Amer A. Alkhatib

Gastric Acid–Reducing Medications and Clopidogrel: What Are the Latest FDA Recommendations?

Gastric Acid–Reducing Medications and Clopidogrel: What Are the Latest FDA Recommendations?

RIFLE criteria accurately identifies renal dysfunction and renal failure in elderly patients with upper gastrointestinal hemorrhage: a pilot study.

Background: The incidence of acute kidney injury (AKI) as a complication of acute upper gastrointestinal bleeding (AUGIB) is not known. Recently, RIFLE criteria were used widely in the medical research to identify patients with different degrees of renal insufficiency. Objectives: Our purpose is to determine the incidence, clinical presentations, endoscopic findings and outcomes of AKI in the elderly presenting with AUGIB using RIFLE criteria. The study was conducted in a community hospital in Washington State. This was a retrospective pilot study of elderly patients (≥60 years old) presenting with AUGIB. Categorical variables were analyzed using the Chi-square test. The Student t-test was used to compare continuous variables. A total of 113 patients were included (52 males and 61 females) in the study. The patients were classified into those with AKI based on RIFLE criteria and those without. The two groups were compared in regard to clinical presentations, laboratory and endoscopic findings, complications, length and cost of hospitalization. Results: Fifty five patients (48.7%) met RIFLE criteria for AKI, while 58 patients did not develop any renal dysfunction. Patients with AUGIB complicated with AKI tend to be residents at nursing homes (38% vs. 14%, P < 0.004), present with weakness (49% vs 29%., P < 0.04) and altered mental status (25% vs. 55%, P < 0.003), have higher serum creatinine at presentation (1.8 mg/dL vs. 1.2 mg/dL, P < 0.002), have less incidence of gastritis/gastric ulcers (67% vs. 42%, P < 0.007), have nondiagnostic upper endoscopic examination (29% vs. 14%, P < 0.05), higher incidences of cardiac complications including myocardial infarction (9% and 0%, P < 0.02), longer lengths of stay (5.0 days vs. 2.37 days, P < 0.005) and higher hospitalization costs (

Incidental Pancreatography via ERCP in Patients with Anomalous Pancreaticobiliary Junction Does Not Result in Pancreatitis in a North American Population

20,230 vs.

High prevalence of vitamin D deficiency among patients with fecal incontinence.

11,779, P < 0.02). Conclusion: The incidence of developing AKI as a consequence of AUGIB in the elderly is very common. Those with AKI tend to have a more complicated clinical course in the hospital.

Rizatriptan induced acute on top of chronic ischemic colitis

IntroductionAnomalous pancreaticobiliary junction (APBJ) is the term used to describe anatomical variants of pancreatic and biliary ductal junctional anatomy. Patients have junction of the pancreatic and bile ducts located outside the duodenal wall, forming a long common channel. We report our findings and clinical outcomes in a North American series of patients with APBJ undergoing ERCP.MethodsRetrospective chart review.ResultsWe reviewed 2,218 ERCP performed on 1,050 patients. Twelve patients (1.1%) with APBJ were identified (5F, 7M). No patient had an associated choledochocele. Mean age was 53.2 (range 17–85). A total of 43 ERCP procedures were performed on these 12 patients. All patients experienced passive pancreatography. No patient developed post-ERCP pancreatitis. Only one patient had a history of antecedent pancreatitis.ConclusionsIn North American patients undergoing ERCP, 1.1% of patients had APBJ. Our study population was predominately Caucasian, male, and in all but one patient lacked a history of prior pancreatitis. No patient developed post-ERCP pancreatitis. This suggests that APBJ may have different clinical manifestations in a North American population when compared to Asian populations.

ERCP and fluoroscopy time.

To the Editor, Fecal incontinence is a common problem with a prevalence ranging from 0.7 to 24% depending on the population that is being studied [1]. The functional integrity of the internal and external anal sphincters requires normal functioning of the pelvic floor muscles to maintain continence [2]. Vitamin D deficiency is associated with muscle weakness and vitamin D plays an important role in muscle strength [3]. It is not known if vitamin D deficiency is associated with fecal incontinence. We evaluated serum vitamin D (25-hyroxy-cholecalciferol) levels of ten consecutive patients with fecal incontinence attending the gastroenterology clinic at a tertiary care center. Patients with infectious diarrhea and anorectal surgery were excluded. Patients with known cause of vitamin D deficiency including chronic kidney and liver diseases were also excluded from the study. Fecal incontinence was defined as recurrent uncontrolled passage of fecal material for at least 1 month. Normal vitamin D level was defined as 30 ng per milliliter or greater. Relative vitamin D insufficiency was defined as 20–29 ng per milliliter. Levels below 20 ng per liter were defined as vitamin D deficient [4, 5]. Ten patients were found to fulfill the inclusion criteria (eight males, two females). The median age was 56.7 years (range, 30–80). Mean body mass index was 31.9 (range, 19.8–38.3). All patients except one had loose stool. The average duration of fecal incontinence was 18.3 months (range, 1–240 months). The average frequency of fecal incontinence was 10.9 episodes per month (range, 2–30 episodes per month). All patients with fecal incontinence had hypovitaminosis D (60% had vitamin deficiency and 40% with relative vitamin D insufficiency). The mean vitamin D level in patients with fecal incontinence was 17 ng per milliliter (range 5.4–22.2 ng per milliliter). Historical data demonstrate that 36–57% of people have vitamin D deficiency or relative insufficiency [5]. In conclusion, in this small cohort study all patients with fecal incontinence had vitamin D deficiency or relative insufficiency. This is significantly higher than reported prevalence of vitamin deficiency or insufficiency in the general population. A prospective cross section study is warranted to determine if patients with fecal incontinence have a higher prevalence of vitamin D deficiency compared to a control group. Further research is required to determine whether hypovitaminosis D is a risk factor or a consequence of fecal incontinence.

Choledocholithiasis in Roux-en-Y gastric bypass patients

i.e., perisplenitis, spleen infarction, and PAS-positive infi ltration, may cause splenomegaly (9,10) , hyposplenism should be suspected even in Whipple ’ s disease patients with increased spleen size. In conclusion, these fi ndings extend the knowledge of splenic function in Whipple ’ s disease by showing a considerable prevalence of hyposplenism and strengthening the pathogenic link between impaired splenic function and thrombocytosis. As the degree of hyposplenism is quite mild and we did not observe any pneumococcal infection in our series, the need to administer pneumococcal vaccination to Whipple ’ s disease patients remains under debate.

Primary papillary thyroid carcinoma diagnosed by using endoscopic ultrasound with fine needle aspiration.

To the Editor: We read with interest the study of Romagnuolo and Cotton (1). The study reported different factors that predict prolonged fluoroscopy time (FT) during endoscopic retrograde cholangiopancreatography (ERCP) (1). In our multicenter study (n=414, ERCP procedure performed by six endoscopists in three American centers) that was partially published as an abstract and presented as poster in ACG meeting 2013, the strongest predictive factor of prolonged FT utilization during ERCP procedure was the anatomical location of the pathology being treated (intrahepatic vs. pancreatic vs. extrahepatic) with mean FT 4.96 min for extrahepatic cases, 6.75 min for pancreatic cases, and 12.9 min for intrahepatic cases (P<0.05) (2). It would be interesting if the authors can extract the relationship between FT and anatomical location of the pathology from the ERCP Quality Network.

Bloody diarrhoea secondary to cytomegalovirus ileitis

To the Editor: We read with interest the eloquent article written by Schulman et al. The authors briefly described different options to manage choledocholithiasis in patients with Roux-en-Y gastric bypass. One of the options that was listed in one of the tables was laparoscopic-assisted ERCP [1]. It is worth pointing out that laparoscopic-assisted ERCP (LA-ERCP) has shown to be one of the most successful endoscopic procedures to remove biliary stones in the setting of Roux-en-Y gastric bypass. Since first described in 2002, LA-ERCP has been gaining popularity as it provides the endoscopist an easy access to the ampulla and empowers him/ her to utilize the typical endoscopic accessories to remove the stones [2]. Furthermore, concomitant cholecystectomy can be performed at the same time LA-ERCP is done [2]. Recently, a large multicenter retrospective study that included 597 patients with Roux-en-Y gastric bypass from 34 centers underwent LA-ERCP reported 98% procedural success. Nonetheless, there were 8% severe complications and one death [2]. Another study compared balloon enteroscopy-assisted ERCP versus laparoscopy-assisted ERCP (LA-ERCP) in post-Roux-en-Y gastric bypass patients. The study concluded that LA-ERCP is superior to balloon enteroscopy-assisted ERCP in therapeutic success (100% vs 59%, P < 0.001). In addition, it showed no significant difference in post-procedure hospital stay or complication rate between the two groups [3].

Obscure Gastrointestinal Bleeding in a Patient With Orthotopic Heart Transplantation

There is paucity in the literature on the use of endoscopic ultrasound (EUS) for evaluating the thyroid gland. We report the first case of primary papillary thyroid cancer diagnosed by using EUS and fine needle aspiration (FNA). A 66-year-old man underwent EUS for the evaluation of mediastinal lymphadenopathy. FNA of the lymph nodes showed benign findings. A hypoechoic mass was noted in the right lobe of the thyroid gland. Therefore, FNA was performed. The cytological results were consistent with primary papillary thyroid cancer.