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Blue light imaging (BLI) has been shown to improve the characterization of colorectal polyps among the endoscopy experts. We aimed to determine if this technology could be taught to endoscopy trainees while maintaining high accuracy and interobserver agreement.Twenty-one gastroenterology trainees (fellows) from two academic institutions participated in this prospective study. Each trainee completed a web-based learning comprising four modules: pre-test, didactic videos explaining the BLI Adenoma Serrated International Classification (BASIC), interactive examples, and post-test assessment. The pre- and post-test modules consisted of reviewing video images of colon polyps in high definition white light imaging and BLI and then applying the BASIC classification to determine if the polyps were likely to be adenomatous. Confidence in adenoma identification (rated '1' to '5'), accuracy in polyp (adenoma vs. non-adenoma) identification, and agreement in characterization per BASIC criteria were derived.Trainee accuracy in the adenoma diagnosis improved from 74.7% (pre-test) to 85.4% (post-test) (P 0.01). There was a trend towards higher accuracy in polyp characterization with subsequent years of training (1st year fellows 77.4%, 2nd year 88.5%, and final year 94.0%) with consistent improvements after the e-learning across years of trainees. Overall, trainees were able to identify adenoma with a high sensitivity of 86.9%, specificity 83.9%, positive predictive value of 84.4%, and negative predictive value of 86.5%. However, their interobserver agreement in adenoma diagnosis was moderate (k = 0.52).The novel BLI classification can be easily taught to gastroenterology trainees using an online module and accuracy improves with years of training reaching90% for colorectal polyp characterization.

Snare entrapment is a rare complication of hot snare polypectomy of large colon polyps. We report a case of snare entrapment in our unit and its management. This report highlights the method of delayed removal of snare followed by repeat colonoscopy.

Introduction Elective therapeutic endoscopy is an important component of care of cirrhotic patients, but there are concerns regarding the risk of bleeding. This study examined the incidence, risk factors, and outcomes of bleeding after endoscopic variceal ligation (EVL), colonoscopic polypectomy, and endoscopic retrograde cholangiopancreatography with sphincterotomy in cirrhotic patients. Methods A cohort study of patients with cirrhosis who underwent the above procedures at a single center between 2012 and 2014 was performed. Patients with active bleeding at the time of procedure were excluded. Patients were followed for 30 days to assess for postprocedural bleeding and for 90 days for mortality. Results A total of 1,324 procedures were performed in 857 patients (886 upper endoscopies, 358 colonoscopies, and 80 endoscopic retrograde cholangiopancreatograpies). After EVL, bleeding occurred in 2.8%; after polypectomy, bleeding occurred in 2.0%; and after sphincterotomy, bleeding occurred in 3.8%. Independent predictors of bleeding after EVL and polypectomy included younger age and lower hemoglobin. For EVL, bleeding was also associated with infection and model for end-stage liver disease-Na. International normalized ratio was associated with bleeding in univariate analysis only, and platelet count was not associated with bleeding in any procedure. Bleeding after EVL was associated with 29% 90-day mortality, and bleeding after polypectomy was associated with 14% mortality. Of the 3 patients with postsphincterotomy bleeding, none were outliers regarding their baseline characteristics. Discussion In patients with cirrhosis, bleeding occurs infrequently after elective therapeutic endoscopy and is associated with younger age, lower hemoglobin, and high mortality. Consideration of these risk factors may guide appropriate timing and preprocedural management to optimize outcomes.

Introduction Clostridioides difficile infection (CDI) is common in patients with cirrhosis and is associated with poor outcomes. CDI risk factors in this population have been well characterized; however, risk factors of recurrent CDI (R-CDI) after treatment have not been explored. We sought to estimate the incidence of R-CDI and its associated risk factors in patients with cirrhosis. Methods We performed a cohort study of patients with cirrhosis hospitalized with CDI between 2012 and 2016. We collected patient characteristics, including detailed information on the CDI, features of the underlying liver disease, and outcomes including R-CDI, hospital readmission, and mortality. R-CDI was defined as CDI occurring 2-8 weeks after the initial episode. Cox proportional hazards model was used to identify variables independently associated with the outcomes. Results A total of 257 hospitalized patients with cirrhosis and CDI were included. CDI was community associated in 22.6%. The incidence of R-CDI was 11.9%. R-CDI was not significantly associated with medications at hospital admission or discharge. Independent risk factors of R-CDI included increased Charlson Comorbidity Index (hazard ratio [HR] 1.30; 95% confidence interval [CI]: 1.09-1.55) and use of lactulose (HR 2.58; 95% CI: 1.09-6.09). The 30-day readmission rate was 37%, and readmission was associated with increased Charlson Comorbidity Index (HR 1.12; 95% CI: 1.03-1.23) and Model for End-Stage Liver Disease score (HR 1.04; 95% CI: 1.01-1.07). The 90-day mortality was 22.8%. Discussion In patients with cirrhosis, R-CDI is associated with comorbidity burden and lactulose use. Attention to these factors might aid clinicians in efforts to prevent R-CDI and improve outcomes in this population.

Introduction. Individuals with inflammatory bowel disease (IBD) have an increased risk of osteoporosis compared to the general population. We aimed to improve the osteoporosis screening rate in the IBD patient population of the gastroenterology (GI) fellows’ continuity clinics. Methods. Baseline preintervention data were collected on patients seen from July through September of 2018. Four simplified criteria for osteoporosis screening were extrapolated from 3 national guidelines. Among patients who met any of these criteria, we determined the baseline screening rate. Fellows were then educated with a didactic session and handout material, and a standardized template was incorporated into clinic notes. Following this intervention, screening rates were reassessed from December 2018 through February 2019. Results. During the preintervention phase, fellows saw 80 patients with IBD. Dual-energy X-ray absorptiometry (DEXA) scan was obtained in 44% of IBD patients who qualify for screening at the county hospital clinic compared to 21% of veterans’ clinic IBD patients. In the postintervention period, screening rates remarkably improved to 100% in the county hospital clinic and to 75% in the veterans’ clinic. Overall, the screening rate increased by 56% (P<0.001). Conclusions. A large percentage of IBD patients at risk for osteoporosis did not have appropriate bone mass density testing. Educating GI fellows and adding a template to clinic notes were effective in significantly improving the number of patients at risk of osteoporosis to receive appropriate screening test, a DEXA scan. Similar educational interventions should be considered for providers caring for IBD patients to prevent complications of osteoporosis in these patients.

Transjugular intrahepatic portosystemic shunt (TIPS) creation can be very beneficial to decrease high portal pressure and its consequent dreadful complications, such as variceal hemorrhage. However, some anatomical limitations such as portal vein thrombosis can make TIPS technically impossible to perform. Here, we describe a case of a 72-year-old female patient who previously had a Roux-En-Y choledochojejunostomy, which was complicated by portal vein thrombosis. The patient subsequently developed portal hypertension, and this was successfully treated with endovascular mesocaval shunt creation, given that TIPS was not a viable option.

Aims Clostridium difficile infection (CDI) is a major concern for public health worldwide. Interestingly, the risk of poor clinical outcomes of CDI in patients with nasogastric tube (NGT) insertion is still controversial. The aim of this study was to assess the outcomes of CDI in patients with NGT insertion. Methods A literature search was performed using MEDLINE, EMBASE, and The Cochrane Database of Systematic Reviews from inception through November 2017. Studies that reported relative risks, odds ratios, or hazard ratios comparing the clinical outcome of CDI in patients with NGT versus those who did not were included. Pooled risk ratios (RR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method. Results Eight observational studies were included in our analysis to assess the association between NGT insertion and risk of poor outcome of CDI. The pooled RR of severe or complicated clinical outcomes of CDI in patients with NGT insertion was 1.81 (95% CI: 1.17 to 2.81). Conclusions This study demonstrated a statistically significant association between NGT insertion and risk of poor outcomes of CDI. This finding may impact clinical management and primary prevention of CDI. Avoidance of unnecessary NGT uses would improve the clinical outcomes of CDI.

Background and aim Currently available staging systems for cholangiocarcinoma (CCA) are not applicable to patients with unresectable stage. A new clinical staging system for perihilar CCA (pCCA) subtype has been recently developed in a US cohort, with a good performance in predicting survival of all pCCA patients. We aimed to determine outcomes of pCCA patients and evaluate predictive performance of this staging system in an Asian population. Methods All 141 patients diagnosed with pCCA between 2003 and 2012 were identified. Clinical information was retrospectively abstracted. Patients were classified into four stages based on the new staging system. Survival predictors were analyzed using the Cox proportional hazard analysis. Results Of the 141 pCCA patients, 38 (27%), 101 (72%), and 2 (1%) received resection, palliative biliary drainage ± chemotherapy, and best supportive care, respectively. Survival predictors included resectable disease, tumor size, distant metastasis, and cancer antigen 19-9 ≥ 1000 U/mL. When classified by clinical stages, 13, 4, 99, and 25 patients were in stages I, II, III, and IV, with median survivals of 18.4, 7.3, 6.3, and 2.6 months; and hazard ratio (95% confidence interval) of 1.0 (reference), 1.7 (0.5-5.5), 3.2 (1.5-6.7), and 10.8 (4.6-25.0), respectively. Conclusion The clinical staging system has a limited performance in differentiating stage II pCCA patients from stage III patients in the Thai cohort. This can be due to differences in patient characteristics and treatment modalities between the Asian and White pCCA populations. However, the median survivals of patients with other stages are significantly different.

Background/Aims: Hepatitis C virus (HCV) infection is one of the most common infections worldwide. Several epidemiologic studies have suggested that patients with HCV infection might be at an increased risk of osteoporosis. However, the data on this relationship remains inconclusive. This meta-analysis was conducted with the aim to summarize all available evidence. Materials and Methods: A literature search was performed using MEDLINE and EMBASE databases from inception to June 2016. Studies that reported relative risks, odd ratios (OR), or hazard ratios comparing the risk of osteoporosis among HCV-infected patients versus those without HCV infection were included. Pooled OR and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method. Results: Four studies met our eligibility criteria and were included in the analysis. We found a higher risk of osteoporosis among patients with chronic HCV with OR of 1.65 (95% CI: 0.98–2.77). Sensitivity analysis including only studies with higher quality yielded a higher OR, and the result was statistically significant (OR: 2.47; 95% CI: 1.03–5.93). Conclusions: Our study demonstrated a higher risk of osteoporosis among HCV-infected patients. Further studies are required to clarify how this risk should be addressed in clinical practice.

Background/objectives Clostridium difficile-associated diarrhea (CDAD) is a major concern of public health worldwide. The risk of CDAD in patients with nasogastric tube (NGT) insertion is controversial. The aim of this study was to assess the risk of incidence of CDAD in patients with NGT insertion. Methods A literature search was performed using MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews from inception through August 2015. Studies that reported relative risks, odds ratios, or hazard ratios comparing the risk of CDAD in patients with NGT insertion versus those who did not were included. Pooled risk ratios (RR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method. Results Eleven observational studies were included in our analysis to assess the association between NGT insertion and risk of CDAD. The pooled RR of CDAD in patients with NGT insertion was 1.87 (95% CI, 1.06–3.28, I2 = 73). When meta-analysis was limited only to cohort and case-control studies, the pooled RR of CDAD was 1.99 (95% CI, 1.05–3.77, I2 = 76). Conclusions Our study demonstrated a statistically significant association between NGT insertion and risk of CDAD. This finding may impact clinical management and primary prevention of CDAD.

Myeloid sarcoma (MS), an extramedullary tumor of immature granulocytic cells, affects the gastrointestinal tract in approximately 10% of cases. MS involvement of the colon and rectum is considered to be extremely rare. We present a 36-year-old woman with acute myeloid leukemia and allogenic hematopoietic stem cell transplant 2 years before who was admitted with abdominal pain and nonmucous, nonbloody diarrhea. Colonoscopy revealed an ulcerated mass in the proximal colon, and biopsies showed MS compatible with acute myeloid leukemia relapse.

Background: Patients with cirrhosis may be at increased risk of bleeding after invasive procedures due to defects in coagulation; however the bleeding risk following therapeutic endoscopy remains poorly understood. We aimed to determine the incidence and risk factors for post-procedural bleeding for patients with cirrhosis undergoing therapeutic endoscopy. Methods: We performed a retrospective cohort study of patients undergoing three common endoscopic procedures (colonoscopic polypectomy, endoscopic variceal ligation, and biliary sphincterotomy) at Indiana University Hospital between 2007 and 2014. Clinical and procedural data were collected, including complications in the 30 days following the proceduress. Results: We identified 447 procedures: 128 polypectomies, 63 sphincterotomies, and 256 variceal ligations. The incidence of bleeding was 2% (4 polypectomies, 1 sphincterotomy, and 4 variceal ligations) after a median of 4.5 days. . Prophlactic platelet transfusions were provided to 11 patients and plasma was transfused in 17 patients. Of those who received prophylactic transfusions, only one bled (post-polypectomy despite prophylactic hemoclip placement). The patients that bled had a median INR of 1.48 which was slightly elevated compared to the overall median INR 1.26. Post-polypectomy bleeding occurred following removal of fairly large polyps (8, 9, 10, 25 mm) compared to the median overall polyp size of 5 mm. Conclusion: The incidence of bleeding for patients with cirrhosis undergoing therapeutic endoscopy is low. More data on post-procedural bleeding are needed to determine risk factors and to inform appropriate prophylactic measures. These data may be used to guide clinicians in counseling patients prior to these procedures.

SummaryBackground The objective of this systematic review and meta-analysis was to assess the clinical outcomes of Clostridium difficile infection (CDI) in patients with chronic kidney diseases (CKD) and end-stage renal disease (ESRD). Methods A literature search was performed from inception through February 2015. Studies that reported relative risks, odds ratios or hazard ratios comparing the clinical outcomes of CDI in patients with CKD or ESRD and those without CKD or ESRD were included. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using a random-effect, generic inverse variance method. Results Nineteen studies (a case–control and 18 cohort studies) with 116,875 patients assessing clinical outcomes of CDI were included in the meta-analysis. Pooled RR of severe or complicated CDI in CKD patients was 1.51 (95% CI: 1.00–2.28). The risk of recurrent CDI is significant higher in patients with a pooled RR of 2.73 (95% CI: 1.36–5.47). The pooled RR of mortality risk of CDI in patients with CKD, ESRD and CKD or ESRD were 1.76 (95% CI: 1.26–2.47), 1.58 (1.37–1.83) and 1.76 (1.32–2.34) respectively. Conclusion This meta-analysis demonstrates poor outcomes of CDI including severe and recurrent CDI in CKD patients. History of CKD and ESRD are both associated with increased mortality risk in patients with CDI.

BACKGROUND Noninvasive diagnostic criteria for cirrhotic hepatocellular carcinoma (HCC) were first established in 2001 by the European Association for the Study of the Liver. OBJECTIVES The aim of this study was to evaluate adherence to the HCC diagnostic algorithm over time and identify factors associated with nonadherence. METHODS Between 2001 and 2013, 224 consecutive cirrhotic HCC cases were retrospectively reviewed. Nonadherent biopsy (NAB) was defined as cases diagnosed either by biopsy despite meeting noninvasive criteria for HCC or by biopsy in place of an optional second imaging modality. Nonadherent nonbiopsy (NANB) was defined as cases diagnosed without performing biopsy when noninvasive criteria were not met. Factors associated with nonadherence were identified using multivariate analysis. RESULTS Nonadherence rate decreased from 52 to 30% over the study period (P = 0.003). Among all patients, there were 34% NAB and 13% NANB cases. Compared with the adherence group, both NAB and NANB groups were likely to undergo only computed tomography scanning [odds ratio (OR) 3.08, 95% confidence interval (CI) 1.71-5.66 and OR 3.18, 95% CI 1.28-8.27, respectively] and were less likely to undergo MRI (OR 0.29, 95% CI 0.16-0.53 and OR 0.26, 95% CI 0.10-0.66, respectively). In addition, the NAB group was less likely to be presented in a multidisciplinary tumor conference (OR 0.12, 95% CI 0.02-0.61). CONCLUSION This is the first study to report adherence to HCC diagnostic guidelines over time in a veteran hospital. Despite overall improvement, nonadherence at the present time is still high (∼ 30%). Underutilization of MRI and the multidisciplinary tumor conference is associated with nonadherence, representing a potential area for improvement.

The objective of this systematic review and meta-analysis was to evaluate the mortality risk in patients with chronic kidney diseases (CKD) and end stage renal disease (ESRD) requiring dialysis withA literature search was performed from inception through February 2015. Studies that reported relative risks, odds ratios, or hazard ratios comparing the mortality risk of CKD or ESRD patients with CDI versus those without CDI were included. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using a random-effect, generic inverse variance method.Four cohort studies with 8,214,676 patients were included in the meta-analysis. Pooled RR of mortality in CKD patients with CDI was 1.73 (95% CI 1.39-2.15). When meta-analysis was limited only to included studies with ESRD patients, the pooled RR of mortality in patients with ESRD was 2.15 (95% CI, 2.07-2.23).This meta-analysis demonstrates significantly increased risks of mortality in CKD and ESRD patients with CDI. The magnitudes of mortality risk are high.

The objective of this systematic review and meta-analysis was to assess the risks of incident and recurrent Clostridium difficile-associated diarrhea in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) requiring dialysis. A literature search was performed from inception to February 2015. Studies that reported relative risks, odds ratios, or hazard ratios comparing the risks of C. difficile-associated diarrhea in patients with CKD or ESRD versus those without CKD or ESRD were included. Pooled risk ratios (RRs) and 95 % confidence intervals (CIs) were calculated using a random-effect, generic inverse variance method. Twenty studies (nine case–control, seven cohort, and four cross-sectional studies with 162,218,041 patients) were included in the meta-analysis. Pooled RRs of C. difficile-associated diarrhea in patients with CKD and ESRD were 1.95 (95 % CI 1.81–2.10) and 2.63 (95 % CI 2.04–3.38), respectively. When meta-analysis was limited only to cohort and case–control studies with confounder-adjusted analysis, the pooled RRs of C. difficile-associated diarrhea in patients with CKD and ESRD were 1.89 (95 % CI 1.75–2.05) and 2.50 (95 % CI 1.49–4.17), respectively. The pooled RR of recurrent C. difficile-associated diarrhea in patients with CKD was 2.61 (95 % CI 1.53–4.44). Data on the risk of recurrent C. difficile-associated diarrhea were limited. This meta-analysis demonstrates significantly increased risks of incident and recurrent C. difficile-associated diarrhea in patients with CKD. Furthermore, the magnitude of increased risk of C. difficile-associated diarrhea in ESRD patients is even higher.

Several immune disorders are often associated with thymoma. The aim of this study was to analyze the correlation between clinicopathological features of Thai patients with thymoma and concomitant immune-mediated diseases. Medical records of 87 patients diagnosed with thymoma during a 10-year period were retrospectively reviewed. Peripheral blood T cell subsets along with cytokine responses in 15 thymoma patients and 15 healthy controls were comparatively analyzed. The results demonstrated that thymoma type AB and B2 were the most common types among patients diagnosed with thymoma. The most common presentation was incidentaloma, followed by local chest symptoms and autoimmune diseases. The prevalence of autoimmune diseases, immunodeficiency states, and secondary neoplasms was 34.5, 10.3, and 10.3 %, respectively. Autoimmune diseases were most frequently found in thymoma type B2 and sometimes associated with clinical immunodeficiency, although classic Good's syndrome was rare. Patients with thymoma had significantly lower percentage CD4(+ve) T cells and interferon γ response, but higher percentage regulatory T cells than those in healthy controls. This study indicated that the aberrant immunologic disorders comprising autoimmune diseases, immunodeficiency states, and secondary neoplasms were found in almost 40 % of Thai patients with thymoma and possibly related to defectiva cytokine responses and altered T cell subsets.

Introduction Clinical data, risk factors and survival of patients with intrahepatic cholangiocarcinoma (ICC) are limited. Our study is to compare the clinical data, risk factors and survival of patients with ICC and those with extrahepatic cholangiocarcinoma (ECC), in Thailand. Methods Six hundred and forty patients with cholangiocarcinoma were recruited during January 2003September 2012. Diagnosis of cholangiocarcinoma was definitely diagnosed by imaging and/or histopathology. Demographic, risk exposure, clinical presentation, laboratory data, treatment, survival time and clinical outcome were collected. Patients were classified into ICC or ECC by anatomical location of tumor at above or below the second order of bile ducts. Results Three hundred and eighty two males and 258 females at a mean age of 59.8±12.1 years were diagnosed with cholangiocarcinoma. In this study, 216 of 640 patients (33.8%) were diagnosed ICC. We found that ECC patients presented with painless jaundice and cholangitis more often than ICC patients, significantly (80% vs. 4.6%, p ,0.001). Demographic data of both groups were not statistically different (Table 1). Baseline serum TB, DB and ALP of ICC patients were statistically lower than those of ECC (TB 1.7±4.6 vs. 16.8±12.2mg/dl, DB 1.0±3.6 vs. 12.8±8.9 mg/dl, ALP 282.5±216.1 vs. 487.3±334.1 U/L, respectively; p,0.01). Serum CEA and AFP were higher in ICC patients than those of ECC patients (CEA 107.3±609.3 vs. 28.7±84.5ng/ml, respectively; p=0.11, AFP 31.5±102.1 vs. 10.2±31.3ng/ml, respectively; p,0.01), in contrast to CA19-9 which was statistically lower in ICC patients (473.5±475.4 vs. 558.5±422.7ng/ml, respectively; p=0.04). Supportive care and selection of treatment were based on clinicians' decision and 20% of them underwent curative surgery. The median survival of patients with ICC and ECC were 51 and 18 months, respectively (Figure 1). Predictors of mortality for the overall group of patients with cholangiocarcinoma were underlying of cirrhosis and HIV infection (hazard ratio, 2.3; 95% CI, 1.2 to 4.3 and 8.0; 95% CI, 2.5 to 26.3; p ,0.01, respectively). Conclusion Higher survival rate was observed in ICC patients compared to those with ECC and the predictors of mortality were underlying of cirrhosis and HIV infection. Table 1. Demographic, risk exposure, baseline laboratory data and clinical outcomes of cholangiocarcinoma patients classified by type of cholangiocarcinoma (ICC and ECC) at KCMH, 2003-2012.

A 24-year-old male with a history of spondyloarthropathy presented with high fever, cervical lymphadenopathy and generalized maculopapular rash. He was treated with prednisolone for chronic uveitis before being switched to sulfasalazine 3 weeks prior to admission. Laboratory findings revealed marked leukocytosis with frequent atypical lymphocytes. Sulfasalazine was discontinued and the etiology of mononucleosis syndrome explored. During admission, he developed acalculous cholecystitis and hypotension. All symptoms quickly improved following administration of systemic corticosteroids. The investigation for infectious mononucleosis yielded negative results and a diagnosis of sulfasalazine-induced hypersensitivity syndrome was confirmed using enzyme-linked immunospot assays.