Amnon Sonnenberg

Prevalence and Socioeconomic Impact of Upper Gastrointestinal Disorders in the United States: Results of the US Upper Gastrointestinal Study

BACKGROUND & AIMS This study examined the prevalence of upper gastrointestinal (GI) symptoms and symptom groupings and determined impact on disability days in a nationally representative US sample. METHODS A telephone survey of 21,128 adults was conducted including questions about the presence of upper GI symptoms during the past 3 months. Respondents were categorized as symptomatic (ie, reported GI symptoms once per month) or asymptomatic. The survey included questions about missed work, leisure activity, or household activity days. Symptom groupings were identified by using factor analysis, and cluster analysis was used to assign respondents into distinct groups on the basis of these symptom groupings. RESULTS The prevalence of an average of 1 or more upper GI symptoms during the past 3 months was 44.9%. The most common symptoms experienced during the past 3 months were early satiety, heartburn, and postprandial fullness. Factor analysis identified 4 symptom groupings: (1) heartburn/regurgitation; (2) nausea/vomiting; (3) bloating/abdominal pain; and (4) early satiety/loss of appetite. Five respondent clusters were identified; the largest clusters were primarily early satiety/fullness (44%) and gastroesophageal reflux disease-like symptoms (28%). Two small clusters reflected nausea and vomiting (7%) and a heterogeneous symptom profile (4%). Symptomatic respondents reported significantly more missed work, leisure, and household activity days than asymptomatic respondents (all P < .0001). CONCLUSIONS Factor analysis separated GI symptoms into groupings reflecting gastroesophageal reflux disease and dyspepsia: early satiety, postprandial fullness, and loss of appetite; bloating and abdominal pain/discomfort; and nausea and vomiting. These upper GI symptoms were associated with significant loss of work and activity days.

A National Study of Helicobactor pylori Infection in Gastric Biopsy Specimens

BACKGROUND & AIMS We investigated whether infection with Helicobacter pylori and signs of chronic active gastritis and intestinal metaplasia in gastric biopsy samples were inversely associated with Barretts metaplasia. METHODS We studied gastric biopsy samples from 78,985 unique patients. Histologic findings were correlated with sociodemographic patient characteristics using multivariate logistic regression to calculate odds ratios and 95% confidence intervals. RESULTS H pylori infection, chronic active gastritis, and intestinal metaplasia had similar epidemiologic patterns. The presence of each, based on histology analyses, was significantly associated with that of the others. They were also characterized by similar geographic distributions within the United States. All 3 disorders were more common among men and among Medicaid patients (compared with those with other insurance) and were inversely associated with Barretts metaplasia (less frequent in patients with Barretts metaplasia). CONCLUSIONS H pylori infection and associated disorders, such as chronic active gastritis and intestinal metaplasia, are inversely associated with Barretts metaplasia.

Patterns of endoscopy in the United States: analysis of data from the Centers for Medicare and Medicaid Services and the National Endoscopic Database

BACKGROUND Patterns of GI endoscopy are influenced by the underlying epidemiology of GI disease, as well as by policy and practice guidelines. OBJECTIVE To compare practice patterns of GI endoscopy between two large national databases of the United States. DESIGN Descriptive database analysis. SETTING A 5% sample of the entire U.S. Medicare population (Centers for Medicare and Medicaid Services, CMS data files) and endoscopic data repository of U.S. gastroenterology practices (Clinical Outcomes Research Initiative, CORI database) from 1999 to 2003. PATIENTS The study population included 1,121,215 Medicare and 635,573 CORI patients undergoing various types of GI endoscopy. INTERVENTIONS EGD, colonoscopy, and flexible sigmoidoscopy. MAIN OUTCOME MEASUREMENTS Patient demographics, endoscopic diagnoses, time trends of diagnoses. RESULTS A colonoscopy was the most common endoscopic procedure performed (CMS 53%, CORI 58%), followed by an EGD (37%, 32%), and a flexible sigmoidoscopy (10%, 10%). In the CMS data, women accounted for 59% of the EGDs, 57% of the colonoscopies, and 56% of the flexible sigmoidoscopies, and in the CORI data, the corresponding numbers were 57%, 55%, and 54%, respectively. Compared with their distribution in the U.S. census population, nonwhite patients in both databases underwent relatively more EGDs and fewer colonoscopies. The most common upper-GI diagnosis was GERD, followed by GI bleeding, gastric ulcer, and duodenal ulcer. The most common lower-GI diagnosis was colorectal polyp. Over the period of 1999 to 2003, the rates of colorectal cancer diagnosed with colonoscopy declined. LIMITATIONS Only a limited amount of information about individual patients was retrievable from the electronic databases. CONCLUSIONS A colonoscopy is now the most common endoscopic procedure in the United States. Women undergo both upper and lower endoscopic procedures more often than men. Nonwhite patients are underrepresented in the use of colonoscopy relative to the prevalence of nonwhite persons in the U.S. population. Increased use of a colonoscopy for colon screening and surveillance has been associated with a decreased rate of cancer diagnosis.

Helicobacter pylori is a Risk Factor for Colonic Neoplasms

OBJECTIVES:It has been suggested that Helicobacter pylori (H. pylori) constitutes a risk for the development of adenomatous polyps and adenocarcinoma of the colon. Our aim was to study the association between H. pylori-positive gastritis and the occurrence of any colonic neoplasm.METHODS:From a computerized database of surgical pathology reports, we selected 156,000 subjects who underwent colonoscopy and esophago-gastro-duodenoscopy with biopsy results from both procedures.RESULTS:Compared with normal gastric mucosa, H. pylori gastritis occurred more frequently among patients with hyperplastic polyps (OR=1.24, 95% CI: 1.18–1.30), adenomatous polyps (1.52, 1.46–1.57), advanced adenomas (1.80, 1.69–1.92), villous adenomas or adenomas with high-grade dysplasia (1.97, 1.82–2.14), and adenocarcinomas (2.35, 1.98–2.80). Similarly, the strength of the association between H. pylori-positive gastritis and colonic neoplasm increased with size and number of the adenomas. The association between H. pylori gastritis and the occurrence of colonic neoplasm was similar for different locations of the large bowel. Other gastric conditions etiologically associated with H. pylori, such as intestinal metaplasia, adenoma, lymphoma, and adenocarcinoma, were also significantly associated with an increased risk of colonic neoplasm.CONCLUSIONS:Various forms of gastritis related to H. pylori infection confer an increased risk for colonic neoplasm. In the past, when H. pylori infection was more prevalent, its attributable risk to the occurrence of colorectal neoplasm may have been quite substantial.

The stomach in health and disease

The stomach is traditionally regarded as a hollow muscular sac that initiates the second phase of digestion. Yet this simple view ignores the fact that it is the most sophisticated endocrine organ with unique physiology, biochemistry, immunology and microbiology. All ingested materials, including our nutrition, have to negotiate this organ first, and as such, the stomach is arguably the most important segment within the GI tract. The unique biological function of gastric acid secretion not only initiates the digestive process but also acts as a first line of defence against food-borne microbes. Normal gastric physiology and morphology may be disrupted by Helicobacter pylori infection, the most common chronic bacterial infection in the world and the aetiological agent for most peptic ulcers and gastric cancer. In this state-of-the-art review, the most relevant new aspects of the stomach in health and disease are addressed. Topics include gastric physiology and the role of gastric dysmotility in dyspepsia and gastroparesis; the stomach in appetite control and obesity; there is an update on the immunology of the stomach and the emerging field of the gastric microbiome. H. pylori-induced gastritis and its associated diseases including peptic ulcers and gastric cancer are addressed together with advances in diagnosis. The conclusions provide a future approach to gastric diseases underpinned by the concept that a healthy stomach is the gateway to a healthy and balanced host. This philosophy should reinforce any public health efforts designed to eradicate major gastric diseases, including stomach cancer.

Epidemiology of Noncardia Gastric Adenocarcinoma in the United States

OBJECTIVES:Adenocarcinomas of the cardia (International Classification of Diseases (ICD)-9 code 151.0) and stomach (ICD-9 codes 151.1–151.9) are frequently grouped together in epidemiologic statistics, but are clearly distinct diseases. The objective of this study was to describe the current epidemiology of noncardia gastric cancer (noncardia gastric adenocarcinoma (NCGA)) in the United States.METHODS:Rates of NCGA in the United States from 1997 to 2008 were analyzed in three national databases: the Surveillance, Epidemiology, and End Results registry was used for incidence, the Healthcare Costs and Utilization Project for hospitalizations, and the Compressed Mortality File for mortality. Population-based rates were calculated and age-adjusted to the US 2000 population using direct standardization. Odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated and adjusted for confounders with the Mantel–Haenszel method.RESULTS:Annually, NCGA was associated with 18,873 incident cases, 17,284 hospitalizations for principal discharge diagnoses, 31,354 hospitalizations for all-listed diagnoses, and 11,562 deaths. Incidence was greater in men (OR=1.56, CI=1.53–1.59) and non-White races (OR=2.38, 2.33–2.43). Hospitalization was more common in men (1.82, 1.81–1.83) and non-White races (2.13, 2.10–2.15). Mortality was more common in men (1.83, 1.81–1.86) and non-White races (2.23, 2.20–2.26). NCGA rates showed a marked age-dependent rise (P<0.001). Hospitalization and mortality were greatest in the Northeast region of the United States (P<0.001).CONCLUSIONS:Epidemiologic patterns of NCGA were congruent in three national databases. Older age, male gender, non-White race, and residence in the Northeast region were associated with increased risk. These patterns may reflect the underlying variations in Helicobacter pylori, lifestyle, and environmental exposures.

Low prevalence of Helicobacter pylori infection among patients with inflammatory bowel disease

There is some preliminary evidence to suggest that patients with inflammatory bowel disease (IBD) are less frequently infected with Helicobacter pylori than the general population.

Medical decision analysis of chemoprevention against esophageal adenocarcinoma.

BACKGROUND & AIMS Chemoprevention of esophageal adenocarcinoma using nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce the risk of cancer in patients with Barretts esophagus. The aim of the study was to assess the cost-effectiveness of this strategy. METHODS The incremental cost-effectiveness ratio (ICER) of chemoprevention (compared with endoscopic surveillance or with no surveillance) was analyzed with a computer model of a Markov process. RESULTS Under baseline conditions for all patients with Barretts esophagus (neoplastic and nonneoplastic), the ICER of chemoprevention ranges between

Survival and Cost-Effectiveness Analysis of Competing Strategies in the Management of Small Hepatocellular Carcinoma

12,700 and

Epidemiology and practice patterns of achalasia in a large multi-centre database.

18,500 US dollars per life-year saved. However, these cost values are sensitive to variations in the costs of chemoprevention, incidence of cancer in patients with Barretts esophagus, and efficacy of NSAIDs in reducing the incidence of cancer, which can shift the ICER into a cost range that is prohibitively expensive. Conversely, in those patients with Barretts esophagus and high-grade dysplasia, the ICER ranges between