Impact of sedation type on adenoma detection rate by colonoscopy

BACKGROUND & AIMS

Endoscopic detection of polyps and adenomas decreases the incidence and mortality of colorectal cancer. The available data concerning the relationship between the sedation type and adenoma detection rate (ADR) or polyp detection rate (PDR) is inconclusive. The aim of our study was to evaluate the impact of conscious vs. deep (propofol) sedation on the ADR/PDR in diagnostic and screening colonoscopies.

METHODS

This was a retrospective cohort study. Patients aged 50-75 years old presenting for a first screening or diagnostic colonoscopy were included. Baseline demographic characteristics were collected, as well as PDR and ADR. Endoscopic withdrawal time and quality of bowel preparation rated in a binary fashion were also collected. Two multivariate logistic regression models were used to evaluate the independent predictors of endoscopic detection of polyps and adenomas.

RESULTS

574 patients met our inclusion criteria. Mean age was 59.26 ± 7.21 with 52.4% females and an average BMI of 28.08 ± 4.89. 374 patients (65.2%) underwent screening colonoscopies, and deep sedation was performed in 200 patients (34.8%). Only 4.7% had bad bowel preparation. PDR was 70% and ADR was 52%. On bivariate analysis, no significant difference was shown in PDR and ADR between conscious and deep sedation groups (0.70, 0.71; p = 0.712 and 0.50, 0.54; p = 0.394, respectively). On multivariate analysis for PDR, age and withdrawal time were independent predictors. For ADR, age, female sex, and withdrawal time were independent predictors. Sedation type and the indication did not reach statistical significance in both models.

CONCLUSION

The use of deep sedation didn't influence the ADR/PDR quality metrics in our mixed cohort of screening and diagnostic colonoscopies.

Validation of the new ABC score for predicting 30-day mortality in gastrointestinal bleeding

BACKGROUND/AIM

The ABC score is a new pre-endoscopic scoring system that was recently developed to accurately predict one-month mortality in upper and lower gastrointestinal bleeding (GIB). We aim to validate this new score on a cohort of Lebanese patients treated in a tertiary care center and to compare it to currently existing scores.

METHODS

Adult patients admitted to the American University of Beirut Medical Center (AUBMC) with overt GIB between January 2013 and August 2020 were included. The area under receiver operating characteristic (AUROC) curves of the ABC score in predicting 30-day mortality was calculated using the SPSS software. Other optimal existing scores for predicting mortality (the Oakland score for lower GIB, the AIMS-65 and the Rockall scores for upper GIB)s were also assessed and compared to the ABC score.

RESULTS

A total of 310 patients were included in our study. For upper GIB, the ABC score showed good performance in predicting 30-day mortality (AUROC: 0.79), outperforming both the AIMS-65 score (AUROC 0.67, p < 0.001) and the Rockall score (AUROC: 0.62, p < 0.001). For lower GIB, the ABC score also had good performance which was comparable to the Oakland score (AUROC: 0.70 vs 0.56, p = 0.26).

CONCLUSION

In our cohort of patients, the ABC score demonstrated good performance in predicting 30-day mortality for patients with upper and lower GIB compared to other established risk scores, which may help guide management decisions. This simple and novel score provides valuable prognostic information for patients presenting with GIB and appears to be reproducible in different patient populations.

The burden of Hepatitis E virus in the Middle East and North Africa region: a systematic review

INTRODUCTION

Hepatitis E virus is a leading cause of hepatitis in the Middle East and North Africa region. Although several countries in this area were shown to be endemic for hepatitis E, little is known about the epidemiology and possible preventive measures. In this manuscript, we present the results of a systematic review addressing the seroprevalence of hepatitis E antibodies in the Middle East and North Africa region. Subsequently, we discuss the main prevention strategies for this virus.

METHODOLOGY

We performed a literature review using the PubMed Database of all the Studies reporting data on hepatitis E seroprevalence (Anti-hepatitis E IgM and IgG) among the 20 countries of the Middle East and North Africa region from January 2000 to July 2021.

RESULTS

Eighty-nine articles were identified and included in our review. Ten of the MENA countries did not have any study that fits our criteria. Egypt and Iran were the countries with the highest IgG seroprevalence for hepatitis E reaching 85.1% and 68.6% respectively. Concerning acute hepatitis E presentations, Iraq and Egypt were shown to have the highest IgM seroprevalence reaching 38.1% and 35.3% respectively. Hemodialysis and poly-transfused patients as well as patients with concomitant hepatotropic viruses' infections were reported to have a higher seroprevalence than the general population.

CONCLUSIONS

Hepatitis E is a major healthcare problem in the endemic Middle East and North Africa region. Even though no definite prevention strategy was described until today, implementing multiple minor precautionary approaches could help reduce the virus spread.

Pancreatic cancer in the MENA region, a bibliometric review

Background

Methods

Results

Conclusion

Intragastric balloon treatment of obesity: Long-term results and patient satisfaction

BACKGROUND/AIMS

Intragastric balloon (IGB) treatment of obesity is a minimally invasive outpatient procedure that has been shown to help weight loss in some patients. The aim of this study is to analyze the long-term results regarding the effectiveness, tolerability, and patient satisfaction in a cohort of patients undergoing the IGB insertion.

MATERIALS AND METHODS

Using a retrospective cohort study design, patients who had their IGB inserted/removed between the years 2009 and 2016 were contacted by phone and asked to answer a short questionnaire. The baseline characteristics, pre- and post- IGB weight, as well as their current weight were recorded. Different parameters of satisfaction were noted in addition to whether patients resorted to alternative weight-reduction measures.

RESULTS

Ninety-nine eligible patients were contacted, and 65 consented to the study. The average weight loss achieved at the end of the treatment period (3 to 10 months) was approximately a 12% decrease from the baseline. Only 39% of patients were satisfied with the procedure, and less than 50% were satisfied with the weight loss achieved. When assessing the long-term follow-up, years after the IGB removal (3.3±1.76 years), the vast majority of patients (78.7%) regained weight or resorted to further bariatric measures.

CONCLUSION

IGB leads to weight loss among most patients, but it does not appear to fulfill patients' expectations. Further, the initial weight loss is not sustainable over time.

Prevalence of gastroesophageal reflux and risk factors for erosive esophagitis in obese patients considered for bariatric surgery

BACKGROUND

Gastroesophageal reflux disease (GERD) is common in obese individuals. Prospective studies investigating validated GERD questionnaires and clinical parameters at identifying erosive esophagitis (EE) in this population are limited.

OBJECTIVE

To prospectively evaluate the prevalence of GERD in obese patients considered for bariatric surgery and identify risk and predictive factors for EE.

METHODS

Eligible patients completed two validated questionnaires: GERDQ and Nocturnal Symptom Severity Impact (N-GSSIQ) before routine esophagogastroduodenoscopy.

RESULTS

242 consecutive patients were enrolled (130 females; mean age 37.8 ± 11.8 years; mean BMI 40.4 ± 5.3 kg/m²). The overall prevalence of gastroesophageal reflux (GERDQ ≥ 8, EE and/or PPI use) was 62.4%. EE was identified in 82 patients (33.9%) including 13/62 (21.0%) receiving PPIs at baseline. Multivariate logistic regression identified GERDQ ≥ 8 (OR = 6.3, 95%CI 3.0-13.1), hiatal hernia (OR = 4.2, 95%CI 1.6-10.7), abnormal Hill grade (OR = 2.7, 95%CI 1.4-5.4), and tobacco use (OR = 2.5, 95%CI 1.2-4.9) as independent risk factors for EE. A pre-endoscopic composite assessment including GERDQ ≥ 8 and presence of severe nocturnal reflux symptoms had 90% specificity and 20.7% sensitivity in identifying EE (NPV 68.9% and PPV 51.5%).

CONCLUSION

GERD is highly prevalent in obese patients. Anthropometric data and GERD questionnaires have limited accuracy at predicting erosive disease. Pre-operative endoscopic assessment in this population appears warranted.

Site specific diagnostic yield of endoscopic biopsies in Gastrointestinal Graft-versus-Host Disease: A tertiary care Center experience

BACKGROUND

Gastrointestinal (GI) graft versus host disease (GVHD) occurs in up to 40% of patients undergoing allogenic hematopoietic stem cell transplantation (HSCT). However, the optimal endoscopic approach is still unclear and the area of the GI tract with the highest diagnostic yield is still a topic of debate.

OBJECTIVE

We compared the diagnostic yield of different anatomic site biopsies in the diagnosis of GI GVHD and assessed the correlation of endoscopic findings with histopathology.

METHODS

All cases of biopsy proven GI GVHD were obtained from pathology database AUBMC between 1/1/2005 and 31/8/2017. We retrospectively analyzed the demographical, clinical and endoscopic data.

RESULTS

Nineteen patients were diagnosed with GI GVHD over 17.6 years. The most common presenting symptom was severe diarrhea (18 patients, 94.7%). Combining upper endoscopy and sigmoidoscopy with biopsies had the highest diagnostic yield of 90% in diagnosing GI GVHD compared to 63.6%, 78.6% and 77.8% for upper endoscopy, sigmoidoscopy and colonoscopy respectively. In macroscopically normal mucosa, the recto-sigmoid and duodenal biopsies had the highest diagnostic yield (75%). As for the macroscopically abnormal mucosa, the highest yield was for the recto-sigmoid biopsies (100%) in lower endoscopy and duodenal biopsies in the upper endoscopy (60%).

CONCLUSION

In a patient suspected to have GI GVHD, the best endoscopic approach is the combination of upper endoscopy and flexible sigmoidoscopy with biopsies of normal as well as abnormal mucosa. It should be emphasized that normal mucosa be biopsied especially in the duodenum and recto-sigmoid for a better diagnostic yield.

The Prevalence of Helicobacter pylori Remains High in African American and Hispanic Veterans

BACKGROUND

Helicobacter pylori in the United States has been declining in the 1990s albeit less so among blacks and Hispanics. As the socioeconomic status of racial groups has evolved, it remains unclear whether the prevalence or the racial and ethnic disparities in the prevalence of H. pylori have changed.

METHODS

This is a cross-sectional study from a Veteran Affairs center among patients aged 40-80 years old who underwent a study esophagogastroduodenoscopy with gastric biopsies, which were cultured for H. pylori irrespective of findings on histopathology. Positive H. pylori was defined as positive culture or histopathology (stained organism combined with active gastritis). We calculated age-, race-, and birth cohort-specific H. pylori prevalence rates and examined predictors of H. pylori infection in logistic regression models.

RESULTS

We analyzed data on 1200 patients; most (92.8%) were men and non-Hispanic white (59.9%) or black (28.9%). H. pylori was positive in 347 (28.9%) and was highest among black males aged 50-59 (53.3%; 44.0-62.4%), followed by Hispanic males aged 60-69 (48.1%; 34.2-62.2%), and lowest in non-Hispanic white males aged 40-49 (8.2%; 2.7-20.5%). In multivariate analysis, age group 50-59 was significantly associated with H. pylori (adjusted odds ratio (OR), 2.32; 95% confidence interval (CI), 1.21-4.45) compared with those aged 40-49, and with black race (adjusted OR, 2.57; 95% CI, 1.83-3.60) and Hispanic ethnicity (adjusted OR, 3.01; 95% CI, 1.70-5.34) compared with non-Hispanic white. Irrespective of age group, patients born during 1960-1969 had a lower risk of H. pylori (adjusted OR, 0.45; 95% CI, 0.22-0.96) compared to those born in 1930-1939. Those with some college education were less likely to have H. pylori compared to those with no college education (adjusted OR 0.51; 95% CI, 0.37-0.69).

CONCLUSION

Among veterans, the prevalence of active H. pylori remains high (28.9%) with even higher rates in blacks and Hispanics with lower education levels.

Visceral abdominal obesity measured by CT scan is associated with an increased risk of Barrett's oesophagus: a case-control study

OBJECTIVE

Abdominal obesity has been associated with increased risk of Barrett's oesophagus (BE) but the underlying mechanism is unclear. We examined the association between visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) and the risk of BE.

DESIGN

A case-control study among eligible patients scheduled for elective oesophagastroduodenoscopy (EGD) and in a sample of patients eligible for screening colonoscopy recruited at the primary care clinic. All cases with definitive BE and a random sample of controls without BE were invited to undergo standardised mid-abdomen non-contrast computerised axial tomography images, which were analysed by semiautomated image segmentation software. The effect of VAT and SAT surface areas and their ratio (VAT to SAT) on BE were analysed in logistic regression models.

RESULTS

A total of 173 BE cases, 343 colonoscopy controls and 172 endoscopy controls underwent study EGD and CT scan. Participants with BE were more than twice as likely to be in the highest tertile of VAT to SAT ratio (OR: 2.42 (1.51 to 3.88) and adjusted OR 1.47 (0.88 to 2.45)) than colonoscopy controls, especially for those long (≥3 cm) segment BE (3.42 (1.67 to 7.01) and adjusted OR 1.93 (0.92 to 4.09)) and for white men (adjusted OR 2.12 (1.15 to 3.90)). Adjustment for gastroesophageal reflux disease (GERD) symptoms and proton pump inhibitors (PPI) use attenuated this association, but there was a significant increase in BE risk even in the absence of GERD or PPI use.

CONCLUSIONS

Large amount of visceral abdominal fat relative to subcutaneous fat is associated with a significant increase in the risk of BE. GERD may mediate some but not all of this association.

Treatment of chronic radiation proctitis with cryoablation

BACKGROUND

Chronic radiation proctitis (CRP) is a common problem in patients receiving pelvic radiation. Current therapies have the potential for deep tissue injury with ulcerations, perforation, and fistula formation. Cryospray ablation therapy offers superficial ablation of mucosa and is a potential method to endoscopically treat CRP safely and effectively.

OBJECTIVE

To determine tolerability of and response to cryotherapy in patients with radiation proctitis.

DESIGN

Prospective case-series pilot study.

SETTING

Baylor College of Medicine, Michael E. DeBakey Medical Center, Houston, Texas.

PATIENTS

Ten patients were prospectively recruited with chronic hemorrhagic radiation proctitis.

INTERVENTIONS

Endoscopic cryoablation of CRP.

MAIN OUTCOME MEASUREMENTS

Symptom severity of CRP was obtained by using the Radiation Proctitis Severity Assessment Scale (RPSAS). Endoscopic assessment was obtained using the rectal telangiectasia density grade. The primary endpoint of the study was endoscopic improvement of CRP based on the change in rectal telangiectasia density at 3-month follow-up. Secondary endpoints included symptomatic improvement based on RPSAS and adverse events at 3 months.

RESULTS

Ten patients with hemorrhagic radiation proctitis were treated with endoscopic cryoablation. Endoscopic severity improved as measured by rectal telangiectasia density from 2.7 to 1.7 (P=.004). Overall subjective clinical scores improved as determined by the Radiation Proctitis Severity Assessment Scale from 27.7 to 13.6 (P=.003). Endoscopic improvement correlated with symptom improvement.

LIMITATIONS

Nonpowered case series pilot study.

CONCLUSIONS

Cryoablation improved clinical and endoscopic indices in CRP. Further controlled studies are needed to identify the safety and efficacy of cryoablation for CRP.

The impact of curative intent surgery on the survival of pancreatic cancer patients: a U.S. Population-based study

OBJECTIVES

Pancreatic cancer is the fourth leading cause of cancer death in the United States. Curative intent surgery (CIS) is presumed to be the only curative option in the treatment of pancreatic cancer. The determinants and the outcomes of surgical resection are not clear at the population level.

METHODS

Using data from nine registries of the Surveillance Epidemiology and End Results (SEER) program, we examined the predictors of receiving CIS as well as the survival of patients receiving CIS between 1987 and 2001. The definition of CIS in SEER is accurate and has been previously validated and found to be highly accurate. Cox proportional hazard model was used to examine the effect of potential determinants on survival.

RESULTS

We identified 32,348 cases of pancreatic cancer. Of those, 3,545 (10.9%) received CIS. The proportion of patients receiving CIS decreased significantly with age (P < 0.0001), was similar across all racial groups (10.8% in whites, 11.4% in blacks, 11.5% in Asians, and 11.2 % in Hispanics, P= 0.5), was slightly higher in men (11.3%vs 10.5%, P= 0.02), decreased with advanced disease stage (P < 0.0001), progressively increased over time (7.5% in 1987-89, 9.1% in 1990-92, 10.4% in 1993-95, 12.4% in 1996-98, and 13.4% in 1999-2001, P < 0.0001), and differed significantly across different SEER registries (9.7% in San Francisco, 11.8% in Connecticut, 12.5% in Detroit, 11.7% in Hawaii, 9.3% in Iowa, 10.05% in New Mexico, 9.5% in Seattle, 13.2% in Utah, 11.4% in Atlanta, P < 0.0001). In the multivariable logistic regression analysis, more recent time periods, younger age, early disease stage, and geographic location, but not race or gender, were independent predictors of receiving CIS. In the Cox survival analysis, younger age, early disease stage, more recent time period, geographic location, and receipt of CIS were independent predictors of improved survival and black race was an independent predictor of shorter survival.

CONCLUSIONS

Early stage disease, female gender, younger age, geographic location, and more recent time periods are predictors of receiving CIS. Early disease stage and receipt of CIS are the strongest predictors of improved survival among patients with pancreatic cancer. Black race is an independent predictor of shorter survival.

Diabetes increases the risk of hepatocellular carcinoma in the United States: a population based case control study

BACKGROUND

Diabetes has been associated with an increased risk of hepatocellular carcinoma (HCC) in studies of referred patients. This is the first population based case control study in the USA to examine this association while adjusting for other major risk factors related to HCC.

METHODS

We used the Surveillance Epidemiology and End-Results Program (SEER)-Medicare linked database to identify patients aged 65 years and older diagnosed with HCC and randomly selected non-cancer controls between 1994 and 1999. Only cases and controls with continuous Medicare enrollment for three years prior to the index date were examined. Inpatient and outpatient claims files were searched for diagnostic codes indicative of diabetes, hepatitis C virus (HCV), hepatitis B virus (HBV), alcoholic liver disease, and haemochromatosis. HCC patients without these conditions were categorised as idiopathic. Unadjusted and adjusted odds ratios were calculated in logistic regression analyses.

RESULTS

We identified 2061 HCC patients and 6183 non-cancer controls. Compared with non-cancer controls, patients with HCC were male (66% v 36%) and non-White (34% v 18%). The proportion of HCC patients with diabetes (43%) was significantly greater than non-cancer controls (19%). In multiple logistic regression analyses that adjusted for demographics features and other HCC risk factors (HCV, HBV, alcoholic liver disease, and haemochromatosis), diabetes was associated with a threefold increase in the risk of HCC. In a subset of patients without these major risk factors, the adjusted odds ratio for diabetes declined but remained significant (adjusted odds ratio 2.87 (95% confidence interval 2.49-3.30)). A significant positive interaction between HCV and diabetes was detected (p<0.0001). Similar findings persisted in analyses restricted to diabetes recorded between two and three years prior to HCC diagnosis.

CONCLUSIONS

Diabetes is associated with a 2-3-fold increase in the risk of HCC, regardless of the presence of other major HCC risk factors. Findings from this population based study suggest that diabetes is an independent risk factor for HCC.

The prevalence and risk factors of functional dyspepsia in a multiethnic population in the United States

BACKGROUND AND AIMS

The prevalence of functional dyspepsia (FD) in the general population is not known. The aim of this study is to measure the prevalence of FD and its risk factors in a multiethnic volunteer sample of the U.S. population.

METHODS

One thousand employees at the Houston VA Medical Center were targeted with a symptom questionnaire asking about upper abdominal symptoms, followed by a request to undergo endsocopy. Dyspepsia was defined by the presence of epigastric pain, fullness, nausea, or vomiting, and FD was defined as dyspepsia in the absence of esophageal erosions, gastric ulcers, or duodenal ulcers or erosions. The presence of dyspepsia and FD was examined in multiple logistic regression analyses.

RESULTS

A total of 465 employees completed the relevant questions and of those 203 had endoscopic examination. The age-adjusted prevalence rate of dyspepsia was 31.9 per 100 (95% CI: 26.7-37.1), and 15.8 per 100 (95% CI: 9.6-22.0) if participants with concomitant heartburn or acid regurgitation were excluded. Subjects with dyspepsia were more likely to report smoking, using antacids, aspirin or nonsteroidal antiinflammatory drugs (NSAIDs), and consulting a physician for their symptoms (p < 0.05) than participants without dyspepsia. Most (64.5%) participants with dyspepsia who underwent endoscopy had FD. The age-adjusted prevalence rate of FD was 29.2 per 100 (95% CI: 21.9-36.5), and 15.0 per 100 (6.7-23.3) if subjects with GERD were excluded. Apart from a trend towards association with older age in the multiple regression analysis, there were no significant predictors of FD among participants with dyspepsia.

CONCLUSIONS

Most subjects with dyspepsia have FD. The prevalence of FD is high but predictors of FD remain poorly defined.

Hepatitis C infection and the increasing incidence of hepatocellular carcinoma: a population-based study

BACKGROUND AND AIMS

A significant increase in the incidence of hepatocellular carcinoma (HCC) has been reported in the United States. The risk factors underlying this increase remain unclear.

METHODS

By using Surveillance, Epidemiology, and End-Results program (SEER)-Medicare-linked data, we conducted a population-based study to examine temporal changes in risk factors for patients 65 years and older diagnosed with HCC between 1993 and 1999. Only patients with continuous Medicare enrollment for 2 years before and up to 2 years after HCC diagnosis were examined. Univariate and multiple logistic regression analyses were used to evaluate changes in risk factors over time (January 1993-June 1996 and July 1996-December 1999).

RESULTS

The age-adjusted incidence of HCC among persons 65 years of age and older significantly increased from 14.2 per 100,000 in 1993 to 18.1 per 100,000 in 1999. We identified 2584 patients with continuous Medicare enrollment 2 years before and up to 2 years after HCC diagnosis. The proportion of hepatitis C virus (HCV)-related HCC increased from 11% during January of 1993 to June of 1996 to 21% during July of 1996 to December of 1999, whereas hepatitis B virus (HBV)-related HCC increased from 6% to 11% ( P < .0001). In multiple logistic regression analyses that adjusted for age, sex, race, and geographic region, the risk for HCV-related HCC and HBV-related HCC increased by 226% and 67%, respectively. Idiopathic HCC decreased from 43% to 39%. This decrease did not fully account for the significant increases observed for HCV and HBV. No significant changes over time were observed for alcohol-induced liver disease, nonspecific cirrhosis, or nonspecific hepatitis.

CONCLUSIONS

There has been a significant recent increase in HCV- and HBV-related HCC. Increasing rates of HCV-related HCC can explain a substantial proportion of the reported increase in HCC incidence during recent years.

The epidemiology of cholangiocarcinoma

The incidence rates of cholangiocarcinoma (CC) vary greatly among different areas of the world, and this variation is related to distribution of risk factors. Intrahepatic cholangiocarcinoma (ICC) and extrahepatic cholangiocarcinoma (ECC) have different epidemiological features. Recent data show that the incidence and mortality rates of ICC have been increasing in several areas around the world. On the other hand, the incidence and mortality rates of ECC have been decreasing. For example, in the United States, the age-adjusted incidence rates of ICC increased by 165% from 0.32 per 100,000 in 1975 to 1979 to 0.85 per 100,000 in 1995 to 1999, whereas ECC declined by 14%. In the meantime, there has been very little improvement in long-term survival, which remains dismal (3.5%). Men are affected 1.5 times more than women are, and Asians are affected almost 2 times more than whites and blacks. There are few well-established risk factors for CC, including primary sclerosing cholangitis, liver fluke infestations, hepatolithiasis, Thorotrast exposure, and choledochal cysts. None of these risk factors can explain the recent increasing trends of ICC in the United States. Some data, however, point to a potential role for chronic liver disease, hepatitis C, and probably hepatitis B infections in the development of ICC.