Omar Y. Mousa

Association between smoking and risk of primary sclerosing cholangitis: A systematic review and meta-analysis:

Background/Objectives Studies have suggested that smokers may have a lower risk of primary sclerosing cholangitis (PSC) although the results have been inconsistent. This systematic review and meta-analysis was conducted to summarize all available data to better characterize this association. Methods A comprehensive literature review was conducted using Medline and Embase databases through January 2018 to identify all studies that compared the risk of PSC among current/former smokers versus nonsmokers. Effect estimates from each study were extracted and combined using the random-effect, generic inverse variance method of DerSimonian and Laird. Results Seven case-control studies with 2,307,393 participants met the eligibility criteria and were included in the meta-analysis. The risk of PSC among current smokers and former smokers was significantly lower than nonsmokers with the pooled odds ratio of 0.31 (95% CI, 0.18–0.53) and 0.52 (95% CI, 0.44–0.61), respectively. The risk remained significantly lower among current smokers and former smokers compared with nonsmokers even when only patients with PSC without inflammatory bowel disease were included. Conclusions A significantly decreased risk of PSC among current and former smokers was demonstrated in this study.

Racial, Ethnic, and Age Disparities in Incidence and Survival of Intrahepatic Cholangiocarcinoma in the United States; 1995-2014

Background and rationale for the study. Bacterial translocation is an important triggering factor of infection and mortality in cirrhosis. In a rat model using bile duct ligation (BDL), bacterial translocation appears within 24 h after ligation. The dynamic between TH1/TH2/TH17 cytokines and the integrity of the colonic mucosa in the context of cirrhosis is little known. This study aims to determine the link between bacterial translocation and intestinal inflammation in a cholestasis model. Additionally, alterations of the colonic mucus layer and the bacterial load were also addressed. Results. Bacterial translocation detected by microbiological cultures and MALDI-TOF showed that Escherichia coli predominates in mesenteric lymph nodes of BDL rats. Intestinal bacterial load analyzed by qPCR indicates a dramatic Escherichia/Shigella overgrowth at 8 and 30 days post-BDL. IFN-γ, IL-4, and IL-17 evaluated by Western blotting were increased at 8 and 30 days in the small intestine. In the colon, in contrast, only IFN-γ was significantly increased. The colonic mucus layer and mucin-2 expression determined by Alcian blue staining and immunohistochemistry surprisingly showed an increase in the mucus layer thickness related to increased mucin-2 expression during the entire process of liver damage. Hepatic enzymes, as well as collagen I, collagen III, TNF-α, and IL-6 liver gene expression were increased. In conclusion, bacterial overgrowth associated with bacterial translocation is linked to the over-expression of IFN-γ, IL-4, IL-17 and mucin-2. These molecules might facilitate the intestinal permeability through exacerbating the inflammatory process and disturbing tight junctions, leading to the perpetuation of the liver damage.INTRODUCTION Despite reports of increased incidence of intrahepatic cholangiocarcinoma (iCCA) in the United States, the impact of age or influences of race and ethnicity are not clear. Disparities in iCCA outcomes across various population subgroups also are not readily recognized due to the rarity of this cancer. We examined ethnic, race, age, and gender variations in iCCA incidence and survival using data from the Surveillance, Epidemiology, and End Results Program (1995-2014). MATERIALS AND METHODS We assessed age-adjusted incidence rates, average annual percentage change in incidence, and hazard ratios (HRs) with 95% confidence intervals (CIs) for all-cause and iCCA-specific mortality. RESULTS Overall, 11,127 cases of iCCA were identified, with an age-adjusted incidence rate of 0.92 per 100,000. The incidence rate increased twofold, from 0.49 per 100,000 in 1995 to 1.49 per 100,000 in 2014, with an average annual rate of increase of 5.49%. The iCCA incidence rate was higher among persons age 45 years or older than those younger than 45 years (1.71 vs. 0.07 per 100,000), among males than females (0.97 vs. 0.88 per 100,000) and among Hispanics than non-Hispanics (1.18 vs. 0.89 per 100,000). Compared to non-Hispanics, Hispanics had poorer 5-year all-cause mortality (HR=1.11, 95%CI: 1.05-1.19) and poorer iCCA-specific mortality (HR=1.15, 95%CI: 1.07-1.24). Survival rates were poor also for individuals age 45 years or older, men, Blacks, and American Indians/Alaska Natives. CONCLUSION The results demonstrate ethnic, race, age and gender disparities in iCCA incidence and survival, and confirm continued increase in iCCA incidence in the United States.

Treatment Modalities for Achalasia

Esophageal achalasia is an uncommon motility disorder of the esophagus characterized by failure of relaxation of the lower esophageal sphincter (LES) and absence of progressive peristalsis in the distal esophagus. Prior to treatment, it is imperative that other processes that may mimic achalasia are ruled out. Diagnosis is established by way of esophageal manometry in conjunction with an esophagram and esophagogastroduodenoscopy. A variety of treatment options are available to relieve outflow obstruction and improve symptoms with per-oral endoscopic myotomy (POEM) emerging as a novel and effective endoscopic approach in the management of the disease. This chapter will review treatment modalities for achalasia.

Volumetric laser endomicroscopy in the biliary and pancreatic ducts: a feasibility study with histological correlation

BACKGROUND Volumetric laser endomicroscopy (VLE) provides circumferential images 3 mm into the biliary and pancreatic ducts. We aimed to correlate VLE images with the normal and abnormal microstructure of these ducts. METHODS Samples from patients undergoing hepatic or pancreatic resection were evaluated. VLE images were collected using a low-profile VLE catheter inserted manually into the biliary and pancreatic ducts ex vivo. Histological correlation was assessed by two unblinded investigators. RESULTS 25 patients (20 liver and 5 pancreatic samples) and 111 images were analyzed. VLE revealed three histological layers: epithelium, connective tissue, and parenchyma. It identified distinctive patterns for primary sclerosing cholangitis (PSC), pancreatic cysts, neuroendocrine tumor, and adenocarcinoma adjacent to the pancreatic duct or ampulla. VLE failed to identify dysplasia in a dominant stricture and inflammatory infiltrates in PSC. Reflectivity measurements of the liver parenchyma diagnosed liver cirrhosis with high sensitivity. CONCLUSIONS VLE can identify histological changes in the biliary and pancreatic ducts allowing real-time diagnosis. Further studies are needed to measure the accuracy of VLE in a larger sample and to validate our findings in vivo.

Heavy Coffee Consumption and Risk of Pancreatitis: A Systematic Review and Meta-Analysis

Background/ObjectivesHeavy consumption of coffee may have a protective effect against pancreatitis although results from previous studies were inconsistent. This meta-analysis was conducted with the aim to summarize all available data.MethodsThis meta-analysis included observational studies that compared the risk of pancreatitis between heavy coffee-drinkers and individuals who were not heavy coffee-drinkers. Pooled risk ratios (RRs) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method.ResultsOut of 219 retrieved articles, four studies with 351,137 participants met the eligibility criteria and were included in the analysis. The risk of pancreatitis among heavy coffee-drinkers was significantly lower than individuals who were not heavy coffee-drinkers with the pooled RR of 0.78 (95% CI 0.67–0.91). The statistical heterogeneity between the studies was insignificant (I2 = 0%).ConclusionsThis meta-analysis demonstrated a significantly decreased risk of pancreatitis among heavy coffee-drinkers. However, further investigations are still required to determine causality and potential clinical application.

Clinical and endoscopic manifestations in gastrointestinal amyloidosis: a case series

Gastrointestinal (GI) amyloidosis is rare and has varying clinical and endoscopic presentations. In this case series, we present three patients with primary systemic amyloid-light chain (AL) amyloidosis with GI involvement and complications of GI bleeding. We also provide a brief review of the literature, including clinical presentation, endoscopic findings, pathology, and management of GI amyloidosis. The endoscopic findings of GI amyloidosis can vary, including friable mucosa with erosions, ulcers, and submucosal hematomas or mucosal thickening with polypoid protrusions. The endoscopic findings may correlate with the pathologic deposition of amyloid fibrils. Treatment of GI amyloidosis is generally focused on management of the underlying condition and supportive care. Gastroenterologists should be familiar with the endoscopic findings as they may be the first suggestion of disease and allow for definitive diagnosis.

Association between appendectomy and risk of primary sclerosing cholangitis: A systematic review and meta-analysis

BACKGROUND/OBJECTIVES Recent epidemiologic studies have suggested that appendectomy could be a risk factor for primary sclerosing cholangitis (PSC) although the results were inconsistent. This systematic review and meta-analysis was conducted to summarize all available evidence. METHODS A comprehensive literature review was conducted using MEDLINE and EMBASE database through January 2018 to identify all studies that reported the risk of PSC among individuals who had appendectomy versus those with no history of appendectomy. Effect estimates from each study were extracted and combined together using the random-effect, generic inverse variance method of DerSimonian and Laird. RESULTS A total of 6 case-control studies with 2432 participants met the eligibility criteria and were included in the meta-analysis. The risk of PSC in individuals who had appendectomy was significantly higher than those with no history of appendectomy with the pooled odds ratio of 1.37 (95% CI: 1.15-1.63). The statistical heterogeneity was insignificant with an I2 of 0%. CONCLUSIONS A significantly increased risk of PSC among individuals who had a history of appendectomy was found in this study.

A hybrid endoscopic technique to close tracheoesophageal fistula

Tracheoesophageal fistula (TEF) is a congenital or with literature reporting up to 20% recurrence. Here we acquired pathologic entity characterized by an abnormal communication between the posterior aspect of the trachea and the anterior wall of the esophagus. Acquired TEF is a not uncommon adverse event secondary to mechanical ventilation, trauma, esophageal tumor, prior laryngectomy, or esophagectomy. Given the potential serious consequence of possible fatal pulmonary aspiration, prompt closure of TEFs is critical. Although an endoscopic approach to TEFs has been optimized over the past years, including endoscopic stent placement and over-the-scope clip system, recurrent TEFs remain a therapeutic challenge,

Endoscopic salvage of a large esophagojejunostomy dehiscence

Figure 2. Fully covered metal stent (18 mm 150 mm) was placed as a bridge for surgery. Esophagojejunostomy anastomosis (EJA) dehiscence is not uncommon (up to 3% to 15%). Management can be challenging depending on the size and location, and it frequently requires surgical repair, which is associated with significant morbidity and mortality. Although endoscopic clipping is commonly described in the literature for a dehiscence smaller than 2 cm, we describe the successful endoscopic salvage of a large 4-cm EJA dehiscence by use of a combined technique of flexible endoscopic suturing and covered metal stent placement. Our patient was a 34-year-old woman with invasive diffuse gastric adenocarcinoma who underwent total gastrectomy with en bloc splenectomy, distal esophagectomy, subtotal pancreatectomy, and intraoperative percutaneous jejunal tube placement. Seven days postoperatively she experienced septic shock, empyema, and tension pneumothorax, resulting in the placement of chest tubes. An EJA leak was suspected, and upper endoscopy showed a greater than 50% circumferential dehiscence of the EJA (Fig. 1). On endoscopy, lavage of the pleural cavity was done with a total of 500 mL of 1.5% hydrogen peroxide and normal saline solution with scant indigo carmine. The latter was used to observe the change in color of chest tube output and to determine whether this cavity was actively being drained. This was followed by placement of an 18 mm 150 mm fully covered metal stent as a bridge for surgery (Fig. 2). The stent was clipped to the esophageal wall to prevent stent migration. Clipping was possible, given that an adequate fold was obtained, with sufficient grasp of tissue and stent allowing for a fixation. Suturing can help to obviate migration, but migration can still occur with sutures as a result of metal scaffold cutting into the thread. Furthermore, the use of clips is less expensive than the endoscopic suturing kit. Four weeks later, she was still dependent on 1 chest tube, and an esophagogram showed a persistent leak at the EJA, even though the stent was in place. A multidisciplinary team, including the patient and her family, reached a consensus to attempt endoscopic closure of the EJA dehiscence instead of surgery. At subsequent endoscopy, the old stent was removed and thedehiscencewasevaluated (Fig. 3). Lavageof thepleural cavity was repeated. The surface of the EJA dehiscence was debrided, and the proximal loop of the jejunum was

Chronic Abdominal Pain and Cutaneous Swelling

DIS 5.5.0 DTD YGAST61119 proof 2 August 2017 2:15 pm 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 Question: A 51-year-old man was referred to our tertiary medical center for a 3-year history of intermittent abdominal pain, diarrhea, and associated nontender, nonitchy cutaneous erythema and swelling of his upper and lower extremities (Figure A) and scrotum. Each episode lasted for 5 to 8 weeks before resolution. Medical history included gastroesophageal reflux disorder (on pantoprazole 40 mg/d) and essential hypertension (on losartan 50mg/d for the past 3 years). Previous 85 86 87 88 89 90 91 workup included unremarkable findings in esophagogastroduodenal scope and colonoscopy examinations within past 1 year. An abdominal examination was remarkable for mild periumbilical tenderness. A contrast-enhanced computed tomography (CT) scan of abdomen and pelvis showed segmental jejunal wall thickening (arrow) suggestive of jejunal enteritis or edema (Figure B). Tests for serum tryptase and C4 and C1 esterase inhibitors were negative. What is the diagnosis? Look on page 000 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. 92 93 94 95 96 97 98 99 *Authors share co-first authorship.