Sameer Dhalla

Association of tattooing and hepatitis C virus infection: a multicenter case-control study.

Although injection drug use (IDU) and blood transfusions prior to 1992 are well‐accepted risk factors for hepatitis C virus (HCV) infection, many studies that evaluated tattooing as a risk factor for HCV infection did not control for a history of IDU or transfusion prior to 1992. In this large, multicenter, case‐control study, we analyzed demographic and HCV risk factor exposure history data from 3,871 patients, including 1,930 with chronic HCV infection (HCV RNA–positive) and 1,941 HCV‐negative (HCV antibody–negative) controls. Crude and fully adjusted odds ratios (ORs) of tattoo exposure by multivariate logistic regression in HCV‐infected versus controls were determined. As expected, IDU (65.9% versus 17.8%; P < 0.001), blood transfusion prior to 1992 (22.3% versus 11.1%; P < 0.001), and history of having one or more tattoos (OR, 3.81; 95% CI, 3.23‐4.49; P < 0.001) were more common in HCV‐infected patients than in control subjects. After excluding all patients with a history of ever injecting drugs and those who had a blood transfusion prior to 1992, a total of 1,886 subjects remained for analysis (465 HCV‐positive patients and 1,421 controls). Among these individuals without traditional risk factors, HCV‐positive patients remained significantly more likely to have a history of one or more tattoos after adjustment for age, sex, and race/ethnicity (OR, 5.17; 95% CI, 3.75‐7.11; P < 0.001). Conclusion: Tattooing is associated with HCV infection, even among those without traditional HCV risk factors such as IDU and blood transfusion prior to 1992. (HEPATOLOGY 2013;57:2117–2123)

Refractory gastroparesis can be successfully managed with endoscopic transpyloric stent placement and fixation (with video).

BACKGROUND AND AIMS Medical treatment options for gastroparesis are limited. Data from studies of botulinum toxin and surgical pyloroplasty suggest that disruption of the pylorus can result in symptomatic improvement in some patients with refractory gastroparetic symptoms. The aim of this study was to determine the clinical response to transpyloric stent (TPS) placement in patients with gastroparetic symptoms refractory to standard therapy. METHODS Patients with gastroparesis refractory to medical treatment were referred for TPS placement for salvage therapy. Self-reported symptom improvement, stent migration rate, and pre- and post-stent gastric-emptying study results were collected. RESULTS A total of 30 patients with refractory gastroparesis underwent 48 TPS procedures. Of these, 25 of 48 (52.1%) were performed in patients admitted to the hospital with intractable gastroparetic symptoms. Successful stent placement in the desired location across the pylorus (technical success) was achieved during 47 procedures (98%). Most (n = 24) stents were anchored to the gastric wall by using endoscopic suturing with a mean number of sutures of 2 (range 1-3) per procedure. Clinical response was observed in 75% of patients, and all inpatients were successfully discharged. Clinical success in patients with the predominant symptoms of nausea and vomiting was higher than in those patients with a predominant symptom of pain (79% vs 21%, P = .12). A repeat gastric-emptying study was performed in 16 patients, and the mean 4-hour gastric emptying normalized in 6 patients and significantly improved in 5 patients. Stent migration was least common (48%) when stents were sutured. CONCLUSION TPS placement is a feasible novel endoscopic treatment modality for gastroparesis and improves both symptoms and gastric emptying in patients who are refractory to medical treatment, especially those with nausea and vomiting. TPS placement may be considered as salvage therapy for inpatients with intractable symptoms or potentially as a method to select patients who may respond to more permanent therapies directed at the pylorus.

Herbal Therapy Is Equivalent to Rifaximin for the Treatment of Small Intestinal Bacterial Overgrowth

Objective: Patients with small intestine bacterial overgrowth (SIBO) have chronic intestinal and extraintestinal symptomatology which adversely affects their quality of life. Present treatment of SIBO is limited to oral antibiotics with variable success. A growing number of patients are interested in using complementary and alternative therapies for their gastrointestinal health. The objective was to determine the remission rate of SIBO using either the antibiotic rifaximin or herbals in a tertiary care referral gastroenterology practice. Design: One hundred and four patients who tested positive for newly diagnosed SIBO by lactulose breath testing (LBT) were offered either rifaximin 1200 mg daily vs herbal therapy for 4 weeks with repeat LBT post-treatment. Results: Three hundred ninety-six patients underwent LBT for suspected SIBO, of which 251 (63.4%) were positive 165 underwent treatment and 104 had a follow-up LBT. Of the 37 patients who received herbal therapy, 17 (46%) had a negative follow-up LBT compared to 23/67 (34%) of rifaximin users (P=.24). The odds ratio of having a negative LBT after taking herbal therapy as compared to rifaximin was 1.85 (CI=0.77-4.41, P=.17) once adjusted for age, gender, SIBO risk factors and IBS status. Fourteen of the 44 (31.8%) rifaximin non-responders were offered herbal rescue therapy, with 8 of the 14 (57.1%) having a negative LBT after completing the rescue herbal therapy, while 10 non-responders were offered triple antibiotics with 6 responding (60%, P=.89). Adverse effects were reported among the rifaximin treated arm including 1 case of anaphylaxis, 2 cases of hives, 2 cases of diarrhea and 1 case of Clostridium difficile. Only one case of diarrhea was reported in the herbal therapy arm, which did not reach statistical significance (P=.22). Conclusion: SIBO is widely prevalent in a tertiary referral gastroenterology practice. Herbal therapies are at least as effective as rifaximin for resolution of SIBO by LBT. Herbals also appear to be as effective as triple antibiotic therapy for SIBO rescue therapy for rifaximin non-responders. Further, prospective studies are needed to validate these findings and explore additional alternative therapies in patients with refractory SIBO.

What is the clinical significance of esophagogastric junction outflow obstruction? evaluation of 60 patients at a tertiary referral center

Esophagogastric junction (EGJ) outflow obstruction (EGJOO) is characterized by impaired EGJ relaxation with intact or weak peristalsis. Our aims were to evaluate: (i) prevalence, (ii) yield of fluoroscopy, endoscopy, and endoscopic ultrasound (EUS), (iii) outcomes, and (iv) whether this data differed based on quantitative EGJ relaxation.

Learning curve for peroral endoscopic myotomy

Background and study aims: Although peroral endoscopic myotomy (POEM) is being performed more frequently, the learning curve for gastroenterologists performing the procedure has not been well studied. The aims of this study were to define the learning curve for POEM and determine which preoperative and intraoperative factors predict the time that will be taken to complete the procedure and its different steps. Patients and methods: Consecutive patients who underwent POEM performed by a single expert gastroenterologist for the treatment of achalasia or spastic esophageal disorders were included. The POEM procedure was divided into four steps: mucosal entry, submucosal tunneling, myotomy, and closure. Nonlinear regression was used to determine the POEM learning plateau and calculate the learning rate. Results: A total of 60 consecutive patients underwent POEM in an endoscopy suite. The median length of procedure (LOP) was 88 minutes (range 36 – 210), and the mean (± standard deviation [SD]) LOP per centimeter of myotomy was 9 ± 5 minutes. The total operative time decreased significantly as experience increased (P < 0.001), with a “learning plateau” at 102 minutes and a “learning rate” of 13 cases. The mucosal entry, tunneling, and closure times decreased significantly with experience (P < 0.001). The myotomy time showed no significant decrease with experience (P = 0.35). When the mean (± SD) total procedure times for the learning phase and the corresponding comparator groups were compared, a statistically significant difference was observed between procedures 11 – 15 and procedures 16 – 20 (15.5 ± 2.4 min/cm and 10.1 ± 2.7 min/cm, P = 0.01) but not thereafter. A higher case number was significantly associated with a decreased LOP (P < 0.001). Conclusion: In this single-center retrospective study, the minimum threshold number of cases required for an expert interventional endoscopist performing POEM to reach a plateau approached 13.

Gender is a determinative factor in the initial clinical presentation of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease resulting in symptoms of esophageal dysmotility. Abnormalities include dysphagia, food impaction and reflux. Although men appear to comprise a majority of the EoE population, few studies have directly assessed gender-associated clinical differences. The aim of this study is to identify the effect of gender on the initial clinical presentation of adult-onset EoE patients. We reviewed our electronic medical record database from January 2008 to December 2011 for adults diagnosed with EoE per the 2011 updated consensus guidelines. Patient demographics, presenting symptoms, endoscopy findings and complications were recorded. Proportions were compared using chi-squared analysis, and means were compared using the Students t-test. A total of 162 patients met the inclusion criteria and 71 (44%) were women. Women were more likely to report chest pain (P = 0.03) and heartburn (P = 0.06), whereas men more commonly reported dysphagia (P = 0.04) and a history of food impaction (P = 0.05). Endoscopic findings were similar between groups. No patients suffered esophageal perforations. These data suggest that men report more fibrostenotic symptoms and women report more inflammatory symptoms at the time of diagnosis. There was no difference in endoscopic findings between genders. This is one of the only reviews comparing differences in clinical presentation, endoscopic findings and complications between gender for EoE. The current recommended guidelines state that any patient with symptoms of esophageal dysfunction should be biopsied for EoE. Our findings support biopsying patients with typical and atypical symptoms of dysmotility including heartburn and chest pain.Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease resulting in symptoms of esophageal dysmotility. Abnormalities include dysphagia, food impaction and reflux. Although men appear to comprise a majority of the EoE population, few studies have directly assessed gender-associated clinical differences. The aim of this study is to identify the effect of gender on the initial clinical presentation of adult-onset EoE patients. We reviewed our electronic medical record database from January 2008 to December 2011 for adults diagnosed with EoE per the 2011 updated consensus guidelines. Patient demographics, presenting symptoms, endoscopy findings and complications were recorded. Proportions were compared using chi-squared analysis, and means were compared using the Students t-test. A total of 162 patients met the inclusion criteria and 71 (44%) were women. Women were more likely to report chest pain (P = 0.03) and heartburn (P = 0.06), whereas men more commonly reported dysphagia (P = 0.04) and a history of food impaction (P = 0.05). Endoscopic findings were similar between groups. No patients suffered esophageal perforations. These data suggest that men report more fibrostenotic symptoms and women report more inflammatory symptoms at the time of diagnosis. There was no difference in endoscopic findings between genders. This is one of the only reviews comparing differences in clinical presentation, endoscopic findings and complications between gender for EoE. The current recommended guidelines state that any patient with symptoms of esophageal dysfunction should be biopsied for EoE. Our findings support biopsying patients with typical and atypical symptoms of dysmotility including heartburn and chest pain.

Pancreatic metastasis from a solitary fibrous tumor of the kidney: A rare cause of acute recurrent pancreatitis

Solitary fibrous tumors are unusual spindle cell neoplasms that uncommonly originate from the kidney. We report a case of a 43-year old male who presented with acute recurrent pancreatitis secondary to a mass in the head of the pancreas. Endoscopic ultrasound with fine needle aspiration (EUS-FNA) was performed. Cytology revealed solitary fibrous tumor of the kidney. This is the first reported case of solitary fibrous tumor metastasizing to the pancreas and presenting as acute recurrent pancreatitis.

Su1449 Incidence and Clinical Significance of Delayed Gastric Emptying for Liquids in Gastroparesis and Chronic Unexplained Nausea and Vomiting (CUNV)

Introduction. Diabetic gastroparesis is defined as delayed gastric emptying not caused by obstruction or structural abnormality. Normal function of the gastric and intestinal mechanical activity is mediated by slow wave electrical activity in the stomach and small bowel. Previous studies using both electrogastrogram and magnetogastrogram have shown gastric slowwave dysrhythmias associated with gastroparesis, but no study has yet examined possible effects of gastroparesis on the intestinal slow wave. Methods. We recorded intestinal slow waves in diabetic patients with gastroparesis (N=7) and healthy controls (N=7) using the magnetoenterogram (MENG), which uses a Superconducting QUantum Interference Device (SQUID) to convert magnetic fields associated with intestinal slow waves into voltage signals. Second Order Blind Identification (SOBI) was used to reduce noise and isolate the intestinal slow wave signal from confounding magnetic artifact, and we computed the power spectrum of the intestinal slow wave using a Fast Fourier Transform technique. We analyzed dominant frequency, amplitude and percentage of power distributed (PPD) in brady, normo and tachyarrhythmic frequency ranges. Results. In gastroparesis patients, we found a significant decrease in postprandial dominant intestinal slow wave frequency from 10.2 ± 0.4 cpm to 8.8 ± 0.5 cpm (p<0.05) whereas the dominant frequency for control subjects increased from 9.9 ± 0.5 cpm to 10.8 ± 0.4 cpm (p<0.05). We did not observe significant differences in preand postprandial PPDs computed from controls or patients. Conclusions. Diabetic gastroparesis is associated with bradyarrhythmia, but not uncoupling, of the intestinal slow wave. Biomagnetic measurements of the MENG can assess intestinal slow wave activity in healthy and diseased tissue noninvasively.

Mo2092 Wireless Motility Capsule Alters Diagnosis and Affects Clinical Management in Patients With Suspected Gastrointestinal Dysmotility

BACKGROUND: The wireless motility capsule (WMC) is a novel device which is FDAapproved for the evaluation of suspected gastroparesis and slow-transit constipation. WMC provides information regarding pH, temperature and pressure throughout the GI tract and can be used to assess regional and whole-gut transit and pressure patterns. Several studies have validated WMC findings versus standard motility testing; however, there is limited data examining how WMC findings affect clinical care. AIMS: Aims were to investigate (1) the diagnostic yield of WMC in patients with suspected dysmotility and (2) change in clinicalmanagement afterWMC testing, includingmedication changes, referrals for additional diagnostic tests, and outside referrals. METHODS: We retrospectively reviewed 51 consecutive patients referred for WMC at a single, academic tertiary care center from April 2009 to October 2012. Information on demographics, past medical and surgical history, indications for WMC, WMC transit times, and relevant diagnostic studies were collected. Changes in clinical management at the first clinic visit after WMC testing were identified. Patients were excluded if WMC testing was incomplete or if no follow-up information was available. RESULTS: Patient characteristics including demographics and indications are summarized in Table 1. Results of positive WMC testing are summarized in Table 2A. Pan-GI dysmotility was present in 53% of patients with positive WMC testing. Effects of WMC results on diagnosis and management are summarized in Table 2B. Medication changes were more commonly seen in patients with an abnormal WMC test and included the addition or removal of prokinetics, antibiotics, herbal supplements, and neuromodulators. There were no statistically significant differences in additional imaging studies and referrals between the two groups. Referrals to non-GI providers included psychiatry, surgery, nutrition, acupuncture, and biofeedback. The presence of existing psychiatric comorbidities was also similar between groups. Of note, 80% of patients had other diagnostic studies obtained concurrently with WMC testing; however, attempts were made to isolate clinical changes made from WMC results specifically. CONCLUSIONS:WMC affects clinical management in the majority of patients referred for suspected dysmotility. Alteration in diagnosis was frequent, and change in medication was made for the majority of patients with abnormal WMC testing. Pan-GI dysmotility was common in patients referred for suspected regional dysmotility. Normal WMC testing changed clinical management in over 50% of cases. Our results suggest that WMC testing impacts patient care by altering diagnosis and clinical management. Prospective studies are needed to determine how WMC may affect long-term outcomes. Table 1. Patient Characteristics (N=51)

The Effect of Race in Patients with Achalasia Diagnosed With High-Resolution Esophageal Manometry

Background: The advent of the Chicago Classification for esophageal motility disorders allowed for clinically reproducible subgrouping of patients with achalasia based on manometric phenotype. However, there are limited data with regards to racial variation using high‐resolution esophageal manometry (HREM). The aim of our study was to evaluate the racial differences in patients with achalasia diagnosed with HREM using the Chicago Classification. We evaluated the clinical presentation, treatment decisions and outcomes between blacks and non‐blacks with achalasia to identify potential racial disparities. Materials and Methods: We performed a retrospective review of consecutive patients referred for HREM at a single tertiary referral center from June 2008 through October 2012. All patients diagnosed with achalasia on HREM according to the Chicago Classification were included. Demographic, clinical and manometric data were abstracted. All studies interpreted before the Chicago Classification was in widespread use were reanalyzed. Race was defined as black or non‐black. Patients who had missing data were excluded. Proportions were compared using chi‐squared analysis and means were compared using the Student’s t‐test. Results: A total of 1,268 patients underwent HREM during the study period, and 105 (8.3%) were manometrically diagnosed with achalasia (53% female, mean age: 53.8 ± 17.0 years) and also met the aforementioned inclusion and exclusion criteria. A higher percentage of women presented with achalasia in blacks as compared to whites or other races (P < 0.001). Non‐blacks were more likely to present with reflux than blacks (P = 0.01), while blacks were more likely to be treated on the inpatient service than non‐blacks (P < 0.001). There were no other significant differences noted in clinical presentation, treatment decisions and treatment outcomes among blacks and non‐blacks. Conclusions: Our study highlights possible racial differences between blacks and non‐blacks, including a higher proportion of black women diagnosed with achalasia and most blacks presenting with dysphagia. There is possibly a meaningful interaction of race and sex in the development of achalasia that might represent genetic differences in its pathophysiology. Further prospective studies are required to identify such differences.