populations at risk, as well as the available data on when to start screening. The chapter will also discuss the advantages and pitfalls of the different diagnostic modalities and briefly touch on current and future research endeavors.

Background. The natural history of colonic diverticulosis is unclear.Methods. Patients with incidental diverticulosis identified in a previous prospective cross-sectional screening colonoscopy study were evaluated retrospectively for clinic or hospital visit(s) for diverticular disease (DD= acute diverticulitis or diverticular bleeding) using review of electronic health records and patient phone interview.Results. 826 patients were included in the screening colonoscopy study. Three were excluded for prior DD. In all, 224 patients (27.2%; mean age 62.3 ± 8.2) had incidental diverticulosis distributed in the left colon (67.4%), right colon (5.8%), or both (22.8%). Up-to-date information was available on 194 patients. Of those, 144 (74.2%) could be reached for detailed interview and constituted the study population. Over a mean follow-up of 7.0 ± 1.7 years, DD developed in 6 out of 144 patients (4.2%) (4 acute cases of diverticulitis, 1 probable case of diverticular bleeding, and 1 acute case of diverticulitis and diverticular bleeding). Two patients were hospitalized, and none required surgery. The time to event was 5.1 ± 1.6 years and the incidence rate was 5.9 per 1000 patient-years. On multivariate analysis, none of the variables collected at baseline colonoscopy including age, gender, obesity, exercise, fiber intake, alcohol use, constipation, or use of NSAIDs were associated with DD.Conclusion. The natural history of incidental diverticulosis on screening colonoscopy was highly favorable in this well-defined prospectively identified cohort. The common scenario of incidental diverticulosis at screening colonoscopy makes this information clinically relevant and valuable to physicians and patients alike.

Introduction: COVID-19 infection is associated with liver injury that increases in severity in sicker patients. This is thought to be due to the cytokine storm phenomenon which can paradoxically suppress other underlying chronic viral infections. We report the 1st case of suppressed HCV viral load and undetectable HCV genotype in the setting of COVID-19. Case Description/Methods: A 77-year-old man with chronic hepatitis C (HCV) secondary to intravenous drug use was seen at the gastroenterology clinic for initiation of HCV treatment. Four months prior to presentation, HCV screening showed a positive HCV antibody and HCV viral load of 127330 IU/mL. Further testing for initiation of HCV therapy was remarkable for a markedly decreased HCV viral load of 31 IU/mL. Genotype could not be evaluated as the test requires a viral load of ≥1000 IU/mL. FibroSure revealed F1 fibrosis. Around that time, the patient reported body aches, fevers, and an exposure to a person with upper respiratory tract symptoms. Four days later, he tested positive for COVID-19, then quarantined and recovered. As the marked drop in HCV viral load was felt to be secondary to cytokine response in COVID-19 infection, a decision was made to repeat HCV viral load and genotyping 3 months later. The results revealed a viral load of 9010000 IU/ml and genotype 2b. The patient's liver function tests and INR remained normal and he was initiated on glecaprevir/pibrentasvir. Discussion: While liver injury from cytokine storm in COVID-19 is well recognized, there is paucity of data on its effect on chronic viral infections. This is the first report of documented transient reduction in HCV viral load in COVID-19, presumably secondary to the cytokine response. It is notable that the HCV viral load reduction in this case was to such an extent that genotyping was not possible. Therefore, we believe that reductions to below the lower limit of detection are possible resulting in false negative HCV PCR results. Since it is standard practice to interpret a one-time negative HCV viral load to be indicative spontaneous viral clearance, such a result could lead to a mistaken diagnosis. Clinicians need to be mindful of the coexistent clinical conditions while interpreting HCV PCR results. Additionally, there may be a role for repeating HCV PCR after an interval if a negative result was obtained during a period of widespread community transmission of COVID- 19 or other viral epidemics. Further research is required to validate the appropriateness of such a testing strategy. (Figure Presented).

Background It is unclear whether the combination of adalimumab (ADA) and immunomodulators is superior to ADA monotherapy in patients with Crohn's disease. Methods PubMed, Medline, Embase, Web of Science, and other databases were searched. Randomized controlled trials, open-label, prospective cohort, and retrospective studies, and pooled analyses were included. Primary outcomes were induction (≤12 wk) and maintenance (up to 56 wk) of remission and response. Secondary outcomes were severe adverse events, opportunistic infections, and development of antibodies to adalimumab. Results Twenty-four of 1194 articles were eligible for inclusion. No significant difference was noted between regimens for induction of remission (odds ratio [OR] 0.86; 95% confidence interval [CI]: 0.70-1.06; P = 0.19) and response (OR 1.01; 95% CI: 0.62-1.65; P = 0.96). Similarly, no difference was noted for maintenance of remission (OR 0.97; 95% CI: 0.79-1.14; P = 0.75) or response (OR 0.91; 95% CI: 0.54-1.54; P = 0.74). Severe adverse events and opportunistic infections were not different between arms. Patients on combination therapy had lower odds of developing antibodies to adalimumab (OR 0.24; 95% CI: 0.07-0.82; P = 0.02). Subgroup and sensitivity analyses showed significantly higher odds of successful induction (OR 1.26; 95% CI: 1.06-1.49, P = 0.008) and opportunistic infections (OR 2.44; 95% CI: 1.07-5.54, P = 0.03) in anti-TNF-experienced patients. Conclusions The combination of ADA and immunomodulators does not seem superior to ADA monotherapy for induction and maintenance of remission and response in Crohn's disease. Combination therapy is associated with lower immunogenicity. Analyses associating combination therapy with better induction of remission in anti-TNF-experienced patients and a higher rate of opportunistic infections deserve further evaluation.

An adequate bowel preparation is an important quality measure for optimal colonoscopy.The aim of this article is to study the burden of bowel preparations by examining seven specific variables (hunger, taste, volume, sleep, social, work, and adverse events (AEs)).Ambulatory patients undergoing elective colonoscopy completed a questionnaire regarding their experience with the prescribed preparation. The seven study variables were graded using a numerical scale of 0-10 (best to worst). A score6 was considered to indicate a significant impact and used as primary outcome. Patients were also asked to grade in descending order what they perceived as the worst aspect of the preparation.A total of 216 patients completed the survey. Preparations consisted of split-dose sodium picosulfate (SPS) (n = 49), split-dose 4 l PEG ± menthol (n = 49), full-dose PEG (n = 68), and 2 l split-dose PEG + ascorbic acid (n = 50). Except for work and AEs, all variables were considered to have a negative impact by20% of patients (range 20.4-34.2). SPS was superior to PEG regimens in taste (4.1% vs. 35.9%) and volume (0% vs. 44.9%) (p 0.05 for both) but inferior for hunger (30.6% vs. 19.2%; p = 0.09). The addition of menthol to PEG significantly improved taste (22.4% vs. 41.5%; p = 0.02). Sleep disturbances were most common with SPS and least with split-dose PEG (30.6% vs. 17.4%; p 0.05). Overall, patients ranked volume, taste, and hunger as most burdensome.The burden of bowel preparation is substantial. An informed personalized choice of preparation may improve adherence, tolerability and colon cleansing.

A brain abscess is defined as a focal intracerebral infection consisting of an encapsulated collection of pus, which can be a life-threatening complication of infections, trauma, or surgery. While immunocompromised patients can have a wide array of causative organisms, bacterial species represent the most common etiology in immunocompetent individuals. The incidence of brain abscesses ranges from 0.4 to 0.9 per 100,000, with a high predisposition among immunocompromised patients and in those with disruption of the blood-brain barrier. The most common causative organisms found were Streptococcus species, particularly S. viridians and S. pneumonia, Enterococcus, and Staphylococcus species, mainly S. aurieus and S. epidermidis. Microorganism can invade the brain through different mechanisms, either directly by contiguous spread and odontogenic infections, which usually cause a single brain abscess, or indirectly through hematogenous spread which can cause multiple brain abscesses. Both surgical and conservative dental procedures contribute to hematogenous spreading of oral microorganisms. Although most of those organisms are eliminated shortly after they gain access to the bloodstream, some can persist and contribute to the pathogenesis of abscesses in the appropriate environment. Odontogenic origins are rarely implicated in the formation of brain abscesses, and oral foci comprise approximately 5% of identified cases. We report a case of brain and diverticular abscesses due to S. intermidius occurring two months after dental extraction. This case highlights the fact that even usual dental workup can result in the development of bacteremia and disseminated abscesses including but not restricted to the brain. Consequently, in addition to identifying the possible source of bacteremia with an extensive history and physical exam, the diagnosis of Streptococcus milleri organisms should prompt the physicians to screen for sites of possible metastatic infection spread.

Background Patients with chronic kidney disease (CKD) undergoing coronary angiography (CA), adequate hydration and minimizing volume of contrast media (CM) are class 1b recommendations for preventing contrast induced nephropathy (CIN). Current data are insufficient to justify specific recommendations about isoosmolar vs. low-osmolar contrast media by the ACCF/AHA/ SCA I guidelines. Methods Randomized trials comparing IOCM to LOCM in CKD stage 3 and above patients undergoing CA, and reporting incidence of CIN (defined by a rise in creatinine of 25% from baseline) were included in the analysis. The secondary outcome of the study was the incidence of serum creatinine increase by >1mg/dl. Results A total of 2839 patients were included in 10 trials, in which 1430 patients received IOCM and 1393 received LOCM. When compared to LOCM, IOCM was not associated with significant benefit in preventing CIN (OR=0.72, [CI: 0.50–1.04], P =0.08, I2=59%). Subgroup analysis revealed non-significant difference in incidence of CIN based on baseline use of N -acetylcystine (NAC), diabetes status, ejection fraction, and whether percutaneous coronary intervention vs coronary angiography alone was performed. The difference between IOCM and LOCM was further attenuated when restricted to studies with larger sample size (>250 patients) (OR=0.93; [CI: 0.66–1.30]) or when compared with non-ionic LOCM (OR=0.79, [CI: 0.52–1.21]). Conclusion In patients with CKD stage 3 and above undergoing coronary angiography, use of IOCM showed overall non-significant difference in incidence of CIN compared to LOCM. The difference was further attenuated when IOCM was compared with non-ionic LOCM.

Background & Aims Chronic intake of proton pump inhibitors (PPI) has been associated with hypomagnesemia, but prevalence of PPI-associated hypomagnesemia is not known. Methods We examined the prevalence of hypomagnesemia among long-term PPI recipients by using a large health maintenance organization database. We collected data on 10,167 participants eligible for chronic drug prescriptions from 2008 through 2013. Adult subjects receiving continuous PPI therapy for ≥6 months between 2008 and 2013 and ≥1 serum magnesium determination(s) were identified. Patients with any magnesium levels less than 1.6 mg/dL were selected for analysis; those with recognizable causes of altered magnesium homeostasis were excluded. Results Five hundred ninety participants received long-term PPIs, and 414 (70.2%) met the inclusion criteria for a total exposure of 2293 PPI-years (average, 5.7 years/subject). Of these patients, 57 (13.8%) had ≥1 low serum magnesium; 5 were no longer on PPIs, and 44 had other recognizable causes for hypomagnesemia (25 receiving diuretics, 8 with chronic diarrhea, 8 with chronic kidney disease, and 3 with malignancies). Of the 8 remaining patients (7 female; mean age, 71.2 ± 13.4 years; mean daily medications, 5.4 ± 1.1), mild hypomagnesemia (range, 1.2–1.5 mg/dL) was noted in 13.9% of 289 measurements. All 8 patients had normal serum levels of magnesium at their final measurement. Conclusions In the absence of known precipitating factors, chronic PPI use does not appear to be associated with hypomagnesemia.

Background/Aims: To determine the prevalence of Barrett’s Esophagus (BE) in a tertiary care center in Lebanon and to compare IT with regional and global data. Materials and Methods: All esophagogastroduodenoscopies (EGDs) performed between January 2003 and October 2013 at the American University of Beirut Medical Center (AUBMC) were reviewed, and cases of endoscopically suspected esophageal metaplasia (ESEM) were identified. Definite BE was considered only if histologically proven intestinal metaplasia was present. Results: Totally, 16,787 patients underwent EGD; 219 patients (1.3%) were labeled as having ESEM. Only 41 patients had biopsyproven BE (18.7% of ESEM and 0.24% of total patients). The mean age of the patients with BE was 58.1 years [Standard deviation (SD) =13.7] and 78% were men. Of the 41 patients, 14 (34.1%) had long-segment BE (LSBE) (>3 cm) while 27 had short segment Barrett’s Esophagus (SSBE) (≤3 cm). Hiatal hernia was identified in 54% of the patients, more commonly in those with LSBE. Only four patients had low-grade dysplasia, and none had high-grade dysplasia. Conclusion: The prevalence of BE in Lebanon is much lower than that in Western countries. The reasons for this East-West divide are unknown and require further investigation.

Background and study aims Obesity is a recognised risk factor for poor bowel preparation in retrospective studies whilst corresponding data in prospective trials are marginally reported. Aims are to evaluate the relation between body mass index (BMI) and preparation quality in retrospective and interventional prospective settings and within a single centre. Patients and methods Data from a recent colorectal cancer screening registry were retrospectively analysed for the relation between BMI and adequacy of preparation. Patients were categorised as underweight (BMI 2 ), normal (20–25 kg/m 2 ), overweight (25–30 kg/m 2 ), and obese (>30 kg/m 2 ). Data from a recent prospective colon preparation trial were similarly analysed. Results 541 registry patients were included. Multivariate analysis showed BMI to be an independent risk factor for inadequate preparation. Obesity was associated with odds ratio (OR) of 5.3 [95% confidence interval (CI) 1.4–19.8; p = 0.01] compared to normal BMI. A significant difference was also noted in underweight but otherwise healthy individuals (OR = 11.1, 95% CI 2–60; p = 0.005). In the prospective study of 195 patients, obese patients had comparable rates of inadequate preparation to normal-weight individuals (OR = 0.7, 95% CI 1.1–3.96; p = 0.68). Underweight patients had a significantly worse preparation compared to normal BMI individuals (OR = 8, 95% CI 1.1–58; p = 0.04). Conclusions In real life, bowel preparations in obese individuals have a lower quality in comparison to normal individuals. This finding is not replicated in clinical trials. This discrepancy is likely the result of focused patient education suggesting that this is primarily a dietary compliance phenomenon. Underweight individuals appear to have worse quality of preparation independent of study design or setting.

SummaryBackground Half-dose regimens may be equally effective but associated with diminished adverse events (AE) than standard-dose regimens. Aim To assess efficacy and safety of full- vs. half-dose clarithromycin in the treatment of H. pylori. Methods Medline, EMBASE and PubMed databases were searched for randomised controlled trials (RCTs) that meet eligibility criteria. Only parallel group RCTs with ≥2 arms were eligible. Studies comparing triple, quadruple or sequential therapy for 7–14 days were selected. Regimens had to contain the same drug combination, differing only in dosage; the comparison of full- vs. half-dose clarithromycin was required, regardless if other drugs were dose-reduced or not. Data extraction was performed for primary outcome [eradication by intent-to-treat (ITT) and per-protocol (PP) analyses] and secondary outcome (AE). Results A total of 1622 articles were identified, of which 19 studies were eligible. Overall, eradication was achieved in 82.5% of half-dose (n = 2115) vs. 83.4% of full-dose recipients (n = 2109) on ITT (87.1% vs. 88.4% on PP respectively). Pooled relative risk in the half- vs. full-dose regimen was 0.98 (95% CI: 0.95–1.02) on ITT and 0.99 (95% CI: 0.97–1.01) on PP by the random effects model. Heterogeneity was significant (chi-squared statistic P = 0.05, I2 = 37%). AE were reported in 29.3% of half- vs. 44.0% of full-dose recipients [pooled RR 0.67 (95% CI: 0.60–0.75)]. Pre-planned subgroup analyses of dose modification, sample size, study origin and treatment duration, as well as sensitivity analysis showed no significant differences between arms. Conclusion A half-dose clarithromycin-based regimen is equally effective yet better tolerated than its full-dose counterpart in the treatment of H. pylori.