Amrit K. Kamboj

The Changing Epidemiology of Acute Pancreatitis Hospitalizations: A Decade of Trends and the Impact of Chronic Pancreatitis

Objectives The epidemiological trends contributing to increasing acute pancreatitis (AP) hospitalizations remain unknown. We sought to analyze etiological factors and outcomes of increasing AP hospitalizations. Methods Utilizing the Nationwide Inpatient Sample, retrospective analyses of adult (≥18 years) inpatient admissions with a primary diagnosis of AP (N = 2,016,045) were performed. Patient hospitalizations from 2009 to 2012 were compared with those from 2002 to 2005. Results Compared with 2002–2005, there was a 13.2% (P < 0.001) increase in AP admissions in 2009–2012. Multivariate analysis adjusted for “period,” patient and hospital demographics, AP etiologies, and disease associations demonstrated an increase in the odds of associated chronic pancreatitis (CP) [2002–2005: odds ratio, (OR), 32.04; 95% confidence interval (CI), 30.51–33.64; 2009–2012: OR, 35.02; 95% CI, 33.94–36.14], whereas associated odds of gallstones (2002–2005: OR, 36.37; 95% CI, 35.32–37.46; 2009–2012: OR, 29.85; 95% CI, 29.09–30.64) decreased. Compared with 2002–2005, the AP-related mortality decreased in 2009–2012 (1.62%–0.79%, P < 0.001) and was lower in AP with associated CP (0.65%–0.26%; P < 0.001) compared with AP without CP. Conclusion In the preceding decade, AP hospitalizations increased, but associated mortality declined. Associated CP has emerged as a leading contributor for AP-related hospitalizations. Further research is needed to identify novel interventions to prevent disease progression of AP.

In vivo and ex vivo confocal endomicroscopy of pancreatic cystic lesions: A prospective study

AIM To investigate the reproducibility of the in vivo endoscopic ultrasound (EUS) - guided needle based confocal endomicroscopy (nCLE) image patterns in an ex vivo setting and compare these to surgical histopathology for characterizing pancreatic cystic lesions (PCLs). METHODS In a prospective study evaluating EUS-nCLE for evaluation of PCLs, 10 subjects underwent an in vivo nCLE (AQ-Flex nCLE miniprobe; Cellvizio, MaunaKea, Paris, France) during EUS and ex vivo probe based CLE (pCLE) of the PCL (Gastroflex ultrahigh definition probe, Cellvizio) after surgical resection. Biopsies were obtained from ex vivo CLE-imaged areas for comparative histopathology. All subjects received intravenous fluorescein prior to EUS and pancreatic surgery for in vivo and ex vivo CLE imaging respectively. RESULTS A total of 10 subjects (mean age 53 ± 12 years; 5 female) with a mean PCL size of 34.8 ± 14.3 mm were enrolled. Surgical histopathology confirmed 2 intraductal papillary mucinous neoplasms (IPMNs), 3 mucinous cystic neoplasms (MCNs), 2 cystic neuroendocrine tumors (cystic-NETs), 1 serous cystadenoma (SCA), and 2 squamous lined PCLs. Characteristic in vivo nCLE image patterns included papillary projections for IPMNs, horizon-type epithelial bands for MCNs, nests and trabeculae of cells for cystic-NETs, and a “fern pattern” of vascularity for SCA. Identical image patterns were observed during ex vivo pCLE imaging of the surgically resected PCLs. Both in vivo and ex vivo CLE imaging findings correlated with surgical histopathology. CONCLUSION In vivo nCLE patterns are reproducible in ex vivo pCLE for all major neoplastic PCLs. These findings add further support the application of EUS-nCLE as an imaging biomarker in the diagnosis of PCLs.

Pokémon GO: An innovative smartphone gaming application with health benefits

Obesity is a leading public health epidemic worldwide and its prevalence is increasing. While diet and exercise are the cornerstones in the prevention and treatment of obesity and its associated complications, patients often find it difficult to make lifestyle changes. Smartphones are increasingly becoming integrated into our society and can serve as a tool to improve health outcomes. Here, we illustrate the positive health impacts of an innovative smartphone gaming application, Pokémon GO (Niantic Incorporation, San Francisco, California), which is used by millions of users worldwide. The aim of this game is to catch fictional characters known as Pokémon, which users encounter when walking around as opposed to traditional stationary-seated games. Sedentary lifestyle has long been associated with increased risk of diabetes and cardiovascular diseases. Pokémon GO exemplifies a highly successful smartphone application promoting health specifically by rewarding the simplest effective exercise of walking. This application, while representing the next interactive level of gaming, is as an important example of how positive reinforcement can serve as a successful motivation technique.

Helicobacter pylori: The Past, Present, and Future in Management

Abstract Helicobacter pylori is a common bacterial pathogen responsible for substantial gastrointestinal morbidity worldwide. Helicobacter pylori infection can be clinically challenging, given the numerous diagnostic and therapeutic options available. In this article, we provide a systematic review of H pylori epidemiology and pathogenesis. In addition, we provide a simplified approach to the diagnosis and treatment of H pylori infection, suitable for application in the primary care setting. On completion of this article, one should be able to (1) state the indications for H pylori testing; (2) identify noninvasive and invasive tests to diagnose H pylori infection; and (3) describe the advantages and disadvantages of various treatment regimens.

Clinical and Histologic Mimickers of Celiac Disease

&NA; Celiac disease is an autoimmune disorder of the small bowel, classically associated with diarrhea, abdominal pain, and malabsorption. The diagnosis of celiac disease is made when there are compatible clinical features, supportive serologic markers, representative histology from the small bowel, and response to a gluten‐free diet. Histologic findings associated with celiac disease include intraepithelial lymphocytosis, crypt hyperplasia, villous atrophy, and a chronic inflammatory cell infiltrate in the lamina propria. It is important to recognize and diagnose celiac disease, as strict adherence to a gluten‐free diet can lead to resolution of clinical and histologic manifestations of the disease. However, many other entities can present with clinical and/or histologic features of celiac disease. In this review article, we highlight key clinical and histologic mimickers of celiac disease. The evaluation of a patient with serologically negative enteropathy necessitates a carefully elicited history and detailed review by a pathologist. Medications can mimic celiac disease and should be considered in all patients with a serologically negative enteropathy. Many mimickers of celiac disease have clues to the underlying diagnosis, and many have a targeted therapy. It is necessary to provide patients with a correct diagnosis rather than subject them to a lifetime of an unnecessary gluten‐free diet.

Immune modulator therapy for microscopic colitis in a case series of 73 patients

Microscopic colitis (MC) is a common cause of chronic diarrhoea. Various treatment options have been described, but there are limited data describing outcomes of corticosteroid‐sparing treatments.

Novel technique for diagnosis of mucinous cystic neoplasms: in vivo and ex vivo confocal laser endomicroscopy

A 51-year-old woman presented with abdominal pain, and a CT scan of the abdomen revealed a cystic lesion in the tail of the pancreas measuring 4.4 cm 3.8 cm. An EUS demonstrated a 4.1 cm 4.0 cm anechoic cystic lesion without main pancreatic duct involvement. The differential diagnosis was broad and included intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), and serous cystadenoma (SCA). However, MCN was slightly higher on the differential diagnosis because these lesions are typically seen in middle-aged women, with the majority of lesions seen in the pancreatic body or tail without communication with the main pancreatic duct. Here we present a relatively new technique, needlebased confocal laser endomicroscopy (nCLE), which allows for real-time image acquisition during EUS. The nCLE demonstrated solitary epithelial bands without any papillary conformation (Video 1, available online at www.VideoGIE.org) (Fig. 1). These bands are best described as having a horizon-type configuration with variable thickness, suggestive of a diagnosis of MCN.

A comprehensive examination of the novel techniques used for in vivo and ex vivo confocal laser endomicroscopy of pancreatic cystic lesions

re 1. A, In vivo needle-based confocal laser endomicroscopic view of an intraductal papillary mucinous neoplasm. B, Ex vivo confocal laser endooscopic view of an intraductal papillary mucinous neoplasm. Both demonstrate fingerlike projections, or papillae. C, Histopathologic view of an intral papillary mucinous neoplasm showing tall columnar epithelium with elongated nuclei and goblet cells (H&E, orig. mag. 40).

Non–Health Care Facility Cardiovascular Medication Errors in the United States

Background: Prior studies have not examined national trends and characteristics of unintentional non–health care facility (HCF) medication errors associated with cardiovascular drugs. Objective: To investigate non-HCF medication errors associated with cardiovascular drugs reported to poison control centers in the United States. Methods: A retrospective analysis of non-HCF medication errors associated with cardiovascular drugs from 2000 to 2012 was conducted using the National Poison Data System database. Results: There were 278 444 medication errors associated with cardiovascular drugs reported to US poison control centers during the study period, averaging 21 419 exposures annually. The overall rate of cardiovascular medication errors per 100 000 population increased 104.6% from 2000 to 2012 (P < 0.001) and the highest rates were among older adults. Most cases (83.6%) did not require treatment at a HCF. Serious medical outcomes were reported in 4.0% of exposures. The cardiovascular drugs most commonly implicated in medication errors were β-blockers (28.2%), calcium antagonists (17.7%), and angiotensin-converting enzyme inhibitors (15.9%). Most of the 114 deaths were associated with cardiac glycosides (47.4%) or calcium antagonists (29.8%). Most medication errors involved taking or being given a medication twice (52.6%). Conclusions: This study describes characteristics and trends of non-HCF cardiovascular medication errors over a 13-year period in the United States. The number and rate of cardiovascular medication errors increased steadily from 2000 to 2012, with the highest error rates among older adults. Further research is needed to identify prevention strategies for these errors, with a particular focus on the older adult population.

Gastrointestinal Bleeding Secondary to Iliac Artery Pseudoaneurysm in a Patient with Remote Pancreas Transplant: A Case Report

BACKGROUND Vascular complications represent the most common cause of early graft failure after pancreatic transplantation (PT). Pseudoaneurysms are uncommon vascular complications that usually present within the first year post transplantation. CASE REPORT A 49-year-old man with history of type 1 diabetes mellitus presented for evaluation with a 2-day history of painless hematochezia. He had undergone PT 4 years prior to presentation, which failed due to acute cellular rejection after 1 year. Both extended upper endoscopy and colonoscopy did not identify an active bleeding source. After an episode of massive hematochezia, he became hemodynamically unstable with peritoneal signs noted on physical examination. An abdominal angiogram was unable to identify active hemorrhage, and the patient was transferred to the operating room for open laparotomy. Exploration revealed a right common iliac artery pseudoaneurysm eroding into the pancreatic-ileal anastomosis, which required initial digital compression for initial hemostasis. After combined endovascular procedure with ballooning and stenting of the right iliac artery, optimal hemostasis was achieved without further episodes of hematochezia. DISCUSSION Gastrointestinal bleeding (GIB) has been reported to occur in 11% of enteric-drained PT. Even though infectious causes have been reported, culprits are more commonly associated with vascular or enteric surgical anastomosis and usually occur within the early postoperative course. Here we report an uncommon cause of GIB, a late complication of PT, and review important points associated with the management of GIB, anatomy of PT, and potential etiologies for early and late GIB in the setting of PT.