Shailesh C. Kadakia

Nonalcoholic steatohepatitis: what we know in the new millennium

Nonalcoholic steatohepatitis (NASH) is a liver disease characterized by diffuse fatty infiltration and inflammation. The exact prevalence of NASH is unclear, but it is becoming more evident that the disease is much more common than previously thought. Although generally a benign, indolent process, it can progress to advanced liver disease in approximately 15–20% of patients. Clinical characteristics associated with NASH include obesity, hyperlipidemia, diabetes mellitus, and hypertension, all of which have been associated with underlying insulin resistance. Typically, this disease becomes evident in the fourth or fifth decade of life with an equal sex predilection. NASH is thought to be caused, in part, by impaired insulin signaling, leading to elevated circulating insulin levels and subsequent altered lipid homeostasis. This process is likely multifactorial and includes both genetic and environmental factors. Treatment options to date are limited and are based on very small clinical trials. Current investigations are focusing on improving the underlying insulin resistance that has been associated with NASH as well as other therapies that decrease oxidative stress or improve hepatocyte survival.

Comparison of 10 French gauge stent with 11.5 French gauge stent in patients with biliary tract diseases

We retrospectively compared the efficacy and complications of 10 F biliary stents with 11.5 F stents in the management of malignant and benign biliary tract diseases. Thirty-three patients treated with 10 F stents inserted on 46 occasions and 30 patients with 11.5 F stents inserted on 43 occasions were evaluated. The success of insertion, relief of jaundice, decline in total bilirubin, stent survival, and complications due to stents were compared. Patients with multiple stents, preoperative biliary drainage, stents smaller than 10 F, larger than 11.5 F, nasobiliary catheter drainage, and percutaneous biliary drainage were excluded. When comparing 10 F stents to 11.5 F stents, the success of insertion was 85% vs. 79% (p = 0.52), relief of jaundice was 88% vs. 90% (p = 0.79), and the decline in total bilirubin was 7.4 mg/100 ml vs. 8.3 mg/100 ml (p = 0.67). The complications, including stent clogging, cholangitis, stent migration, and pancreatitis occurred on seven occasions in patients with 10 F stents and on six occasions in patients with 11.5 F stents. This difference was statistically not significant (p = 0.87). We conclude that 10 F stents have the same success rate and complication rate as 11.5 F stents in the management of biliary tract diseases, and offer no significant advantage.

The prevalence of celiac disease autoantibodies in patients with systemic lupus erythematosus.

OBJECTIVE:Systemic lupus erythematosus has been associated with false positive autoantibodies for primary biliary cirrhosis, chronic active hepatitis, Sjogrens syndrome, rheumatoid arthritis, thyroid disorders, syphilis, and scleroderma. An increased prevalence of autoantibodies are found in celiac disease and systemic lupus erythematosus, which share the human lymphocyte HLA-B8 and HLA-DR3 histocompatibility antigens. This study examines the prevalence of celiac disease autoantibodies in systemic lupus erythematosus patients.METHODS:Patients observed in the Department of Rheumatology at our institutions in San Antonio, Texas with known systemic lupus erythematosus were offered participation in the study. One hundred three of the 130 patients contacted agreed to participate. Patients were excluded if they were pregnant or medically unable to undergo endoscopy. All volunteers were tested for the serological presence of IgA and IgM antigliadin and IgA antiendomysial antibodies. Those with positive serology underwent esophagogastroduodenoscopy with duodenal mucosal biopsy.RESULTS:Twenty-four of 103 (23.3%) systemic lupus erythematosus patients tested positive for either antigliadin antibody, whereas none of the 103 patients tested positive for antiendomysial antibody. None of the 24 antigliadin positive patients were found to have endoscopic or histological evidence of celiac disease, making the false positive rate of antigliadin antibody 23%.CONCLUSION:The presence of false positive antigliadin antibodies in patients with systemic lupus erythematosus is common. Despite shared human lymphocyte antigen loci there does not seem to be an association between celiac disease and systemic lupus erythematosus.

Prevalence of proximal colonic polyps in average-risk asymptomatic patients with negative fecal occult blood tests and flexible sigmoidoscopy

BACKGROUND Proximal colonic adenomas were found in 13% to 37% of patients without distal adenomas who underwent colonoscopy. Fiberoptic flexible sigmoidoscopy (FFS) was not performed prior to colonoscopy in all studies except one. The proximal colon at colonoscopy was defined as that portion of the colon proximal to either the descending-sigmoid junction or 60 cm from the anus while withdrawing the colonoscope. These estimates may not reflect exact colonic location when a 60 cm length sigmoidoscope is fully inserted. Therefore, the aim of our study was to determine the prevalence of proximal colonic neoplasms in asymptomatic patients with average risk for colon cancer, aged 50 years and over, with negative fecal occult blood tests and without adenomas at FFS. METHODS Colonoscopy was performed in 80 patients without and 95 patients with adenomas at FFS. Polypectomy was done using hot biopsy forceps or snare cautery. RESULTS Twenty-four proximal colonic adenomas (19 < 1 cm and 5 > or = 1 cm) were found in 18 of 80 patients (23%) with normal FFS compared with 39 proximal colonic adenomas (32 < 1 cm and 7 > or = 1 cm), in 28 of 95 patients (29%) with adenomas at FFS (p = 0.31). In patients with normal FFS, there were 20 tubular, 2 tubulovillous, and 2 villous (1 with severe dysplasia) adenomas. In patients with adenomas at FFS, there were 31 tubular, 5 tubulovillous, and 3 villous (1 with severe dysplasia) adenomas. CONCLUSIONS Proximal colonic adenomas are found in up to one fourth of asymptomatic average-risk patients with negative fecal occult blood test and both with and without adenomas at FFS. The adenomas in both groups have similar size, histology, and location. Severe dysplasia is rarely present.

Rapid diagnosis of infected ascitic fluid using leukocyte esterase Dipstick testing

OBJECTIVES:Ascitic fluid infection is presumptively diagnosed when the fluid polymorphonuclear leukocyte (PMN) concentration equals or exceeds 250 cells/μl. The leukocyte esterase (LE) test has been shown to be a good predictor of the presence of PMNs and bacteria in urine and other body fluids. This study examines the value of the Multistix® 10 SG LE Dipstick test for the rapid diagnosis of infected ascitic fluid.METHODS:One hundred thirty-six ascitic fluid samples were evaluated by PMN count, culture, and LE Dipstick testing. LE dipstick values of “small” or greater were considered positive. For each sample, the LE test result was compared to the corresponding PMN count and culture result.RESULTS:Ten of the 11 LE-positive samples had PMN ≥250 cells/μl, while 10 of 12 samples with PMN ≥250 cells/μl were also LE-positive. Of the 125 LE-negative samples, 123 were also negative by PMN count. One hundred twenty-three of the 124 samples with PMN <250 cells/μl had negative LE tests. There was a less concordant relationship between the LE test and culture results. The sensitivity and specificity of the LE test for detecting ascitic fluid PMN ≥250 cells/μl were 83% and 99%, respectively, with a positive predictive value of 91% and a negative predictive value of 98%.CONCLUSIONS:The Multistix® leukocyte esterase test is useful for the prompt detection of an elevated ascitic fluid PMN count, and represents a convenient new method for the rapid diagnosis of infected ascitic fluid.

Serum electrolyte, mineral, and blood pH changes after phosphate enema, water enema, and electrolyte lavage solution enema for flexible sigmoidoscopy☆

Hypertonic sodium phosphate (Fleet) enema is a commonly used preparation for fiberoptic flexible sigmoidoscopy. Unfortunately, Fleet has been associated with complications in children and adults. The purpose of this study was to compare the serum electrolytes, mineral, and blood pH changes before and after the administration of Fleet with water and polyethylene glycol electrolyte lavage solution (Golytely) as enemas in an adult population undergoing flexible sigmoidoscopy. Sixty-six patients were randomized in a double-blind fashion to receive two enemas of either Fleet (N = 22), water (N = 20), or Golytely (N = 24). The cleansing ability was graded from 1 to 4 (1 = poor, 4 = excellent). The Fleet had significantly better optimal cleansing efficacy compared with water (p < 0.05) but not to Golytely (p > 0.05). There was a significant increase in the serum phosphorus in the Fleet group compared with water (p < 0.001) or Golytely (p < 0.001). However, absolute serum phosphorus values after Fleet enema always remained within normal range in all but one patient. The changes in other electrolytes, minerals, and venous pH were insignificant.

India ink tattooing in the esophagus

BACKGROUND Precise endoscopic measurement of esophageal landmarks is difficult and inaccurate because of the ability of the esophagus to lengthen and foreshorten. METHODS Nineteen patients enrolled to date in a study of Barretts esophagus had an India ink tattoo placed at the most proximal level of the squamocolumnar junction and were examined endoscopically at 3, 9, 15, 24, and 36 months. RESULTS Eighteen of nineteen patients (94.7%) were judged to have a good to excellent tattoo persistence at 3 months. One of the 19 patients (5.3%) had poor tattoo persistence and was retattooed at the 3-month interval. Eventually, 15 of the 15 patients (100%) who remained in the study had a good or excellent tattoo persistence at 36 months. There were no complications related to India ink tattooing including chest pain, bleeding, or perforation. At follow-up endoscopy, no ulcers, inflammation, break in the mucosa, or pain were noted. CONCLUSION India ink tattooing in the esophagus is safe and persistent and may be used as an effective method for longitudinal follow-up of lesions in the esophagus.

D-lactic acidosis in a patient with jejunoileal bypass.

D-Lactic acidosis is an unique complication of jejunoileal bypass occurring because of alteration of colonic bacterial flora with selective proliferation of D-lactate-producing bacteria. The D-lactate accumulation in the serum is associated with encephalopathy, which responds to oral antibiotic drugs in most patients. Because gastroenterologists may encounter such patients for some time to come, we report a new case and review the literature.

Comparison of Foley catheter as a replacement gastrostomy tube with commercial replacement gastrostomy tube: a prospective randomized trial

Percutaneous endoscopic gastrostomy (PEG) provides a non-surgical alternative to long-term enteral feeding. The gastrostomy tube, however, may deteriorate, malfunction, or be accidentally expelled, requiring replacement. A commercial gastrostomy tube is commonly used for replacement. However, a commercial replacement gastrostomy tube is many times more expensive than a Foley catheter, and the two have never been compared. We compared the efficacy and safety of an all-silicone Foley catheter used as a replacement feeding gastrostomy tube with the effectiveness of a commercial replacement gastrostomy tube in 46 patients undergoing long-term enteral feedings per gastrostomy. Twenty-four patients were randomized to the Foley group and 22 patients to the commercial replacement gastrostomy tube group. The Foley catheter functioned well without need for replacement in 16 (66%) patients for 27.4 +/- 14.8 (mean +/- SD) weeks; the commercial replacement gastrostomy tube functioned in 13 (59%) patients for 24.5 +/- 13.6 weeks (p > 0.05, NS). The Foley catheter needed to be replaced because of malfunction in 8 (34%) patients and the commercial replacement gastrostomy tube in 9 (41%) patients after 21.6 +/- 11.5 weeks and 19.3 +/- 9.3 weeks, respectively (p > 0.05, NS). Neither the Foley catheter nor the commercial replacement gastrostomy tube migrated; this was the most striking finding, in contrast to case reports in the literature. Our data suggest that the Foley catheter can be safely used as a replacement gastrostomy tube; it is considerably cheaper than the commercial replacement gastrostomy tube, and its efficacy and complication rates are similar to those of the commercial replacement gastrostomy tube.

Acute Effect of Nicotine Patch on Gastric Emptying of Liquid and Solid Contents in Healthy Subjects

The effect of nicotine on gastric emptyingremains controversial. Gastric emptying is delayed inchronic smokers after smoking high-dose nicotinecigarettes, but it is unchanged after chewing nicotinegums. No information is available on the effect oftransdermal nicotine patches on the gastric emptying ofsolid and liquid contents in healthy nonsmokers. Ourobjective was to prospectively evaluate the effect of the nicotine patch on gastric emptying ofliquid and solid contents in healthy nonsmokers. Tenhealthy nonsmoking volunteers under-went a baselinedual-isotope gastric scintigraphy with[111In]-diethylenetriaminepantaacetic acid (DTPA) and [99mTc]sulfurcolloid isotopes to evaluate prospectively the gastricemptying of liquid and solid contents, respectively. Thegastric scintigraphy was repeated after placing a transdermal nicotine patch (Habitrol) for 12 hrdesigned to deliver 14 mg of nicotine per day. Plasmanicotine level was measured prior to baseline gastricscintigraphy and after 12 hr placing the nicotine patch. Plasma nicotine was absent in allsubjects at baseline and but was significantly elevatedafter 12 hr of nicotine patch (P < 0.009). The meanhalf-emptying times (T1/2) for the gastricemptying of liquids before and after nicotine patchplacement were 31.2 ± 23.3 and 25.6 ± 8.4min, respectively (P = 0.498). The mean T1/2sfor the gastric emptying of solids before and afternicotine patch placement were 70.1 ± 34.0 and 59.7± 31.4 min, respectively (P = 0.202). There wasno correlation between the plasma nicotine level andgastric emptying of liquid and solid contents(correlation coefficient = –0.23 and –0.01, respectively).In conclusion, acute transdermal delivery of nicotinedoes not affect the gastric emptying of solid and liquidcontents in healthy nonsmoking subjects.