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Pancreatitis is the most common adverse event of endoscopic retrograde cholangiopancreatography, with the potential for clinically significant morbidity and mortality. Several patient and procedural risk factors have been identified that increase the risk of post–endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Considerable research efforts have identified several pharmacologic and procedural interventions that can drastically affect the incidence of PEP. This review article addresses the underlying mechanisms at play for the development of PEP, identifying patient and procedural risk factors and meaningful use of risk-stratification information, and details current interventions aimed at reducing the risk of this complication.

Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly used class of medications worldwide. It is estimated that more than 20 million people take NSAIDs daily. We examined the underreported use of NSAIDs on a standardized office intake assessment questionnaire of patient reported medications. A questionnaire was administered to patients following written and verbal confirmed report of current medications to nursing staff. One hundred consecutive patient intake assessments were evaluated from the patient intake sheets for a busy private gastroenterology specialty practice. After patients listed their current medications, they were given a survey and asked to acknowledge any use of 30 non-prescription formulations that contained NSAIDs. Patients filled these surveys while waiting for the health care provider who then reviewed the response accuracy with the patient during the visit. Changes in the patient‘s initial and subsequently corroborated use or non-use of NSAIDs were recorded and tabulated. The educational level of all participants was also assessed. Of the 100 surveys completed, 6% of patients had not completed high school, 19% had completed high school, 8% had started but not finished college, 54% had completed college, 2% had started but not finished graduate school, and 11% had completed graduate school. The educational level of the patients did not correlate with underreporting of NSAID usage. On the survey, 18% of patients noted use of an NSAID listed that had not been reported verbally to nursing staff; 8% of those patients reported daily use, 15% weekly use and 76% reported use within the last month. Patients were then asked in the questionnaire as to the reason for not reporting medication intake to nurse; 14% stated they were never asked about the specific medication, 22% did not think the medications were important enough to list, 34% bought the medication with prescriptions, and 30% noted their reason as their doctor did not prescribe the medication to them. Using a prospective questionnaire in a private practice gastrointestinal office, these data show that patients underreport use of non-prescription NSAIDs. Based on the data, it is clear that this underreporting can have a detrimental effect on procedure related as well as long-term patient care. Future studies would be needed to examine the incidence of side effects due to underreporting of NSAIDs.

Background: The percentage of individuals in the United States who are obese is increasing. Diet and activity programs in clinical trials provide both modest weight loss (average 7 kg at 1 year) and poor maintenance of weight loss; therefore patients with medically-complicated obesity consider surgical options. Adjustable gastric banding is a newer, lower risk bariatric surgery and we hypothesized that a hobby, as a behavioral modification program, would improve post-operative weight loss after gastric banding. Methods: This is a retrospective database review of 74 patients at the Washington Hospital Center who underwent gastric adjustable band surgery from August 2008 to May 2010. We identified pre-operative weight, body mass index, ideal body weight, excess body weight lost at 6 months and 1 year, and presence or absence of a hobby. Results: At 6 months, compared to published diet and activity programs, only 4 gastric band patients did not have significant weight loss. Among 70 patients with significant weight loss, 40 patients had a hobby (mean weight loss 17.3 kg) compared to 30 patients with no hobby (mean weight loss 13.6 kg). At 1 year, 10 patients did not have significant weight loss; among 64 patients with significant weight loss, 37 had a hobby compared to 27 without (chisquare test: p < .05). At 1 year post-operative date, the average weight losses for patients with a hobby and those without were 19.3 kg and 16.9 kg, respectively. Conclusion: There was a significant association between improvements in weight loss 1 year after gastric band surgery in patients who had a hobby compared to those without. The results support the proposal that yoga could serve as a post-operative behavioral modification program to improve weight loss after adjustable gastric band surgery.

Symptoms of gastro-oesophageal reflux disease (GORD or GERD) are estimated to occur in 30-50% of pregnancies, with the incidence approaching 80% in some populations. As with many other conditions in pregnancy, medical therapy with pharmaceutical agents is a concern, as the potential teratogenicity of medications is not well known. Although prevalence numbers are high, many patients have mild and infrequent symptoms, which often respond to lifestyle and dietary modifications. The exact mechanism and pathogenesis of GERD associated with pregnancy is likely multifactorial. Treatment strategies for patients not responding to conservative therapies include a step-up approach initially starting with antacids and alginates, and progressing to histamine H(2) receptor antagonists followed by proton pump inhibitor (PPI) therapy if indicated by symptoms. Although PPI therapy is the most effective treatment available for GERD, the data related to the safety for use during pregnancy and postpartum breastfeeding are mostly obtained from cohort analysis. Given the significant adverse impact of GERD on quality of life and functionality, the use of this class of medications should not be overly restricted based solely on the pregnancy. Based on the studies presented, exposure to PPI therapy during pregnancy seems to predispose the fetus to minimal risk and, overall, these medications should be discussed with the primary physician if symptomatically necessary in the pregnant patient. This evidence-based review will address the management and safety of PPI therapy during pregnancy and lactation, and briefly review the pathogenesis, clinical presentation and diagnosis of GERD in this population.

The percentage of individuals in the United States who are obese continues to grow. Obesity is associated with the development of a broad group of malignant, metabolic, cardiovascular, and neurological disorders. The origins for this major health crisis are presently under investigation. However, potential explanations for this rise in the prevalence of obesity include a sedentary life style, increased number of daily meals, the presence of an eating disorder, a changing job market, or an effect of a yet unidentified environmental agent or exposure. Diet and activity programs in clinical trials provide only modest weight loss, with poor long term maintenance of weight loss. Many patients with medically-complicated obesity therefore consider surgical options for weight loss, termed bariatric surgery. A percentage of individuals do not lose weight after bariatric surgery, while the risk of weight regain after Roux-en-Y gastric bypass surgery may be as high as 40% among post-operative patients. The potential role of yoga in the promotion of post-operative weight loss and the prevention of post-operative weight regain remains to be more fully explored.

Liver biopsy remains the cornerstone in the diagnosis and management of liver disorders. Results of liver biopsy can often drive therapeutic decision-making. Unfortunately, studies have shown conventional biopsy techniques to carry significant sampling variability that can potentially impact patient care. Endoscopic ultrasound (EUS) is gaining traction as an alternative method of biopsy. For parenchymal disease, it can decrease sampling variability. It offers a more targeted approach for focal lesions. Its diagnostic yield and limited adverse event profile make it a promising approach for liver biopsy.