Fazia Mir

Optimizing bowel preparation for colonoscopy: a guide to enhance quality of visualization

Colonoscopy is an important screening and therapeutic modality for colorectal cancer. Unlike other screening tests, colonoscopy is dependent on pre-procedure bowel preparation. If the bowel preparation is poor, significant pathology may be missed. Many factors are known to improve bowel preparation. This review will highlight those factors that may optimize the bowel preparation, including choice of bowel preparation, grading or scoring of the bowel preparation, special factors that influence preparation, and diet prior to colonoscopy that affects bowel preparation. The aim of the review is to offer suggestions and guide endoscopists on how to optimize the bowel preparation for the patients undergoing colonoscopy.

Successful treatment of chronic refractory pouchitis with vedolizumab

Dear Editor: We enjoyed to read the case report by Schmid et al. in this journal [1]. The authors reported a chronic pouchitis case successfully treated with vedolizumab. The effect of vedolizumab treatment on chronic antibiotic refractory pouchitis (CARP) is very limited. CARP is a challenging complication in patients with ulcerative colitis who undergo proctocolectomy with ileal pouch–anal anastomosis (IPAA). CARP occurs when patients do not respond to a 2-week course of ciprofloxacin, metronidazole, or rifaximin for pouchitis [2]. Vedolizumab is a monoclonal antibody that selectively blocks gut lymphocyte trafficking by interacting with α4β7 heterodimer [3]. A 41-year-old female with pancolonic ulcerative colitis since the age of 13 with secondary failure of infliximab and mesalamine and primary failure of azathioprine and adalimumab underwent a total proctocolectomy with IPAA in 2013. She developed chronic diarrhea in May 2015 with bowel movements being watery, ten per day and accompanied with blood, mucus affecting her quality of life. Stool studies for clostridium difficile, viruses, and bacteria were negative. A pouchoscopy was performed that demonstrated diffuse erythema and multiple superficial ulcers in the pouch. Biopsies obtained were negative for cytomegalovirus. An upper endoscopy done in the same sitting to evaluate for diarrhea was normal. Duodenal biopsy was negative for the presence of celiac disease. Laboratory work-up revealed erythrocyte sedimentation rate (ESR) of 46 mm/h and C-reactive protein (CRP) of 1.3 mg/dl with no liver function test abnormalities. She denied sudden weight gain or weight loss. She was prescribed metronidazole 500 mg orally three times daily as she was allergic to ciprofloxacin, trimethoprim-sulfamethoxazole but she was unable to tolerate the metronidazole. She was then prescribed rifaximin 550 mg orally three times daily for 14 days which she was able to complete. The blood in her diarrheal movements resolved but she continued to have anywhere from ten to 20 bowel movements per day with mucus. She was then prescribed hyoscyamine as needed, cholestyramine, loperamide, acetaminophen with codeine, diphenoxylate-atropine. As prescribed probiotics were cost prohibitive, she supplemented her diet with kefir (cultured yogurt) and regular yogurt to get her daily dose for probiotics. She was additionally tested for autoimmune pouchitis with IgG4, anti-nuclear antibody, and anti-mitochondrial antibody that were negative. After initiation of vedolizumab 300 mg parenterally at 0, 2, and 6 weeks then every 8 weeks, thereafter, patient was followed in clinic every 6 weeks. She reported improvement in clinical symptoms at week 6 of decreased frequency of bowel movements to four to six bowel movements per day without blood or mucus. Her abdominal pain improved. A repeat pouchoscopy demonstrated only a single linear ulcer and healthy pouch mucosa after 6 months of initiation of vedolizumab. Her CRP and ESR also normalized on repeat testing. Clinicians treating chronic refractory pouchitis may have vedolizumab in their armamentarium when all other therapies * Veysel Tahan tahanv@health.missouri.edu

Sofosbuvir/velpatasvir regimen promises an effective pan-genotypic hepatitis C virus cure

Hepatitis C virus (HCV) is a global pandemic, with nearly 200 million infected patients worldwide. HCV is the most common blood-borne infection in the US with numerous health implications including liver fibrosis, cirrhosis, and hepatocellular cancer. Traditional genotype-based HCV therapies with interferon resulted in moderate success in the sustained elimination of viral genome. Recent clinical trials of the once-daily combination tablet of sofosbuvir, a nonstructural (NS) 5B polymerase inhibitor, and velpatasvir, an NS5A inhibitor, demonstrate sustained virologic response rates of about 95%, regardless of prior treatment experience or presence of cirrhosis across all HCV genotypes. Patients reported improvements in general health, fatigue, and emotional and mental well-being after completing combination therapy. The combination treatment is effective, but does need to be administered with caution in patients receiving certain medications or with certain diseases. Herein, we review the safety and efficacy of sofosbuvir/velpatasvir combination regimen for all HCV genotypes.

Prophylactic clipping and post-polypectomy bleeding: a meta-analysis and systematic review

Background Bleeding after polypectomy is a common issue associated with colonoscopy. To help prevent post-polypectomy bleeding, many endoscopists place clips at the site. However, this practice remains controversial. Therefore, we performed a meta-analysis of the efficacy of clip placement in the prevention of post-polypectomy bleeding. Methods Multiple databases, including Embase, Scopus, MEDLINE/PubMed, CINAHL, Cochrane databases, and recent abstracts from major American meetings were searched in April 2016. Using the DerSimonian and Laird (random effects) model with odds ratio (OR), a meta-analysis was performed of post-polypectomy bleeding with prophylactic clip versus no prophylactic clip. Results Five hundred and thirty potential articles and abstracts were discovered. Thirty-five articles were reviewed, with 12 studies satisfying the inclusion criteria. No statistically significant difference in prophylactic clipping versus no prophylactic clipping for post-polypectomy bleeding in all polyps was found when all studies (OR 1.49; 95% CI: 0.56–4.00; P=0.42), only peer-reviewed studies where abstracts were excluded (OR 0.84; 95% CI: 0.42–1.69; P=0.63), and only randomized controlled trials (OR 1.24; 95% CI: 0.69–2.24; P=0.47) were analyzed. Conclusions The use of prophylactic clipping for all polypectomies does not seem to prevent post-polypectomy bleeding and should not be a routine practice. However, for large polyps (>2 cm), prophylactic clipping may or may not be beneficial in preventing post-polypectomy bleeding. Further studies are required to fully evaluate this subgroup.

Cap-assisted colonoscopy versus standard colonoscopy: is the cap beneficial? A meta-analysis of randomized controlled trials

Background: In an effort to improve visualization during colonoscopy, a transparent plastic cap or hood may be placed on the end of the colonoscope. Cap-assisted colonoscopy (CAC) has been studied and is thought to improve polyp detection. Numerous studies have been conducted comparing pertinent clinical outcomes between CAC and standard colonoscopy (SC) with inconsistent results. Methods: Numerous databases were searched in November 2016. Only randomized controlled trials (RCTs) involving adult subjects that compared CAC to SC were included. Outcomes of total colonoscopy time, time to cecum, cecal intubation rate, terminal ileum intubation rate, polyp detection rate (PDR), and adenoma detection rate (ADR) were analyzed in terms of odds ratio (OR) or mean difference (MD) with fixed effect and random effects models. Results: Five hundred eighty-nine articles and abstracts were discovered. Of these, 23 RCTs (n=12,947) were included in the analysis. CAC showed statistically significant superiority in total colonoscopy time (MD -1.51 min; 95% confidence interval [CI] -2.67 to -0.34; P<0.01) and time to cecum (MD -0.82 min; 95%CI -1.20 to -0.44; P<0.01) compared to SC. CAC also showed better PDR (OR 1.17; 95%CI 1.06-1.29; P<0.01) but not ADR (OR 1.11; 95%CI 0.95-1.30; P=0.20). In contrast, on sensitivity analysis, ADR was better with CAC. Terminal ileum intubation and cecal intubation rates demonstrated no significant difference between the two groups (P=0.11 and P=0.73, respectively). Conclusions: The use of a transparent cap during colonoscopy improves PDR while reducing procedure times. ADR may improve in cap-assisted colonoscopy but further studies are required to confirm this.

Dual Infection with Hepatitis B and Epstein-Barr Virus Presenting with Severe Jaundice, Coagulopathy, and Hepatitis B Virus Chronicity Outcome

Patient: Female, 34 Final Diagnosis: HBV and EBV dual infection Symptoms: Jaundice • fatigue • anorexia • subjective weight loss Medication: — Clinical Procedure: — Specialty: Gastroenterology and Hepatology Objective: Rare co-existance of disease or pathology Background: Hepatitis B virus (HBV) has been reported as a coinfection with hepatitis C virus (HCV), hepatitis D virus (HDV), cytomegalovirus (CMV), and human immunodeficiency virus (HIV). Case Report: A 34-year-old female presented to our clinic with epigastric pain and severe acute hepatitis manifested as jaundice associated with hyperbilirubinemia, elevated transaminases, and coagulopathy. The patient was diagnosed with acute HBV with Epstein-Barr virus (EBV) coinfection leading to subsequent chronic hepatitis B. Conclusions: To our knowledge, this patient case is the first reported case of HBV and EBV coinfection reported in the literature. HBV and EBV coinfection may cause severe acute hepatitis with HBV chronicity.

Long-Term Nutrition A Clinician’s Guide to Successful Long-Term Enteral Access in Adults

Long-term nutrition support requires long-term enteral access. To ensure the success of long-term enteral access, many factors need to be taken into consideration. This article represents a guide to placing and maintaining access in patients requiring long-term nutrition and addresses many of the common questions regarding long-term enteral access, such as indications, types of access, feeding after access placed, and recognition and treatment of potential complications. This guide will help the clinician establish and maintain access to maximize nutrition in patients requiring long-term nutrition.Long-term nutrition support requires long-term enteral access. To ensure the success of long-term enteral access, many factors need to be taken into consideration. This article represents a guide to placing and maintaining access in patients requiring long-term nutrition and addresses many of the common questions regarding long-term enteral access, such as indications, types of access, feeding after access placed, and recognition and treatment of potential complications. This guide will help the clinician establish and maintain access to maximize nutrition in patients requiring long-term nutrition.

Health Maintenance in Inflammatory Bowel Disease

Purpose of ReviewPatients with inflammatory bowel disease (IBD) are not receiving preventative care services at the same rate as the general population. IBD patients are at increased risk for infections, osteoporosis, and certain malignancies secondary to their disease and as they are on immunosuppressive therapy. They are a younger population and often times consider their gastroenterologist as their primary care physician. In this review, we discuss up-to-date evidence pertaining to vaccine-preventable illnesses in the immunosuppressed IBD patient, screening for bone health, cervical cancer, skin malignancies, psychological wellbeing, and smoking cessation.Recent FindingsVaccinations are recommended in the IBD population as they are immunosuppressed and at increased risk for acquiring influenza and pneumonia. Not only are they at greater risk to acquire it but they also have a much severe complicated course. Ideally, IBD patients should be vaccinated prior to initiating immunosuppression and most inactive vaccines can be administered to them while they are on therapy. All IBD patients should be encouraged to stop smoking and have adequate vitamin D intake along with appropriate applicable cancer screenings.SummaryGastroenterologists must work in collaboration with primary care providers along with other specialists to help provide our patients well-rounded care for their IBD.

Undigested Pills in Stool Mimicking Parasitic Infection.

Background. Orally ingested medications now come in both immediate release and controlled release preparations. Controlled release preparations were developed by pharmaceutical companies to improve compliance and decrease frequency of pill ingestion. Case Report. A 67-year-old obese male patient presented to our clinic with focal abdominal pain that had been present 3 inches below umbilicus for the last three years. This pain was not associated with any trauma or recent heavy lifting. Upon presentation, the patient reported that for the last two months he started to notice pearly oval structures in his stool accompanying his chronic abdominal pain. This had coincided with initiation of his nifedipine pills for his hypertension. He reported seeing these undigested pills daily in his stool. Conclusion. The undigested pills may pose a cause of concern for both patients and physicians alike, as demonstrated in this case report, because they can mimic a parasitic infection. This can result in unnecessary extensive work-up. It is important to review the medication list for extended release formulations and note that the outer shell can be excreted whole in the stool.

To chromo or not to chromo: That is the question!

Ulcerative colitis and Crohn’s disease increase the risk of colon cancer by two fold over the lifetime of the patient compared to the general North American population (1). Other factors that compound this elevated risk in our Inflammatory bowel disease (IBD) patients include the extent of disease, duration of disease, a family history of colon cancer and concomitant diagnosis of primary sclerosing cholangitis (PSC). Most society guidelines have endorsed IBD surveillance in the form of 4 quadrant biopsies every 10 cm with a total of 32 biopsy specimens. This technique is far from being ideal as random biopsies lack sensitivity at detecting dysplasia with dysplasia detection confidence being in only 5% of the colon surface area and 80% of the time with this technique (2). Most recently the SCENIC consensus statement favored the use of dye-spray chromoendoscopy (CE) as the ideal surveillance modality for our IBD patients. A large retrospective study published in 2015 showed that using dye-spray CE did not increase dysplasia yield when compared to standard white light or random biopsies (3). Clinical practice continues to be heterogeneous between gastroenterologists pertaining to surveillance methods used and even on the number of random biopsies obtained (4). With high definition white light colonoscopies and the ability to evaluate the mucosa with enhanced image resolution (5); are these random biopsies truly necessary and whether dye spray CE only needs to be performed in high risk patients?