Daniel C. Buckles

Delayed Gastric Emptying in Gastroesophageal Reflux Disease: Reassessment with New Methods and Symptomatic Correlations

Background: Previous studies have shown that patients with gastroesophageal reflux disease (GERD) have slower rates of gastric emptying than control subjects, but the prevalence has differed because of variations in methodology. The recent establishment of international control values for scintigraphic gastric emptying assessment makes standardization of this technique possible. It would also be useful to determine whether specific gastrointestinal symptoms predicted delayed gastric emptying in GERD. Methods: Forty‐nine patients (mean age, 42.9 years; range, 24–65 years; 35 women, 14 men) who were diagnosed with GERD in the previous 12 months were given a standardized 280‐kcal 99Tc‐labeled low fat meal (egg beater). Percentage of intragastric residual content was recorded at baseline and at hourly intervals for 240 minutes by scintigraphy. Patients were also asked about the presence of dyspepsia (bloating, postprandial discomfort or belching, or early satiety), dysphagia, or regurgitation. Results: Sixteen patients (33%) had intragastric residual contents greater than the 95th percentile (>40%) at 120 minutes, and 13 (26%) had abnormal results at 240 minutes (>6%). Dyspepsia was present in all patients. Regurgitation and dysphagia were common (present in approximately 80% and 40% of patients, respectively) and the prevalence of these symptoms did not differ between patients with normal versus delayed gastric emptying. Conclusions: Using standardized techniques: 1) delayed gastric emptying is common in patients presenting with GERD at both 120 and 240 minutes after ingestion of a solid meal and 2) symptoms alone are not a useful predictor of this pathophysiology. Awareness of this subgroup of patients can be important in treatment strategies and long‐term therapy.

Impact of a computer-based teaching module on characterization of diminutive colon polyps by using narrow-band imaging by non-experts in academic and community practice: a video-based study

BACKGROUNDnExperts can accurately characterize the histology of diminutive polyps with narrow-band imaging (NBI). There are limited data on the performance of non-experts.nnnOBJECTIVEnTo assess the impact of a computer-based teaching module on the accuracy of predicting polyp histology with NBI by non-experts (in academics and community practice) by using video clips.nnnDESIGNnProspective, observational study.nnnSETTINGnAcademic and community practice.nnnPARTICIPANTSnA total of 15 gastroenterologists participated-5 experts in NBI, 5 non-experts in academic practice, and 5 non-experts in community practice.nnnINTERVENTIONnParticipants reviewed a 20-minute, computer-based teaching module outlining the different NBI features for hyperplastic and adenomatous polyps.nnnMAIN OUTCOME MEASUREMENTSnPerformance characteristics in characterizing the histology of diminutive polyps with NBI by using short video clips before (pretest) and after (posttest) reviewing the teaching module.nnnRESULTSnNon-experts in academic practice showed a significant improvement in the sensitivity (54% vs 79%; Pxa0< .001), accuracy (64% vs 81%; Pxa0< .001), and proportion of high-confidence diagnoses (49% vs 69%; Pxa0< .001) in the posttest. Non-experts in community practice had significantly higher sensitivity (58% vs 75%; Pxa0= .004), specificity (76% vs 90%; Pxa0= .04), accuracy (64% vs 81%; Pxa0< .001), and proportion of high-confidence diagnoses (49% vs 72%; Pxa0< .001) in the posttest. Performance of experts in NBI was significantly better than non-experts in both academic and community practice.nnnLIMITATIONSnSelection bias in selecting good quality videos. Performance not assessed during live colonoscopy.nnnCONCLUSIONnAcademic and community gastroenterologists without prior experience in NBI can achieve significant improvements in characterizing diminutive polyp histology after a brief computer-based training. The durability of these results and applicability in everyday practice are uncertain.

Implementation intentions and colorectal screening: a randomized trial in safety-net clinics.

CONTEXTnLow-income and racial/ethnic minority populations experience disproportionate colorectal cancer (CRC) burden and poorer survival. Novel behavioral strategies are needed to improve screening rates in these groups.nnnBACKGROUNDnThe study aimed to test a theoretically based implementation intentions intervention for improving CRC screening among unscreened adults in urban safety-net clinics.nnnDESIGNnRandomized controlled trial.nnnSETTING/PARTICIPANTSnAdults (N=470) aged ≥50 years, due for CRC screening, from urban safety-net clinics were recruited.nnnINTERVENTIONnThe intervention (conducted in 2009-2011) was delivered via touchscreen computers that tailored informational messages to decisional stage and screening barriers. The computer then randomized participants to generic health information on diet and exercise (Comparison group) or implementation intentions questions and planning (Experimental group) specific to the CRC screening test chosen (fecal immunochemical test or colonoscopy).nnnMAIN OUTCOME MEASURESnThe primary study outcome was completion of CRC screening at 26 weeks based on test reports (analysis conducted in 2012-2013).nnnRESULTSnThe study population had a mean age of 57 years and was 42% non-Hispanic African American, 28% non-Hispanic white, and 27% Hispanic. Those receiving the implementation intentions-based intervention had higher odds (AOR=1.83, 95% CI=1.23, 2.73) of completing CRC screening than the Comparison group. Those with higher self-efficacy for screening (AOR=1.57, 95% CI=1.03, 2.39), history of asthma (AOR=2.20, 95% CI=1.26, 3.84), no history of diabetes (AOR=1.86, 95% CI=1.21, 2.86), and reporting they had never heard that cutting on cancer makes it spread (AOR=1.78, 95% CI=1.16, 2.72) were more likely to complete CRC screening.nnnCONCLUSIONSnThe results of this study suggest that programs incorporating an implementation intentions approach can contribute to successful completion of CRC screening even among very low-income and diverse primary care populations. Future initiatives to reduce CRC incidence and mortality disparities may be able to employ implementation intentions in large-scale efforts to encourage screening and prevention behaviors.

Are endoscopic ultrasonography imaging characteristics reliable for the diagnosis of small upper gastrointestinal subepithelial lesions

Purpose of the Study To compare the accuracy of endoscopic ultrasonography (EUS) imaging with histopathology in the diagnosis of upper gastrointestinal subepithelial lesions. Methods Thirty-seven patients (21 female; mean age: 55 y) underwent endoscopic submucosal resection (ESMR) of upper gastro intestinal subepithelial lesions at a tertiary care facility. All patients underwent EUS before ESMR of the lesion. Information regarding location, size, echogenecity, layer of origin, presumptive diagnosis based on EUS imaging, and histopathology diagnosis after ESMR of the subepithelial lesion was recorded. Results Twenty-seven subepithelial lesions were resected from the stomach, 5 from the esophagus, and 5 from the duodenum. The mean size of the lesions was 9 mm (range, 6-18 mm). Thirty-six lesions originated from the submucosa, and 1 from the muscularis propria. Using histopathology as the gold standard, the overall diagnostic accuracy of EUS imaging was 49% (18 out of 37). The accuracy of EUS imaging for the diagnosis of esophageal, gastric, and duodenal subepithelial lesions was 20%, 56%, and 40%, respectively. One patient developed a microperforation, and 1 developed bleeding during the ESMR procedure. No complications were reported with the EUS procedure. Conclusions The diagnostic accuracy of EUS imaging is inferior to histopathology in the diagnosis of small upper gastrointestinal subepithelial lesions. Endoluminal resection is a relatively safe and noninvasive modality that not only provides tissue sample for accurate diagnostic interpretation, but also aids in the complete removal of small subepithelial lesions of the upper gastrointestinal tract.

Effectiveness of focal vs. balloon radiofrequency ablation devices in the treatment of Barrett’s esophagus

Background and aims The safety and efficacy of radiofrequency ablation (RFA) in treatment of Barrett’s esophagus (BE)-associated dysplasia has been well established. The effectiveness of focal and balloon RFA devices has not been compared. Therefore, the aim of our study was to assess the effectiveness of focal and balloon RFA devices in the treatment of BE by calculating absolute and percentage change in BE length with RFA therapy by comparing pre- and post-treatment BE length. Patients and methods This is a retrospective cross-sectional study of patients who underwent at least one treatment with either focal and/or balloon RFA devices who were identified from two tertiary centers. Patients’ demographics, hiatal hernia, pre- and post-treatment BE length, prior use of endoscopic therapies and number of sessions were recorded. Results Sixty-one patients who had undergone 161 RFA treatment sessions met inclusion criteria. There was no significant difference in percentage change in BE length with greater number of RFA sessions. RFA with a focal device resulted in greater percentage reduction in BE length compared to the balloon system (73% vs. 39%, pu2009<u20090.01). After adjusting for initial BE length, pre-treatment BE length, hernia status, prior endoscopic mucosal resection (EMR), prior RFA, and prior EMR/RFA sessions, RFA with a focal device at each session remained an independent predictor for a significant reduction in BE extent as compared to the balloon system. Conclusion The focal RFA device alone was more effective in treatment of BE compared to the balloon system, with a greater reduction in extent of BE. The focal RFA device for endoscopic eradication therapy of BE should be considered the preferred technique.

Treatment of Barrett’s esophagus with high-grade dysplasia

The incidence of esophageal adenocarcinoma is increasing in the USA, now accounting for at least 4% of US cancer-related deaths. Barrett’s esophagus is the main risk factor for the development of esophageal adenocarcinoma. The annual incidence of development of adenocarcinoma in Barrett’s esophagus is approximately 0.5% per year, representing at least a 30–40-fold increase in risk from the general population. High-grade dysplasia is known to be the most important risk factor for progression to adenocarcinoma. Traditionally, esophagectomy has been the standard treatment for Barrett’s esophagus with high-grade dysplasia. This practice is supported by studies revealing unexpected adenocarcinoma in 29–50% of esophageal resection specimens for high-grade dysplasia. In addition, esophagectomy employed prior to tumor invasion of the muscularis mucosa results in 5-year survival rates in excess of 80%. Although esophagectomy can result in improved survival rates for early-stage cancer, it is accompanied by significant morbidity and mortality. Recently, more accurate methods of surveillance and advances in endoscopic therapies have allowed scientists and clinicians to develop treatment strategies with lower morbidity for high-grade dysplasia. Early data suggests that carefully selected patients with high-grade dysplasia can be managed safely with endoscopic therapy, with outcomes comparable to surgery, but with less morbidity. This is an especially attractive approach for patients that either cannot tolerate or decline surgical esophagectomy. For patients that are surgical candidates, high-volume centers have demonstrated improved morbidity and mortality rates for esophagectomy. The addition of laparoscopic esophagectomy adds a less invasive surgical resection to the treatment armanentarium. Esophagectomy will remain the gold-standard treatment of Barrett’s esophagus with high-grade dysplasia until clinical research validates the role of endoscopic therapies. Current treatment strategies for Barrett’s esophagus with high-grade dysplasia will be reviewed.

Relating Stool Microbial Metabolite Levels, Inflammatory Markers and Dietary Behaviors to Screening Colonoscopy Findings in a Racially/Ethnically Diverse Patient Population

Colorectal cancer (CRC) is the third leading cause of cancer death for both men and women in the United States, yet it is treatable and preventable. African Americans have higher incidence of CRC than other racial/ethnic groups, however, it is unclear whether this disparity is primarily due to environmental or biological factors. Short chain fatty acids (SCFAs) are metabolites produced by bacteria in the colon and are known to be inversely related to CRC progression. The aim of this study is to investigate how stool SCFA levels, markers of inflammation in stool and dietary intake relate to colonoscopy findings in a diverse patient population. Stool samples from forty-eight participants were analyzed for SCFA levels and inflammatory markers (lysozyme, secretory IgA, lactoferrin). Additionally, participants completed the National Cancer Institute’s Diet History Questionnaire II (DHQ II) to report dietary intake over the past year. Subsequently, the majority of participants underwent screening colonoscopy. Our results showed that African Americans had higher total levels of SCFAs in stool than other racial/ethnic groups, significantly lower intake of non-starchy vegetables and similar inflammatory marker expression and colonoscopy outcomes, compared to others. This work is an initial exploration into the biological and clinical factors that may ultimately inform personalized screening approaches and clinical decision-making to improve colorectal cancer disparities for African Americans.

M1333 Irritable Bowel Syndrome and the Association With Small Intestinal Bacterial Overgrowth: Putting the Concept in Perspective

Aim: To explore triggers and warning sensations that precede diarrhea and how individuals make use of these. Methods: 579 individuals (68.6% female; ages 19-71, mean=30.5) with recurring diarrhea completed an internet survey including the Rome III diagnostic functional bowel disorders modules and a detailed questionnaire asking about diarrhea history, triggers, warning sensations and self-management. Individuals with inflammatory bowel disease, celiac disease, lactose intolerance or GI surgery history were excluded. Results: Most respondents (90.7%) had diarrhea at least 2-3 times per month. 23.7% had consulted health care providers about diarrhea. 70.5% met Rome III irritable bowel syndrome criteria but only 0.3% met functional diarrhea criteria. Diarrhea was self-defined by survey respondents, and typically considered to be characterized by loose/watery stools (92.5%), urgency (56.4%), pain/ discomfort (40.2%) and frequent stools (35.3%). 79.8% of subjects reported specific diarrhea triggers (i.e., actions or experiences they knew might result in diarrhea), and 44.0% stated that diarrhea resulted half or more of the times that these triggers occurred. Most common triggers were specific foods or drinks (72.3% of subjects), especially high-fat or spicy foods or caffeine beverages; stress/anxiety (49.7%); and large meals (25.2%). 83% of subjects with triggers rated stress/anxiety as the most frequent trigger. Nearly all subjects (95.6%) reported one or more types of physical warning sensations in advance of diarrhea, usually the same in nature for each subject and generally first occurring 10-25 minutes before diarrhea. The earliest warnings were typically either pain/discomfort (44.6%) or rumbling/bowel sounds (29.1%). 84.9% reported doing nothing to prevent or diminish diarrhea after warning sensations, but 15.1% used anti-diarrheal or antispasmodic drugs to counter the anticipated diarrhea. 74.4% used no medication once diarrhea started, 9.9% took medication early after onset, and 13.3% only later if it did not stop on its own. Warning sensations preceded at least half of all diarrhea bowel movements for 84.5% of subjects. Conclusions: Recognizable triggers and warning sensations precede diarrhea in most individuals, but few make efforts to prevent anticipated diarrhea. [Supported by McNeil Consumer Healthcare and R24 DK067674]

Delayed gastric emptying in gastroesophageal reflux disease: reassessment with new methodologies and clinical correlations

Delayed gastric emptying in gastroesophageal reflux disease: reassessment with new methodologies and clinical correlations