Christian S. Jackson

Management of Gastrointestinal Angiodysplastic Lesions (GIADs): A Systematic Review and Meta-Analysis

OBJECTIVES:Gastrointestinal angiodysplastic lesions (GIADs) are defined as pathologically dilated communications between veins and capillaries. The objective of this systematic review and meta-analysis was to determine the efficacy of available treatment modalities for GIADs.METHODS:We identified eligible studies by searching through PubMed, SCOPUS, and Cochrane central register of controlled trials. We searched for clinical trials examining the efficacy of endoscopic, pharmacologic, or surgical therapy for GIADs. Data were pooled using a random-effects model, and the effect of response to medical or surgical therapy was reported as odds ratios with 95% confidence intervals (CIs). Data and quality indicators were extracted by two authors from 22 studies, including 831 individuals with GIADs. The analysis included 623 patients treated with endoscopic therapy, 63 with hormonal therapy, 72 patients with octreotide, and 73 status post aortic valve replacement surgery.RESULTS:Hormonal therapy, based on two case–control studies, was not effective for bleeding cessation (odds ratio: 1.0, 95% CI: 0.5–1.96). On the basis of 14 studies including patients with gastric, colonic, and small-bowel GIADs, endoscopic therapy was effective as initial therapy, but the pooled recurrence bleeding rate was 36% (95% CI: 28–44%) over a mean (±s.d.) of 22±13 months. The event rate for re-bleeding increased to 45% (95% CI: 37–52%) when studies including only small-bowel GIADs were included (N=341). In four studies assessing the efficacy of somatostatin analogs, the pooled odds ratio was 14.5 (95% CI: 5.9–36) for bleeding cessation. In two studies assessing the role of aortic valve replacement (AVR) in 73 patients with Heydes syndrome, the event rate for re-bleeding was 0.19 (95% CI: 0.11–0.30) over a mean follow-up period of 4 years postoperatively.CONCLUSIONS:Over one-third of patients with GIADs experienced re-bleeding after endoscopic therapy. Somatostatin analogs and AVR for Heydes syndrome appeared to be effective therapy for GIADs.

Increased risk for colorectal cancer under age 50 in racial and ethnic minorities living in the United States.

Colorectal cancer (CRC) is the second most common cause of cancer death in USA. We analyzed CRC disparities in African Americans, Hispanics, Asians/Pacific Islanders, and American Indians/Alaska Natives compared to non‐Hispanic Whites. Current guidelines recommend screening for CRC beginning at age 50. Using SEER (Surveillance, Epidemiology, and End Results) database 1973–2009 and North American Association of Central Cancer Registries (NAACCR) 1995–2009 dataset, we performed frequency and rate analysis on colorectal cancer demographics and incidence based on race/ethnicity. We also used the SEER database to analyze stage, grade, and survival based on race/ethnicity. Utilizing SEER database, the median age of CRC diagnosis is significantly less in Hispanics (66 years), Asians/Pacific Islanders (68 years), American Indians/Alaska Natives (64 years), and African Americans (64 years) compared to non‐Hispanic whites (72 years). Twelve percent of Asians/Pacific Islanders, 15.4% Hispanics, 16.5% American Indians/Alaska Natives, and 11.9% African Americans with CRC are diagnosed at age <50 years compared to only 6.7% in non‐Hispanic Whites (P < 0.0001). Minority groups have more advanced stages at diagnosis compared to non‐Hispanic Whites. Trend analysis showed age‐adjusted incidence rates of CRC diagnosed under the age of 50 years have significantly increased in all racial and ethnic groups but are stable in African Americans. These results were confirmed through analysis of NAACCR 1995–2009 dataset covering nearly the entire USA. A significantly higher proportion of minority groups in USA with CRC are diagnosed before age 50 compared to non‐Hispanic Whites, documenting that these minority groups are at higher risk for early CRC. Further studies are needed to identify the causes and risk factors responsible for young onset CRC among minority groups and to develop intervention strategies including earlier CRC screening, among others.

Prevention of colorectal cancer with vitamin D

Abstract The fact that colorectal cancer (CRC) is the second leading cause of cancer mortality in the United States emphasizes the need for more effective preventive and therapeutic modalities. There is growing evidence that vitamin D may reduce the incidence of CRC. Results of epidemiologic, in vitro, in vivo animal and clinical studies suggest that a low serum vitamin D level may be a serious risk factor for CRC and a high serum vitamin D level may reduce the risk of CRC. On a molecular level, vitamin D suppresses CRC development and growth by affecting cell proliferation, differentiation, apoptosis, and angiogenesis. Vitamin D insufficiency and CRC are common in the elderly population. Vitamin D insufficiency is simple to screen for and treatable with vitamin D supplementation. Serum 25-hydroxyvitamin D (calcidiol) is the best measure of vitamin D status and should be checked routinely for individuals with risk factors for CRC. Maintaining serum concentrations of calcidiol above 32 ng/ml (80 nmol/l) in individuals whose serum calcidiol level is low may help prevent CRC as well as osteoporosis, fractures, infections, and cardiovascular disease. Daily calcidiol intake of 1000 International Units can increase serum vitamin D to sufficient levels in most elderly persons and, based on available data, may substantially lower the incidence of CRC with minimal risks.

Gastrointestinal angiodysplasia is associated with significant gastrointestinal bleeding in patients with continuous left ventricular assist devices

Background and study aims: Patients with a continuous-flow left ventricular assist device (LVAD) have a 65 % incidence of bleeding events within the first year. The majority of gastrointestinal bleeding (GIB) is from gastrointestinal angiodyplasia (GIAD). The primary aim of the study was to determine whether GIAD was associated with a higher rate of significant bleeding, an increased number of bleeding events per year, and a higher rate of transfusion compared to non-GIAD sources. Patients and methods: This retrospective cohort study included 118 individuals who received a LVAD at a tertiary medical center from 2006 through 2014. Patients were subdivided into GIB and non-GIB for comparison of patient demographics, comorbid conditions, and laboratory data. GIB was further divided into sources of GIB, GIAD, obscure, or non-GIAD to establish severity of bleeding, rate of re-bleeding, and transfusion rate. Results: GIAD is associated with an increased number of bleeding events compared to non-GIAD sources of GIB (2.07 vs 1.23, P = 0.01) and a higher number of bleeding events per year (0.806 vs. 0.455 P = 0.001). GIAD compared to non-GIAD sources of GIB was associated with an increased incidence of major bleeding (100 % vs 60 %, P = 0.006) and increased rates of transfusion (8.8 vs 2.95 units, P = 0.0004). Cox Regression analysis between non-GIB and GIAD demonstrated increased risk with age (P = 0.001), history of chronic kidney disease (P = 0.005), and length of stay after LVAD implantation of more than 45 days (P = 0.04). History of hypertension (P = 0.045), diabetes mellitus (P = 0.016), and male gender was associated with decreased risk (P = 0.04). Conclusion: Patients with a continuous-flow LVAD who develop a GIB secondary to GIAD have a higher rate of major bleeding, multiple bleeding events, and require more transfusions to achieve stabilization compared to patients who do not have GIAD.

Helicobacter pylori breath testing in an open access system has a high rate of potentially false negative results due to protocol violations.

Among available tests to detect Helicobacter pylori (H. pylori), urea breath test (UBT) is the most accurate when performed correctly in research protocols with unknown validity in clinic settings.

Endocuff assisted colonoscopy significantly increases sessile serrated adenoma detection in veterans

BACKGROUND Colorectal cancer (CRC) is the second most common cause of cancer related deaths in the United States. Colonoscopy is the gold standard for the detection of CRC. There are many colonoscopy quality measures and among these the adenoma detection rate (ADR) has demonstrated a significant impact in reducing mortality from CRC. The primary aim of our study was to compare ADR and distribution of polyp type in patients undergoing Endocuff-assisted colonoscopy (EAC) versus standard colonoscopy (SC) in a VA system. METHODS Retrospective data was collected from 496 patients who underwent routine screening, surveillance and diagnostic colonoscopies either via SC from January 6, 2014 through March 12, 2014 or EAC from September 24, 2014 through February 19, 2015. A total of 54 patients were excluded based on a personal history of CRC and prior resection, incomplete colonoscopy due to poor bowel preparation, and removal or loss of Endocuff (EC). Primary outcomes measured and compared were ADR and types of polyps found. RESULTS The overall ADR in the EAC group was higher at 59.91% versus 50.66% for SC, accounting for a 9% increase (P=0.0508). EAC was able to detect a total of 59 sessile serrated adenoma/polyps (SSA/Ps) compared to SC only detecting 8 (P≤0.0001). There was a significant increase in the SSA/P detection rate with EAC at 15% versus 3% in the SC group (P≤0.0001). CONCLUSIONS EAC significantly increases the detection of SSA/P and has shown a trend in improving ADR in our veteran population.

The Dieulafoy's Lesion: An Update on Evaluation, Diagnosis, and Management.

Dieulafoy’s lesion (DL) is a persistently wide caliber artery that is observed more frequently at the fifth decade of life in the male population with multiple comorbidities. There are a variety of endoscopic therapies that have been used to treat DL; however, there are no clear guidelines on the best treatment modality. This article systematically reviews the diagnosis, the most commonly reported therapies of DL, and offers a suggested algorithm based upon efficacy of treatment such as initial hemostasis, rebleeding rates, and mortality.

Obese minorities have a higher prevalence of H. pylori than do whites, but nonsignificant differences in upper gastrointestinal tract findings, before laparoscopic adjustable gastric banding.

To the Editor: Laparoscopic adjustable gastric banding (LAGB) has become one of the most common weight-loss surgical procedures in the United States, with a reported 329% increase from 2004 to 2007.1 Before performing bariatric surgery, an extensive preoperative assessment needs to be made. Part of the preoperative assessment is performing an esophagogastroduodenoscopy (EGD),2 but its role is controversial. The purpose of performing EGD before bariatric surgery is to diagnose pathology, which may influence the perxformance of the surgery—for example, severe sequelae of gastroesophageal reflux disease, esophageal strictures, peptic ulcers, and tumors of the esophagus or stomach.2,3 While performing preoperative EGDs we anecdotally noted that the mostly asymptomatic patients had a lot of positive endoscopic findings, more so than our symptomatic nonobese population. That is why we decided to conduct a retrospective analysis of the findings, as there have been no previous studies on routine EGDs in asymptomatic patients before bariatric surgery. Because a large portion of the bariatric group is made up of minority patients, we also wanted to compare them with whites in the cohort. We hypothesized that there would be no clinically significant differences between the groups, because they were generally asymptomatic. From May to September 2009, a consecutive series of 253 obese patients (body mass index was 42.4±5.5; female: 68%, mean age 38.5±10.5; male: 32%, mean age 38.2±9.7) underwent EGD before LAGB. Most patients were of Hispanic origin (58%), followed by whites (28%) and African Americans (14%). Ninety-eight percent of the patients who presented for EGD were asymptomatic. Most patients reported not consuming any nonsteroidal anti-inflammatory drugs (NSAIDs) (99%), tobacco (87%), or alcohol (85%). Helicobacter pylori was positive in 29% of the gastric biopsies. Fifty-four percent had nonerosive gastropathy and 24% had erosive gastropathy; 2% had duodenal ulcers, and 8% had gastric ulcers. Esophageal ulcers were found in 6% of patients and were subsequently classified as idiopathic, considering that cytomegalovirus or herpes simplex virus was not found on biopsy and they were not observed in the setting of Barrett mucosa. The Los Angeles classification was used to diagnose erosive esophagitis, and the raw data revealed 3 patients with Los Angeles grade A, 5 patients with grade B, and no patients with grade C or D. These cases were categorized together under esophagitis for a total of 3% of the patients. A hiatal hernia was found in 20% of the patients. No upper gastrointestinal tract (UGI) malignancies were found. Analysis of variance found a significant difference in age among the different race groups with white being the oldest at 42.7 years, followed by African Americans at 39.9 years, and Hispanic patients the youngest at 35.8 years of age (P<0.0001). There was a difference in the prevalence of H. pylori infection among race groups: 36% in Hispanics, 29% in African Americans, and 15% in whites (P=0.008). The Hispanics and African Americans combined had an H. pylori prevalence of 34% (P=0.003) compared with whites. There were no significant differences between the different race groups and body mass index, protonpump inhibitor use (P=0.38), NSAIDs, tobacco, or alcohol. Among the bariatric patient population, there are no studies that screen asymptomatic patients in a minority population before LAGB. The basis of the null hypothesis for this study was that any pathology on upper endoscopic evaluation of asymptomatic, obese patients before LAGB would not be found, and thus differences between ethnic groups would not be significant. Even though the results of this study cannot form a cause and effect relationship, interesting conclusions can be drawn. First and foremost, the most striking result of this study is that of all the patients with positive endoscopic findings 78% had undergone gastropathy. This is higher than what had been previously reported in the literature. The majority of patients did not have identifiable risk factors for the development of gastritis: NSAIDs (1%), tobacco (13%), or alcohol (15%). It is especially notable because, of these patients, only 33% were H. pylori positive, in contrast to another study in which the prevalence of H. pylori infection was 53%.4 Even though our percentage of biopsy-proven H. pylori was lower than what has been previously reported, the eradication of H. pylori before surgery is important as studies have shown that H. pylori infection may lead to the development of postoperative marginal ulcers and strictures.5 Statistically significant differences were found in certain aspects of this study. One was in the mean age of the patients when compared across race. White patients were typically older (42.7±10.8) than African Americans (39.9±11.2) and Hispanics (35.8±8.9). Diabetes and the presence of the metabolic syndrome are more prevalent in the African American and Hispanic populations.6,7 African Americans and Hispanics tend to be obese at an earlier age and thus may seek bariatric weight-loss options earlier than whites.8 Another statistically significant finding was the higher biopsy-proven H. pylori infection found in African American and Hispanic patients (P< 0.05). This was expected, as it has been published in multiple articles that African Americans and Hispanics consistently have higher infection rates of H. pylori.9 This has also been shown when H. pylori infection rates among obese African Americans and Hispanics were compared with those of whites.10 These data were considered with some caution, because there is evidence to show that the incidence of Guarantor of the Article: Dr Ariel Malamud. The authors declare that they have nothing to disclose. LETTERS TO THE EDITOR

Bleeding Meckel's diverticulum diagnosed and treated by double-balloon enteroscopy

Meckels diverticulum (MD) is the most common congenital anomaly of the gastrointestinal (GI) tract. The diagnosis of symptomatic MD has been cumbersome. Several case reports been published regarding direct visualization of MD with double balloon enteroscopy (DBE); diagnosing a bleeding MD leading to surgical resection. We report the use of DBE for the treatment of a bleeding MD.

Push enteroscopy has a 96% cecal intubation rate in colonoscopies that failed because of redundant colons

BACKGROUND Performing a complete colonoscopy to the cecum is important for ruling out malignancy and other lesions, but failure rates are significant with a standard colonoscope. A previous study using a push enteroscope for failed colonoscopies had a completion rate of 68.7%. OBJECTIVE To improve the cecal intubation rate by using a newer version of a push enteroscope. DESIGN Retrospective study at first, then a prospective study. SETTING Single-center veterans health care system. PATIENTS A total of 47 patients in whom the cecum was not reached with a regular adult colonoscope between January 2007 and December 2010 were included. Those with poor bowel preparation were excluded. INTERVENTIONS Repeat colonoscopy using a new version of a push enteroscope. MAIN OUTCOME MEASUREMENTS The rate of cecal intubation and additional pathological findings. RESULTS The cecum or terminal ileum was reached in 45 patients (96%). Additional significant pathological findings in the previously unexamined colon were seen in 18 patients (38%). LIMITATIONS Small sample size, lack of comparison with other endoscopes. CONCLUSIONS Colonoscopy with a push enteroscope could be advanced to either the terminal ileum or cecum in 96% of patients, which is one of the highest known completion rates in patients in whom colonoscopy failed. Clinical management changed in all patients with additional findings.