To the Editor: Laparoscopic adjustable gastric banding (LAGB) has become one of the most common w... more To the Editor: Laparoscopic adjustable gastric banding (LAGB) has become one of the most common weight-loss surgical procedures in the United States, with a reported 329% increase from 2004 to 2007.1 Before performing bariatric surgery, an extensive preoperative assessment needs to be made. Part of the preoperative assessment is performing an esophagogastroduodenoscopy (EGD),2 but its role is controversial. The purpose of performing EGD before bariatric surgery is to diagnose pathology, which may influence the perxformance of the surgery—for example, severe sequelae of gastroesophageal reflux disease, esophageal strictures, peptic ulcers, and tumors of the esophagus or stomach.2,3 While performing preoperative EGDs we anecdotally noted that the mostly asymptomatic patients had a lot of positive endoscopic findings, more so than our symptomatic nonobese population. That is why we decided to conduct a retrospective analysis of the findings, as there have been no previous studies on routine EGDs in asymptomatic patients before bariatric surgery. Because a large portion of the bariatric group is made up of minority patients, we also wanted to compare them with whites in the cohort. We hypothesized that there would be no clinically significant differences between the groups, because they were generally asymptomatic. From May to September 2009, a consecutive series of 253 obese patients (body mass index was 42.4±5.5; female: 68%, mean age 38.5±10.5; male: 32%, mean age 38.2±9.7) underwent EGD before LAGB. Most patients were of Hispanic origin (58%), followed by whites (28%) and African Americans (14%). Ninety-eight percent of the patients who presented for EGD were asymptomatic. Most patients reported not consuming any nonsteroidal anti-inflammatory drugs (NSAIDs) (99%), tobacco (87%), or alcohol (85%). Helicobacter pylori was positive in 29% of the gastric biopsies. Fifty-four percent had nonerosive gastropathy and 24% had erosive gastropathy; 2% had duodenal ulcers, and 8% had gastric ulcers. Esophageal ulcers were found in 6% of patients and were subsequently classified as idiopathic, considering that cytomegalovirus or herpes simplex virus was not found on biopsy and they were not observed in the setting of Barrett mucosa. The Los Angeles classification was used to diagnose erosive esophagitis, and the raw data revealed 3 patients with Los Angeles grade A, 5 patients with grade B, and no patients with grade C or D. These cases were categorized together under esophagitis for a total of 3% of the patients. A hiatal hernia was found in 20% of the patients. No upper gastrointestinal tract (UGI) malignancies were found. Analysis of variance found a significant difference in age among the different race groups with white being the oldest at 42.7 years, followed by African Americans at 39.9 years, and Hispanic patients the youngest at 35.8 years of age (P<0.0001). There was a difference in the prevalence of H. pylori infection among race groups: 36% in Hispanics, 29% in African Americans, and 15% in whites (P=0.008). The Hispanics and African Americans combined had an H. pylori prevalence of 34% (P=0.003) compared with whites. There were no significant differences between the different race groups and body mass index, protonpump inhibitor use (P=0.38), NSAIDs, tobacco, or alcohol. Among the bariatric patient population, there are no studies that screen asymptomatic patients in a minority population before LAGB. The basis of the null hypothesis for this study was that any pathology on upper endoscopic evaluation of asymptomatic, obese patients before LAGB would not be found, and thus differences between ethnic groups would not be significant. Even though the results of this study cannot form a cause and effect relationship, interesting conclusions can be drawn. First and foremost, the most striking result of this study is that of all the patients with positive endoscopic findings 78% had undergone gastropathy. This is higher than what had been previously reported in the literature. The majority of patients did not have identifiable risk factors for the development of gastritis: NSAIDs (1%), tobacco (13%), or alcohol (15%). It is especially notable because, of these patients, only 33% were H. pylori positive, in contrast to another study in which the prevalence of H. pylori infection was 53%.4 Even though our percentage of biopsy-proven H. pylori was lower than what has been previously reported, the eradication of H. pylori before surgery is important as studies have shown that H. pylori infection may lead to the development of postoperative marginal ulcers and strictures.5 Statistically significant differences were found in certain aspects of this study. One was in the mean age of the patients when compared across race. White patients were typically older (42.7±10.8) than African Americans (39.9±11.2) and Hispanics (35.8±8.9). Diabetes and the presence of the metabolic syndrome are more prevalent in the African…
BackgroundAmong available tests to detect Helicobacter pylori (H. pylori), urea breath test (UBT)... more BackgroundAmong available tests to detect Helicobacter pylori (H. pylori), urea breath test (UBT) is the most accurate when performed correctly in research protocols with unknown validity in clinic settings.Material and MethodsA total of 595 subjects at a gastroenterology clinic were tested 620 times with UBT. Detailed information about three known factors (recent proton‐pump inhibitors (PPI), antibiotics, or bismuth, H. pylori eradication treatment finished &lt;4 weeks ago, and gastric resection) to make UBT unreliable were prospectively recorded before each test.ResultsTwenty‐three percent (120 of 526) of all negative tests fell in one or more of the three categories, which had the potential to make UBT unreliable. Of those carried out on persons without being treated before, the potential false negative rate was 15%. Among those with previous eradication treatment, the rate was around 45%.ConclusionsIf a negative UBT could be false negative in up to 23% of cases, then it has a serious lack of negative predictive value. A negative UBT should be considered false negative until potential protocol violations are excluded.
Helicobacter pylori (H. pylori) testing in patients with bleeding ulcers is recommended by societ... more Helicobacter pylori (H. pylori) testing in patients with bleeding ulcers is recommended by society guidelines and considered a quality indicator. The aim of the study is to examine the proportion of patients with bleeding ulcers who had H. pylori testing and identify predictors associated with H. pylori testing. Consecutive hospitalized patients with bleeding ulcers documented endoscopically at a single center from 10/2004-5/2011 were identified retrospectively from an endoscopy database. The proportion of patients undergoing direct H. pylori testing (histology, rapid urease test, breath test or stool antigen) and any H. pylori testing (direct or serologic) were determined. Among 330 patients with bleeding ulcers, 105 (32%, 95% CI 27-37%) underwent direct testing and another 52 (16%, 95% CI 12-20%) had serologic testing during a median follow-up of 9 months (range, 0-86). H. pylori testing occurred at the index hospitalization in 146 (93%) of the 157 patients tested. Among the 105 patients who had direct H. pylori testing, 90 (86%) had biopsy-based testing during the initial endoscopy. On multivariate analysis, undergoing biopsy of a gastric ulcer was strongly associated with having direct H. pylori testing performed (OR = 5.1, 95% CI 2.3-11.5; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001). Among patients hospitalized with bleeding ulcers, less than half received H. pylori testing and less than a third received the more accurate direct testing. Most of the direct H. pylori testing was biopsy-based with very few being tested after the index hospitalization. Efforts to increase H. pylori testing in patients with bleeding ulcers are needed to improve outcomes.
The American Journal of Gastroenterology, Dec 1, 2008
Clostridium difficile infection (CDI) is a frequent cause of morbidity and mortality among elderl... more Clostridium difficile infection (CDI) is a frequent cause of morbidity and mortality among elderly hospitalized patients. A small but increasing number of patients have developed fulminant CDI, and a significant number of these patients require emergency colectomy. In this review, we discuss the risk factors, pathophysiology, diagnosis, and management of fulminant CDI. A literature search (Medline, Embase, Cochrane Library, Biosis, Science Citation Index, Ovid Journals) was performed from the period between January 1980 and June 2008 using the key words &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;Clostridium difficile,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;pseudomembranous enterocolitis,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;colectomy,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;acute abdomen,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;antibiotic-associated diarrhea,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; or &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;fulminant Clostridium difficile colitis.&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; Articles not in English or not related to human subjects were excluded. For this review, we analyzed the articles identified in our original search and those articles cited in the original review articles. No randomized trials were found on the surgical management of fulminant CDI and only retrospective studies with a minimum of five patients were used in the review. With respect to medical treatment, we based our review on guideline articles, systematic reviews, and available randomized trials. Both the incidence and severity of CDI are increasing. Fulminant CDI is underappreciated as a life-threatening disease because of a lack of awareness of its severity and its nonspecific clinical syndrome. Early diagnosis and treatment are essential for a good outcome, and early surgical intervention should be used in patients who are unresponsive to medical therapy. The surgical procedure of choice is a total abdominal colectomy with end ileostomy, although the mortality rate remains high.
The cardinal indication for surgical treatment of gallstones is pain attacks. However, following ... more The cardinal indication for surgical treatment of gallstones is pain attacks. However, following cholecystectomy, 20% of patients remain symptomatic. It is unclear to what extent post-cholecystectomy symptoms can be ascribed to persistence of preoperative symptoms or to new pathology. The pain and digestive pattern in gallstone patients has not been defined in a recent setting with ultrasonography as the diagnostic method. The aim of this study was to characterize a pain pattern that is typical for gallstone disease and to describe the extent of associated dyspepsia. A total of 220 patients with symptomatic gallstone disease including complicated disease (acute cholecystitis and common bile duct stones) were interviewed using detailed questionnaires to disclose pain patterns and symptoms of indigestion. All patients had pain in the right upper quadrant (RUQ) including the upper midline epigastrium. The pain was localized to the right subcostal area in 20% and to the upper epigastrium in 14%, and in the rest (66%) it was more evenly distributed. An area of maximal pain could be defined in 90%. Maximal pain was located under the costal arch in 51% of patients and in the epigastrium in 41%, but in 3% behind the sternum and in 5% in the back. The pain was referred to the back in 63% of the patients. The mean visual analogue scale (VAS) score was very high: 90 mm on a 0-100 scale. A pattern of incipient or low-grade warning pain with a subsequent relatively steady state until subsiding in the same fashion was present in 90% of the patients. An urge to walk around was experienced by 71%. Pain attacks usually occurred in the late evening or at night (77%), with 85% of the attacks lasting for more than one hour and almost never less than half an hour. Sixty-six percent of the patients were intolerant to at least one kind of food, but only 48% to fatty foods. Symptoms of functional indigestion (gastroesophageal reflux, dyspepsia or irritable bowel symptoms) were seen in the vast majority in association with attacks. Gallstone-associated pain follows a certain pattern in the majority of patients. The pain is located in a defined area with a point of maximum intensity, is usually referred, and occurs mainly at night with duration of more than one hour. The majority of patients experience functional indigestion, mainly of the reflux type or dyspepsia.
Purpose: Dry eye (DED) is a multifactorial disease of the ocular surface in which ocular surface ... more Purpose: Dry eye (DED) is a multifactorial disease of the ocular surface in which ocular surface inflammation and damage play etiological roles. In the present study, we compared symptoms and signs in patients with DED treated with 0.1% Cyclosporine A (CsA) cationic emulsion (Ikervis, Santen) and 0.05% CsA anionic emulsion (Restasis, Allergan).Methods: Single-center, retrospective, 202 consecutive DED patients were treated with 0.1% CsA cationic emulsion (Ikervis, n=101) or 0.05% CsA anionic emulsion (Restasis, n=101) over six months. Ophthalmological work-up included Ocular Surface Disease Index (OSDI) questionnaire, fluorescein break-up time (FBUT), fluorescein ocular surface staining (OSS), Schirmer’s test, meibum expressibility (ME), and meibum quality (MQ). Results: In both treatment groups, subgroup analysis revealed a significant improvement of OSDI only in patients with severe symptoms at baseline (OSDI 33-100). Ikervis-treated patients with OSDI <23 at baseline had a sig...
To the Editor: Laparoscopic adjustable gastric banding (LAGB) has become one of the most common w... more To the Editor: Laparoscopic adjustable gastric banding (LAGB) has become one of the most common weight-loss surgical procedures in the United States, with a reported 329% increase from 2004 to 2007.1 Before performing bariatric surgery, an extensive preoperative assessment needs to be made. Part of the preoperative assessment is performing an esophagogastroduodenoscopy (EGD),2 but its role is controversial. The purpose of performing EGD before bariatric surgery is to diagnose pathology, which may influence the perxformance of the surgery—for example, severe sequelae of gastroesophageal reflux disease, esophageal strictures, peptic ulcers, and tumors of the esophagus or stomach.2,3 While performing preoperative EGDs we anecdotally noted that the mostly asymptomatic patients had a lot of positive endoscopic findings, more so than our symptomatic nonobese population. That is why we decided to conduct a retrospective analysis of the findings, as there have been no previous studies on routine EGDs in asymptomatic patients before bariatric surgery. Because a large portion of the bariatric group is made up of minority patients, we also wanted to compare them with whites in the cohort. We hypothesized that there would be no clinically significant differences between the groups, because they were generally asymptomatic. From May to September 2009, a consecutive series of 253 obese patients (body mass index was 42.4±5.5; female: 68%, mean age 38.5±10.5; male: 32%, mean age 38.2±9.7) underwent EGD before LAGB. Most patients were of Hispanic origin (58%), followed by whites (28%) and African Americans (14%). Ninety-eight percent of the patients who presented for EGD were asymptomatic. Most patients reported not consuming any nonsteroidal anti-inflammatory drugs (NSAIDs) (99%), tobacco (87%), or alcohol (85%). Helicobacter pylori was positive in 29% of the gastric biopsies. Fifty-four percent had nonerosive gastropathy and 24% had erosive gastropathy; 2% had duodenal ulcers, and 8% had gastric ulcers. Esophageal ulcers were found in 6% of patients and were subsequently classified as idiopathic, considering that cytomegalovirus or herpes simplex virus was not found on biopsy and they were not observed in the setting of Barrett mucosa. The Los Angeles classification was used to diagnose erosive esophagitis, and the raw data revealed 3 patients with Los Angeles grade A, 5 patients with grade B, and no patients with grade C or D. These cases were categorized together under esophagitis for a total of 3% of the patients. A hiatal hernia was found in 20% of the patients. No upper gastrointestinal tract (UGI) malignancies were found. Analysis of variance found a significant difference in age among the different race groups with white being the oldest at 42.7 years, followed by African Americans at 39.9 years, and Hispanic patients the youngest at 35.8 years of age (P<0.0001). There was a difference in the prevalence of H. pylori infection among race groups: 36% in Hispanics, 29% in African Americans, and 15% in whites (P=0.008). The Hispanics and African Americans combined had an H. pylori prevalence of 34% (P=0.003) compared with whites. There were no significant differences between the different race groups and body mass index, protonpump inhibitor use (P=0.38), NSAIDs, tobacco, or alcohol. Among the bariatric patient population, there are no studies that screen asymptomatic patients in a minority population before LAGB. The basis of the null hypothesis for this study was that any pathology on upper endoscopic evaluation of asymptomatic, obese patients before LAGB would not be found, and thus differences between ethnic groups would not be significant. Even though the results of this study cannot form a cause and effect relationship, interesting conclusions can be drawn. First and foremost, the most striking result of this study is that of all the patients with positive endoscopic findings 78% had undergone gastropathy. This is higher than what had been previously reported in the literature. The majority of patients did not have identifiable risk factors for the development of gastritis: NSAIDs (1%), tobacco (13%), or alcohol (15%). It is especially notable because, of these patients, only 33% were H. pylori positive, in contrast to another study in which the prevalence of H. pylori infection was 53%.4 Even though our percentage of biopsy-proven H. pylori was lower than what has been previously reported, the eradication of H. pylori before surgery is important as studies have shown that H. pylori infection may lead to the development of postoperative marginal ulcers and strictures.5 Statistically significant differences were found in certain aspects of this study. One was in the mean age of the patients when compared across race. White patients were typically older (42.7±10.8) than African Americans (39.9±11.2) and Hispanics (35.8±8.9). Diabetes and the presence of the metabolic syndrome are more prevalent in the African…
BackgroundAmong available tests to detect Helicobacter pylori (H. pylori), urea breath test (UBT)... more BackgroundAmong available tests to detect Helicobacter pylori (H. pylori), urea breath test (UBT) is the most accurate when performed correctly in research protocols with unknown validity in clinic settings.Material and MethodsA total of 595 subjects at a gastroenterology clinic were tested 620 times with UBT. Detailed information about three known factors (recent proton‐pump inhibitors (PPI), antibiotics, or bismuth, H. pylori eradication treatment finished &lt;4 weeks ago, and gastric resection) to make UBT unreliable were prospectively recorded before each test.ResultsTwenty‐three percent (120 of 526) of all negative tests fell in one or more of the three categories, which had the potential to make UBT unreliable. Of those carried out on persons without being treated before, the potential false negative rate was 15%. Among those with previous eradication treatment, the rate was around 45%.ConclusionsIf a negative UBT could be false negative in up to 23% of cases, then it has a serious lack of negative predictive value. A negative UBT should be considered false negative until potential protocol violations are excluded.
Helicobacter pylori (H. pylori) testing in patients with bleeding ulcers is recommended by societ... more Helicobacter pylori (H. pylori) testing in patients with bleeding ulcers is recommended by society guidelines and considered a quality indicator. The aim of the study is to examine the proportion of patients with bleeding ulcers who had H. pylori testing and identify predictors associated with H. pylori testing. Consecutive hospitalized patients with bleeding ulcers documented endoscopically at a single center from 10/2004-5/2011 were identified retrospectively from an endoscopy database. The proportion of patients undergoing direct H. pylori testing (histology, rapid urease test, breath test or stool antigen) and any H. pylori testing (direct or serologic) were determined. Among 330 patients with bleeding ulcers, 105 (32%, 95% CI 27-37%) underwent direct testing and another 52 (16%, 95% CI 12-20%) had serologic testing during a median follow-up of 9 months (range, 0-86). H. pylori testing occurred at the index hospitalization in 146 (93%) of the 157 patients tested. Among the 105 patients who had direct H. pylori testing, 90 (86%) had biopsy-based testing during the initial endoscopy. On multivariate analysis, undergoing biopsy of a gastric ulcer was strongly associated with having direct H. pylori testing performed (OR = 5.1, 95% CI 2.3-11.5; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001). Among patients hospitalized with bleeding ulcers, less than half received H. pylori testing and less than a third received the more accurate direct testing. Most of the direct H. pylori testing was biopsy-based with very few being tested after the index hospitalization. Efforts to increase H. pylori testing in patients with bleeding ulcers are needed to improve outcomes.
The American Journal of Gastroenterology, Dec 1, 2008
Clostridium difficile infection (CDI) is a frequent cause of morbidity and mortality among elderl... more Clostridium difficile infection (CDI) is a frequent cause of morbidity and mortality among elderly hospitalized patients. A small but increasing number of patients have developed fulminant CDI, and a significant number of these patients require emergency colectomy. In this review, we discuss the risk factors, pathophysiology, diagnosis, and management of fulminant CDI. A literature search (Medline, Embase, Cochrane Library, Biosis, Science Citation Index, Ovid Journals) was performed from the period between January 1980 and June 2008 using the key words &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;Clostridium difficile,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;pseudomembranous enterocolitis,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;colectomy,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;acute abdomen,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;antibiotic-associated diarrhea,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; or &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;fulminant Clostridium difficile colitis.&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; Articles not in English or not related to human subjects were excluded. For this review, we analyzed the articles identified in our original search and those articles cited in the original review articles. No randomized trials were found on the surgical management of fulminant CDI and only retrospective studies with a minimum of five patients were used in the review. With respect to medical treatment, we based our review on guideline articles, systematic reviews, and available randomized trials. Both the incidence and severity of CDI are increasing. Fulminant CDI is underappreciated as a life-threatening disease because of a lack of awareness of its severity and its nonspecific clinical syndrome. Early diagnosis and treatment are essential for a good outcome, and early surgical intervention should be used in patients who are unresponsive to medical therapy. The surgical procedure of choice is a total abdominal colectomy with end ileostomy, although the mortality rate remains high.
The cardinal indication for surgical treatment of gallstones is pain attacks. However, following ... more The cardinal indication for surgical treatment of gallstones is pain attacks. However, following cholecystectomy, 20% of patients remain symptomatic. It is unclear to what extent post-cholecystectomy symptoms can be ascribed to persistence of preoperative symptoms or to new pathology. The pain and digestive pattern in gallstone patients has not been defined in a recent setting with ultrasonography as the diagnostic method. The aim of this study was to characterize a pain pattern that is typical for gallstone disease and to describe the extent of associated dyspepsia. A total of 220 patients with symptomatic gallstone disease including complicated disease (acute cholecystitis and common bile duct stones) were interviewed using detailed questionnaires to disclose pain patterns and symptoms of indigestion. All patients had pain in the right upper quadrant (RUQ) including the upper midline epigastrium. The pain was localized to the right subcostal area in 20% and to the upper epigastrium in 14%, and in the rest (66%) it was more evenly distributed. An area of maximal pain could be defined in 90%. Maximal pain was located under the costal arch in 51% of patients and in the epigastrium in 41%, but in 3% behind the sternum and in 5% in the back. The pain was referred to the back in 63% of the patients. The mean visual analogue scale (VAS) score was very high: 90 mm on a 0-100 scale. A pattern of incipient or low-grade warning pain with a subsequent relatively steady state until subsiding in the same fashion was present in 90% of the patients. An urge to walk around was experienced by 71%. Pain attacks usually occurred in the late evening or at night (77%), with 85% of the attacks lasting for more than one hour and almost never less than half an hour. Sixty-six percent of the patients were intolerant to at least one kind of food, but only 48% to fatty foods. Symptoms of functional indigestion (gastroesophageal reflux, dyspepsia or irritable bowel symptoms) were seen in the vast majority in association with attacks. Gallstone-associated pain follows a certain pattern in the majority of patients. The pain is located in a defined area with a point of maximum intensity, is usually referred, and occurs mainly at night with duration of more than one hour. The majority of patients experience functional indigestion, mainly of the reflux type or dyspepsia.
Purpose: Dry eye (DED) is a multifactorial disease of the ocular surface in which ocular surface ... more Purpose: Dry eye (DED) is a multifactorial disease of the ocular surface in which ocular surface inflammation and damage play etiological roles. In the present study, we compared symptoms and signs in patients with DED treated with 0.1% Cyclosporine A (CsA) cationic emulsion (Ikervis, Santen) and 0.05% CsA anionic emulsion (Restasis, Allergan).Methods: Single-center, retrospective, 202 consecutive DED patients were treated with 0.1% CsA cationic emulsion (Ikervis, n=101) or 0.05% CsA anionic emulsion (Restasis, n=101) over six months. Ophthalmological work-up included Ocular Surface Disease Index (OSDI) questionnaire, fluorescein break-up time (FBUT), fluorescein ocular surface staining (OSS), Schirmer’s test, meibum expressibility (ME), and meibum quality (MQ). Results: In both treatment groups, subgroup analysis revealed a significant improvement of OSDI only in patients with severe symptoms at baseline (OSDI 33-100). Ikervis-treated patients with OSDI <23 at baseline had a sig...
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