Search

Patients with poorly controlled eosinophilic esophagitis (EoE) may require unplanned emergency department (ED) visits for the management of dysphagia or food impactions. We evaluated the epidemiologic burden of EoE on ED utilization in the United States. Data from the US Nationwide Emergency Department Sample were used to estimate weighted annual EoE-associated ED visits from 2009 to 2019. Temporal trends in population-adjusted rates of EoE visits were assessed using joinpoint regression. Autoregressive integrated moving average models were used to project EoE-associated ED visits to 2030. We also evaluated endoscopic utilization, requirement for hospitalization, and ED-related charges in patients with EoE presenting to the ED. A total of 11,125 unweighted (49,507 weighted) ED visits for EoE were included (69.0% male; mean age, 32.4 y). The annual volume of EoE-associated ED visits increased from 2934 (95% CI, 2437–3431) in 2009 to 8765 (95% CI, 7514–10,015) in 2019, and is projected to reach 15,445 (95% prediction interval, 14,672–16,218) by 2030. From 2009 to 2019, the number of EoE-associated ED visits increased by an average of 11.5% per year (95% CI, 10.3%–12.7%). The proportion of patients admitted to the hospital from the ED decreased from 25.6% in 2009 to 2011 to 14.0% in 2017 to 2019. Half of EoE patients presenting to the ED required an endoscopy, and nearly 40% required an esophageal foreign body removal. Total mean inflation-adjusted charges for an EoE-associated ED visit were $9025 US dollars in 2019. The volume of EoE-associated ED visits tripled between 2009 and 2019 and is projected to further double by 2030. This represents a substantial burden of unanticipated health care resource utilization and highlights a potential opportunity to optimize outpatient EoE care. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: Capsule endoscopy is a noninvasive method for examining the small intestine. Recently, this method has been used to visualize the colon. However, the capsule often tumbles in the wider colon lumen, resulting in potentially missed pathology. In addition, the capsule does not have the ability to distend collapsed segments of the organ. Self-stabilizing capsule endoscopy is a new method of visualizing the colon without tumbling and with the ability to passively distend colon walls. Objective: To quantitatively compare the detection rate of intraluminal suture marker lesions for colonoscopy by using a custom-modified, self-stabilizing capsule endoscope (SCE); an unmodified capsule endoscope (CE) of the same brand; and a standard colonoscope. Design: Four mongrel dogs underwent laparotomy and the implantation of 5 to 8 suture markers to approximate colon lesions. Each dog had both capsule endoscopy and self-stabilizing capsule endoscopy, administered consecutively in random order. In each case, the capsule was inserted endoscopically into the proximal lumen of the colon followed by pharmacologically induced colon peristalsis to propel it distally through the colon. Blinded standard colonoscopy was performed by an experienced gastroenterologist after the capsule endoscopies. Setting: Experimental study in a live canine model. Subjects: Four dogs. Intervention: Laparotomy, capsule endoscopy, colonoscopy. Main Outcome Measurements: Comparison of the marker detection rate of the SCE to that of the unmodified MiroCam CE and a colonoscope. Results: The average percentages of the marker detection rate for unmodified capsule endoscopy, self-stabilizing capsule endoscopy, and colonoscopy, respectively, were 31.1%, 86%, and 100% (P < .01), with both self-stabilizing capsule endoscopy and colonoscopy performing significantly better than the unmodified capsule endoscopy. Limitations: Acute canine model, suture markings poorly representative of epithelial polyps, limited number of animals. Conclusion: The proposed self-stabilizing capsule endoscope delivered a significant improvement in detection rates of colon suture markings when compared with the unmodified capsule endoscope. [Copyright &y& Elsevier]

Abstract: Gut motility and visceral sensation are two important components of normal gastrointestinal (GI) tract function. Disordered gut motility and sensation can cause significant symptoms which not only pose a health burden to patients, but may also mimic structural diseases and may generate many surgical referrals from primary care. Unfortunately, diagnostic testing for disorders of function lags well behind that for structural disease. In this article we review common presentations of functional disorders in surgical clinics, and relevant testing modalities. [Copyright &y& Elsevier]

Background: GI neuromuscular diseases (GINMD) can cause severe dysmotility and symptoms. Full-thickness biopsy specimens may help diagnose these disorders histologically. Objective: To assess a novel percutaneous endoscopically assisted transenteric (PEATE) biopsy method for obtaining full-thickness gastric tissue in patients with suspected GINMD. Design: Prospective proof-of-concept case series. Setting: Tertiary care gastroenterology unit. Patients: Ten patients (8 women, mean [standard deviation] age 43 [10] years) with gastroparesis-like symptoms (mean [standard deviation] gastroparesis cardinal symptom index 3.28 [1.46] out of 5) and/or clinical findings suggestive of a gastric GINMD. Interventions: All patients underwent PEATE biopsy during standard gastroscopy as an outpatient procedure. Tissue was stained for histology and immunohistochemistry of gut wall elements. Interstitial cells of Cajal (ICC) counts were compared with archived normal gastric tissue from control gastrectomies. Main Outcome Measurements: Biopsy success, complications, histopathological findings according to the London Classification of GINMD. Results: Full-thickness antral tissue suitable for analysis was obtained in 9 in 10 patients (90%). PEATE biopsy was well tolerated by all patients without complications. Histology suggested GINMD in 4 of 9 cases (44%), with possible degenerative leiomyopathy in 2, probable inflammatory leiomyopathy in 1, and abnormal ICC networks (>50% reduction in ICC counts) in 1 patient. Limitations: PEATE biopsy specimen size is smaller than a standard laparoscopic full-thickness biopsy. Conclusions: PEATE full-thickness gastric biopsy is a simple and safe method of assessing histopathological abnormalities in gastric GINMD without the need for laparoscopy or general anesthesia. [Copyright &y& Elsevier]

Background: Pathologic changes of the enteric nervous system of the stomach have been described in gastroparesis. Because the enteric nervous system lies within the myenteric plexus between the muscle layers of the stomach, it is not accessible by standard biopsy forceps. Thus, tissue must be obtained by laparoscopy or laparotomy. Obtaining full-thickness biopsies with a less-invasive method would be an ideal alternative. Objective: To assess the safety and feasibility of a novel method of gastric, full-thickness biopsy by using a percutaneous, endoscopically assisted, transenteric approach. Design: Experimental pilot study in 3 dogs, approved by the animal care committee. Intervention: Under general anesthesia, dogs underwent gastroscopy, and a suitable biopsy area was chosen, based on indentation of the anterior stomach wall by external finger pressure on the abdominal skin and by endoscope transillumination. Using sterile technique, we made a 3-mm incision through the abdominal skin, and a spring-loaded, 14-gauge biopsy needle was used to take 4 separate antral biopsies from each dog, with no mucosal or abdominal closure intervention. Main Outcome Measurements: Feasibility of obtaining enteric nervous system tissue; morbidity and mortality at 4 weeks; gross pathology at necropsy. Results: The procedure was well tolerated by the dogs, with no morbidity or mortality at any time, up to 4 weeks after the procedure. Adequate tissue specimens were obtained for histologic analysis of all layers of the stomach, including enteric nervous system elements. Limitations: Biopsy size was smaller than a surgical biopsy size. Conclusion: The percutaneous, endoscopically assisted, transenteric approach, full-thickness biopsy technique is safe and obtains enteric nervous tissue in a simple, minimally invasive manner. [Copyright &y& Elsevier]

Background & Aims: Irritable bowel syndrome (IBS) has been associated with mucosal dysfunction, mild inflammation, and altered colonic bacteria. We used microarray expression profiling of sigmoid colon mucosa to assess whether there are stably expressed sets of genes that suggest there are objective molecular biomarkers associated with IBS. Methods: Gene expression profiling was performed using Human Genome U133 Plus 2.0 (Affymetrix) GeneChips with RNA from sigmoid colon mucosal biopsy specimens from 36 IBS patients and 25 healthy control subjects. Real-time quantitative polymerase chain reaction was used to confirm the data in 12 genes of interest. Statistical methods for microarray data were applied to search for differentially expressed genes, and to assess the stability of molecular signatures in IBS patients. Results: Mucosal gene expression profiles were consistent across different sites within the sigmoid colon and were stable on repeat biopsy over approximately 3 months. Differentially expressed genes suggest functional alterations of several components of the host mucosal immune response to microbial pathogens. The most strikingly increased expression involved a yet uncharacterized gene, DKFZP564O0823. Identified specific genes suggest the hypothesis that molecular signatures may enable distinction of a subset of IBS patients from healthy controls. By using 75% of the biopsy specimens as a validation set to develop a gene profile, the test set (25%) was predicted correctly with approximately 70% accuracy. Conclusions: Mucosal gene expression analysis shows there are relatively stable alterations in colonic mucosal immunity in IBS. These molecular alterations provide the basis to test the hypothesis that objective biomarkers may be identified in IBS and enhance understanding of the disease. [Copyright &y& Elsevier]

Background & Aims: The pathophysiology of irritable bowel syndrome (IBS) remains enigmatic; abnormalities in serotonin metabolism have been implicated. Two proteins that influence the function of serotonin and serotonergic receptors are serotonin transporter protein (SERT or soluble carrier protein, SLC6A4) and p11 (S-100A10, or calpactin I light chain). Both proteins are reported to be associated with depression-like states, a frequent comorbid condition in IBS. We explored the hypothesis that expression of these 2 proteins in colonic and rectal mucosa is abnormal in patients with IBS as compared with healthy controls. Methods: Messenger RNA (mRNA) expression of SLC6A4 and p11 was measured in sigmoid and rectal mucosal biopsy specimens. Genotype of the promoter for SLC6A4 was also assessed in all participants. Validation studies explored reproducibility of 2 biopsy specimens taken from the same region and biopsy specimens taken an average of ∼3 months apart. Results: We found normal colonic mucosal expression of SLC6A4 in diarrhea (IBS-D)- or constipation-predominant IBS (IBS-C). On the other hand, p11 expression was increased in IBS. No significant effect on p11 mRNA expression in sigmoid colon or rectum was noted from antidepressant treatment in any of the analyzed subgroups. Conclusions: Colonic mucosal expression of SLC6A4 in IBS is normal. Given that overexpression of p11 can increase serotonergic receptor functions (eg, 5-HT1B receptors), these data support the need for further study of the interaction between p11 expression in health and disease and its role in the therapeutic response to serotonergic agents, including antidepressants. [Copyright &y& Elsevier]

Functional bowel disorders (FBDs) are the most common gastrointestinal problems managed by physicians. We aimed to assess the burden of chronic symptomatic FBDs on ambulatory care delivery in the United States and evaluate patterns of treatment. Data from the National Ambulatory Medical Care Survey were used to estimate annual rates and associated costs of ambulatory visits for symptomatic irritable bowel syndrome, chronic functional abdominal pain, constipation, or diarrhea. The weighted proportion of visits associated with pharmacologic and nonpharmacologic (stress/mental health, exercise, diet counseling) interventions were calculated, and predictors of treatment strategy were evaluated in multivariable multinomial logistic regression. From 2007–2015, approximately 36.9 million (95% CI, 31.4–42.4) weighted visits in patients of non-federally employed physicians for chronic symptomatic FBDs were sampled. There was an annual weighted average of 2.7 million (95% CI, 2.3–3.2) visits for symptomatic irritable bowel syndrome/chronic abdominal pain, 1.0 million (95% CI, 0.8–1.2) visits for chronic constipation, and 0.7 million (95% CI, 0.5–0.8) visits for chronic diarrhea. Pharmacologic therapies were prescribed in 49.7% (95% CI, 44.7–54.8) of visits compared to nonpharmacologic interventions in 19.8% (95% CI, 16.0–24.2) of visits (P <.001). Combination treatment strategies were more likely to be implemented by primary care physicians and in patients with depression or obesity. The direct annual cost of ambulatory clinic visits alone for chronic symptomatic FBDs is approximately US$358 million (95% CI, 233–482 million). The management of chronic symptomatic FBDs is associated with considerable health care resource use and cost. There may be an opportunity to improve comprehensive FBD management because fewer than 1 in 5 ambulatory visits include nonpharmacologic treatment strategies. [ABSTRACT FROM AUTHOR]