Clinical Gastroenterology and Hepatology

Editor picks for Clinical Gastroenterology and Hepatology

Diffuse Esophageal Glycogenic Acanthosis and Colon Polyposis in a Patient With Cowden Syndrome A 45-year-old man with a history of Cowden Syndrome with confirmed pathogenic phosphatase and tensin homolog mutation was referred because of a history of intestinal polyposis.
Aug. 1, 2017

Ball Valve Syndrome Caused by the Migration of Gastrostomy Catheter Tip A 70-year-old bedridden Japanese man was referred because of fever and vomiting that started the day before.
Aug. 1, 2017

Ileocolonic Histoplasmosis Complicating Crohn’s Disease A 37-year-old woman presented to the clinic with right lower-quadrant abdominal pain, persistent nausea, intermittent fever , night sweats, and weight loss.
Aug. 1, 2017

Green Sputum From a Patient With Primary Sclerosing Cholangitis A 44-year-old woman with primary sclerosing cholangitis presented with a cough of 4 months’ duration.
Aug. 1, 2017

Primary Multifocal Small Bowel Follicular Lymphoma Discovered Incidentally on Diagnostic Endoscopy A 34-year-old man with GERD presented with 3 years of nonprogressive solid food dysphagia.
Aug. 1, 2017

Lymphogranuloma Venereum Proctitis A 43-year-old man presented with bright red blood per rectum, bilateral groin swelling, and lower abdominal pain.
Aug. 1, 2017

Incidence and Determinants of Hepatocellular Carcinoma in Autoimmune Hepatitis: A Systematic Review and Meta-analysis We conducted a systematic review and meta-analysis of the incidence of HCC and associated risk factors among patients with AIH.
Aug. 1, 2017

Comparison of Endoscopic Dilation vs Surgery for Anastomotic Stricture in Patients With Crohn's Disease Following Ileocolonic Resection We aimed to compare long-term outcomes of patients who underwent EBD versus surgery for ICA stricture.
Aug. 1, 2017

Familial Risk and Heritability of Colorectal Cancer in the Nordic Twin Study of Cancer We analyzed data from twins to determine how much the familial risk of colorectal cancer can be attributed to genetic factors vs environment.
Aug. 1, 2017

Implementing the Concept of Continuous Clinical Response Into Clinical Practice for Ulcerative Colitis We review the current evidence to assess the feasibility, value, and impact of integrating continuous clinical response as a patient-reported outcome into routine management of UC.
Aug. 1, 2017

Clinical Gastroenterology & Hepatology RSS

  • Fifteen years since the advent of double-balloon endoscopy

  • 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

  • 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).
  • Issue Highlights

    Patients with recurrent or persistent symptoms of achalasia after Heller myotomy (HM) commonly undergo one of two procedures, namely redo myotomy or pneumatic dilation (PD). Peroral endoscopic myotomy (POEM) is another treatment option for these refractory patients, but data on the effectiveness and safety of this approach are limited. In this context, Ngamruengphong etal undertook this multicenter retrospective cohort study comparing the technical success, safety, and clinical efficacy of POEM for patients with prior HM as compared to those without previous surgery.
  • Exam 2: Statin Use and Risk of Cirrhosis and Related Complications in Patients with Chronic Liver Diseases: A Systematic Review and Meta-analysis

  • Exam 1: Progression of Unresected Intraductal Papillary Mucinous Neoplasms of the Pancreas to Cancer: A Systematic Review and Meta-analysis

  • Serrated Colorectal Neoplasia: From Sideshow to Center Stage

  • 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 post-marketing surveillance.
  • Silymarin in non-alcoholic steatohepatitis a new kid on the block ?

  • A Case of a Giant Fecaloma

  • Widespread endoscopic mucosal resection for treatment of proximal esophageal leukoplakia

  • High Rate of Mortality More than 30 Days After Upper Gastrointestinal Bleeding

  • Irritable Bowel Syndrome

    What is irritable bowel syndrome (IBS)? IBS is a health issue in your intestines (gut). IBS can cause symptoms such as belly pain, cramping, gas, bloating (or swelling) of the belly, and changes in stool. There are different types of IBS, so each person may not have the same symptoms.
  • More sensitivity analysis of Share 35, HIV co-infection, delist, hospital cost on cost-effectiveness of DAAs for LT HCV patients

  • The Gluten-Free Diet Epidemic: Socioeconomic Factors Predict Google Search Trends More Than Health Related Factors

  • Prevalence of Dyspepsia in Individuals with Gastro-Esophageal Reflux-Type Symptoms in the Community: A Systematic Review and Meta-Analysis

    Dyspepsia and gastro-esophageal 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 gastro-esophageal reflux symptoms (GERS), and to quantify overlap between the disorders.
  • EDITORIAL: Can we Accurately Predict Survival in Patients with Perihilar Cholangiocarcinoma?

  • Bringing Assessment of Patient-reported Outcomes to Hepatology Practice

  • Reappraisal of Endoscopic Papillary Balloon Dilation vs Sphincterotomy for Choledocholithiasis Time for a New Trial

  • High Prevalence of Ibuprofen Drug-induced Liver Injury in Spanish and Latin-American Registries

  • Plasmablastic Lymphoma in a Patient with Crohn's Disease After Extensive Immunosuppressive Therapy

  • Evaluation of Metals Exposure in Adults on a Gluten-Free Diet

  • Reply to "More benefits from interrupted time series in evaluating recent market release of DAAs..."

  • 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 AIP in patients with AIP.
  • 6-thioguanine is a safe and effective second-line treatment for autoimmune hepatitis

  • Hepatitis C Treatment is Cost-Saving Irrespective of the Perspective

  • ERCP (Ensuring Really Competent Practitioners). Action please

  • The Distensibility Index as a biomarker for lower esophageal sphincter opening pressure

  • Migrated replacement PEG-tube leading to jejunoduodenal intussusception

  • Portal Vein Thrombosis After Percutaneous Liver Biopsy

  • Hereditary angioedema: an overlooked cause of recurrent abdominal pain and free peritoneal fluid

  • An Unusual Porta Mass: EUS FNA solves the mystery

  • Celiac Disease

    Celiac disease is a health condition of the small intestine in which you cannot eat gluten. When a person with celiac disease eats gluten, the immune system, which is supposed to help protect the body against disease, reacts by harming the cells of the lining of the small intestine and also may harm other parts of the body, such as the skin, bones, or brain (nervous system). Both dietary and genetic factors cause the disease.
  • 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 incidence 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 based on clinically relevant variables.
  • 'Patients with Ulcerative Colitis and Primary Sclerosing Cholangitis Frequently Have Subclinical Inflammation in the Proximal Colon'

    Primary sclerosing cholangitis (PSC) patients with ulcerative colitis (UC) have a high risk of colonic neoplasia. As histologic inflammation is an independent risk factor for the development of neoplasia, we hypothesized that 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

  • 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

  • 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).
  • Exam 1: Diagnostic Accuracy of Noninvasive Fibrosis Scores in a Population of Individuals With a Low Prevalence of Fibrosis

  • 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 Nave Chronic HBV with Elevated HBV DNA and Normal Alanine Aminotransferase

  • Cost-effectiveness of High-performance Biomarker Tests vs Fecal Immunochemical Test for Non-Invasive Colorectal Cancer Screening

    Biomarker assays could increase the accuracy of non-invasive 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 to FIT screens of average risk individuals.
  • Analysis of FNB vs FNA 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) vs fine-needle aspiration (FNA) for patients with pancreatic and non-pancreatic 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.
  • Issue Highlights

    Many patients feel that diet impacts disease activity in inflammatory bowel disease, but evidence-based data regarding specific dietary recommendations for Crohns disease and ulcerative colitis (UC) are relatively scarce. Moreover, studying this topic can be difficult because disease activity may impact dietary choices. In this issue of Clinical Gastroenterology and Hepatology, Barnes and colleagues analyzed data from a prospective multicenter study of patients with UC who were in remission on 5-ASA therapy on study entry.
  • Place of Death and Hospice Utilization among Patients Who Die from Cirrhosis in the United States

  • 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.
  • Reply

    We received the letter of correspondence regarding our original article entitled Palliative Care and Health Care Utilization for Patients With End-Stage Liver Disease at the End of Life. The authors of the letter described concerns with the methodology used in our article, which we would like to address.
  • 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 Distension by Biofeedback-guided Control of Abdomino-thoracic Muscular Activity in a Randomized, Placebo-Controlled Trial

    Abdominal distension is produced by abnormal somatic postural tone; we developed an original biofeedback technique based on electromyography-guided control of abdomino-thoracic muscular activity. We performed a randomized, placebo-controlled study demonstrate the superiority of biofeedback to placebo for the treatment of abdominal distension.
  • 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 (IBDs), such as ectopic pregnancy. We assessed the risk of an 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 Crohn`s Disease, Assessed by Magnetic Resonance Enterography and the Lemann Index

    Magnetic Resonance Enterography (MRE) is used to evaluate the extent and complications of Crohns disease (CD) and has recently been included in a score for bowel damage, the Lemann Index (LI). The long-term outcomes of CD are still uncertain and we aimed to assess the structural bowel changes after 20 years of CD by means of MRE and LI score.
  • 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 or tissue?

  • High Value Care: Hepatocellular Carcinoma Surveillance

  • AGA Institute Series: Focus on Enhancing High-Value Care When does assessment for bile duct stones need to be performed prior to cholecystectomy for calculus gallbladder disease?

  • 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 Li 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.1 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.2 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

  • 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 Surgeries among Patients with Crohns Disease with Short Bowel 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 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 levels of primary and secondary BAs in fecal samples collected over a 48-hr period from patients with IBS-C on a diet that contained 100 g fat per day, and compared them will 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 healthcare system. A systematic review was conducted to evaluate the existing literature on the disease burden of EoE for patients and their caregivers.
  • The Esophageal Epithelial Barrier in Health and Disease

    Dysfunction in the esophageal epithelial barrier function is a major source for morbidity. 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.
  • Insulin Expressing Pancreatic Neuroendocrine Tumor Associated With Intratumor Amyloidosis

    A 54-year-old woman presented with a 1-week history of abdominal pain and nonbloody watery diarrhea. She has a genetic diagnosis of multiple endocrine neoplasia type 1 (MEN1) that she shares with her father and 2 brothers. She manifested MEN1 syndrome in the form of pituitary macro-adenoma, primary hyperparathyroidism, and gastrinoma in the tail of the pancreas. She underwent distal pancreatectomy. A few years later, she presented with a 1-week history of pain in the epigastrium and nonbloody watery diarrhea.
  • Aseptic Liver Abscess Induced by Crohns Disease Successfully Treated by 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 stimulation for fecal incontinence: a post-hoc analysis of a randomized trial

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

    A previously healthy 86-year-old woman presented with a 3-month history of intermittent anal bleeding. Digital examination was performed and several smooth, protruded, rectal lesions and mixed hemorrhoids were found. The patient presented with good appetite and no weight loss. Colonoscopic examination (Figure A) showed multiple protruded lesions extending from the descending colon to the rectum. The lesions increasingly were evident near the rectum. Abdominopelvic computed tomography (Figure B) showed multiple segmental calcified lesions in the colorectal walls, which were thickened.
  • 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 versus 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.
  • Diagnosis of Autoimmune Pancreatitis: The Evolution of Diagnostic Criteria for a Rare Disease

    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.
  • 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.
  • Association of Transferrin Saturation With the Arthropathy of Hereditary Hemochromatosis

    Hereditary hemochromatosis (HH) is an inherited metabolic disorder that can result in systemic iron overload affecting the pancreas, liver, heart, endocrine glands, skin, and joints.1 This condition affects approximately 1 in 200 people, most commonly those of Northern European descent, and 90% of subjects with HH are homozygous for the missense mutation that results in the substitution of tyrosine for cysteine at amino acid 282 (C282Y).1 This mutation results in reduced synthesis of hepcidin, a key negative regulator of dietary iron absorption, iron release from macrophages, and hepatic iron stores.
  • 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).
  • Comparing Endoscopic UltrasoundFine-needle Aspiration and Endoscopic UltrasoundFine-needle Biopsy for Solid Lesions: AMulticenter, Randomized TrialThe New York Endoscopic Research Outcomes Group (NYERO)

    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-YearFollow-Up Evaluation of a Randomized Controlled Trial(HEP-FYN)

    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 ERCP Volume with Procedure Success and Adverse Outcomes: A Systematic Review and Meta-Analysis

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

    Colorectal cancer (CRC) screening aims to detect CRC and its precursors in an early phase, thereby reducing disease burden.1 This field is evolving rapidly, with an emphasis on population coverage, quality assurance, new screening methods, and individualized screening. There are various screening modalities available, each with their advantages and disadvantages.2 Guaiac fecal occult blood test (gFOBT) and sigmoidoscopy are the only strategies supported by evidence fromprospective randomized controlled trials with CRC-related mortality as the end point.
  • Colonic Diverticula Are Not Associated With Mucosal Inflammation or Chronic Gastrointestinal Symptoms

    Colonic diverticulosis has been reported to be associated with low-grade mucosal inflammation, possibly leading to chronic gastrointestinal symptoms. However, there is poor evidence for this association. We aimed to determine whether colonic diverticula are associated with mucosal inflammation and whether diverticula are associated with chronic gastrointestinal symptoms. We explored whether inflammation was present among symptomatic participants with and without diverticula.
  • Improved Outcomes With Proactive Versus Reactive Therapeutic Drug Monitoring of Infliximab in Inflammatory Bowel Disease

    We thank Headlam etal1 for their comments on our work that showed that proactive therapeutic drug monitoring (TDM) of infliximab was associated with better clinical outcomes than reactive TDM in patients with inflammatory bowel disease. As they pointed out and as we described in the discussion of the article, the proactive and the reactive TDM groups were to some extent inherently different,2 because proactive TDM is applied in patients with clinical benefit, whereas reactive TDM typically is performed in symptomatic patients with a potential loss of response.
  • 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 Versus 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 (IBD; Crohns disease (CD), ulcerative colitis (UC)) are global diseases. Similarities and differences in disease presentation and outcomes across different geographic regions and ethnic groups have not been compared previously.
  • Workplace Accommodation for Persons With IBD: What Is Needed and What Is Accessed

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

    Predniso(lo)ne, alone or in combination with azathioprine, is the standard-of-care (SOC) therapy for autoimmune hepatitis (AIH). However, the SOC therapy is poorly tolerated or does not control disease activity in up to 20% of patients. We assessed the efficacy of mycophenolate mofetil (MMF) and tacrolimus as second-line therapy for patients with AIH.
  • 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.
  • Reply

    We read with interest the comments by Li etal.1 Our reported case developed corticosteroid-resistant, severely active, nivolumab-induced colitis.2 Our initial treatment with intravenous corticosteroids (1000 mg methylprednisolone) for 3 days followed by oral prednisolone (90 mg/d) for 2 weeks was ineffective. We therefore started intravenous administration of infliximab, which resulted in resolution of both the patients symptoms and colonoscopic findings.2 Pags etal3 and Marthey etal4 also reported that infliximab was effective for corticosteroid-resistant immune checkpoint inhibitorinduced severe colitis.
  • 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 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. Attempted hemostasis with adrenalin resulted in a small perforation of the thin wall of the diverticulum.
  • Delayed Presentation of 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).
  • Acute Pancreatitis Has a Long-term Deleterious Effect on Physical Health Related Quality of Life

    It is not clear how acute pancreatitis (AP) affects health related quality of life (HRQOL). We aimed to determine the long-term independent effect of AP on physical and mental HRQOL.
  • 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.
  • The TREAT Registry: Evolution of Knowledge From 1999 to 2017: Lessons Learned

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

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

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

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

    We read with interest the article by Crowell etal1 regarding the prevalence and type of esophageal motor abnormalities in systemic scleroderma patients. In thatstudy, which involved 200 patients and 102 controls, the distinctive features of scleroderma esophagus (hypotensive esophagogastric junction pressure with absent contractility) were detected in only one third of patients. Moreover, the spectrum of esophageal motor abnormalities was heterogeneous, the most frequent finding being an absent contractility, as detected in 56%, followed by normal motility in 26%, and ineffective esophageal motility in 10% of patients.
  • Drug-Induced Autoimmune Hepatitis: Response to Corticosteroids and Lack of Relapse After Cessation of Steroids

    Drug-induced autoimmune hepatitis (DIAIH) is an increasingly recognized phenotype of drug-induced liver injury (DILI).13 There are few data on treatment of patients with DIAIH.3 We aimed to determine the frequency of DIAIH in Iceland, its causative agents, response to corticosteroids, and risk of relapse.
  • Reply

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

    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 two-fifths and three-fifths 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). Magnetic resonance imaging of the lumbar spine showed diffuse enhancement and thickening of multiple nerve roots, suggestive of acute inflammatory demyelinating polyneuropathy, which was confirmed with electromyographic and nerve conduction studies.
  • Gastric Cancer as Preventable Disease

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

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

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

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

    Hepatocellular carcinoma (HCC) is a primary malignancy of the liver and is associated almost universally with chronic liver disease and cirrhosis. Risk factors for HCC generally vary by geographic region. To date, studies have focused on characterizing patients with HCC in Europe, North America, Asia, and, to a lesser extent, Africa.1,2 However, little is known about the underlying demographic characteristics and risk factors for HCC in South America, particularly the association between viral hepatitis and HCC.
  • Caregiver Burden in Adults With Inflammatory Bowel Disease

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

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

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

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

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

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

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

    A 36-year-old woman with a history of thyroid goiter was found incidentally to have a hepatic tumor at a local clinic. She was referred to our hospital for further survey. The physical examination was negative. She denied a history of hepatitis and contraceptive pill use. The serum -fetoprotein, carcinoembryonic antigen, CA 125, and carbohydrate antigen 19-9 levels were within normal limits.
  • Erosion of the Duodenum by an Aortic Graft, Leading to Recurrent Sepsis

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

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

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

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

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

    Nonalcoholic fatty liver disease (NAFLD) is an increasingly common clinical problem found in the primary care setting. The typical scenario includes a patient in whom a mild elevation of transaminases leads to an imaging study reporting a bright liver compatible with fatty liver. This finding opens a Pandoras box of multiple tests and imaging, and sometimes the need for liver biopsy with associated physical, emotional, and financial harms. Ultimately, only a small proportion of these patients will have evidence of advanced fibrosis opening the pathway of care for cirrhosis and subsequent surveillance for liver cancer, and in some instances, the need for esophageal varices screening.
  • Effects of Exercise on Liver Fat and Metabolism in Alcohol Drinkers

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

    Early placement of a transjugular intrahepatic porto-systemic shunts (TIPS) is considered the treatment of choice for patients with acute variceal bleeding (AVB) and cirrhosis who have a high risk of death (Child-Pugh class B with active bleeding at endoscopy or Child-Pugh class C). It has been proposed that patients of Child-Pugh class B, even with active bleeding, should not be considered high risk. Alternative criteria have been proposed for identification of high-risk patients, such as Child-Pugh class C with plasma level of creatinine of 1 mg/dl or more (ChildC-C1) and a model for end-stage liver disease (MELD) score of 19 or more.
  • Histologic Scores for Fat and Fibrosis Associate With Development of Type 2 Diabetes in Patients With Nonalcoholic Fatty Liver Disease

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

    Statins have been variably shown to decrease risk and complications of chronic liver diseases (CLDs). We performed a systematic review and meta-analysis to evaluate the association between statins and risk of cirrhosis and related complications in patients with CLDs.
  • Magnitude and Kinetics of Decrease in Liver Stiffness After 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).
  • Porphyria Cutanea Tarda as the Initial Manifestation of Subclinical Hereditary Hemochromatosis

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

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

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

    Nonvitamin K antagonist oral anticoagulants (novel 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.
  • Do Shared Exposures Link the Lungs and Gut? Association Between Asthma and InflammatoryBowel Disease

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

    I read with interest the article by Schulman etal1 and the accompanying editorial by Tansel etal.2 Simply opening the capsule increased the efficacy of the proton pump inhibitors (PPIs) in healing marginal ulcers in patients with a Roux-en-Y gastric bypass, but these ulcers still took a median of 3 months to heal, and it is possible that therapy could be further optimized.
  • 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.
  • Prevalence of Celiac Disease Autoimmunity Among Adolescents and Young Adults in China

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

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

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

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

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

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

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

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

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

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

    Is the higher reported colorectal cancer (CRC) mortality in blacks versus whites in the United States due to pathology or disparities in screening? Our study used patient navigation (PN) to facilitate blacks and whites adherence to screening colonoscopy and compared adenomas detected in each group.
  • 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).
  • The Long Winding Road to Transplant: How Sarcopenia and Debility Impact Morbidity and Mortality on the Waitlist

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

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

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

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

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

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

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

    In their letter on the systematic review and meta-analysis by Wadhwa etal,1 Goudra and Singh2 call for re-evaluation of the statistical aspects of the analysis. As a statistician who follows meta-analysis, I would like to mention some major shortcomings in the statistical analysis and other aspects of the article.
  • Association Between Ustekinumab Trough Concentrations and Clinical, Biomarker, and Endoscopic Outcomes in Patients With Crohns Disease

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

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

    Guidelines recommend slow titration of sedatives for moderate sedation. Bolus sedation, in which a larger weight-based dose of medication is given upfront, has been shown in a single trial to be beneficial. We evaluated the effects of bolus sedation on procedural safety, efficiency, and patient experience.
  • Pyogenic Granuloma of the Esophagus

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

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

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

    A 67-year-old Caucasian man with a past history of colorectal cancer status-post subtotal colectomy and decompensated cirrhosis secondary to alcohol abuse presented with large-volume hematemesis and hepatic encephalopathy. Physical examination showed tachypnea, tachycardia, and abdominal distention with dullness on percussion. Laboratory data were significant for a hemoglobin level of 6.8 g/dL with a baseline level of 9.5 g/dL 3 months ago, lactic acid level of 4.0 mmol/L, creatinine level of 3.66 mg/dL, and a prothrombin time of 24.5 seconds.
  • Asthma Is Associated With Subsequent Development ofInflammatory Bowel Disease: A Population-based CaseControl Study

    Asthma and the inflammatory bowel diseases (IBD) each arise through complex interactions between genetic and environmental factors, and share many environmental risk factors. We examined the association between asthma and Crohns disease or ulcerative colitis.
  • Progression of Unresected Intraductal Papillary Mucinous Neoplasms of the Pancreas to Cancer: A Systematic Review andMeta-analysis

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

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

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

    A 66-year-old man with a 15-year history of peptic ulcer disease and refractory heartburn presented with recurrent bleeding duodenal ulcers and diminutive fleshy nodules in the stomach. Biopsy of the gastric lesions revealed carcinoid. He was referred for endoscopic ultrasound to evaluate the gastric lesions, which were found to be multifocal and diminutive. At the time of the procedure a subtle 2-cm umbilicated lesion in the duodenum (Figure A) associated with heterogenous thickening of the submucosal layer on endosonography was identified (Figure B).
  • Patient Sex, Reproductive Status, and Synthetic Hormone Use Associate With Histologic Severity of Nonalcoholic Steatohepatitis

    Yang etal1 on behalf of the Nonalcoholic Steatohepatitis (NASH) Clinical Research Network reviewed the liver biopsies of premenopausal women with NASH. They have demonstrated high Nonalcoholic Fatty Liver Disease Activity Score (NAS) scores in these women compared with men or postmenopausal women. The authors noted that this population of premenopausal women exhibits a better prognosis than postmenopausal women or men, while showing that the fibrosis scores in the premenopausal cohort were lower as well.
  • 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.
  • Coping Skills Are Associated With Gastrointestinal Symptom Severity and Somatization in Patients With Irritable BowelSyndrome

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

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

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

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

    Many first-degree relatives of patients with Crohns disease (CD) have increased intestinal permeability. Video capsule endoscopy (VCE) is the most sensitive imaging test to identify small bowel mucosal lesions that could indicate subclinical CD. We aimed to estimate the association of increased intestinal permeability with small bowel ulcerations detectable by VCE in healthy first-degree relatives of patients with CD.
  • Suboptimal Implementation of Evidence-based Therapy for Acute Variceal Hemorrhage: A Systematic Review of Observational Studies

    Gastroenterologists should strive to improve the outcomes associated with acute variceal hemorrhage (AVH) by optimizing care delivery and clinician preparedness through training. Unfortunately, data regarding contemporary outcomes and management of AVH are limited.
  • Cost Effectiveness of Screening Patients With Gastroesophageal Reflux Disease for Barretts Esophagus With a Minimally Invasive Cell Sampling Device

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

    Mucosal healing, determined by histologic analysis, is a potential therapeutic target for patients with ulcerative colitis (UC). However, the histologic features of tissue normalization, as an outcome of treatment, have not been well described. We examined the prevalence and predictive values of normalization of the colonic mucosa, based on histologic analysis (histologic normalization) in patients with UC, and determined its association with risk of clinical relapse, compared with histologic disease quiescence and endoscopic mucosal healing.
  • Increases in IgE, Eosinophils, and Mast Cells Can be Used in Diagnosis and to Predict Relapse of IgG4-Related Disease

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

    A 78-year-old man with primary hypertension, dyslipidemia, and cerebrovascular disease presented with severe gastrointestinal bleeding. His medication included low-dose aspirin (100 mg/day). Twenty-four hours before admission, he started complaining of intense back pain unrelieved by ibuprofen. He later developed hematemesis with syncope and was admitted to our intensive care unit for resuscitation. Initial blood tests showed normocytic anemia (hemoglobin, 8.0 g/dL; 13.017.5), mild leukocytosis (12.2 109/L; 4.011.0), and normal platelets (276; 150450) and prothrombin time (13.9; <11.6).
  • Accumulation of Heavy Metals in People on a Gluten-Free Diet

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

    It is not clear whether combination therapy with immunomodulators affects the immunogenicity of tumor necrosis factor (TNF) antagonists in patients with inflammatory bowel disease. We performed a meta-analysis to quantify the effects of combined immunomodulator therapy on the presence of antibodies against TNF antagonists (antidrug antibodies [ADAs]) and trough levels of anti-TNF agents.
  • Esophageal Mammary Analogue Secretory Carcinoma

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

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

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

    A 64-year-old woman was referred to our hospital because of a gradually enlarged submucosal tumor (SMT), which was followed to that point by a local medical doctor. Laboratory investigations, including serum carcinoembryonic antigen and cancer antigen 19-9 analyses, showed no significant abnormalities. Esophagogastroduodenoscopy revealed an irregular elevated lesion in the top of a SMT in the middle third of the stomach (Figure A), which was confirmed as the mass located predominantly within the muscularis propria and the submucosa by endoscopic ultrasonography (Figure B, arrows).
  • Efficacy and Limitations of Budesonide as a Second-Line Treatment for Patients With Autoimmune Hepatitis

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

    Even if patients with hemochromatosis maintain low serum levels of ferritin, they still have an increased risk of general and joint symptoms, which reduce quality of life. This could be related to persistently increased transferrin saturation. We assessed whether duration of exposure to increased transferrin saturation during maintenance therapy is associated with more severe general and joint symptoms.
  • High Dietary Intake of Specific Fatty Acids Increases Risk of Flares in Patients With Ulcerative Colitis in Remission During Treatment With Aminosalicylates

    Dietary factors may have a significant role in relapse of disease among patients with ulcerative colitis (UC). However, the relationship between diet and UC is inadequately understood. We analyzed data from the diets role in exacerbations of mesalamine maintenance study to determine whether dietary factors affect the risk of disease flares in patients with UC.
  • A Dumbbell-Shaped Hyperechoic Mass in the Common Hepatic Artery Swinging With the Heartbeat

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

    The incidence of esophageal adenocarcinoma (EAC) has risen dramatically during the past 4 decades in the United States and much of the Western world.1 Most clinical guidelines recommend patients with Barretts esophagus (BE) undergo endoscopic surveillance with tissue biopsy to grade the severity of precursor lesions and detect curable neoplasia.2 In addition, techniques for endoscopic eradication treatment of BE, such as endoscopic mucosal resection and radiofrequency ablation (RFA), have increasingly been used to limit progression to EAC.
  • A Rare Case of Esophageal Verrucous Squamous Cell Carcinoma in a Patient With Achalasia

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

    A magnetic implant for the treatment of gastroesophageal reflux disease (GERD) was Food and Drug Administrationapproved in 2012 and has been extensively evaluated. The device is a ring of magnets that are placed around the gastroesophageal junction, augmenting the native lower esophageal sphincter and preventing reflux yet preserving lower esophageal sphincter physiologic function and allowing belching and vomiting. Magnetic force is advantageous, being permanent and precise, and forces between magnets decrease with esophageal displacement.
  • 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.
  • Fresh vs Frozen Samples and Ambient Temperature Have Little Effect on Detection of Colorectal Cancer or Adenomas by a Fecal Immunochemical Test in a Colorectal Cancer Screening Cohort in Germany

    Fecal immunochemical tests (FITs) are used in colorectal cancer (CRC) screening. We compared detection of CRCs and colorectal neoplasms by FITs using fresh samples (collected into buffer-filled tubes) vs frozen samples, and we assessed the effects of seasonal variations in ambient temperature on test performance.
  • 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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  • The Evolving Payment Reform Landscape: New Opportunities forGastroenterology Leadership

    To date, Congressional efforts to repeal or reform key provisions of the Affordable Care Act have focused almost entirely on insurance coveragehow people get it, who pays for it, and what it coversand have been contentious largely because of the high and increasing costs of health care. Regardless of whether a new health care reform bill becomes law, an equally important discussion must continue on how to deliver and pay for care in a way that addresses these high costs and makes coverage more affordable through more efficient and high-quality approaches.