David C. Metz

Systematic Review of the Epidemiology of Complicated Peptic Ulcer Disease: Incidence, Recurrence, Risk Factors and Mortality

Background/Aims: The incidence of uncomplicated peptic ulcer has decreased in recent years. It is unclear what the impact of this has been on the epidemiology of peptic ulcer complications. This systematic review aimed to determine the incidence, recurrence and mortality of complicated peptic ulcer and the risk factors associated with these events. Methods: Systematic PubMed searches. Results: Overall, 93 studies were identified. Annual incidence estimates of peptic ulcer hemorrhage and perforation were 19.4–57.0 and 3.8–14 per 100,000 individuals, respectively. The average 7-day recurrence of hemorrhage was 13.9% (95% CI: 8.4–19.4), and the average long-term recurrence of perforation was 12.2% (95% CI: 2.5–21.9). Risk factors for peptic ulcer complications and their recurrence included nonsteroidal anti-inflammatory drug and/or acetylsalicylic acid use, Helicobacter pylori infection and ulcer size ≧1 cm. Proton pump inhibitor use reduced the risk of peptic ulcer hemorrhage. Average 30-day mortality was 8.6% (95% CI: 5.8–11.4) after hemorrhage and 23.5% (95% CI: 15.5–31.0) after perforation. Older age, comorbidity, shock and delayed treatment were associated with increased mortality. Conclusions: Complicated peptic ulcer remains a substantial healthcare problem which places patients at a high risk of recurrent complications and death.

Congenital esophageal stenosis in adults

Abstract OBJECTIVE: Congenital esophageal stenosis is thought to be a rare disease confined to infancy and childhood with only a few case reports in adults described. METHODS: We report five patients between the ages of 19 and 46 yr who presented with this disorder over a 2-yr period. RESULTS: Patients had been labeled with reflux strictures, webs, or as idiopathic in the past. All patients had chronic solid food dysphagia, some since early childhood. The location of the stricture varied, occurring in the mid or proximal esophagus in four, but throughout the esophagus in one. Radiographic and endoscopic appearance was a smooth concentric stricture or multiple rings, sometimes tracheal in appearance. Endosonography was performed in two patients, both of whom had focal circumferential hypoechoic wall thickening with disruption of the normal layer pattern corresponding to the areas of luminal narrowing. All patients dilated had good symptomatic response, with resolution of symptoms up to 6 months in follow-up. CONCLUSIONS: We suggest that congenital esophageal stenosis does occur in adults and may be underrecognized. Its endosonographic appearance is described.

Hepatitis C Knowledge among Primary Care Residents: Is Our Teaching Adequate for the Times?

BACKGROUND:Increasingly, primary care (PC) physicians will be the first to encounter patients with hepatitis C virus (HCV) infection.AIM:To determine opinions and practices of PC residents regarding HCV.METHODS:We administered a one-page questionnaire to 180 PC residents at five U.S. training programs.RESULTS:Respondents were distributed equally across postgraduate year, 83% were U.S. graduates, and 44% had seen >11 (HCV) patients in the past year. Residents tested for HCV in persons with: increased transaminases (83%), history of blood transfusion (46%), multiple tattoos (57%), +ANCA (16%), and alcohol abuse (31%). Sixteen percent of respondents tested all patients. Forty-one percent would vaccinate HCV patients for hepatitis A and 65% for hepatitis B while only 19% and 78% knew the respective vaccination schedules. Although no vaccine is available, 66% recommended vaccination for HCV. Only 37% and 29%, respectively, reported HCV genotype 1 as most common and most resistant to treatment. Fifty-three percent recommend liver biopsy before treating HCV. Only 52% reported α-interferon (IFN) with ribavirin as initial treatment for HCV while 28% recommend ribavirin or lamivudine alone or combinations of IFN and lamivudine or amantadine. As contraindications to treatment, 33% reported AIDS with PCP infection, 19% coronary artery disease, and 19% suicidal ideation. Sixty-nine percent felt that there was insufficient information on HCV.CONCLUSIONS:Many PC residents lack adequate knowledge of recommended guidelines for the management of HCV. Many test for HCV in inappropriate situations, are unclear regarding available vaccines and their administration, and are uncertain about current treatment. Education of PC residents on guidelines for detection and management of HCV must be improved.

Prevalence, etiology, and prognostic significance of upper gastrointestinal hemorrhage in diabetic ketoacidosis.

We reviewed the discharge records of all diabetic ketoacidosis hospitalizations over 30 months for the presence of clinically significant upper gastrointestinal hemorrhage. Of 284 hospitalizations in 193 patients, hemorrhage occurred in 26 hospitalizations (9%) in 25 patients (13%). None required invasive therapy to achieve hemostasis, and there were no bleeding recurrences and no deaths due to bleeding. Endoscopy in eight revealed esophagitis in all (five had erosions or ulcerations), one Mallory-Weiss tear, five with gastritis (mild in four), four with duodenitis (one erosive), one duodenal ulcer, and no gastric ulcers. Hemorrhage patients had a longer diabetes duration (14.85 vs 9.16 years,P<0.02), and more nephropathy (40% vs 11%,P<0.001), retinopathy (28% vs 12%,P<0.03) and gastroparesis (36% vs 10%,P<0.002) than those without hemorrhage. Ulcer medication (42% vs 23%,P<0.03) or anticoagulant (12% vs 1%,P<0.005) but not nonsteroidal antiinflammatory drug usage (12% vs 12%) was higher in the hemorrhage group. Admission glucose (P<0.02), BUN (P<0.04), and creatinine (P<0.02) levels were higher in hemorrhage patients, but arterial pH, serum ketones, hemoglobin, platelet count, and coagulation values were not. Hemorrhage patients required more blood transfusions (27% vs 10%,P<0.003) and intensive care unit admissions (69% vs 43%,P<0.009). Total (15% vs 3%,P<0.003) and intensive care unit mortality (22% vs 6%,P<0.026) were higher in the hemorrhage group. We conclude that upper gastrointestinal hemorrhage complicates 9% of diabetic ketoacidosis hospitalizations. Blood transfusion may be required, but the bleeding is self-limited and not severe. The most common lesion is erosive esophagitis. Hemorrhage correlates with glucose level, admission to the intensive care unit, duration of diabetes, the presence of diabetic complications, and portends a high non-bleeding-related mortality.

Helicobacter pylori gastritis therapy with omeprazole and clarithromycin increases serum carbamazepine levels.

An antibiotic combination that includes a proton pump inhibitor such as omeprazole and an antibiotic such as clarithromycin is likely to become the new standard regimen for treatment of Helicobacter pylori gastritis because this combination is extremely effective and very well tolerated. The current report highlights a potentially significant pharmakokinetic drug interaction between clarithromycin and carbamazepine in two patients with long-standing epilepsy who were given such therapy for Helicobacter pylori gastritis. In both cases, clarithromycin therapy was temporally related to an increase in serum carbamazepine levels, which returned to the therapeutic range following cessation of clarithromycin therapy. The potential implications of this newly recognized drug interaction are discussed.

Appropriate Use Criteria for Somatostatin Receptor PET Imaging in Neuroendocrine Tumors

NETs nNETs are relatively rare and encompass a heterogeneous group of tumors with an incidence of approximately 7.0 in 100,000 (1,2), although it is increasing. The most common type is gastroenteropancreatic NETs, which are broken down by sites of origin into gastric, pancreatic, small bowel, colorectal, and those of unknown origin. In addition to gastroenteropancreatic NETs, there are many subtypes of NETs, including pheochromocytomas, paragangliomas, medullary thyroid cancer, Merkel cell cancer, and bronchial carcinoids. Given the lack of evidence in other disease subtypes, these AUC will focus on the role of SSTR PET in well-differentiated gastroenteropancreatic NETs. The belief is that SSTR PET will be valuable in many SSTR-positive diseases beyond gastroenteropancreatic NETs, although these other diseases are not covered in the clinical scenarios in this document.

Embolotherapy for Neuroendocrine Tumor Liver Metastases: Prognostic Factors for Hepatic Progression-Free Survival and Overall Survival

PurposeThe purpose of the study was to evaluate prognostic factors for survival outcomes following embolotherapy for neuroendocrine tumor (NET) liver metastases.Materials and MethodsThis was a multicenter retrospective study of 155 patients (60xa0years mean age, 57xa0% male) with NET liver metastases from pancreas (nxa0=xa071), gut (nxa0=xa068), lung (nxa0=xa08), or other/unknown (nxa0=xa08) primary sites treated with conventional transarterial chemoembolization (TACE, nxa0=xa050), transarterial radioembolization (TARE, nxa0=xa064), or transarterial embolization (TAE, nxa0=xa041) between 2004 and 2015. Patient-, tumor-, and treatment-related factors were evaluated for prognostic effect on hepatic progression-free survival (HPFS) and overall survival (OS) using unadjusted and propensity score-weighted univariate and multivariate Cox proportional hazards models.ResultsMedian HPFS and OS were 18.5 and 125.1xa0months for G1 (nxa0=xa075), 12.2 and 33.9xa0months for G2 (nxa0=xa060), and 4.9 and 9.3xa0months for G3 tumors (nxa0=xa020), respectively (pxa0<xa00.05). Tumor burdenxa0>50xa0% hepatic volume demonstrated 5.5- and 26.8-month shorter median HPFS and OS, respectively, versus burdenxa0≤50xa0% (pxa0<xa00.05). There were no significant differences in HPFS or OS between gut or pancreas primaries. In multivariate HPFS analysis, there were no significant differences among embolotherapy modalities. In multivariate OS analysis, TARE had a higher hazard ratio than TACE (unadjusted Cox model: HR 2.1, pxa0=xa00.02; propensity score adjusted model: HR 1.8, pxa0=xa00.11), while TAE did not differ significantly from TACE.ConclusionHigher tumor grade and tumor burden prognosticated shorter HPFS and OS. TARE had a higher hazard ratio for OS than TACE. There were no significant differences in HPFS among embolotherapy modalities.

Low yield for non-targeted biopsies of the stomach and esophagus during elective esophagogastroduodenoscopy

Background and study aims u2002Biopsies of non-specific mucosal findings are often performed during esophagogastroduodenoscopy (EGD). We sought to determine the prevalence and clinical utility of non-targeted biopsies of the stomach and esophagus. Patients and methods u2002We conducted a retrospective review of 949 outpatient EGDs performed at a US tertiary referral center. Non-targeted biopsies of the stomach were defined as either “normal” or “mild” to “moderate” “erythema” or “inflammation” without other endoscopic features. Non-targeted biopsies of the esophagus and gastroesophageal junction (GEJ) were defined as endoscopically “normal” mucosa. The primary outcome was the proportion of non-targeted biopsies resulting in “definite management change.” Secondary outcomes included histopathologic diagnoses of Helicobacter pylori, intestinal metaplasia and esophageal eosinophilia. Results u2002Of 949 EGDs, 332 (35.0u200a%, 95u200a% CI 31.9u200a–u200a38.1u200a%) had a non-targeted biopsy taken at any site. Erythema in the gastric body and antrum was biopsied at a rate of 83u200a–u200a86u200a%, while biopsies of “normal”-appearing mucosa occurred at rates from 3u200a% (GEJ) to 15u200a% (body and antrum). The percentage of non-targeted biopsies that led to definite management change ranged from 5u200a% in the GEJ and esophagus to 9u200a% in the antrum, but did not significantly differ by mucosal appearance. Multivariable regression analyses suggested associations of language and age >u200a50 with management change from non-targeted gastric biopsy. Conclusions u2002Non-targeted biopsies of the stomach and esophagus led to definite management change in a small proportion of patients. Further studies are needed to identify patient and/or endoscopic characteristics and techniques to improve the yield of this practice.