Joel H. Rubenstein

American Gastroenterological Association Institute Guideline on the Diagnosis and Management of Asymptomatic Neoplastic Pancreatic Cysts

This article has an accompanying continuing medical education activity on page e12. Learning Objective: At the conclusion of this exercise, the learner will understand the approach to counseling patients regarding the optimal method and frequency of radiologic imaging, indications for invasive tests like endoscopic ultrasonography (EUS) and surgery, select patients for follow-up after surgery, decide the duration of such follow-up, and decide when to stop surveillance for those with and without surgery.

Infliximab decreases resource use among patients with Crohn's disease

Goals Surgery accounts for one half, and hospitalizations for one third, of overall costs for patients with Crohns disease (CD). Infliximab induces remission and heals fistulas in CD but is more costly than traditional therapies. Its impact upon resource use in CD is unknown. Study The medical records were reviewed for all CD patients managed at our institution for at least 1 full year both before and after initial infliximab infusion. The incidences of hospitalizations, hospitalized days, surgeries, endoscopies, radiologic examinations, outpatient and emergency room (ER) visits were studied (weighted according to time period). Results There were 79 patients (59% female, mean age 38.6 years). A decrease was seen in the annual incidence of all surgeries (38%, p < 0.01), gastrointestinal (GI) surgeries (18%, p < 0.05), endoscopies (43%, p < 0.01), ER visits (66%, p < 0.05), all outpatient visits (16%, p < 0.05), outpatient GI visits (20%, p < 0.01), all radiologic examinations (12%, p < 0.01), and non-plain films (13%, p < 0.01). Fistula patients (n = 37) had decreases in hospitalizations (59%, p < 0.05); GI surgeries (59%, p < 0.01); all surgeries (66%, p < 0.01); all, GI, and surgical outpatient visits (27%, 26%, and 70%, respectively, p < 0.05 for all); ER visits (64%, p < 0.05); all radiologic examinations (40%, p < 0.05); and non-plain films (61%, p < 0.05). Patients with luminal disease(n = 42) had decreases in endoscopies (52%, p < 0.05), and ER visits (69%, p < 0.05). Patients of both genders and all ages experienced decreases in resource use. Conclusion Patients with CD decreased their use of some services, with a decreased number of hospitalizations and a decrease in the use of surgical services seen primarily in the patients infused for fistulas. This decrease in use of healthcare resources raises the potential of overall cost savings in CD patients receiving this drug.

Meta-analysis: the association of oesophageal adenocarcinoma with symptoms of gastro-oesophageal reflux

Aliment Pharmacol Ther 2010; 32: 1222–1227

The Yield of Colonoscopy in Patients With Non-Constipated Irritable Bowel Syndrome: Results From a Prospective, Controlled US Trial

OBJECTIVES:There are limited data on the yield of colonoscopy in patients with irritable bowel syndrome (IBS). This study compared the prevalence of structural colonic lesions in patients with suspected non-constipation-predominant IBS and healthy volunteers. We also determined the yield of rectosigmoid biopsies in patients with suspected IBS.METHODS:This was a prospective, case–control study conducted at three US sites. Patients with suspected non-constipation-predominant IBS (Rome II) underwent colonoscopy with rectosigmoid biopsies. Healthy persons undergoing colonoscopy for colorectal cancer screening or polyp surveillance comprised the control group. Abnormalities identified at colonoscopy were compared between suspected IBS and control groups.RESULTS:In all, 466 suspected IBS patients and 451 controls were enrolled. Suspected IBS patients were significantly younger (P<0.0001) and more frequently female (P<0.0001) than controls. The most common lesions in suspected IBS patients were hemorrhoids (18.2%), polyps (14.6%), and diverticulosis (8.8%). Suspected IBS patients had a lower prevalence of adenomas (7.7% vs. 26.1%, P<0.0001) and diverticulosis (8.8% vs. 21.3%, P<0.0001) and higher prevalence of mucosal erythema or ulceration (4.9% vs. 1.8%, P<0.01) compared with controls. Logistic regression found the between-group differences in adenoma prevalence to be robust after correction for demographic factors. The overall prevalence of microscopic colitis in suspected IBS patients was 1.5% (7/466) and 2.3% (4/171) in those ≥45 years of age.CONCLUSIONS:The prevalence of structural abnormalities of the colon is no higher in suspected non-constipation IBS patients than in healthy controls. Microscopic colitis can be identified in a small proportion of persons with IBS symptoms.

The Cost Effectiveness of Radiofrequency Ablation for Barrett's Esophagus

BACKGROUND & AIMS Radiofrequency ablation (RFA) reduces the risk of esophageal adenocarcinoma (EAC) in patients with Barretts esophagus (BE) with high-grade dysplasia (HGD), but its effects in patients without dysplasia are debatable. We analyzed the effectiveness and cost effectiveness of RFA for the management of BE. METHODS We constructed a decision analytic Markov model. We conducted separate analyses of hypothetical cohorts of patients with BE with dysplasia (HGD or low-grade [LGD]) and without dysplasia. In the analysis of the group with HGD, we compared results of initial RFA with endoscopic surveillance with surgery when cancer was detected. In analyzing the group with LGD or no dysplasia, we compared 3 strategies: endoscopic surveillance with surgery when cancer was detected (S1), endoscopic surveillance with RFA when HGD was detected (S2), and initial RFA followed by endoscopic surveillance (S3). RESULTS Among patients with HGD, initial RFA was more effective and less costly than endoscopic surveillance. Among patients with LGD, when S3 was compared with S2, the incremental cost-effectiveness ratio was

The Impact of Rotating Shift Work on the Prevalence of Irritable Bowel Syndrome in Nurses

18,231/quality-adjusted life-year, assuming an annual rate of progression rate from LGD to EAC of 0.5%/year. For patients without dysplasia, S2 was more effective and less costly than S1. In a comparison of S3 with S2, the incremental cost-effectiveness ratios were

The Prevalence of Celiac Disease Among Patients With Nonconstipated Irritable Bowel Syndrome Is Similar to Controls

205,500,

The influence of co-morbid IBS and psychological distress on outcomes and quality of life following PPI therapy in patients with gastro-oesophageal reflux disease

124,796, and

Epidemiology, Diagnosis, and Management of Esophageal Adenocarcinoma

118,338/quality-adjusted life-year using annual rates of progression of no dysplasia to EAC of 0.12%, 0.33%, or 0.5% per year, respectively. CONCLUSIONS By using updated data, initial RFA might not be cost effective for patients with BE without dysplasia, within the range of plausible rates of progression of BE to EAC, and be prohibitively expensive, from a policy perspective. RFA might be cost effective for confirmed and stable LGD. Initial RFA is more effective and less costly than endoscopic surveillance in HGD.

Prediction of barrett's esophagus among men

OBJECTIVES:Shift work has been associated with gastrointestinal symptoms such as abdominal pain, constipation, and diarrhea. These symptoms overlap with those reported by patients with functional bowel disorders. Because shift work will lead to misalignment between the endogenous circadian timing system and the external 24 h environment, we hypothesized that nurses participating in shift work will have a higher prevalence of functional bowel disorders when compared with nurses participating in day shifts.METHODS:Nurses engaged in patient care were invited to complete Rome III, irritable bowel syndrome–quality of life measure (IBS-QOL) and modified Sleep-50 questionnaires. Respondents were classified as working day, night, or rotating shifts. The prevalence of IBS, functional constipation, functional diarrhea, and individual gastrointestinal symptoms was determined.RESULTS:Data were available for 399 nurses (214 day shift, 110 night shift, and 75 rotating shift workers). Rotating shift nurses had a significantly higher prevalence of IBS compared to day shift nurses (48% vs. 31%, P<0.01). Multivariable logistic regression correcting for age, gender, and sleep quality proved this association robust. IBS-QOL scores among groups were similar. Prevalence of functional constipation and functional diarrhea was similar between groups. Rotating shift nurses had a significantly higher prevalence of abdominal pain compared to day shift (81% vs. 54%, P<0.0001) and night shift workers (61%, P=0.003).CONCLUSIONS:Participation in shift work, especially rotating shift work, is associated with the development of IBS and abdominal pain that is independent of sleep quality. Circadian rhythm disturbances may have a function in the pathogenesis of IBS and abdominal pain.