Clinical Gastroenterology and Hepatology

Editor picks for Clinical Gastroenterology and Hepatology


Effects of Combination Therapy With Immunomodulators on Trough Levels and Antibodies Against Tumor Necrosis Factor Antagonists in Patients With Inflammatory Bowel Disease: A Meta-analysis We associated combined treatment with immunomodulators with reduced risk of formation of antibodies against TNF antagonists in patients with IBD.
Sept. 1, 2017

A Modern Magnetic Implant for Gastroesophageal Reflux Disease Magnetic augmentation of the lower esophageal sphincter is a safe and effective operation for GERD.
Sept. 1, 2017

Cost Effectiveness of Screening Patients With Gastroesophageal Reflux Disease for Barrett’s Esophagus With a Minimally Invasive Cell Sampling Device We found Cytosponge screening with endoscopic confirmation to be a cost-effective strategy.
Sept. 1, 2017

Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits This review summarizes the most recent data in these areas.
Sept. 1, 2017

High Dietary Intake of Specific Fatty Acids Increases Risk of Flares in Patients With Ulcerative Colitis in Remission During Treatment With Aminosalicylates We associated high dietary intake of specific fatty acids, including myristic acid with an increased risk of flare.
Sept. 1, 2017

Asthma Is Associated With Subsequent Development of Inflammatory Bowel Disease: A Population-based Case–Control Study We associated asthma with Crohn’s disease, and with early and late-onset ulcerative colitis.
Sept. 1, 2017

Bolus Administration of Fentanyl and Midazolam for Colonoscopy Increases Endoscopy Unit Efficiency and Safety Compared With Titrated Sedation We found that compared with titrated administration of sedative, bolus dosing improves endoscopy unit efficiency and safety and decreases the amount of sedative required.
Sept. 1, 2017

Increases in IgE, Eosinophils, and Mast Cells Can be Used in Diagnosis and to Predict Relapse of IgG4-Related Disease We associated IgG4-RD with allergy, atopy, eosinophilia, increased serum levels of IgE, and IgE-positive mast cells in lymphoid, biliary, and pancreatic tissue.
Sept. 1, 2017

Diagnostic Accuracy of Noninvasive Fibrosis Scores in a Population of Individuals With a Low Prevalence of Fibrosis In low-risk populations, negative results from noninvasive scoring systems reliably exclude advanced fibrosis, without requirements for further tests.
Sept. 1, 2017

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.
Sept. 1, 2017

Clinical Gastroenterology & Hepatology RSS

  • Mycophenolate Mofetil In Autoimmune Hepatitis Patients With Suboptimal Outcomes To Standard Therapy: The Tapestry Study

    The outcomes of mycophenolate mofetil (MMF) as rescue therapy for AIH patients who have a suboptimal outcome to standard therapy remain unclear. We evaluated the efficacy and safety of MMF in patients who had failed or were intolerant to corticosteroids with/without azathioprine.
  • NonClostridium difficile Bacterial Infections Are Rare in Patients With Flares of Inflammatory Bowel Disease

    Clostridium difficile infection (CDI) causes flares in patients with inflammatory bowel disease (IBD). We investigated the frequency and outcomes of non-CDI bacterial enteric infections in symptomatic patients with IBD.
  • Exam 1: Association Between Endoscopist and Center Endoscopic Retrograde Cholangiopancreatography Volume With Procedure Success and Adverse Outcomes: A Systematic Review and Meta-analysis

  • Twenty-year Comparative Analysis of Patients With Autoimmune Liver Diseases on Transplant Waitlists

    The rarity of autoimmune liver disease poses challenges to epidemiology studies. However, waitlists for liver transplantation can be used to study patients with end-stage liver diseases. We used these waitlists to assess trends in numbers and demographics patients awaiting liver transplant for primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), or autoimmune hepatitis (AIH).
  • Outcomes 7 Years After Infliximab Withdrawal for Patients With Crohns Disease in Sustained Remission

    Little is known about long-term outcomes of patients with Crohns disease (CD) after infliximab withdrawal. We aimed to describe the long-term outcomes of patients with CD in clinical remission after infliximab treatment was withdrawn.
  • Regional patterns of olmesartan prescription and the prevalence of duodenal villous atrophy throughout the united states

  • Fecobionics: Integrating anorectal function measurements

  • Volatile Organic Compounds in Feces Associate With Response to Dietary Intervention in Patients With Irritable Bowel Syndrome

    Dietary interventions are effective in management of patients with irritable bowel syndrome (IBS), although responses vary. We investigated whether fecal levels of volatile organic compounds (VOCs) associate with response to dietary interventions in patients with IBS.
  • Improved Bone Microarchitecture in Patients With Celiac Disease After 3 Years on a Gluten-Free Diet

    Celiac disease (CD) is chronic autoimmune systemic disorder affecting up to 1% of the population worldwide.1 The disorder, triggered by dietary gluten, is characterized by a variety of intestinal and extraintestinal manifestations.2 One of the most common and best described extraintestinal manifestations is the presence of osteopenia and osteoporosis and the consequent higher fracture risk.3 We have shown that a gluten-free diet (GFD) improves bone mineralization and, although with some controversy, more recent studies have proved a long-term normalization of the rate of fractures by treatment.
  • Pilot Study of Screening Patients for Hepatitis C Virus Infection During Outpatient Endoscopy

  • Another Reason to Avoid the Gluten-Free Fad?

    The health hazards of heavy metal bioaccumulation are well known. Exposure to metals such as lead, cadmium, mercury, and arsenic continues to increase worldwide owing to the utilization of these metals in industrial and agricultural processes, and the subsequent contamination of drinking water sources.1 At toxic levels, the harmful effects are numerous, stemming predominantly from an accumulation of these metals in vital organs, with the development of increased reactive oxygen species and the subsequent generation of oxidative stress resulting in carcinogenesis, neurologic disorders, and other major organ injury.
  • Colorectal Cancer Genetics Screening in the Community: Are we Ready? Can we Do It?

    In a recent issue of Clinical Gastroenterology and Hepatology, Luba etal1 attempted to determine whether personal and family history can be collected routinely in a community gastroenterology (GI) practice so as to apply a risk-assessment tool designed to identify patients who would benefit from genetic cancer susceptibility testing. To roll this out, the doctors and staff went through a training period. The process and content of this were developed by a group of outside academics, genetic counselors, and others from the study sponsor (Myriad Genetics, a commercial genetic testing laboratory), and the practice staff themselves.
  • Patients Are Willing to Repeat Colonoscopy at a Short Interval When Bowel Preparation Quality Is Suboptimal

    The US Multi-Society Task Force recommends repeat colonoscopy within 1 year of an examination with inadequate bowel preparation.1 Prior studies have shown that endoscopists recommendations for timing of colonoscopy in this context are variable.2,3 One factor that may influence endoscopists willingness to recommend early repeat colonoscopy is concern about patients willingness to repeat the preparation and procedure at a short interval. The aim of this study was toassess patient preferences for the timing of repeat colonoscopy using a hypothetical suboptimal bowel preparation scenario.
  • A Comparison of Staging Systems for Hepatocellular Carcinomain a Multicenter US Cohort

    Hepatocellular carcinoma (HCC) staging guides patient prognosis and treatment allocation; however, there is no universally accepted staging system for HCC. The most widely endorsed staging system is the Barcelona Clinic Liver Cancer (BCLC) system, which incorporates tumor burden, functional status, and liver function.1 We aimed to compare the discriminant ability of several staging systems for HCC in a geographically diverse multicenter US cohort.
  • Optimal Histologic Cutpoints for Treatment Response in Patients With Eosinophilic Esophagitis: Analysis of Data From a Prospective Cohort Study

    No prospective studies substantiate 15 eos/hpf as an appropriate endpoint for treatment of eosinophilic esophagitis (EoE). We aimed to determine a histologic cutpoint that identifies successful treatment of EoE by assessing symptomatic and endoscopic improvement.
  • AGA Institute High-Value Care Statement: Is High-Resolution Manometry Always Needed for the Diagnosis of Achalasia?

    This article is part of a series on Enhancing the Value of Care in Gastroenterology and Hepatology. Each article in this series examines specific clinical scenarios in which the value of care can be improved over a range of sub-specialties in the field.David A. Katzka, MD Special Section Editor
  • Association Between Hepatic Steatosis, Measured by Controlled Attenuation Parameter, and Fibrosis Burden in Chronic Hepatitis B

    The interaction between chronic hepatitis B (CHB) and hepatic steatosis is poorly understood. We investigated whether measurement of controlled attenuation parameter (CAP), a non-invasive method to quantify steatosis, can assist in monitoring patients with CHB.
  • Fructans Exacerbate Symptoms in a Subset of Children with Irritable Bowel Syndrome

    Dietary fructans exacerbate symptoms in some, but not all, adults with irritable bowel syndrome (IBS). We sought to determine whether fructans worsen symptoms in children with IBS and whether clinical and psychosocial factors, and/or gas production, can identify those who are fructan sensitive.
  • Racial and Ethnic Disparities in Non-alcoholic Fatty Liver Disease Prevalence, Severity, and Outcomes in the United States: A Systematic Review and Meta-analysis

    Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in the United States, affecting 75100 million Americans. However, the disease burden may not be equally distributed among races or ethnicities. We conducted a systematic review and meta-analysis to characterize racial and ethnic disparities in NAFLD prevalence, severity, and prognosis.
  • Interchageable Use of Proton Pump Inhibitors Based on Relative Potency

    Although proton pump inhibitors (PPIs) are widely used, their relative potency and ideal dosing regimens remain unclear. We analyzed data from randomized clinical trials that performed pH testing in patients receiving solid-dose PPI formulations (omeprazole, esomeprazole, lansoprazole, pantoprazole, rabeprazole) for a minimum of 5 days. We used omeprazole equivalency and the surrogate biomarker, pH4time (percentage time pH>4 over 24-hour period), to compare PPI effectiveness for different PPIs given once, twice or three times daily.
  • Effect of Nucleos(t)ide Analogue Therapy on Risk of Intra-hepatic Cholangioarcinoma in Patients With Chronic Hepatitis B

    Chronic infection with hepatitis B virus (HBV) increases risk of intrahepatic cholangiocarcinoma (ICC), but it is not clear whether antiviral therapy reduces risk. We investigated the association between nucleos(t)ide analogue therapy and ICC risk.
  • Efficacy of Glecaprevir/Pibrentasvir for 8 or 12 Weeks in Patients with HCV Genotype 2, 4, 5, or 6 Infection Without Cirrhosis

    Hepatitis C virus (HCV) has high genotypic diversity and global distribution. Agents that are effective against all major HCV genotypes, with shorter treatment duration, are needed to reduce disease burden. Glecaprevir (an NS3/4A protease inhibitor) and pibrentasvir (an NS5A inhibitor) have a high barrier to resistance and synergistic antiviral activity. We evaluated the safety and efficacy of 8 and 12 weeks treatment with glecaprevir/pibrentasvir in patients with HCV genotype 2, 4, 5, or 6 infection without cirrhosis in 3 separate phase 3 trials.
  • Exam 2: Chromoendoscopy for Surveillance in Ulcerative Colitis and Crohn's Disease: A Systematic Review of Randomized Trials

  • Increased Level of Interleukin 6 Associates With Increased 90-day and 1-year Mortality in Patients With End-stage Liver Disease

    Organ allocation for liver transplantation is based on prognosis, using the model for end-stage liver disease (MELD) or MELD-Na score. These scores do not consider systemic inflammation and septic complications. Blood level of C-reactive protein (CRP), in addition to the MELD score, associates with mortality in patients with end-stage liver disease, whereas levels of interleukin 6 (IL6) have not been systematically studied.
  • Anniversary Tribute from the Editors of Clinical Gastroenterology and Hepatology

  • Reply

    Thank you to Dr Matuchansky for the excellent editorial response letter. I appreciate the additional references that Dr Matuchansky has provided in regards to the large population-based study of familial colorectal cancer (CRC) risk in Denmark.1 Indeed, this study showed a significantly higher risk of CRC in siblings compared with other first-degree relative (FDR) types (ie, parents). Because all of the quoted studies24 showed a markedly increased risk of CRC for all classes of FDRs, although the absolute estimates differed as to whether one group (parents vs siblings vs children) had a higher risk than the other, it is prudent for clinicians to counsel all FDRs about the increased CRC risk, with particular attention to siblings, advising an earlier age of initiation and a shorter surveillance interval for colonoscopy.
  • Suboptimal Agreement Among Cytopathologists in Diagnosis of Malignancy Based on Endoscopic Ultrasound Needle Aspirates of Solid Pancreatic Lesions: A Validation Study

    Despite the widespread use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) to sample pancreatic lesions and the standardization of pancreaticobiliary cytopathologic nomenclature, there are few data on inter-observer agreement among cytopathologists evaluating pancreatic cytologic specimens obtained by EUS-FNA. We developed a scoring system to assess agreement among cytopathologists in overall diagnosis and quantitative and qualitative parameters, and evaluated factors associated with agreement.
  • Administration of Albumin Solution Increases Serum Levels of Albumin in Patients With Chronic Liver Failure in a Single-Arm Feasibility Trial

    Infections are life-threatening to patients with acute decompensation and acute-on-chronic liver failure (AD/ACLF). Patients with AD/ACLF have prostaglandin E2mediated immune suppression, which can be reversed by administration of albumin; infusion of 20% human albumin solution (HAS) might improve outcomes of infections. We performed a feasibility study to determine optimal trial design, assess safety, and validate laboratory assessments of immune function to inform design of a phase 3 trial.
  • Postprandial High-Resolution Impedance Manometry Identifies Mechanisms of Nonresponse to Proton Pump Inhibitors

    Recognition of rumination and supragastric belching is often delayed as symptoms may be mistakenly attributed to gastroesophageal reflux disease. However, distinct from gastroesophageal reflux disease, rumination and supragastric belching are more responsive to behavioral interventions than to acid-suppressive and antireflux therapies. Postprandial high-resolution impedance manometry (PP-HRIM) is an efficient method to identify rumination and belches. We investigated the distribution of postprandial profiles determined by PP-HRIM, and identified patient features associated with postprandial profiles among patients with nonresponse to proton pump inhibitors (PPIs).
  • Pearly Esophageal Papules: An Innocent Bystander in the Evaluation of Dysphagia

    A 66-year-old man with a history of gastroesophageal reflux disease presented with esophageal dysphagia over a period of 2 years. He was receiving proton pump inhibitors and denied any history of weight loss, odynophagia, or melena. Physical examination and laboratory test results were within normal limits. Upper endoscopy (esophagogastroduodenoscopy) showed multiple pearly papules along the entire esophagus (Figure A) and the papules were examined by biopsy (Figures B and C). The pathology showed ectopic sebaceous glands in the esophagus.
  • Successful Treatment of a Patient With Gastric Mucosa-Associated Lymphoma

    A 59-year-old woman with a history of intermittent epigastric pain for 4 months underwent esophagogastroduodenoscopy (EGD), which showed a large 2-cm gastric ulcer (Figure A). She was negative for Helicobacter pylori. Excisional biopsy specimens of the ulcer showed atypical lymphoid cells and lymphoepithelial lesions (Figure B), with positive PAX-5 immunostaining consistent with a primary gastric mucosaassociated lymphoid tissue (MALT) lymphoma (Figure C).
  • Obesity, but Not Physical Activity, Is Associated With Higher Prevalence of Asymptomatic Diverticulosis

    Colonic diverticulosis is a common condition of the large intestine diagnosed on colonoscopy.1 More than 50% of people older than age 70 in the United States have diverticulosis,1 with up to 20% of them experiencing complications including diverticulitis and diverticular hemorrhage.2 However, data on determinants of diverticulosis have been sparse, with prior studies on the role of obesity and physical activity showing inconsistent results.36 We therefore examined the association between obesity and physical activity, and the prevalence of diverticulosis.
  • Detection of Arteriovenous Malformations on the Underside of the Duodenal Papilla

    An 85-year-old woman with a history of recurrent gastrointestinal bleeding caused by duodenal arteriovenous malformations (AVMs) presented to the hospital with recurrent melena and symptomatic anemia.
  • Large Meckels Diverticulum and Dilated Adjacent Small Intestine Presenting With Intestinal Obstruction

    A 49-year-old woman presented 5 months after passage of bloody stools. Upper gastrointestinal endoscopy, colonoscopy, and ileal and colonic biopsies for Crohns disease all were negative. Capsule endoscopy showed 2 small intestinal ulcers attributed to intake of nonsteroidal anti-inflammatory drugs for shoulder pain. Five weeks before presentation, she experienced central infra-umbilical pain in the postprandial period and, 2 weeks later, an episode of severe abdominal pain diagnosed elsewhere as small-bowel obstruction, which resolved without any surgical intervention.
  • Definition, Pathogenesis and Management of that cursed Dyspepsia

    Dyspepsia is an umbrella term used to encompass a number of symptoms thought to originate from the upper gastrointestinal tract. These symptoms are relatively non-specific; not surprisingly, therefore, a myriad of conditions may present with any one or a combination of these symptoms. Therein lies the clinicians first challenge: detecting the minority who may have a potentially life-threatening disorder, such as gastric cancer, from a population whose symptoms are, for the most part, considered functional in origin.
  • Exam 1: Risk of Gastrointestinal Bleeding in Patients Taking Non-Vitamin K Antagonist Oral Anticoagulants: A Systematic Review and Meta-analysis

  • Boerhaaves Syndrome: A Window to the Heart

    A 63-year-old man presented with atrial fibrillation and hematemesis. A chest computed tomography (CT) showed esophageal rupture and oral contrast extravasation (Figure A). Chest tubes were placed but surgical repair was not feasible owing to comorbidities and the high location of the perforation in the thorax caused by a hiatal hernia. An esophagogastroduodenoscopy (EGD) showed a 2.5-cm perforation with a pulsatile visceral surface protruding into the esophageal lumen. Insufflation displaced the lumen away from suspected pericardium (Figure B).
  • Reply

    We thank Efe et al1,2 for their response and contribution of a further case describing the use of methotrexate (MTX) for autoimmune hepatitis. MTX has demonstrable efficacy in a number of autoimmune diseases that commonly are associated with autoimmune hepatitis such as rheumatoid arthritis, systemic lupus erythematosus, and psoriasis.36 MTX therefore should be considered a viable therapeutic option in patients who have additional indications such as thecase described by Efe etal.1 We agree that MTXdoes carry a vastly different side-effect profile to thiopurines and other second-line agents, however, there is a large repository of long-term safety data for MTX use in both rheumatologic and dermatologic literature.
  • Issue Highlights

    Eosinophilic esophagitis (EoE) is an immune-mediated condition that affects children and adults, and is believed to be triggered by food antigens. Use of a 6-food elimination diet (SFED) that excludes cows milk, wheat, egg, soy, peanut/tree nuts, and fish/shellfish has been shown to induce clinical as well as histologic remission in most children and adults with EoE, with cows milk, wheat, egg and soy identified as the four most common trigger foods. In this issue of Clinical Gastroenterology and Hepatology, Kagalwalla and colleagues analyzed the results of a prospective multicenter study of pediatric patients with EoE to determine if exclusion of only 4 foods (4-FED: cows milk, wheat, egg, and soy) was effective in inducing clinical, endoscopic, and histologic remission.
  • Timing of Endoscopy in Acute Nonvariceal Gastrointestinal Bleeding: Still Looking for the Answer

    We read with great interest the article by Cho etal1 reporting better outcomes in high-risk patients with upper nonvariceal gastrointestinal bleeding (UGIB) (GlasgowBlatchford score, >7) who underwent endoscopy in the first 6 hours after emergency department presentation when compared with patients undergoing endoscopy 6 to 48 hours after presentation. The issue of the best timing for endoscopy undoubtedly is important, and because of the difficulty in conducting randomized clinical trials in this area, observational studies can have an important role in answering this question.
  • Short Sleep Duration Is Associated With Abnormal Serum Aminotransferase Activities and Nonalcoholic Fatty Liver Disease

    The proportion of adults in the United States who report sleeping 6 or fewer hours per night increased from 22.3% in 1985 to 29.2% in 2012 despite recommendations that adults maintain sleep duration of 7 hours or more for optimal health.1,2 Sleep deprivation increases metabolic risks known to be associated with nonalcoholic fatty liver disease (NAFLD). We studied the association between duration and quality of sleep and indicators of NAFLD in the US general population.
  • Risk of Colorectal Carcinoma in Siblings ofProbands With Common ColorectalCarcinoma

    I read with great interest the article by Graaf etal,1 and the accompanying editorial by Sammader etal,2 about the familial risk and heritability of colorectal cancer (CRC) in the Nordic Twin Study of Cancer. Graaf etal1 clearly showed that twins, especially monozygotic twins, of affected co-twins were at substantially increased risk of CRC relative to the general population and should consider personalized screening.1 In their discussion, they rightly suggested that siblings, who are as genetically similar as dizygotic twins, of affected individuals should be encouraged to undergo routine CRC screening, but they did not quote references specifically concerning nontwin siblings to support their suggestion.
  • Gastric Mucosal Staining After Ethylene Vinyl AlcoholEmbolization

    Ethylene vinyl alcohol (EVOH) is an inherently black embolic approved for use in cerebrovascular applications, and also is used in other territories including the gastrointestinal (GI) system. Its use in the GI tract is relatively new but it has been shown to be both safe and successful in upper- and lower-GI hemorrhage. EVOH is known to cause black skin discoloration when used in peripheral applications.
  • Endoscopic Resolution of Black Esophagus With Treatment of Diabetic Ketoacidosis

    A 55-year-old woman with poorly controlled type II diabetes mellitus (hemoglobin A1C, 15.6%) presented to the hospital with diabetic ketoacidosis (DKA) and coffee-ground emesis. Treatment of DKA with insulin infusion and intravenous fluids was instituted, in addition to high-dose proton pump inhibitor (PPI) therapy for a presumed upper gastrointestinal bleed. An esophagastroduodenoscopy the day after admission showed near-circumferential, black, necrotic-appearing, esophageal mucosa from the midesophagus to the gastroesophageal junction (Figure A), where there was an abrupt transition to normal-appearing mucosa (Figure B).
  • Cholelithiasis in a Patient With History of Cholecystectomy

    A 57-year-old woman with a history of alcohol abuse and a past medical history of diabetes mellitus, hypertension, and open cholecystectomy in 2005, presented with right upper-quadrant abdominal pain and jaundice. She reported no fever, nausea, or vomiting. Physical examination showed scleral icterus and a positive Murphy sign. Laboratory test results indicated a normal white count, serum aspartate aminotransferase level of 212 IU (normal range, 541 IU), alanine aminotransferase level of 96 IU (normal range, 537 IU), total bilirubin level of 4 mg/dL (normal range, 01 mg/dL), direct bilirubin level of 2.5 mg/dL (normal range, 00.2 mg/dL), and an alkaline phosphatase level of 111 IU (normal range, 35129 IU).
  • Splenic Abscesses Caused by Salmonella D9

    An 82-year-old man was admitted to the hospital with abdominal pain. He was immunocompetent and had no prior history of abdominal trauma or recent travel. Examination showed a distended abdomen. An abdominal computed tomography showed submucosal edema in the duodenum and pyloric antrum, partial thrombosis in the splenic artery, and hypodense areas in the splenic parenchyma (Figure A). One day after admission, the patient had an episode of hematochezia. Endoscopy showed superficial esophageal and gastric ulcers and a deep 20-mmdiameter ulcer with an adherent clot in the second portion of the duodenum (Figure B).
  • Videocapsule Endoscopy Identifies Small Bowel Lesions in Patients With Eosinophilic Enteritis

    A 2-year-old boy presented with fatigue, anorexia, iron-deficiency anemia (hemoglobin level, 8.5 g/dL; mean corpuscular volume, 62.5 FL), hemoccult-positive stool, and peripheral eosinophilia (880 cells/L). Upper endoscopy and colonoscopy were grossly and histologically unremarkable. Video capsule endoscopy (VCE) showed jejunal and proximal ileal salmon-colored patches (Figures A and B). Push enteroscopy (Figure C) showed jejunal eosinophilia with 72 eosinophils per high-power field, densely packed in the lamina propria (Figure D).
  • Role of Age and Race in the Risk of Hepatocellular Carcinoma in Veterans With Hepatitis B Virus Infection

    & Aims: Hepatocellular (HCC) surveillance guidelines for patients with chronic hepatitis B virus (HBV) infection are based on race- and age-specific estimates of HCC risk, derived from studies conducted in areas in which HBV is endemic.
  • Use of Biologic Therapy by Pregnant Women With Inflammatory Bowel Disease Does Not Affect Infant Response to Vaccines

    In women with inflammatory bowel diseases (IBDs), exposure to immunomodulator or biologic therapy has not been associated with adverse events during pregnancy or outcomes of newborns. We investigated whether exposure of patients to these agents during pregnancy affects serologic responses to vaccines in newborns.
  • The Combination Use of an Acetic Acid Indigo Carmine Mixture and Linked-Color Imaging to Detect Early Gastric Cancer

    Chromoendoscopy (CE) and image-enhanced endoscopy are useful for accurately diagnosing gastric neoplasms. However, unclear lesions, such as those with a flat morphology or normochromic color, sometimes can be missed. We herein present a case in which CE was performed with the combined use of anacetic acid indigo carmine mixture (AIM) and linked-color imaging (LCI), and this method was effective for detecting early gastric cancer. A Japanese man in his70s underwent esophagogastroduodenoscopy forscreening purposes.
  • Ascariasis Diagnosed by Wireless Capsule Endoscopy

    A 62-year-old Caucasian man presented with iron-deficiency anemia. The patient had no significant past medical or travel history but had guaiac-positive stool on rectal examination. Laboratory results showed a hemoglobin level of 13.4 g/dL with an iron saturation of 9%. Upper endoscopy was negative for ulcers/gastritis and colonoscopy showed diverticulosis without bleeding. The patient underwent wireless capsule endoscopy and a live worm was visualized in the duodenum (Figures A and B). The worm was identified as an Ascaris lumbricoides (Video 1).
  • Efficacy of a Surveillance Endoscopy Afteran Ileorectal Anastomosis in PatientsWith Ulcerative Colitis

    We read with great interest the article titled, Risk of Rectal Cancer After Colectomy for Patients With Ulcerative Colitis: A National Cohort Study written by Abdalla etal.1 They investigated the risk of the development of rectal cancer after surgery in patients diagnosed with ulcerative colitis (UC) using a national cohort from Sweden and showed that the incidence of rectal cancer was not very high after both an ileal-pouch anal anastomosis (IPAA) and an ileorectal anastomosis (IRA) procedure.
  • Management of Acute Variceal Hemorrhage as a Model of Individualized Care for Patients WithCirrhosis

    Variceal hemorrhage is a complication of cirrhosis that denotes decompensation and that still has a high mortality rate.1 Portal pressure is the main driver of variceal hemorrhage and a main predictor of decompensation and therefore it is not surprising that portal pressure, as determined by the hepatic venous pressure gradient (HVPG) and measured within 48 hours of admission, is the main predictor of treatment failure and death in patients with cirrhosis and acute variceal hemorrhage.2 The HVPG cut-off level identified as having the best accuracy in predicting death in these patients was greater than 20 mm Hg.
  • Uncoiling the Coil: Coil Extrusion After Coil Assisted Retrograde Transvenous Obliteration for Gastric Variceal Bleeding

    An 83-year-old woman with cryptogenic cirrhosis (Model for End-stage Liver Disease score, 7) presented with melena 7 months after successful coil-assisted retrograde transvenous obliteration treatment of hemodynamically unstable bleeding gastric varices (gastroesophageal varix 2) (Figure A). Previously, embolization of the gastrorenal shunt and bleeding gastric varices was successful with 3% Sotradecol, lipidol, and Interlock-35 fibered and Azur detachable coils. During her current hospitalization, she underwent standard medical management for suspected variceal bleeding.
  • Two Colonic Masses: Twice the Enigma

    A 65-year-old male active smoker who had a history of hypertension, obesity, and chronic obstructive pulmonary disease presented with right lower-abdominal pain a few days after a self-limited episode of nausea and vomiting leading to volume depletion. A computed tomography scan of the abdomen and pelvis with intravenous contrast showed irregular cecal wall thickening that was suspicious for malignancy but no lymphadenopathy or distant spread. Colonoscopy showed a large half-circumferential, malignant-appearing, ulcerated mass infiltrating the ileocecal region and a similar 2-cm ascending colon mass.
  • Leukemic Infiltration of Colon in a Case of Diarrhea Post Hematopoietic Cell Transplantation (HCT)

    A 65-year-old man with a history of myelodysplastic syndrome that transformed into acute myeloid leukemia (AML) presented with a history of diarrhea for 6 to 8 weeks. Allogenic stem cell transplantation was performed 12 months before this presentation. Stool for gastrointestinal multiplex panel and Clostridium difficile toxin was negative. The patient underwent a flexible sigmoidoscopy with biopsy. On sigmoidoscopy, the sigmoid colon was seen to have patchy areas of erythema with boggy, edematous, and nodular mucosa (Figures A and B).
  • Spontaneous Tear after Insufflation: A Unique Finding of Collagenous Colitis

    A 74-year-old Caucasian woman was hospitalized with 5 weeks of profuse diarrhea. Two months ago she was started on omeprazole because of reflux symptoms. Clostridium difficile and the gastrointestinal pathogen panel were negative. Computerized tomography of the abdomen showed thickening of the rectosigmoid colon. On colonoscopy, the colonic mucosa appeared swollen. Upon advancing the colonoscope in the splenic flexure, 2 mucosal separations appeared on air insufflation with visualization of submucosa (Figure A).
  • Reply

    We thank Yoo etal for their interest in our study evaluating the cost-effectiveness of pre- vs post-liver transplant (LT) treatment of hepatitis C virus (HCV) with oral direct-acting antivirals (DAAs).1
  • Albumin Counteracts Immune-Suppressive Effects of Lipid Mediators in Patients With Advanced Liver Disease

    Patients with acute decompensation and acute-on-chronic liver failure (AD/ACLF) have immune dysfunction, which increases their risk for infections; however, there are no effective treatments to restore their immune function. We investigated whether the potentially immune-restorative effects of albumin are mediated by its effects on prostaglandin E2 (PGE2) and other lipids.
  • Methotrexate in the Treatment of Autoimmune Hepatitis

    Corticosteroids and azathioprine (AZA) are standard initial treatment of autoimmune hepatitis (AIH) while up to 20% of patients do not respond, or are intolerant to this treatment.1 Clinical Gastroenterology and Hepatology, several reports have shown that mycophenolate mofetil, tacrolimus, 6-mercaptopurine, and 6-thioguanine are effective and safe second-line therapies for AIH.26 More recently, Haridy etal7 reported efficacy and safety of methotrexate (MTX) as alternative therapy in 11 adult AIH patients.
  • Reply

    This article is in response to a letter by ODea, The Distensibility Index as a Biomarker for Lower Esophageal Sphincter Opening Pressure.1 O'Dea is in opposition to my opinions in a recent article criticizing the distensibility index (DI) and compliance.2
  • The Blind Firing Squad

    It seems that my life as gastroenterologist is fraught with danger. On any given day, I may be blamed for some adverse events associated with endoscopy, patient management, or professional conduct. My patients suffer from chronic and severe diseases with potentially bad outcomes. A large variety of endoscopic procedures are accompanied by potential adverse events. Besides their gastrointestinal complaints, older patients suffer from comorbid conditions that render even routine interventions more dangerous.
  • Heterogeneity in Definitions of Endpoints for Clinical Trials of Ulcerative Colitis: A Systematic Review for Development of a Core Outcome Set

    Advances in development of therapeutic agents for ulcerative colitis (UC) have been paralleled by innovations in trial design. It would be useful to identify a core outcome set, to standardize outcome definitions for efficacy and safety in clinical trials. We performed a systematic review of efficacy and safety outcomes reported in placebo-controlled randomized controlled trials of patients with UC.
  • Non-invasive Tests Do Not Accurately Differentiate Non-alcoholic Steatohepatitis From Simple Steatosis: ASystematic Review and Meta-Analysis

    Non-alcoholic fatty liver disease is a rapidly increasing health problem. Liver biopsy analysis is the most sensitive test to differentiate between non-alcoholic steatohepatitis (NASH) and simple steatosis, but non-invasive methods are needed. We performed a systematic review and meta-analysis of non-invasive tests for differentiating NASH from simple steatosis, focusing on blood markers.
  • Surgical Interventions and the Use of Device-Aided Therapy for the Treatment of Fecal Incontinence and Defecatory Disorders

    The purpose of this clinical practice update expert review is to describe the key principles in the use of surgical interventions and device-aided therapy for managing fecal incontinence (FI) and defecatory disorders. The best practices outlined in this review are based on relevant publications, including systematic reviews and expert opinion (when applicable).Best Practice Advice 1: A stepwise approach should be followed for management of FI. Conservative therapies (diet, fluids, techniques to improve evacuation, a bowel training program, management of diarrhea and constipation with diet and medications if necessary) will benefit approximately 25% of patients and should be tried first.
  • Esophageal Adenocarcinoma 10 Years After Surgical Resectionof Barretts Esophagus: Unusual Presentation asSubepithelial Tumor

    A 58-year-old man presented for follow-up of a subepithelial tumor in the distal esophagus. Ten years earlier partial esophagectomy with jejunal interposition (Merendino procedure) had been performed for esophageal adenocarcinoma arising within Barretts esophagus C1M2. R0 resection of the cancer (pT1a pN0 G1 L0 V0) and the Barretts epithelium had been confirmed in the specimen. Five years later a small submucosal tumor was diagnosed 10 mm proximal to the esophagoenteral anastomosis during routine follow-up.
  • External Validation of a Thiopurine Monitoring Algorithm on the SONIC Clinical Trial Dataset

    Several reports leverage patterns in electronic medical record data to create algorithms to optimize outcomes in healthcare.13 More recently, there has been an increasing call for the use of clinical trial data repositories.4 Open clinical trial data sharing has allowed us evaluate the generalizability of algorithms to predict response to thiopurines in patients with inflammatory bowel disease (inflammatory bowel disease). Yale University Open Data Access (http://yoda.yale.edu/) is a data-sharing platform that provides access to multiple clinical trial datasets.
  • Improved Outcomes in HCV Patients Following Liver Transplantation During the Era of Direct-Acting Antiviral Agents

    Despite improvement in treatment options, chronic hepatitis C virus (HCV) infection remains the leading indication for liver transplantation in the United States, with universal post-transplant recurrence in patients who are viremic at the time of liver transplant (LT) surgery.1 Following LT, a subset of LT recipients can develop an aggressive form of recurrent HCV infection, resulting in higher mortality and graft failure compared with non-HCV etiologies.2
  • Ethyl Glucuronide in Hair Is an Accurate Biomarker of Chronic Excessive Alcohol Use in Patients With Alcoholic Cirrhosis

    The assessment of ongoing alcohol use in patients with alcoholic liver disease remains a major diagnostic challenge.1,2 Ethyl glucuronide in scalp hair (hair ethyl glucuronide [hEtG]) is an attractive direct alcohol biomarker with a diagnostic time window of several months, but validation in patients with cirrhosis is required.3 In this study, we tested the diagnostic accuracy of hEtG in a cohort of healthy volunteers and patients with alcoholic cirrhosis and a reliable self-reported alcohol intake.
  • Fifteen Years Since the Advent of Double-Balloon Endoscopy

    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.
  • Worldwide Burden of and Trends in Mortality From Gallbladder and Other Biliary Tract Cancers

    Gallbladder cancer has a low rate of survival, a unique geographic distribution, and is associated with lifestyle factors that have changed in recent decades. Little is known about the extent to which behavioral patterns have affected global trends in gallbladder cancer. We investigated recent mortality patterns and trends worldwide.
  • Patient Characteristics Associated with Quality of Colonoscopy Preparation: A Systematic Review and Meta-analysis

    Some features of patients are associated with inadequate bowel preparation, which reduces the effectiveness of colonoscopy examination. We performed a systematic review and meta-analysis of the association between patients sociodemographic characteristics, health conditions, and medications with inadequate bowel preparation.
  • Low-FODMAP Diet

    FODMAP is a group of 5 sugars found in certain foods. These sugars are lactose, fructose, fructans, galactans, and polyols. FODMAP stands for:
  • Subclinical Hypothyroidism and Low-Normal Thyroid Function Are Associated With Nonalcoholic Steatohepatitis and Fibrosis

    Variations in level of thyroid-stimulating hormone (TSH) within the reference range of thyroid hormone could have negative health effects. We evaluated the effect of plasma TSH levels within the euthyroid range on the severity of histological damage associated with nonalcoholic fatty liver disease (NAFLD).
  • Serrated Colorectal Neoplasia: From Sideshow to Center Stage

    The following commentary discusses a landmark article published in CGH and ispart 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.
  • Effects of a Brief Educational Program on Optimization of Fluoroscopy to Minimize Radiation Exposure During Endoscopic Retrograde Cholangiopancreatography

    Fluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) is increasingly performed by therapeutic endoscopists, many of whom have not received formal training in modulating fluoroscopy use to minimize radiation exposure. Exposure to ionizing radiation has significant health consequences for patients and endoscopists. We aimed to evaluate whether a 20-minute educational intervention for endoscopists would improve use of fluoroscopy and decrease ERCP-associated exposure to radiation for patients.
  • Development and Validation of Trigger Algorithms to Identify Delays in Diagnostic Evaluation of Gastroenterological Cancer

    Colorectal cancer (CRC) and hepatocellular cancer (HCC) are common causes of death and morbidity, and patients benefit from early detection. However, delays in follow-up of suspicious findings are common, and methods to efficiently detect such delays are needed. We developed, refined, and tested trigger algorithms that identify patients with delayed follow-up evaluation of findings suspicious of CRC or HCC.
  • Risk of Pancreatitis Following Treatment of Irritable Bowel Syndrome With Eluxadoline

    The Food and Drug Administration approved eluxadoline for the treatment of diarrhea-predominant irritable bowel syndrome despite cases of pancreatitis in early stage trials. We investigated the frequency of pancreatitis attributed to eluxadoline in postmarketing surveillance.
  • Silymarin in Nonalcoholic SteatohepatitisA New Kid on the Block?

    In this issue of Clinical Gastroenterology and Hepatology, Chan etal1 reported on the efficacy and safety of the herbal product silymarin (SM) in a randomized, double-blind, placebo-controlled, single-center trial in patients with nonalcoholic steatohepatitis (NASH).
  • A Case of a Giant Fecaloma

    A 70-year-old man with history of lumbar radiculopathy status post spinal cord stimulator presented with worsening back pain and increasing opioid requirement. The patient reported longstanding constipation and previous fecal impaction. After a week, the patient denied bowel movements despite stool softeners, enemas, and laxatives. Because the patient reported worsening abdominal distention and pain, an abdominal radiograph was obtained and showed a 27-cm fecaloma in the rectosigmoid colon (Figure A).
  • Widefield Endoscopic Mucosal Resection for Treatment of Proximal Esophageal Leukoplakia

    An 81-year-old woman was referred to our facility for the management of new onset dysphagia to solids. She had a history of oropharyngeal leukoplakia, which was being followed by ear, nose, and throat doctor. She had several medical comorbidities including ischemic heart disease with automatic implantable cardioverter-defibrillator. She denied any tobacco or alcohol use. Esophagogastroduodenoscopy showed narrowing of the proximal esophagus with characteristic white plaques suggestive of esophageal leukoplakia (Figure A).
  • High Rate of Mortality More Than 30 Days After Upper Gastrointestinal Bleeding

    It is assumed that in the modern era of effective medical and endoscopic treatments both short-term and long-term prognosis is good after an episode of peptic ulcer bleeding. Despite advances in pharmacologic and endoscopic treatments, the fatality rate associated with peptic ulcer bleeding has not improved.1 Peptic ulcer bleedingrelated 30-day mortality rates range from 5% to 12% from studies across the United States, Europe, and Asia.2 Moreover, after surviving the bleeding episode, patients may be at risk for potential excess long-term mortality from reasons other than peptic ulcer bleeding.
  • More Sensitivity Analysis of Share 35, Human Immunodeficiency Virus Co-infection, Delist, Hospital Cost on Cost Effectiveness of Direct-Acting Antiviral Agents for Liver Transplant Hepatitis C Virus Patients

    We read with interest the study by Samur etal1 assessing the cost effectiveness of pre- vs post-liver transplant (LT) treatment for hepatitis C virus (HCV) with oral direct-acting antivirals (DAAs).
  • Socioeconomic vs Health-related Factors Associated With Google Searches for Gluten-Free Diet

    A gluten-free diet is the treatment for celiac disease (CD).1 This diet has gained popularity in the United States out of proportion to shifts in diagnosis and incidence of CD.2 Sociodemographic factors can affect food purchases and nutritional habits, and popular diets may be unrelated to recommendations from medical professionals.3 The aim of this study was to test whether sociodemographic and health data predict the popularity of Google searches for gluten-free diet.
  • Prevalence of Dyspepsia in Individuals With Gastroesophageal RefluxType Symptoms in the Community: A Systematic Review and Meta-Analysis

    Dyspepsia and gastroesophageal reflux are highly prevalent in the general population, but they are believed to be separate entities. We conducted a systematic review and meta-analysis to estimate the prevalence of dyspepsia in individuals with gastroesophageal reflux symptoms (GERS), and to quantify overlap between the disorders.
  • Can We Accurately Predict Survival in Patients With Perihilar Cholangiocarcinoma?

    Cholangiocarcinomas are a group of epithelial cancers that commonly are diagnosed at late stage and are highly fatal.1 Perihilar cholangiocarcinoma (PHC) is the most common malignancy arising from the hilar plate of the biliary tree. Although curative treatments are available for some PHC patients, overall survival rates for patients with PHC remain poor. Five-year survival rates after surgical resection of PHC ranges from 10% to 40%; however, fewer than half of all PHC patients are diagnosed with resectable tumors, and limited treatment options are available to these patients.
  • Bringing Assessment of Patient-reported Outcomes to Hepatology Practice

  • Reappraisal of Endoscopic Papillary Balloon Dilation Versus Sphincterotomy for CholedocholithiasisTime for a New Trial

    Endoscopic sphincterotomy (EST) first was performed in 1973 and reported shortly after by Nakajima etal1 and by Classen and Demling.2 The earliest report of endoscopic papillary balloon dilation (EPBD) was by Staritz etal3 in 1982. In the intervening 3 to 4 decades there have been many advances in the field of pancreaticobiliary endoscopy, but the debate as to how to remove stones from the bile duct most optimally by endoscopic retrograde cholangiopancreatography (ERCP) persists.
  • High Prevalence of Ibuprofen Drug-Induced Liver Injury in Spanish and Latin-American Registries

    Nonsteroidal anti-inflammatory drugs (NSAIDs) are responsible for 3% to 10% of idiosyncratic drug-induced liver injury (DILI) cases in the Western world.13 Ibuprofen is a widely prescribed NSAID available as over-the-counter medication (OTC), and perceived as having a better safety profile than many other NSAIDs. Interestingly, striking regional differences in the frequency of ibuprofen hepatotoxicity were noted in a comparison of causative DILI agents among large DILI cohorts in 2010.4 Based on the limited information available on this type of DILI, we aimed to analyze the clinical presentation of ibuprofen-associated hepatotoxicity in the search for a potential drug signature.
  • Plasmablastic Lymphoma in a Patient With Crohn's Disease After Extensive Immunosuppressive Therapy

    A 29-year-old woman with Crohn's fistulizing ileocolitis presented for colonoscopy. During the previous 10 years, she had persistent loose stools and abdominal pain with mesalamine/prednisone, infliximab, adalimumab, certolizumab pegol, natalizumab, and then methotrexate. Each treatment was trialed sequentially for approximately 1 year before determining non-response. After 3 years of standard-dose ustekinumab therapy, the patient had fewer loose stools and less pain/bloating, but routine magnetic resonance imaging scan revealed active Crohns disease from the splenic flexure to the anus with possible stricture.
  • Evaluation of Metals Exposure in Adults ona Gluten-Free Diet

    In a well-designed study, Raehsler etal1 add important new data to the evidence regarding the association between nonessential major toxic metals and gluten-free foods.
  • Reply

    We read the letter from Liu etal regarding our recent publication and appreciate their interests and insightful comments.1,2 As the authors mentioned, policies on the coverage of direct-acting antiviral agents (DAA) from Medicare/Medicaid and private or commercial insurance companies have changed rapidly over the past few years. This is a highly relevant point in the interpretation of the study finding because effectiveness of DAA treatment at the population level is a product of efficacy of treatment in eradicating hepatitis C virus (HCV) and its availability to the general population.
  • Features of Autoimmune Pancreatitis Associated With Inflammatory Bowel Diseases

    Few people know of autoimmune pancreatitis (AIP), a rare disorder associated with inflammatory bowel diseases (IBD). We aimed to describe phenotype and outcomes of IBD and AIP when associated.
  • Safety and Efficacy of 6-thioguanine as a Second-line Treatment for Autoimmune Hepatitis

    Corticosteroids and azathioprine provide complete response with good tolerance in most patients for the treatment of autoimmune hepatitis (AIH).1,2 Although some patients require second-line treatments, scarce data and side effects hamper consensus on them. Inflammatory bowel diseases yielded increasing consideration for azathioprine metabolism and the use of 6-mercaptopurine (6-MP) or 6-thioguanine (6-TG), which both exhibit a more direct metabolism to the active metabolite of azathioprine: 6-TG nucleotides.
  • Reply

    I thank Liu and colleagues for interest in our systematic review of cost-effectiveness of direct-acting antivirals (DAAs).1 They emphasized on the perspective of cost-effectiveness analysis and timely treatment of patients with hepatitis C.
  • ERCP (Ensuring Really Competent Practitioners): Action Please

    In this issue of Clinical Gastroenterology and Hepatology, Keswani etal review the published data on the correlation between the outcomes of endoscopic retrograde cholangiopancreatography (ERCP) and the case volumes of the endoscopists (ERCPists) and centers. They confirmed that more is better, concluding that they propose that providers and payers consider consolidating ERCP to high-volume endoscopists to improve ERCP outcomes and value. Unfortunately, they provide no guidance on what that volume should be, or how consolidation might occur.
  • The Distensibility Index as a Biomarker forLower Esophageal Sphincter Opening Pressure

    I read with interest the letter by Dr Gregersen.1 His role, and that of coworker Barry McMahon, will always be recognized in the history of the development of this new and useful technology. As the letter addresses aspects of the commercial translation and implementation of the technology, and in particular the role of distensibility as a biomarker, I would be grateful to be afforded the opportunity to respond on a number of points. Compliance as a biomarker is a well-understood and clinically useful biomechanical marker in a number of areas of medicine, most particularly in lung mechanics.
  • Migrated Replacement Percutaneous Endoscopic Gastrostomy Tube Leading To Jejunoduodenal Intussusception

    A 73-year-old woman with a medical history of severe cognitive impairment, stroke, and progressive dysphagia requiring a percutaneous endoscopic gastrostomy (PEG) tube placement 3 years earlier presented with sepsis and acute colonic pseudo-obstruction. By hospital day 10 after making significant clinical improvement in the days prior, she began to have repeated episodes of non-bloody, bilious emesis. Her tube feedings were discontinued. Serial plain films of the abdomen showed improving colonic distention.
  • Portal Vein Thrombosis After Percutaneous Liver Biopsy

    Liver biopsy is often performed for evaluation of chronically elevated liver tests to aid in diagnosis and fibrosis staging; however, it is not without risk.1 Commonly reported complications of liver biopsy include pain, occurring in up to 83% of patients,2 bleeding in 18%20% of patients, encompassing hemoperitoneum, intrahepatic hematoma, hemobilia, and hemothorax,1 and iatrogenic puncture of another organ such as lung, kidney, colon, or gallbladder. Multiple rare complications from liver biopsy have been reported.
  • Hereditary Angioedema: An Overlooked Cause of Recurrent Abdominal Pain and Free Peritoneal Fluid

    A 30-year-old woman with episodes of severe abdominal pain, vomiting, diarrhea, and light-headedness was seen in our gastroenterology clinic. Attacks, which each lasted up to several days, had been occurring every 23 months for years. She also reported several episodes of minimal swelling of her arms, legs, and face, which were attributed to allergic reactions (Figure A). She was known to have recurrent free fluid in the pouch of Douglas of unclear etiology, which was previously investigated with imaging, endoscopy, and a diagnostic laparoscopy.
  • An Unusual Porta Mass: Endoscopic Ultrasonography Fine-needle Aspiration Solves the Mystery

    A 60-year-old woman presented with recurrent episodes of dull aching right upper quadrant pain of 3 months duration. Investigations revealed anemia, raised erythrocyte sedimentation rate, and azotemia (serum creatinine, 2.5 mg%). Computed tomography scan without parenteral contrast enhancement showed a 5 5 cm hypodense mass lesion at porta hepatis (Figure A). Endoscopic ultrasonography (EUS) examination revealed a well-defined rounded 6 6 cm hypoechoic periportal mass without any vascular invasion (Figure B; CBD, common bile duct; PV, portal vein).
  • Healthcare Costs Related to Treatment of Hepatocellular Carcinoma Among Veterans With Cirrhosis in the United States

    It is important to quantify medical costs associated with hepatocellular carcinoma (HCC), the incidence of which is rapidly increasing in the United States, for development of rational healthcare policies related to liver cancer surveillance and treatment of chronic liver disease. We aimed to comprehensively quantify healthcare costs for HCC among patients with cirrhosis in an integrated health system and develop a model for predicting costs that is based on clinically relevant variables.
  • Patients With Ulcerative Colitis and Primary Sclerosing Cholangitis Frequently Have Subclinical Inflammation in the Proximal Colon

    Patients with primary sclerosing cholangitis (PSC) and ulcerative colitis (UC) have a high risk of colonic neoplasia. Histologic inflammation is an independent risk factor for the development of neoplasia; we investigated whether patients with UC and PSC have more subclinical disease activity than patients with UC alone.
  • Toward More Efficient Dietary Elimination Therapy for Eosinophilic Esophagitis: The Fantastic 4?

    First-line treatment for eosinophilic esophagitis (EoE) after proton pump inhibitor nonresponse consists primarily of pharmacologic or dietary therapy.1,2 Dietary therapy is centered on eliminating food triggers that drive the pathogenesis of EoE,3 and currently consists of 3 main modalities: elemental diet, allergy testingdirected food elimination, and empiric 6-food elimination diet (SFED). Although elemental diet is the most effective of the 3 methods in achieving histologic remission,4 it has limitations that make adherence difficult, such as the need to avoid regular foods, high cost, and, in some cases, unpalatable taste.
  • Rectal Diverticula in an Infant

    A dysmorphic 6-week-old girl presented with abdominal distension, microcephaly, and failure to thrive. Her features included single palmar creases, hypertelorism, triangular facies, low-set ears, and a flat nasal bridge without an obvious unifying diagnosis. She had significant abdominal distension with prominent veins but no organomegaly. She passed meconium within 24 hours and had a normal rectal suction biopsy, however, she required enemas to aid in defecation. Barium follow-through showed gastrooesophageal reflux but normal transit.
  • Efficacy of Over-the-Scope Clips in Management of High-Risk Gastrointestinal Bleeding

    Standard endoscopic therapies do not control bleeding or produce complications in as many as 20% of patients with nonvariceal gastrointestinal bleeding. Most bleeding comes from ulcers with characteristics such as high-risk vascular territories and/or large vessels. We evaluated the efficacy of using over-the-scope clips (OTSCs) as primary or rescue therapy for patients with bleeding from lesions that have a high risk for adverse outcomes.
  • An Unusual Diagnosis for a Bile Duct Mass: Eosinophilic Cholangitis Diagnosed by Digital Cholangioscopy

    A 20-year-old man presented to our medical center with right upper quadrant pain, fatigue, and weight loss. On examination he had right upper quadrant tenderness. His laboratory values were significant for abnormal liver function tests in a hepatocellular pattern (aspartate aminotransferase, 181 U/L; alanine aminotransferase, 374 U/L; total bilirubin, 2.3 mg/dL; alkaline phosphatase, 234 U/L) and peripheral eosinophilia to 18% (normal, 0%6%). The patient underwent magnetic resonance cholangiopancreatography, which showed a bile duct mass below the hilum causing a stricture concerning for cholangiocarcinoma (Video).
  • Cholangiohepatitis With Extensive Intrahepatic Choledocholithiasis

    A 51-year-old Salvadoran woman who had previously undergone Roux-en-Y choledochojejunostomy was referred to our institution for balloon enteroscope-assisted endoscopic retrograde cholangiography for endoscopic management of choledocholithiasis. On presentation, she reported epigastric pain radiating to the right upper quadrant of the abdomen and back, was febrile and tachycardic, with laboratory tests significant for a leukocyte count of 12.3 109/L and alkaline phosphatase of 178 units/L (upper limit of normal 108).
  • Addressing Physician Burnout Among Practicing Physicians

    We read with great interest Lacy and Chans Physician Burnout: The Hidden Health Care Crisis,1 given the urgency that this epidemic demands. Physician burnout has the power to pervade not only the life of the physician in crisis, but may also have deleterious effects on his or her patients, and the healthcare system at large.
  • Sessile Serrated Adenoma of the Appendix in an Asymptomatic Patient

    A 63-year-old Hispanic man with a history of hypertension and nephrolithiasis underwent a colonoscopy for average-risk colorectal cancer screening. Upon intubation of the cecum, a large and firm submucosal lesion was found arising at the appendiceal orifice. The lesion had a central impression with yellowish mucus similar in appearance to the volcano sign described in mucocele of the appendix (Figure A). Histology of the endoscopic biopsy of the overlying mucosa showed a sessile serrated adenomatous tissue.
  • Immunoprophylaxis Failure of Infants Born to Hepatitis B Carrier Mothers Following Routine Vaccination

    Hepatitis B virus (HBV) infection remains the most common form of chronic hepatitis worldwide. The risk of vertical transmission leading to chronic infection is dramatically reduced by administering hepatitis B immunoglobulin to newborns at birth together with a complete course of HBV vaccination.1 A high maternal HBV DNA level during pregnancy is the strongest risk factor leading to immunoprophylaxis failure (IF).2 Because of the retrospective nature,3 heterogeneity of the studied population,4 and different or unknown timing of HBV DNA quantification,35 the optimal HBV DNA level to identify pregnancies associated with subsequent IF remains unclear.
  • Significant Hepatic Fibrosis Among Treatment-Naive Chronic Hepatitis B Virus With Increased Hepatitis B Virus DNA and Normal Alanine Aminotransferase

    Current treatment guidelines for chronic hepatitis B (CHB) base treatment recommendations on a combination of serum alanine aminotransferase (ALT), hepatitis B virus (HBV) DNA, and hepatic necroinflammation/fibrosis.13 Although accurate assessment of liver histologic abnormalities is crucial for determining disease severity, liver biopsy rarely is performed and the findings may not always be accurate. Although elastography and serologic markers can be used to assess fibrosis, in clinical practice treatment decisions often are based on ALT and HBV DNA alone.
  • Cost-effectiveness of High-performance Biomarker TestsvsFecal Immunochemical Test for Noninvasive ColorectalCancer Screening

    Biomarker assays could increase the accuracy of noninvasive detection of colorectal cancer (CRC); fecal immunochemical tests (FITs) are estimated to miss 27%47% of CRCs and 70%80% of advanced adenomas per round of screening. We investigated the conditions under which biomarker screens would be cost-effective compared with FIT screens of average-risk individuals.
  • Analysis of Fine-Needle Biopsy Versus Fine-Needle Aspiration in Diagnosis of Pancreatic and Abdominal Masses: A Prospective, Multicenter, Randomized Controlled Trial

    Endoscopic ultrasound (EUS)-guided fine needles with side fenestrations are used to collected aspirates for cytology analysis and biopsy samples for histologic analysis. We conducted a large, multicenter study to compare the accuracy of diagnosis via specimens collected with fine-needle biopsy (FNB) versus fine-needle aspiration (FNA) for patients with pancreatic and nonpancreatic masses.
  • An Ill-Defined Upper Abdominal Mass

    A 53-year old man presented with a 2-month history of constant epigastric discomfort with no relation to diet. He did not have nausea or vomiting and mentioned no weight loss. He was a teacher and did not recently travel or have any high-risk close contacts. On physical examination, a firm ill-defined fullness was found in his epigastric area measuring approximately 10 10 cm.
  • Place of Death and Hospice Utilization Among Patients Who Die From Cirrhosis in the United States

    Cirrhosis is the 12th leading cause of death in the United States.1 Complications of cirrhosis, such as ascites, variceal hemorrhage, hepatic encephalopathy, and renal impairment have a negative impact on patients health-related quality of life, and account for most deaths in patients with cirrhosis.2
  • Recurrent Jejunal Intussusception Caused by Heterotopic Pancreas Mass

    A 39-year-old pilot presented at a local hospital with a 1-year history of recurrent left midabdominal discomfort. Contrast-enhanced computed tomography (Figure A) showed 2 areas of jejunal intussusception without upstream bowel obstruction (arrows), but subsequent diagnostic laparoscopy was unrevealing. Given the patient's ongoing recurrent pain, he was referred to our institution for further evaluation. On examination, the patient appeared healthy but had tenderness to palpation in the left midabdomen; no mass was appreciated.
  • AGA Institute Series: Focus on Enhancing High-Value Care Cost effective therapy for Sphincter of Oddi dysfunction

  • Methotrexate Therapy for Autoimmune Hepatitis

    Autoimmune hepatitis (AIH) is a chronic immune-mediated inflammatory condition characterized by hepatocellular inflammation, hypergammaglobulinemia, serum autoantibodies, and an association with HLA DR3 and DR4.1,2 Immunosuppression and modulation in the form of corticosteroids and azathioprine are accepted first-line therapies, leading to biochemical remission in almost 80% of patients within 3 years.2 Untreated severe disease inevitably progresses to cirrhosis, with treatment conferring a benefit to survival, histology, and symptoms.
  • Amyloidosis: An Unusual Cause of Intestinal Pseudo-Obstruction

    A 63-year-old woman presented with intermittent abdominal pain and vomiting over 1 month. The pain was located in the periumbilical area, and the vomiting was associated with postprandial occurrence. The symptoms resolved spontaneously, and her medical history was insignificant. Physical examination indicated a soft abdomen, and no masses were palpable. An occult blood test of the stool was positive. Complete blood count, rheumatologic testing, tumor biomarkers, and erythrocyte sedimentation rate all were within the normal range.
  • Effects of the 2009 Medical Cannabinoid Legalization PolicyonHospital Use for Cannabinoid Dependency and Persistent Vomiting

    In 2009, the U.S. Department of Justice issued a memo stating that it would not prosecute users and sellers who complied with the state laws allowing for medical use of marijuana. There are growing concerns about legalization of marijuana use and its related public health effects. We performed an interrupted time series analysis to evaluate these effects.
  • Correction of Abdominal Distention by Biofeedback-Guided Control of Abdominothoracic Muscular Activity in a Randomized, Placebo-Controlled Trial

    Abdominal distention is produced by abnormal somatic postural tone. We developed an original biofeedback technique based on electromyography-guided control of abdominothoracic muscular activity. We performed a randomized, placebo-controlled study to demonstrate the superiority of biofeedback to placebo for the treatment of abdominal distention.
  • Risk of Ectopic Pregnancy in Women With Inflammatory BowelDisease: A 22-Year Nationwide Cohort Study

    Few data are available on adverse events of pregnancy in women with inflammatory bowel diseases (IBD), such as ectopic pregnancy. We assessed the risk of ectopic pregnancy in pregnancies of women in Denmark with IBD compared with those without IBD over a 22-year period. We also examined the disease-specific risks of ectopic pregnancies in pregnancies of women with ulcerative colitis (UC) or Crohns disease (CD) who underwent IBD-related surgical procedures.
  • Bowel Damage in Patients With Long-term Crohns Disease, Assessed by Magnetic Resonance Enterography and the Lmann Index

    Magnetic resonance enterography (MRE) is used to evaluate the extent and complications ofCrohns disease (CD). MRE results are used in calculation of the Lmann index (LI) score,which quantifies bowel damage. The long-term outcomes of CD are uncertain; we aimed to assess bowel disease and damage in patients with CD for 20 years using MRE and the LI.
  • Inflammatory Bowel Disease and Small Bowel Cancer Risk,Clinical Characteristics, and Histopathology: APopulation-Based Study

    Inflammatory bowel disease (IBD) may increase risk of small bowel cancer (SBC). However, little is known of the characteristics and features of IBD-SBC, due to a low number of cases worldwide. We performed a population-based study of IBD and SBC to calculate risk and increase our understanding of clinical characteristics and histopathological and molecular features.
  • Diagnosing Liver Fibrosis and Cirrhosis: Serum, Imaging orTissue?

    This article is part of a series on Enhancing the Value of Care in Gastroenterology and Hepatology. Each article in this series examines specific clinical scenarios in which the value of care can be improved over a range of sub-specialties in the field.David A. Katzka, MD Special Section Editor
  • High Value Care: Hepatocellular Carcinoma Surveillance

    This article is part of a series on Enhancing the Value of Care in Gastroenterology and Hepatology. Each article in this series examines specific clinical scenarios in which the value of care can be improved over a range of sub-specialties in the field.David A. Katzka, MD, Special Section Editor
  • When Does Assessment for Bile Duct Stones Need to Be Performed Prior to Cholecystectomy for Calculus Gallbladder Disease?

    This article is part of a series on Enhancing the Value of Care in Gastroenterology and Hepatology. Each article in this series examines specific clinical scenarios in which the value of care can be improved over a range of sub-specialties in the field.David A. Katzka, MD Special Section Editor
  • Physician Burnout: The Hidden Health Care Crisis

    Physician burnout is an under-recognized and under-reported problem. Characterized by a state of mental exhaustion, depersonalization, and a decreased sense of personal accomplishment, burnout may affect more than 60% of family practice providers and at least one third of gastroenterologists. Some studies have shown that younger physicians, physicians performing high-risk procedures, and physicians experiencing work-life conflicts are at greatest risk. If unrecognized, the costs to the physician and to the health care system can be enormous because physician burnout is associated with increased rates of depression, alcohol and drug abuse, divorce, suicide, medical errors, difficult relationships with coworkers, and patient dissatisfaction, as well as physician attrition.
  • Reply

    We thank Guo and Li1 for their interest in our systematic review and meta-analysis examining the risk of gastrointestinal (GI) bleeding associated with nonvitamin K antagonist oral anticoagulants (NOACs) compared with conventional anticoagulation.2 We are in agreement that network meta-analysis is a potentially useful tool to estimate the comparative effects of multiple interventions indirectly in the absence of head-to-head randomized controlled trial data.3 In light of results from our subgroup analyses that suggested variability across NOACs, we believe a properly conducted network meta-analysis may contribute valuable data by indirectly comparing NOACs with each other.
  • A Diet Low in Fermentable Oligo-, Di-, and Monosaccharides andPolyols Improves Quality of Life and Reduces ActivityImpairment in Patients With Irritable Bowel Syndromeand Diarrhea

    We investigated the effects of a diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) vs traditional dietary recommendations on health-related quality of life (QOL), anxiety and depression, work productivity, and sleep quality in patients with irritable bowel syndrome and diarrhea (IBS-D).
  • Community Practice Implementation of a Self-administered Version of PREMM1,2,6 to Assess Risk for Lynch Syndrome

    Lynch syndrome is a genetic disorder that greatly increases risk for colorectal and other cancers, although it is underdiagnosed. Prediction of MLH1, MSH2, and MSH6 (PREMM1,2,6) is a web-based tool that analyzes individuals personal/family histories of cancer to quantify their likelihood of carrying a germline mutation associated with Lynch syndrome. We investigated the feasibility of systematic risk assessment for Lynch syndrome in a community gastroenterology practice using a patient-completed version of PREMM1,2,6.
  • Sarcina ventriculi in a Patient With Slipped Gastric Band and Gastric Distention

    A 43-year-old woman with an open nonadjustable gastric band insertion in 1997 presented to the emergency room for sudden onset of severe abdominal pain, dry heaving, and tachycardia. Imaging revealed massive stomach distention spanning from the xiphoid process to umbilicus with pneumatosis of the gastric wall concerning for gastric ischemia and slipped band (Figure1A). The patient was taken to the operating room where 75% of the stomach was necrotic. A subtotal gastrectomy with Roux-en-Y gastrojejunostomy was performed.
  • Bleeding With Direct Oral Anticoagulants: The Gastrointestinal Tract and Beyond

    Direct oral anticoagulants (DOACs) have enjoyed a rapid adoption in the United States since the initial approval of dabigatran in 2010. By 2014, use of DOACs was similar to the use of warfarin among US patients with atrial fibrillation.1 Four DOACs are approved in the United States: the thrombin inhibitor dabigatran and the Factor Xa inhibitors rivaroxaban, apixaban, and edoxaban. All 4 are approved for reduction of stroke/systemic embolism in nonvalvular atrial fibrillation (edoxaban only if creatinine clearance is 95 mL/min) and treatment of deep venous thrombosis and pulmonary embolism.
  • Treatment With Biologic Agents Has Not Reduced SurgeriesAmong Patients With Crohns Disease With ShortBowel Syndrome

    Little is known about the effects of biologic agents used to treat Crohns disease (CD) on its long-term complications, such as short bowel syndrome and intestinal failure (SBS-IF). We evaluated trends in small bowel resections and health care utilization among patients with CD with and without SBS-IF.
  • Bile Acid Deficiency in a Subgroup of Patients With Irritable Bowel Syndrome With Constipation Based on Biomarkers in Serum and Fecal Samples

    Short-term administration of delayed-release chenodeoxycholic acid to patients with irritable bowel syndrome with constipation (IBS-C) accelerates colonic transit and reduces symptoms. A preliminary study has shown that patients with IBS-C have reduced levels of bile acids (BAs) in feces and reduced synthesis of BA. We compared the levels of primary and secondary BAs in fecal samples collected over a 48-hour period from patients with IBS-C on a diet that contained 100 g fat per day, and compared them with levels in samples from healthy volunteers (controls).
  • 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 health care 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. To better understand the pathophysiologic pathways of the diseases associated with barrier dysfunction, including gastroesophageal reflux disease, eosinophilic esophagitis, Barretts esophagus, and obesity, it is important to understand the esophageal epithelial embryologic development, microscopic anatomy with a special focus on the barrier structure and function, extraepithelial defense mechanisms, and how these change in the diseased state.
  • Treatment of Aseptic Liver Abscess Due to Crohn's Disease Using Infliximab

    A 24-year-old girl with Crohns disease (CD) was admitted to our department for abdominal pain, weakness, poor appetite, and intermittent fever for 2 weeks. There were no other complaints. The patient was diagnosed with CD 1 year earlier, manifested by abdominal pain and intermittent bloody diarrhea and demonstrated by colonoscopy with multiple biopsies. Her past medical history was significant only for CD. There was no history of extraintestinal manifestations. Her CD had been poorly controlled more than 6 months with only mesalazin for treatment; disease flares were infrequent and mild, characterized by episodes of abdominal pain, bloody diarrhea, with no fever.
  • Predictors of Efficacy of Percutaneous Tibial Nerve Stimulationfor Fecal Incontinence: A Post Hoc Analysis ofaRandomized Trial

    A recent UK multicenter, phase III trial (the CONtrol of Fecal Incontinence using Distal NeuromodulaTion Trial), demonstrated no significant clinical benefit of percutaneous tibial nerve stimulation (PTNS) over sham stimulation; however, this study did not analyze 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.
  • Obesity and Risk of Nonalcoholic Fatty Liver Disease: A Comparison of Bioelectrical Impedance Analysis and Conventionally-Derived Anthropometric Measures

    Increased body fat, particularly abdominal visceral fat, is central in the pathogenesis of nonalcoholic fatty liver disease (NAFLD).1,2 Identifying a clinically feasible fat assessment method thus is important. Body mass index (BMI) and waist circumference (WC) convey insufficient information on body composition, fat distribution, and visceral fat.3,4 BMI limitations are most evident in cases of lean but metabolically unhealthy individuals who, despite a normal BMI, have increased central adiposity and a predisposition to cardiometabolic complications including NAFLD.
  • 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 HistopathologyExamination

    A 52-year-old man presented with a 1-month history of tenesmus and increased defecation frequency as well as occasional and minor bloody stool. He had a history of hypertension and showed no signs of gastrointestinal disease. A digital rectal examination revealed a relatively tough immobile mass with a smooth mucosal surface at 13 oclock (lithotomy position) and approximately 4 cm from the anal verge. Laboratory tests were unremarkable. An initial retroflexion colonoscopy view showed limited information regarding a lobulated uplift (1.2 0.7 cm) in the terminal rectum without exudate, ulcers, or other abnormities (Figure A).
  • 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 vs West

    Surgical resection is the standard option and treatment of choice for localized hepatocellular carcinoma (HCC).1,2 Difference in candidate selection and surgical practice of liver resection for HCC has been widely acknowledged between Eastern and Western centers.3,4 However, direct comparisons between the 2 regions are still lacking, especially those that identify the differences in their surgical safety and long-term efficacy. This study aimed to compare the patterns and outcomes of liver resection for HCC between 2 large centers in the East and the West.
  • Cost Effectiveness of Pre vs PostLiver 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 postliver transplant (LT) patients. However, whether to treat HCV patients before vs after LT is not clear because 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 vs post-LT HCV treatment with oral DAAs in decompensated cirrhotic patients on the LT waiting list.
  • Risk of Pneumonia Caused by Pneumocystis jiroveci in Inflammatory Bowel Disease: The Role of Concomitant Pulmonary Comorbidities

    We read with interest the recent work by Cotter etal1 reporting the results of their population-based cohort study on the risk of Pneumocystis jiroveci pneumonia (PJP) in patients with inflammatory bowel disease (IBD) treated with corticosteroids, immune-suppressive medications, and biologics. We believe that this was a relevant study because opportunistic infections still remain the main concern in the use of immunomodulatory therapy in IBD,2,3 and PJP may be very difficult to treat, and even fatal, especially when a calcineurin inhibitor is used.
  • Natural History of Adult Ulcerative Colitis in Population-based Cohorts: A Systematic Review

    A comprehensive knowledge of the natural history of ulcerative colitis (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 Study

    On the basis of 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) by using a large national sample of training programs and to develop a centralized database that allows assessment of performance in relation to peers.
  • Colon Pathology Characteristics in LiFraumeni Syndrome

    LiFraumeni syndrome (LFS) is a rare autosomal-dominant hereditary cancer syndrome associated with germline mutations in the TP53 tumor-suppressor gene. The lifetime risk of cancer is up to 70% in men and almost 100% in women.1 Studies continue to show that the tumor spectrum of TP53 mutation carriers is wider than previously thought and includes early onset colorectal cancer (CRC).24
  • 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 often requires multiple procedures before achieving stricture resolution. To date, studies using covered self-expandable metallic stent (cSEMS) in ABS management reported varying degrees of efficacy. The aim of this study was to analyze long-term efficacy of cSEMS in patients with ABS and identify factor(s) influencing the probability of stricture resolution.
  • Diffuse Enlargement of the Pancreas: An Unusual Radiologic Presentation of a Pancreatic Neuroendocrine Tumor

    A 38-year-old previously healthy man presented with a 2-year history of intermittent melena and hematemesis. No abnormalities were found on physical examination. Blood tests revealed anemia (hemoglobin, 10 g/dL) but were otherwise unremarkable. Esophageal varices were identified at upper endoscopy, which were treated by sclerotherapy and band ligation. Abdominal computed tomography scan demonstrated dilated and tortuous veins in the periportal and perisplenic systems. The pancreas was markedly enlarged with a nodular appearance, multiple calcifications, and low enhancement during the arterial phase suggestive of diffuse type autoimmune pancreatitis or an infiltrative process (Figures A and B).
  • Comparison of Endoscopic UltrasoundFine-needle Aspiration and Endoscopic UltrasoundFine-needle Biopsy for Solid Lesions in aMulticenter, Randomized Trial

    Endoscopic ultrasound with fine-needle aspiration (FNA) is the standard of care for tissue sampling of solid lesions adjacent to the gastrointestinal 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 Behavior Change in Patients With Nonalcoholic Fatty Liver Disease: A Qualitative Study of Clinical Practice

    Nonalcoholic fatty liver disease (NAFLD) is the most common liver condition worldwide and is linked largely to obesity and inactivity. Lifestyle modification is the primary treatment for NAFLD targeting dietary change, physical activity, and exercise to facilitate weight loss and weight loss maintenance.13 This has been shown to reduce steatosis and ameliorate steatohepatitis. European Clinical Practice Guidelines for the management of NAFLD3 highlight the importance of targeting lifestyle behavior change in all patients with NAFLD regardless of disease severity.
  • Societal Perspectives and Patient/Public Involvement in Direct-Acting Antiviral Agent Coverage of Hepatitis C Treatment inthe United States

    We read with interest the study by Chhatwal etal1 examining the cost effectiveness of direct-acting antiviral agents (DAAs) for treating hepatitis C virus (HCV) genotype 1. The main findings were that DAAs would be cost effective at $120,100 for first-generation DAAs and at $227,200 for second-generation DAAs, and that at the current price of $60,000, most studies found the second-generation DAAs to be cost-saving.
  • Occurrence of IgG4 in Esophageal Lichen Planus

    Lichen planus frequently involves the esophagus, does not respond well to medications, and commonly leads to stricture formation.1,2 Recently, IgG4 was shown to be present in the epithelium in eosinophilic esophagitis3 and to be associated with esophageal stricture formation in IgG4 disease.4 The aim of this study was to determine if tissue IgG4 is present in esophageal lichen planus as a marker of esophageal fibrosis.
  • 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 (IBDs). 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; Bhlmann Laboratories AG,Schnenbuch, Switzerland) that turns a smartphone camera into a results reader. Wecompared results from this method with those from the hospital-based reader (Quantum Blue; Bhlmann Laboratories AG) and enzyme-linked immunosorbent assay (ELISA) analysis.
  • Effects of Community Screening for Helicobacter pylori: 13-Year Follow-Up Evaluation of a Randomized Controlled Trial

    Helicobacter pylori eradication improves the prognosis of peptic ulcer disease (PUD), dyspepsia, and possibly gastric cancer. H pylori screening tests are accurate and eradication therapy is effective. H pylori population screening seems attractive. The aim of this study was to evaluate the long-term effect of H pylori 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 Endoscopic Retrograde Cholangiopancreatography Volume With Procedure Success and Adverse Outcomes: A Systematic Review and Meta-analysis

    Endoscopic retrograde cholangiopancreatography (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 ERCP success and adverse event (AE) rates.
  • 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 mucosal inflammation and whether diverticula are associated with chronic gastrointestinal symptoms. We explored whether inflammation was present among symptomatic participants with and without diverticula.
  • An Uncommon Gastric Submucosal Tumor With Mucosal Erosion

    A 54-year-old man with no prior medical history was referred to our hospital for a gastric lesion. An upper endoscopy showed a subepithelial tumor with a central erosion measuring 35 mm in size, located on the posterior wall of the gastric body (Figure A). Biopsy specimens from the depressed and elevated areas showed no neoplastic changes. Endoscopic ultrasonography showed a multicystic heterogeneous component (Figure B). Contrast-enhanced computed tomography showed that some of the cystic components showed contrast (Figure C).
  • 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 eosinophilic colitis (EoC) in the United State.
  • 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 for choledocholithiasis. Unlike endoscopic sphincterotomy, 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 postendoscopic 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 (IBDs) (Crohns disease [CD], ulcerative colitis) are global diseases. Similarities and differences in disease presentation and outcomes across different geographic regions and ethnic groups have not been compared previously.
  • 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.
  • Diagnosis of Primary Splenic Flexure Schwannoma Before Surgery Based on Endoscopic-UltrasoundGuided Fine-Needle Biopsy

    A 60-year-old white woman with a history of hypertension, hyperlipidemia, and hypothyroidism presented with intermittent hematochezia for 1 month, with a stable hemoglobin level. Colonoscopy showed a 4-cm noncircumferential submucosal mass at the splenic flexure (Figure A), which on tunnel biopsy showed only colonic mucosa with prominent lymphoid aggregate. A contrast-enhanced computerized tomography of the pelvis showed a 3.5 2.4 2.5 cm ovoid, homogenously enhancing, exophytic mass in the posterior wall of the splenic flexure.
  • Increased Risk of Death, in the Hospital and Outside the Intensive Care Unit, for Patients With Cirrhosis After Cardiac Arrest

    Cirrhosis is a growing problem, with a sharp increase in the number of deaths resulting from this, from 676,000 in 1980 to more than 1 million in 2013. In the United States alone there were 53,252 deaths attributable to cirrhosis in 2013 compared with 37,419 in 1980.14 Patients with decompensated cirrhosis routinely are admitted to the hospital and impact in-hospital mortality.5,6 However, there are limited data on the etiology and outcomes of in-patient cardiac arrest in cirrhotic patients. This study aimed to provide novel data on the causes, underlying rhythms, and survival after in-hospital cardiac arrest in patients with cirrhosis compared with patients without cirrhosis at a large tertiary care center.
  • More Benefits From Interrupted Time Series in Evaluating the Recent Market Release of Direct-Acting Antiviral Agents and State Medicaid Reimbursement Programs

    We read with interest the study by Yang etal1 that assessed the epidemiologic trends of pretransplant and post-transplant outcomes for patients with hepatitis C virus (HCV) infection before and after the introduction of direct-acting antiviral agents (DAAs). The investigators identified that the post-DAA era (20112014) was associated with a decreased risk of graft loss or death, with the largest effect seen in HCV-infected recipients. However, according to Chhatwal etal,2 DAAs were cost effective when they cost less than $227,200.
  • 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 because of 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 estimate true GFR more accurately.
  • Duodenal Diverticular Bleeding Managed Using an Over-the-Scope Clip

    A 76-year-old man presented with melena, severe anemia, and hypovolemic shock. His medical history was relevant for obstructive hypertrophic myocardiopathy and atrial fibrillation, for which he was receiving the anticoagulant rivaroxaban. After hemodynamic resuscitation and attempted reversal of coagulopathy, an upper-gastrointestinal endoscopy was performed, showing a large diverticulum in the third portion of the duodenum with a vascular lesion oozing in its center (Figure A). Attempted hemostasis with adrenalin resulted in a small perforation of the thin wall of the diverticulum.
  • Late-Onset Biallelic Mismatch Repair Deficiency Syndrome

    A 33-year-old man with a history of successfully treated low-grade follicular lymphoma 2-years prior was evaluated for recurrent aching upper abdominal pain, early satiety, and fatigue. He denied overt gastrointestinal bleeding, but reported occasional night sweats, chills, and weight loss. His family history was notable for esophageal cancer in his father and gastric cancer in his mother.
  • Gastrointestinal Safety Profiles Differ Among NonVitamin K Antagonist Anticoagulants?

    The article by Miller etal1 published in the April 2017 issue of Clinical Gastroenterology and Hepatology deals with the important topic of nonvitamin K antagonist anticoagulants (NOACs). In this regard, Miller etal1 conducted a pairwise meta-analysis to evaluate the gastrointestinal (GI) bleeding risk of 4 NOACs (rivaroxaban, dabigatran, apixaban, and edoxaban).
  • 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. The authors 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. The authors investigated whether menopause hormone therapy (MHT) affects risk, age at onset, or outcome of HCC.
  • Epiploic Appendagitis: The Uncommon Intestinal Imitator

    A 22-year-old Caucasian man with no significant past medical history presented to the hospital with acute-onset sharp left lower-quadrant abdominal pain. He denied having any other associated symptoms. His physical examination showed moderate left lower-quadrant tenderness. He had a normal white blood cell count and a comprehensive metabolic panel. Imaging studies included a computerized tomography (CT) scan of the abdomen with contrast, which initially was read as circumferential inflammation of the descending colon suggestive of diverticulitis and possible microperforation.
  • 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/AntiHepatitisC Virus Positive Patients: The Need toControlHepatitis 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) was first synthesized in 1908. Aside from leprosy, it has been used for the treatment of many other dermatologic and nondermatologic conditions.
  • Gastroduodenal Burkitt Lymphoma Presenting as Demyelinating Polyneuropathy

    A 34-year-old black man presented to the hospital with a 2-month history of progressive bilateral lower-extremity pain and weakness. A review of systems was positive for a 30-pound weight loss, dysphagia, odynophagia, and headache. Examination was significant for a pulse of 134 beats per minute, and grade two out of five and three out of five muscle strength in the left and right lower extremities, respectively. He was found to be human immunodeficiency virus (HIV) positive (CD4 count, 54 cells/m3).
  • 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.
  • 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 radiologic variables, but has not yet been validated. We performed a retrospective study to validate the Mayo Clinic staging system.
  • 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.
  • 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.
  • 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, carbohydrate antigen 125, and carbohydrate antigen 19-9 levels were within normal limits.
  • 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.
  • 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.
  • 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.
  • Magnitude and Kinetics of Decrease in Liver Stiffness After Antiviral Therapy in Patients With Chronic Hepatitis C: ASystematic 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 Cvirus infection who achieved a sustained virologic response (SVR).
  • 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.
  • Risk of Gastrointestinal Bleeding in Patients Taking NonVitamin K Antagonist Oral Anticoagulants: ASystematicReview and Meta-analysis

    Nonvitamin K antagonist oral anticoagulants (NOACs) are convenient and effective in the prevention and treatment of venous thromboembolism and the prevention of stroke in patients with atrial fibrillation. However, these drugs have been associated with an 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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).
  • 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.
  • 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.
  • 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.
  • 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.
  • 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).
  • 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.
  • 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.
  • 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.
  • 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.
  • 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 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.
  • 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.
  • 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.
  • 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.
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    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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  • Making Social Media Work for Your Practice

    Social media (SoMe) use is ubiquitous and, in the digital age, it is the ascendant form of communication. Individuals and organizations, digital immigrants (those born before the widespread adoption of digital technology), and digital natives alike are leveraging SoMe platforms, such as blogs, Facebook, Twitter, YouTube, and LinkedIn, to curate, consume, and share information across the spectrum of demographics and target audiences. In the United States, 7 in 10 Americans are using SoMe and, although young adults were early adopters, use among older adults is increasing rapidly.