Tony S. Brar

Endoluminal Therapy for Gastroesophageal Reflux Disease: In Between the Pill and the Knife?

Gastroesophageal reflux disease (GERD) is a chronic disease characterized by symptoms of heartburn and acid regurgitation. Uncontrolled GERD can significantly impact quality of life, can lead to complications, and increases the risk of esophageal cancer. Over the past few decades, there has been an increasing prevalence of GERD among adults in Western populations. The use of proton pump inhibitors (PPI) in conjunction with lifestyle modifications remains the mainstay therapy. However, the efficacy of this intervention is often hampered by adherence, costs, and the risks of long-term PPI use. Anti-reflux surgery is an option for patients with refractory symptoms or in those in whom medical therapy is contraindicated or not desirable. While conventional surgery has an acceptable safety profile, there has been an increasing interest in alternate treatments that may potentially offer similar results and be associated with a faster recovery. Recent advances in interventional endoluminal techniques have introduced novel incisionless anti-reflux procedures. While the current data are promising, further larger prospective studies are needed in order to assess the long-term efficacy of endoluminal therapies and its place among the treatment options for GERD.

Does carbon dioxide insufflation impact adenoma detection rate? A single-center retrospective analysis

Background and study aims: Carbon dioxide (CO2) has been associated with reduced post-procedural pain and improved patient satisfaction when compared to air insufflation (AI). The effect of CO2 insufflation (CO2I) on the adenoma detection rate (ADR) remains unclear. The aims of this study are to compare ADR in patients undergoing screening colonoscopy with AI vs. CO2I and identify predictors of ADR. Patients and methods: Single-center retrospective cohort study of 2,107 patients undergoing screening colonoscopy at the University of Florida Hospital between November 2011 and June 2015. Patient demographics, procedural parameters, and histology results were retrospectively obtained from a prospectively maintained colonoscopy database. Univariate and multivariate analysis were performed to identify predictors of ADR. Results: A total of 2107 colonoscopies (644 with AI and 1463 with CO2I) were analyzed. Overall ADR was 27.8 %. There was no significant difference in ADR between AI (27.6 %) vs. CO2I (27.8 %) (P = 0.93). Method of insufflation (AI vs. CO2I) was not significantly associated with ADR (OR 0.9; 95 % CI:0.7 – 1.2). Older age (OR: 1.02; 95 % CI: 1.001 – 1.03 per year increase), male gender (OR 1.48; 95 % CI: 1.17 – 1.87), and longer scope withdraw time (OR 1.13; 95 % CI: 1.1 – 1.16 per minute) were associated with a higher ADR. Fellow involvement was negatively associated with ADR (OR 0.60; 95 % CI: 0.47 – 0.77). Conclusion: ADR was similar between patients who underwent screening colonoscopy with AI vs. CO2I. While CO2I has been associated with improved patient comfort and post-procedural recovery time, there is no definitive evidence to suggest that this method of luminal distention enhances ADR.

Etiology and Pathogenesis of Hepatocellular Carcinoma

Throughout the world, hepatocellular carcinoma (HCC) ranks as the third leading cause of cancer-related deaths. This chapter summarizes the etiology and pathogenesis of HCC. There are various risk factors associated with HCC including viral hepatitis, cirrhosis (with any underlying etiology including nonalcoholic fatty liver disease (NAFLD)), and toxin-mediated disease. The two main hepatitis viruses associated with the development of HCC are hepatitis B virus (HBV) and hepatitis C virus (HCV). Virtually all cirrhosis-inducing conditions can increase the risk of HCC. There are other etiological factors that have been proposed to develop into HCC but at a much lower frequency. As we continue to further our understanding of human HCC and the mechanisms involved, the field will gain a solid foundation that can help to refine animal models and truly comprehend the entire range of human disease.

Adherence to quality indicators and surveillance guidelines in the management of Barrett’s esophagus: a retrospective analysis

Background  Adherence to quality indicators and surveillance guidelines in the management of Barrett’s esophagus (BE) promotes high-quality, cost-effective care. The aims of this study were (1) to evaluate adherence to standardized classification (Prague Criteria) and systematic (four-quadrant) biopsy protocol, (2) to identify predictors of practice patterns, and (3) to assess adherence to surveillance guidelines for non-dysplastic BE (NDBE). Methods  This was a single-center retrospective study of esophagogastroduodenoscopy (EGD) performed for BE (June 2008 to December 2015). Patient demographics, procedure characteristics, and histology results were obtained from the procedure report-generating database and chart review. Adherence to Prague Criteria and systematic biopsies was based on operative report documentation. Multiple logistic regression analysis was performed to identify predictors of practice patterns. Guideline adherent surveillance EGD was defined as those performed within 6 months of the recommended 3- to 5-year interval. Results  In total, 397 patients (66.5 % male; mean age 60.1 ± 12.5 years) had an index EGD during the study period. Adherence to Prague Criteria and systematic biopsies was 27.4 % and 24.1 %, respectively. Endoscopists who performed therapeutic interventions for BE were more likely to use the Prague Criteria (OR: 3.16; 95 %CI: 1.47 – 6.82; P  < 0.01) than those who did not. Longer time in practice was positively associated with adherence to Prague Criteria (OR 1.07; 95 %CI: 1.02 – 1.12; P  < 0.01) but with a lower likelihood of performing systematic biopsies (OR 0.91; 95 %CI: 0.85 – 0.97; P  < 0.01). More than half (55.6 %) of patients with NDBE underwent surveillance EGD sooner (range 1 – 29 months) than the recommended interval. Conclusion  Adherence to quality indicators and surveillance guidelines in BE is low. Operator characteristics, including experience with endoscopic therapy for BE and time in practice predicted practice pattern. Future efforts are needed to reduce variability in practice and promote high-value care.

Carbon dioxide insufflation is associated with increased serrated polyp detection rate when compared to room air insufflation during screening colonoscopy

Background and study aims  Sessile serrated adenomas (SSA) and traditional serrated adenomas (TSA) have been increasingly recognized as precursors of colorectal cancer. The aim of this study was to compare the effect of carbon dioxide insufflation (CO 2 I) vs. room air insufflation (AI) on serrated polyp detection rate (SPDR) and to identify factors associated with SPDR. Patients and methods  Single-center retrospective cohort study of 2083 screening colonoscopies performed with AI (November 2011 through January 2013) or CO 2 I (February 2013 to June 2015). Data on demographics, procedure characteristics and histology results were obtained from a prospectively maintained endoscopy database and chart review. SPDR was defined as proportion of colonoscopies in which ≥ 1 SSA, TSA or hyperplastic polyp (HP) ≥ 10 mm in the right colon was detected. Multi-variate analysis (MVA) was performed to identify predictors of SPDR. Results  A total of 131 histologically confirmed serrated polyps (129 SSA, 2 TSA and 0 HP ≥ 10 mm) were detected. SPDR was higher with CO 2 I vs. AI (4.8 % vs. 1.4 %; P  < 0.0001). On MVA, CO 2 I was associated with higher SPDR when compared to AI (OR: 9.52; 95 % CI: 3.05 – 30.3). Both higher body mass index (OR 1.05; 95 % CI:1.02 – 1.09) and longer colonoscope withdrawal time (OR 1.11; 95 % CI: 1.07 – 1.16) were also associated with higher SPDR. Conclusion  CO 2 I is associated with higher SPDR when compared to AI during screening colonoscopy. While the mechanism remains unknown, we speculate that the favorable gas characteristics of CO 2 compared to room air results in improved polyp detection by optimizing bowel insufflation. These findings suggest an additional reason to prefer the use of CO 2 I over AI during colonoscopy.

Survey study on the practice patterns in the endoscopic management of malignant distal biliary obstruction

Background and study aim  Endoscopic biliary drainage for malignant distal biliary obstruction (MDBO) is a common practice. Controversy persists with regard to its role in resectable MDBO, the optimal technical method and type of stent. The aim of this study was to evaluate practice patterns in the treatment of MDBO among endoscopists with varying levels of experience and practice backgrounds. Methods  Electronic survey distributed to members of the American Society for Gastrointestinal Endoscopy (ASGE). The main outcome measures included practice setting (academic vs. community), volume of endoscopic retrograde cholangiopancreatographies (ERCPs), reasons for endoscopic drainage in MDBO, and technical approach. Results  A total of 335 subjects (54 % community-based endoscopists) completed the survey. Most academic physicians (69 %) reported performing ≥ 150 ERCPs annually compared to 18.8 % of community physicians ( P  < 0.001). In aggregate, 13.1 % of respondents performed ERCP in resectable MDBO because of surgeon preference or as the standard of care at their institution. The use of metal vs. plastic stents in MDBO varied based on practice setting. Routine sphincterotomy for MDBO was more common among community (78 %) vs academic endoscopists (61.1 %) ( P  < 0.001). Over half (58 %) of the subjects avoided covering the cystic duct take-off during stenting MDBO if there was a gallbladder in situ. Conclusion  There is significant variability in practice patterns for the treatment of MDBO. In spite of the recent ASGE guideline recommendations, some patients with resectable MDBO still undergo preoperative ERCP. Current clinical practices are not clearly supported by available data and underscore the need to increase adherence to gastrointestinal societal recommendations and an evidence-based approach to standardized patient care.

Lung Adenocarcinoma Presenting as Worsening of Chronic Neck Pain—A Cautionary Tale:

Introduction: Neck pain is a common musculoskeletal problem that up to 70% of the world population will experience at some point in their lives. Intramedullary spinal cord metastasis is an exceedingly rare complication of malignancy that affects less than 1% of all patients with cancer. Case report: We report a case of a 61-year-old man who presented to primary care clinic with 1-month history of worsening neck pain with associated neurologic deficits. Despite initial conservative management, the patient continued to have progressive worsening of sensory and motor deficits. Magnetic resonance imaging of the cervical spine showed vasogenic edema of the brain and spinal cord and nodularity at the C4-C5 level. A computed tomography of the chest showed a dense lesion in the left lower lobe of the lung; histopathology of the biopsied specimen was consistent with moderately differentiated lung adenocarcinoma. Conclusions: A high index of suspicion is necessary when chronic neck pain acutely worsens, changes in character, or is accompanied by neurologic deficits. These clinical signs warrant further investigation into a secondary cause of neck pain. Intramedullary spinal cord metastases are rare complications of systemic cancer that commonly present with neck pain and upper extremity paraesthesias; early diagnosis and management are necessary to prevent complications such as spinal cord hemisection syndrome or spinal cord transection.

Intractable Fasting Hypoglycemia as a Manifestation of Hepatocellular Carcinoma

Non-islet cell tumor hypoglycemia (NICTH) is a rare and serious paraneoplastic complication of both malignant and benign tumors to consider when evaluating fasting hypoglycemia, especially in the setting of liver diseases. We present a case of NICTH in a 54-year-old male with hepatocellular carcinoma (HCC) who presented with symptomatic intractable hypoglycemia (IH) after bowel preparation and fasting for screening upper endoscopy and colonoscopy.

Shortness of breath: Patient history not always indicative of the cause

This is a 78 year old male with a past medical history of coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), hypertension (HTN), and gastroesophageal reflux disorder (GERD) who presented to the emergency room with worsening shortness of breath (SOB) and low-grade fevers for one week prior to admission. He was originally diagnosed with healthcare associated pneumonia (HCAP) and an acute on chronic COPD exacerbation and treated with prednisone, inhalers, ipratropium/albuterol, and broad-spectrum antibiotics. His symptoms were slow to respond to therapy and he continued to have end-expiratory wheezes with persistent SOB. A CT of his chest was ordered to rule out a possible pulmonary embolus (PE) and instead showed an obstructing mass in the bronchus. Pulmonology was consulted and performed a bronchoscopy, which revealed a foreign body (bean) causing the obstruction, which was removed, and the patient’s symptoms improved shortly thereafter.

Endoscopic Tattooing: From Blue to Black

CASE REPORT A 66-year-old female underwent a colonoscopy for evaluation of diarrhea. Two polyps were seen (10 mm and 20 mm) in the ascending colon. Due to poor preparation in the right colon, a polypectomy was not pursued. Because the lesions were hard to identify, 2 tattoos were placed 3 cm distal to each polyp. It was discovered that instead of Endomark (PMT Corporation, Chanhassen, MN), undiluted methylene blue was injected in the submucosa (Figure 1). Eight days later a repeat colonoscopy was performed to attempt polypectomy. Two deep, necrotic, exudate-covered ulcers were at the site of the tattoos, each measuring about 20 mm (Figure 2). No bleeding was present. The polyps were successfully removed with saline injection snare