Eosinophilic Esophagitis and IgG4: Is There a Relationship?

Our knowledge of the pathophysiology of eosinophilic esophagitis is constantly evolving. There is significant association between eosinophilic esophagitis and atopy; however, multiple studies have refuted the role of IgE in its pathogenesis. Instead, new data have demonstrated an elevated IgG4 level in patients with eosinophilic esophagitis. We review the current understanding of eosinophilic esophagitis pathogenesis and highlight the increasing evidence for the role of IgG4.

Anticoagulation and antiplatelet management in gastrointestinal endoscopy: A review of current evidence

The role of endoscopic procedures, in both diagnostic and therapeutic purposes is continually expanding and evolving rapidly. In this context, endoscopists will encounter patients prescribed on anticoagulant and antiplatelet medications frequently. This poses an increased risk of intraprocedural and delayed gastrointestinal bleeding. Thus, there is now greater importance on optimal pre, peri and post-operative management of anticoagulant and/or antiplatelet therapy to minimise the risk of post-procedural bleeding, without increasing the risk of a thromboembolic event as a consequence of therapy interruption. Currently, there are position statements and guidelines from the major gastroenterology societies. These are available to assist endoscopists with an evidenced-based systematic approach to anticoagulant and/or antiplatelet management in endoscopic procedures, to ensure optimal patient safety. However, since the publication of these guidelines, there is emerging evidence not previously considered in the recommendations that may warrant changes to our current clinical practices. Most notably and divergent from current position statements, is a growing concern regarding the use of heparin bridging therapy during warfarin cessation and its associated risk of increased bleeding, suggestive that this practice should be avoided. In addition, there is emerging evidence that anticoagulant and/or antiplatelet therapy may be safe to be continued in cold snare polypectomy for small polyps (< 10 mm).

An effective diagnostic strategy for accurate detection of RhD variants including Asian DEL type in apparently RhD-negative blood donors in Korea

BACKGROUND AND OBJECTIVES

The purpose of this study was to provide an effective RHD genotyping strategy for the East Asian blood donors.

MATERIAL AND METHODS

RhD phenotyping, weak D testing and RhCE phenotyping were performed on 110 samples from members of the RhD-negative club, private organization composed of RhD-negative blood donors, in the GwangJu-Chonnam region of Korea. The RHD promoter, intron 4, and exons 7 and 10 were analysed by real-time PCR. Two nucleotide changes (c.1227 G>A, and c.1222 T>C) in exon 9 were analysed by sequencing.

RESULTS

Of 110 RhD-negative club members, 79 (71·8%) showed complete deletion of the RHD gene, 10 (9·1%) showed results consistent with RHD-CE-D hybrid, and 21 (19·1%) showed amplification of RHD promoter, intron 4, and exons 7 and 10. Of the latter group, 16 (14·5%) were in the DEL blood group including c.1227 G>A (N = 14) and c.1222 T>C (N = 2), 2 (1·8%) were weak D, 1(0·9%) was partial D, and 2 (1·8%) were undetermined. The RhD-negative phenotype samples consisted of 58 C-E-c+e+, 19 C-E+c+e+, 3 C-E+c+e-, 21 C+E-c+e-, 6 C+E-c+e+ and 3 C+E-c-e + . Notably, all 58 samples with the C-E-c+e+ phenotype were revealed to have complete deletion of the RHD gene. The C-E-c+e+ phenotype showed 100% positive predictive value for detecting D-negative cases.

CONCLUSIONS

RHD genotyping is not required in half of D-negative cases. We suggest here an effective RHD genotyping strategy for accurate detection of RhD variants in apparently RhD-negative blood donors in East Asia.

Long-term outcomes of direct percutaneous endoscopic jejunostomy: a 10-year cohort

STUDY AIM

To assess the clinical outcomes of patients who received direct percutaneous endoscopic jejunostomy (DPEJ) for enteral feeding.

MATERIALS AND METHODS

This is a 10-year cohort study in a single tertiary center. Main outcome measurements were technical success, and short- and long-term outcomes. DPEJ was attempted in 83 patients (51 men; 55 ± 2 years) for dysphagia (n = 35), gastroparesis with recurrent aspiration (n = 30), and levodopa drug infusion for severe Parkinson's disease (n = 18).

RESULTS

DPEJ was successful in 75 (90 %) patients. All technical failures were related to the inability to find adequate trans-illumination, and were not influenced by BMI, age, gender, or indication. Peri-operative (30-day) adverse events occurred in 11 (13 %) patients, including wound infection (3), leakage around the stoma (4), minor bleeding requiring no intervention (2), and aspiration (1). There was one case (1.2 %) of gastric perforation after PEJ insertion for levodopa drug infusion trial. This 60-year-old woman required an emergency laparotomy with nil complications, and levodopa drug infusion recommenced successfully. One case of intestinal perforation (1.2 %) occurred after jejunostomy tube replacement at 6 months of insertion, which was successfully managed with surgery. There were no peri-operative deaths. Adequate delivery of enteral feeding or Duodopa drug was achieved in 66/73 (90 %) patients, with evidence of weight gain or improvement in Parkinson's disease. Seven (8 %) continued to have clinical regurgitation but not aspiration. After a median follow-up of 84 months, 27 (33 %) patients died of their underlying diseases. Seven (8 %) had marked improvement in their underlying disease and had PEJ removed after 5 months (range 1 - 8 months).

LIMITATIONS

Single center study.

CONCLUSIONS

DPEJ is associated with a high technical success rate (90 %), a relatively low rate of peri-operative adverse events (13 %) and an improvement in long-term nutritional support in the majority of patients (90 %). DPEJ should be the procedure of choice to gain enteral access for feeding or drug delivery prior to considering surgery.

Clinical audit: recent practice in caring for patients with acute severe colitis compared with published guidelines--is there a problem?

BACKGROUND

Acute severe colitis (ASC) is a serious condition with possible outcomes of emergency colectomy and mortality. Validated guidelines exist to help avoid these.

AIMS

To examine local adherence to guidelines and identify (a) opportunities to improve care and (b) possible barriers to adherence.

METHODS

Retrospective, hospital-wide audit of all patients with ASC during a 2-year period (2009-2010) at a major metropolitan hospital. Cases were identified by an electronic search of all discharges with International Classification of Diseases-10 codes for colitis, colectomy, ulcerative colitis or Crohn disease.

RESULTS

Twenty-six patients had 30 ASC admissions (14 female). Most admissions were under gastroenterology (25), 4 (13%) were under general medicine and 1 was under general surgery. Only 8 patients' (26%) management (all under gastroenterology) included all major details: blood investigations, Clostridium difficile test, abdominal X-ray, colonic examination and venous thromboembolism prophylaxis. Only one patient had formal severity scoring on admission, and seven patients (24%) had descriptive severity recorded. On day 3, nine patients (30%) had some recorded severity assessment; however, no formal criteria were used. Four had colectomy, three during first admission and one on re-admission. Of these patients, three received cyclosporine prior to colectomy. The mean duration of admission was 10 days (standard deviation 10.54, range 1-61).

CONCLUSION

Opportunities to optimise care exist including formal severity assessments on days 1 and 3, better deep vein thrombosis/pulmonary embolism prophylaxis and prompt colonic examination. Admission under teams other than gastroenterology appeared to be a barrier to better care. Despite the low rate of ideal management, the colectomy rate was acceptably low at 20%.

A novel HLA-A*31 allele, A*31:57, identified by sequence-based typing

The novel allele A*31:57 allele showed a single nucleotide difference with A*31:01:02 at nt 235 G>C in exon 2.

A novel HLA-DRB1*12 allele, DRB1*12:16:02, identified by sequence-based typing

The novel allele DRB1*12:16:02 allele showed two single nucleotide differences with HLA-DRB1*12:16:01 at nucleotides 303 G>C and 321 C>T in exon 2.