Cecilio Azar

A randomized single-blind trial of split-dose PEG-electrolyte solution without dietary restriction compared with whole dose PEG-electrolyte solution with dietary restriction for colonoscopy preparation

BACKGROUND Colonoscopy preparation regimens are poorly tolerated, requiring the use of a large volume of an unpalatable solution and diet restriction for adequate cleansing. The aim of this study was to compare the efficacy of two regimens of bowel preparation before colonoscopy: a whole dose of polyethylene glycol electrolyte solution (PEG-E), with diet restriction vs. a split dose with no diet restriction. METHODS A total of 141 patients (ages 20-84 years, 81 men) were randomly assigned to receive either 4 L PEG-E, along with a liquid diet the day before colonoscopy (Group A) or 2 L PEG-E with a regular diet the day before colonoscopy followed by another 2 L PEG-E on the day of the procedure (Group B). The quality of the preparation was graded by the endoscopist (poor to excellent), who was blinded to the type of preparation. Tolerability of the assigned preparation and adverse effects were recorded by an independent investigator by using a questionnaire administered before colonoscopy. Intra- and interobserver variability was studied by using randomly chosen videotapes of colonoscopies performed as part of the study. RESULTS There were 73 patients in Group A and 68 patients in Group B. The quality of the preparation was significantly better in Group B ( p = 0.011). The tolerability of the preparation regimen was not different overall between study groups in terms of side effects (except for bloating, which was more frequent in Group B, p = 0.039) or willingness to repeat the preparation. There was a nonsignificant trend toward improved adherence to the assigned preparation in favor of Group B ( p = 0.062). Inter- and intraobserver variability analysis showed good to excellent correlation among endoscopists. CONCLUSIONS Colonic preparation with split-dose PEG-E and no dietary restriction provides better quality colon cleansing than whole-dose preparation, with no significant impact on patient tolerability and side effects.

Clinical epidemiology of inflammatory bowel disease in Lebanon

Background: The objectives of this study were to determine the prevalence and incidence of inflammatory bowel disease (IBD) in a representative Lebanese cohort and to describe practice prevalence trends, disease characteristics, and impact on quality of life (QoL) of IBD patients in Lebanon. Methods: All of a university‐based health programs 2000–2004 computerized records that listed a diagnosis of Crohns disease (CD) or ulcerative colitis (UC) were reviewed. In addition, data on patients seen in the gastroenterology clinics and data from the IBD registry at the American University of Beirut Medical Center (AUBMC) from the same period were analyzed. Results: Of 15,073 insured individuals, 8 had a diagnosis of CD and 16 of UC, giving an age‐adjusted prevalence of 53.1 per 100,000 people for CD and 106.2 per 100,000 people for UC. The mean age at diagnosis for patients with CD and UC was 28.8 ± 11.1 and 32.0 ± 13.4 years, respectively, and there was a slight female predominance. The mean annual incidence was 4.1 per 100,000 people for UC and 1.4 per 100,000 people for CD (range, 0–6.9/100,000 for both). Of the 10,383 patients seen in the gastroenterology clinic from 2000 to 2004, 251 (2.4%) had IBD (142 UC, 100 CD, and 9 indeterminate), a ratio that trended upward over time (range, 1.8%–2.7%). The median IBD Quality‐of‐Life (IBDQ) questionnaire score was 124.9 ± 30.5, indicating that the disease had a moderately severe impact on QoL. Conclusions: The prevalence of IBD in this representative Lebanese cohort falls in the intermediate range of that reported for white populations in Europe and North America. Future studies are needed to examine local risk factors, disease genotypes and phenotypes, and epidemiologic time trends. The psychosocial burden of IBD in Lebanon appears significant.

A randomized, controlled, double-blind trial of the adjunct use of tegaserod in whole-dose or split-dose polyethylene glycol electrolyte solution for colonoscopy preparation

BACKGROUND Problems of compliance, quality, and safety of colon preparation regimens have prompted continued investigation with alternative forms of cleansing. OBJECTIVE To evaluate the efficacy of tegaserod as an adjunct to a polyethylene glycol electrolyte solution (PEG-E), given as a whole dose or split dose, in colonoscopy preparation. DESIGN Randomized, placebo-controlled, double-blind trial. SETTING A single university-based hospital. PATIENTS Patients who were undergoing elective colonoscopy. INTERVENTIONS A 4-arm randomization scheme that compared tegaserod with a placebo, each with whole-dose or split-dose PEG-E preparation. MAIN OUTCOME MEASUREMENTS Efficacy of colon cleansing was the primary outcome. Secondary outcomes included adherence, tolerability, adverse effects, and patient perceptions of their preparation quality. RESULTS A total of 382 patients completed the trial. Patients who received the split-dose preparation had significantly better colon cleansing than those who received the whole-dose preparation (88.9% vs 42.6%, P < .001). The addition of tegaserod did not significantly improve the overall colonoscopy preparation quality compared with a placebo. However, there were fewer poor preparations in the whole-dose PEG-E group (12.4% vs 1.1%, P = .002, Bonferroni correction removes significance) and more excellent preparations in the split-dose group (53.3% vs 38.3%, P = .035, Bonferroni correction removes significance) in favor of tegaserod. Interobserver and intraobserver variability analysis showed substantial agreement among endoscopists. Adherence was significantly lower in the whole-dose group versus the split-dose PEG-E group (68.8% vs 91%, P < .001), independent of the use of tegaserod. Adverse effects were not different between study groups. LIMITATIONS A 4-arm randomization and the single-center nature of the study. CONCLUSIONS Tegaserod has a marginal effect on the quality of colonoscopy preparation when used as an adjuvant to PEG-E. The split-dose PEG-E was superior to the whole-dose PEG-E and resulted in better colon cleansing, adherence, and tolerance.

Prevalence of endoscopically identified heterotopic gastric mucosa in the proximal esophagus : Endoscopist dependent?

Goals The aim of this study is to determine the prevalence of heterotopic gastric mucosa in the proximal esophagus (HGMPE) and whether thorough endoscopic search may influence such prevalence. Background Heterotopic gastric mucosa in the esophagus (sometimes known as inlet patch) refers to a discrete area of gastric mucosa, with a spherical or ellipsoid configuration, that is typically located in the proximal esophagus. The prevalence of endoscopically diagnosed HGMPE varies from 0.1% to 10%. Endoscopic detection may be difficult as HGMPE is often located at or just below the upper esophageal sphincter. It might be associated with severe complications such as bleeding, perforation, fistula, and stricture formation, in addition to the development of adenocarcinoma. Study During a 2-year period, 455 consecutive patients with various gastrointestinal complaints underwent esophagogastroduodenoscopy by a single endoscopist (group 1). This endoscopist paid special attention to detecting HGMPE by thoroughly examining the proximal esophagus upon withdrawal of the endoscope. During the same period of time, endoscopy reports of 472 patients who underwent esophagogastroduodenoscopy in the same hospital by 3 other endoscopists were retrospectively reviewed (group 2). These endoscopists were aware of the existence of the HGMPE and reported that the presence of HGMPE would be included as an endoscopic finding in their reports. Results In the first group, HGMPE was identified in 12 out of 455 patients (2.6%). Whereas in the second group, only 2 out of 472 patients (0.4%) had reports identifying HGMPE (P<0.01). Conclusions Endoscopic detection of HGMPE is influenced by the endoscopists thorough search of this entity, and thus, more time devoted to such a search may lead to higher detection rates.

Clinical trial: a randomized controlled cross‐over study of flupenthixol + melitracen in functional dyspepsia

Background  Functional dyspepsia is a prevalent condition associated with diminished quality of life (QoL) and high economic burden.

Endoscopic ultrasound-guided celiac plexus neurolysis

Endoscopic celiac plexus neurolysis (CPN) has become the procedure of choice for the management of patients with pancreatic cancer and abdominal pain unresponsive to medical treatment. It is necessary to differentiate between CPN and endoscopic celiac plexus block performed in patients with benign disease. In this review we describe the technique of this procedure with special emphasis on technical details.

Challenging the dogma: a randomized trial of standard vs. half-dose concomitant nonbismuth quadruple therapy for Helicobacter pylori infection

Background Current treatment of Helicobacter pylori consists of three or four drugs for 7–14 days with important associated cost and adverse events. Aims This study compared efficacy and safety of standard dose vs. half-dose concomitant nonbismuth quadruple therapy (NBQT) for 7 days. The standard dose consisted of twice daily rabeprazole 20 mg, amoxicillin 1 g, metronidazole 500 mg, and clarithromycin 500 mg. Methods This was a prospective randomized trial. 14C-urea breath test was performed ≥4 weeks after treatment and ≥2 weeks off acid suppressive therapy. Compliance and adverse events were monitored during treatment. Results A total of 200 consecutive treatment-naïve patients were enrolled. Baseline characteristics were similar between groups, with 15.5% of subjects reporting prior macrolide use. Eradication occurred in 78% (95% CI 68.6–85.7%) in both groups on intention-to-treat analysis. Per-protocol rates were 82.1 vs. 83.9% for standard-dose patients vs. half-dose patients, respectively (p = NS). Adverse events (only mild) were reported in 57 vs. 41% of standard-dose patients vs. half-dose patients (p = 0.024), with metallic taste and nausea notably less frequent in the latter (36 vs. 12% and 18 vs. 7%, respectively; p < 0.05 for both). Overall, eradication failed in 38.7% of prior macrolide users vs. 18.9% without such exposure (p = 0.019). On multivariate logistic regression, prior macrolide exposure was the only factor associated with failed eradication (OR 2.60, 95% CI 1.06–6.39; p = 0.038). Treatment was cheaper with the half-dose regimen. Interpretation A 50% reduction in antibiotic dosage does not diminish efficacy of concomitant nonbismuth quadruple therapy but leads to significant reduction in cost and adverse events. Seven-day concomitant NBQT is suboptimal for H. pylori independent of prior macrolide exposure.

Severe hepatotoxicity associated with the combination of spiramycin plus metronidazole.

Drug-induced liver injury (DILI) is a leading cause of acute liver failure and is the most frequent reason for post-marketing drug withdrawal. The spectrum of liver injury is wide, ranging from mild and subclinical injury, noticeable only on routine biochemical testing, to fulminant liver failure and death. Antibiotics, as a group, are a leading cause of DILI. We herein describe 4 patients who developed moderate to severe hepatotoxicity after exposure to a commercially - available combination of two antibiotics - spiramycin and metronidazole - commonly used for the treatment and prevention of periodontal infections. No other aetiology for liver injury could be identified in all cases. Two patients recovered spontaneously, and two had a more severe course, one responding to corticosteroids and mycophenolate mofetil and the other requiring liver transplantation for subacute massive necrosis.

Budd-Chiari syndrome with underlying homozygous factor V Leiden and heterozygous methylenetetrahydrofolate reductase mutations.

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