Samer El-Dika

Morbid Obesity Is Associated With Adverse Clinical Outcomes in Acute Pancreatitis: A Propensity-Matched Study.

OBJECTIVES:Morbid obesity may adversely affect the clinical course of acute pancreatitis (AP); however, there are no inpatient, population-based studies assessing the impact of morbid obesity on AP-related outcomes. We sought to evaluate the impact of morbid obesity on AP-related clinical outcomes and health-care utilization.METHODS:The Nationwide Inpatient Sample (2007–2011) was reviewed to identify all adult inpatients (≥18 years) with a principal diagnosis of AP. The primary clinical outcomes (mortality, renal failure, and respiratory failure) and secondary resource outcomes (length of stay and hospital charges) were analyzed using univariate and multivariate comparisons. Propensity score-matched analysis was performed to compare the outcomes in patients with and without morbid obesity.RESULTS:Morbid obesity was associated with 3.9% (52,297/1,330,302) of all AP admissions. Whereas the mortality rate decreased overall (0.97%0.83%, P<0.001), it remained unchanged in those with morbid obesity (1.02%1.07%, P=1.0). Multivariate analysis revealed that morbid obesity was associated with increased mortality (odds ratio (OR) 1.6; 95% confidence interval (CI) 1.3, 1.9), prolonged hospitalization (0.4 days; P<0.001), and higher hospitalization charges (

Colonic manifestations of PTEN hamartoma tumor syndrome: Case series and systematic review

5,067; P<0.001). A propensity score-matched cohort analysis demonstrated that the primary outcomes, acute kidney failure (10.8 vs. 8.2%; P<0.001), respiratory failure (7.9 vs. 6.4%; P<0.001), and mortality (OR 1.6, 95% CI 1.2, 2.1) were more frequent in morbid obesity.CONCLUSIONS:Morbid obesity negatively influences inpatient hospitalization and is associated with adverse clinical outcomes, including mortality, organ failure, and health-care resource utilization. These observations and the increasing global prevalence of obesity justify ongoing efforts to understand the role of obesity-induced inflammation in the pathogenesis and management of AP.

Validation of diagnostic characteristics of needle based confocal laser endomicroscopy in differentiation of pancreatic cystic lesions

AIM To investigate our clinical experience with the colonic manifestations of phosphatase and tensin homolog on chromosome ten (PTEN) hamartoma tumor syndrome (PHTS) and to perform a systematic literature review regarding the same. METHODS This study was approved by the appropriate institutional review board prior to initiation. A clinical genetics database was searched for patients with PHTS or a component syndrome that received gastrointestinal endoscopy or pathology interpretation at our center. These patients records were retrospectively reviewed for clinical characteristics (including family history and genetic testing), endoscopy results and pathology findings. We also performed a systematic review of the literature for case series of PHTS or component syndromes that reported gastrointestinal manifestations and investigations published after consensus diagnostic criteria were established in 1996. These results were compiled and reported. RESULTS Eight patients from our institution met initial inclusion criteria. Of these, 5 patients underwent 4.2 colonoscopies at mean age 45.8 ± 10.8 years. All were found to have colon polyps during their clinical course and polyp histology included adenoma, hyperplastic, ganglioneuroma and juvenile. No malignant lesions were identified. Two had multiple histologic types. One patient underwent colectomy due to innumerable polyps and concern for future malignant potential. Systematic literature review of PHTS patients undergoing endoscopy revealed 107 patients receiving colonoscopy at mean age 37.4 years. Colon polyps were noted in 92.5% and multiple colon polyp histologies were reported in 53.6%. Common polyp histologies included hyperplastic (43.6%), adenoma (40.4%), hamartoma (38.3%), ganglioneuroma (33%) and inflammatory (24.5%) polyps. Twelve (11.2%) patients had colorectal cancer at mean age 46.7 years (range 35-62). Clinical outcomes secondary to colon polyposis and malignancy were not commonly reported. CONCLUSION PHTS has a high prevalence of colon polyposis with multiple histologic types. It should be considered a mixed polyposis syndrome. Systematic review found an increased prevalence of colorectal cancer and we recommend initiating colonoscopy for colorectal cancer surveillance at age 35 years.

Reaching Safe Harbor: Legal Implications of Clinical Practice Guidelines.

Background and aims: Endoscopic ultrasound (EUS)-guided needle-based Confocal Laser Endomicroscopy (nCLE) characteristics of pancreatic cystic lesions (PCLs) have been identified in studies where the gold standard surgical histopathology was available in a minority of patients. There are diverging reports of interobserver agreement (IOA) and paucity of intraobserver reliability (IOR). Thus, we sought to validate current EUS-nCLE criteria of PCLs in a larger consecutive series of surgical patients. Methods: A retrospective analysis of patients who underwent EUS-nCLE at a single center was performed. For calculation of IOA (Fleiss’ kappa) and IOR (Cohen’s kappa), blinded nCLE-naïve observers (n = 6) reviewed nCLE videos of PCLs in two phases separated by a 2-week washout period. Results: EUS-nCLE was performed in 49 subjects, and a definitive diagnosis was available in 26 patients. The overall sensitivity, specificity, and accuracy for diagnosing a mucinous PCL were 94 %, 82 %, and 89 %, respectively. The IOA for differentiating mucinous vs. non-mucinous PCL was “substantial” (κ = 0.67, 95 %CI 0.57, 0.77). The mean (± standard deviation) IOR was “substantial” (κ = 0.78 ± 0.13) for diagnosing mucinous PCLs. Both the IOAs and mean IORs were “substantial” for detection of known nCLE image patterns of papillae/epithelial bands of mucinous PCLs (IOA κ = 0.63; IOR κ = 0.76 ± 0.11), bright particles on a dark background of pseudocysts (IOA κ = 0.71; IOR κ = 0.78 ± 0.12), and fern-pattern or superficial vascular network of serous cystadenomas (IOA κ = 0.62; IOR κ = 0.68 ± 0.20). Three (6.1 % of 49) patients developed post-fine needle aspiration (FNA) pancreatitis. Conclusion: Characteristic EUS-nCLE patterns can be consistently identified and improve the diagnostic accuracy of PCLs. These results support further investigations to optimize EUS-nCLE while minimizing adverse events. Study registration: NCT02516488

Insights into insulin resistance, lifestyle, and anthropometric measures of patients with prior colorectal cancer compared to controls: A National Health and Nutrition Examination Survey (NHANES) Study

*Division of Gastroenterology and Liver Diseases, Yale New Haven Medical Center, New Haven, Connecticut; Division of Gastroenterology, Hepatology and Nutrition, Ohio State University-Wexner Medical Center, Columbus, Ohio; Division of Gastroenterology, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan; kInstitute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan

Proximal Serrated Polyp Detection Rate Correlates with Adenoma DetectionRate and is Impacted by Mean Withdrawal Time: A Retrospective Study

BACKGROUND Insulin resistance (IR) increases the risk of index colorectal cancer (CRC) development. Limited data exist on IR values, lifestyle, and anthropometric alterations of patients after CRC diagnosis, a population at high risk for CRC recurrence. METHODS This is a retrospective cohort study using the National Health and Nutrition Examination Survey (NHANES), 1999-2010. We identified patients with and without prior CRC above age 50. Our outcomes were lifestyle, anthropometric measures, and IR measured using the triglyceride to high-density lipoprotein ratio and the homeostasis model assessment IR. RESULTS There were 146,841 patients with prior CRC and 26,979,507 without prior cancer (controls) in our cohort. Prior patients with CRC were significantly older than controls (75.8 vs 62.3, P < 0.01), however, there were no significant differences in gender, ethnicity, income, caloric intake, tobacco use or alcohol consumption between both groups. Multivariate analysis revealed no difference between prior patients with CRC and controls in triglyceride to high-density lipoprotein ratio (adjusted percentage change = -2.17; 95% CI: -27.96 to 18.43) or homeostasis model assessment IR (adjusted percentage change = -6.85; 95% CI: -35.74 to 15.90). Despite similar weight at age 25, prior CRC subjects had lower weights compared to controls (at time of NHANES survey, one and 10 years before survey and greatest weight). Furthermore prior CRC subjects gained less weight in the 10 years before survey. CONCLUSION Patients with prior CRC above age 50 have no conclusive evidence of increased IR compared to non-CRC controls. This is possibly due to lesser weight gain in the peri-CRC diagnosis or treatment period. Future efforts should focus on alternate etiologies for the increased CRC recurrence in this high-risk group.

Making the Diagnosis: Gastroenterology

Background: Given the implicated role of proximal serrated polyps (PSP) in the development of interval colon cancer, it is important to investigate if proximal serrated polyp detection rate (PSPDR) correlates with adenoma detection rate (ADR) and the factors that are associated with higher detection rates. Methods: We performed a retrospective review of medical records of average-risk patients who underwent a screening colonoscopy at a tertiary care academic center. A total of 851 screening colonoscopies were analyzed. Results: Gastroenterologists (n=22) performed the 851 colonoscopies. In univariable logistic regression, endsocopists with a mean WT ≥11 minutes had a higher odds of detecting a PSP compared to endoscopists with a mean withdrawal time WT <11 minutes (p<0.001; OR 5.3; 95% CI 2.6-10.8). Odds of PSP detection were greater in males than females (p=0.01; OR 2.2; 95% CI 1.2-4.1). The multivariable regression analyses confirmed that PSPDR was higher for endoscopists with mean WT ≥11 minutes (p<0.001). In addition, there was a significant correlation between ADR and PSPDR among endoscopists who performed at least 50 colonoscopies during the study period (r=0.89, p=0.04). Conclusions: We concluded that there is a strong correlation between PSPDR and ADR and that a mean WT ≥11 minutes is an independent predictor of higher PSPDR.

Diverticulitis in HIV-infected patients within the United States.

Choledocholithiasis describes the presence of a stone impacted in the common bile duct (CBD). It has a varied presentation, ranging from incidentally noted stones to potentially life-threatening cholangitis. When an obstructive stone is found, it usually requires removal, and there are multiple modalities to choose from including endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic bile duct exploration. The best initial imaging test is with transabdominal ultrasound, but this frequently shows only a dilated CBD and not an actual stone. This creates diagnostic challenges, as missing and not removing a CBD stone can lead to recurrent or new disease in the future. Fortunately, by combining laboratory data with imaging, individuals with disease can be risk-stratified for the presence of a CBD stone, which facilitates cost-effective evaluation and treatment. The timing of intervention is also significant, as data shows an association with worse outcomes in certain groups if intervention is delayed.

Incidental Subepithelial Sigmoid Colon Lesion

Diverticulitis in patients on immunosuppressant therapy has been associated with increased mortality, but there are no data for HIV‐infected patients. Our aim was to compare the outcomes of hospitalizations for diverticulitis in patients with and without HIV infection.

A mechanistic radiographic and biologic phase 2 study of sunitinib in relapsed/refractory esophageal (E) and gastroesophageal (GE) cancers.

63-year-old woman presented for screening coAlonoscopy that revealed a 15-mm subepithelial lesion on a short stalk in the sigmoid colon (Figure A). Endoscopic ultrasound showed a well-defined, hypoechoic lesion limited to the muscularis mucosae (MM) (Figure B). To decrease the risk of postpolypectomy bleeding, a detachable endoloop (HX-400U-30; Olympus Corporation, Tokyo, Japan) was placed at the base of the lesion, which was then successfully resected without complications. Histopathology showed proliferation of smooth muscle cells in the MM with negative resection margins (Figure C). Immunohistochemistry was positive for smooth muscle actin and negative for CD-117, DOG1, and S-100. These findings were consistent with a colonic leiomyoma. Gastrointestinal leiomyomas, subepithelial benign smooth muscle tumors, are most commonly found in the esophagus. Colonic leiomyomas (Figure A) are rare, constitute only 3% of these tumors, and are usually located in the rectosigmoid area. They are most commonly asymptomatic but can present with abdominal pain, obstruction, bleeding, or perforation. Endoscopic resection is a safe option in select lesions. If the tumor is confirmed by endoscopic ultrasound to arise from the MM (Figure B), it can be safely resected during endoscopy. Alternatively, safety of resection can be confirmed by submucosal injection technique in an attempt to lift the lesion. Positive non-lifting sign is