Juan C. Munoz

Overuse of acid suppression therapy in hospitalized patients

Background: Acid suppression therapy (AST) is one of the most commonly prescribed classes of medications in hospitalized patients. Multiple studies have shown that AST is overused during inpatient admissions. However, minimal data is available regarding the frequency and patient characteristics of those discharged on unnecessary AST. The aims of the study were to examine administration of AST on admission, to characterize the patient population discharged on unnecessary AST and to determine predictive factors for inappropriate administration of AST in hospitalized patients. Methods: A retrospective chart review of randomly selected patients admitted to the general medicine service at University of Florida Health Science Center/Jacksonville from August to October 2006 for appropriateness of AST was done. The admitting diagnosis, indications for starting AST, type of AST used, and discharge on these medications was recorded on a case by case basis. Results: Seventy percent of patients were started on AST on admission. Of these, 73% were unnecessary. Stress ulcers prophylaxis in low risk patients or the concomitant use of ulcerogenic drugs motivated initiation of therapy most frequently. Sixty nine percent of patients started on inappropriate AST were discharged on the same regimen. Admitting diagnosis, age of patient, length of stay, or concomitant use of ulcerogenic drugs did not predict continuation of unnecessary AST at discharge. Conclusion: AST is overused in hospitalized patients. This primarily occurred in low risk patients and was compounded by continuation at discharge. This significantly increases cost to the health care system and the risk of drug interactions.

Neuroendocrine tumors of the gastrointestinal tract: Case reports and literature review

Neuroendocrine tumors (NET) previously called carcinoid tumors are neoplasms of enterochromaffin/neuroendocrine cell origin which display neurosecretory capacity that may result in the carcinoid syndrome. The annual incidence of patients with NET is 8.4 per 100000; yet many NET remain asymptomatic and clinically undetected. A majority of NET follows a benign course; however, some will display malignant characteristics. NET most commonly occur in the gastrointestinal tract (67%) and bronchopulmonary system (25%). Gastrointestinal NET occur within the stomach, small intestine, liver, and rectum. We report a retrospective study of 11 subjects: Eight with benign carcinoid tumors: duodenal bulb (n = 2), terminal ileum (n = 1), sigmoid colon (n = 2), and rectum (n = 3); three with malignant carcinoid: liver (n = 1) and intra-abdominal site (n = 2). The diagnosis, endoscopic images, outcome, treatment and review of the literature are presented.

Decreased acid suppression therapy overuse after education and medication reconciliation

Background:  Acid suppression therapy (AST) is commonly overprescribed in hospitalised patients. This indiscriminate use increases cost and drug‐related side effects. Minimal data is available on interventions aimed at reducing the burden of overprescription. The aim of our study was to evaluate the impact of education and medication reconciliation forms use on admission as well as discharge, on AST overuse in hospitalised patients.

Palliation of malignant rectal obstruction from invasive prostate cancer with multiple overlapping self-expanding metal stents.

Self-expandable metal stents (SEMS) are used for colonic neoplastic and extracolonic metastatic obstruction relief. Limited data exists on their use for locally invasive prostate cancer. We describe a unique approach using overlapping SEMS to alleviate a rectosigmoid obstruction from locally invasive prostate cancer. A patient with locally advanced prostate cancer presented with obstipation and lymphedema. Placement of overlapping rectosigmoid SEMS was performed, relieving the visualized rectosigmoid obstruction.

Gastrointestinal Kaposi’s sarcoma: Case report and review of the literature

Kaposis sarcoma (KS) of the gastrointestinal tract is not an uncommon disease among individuals with acquired immunodeficiency syndrome (AIDS). The majority is asymptomatic, and for this reason, gastrointestinal KS (GI-KS) remains undiagnosed. With continued tumor growth, considerable variation in clinical presentation occurs including abdominal pain, nausea, vomiting, iron deficiency anemia (either chronic or frank gastrointestinal bleeding), and rarely mechanical obstruction alone or combined with bowel perforation. Endoscopy with biopsy allows for histological and immunohistochemical testing to confirm the diagnosis of GI-KS among those with clinical symptoms. In previous studies, dual treatment with highly active antiretroviral therapy and systemic chemotherapy have been associated with improved morbidity and mortality in individuals with visceral KS. Therefore, investigators have suggested performing screening endoscopies in select patients for early detection and treatment to improve outcome. In this review, we describe a 44 years old man with AIDS and cutaneous KS who presented for evaluation of postprandial abdominal pain, vomiting, and weight loss. On upper endoscopy, an extensive, infiltrative, circumferential, reddish mass involving the entire body and antrum of the stomach was seen. Histologic examination later revealed spindle cell proliferation, and confirmatory immunohistochemical testing revealed human herpes virus 8 latent nuclear antigen expression consistent with a diagnosis of gastric KS. Following this, we present a comprehensive review of literature on KS with emphasis on gastrointestinal tract involvement and management.

Extraction of hollow gastric foreign bodies by flexible upper endoscopy assisted by a through-the-scope balloon catheter for anchoring

BACKGROUND Various methods have been used to remove foreign bodies; hollow foreign bodies deserve special consideration. The main difficulty encountered in such situations is the anatomic obstacle of the lower and upper esophageal sphincters along with a risk of perforation. OBJECTIVE We describe a unique approach by using an esophageal balloon dilator to anchor a hollow foreign body onto an endoscope, which allows for the successful extraction of such objects with minimal risk. DESIGN Case series. SETTING Shands Jacksonville and University of Florida/Jacksonville, Jacksonville, Florida. PATIENTS Two consecutive patients with hollow foreign bodies in the stomach that required removal. INTERVENTIONS A combined approach by using an endoscope and a 20-mm by 8-cm esophageal balloon dilator to remove hollow foreign bodies from the stomach. MAIN OUTCOME MEASUREMENTS Nonsurgical removal of hollow gastric foreign bodies. RESULTS Both foreign bodies were successfully removed from the stomach and extracted by mouth with this technique. There were no complications after both procedures. CONCLUSIONS The inflated esophageal balloon that anchors a hollow foreign body onto a flexible endoscopic technique is a safe and effective alternative to previously described methods for removal of such foreign bodies in the gastric cavity. This method may be applicable to the removal of other hollow objects within the gastric lumen.

Modified technique to extract malpositioned or migrated self-expanding stents from the esophagus and stomach

Background and Aim:  Various methods have been used to remove self expandable stents (SES) because of either malposition or migration. The main difficulties encountered in such situations are the anatomic obstacle of the lower and upper esophageal sphincters as well as risk of mucosal injury during removal.

Ultrasound marking by gastroenterologists prior to percutaneous liver biopsy removes the need for a separate radiological evaluation

BACKGROUND/AIM Ultrasound marking by radiologists prior to percutaneous liver biopsy (PLB) results in biopsy site adjustment, decreased pain related complications and improved tissue yield. Minimal data exists on the impact of ultrasound marking by gastroenterologists on these parameters. The study aim was to evaluate whether ultrasound marking by gastroenterologists results in improved PLB tissue yield, fewer needle passes and decreased biopsy failure rates compared to blind biopsy, eliminating the need for a separate radiological evaluation. METHODOLOGY All PLB performed by gastroenterologists from June 1999 to February 2003 at the University of Florida College of Medicine, Jacksonville, were reviewed retrospectively. Data collected included ultrasound marked or blind PLB, demographics, indication, number of passes performed, and specimen length, if obtained. RESULTS Four hundred and eighty PLB were included: 328 performed with ultrasound marking and 152 blind. Ultrasound marking by gastroenterologists prior to PLB resulted in fewer passes and longer specimens as well as a decreased failure rate in ultrasound marked compared to blind PLB. CONCLUSIONS Ultrasound marking by gastroenterologists prior to PLB provided significantly larger tissue samples, fewer needle passes and a decreased biopsy failure rate compared to blind PLB. This removes the need for a separate radiological evaluation on the procedure day.

African American ethnicity is not associated with development of Barrett's oesophagus after erosive oesophagitis

BACKGROUND Barretts oesophagus is the primary risk factor for oesophageal adenocarcinoma; erosive oesophagitis is considered an intermediate step with Barretts oesophagus development potential upon healing. Barretts oesophagus occurs in 9-19% following erosive oesophagitis but minimal data exists in African Americans. The study aim was to determine if ethnicity is associated with Barretts oesophagus formation following erosive oesophagitis. METHODS Retrospective review of endoscopies from September 2007 to December 2012 was performed. Inclusion criteria were erosive oesophagitis on index endoscopy, repeat endoscopy ≥6 weeks later and non-Hispanic white or African American ethnicity. Barretts oesophagus frequency following erosive oesophagitis by ethnicity was compared. RESULTS A total of 14,303 patients underwent endoscopy during the study period; 1636 had erosive oesophagitis. Repeat endoscopy was performed on 125 non-Hispanic white or African American patients ≥6 weeks from the index procedure. Barretts oesophagus occurred in 8% of non-Hispanic whites while no African American developed it on repeat endoscopy following erosive oesophagitis (p=0.029). No significant difference was seen between ethnic groups in any clinical parameter assessed. CONCLUSIONS African American ethnicity appears to result in decreased Barretts oesophagus formation following erosive oesophagitis. Further investigation to demonstrate factors resulting in decreased Barretts oesophagus formation among African Americans should be performed.

Protective Propensity of Race or Environmental Features in the Development of Barrett's Esophagus in African Americans – A Single Center Pilot Study

BACKGROUND AND STUDY AIMS Barretts Esophagus (BE) is a well-recognized pre-malignant condition. Previous data indicate histologically confirmed BE frequency varies by ethnicity in the United States. However, clinical factor assessment to explain this has only occurred in a veteran population to date. The study aim was to determine which clinical factors may be associated with the ethnic variation seen in histologically confirmed BE among a general population. PATIENTS AND METHODS The University of Florida-Jacksonville endoscopy database was searched for all cases of endoscopic BE from September 2002 to October 2012. Histologic BE was diagnosed only if salmon colored, columnar-appearing esophageal mucosa was seen at endoscopy and biopsy revealed intestinal metaplasia with Alcian blue-stained goblet cells. Data collected included: age/BMI at diagnosis, ethnicity, sex, GERD history, atypical manifestations, endoscopic BE length, presence of esophageal stricture/ulcer/hiatal hernia, presence/absence of dysplasia and medication use (aspirin/NSAIDs/statin/PPI). RESULTS Salmon colored esophageal mucosa was observed in 1105 of 15,564 patients (7.1%) with BE histologically confirmed in 249 of 1105 patients (23%). Ethnic distribution of histologic BE patients: 83% non-Hispanic white (nHw), 13% African American (AA) and 4% other. No difference was seen between groups with regard to BMI, GERD symptom/complications, BE length, and cigarette, alcohol or medication use. CONCLUSION BE occurs primarily in nHw in north Florida. This occurs despite similarities in GERD history, cigarette/alcohol use, medications prescribed and BMI. Molecular level investigation is necessary to explain this observed disparity between nHw and AA.