Clinical Gastroenterology and Hepatology

Editor picks for Clinical Gastroenterology and Hepatology

Clinical Manifestations of Helicobacter pylori–Negative Gastritis We found that H pylori–negative gastritis was present in approximately 18% of patients with gastritis.
June 22, 2017

Tetrahydrocannabinol Does Not Reduce Pain in Patients With Chronic Abdominal Pain in a Phase 2 Placebo-controlled Study We found no difference between THC and placebo tablets in reducing pain measures in patients with chronic abdominal pain.
June 22, 2017

Mood and Anxiety Disorders Precede Development of Functional Gastrointestinal Disorders in Patients but Not in the Population We found 2-fold more patients to receive a diagnosis of a mood or anxiety disorder before an FGID.
June 22, 2017

White Paper AGA: The Impact of Mental and Psychosocial Factors on the Care of Patients With Inflammatory Bowel Disease This white paper details psychosocial care that is integrated into IBD practices as well as innovative methods that provide remote patient management.
June 22, 2017

Urine Interleukin 18 and Lipocalin 2 Are Biomarkers of Acute Tubular Necrosis in Patients With Cirrhosis: A Systematic Review and Meta-analysis We found that urine levels of IL18 and NGAL from patients with cirrhosis discriminate between those with ATN and other types of kidney impairments.
June 22, 2017

Prophylaxis for Stress Ulcers With Proton Pump Inhibitors Is Not Associated With Increased Risk of Bloodstream Infections in the Intensive Care Unit In a retrospective study of patients in the ICU, administration of PPIs to prevent bleeding was not associated with increased risk of BSI.
June 22, 2017

Gastrostomies Preserve But Do Not Increase Quality of Life for Patients and Caregivers We performed a mixed-methods prospective study of the effects of gastrostomy feeding on HRQoL.
June 22, 2017

Risk of Rectal Cancer After Colectomy for Patients With Ulcerative Colitis: A National Cohort Study We found that the risk for rectal cancer after colectomy in patients with UC is low, in relative and absolute terms, after reconstruction with an IPAA.
June 22, 2017

Temporal Trends in Initiation of Therapy With Tumor Necrosis Factor Antagonists for Patients With Inflammatory Bowel Disease: A Population-based Analysis Use of anti-TNF agents increased from 2001 through 2014, with a concomitant significant decrease in cumulative use of corticosteroids before anti-TNF therapy for patients with UC.
June 22, 2017

Increasing Number of Passes Beyond 4 Does Not Increase Sensitivity of Detection of Pancreatic Malignancy by Endoscopic Ultrasound–Guided Fine-Needle Aspiration We found 4 passes of EUS-FNA to be sufficient to detect malignant pancreatic masses; increasing the number of passes did not increase the sensitivity of detection.
June 22, 2017

Clinical Gastroenterology & Hepatology RSS

  • Health-related Quality of Life and Costs Associated With Eosinophilic Esophagitis: A Systematic Review

    Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease characterized by esophageal inflammation and dysfunction. Little is known about the humanistic and economic burden of the disease on patients, their caregivers and the healthcare system. A systematic review was conducted to evaluate the existing literature on the disease burden of EoE for patients and their caregivers.
  • The Esophageal Epithelial Barrier in Health and Disease

    Dysfunction in the esophageal epithelial barrier function is a major source for morbidity. In order to better understand the pathophysiologic pathways of the diseases associated with barrier dysfunction, including gastroesophageal reflux disease (GERD), eosinophilic esophagitis (EoE), Barretts esophagus (BE) and obesity, it is important to understand the esophageal epithelial embryologic development, microscopic anatomy with a special focus on the barrier structure and function, extra-epithelial defense mechanisms and how these change in the diseased state.
  • Insulin expressing Pancreatic Neuroendocrine Tumor associated with Intratumor Amyloidosis

  • Aseptic Liver abscess-Induced by Crohns Disease Successfully Treated by Infliximab

  • Predictors of efficacy of percutaneous tibial nerve stimulation for fecal incontinence: a post-hoc analysis of a randomized trial

    A recent UK multicentre, phase III trial [The CONFIDeNT Trial: Lancet 2015; 386: 1640-48], demonstrated no significant clinical benefit of percutaneous tibial nerve stimulation (PTNS) over sham stimulation; however this study did not analyse predictors of response. This study aimed to determine predictors of PTNS efficacy in adults with fecal incontinence (FI) using data from this randomized controlled trial.
  • Radial Endoscopic Ultrasound for the Diagnosis of Chronic Schistosomiasis in the Colorectum

  • Obesity and Risk of NAFLD: A Comparison of Bioelectrical Impedance Analysis and Conventional Derived Anthropometric Measures

  • Exam 1: Comparison of Endoscopic Dilation vs Surgery for Anastomotic Stricture in Patients With Crohn's Disease Following Ileocolonic Resection

  • Outcomes and role of urgent endoscopy in high-risk patients with acute nonvariceal gastrointestinal bleeding

    We investigated clinical outcomes in high-risk patients with acute nonvariceal upper gastrointestinal bleeding (UGIB), and determined if urgent endoscopy is effective.
  • Acute Severe Gastrointestinal Tract Bleeding is Associated with an Increased Risk of Thromboembolism and Death

    We performed a retrospective cohort study of patients with and without gastrointestinal bleeding (GIB) to determine whether GIB increases the risks of thromboembolism and death.
  • A terminal rectal mass ultimately identified by histopathology examination

  • Tongxie Formula Reduces Symptoms of Irritable Bowel Syndrome

    Irritable bowel syndrome (IBS) is the most common chronic gastrointestinal disorder, yet few drugs are effective in reducing symptoms. Approximately 50% of patients with IBS attempt herbal therapy at least once. We performed a randomized controlled trial to compare the efficacy of the herb formulation tongxie vs placebo or pinaverium (an antispasmodic agent) in reducing symptoms of IBS.
  • Comparison of Patterns and Outcomes of Liver Resection for Hepatocellular Carcinoma: East versus West

  • Cost-Effectiveness of Pre versus Post Liver Transplant Hepatitis C Treatment with Direct-Acting Antivirals

    Oral direct-acting antivirals (DAAs) for hepatitis C virus (HCV) treatment offer new hope to both pre- and post-liver transplant (LT) patients. However, whether to treat HCV patients pre- versus post-LT is not clear, as treatment can improve liver function but could reduce the chance of receiving a LT while on the waiting list. Our objective was to evaluate the cost-effectiveness of pre-LT versus post-LT HCV treatment with oral DAAs in decompensated cirrhotic patients on the LT waiting list.
  • Diagnosis of Autoimmune Pancreatitis: The Evolution of Diagnostic Criteria for a Rare Disease

  • Risk of pneumonia caused by Pneumocystis jirovecii in inflammatory bowel disease: the role of concomitant pulmonary comorbidities

  • Natural History of Adult Ulcerative Colitis in Population-based Cohorts: A Systematic Review

    A comprehensive knowledge of the natural history of UC helps understand disease evolution, identify poor prognostic markers and impact of treatment strategies and facilitates shared decision-making. We systematically reviewed the natural history of UC in adult population-based cohort studies with long-term follow-up.
  • A Prospective Multicenter Study Evaluating Learning Curves and Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography Among Advanced Endoscopy Trainees: The Rapid Assessment of Trainee Endoscopy Skills (RATES) Study

    Based on the Next Accreditation System, trainee assessment should occur on a continuous basis with individualized feedback. We aimed to validate endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) learning curves among advanced endoscopy trainees (AETs) using a large national sample of training programs and to develop a centralized database that allows assessment of performance in relation to peers.
  • Constructing an Inflammatory Bowel Disease PatientCentered Medical Home

    Inflammatory bowel diseases (IBDs) including Crohns disease and ulcerative colitis are life-long chronic diseases with high morbidity. Recent studies have shown increasing global IBD incidence and prevalence rates. Furthermore, there has been remarkable progress in the understanding of disease pathophysiology, leading to new medical therapies and surgical approaches for the management of IBD. These trends have resulted in a marked increase in the cost of IBD care, with current estimates ranging from $14 to $31 billion in both direct and indirect costs in the United States.
  • Association of transferrin saturation with the arthropathy of hereditary haemochromatosis

  • Colon Pathology Characteristics in Li-Fraumeni Syndrome

  • Efficacy and optimal duration of metallic stent in the management of refractory anastomotic stricture after liver transplantation

    Anastomotic bile duct stricture (ABS) remains as one of the most common complications in liver transplant patients. Current practice of endoscopic retrograde cholangiopancreatography (ERCP) with insertion of plastic stent (PS) often requires multiple procedures before achieving stricture resolution. To date, studies utilizing covered self-expandable metallic stent (cSEMS) in ABS management reported varying degree of efficacy. The aim of this study was to analyze long term efficacy of cSEMS in patients with ABS, and identifying factor(s) influencing the probability of stricture resolution.
  • Diffuse Enlargement of the Pancreas: An Unusual Radiologic Presentation of a Pancreatic Neuroendocrine Tumor

  • Comparing EUS-Fine Needle Aspiration and EUS-Fine Needle Biopsy for Solid Lesions: A Multicenter, Randomized Trial

    Endoscopic ultrasound (EUS) with fine needle aspiration (FNA) is the standard of care for tissue sampling of solid lesions adjacent to the GI tract. Fine needle biopsy (FNB) may provide higher diagnostic yield with fewer needle passes. The aim of this study was to assess the difference in diagnostic yield between FNA and FNB.
  • Lifestyle behaviour change in patients with non-alcoholic fatty liver disease: A qualitative study of clinical practice

  • Issue highlights

    Patients with cirrhosis have been shown to have a decrease in health-related quality of life (HRQOL). These patients also report sleep disturbances, which can negatively affect HRQOL. In this issue of Clinical Gastroenterology and Hepatology, Ghabril and colleagues measured the prevalence of disturbed sleep and its impact on HRQOL in 193 ambulatory patients with cirrhosis. Of these, 154 patients had decompensated cirrhosis but did not have any evidence of overt hepatic encephalopathy. The authors also compared neurocognitive function, actigraphy (measuring sleep time, latency, awakenings), and non-targeted serum metabolic profiling in subsets of patients with normal and disturbed sleep.
  • Societal perspectives and patient/public involvement in DAAs coverage of hepatitis C treatment in the U.S.

  • Occurrence of IgG4 in Esophageal Lichen Planus

  • Agreement Between Home-based Measurement of Stool Calprotectin and ELISA Results for Monitoring Inflammatory Bowel Disease Activity

    An increasing number of physicians use repeated measurements of stool calprotectin to monitor intestinal inflammation in patients with inflammatory bowel diseases (IBD). A lateral flow-based rapid test allows patients to measure their own stool calprotectin values at home. The test comes with a software application (IBDoc) that turns a smartphone camera into a results reader. We compared results from this method with those from the hospital-based reader (Quantum Blue) and ELISA analysis.
  • Effects of Community Screening for Helicobacter pylori: 13-Year Follow-up of a Randomized Controlled Trial (HEP-FYN)

    Helicobacter pylori (Hp) eradication improves the prognosis of peptic ulcer disease (PUD), dyspepsia, and possibly gastric cancer. Hp screening tests are accurate and eradication therapy is effective. Hp population screening seems attractive.The aim of this study was to evaluate the long-term effect of Hp population screening and eradication on dyspepsia prevalence and the incidence of PUD, and as secondary outcomes to assess the effect on health-care consumption and quality of life.
  • Association between Endoscopist and Center ERCP Volume with Procedure Success and Adverse Outcomes: A Systematic Review and Meta-Analysis

    ERCP has become a predominantly therapeutic intervention with a resultant increase in complexity. The relationship between ERCP volume and outcomes is unclear. We aimed to conduct a systematic review and meta-analysis assessing the relationship between endoscopist and center ERCP volume with (i) ERCP success; and (ii) adverse event (AE) rates.
  • Optimizing Fecal Immunochemical Testing for Colorectal Cancer Screening

  • Colonic Diverticula Are Not Associated with Mucosal Inflammation or Chronic Gastrointestinal Symptoms

    Colonic diverticulosis has been reported to be associated with low-grade mucosal inflammation possibly leading to chronic gastrointestinal symptoms. However, there is poor evidence for this association. We aimed to determine whether colonic diverticula are associated with mucosal inflammation and whether diverticula are associated with chronic gastrointestinal symptoms. We explored whether inflammation was present among symptomatic participants with and without diverticula.
  • Improved outcomes with proactive versus reactive therapeutic drug monitoring of infliximab in IBD

  • An uncommon gastric submucosal tumor with mucosal erosion

  • Prevalence of Eosinophilic Gastroenteritis and Colitis in a Population-Based Study, From 2012 to 2017

    Although eosinophilic esophagitis (EoE) has been extensively studied, there have been few epidemiology studies of other eosinophilic gastrointestinal disorders (EGIDs). Using a large, population-based database, we investigated epidemiologic features of eosinophilic gastroenteritis (EoGE), and colitis (EoC) in the United States (US).
  • Comparable Long-term Outcomes of 1-minute vs 5-minute Endoscopic Papillary Balloon Dilation for Bile Duct Stones

    Endoscopic papillary balloon dilation (EPBD) is an alternative to endoscopic sphincterotomy (EST) for choledocholithiasis. Unlike EST, EPBD preserves biliary sphincter function, reducing long-term risk of recurrent choledocholithiasis by 50%. Guidelines recommend that duration of EPBD exceeds 2 minutes, to adequately loosen the sphincter and reduce risks of failed stone extraction and post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. However, it is unclear whether this long duration of EPBD impairs sphincter function and negates the long-term benefit of EPBD.
  • Efficacy of a 4-Food Elimination Diet for Children With Eosinophilic Esophagitis

    A 6-food elimination diet induces remission in most children and adults with eosinophilic esophagitis (EoE). The effectiveness of empiric elimination of only 4 foods has not been studied in children. We performed a prospective observational outcome study in children with EoE treated with dietary exclusion of cow's milk, wheat, egg, and soy. The objective was to assess the clinical, endoscopic, and histologic efficacy of this treatment in EoE.
  • Ethnicity influences Phenotype and Outcomes in Inflammatory Bowel Disease: A Systematic Review and Meta-analysis of Population-Based Studies

    Inflammatory bowel diseases (IBD; Crohns disease (CD), ulcerative colitis (UC)) are global diseases. Similarities and differences in disease presentation and outcomes across different geographic regions and ethnic groups have not been compared previously.
  • Workplace accommodation for persons with IBD: What is needed and what is accessed

    People with inflammatory bowel disease (IBD) often experience periods of illness that interfere with their ability to work. We aimed to understand the need for workplace accommodation during periods of acute illness among persons IBD.
  • Efficacy and Safety of Mycophenolate Mofetil and Tacrolimus as Second-line Therapy for Patients with Autoimmune Hepatitis

    Predniso(lo)ne, alone or in combination with azathioprine, is the standard of care (SOC) therapy for autoimmune hepatitis (AIH). However, the SOC therapy is poorly tolerated or does not control disease activity in up to 20% of patients. We assessed the efficacy of mycophenolate mofetil (MMF) and tacrolimus as second-line therapy for patients with AIH.
  • Primary splenic flexure schwanomma- pre-operatively diagnosed with EUS guided fine needle biopsy

  • Increased risk of in-hospital mortality and non-ICU death in patients with cirrhosis after cardiac arrest

  • More Benefits from Interrupted Time Series in Evaluating Recent Market Release of DAAs and State Medicaid Reimbursement Programs

  • Should Nibolmab-Induced Colitis be Treated by Infliximab?

  • New Developments in Hepatorenal Syndrome

    Hepatorenal Syndrome (HRS) continues to be one of the major complications of decompensated cirrhosis leading to death in the absence of liver transplantation. Challenges in precisely evaluating renal function in the patient with cirrhosis remain due to the limitations of serum creatinine (Cr) alone in estimating glomerular filtration rate (GFR); current GFR estimating models appear to underestimate renal function. Newer models incorporating renal biomarkers, such as the Cr-Cystatin C GFR Equation for Cirrhosis appear to more accurately estimate true GFR.
  • Duodenal diverticular bleeding managed using an Over-the-scope-clip

  • Delayed Onset Biallelic Mismatch Repair Deficiency Syndrome

  • Gastrointestinal safety profiles differ among non-vitamin K antagonist anticoagulants?

  • Food Allergies and Intolerances

    Food allergies and food intolerances are both caused by reactions to certain foods, but they are not the same. The strength and type of reaction can help indicate whether you are having an allergic reaction to a food or a food intolerance. It is vital to see a doctor if you think you have a food allergy or intolerance before getting rid of any foods from your diet.
  • Acute Pancreatitis has Long-term Deleterious Effect on Physical Quality of Life

    It is not clear how acute pancreatitis (AP) affects quality of life (QOL). We aimed to determine the long-term independent effect of AP on physical and mental QOL.
  • Confluence of Epidemics of Hepatitis C, Diabetes, Obesity, and Chronic Kidney Disease in the United States Population

    Obesity, kidney disease, and diabetes are common conditions that can affect outcomes of patients with chronic hepatitis C. We aimed to quantify the burden of these comorbid conditions among adults with chronic hepatitis C in the United States and to estimate the risk of death among people with chronic hepatitis C and comorbidities.
  • Estrogen Replacement Reduces Risk and Increases Survival Times of Women With Hepatocellular Carcinoma

    Environmental factors have been identified that affect risk of hepatocellular carcinoma (HCC), but little is known about the effects of sex hormones on liver cancer development or outcome. We investigated whether menopause hormone therapy (MHT) affects risk, age at onset, or outcome of HCC.
  • The TREAT Registry: Evolution of Knowledge from 1999 to 2017: Lessons Learned

    The following commentary discusses a landmark article published in CGH and is part of a series that celebrates the journals 15th year of publication. Landmark articles were chosen by the CGH Board of Editors and represent discoveries that advanced the science and practice of gastroenterology.
  • Epiploic Appendagitis: The Uncommon Intestinal Imitator

  • Liver and Cardiovascular Damage in Patients With Lean Nonalcoholic Fatty Liver Disease, and Association With Visceral Obesity

    Lean nonalcoholic fatty liver disease (NAFLD) is defined as NAFLD that develops in patients with a body mass index (BMI) less than 25 kg/m2. We investigated the differences between lean NAFLD and NAFLD in overweight and obese persons, factors associated with the severity of liver and cardiovascular disease, and the effects of visceral obesity.
  • No Association Between Quick Sequential Organ Failure Assessment and Outcomes of Patients With Cirrhosis and Infections

    Clinical scoring systems such as the systemic inflammatory response syndrome (SIRS) and sequential organ failure assessment (SOFA), which can predict outcomes in noncirrhotic patients, often are not as useful in cirrhosis. This may be because of the constant inflammatory response that is prevalent in this population.1,2 Recently, in the noncirrhotic population, the prediction of negative outcomes related to infections has been studied with the application of the quick sequential organ failure assessment (qSOFA) score.
  • Interferon-Free Regimens in Hepatitis B Surface Antigen/AntiHepatitis C Virus Patients: The Need to ControlHepatitis BVirus Replication to Avoid Hepatitis BVirusReactivation

    The data on the efficacy of directly acting antiviral agent (DAA) regimens in hepatitis B virus (HBV)/hepatitis C virus (HCV) chronic co-infection are very few, and suggest a possible reactivation of HBV infection (rHBV) after HCV control.13 The efficacy of DAA-based regimens was evaluated in 29 hepatitis B surface antigen/anti-HCV/HCV RNApositive patients in terms of sustained virologic response for HCV and of rHBV.
  • Features and Treatment of Dapsone-Induced Hepatitis, Based on Analysis of 44 Cases and Literature Review

    Dapsone (4,4 diaminodiphenysulphone) first was synthesized in 1908. Aside from leprosy, it has been used for the treatment of many other dermatologic and nondermatologic conditions.
  • High Resolution Manometry in Scleroderma Patients

    We read with interest the article by Crowell etal1 regarding the prevalence and type of esophageal motor abnormalities in systemic scleroderma patients. In thatstudy, which involved 200 patients and 102 controls, the distinctive features of scleroderma esophagus (hypotensive esophagogastric junction pressure with absent contractility) were detected in only one third of patients. Moreover, the spectrum of esophageal motor abnormalities was heterogeneous, the most frequent finding being an absent contractility, as detected in 56%, followed by normal motility in 26%, and ineffective esophageal motility in 10% of patients.
  • Long-Term Outcomes of Nonalcoholic Fatty Liver Disease: From Nonalcoholic Steatohepatitis to Nonalcoholic Steatofibrosis

    The following commentary discusses a landmark article published in CGH and is part of a series that celebrates the journals 15th year of publication. Landmark articles were chosen by the CGH Board of Editors and represent discoveries that advanced the science and practice of gastroenterology.
  • Drug-Induced Autoimmune Hepatitis: Response to Corticosteroids and Lack of Relapse After Cessation of Steroids

    Drug-induced autoimmune hepatitis (DIAIH) is an increasingly recognized phenotype of drug-induced liver injury (DILI).13 Recently, no data on treatment were reported in patients with DIAIH.3 We aimed to determine the frequency of DIAIH in Iceland, its causative agents, response to corticosteroids, and risk of relapse.
  • Reply

    We would like to thank Dr Maton for his thoughtful editorial. We are pleased that he enjoyed our article.1 We agree that there is room for improvement in the management of gastric bypass patients with marginal ulceration, and that the optimal method of proton pump inhibitor administration remains unclear. The recommendations provided in his editorial are sound, and worthy of further study.
  • Gastroduodenal Burkitt Lymphoma Presenting as Demyelinating Polyneuropathy

  • Gastric Cancer as Preventable Disease

    Gastric cancer, 1 of the 5 most common causes of cancer death, is associated with a 5-year overall survival rate less than 30%. A minority of cancers occurs as part of syndromic diseases; more than 90% of adenocarcinomas are considered as the ultimate consequence of a longstanding mucosal inflammation. Helicobacter pylori infection is the leading etiology of nonself-limiting gastritis, which may result in atrophy of the gastric mucosa and impaired acid secretion. Gastric atrophy establishes a field of cancerization prone to further molecular and phenotypic changes, possibly resulting in cancer growth.
  • One-Day Behavioral Intervention for Patients With Inflammatory Bowel Disease and Co-Occurring Psychological Distress

    The prevalence of depression and anxiety among patients with inflammatory bowel disease (IBD) ranges from 29% to 35% in remission to 80% during disease flares.1 Despite their high prevalence and deleterious impact on health-related quality of life (HRQoL), depression and anxiety are undertreated in patients with IBD owing to poor recognition and lack of evidence to guide interventions.2
  • Validation of the Mayo Clinic Staging System in Determining Prognoses of Patients with Perihilar Cholangiocarcinoma

    Most systems for staging perihilar cholangiocarcinoma (PHC) have been developed for the minority of patients with resectable disease. The recently developed Mayo Clinic system for staging PHC requires only clinical and radiological variables, but has not yet been validated. We performed a retrospective study to validate the Mayo Clinic staging system.
  • Reply

    There is substantial evidence that acidity plays a major role in the pathophysiology of marginal ulceration in Roux-en-Y gastric bypass (RYGB), with the mainstay of treatment being proton pump inhibitors (PPIs). PPI capsules are designed to break down in the stomach. Patients with gastric bypass only have a small gastric pouch and rapid small-bowel transit, limiting the opportunity for capsular breakdown and medication absorption. Some capsules may even make their way to the colon before breakdown occurs.
  • Early-age hepatocellular carcinoma associated with hepatitis B infection in South America

  • Caregiver Burden in Adults With Inflammatory Bowel Disease

    Inflammatory bowel disease (IBD) is a chronic condition that has a relapsing and remitting disease course. There is high degree of inpatient and outpatient health care utilization by IBD patients along with a great deal of psychosocial stress associated with the condition. Patients frequently rely on family, friends, and other informal caregivers to provide medical, instrumental, and emotional support. The role of caregiving for adult IBD patients can lead to significant caregiver burden. At present, there are limited data on the existence of caregiver burden in adult IBD patients.
  • 10-Year Retained Video Capsule With Crohns-Associated Small-Bowel Adenocarcinoma

    A 66-year-old man with small-bowel Crohns disease (CD) diagnosed in the 1970s presented for a second opinion regarding Crohns disease treatment. He had no significant comorbidities or prior intestinal surgeries. He was treated with mesalamine alone for most of the past 40 years, but subsequently developed anemia, diarrhea, abdominal pain, and weight loss. Because of these new symptoms, he recently had started adalimumab and azathioprine. His pain was exacerbated by meals and associated with nausea and bloating.
  • Cirrhosis Presenting as Cutaneous Calciphylaxis

    A 73-year-old woman with a history of hypertension presented with a 3-month history of a painful, non-healing right calf ulcer and 23 weeks of painful, dusky purple patches on the right thigh. Before our evaluation, she underwent right iliac stent placement for peripheral artery disease without improvement in her pain or ulcer. She reported a recent 15-pound weight loss attributed to decreased appetite and stomach discomfort. She was an active smoker with a 60 pack-year smoking history and consumed 4 alcoholic drinks per night.
  • Reactive Versus Proactive Therapeutic Drug Monitoring in Inflammatory Bowel Disease Patients Treated With Infliximab: ASelf-Fulfilling Prophecy

    We read the article by Papamichael etal1 with interest. This was a retrospective cohort study comparing the long-term outcomes of inflammatory bowel disease (IBD) patients treated with infliximab. The investigators concluded that proactive therapeutic drug monitoring (TDM) was associated with better clinical outcomes including greater drug durability, less need for IBD-related surgery or hospitalization, and a lower risk of developing antibodies to infliximab than those in whom TDM was reactive.
  • Treatment of Crohns Disease Anastomotic Stricture With aLumen-apposing Metal Stent

    A 63-year-old woman with a 35-year history of fistulizing and stricturing ileocolonic Crohns disease presented with bloating, distention, and lower abdominal pain. Eight years prior, she underwent a hemicolectomy with ascending colon to rectal end-to-side anastomosis for a 7-cm transverse colonic stricture. Postoperatively the patient was placed on mercaptopurine monotherapy for prophylaxis, followed by quiescent disease. Physical exam was only significant for mild left lower quadrant abdominal tenderness.
  • Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits

    The use of opioid medications on both an acute and chronic basis is ubiquitous in the United States. As opioid receptors densely populate the gastrointestinal tract, symptoms and side effects can be expected in these patients. In the esophagus, dysmotility may result, manifesting with dysphagia and a syndrome indistinguishable from primary achalasia. In the stomach, a marked delay in gastric emptying may ensue with postprandial nausea and early satiety. Postoperatively, particularly with abdominal surgery, opioid-induced ileus may ensue.
  • White Paper AGA: Functional Dyspepsia

    Dyspepsia is a widely prevalent disorder throughout the world with population-based estimates varying according to the definition used. The prevalence decreases as the definition becomes more restrictive, with 7% (95% confidence interval [CI], 5%11%) of the general population having Rome III criteria dyspepsia.1 The majority of patients with dyspepsia have no organic pathology identified at esophagogastroduodenoscopy that could explain symptoms and thus fulfill the definition of functional dyspepsia (FD; previously called nonulcer dyspepsia).
  • Should Nivolumab-Induced Colitis Be Treated by Infliximab?

    We read with interest the case described by Yanai etal1 in which these investigators described a patient who developed ulcerative colitis under uveal melanoma-indicated nivolumab therapy. Nivolumab is an immunologic check-point inhibitor that combats oncologic disease by removing regulatory control on the T-cell compartment and thus up-regulating cytotoxic T-cellmediated antitumor immunity. The resulting up-regulation of T-cell immunity, however, can be accompanied by autoimmunity, and colitis is especially a side effect of immune check-point inhibition.
  • A Rare Hepatic Tumor

    A 36-year-old woman with a history of thyroid goiter was found incidentally to have a hepatic tumor at a local clinic. She was referred to our hospital for further survey. The physical examination was negative. She denied a history of hepatitis and contraceptive pill use. The serum -fetoprotein, carcinoembryonic antigen, CA 125, and carbohydrate antigen 19-9 levels were within normal limits.
  • Exam 2: Increasing Number of Passes Beyond 4 Does Not Increase Sensitivity of Detection of Pancreatic Malignancy by Endoscopic Ultrasound-Guided Fine-Needle Aspiration

  • Exam 1: Risk of Rectal Cancer After Colectomy for Patients With Ulcerative Colitis: A National Cohort Study

  • Erosion of the Duodenum by an Aortic Graft, Leading to Recurrent Sepsis

    A 56-year-old man with long-standing Behets disease presented with recurrent sepsis attacks resulting from an aortoenteric stent placed 2 years previously. The patient initially was evaluated for abdominal pain with a computed tomography (CT) scan that showed a 5 3-cm aortic aneurysm. A laparotomy was performed and a Dacron graft was placed after the removal of the aneurysmatic aortic segment. One year after surgery, the patient was hospitalized for osteomyelitis and an abscess in the fascial planes surrounding the femur.
  • Chronic Diarrhea Caused by Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma With Colorectal Involvement

    A 65-year-old man with a history of hypogammaglobulinemia and recurrent sinusitis presented with worsening diarrhea and fecal urgency over 6 months. The diarrhea was associated with abdominal pain, early satiety, anorexia, fatigue, and weight loss. Laboratory investigations showed mild absolute lymphocytosis and a slight increase of 2 microglobulin levels. An extensive work-up for enteric infections, including Clostridium difficile toxin, was negative. The diarrhea was refractory to treatment with various antibiotics and loperamide.
  • Issue Highlights

    Cross-sectional studies and clinical experience suggest there is a higher prevalence of depression and anxiety in patients with functional gastrointestinal diseases (FGID). To what extent this reflects the impact of disease symptoms on mood and whether mood disorders precede and may indeed be causally implicated in the pathogenesis of FGID has not been well established. In this issue of Clinical Gastroenterology and Hepatology, Jones etal present a study that examined the bidirectional association between mood disorders and FGID in two population-based databases.
  • Reply

    We appreciate the letter from Dr Smith etal.1 regarding our recent publication. We agree that the most significant histologic feature of nonalcoholic fattyliver disease (NAFLD) is the degree of fibrosis, which predicts long-term clinical outcome in patients with NAFLD24 We also agree that the NAFLD activityscore (NAS), although useful for clinical research in nonalcoholic steatohepatitis, is not an ideal prognosticator of outcomes for patients with NAFLD.24 The NAS was developed in 2005 to provide a standardized scoring system for clinical trials, and was created to encompass the full spectrum of NAFLD histology in both adults and children.
  • Glomus Tumor of the StomachA Tumor That Needs to Be Differentiated From Gastrointestinal Stromal Tumor

    A 61-year-old man presented with 3 months of epigastric pain, nausea, and vomiting before admission. The symptoms worsened with hunger and were relieved after eating a meal. No other symptoms or signs were present. He was treated for peptic ulcer at a local hospital (detailed information was lost), but the discomfort persisted. Laboratory tests, including tumor markers, showed no significant abnormal findings.
  • Promising Modalities to Identify and Monitor Eosinophilic Esophagitis

    Eosinophilic esophagitis (EoE) is an allergen-mediated condition characterized by symptoms of esophageal dysfunction and histologic evidence of intense eosinophilic inflammation involving the esophagus in the absence of overlapping conditions such as gastroesophageal reflux disease. Since the initial description as a distinct entity approximately 2 decades ago, there has been a remarkable increase in the recognition of this clinicopathologic entity. The current approach to diagnose and monitor EoE requires repeated esophagogastroduodenoscopies, with associated sedation/anesthesia, to visualize mucosal abnormalities, and to obtain multiple biopsy specimens for histologic assessment and to evaluate treatment response.
  • High negative predictive value, low prevalence and spectrum effect: caution in the interpretation

  • Effects of Exercise on Liver Fat and Metabolism in Alcohol Drinkers

    Exercise is an important component of obesity associated disorders and has been shown to reduce markers of non-alcoholic fatty liver disease (NAFLD). However, little is known about how these effects are influenced by alcohol intake. We performed a randomized controlled trial to investigate the effects of exercise on hepatic triglyceride content (HTGC) and metabolism in overweight or obese patients who consume alcohol.
  • Multicenter External Validation of Risk Stratification Criteria for Patients With Variceal Bleeding

    Early placement of a transjugular intrahepatic porto-systemic shunts (TIPS) is considered the treatment of choice for patients with acute variceal bleeding (AVB) and cirrhosis who have a high risk of death (Child-Pugh class B with active bleeding at endoscopy or Child-Pugh class C). It has been proposed that patients of Child-Pugh class B, even with active bleeding, should not be considered high risk. Alternative criteria have been proposed for identification of high-risk patients, such as Child-Pugh class C with plasma level of creatinine of 1 mg/dl or more (ChildC-C1) and a model for end-stage liver disease (MELD) score of 19 or more.
  • Biopsy Specimens From Allograft Liver Contain Histologic Features of Hepatitis C Virus Infection After Virus Eradication

    Most patients, even those who have received a liver transplant, achieve a sustained virologic response (SVR) to therapy for hepatitis C virus (HCV) infection. Little is known about the histologic features of liver biopsy specimens collected after SVR, particularly in patients who have received a liver transplant. We aimed to better characterize the histologic features of allograft liver biopsy specimens from patients who achieved SVR to anti-HCV therapy after liver transplantation.
  • Histologic Scores for Fat and Fibrosis Associate With Development of Type 2 Diabetes in Patients With Non-alcoholic Fatty Liver Disease

    Non-alcoholic fatty liver disease (NAFLD) is a strong risk factor for development of type 2 diabetes, but little is known about how long-term NAFLD or its histologic features affect risk. We aimed to investigate the cumulative incidence of type 2 diabetes in patients with NAFLD, and to identify histologic factors that affect risk of diabetes.
  • Statin Use and Risk of Cirrhosis and Related Complications in Patients with Chronic Liver Diseases: a Systematic Review and Meta-analysis

    Statins have been variably shown to decrease risk and complications of chronic liver diseases (CLDs). We performed a systematic review and meta-analysis to evaluate the association between statins and risk of cirrhosis and related complications in patients with CLDs.
  • Magnitude and Kinetics of Decrease in Liver Stiffness After Anti-viral Therapy in Patients With Chronic Hepatitis C: A Systematic Review and Meta-analysis

    We performed a systematic review and meta-analysis to estimate the decrease in liver stiffness, measured by vibration-controlled transient elastrography (VCTE), in patients with hepatitis C virus (HCV) infection who achieved a sustained virologic response (SVR).
  • Reply

    We would like to thank Dr Gregersen1 for his comments and appreciate the concerns he has raised regarding the limitations of the analysis for the device he invented with Dr Barry McMahon.2 The data obtained with functional luminal imaging probe (FLIP) topography are extremely robust and complex and our current available FLIP metrics are only scratching the surface of what can be done with this tool. However, we feel comfortable that relevant clinical data can be obtained within the current FLIP paradigm if one recognizes the limitations and works within the construct of the disease and existing outcome measures.
  • Infliximab vs Adalimumab for UC: IsThere A Difference?

    Antitumor necrosis factor (anti-TNF) therapy has been transformational for the treatment of inflammatory bowel disease (IBD), beginning with Crohns disease (CD) in 19981 and extending to ulcerative colitis (UC) in the 2005.2 Since their initial approval we have learned a great deal about these drugs for the treatment of IBD, some of which has differed from their use in other diseases. For instance, we have come to understand the value of induction therapy,3 scheduled as opposed to episodic therapy,4 combination therapy with immunomodulators,5 and therapeutic drug monitoring with a focus on the importance of drug concentration and immunogenicity and factors, which influence both of these.
  • Reply

    We thank Hirten and Colombel1 for their erudite commentary on our recently published work.2 The findings of our study highlight the association between irritable bowel syndrome (IBS)type symptoms in patients with quiescent inflammatory bowel disease (IBD) as well as psychological comorbidity and poor quality of life, and are in keeping with those of another large study from Sweden, reporting that 18% of patients with ulcerative colitis (UC) in deep remission report these symptoms.3 These studies highlight a hitherto poorly characterized cohort of patients with unmet needs, for which the therapeutic options are limited.
  • Porphyria Cutanea Tarda as the Initial Manifestation of Subclinical Hereditary Hemochromatosis

    A 34-year-old man presented for the evaluation of skin fragility and episodic painful blisters on his hands. The problem first developed 2 years earlier, and he had noticed that his skin lesions were provoked by minor trauma sustained while working as an automobile mechanic. The patient reported consuming 3 alcoholic beverages per day for the past several years, but otherwise was healthy.
  • Rare Case of Hematemesis: Calciphylaxis of the Esophagus

    A 57-year-old woman with a history of end-stage renal disease on peritoneal dialysis for 17 months, diabetes mellitus, hypertension, and hyperparathyroidism presented with nausea and malaise. ST segment elevation myocardial infarction with an ejection fraction of 20% was diagnosed along with triple-vessel coronary artery disease not amenable to percutaneous coronary intervention, requiring a ventricular assist device and anticoagulation with a heparin drip. She had reported dysphagia and initially received nutrition through a Dobhoff tube for 6 days.
  • Refractory Achalasia: Is POEM Changing the Paradigm?

    Achalasia is the most studied esophageal motility disorder with rising annual incidence of approximately 12.92/100,000 that is thought to be related to advent of improved diagnostic tools such as high-resolution manometry (HRM) in 2008 and better recognition of the disease.1,2 Achalasia is characterized by esophageal aperistalsis and impaired relaxation of the lower esophageal sphincter during deglutination. Patients frequently present with dysphagia to solids and liquids, severe regurgitation, varying degree of weight loss, heartburn, and chest pain.
  • Risk of Gastrointestinal Bleeding in Patients Taking Non-vitamin K Antagonist Oral Anticoagulants: a Systematic Review and Meta-analysis

    Non-vitamin K antagonist oral anticoagulants (NOACs) are convenient and effective in prevention and treatment of venous thromboembolism and prevention of stroke in patients with atrial fibrillation. However, these drugs have been associated with increased risk of gastrointestinal (GI) bleeding. We conducted a systematic review and meta-analysis to determine the risk of GI bleeding in patients receiving these drugs.
  • Do Shared Exposures Link the Lungs and Gut? Association Between Asthma and InflammatoryBowel Disease

    Immune-mediated, inflammatory conditions of the gut (eg, inflammatory bowel disease [IBD]) and the lungs (eg, asthma) may be driven by common factors including the interplay between genetic risk factors and environmental exposures that impact the microbiome.14 The increasing incidence of these immune-mediated conditions in recent years has been attributed frequently to the hygiene hypothesis,5 which postulates that IBD, asthma, and related immune-mediated conditions are results of improved sanitation including clean water, decreased family size, and improved living conditions.
  • Healing Marginal Ulcers in Patients Who Have Had a Roux-en-Y Gastric Bypass

    I read with interest the article by Schulman etal1 and the accompanying editorial by Tansel etal.2 Simply opening the capsule increased the efficacy of the proton pump inhibitors (PPIs) in healing marginal ulcers in patients with a Roux-en-Y gastric bypass, but these ulcers still took a median of 3 months to heal, and it is possible that therapy could be further optimized.
  • Endoscopic Balloon Dilation vs Surgery for Crohn's Disease-related Strictures

    The lifetime need for intestinal resection in patients with Crohns disease depends on the disease location, age of onset, and disease severity but amounts to 80% and has been reduced by the advent of thiopurines and biological treatments.1 Over time most patients who undergo an ileocecal or partial colonic resection will need a second surgery, potentially even more; therefore, bowel-conserving procedures to avoid the risk of short bowel and surgical complications have been developed.2 Both endoscopic and surgical strictureplasty have matured during the last 20 years and hold a promise of bowel conservation rather than resection of valuable small bowel surface.
  • Spontaneous Intramural Esophageal Hematoma

    A 97-year-old man with a history of rheumatoid arthritis, coronary artery disease, 3-vessel coronary artery bypass graft, and atrial fibrillation on apixaban was admitted for hematemesis associated with sudden-onset dysphagia after chest pain. Physical examination was unremarkable. Initial investigations showed a hemoglobin level of 10.9 g/dL, platelet level of 202,000 mm3, international normalized ratio of 1.3, creatinine level of 0.86, and an initial troponin level of 0.512 with a normal electrocardiography.
  • AGA Educational Tools Engage Patients and Can Improve Patient Conversations

    A growing body of evidence demonstrates that patient engagement improves health outcomes and lowers costs. But what is patient engagement and how can the American Gastroenterological Association (AGA) help you better care for patients? Patient engagement involves educating patients and preparing them to be more actively involved in making decisions about their care. It is one strategy that helps us achieve the triple aim of improved health outcomes, better patient care, and lower costs.
  • Prevalence of Celiac Disease Autoimmunity Among Adolescents and Young Adults in China

    In China, epidemiologic information on celiac disease autoimmunity is scarce and fragmented. We investigated the prevalence of celiac disease autoimmunity in the general Chinese population.
  • Needle Tract Tumor Seeding Following Endoscopic UltrasoundGuided Fine Needle Aspiration of Metastatic Squamous Cell Carcinoma

    A 57-year-old Caucasian man with a history of poorly differentiated carcinoma of unknown primary (CUP) presented with melena. He was found to have a bleeding mass in the gastric cardia at the site of previous endoscopic ultrasoundguided fine needle aspiration (EUS-FNA) (Figure1A). Three years prior to this the patient presented feeling unwell and was found to have cervical lymphadenopathy. Biopsy revealed a poorly differentiated carcinoma, but despite comprehensive examination and investigations a primary tumor could not be identified.
  • Efficacy of Balloon Overtube-Assisted Colonoscopy in PatientsWith Incomplete or Previous Difficult Colonoscopies: AMeta-Analysis

    Colonoscopy is an effective tool to diagnose and treat colorectal conditions. Cecal intubation rates (CIRs) of 95% or greater for screening and of 90% or greater for all colonoscopies have been advocated as measures for a good quality colonoscopy.1 Factors associated with failed colonoscopy include older age, female sex, and previous abdominopelvic surgeries.2 Options for previously failed colonoscopy include using a smaller-caliber endoscope, water-assisted, cap-assisted, magnetic endoscope imaging (MEI), and balloon overtube-assisted colonoscopy (BOAC).
  • The Impact of Family History on the Risk of Colorectal Neoplasia and Screening Practices

    Colorectal cancer (CRC) is the fourth most common cancer among men and women in the United States, with almost 137,000 new cases diagnosed in 2015 and over 50,000 resultant deaths.1 Genetic alterations play a role in the development of all CRCs. Approximately 3%6% of all CRC cases are associated with highly penetrant hereditary gastrointestinal cancer syndromes that are now well characterized.2 More importantly from a population health perspective, another 25%30% of individuals with CRC report having 1 or more relatives diagnosed with CRC; we have used the term common familial CRC for this group.
  • Dietary Recommendations for Ulcerative Colitis Remain a Mystery

    There is tremendous patient and provider interest in the relationship between diet and inflammatory bowel disease (IBD) activity. However, there is lack of consistent data to support practical recommendations. Patients make an intuitive association between diet and IBD symptoms and disease activity. However, this nonsystematic approach may result in unnecessarily restrictive eating patterns and resultant micronutrient deficiencies. Similarly, in the absence of formal medical recommendations for diet, IBD patients continue to seek dietary advice from the internet and friends that can be scientifically inaccurate or overly restrictive.
  • All Wired Up: Migration of Endovascular Coils to the Common Bile Duct

    An 82-year-old man presented with hemobilia secondary to rupture of a pseudoaneurysm of the cystic artery 7 months after cholecystectomy. Coil embolization of the cystic artery was performed.
  • Metastatic Breast Cancer Presenting as Esophageal Stricture

    A 56-year-old woman was referred for esophagogastroduodenoscopy due to new onset progressive dysphagia to solid foods. Barium esophagram revealed a short stricture in the middle third of thoracic esophagus. Esophagogastroduodenoscopy showed 1 severe malignant-appearing, intrinsic stenosis with friable mucosa in the midesophagus. Stricture measured about 2 cm in length with a residual lumen of about 4 mm diameter and was not traversed by standard upper endoscope (Figure1A). Wire guided through the scope balloon dilation was performed serially with 812 mm dilating balloon.
  • Pedunculated Laryngeal Hemangioma in a Patient With Suspected Atypical Symptoms of GERD

    A 56-year-old man with a diagnosis 5 years prior of gastroesophageal reflux disease (GERD) with typical symptoms (heartburn) responsive to proton pump inhibitor (PPI) therapy was referred to our Gastroenterology Department having experienced chronic dry cough and pharyngeal foreign body sensation over a period of 2 years. He had no complaints of heartburn, dysphagia, dyspnea, choking, or hoarseness. He had history of neither smoking nor alcohol abuse. Both symptomatic specific treatments (dextromethorphan and benzocaine lozenges) and proton pump inhibitors (twice daily over a period of 3 months) had been only partially effective, as mild symptoms still persisted.
  • Reply

    We agree with Dr Howden that management of marginal ulceration after Roux-en-Y gastric bypass isdifficult.1 Available data suggests little role forsucralfate (eg, excluding sucralfate did not change healing rates).2 PPI bioavailability is compromised by(1) elimination of food-mediated increase in serum gastrin, which limits parietal cell activation; (2) absence of the reservoir function of the stomach withrapid gastric emptying; and (3) a short time available for the capsule to release and dissolve its granules within a limited absorptive surface.
  • Endoscopic Ultrasound Liver Biopsies Accurately Predict the Presence of Fibrosis in Patients With Fatty liver

    Nonalcoholic fatty liver disease (NALFD) is a prevalent cause of chronic liver disease, and affects more than 100 million individuals in the United States alone.1 Studies have shown that fibrosis in patients NAFLD is a positive predictor of worsening liver-related morbidity and mortality.2
  • A Randomized Trial of Silymarin for the Treatment ofNonalcoholic Steatohepatitis

    Silymarin is a complex mixture of 6 major flavonolignans and other minor polyphenolic compounds derived from the milk thistle plant Silybum marianum; it has shown antioxidant, anti-inflammatory and antifibrotic effects, and may be useful in patients with nonalcoholic fatty liver disease (NAFLD). We aimed to study the efficacy of silymarin in patients with nonalcoholic steatohepatitis (NASH)the more severe form of NAFLD.
  • Adenoma Prevalence in Blacks and Whites Having Equal Adherence To Screening Colonoscopy: The National Colonoscopy Study

    Is the higher reported colorectal cancer (CRC) mortality in blacks versus whites in the United States due to pathology or disparities in screening? Our study used patient navigation (PN) to facilitate blacks and whites adherence to screening colonoscopy and compared adenomas detected in each group.
  • Making a Great Journal Even Better

    With this issue, a new board of editors (BOE) will assume leadership of Clinical Gastroenterology and Hepatology (CGH). We follow in the footsteps of exceptional leaders in our field whose vision and commitment has positioned CGH as one of the most respected journals in digestive diseases.1 Currently, CGH has more than 18,500 subscribers with over 875,000 page views and 322,000 unique users each year, with a truly global footprint. CGHs readership includes constituencies in the United States, Canada, Mexico, South America, Europe, Asia, Africa, and Australia.
  • Gastroparesis: Clinical and Regulatory Insights for Clinical Trials

    Gastroparesis continues to represent a large unmet clinical need and a major opportunity for new drug development. This has led to increasing interest by federal funding agencies, regulatory bodies, and industry. This article summarizes the proceedings of the gastroparesis section of the Drug Development Conference: Clinical Endpoints in Upper GI Disorders organized by the American Gastroenterological Association in Washington, DC, on October 2728, 2016. The presentation, diagnosis, and current therapeutic strategies are briefly reviewed, followed by a detailed discussion of the regulatory strategy, recommended endpoints, and future directions.
  • Analysis of Functional Luminal Imaging Probe Data

    I read with interest the expert review by Hirano etal1 on the functional luminal imaging probe (FLIP) for the management of esophageal disorders. As one of the inventors of the FLIP technology2,3 and of the impedance planimetry technology behind FLIP, I have interest in the technology and its applications. It is a translated product from basic (biomechanical) science projects in the digestive tract. It has developed tremendously in recent years and now finds applications in several parts of the gastrointestinal tract and in the uterine cervix.
  • Unusual Submucosal Tumor in the Rectosigmoid Colon

    Screening colonoscopy in a 45-year-old woman revealed a protruding mass in the rectosigmoid colon. She had no specific medical history, and physical examination was unremarkable. Laboratory tests showed a white blood cell count of 5.4 103 cells/L, hemoglobin level of 12.4 g/dL, carcinoembryonic antigen level of 1.6ng/mL, and cancer antigen 19-9 level of 8.4international units/mL; other tests were unremarkable. Colonoscopy demonstrated luminal narrowing in the rectosigmoid colon and an eccentric subepithelial mass covered with normal mucosa (Figure1A).
  • Need for Caution in Diagnosis of Irritable Bowel Syndrome in Patients With Inflammatory Bowel Disease

    We read with interest the article by Gracie etal,1 which reported the prevalence of irritable bowel syndrome (IBS)-type symptoms in patients with Crohns disease (CD) and ulcerative colitis (UC) in remission to be 27.7% and 19.8%, respectively. We would like to raise several concerns regarding the interpretation of their findings.
  • The Long Winding Road to Transplant: How Sarcopenia and Debility Impact Morbidity and Mortality on the Waitlist

    Frailty and sarcopenia are common complications of cirrhosis. Frailty has been described as an increased susceptibility to stressors secondary to a cumulative decline in physiologic reserve; this decline occurs with aging or is a result of the disease process, across multiple organ systems. Sarcopenia, a key component of frailty, is defined as progressive and generalized loss of skeletal muscle mass and strength. The presence of either of these complications is associated with increased morbidity and mortality, as these are tightly linked to decompensation and increased complication rates.
  • Concerns for the Methodology and Results Described in Palliative Care and Health Care Utilization for Patients with End-Stage Liver Disease at the End of Life

    We read with great intrigue the recently published paper using the Nationwide Inpatient Sample (NIS) entitled Palliative Care and Health Care Utilization for Patients with End-Stage Liver Disease at the End of Life by Patel etal.1 Although we applaud the authors for working in this important area in the care of patients with end-stage liver disease (ESLD), we observed several statistical inconsistencies and methodological issues that give rise to serious concern.
  • Rare Case of Madelungs Disease

    A 55-year-old woman with compensated alcoholic cirrhosis and active alcohol use was referred to our center for management of her liver disorder. She drank 68 beers a day and complained of significant weight gain over the past year. Her body fat was disproportionately distributed in the upper body with almost complete sparing of her lower extremities (Figure1A). There were prominent fat deposits in the neck, shoulders, and arms (Figure1B), which were causing disfigurement and pain while sleeping.
  • Effects of Different Coping Strategies on Physical and Mental Health of Patients With Irritable Bowel Syndrome

    In a cross-sectional study of 216 patients (70% female) with irritable bowel syndrome (IBS) who presented to a tertiary care center in Sweden, Wilpart etal1 examined the role of both mental health symptoms and coping resources on gastrointestinal (GI) symptoms and somatization. Improved physical coping in these patients (eg, healthier diets, physical activity) was independently associated with lower GI symptom severity as well as somatization scores (unexplained somatic complaints). This relationship was partially mediated by the effect of coping on anxiety and depressive symptoms.
  • The Right Idea for the Wrong Patient: Results of a National Survey on Stopping PPIs

    Recent studies have linked proton pump inhibitor (PPI) use to serious adverse effects, including bone fracture, chronic kidney disease, dementia, and ischemic stroke. Although it remains unclear whether PPIs truly cause these adverse effects, this potential has forced physicians to carefully consider the safety and utility of long-term PPI use in their patients, a topic included in the American Board of Internal Medicine Foundations Choosing Wisely campaign.1 Using case vignettes, we sought to evaluate how internists willingness to stop PPI varies according to drug indication.
  • Healing of Tonsillar Crohns Disease With Infliximab

    An 18-year-old female patient with a 6-year history of ileocolonic Crohns disease maintained on azathioprine (125 mg/day) presented to the gastroenterology clinic with a 3-week history of sore throat. In addition, she complained of abdominal cramping in her lower abdomen, with 5 loose bowel movements per day with blood and tenesmus. She denied a history of fever, chronic cough, or rashes. On physical examination, bilateral swelling of her tonsils with abscess formation was observed (Figure A). There was tenderness to palpation in the lower abdomen without an abdominal mass.
  • Reply

    Drs Garg and Hanuaer both pointed-out that there is no clear linear dose-response relationship between serum 25(OH)D levels and risk of relapse in our study.1 We were not surprised by this finding, because clinical relapse is a complex outcome, and measured over a 12-month period any direct relationship between dose of vitamin D and relapse was likely dissipated. Studies of therapies for inflammatory bowel disease have not demonstrated linear dose-response relationships for clinical outcomes over medium- to long-term outcomes.
  • Reply

    We appreciate the interest from Drs Archibugi and Capurso in our paper reporting several dietary factors associated with pancreatitis risk in the Multiethnic Cohort.1 Regarding the first point, the reason we excluded subjects from the analysis who underwent cholecystectomy at baseline or before the index date (the sentinel date for the acute pancreatitis case) was because these subjects were either no longer or at least at a much lower risk of developing biliary acute pancreatitis.
  • Open vs Intact Proton Pump Inhibitor Capsules for Treatment of Marginal Ulcers

    In their recent publication, Schulman etal1 reported that patients with marginal ulcers following Roux-en-Y gastric bypass (RYGB) who were treated with opened proton pump inhibitor (PPI) capsules had faster ulcer healing than those who received intact PPI capsules. Their study was conducted retrospectively and the decision of how patients should take their PPI was at the discretion of individual physicians.
  • A Flawed Meta-analysis? Similar Risk of Cardiopulmonary Adverse Events Between Propofol and Traditional Anesthesia for Gastrointestinal Endoscopy

    In their letter on the systematic review and meta-analysis by Wadhwa etal,1 Goudra and Singh2 call for re-evaluation of the statistical aspects of the analysis. As a statistician who follows meta-analysis, I would like to mention some major shortcomings in the statistical analysis and other aspects of the article.
  • Lymphogranuloma Venereum Proctitis

    A 43-year-old man presented with bright red blood per rectum, bilateral groin swelling, and lower abdominal pain. He had experienced an approximately 30-pound weight loss over the previous 6 months. He denied urinary symptoms, urethral discharge, and genital rashes or lesions. He previously was married but had been separated. Since his separation, he had 5 male sexual partners and had engaged in receptive unprotected anal intercourse. Physical examination showed tender inguinal lymphadenopathy and perineal fullness.
  • Association Among Ustekinumab Trough Concentrations and Clinical, Biomarker, and Endoscopic Outcomes in Patients With Crohns Disease

    Ustekinumab, an inhibitor of the p40 subunit of interleukins 12 and 23, is an effective treatment for patients with Crohn's disease (CD). Trough concentrations of tumor necrosis factor (TNF) antagonists and presence of anti-drug antibodies are associated with important clinicaland endoscopic outcomes. We investigated associations between trough concentrations ofustekinumab and clinical, biomarker, and endoscopic outcomes of real-world patients withCD.
  • Improved Long-Term Outcomes of Patients With Inflammatory Bowel Disease Receiving Proactive Compared With Reactive Monitoring of Serum Concentrations of Infliximab

    Monitoring serum concentrations of tumor necrosis factor antagonists in patients receiving these drugs as treatment for inflammatory bowel disease (IBD), also called therapeutic drug monitoring, is performed either after patient loss of response (reactive drug monitoring) or in patients in clinical remission whose drug has been titrated to a target concentration (proactive drug monitoring). We compared long-term outcomes of patients with IBD undergoing proactive vs reactive monitoring of serum concentrations of infliximab.
  • Bolus Administration of Fentanyl and Midazolam for Colonoscopy Increases Endoscopy Unit Efficiency and Safety Compared With Titrated Sedation

    Guidelines recommend slow titration of sedatives for moderate sedation. Bolus sedation, in which a larger weight-based dose of medication is given upfront, has been shown in a single trial to be beneficial. We evaluated the effects of bolus sedation on procedural safety, efficiency, and patient experience.
  • Phytobezoar-Induced Small-Bowel Obstruction Successfully Diagnosed and Treated by Single-Balloon Enteroscopy

    A 69-year-old man was admitted because of repeated vomiting, intermittent abdominal pain, and not passing gas for 4 days. He had a history of eating raw hawthorns 4 days previously. He had undergone subtotal gastrectomy for gastric ulcer perforation and cholecystectomy 30 years ago.
  • Pyogenic Granuloma of the Esophagus

    A 59-year-old man had a 1-month history of intermittent dysphagia for solid food. There was no odynophagia, heartburn, regurgitation, or weight loss. Esophagogastroduodenoscopy showed a pedunculated red polyp measuring approximately 15 mm in diameter in the esophagus 25 cm from the incisor teeth and an adherent white deposit on the head (Figure A). Thus, he was referred for management. The physical examination and laboratory testing revealed no remarkable abnormalities. The tumor markers, including carcinoembryonic antigen, carbohydrate antigen 19-9, and alpha fetoprotein, were within normal limits.
  • A Rare Cause of Duodenal Obstruction: Metastatic Parotid Mucoepidermoid Carcinoma

    A 76-year-old-man with a history of a parotid mucoepidermoid carcinoma presented with a 3-week history of postprandial nausea and vomiting with a 10-pound unintentional weight loss. Two years earlier, he presented with a left parotid mass, with biopsy demonstrating a carcinoma. He underwent a left total parotidectomy and left neck dissection. On surgical pathology, he had a high-grade, poorly differentiated mucoepidermoid carcinoma with 9 of 49 lymph nodes involved by tumor. He was treated with adjuvant chemoradiation, with no evidence of recurrence by subsequent positron emission tomography scan.
  • Nivolumab-Associated Colitis Mimicking Ulcerative Colitis

    Nivolumab was initiated in an 82-year-old man after failing first-line docetaxel for postoperative recurrence of nonsmall-cell lung cancer, continued along with symptomatic therapy after onset of grade 1 diarrhea after 4 cycles. Nivolumab was discontinued after onset of grade 3 abdominal pain and diarrhea after 7 cycles. Colonoscopic examination showed nivolumab-associated colitis (NAC) mimicking ulcerative colitis (UC) characterized by edema, erythema, exudate, and sequential loss of vascular pattern in the left side of the colon including the rectum (Figures A and B).
  • Endoscopic Appearance of Multifocal Primary Gastric Diffuse Large B-Cell Lymphoma

    A 67-year-old Caucasian man with a past history of colorectal cancer status-post subtotal colectomy and decompensated cirrhosis secondary to alcohol abuse presented with large-volume hematemesis and hepatic encephalopathy. Physical examination showed tachypnea, tachycardia, and abdominal distention with dullness on percussion. Laboratory data were significant for a hemoglobin level of 6.8 g/dL with a baseline level of 9.5 g/dL 3 months ago, lactic acid level of 4.0 mmol/L, creatinine level of 3.66 mg/dL, and a prothrombin time of 24.5 seconds.
  • Association Between Mechanical, Inflammatory, and Functional Complications of the Ileal Pouch: Another Chicken-Or-Egg Story

    Ileal pouchanal anastomosis (IPAA) after total proctocolectomy is the standard surgical therapy for most patients with ulcerative colitis or familial adenomatous polyposis who require colectomy. The main advantage of IPAA over permanent end ileostomy isthe avoidance of an ileostomy bag, leading to the improvement in patients quality of life. However, IPAAisa complex surgical procedure involving the reconstruction of the bowel, mobilization of mesentery, and anastomosis almost at the same plane of the pelvic floor, risking damage to nerves and vessels.
  • Old Farts Fact or Fiction? Results From a Population-Based Survey of 16,000 Americans Examining the Association Between Age and Flatus

    An old fart, according to the Oxford English Dictionary, is a contemptible or tiresome person, especially one who is old-fashioned, stuffy, or close-minded.1 However, old fart could also mean that elderly individuals pass flatus more often. Although there are limited data on the association between age and flatulence frequency,2 it is physiologically possible that older individuals pass gas more than their younger counterparts. For example, increased age has been linked to lactose intolerance, a relatively common reason why people break wind.
  • Lifestyle and Clinical Correlates of Hepatocellular Carcinoma in South Texas: A Matched Case-control Study

    The incidence of hepatocellular carcinoma (HCC) in the United States is rising even as overall cancer rates are declining, and Latinos are disproportionately affected, especially in Texas. Our case-control study sought to determine relative etiologic contributions of lifestyle-related risk factors in South Texas.
  • AGA White Paper: Optimal Strategies to Define and Diagnose Gastroesophageal Reflux Disease

    Gastroesophageal reflux disease (GERD) is a common condition affecting up to 20% of the Western world.1 It is a condition that develops when reflux of gastric contents causes troubled symptoms and/or complications.2 Heartburn and regurgitation are the 2 cardinal symptoms of GERD, although it may present with other symptoms, such as chest pain; pulmonary; or ear, nose and throat symptoms.3 Heartburn and regurgitation have suboptimal sensitivity (30%76%) andspecificity (62%96%) in diagnosing GERD.
  • Asthma Is Associated With Subsequent Development ofInflammatory Bowel Disease: A Population-based CaseControl Study

    Asthma and the inflammatory bowel diseases (IBD) each arise through complex interactions between genetic and environmental factors, and share many environmental risk factors. We examined the association between asthma and Crohns disease or ulcerative colitis.
  • Use of Thiopurines During Conception and Pregnancy Is Not Associated With Adverse Pregnancy Outcomes or Health of Infants at One Year in a Prospective Study

    Most data on the safety of thiopurine therapy for inflammatory bowel disease (IBD) during pregnancy come from retrospective studies, which makes it difficult to adjust for confounding factors. We performed a prospective cohort study to determine whether thiopurine use affects pregnancy outcomes or health outcomes of children.
  • Waist/Hip Ratio Better Predicts Development of Severe Liver Disease Within 20 Years Than Body Mass Index: A Population-based Cohort Study

    Obesity, commonly assessed based on body mass index (BMI), is associated with an increased risk for severe liver disease. It is not known if other measures of body composition are better determinants of risk for severe liver disease, and/or if these differ between women and men. We investigated the body composition measures that best predict the development of severe liver disease.
  • Progression of Unresected Intraductal Papillary Mucinous Neoplasms of the Pancreas to Cancer: A Systematic Review andMeta-analysis

    It is not clear how best to manage patients with low-risk intraductal papillary mucinous neoplasms (IPMNs) of the pancreas because little is known about IPMN progression to cancer. We sought to determine the cumulative incidence of development of pancreatic cancer in persons with unresected IPMNs (particularly low-risk IPMNs).
  • A Model To Identify Individuals at High Risk for Esophageal Squamous Cell Carcinoma and Precancerous Lesions in Regions of High Prevalence in China

    We aimed to develop a population-based model to identify individuals at high risk for esophageal squamous cell carcinoma (ESCC) in regions of China with a high prevalence of this cancer.
  • An Unusual Flat Anorectal Lesion Mimicking a Laterally Spreading Tumor

    A 47-year-old woman underwent a colonoscopy after experiencing hematochezia and anal discomfort for 6 months. A lesion was detected and the patient was referred to our hospital for treatment. She had no remarkable past history or family history. Laboratory data all were within normal limits. Colonoscopy showed a flat, whitish, and widespread lesion extending from the anal canal to the lower rectum that looked like a laterally spreading tumor (LST) (Figure A). Narrow-band imaging (NBI) without magnification showed brown vessels surrounded by white structures (Figure B).
  • Upper Gastrointestinal Bleeding Caused by Hereditary Hemorrhagic Telangectasia

    A 50-year-old Caucasian woman presented with hematemesis. She had a past medical history of asthma. There was no family history of coagulopathies. Physical examination showed pale conjunctiva with a single oral telangiectasia. Her laboratory analysis showed a hemoglobin level of 103 g/L, platelet count of 97 109/L, serum albumin level of 43 g/L, bilirubin level of 15 mol/L, alkaline phosphatase level of 147 U/L, aspartate aminotransferase level of 28 U/L, -glutamyl transferase level of 70 U/L, -fetoprotein level of less than 3 ng/mL, and a negative liver screen.
  • White Paper AGA: Eosinophilic Esophagitis

    Since first characterized in 2 small case series in the early 1990s, eosinophilic esophagitis (EoE) has emerged as a commonly identified cause of esophageal symptoms in children and adults.1,2 Although several highly effectively dietary, pharmacologic, and endoscopic therapies have been reported, none is currently approved by either the US Food and Drug Administration (FDA) or European regulatory authorities. Evolving diagnostic criteria have challenged drug development, in particular the recognition of complex interactions with the most prevalent esophageal disorder, gastroesophageal reflux disease (GERD).
  • Colonic Schwannoma Diagnosed by Endoscopic Ultrasound WithFine-Needle Aspiration

    A 73-year-old man with human immunodeficiency virus on highly active antiretroviral therapy presented with a 30-year history of rectal pain and constipation. The rectal pain was precipitated by hard bowel movements. He denied rectal bleeding, a family history of colorectal cancer, or prior colonoscopy or abdominal imaging. Physical examination and laboratory testing were unremarkable. He underwent a colonoscopy, which showed a 3-cm subepithelial lesion in the sigmoid colon (Figure A). A radial array echoendoscope (GF-UE160-AL5; Olympus America, Melville, NY) was advanced to 25 cm from the anus to examine the lesion.
  • Reply

    We appreciate the authors for their interest and comments on the article Vigorous periprocedural hydration with lacated Ringers solution reduces the risk of pancreatitis after retrograde cholangiopancreatography in hospitalized patients.1,2 At the present time, post endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis prophylaxis is mainly focused on theuse of rectal indomethacin and pancreatic duct stentplacement for high-risk patients. The present study suggest that high-volume intravenous fluid resuscitation with lactated Ringers solution is beneficial prophylaxis, although further evaluation of its efficacy as both an additive and alternative to rectal indomethacin is needed.
  • Gastrostomy Tubes and Quality of Life: Is the Glass Half Empty or Half Full?

    Placing a feeding gastrostomy (G) tube in the neurologically impaired can be an emotionally charged decision for the patient, caregiver, and physician alike. Since the first descriptions of percutaneous endoscopic G tube placement in 1980 in children, there has been significant research on techniques, applications, nutritional effects, and morbidity and mortality. The most common groups receiving a G tube include patients with dysphagia after stroke, dementia, head-neck cancer, and neurodegenerative diseases.
  • Development and Evaluation of an Online Resource for Hepatopulmonary Syndrome Patients and Caregivers:

    Hepatopulmonary syndrome (HPS) is a shunting lung disease affecting 5% to 30% of cirrhotic patients. Patients being assessed for this complex condition (and their families) have high informational needs.
  • A Specialty Clinic for Functional Gastrointestinal Disorders in Tertiary Care: Concept and Patient Population

    Functional gastrointestinal disorders (FGIDs) are common disorders of the gut-brain interaction classified by gastrointestinal (GI) symptoms related to any combination of the following: motility disturbance, visceral hypersensitivity, altered mucosal and immune function, altered gut microbiota, and altered central nervous system processing.1 FGIDs are classified according to the Rome criteria, which are primarily based on symptom patterns, related to organ location or overarching dysregulation of symptom control pathways.
  • Primary Multifocal Small Bowel Follicular Lymphoma Discovered Incidentally on Diagnostic Endoscopy

    A 34-year-old man with gastroesophageal reflux disease presented with 3 years of nonprogressive solid food dysphagia. He had associated left-sided chest pain and regurgitation despite esomeprazole 40 mg daily. He denied fevers, chills, diaphoresis, nausea, vomiting, pyrosis, odynophagia, melena, abdominal pain, or weight loss. He denied tobacco or alcohol use. Family history was negative for gastrointestinal malignancies. Esophagogastroduodenoscopy revealed a pale hemicircumferential plaque-like lesion on the duodenal wall opposite the ampulla (Figure A) with biopsy demonstrating a florid lymphocytic infiltrate organized in discrete follicles with mainly centrocytes and rare large centroblasts (Figure B) that were immunopositive for CD10, CD20, BCL2, and BCL6, and immunonegative for CD3, CD5, and BCL1.
  • Duodenal Gastrinoma Discovered on Evaluation for Incidental Gastric Carcinoid

    A 66-year-old man with a 15-year history of peptic ulcer disease and refractory heartburn presented with recurrent bleeding duodenal ulcers and diminutive fleshy nodules in the stomach. Biopsy of the gastric lesions revealed carcinoid. He was referred for endoscopic ultrasound to evaluate the gastric lesions, which were found to be multifocal and diminutive. At the time of the procedure a subtle 2-cm umbilicated lesion in the duodenum (Figure A) associated with heterogenous thickening of the submucosal layer on endosonography was identified (Figure B).
  • Coffee Drinking and Alcoholic and Nonalcoholic Fatty Liver Diseases and Viral Hepatitis in the Multiethnic Cohort

    Chronic hepatitis C (CHC) and alcoholic liver disease (ALD) are major causes of chronic liver disease (CLD), but nonalcoholic fatty liver disease (NAFLD) has now become the most common cause of CLD.1 Coffee consumption has been inversely associated with CLD severity,2 but studies were mainly conducted in CHC, and fewer studies have been done in other etiologies. We examined the association between coffee consumption and CLD with and without cirrhosis by underlying etiology in African Americans, Native Hawaiians, Japanese Americans, Latinos, and whites in the Multiethnic Cohort (MEC).
  • Diet and the Risk of Acute Pancreatitis

    We read with great interest the article by Setiawan etal1 regarding the association between certain dietary patterns and the risk of acute pancreatitis (AP) in a large US cohort study. The authors found that the dietary intake of food rich in saturated fat and cholesterol such as red meat and eggs was associated with an increased risk of biliary AP, whereas fiber intake was inversely associated with both biliary and non-biliary AP. Vitamin D intake was inversely associated with biliary AP, whereas coffee intake was protective toward non-biliary AP and recurrent or chronic pancreatitis.
  • White Paper AGA: The Impact of Mental and Psychosocial Factors on the Care of Patients With Inflammatory BowelDisease

    Patients with chronic medically complex disorders like inflammatory bowel diseases (BD) often have mental health and psychosocial comorbid conditions. There is growing recognition that factors other than disease pathophysiology impact patients' health and wellbeing. Provision of care that encompasses medical care plus psychosocial, environmental and behavioral interventions to improve health has been termed whole person care and may result in achieving highest health value. There now are multiple methods to survey patients and stratify their psychosocial, mental health and environmental risk.
  • Patient Sex, Reproductive Status, and Synthetic Hormone Use Associate With Histologic Severity of Nonalcoholic Steatohepatitis

    Yang etal1 on behalf of the Nonalcoholic Steatohepatitis (NASH) Clinical Research Network reviewed the liver biopsies of premenopausal women with NASH. They have demonstrated high Nonalcoholic Fatty Liver Disease Activity Score (NAS) scores in these women compared with men or postmenopausal women. The authors noted that this population of premenopausal women exhibits a better prognosis than postmenopausal women or men, while showing that the fibrosis scores in the premenopausal cohort were lower as well.
  • External Validation of the Michigan Barretts Esophagus Prediction Tool

    Barretts esophagus (BE) is a premalignant lesion for esophageal adenocarcinoma, a rapidly increasing, highly fatal cancer.1 Clinical guidelines recommend screening for BE in those with chronic gastroesophageal reflux disease (GERD) and at least 2 risk factors (eg, >50 years of age, white race, obese, tobacco smoking history).2,3 However, providing clinicians with a tool that allows them to estimate a patients risk may better aid them in deciding who to screen for BEand make future resource utilization more efficient.
  • The Countdown to a Paradigm Shift in Diagnosing Pancreatic Ductal Adenocarcinoma

    The volume of endoscopic ultrasound (EUS) procedures performed in the United States has increased exponentially as more endoscopists are trained, facilities are equipped, and the devices required for EUS-guided fine-needle aspiration (EUS-FNA) are improved.1 EUS is now a mainstay in the diagnostic algorithm of several gastrointestinal cancers, including pancreatic ductal adenocarcinoma (PDAC). Despite its widespread adoption in clinical practice, little is known about the quality of EUS services in the United States.
  • American Gastroenterological Association Drug Development Conferences: A Model for Future Collaborations

    In 2014, the American Gastroenterological Association (AGA) established its third specialty center, the Center for Diagnostics and Therapeutics (CDT). The mission of the CDT is To support the development of therapies and diagnostic tests that will enhance human health and improve the lives of patients with digestive disorders. CDT governance is through its Scientific Advisory Board (SAB), the composition of which can be found at The SAB has a diverse membership and includes representatives from the U.S.
  • Hookworm-Induced Obscure Overt Gastrointestinal Bleeding

    A 72-year-old man with Parkinson disease presented with fatigue, dyspnea on exertion, and intermittent melena for 3 months. He had recently been diagnosed with iron deficiency anemia (hemoglobin, -6.8 g/dL) requiring transfusion of 8 units of packed red blood cells. Esophagogastroduodenoscopy and colonoscopy were nondiagnostic. Although he was referred for capsule endoscopy we first repeated the esophagogastroduodenoscopy, which revealed multiple live worms attached to the duodenal mucosa sucking blood (Figure A).
  • Epidermoid Cyst in an Intrapancreatic Accessory Spleen Diagnosed by Typical Radiographic Images and Endoscopic Ultrasound Fine-Needle Aspiration Findings With Contrast Agent

    A 40-year-old woman was referred to our hospital for detailed examination of a cystic lesion in the pancreas revealed by abdominal ultrasound at a health checkup. She was asymptomatic. Cancer antigen 19-9 and carcinoembryonic antigen values were normal. Contrast-enhanced computed tomography (CE-CT) showed a 15-mm multilocular cystic lesion in the pancreatic tail. The periphery of the lesion was solid (arrow), with the same enhancement as the spleen in the early arterial phase (FigureA). On magnetic resonance imaging (MRI), the lesions cystic portion showed a high signal both on T1- (FigureB, arrow) and T2-weighted images (FigureC, arrow); thus the content was considered to be mucinous or bloody liquid.
  • Exception Points and Body Size Contribute to Gender Disparity in Liver Transplantation

    Women are significantly less likely than men to receive a liver transplant and more likely to die on the waitlist. We investigated potential reasons for these disparities, including match run positioning and organ declines caused by small stature of female recipients.
  • Coping Skills Are Associated With Gastrointestinal Symptom Severity and Somatization in Patients With Irritable BowelSyndrome

    Coping resources and processes are altered in patients with irritable bowel syndrome (IBS). We investigated the relationship between coping resources and gastrointestinal (GI) and extraintestinal symptom severity in patients with IBS and potential mediators of this relationship.
  • Diagnostic Accuracy of Noninvasive Fibrosis Scores in a Population of Individuals With a Low Prevalence of Fibrosis

    Noninvasive scoring systems for fibrosis are increasingly used in the clinic and in research because of their ease of use, accessibility, and low cost. However, test performance characteristics were established in groups of patients with a high prevalence of advanced fibrosis; little is known about diagnostic accuracy in low-risk populations.
  • In Children With Nonalcoholic Fatty Liver Disease, Zone 1 Steatosis Is Associated With Advanced Fibrosis

    Focal zone 1 steatosis, although rare in adults with nonalcoholic fatty liver disease (NAFLD), does occur in children with NAFLD. We investigated whether focal zone 1 steatosis and focal zone 3 steatosis are distinct subphenotypes of pediatric NAFLD. We aimed to determine associations between the zonality of steatosis and demographic, clinical, and histologic features in children with NAFLD.
  • Endoscopic and Histologic Healing in Children With Inflammatory Bowel Diseases Treated With Thalidomide

    Mucosal healing, determined by endoscopic evaluation, is one of the most important prognostic markers for patients with inflammatory bowel diseases. Findings from histologic evaluation, however, could complement findings from endoscopy in assessing mucosal responses to treatment. We analyzed long-term results of children treated with thalidomide to determine the association between clinical response and histology and endoscopy findings.
  • Increased Intestinal Permeability in Relatives of Patients With Crohns Disease Is Not Associated With Small Bowel Ulcerations

    Many first-degree relatives of patients with Crohns disease (CD) have increased intestinal permeability. Video capsule endoscopy (VCE) is the most sensitive imaging test to identify small bowel mucosal lesions that could indicate subclinical CD. We aimed to estimate the association of increased intestinal permeability with small bowel ulcerations detectable by VCE in healthy first-degree relatives of patients with CD.
  • Efficacy of Rectal Tacrolimus for Induction Therapy in Patients With Resistant Ulcerative Proctitis

    Resistant ulcerative proctitis can be extremely difficult to manage. Topically administered tacrolimus, however, may be effective in difficult-to-treat proctitis. This was a randomized, double-blind, placebo-controlled induction trial of rectal tacrolimus in patients with active ulcerative colitis.
  • Level of -glutamyltransferase in 2-Year-old Children WithBiliary Atresia Associates With Progression of PortalHypertension

    Biliary atresia (BA) is an obstructive neonatal cholangiopathy of unknown cause. Even with Kasai hepatoportoenterostomy to relieve extrahepatic obstruction, approximately half of infants require liver transplantation by 2 years of age, whereas the remaining infants who survive with native liver (SNL) are at substantial risk for sequelae of chronic cholestatic liverdisease, portal hypertension, and progression to liver transplantation.13 There is limited information regarding the subsequent clinical course in BA SNL children who do not require early liver transplantation by age2.
  • Nonrelaxing Pelvic Floor Dysfunction Is an Underestimated Complication of Ileal PouchAnal Anastomosis

    Nonrelaxing pelvic floor dysfunction (N-RPFD), or dyssynergic defecation, is the paradoxical contraction and/or impaired relaxation of pelvic floor and anal muscles during defecation. Few studies have evaluated this disorder in patients with an ileal pouchanal anastomosis (IPAA). We investigated the frequency of N-RPFD in patients with and without chronic pouchitis following IPAA and the effectiveness of biofeedback therapy within this population.
  • Suboptimal Implementation of Evidence-based Therapy for Acute Variceal Hemorrhage: A Systematic Review of Observational Studies

    Gastroenterologists should strive to improve the outcomes associated with acute variceal hemorrhage (AVH) by optimizing care delivery and clinician preparedness through training. Unfortunately, data regarding contemporary outcomes and management of AVH are limited.
  • Management of Asymptomatic Mucosa-Associated Lymphoid Tissue Lymphoma of the Colon Found Incidentally on Colonoscopy

    Mucosa-associated lymphoid tissue (MALT) lymphoma of the colon is a rare disorder without a standardized treatment approach. Treatment modalities include surgical resection, antibiotic therapy, and chemotherapy.1,2 MALT lymphoma is defined by the World Health Organization as a subtype of non-Hodgkin lymphoma and classified as an extranodal marginal zone B-cell lymphoma. MALT lymphoma has been diagnosed in different tissues throughout the body, and most commonly the gastrointestinal tract. Gastrointestinal lymphomas constitute 10%15% of all non-Hodgkin lymphomas.
  • Serum Vitamin D and Risk of Clinical Relapse in Patients With Ulcerative Colitis

    We read with interest the article by Gubatan and etal,1 who reported that serum 25-hydroxy vitamin D (25(OH)D) level less than 35 ng/mL (87.5 nmol/L) is associated with histologic remission at baseline and predicts risk of clinical relapse in patients with inflammatory bowel disease during the subsequent 12 months. As pointed out in a subsequent editorial by Hanauer,2 however, there was no clear linear dose-response relationship between serum 25(OH)D levels and risk of relapse. Other studies have previously reported inverse relationships between serum vitamin D status and objective markers of disease activity and a potential threshold effect at serum 25(OH)D of 100 nmol/L (40 ng/mL).
  • Cost-Effectiveness of Screening Patients with Gastroesophageal Reflux Disease for Barretts Esophagus With a Minimally Invasive Cell Sampling Device

    It is important to identify patients with Barretts esophagus (BE), the precursor to esophageal adenocarcinoma (EAC). Patients with BE are usually identified by endoscopy, which is expensive. The cytosponge, which collects tissue from the esophagus non-invasively, could be a cost-effective tool for screening individuals with gastroesophageal reflux disease (GERD), who are at increased risk for BE. We developed a model to analyze the cost effectiveness of using cytosponge in first-line screening of patients with GERD for BE with endoscopic confirmation, compared to endoscopy screening only,
  • Histologic Normalization Occurs in Ulcerative Colitis and Is Associated With Improved Clinical Outcomes

    Mucosal healing, determined by histologic analysis, is a potential therapeutic target for patients with ulcerative colitis (UC). However, the histologic features of tissue normalization, as an outcome of treatment, have not been well described. We examined the prevalence and predictive values of normalization of the colonic mucosa, based on histologic analysis (histologic normalization) in patients with UC, and determined its association with risk of clinical relapse, compared with histologic disease quiescence and endoscopic mucosal healing.
  • Temporal Trends in Initiation of Therapy With Tumor Necrosis Factor Antagonists for Patients With Inflammatory Bowel Disease: A Population-based Analysis

    Anti-tumor necrosis factor (anti-TNF) agents are effective treatments for Crohns disease (CD) and ulcerative colitis (UC). We aimed to determine their patterns of use and changes in these patterns over time, as well as use of immunomodulators and corticosteroids before anti-TNF therapy for persons with inflammatory bowel diseases.
  • Indomethacin and Short-Duration Intravenous Hydration as a More Feasible Regimen for Risk Reduction of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis

    We read with great interest the article by Choi etal1 and the elegant accompanying editorial by Singh2 usingvigorous peri-procedural intravenous hydration withlactated Ringers solution for risk reduction of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). This study and an earlier study by Buxbaum etal3 focus on adequate intravenous lactated Ringers solution with reduction of incidence of PEP. The drawback, as pointed out in the accompanying editorial, to each of these peri-procedural regimens is thatthey encompass infusions over a prolonged period oftime.
  • Increases in IgE, Eosinophils, and Mast Cells Can be Used in Diagnosis and to Predict Relapse of IgG4-Related Disease

    IgG subclass 4related disease (IgG4-RD) is characterized by increased serum levels of IgG4 and infiltration of biliary, pancreatic, and other tissues by IgG4-positive plasma cells. We assessed the prevalence of allergy and/or atopy, serum, and tissue IgE antibodies, and blood and tissue eosinophils in patients with IgG4-RD. We investigated the association between serum IgE and diagnosis and relapse of this disease.
  • Gastrointestinal Bleeding Caused by a Penetrating Aortic Ulcer

    A 78-year-old man with primary hypertension, dyslipidemia, and cerebrovascular disease presented with severe gastrointestinal bleeding. His medication included low-dose aspirin (100 mg/day). Twenty-four hours before admission, he started complaining of intense back pain unrelieved by ibuprofen. He later developed hematemesis with syncope and was admitted to our intensive care unit for resuscitation. Initial blood tests showed normocytic anemia (hemoglobin, 8.0 g/dL; 13.017.5), mild leukocytosis (12.2; 4.011.0), and normal platelets (276; 150450) and prothrombin time (13.9; <11.6).
  • Cryptosporidium Pouchitis

    A 43-year-old man with ulcerative colitis and a history of total proctocolectomy with subsequent ileal pouch anal anastamosis for toxic megacolon in 1999 was admitted to the hospital after 8 days of diarrhea 1015 times per day, left lower quadrant abdominal pain, nausea, vomiting, and fever up to 103F. He was treated with a 3-day course of azithromycin as an outpatient, with only transient improvement before hospital admission. He reported about 4 episodes of pouchitis per year that generally lasted 34 days with prompt antibiotic treatment, but he stated that the present episode was significantly more severe than any of his prior episodes of pouchitis.
  • Green Sputum From a Patient With Primary SclerosingCholangitis

    A 44-year-old woman with primary sclerosing cholangitis (PSC) presented with a cough of 4 months duration. At cough onset the patient had Escherichia coli bacteremia and pneumonia as a result ofascending cholangitis managed with antibiotics. The cough continued, with progression of green sputum production to 500 mL daily.
  • Accumulation of Heavy Metals in People on a Gluten-Free Diet

    Specific foods such as fish and rice have high concentrations of metals such as arsenic, mercury, lead, cadmium, and cobalt. Many gluten-free diets (GFDs) include these foods, so we evaluated whether a GFD was associated with increased metal bioaccumulation.
  • Effects of Combination Therapy with Immunomodulators on Trough Levels and Antibodies Against Tumor Necrosis Factor Antagonists in Patients With Inflammatory Bowel Disease: AMeta-Analysis

    It is not clear whether combination therapy with immunomodulators affects the immunogenicity of tumor necrosis factor (TNF) antagonists in patients with inflammatory bowel disease. We performed a meta-analysis to quantify the effects of combined immunomodulator therapy on the presence of antibodies against TNF antagonists (antidrug antibodies [ADAs]) and trough levels of anti-TNF agents.
  • Incidence and Determinants of Hepatocellular Carcinoma in Autoimmune Hepatitis: A Systematic Review and Meta-analysis

    The risk of hepatocellular carcinoma (HCC) in patients with autoimmune hepatitis (AIH) is unclear. We conducted a systematic review and meta-analysis of the incidence of HCC and associated risk factors among patients with AIH.
  • Factors Associated With Persistent Increase in Level of Alanine Aminotransferase in Patients With Chronic Hepatitis B Receiving Oral Antiviral Therapy

    Despite complete suppression of viral DNA with antiviral agents, in some patients with chronic hepatitis B (CHB), serum levels of alanine aminotransferase (ALT) do not normalize. We investigated factors associated with persistent increases in ALT level in patients with CHB given long-term tenofovir disoproxil fumarate.
  • Esophageal Mammary Analogue Secretory Carcinoma

    An 85-year-old man who had experienced acid regurgitation and epigastric pain since 2011 visited our hospital for medical help. His physical examination and laboratory test results were unremarkable. Esophagogastroduodenoscopy showed an 8 6 mm subepithelial nodule in the upper esophagus, 22 cm from the incisor (Figure A). Regular follow-up was suggested. The growth of a polypoid nodule, 15 8 mm in size, was observed via repeat esophagogastroduodenoscopy in 2015 (Figure B). Chest computed tomography showed no definite tumor or enlarged lymph node.
  • Efficacy and Safety of Peroral Endoscopic Myotomy for Treatment of Achalasia After Failed Heller Myotomy

    In patients with persistent symptoms after Heller myotomy (HM), treatment options includerepeat HM, pneumatic dilation, or peroral endoscopic myotomy (POEM). We evaluatedthe efficacy and safety of POEM in patients with achalasia with prior HM vs without priorHM.
  • Palliative Care and Health Care Utilization for Patients WithEnd-Stage Liver Disease at the End of Life

    There has been increased attention on ways to improve the quality of end-of-life care for patients with end-stage liver disease, however, there have been few reports of care experiences for patients during terminal hospitalizations. We analyzed data from a large national database to increase our understanding of palliative care for and health care utilization by patients with end-stage liver disease.
  • Gastric Schwannoma With Regional Lymphadenopathy

    A 64-year-old woman was referred to our hospital because of a gradually enlarged submucosal tumor (SMT), which was followed to that point by a local medical doctor. Laboratory investigations, including serum carcinoembryonic antigen and cancer antigen 19-9 analyses, showed no significant abnormalities. Esophagogastroduodenoscopy revealed an irregular elevated lesion in the top of a SMT in the middle third of the stomach (Figure A), which was confirmed as the mass located predominantly within the muscularis propria and the submucosa by endoscopic ultrasonography (Figure B, arrows).
  • Most Individuals With Advanced Cirrhosis Have Sleep Disturbances, Which Are Associated With Poor Quality of Life

    Sleep disturbances are common in patients with cirrhosis, but their determinants and effects on health-related quality of life are not well-understood. We investigated the prevalence of disturbed sleep in these patients, factors associated with sleep disruption, and effects on quality of life.
  • Eluxadoline Demonstrates a Lack of Abuse Potential in Phase 2and 3 Studies of Patients With Irritable Bowel Syndrome WithDiarrhea

    Eluxadoline is approved by the Food and Drug Administration for the treatment of adults with irritable bowel syndrome with diarrhea (IBS-D). Eluxadoline is a locally acting mixed -opiod and -opioid receptor agonist and -opioid receptor antagonist. The abuse potential of eluxadoline was evaluated as part of the Phase 2 and 3 clinical trials assessing the efficacy, safety, and tolerability of the drug.
  • Replacing the Guaiac Fecal Occult Blood Test With the Fecal Immunochemical Test Increases Proportion of Individuals Screened in a Large Healthcare Setting

    The most commonly used noninvasive test for colorectal cancer (CRC) screening has been the guaiac fecal occult blood test (gFOBT). The fecal immunochemical test (FIT) detects CRC and colorectal polyps with higher levels of sensitivity than the gFOBT, and may be more acceptable to patients. However, the FIT has not replaced the gFOBT in many clinical settings. We analyzed data from a large healthcare system that replaced the gFOBT with the FIT to determine the effects on CRC screening.
  • Ileocolonic Histoplasmosis Complicating Crohns Disease

    A 37-year-old woman presented to the clinic with a 3-month history of right lower-quadrant abdominal pain, persistent nausea, intermittent fever up to 101F, night sweats, and a 10-pound weight loss. Her past medical history was significant for ileocolonic Crohns disease, and her current maintenance therapy was adalimumab and azathioprine. The patient denied any melena, hematochezia, or recent changes in the form or frequency of bowel habits. Physical examination showed abdominal pain upon palpation of the right lower quadrant without rebound tenderness or guarding.
  • Familial Risk and Heritability of Colorectal Cancer in the Nordic Twin Study of Cancer

    We analyzed data from twins to determine how much the familial risk of colorectal cancer can be attributed to genetic factors vs environment. We also examined whether heritability is distinct for colon vs rectal cancer, given evidence of distinct etiologies.
  • Efficacy and Limitations of Budesonide as a Second-Line Treatment for Patients With Autoimmune Hepatitis

    Many patients with autoimmune hepatitis (AIH) develop steroid-specific side effects or require doses of steroids that are unacceptable for long-term treatment. We investigated the efficacy of budesonide as an alternative steroid for patients previously treated with prednisolone who developed side effects or were unable to reduce their dose of prednisolone below acceptable levels. We also report the effects of more than 12 months of budesonide treatment in a large cohort of patients with AIH.
  • Worse Outcomes of Patients With HFE Hemochromatosis With Persistent Increases in Transferrin Saturation During Maintenance Therapy

    Even if patients with hemochromatosis maintain low serum levels of ferritin, they still have an increased risk of general and joint symptoms, which reduce quality of life. This could be related to persistently increased transferrin saturation. We assessed whether duration of exposure to increased transferrin saturation during maintenance therapy is associated with more severe general and joint symptoms.
  • Assessment of Abilities of Gastroenterology Fellows to Provide Information to Patients With Liver Disease

    Patient education is critical in ensuring patient compliance and good health outcomes. Fellows must be able to effectively communicate with their patients, delivering enough information for the patient to understand their medical problem and maximize patient compliance. We created an objective structured clinical examination (OSCE) with 4 liver disease cases to assess fellows knowledge and ability to inform standardized patients (SPs) about their clinical condition.
  • High Dietary Intake of Specific Fatty Acids Increases Risk of Flares in Patients With Ulcerative Colitis in Remission During Treatment With Aminosalicylates

    Dietary factors may have a significant role in relapse of disease among patients with ulcerative colitis (UC). However, the relationship between diet and UC is inadequately understood. We analyzed data from the diets role in exacerbations of mesalamine maintenance study to determine whether dietary factors affect the risk of disease flares in patients with UC.
  • Clinical Manifestations of Helicobacter pyloriNegative Gastritis

    There are data to suggest the existence of nonHelicobacter pylori gastritis. However, the risk factors and clinical course for H pylorinegative gastritis remain unclear. We aimed to examine the prevalence and determinants of H pylorinegative gastritis in a large multiethnic clinical population.
  • Prophylaxis for Stress Ulcers With Proton Pump Inhibitors Is Not Associated With Increased Risk of Bloodstream Infections in the Intensive Care Unit

    Proton pump inhibitors (PPIs) have been associated with increased risk of infection, likely because of changes in intestinal epithelial permeability and the gastrointestinal microbiome. PPIs are frequently given to patients in the intensive care unit (ICU) to prevent stress ulcers. These patients are at risk for bloodstream infections (BSIs), so we investigated the relationship between PPI use and BSIs among patients in the ICU.
  • A Dumbbell-Shaped Hyperechoic Mass in the Common Hepatic Artery Swinging With the Heartbeat

    A 65-year-old woman visited our hospital with a complaint of epigastric pain lasting for several hours. She had been receiving hemodialysis for end-stage renal disease, and was taking a low-dose aspirin (100mg/d) for the prevention of atherothrombotic events. Vital signs were stable, but physical examination showed severe tenderness in the epigastric region. Blood examination showed an increase of pancreatic enzyme activities (amylase, 278 U/L; lipase, 272 U/L). However, images of contrast-enhanced computed tomography lacked the typical findings of acute pancreatitis (ie,swelling of pancreas parenchyma or extrapancreatic fluid collection), although a small number of irregular-shaped hypoenhanced lesions were found in the pancreas body (Figure A), from which pancreatic infarction rather than acute pancreatitis was suggested.
  • Ball Valve Syndrome Caused by the Migration of Gastrostomy Catheter Tip

    A 70-year-old bedridden Japanese man was referred to our hospital because of fever and vomiting that started the day before. Because of neurogenic dysphagia from a previous stroke, he had just undergone percutaneous endoscopic gastrostomy (PEG) for long-term enteral nutrition 2 months ago. He had a mild fever of 37.7C but was otherwise unremarkable at presentation. Other than a slightly elevated white blood cell count (12,510/L), C-reactive protein (4.19 mg/dL), and blood urea nitrogen (27.3 mg/dL), blood tests were mostly within the normal limits.
  • Radiofrequency Ablation of Barrett's Esophagus Reduces Esophageal Adenocarcinoma Incidence and Mortality in a Comparative Modeling Analysis

    The incidence of esophageal adenocarcinoma (EAC) has risen dramatically during the past 4 decades in the United States and much of the Western world.1 Most clinical guidelines recommend patients with Barretts esophagus (BE) undergo endoscopic surveillance with tissue biopsy to grade the severity of precursor lesions and detect curable neoplasia.2 In addition, techniques for endoscopic eradication treatment of BE, such as endoscopic mucosal resection and radiofrequency ablation (RFA), have increasingly been used to limit progression to EAC.
  • Mood and Anxiety Disorders Precede Development of Functional Gastrointestinal Disorders in Patients but Not in the Population

    Understanding the interactions between brain and gastrointestinal disorders requires analysis of the order of disease onset. We analyzed data from 2 independent studies to determine the proportion of individuals with diagnoses of functional gastrointestinal disorders (FGIDs) before diagnoses of mood or anxiety disorders (gut to brain), and vice versa (brain to gut).
  • Hepatic Hydatid Cysts Causing Biliary Obstruction

    A 66-year-old man was hospitalized with a 3-day history of upper right-quadrant pain and jaundice. The patient described similar recurrent episodes during the past 3 months. The physical examination showed fever, an icteric sclera, and tenderness at the upper right quadrant of the abdomen as well as the epigastric area; there was no rigidity or rebound tenderness. Laboratory tests showed a total serum bilirubin level of 5.2 mg/dL (normal level, 0.31.2 mg/dL), a direct bilirubin level of4.3 mg/dL (normal level, 0.10.4 mg/dL), an aspartate aminotransferase level of 84 U/L (normal level, 545 U/L), an alanine aminotransferase level of 76 U/L (normal level, 050 U/L), and a serum alkaline phosphatase levelof 433 IU/L (normal level, 25230 U/L).
  • Recurrent Ileal Subocclusion Related to Multiple Polyps and Misdiagnosed as Crohns Disease

    A 46-year-old woman presented with subacute symptoms preceding intestinal obstruction. Her medical history was remarkable for Crohns disease, diagnosed on capsule endoscopy (ileal ulcerations, and stagnation for 8 days) and treated medically (double immunosuppression), 2 years earlier. At that time, upperand lower endoscopy showed no other lesion, but computed tomography scan revealed ileal inflammation with retrodilatation consistent with Crohns disease. Her familial history was also remarkable for Crohns disease in her aunt (unknown surgery).
  • A Rare Case of Esophageal Verrucous Squamous Cell Carcinoma in a Patient With Achalasia

    A 51-year-old man with long-standing complaints of dysphagia and rumination underwent high-resolution manometry and was diagnosed with achalasia type II (Figure A). He was treated with endoscopic pneumatic dilatation of the gastroesophageal sphincter, initially up to 30 mm and after 2 weeks to 35 mm. However, he experienced no improvement of his symptoms and was scheduled for per-oral endoscopic myotomy 5 months after the last dilatation. During the endoscopy for the per-oral endoscopic myotomy procedure, the esophagus appeared very wide and inflamed, because of chronic stasis of food and fluids.
  • A Modern Magnetic Implant for Gastroesophageal RefluxDisease

    A magnetic implant for the treatment of gastroesophageal reflux disease (GERD) was Food and Drug Administrationapproved in 2012 and has been extensively evaluated. The device is a ring of magnets that are placed around the gastroesophageal junction, augmenting the native lower esophageal sphincter and preventing reflux yet preserving lower esophageal sphincter physiologic function and allowing belching and vomiting. Magnetic force is advantageous, being permanent and precise, and forces between magnets decrease with esophageal displacement.
  • Increasing Number of Passes Beyond 4 Does Not Increase Sensitivity of Detection of Pancreatic Malignancy by Endoscopic UltrasoundGuided Fine-Needle Aspiration

    It is not clear exactly how many passes are required to determine whether pancreatic masses are malignant using endoscopic ultrasoundguided fine-needle aspiration (EUS-FNA). We aimed to define the per-pass diagnostic yield of EUS-FNA for establishing the malignancy of a pancreatic mass, and identify factors associated with detection of malignancies.
  • Measurement of Spleen Stiffness With Acoustic Radiation ForceImpulse Imaging Predicts Mortality and Hepatic Decompensation in Patients With Liver Cirrhosis

    Hepatic venous pressure gradient can predict mortality and hepatic decompensation in patients with cirrhosis. Measurement of hepatic venous pressure gradient requires an invasive procedure; therefore, prognostic markers are needed that do not require invasive procedures. We investigated whether measurements of spleen stiffness, made by acoustic radiation force impulse (ARFI) imaging, associated with mortality and decompensation in patients with cirrhosis, compared with liver stiffness and other markers.
  • Risk of Rectal Cancer After Colectomy for Patients With Ulcerative Colitis: A National Cohort Study

    Patients with ulcerative colitis (UC) have an increased risk of rectal cancer, therefore reconstruction with an ileal pouchanal anastomosis (IPAA) generally is preferred to an ileorectal anastomosis (IRA) after subtotal colectomy. Similarly, completion proctectomy is recommended for patients with ileostomy and a diverted rectum, although this approach has been questioned because anti-inflammatory agents might reduce cancer risk. We performed a national cohort study in Sweden to assess the risk of rectal cancer in patients with UC who have an IRA, IPAA, or diverted rectum after subtotal colectomy.
  • Urine Interleukin 18 and Lipocalin 2 Are Biomarkers of Acute Tubular Necrosis in Patients With Cirrhosis: A Systematic Review and Meta-analysis

    Acute kidney injury (AKI) is a common complication in patients with cirrhosis that increases mortality. The most common causes of AKI in these patients are prerenal azotemia, acute tubular necrosis (ATN), and hepatorenal syndrome; it is important to determine the etiology of AKI to select the proper treatment and predict patient outcome. Urine biomarkers could be used to differentiate between patients with ATN and functional causes of AKI. We performed a systematic review and meta-analysis of published studies to determine whether urine levels of interleukin (IL)18 and lipocalin 2 or neutrophil gelatinase-associated lipocalin (NGAL) are associated with the development of ATN in patients with cirrhosis.
  • Diffuse Esophageal Glycogenic Acanthosis and Colon Polyposis in a Patient With Cowden Syndrome

    A 45-year-old man with a history of Cowden Syndrome (CS) with confirmed pathogenic phosphatase and tensin homolog (PTEN) mutation (802-1G>T substitution) was referred because of a history of intestinal polyposis. He had macrocephaly and classic mucocutaneous findings including trichilemmomas and oral papillomas. An upper endoscopy was performed that showed diffuse glycogenic acanthosis in the entire esophagus (Figure A), which was confirmed on histology with squamous epithelium having abundant clear cytoplasm, sparing the basal-most layers (Figure B).
  • Comparison of Infliximab and Adalimumab in Biologic-Naive Patients With Ulcerative Colitis: A Nationwide Danish CohortStudy

    This study compares the effectiveness and safety of infliximab and adalimumab in biologic-naive patients with ulcerative colitis (UC), in a nationwide register-based propensity scorematched cohort study.
  • Association Between Low Trough Levels of Vedolizumab During Induction Therapy for Inflammatory Bowel Diseases and Need for Additional Doses Within 6 Months

    We investigated whether serum trough levels of vedolizumab, a humanized monoclonal antibody against integrin 47, during the induction phase of treatment can determine whether patients will need additional doses (optimization of therapy) within the first 6 months.
  • Chromoendoscopy for Surveillance in Ulcerative Colitis and Crohns Disease: A Systematic Review of Randomized Trials

    Key international guideline agencies recommend dysplasia surveillance in inflammatory bowel diseases with chromoendoscopy. We performed a systematic review of randomized trials comparing chromoendoscopy vs other endoscopic techniques for dysplasia surveillance in inflammatory bowel diseases.
  • Dysphagia Caused by Extrinsic Esophageal Compression From Mediastinal Lymphadenopathy in Patients With Sarcoidosis

    Esophageal involvement in sarcoidosis is extremely rare. Dysphagia is the most common presentation in these patients and can be attributed to various mechanisms. This article highlights extrinsic esophageal compression as a possible mechanism behind dysphagia in sarcoidosis and underscores the importance of prompt diagnosis in such patients.
  • Gastrostomies Preserve But Do Not Increase Quality of Life forPatients and Caregivers

    Gastrostomies are widely used to provide long-term enteral nutrition to patients with neurologic conditions that affect swallowing (eg, following a cerebrovascular accident or for patients with motor neuron disease) or with oropharyngeal malignancies. The benefits derived from this intervention are uncertain for patients and caregivers. We conducted a prospective, multicenter cohort study to determine how gastrostomies affect health-related quality of life (HRQoL) in recipients and caregivers.
  • Comparison of Endoscopic Dilation vs Surgery for AnastomoticStricture in Patients With Crohn's Disease Following Ileocolonic Resection

    It is not clear whether endoscopic balloon dilation (EBD) or surgery is a more effective treatment for ileocolonic anastomosis (ICA) stricture in patients with Crohns disease. We aimed to compare long-term outcomes of patients who underwent EBD versus surgery for ICA stricture.
  • Fresh vs Frozen Samples and Ambient Temperature Have Little Effect on Detection of Colorectal Cancer or Adenomas by a Fecal Immunochemical Test in a Colorectal Cancer Screening Cohort in Germany

    Fecal immunochemical tests (FITs) are used in colorectal cancer (CRC) screening. We compared detection of CRCs and colorectal neoplasms by FITs using fresh samples (collected into buffer-filled tubes) vs frozen samples, and we assessed the effects of seasonal variations in ambient temperature on test performance.
  • Implementing the Concept of Continuous Clinical Response Into Clinical Practice for Ulcerative Colitis

    Ulcerative colitis (UC) is a complex and progressive disease that has a significant humanistic and economic impact in patients and the wider society. Disease control is still an unmet need for a large proportion of patients. The aim of this article was to review the current evidence to assess the feasibility, value, and impact of integrating continuous clinical response (CCR) as a patient-reported outcome into routine management of UC.
  • Tetrahydrocannabinol Does Not Reduce Pain in Patients With Chronic Abdominal Pain in a Phase 2 Placebo-controlled Study

    Delta-9-tetrahydrocannabinol (THC) is the most abundant cannabinoid from the plant Cannabis sativa. There is only equivocal evidence that THC has analgesic effects. We performed a phase 2 controlled trial to evaluate the analgesic efficacy, pharmacokinetics, safety, andtolerability of an oral tablet containing purified THC in patients with chronic abdominal pain.
  • New Pharmacologic Agents That Target Inflammation and Fibrosis in Nonalcoholic SteatohepatitisRelated Kidney Disease

    Epidemiologic data show an association between the prevalence and severity of nonalcoholic fatty liver disease and the incidence and stage of chronic kidney disease (CKD); furthermore, nonalcoholic steatohepatitis (NASH)-related cirrhosis has a higher risk of renal failure, a greater necessity for simultaneous liver-kidney transplantation, and a poorer renal outcome than cirrhosis of other etiologies even after simultaneous liver-kidney transplantation. These data suggest that NASH and CKD share common proinflammatory and profibrotic mechanisms of progression, which are targeted incompletely by current treatments.
  • A System to Assess the Competency for Interpretation of Esophageal Manometry Identifies Variation in Learning Curves

    Quality esophageal high-resolution manometry (HRM) studies require competent interpretation of data. However, there is little understanding of learning curves, training requirements, or measures of competency for HRM. We aimed to develop and use a competency assessment system to examine learning curves for interpretation of HRM data.
  • Inflammatory Bowel Disease

    Inflammatory bowel disease, or IBD, is an autoimmune, longterm health issue that causes inflammation, or swelling, and ulcerations, or sores, in the gastrointestinal (GI) tract. There are two main types of inflammatory bowel disease: ulcerative colitis and Crohns disease.
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  • Information for Authors

    Clinical Gastroenterology and Hepatology (CGH) publishes clinical articles on all aspects of the digestive system, including the liver and pancreas. The types of articles Clinical Gastroenterology and Hepatology publishes include original papers,review articles, and special category manuscripts. Manuscripts must be prepared in accordance with the Uniform Requirements for Manuscripts Submitted toBiomedical Journals developed by the International Committee of Medical Journal Editors (ICMJE) (
  • Information for Authors and Readers

    Clinical Gastroenterology and Hepatology is the go-to resource on a broad spectrum of themes in clinical gastroenterology and hepatology. The official clinical practice journal of the AGA Institute brings you the best original research in the field with a unique combination of reviews, editorials, podcasts, video abstracts, and outcomes researchall supporting clinical practice. Articles on education, policy, and practice management highlight issues pertinent to clinicians.
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  • Editorial Board

  • Cultivating Competencies for Value-Based Care

    It is my privilege this month to assume responsibility for the Practice Management: The Road Ahead section of Clinical Gastroenterology andHepatology. I am honored to join an impressive board of editors led by Dr Fasiha Kanwal, and anchored by global leaders in the field of gastroenterology and hepatology. This board of editors promises to continue the high level of excellence that has propelled the journal to its preeminent position among clinical journals. I am confident that the practice management section will uphold that tradition and continue to meet the expectation of our readers.