Sarah B. Umar

Esophageal cancer: epidemiology, pathogenesis and prevention

Esophageal cancer is highly aggressive and is a common cancer both worldwide and in the US. In the past two decades, the incidence and mortality of esophageal cancer in the US have both increased, whereas the incidence and mortality of other cancers have decreased. Although esophageal squamous cell carcinoma and esophageal adenocarcinoma differ in their histology and epidemiologic distribution, some of their risk factors (e.g. dietary deficiencies and tobacco) and underlying mechanisms of carcinogenesis are the same. Intensive research into risk factors combined with the ability to identify precursor lesions (e.g. squamous dysplasia in esophageal squamous cell carcinoma and Barretts esophagus in esophageal adenocarcinoma) has paved the way for studies of chemoprevention for esophageal cancer, some of which have shown promising results.

Protein-Losing Enteropathy: Case Illustrations and Clinical Review

Protein-losing enteropathy (PLE) is a rare syndrome of gastrointestinal protein loss that may complicate a variety of diseases. The primary causes can be divided into erosive gastrointestinal disorders, nonerosive gastrointestinal disorders, and disorders involving increased central venous pressure or mesenteric lymphatic obstruction. The diagnosis of PLE should be considered in patients with hypoproteinemia after other causes, such as malnutrition, proteinuria, and impaired protein synthesis due to cirrhosis, have been excluded. The diagnosis of PLE is most commonly based on the determination of fecal α-1 antitrypsin clearance. Treatment of PLE targets the underlying disease but also includes dietary modification, supportive care, and maintenance of nutritional status. In this article, cases illustrating a variety of clinical presentations and etiologies of PLE are presented, and its diagnostic approach and treatment are reviewed.

Esophageal Motor Abnormalities in Patients With Scleroderma: Heterogeneity, Risk Factors, and Effects on Quality of Life

BACKGROUND & AIMS: Systemic scleroderma (SSc) is associated with esophageal aperistalsis and hypotensive esophagogastric junction pressure, although there could be a gradation in esophageal motor dysfunction. We characterized esophageal motor function by high‐resolution esophageal manometry (HRM) and assessed associations between SSc severity, health‐related quality of life (HRQOL), and HRM findings in patients. METHODS: We performed a prospective study of 200 patients with SSc and 102 patients without SSc (controls) who underwent HRM at Mayo Clinic Arizona from May 2006 through January 2015. We used data on integrated relaxation pressure, distal contractile integral, and distal latency to classify esophageal motility disorders according to the Chicago Classification v 3.0. A subset of subjects (n = 122) completed SSc‐specific gastrointestinal symptom and HRQOL questionnaires. HRM findings, symptoms, and HRQOL data were compared among diffuse SSc, limited SSc, and control subjects. Categorical variables were compared by using the χ2 or Fisher exact test; continuous variables were compared by using Mann‐Whitney or Kruskal‐Wallis test. Multivariable logistic regression was used to assess the association between severity of esophageal dysmotility and baseline clinical factors. RESULTS: Among patients with SSc, 83 had diffuse SSc (42%), and 117 had limited SSc (58%). Absent contractility was more frequent in patients with SSc than in controls (56% vs 13%; P < .001). HRM findings varied among the patients; absent contractility (56%) was the most frequent diagnosis, followed by normal motility (26%) and ineffective esophageal motility (10%). Classic scleroderma esophagus (esophagogastric junction pressure with absent contractility) was only observed in 33% of patients (34% with diffuse SSc vs 32% limited SSc) (P = .880). Severe esophageal dysmotility was associated with disease duration, interstitial lung disease, and higher gastrointestinal symptom scores (P < .001). HRQOL was decreased in patients with SSc and severe esophageal dysmotility. CONCLUSIONS: Although severe dysmotility is more common in patients with SSc than in controls, we observed the so‐called scleroderma esophagus in only one‐third of patients with SSc. Esophageal motor function appears to be heterogeneous in SSc. Esophageal dysmotility reduces HRQOL in patients with SSc.

Personality Traits and Impaired Health-Related Quality of Life in Patients With Functional Gastrointestinal Disorders

BACKGROUND & AIMS Negative affectivity and social isolation (Type D personality) are personality traits associated with poor health-related quality of life (HRQoL). We hypothesized these traits would be associated with impaired HRQoL and increased gastrointestinal symptom severity in functional gastrointestinal disorders. METHODS Data were collected from patients undergoing breath testing. Patients completed the Type D Scale-14, Gastrointestinal Symptoms Severity Index and Short-Form Health Survey 12. RESULTS Of 230 patients evaluated, 37% met criteria for Type D personality. Type D was associated with a decreased Mental Component score on the Short-Form Health Survey 12 (mean difference = -8.29; 95% confidence interval, 5.2-11.4; P < .001). On the Gastrointestinal Symptoms Severity Index, severity of symptoms was significantly higher in Type D patients compared with non Type D patients (P < .001). CONCLUSIONS Type D personality was associated with decreased perceived HRQoL and reporting of more severe gastrointestinal symptoms. Type D personality construct may be an important consideration when assessing HRQoL outcomes. Consideration of personality traits could improve risk stratification in research and clinical practice in this patient group.

The Impact of Pelvic Floor and Lower Gastrointestinal Symptoms on Quality of Life in Women With Systemic Sclerosis.

Background: Systemic sclerosis (SSc) patients with gastrointestinal (GI) involvement have a lower quality of life (QoL) and while the impact of upper GI symptoms on QoL in SSc patients has been described few data exist on the presence and impact of lower gastrointestinal (LGI) and pelvic floor symptoms in SSc. Our goal was to assess the prevalence of these symptoms in women with SSc and evaluate their impact on QoL. A secondary hypothesis was that the impact of LGI symptoms on QoL is mediated by depression. Study: Women with SSc (n=175) attending an outpatient scleroderma clinic completed multiple validated questionnaires. Pelvic floor and LGI symptoms included fecal incontinence (FI), urinary incontinence (UI), dual incontinence (DI), chronic constipation, diarrhea, and pelvic pain. The Student t tests adjusted for multiple comparisons were used to evaluate group differences at the 0.05 level. Results: Complete data were available for 160 women. FI was reported by 65, UI by 64, DI by 40, chronic constipation by 94, diarrhea by 82, and pelvic pain by 35 of SSc patients. Overall QoL was reduced in SSc patients with FI (0.96 vs. 0.63; P=0.007), UI (0.96 vs. 0.65; P=0.01), DI (1.11 vs. 0.67; P=0.002), and pelvic pain (1.01 vs. 0.70; P=0.04). Antidepressant use was reported by 26%. The negative impact on QoL in patients with pelvic floor symptoms was partially mediated by depression. Conclusions: Women with SSc suffer from an increased prevalence of LGI and pelvic floor symptoms including FI, UI, diarrhea, constipation, and pelvic pain and this effect seems to be partially mediated by depression.

Irritable Bowel Syndrome and Female Patients

Irritable bowel syndrome is probably the most common functional gastrointestinal disorder and is characterized by abdominal pain along with altered bowel function. It is a disorder of female predominance. This article focuses on how being female influences the pathophysiology, diagnosis, management, and treatment of this common disorder and discusses the evidence and important controversies related to these areas.

Deglutition Syncope: A Case Report and Review of the Literature

Deglutition syncope (DS) is a rare, neurally-mediated syncopal syndrome arising from an aberrant vagotonic reflex during swallow-associated esophageal dilation. Its association with gastroesophageal disorders often prompts gastroenterology consultation. An 89-year-old man with recent dysphagia and otalgia was admitted after a syncopal episode occurred while eating. Esophageal imaging and endoscopy demonstrated no causative abnormalities. Maxillofacial imaging revealed chronic sinusitis and mastoiditis. Telemetry monitoring demonstrated high-grade atrioventricular block and pause associated with swallowing. His symptoms and swallow-associated arrhythmia resolved after dual chamber pacemaker implantation. DS is highly treatable once identified and multidisciplinary coordination is helpful in optimizing outcomes and avoiding superfluous testing.

Postcolonoscopy Followup Recommendations: Comparison with and without Use of Polyp Pathology

Background. Appropriate recommendations for a followup exam after an index colonoscopy are an important quality indicator. Lack of knowledge of polyp pathology at the time of colonoscopy may be one reason that followup recommendations are not made. Aim. To describe and compare the accuracy of followup recommendations made at colonoscopy based on the size and number of polyps with recommendations made at a later date based on actual polyp pathology. Methods. All patients who underwent screening and surveillance colonoscopy from March, 2012, to August, 2012, were included. Surveillance recommendations from the endoscopy reports were graded as “accurate” or “not accurate” based on the postpolypectomy surveillance guidelines established by US Multisociety Task Force on Colon Cancer. Polyp pathology was then used to regrade the surveillance recommendations. Results. Followup recommendations were accurate in 759/884 (86%) of the study colonoscopies, based upon size and number of polyps with the assumption that all polyps were adenomatous. After incorporating actual polyp pathology, 717/884 (81%) colonoscopies had accurate recommendations. Conclusion. In our practice, the knowledge of actual polyp pathology does not change the surveillance recommendations made at the time of colonoscopy in the majority of patients.

Impact of feedback on adenoma detection rates: Outcomes of quality improvement program

Feedback has been shown to improve performance in colonoscopy including adenoma detection rate (ADR). The frequency at which feedback should be given is unknown. As part of a quality improvement program, we sought to measure the outcome of providing quarterly and monthly feedback on colonoscopy quality measures.

Is the level of cleanliness using segmental boston bowel preparation scale associated with a higher adenoma detection rate

Background The impact of Boston bowel preparation scale (BBPS) scores on the adenoma detection rate (ADR) in each segment has not been adequately addressed. The aim of this study was to determine the association between segmental or overall ADR and serrated polyp detection rate (SDR) with segmental and total BBPS scores. Methods All outpatient screening colonoscopies with documented BBPS scores were retrospectively reviewed at a tertiary institution from January to December 2013. Chi-square tests and logistic regression were used to analyze the detection rates of adenomas and serrated polyps with bowel prep scores. Odds ratios were calculated using logistic regression that controlled for withdrawal time, age, body mass index, diabetes status and sex. Results We analyzed 1991 colonoscopies. The overall ADR was 37.5% (95% confidence interval [CI], 35.3-39.6). There was a significant difference in the overall ADR, and in SDR across all bowel category groups, with total BBPS scores of 8 and 9 having lower detection rates than scores of 5, 6 and 7. As the quality of bowel preparation increased, there was a statistical decrease in the ADR (odds ratio [OR] 0.79 [CI 0.66-0.94], P=0.04) of the right colon, while in the left colon, there was a statistical decrease in SDR (OR 0.78, [CI 0.65-0.92] P=0.019). Conclusion Segmental ADR and SDR both decreased as prep scores increased, decreasing notably in patients with excellent prep scores of 8 and 9. A possible explanation for this unexpected discrepancy may be related to longer and better visualization of the mucosa when cleansing and suctioning is necessary.