Neil Stollman

Diverticular disease of the colon.

Diverticular disease of the colon is quite common in developed countries, and its prevalence increases with age. Although present in perhaps two thirds of the elderly population, the large majority of patients will remain entirely asymptomatic. Nonetheless, an estimated 20% of those affected may manifest clinical illness, mainly diverticulitis, with its potential complications of abscesses, fistulas, and obstruction, as well as lower intestinal hemorrhage. The purpose of this report is to review our understanding of the epidemiology, pathophysiology, clinical presentation, and treatment options for this disorder.

Fecal flora reconstitution for recurrent Clostridium difficile infection: results and methodology.

Goals Recurrent Clostridium difficile infection (RCDI) is an increasingly common clinical problem without ideal treatment options. Our aim was to evaluate our results using Fecal Flora Reconstitution (FFR), and promulgate our methodology to the GI community to foster its more widespread use in appropriate candidates. Background FFR, sometimes termed “fecal transplantion” has been shown in numerous reports to be an effective treatment of RCDI, however, most of these studies have small sample sizes and few focus specifically on the methodology used in colonoscopic preparation and delivery of donated stool. Study Nineteen patients with confirmed multiply recurrent CDI were treated by infusing donor stool through a colonoscope. Results Out of 19 patients, 18 initially responded to treatment with a single FFR treatment, 1 patient responded after a second FFR infusion. All 19 patients maintained prolonged cured status followed until submission, ranging from 6 months to 5 years. Three patients were presumed reinfected after remaining symptom free for a period spanning from 6 months to 4 years. These patients tested positive for C. difficile after prescription of additional antibiotics for unrelated infections. Conclusions Fecal Flora Reconstitution is an effective, viable, and simple method of treatment for the difficult to treat patients with RCDI who fail standard therapy.

Fecal microbiota transplantation in relapsing Clostridium difficile infection.

Clostridium difficile infection rates are Climbing in frequency and severity, and the spectrum of susceptible patients is expanding beyond the traditional scope of hospitalized patients receiving antibiotics. Fecal microbiota transplantation is becoming increasingly accepted as an effective and safe intervention in patients with recurrent disease, likely due to the restoration of a disrupted microbiome. Cure rates of > 90% are being consistently reported from multiple centers. Transplantation can be provided through a variety of methodologies, either to the lower proximal, lower distal, or upper gastrointestinal tract. This review summarizes reported results, factors in donor selection, appropriate patient criteria, and the various preparations and mechanisms of fecal microbiota transplant delivery available to clinicians and patients.

The uncleared fundal pool in acute upper gastrointestinal bleeding: implications and outcomes

BACKGROUNDnThe implications and outcomes of patients with an uncleared fundal pool of blood found at emergent upper endoscopy are not well described.nnnMETHODSnWe reviewed the records of 484 consecutive patients who presented over a 12-month period to our medical center with acute upper gastrointestinal hemorrhage. All patients underwent upper endoscopy within 24 hours of their initial presentation. Patients with an uncleared fundal pool of blood at initial endoscopy were included in this study, and their findings and outcomes were compared with a randomly selected subgroup of these same patients who did not have residual gastric blood.nnnRESULTSnSixty-one patients (13%) had uncleared fundal pools despite gastric lavage and patient positioning. Findings on initial endoscopy included esophageal varices in 29 (47%), gastric ulcer in 12 (20%), portal hypertensive gastropathy in 5 (8%), Mallory-Weiss tear in 5 (8%), duodenal ulcer in 5 (8%), gastric varices in 4 (7%), Dieulafoys lesion in 2 (3%), and other in 7 (11%). Twelve of these 61 patients had multiple findings and 4 (7%) had no lesion identified. Thirty-two of the 61 patients (52%) had at least one follow-up endoscopy, with new fundal lesions identified in 13 (41%): portal hypertensive gastropathy in 8, gastric ulcer in 2, gastric varices in 2, and leiomyoma in 1. Of these 13 new findings, 5 (38%) were judged significant either by the presence of active bleeding or stigmata of recent hemorrhage. Of the 4 patients with no identifiable lesion on initial endoscopy, 3 had a follow-up endoscopy and 2 were found to have a significant new finding in the fundus. The control group had a statistically significant lower percentage of endoscopic findings related to portal hypertension. Recurrent bleeding during the index hospitalization occurred in 54% of the patients with uncleared fundal pools versus 11% of the control group (0 < 0.01). Length of stay, number of units of blood transfused, need for emergent surgery for bleeding, as well as overall and bleeding-related mortality were all significantly greater in the patients with the uncleared fundal pool than in the control patients.nnnCONCLUSIONSnThe inability to clear a fundal pool of blood at emergent upper endoscopy is associated with significant morbidity and mortality. Further, new fundal lesions can be identified in 41% of patients on follow-up examination, with many being clinically significant. These data support the importance of clearing a fundal pool in patients undergoing endoscopy for upper gastrointestinal bleeding.

The Efficacy of Proton-pump Inhibitors in Acute Ulcer Bleeding: A Qualitative Review

Despite remarkable progress in the treatment of chronic peptic ulcer disease, acute gastroduodenal ulcer hemorrhage remains a therapeutic challenge. Numerous trials of H-2 receptor antagonists have not consistently shown a significant benefit in such patients. Proton-pump inhibitors, which more profoundly suppress gastric acid, are being increasingly evaluated. We have performed a qualitative systematic review to analyze the results of these trials to determine if a reasonable consensus can be reached. We searched for all published, randomized, controlled studies that evaluated proton-pump inhibitors in patients with acute peptic ulcer hemorrhage. The primary outcomes evaluated were: (A) persistent or recurrent bleeding; (B) need for surgery; and (C) mortality. Sixteen trials were evaluated, enrolling 3154 patients. Four of the sixteen studies showed a statistically significant decrease in overall rebleeding rate, and two described specific benefit in patients with Type IIa and IIb endoscopic stigmata. Four studies also showed a significantly decreased surgery rate, but none demonstrated a significant mortality reduction. Proton-pump inhibitors may improve outcome in acute peptic ulcer bleeding, but the available clinical data remain inconsistent. Further study is necessary to define the optimal dosage, route of administration, duration of therapy, and subsets of patients most likely to benefit.

Frozen Encapsulated Stool in Recurrent Clostridium difficile: Exploring the Role of Pills in the Treatment Hierarchy of Fecal Microbiota Transplant Nonresponders

Frozen Encapsulated Stool in Recurrent Clostridium difficile : Exploring the Role of Pills in the Treatment Hierarchy of Fecal Microbiota Transplant Nonresponders

4909 Radiofrequency energy application to the gastroesophageal junction for the treatment of gastroesophageal reflux disease.

Background: In this multi-center trial, we investigated the safety, feasibility, and efficacy of endoscopic radiofrequency energy (RFe) delivery to the smooth muscle of the gastroesophageal junction (GEJ) for the treatment of GERD. Methods: We studied patients with chronic heartburn, acid exposure time >4% or DeMeester score>14.7, and daily anti-secretory requirement. We delivered RFe (outpatient, conscious sedation) with a 4-needle catheter and thermocouple-controlled generator to create rings of thermal lesions in the GEJ. Before and 6 months after RFe we assessed: quality of life (QOL) with SF-36 (general) and GERD-QOL (specific) surveys, medication use, endoscopy, esophageal motility and 24-hr pH. Results: Twenty males and 8 females (mean age 50, range 22-67 yrs), underwent RFe delivery (mean RFe time=24 min). There were no significant adverse events. Upon entry, all patients required daily anti-secretory drugs (14 PPI bid, 12 PPI qd, 2 H2RA). At 6 mos, 22 patients (79%) are off all anti-secretory drugs (22 no drug, 2 PPI qd, 4 H2RA). 24-hr pH (% time pH

UNIVERSITY OF MIAMI DIVISION OF CLINICAL PHARMACOLOGY THERAPEUTIC ROUNDS :UPDATE ON DIAGNOSIS AND TREATMENT OF GASTROPARESIS

Gastroparesis, defined as delayed gastric emptying because of abnormal gastric motility in the absence of mechanical outlet obstruction, is a common problem causing significant morbidity. Although many cases are caused by diabetes, more than 90 different conditions are known to interfere with normal gastric motor function (Scand J Gastroenterol 1995;30[suppl]:7-16). Patients may present with nausea, vomiting, heartburn, early satiety, or postprandial pain. The current gold standard for quantifying gastric emptying is nuclear scintigraphy. The main goal of treatment is to improve patient comfort by accelerating the rate of gastric emptying, which may be achieved through dietary changes and the use of prokinetic agents. In rare instances, relief can only be obtained with surgical intervention. This report reviews the pathophysiology, clinical presentation, evaluation, and treatment of patients with gastroparesis, an understanding of which will lead to more effective patient care.

Endoluminal therapies for gastroesophageal reflux disease.

While medical therapy, particularly with proton pump inhibitors, is effective for the large majority of patients with reflux disease, there remains a subset of patients who are dissatisfied, due to cost, side effects of medications, or persistent symptoms such as regurgitation. For this population, surgical fundoplication has been, and remains, an appropriate option. A new class of endoluminal interventions, attempting to create a mechanical antireflux barrier, has emerged recently. Three such devices are currently approved and available, and a number of others are in various stages of evaluation. This article will review the approved technologies, as well as selected promising emerging ones, with particular emphasis on the scientific evidence available to date supporting their efficacy.

Antibiotics for Acute Uncomplicated Diverticulitis: Time for a Paradigm Change?

or years, acute uncomplicated Fdiverticulitis (AUD) has been considered a relatively straightforward disease to treat. Patients typically present to the emergency department or their primary care provider with newonset abdominal pain, often (but not always) in the left lower quadrant. After a presumptive clinical diagnosis ismade, or with a confirmatory computed tomography scan, even a fresh-faced July intern knows that the only real clinical management question is deciding on inpatient or outpatient treatment. If the patient can take liquids, has tolerable pain, and a supportive home environment, we send them home with oral antibiotics. If not, we admit them for intravenous antibiotics, fluids, and pain control. Either way, the prescription of antibiotics have always been a given in the management algorithm, a practice uniformly advocated in practice guidelines, book chapters, and review articles. In this month’s issue of Gastroenterology, the American Gastroenterological Association hasmade things a littlemore complicated for that intern, as well as for the emergency department provider, the primary care provider, and the potential GI consultant. New guidelines for the management of acute diverticulitis suggest that antibiotics be used selectively, rather than routinely, in patients with AUD. The guidelines are accompanied by a detailed technical review. The recommendation itself is based on 2 large multicenter trials. The first,