Mohammed Saadi

Gastric polyps: Association with Helicobacter pylori status and the pathology of the surrounding mucosa, a cross sectional study.

AIM To assess the endoscopic characteristics of gastric polyps and their association with Helicobacter pylori (H. pylori) status in a predominantly Hispanic population. METHODS We conducted a retrospective study of all esophagogastroduodenoscopies performed at our institution. Demographic, endoscopic and histopathological data were reviewed. Categorization of patients into Hispanic and Non-Hispanic was based on self-identification. Patients without resection/biopsy were not included in the analysis. Identification of polyps type was based on histological examination. One way analysis of variance was used to compare continuous variables among different polyp types and Fishers exact test was used compare categorical variables among polyp types. Unadjusted and adjusted comparisons of demographic and clinical characteristics were performed according to the H. pylori status and polyp type using logistic regressions. RESULTS Of 7090 patients who had upper endoscopy, 335 patients had gastric polyps (4.7%). Resection or biopsy of gastric polyps was performed in 296 patients (88.4%) with a total of 442 polyps removed or biopsied. Of 296 patients, 87 (29%) had hyperplastic polyps, 82 (28%) had fundic gland polyps and 5 (1.7%) had adenomatous polyps. Hyperplastic polyps were significantly associated with positive H. pylori status compared with fundic gland polyps (OR = 4.621; 95%CI: 1.92-11.13, P = 0.001). Hyperplastic polyps were also found to be significantly associated with portal hypertensive gastropathy compared with fundic gland polyps (OR = 6.903; 95%CI: 1.41-33.93, P = 0.0174). Out of 296 patients, 30 (10.1%) had a follow-up endoscopy with a mean duration of 26 ± 16.3 mo. Interval development of cancer was not noted in any of the patients during follow up period. CONCLUSION Gastric hyperplastic polyps were significantly associated with positive H. pylori status and portal hypertensive gastropathy as compared with fundic gland polyps.

Frequency of Jackhammer Esophagus as the Extreme Phenotypes of Esophageal Hypercontractility Based on the New Chicago Classification.

Background: Jackhammer Esophagus is defined as intact esophageal peristaltic contractions with extremely elevated amplitudes. We conducted a retrospective study to identify the frequency of esophageal hypercontractility and the clinical characteristics of Jackhammer Esophagus. Methods: Charts for the patients referred for manometric study at a tertiary-care motility center were reviewed. Data were collected utilizing the new Chicago classification criteria for Jackhammer Esophagus. Concomitant clinical variables were also explored. Results: Eight patients were identified with Jackhammer Esophagus from a total of 205 (127 female/77 male) patients referred for high-resolution esophageal manometry. Jackhammer patients had an average distal contractile integral (DCI) of 9061 mmHg/ sec/ cm and median maximal DCI of 16,433 mmHg/ sec/ cm. The greatest DCI from 15 swallows was 28,875 mmHg/ sec/ cm. Hypercontractility was associated with multipeaked contractions in every Jackhammer patient. The mean lower esophageal sphincter (LES) pressure was 41 mm Hg with 4 patients having a hypertensive pressure of >40 mm Hg. Three of the 8 (37.5%) Jackhammer group had incomplete LES relaxation by integrated relaxation pressure criteria (>15 mm Hg residual pressure). Dysphagia (8/8) was the dominant indication for the manometric study, whereas the clinical background setting was gastroesophageal reflux disease (4/8) and hiatal hernia (1/8). Treatments included smooth muscle relaxation, antireflux regimens, and pneumatic dilation of the LES. Conclusions: Jackhammer Esophagus, an extreme manometric phenotype, was identified in 4.0% of patients referred to a University Motility Center. The patients with these esophageal hypercontractility states present mainly with dysphagia. A subgroup of Jackhammer did have accompanying incomplete LES relaxation and responded to targeted therapy with pneumatic dilatation.

A Review of the Challenges Associated with the Diagnosis and Therapy of Primary Sclerosing Cholangitis.

Primary sclerosing cholangitis (PSC) is a chronic and progressive cholestatic liver disease that often leads to the development of cirrhosis. Complications of PSC include pruritus, fatigue, vitamin deficiencies, metabolic bone disease, dominant biliary strictures, gallstones, and hepatobiliary malignancies, most commonly cholangiocarcinoma (CCA). Despite the presumed autoimmune etiology of PSC, a clear benefit from immunosuppressive agents has not yet been established, and their use is limited by their side effects. Endoscopy is required in evaluation of biliary strictures in PSC to rule out the possibility of CCA. Liver transplantation is currently the only life-extending therapy for patients with end-stage disease. However, disease recurrence can be a source of morbidity and mortality as transplanted patients survive longer. Further studies are needed to develop an optimal therapeutic strategy for patients with PSC to decrease the incidence of complications of the disease, to decrease the need for transplantation, and to extend life expectancy.

Extended Cystogastrostomy with Hydrogen Peroxide Irrigation Facilitates Endoscopic Pancreatic Necrosectomy

Introduction Walled-off pancreatic necrosis (WOPN) is a major complication of acute pancreatitis. We hypothesized that an extended (2 cm) cystogastrostomy opening combined with hydrogen peroxide irrigation can increase the success of endoscopic necrosectomy and decrease the number of required endoscopic interventions. The aim of the study is to assess the safety and feasibility of the technique in the management of WOPN. Methods This is a retrospective chart review of all cases that underwent EUS with extended cystogastrostomy and hydrogen peroxide irrigation prior to necrosectomy in a tertiary referral medical center. Clinical success was defined as complete resolution of the cyst cavity or a cyst cavity less than 2 cm in size on follow-up imaging. Results 19 patients satisfied the inclusion criteria. The mean size of the walled-off cavity was 11 + 0.9 cm. Technical success of the procedure was 100%. The median number of necrosectomy sessions was 2 (range 1 to 7). Cavity resolution was noted in 18 out of 19 patients resulting in a clinical success of 94.7%. The median follow-up period was 12 months. The adverse events rate in our cohort was 15.7%. Conclusion Extended cystogastrostomy coupled with hydrogen peroxide irrigation of WOPN cavity is safe and feasible.

Características del esfínter pilórico utilizando EndoFLIP® en gastroparesia

INTRODUCTION AND AIMS Pyloric sphincter abnormalities may be detected in gastroparesis. Botulinum toxin A (BoNT/A) injection into the pylorus has been used to treat gastroparesis with varying results. The aim of the present article was to assess whether pyloric sphincter characteristics using the endoscopic functional lumen imaging probe (EndoFLIP®) with impedance planimetry in patients with gastroparesis correlated with symptoms, gastric emptying, and therapeutic response to pyloric sphincter BoNT/A injection. METHODS EndoFLIP® study was performed on patients undergoing gastroparesis treatment with BoNT/A. The gastroparesis cardinal symptom index (GCSI) was applied prior to treatment and at post-treatment weeks 2, 4, 8, and 12. RESULTS Forty-four patients were enrolled (30 with idiopathic gastroparesis, 14 with diabetic gastroparesis). Smaller pyloric diameter, cross-sectional area (CSA), and distensibility correlated with worse vomiting and retching severity at baseline. Greater gastric retention tended to correlate with decreased CSA and pyloric distensibility. BoNT/A treatment resulted in a significant decrease in the GCSI score at 2 and 4 weeks after treatment, but not at post-treatment weeks 8 or 12. Nausea, early satiety, postprandial fullness, and upper abdominal pain improved up to 12 weeks, whereas loss of appetite, stomach fullness, and stomach visibly larger improved only up to 4 weeks. Retching and vomiting failed to improve. Greater pyloric compliance at baseline correlated with greater improvement in early satiety and náusea at 8 weeks and greater pyloric distensibility correlated with improvement in upper abdominal pain. CONCLUSIONS EndoFLIP® characteristics of the pylorus provided important pathophysiologic information in patients with gastroparesis, in relation to symptoms, gastric emptying, and predicting the response to treatment directed at the pylorus.

Effectiveness of Bulking Agent (Solesta) Therapy in Fecal Incontinence in Patients Refractory to Conventional Therapies

Background: Fecal incontinence is a problem that imposes considerable socioeconomic consequences. Despite many medical therapies, unmet needs remain. A new treatment option is a biocompatible bulking agent (Solesta) administered by submucosal injection in the distal rectum. The aims of this study are as follows: (1) To evaluate the efficacy and safety of this bulking agent in decreasing the severity of fecal incontinence (FI) and improving quality of life. (2) To obtain objective evidence of changes in anorectal physiology by high‐resolution anorectal manometry pretreatment and posttreatment. Materials and Methods: From January 2014 to June 2015, 17 patients who had failed medical therapy for FI received stabilized hyaluronate injected submucosally into the rectum under direct anoscopic visualization. The treatment was considered successful if patients achieved >50% reduction in FI events during monitoring for up to 12 months. Results: After the first treatment session, 14 patients (82.3%) had a successful outcome. The remaining 3 patients received a second therapy 3 months later to achieve this result. At last follow‐up, 7 of the 17 patients (41%) were having no FI events. The remaining patients had reduction in fecal accidents from a mean of 6.4/week baseline to 2.8/week during follow‐up. Conclusions: Intrarectal injection of stabilized hyaluronate is effective for treating FI in patients who had failed standard medical treatments and is technically easy and safely performed as an outpatient procedure.

Taste and Smell Disturbances in Patients with Gastroparesis and Gastroesophageal Reflux Disease

Background/Aims Patients with gastroparesis and gastroesophageal reflux disease (GERD) often report decreased enjoyment when eating. Some patients remark that food does not smell or taste the same. To determine if taste and/or smell disturbances are present in patients with gastroparesis and/or GERD and relate these to gastrointestinal symptom severity. Methods Patients with gastroparesis and/or GERD completed questionnaires evaluating taste and smell (Taste and Smell Survey [TSS]), Patient Assessment of Upper Gastrointestinal Symptom Severity Index (PAGI-SYM), and Demographics. TSS questioned the nature of taste/smell changes and the impact on quality of life. PAGI-SYM was used to calculate Gastroparesis Cardinal Symptom Index (GCSI) and Heartburn and Regurgitation Score (HB/RG). Results Seventy-six subjects were enrolled: healthy controls (n = 13), gastroparesis alone (n = 30), GERD alone (n = 10), and both gastroparesis and GERD (n = 23). Taste and smell disturbances were higher in patients with gastroparesis, GERD, and both gastroparesis and GERD compared to healthy controls. Taste and smell abnormalities were significantly correlated (r = 0.530, P < 0.001). Taste score was strongly correlated with HB/RG (r = 0.637, P < 0.001) and with GCSI (r = 0.536, P < 0.001). Smell score was also strongly correlated to HB/RG (r = 0.513, P < 0.001) and GCSI (r = 0.495, P < 0.001). Conclusions Taste and smell abnormalities are prominent in gastroparesis and GERD patients. Abnormalities in taste and smell are significantly correlated with both gastroparesis and GERD symptom severity. Awareness of this high prevalence of taste and smell dysfunction among patients with gastroparesis and GERD may help to better understand the food intolerances these patients often have.

Video Capsule Endoscopy: A Tool for the Assessment of Small Bowel Transit Time

Purpose Video capsule endoscopy (VCE) is a procedure that uses a wireless camera to take pictures of the gastrointestinal (GI) tract. A wireless motility capsule (WMC) of a similar size has been developed, which measures pH, pressure, and temperature and can be used to assess regional and total GI transit times. VCE could also potentially be used as a tool for measuring small bowel transit time (SBTT). Methods This study was designed to obtain SBTT from VCE and compare it with historical data generated by WMC. Gastric transit time (GTT) was also measured. Patients were included if the indication for VCE was either iron deficiency anemia (IDA) or overt obscure GI bleed (OOGIB), and they did not have any known motility disorder. Results from VCE were also compared in diabetic vs. non-diabetic patients. Results There were a total of 147 VCE studies performed, including 42 for OOGIB and 105 for IDA. Median GTT and SBTT were 0.3 and 3.6 h, respectively. The overall median GTT and SBTT were 0.3 and 3.6 h, respectively, in the IDA group compared with 0.3 and 3.4 h in the OOGIB group. When compared with WMC, the GTT and SBTT were significantly faster in both groups (GTT: 3.6 h and SBTT: 4.6 h). The median GTT and SBTT were not significantly different in diabetics vs. non-diabetics [GTT: 17.5 vs. 18.0 min (P = 0.86) and SBTT: 3.9 h (237 min) vs. 3.8 h (230 min), respectively (P = 0.90)]. Conclusion SBTT as measured using VCE is not significantly different in OOGIB compared with IDA. Both GTT and SBTT are significantly faster as assessed by VCE, which is initiated in the fasting state, compared with WMC measurement, which is initiated after a standard meal. In summary, VCE could potentially be used for measuring SBTT in the fasting state.