Keith Bruninga

Endoscopy in eosinophilic esophagitis: “feline” esophagus and perforation risk

BACKGROUND & AIMS Idiopathic eosinophilic esophagitis is an underdiagnosed disease with typical endoscopic findings, which have not been well described. METHODS Charts and pathology reports at two tertiary care centers from June 1993 to April 2002 were reviewed to describe the endoscopic findings of this disease and to correlate them with clinical characteristics. Eight patients were identified as having eosinophilic esophagitis based on clinical symptoms and pathology reports. RESULTS Soft and subtle ring(s) in the esophagus were found in 7 of 8 patients. In 3 of 8 patients, the esophagus appeared rigid. Mucosal rents occurred with simple passage of the endoscope in 5 of 8 patients. One patient developed a perforation after simple passage of the endoscope. Endoscopic findings can be normal or very subtle in these patients, and the findings can easily be missed during endoscopy. Tearing of the esophagus can occur with simple passage of the endoscope or biopsy even in the absence of overt rings. A minimum of 8 weeks of medical therapy (proton pump inhibitor, histamine antagonists, immunosuppressants) should be undertaken before considering dilation because of the high risk involved with the procedure and the good response to medical therapy. CONCLUSIONS We recommend considering dilation only in patients with eosinophilic esophagitis who do not respond to medical therapy and have rings that appear to be obstructing the lumen.

Successful and sustained treatment of chronic radiation proctitis with antioxidant vitamins E and C

OBJECTIVE:Chronic radiation proctitis, a common sequelae of pelvic radiation, is characterized by obliteration of the submucosal vasculature with subsequent ischemia and reperfusion injury. Oxidative stress is thought to be a major mechanism in radiation proctitis. Therefore, antioxidants (vitamins E and C) may be beneficial.METHODS:Twenty consecutive symptomatic outpatients with endoscopically documented radiation proctitis seen in a single gastroenterology clinic were given a combination of vitamin E (400 IU tid) and vitamin C (500 mg tid). Previous radiation therapy was given for prostatic (n = 10) or gynecological (n = 10) malignancies. These patients presented with one or more of the following symptoms: rectal bleeding, rectal pain, diarrhea, or fecal urgency. Using a questionnaire, these symptoms were rated by the patients in terms of their severity (grade 0–4) and frequency (grade 0–4) before and after treatment with vitamins E and C. A symptom index was calculated by the addition of the severity and frequency scores (8 = most symptomatic). The lifestyle impact of the symptoms was also assessed by questionnaire grading from 0 (no effect on daily activity) to 4 (afraid to leave home). Among these 20 patients, 10 patients who received vitamins E and C for 1 yr were assessed again to determine whether their initial responses were sustained.RESULTS:There was a significant (p < 0.05; Wilcoxon rank) improvement in the symptom index (before treatment vs after treatment with vitamins E and C) for bleeding (median score: 4 vs 0), diarrhea (median score: 5 vs 0), and urgency (median score: 6 vs 3). Patients with rectal pain did not improve significantly. Bleeding resolved in four of 11 patients, diarrhea resolved in eight of 16 patients, fecal urgency resolved in three of 16 patients, and rectal pain resolved in two of six patients. Lifestyle improved in 13 patients, including seven patients who reported a return to normal. Two of the patients with no improvement in their daily symptoms also had radiation ileitis. All 10 patients who underwent a second follow-up interview reported sustained improvement in their symptoms 1 yr later.CONCLUSION:A substantial number of patients with radiation proctitis seem to benefit from antioxidant therapy. A double-blind placebo-controlled trial is needed to confirm this open-labeled pilot study.

Irritable bowel syndrome: an update on therapeutic modalities.

Irritable bowel syndrome (IBS) is the most common condition that a physician faces in the GI clinic. Of the general population, 10 - 25% suffer from symptoms judged to be IBS. The negative impact of this disease includes not only pain, suffering and direct medical expenses but also significant social and job-related consequences. IBS can be the result of dysfunction in any part of the brain-gut axis: alterations in the CNS caused by psychological or other factors, abnormal gastrointestinal motility, or heightened visceral sensations. Diagnosis is based on either the Manning or Rome-II criteria. Education, reassurance and emotional support are the cornerstones of successful treatment. The mainstays of the current therapeutic approach continue to be: stress management strategies, dietary modification entailing addition of dietary fibre and pharmacotherapy. Pharmacotherapy is still limited to treating symptoms. Newer drugs that modulate motility or drugs that modulate visceral sensation may be useful in selected cases. Psychopharmacological agents are useful in the treatment of IBS, especially in those with psychological co-morbidity. Alternative therapies such as homeopathy, acupuncture, special diets, herbal medication and several forms of psychological treatments and hypnotherapy are sought by many patients and are now being offered by physicians as treatment options, either alone or in conjunction with conventional forms of therapy in patients with refractory symptoms.

Physiology of the aerodigestive system and aberrations in that system resulting in aspiration.

BACKGROUND Aspiration pneumonia remains a significant and often devastating problem in critically ill patients. It is unclear whether aspiration pneumonia occurs because of problems in the handling of oropharyngeal secretions or if the reflux of gastric contents is the major etiological factor. Additionally, the obvious breakdown of upper aerodigestive protective mechanisms in the critically ill patient population is largely unstudied. Finally, the impact and contribution of tubes, both endotracheal and nasoenteral, on aspiration pneumonia is unclear. METHODS A Medline literature search on scientific and review articles concerning the normal physiology of the aerodigestive tract and factors that compromised normal physiology was undertaken. Readings were supplemented by expert outside opinion from researchers in these fields and from the combined expertise from a multidisciplinary panel of experts assembled at a recent summit on aspiration pneumonia. RESULTS Changes in the normal physiology of the aerodigestive tract are vast and varied and dependent on the response to injury, iatrogenic interventions, and the use of nasoenteral and endotracheal tubes. The effects on gastric and esophageal motility are likely dynamic and represent an ongoing but changing risk of reflux for the patient. Nasoenteral and endotracheal tubes likely compromise upper aerodigestive protective mechanisms. CONCLUSIONS More research is needed on the functioning of the aerodigestive protective mechanisms in critically ill patients. Understanding of the dynamic changes in gastrointestinal motility will also be an important factor to decrease the incidence of aspiration pneumonia in this patient population.

Hepatitis B vaccination in patients with inflammatory bowel disease

AIM To determine the prevalence for hepatitis B virus (HBV) and HBV screening and vaccination practices for inflammatory bowel disease (IBD). METHODS This study is a retrospective, cross-sectional observational study. A retrospective chart review was performed in 500 patients who have been consecutively treated for IBD between September 2008 and January 2013 at the Rush University Medical Center Gastroenterology section. The patients were identified through the electronic medical record with the criteria that they attended the gastroenterology clinic, and that they had a diagnosis of IBD at the time of visit discharge. Once identified, each record was analyzed to determine whether the subject had been infected with HBV in the past, already been vaccinated against HBV, or advised to get vaccinated and followed through with the recommended vaccination. RESULTS About 254 out of 500 patients (51%) had HBV screening ordered. Among those ordered to have screening tests, 86% followed through with HBV serology. Gastroenterology physicians had significantly different screening ratios from each other (P < 0.001). There were no significant differences in the ratios of HBV screening when IBD specialists were compared to other gastroenterology physicians (0.505 ± 0.023 vs 0.536 ± 0.066, P = 0.66). Of those 220 patients screened, 51% of IBD patients were found not to be immune against HBV. Approximately 50% of gastroenterology physicians recommended HBV vaccinations to their patients in whom serology was negative for antibodies against HBV. IBD specialists recommended vaccinations to a higher percentage of their patients compared to other gastroenterology physicians (0.168 ± 0.019 vs 0.038 ± 0.026, P = 0.015). Present and/or past HBV infection was found in 3.6% of the patients who had serology checked. There was no statistically significant difference in the prevalence of hepatitis B surface antigen (HBsAg) between our study and that reported in previous studies done in Spain (4/220 vs 14/2076 respectively, P = 0.070); and in France (4/220 vs 3/315 respectively, P = 0.159). But, the prevalence of anti-HBcAb in this study was less than that reported in the study in Spain (7/220 vs 155/2076 respectively, P = 0.006); and was not significantly different from that reported in the study in France (7/220 vs 8/315 respectively, P = 0.313). CONCLUSION The prevalence of HBsAg in our IBD patients was not higher than previously reported European studies. Most IBD patients are not routinely screened or vaccinated against HBV at a tertiary referral center in the United States.

Optimization of sacral ventral root stimulation following SCI: Two case reports with six-month follow-up

Sacral ventral root stimulation in conjunction with sacral dorsal rhizotomy has been effective in promoting voiding in individuals with upper-motor-neuron spinal cord injury. We report on two patients who had variable voiding responses to stimulation during the first six months after electrode implantation. We used videourodynamic records and daily voiding records to characterize their voiding difficulties. Different methods were used to improve voiding, including seating adjustments and changes in stimulation parameters. The first patient was unable to empty his bladder on a regular basis with stimulation using 24 pulses per sec stimulating frequency for the first two months after implantation. Voiding was substantially improved by using 35 pulses per sec. At the end of six months, he is regularly emptying his bladder with stimulation and is on an every-second-day bowel program. However, his bowel program has been irregular. The second patient had very good voiding when stimulation was applied in bed, but he had poor voiding with high residual volumes when sitting in his wheelchair. Voiding was improved when he used a wheelchair cushion that was cut out in the back or lifted his buttocks off the chair. These procedures appeared to reduce perineal pressures. This patient has bowel care on alternate days and his bowel care time has been reduced following implantation of the device. Neither of the patients experienced an erection with the device. Both patients feel positive about their implant experience.

Direct electrical stimulation for constipation treatment after spinal cord injury

The effect of direct electrical stimulation on colonic transit and manometric recordings following a spinal cord injury (SCI) at T4 were assessed in five adult male cats. Animals were evaluated under three conditions: before SCI, after SCI, and after SCI with direct electrical stimulations of the colon. Electrical stimulation protocols compared pulse durations of 0.1 and 1.0 ms, frequencies of 10 and 40 pps, and stimulating currents ranging from 0-50 mA. Colonic transit times were determined for each of the three animal conditions. SCI was found to prolong (P<0.05) transit when compared to the transit before SCI. Electrical stimulation following SCI was found to decrease transit to values not significantly different from those before SCI. Manometric defecation patterns were recorded for PreSCI, SCI, and SCI+stim. Using a criterion based scale, it was possible to identify each type of spontaneous and stimulation induced contraction. Before SCI the most frequent event was a colonic contraction (38%) compared to an abdominal contraction (38%) after SCI+stim. The number of phasic contractions/hr was determined in the fasting and postprandial states and was not found to be significantly different. These findings demonstrate direct electrical stimulation of the colon following SCI improves colonic transit and does not appear to affect phasic colonic activity in this animal model.

Breath Methane Levels Are Associated With Diverticulosis and Bacterial Overgrowth but Not BMI

Background: Methanogenic archae have been implicated in the pathogenesis of obesity and it is postulated that methanogens regulate the speed with which hydrogen is generated in the colon. Whether there is an association between methanogens and GI tract disease is largely unknown. Aim: To determine if there is an association between breath methane levels (BML) on hydrogen breath testing (HBT) and BMI, or GI tract pathology in human subjects Methods: 406 human subjects who have underwent HBT at Rush University from 2003 to 2010 were randomly identified using the HBT database at Rush. For HBT subjects received either 25 gm of lactose or 20 gm of lactulose. Two baseline breath samples and samples every 15 mins were taken upto 150 min. Breath samples were then analyzed using the Quinton Microlyzer for methane, carbon dioxide and hydrogen. The clinical patient characteristics and the HBT results were obtained with chart review and were analyzed with chi-square or Fisher exact tests for categorical data and T-tests for continuous variables. Methane producers were defined as having a baseline fasting BML>5ppm. Pearson correlation coefficients between BMI and methane levels and univariate linear regression analyses were calculated using SPSS v17.0. Results: The two baseline BML as well as follow up BML were highly correlated (n=406, Pearson Corr. Coef. > 0.87 for all). Therefore the first baseline BML was used for further analyses. When methane producers (n=83) were compared to non-producers (n=323), there were no significant differences in clinical variables such as age, gender, ethnicity, presenting symptoms, medication use, social and family history, frequency of bowel movements, and hemoglobin or albumin levels. Methane producers were more likely to have bacterial overgrowth (26.3% vs 13.3%, p=0.006), were prescribed antibiotics more often after HBT (26.2% vs 12.8%, p=0.002) and responded more often with a complete resolution of symptoms (15/49 (30.6%) vs 24/124 (19.3%), p=0.044). Methane producers had a higher incidence of diverticulosis on a recent colonoscopy (n= 264, 27/53(50.9%) vs 72/211(34.1%), p=0.021) but were not older (mean age= 51.5 vs 51.1, p=0.813) or having less frequent BMs (mean BM/day=2.7 vs 2.6, p=0.835). There was no correlation between BML and BMI in all patients or methane producers (n=262 and 43, Pearson Corr. Coef. =-0.016 and -0.148 respectively). Obesity (i.e. BMI>30) was not more frequent among methane producers (13/43 (30.2%) vs. 67/219(30.6%), p=0.963) Conclusions: Breath methane production is associated with diverticulosis and bacterial overgrowth. There is no correlation between BMI and methane producing status in symptomatic patients undergoing HBT.