Anish A. Sheth

Diverticular Disease and Diverticulitis

Diverticular disease is one of the most prevalent medical conditions to affect Western populations. Symptomatic diverticular disease can range from mild, low-level symptomatology similar to that seen in irritable bowel syndrome to acute bouts of diverticulitis complicated by abscess or frank perforation. This review discusses the epidemiology, pathophysiology, clinical presentation, and management of the spectrum of diverticular disease, including mention of recent advances in the treatment of chronic diverticular disease with aminosalicyclates and probiotics.

Probiotics and liver disease.

Modulation of intestinal flora through the use of probiotics is an emerging therapeutic strategy in the management of chronic liver diseases. This article focuses on the pathophysiologic basis for using probiotics in liver disease and reviews the existing literature on the subject. The role of probiotics is examined in the following areas: a) prevention of infection, b) the hyperdynamic circulatory state of cirrhosis, c) hepatic encephalopathy, d) liver function, and e) nonalcoholic fatty liver disease.

24 Versus 48-hour bravo pH monitoring.

Background: Historical ambulatory pH monitoring systems for the evaluation of gastroesophageal reflux disease have been catheter based and uncomfortable for patients, commonly limiting both their diet and activities. Catheter-based studies have also been reported to underestimate the amount of reflux a patient may have in a normal, routine day. Compared with conventional catheter-based pH monitoring systems, wireless (Bravo) pH monitoring is better tolerated by patients and allows for an increased duration of pH recording. Currently, there is lack of data regarding the optimal duration of wireless studies and concern that day 1 results are not typical of a patient’s routine lifestyle, given the effects of sedation. Few studies have evaluated the merits of 24 versus 48-hour wireless pH monitoring. Aims: The aims of this study were (1) to identify differences in reflux parameters between 24 versus 48-hour testing as measured by wireless pH monitoring and (2) to assess the effect of 48-hour studies on the number of reflux episodes and symptom correlation as compared with 24-hour studies. Methods: A retrospective chart review of 124 consecutive patients who underwent 48-hour wireless esophageal pH monitoring studies was prepared. All patients underwent esophagogastroduodenoscopy using intravenous conscious sedation before wireless capsule placement. Acid reflux variables (including total reflux time, number of reflux episodes, and total percent time of pH<4) and symptom-association probability (SAP) scores were compared for day 1 versus day 2 versus total. Results: Forty-eight-hour SAP scores were significantly higher when compared with the first 24 hours for all reported primary symptoms. SAP scores were calculated at 24 and 48 hours, respectively for heartburn (56 vs. 65, P<0.0001), regurgitation (65 vs. 80, P<0.0001), chest pain (59 vs. 78, P=0.0009), and cough (55 vs. 64, P=0.0027). In addition, the percentage of SAP scores >95 was significantly higher for both heartburn and regurgitation (34% vs. 48%, P=0.003 and 38% vs. 62%, P=0.005). As expected, 48-hour testing also captured a significantly higher number of reflux episodes as compared with day 1 results alone (97 vs. 47, P<0.0001). There were no statistical differences noted between the 2 days for total percent time of pH <4. Conclusions: Forty-eight-hour wireless (Bravo) pH monitoring strengthens symptom correlation as compared with 24-hour results alone and yields a greater percentage of SAP scores >95 for typical symptoms of gastroesophageal reflux disease. Prolonged recording of patient symptoms and/or sedation effects may account for the better symptom correlation. Although there were no statistical differences seen in this study between 24 and 48-hour studies for total percent time pH <4, 48-hour studies captured significantly more reflux episodes as compared with 24 hours of monitoring alone. These results suggest that patients undergoing wireless pH monitoring should have 48-hour studies performed as a standard of practice.

Decompensated cirrhotics have slower intestinal transit times as compared with compensated cirrhotics and healthy controls.

Background: Altered small intestinal motility in cirrhotics may play a major role in the development of bacterial translocation (BT) by leading to small intestinal bacterial overgrowth. BT has been implicated in the development of several complications including spontaneous bacterial peritonitis, esophageal variceal hemorrhage, and hepatorenal syndrome. Prior studies using antroduodenal manometry to evaluate intestinal motility have shown discrepancies regarding the relationship between dysmotility and the severity of cirrhosis. Objectives: (1) To characterize the frequency of small bowel motility disturbances in cirrhotic patients using a wireless motility capsule (SmartPill); (2) To assess the relationship of intestinal dysmotility with liver disease severity and cirrhosis complications; and (3) To compare intestinal transit times and motility indices among cirrhotics and healthy controls. Methods: We conducted a prospective study of 20 patients with cirrhosis (10 compensated, 10 decompensated) who were recruited from Yale New Haven Hospital and Hepatology clinics (February 2011 to July 2011). All patients underwent and completed SmartPill studies. Intestinal transit times were calculated, analyzed, and compared among compensated versus decompensated cirrhotics versus historical, healthy controls. Intestinal transit delays/motility indices were correlated with disease severity and complications. Results: Decompensated cirrhotics had significantly longer small bowel transit times (SBTT) as compared with compensated cirrhotics (6.17 vs. 3.56 h, P=0.036). There was a significant correlation (r=0.77, P=0.0003) between SBTT and cirrhosis severity as assessed by Child-Pugh score. There were no statistical differences noted between the groups for gastric or colonic transit times, although there was a trend toward prolonged transit throughout the gut in decompensated. Cirrhotics with spontaneous bacterial peritonitis and ascites also had significantly longer SBTT as compared with those without. Conclusions: This study demonstrates that decompensated cirrhotics have slower intestinal transit times as compared with compensated cirrhotics and healthy controls. Additional prospective studies are needed to further characterize dysmotility in cirrhotics and its relationship to complications related to BT. This would aid in the identification of patients at risk for developing severe complications and who may benefit from prophylactic prokinetic and/or antimicrobial therapy.

Probiotics and Diverticular Disease

Diverticular disease is one of the most common medical conditions affecting Western populations. Inflammatory complications are the most common manifestation of the disease and typically cause acute bouts of abdominal pain and fever. Chronic symptoms can also occur and can be mistakenly attributed to irritable bowel syndrome and rarely to inflammatory bowel disease. Alterations in peridiverticular bacterial flora are thought to play a role in the pathogenesis of diverticular inflammation. This article discusses the rationale and reviews the existing clinical data regarding the role of probiotics in the management of diverticular disease.

Liver Disease From Asymptomatic Constrictive Pericarditis

Congestive hepatopathy is a known complication of cardiac disease and is typically identified in the context of an established cardiac diagnosis and profound cardiopulmonary symptoms. We report the case of a 28-year-old man with liver disease secondary to asymptomatic constrictive pericarditis. This case highlights the need for gastroenterologists to consider occult cardiac disease as a cause of unexplained liver dysfunction.

48 Hour BRAVO (Wireless) Esophageal pH Monitoring Improves Symptom Correlation as Compared to 24 Hour Studies Alone

Background: Historical ambulatory pH monitoring systems for the evaluation of GERD have been catheter-based and uncomfortable for patients, commonly limiting both their diet and activities. These studies may also underestimate the amount of reflux a patient has in a routine day. Compared to conventional catheter based pH monitoring systems, wireless (Bravo) pH monitoring is better tolerated by patients and allows for an increased duration of pH recording. Currently, there is lack of data regarding the optimal duration of wireless studies and concern that day 1 results are not typical of a patients routine lifestyle given the effects of sedation. Few studies have evaluated the merits of 24 versus 48 hour wireless pH monitoring. Aims: The aims of this study were: 1)To identify differences in reflux parameters between day 1 and day 2 as measured by wireless pH monitoring and 2)To assess the effect of 48 hour studies on the number of reflux episodes and symptom correlation as compared to 24 hour studies. Methods: A retrospective chart review of 124 consecutive patients who underwent 48 hour wireless esophageal pH monitoring studies. All patients underwent EGD using IV conscious sedation prior to wireless capsule placement. Acid reflux variables [including total reflux time, number of reflux episodes, and total percent time of pH 95 was significantly higher at 48 hrs vs 24 hrs for both heartburn and regurgitation (31% vs 22%, p=0.003 and 21% vs 13%, p= 0.005). As expected, 48 hour testing also captured a significantly higher number of reflux episodes as compared to 24 hour results alone (97 vs 47, p 95 for typical symptoms of GERD. Prolonged recording of patient symptoms and/or sedation effects may account for the better symptom correlation. Although there were no statistical differences seen in this study between 24 and 48 hour studies for total percent time pH <4, 48 hr studies captured significantly more reflux episodes as compared to 24 hr monitoring alone. These results suggest that patients undergoing wireless pH monitoring should have 48 hour studies performed as standard of practice.

Mosapride in the Treatment of Gastrointestinal Disorders

Prokinetic drugs are being used with increasing frequency in the treatment of functional gastrointestinal disorders including functional dyspepsia (FD) and constipation-predominant Irritable Bowel Syndrome (IBS-C). Mosapride is a gastro-prokinetic agent that acts as a selective 5-HT4 agonist thereby accelerating gastric emptying. It has been used for the treatment of irritable bowel syndrome (IBS), functional dyspepsia (FD), and gastroesophageal reflux (GERD). Mosapride shares physiologic effects with previous 5-HT4 agonists, cisapride and tegaserod, but with a safer cardiac profile.