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BACKGROUND: Relative to men, women are diagnosed more frequently with functional gastrointestinal (GI) disorders. With increased awareness of basic gender differences in perception and treatment of visceral pain, there has been new interest in research on gender disparity in the care of people with functional GI disorders. Past attention has focused on irritable bowel syndrome, whereas gender differences in other disorders are less well described. OBJECTIVE: Our aim was to systematically review studies that have examined gender-related differences among patients with dyspepsia. METHODS: MEDLINE, HealthSTAR, and PsycINFO databases were searched for English-language articles on dyspepsia published between 1966 and August 2001. Epidemiologic studies, clinical trials, review articles, and conceptual articles from peer-reviewed journals were included for review. Findings were summarized and discussed within a framework of biological and psychosocial factors. Statistical analysis of combined data was inappropriate because of the inconsistent definition of dyspepsia among different studies and wide variation in the types of articles reviewed. RESULTS: Studies that examine gender-related differences in patients with dyspepsia have focused their investigations on the clinical epidemiology and pathophysiology of dyspepsia. In most epidemiologic studies, no gender analysis was performed beyond a description of sample demographics, and when statistical significance was tested, few consistent gender differences were found. Overall, it appears that men and women with dyspepsia possibly differ with respect to pattern of symptoms, pain perception or modulation, and antinociceptive mechanisms, but these observations have not been confirmed. No study evaluated the clinical implications of these possible differences. CONCLUSIONS: Future efforts should be directed to not only examine gender-related differences in the clinical epidemiology of dyspepsia, but also understand their clinical significance. Therefore, well-designed population-based studies using a consistent definition of dyspepsia are needed to investigate the prevalence of dyspepsia symptoms and patterns of dyspepsia management among men and women. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To validate a simplified version of the Walsh clinical prediction rules (CPRs) for the presence of streptococcal pharyngitis in an inner-city, ethnically diverse population. PATIENTS AND METHODS: This prospective study conducted in New York City, NY, from January 1,1997, to May 31,1997, consisted of 171 consecutive adult walk-in patients who presented with symptoms of upper respiratory tract infection and/or sore throat. The patients were assessed by using 5 clinical factors: cough, exposure to known streptococcal contact, temperature, tonsillar-pharyngeal exudates, and cervical lymphadenopathy. Throat cultures for group A beta-hemolytic streptococcus were obtained from all patients. Clinicians assessing the patients were unaware of throat culture results, and those processing the throat cultures were blinded to the clinical predictors. RESULTS: The prevalence of streptococcal pharyngitis was 24% (95% confidence interval, 18%-30%). The simplified version of the Walsh CPR for streptococcal pharyngitis predicted accurately the probability of a positive culture in our diverse population (area under the receiver operating characteristic curve, 0.71). The simplified CPR also showed clinically useful likelihood ratios and posterior probabilities. CONCLUSION: A simplified version of the Walsh CPR is accurate for diagnosing streptococcal pharyngitis in an inner-city population. This finding should provide clinicians more confidence in applying the CPR in similar clinical settings. [ABSTRACT FROM AUTHOR]

Background and Aims: Traditional management for infected necrotizing pancreatitis (INP) often utilizes open necrosectomy, which carries high morbidity and complication rates. Thus, minimally invasive strategies have gained favor, specifically step-up approaches utilizing endoscopic or minimally-invasive surgery (MIS); however, the ideal management modality for INP has not been identified., Methods: A decision tree model was designed to analyze costs and survival associated with open necrosectomy, endoscopic step-up, and MIS step-up protocols for management of INP after 4 weeks of necrosis development with adequate retroperitoneal access. Costs were based on a third-party payer perspective using Medicare reimbursement rates. The model's effectiveness was represented by quality-adjusted life-years (QALYs). Sensitivity analyses were performed to validate results., Results: Endoscopic step-up was the dominant economic strategy with 7.92 QALYs for $90,864.09. Surgical step-up resulted in a decrease of 0.09 QALYs and a cost increase of $10,067.89 while open necrosectomy resulted in a decrease of 0.4 QALYs and an increased cost of $18,407.52 over endoscopic step-up. In 100,000 random-sampling simulations, 65.5% of simulations favored endoscopic step-up. MIS step-up was favored when MIS acute mortality rates fell and when MIS drainage success rates rose., Conclusions: In our simulated patients with INP, the most cost-effective management strategy is endoscopic step-up. Cost-effectiveness varies with changes in acute mortality and drainage success, which will depend on local expertise., Competing Interests: Declaration of competing interest Vishnu Prasath, Dr. Patrick L. Quinn, Dr. Joseph B. Oliver, Simran Arjani, Dr. Sushil K. Ahlawat, and Dr. Ravi J. Chokshi have no conflicts of interest or financial ties to disclose., (Copyright © 2021 IAP and EPC. All rights reserved.)

Background: Endoscopic stenting has demonstrated value over emergent surgery as a palliative intervention for patients with acute large bowel obstruction due to advanced colorectal cancer. However, concerns regarding high reintervention rates and the risk of perforation have brought into question its cost-effectiveness., Methods: A decision tree analysis was performed to analyze costs and survival in patients with unresectable or metastatic colorectal cancer who present with acute large bowel obstruction. The model was designed with two treatment arms: self-expanding metallic stent (SEMS) placement and emergent surgery. Costs were derived from medicare reimbursement rates (US$), while effectiveness was represented by quality-adjusted life years (QALYs). The primary outcome measure was the incremental cost-effectiveness ratio (ICER). The model was tested for validation using one-way, two-way, and probabilistic sensitivity analyses., Results: Endoscopic stenting resulted in an average cost of $43,798.06 and 0.68 QALYs. Emergent surgery cost $5865.30 more, while only yielding 0.58 QALYs. This resulted in an ICER of - $58,653.00, indicating that SEMS placement is the dominant strategy. One-way and two-way sensitivity analyses demonstrated that emergent surgery would require an improved survival rate in comparison to endoscopic stenting to become the favored treatment modality. In 100,000 probabilistic simulations, endoscopic stenting was favored 96.3% of the time., Conclusions: In patients with acute colonic obstruction in the presence of unresectable or metastatic disease, endoscopic stenting is a more cost-effective palliative intervention than emergent surgery. This recommendation would favor surgery over SEMS placement with improved surgical survival, or if the majority of patients undergoing stenting required reintervention.

A 42-year-old African American woman presented with 4 days of worsening midepigastric pain that radiated to her back. Computed tomography confirmed a diagnosis of acute pancreatitis and revealed a mass within the distal body and tail of the pancreas. After an endoscopic ultrasound with fine-needle aspiration yielding atypical cells suspicious for adenocarcinoma, the patient underwent an en bloc resection of the intra-abdominal mass with subtotal pancreatectomy, splenectomy, left colectomy, and left partial adrenalectomy. Histopathologic examination findings, in addition to immunohistochemical staining, revealed a diagnosis of pancreatic carcinosarcoma. Postoperatively, the patient has undergone 20 cycles of chemotherapy and has been transitioned to comfort measures at 16 months postoperatively because of progressive disease., (© 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.)

Background: Challenges still exist in differentiating pancreatic adenocarcinoma from benign disease. The use of adjuvant testing of tissue biopsies has demonstrated potential diagnostic value. We designed a proof of concept study to first validate four individual immunohistochemistry biomarkers and then combine them into a panel to boost overall diagnostic sensitivity., Methods: Malignant and benign pancreas from 27 pancreaticoduodenectomy specimens underwent immunohistochemistry staining with VHL, IMP3, S100A4, S100P. Using ROC curve analysis, threshold criteria for number of cells staining were chosen for each biomarker. Biomarkers were then evaluated as a panel for their ability to discriminate malignant from benign specimens., Results: Diagnostic sensitivity of VHL, IMP3, S100A4, and S100P were 75.0%, 79.2%, 45.8%, and 0%. When VHL, IMP3, and S100A4 were grouped into a panel, they were able to distinguish cancer from normal tissue with a sensitivity of 100% and a specificity of 96%., Conclusions: The high diagnostic value of an IHC panel consisting of VHL, IMP3, and S100A4 on surgical specimens suggests the need for future prospective studies of these biomarkers on biopsy specimens., (Copyright © 2019 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

A 56-year-old man presented to the emergency department with painless jaundice and weight loss. Abdominal ultrasound detected dilation of the common bile duct and the intrahepatic bile ducts. Follow-up with endoscopic retrograde cholangiography exposed a stricture of the common hepatic duct, with cholangioscopy identifying an infiltrating tumor. Biopsy revealed a granular cell tumor, which was confirmed by positive S-100 immunohistochemical staining. Surgical excision confirmed granular cell tumor of the bile duct with morphological features suggestive of malignancy., (© 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.)

Goals: To investigate the time trends of the prevalence and predictors of acute gastroenteritis (AGE) in the United States from 2005 to 2014 using nationally representative data., Background: AGE results in numerous visits to emergency departments and outpatient clinics annually in the United States with the estimated attributable cost to the US economy up to $145 billion dollars. However, time trends and predictors of AGE are not fully understood., Methods: Data were obtained from the National Health and Nutrition Survey (NHANES) 2005 to 2014, a nationally representative health survey. AGE was defined by a medical question (Do you have a stomach or intestinal illness with vomiting or diarrhea that started during last 30 d?). Prevalence of AGE was estimated in the total population as well as by selected demographic variables. Predictors of AGE and time trends of prevalence over survey periods were also investigated., Results: Overall monthly prevalence of AGE was 8.31% (95% confidence interval, 7.81-8.81), corresponding to 22.8 million people. AGE was associated with a younger age group, the highest in ages 0 to 9 years old, females, winter to early spring season, US born, divorced/separated/widowed individuals, current smokers, heavy alcohol users, and low household income. In the trends analyses, the prevalence of AGE significantly decreased over the study periods: 10.23% in 2005 to 2006, 9.89% in 2007 to 2008, 7.58% in 2009 to 2010, 6.44% in 2011 to 2012, and 7.47% in 2013 to 2014 (trend P<0.001)., Conclusion: In the United States from 2005 to 2014, the monthly prevalence of AGE was 8.31% and has been significantly decreasing over time.

Background: Despite unclear benefits of gluten-free diets (GFD) in the general population, gluten-free followers without medical indications are driving the market. Few studies have investigated health benefits of GFD in the general population., Aims: To estimate metabolic and cardiovascular disease (CVD) risk profiles among gluten-free followers without celiac disease (CD)., Methods: Data were obtained from the National Health and Nutrition Examination Survey (NHANES) 2009-2014. There were 13,523 persons without CD who had GFD information. People with known CVD were excluded. We compared gluten-free followers without CD and the general population by selective metabolic and CVD risk profiles using survey-weighted generalized logistic regression., Results: There were 155 gluten-free followers without CD and CVD, corresponding to a weighted prevalence of 1.3% (3.2 million Americans). Gluten-free followers tended to be women and have a smaller waist circumference and higher HDL cholesterol. They also had a lower BMI with a borderline p value (0.053) and significant self-reported weight loss (-1.33 kg) over one year. Moreover, gluten-free followers were more likely to consider their weight appropriate. There was no statistical difference by age, smoking, hypertension, total cholesterol, triglyceride cholesterol, HbA1c, or fasting glucose. Despite a lower probability of having metabolic syndrome (33.0 vs 38.5%) and lower 10-year CVD risk score (4.52 vs 5.70%) in gluten-free followers, there was no statistical difference., Conclusions: Although being on a GFD may be beneficial in weight management, there was no significant difference in terms of prevalence of metabolic syndrome and CVD risk score in gluten-free followers without CD.

Background and Aims: Since 1985, the American Society for Gastrointestinal Endoscopy (ASGE) has awarded grants for endoscopic-related research. The goals of this study were to examine trends in ASGE grant funding and to assess productivity of previous recipients of the ASGE grant awards., Methods: This was a retrospective cohort analysis of all research grants awarded by the ASGE through 2009. Measures of academic productivity and self-assessment of the ASGE awards' impact on the recipients' careers were defined by using publicly available resources (eg, National Library of Medicine-PubMed) and administration of an electronic survey to award recipients., Results: The ASGE awarded 304 grants totaling $12.5 million to 214 unique awardees. Funding increased 7.5-fold between 1985 and 1989 (mean $102,000/year) and between 2005 and 2009 (mean $771,000/year). The majority of awardees were men (83%), were at or below the level of assistant professor (82%), with a median of 3 years of postfellowship experience at the time of the award, and derived from a broad spectrum of institutions as measured by National Institutes of Health funding rank (median 26, interquartile range [IQR] 12-64). Nineteen percent had a master's degree in a research-related field. Awardees' median publications per year increased from 3.5 (IQR 1.2-9.0) before funding to 5.7 (IQR 1.8-9.5) since funding; P = .04, and median h-index scores increased from 3 (IQR 1-8) to 17 (IQR 8-26); P < .001. Multivariate analysis found that the presence of a second advanced degree (eg, masters or doctorate) was independently predictive of high productivity (odds ratio [OR] 2.92; 95% confidence interval [CI], 1.09-7.81). Among 212 unique grant recipients, 82 (40%) completed the online survey. Of the respondents, median peer-reviewed publications per year increased from 3.4 (IQR 1.9-5.5) to 4.5 (IQR 2.0-9.5); P = .17. Ninety-one percent reported that the ASGE grant had a positive or very positive impact on their careers, and 85% of respondents are currently practicing in an academic environment. Most of the grants resulted in at least 1 peer-reviewed publication (67% per Internet-based search and 81% per survey)., Conclusions: The ASGE research program has grown considerably since 1985, with the majority of grants resulting in at least 1 grant-related publication. Overall academic productivity increased after the award, and the majority of awardees report a positive or very positive impact of the award on their careers. Medical professional societies are an important sponsor of clinical research., (Copyright © 2016. Published by Elsevier Inc.)

Goals: The aim of this study was to assess the cumulative radiation exposure incurred by patients when using single-frame fluoroscopy., Background: Single-frame fluoroscopy is a technique that can be used instead of pulsed fluoroscopy or continuous live fluoroscopy to minimize radiation exposure during endoscopic retrograde cholangiopancreatography (ERCP)., Study: We retrospectively reviewed ERCPs performed at our academic medical center. We recorded fluoroscopy time (FT, minutes), total radiation dose (mGy), dose area product (DAP, Gy cm²), and effective dose (ED, mSv). ERCP degree of difficulty was graded based on procedure complexity level., Results: There were 400 ERCP procedures performed on 210 patients, 32 ERCPs were unsuccessful. The mean FT for all procedures was 1.57 minutes (median, 1.2 min); the mean FT for complexity score 1 procedures (0.78 min) was significantly shorter than for all other procedures (P<0.0001). The mean total radiation dose delivered for all procedures was 23.02 mGy (median, 14.95 mGy). The total radiation dose for complexity score 1 procedures (13.15 mGy) was significantly lower than for all other complexity scores (P<0.0001). The mean total DAP was 3.62 Gy cm² and the mean ED was 0.94 mSv. Procedure complexity score 1 DAP (2.1 Gy cm²) and ED (0.55 mSv) were significantly lower than for all other procedures (P<0.0001 for both). There was no statistically significant difference in these parameters when comparing successful and unsuccessful procedures., Conclusions: Successful ERCP can be performed using single-frame fluoroscopy only. Our results demonstrate lower radiation exposure using this technique than what is reported in the literature.

Dysplasia in Barrett's esophagus (BE) occurs as a flat, grossly undetectable lesion. Dysplasia growing as a polypoid lesion in BE is extremely rare. Only a handful of cases are reported in the literature. BE associated polypoid dysplastic lesions have been referred to as "adenomas" because of their histologic similarity to a colonic adenoma. We describe a patient with esophageal polypoid lesion associated with BE and review clinical and pathological features of other cases of BE associated polypoid dysplasia or "adenomas" as reported in the literature.

Background and Study Aims: High rate of malignancy has been reported in large colorectal polyps. However, studies were limited by including surgically resected polypoid lesions, only polyp ≥3 cm, only sessile polyps or carcinoma in situ. The aim of the study was to define the prevalence of invasive carcinoma among colorectal polyps ≥2 cm in diameter detected by colonoscopy and also to study the success of endoscopic resection., Patients and Methods: All polypectomies of ≥2 cm colorectal polyps were identified from our endoscopy and pathology database and patients' medical records were reviewed for gross features, techniques of resection, complications, histology, and follow-up. Standard statistical tests were applied for calculating the rates, prevalence, and difference in proportions., Results: Colonoscopic resection of 183 large polyps was performed in 174 patients over a period of 6 years (55% men and 45% women), mean age 64 years (median 67 y and range 25-91 y). The majority of polyps were sessile (84%). Fifty-six percent were located in the right colon. Invasive cancer was found in 10% of polyps. Endoscopic resection was successful in 89% of patients. Postpolypectomy bleeding and perforation was noted in 5% and 2% of patients, respectively. No death was observed. Seventy-eight percent of patients completed >1 year of follow-up after initial polypectomy. Recurrence of adenoma was noted in 12%, which was managed successfully by colonoscopic polypectomy techniques., Conclusions: The rate of invasive cancer is low among endoscopically resected large colorectal polyps and most of these polyps can be resected successfully via colonoscopy with minimal morbidity and no mortality. A close endoscopic follow-up is required to monitor for recurrence.

Endoscopic ultrasound (EUS) is considered a safe procedure; however, rare deaths have been reported due to complications such as perforation of the gastrointestinal tract. Several factors including age, the presence or absence of cervical osteophytes or duodenal diverticula, history of difficult intubation with prior endoscopic procedure, endosonographer's inexperience, or EUS guided interventions such as the drainage of the pancreatic duct or pseudocyst and fine needle aspiration may increase the risk of EUS related perforation of the gastrointestinal tract. We report a patient with pancreatic mass who developed duodenal perforation during EUS and was treated successfully with an immediate closure of perforation using endoscopic clips combined with bowel rest and antibiotics. Based on our patient and others reported in the literature, immediate recognition and closure of perforation with endoscopic clips may be useful in the management of patients with EUS induced duodenal perforation. However, surgical consultation and close clinical monitoring is required in the management of these patients.

Mirizzi syndrome, a rare complication of chronic cholelithiasis, is caused by an impacted stone in the cystic duct or the neck of the gallbladder. Patients present with abdominal pain, fever, and obstructive jaundice. The cholangiographic finding is a smooth stricture caused by lateral compression of the common hepatic duct. A similar appearance on cholangiogram can result from carcinoma of the gallbladder, carcinoma of the cystic duct, or hilar adenopathy. Acute acalculous cholecystitis simulating Mirizzi syndrome is extremely rare. This is the report of such a case in which marked inflammatory changes around the neck of the gallbladder likely caused significant mechanical obstruction of the common hepatic duct.

Cystic duct remnant mucocele is an extremely rare complication of liver transplantation in children. Surgical correction is usually required for cystic duct remnant mucocele when it causes biliary obstruction. We describe a 14-month-old liver transplant recipient who presented with biliary obstruction 1 month after orthotopic liver transplantation with an end-to-end choledochocholedocal biliary anastomosis for hepatoblastoma. US, CT and cholangiography findings were consistent with mucocele of the allograft cystic duct remnant. Surgery was not needed in our patient because the mucocele and biliary obstruction had resolved on repeat imaging most likely due to guidewire manipulation during cholangiography, resulting in opening of the cystic duct remnant orifice and drainage into the common duct.

Background: Dysphagia, usually due to proximal esophageal strictures, is a debilitating complication of therapy (surgery, radiotherapy, or chemotherapy) for head and neck malignancy. Scant attention has been given in the literature to the endoscopic management of these proximal esophageal strictures., Objective: Our purpose was to assess the technical and functional outcomes of endoscopic management of proximal esophageal strictures after therapy for head and neck cancers., Design: Retrospective case series., Setting: Academic medical center., Patients: Consecutive patients undergoing endoscopy and dilation of proximal esophageal strictures caused by chemoradiation or surgery for head and neck malignancy., Main Outcome Measurement: Technical and functional success after endoscopic dilation., Results: Twenty-four patients were included. The mean age of patients was 70.4 years (range 42 to 82 years). The primary tumor site was larynx in 10 patients, oropharynx or hypopharynx in 4 patients, upper esophagus in 4 patients, and other sites in the remainder. Technical success (a luminal diameter of 42F or greater) was achieved in 80% of patients. Adequate dysphagia relief was achieved in 84% of patients whose esophageal stricture was dilated at least up to 42F. The average follow-up was 22 months (range 1-96 months). Repeat dilation was needed in 58% of patients. No complications or death occurred during the study period., Limitations: Retrospective design and highly selected patient population. Dysphagia assessment in conjuction with a speech pathologist was not performed in all patients. Results may not be applicable to other settings., Conclusion: In this case series, proximal esophageal strictures after treatment of head and neck malignancy were amenable to antegrade endoscopic dilation; however, no patient in our study had complete lumen obstruction. Repeat dilations are often needed and are effective in achieving and maintaining adequate dysphagia relief.

Endoscopic management of complete or near complete upper esophageal strictures is challenging. Current methods such as retrograde esophageal access are high risk and may require additional abdominal surgery. A biliary cannulation technique with a 0.035 inch guidewire was utilized to obtain antegrade esophageal access in a patient with near complete high esophageal stricture due to chemo radiation and surgery for head and neck cancer. Biliary accessories including bougie and balloon dilators were used for the initial dilation of the esophageal stricture, followed by the traditional approach of stricture dilation using over-the-wire dilators. The procedure was successfully performed in a patient with near complete upper esophageal stricture due to chemo radiation and surgery for recurrent laryngeal cancer. The dysphagia of this patient was resolved following serial esophageal dilations and his esophageal stricture was wide open on the last upper endoscopy. Biliary accessories can be safely used for obtaining antegrade esophageal access and dilation of near complete upper esophageal strictures. This approach should be considered in patients with complex esophageal strictures, especially after chemo radiation or surgery for head and neck cancer and prior to seeking other more complex alternatives involving retrograde esophageal access.

Mirizzi syndrome is an important complication of gallstone disease. If not recognized preoperatively, it can result in significant morbidity and mortality. Preoperative diagnosis may be difficult despite the availability of multiple imaging modalities. Ultrasonography (US), CT, and magnetic resonance cholangiopancreatography (MRCP) are common initial tests for suspected Mirizzi syndrome. Typical findings on US suggestive of Mirizzi syndrome are a shrunken gallbladder, impacted stone(s) in the cystic duct, a dilated intrahepatic tree, and common hepatic duct with a normal-sized common bile duct. The main role of CT is to differentiate Mirizzi syndrome from a malignancy in the area of porta hepatis or in the liver. MRI and MRCP are increasingly playing an important role and have the additional advantage of showing the extent of inflammation around the gallbladder that can help in the differentiation of Mirizzi syndrome from other gallbladder pathologies such as gallbladder malignancy. Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard in the diagnosis of Mirizzi syndrome. It delineates the cause, level, and extent of biliary obstruction, as well as ductal abnormalities, including fistula. ERCP also offers a variety of therapeutic options, such as stone extraction and biliary stent placement. Percutaneous cholangiogram can provide information similar to ERCP; however, ERCP has an additional advantage of identifying a low-lying cystic duct that may be missed on percutaneous cholangiogram. Wire-guided intraductal US can provide high-resolution images of the biliary tract and adjacent structures. Treatment is primarily surgical. Open surgery is the current standard for managing patients with Mirizzi syndrome. Good short- and long-term results with low mortality and morbidity have been reported with open surgical management. Laparoscopic management is contraindicated in many patients because of the increased risk of morbidity and mortality associated with this approach. Endoscopic treatment may serve as an alternative in patients who are poor surgical candidates, such as elderly patients or those with multiple comorbidities. Endoscopic treatment also can serve as a temporizing measure to provide biliary drainage in preparation for an elective surgery.

Context: EUS-guided transmural drainage of pancreatic pseudocyst has been reported using a linear array echoendoscope; however, placement of large 10 French stent was not feasible because of the limited diameter of the working channel. Recently linear array echoendoscopes with large working channel (3.7 to 3.8 mm) and newer accessories for pancreatic cyst puncture have become available; however, clinical data on their efficacy and safety in pancreatic pseudocyst drainage is not available., Objective: To evaluate efficacy and safety of a one-step real time EUS-guided pancreatic pseudocyst drainage approach using a 3.8 mm channel linear array echoendoscope and cystotome., Design: Prospective case series., Setting: Tertiary care hospital endoscopy unit., Patients and Interventions: A total of 12 EUS-guided pancreatic pseudocyst drainage procedures were performed in 11 patients with symptomatic pancreatic pseudocyst using a 3.8 mm channel linear array echoendoscope and cystotome., Main Outcome Measurements: Complete resolution of pancreatic pseudocyst on imaging., Results: Successful puncture of pancreatic pseudocyst and placement of 1 or 2 stents (10 Fr) was successful in all patients who were considered eligible for EUS-guided pancreatic pseudocyst drainage. Overall 9 patients out of a total of 11 (82%) were managed successfully with EUS-guided pseudocyst drainage. Two recurrences were noted over a mean follow-up period of 4 months (range 3-6 months). One patient underwent successful repeat drainage and the other patient was managed with surgical cystogastrostomy because of infected cyst contents. No major complication occurred., Limitations: Uncontrolled, small sample size., Conclusions: A single-step approach using a large channel (3.8 mm) linear array echoendoscope and cystotome appears feasible. This approach appears safe and effective in managing selected patients with symptomatic pancreatic pseudocysts.

Background: In the West, urbanization has been accompanied by a rise in the rate of coronary heart disease. This trend has gone hand in hand with an increased consumption of processed, energy-dense food and dependence on machines for physical work. To examine whether a similar trend is underway in northern India, the prevalence of and risk factors for coronary heart disease were compared in rural, semi-urban and urban communities., Methods and Results: A total of 7,169 adults were interviewed and examined during 1995-2000 in cross-sectional cluster sample surveys from a rural area of Haryana (Raipur Rani block), two semi-urban areas of Punjab (Mandi Gobindgarh and Morinda), and Chandigarh city. The study, which covered people in the age-group of 35+ years, also estimated the lipid, glucose and insulin levels of a sub-sample of 186 persons who did not have coronary heart disease or hypertension. The prevalence of coronary heart disease among males in the villages, towns and city was 1.7%, 2.5% and 7.4%, respectively, and among females, 1.5%, 3.4% and 7.1%,respectively. The age- and sex-adjusted prevalence odds ratio of coronary heart disease, in comparison to the villages, was 1.9 (95% CI; 1.1-3.2) in the towns and 4.9 (95% CI: 2.9-8.2) in the city. Hypertension, diabetes, obesity and physical inactivity were significantly more common in the urban areas, while the rate of tobacco smoking was significantly higher in the rural areas ( p< 0.05). The alcohol consumption rates for the urban and rural communities were similar (p> 0.05). The quantity of the food items commonly consumed, as well as the frequency with which particular items were consumed, varied across the rural, semi-urban and urban areas ( p< 0.05). The urban population had significantly higher levels of lipids and serum insulin than did the rural population, but a lower level of plasma glucose ( p< 0.05)., Conclusion: The urban way of living is leading to an increase in the prevalence of the well-known risk factors for, as well as the rate of, coronary heart disease. Attempts to preserve the traditional lifestyle are necessary in order to prevent an epidemic of coronary heart disease in the developing countries.

Background: Rectosigmoid endometriosis is an underrecognized cause of GI symptoms in women. Pelvic magnetic resonance imaging and CT have a low sensitivity in making this diagnosis. The role of EUS and EUS-guided FNA (EUS-FNA) in the diagnosis of rectosigmoid endometriosis in symptomatic patients is not well studied., Methods: A review of medical records identified 5 women who were diagnosed with rectosigmoid endometriosis by EUS and EUS-FNA over a period of 1 year., Observations: Five women with nonspecific GI complaints underwent EUS examination of a rectosigmoid subepithelial mass found on colonoscopy. EUS revealed a hypoechoic lesion infiltrating the muscularis propria and the serosa of the rectal wall, and extending outside the rectal wall, findings consistent with rectosigmoid endometriosis. This diagnosis was confirmed by EUS-FNA, surgical exploration, and/or the patient's clinical course., Conclusions: EUS and EUS-FNA are noninvasive, sensitive techniques for the diagnosis of rectosigmoid endometriosis in symptomatic patients.

Background & Goals: The wireless pH monitoring system such as the BRAVO pH system is a significant advancement in the evaluation of patients with gastroesophageal reflux because of its potentially better tolerability and the ability to record data over a 48-hour period. The aim of our study was to evaluate safety, performance, tolerability, and day-to-day variability in acid reflux patterns using the BRAVO pH system., Methods: A total of 90 consecutive patients (48 men and 42 women) with persistent reflux symptoms underwent BRAVO pH capsule placement from October 2002 to August 2003 at a tertiary care hospital. The BRAVO pH capsule was deployed 6 cm proximal to the squamocolumnar junction under endoscopic guidance. The pH recordings over 48 hours were obtained after uploading data to a computer from the pager-like device that recorded pH signals from the BRAVO pH capsule., Results: Successful pH data over 48 hours was obtained in 90% of patients. Nearly two thirds of patients experienced a variety of symptoms ranging from a foreign body sensation to chest discomfort or pain. Four patients had severe chest pain, 3 of whom required endoscopic removal of the BRAVO pH capsule. In 74.4% of patients, number of reflux events as well as time (%) pH<4 correlated from the first 24-hour period to the second 24-hour period. However, in 28% of patients, no predictable pattern of (%) time pH<4 in the supine position was reproduced from one 24-hour period to the next 24-hour period., Conclusions: The BRAVO pH system appears a safe and effective method of recording esophageal acid exposure. It is an acceptable alternative for patients who are unwilling or unable to tolerate nasopharyngeal catheter-based pH studies, and it has a potential advantage of the 2-day recording period.

Context: Isolated pancreatic tuberculosis is rare in the Western world. Its clinical presentation often mimics pancreatic malignancy and the diagnosis is usually not suspected or confirmed prior to laparotomy. Endoscopic ultrasound guided fine needle aspiration cytology has proved to be an excellent tool for the cytological diagnosis of pancreatic and peripancreatic masses. However, this technique has not been reported for diagnosing pancreatic or peripancreatic tuberculosis., Case Report: We describe a 57-year-old South Asian man with pancreatic tuberculosis who presented with fever of undetermined origin and a pancreatic mass on imaging. He was successfully treated with anti-tuberculosis regimen following confirmation of his diagnosis with endoscopic ultrasound guided fine needle aspiration cytology., Conclusions: Pancreatic tuberculosis should be suspected in patients having a pancreatic mass, particularly if patient presents with fever and lived in, or traveled to, an area of endemic tuberculosis or exposed to tuberculosis. When the diagnosis is suspected, endoscopic ultrasound guided fine needle aspiration cytology of the pancreatic lesion can confirm the diagnosis and so avoid an unnecessary explorative laparotomy or pancreatic resection.

A number of factors have been proposed to account for the lack of response to medical therapy in patients with gastroesophageal reflux; however, no controlled studies are available in the literature. The goal of this study was to determine possible causes of medical refractoriness in patients with gastroesophageal reflux. Gastric acid output and esophageal acid exposure were measured in patients who continue to have reflux symptoms despite aggressive antisecretory therapy. In addition, an upper endoscopy was also performed in each patient. Patients with a drug-controlled acid output < 1 mEq/hr and a supine total esophageal pH < 4 for less than 1.7% of the time measured were considered responsive to therapy; on the other hand, those with a drug-controlled gastric acid output > 1 mEq/hr and a supine esophageal pH < 4 for more than 1.7% of the time measured were considered resistant to therapy. Twenty-four patients met the inclusion criteria (13 male and 11 female; mean age, 52). Drug-controlled gastric acid output was more than 1 mEq/hr in 25% of patients and less than 1 mEq/hr in the remainder. Of those patients with a gastric acid output of less than 1 mEq/hr (18 patients), 8(44%) had a supine esophageal pH < 4 for more than 1.7% of the time, suggesting that factors other than gastroesophageal reflux likely contributed to their reflux-like symptoms. Acid suppression appears adequate in the majority of patients with gastroesophageal reflux refractory to medical therapy. The exact cause of persistent reflux-like symptoms in patients who fail medical treatment is uncertain but may be related to non-acid-related factors such as esophageal hypersensitivity to physiologic reflux, increased intake of air resulting in aerophagia, or other factors such as bile reflux.

Background: Although dyspepsia is common, management patterns in the United States are unknown., Aim: To determine the pattern of dyspepsia evaluation and treatment over 20 years in a population-based cohort, and test the hypothesis that the management was influenced by dyspepsia subgroup and gender., Methods: The validated Bowel Disease Questionnaire was mailed to a random sample of Olmsted County, Minnesota residents (1988-1990). Of the 835 survey respondents, 213 subjects were identified as having dyspepsia according to Rome I Criteria. The medical chart of each dyspeptic subject who had not denied research authorization (n = 206) was reviewed to identify all episodes of care for dyspepsia symptoms 10 years before and 10 years after the date the Bowel Disease Questionnaire was completed. Of these 206 subjects (mean age 47 years, 48% female), 34% had ulcer-like dyspepsia, 32% had dysmotility-like dyspepsia, and 37% had reflux-like dyspepsia., Results: Nearly half (n = 98, 48%) had episodes of care for dyspepsia symptoms over 20 years. Of these 98 subjects, 49% had upper gastrointestinal endoscopy, 4% motility studies and 12% were tested for Helicobacter pylori. At the first visit of the episode of care closest to Bowel Disease Questionnaire completion, 72% were seen in primary care, 16% in emergency medicine and 2% in gastroenterology. In addition, 13% were referred to gastroenterology clinic within this episode. During the study period, 70% were given an 'acid' diagnosis, 7% a 'motility' diagnosis and 54% a 'functional' diagnosis; 78% received acid suppression agents (28% proton pump inhibitors), 18% psychotropic agents and 7% prokinetic agents. No significant association was found between gender and test usage, specialty referral or type of treatment, although women were three times less likely to receive proton pump inhibitors (odds ratio 3.3, 95% CI: 1.2-9.1). Symptom severity, frequency and pattern were risk factors for health care seeking in dyspepsia., Conclusions: Delivery of care for dyspepsia was similar among dyspepsia subgroups and in men and women.

To estimate the changes in the prevalence of hypertension and associated risk factors over a 30 years period a cross-sectional population survey in three randomly selected sectors of Chandigarh city was carried out. Study population consisted of 1181 individuals (570 males and 611 females) aged 35 years and above. A total of 1049 subjects were interviewed using a structured interview schedule, and 937 were examined by a physician. Blood pressure and anthropometric measurements were recorded. Physical activity was graded according to the job performed by the individual. Guidelines of the Fifth Joint National Committee (JNC-V) of USA were used for diagnosis of hypertension. Estimation of body fat from skin fold thickness was done by applying Grande's formula and the method of Pascale et al. Data were compared to that of year 1968 when a similar cross-sectional survey had been carried out in Chandigarh. Age and sex standardised prevalence of hypertension according to JNC-V criteria increased from 26.9 per cent in 1968 to 44.9 per cent in 1996-97. In 1968, 70% of the male population were engaged in sedentary and light physical activity compared to 73.7 per cent in 1996-97. Total body fat has increased in both men and women. High and high middle income groups in males were 61.2% in 1996-97 compared to 37.4% in 1968. Smoking rates, however, remained unchanged, 25.4 per cent men smoked in 1968 compared to 24.6 per cent in 1996-97. The prevalence of hypertension has almost doubled over 30 years in Chandigarh. Unfavourable change in prevalence of hypertension, physical activity and body fat makes this population highly vulnerable to cardiovascular morbidity and mortality.

Unlabelled: We report on a young woman with pheochromocytoma associated with pregnancy and review 41 other cases reported in the literature from 1988 to 1997. This review reveals that the overall maternal mortality was 4 percent and the fetal loss 11 percent; antenatal diagnosis of pheochromocytoma reduced maternal mortality to 2 percent; however, fetal loss was 14 percent. Diagnosis of pheochromocytoma was made antepartum in 83 percent of the cases. Although pheochromocytoma associated with pregnancy is rare, a high index of clinical suspicion must be kept and all those at risk must be investigated to achieve an early diagnosis and improved outcome. Once the diagnosis is confirmed, alpha-adrenergic blockade is essential and beta-blockade may be required. Magnetic resonance imaging and computerized tomography scan may be used to localize the tumor during the antenatal period. In early pregnancy, i.e., before 24 weeks, both tumor resection and medical treatment are associated with good fetal outcome; in later pregnancy, elective cesarean delivery followed by tumor resection results in favorable maternal and fetal outcome., Target Audience: Obstetricians & Gynecologists, Family Physicians., Learning Objectives: After completion of this article, the reader will be able to understand the clinical manifestations of a pheochromocytoma during pregnancy, how to make the diagnosis of a pheochromocytoma during pregnancy, and to know the medical and surgical management of a pheochromocytoma during pregnancy.

Hypokalaemic paralysis is a relatively uncommon but potentially life-threatening clinical syndrome. If recognised and treated appropriately, patients recover without any clinical sequellae. The syndrome of hypokalaemic paralysis represents a heterogeneous group of disorders characterised clinically by hypokalaemia and acute systemic weakness. Most cases are due to familial or primary hypokalaemic periodic paralysis; sporadic cases are associated with numerous other conditions including barium poisoning, hyperthyroidism, renal disorders, certain endocrinopathies and gastrointestinal potassium losses. The age of onset, race, family history, medications, and underlying disease states can help in identifying the cause of hypokalaemic paralysis. Initial therapy of the patient with hypokalaemic paralysis includes potassium replacement and search for underlying aetiology. Further management depends on the aetiology of hypokalaemia, severity of symptoms, and duration of disease. This review presents the differential diagnosis for hypokalaemic paralysis and discusses management of the syndrome.

Aluminum phosphide poisoning is common in the rural belt of Northern India. The release of cytotoxic phosphine gas primarily affects the heart, lungs, gastrointestinal tract and kidneys, although all organs can be involved. The cellular site of action of phosphine requires further definition. Diagnosis is made by clinical suspicion, silver nitrate test and biochemical examination of the gastric aspirate and viscera. Treatment consists of early gastric lavage, vasopressors and supportive care. Specific therapy with intravenous magnesium sulphate is recommended.

Alcohol affects the heart and circulation in several ways. Chronic alcohol consumption can be associated with a variety of cardiovascular disorders, ranging from hypertension and stroke to heart failure and sudden death. At the same time an inverse correlation has been found between moderate drinking and incidence of coronary artery disease, perhaps due to its favourable effects on lipoprotein levels. Reports on acute effects of alcohol on coronary circulation, which may be of great significance in patients with pre-existing heart disease, have been contradictory. However, clinical studies have demonstrated an adverse effect of acute alcohol intake in low to moderate doses on coronary supply-demand relation in patients with angina pectoris. Considering the overall health hazard of alcohol consumption, a recommendation that patients increase their alcohol intake or that they start to drink if they do not already would probably be unjustifiable.