Christine Hachem

Meeting vaccination quality measures for hepatitis A and B virus in patients with chronic hepatitis C infection

Coinfection with hepatitis A virus (HAV) or hepatitis B virus (HBV) in patients with chronic hepatitis C virus (HCV) is associated with increased morbidity and mortality. The Center for Medicare and Medicaid Services has identified HAV and HBV vaccination as a priority area for quality measurement in HCV. It is unclear to what extent patients with HCV meet these recommendations. We used national data from the Department of Veterans Affairs HCV Clinical Case Registry to evaluate the prevalence and predictors of meeting the quality measure (QM) of receiving vaccination or documented immunity to HAV and HBV in patients with chronic HCV. We identified 88,456 patients who had overall vaccination rates of 21.9% and 20.7% for HBV and HAV, respectively. The QM rates were 57.0% and 45.5% for HBV and HAV, respectively. Patients who were nonwhite or who had elevated alanine aminotransferase levels, cirrhosis, or human immunodeficiency virus were more likely to meet the HBV QM. Factors related to HCV care were also determinants of meeting the HBV QM. These factors included receiving a specialist consult, genotype testing, or HCV treatment. Patients who were older, had psychosis, and had a higher comorbidity score were less likely to meet the HBV QM. With a few exceptions, similar variables were related to meeting the HAV QM. The incidence of superinfection with acute HBV and HAV was low, but it was significantly lower in patients who received vaccination than in those who did not. Conclusion: Quality measure rates for HAV and HBV are suboptimal for patients with chronic HCV. In addition, several patient‐related factors and receiving HCV‐related care are associated with a higher likelihood of meeting QMs. (HEPATOLOGY 2011)

Diagnosis and Management of Functional Heartburn

Heartburn is among the most common gastrointestinal symptoms presenting to both generalist physicians and gastroenterologists. Heartburn that does not respond to traditional acid suppression is a diagnostic and therapeutic dilemma. In the era of high utilization of proton pump inhibitors, a substantial proportion of patients presenting to the gastroenterologist with chronic symptoms of heartburn do not have a reflux-mediated disease. Subjects without objective evidence of reflux as a cause of their symptoms have “functional heartburn”. The diagnostic role of endoscopy, reflux and motility testing in functional heartburn (FH) patients is discussed. Lifestyle modifications, pharmacological interventions, and alternative therapies for FH are also presented. Recognition of patients with FH allows earlier assignment of these patients to different treatment algorithms, which may allow greater likelihood of success of treatment, diminished resource utilization and improved quality of life. Further data on this large and understudied group of patients is necessary to allow improvement in treatment algorithms and a more evidence-based approach to care of these patients.

Recurrent Nausea, Vomiting, and Abdominal Pain

C uestion: A 34-year-old woman presented with recurrent ausea, vomiting, and abdominal pain over a 6-month peiod. She denied respiratory or cutaneous symptoms. Her ast medical history was significant for a history of hyperension, gastroesophageal reflux, and melanoma, which was esected from her left thigh 3 years ago. Lymph node issection at the time was negative. During these epiodes, she was afebrile and had a normal serum white lood cell count, electrolytes, and liver function tests. omplement and C1 esterase inhibitor levels were noral. However, her C-reactive protein was elevated. Her edications included lisinopril, hydrochlorothiazide, rotonix, an oral contraceptive, iron, and occasional nonteroidal anti-inflammatory drugs. For each episode, she as admitted to the hospital and nonspecific bowel wall hickening was noted on cross-sectional imaging. Magetic resonance imaging (MRI) performed during an epsode of pain revealed segmental ileal wall thickening ith associated ascites (Figures A and B). She was initially treated with steroids and antibiotics ith resolution of symptoms. However, symptoms coninued to recur inspite of steroid use. Upper and lower ndoscopies with biopsies were unrevealing. Laparoscopic urgery and biopsies performed during an episode were also nrevealing. In between episodes, she was asymptomatic nd imaging normalized. With a therapeutic maneuver, no urther episodes occurred. What is the most likely diagnois? See the GASTROENTEROLOGY web site (www.gastrojournal. rg) for more information on submitting your favorte image to Clinical Challenges and Images in GI. CHRISTINE Y. HACHEM, MD Department of Medicine Division of Gastroenterology Saint Louis University N. CEM BALCI, MD Department of Radiology Saint Louis University DEVANG DESAI, MD Department of Radiology St. John’s Mercy Medical Center Saint Louis, Missouri

Continuing Medical Education Questions: July 2018

3. Your patient with autoimmune hepatitis on prednisone and azathioprine has normalized her liver transaminases and IgG level. However, she returns for her 18-month follow-up visit with more fatigue and anorexia. She has lost 15 pounds and her body mass index is 16 kg/m2. Blood work demonstrates rising AST and ALT levels >200 U/L. Normal bilirubin and alkaline phosphatase is noted. Her 6-thioguanine nucleotide level is 50 pmol/8 × 108 red blood cells. Her 6-methylmercaptopurine level is low. What do you suspect is the most likely cause of her rise in transaminases?

Mixed Adenocarcinoma and Squamous Cell Carcinoma of Duodenum: A Case Report and Review of the Literature

Despite being the largest part of the human gastrointestinal (GI) tract, the small intestine accounts for only 1–1.4% of all GI malignancies. Adenocarcinoma is the most common primary small bowel malignancy, with the most common site being the duodenum. On the other hand, squamous cell carcinoma (SCC) of the duodenum is extremely uncommon. We report the first case of mixed adenocarcinoma and SCC occurring in the third part of duodenum (D3). Our patient, a 64-year-old female with history of GERD, hypertension, and IDDM presented with 4 weeks of nausea, vomiting, and abdominal pain. Tomographic imaging of her abdomen demonstrated a distended stomach and a proximal duodenum with narrow caliber changes at the level of D3. An EGD revealed a tight stricture at D3 that could not be traversed. Stricture biopsies revealed duodenal mucosa with two small foci of SCC (positive for p63 and CK5/6) and adenocarcinoma (positive for CK7 and Moc31). Peritoneal metastases were detected on exploratory laparotomy, making the tumor surgically incurable. As she progressively declined and with worsening liver enzymes and general debility, she was not a candidate for chemotherapy and was eventually discharged on home hospice. Small bowel SCC/adenocarcinoma is an exceedingly uncommon cancer, making further case reports such as ours important to understand the nature of this entity and establish management guidelines.

Response to Scaringi et al.

To the Editor: We appreciate the interest of Dr Scaringi and colleagues ( 1 ) in regard to our article on functional heartburn ( 2 ). Th eir thesis on the dysfunction of the gastro-esophageal junction as a potential contributing factor to functional heart burn is interesting. We agree that, although currently available tests to assess the function of the GE junction are improving, their sensitivity to detect subtle dysfunction that could be the genesis of symptoms, is unclear. Even with high-resolution manometry, impedance, and newer methods of pH testing, the number of equivocal tests remains high. In addition, the thresholds for abnormality are oft en unclear. Th e extent to which these abnormalities represent true pathology, as opposed to variants of normal, will likely determine the degree to which esophagogastric junction patho logy might be responsible for symptoms of functional heartburn. We agree that more studies are needed to evaluate these variables in patients with functional heartburn.

Peritonitis following Endoscopy in a Patient on Peritoneal Dialysis with a Discussion of Current Recommendations on Antibiotic Prophylaxis.

Patients on peritoneal dialysis (PD) are at increased risk for peritonitis. We report a case of a patient with end-stage renal disease on continuous ambulatory PD (CAPD) who developed peritonitis within 24 h of upper endoscopy with biopsy and colonoscopy with polypectomy. He had a previous history of peritonitis unrelated to invasive procedures and eventually was transitioned to hemodialysis because of his recurrent peritonitis. The International Society for Peritoneal Dialysis (ISPD) and newly revised American Society for Gastrointestinal Endoscopy (ASGE) guidelines recommend prophylactic antibiotics for CAPD patients undergoing endoscopic procedures. Other guidelines do not address this issue, and there has been limited evidence to support recommendations.