Shiva K. Ratuapli

NORMAL VALUES FOR HIGH-RESOLUTION ANORECTAL MANOMETRY IN HEALTHY WOMEN: EFFECTS OF AGE AND SIGNIFICANCE OF RECTOANAL GRADIENT

OBJECTIVES:High-resolution manometry (HRM) is used to measure anal pressures in clinical practice but normal values have not been available. Although rectal evacuation is assessed by the rectoanal gradient during simulated evacuation, there is substantial overlap between healthy people and defecatory disorders, and the effects of age are unknown. We evaluated the effects of age on anorectal pressures and rectal balloon expulsion in healthy women.METHODS:Anorectal pressures (HRM), rectal sensation, and balloon expulsion time (BET) were evaluated in 62 asymptomatic women ranging in age from 21 to 80 years (median age 44 years) without risk factors for anorectal trauma. In total, 30 women were aged <50 years.RESULTS:Age is associated with lower (r=−0.47, P<0.01) anal resting (63 (5) (≥50 years), 88 (3) (<50 years), mean (s.e.m.)) but not squeeze pressures; higher rectal pressure and rectoanal gradient during simulated evacuation (r=0.3, P<0.05); and a shorter (r=−0.4, P<0.01) rectal BET (17 (9) s (≥50 years) vs. 31 (10) s (<50 years)). Only 5 women had a prolonged (>60 s) rectal BET but 52 had higher anal than rectal pressures (i.e., negative gradient) during simulated evacuation. The gradient was more negative in younger (−41 (6) mm Hg) than older (−12 (6) mm Hg) women and negatively (r=−0.51, P<0.0001) correlated with rectal BET but only explained 16% of the variation in rectal BET.CONCLUSIONS:These observations provide normal values for anorectal pressures by HRM. Increasing age is associated with lower anal resting pressure, a more positive rectoanal gradient during simulated evacuation, and a shorter BET in asymptomatic women. Although the rectoanal gradient is negatively correlated with rectal BET, this gradient is negative even in a majority of asymptomatic women, undermining the utility of a negative gradient for diagnosing defecatory disorders by HRM.

Phenotypic Identification and Classification of Functional Defecatory Disorders Using High-Resolution Anorectal Manometry

BACKGROUND & AIMS Disordered defecation is attributed to pelvic floor dyssynergia. However, clinical observations indicate a spectrum of anorectal dysfunctions. The extent to which these disorders are distinct or overlap is unclear; anorectal manometry might be used in diagnosis, but healthy persons also can have abnormal rectoanal pressure gradients during simulated evacuation. We aimed to characterize phenotypic variation in constipated patients through high-resolution anorectal manometry. METHODS We evaluated anorectal pressures, measured with high-resolution anorectal manometry, and rectal balloon expulsion time in 62 healthy women and 295 women with chronic constipation. Phenotypes were characterized by principal components analysis of high-resolution anorectal manometry. RESULTS Two healthy persons and 71 patients had prolonged (>180 s) rectal balloon expulsion time. A principal components logistic model discriminated healthy people from patients with prolonged balloon expulsion time with 75% sensitivity and a specificity of 75%. Four phenotypes discriminated healthy people from patients with abnormal balloon expulsion times; 2 phenotypes discriminated healthy people from those with constipation but normal balloon expulsion time. Phenotypes were characterized based on high anal pressure at rest and during evacuation (high anal), low rectal pressure alone (low rectal) or low rectal pressure with impaired anal relaxation during evacuation (hybrid), and a short anal high-pressure zone. Symptoms were not useful for predicting which patients had prolonged balloon expulsion times. CONCLUSIONS Principal components analysis of rectoanal pressures identified 3 phenotypes (high anal, low rectal, and hybrid) that can discriminate among patients with normal and abnormal balloon expulsion time. These phenotypes might be useful to classify patients and increase our understanding of the pathogenesis of defecatory disorders.

Quality of Bowel Cleansing for Afternoon Colonoscopy Is Influenced by Time of Administration

OBJECTIVES:Afternoon colonoscopies have higher failure rates, due primarily to poor bowel cleansing. Hypothesizing that the time of administration influences the quality of bowel cleansing, we compared the quality of bowel cleansing for afternoon colonoscopies in patients completing the preparation on the same day vs. the day before colonoscopy.METHODS:Data on afternoon colonoscopies performed between July 2008 and April 2009 were obtained from our endoscopy database. Bowel-preparation options were 4L polyethylene glycol (PEG) or 2L PEG plus four bisacodyl tablets. Patients could take the preparation on the same day as the procedure or the day prior, or consume half the day prior and half the same day. Bowel-cleansing quality was reported as excellent, good, fair–adequate, inadequate, or poor. Multivariate logistic regression analysis evaluated the association between quality of bowel cleansing and time of preparation administration.RESULTS:Bowel cleansing was reported as poor or inadequate in 7% of patients, adequate in 63%, and good or excellent in 30%. Afternoon colonoscopies using the same-day 4L PEG preparation were 3.14 times more likely to have fair–adequate cleansing and 7.03 times more likely to have good or excellent cleansing when compared with the other options.CONCLUSIONS:Same-day 4L PEG preparation for afternoon colonoscopy confers better-quality cleansing than prior-day preparation.

Opioid-Induced Esophageal Dysfunction (OIED) in Patients on Chronic Opioids

OBJECTIVES:Bowel dysfunction has been recognized as a predominant side effect of opioid use. Even though the effects of opioids on the stomach and small and large intestines have been well studied, there are limited data on opioid effects on esophageal function. The aim of this study was to compare esophageal pressure topography (EPT) of patients taking opioids at the time of the EPT (≤24 h) with chronic opioid users who were studied off opioid medications for at least 24 h using the Chicago classification v3.0.METHODS:A retrospective review identified 121 chronic opioid users who completed EPT between March 2010 and August 2012. Demographic and manometric data were compared between the two groups using general linear models or χ2.RESULTS:Of the 121 chronic opioid users, 66 were studied on opioid medications (≤24 h) and 55 were studied off opioid medications for at least 24 h. Esophagogastric junction (EGJ) outflow obstruction was significantly more prevalent in patients using opioids within 24 h compared with those who did not (27% vs. 7%, P=0.004). Mean 4 s integrated relaxation pressure was also significantly higher in patients studied on opioids (10.71 vs. 6.6 mm Hg, P=0.025). Resting lower esophageal sphincter pressures tended to be higher on opioids (31.61 vs. 26.98 mm Hg, P=0.25). Distal latency was significantly lower in patients studied on opioids (6.15 vs. 6.74 s, P=0.044).CONCLUSIONS:Opioid use within 24 h of EPT is associated with more frequent EGJ outflow obstruction and spastic peristalsis compared with when opioid use is stopped for at least 24 h before the study.

Adenoma detection rate is not influenced by the timing of colonoscopy when performed in half-day blocks

OBJECTIVES:Afternoon colonoscopies have recently been reported to be associated with lower adenoma detection rate (ADR), which was attributed to physician fatigue resulting from the same endoscopist performing procedures throughout the day. The aim of our study was to assess ADR in morning compared with afternoon colonoscopy performed in half-day blocks with different physicians. We evaluated the primary hypothesis that morning and afternoon ADRs would not differ significantly when performed in half-day blocks by different endoscopists.METHODS:Data on all colonoscopies performed between January 2009 and December 2009 were obtained from our endoscopy database. All patients who underwent colonoscopies in 2009 for screening, surveillance, and family history of colon cancer/polyps were included in the study. Morning colonoscopies were defined as those that were performed from 0800 to 1200 hours. Afternoon colonoscopies were defined as those that were performed from 1300 to 1700 hours. Colonoscopies in each block were performed either by different endoscopists working in half-day (morning or afternoon) block schedules or by the same endoscopist working a full-day schedule.RESULTS:A total of 4,665 patients were included in the study. For endoscopists working the full-day, the afternoon ADR was significantly lower than the morning ADR (21 vs. 26.1%; odds ratio (OR)=0.75; 95% confidence interval (CI) 0.59, 0.96; P=0.02). Conversely, in the half-day group, there was no significant difference in ADR between afternoon and morning (27.6 vs. 26.6%; OR=1.05; 95% CI 0.88, 1.26; P=0.56).CONCLUSIONS:Performing colonoscopies in half-day blocks by different endoscopists increases the detection of adenomas in afternoon procedures, probably by reducing physician fatigue.

Safety of Endoscopic Removal of Self-Expandable Stents After Treatment of Benign Esophageal Diseases

BACKGROUND Temporary placement of self-expandable stents has been increasingly used for the management of benign esophageal diseases. OBJECTIVE To evaluate the safety of endoscopic removal of esophageal self-expandable stents placed for the treatment of benign esophageal diseases. DESIGN Multicenter retrospective study. SETTING Six tertiary care centers in the United States and Europe. PATIENTS A total of 214 patients with benign esophageal diseases undergoing endoscopic stent removal. INTERVENTION Endoscopic stent removal. MAIN OUTCOME MEASUREMENTS Endoscopic techniques for stent removal, time to stent removal, and adverse events related to stent removal. RESULTS A total of 214 patients underwent a total of 329 stent extractions. Stents were mainly placed for refractory strictures (49.2%) and fistulae (49.8%). Of the removed stents, 52% were fully covered self-expandable metal stents (FCSEMSs), 28.6% were partially covered self-expandable metal stents (PCSEMSs), and 19.5% were self-expandable plastic stents. A total of 35 (10.6%) procedure-related adverse events were reported, including 7 (2.1%) major adverse events. Multivariate analysis revealed that use of PCSEMSs (P < .001) was a risk factor for adverse events during stent removal. Favorable factors for successful stent removal were FCSEMSs (P ≤ .012) and stent migration (P = .010). No significant associations were found for stent indwelling time (P = .145) and stent embedding (P = .194). LIMITATIONS Retrospective analysis, only tertiary care centers. CONCLUSIONS With an acceptable major adverse event rate of 2.1%, esophageal stent removal in the setting of benign disease was found to be a safe and feasible procedure. FCSEMSs were more successfully removed than self-expandable plastic stents and PCSEMSs. Adverse events caused by stent removal were not time dependent.

Comparison of rectal balloon expulsion test in seated and left lateral positions.

Defecatory disorders can be diagnosed by rectal balloon expulsion (BE) and anorectal manometry, which are traditionally evaluated in the seated and left lateral (LL) positions, respectively. The aims of this study were to compare BE in the LL and seated positions and to compare anorectal manometric parameters to BE performed in the seated and LL positions.

Interrater and Intrarater Agreement of the Chicago Classification of Achalasia Subtypes Using High-Resolution Esophageal Manometry

OBJECTIVES:Subclassification of achalasia based on high-resolution manometry (HRM) may be clinically relevant because response to therapy may vary by subtype. However, the consistency and reliability of subtyping achalasia patients based on HRM remains undefined. The objectives of this study were to assess interrater and intrarater agreement (reliability) of achalasia subtyping using the Chicago classification, and to evaluate the diagnostic consistency between clinicians interpreting HRM.METHODS:After receiving training on the classification criteria, five raters classified 20 achalasia and 10 non-achalasia cases in separate sessions 1 week apart. To further assess agreement, two raters classified all 101 available achalasia HRMs. Agreement for the classification of subtypes of achalasia was calculated using Cohens κ and Krippendorffs α-reliability estimate.RESULTS:Estimates of agreement among raters was good during both sessions (α=0.75; 95% confidence interval=0.69, 0.81 and α=0.75; 95% confidence interval=0.68, 0.81). Both interrater (κ=0.86–1.0) and intrarater (κ=0.86–1.0) agreement were very good for type III achalasia. Agreement between types I and II was more variable. Reliability was improved when type I and type II were combined (α=0.84; 95% confidence interval=0.78, 0.89). When all available cases were classified by two experienced raters, agreement was very good (κ=0.81; 95% confidence interval=0.71, 0.91).CONCLUSIONS:Interobserver and intraobserver agreement for differentiating achalasia from non-achalasia patients using HRM and the Chicago classification was very good to excellent. More variability was seen in agreement when classifying achalasia subtypes. The most variation was observed in classification between type I and type II achalasia, which have similar characteristics. Clearly, differentiating between panesophageal pressurization and compartmentalization should improve discrimination between these subtypes.

Sarcina ventriculi of the stomach: a case report.

Sarcina ventriculi is a Gram positive organism, which has been reported to be found rarely, in the gastric specimens of patients with gastroparesis. Only eight cases of Sarcina, isolated from gastric specimens have been reported so far. Sarcina has been implicated in the development of gastric ulcers, emphysematous gastritis and gastric perforation. We report a case of 73-year-old male, with history of prior Billroth II surgery and truncal vagotomy, who presented for further evaluation of iron deficiency anemia. An upper endoscopy revealed diffuse gastric erythema, along with retained food. Biopsies revealed marked inflammation with ulcer bed formation and presence of Sarcina organisms. The patient was treated with ciprofloxacin and metronidazole for 1 wk, and a repeat endoscopy showed improvement of erythema, along with clearance of Sarcina organisms. Review of reported cases including ours suggests that Sarcina is more frequently an innocent bystander rather than a pathogenic organism. However, given its association with life threatening illness in two reported cases, it may be prudent to treat with antibiotics and anti-ulcer therapy, until further understanding is achieved.

Nonneoplastic polypectomy during screening colonoscopy: the impact on polyp detection rate, adenoma detection rate, and overall cost.

BACKGROUND The frequency of nonneoplastic polypectomy (NNP) and its impact on the polyp detection rate (PDR) is unknown. The correlation between NNP and adenoma detection rate (ADR) and its impact on the cost of colonoscopy has not been investigated. OBJECTIVE To determine the rate of NNP in screening colonoscopy, the impact of NNP on the PDR, and the correlation of NNP with ADR. The increased cost of NNP during screening colonoscopy also was calculated. DESIGN We reviewed all screening colonoscopies. PDR and ADR were calculated. We then calculated a nonneoplastic polyp detection rate (patients with ≥1 nonneoplastic polyp). SETTING Tertiary-care referral center. PATIENTS Patients who underwent screening colonoscopies from 2010 to 2011. INTERVENTIONS Colonoscopy. MAIN OUTCOME MEASUREMENTS ADR, PDR, NNP rate. RESULTS A total of 1797 colonoscopies were reviewed. Mean (±standard deviation) PDR was 47.7%±12.0%, and mean ADR was 27.3%±6.9%. The overall NNP rate was 10.4%±7.1%, with a range of 2.4% to 28.4%. Among all polypectomies (n=2061), 276 were for nonneoplastic polyps (13.4%). Endoscopists with a higher rate of nonneoplastic polyp detection were more likely to detect an adenoma (odds ratio 1.58; 95% confidence interval, 1.1-1.2). With one outlier excluded, there was a strong correlation between ADR and NNP (r=0.825; P<.001). The increased cost of removal of nonneoplastic polyps was