Eric Ormseth

Reflux laryngitis: pathophysiology, diagnosis, and management

Gastroesophageal reflux disease is felt to be associated with a variety of laryngeal conditions and symptoms of which “reflux laryngitis” is perhaps the most common. The most likely mechanism for laryngeal injury and symptoms is secondary to direct acid and pepsin contact, although studies concerning the cause and effect between gastroesophageal reflux disease and laryngeal disorders are conflicting. Likewise, the most effective method to diagnose such patients is unclear. Empiric treatment of patients with reflux laryngitis has been shown to be effective though none of the studies are controlled.

Normalization of intestinal metaplasia in the esophagus and esophagogastric junction: incidence and clinical data.

BACKGROUND:Attention has focused on whether normalization, regression, and development of dysplasia and cancer in specialized intestinal metaplasia (SIM) differ among long-segment Barretts esophagus (LSBE), short-segment BE (SSBE), and esophagogastric junction SIM (EGJSIM). We prospectively followed a cohort of SIM patients receiving long-term antisecretory medications to determine: (a) histologic normalization (no evidence of SIM on biopsy), (b) change in SIM length, (c) incidence of dysplasia and cancer, and (d) factors associated with normalization.METHODS:One hundred forty-eight patients with SIM were identified in our original cohort. Of these, 60.5% (23/38) LSBE, 69.8% (44/63) SSBE, and 72.3% (34/47) EGJSIM patients underwent repeat surveillance over a mean 44.4 ± 9.7 months. Demographic, clinical, and endoscopic data were obtained.RESULTS:(a) With long-term, antisecretory therapy, normalization occurred in 0/23 LSBE, 30% (13/44) of SSBE, and 68% (23/34) of EGJSIM (P < 0.001). (b) Normalization was more likely with EGJSIM (odds ratio [OR] 6.7, CI 2.3–19.3, P = 0.005), female gender (OR 7.3, CI 2.3–23.1, P = 0.001), or absence of hiatal hernia (OR 2.9, CI 1.02–8.06, P = 0.002). (c) A significant decrease in mean SIM length was noted for the entire population (2.5 ± 0.3 to 2.13 ± 0.3 cm, P = 0.004). (d) Follow-up incidence of dysplasia and cancer was 26.1% (3 indefinite, 2 low-grade dysplasia [LGD], 1 cancer) for LSBE, 6.8% (2 indefinite, 1 LGD) for SSBE, and none for EGJSIM (P < 0.004).CONCLUSIONS:(a) Normalization of SIM occurs most frequently in EGJSIM>SSBE>LSBE. (b) Factors associated with normalization favor less severe GER and shorter segments of SIM. (c) Surveillance of LSBE results in the greatest yield for identifying dysplasia and cancer.

Predictive value of diminutive colonic adenoma trial: The PREDICT trial

BACKGROUND & AIMS Diminutive adenomas (1-9 mm in diameter) are frequently found during colon cancer screening with flexible sigmoidoscopy (FS). This trial assessed the predictive value of these diminutive adenomas for advanced adenomas in the proximal colon. METHODS In a multicenter, prospective cohort trial, we matched 200 patients with normal FS and 200 patients with diminutive adenomas on FS for age and gender. All patients underwent colonoscopy. The presence of advanced adenomas (adenoma >or= 10 mm in diameter, villous adenoma, adenoma with high grade dysplasia, and colon cancer) and adenomas (any size) was recorded. Before colonoscopy, patients completed questionnaires about risk factors for adenomas. RESULTS The prevalence of advanced adenomas in the proximal colon was similar in patients with diminutive adenomas and patients with normal FS (6% vs. 5.5%, respectively) (relative risk, 1.1; 95% confidence interval [CI], 0.5-2.6). Diminutive adenomas on FS did not accurately predict advanced adenomas in the proximal colon: sensitivity, 52% (95% CI, 32%-72%); specificity, 50% (95% CI, 49%-51%); positive predictive value, 6% (95% CI, 4%-8%); and negative predictive value, 95% (95% CI, 92%-97%). Male gender (odds ratio, 1.63; 95% CI, 1.01-2.61) was associated with an increased risk of proximal colon adenomas. CONCLUSIONS Diminutive adenomas on sigmoidoscopy may not accurately predict advanced adenomas in the proximal colon.

Hepatic decompensation associated with lamivudine : A case report and review of lamivudine-induced hepatotoxicity

We report a case of a 62-yr-old man with chronic hepatitis B virus (HBV)-related cirrhosis who developed hepatic decompensation after being started on lamivudine requiring liver transplantation. Decompensated liver disease while on lamivudine has been previously reported on two occasions, both HIV coinfected patients on a combination of nucleoside analogues. Our patient is alive and well nearly 2 yr after successful liver transplantation.

The utility of magnetic resonance cholangiopancreatography in the evaluation of patients with acute pancreatitis

The utility of magnetic resonance cholangiopancreatography in the evaluation of patients with acute pancreatitis

3641 THE PREDICT TRIAL: PREDICTIVE VALUE OF DIMINUTIVE COLONIC ADENOMA TRIAL- INTERIM RESULTS.

BACKGROUND/AIMS: Amoung patients with diminutive (1-9 mm in diameter) adenomatous polyps (DAP) found during flexible sigmoidoscopy (FS), the likelihood of identifying advanced adenomas (i.e., adenomas ≥ one cm in diameter, tubulo-villous or villous adenomas, and adenomas with high grade dysplasia) in the proximal colon is uncertain. Our aims: (1) quantify the relative risk of advanced adenomas in the proximal colon in patients with diminutive adenomas on FS compared to control patients with normal FS; and (2) quantify the risk of finding any adenoma (diminutive or advanced) in the proximal colon in patients with diminutive adenomas on FS compared to control patients with normal FS. METHODS: Inclusion criteria: Consecutive patients with diminutive adenomas on FS and consecutive patients with normal FS were offered screening colonoscopy. Exclusion Criteria: Iron deficiency anemia; occult gastrointestinal bleeding; hematochezia; colonoscopy/barium enema in the past 10 years or normal FS within the past 3 years. Prior to colonoscopy, all patients completed screening CBC and screening FOBT. To insure accurate measurement of polyp diameter, colonoscopic measuring guidewires were used to measure polyp diamter in vivo. DATA ANALYSIS: Relative risk and 95% confidence intervals for the presence of advanced adenoma in the proximal colon and for the presence of any adenomas in the proximal colon were calculated using chi-square analysis with standard software (META-ANAL, McMaster University, Hamiltion, Ontario. RESULTS: 186 patients with normal FS and 190 patients with DAP on FS completed the trial. 5.4% of patients with normal FS (10/186) and 5.8% (11/190) of patients with DAP on FS had advanced adenomas. 22% (40/186) of patients with normal FS and 36% (68/190) of patients with DAP on FS had any size adenoma in the proximal colon. Relative risk for advanced adenoma in the proximal colon of patients with DAP: RR = 1.08(95% CI:0.4 to 2.7);p=0.86). Relative risk for any adenoma in the proximal colon of patients with DAP:RR = 1.7(95%CI:1.2 to 2.4;p=0.003). CONCLUSION: Based on an interim analysis, these data suggest that patients with DAP on FS do not have an increased risk of advanced adenomas in the proximal colon compared to patients with normal FS. However, patients with DAP on FS may have an increased risk of any adenoma in the proximal colon compared to patients with normal FS.

A lot of heartburn, a little cancer.

ABSTRACTThis is a well-designed, population-based, case-control, epidemiological study to determine if individuals with symptoms of gastroesophageal reflux disease are at increased risk for the development of adenocarcinoma of the esophagus and gastric cardia. Over a 3-yr period, from 1994 to 1997, all newly diagnosed cases of adenocarcinoma of the esophagus and gastric cardia in Sweden were identified via a comprehensive countrywide network of contact individuals soon after diagnosis and before surgery. Cases were matched for age and sex with case controls. Of 618 eligible patients with adenocarcinoma of the esophagus or gastric cardia, 451 (85%) participated. At index esophagogas-troduodenoscopy, biopsies were obtained at 2-cm intervals beginning at the cardia and extending proximally until normal squamous epithelium was reached. In addition, biopsies were taken of the tumor and surrounding tissue. A total of 424 of the patients underwent surgery, and 97% of biopsy and surgical specimens were reviewed by a single pathologist. All subjects and controls underwent an extensive interview where questions (range 161–553) were asked concerning the frequency, severity, and duration of heartburn symptoms as well as other potential confounding factors.The results of this study indicate that persons who experience symptoms of heartburn and regurgitation at least once a week are nearly 8 times (odds ratio = 7.7) more likely to develop esophageal adenocarcinoma than those without these symptoms. Furthermore, the risk was found to be “dose dependent” where those who had the most severe reflux symptoms were associated with the highest risk. Persons with particularly long-standing and frequent heartburn symptoms were found to be 43 times more likely to develop esophageal adenocarcinoma than asymptomatic individuals. The authors emphasized that the heartburn-cancer association was independent of the presence of Barretts esophagus. They based this statement on the fact that only 62% of those with esophageal adenocarcinoma had Barretts tissue detected. Also of note, the risk of esophageal adenocarcinoma was 3 times higher among those who had used medications for symptomatic reflux compared to those who had not taken medications even after adjusting both groups for severity of symptoms. Reflux symptoms were also associated with a higher risk of adenocarcinoma of the gastric cardia though not nearly as strongly (odds ratio 2.0). As expected, squamous cell cancer was not associated with reflux symptoms (odds ratio 0.9). (Am J Gastroenterol 1999; 94:3061–3062.