Juan E. Corral

Helicobacter pylori recurrence after eradication in Latin America: Implications for gastric cancer prevention

AIM To estimate Helicobacter pylori (H. pylori) recurrence rate in Latin America, a region with a significant H. pylori prevalence and gastric cancer burden. METHODS PubMed, LILACS, SciELO, Cochrane databases and abstracts from relevant meetings were reviewed. Information collected included: Participants’ characteristics, recruitment strategy, diagnostic modality, treatment arms, follow-up and recurrence rates. Recurrence was calculated using 100-patients-year rates, and data were pooled using a random effects model. The I2 statistic assessed between study heterogeneity. Meta-regression analyses evaluated for effect modifying variables. RESULTS Literature search yielded 163 articles. Twelve studies involving 4848 patients from 9 countries met inclusion criteria. Four hundred and thirty-two reinfections were recorded in 5487 person-years of follow-up. Pooled analysis showed a recurrence rate of 7.9 cases per 100 person-years (95%CI: 5.3-10.5). Meta-regression revealed that neither the antibiotic schema, a second antibiotic course, nor the diagnostic modality had an impact on the observed risk of recurrence. The recurrence rate in the first year after treatment, predominantly recrudescence, was 11.2 (6.1-16.4) per 100 patient years. Recurrence in subsequent years, was only 6.2 (3.8-8.7). CONCLUSION H. pylori recurrence rates in Latin America are significant, and with geographic variability, yet are acceptable based upon the current literature for consideration of large scale intervention trials. Further research in Latin America is warranted to evaluate the efficacy, cost-effectiveness, and potential adverse outcomes of proposed eradication programs.

Is Gastroparesis Found More Frequently in Patients with Cystic Fibrosis? A Systematic Review

Cystic fibrosis (CF) is associated with different gastrointestinal motility disturbances and syndromes. We aim to assess gastric emptying in patients with CF compared to healthy controls by a systematic review of existing literature. Medical databases and abstracts from major gastroenterology and CF meetings were reviewed. Emptying times in CF patients were compared with healthy controls using random effects models. Subgroup analysis stratified results by age and diagnostic modality. Nineteen studies from 7 countries included 574 subjects (359 CF patients and 215 controls). Using pooled analysis frequency of gastroparesis was high (38%, 95% CI 30–45%) but results were highly dependent on the diagnostic modality. Delayed gastric emptying is more common in CF compared to general population. Scintigraphy identified rapid gastric emptying in a subgroup of CF patients, but this finding disappeared with adequate pancreatic enzyme replacement and after other diagnostic modalities were included.

Olmesartan-Induced Enteropathy

Olmesartan-induced enteropathy mimics celiac disease clinically and pathologically. As in celiac disease, the pathologic findings are villous atrophy and increased intraepithelial lymphocytes. Clinical presentation of olmesartan-induced enteropathy includes diarrhea, weight loss, and nausea. In contrast to celiac disease, tissue transglutaminase is not elevated and there is no response to a gluten-free diet. Including this entity in the differential diagnosis of sprue-like enteropathy is critical for its early diagnosis since replacing olmesartan with an alternative antihypertensive drug can simplify the diagnostic workup and provide both clinical and histologic improvement.

Clinical preventive services in Guatemala: a cross-sectional survey of internal medicine physicians

Background Guatemala is currently undergoing an epidemiologic transition. Preventive services are key to reducing the burden of non-communicable diseases, and smoking counseling and cessation are among the most cost-effective and wide-reaching strategies. Internal medicine physicians are fundamental to providing such services, and their knowledge is a cornerstone of non-communicable disease control. Methods A national cross-sectional survey was conducted in 2011 to evaluate knowledge of clinical preventive services for non-communicable diseases. Interns, residents, and attending physicians of the internal medicine departments of all teaching hospitals in Guatemala completed a self-administered questionnaire. Participants’ responses were contrasted with the Guatemalan Ministry of Health (MoH) prevention guidelines and the US Preventive Services Task Force (USPSTF) recommendations. Analysis compared knowledge of recommendations within and between hospitals. Results In response to simulated patient scenarios, all services were recommended by more than half of physicians regardless of MoH or USPSTF recommendations. Prioritization was adequate according to the MoH guidelines but not including other potentially effective services (e.g. colorectal cancer and lipid disorder screenings). With the exception of colorectal and prostate cancer screening, less frequently recommended by interns, there was no difference in recommendation rates by level. Conclusion Guatemalan internal medicine physicians’ knowledge on preventive services recommendations for non-communicable diseases is limited, and prioritization did not reflect cost-effectiveness. Based on these data we recommend that preventive medicine training be strengthened and development of evidence-based guidelines for low-middle income countries be a priority.

Impact of Periampullary Diverticulum on ERCP Performance: A Matched Case-Control Study

Background/Aims Periampullary diverticulum (PAD) is frequently encountered during endoscopic retrograde cholangiopancreatography (ERCP) and has been associated with stone formation in the bile duct. The effects of PAD on the ERCP procedure have been often debated. We aimed to compare the therapeutic success of ERCP between patients with PAD and matched controls. Methods We reviewed all ERCPs with findings of PAD in a national database (n=1,089) and compared them with age- and gendermatched controls in a 1:3 fashion (n=3,267). Demographics, endoscopic findings, visualization of main structures, and therapeutic success rates were compared between groups. Secondary analysis compared PAD cases and controls who had gallstone disease. Results The average cohort age was 68.4±14.3 years and 55.1% were male. ERCP success was similar in both groups, and no significant inter-group differences were found in the multivariate analysis. The presence of PAD did not affect the rates of sphincterotomy or visualization of main biliary structures. Secondary analysis showed similar success rates for gallstone removal between patients with PAD and controls. Conclusions PAD may not be considered a hinderance to ERCP success. Further research is needed to determine the best approach to cannulate the ampulla and provide endoscopic therapy for different subtypes of PAD.

Characteristics of illegal and legal cigarette packs sold in Guatemala

BackgroundGuatemala, as a party to the Framework Convention on Tobacco Control (FCTC), is required to regulate cigarette packaging and labeling and eliminate illicit tobacco trade. Current packaging and labeling characteristics (of legal and illegal cigarettes) and their compliance with the FCTC is unknown.MethodsWe sought to analyze package and label characteristics of illegal and legal cigarettes sold in Guatemala. We visited the 22 largest traditional markets in the country to purchase illegal cigarettes. All brands registered on tobacco industry websites were purchased as legal cigarettes. Analysis compared labeling characteristics of illegal and legal packs.FindingsMost (95%) markets and street vendors sold illegal cigarettes; 104 packs were purchased (79 illegal and 25 legal). Ten percent of illegal and none of the legal packs had misleading terms. Half of the illegal packs had a warning label covering 26 to 50% of the pack surface. All legal packs had a label covering 25% of the surface. Illegal packs were more likely to have information on constituents and emissions (85% vs. 45%, p < 0.001) and were less expensive than legal ones (USD 0.70 ± 0.7 and 1.9 ± 1.8, p < 0.001).ConclusionsIn Guatemala, neither illegal nor legal cigarette packs comply with FCTC labeling mandates. Urgent implementation and enforcement of the FCTC is necessary to halt the tobacco epidemic.

Recurrent Cardiac Tamponade: An Unusual Presentation of Intrahepatic Cholangiocarcinoma.

A 48-year-old Egyptian woman presented with 8 months of sharp right upper chest pain and weight loss. She was discovered to have an enlarged cardiac silhouette on chest x-ray, and an echocardiogram revealed a large pericardial effusion with diastolic right atrial collapse. Pericardial window was done, and epithelial membrane antigen-positive neoplastic cells were identified in the pericardial fluid. Computed tomography showed a 6-cm hypermetabolic lesion on the liver segment IV, confirmed on biopsy to be a moderately differentiated adenocarcinoma consistent with intrahepatic cholangiocarcinoma.

Metastatic Colorectal Cancer and the Need for More Endoscopic Tools

Colorectal cancer survival has significantly improved since the mid-1980s. With current chemotherapy treatments, median survival of metastatic disease is longer than 2 years [1, 2]. Metastatectomy of liver and lung lesions have also shown to improve mortality with 5-year survival rates ranging from 24 to 68 % [3]. With such therapeutic advances, complications other than liver failure are seen more commonly; in a single-center experience, 10 % of cases presented with biliary obstruction (53 % intrahepatic and 47 % extrahepatic obstruction) [4]. A 48-year-old man with stage IVB sigmoid adenocarcinoma diagnosed in 2007 treated with five different lines of adjuvant chemotherapy, right lobectomy for liver metastasis, and video-assisted thoracoscopy for pulmonary metastasis presented with jaundice and abdominal pain. Tumor invasion of the common bile duct prompted the placement of an uncovered metal stent and an in-stent stent for recurrent obstruction. Local tumor re-invasion led to multiple episodes of cholangitis requiring permanent percutaneous internalexternal catheter placement in the left hepatic duct (Fig. 1). Endoscopy visualized an ulcerating mass in the first and second portion of duodenum with biliary in-stent stent composite extending from the duodenal papilla (Fig. 2a). Stent removal with a rat-toothed forceps and snare was unsuccessful. A second attempt with a side-viewing duodenoscope, rattoothed forceps and snare also failed. The stent was pulled proximally into the stomach with the snare (Fig. 2b, c). Attempts to relocate it into the duodenum with the forceps and a CRETM balloon were futile. Repeated efforts cutting the distal portion of the stent with argon plasma coagulation (80 W, 1.5 L/min) were ineffective. A CRETM balloon was inserted into the stents’ lumen. Pulling was attempted, but the stents remained in place. The procedure was terminated with the composite of stents suspended in the gastric antrum. Patient subsequently developed symptoms of gastric outlet obstruction, melena, and recurrent episodes of cholangitis over a 3month period until finally expiring under the care of palliative care physicians. The patient survived 7 years from his initial diagnosis of stage IV colorectal cancer with endoscopic and oncologic management.