Alison Schneider

Risk of Clostridium difficile infection in hospitalized patients receiving metronidazole for a non-C difficile infection.

BACKGROUND & AIMSnAntibiotics often are given to prevent infections but also constitute a risk factor for Clostridium difficile infection (CDI). Metronidazole is an effective treatment for CDI. We investigated whether prophylactic administration of metronidazole to patients before they receive other antibiotics reduces the risk of CDI.nnnMETHODSnWe performed a retrospective cohort analysis of data collected from 12,026 high-risk patients admitted to Cleveland Clinic Foundation Hospitals from 2008 through 2012. High-risk patients were defined as age 55 or older who received a broad-spectrum antibiotic (piperacillin-tazobactam or ciprofloxacin) and a gastric acid suppressant (a proton pump inhibitor or a histamine-2 receptor blocker) during their hospitalization. Development of CDI was compared between patients who received metronidazole for non-CDI indications before broad-spectrum antibiotics (n = 811) and those who did not (n = 11,215). Logistic regression was used to control for patient demographics and comorbidities.nnnRESULTSnThe rate of CDI was 1.4% (n = 11) among the patients who received metronidazole for non-CDI indications and 6.5% (n = 728) among those who did not. This was observed to be an 80% reduction in CDI among patients who received metronidazole (odds ratio, 0.21; 95% confidence interval, 0.11-0.38; P < .001), adjusted for age, sex, and comorbidities.nnnCONCLUSIONSnBased on a retrospective analysis, metronidazole might be used to prevent CDI in certain high-risk patients. Prospective controlled trials are necessary before making further recommendations.

The safety of same-day CT colonography following incomplete colonoscopy with polypectomy

Background Concerns about the risk of bowel perforation for same-day computed tomography colonography (CTC) following an incomplete colonoscopy with polypectomy may lead to unnecessarily postponing the CTC. Objective The objective of this article is to describe the complications including colon perforations associated with same-day CTC in a cohort who had polypectomies but an incomplete colonoscopy. Design We conducted a retrospective study. Setting Our study took place in a single, tertiary referral center. Patients We studied consecutive patients who had CTC the same day as an incomplete colonoscopy with polypectomy. Interventions Interventions included optical colonoscopy (OC), endoscopic polypectomies, and same-day CTC. Main outcome measurements: Our main outcome measurements included perforation rate with long-term follow-up. Results A total of 3% of patients undergoing colonoscopy from January 2008 to December 2012 had same-day CTC following incomplete OC, and 72 polypectomies were performed in 34 (or 17%) of these patients. Incomplete colonoscopies were due to colon tortuosity and looping (25), severe angulations (five), colon mass (two), colon stenosis (one), bradycardia (one). Fifty-three percent of the OCs were screening for colon neoplasia, 29% diagnostic and 18% were surveillance of colon polyps. Most polyps wereu2009≤u20095u2009mm, and found in the left colon. There were no reported complications or perforations associated with same-day CTCs during short- and long-term follow-up. Limitations Limitations of our analysis included retrospective single-center design, small number of patients for the occurrence, referral to same-day CTC was not standardized, inability to establish safety of CTC for specific scenarios such as after complex polypectomies, strictures, or advanced IBD. Conclusions Radiologists’ apprehension to perform a CTC the same day as an incomplete colonoscopy following polypectomies because of perceived risk of perforation may be unfounded. More data are needed to determine the safety of same-day CTC in patients with high-risk findings during colonoscopy such as a stricture, severe IBD, and after complex polypectomies.

Issues related to colorectal cancer and colorectal cancer screening practices in women.

Studies have shown that colorectal cancer (CRC) incidence is equal between men and women. However, several studies have demonstrated lower adenoma detection rates in women than in men. Many questions arise about differences in adenomas, CRC, and screening practices between men and women: should screening be the same for both sexes, are there differences in risk factors in the formation of colon cancer, should special groups of women be screened differently from the general population, are colonoscopies tolerated differently in women and why, and what determines if a woman will undergo colonoscopy? This article reviews these issues.

Initial experience with a variable width and extreme tip angulation colonoscope

Screening and surveillance colonoscopies can be affected by colon looping, angulations, diverticulosis, previous surgeries, body mass index, ability to sedate or type of sedation, bowel preparation, and female sex. Incomplete colonoscopies can be economically and emotionally costly and may result in decreased compliance with screening for colon neoplasia [1]. Instruments that improve the cecal intubation and adenoma detection rate, reduce the number of incomplete colonoscopies and improve patient satisfaction are desirable. Studies have shown that pediatric as well as variable stiffness colonoscopes achieve cecal intubation rates similar to standard colonoscopes, but possibly with less pain and with faster cecal intubation times [2, 3]. More recently, ultrathin colonoscopes have been reported to be better at negotiating acute luminal angulations, and patients may require less sedation than when standard colonoscopes are used. However, looping, difficulty removing larger polyps, and a higher ileal intubation failure rate have been reported [1, 4, 5]. We are, to the best of our knowledge, the first to report the ease of use and initial impressions with a newly available variable width colonoscope with extreme tip angulation capability.

Esophageal Motility Disorders after Bariatric Surgery

A 45-year-old female who underwent a Roux-en-Y gastric bypass 10 years prior was referred to our GI clinic by a pulmonologist after an extensive negative workup for chronic cough. She also had complaints of severe regurgitation that did not respond to high-dose acid suppression therapy. An esophagogastroduodenoscopy (EGD) was performed which showed evidence of a tortuous and dilated esophagus. The lower esophageal sphincter (LES) was easily traversed with no narrowing noted. A fairly large gastric pouch was seen prolapsing into the esophagus (Fig. 1a). A barium study showed dilation of the thoracic esophagus, diminished contractility, and gastric pouch distention with compression at the LES (Fig. 1b). A high-resolution esophageal manometry (HRM) revealed aperistalsis in the body of the esophagus with normal LES pressures (Fig. 1c).

Fecal Microbiota Transplantation as Therapy for Inflammatory Bowel Disease

Abstract Although the exact pathogenesis of inflammatory bowel disease (IBD) remains unknown, it is thought to be caused by dysregulated immune response to gut microbiota in genetically predisposed individuals. Given the proposed theory that intestinal dysbiosis can drive inflammation in IBD, there is a great interest in therapy that can manipulate the gut microbiome. Fecal microbiota therapy (FMT) is the process of transferring stool from a healthy donor individual into a recipient with a specific disease that is thought to be secondary to altered microbiome. Treatment with FMT may increase gut microbial diversity and restore a healthy balance of gut flora, which could prove to be beneficial for the treatment of IBD and other conditions. This chapter reviews the currently available literature on the use of FMT in IBD and discusses practical considerations for FMT.

Diagnosis of Barrett’s Esophagus

Barrett’s esophagus is a condition in which normal stratified squamous epithelium of the esophagus is replaced with columnar epithelium. It is the primary precursor lesion for esophageal adenocarcinoma and is thought to progress in a stepwise manner from metaplasia through increasing grades of dysplasia to adenocarcinoma. Diagnosis requires the combination of endoscopic evaluation and histopathological assessment of biopsies taken at the time of endoscopy. There is international disagreement regarding the histologic definition and the requirement of goblet cells in biopsies. This chapter reviews the current histologic and endoscopic definitions of Barrett’s esophagus and controversies surrounding them. Recent advances in endoscopic imaging will also be reviewed as they may improve the diagnosis and management of Barrett’s esophagus in the future.