Endoscopic Management of Gastrointestinal Fistulae

Gastroenterology & Hepatology August 2014, Volume 10, Issue 8 Nitin Kumar, MD, Michael C. Larsen, MD, and Christopher C. Thompson, MD, MSc, FACG, FASGE Dr Kumar […]

A Health Survey of Gastroenterologist Prescribing Practices of Adalimumab for Treatment of Crohn’s Disease: Final Results

troenterology & Hepatology August 2014, Volume 10, Issue 8 Samantha Zullow, MD, Mark H. Flasar, MD, MS,Deborah Greenberg, J. Kathleen Tracy, PhD, Ankur Rustgi, MBBS, MPH, and […]

Effects of Statins on the Risk of Hepatocellular Carcinoma

July 2014, Volume 10, Issue 7 Pejman G. Mansourian, MD, Masato Yoneda, MD, PhD, M. Krishna Rao, Fernando J. Martinez, MD, Emmanuel Thomas, MD, PhD, and […]

Eosinophilic Esophagitis and Proton Pump Inhibitors: Controversies and Implications for Clinical Practice

July 2014, Volume 10, Issue 7 W. Asher Wolf, MD, MPH, and Evan S. Dellon, MD, MPH Dr Wolf is a fellow in gastroenterology and hepatology […]

Obesity and Irritable Bowel Syndrome: A Comprehensive Review

July 2014, Volume 10, Issue 7 Octavia Pickett-Blakely, MD, MHS Dr Pickett-Blakely is the director of the Small Bowel Disorders and Nutrition Program in the Division […]

Immunizations in Children with Inflammatory Bowel Disease Treated with Immunosuppressive Therapy

Gastroenterology & Hepatology June 2014, Volume 10, Issue 6 Ying Lu, MD, and Athos Bousvaros, MD, MPH Dr Lu is an assistant professor in the Division of […]

Gastric Intestinal Metaplasia and Early Gastric Cancer in the West: A Changing Paradigm

Gastroenterology & Hepatology June 2014, Volume 10, Issue 6 Justin M. Gomez, MD, and Andrew Y. Wang, MD, FACG, FASGE Dr Gomez is a clinical instructor in […]

Hepatitis C Virus Infection and Its Rheumatologic Implications

Gastroenterology & Hepatology Volume 10, Issue 5 May 2014 287 Zeynel A. Sayiner, MD, Uzma Haque, MD, Mohammad U. Malik, MD, and Ahmet Gurakar, MD The […]

Common Anorectal Disorders

Gastroenterology & Hepatology May 2014, Volume 10, Issue 5 Amy E. Foxx-Orenstein, DO, Sarah B. Umar, MD, and Michael D. Crowell, PhD Dr Foxx-Orenstein is an associate […]

Controversies in the Diagnosis and Management of NAFLD and NASH

Gastroenterology & Hepatology April 2014, Volume 10, Issue 4 Mary E. Rinella, MD, Rohit Loomba, MD, MHSc, Stephen H. Caldwell, MD, Kris Kowdley, MD, Michael Charlton, MBBS, […]

Intestinal Microbiota and the Efficacy of Fecal Microbiota Transplantation in Gastrointestinal Disease

Gastroenterology & Hepatology April 2014, Volume 10, Issue 4 Olga C. Aroniadis, MD, and Lawrence J. Brandt, MD, AGA-F Dr Aroniadis is a gastroenterology fellow at Montefiore […]

Identifying Patients Most Likely to Have a Common Bile Duct Stone After a Positive Intraoperative Cholangiogram

Gastroenterology & Hepatology April 2014, Volume 10, Issue 4 Raja Vadlamudi, MD, MPH, Jason Conway, MD, MPH, Girish Mishra, MD, MS, John Baillie, MB ChB, FRCP, John […]

Current Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. Despite efforts for prevention and screening as well as development of new technologies for diagnosis and treatment, the incidence of HCC has doubled, and mortality rates have increased in recent decades. A variety of important risk factors are associated with the development of HCC, with any type of cirrhosis, regardless of etiology, being the major contributor. Hepatitis C virus infection with bridging fibrosis or cirrhosis and hepatitis B virus infection are independent risk factors. The diagnosis of HCC is made without liver biopsy in over 90% of cases. Screening with ultrasound and alpha-fetoprotein (AFP) at 6-month intervals is advised; however, it is not adequate for patients on the orthotopic liver transplantation (OLT) list. Triple-phase computed tomography and/or magnetic resonance imaging are used in combination with the detection of AFP, AFP-L3%, and/or des-gamma-carboxy prothrombin due to their superior sensitivities and specificities. Several treatment modalities are available, but only surgical resection and OLT are curative. OLT is available only for patients who meet or are downstaged into Milan or University of California, San Francisco criteria. Other treatment options include radiofrequency ablation, microwave ablation, percutaneous ethanol injection, transarterial chemoembolization, radioembolization, cryoablation, radiation therapy, stereotactic radiotherapy, systemic chemotherapy, and molecularly targeted therapies. The management of HCC is based on tumor size and location, extrahepatic spread, and underlying liver function. Given the complexity of the disease, patients are often best served in centers with experience in HCC management, where a multidisciplinary approach can take place.

Irritable Bowel Syndrome: The Role of Food in Pathogenesis and Management

Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder that affects approximately 10% to 20% of the general adult population in Europe and the Americas and is characterized by abdominal pain and altered bowel habits in the absence of reliable biomarkers. The pathophysiology of IBS is poorly understood and is currently thought to represent a complex interplay among the gut microbiota, low-grade inflammation, impaired mucosal barrier function, visceral hypersensitivity, gut motility, and alterations in the gut-brain axis. In any individual patient, 1 or more of these factors may interact to generate symptoms. Although up to 50% of patients report postprandial exacerbation of symptoms, few studies have critically assessed the role of diet in IBS. Furthermore, although many patients with IBS adopt any one of a host of dietary changes in an attempt to alleviate their symptoms, there has been, up until recently, little scientific basis for any dietary recommendation in IBS. This review discusses the contribution of diet to the pathophysiology and symptoms of IBS.

Frontiers in the Treatment of Hepatitis C Virus Infection

In the United States, chronic hepatitis C virus (HCV) infection is the leading cause of blood-borne, virus-associated death related to advanced liver disease and the leading indication for liver transplantation. Although the diagnostic test for HCV has been available for more than 20 years, the majority of persons with HCV infection still have not received a diagnosis. This has led to a recent change in screening recommendations by the Centers for Disease Control and Prevention. Moreover, new medications were approved in 2011 after nearly a decade of minimal progress in the development of treatments for HCV infection. This was followed by the highly anticipated approval of sofosbuvir and simeprevir in 2013. In the past 3 years, there has been an explosion of reports on medications from different classes, promising a dramatic expansion to an all-oral regimen for the treatment of HCV genotype 1 infection within the next few years. This article reviews the current screening recommendations and standard of care for treatment of HCV infection and highlights specific agents in the pipeline that should change the landscape of how HCV infection is treated in the near future.

Emerging Therapeutic Options for Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus that often occurs in atopic persons. Management strategies include pharmacotherapy, dietary modification, and endoscopic therapy, although patients will often have a relapsing and remitting course. Currently, the primary pharmacotherapy for EoE consists of corticosteroids. Immunomodulators, leukotriene antagonists, biologics, and monoclonal antibodies are currently under study for treatment of EoE. The role of immunoglobulin E–mediated allergic reactions has been well documented and may provide insight into the etiology and effective therapy of EoE.

Gastrointestinal Motility Disorders in Children

The most common and challenging gastrointestinal motility disorders in children include gastroesophageal reflux disease (GERD), esophageal achalasia, gastroparesis, chronic intestinal pseudo-obstruction, and constipation. GERD is the most common gastrointestinal motility disorder affecting children and is diagnosed clinically and treated primarily with acid secretion blockade. Esophageal achalasia, a less common disorder in the pediatric patient population, is characterized by dysphagia and treated with pneumatic balloon dilation and/or esophagomyotomy. Gastroparesis and chronic intestinal pseudo-obstruction are poorly characterized in children and are associated with significant morbidity. Constipation is among the most common complaints in children and is associated with significant morbidity as well as poor quality of life. Data on epidemiology and outcomes, clinical trials, and evaluation of new diagnostic techniques are needed to better diagnose and treat gastrointestinal motility disorders in children. We present a review of the conditions and challenges related to these common gastrointestinal motility disorders in children.

Patterns of Acetaminophen Use Exceeding 4 Grams Daily in a Hospitalized Population at a Tertiary Care Center

Unintentional acetaminophen-induced hepatotoxicity has been increasingly recognized as a significant problem, prompting increased scrutiny and restrictions from the US Food and Drug Administration on products combining acetaminophen with narcotics. Patterns of acetaminophen use have not previously been reported in the hospitalized patient population, which may be especially vulnerable to liver injury. We aimed to quantify the frequency at which acetaminophen dosing exceeded the recommended maximum of 4 g/day in hospitalized patients. This was a retrospective, single-center, cohort study at a large tertiary care academic hospital. We queried our inpatient electronic medical record database to identify patients admitted between 2008 and 2010 who were receiving cumulative daily acetaminophen doses exceeding 4 g on at least 1 hospital day. Of 43,761 admissions involving acetaminophen administration, the recommended maximum cumulative daily dose of 4 g was exceeded in 1119 (2.6%) cases. Patients who were administered a larger number of acetaminophen-containing medications were more likely to receive doses in excess of the recommended maximum. Alanine aminotransferase (ALT) levels were checked within 14 days following acetaminophen exposure in excess of 4 g in 35 (3.1%) cases. Excessive acetaminophen dosing of hospitalized patients, who may be at increased risk for acetaminophen-induced hepatotoxicity, occurred in a minority of patients. The use of multiple acetaminophen-containing medication formulations contributed to excessive dosing. ALT level monitoring in this group was infrequent, precluding assessment of biochemical evidence of liver injury. This cohort of patients may represent an ideal population for further prospective study with more intensive and longer-term biochemical monitoring to assess for evidence of liver injury.

Ethical Considerations for Clinical Trials in Inflammatory Bowel Disease

Although advancements in the field of inflammatory bowel disease (IBD) include effective therapies for many patients with Crohn’s disease and ulcerative colitis, there remains a large unmet need, and there is a large number of investigational agents in the pipeline. Drug development through clinical trials is critical to understanding the safety and efficacy of new therapies in the affected human population, and the need for ethical trial design is of the utmost importance. This paper explores the ethical issues of clinical trials in IBD, focusing on placebo-controlled trials, vulnerable patients, exposure to monoclonal antibodies, globalization of trials, and surgical advances.

Dysphagia in the Elderly

Elderly patients are inherently predisposed to dysphagia predominately because of comorbid health conditions. With the aging of the population in the United States, along with the increased prevalence of obesity and gastroesophageal reflux disease, healthcare providers will increasingly encounter older patients with either oropharyngeal or esophageal disease and complaints of dysphagia. Useful tests to evaluate dysphagia include the videofluoroscopic swallowing study and the fiberoptic endoscopic evaluation of swallowing. Swallow rehabilitation is useful to help patients compensate for swallowing difficulty and ultimately help strengthen the neuromusculature involved in swallowing.