Doron Boltin

Concurrent small bowel adenocarcinoma and carcinoid tumor in Crohn's disease — Case report and literature review

Adenocarcinomas of the large and small bowel, as well as intestinal carcinoid tumors have been reported at increased rates in Crohns disease. We herein report a rare case of concurrent adenocarcinoma and carcinoid tumor of the small bowel presenting as intestinal obstruction and found incidentally at laparotomy in a 55 year old male with longstanding ileal Crohns disease. We performed a Medline Pubmed search for cases of synchronous or composite adenocarcinoma and carcinoid tumor in the setting of Crohns disease and identified four similar cases. Concurrent adenocarcinoma and carcinoid tumor occurred both in newly diagnosed and longstanding Crohns disease, most commonly involved the terminal ileum and presented with symptoms mimicking Crohns disease. Diagnosis was made incidentally at laparotomy in all cases. Lymph node involvement was variable. Clinicians should be aware of this rare entity for expeditious surgical intervention.

Probiotics in Helicobacter pylori-induced peptic ulcer disease

The ideal treatment regimen for the eradication Helicobacter pylori infection has yet to be identified. Probiotics, particularly Lactobacillus, Bifidobacterium and Saccharomyces, have been suggested as adjuncts to antibiotics for the treatment of H. pylori. There is in vitro evidence that probiotics dampen the Th1 response triggered by H. pylori, attenuate H. pylori associated hypochlorhydria and secrete bacteriocidal metabolites. Probiotics interact with the innate host immune system through adherence to the gastric epithelium and secretion of bacterial adhesins. In prospective human studies, probiotic monotherapy effectively decrease H. pylori density (expired (13)CO2) by 2.0%-64.0%. Probiotic monotherapy has also been shown to eradicate H. pylori in up to 32.5%, although subsequent recrudescence is likely. Eleven meta-analyses have evaluated the efficacy of probiotics as adjuvants to antibiotics for the eradication of H. pylori. The addition of a probiotic increased treatment efficacy, OR 1.12-2.07. This benefit is probably strain-specific and may only be significant with relatively ineffective antibiotic regimens. The pooled prevalence of adverse effects was 12.9%-31.5% among subjects receiving adjuvant probiotics, compared with 24.3%-45.9% among controls. Diarrhea in particular was significantly reduced in subjects receiving adjuvant probiotics, compared with controls (OR 0.16-0.47). A reduction in adverse events other than diarrhea is variable. Despite the apparent benefit on efficacy and side effects conferred by probiotics, the optimal probiotic species, dose and treatment duration has yet to be determined. Further studies are needed to identify the probiotic, antibiotic and patient factors which might predict benefit from probiotic supplementation.

Psychological distress is not associated with treatment failure in patients with gastroesophageal reflux disease.

OBJECTIVEnSymptoms of anxiety and depression are common in patients with gastroesophageal reflux disease (GERD). We aim to examine the relationship between psychological distress and response to proton pump inhibitors (PPI).nnnMETHODSnIn this prospective study, GERD patients receiving PPI once or twice daily were divided into 3 groups: responders to PPI once daily (group A, N=111), non-responders to PPI once daily (group B, N=78) and non-responders to PPI twice daily (group C, N=56). All patients completed demographic and clinical questionnaires, Rome III Diagnostic Questionnaire for irritable bowel syndrome, Hospital Anxiety and Depression Scale (HADS), Satisfaction with Life Scale (SWLS) and the Gastroparesis Cardinal Symptom Index (GCSI) questionnaires.nnnRESULTSnA total of 245 patients (59.3% females, 52±17.2 years) participated in this study. No differences were observed between groups with respect to age, sex, psychiatric medications or pre-existing major depression. Anxiety (HADS-anxiety>7) was seen in 32%, 31% and 34% of groups A, B and C, respectively (p=ns). Depression (HADS-depression>7) was present in 30%, 31% and 21% of groups A, B and C, respectively (p=ns). Global satisfaction with life (SWLS>20) was present in 63% of group C patients, compared to 78% of group A and 78% of group B (p=0.04, p=0.05, respectively). GCSI scores (mean±SD) were 11.1±9.2, 14.07±8.5 and 16.3±10.4, for groups A, B and C, respectively (p=0.002). GCSI correlated significantly with HADS-anxiety (r=0.20, p=0.002) and SWLS (r=-0.2, p=0.01).nnnCONCLUSIONnLack of response to PPI was associated with lower life satisfaction but not anxiety or depression. Symptoms suggestive of gastroparesis were associated with anxiety and low satisfaction with life in patients with GERD.

Gut-directed guided affective imagery as an adjunct to dietary modification in irritable bowel syndrome:

This work aimed to study the effect of guided affective imagery on the irritable bowel syndrome. A total of 15 irritable bowel syndrome patients received guided affective imagery and 19 patients served as controls. Symptom severity and irritable bowel syndrome quality of life were measured at baseline and 8u2009weeks. Symptom severity decreased following guided affective imagery compared to controls (−1.5u2009±u20091.9 vs 0.1u2009±u20091.6, pu2009=u20090.04). Irritable bowel syndrome quality of life increased following guided affective imagery compared to controls (12.1u2009±u200912.5 vs −0.7u2009±u200916.2, pu2009<u20090.01). Guided affective imagery predicted reduced symptom severity (odds ratiou2009=u20095.71, pu2009=u20090.02) and increased irritable bowel syndrome quality of life (odds ratiou2009=u200917.88, pu2009=u20090.01). Guided affective imagery combined with dietary modification may be beneficial in the management of irritable bowel syndrome, however larger studies are required.

Smoking increases the likelihood of Helicobacter pylori treatment failure

BACKGROUND AND AIMSnData regarding the impact of smoking on the success of Helicobacter pylori (H. pylori) eradication are conflicting, partially due to the fact that sociodemographic status is associated with both smoking and H. pylori treatment success. We aimed to assess the effect of smoking on H. pylori eradication rates after controlling for sociodemographic confounders.nnnMETHODSnIncluded were subjects aged 15 years or older, with a first time positive C13-urea breath test (C13-UBT) between 2007 to 2014, who underwent a second C13-UBT after receiving clarithromycin-based triple therapy. Data regarding age, gender, socioeconomic status (SES), smoking (current smokers or never smoked), and drug use were extracted from the Clalit health maintenance organization database.nnnRESULTSnOut of 120,914 subjects with a positive first time C13-UBT, 50,836 (42.0%) underwent a second C13-UBT test. After excluding former smokers, 48,130 remained who were eligible for analysis. The mean age was 44.3±18.2years, 69.2% were females, 87.8% were Jewish and 12.2% Arabs, 25.5% were current smokers. The overall eradication failure rates were 33.3%: 34.8% in current smokers and 32.8% in subjects who never smoked. In a multivariate analysis, eradication failure was positively associated with current smoking (Odds Ratio {OR} 1.15, 95% CI 1.10-1.20, p<0.001), female gender (OR 1.20, 95% CI 1.14-1.25, p<0.001) and a low socioeconomic status (OR 1.24, 95% CI 1.17-1.31, p<0.001).nnnCONCLUSIONSnAfter controlling for socio-demographic confounders, smoking was found to significantly increase the likelihood of unsuccessful first-line treatment for H. pylori infection.

Doxycycline-induced pill esophagitis.

A 23-year-old white woman with a past history of chronic urticaria presented to our department following 2 weeks of progressive dysphagia for solids and liquids. She also complained of chest pain, odynophagia, and a 3-kg weight loss. She denied having prior episodes of food impaction, heartburn, or acid regurgitation. She had suffered 3 months earlier from a subacute onset of polyarthritis involving the small and large joints of the lower limbs, and a low-grade fever. At the time, viral serology and immunology tests were negative, and a presumptive diagnosis of serum sickness was made. Her oral contraceptive pill (OCP) was discontinued and her symptoms subsided. She did not receive any further medications, except for a short course of antibiotics for facial acne 2 weeks prior to her current presentation. Her physical examination was unremarkable. Upper gastrointestinal endoscopy revealed a corrugated esophagus with circumferential pseudomembrane formation and discrete areas of ulceration (● Fig.1). The findings were limited to the mid-esophagus. Histopathology demonstrated inflammatory infiltration of the esophageal papillae, with necrosis and detachment of the superficial epithelium. The subepithelium contained fibrinoid nodules, abundant lymphocytes, and eosinophils (10/high-power field [HPF]) (● Fig.2). These findings were consistent with doxycycline-induced esophagitis. Doxycycline is a common yet under-reported cause of pill esophagitis. Mucosal injury is the result of prolonged contact of the acidic drug with the esophageal mucosa. Therefore, patients who ingest the pill with insufficient water and then remain recumbent have the highest risk [1]. Curiously, patients with pre-existing esophageal dysmotility are not at increased risk, perhaps because they are likely to be more careful with their swallowing. Pills tend to lodge at areas of esophageal narrowing, such as the levels of the aortic arch, the left main bronchus, and the gastroesophageal junction [2]. The use of doxycycline for gynecological infections and for acne vulgaris is thought to account for the slight female preponderance of this condition; however, reliable epidemiological data are lacking. Despite her history of atopy, endoscopic and histological findings in this patient were not compatible with a diagnosis of eosinophilic esophagitis. Similarly, the current episode is unlikely to be related to an undiagnosed rheumatological disease, such as Sjögren’s syndrome or scleroderma, given her negative serology and her response to discontinuation of the OCP. Most cases of pill esophagitis heal without intervention over 3–10 days [3]. Our patient had discontinued doxycycline a few days before her presentation. She was managed with anti-secretory medication, although this treatment is unsubstantiated. Her symptoms abated, and a followup endoscopy after 2 weeks was completely normal.

Uptake of influenza vaccine in ulcerative colitis.

BACKGROUNDnThe incidence of vaccine-preventable-disease is increasing. Current practice guidelines recommend annual influenza vaccination for all inflammatory bowel disease (IBD) patients.nnnSTUDYnUsing the Business Objects database of Clalit Health Services in the Tel Aviv district we identified all patients over 18 years-old with a diagnosis of ulcerative colitis (UC) on 31.12.05. This cohort was followed until 31.12.12. Subjects over age 50 without IBD who are also targeted for influenza vaccination served as controls. The uptake of annual influenza vaccination was recorded.nnnRESULTSn470 UC patients were included (241 (51.3%) males, age 50.4 ± 18.4 years, disease duration 158.9 ± 86.5 months), and 2960 controls. During the years 2006, 2007, 2008, 2009, 2010, 2011 and 2012 the uptake of influenza vaccination was 101 (21.5%), 122 (26.0%), 147 (31.3%), 181 (38.5%), 177 (37.7%), 170 (36.2%) and 178 (37.9%) amongst UC patients, and 993 (33.5%), 1360 (45.9%), 1524 (51.5%), 1611 (54.4%), 1446 (48.9%), 1576 (53.2%) and 1557 (52.6%) amongst controls (p<0.0001 for every year). Independent predictors of vaccination included age (OR, 1.05; 95% CI, 1.03-1.06; p<0.001) and cardiovascular risk (OR, 1.81; 95% CI, 1.31-2.49; p<0.01).nnnCONCLUSIONSnAlthough uptake influenza vaccination is consistently lower in UC compared to controls, an upward trend was observed over the study period. Public health initiatives should target this high-risk population to promote immunization.