Emmanuel Coronel

Evaluation of a Trainee-Led Project to Reduce Inappropriate Proton Pump Inhibitor Infusion in Patients With Upper Gastrointestinal Bleeding: Skip the Drips

LESS IS MORE Evaluation of a Trainee-Led Project to Reduce Inappropriate Proton Pump Inhibitor Infusion in Patients With Upper Gastrointestinal Bleeding: Skip the Drips Continuous infusion of proton pump inhibitors (PPIs) is recommended in patients with upper gastrointestinal bleeding (UGIB) for specific situations, such as before endoscopic identification of ulcers with high-risk features1-4 (Box). Unfortunately, PPI infusions may be continued for 72 hours without indication.2,5 Reducing the overuse of these infusions is important because, in addition to increasing the length of stay and cost, PPI overuse is associated with various complications.6 In July 2015, a fellowand resident-led intervention was initiated with the goals of decreasing the inappropriate use of PPI infusions in patients with UGIB and promoting evidencebased care at lower costs for these patients.

State-of-the-art endoscopic procedures for pancreatic cancer

Pancreatic cancer is the twelfth most common cancer worldwide, taking the fourth place in cancer-related mortality in western countries. Despite significant efforts in understanding the tumor biology of pancreatic cancer and introducing new technologies and therapies to improve the detection, staging and treatment of this disease, pancreatic cancer continues to have a high and almost unchanged mortality. In the last few decades, the development of techniques such as endoscopic retrograde cholangio pancreatography and endoscopic ultrasound have allowed us to directly access the pancreaticobiliary system and fight pancreatic cancer and its complications from different fronts. Our goal with this review is to discuss the most cutting-edge endoscopic techniques available in our armamentarium to diagnose, stage and treat pancreatic cancer.

Efficacy, Durability, and Safety of Complete Endoscopic Mucosal Resection of Barrett Esophagus: A Systematic Review and Meta-Analysis.

Goals: To report the rate of eradication and recurrence of both neoplasia and intestinal mucosa and the rate of adverse events for complete endoscopic resection (CER) of Barrett esophagus (BE). Background: There is limited composite data on the clinical efficacy of CER of BE with high-grade dysplasia or neoplasia. Study: We performed a systematic review and meta-analysis of cohort studies that reported the clinical outcome of patients with BE who underwent CER and had at least 15-month follow-up after the time of elimination of BE. Main outcome of interests were pooled estimated rates of complete eradication of intestinal metaplasia and neoplasia, recurrence of intestinal metaplasia and neoplasia, and incidence of esophageal stricture, bleeding, and perforation. Results: We identified 8 studies reporting on 676 patients (high-grade dysplasia 54%) that met our criteria. Pooled estimated rates of complete eradication of intestinal metaplasia and complete eradication of intestinal neoplasia were 85.0% [95% confidence interval (CI), 79.4%-89.2%] and 96.6% (95% CI, 94.0%-98.1%), respectively, and rates of recurrence of intestinal metaplasia and recurrence of intestinal neoplasia were 15.7% (95% CI, 8.0%-28.4%) and 5.8% (95% CI, 3.9%-8.6%), respectively. Estimated incidences of adverse events were stricture 37.4 (95% CI, 24.4%-52.6%), bleeding 7.9% (95% CI, 4.4%-13.8%) and perforation 2.3% (95% CI, 1.3%-4.1%). Conclusions: CER achieves an 85% complete eradication rate of BE with recurrent rate of neoplasia of 6%. Estimated rate of postprocedural stricture was 37.4%. On the basis of this high rate of adverse events and significant heterogeneity in the studies included, the present meta-analysis cannot endorse CER as sole therapy for BE.

Patchy Colitis and Interstitial Lung Disease

Question: A 46-year-old woman with a 30 pack-year history of smoking and suspected Crohn’s disease was referred to our facility for persistent diarrhea. Twenty-three months before presentation, the patient developed diarrhea with 8–10 bowel movements daily. Colonoscopy demonstrated endoscopically moderately active inflammation with diffuse punctate ulcerations of the colon beginning 20 cm from the anal verge and extending to the terminal ileum. She required prior hospitalizations for worsening diarrhea, dehydration, and acute renal failure. Treatments included prednisone, 6-mercaptopurine, and infliximab, all with minimal improvement. At time of our evaluation, the patient had >15 bowel movements daily. She denied hematochezia, weight loss, or nonsteroidal anti-inflammatory drug use. Her past medical history included pulmonary Langerhans cell histiocytosis (LCH), diagnosed during a prior hospitalization for dyspnea and bilateral interstitial pulmonary infiltrates. On physical examination the patient was febrile at 38 C with diffuse abdominal tenderness but normal bowel sounds. There was no organomegaly. Perianal examination was normal. Initial laboratory studies revealed an elevated white blood cell count of 27.1 K/mL with a normocytic anemia (hemoglobin of 10.4 g/dL). Infliximab levels were <0.4 mg/mL with negative anti-infliximab antibodies. Systemic steroids were continued and the colonoscopy biopsy slides were reviewed (Figure A). Subsequent F-18 fluorodeoxyglucose positron emission tomography was performed and demonstrated diffuse, bilateral increased metabolic activity within the lungs and colon (Figure B). What is the cause for this patient’s persistent diarrhea, multisystem organ dysfunction, and abnormal radiographic findings? Look on page 27 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Adherence to postresection colorectal cancer surveillance at National Cancer Institute-designated Comprehensive Cancer Centers

Guidelines recommend surveillance after resection of colorectal cancer (CRC), but rates of adherence to surveillance are variable and have not been studied at National Cancer Institute (NCI)‐designated Comprehensive Cancer Centers. The aim of this study was to determine rates of adherence to standard postresection CRC surveillance recommendations including physician visits, carcinoembryonic antigen (CEA), computed tomography (CT), and colonoscopy after CRC resection at three NCI‐designated centers.

The incredible shrinking waistline: lumen-apposing metal stent treatment of massive ascites

re 1. A, CT view of abdomen showing pancreatic fluid collection compressing the portal vein before entering the liver (arrow). Severe ascites is also e. B, View of patient’s abdomen showing the severity of her ascites before the procedure. C, Control CT view of abdomen after procedure, showing ution of PFC and visualization of lumen-apposing metal stent (LAMS). The portal vein is seen and is widely patent. No ascites is visualized. D, View of nt’s abdomen after procedure, showing complete resolution of ascites. LAMS, lumen-apposing metal stent.

Endoscopic ultrasound-guided gastroenterostomy for the treatment of gastroduodenal obstruction in severe chronic pancreatitis

Endoscopic ultrasound (EUS)-guided gastroenterostomy is a newly described endoscopic technique that can be used to palliate the symptoms of gastroduodenal obstruction due to benign or malignant conditions. Multidisciplinary care, incorporating oncologists, surgeons, radiologists, and gastroenterologists, is strongly encouraged to ensure proper patient selection given the potential for severe adverse events, such as perforation and peritonitis. We report the case of a 63-year-old man with a history of heavy smoking, alcohol abuse, and severe chronic calcific pancreatitis who had been admitted several times over the preceding 2 years because of nausea, vomiting, abdominal pain, and weight loss. During this admission, his nasogastric tube output was more than 5 L per day. Abdominal imaging showed a calcified pancreas, with marked dilatation of the stomach and the first portion of the duodenum (▶Fig. 1). Multiple endoscopic dilations of the duodenum had been performed without clinical success in the past and he was deemed not to be a candidate for surgery. An EUS-guided gastroenterostomy was therefore performed as shown in ▶Video1 and ▶Fig. 2 and ▶Fig. 3. Surgery offers better long-term outcomes; however, it is associated with higher rates of morbidity and mortality when compared to endoscopic stenting. Endoscopic stenting is safe and effective for symptom palliation and, when compared to surgery, it has lower complication rates and patients have shorter hospital stays. However, owing to the uncovered enteral stent design, it may not provide a long-term solution in benign conditions where re-intervention rates may be high because of stent occlusion [1]. The idea of creating a luminal anastomosis between the stomach and small bowel using EUS and dedicated devices was E-Videos