Kevin C. Ruff

Clinical predictors of small intestinal bacterial overgrowth by duodenal aspirate culture

Aliment Pharmacol Ther 2011; 33: 1059–1067

The Rome III Classification of dyspepsia: will it help research?

A major change in the Rome III criteria relates to the condition previously called functional dyspepsia (FD). Rome I and Rome II defined FD as pain or discomfort centered in the upper abdomen without a definite structural or biochemical explanation. The condition was further sub-classified into ulcer-like or dysmotility-like dyspepsia. However, subsequent studies failed to show that single-symptoms are present in the vast majority of patients, and most symptoms failed to correlate with any physiological abnormalities. In Rome III, FD as a broad category was no longer considered useful in terms of research, but rather was defined by two new symptom entities, namely epigastric pain (epigastric pain syndrome) and meal-related symptoms (postprandial distress syndrome). We predict these changes will stimulate new research into the underlying pathophysiological disturbances, as well as impact the diagnosis and treatment of dyspepsia; the classification should advance the field, and we review the challenges ahead.

Characterization of right wrist posture during simulated colonoscopy: an application of kinematic analysis to the study of endoscopic maneuvers

BACKGROUND Endoscopic maneuvers are associated with a high incidence of musculoskeletal injuries. OBJECTIVE To quantify wrist motion patterns during simulated endoscopic procedures to identify potential causes of endoscopy-related overuse injury. DESIGN Twelve endoscopists with different levels of experience were tested on 2 simulated endoscopic procedures that differed in their level of difficulty. SETTING Right wrist movement patterns were recorded during simulated colonoscopies by using a magnetic motion-tracking device. Analysis focused on 3 wrist degrees of freedom: abduction/adduction, flexion/extension, and pronation/supination. INTERVENTIONS Subjects were tested on 2 GI lower endoscopies (colonoscopies) on a simulator. MAIN OUTCOME MEASUREMENTS Time spent within ranges of the entire wrist range of motion for 3 wrist degrees of freedom. RESULTS Endoscopists spent up to 30% of the duration of the procedures at the extremes of the wrist joint range of motion. Endoscopic experience did not affect the time spent at the extremes of the wrist joint of motion. The time spent within each range of motion differed depending on the wrist degrees of freedom and difficulty of procedure. LIMITATIONS This study examined only 1 upper limb joint in a limited number of subjects and did not measure interaction forces with endoscopic tools. CONCLUSIONS We identified wrist movement patterns that can potentially contribute to the occurrence of musculoskeletal injury in endoscopists. This study lays the foundation for future work on establishing links between upper limb movement patterns and the occurrence of overuse injury caused by repetitive performance of endoscopic procedures.

Prevalence of buried Barrett's metaplasia in patients before and after radiofrequency ablation.

BACKGROUND AND STUDY AIM Radiofrequency ablation (RFA) to treat Barretts esophagus is increasingly accepted. Description of the etiology, natural history, and prevalence of buried Barretts metaplasia (BBM) following RFA is limited, although BBM continues to pose a clinical dilemma. We aimed to assess the prevalence, characteristics, and eradication rate of BBM in patients with both dysplastic and nondysplastic Barretts esophagus, treated with RFA and followed over time. PATIENTS AND METHODS The presence of Barretts esophagus, dysplasia, and BBM, before and after RFA, was assessed by two gastrointestinal pathologists in a retrospective chart review of patients who had undergone RFA at our center and had completed appropriate follow-up. RESULTS We identified 112 patients with completed treatment and no further planned RFA. In 108, no residual Barretts esophagus was seen after RFA; 4 patients with persistent Barretts tissue underwent surgery. Regarding BBM, 17/112 patients (15.2%) had evidence of BBM during evaluation. In 12/17 (70.5%) BBM was found during the RFA treatment, with 8 having previously undergone non-RFA therapy and RFA for Barretts esophagus and 4 having no previous intervention. In 5/17 (29.4%), BBM was seen only after RFA monotherapy. All 17 showed no evidence of BBM at final evaluation and were classified in the complete remission group (108/112). CONCLUSION Both Barretts esophagus and BBM were completely eradicated in all patients with long-term follow-up after RFA. Almost half of the patients with BBM had a prior history of non-RFA therapy for Barretts esophagus compared with 26% the non-BBM cohort. All patients with previously identified Barretts esophagus and BBM were completely cleared of disease at final follow-up.

Eosinophilic Granulomatosis with Polyangiitis and Diffuse Gastrointestinal Involvement

Eosinophilic granulomatosis with polyangiitis (EGPA), formerly named Churg-Strauss syndrome, is a rare systemic small- and medium-sized-vessel vasculitis, characterized by the presence of severe asthma as well as blood and tissue eosinophilia. Gastrointestinal (GI) symptoms, like diarrhea and abdominal pain, are common; however, there are few reports of histologic evidence of GI involvement. We report the case of a patient on treatment for EGPA who presented with recurrent small bowel obstruction and choledocholithiasis. Biopsies of the esophagus, small bowel and common bile duct showed diffuse eosinophilia, with clear EGPA in the GI tract. Improved awareness of GI EGPA may allow for timely management of this disorder.

Cronkhite–Canada Syndrome Diagnosis in the Absence of Gastrointestinal Polyps A Case Report

A 66-year-old male patient presented with nausea, abdominal pain, occasional rectal bleeding, progressive dysgeusia, onicodystrophy, and alopecia. Endoscopic exam and biopsies revealed severe atrophy and diffuse marked edema of mucosa of stomach and duodenum. No evidence of polyps was found in any portion of the gastrointestinal tract. The diagnosis of Cronkhite–Canada syndrome (CCS) was rendered. The patient symptoms resolved completely after initiation of steroid treatment. This additional case of CCS illustrates how the diagnosis of CCS does not require the presence of polyps but is defined by the appreciation of the diffuse marked edema and atrophy of the gastrointestinal mucosa.

Is capsule endoscopy effective for screening and surveillance of esophageal varices in patients with portal hypertension

Guidelines for the treatment of portal hypertension recommend that individuals with chronic liver disease undergo endoscopy at diagnosis to screen for esophageal varices, with subsequent periodic surveillance. This strategy is costly, inconvenient, and can have poor compliance. In this commentary, we discuss a study by de Franchis et al. that compared the accuracy of esophageal capsule endoscopy (ECE) with that of esophagogastroduodenoscopy (EGD) for the detection of esophageal varices in patients with portal hypertension. EGD and ECE results were concordant in 86% of cases (kappa score = 0.73). There was agreement between EGD and ECE results for the grading of esophageal varices in 79% of cases (kappa score = 0.68). For differentiating absent or small esophageal varices from medium or large varices, ECE showed an overall agreement with EGD of 91% (kappa score = 0.77). This study demonstrated substantial agreement between ECE and EGD for detecting esophageal varices; however, EGD was superior overall for the detection of esophageal varices and, therefore, remains the gold standard diagnostic procedure in this setting.

Kinematic analysis of wrist motion during simulated colonoscopy in first-year gastroenterology fellows.

Background and study aims: Gastroenterology trainees acquire skill and proficiency in performing colonoscopies at different rates. The cause for heterogeneous competency among the trainees is unclear. Kinematic analysis of the wrist joint while performing colonoscopy can objectively assess the variation in wrist motion. Our objective was to test the hypothesis that the time spent by the trainees in extreme ranges of wrist motion will decrease as the trainees advance through the fellowship year. Subjects and methods: Five first-year gastroenterology fellows were prospectively studied at four intervals while performing simulated colonoscopies. The setting was an endoscopy simulation laboratory at a tertiary care center. Kinematic assessment of wrist motion was done using a magnetic position/orientation tracker held in place by a custom-made arm sleeve and hand glove. The main outcome measure was time spent performing each of four ranges of wrist motion (mid, center, extreme, and out) for each wrist degree of freedom (pronation/supination, flexion/extension, and adduction/abduction). Results: There were no statistically significant differences in the time spent for wrist movements across the three degrees of freedom throughout the study period. However, fellows spent significantly less time in extreme range (1.47 ± 0.34 min vs. 2.44 ± 0.34 min, P = 0.004) and center range (1.02 ± 0.34 min vs 1.9 ± 0.34 min, P = 0.01) at the end of the study compared to the baseline evaluation. The study was limited by the small number of subjects and performance of colonoscopies on a simulator rather than live patients. Conclusions: Gastroenterology trainees alter the time spent at the extreme range of wrist motion as they advance through training. Endoscopy training during the first 10 months of fellowship may have beneficial effects on learning ergonomically correct motion patterns.

Is the level of cleanliness using segmental boston bowel preparation scale associated with a higher adenoma detection rate

Background The impact of Boston bowel preparation scale (BBPS) scores on the adenoma detection rate (ADR) in each segment has not been adequately addressed. The aim of this study was to determine the association between segmental or overall ADR and serrated polyp detection rate (SDR) with segmental and total BBPS scores. Methods All outpatient screening colonoscopies with documented BBPS scores were retrospectively reviewed at a tertiary institution from January to December 2013. Chi-square tests and logistic regression were used to analyze the detection rates of adenomas and serrated polyps with bowel prep scores. Odds ratios were calculated using logistic regression that controlled for withdrawal time, age, body mass index, diabetes status and sex. Results We analyzed 1991 colonoscopies. The overall ADR was 37.5% (95% confidence interval [CI], 35.3-39.6). There was a significant difference in the overall ADR, and in SDR across all bowel category groups, with total BBPS scores of 8 and 9 having lower detection rates than scores of 5, 6 and 7. As the quality of bowel preparation increased, there was a statistical decrease in the ADR (odds ratio [OR] 0.79 [CI 0.66-0.94], P=0.04) of the right colon, while in the left colon, there was a statistical decrease in SDR (OR 0.78, [CI 0.65-0.92] P=0.019). Conclusion Segmental ADR and SDR both decreased as prep scores increased, decreasing notably in patients with excellent prep scores of 8 and 9. A possible explanation for this unexpected discrepancy may be related to longer and better visualization of the mucosa when cleansing and suctioning is necessary.

A Mysterious DRESS Case: Autoimmune Enteropathy Associated with DRESS Syndrome

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a rare but potentially life-threatening cutaneous hypersensitivity reaction characterized by extensive mucocutaneous eruption, fever, hematologic abnormalities, and extensive organ involvement. Here, we present a case of a young woman with DRESS syndrome following exposure to vancomycin with renal, cutaneous, and gastrointestinal involvement. To the best of our knowledge, this is the first case description in the literature of DRESS of the gastrointestinal tract with autoimmune enteropathy.