Kian Makipour

The potential role of N-acetylcysteine for the treatment of Helicobacter pylori.

example, indole induces biofilm formation in many Gram-negative bacteria by serving as a source of carbon in nutrient-poor environments. Indole is formed by the hydrolysis of tryptophan by the enzyme tryptophanase. In addition, polyamines are essential for cell growth by serving as metabolic signals. In V. cholera, the polyamine norspermidine activates biofilm formation. Similarly, inorganic molecules (eg, iron) can serve as positive regulators of biofilm formation. Host-derived molecules such as bile promotes biofilm formation in certain bacteria such as V. cholera.

Double balloon enteroscopy: effective and minimally invasive method for removal of retained video capsules.

Prior case series document removal of retained video capsules predominantly via surgical intervention. Data on endoscopic removal of retained capsules are limited. Our aim was to describe an endoscopic method of retrieval using double balloon enteroscopy (DBE).

Predictors of colorectal cancer testing using the California Health Inventory Survey

AIM To identify key variables associated with colon cancer testing using the 2009 California Health Inventory Survey (CHIS). METHODS The CHIS has been conducted biennially since 2001 using a two-stage, geographically stratified random-digit-dial sample design to produce a representative sample of the entire State. For this study we used survey data from 2001-2009 inclusive. We restricted our analysis to White, Black, and Hispanic/Latinos aged 50-80 years. Weighted data was used to calculate the proportion of participants who underwent some form of colon cancer testing (colonoscopy, flexible sigmoidoscopy or fecal occult blood testing) within the previous 5 years stratified by race/ethnicity. For inferential analysis, boot-strapping with replacement was performed on the weighted sample to attain variance estimates at the 95%CI. For mean differences among categories we used t-tests and for comparisons of categorical data we used Pearsons χ(2). Binary logistic regression was used to identify independent variables associated with undergoing some form of testing. Trend analysis was performed to determine rates of testing over the study period stratified by race. RESULTS The CHIS database for 2009 had 30 857 unique respondents corresponding to a weighted sample size of 10.6 million Californians. Overall, 63.0% (63.0-63.1) underwent a colon cancer test within the previous 5 years; with 70.5% (70.5%-70.6%) of this subset having undergone colonoscopy. That is 44.5% (44.4%-44.5%) of all individuals 50-80 underwent colonoscopy. By multivariable regression, those tested were more likely to be male (OR = 1.06; 95%CI: 1.06-1.06), Black (OR = 1.30; 95%CI: 1.30-1.31), have a family member with colon cancer (OR = 1.71; 95%CI: 1.70-1.72), and have health insurance (OR = 2.71; 95%CI: 2.70-2.72). Progressive levels above the poverty line were also associated with receiving a test (100%-199%: 1.21; 1.20-1.21), (200%-299%:1.41; 1.40-1.42), (> 300:1.69; 1.68-1.70). The strongest variable was physician recommendation (OR = 3.90; 95%CI: 3.88-3.91). For the Hispanic/Latino group, additional variables associated with testing were success of physician-patient communication (OR = 2.44; 95%CI: 2.40-2.48) and naturalized citizenship status (OR = 1.91; 95%CI: 1.89-1.93). Trend analysis demonstrated increased colon cancer testing for all racial/ethnic subgroups from 2001-2009 although the rate remained considerably lower for the Hispanic/Latino subgroup. CONCLUSION Using CHIS we identified California citizens most likely to undergo colon cancer testing. The strongest variable associated with testing for all groups was physician recommendation.

Ileocecal valve dysfunction in small intestinal bacterial overgrowth： A pilot study

AIM To explore whether patients with a defective ileocecal valve (ICV)/cecal distension reflex have small intestinal bacterial overgrowth. METHODS Using a colonoscope, under conscious sedation, the ICV was intubated and the colonoscope was placed within the terminal ileum (TI). A manometry catheter with 4 pressure channels, spaced 1 cm apart, was passed through the biopsy channel of the colonoscope into the TI. The colonoscope was slowly withdrawn from the TI while the manometry catheter was advanced. The catheter was placed across the ICV so that at least one pressure port was within the TI, ICV and the cecum respectively. Pressures were continuously measured during air insufflation into the cecum, under direct endoscopic visualization, in 19 volunteers. Air was insufflated to a maximum of 40 mmHg to prevent barotrauma. All subjects underwent lactulose breath testing one month after the colonoscopy. The results of the breath tests were compared with the results of the pressures within the ICV during air insufflation. RESULTS Nineteen subjects underwent colonoscopy with measurements of the ICV pressures after intubation of the ICV with a colonoscope. Initial baseline readings showed no statistical difference in the pressures of the TI and ICV, between subjects with positive lactulose breath tests and normal lactulose breath tests. The average peak ICV pressure during air insufflation into the cecum in subjects with normal lactulose breath tests was significantly higher than cecal pressures during air insufflation (49.33 ± 7.99 mmHg vs 16.40 ± 2.14 mmHg, P = 0.0011). The average percentage difference of the area under the pressure curve of the ICV from the cecum during air insufflations in subjects with normal lactulose breath tests was significantly higher (280.72% ± 43.29% vs 100% ± 0%, P = 0.0006). The average peak ICV pressure during air insufflation into the cecum in subjects with positive lactulose breath tests was not significantly different than cecal pressures during air insufflation 21.23 ± 3.52 mmHg vs 16.10 ± 3.39 mmHg. The average percentage difference of the area under the pressure curve of the ICV from the cecum during air insufflation was not significantly different 101.08% ± 7.96% vs 100% ± 0%. The total symptom score for subjects with normal lactulose breath tests and subjects with positive lactulose breath tests was not statistically different (13.30 ± 4.09 vs 24.14 ± 6.58). The ICV peak pressures during air insufflations were significantly higher in subjects with normal lactulose breath tests than in subjects with positive lactulose breath tests (P = 0.005). The average percent difference of the area under the pressure curve in the ICV from cecum was significantly higher in subjects with normal lactulose breath tests than in subjects with positive lactulose breath tests (P = 0.0012). Individuals with positive lactulose breath tests demonstrated symptom scores which were significantly higher for the following symptoms: not able to finish normal sized meal, feeling excessively full after meals, loss of appetite and bloating. CONCLUSION Compared to normal, subjects with a positive lactulose breath test have a defective ICV cecal distension reflex. These subjects also more commonly have higher symptom scores.

Population-based assessment of heartburn in urban Black Americans.

Prevalence data for heartburn in the urban Black American community is lacking. In order to estimate prevalence for this community, we analyzed data from an ongoing cohort study in progress at our hospital. Comprehensive interviews allowed for exploration of factors associated with heartburn. Complex, stratified sampling design was the method used. Survey invitations are hand-delivered to random blocks in a single zip code tabulation area. One member per eligible household is invited to complete a computer-based survey. Heartburn was defined as ≥ 3 days/week of symptoms as defined by the Montreal Definition and Classification of gastroesophageal reflux disease. Scaling and weighting factors were utilized to estimate population level prevalence. Multivariate logistic regression was used to identify independent predictor variables for heartburn. Enrolled 379 participants corresponding to a weighted sample size of 22,409 (20,888-23,930) citizens. Demographic characteristics of the sample closely matched those of the entire targeted population. Overall, the weighted prevalence of heartburn ≥ 3 times per week was 17.6% (16.4-18.8%). Variables independently associated with heartburn were body mass index, daily caloric and fat intake, diabetes mellitus (odds ratio = 2.95; 2.59-3.36), cigarette smoking, and alcohol consumption (odds ratio = 2.55; 2.25-2.89). Factors inversely associated included illicit drug use and increased physical activity. Waist : hip ratio showed no relationship. The prevalence of heartburn ≥ 3 times per week is high in the Black American community. Adverse lifestyle behaviors showed particularly important associations. Our study needs to be replicated in other communities with similar demographics.

Sa1188 Age Over 65 Is Independently Associated With Successful Diagnostic Double Balloon Enteroscopy

Double Balloon Enteroscopy (DBE) is used to diagnose and treat both occult and overt obscure gastrointestinal (GI) bleeding. DBE is labor intensive, is only offered in a limited number of centers, and is frequently unrevealing. Factors predictive of a successful diagnostic DBE are needed to guide application of this invasive procedure. We aimed to identify independent predictors of a diagnostic DBE in a large referral population. Methods: All consecutive antegrade and retrograde DBE exams performed for the evaluation of obscure or overt GI bleeding at a single academic tertiary referral center from July 2011 to November 2012 were retrospectively reviewed. The primary outcome was the presence of an endoscopic finding identified on DBE that explains the clinical bleeding (diagnostic yield). Route of DBE (antegrade vs retrograde) was determined by the clinical presentation. Data collected included patient demographics (age dichotomized at 65), body mass index (BMI), duration and time of procedure (AM or PM), fellow involvement, DBE route, and prior abdominal surgery. Multivariate logistic regression was performed to determine independent factors associated with a successful diagnostic DBE. Results: There were 106 patients (mean age 46.9± 30.0 years, 65 female) who underwent DBE (89 antegrade, 36 retrograde, 17 both routes). Negative prior video capsule endoscopy was reported in 71 patients. Bidirectional endoscopy reports were available in the chart for only 77 patients and were negative. The most common indication for DBE was unexplained iron deficiency anemia (n=34) followed by melena (n=23). Forty five (42.5%) DBE exams identified a lesion which explained the clinical bleeding. The most common finding was small bowel angiodysplasia (n=34, 75.6% of findings). The diagnostic yield was similar for antegrade and retrograde exams (45.1 vs. 44.4% respectively). Successful diagnostic DBE studies occurred with similar frequency in the setting of occult and overt bleeding indications (p.0.05). In multivariate analysis, age . 65 was an independent factor associated with identifying a source of bleeding on DBE (adjusted OR =3.50; 1.47-8.35). Gender, BMI, previous abdominal surgery, duration of procedure, time of procedure (AM or PM) and fellow involvement were not significant independent predictors. The diagnostic yield in those age . 65 vs. , 65 was significant (59.5% vs. 31.3%; p = 0.04). Conclusions: In a large tertiary care referral center DBE performed for the evaluation of obscure GI bleeding had a diagnostic yield of 42.5%. Age . 65 was an independent predictor of a successful DBE exam. DBE should be strongly considered in the evaluation of obscure bleeding in patients . 65 years old.

Assessment of Mucosal Movement in the Gastroesophageal Junction High-Pressure Zone During Swallowing Using Simultaneous Endoluminal Ultrasound and Manometry

BACKGROUND & AIM: Allyl isothiocyanate, the pungent ingredient of wasabi and mustard oil, is known to activate transient receptor potential (TRP) cation channels TRPA1. TRPA1 was recently shown to be functionally expressed in the gastrointestinal tract, whose ion channel presents in a subpopulation of primary sensory neurons that coexpressed with TRPV1. Previously, we also reported (1) that TRPV1-expressing sensory nerve fivers abundantly exist around blood vessels in the submucosa in the rat stomach, suggesting that TRPV1 plays an important role in control of local blood flow (Scand J. Gastroenterol. 39, 303-312, 2004), and (2) that allyl isothiocyanate facilitates to increase gastric mucosal blood flow (GMBF) in the rat stomach (Gastroenterology 138 (Suppl.1) S-721, 2010). However, the mechanism for the increased GMBF in response to allyl isothiocyanate remains unknown. In the present studies, we examined the effect of a TRPA1 activator allyl isothiocyanate on GMBF in the ex-vivo stomach of normal and sensory deafferented rats. METHODS: Male SD rats (160-200 g) were used after 18 hr-fasting. GMBFwasmeasured in the ex-vivo stomach of urethane-anesthetized rats by using the laser Doppler flowmeter. Allyl isothiocyanate (0.3310 mM) or a TRPV1 channel activator capsaicin (3.3 mM) was topically applied for 10 min to the rat stomach, and changes in GMBF were monitored. Either a TRPA1 channel blocker HC-030031 (14.1 mM) or a TRPV1 channel blocker BCTC (0.8 mM) was co-applied with allyl isothiocyanate (10 mM) for 10 min to the stomach. RESULTS: Mucosal application of allyl isothiocyanate increased GMBF in a concentration-dependentmanner.When themucosa was exposed to allyl isothiocyanate (10 mM) repeatedly, this response showed a marked desensitization. The increased GMBF response caused by allyl isothiocyanate was entirely blocked by co-application with HC-030031, but not BCTC. Interestingly, the increased GMBF in response to allyl isothiocyanate was significantly attenuated, but not completely disappear, by chemical deafferentation following systemic capsaicin injections (total dose: 100 mg/kg), although the increased GMBF in response to capsaicin was completely abolished by chemical deafferentation. The increased GMBF response to capsaicin was also significantly decreased in allyl isothiocyanate-desensitized preparation of the ex-vivo stomach. CONCLUSION: These results suggested that allyl isothiocyanate increases GMBF through activation of TRPA1, but not TRPV1. It is assumed that the increased GMBF in response to allyl isothiocyanate is mediated by TRPA1 located on both TRPV1-expresseing and TRPV1 nonexpressing sensory nerves.

A Rare Cause of Biliary Obstruction

Objective: To discuss a rare cause of obstructive jaundice. Methods: A case report is presented with emphasis on diagnosis and management. Six month follow up is also presented. Results: A 42 year old African-American male presented with one week of painless jaundice. He underwent imaging via CT abdomen pancreatic protocol and MRCP demonstrating a massively dilated common bile duct of 12 cm and diffuse intrahepatic ductal dilation. He subsequently developed pruritus, RUQ abdominal pain, and cholangitis thus necessitating an endoscopic retrograde cholangiopancreatography (ERCP). ERCP was performed but not useful in delineating the biliary tree anatomy or relieving biliary obstruction. Later percutaneous transhepatic cholangiography (PTC) was performed to provide drainage and was also not useful in delineating his biliary tree anatomy. Shortly thereafter he underwent laparotomy, choledochal cyst and bile duct resection, Roux en Y pancreaticojejunostomy and hepaticojejunostomy. A review of the pathologic specimen indicates the presence of intrapapillary neoplasm of the bile duct (IPNB) which is a rare variant of a bile duct tumor. The specimen was positive for MUC1 and CEA which indicates a high possibility of recurrence. Conclusions: Invasive carcinoma has been found to be present in 70-80% of cases of resected IPNB. However, survival has been shown to be better in patients with IPNB compared to those with conventional bile duct tumors. Given the difficulty of preoperative diagnosis of these lesions and their high predisposition for invasion all IPNB should be surgically resected.

Su1033 Factors Associated With Colon Cancer Testing: the 2009 California Health Inventory Survey

ive fecal occult blood testing (FOBT) should be discussed. Nationally, it is estimated that approximately 60% of age-appropriate adults have had a colonoscopy. The purpose of this quality improvement (QI) project is to determine how many age-appropriate patients in the residency continuity clinic at Lankenau Medical Center have had a colonoscopy, and stratify reasons for those that have not. Additionally, we will prove that yearly highly sensitive FOBT is underutilized as a simple, low-cost, non-invasive method for CRC screening in patients that are unable to or refuse to have a colonoscopy. Methods Electronic medical records (EMR) were reviewed for patients aged 50-90 that were seen in the clinic over a 6 month period, without regard for gender or ethnicity. For those that had a documented colonoscopy, no further review was performed. Those that did not have documentation in the hospital or clinic EMR received a phone call. For patients that reported never having a colonoscopy, the reason was obtained. Additionally, these patients were asked if an alternative screening method was discussed, with a focus on FOBT. Results Information was obtained for 558 patients. Of them, 79.75% had documentation of a colonoscopy, or reported that they had one. Of the remaining 20.25% who never had a colonoscopy, the most common reasons were insurance limitations, fear of or not wanting procedure, other medical issues taking precedence, and “no reason”. Nearly 17% failed to follow-up after being given a referral. Only 10.6% of patients in this subgroup were informed of an alternative screening method, such as FOBT. Conclusion FOBT is low cost, non-invasive and can be performed at home, making it a viable alternative for patients who are unable to or not willing to get a colonoscopy. Stool-based tests improve prognosis by detecting early cancers and potentially advanced adenomas. The sensitivity for detecting CRC with highly sensitive FOBT is 80-92%, and there has been shown to be a 33% CRC mortality reduction at 13 years with yearly FOBT. While disadvantages of the test include a high number of false positives that warrant further workup, as well an inability to detect non-bleeding polyps, with proper counseling and follow-up FOBT is an acceptable alternative for CRC screening when colonoscopy is not readily feasible. Reasons Reported by Patients for Not Having a Colonoscopy

Reflex Increase in the Gastroesophageal Junction High Pressure Zone Pressure During Sedated Endoscopy With Gastric Distension in Normal Volunteers

Background: Gastric distension is a strong trigger for transient lower esophageal sphincter relaxation. In addition, it has been shown in prior unsedated studies that as the stomach is distended the pressure and length within the Gastroesophageal Junction High pressure Zone (GEJHPZ) decreases (Ayazi, Shahin MD et al, Annals of Surgery: July 2010 Volume 252 Issue 1 pp 57-62) Purpose: To evaluate the GEJHPZ pressure during gastric distension. Methods: Five normal volunteers (56.2 Yrs, 4F and 1M) were evaluated during upper endoscopy. A custom made manometry catheter with pressure ports spaced 3mm apart was attached to an Olympus ultrathin endoscope (GIF-N 180). Simultaneous manometry and endoscopy was recorded on an MMS swallowing work station. The endoscopy was performed under conscious sedation with Midazolam and Fentanyl. The endoscope was retroflexed to visualize the manometry catheter placed across the entire GEJHPZ. Baseline sphincter and gastric pressures were measured. Air was then insufflated into the stomach through the air channel of the endoscope with the air flow settings set at low (20ml/sec). Gastric and GEJHPZ pressures were measured continuously during air insufflation until a peak pressure was attained or the sphincter relaxed. All the pressures reported were relative to the gastric baseline pressure. To analyze the data, the start time was selected based on the lowest pressure at or just before the start of air insufflation, and the end point was selected where the pressure reached the peak within the GEJHPZ or just before sphincter relaxation. The duration to reach the peak pressure varied widely from subject to subject so the total duration was converted into 100% and then divided into 5 equal zones and an average pressure was calculated for each zone in the subjects. The peak and baseline pressures within the stomach and GEJHPZ were compared to each other using a paired student T test. The slope of the pressure change was determined. Results: The intragastric pressure increased from a mean of 6.19 mmHg to 12.34 mmHg at a slope of 1.09 (p=0.123). The GEJHPZ pressure increased from a mean 12.16 mmHg to 63.68 mmHg at a slope of 9.47 (p≤0.001). Conclusions: During sedated endoscopy, contrary to prior unsedated studies, gastric distension elicits a marked and significant reflex increase in the pressure and tone within the GEJHPZ as measured by intersphincteric pressure measurements using ultra-high resolution manometry. We measured the absolute change and the slope of the change of the pressures in both the stomach and the GEJHPZ during distension of the stomach with air. We believe that this gastric/GEJHPZ reflex is an important mechanism that protects the esophagus from reflux of gastric contents during increases in intragastric pressure.