Annette Kyprianou

Focal neurological signs in cirrhotic patients with episodes of hepatic encephalopathy.

This issue features a very interesting article suggesting that focal neurological signs are not uncommon in cirrhotic patients experiencing episodes of hepatic encephalopathy (HE) (1). As stated by Adams and Foley in their classic monograph, there are essentially two elements in HE: 1) a disorder of consciousness; and 2) generalized motor disturbances (2). It has been widely accepted that HE as a diffuse metabolic encephalopathy should present with symmetrical neurological abnormalities. However, Adams and Foley clearly mention that there were inequalities of deep tendon reflexes in about 25% of their cases. Our experience has been similar. We often encounter patients with striking asymmetry of hyperreflexia, which fluctuates from hour to hour. No doubt other clinicians have noted this phenomenon from time to time, which raises concerns about structural lesions in the brain.

Severe hemorrhagic gastritis after percutaneous endoscopic gastrostomy tube placement

1. Mansoor H, Masood MA, Yusuf MA. Complications of percutaneous endoscopic gastrostomy tube insertion in cancer patients: a retrospective study. J Gastrointest Cancer 2014;45:452-459. 2. Schurink CA, Tuynman H, Scholten P, et al. Percutaneous endoscopic gastrostomy: complications and suggestions to avoid them. Eur J Gastroenterol Hepatol 2001;13:819-823. 3. Nishiwaki S, Araki H, Takada J, et al. Clinical investigation of upper gastrointestinal hemorrhage aft er percutaneous endoscopic gastrostomy. Dig Endosc 2010;22:180-185. Departments of aMedicine (Abhijeet Waghray); bGastroenterology (Amy Michel-Calderon, Annette Kyprianou, Nisheet Waghray), MetroHealth Medical Center/Case Western Reserve University, Cleveland, OH, USA

Unsedated Transnasal Endoscopy (uTNE): Not Quite Ready to Replace Sedated Esophagogastroduodenoscopy (sEGD).

Unsedated Transnasal Endoscopy (uTNE): Not Quite Ready to Replace Sedated Esophagogastroduodenoscopy (sEGD)

Many factors affecting the quality of bowel preparation need to be discussed when comparing different regimes.

Many Factors Affecting the Quality of Bowel Preparation Need to be Discussed When Comparing Different Regimes

Low-Residue Diet With Bowel Prep: Not for Everyone!

on chronic liver failure, with sepsis, spontaneous bacterial peritonitis, and variceal bleed being the acute insult on underlying chronic liver disease. Mortality in patients with HE varies from 14 % to 62 % according to the severity of liver disease and the grade of HE, as did the results in our study (lactulose and placebo) group ( 3 – 5 ). Our protocol in this study was to take cultures at the time of admission from the patient ’ s blood, the endotracheal tube if the patient is intubated, the urine, the ascitic fl uid if ascitis is present, and from any central line if present before coming to our hospital. When the patient was admitted in the intensive care unit, repeat cultures were taken every fourth day, and if the patient was in the ward cultures were taken only in case of suspicion of disease. Results of these cultures were available to us within 48 hours and the antibiotics were changed accordingly in both groups within 72 h. However, in case of negative cultures and clinical suspicion of infection, the antibiotics were upgraded. Results of this study showed that a combination of therapy (rifaximin and lactulose) was more eff ective in management of overt HE and it decreased hospital stay and in-hospital mortality. However, we agree with the concerns of Congly et al. ( 1 ) that the results of this study should be verifi ed in large multicentre trials with further follow-up at 1,3, and 6 months.

When It Comes to Gastric Cancer, There Is More to It Than H. pylori !

To the Editor: We read with interest the article by Bae et al. ( 1 ) regarding the eff ect of Helicobacter pylori eradication on metachronous recurrence of gastric cancer. Th e article does not provide adequate information regarding additional factors that may aff ect the recurrence rate of metachronous gastric cancer. We also describe the importance of explaining why a signifi cant percentage of patients were not eradicated and how chromoendoscopy has increased the yield in detecting early gastric cancer compared with conventional methods. Although tobacco use was listed as one of the baseline characteristics, no information regarding the number of pack-years was noted. Several meta-analyses demonstrate the eff ect that smoking has on the development of gastric cancer and that the risk increases signifi cantly with increasing number of pack-years ( 2 ). Obesity has been associated with an increased risk for gastric cancer. In a meta-analysis of cohort studies ( 3 ), excess body weight (body mass index (BMI) ≥ 25 kg / m 2 ) was associated with an increased risk for gastric cancer (odds ratio (OR) = 1.22, 95 % confi dence interval (CI) 1.06 – 1.41) and the strength of the association increased with increasing BMI. In addition, there are associations between gastric cancer and socioeconomic status. Several studies ( 4,5 ) discovered that the risk for distal gastric cancer is increased by approximately twofold in populations with low socioeconomic status, whereas proximal gastric cancers have been associated with higher socioeconomic class. antibiotic resistance, proper education, and fi nancial issues could contribute to eradication failure. Several stains have been used to increase the detection rates of early gastric cancer ( 14 ). It is possible that, without these stains, several cancers that were too small to visualize initially may have been undetected, resulting in synchronous gastric cancers in the follow-up period, which were then subsequently misclassifi ed as metachronous cancer. Two studies have shown the utility of these stains ( 15,16 ). Th e detection rate of early gastric cancers increased from 28 % under standard white-light imaging to 89 % aft er methylene blue-Congo red staining in one study ( 15 ). Th is staining technique also facilitated the detection of carcinomatous foci 4 – 10 mm in size not visible with conventional endoscopy ( 16 ). To conclude, Bae et al. ( 1 ) have conducted an important study, but as mentioned there are several other reasons why patients may have a recurrence of gastric cancer.

Re: proton pump inhibitors and risk for recurrent Clostridium difficile infection among inpatients.

Re: Proton Pump Inhibitors and Risk for Recurrent Clostridium difficile Infection Among Inpatients