Nisheet Waghray

Consumer Use of Over-the-Counter Proton Pump Inhibitors in Patients With Gastroesophageal Reflux Disease

OBJECTIVES:Optimal administration of proton pump inhibitor (PPI) for the treatment of gastroesophageal reflux disease (GERD) requires consideration of meal timing. Since becoming available over the counter (OTC), no studies have assessed treatment patterns and symptom control in OTC consumers. The objective of this study was to survey dosing patterns and symptom control in OTC and prescription PPI users.METHODS:Patients at five clinics were surveyed regarding diagnosis of GERD, use of OTC or prescription PPIs, information on time of day dosing, demographics, and Gastroesophageal Reflux Disease Symptom Assessment Scale (GSAS; 2001, Johnson & Johnson).RESULTS:Of the 1,959 patients surveyed, 610 (31%) used PPIs for GERD. Of these, 190 (31%) and 223 (37%) received prescriptions from gastroenterologists (GIs) and primary care physicians (PCPs), respectively; 197 (32%) purchased OTC PPIs. Of the patients prescribed PPIs by GIs, 71% were optimal users, whereas 47% of patients receiving prescriptions from PCPs and 39% of consumers used PPIs optimally (P<0.001 compared with GIs). GSAS symptom, frequency, and severity scores were significantly better in patients prescribed PPIs by GIs (all P<0.001, GI compared with PCP and consumer). GSAS symptom, frequency, and severity scores were also significantly better in patients using PPIs optimally (P<0.001 for all parameters) compared with those taking PPIs suboptimally or excessively.CONCLUSIONS:Patients receiving prescription PPI from a GI are more likely to be optimal users with better symptom control. Conversely, consumers are more likely to be suboptimal users with inadequate symptom control.

Colorectal cancer screening in African Americans: practice patterns in the United States. Are we doing enough?

Background: Colorectal cancer (CRC) is a common form of malignancy and a leading cause of death in the United States. Screening decreases CRC incidence and mortality. African Americans are at an increased risk of developing CRC, and recommendations are to initiate screening at the age of 45. This study aims to assess the rate of screening for colorectal cancer in African Americans between the ages of 45–49. Methods: African Americans between the ages of 45–49 were identified in the Explorys national database. Patients who completed a colonoscopy, sigmoidoscopy or fecal occult blood test were identified and stratified by sex and insurance status. A P value < 0.05 was considered significant. Results: A total of 181 200 African Americans were identified as eligible for screening. Only 31 480 patients (17.4%) received at least one screening procedure for CRC. The majority of patients (66.7%) were screened via colonoscopy. African American females were more likely to complete a screening test (17.8% vs 16.7%; P < 0.01). The majority of patients (66.0%) who completed a screening test had private insurance. Conclusion: Race, gender and barriers to medical care contribute to disparities in CRC screening rates. Among African Americans, CRC screening remains suboptimal. Tailored public health initiatives, medical record alerts and improved communication between providers and patients are fundamental to addressing issues that impact poor adherence to CRC screening in African Americans.

The Role of Nonsteroidal Anti-inflammatory Drugs in the Prevention of Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Post-ERCP pancreatitis (PEP) is the most common major complication associated with ERCP. Beginning with an overview of the risk factors for the development of PEP, this review introduces the mechanism of injury in PEP and the role of pharmacological prevention. NSAIDs are increasingly found to offer prevention against the development of PEP, and their mechanism and supportive data are summarized, especially in relationship to the practice of prophylactic pancreatic duct stenting.

Vaccinating Adult Patients with Cirrhosis: Trends over a Decade in the United States.

Introduction. The progression of chronic liver disease to cirrhosis involves both innate and adaptive immune system dysfunction resulting in increased risk of infectious complications. Vaccinations against pneumococcus, hepatitis A virus (HAV), and hepatitis B virus (HBV) are well tolerated and effective in disease prevention and reduction in morbidity and mortality. Prior studies assessing vaccination rates in patients with cirrhosis have specific limitations and to date no study has provided a comprehensive evaluation of vaccination rates in patients with cirrhosis in the United States. Aim. This study assessed vaccination rates for pneumococcus, HAV, and HBV in patients with cirrhosis. Results. Overall 59.7% of patients with cirrhosis received at least 1 vaccination during the study period. Vaccination rates within the same or following year of cirrhosis diagnosis were 19.9%, 7.7%, and 11.0% against pneumococcus, HAV, and HBV, respectively. Trend analysis revealed significant increases in vaccination rates for pneumococcus in all patients with cirrhosis and within subgroups based on age, gender, and presence of concomitant diabetes. Conclusion. The study demonstrated that vaccination rates in patients with cirrhosis remain suboptimal. Ultimately, the use of electronic medical record (EMR) reminders improved communication between healthcare professionals and public health programs to increase awareness are fundamental to reducing morbidity, mortality, and health-care related costs of vaccine preventable diseases in patients with cirrhosis.

Su1129 Optimal Omeprazole Dosing and Symptom Control - A Randomized Controlled Trial (OSCAR Trial)

Background Proton pump inhibitors (PPIs) are potent inhibitors of acid secretion and are the mainstay of therapy for gastroesophageal reflux disease (GERD). Initially designed to be taken 30 min before the first daily meal, these agents are commonly used suboptimally, which adversely affects symptom relief. No study to date has assessed whether correcting dosing regimens would improve symptom control. The objective of this study was to determine whether patients with persistent GERD symptoms on suboptimal omeprazole dosing experience symptomatic improvement when randomized to commonly recommended dosing regimen and to evaluate the economic impact of suboptimal PPI dosing in GERD patients.

Severe hemorrhagic gastritis after percutaneous endoscopic gastrostomy tube placement

1. Mansoor H, Masood MA, Yusuf MA. Complications of percutaneous endoscopic gastrostomy tube insertion in cancer patients: a retrospective study. J Gastrointest Cancer 2014;45:452-459. 2. Schurink CA, Tuynman H, Scholten P, et al. Percutaneous endoscopic gastrostomy: complications and suggestions to avoid them. Eur J Gastroenterol Hepatol 2001;13:819-823. 3. Nishiwaki S, Araki H, Takada J, et al. Clinical investigation of upper gastrointestinal hemorrhage aft er percutaneous endoscopic gastrostomy. Dig Endosc 2010;22:180-185. Departments of aMedicine (Abhijeet Waghray); bGastroenterology (Amy Michel-Calderon, Annette Kyprianou, Nisheet Waghray), MetroHealth Medical Center/Case Western Reserve University, Cleveland, OH, USA

Sa1213 An Analysis of Crohn's Disease Over the Past Decade in the United States Related to Cost of Hospitalization, Outcome, Length of Stay and Demographics

maintenance infusion and 10.1% of patients received maintenance infusions on average more than one week late. A patient would be expected to accrue a dropped infliximab maintenance dose every 13.9 infusions (112.0 weeks) based on the standard maintenance regimen of infliximab 5mg/kg every eight weeks. However, among the 20 patients experiencing a mean delay in administration of infliximab of over 7 days, a dropped infliximab maintenance dose would be accrued every 33.3 weeks. As a percentage of time on maintenance infliximab, mean cumulative non-adherence was 6.1% (± 5.6%). In multivariate logistic regression analysis, only male gender (OR 1.77 [95% CI 1.01-3.11]) was predictive of non-adherence. Conclusions: While three quarters of patients are adherent with infliximab induction therapy, less than one third remain closely adherent to their maintenance infliximab infusion schedule. This non-adherence may have significant clinical implications for maintenance of remission and eventual secondary loss of response. Table 1: Baseline Patient Demographics and Adherence to Infliximab Therapy

Acute Hepatitis in Pregnancy

DIS 5.2.0 DTD YGAST58998_proof 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 Question: A 19-year-old G1 P0 at 36 weeks gestation presented to our hospital with a 4-day history of fevers/ chills, right upper quadrant abdominal pain, and anorexia. On initial examination, she was febrile (39.1 C) and seemed in moderate distress, but was alert and oriented. There was no jaundice, skin lesions, or oral/genital ulcerations. Abdomen was gravid with moderate tenderness to palpation in the right upper quadrant. Laboratory examinations on admission were as follows: white cell count, 7.4 K/mL (normal, 4.5–11.5; segmented neutrophils, 79% [9% bands]); hemoglobin, 11.0 g/dL (normal, 12–15); platelet count 162 K/mL (normal, 150–400); prothrombin time, 10.4 seconds; albumin, 2.6 g/dL; total bilirubin, 0.5 mg/dL (normal, 0.1–1.5); direct bilirubin, 0.2 mg/dL (normal, 0.1–0.3); alkaline phosphatase, 147 IU/L normal, (40–200), aspartate aminotransferase (AST), 211 85 86 87 88 89 90 91 92 93 94 95 96 IU/L (normal, 7–40); and alanine aminotransferase (ALT), 99 IU/L (normal, 7–0). Serology was negative for hepatitis A, B, and C viruses. Blood, urine, and vaginal cultures were negative. Urine toxicology was negative. Zosyn was initiated because of her fevers and bandemia. A right upper quadrant ultrasound revealed hepatomegaly and increased echogenicity of the portal triads consistent with a starry sky appearance, but no intrahepatic/extrahepatic biliary dilatation (Figure A). On day 3, she remained anicteric with no evidence of encephalopathy. Laboratory data revealed a white cell count of 6.5 K/mL (segmented neutrophils, 26% [39% bands]), total bilirubin of 1.1 mg/dL, direct bilirubin of 0.6 mg/dL, alkaline phosphatase of 232 IU/L, AST of 4482 IU/L, ALT of 1010 IU/L, and prothrombin time of 14.6. Viral serologies for HIV, Epstein-Barr virus, cytomegalovirus, and human papillomavirus were all negative. Given the persistent fevers and transaminase elevation, the patient underwent a C-section with a liver biopsy performed without any complications. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. 97 98 99 100 Acknowledgments The authors give special acknowledgement to Dr Rania Rayes-Danan, Department of Pathology, MetroHealth Medical Center. 101 102 103 104 105 106 107 Conflicts of interest The authors disclose no conflicts.

Treatment Options for Covert Hepatic Encephalopathy

Opinion statementThe main issue with treating covert hepatic encephalopathy (HE) is to establish whether it is cost effective to reverse the neuropsychiatric abnormalities that define this mild form of HE. Until fairly recently, covert HE was rarely diagnosed, but advances in computerized psychometric testing have greatly simplified its detection. The many consequences of covert HE are now being identified, and most have been shown to be reversible with standard HE treatment. Perhaps the most enticing possibility will be the potential that standard HE therapies will postpone the onset of overt HE. This will require further evaluation with large placebo-controlled randomized trials.