Gastroenterology

World Gastroenterology Organisation (WGO) News and Events No abstract available

Recent Trends and the Impact of the Affordable Care Act on Emergency Department Visits and Hospitalizations for Gastrointestinal, Pancreatic, and Liver Diseases Background: The Affordable Care Act (ACA) with Medicaid expansion implemented in 2014, extended health insurance to >20-million previously uninsured individuals. However, it is unclear whether enhanced primary care access with Medicaid expansion decreased emergency department (ED) visits and hospitalizations for gastrointestinal (GI)/pancreatic/liver diseases. Methods: We evaluated trends in GI/pancreatic/liver diagnosis-specific ED/hospital utilization over a 5-year period leading up to Medicaid expansion and a year following expansion, in California (a state that implemented Medicaid expansion) and compare these with Florida (a state that did not). Results: From 2009 to 2013, GI/pancreatic/liver disease ED visits increased by 15.0% in California and 20.2% in Florida and hospitalizations for these conditions decreased by 2.6% in California and increased by 7.9% in Florida. Following Medicaid expansion, a shift from self-pay/uninsured to Medicaid insurance was seen California; in addition, a new decrease in ED visits for nausea/vomiting and GI infections, was evident, without associated change in overall ED/hospital utilization trends. Total hospitalization charges for abdominal pain, nausea/vomiting, constipation, and GI infection diagnoses decreased in California following Medicaid expansion, but increased over the same time-period in Florida. Conclusions: We observed a striking payer shift for GI/pancreatic/liver disease ED visits/hospitalizations after Medicaid expansion in California, indicating a shift in the reimbursement burden in self-pay/uninsured patients, from patients and hospitals to the government. ED visits and hospitalization charges decreased for some primary care-treatable GI diagnoses in California, but not for Florida, suggesting a trend toward lower cost of gastroenterology care, perhaps because of decreased hospital utilization for conditions amenable to outpatient management.

Literature Review: Dietary Intervention Adherence and Adherence Barriers in Functional Gastrointestinal Disorder Studies Dietary management is key in controlling functional gastrointestinal disorders (FGIDs) symptoms. However, the degree to which patients with FGIDs in clinical studies adhere to dietary recommendations is unknown. Our aim was to evaluate adherence, dietary education, and adherence-related factors in FGIDs dietary intervention trials. A literature search was performed using MEDLINE, Google Scholar, and SCOPUS for clinical trials evaluating dietary management of FGIDs. Full manuscripts published from January 2000 through August 2018 were reviewed. Data including definitions of adherence and rates, study design, dietary education, use of a dietitian, provision of study foods, potential adherence barriers, and dropouts were captured. A total of 21 publications were included. Fifteen (67%) focused on the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet, 5 (24%) on fiber supplementation, and 1 (9%) on a low carbohydrate diet. Fifteen (71%) were randomized controlled trials. Meals/supplements were provided to the study participants in 27%, 80%, and 100%, of the low FODMAP, fiber, and low carbohydrate studies, respectively, which appeared to significantly enhance adherence (P<0.03). Eighteen studies (81%) provided either written or oral diet information to study participants. Overall, only 10 publications (48%) provided adherence data. Nine (60%) of the low FODMAP studies provided adherence data (range, 30% to 100%); ranges could not be calculated for the other dietary trials. The most common method to measure adherence was via food diaries. Therefore, adherence is not often measured in FGIDs dietary intervention clinical trials; when reported, rates of adherence range widely. Studies providing food had the highest adherence rates.

Water Exchange (WE) and Quality Improvement—Enhanced Advanced Adenoma Detection: A Pooled Data Analysis of 6 Randomized Controlled Trials Introduction: Advanced adenomas (≥10 mm in diameter, >25% villous, or high-grade dysplasia), a marker of colorectal cancer risk, are used to stratify patients for closer surveillance. Modern accessories, endoscopes, and age-adjusted evaluation have variable impacts on the advanced adenoma detection rate (AADR). In 1 randomized controlled trial (RCT) comparing air insufflation (AI) with water exchange (WE), the right colon AADR was significantly increased by WE. Four network meta-analyses reported that WE significantly increased overall adenoma detection rate (ADR), but the impact on AADR was not addressed. Aim: The aim of this study was to test the hypothesis that WE significantly increased AADR compared with AI. Method: Six Clinicaltrial.gov-registered RCTs were reported by a group of WE investigators. Data including AADR (primary outcome) and overall ADR (secondary outcome) were pooled. Results: A total of 5407 patients were randomized to AI (2699) and WE (2708). Compared with AI, WE significantly increased AADR (5.7% vs. 8.3%, P=0.001) and overall ADR (20.9% vs. 27.4%, P=0.001). Conclusions: In contrast to published reports, which showed variable impacts on AADR, WE was consistent in increasing AADR in 6 reported RCTs. The pooled data confirm that the impact of WE in increasing AADR was significant. The significantly enhanced overall ADR indicated that WE provided a higher quality outcome than AI. The significant improvement in AADR confirmed WE to be clinically relevant and has finally arrived as a timely addition to colorectal cancer prevention programs.

Disparities in Hepatocellular Carcinoma Surveillance: Dissecting the Roles of Patient, Provider, and Health System Factors Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide and remains one of the most rapidly rising cancers among the US adults. While overall HCC survival is poor, early diagnosis via timely and consistent implementation of routine HCC surveillance among at-risk individuals leads to earlier tumor stage at diagnosis, which is directly correlated with improved options for potentially curative therapies, translating into improved overall survival. Despite this well-established understanding of the benefits of HCC surveillance, surveillance among cirrhosis patients remains suboptimal in a variety of practice settings. While the exact reasons underlying the unacceptably low rates of routine HCC surveillance are complex, it likely reflects multifactorial contributions at the patient, provider, and health care system levels. Furthermore, these multilevel challenges affect ethnic minorities disproportionately, which is particularly concerning given that ethnic minorities already experience existing barriers in timely access to consistent medical care, and these populations are disproportionately affected by HCC burden in the United States. In this review, we provide an updated evaluation of the existing literature on rates of HCC surveillance in the United States. We specifically highlight the existing literature on the impact of patient-specific, provider-specific, and health care system-specific factors in contributing to challenges in effective implementation of HCC surveillance.

Predictors of Gastrin Elevation Following Proton Pump Inhibitor Therapy Goals: The goal of this study was to elucidate the most important predictors for elevation of gastrin in patients on long-term PPI therapy through analysis of data from 2 published studies in Icelandic patients with erosive GERD. Background: Gastrin elevation is a known but variable consequence of proton pump inhibitor (PPI) therapy. Concerns have been raised about the clinical importance of chronic PPI induced gastrin elevation. Study: This cross-sectional analysis included patients with endoscopically verified erosive esophagitis receiving long-term PPI therapy. PPI exposure in dosage over weight (mg/kg) and dosage over body surface area (mg/m2) was compared with fasting gastrin levels in two separate multiple linear regression models. Data was collected on age, gender, weight, H. pylori infection, smoking, PPI duration and type. Results: Overall data from 157 patients (78 females) were analyzed. Median serum gastrin levels were higher in females than males (92 vs. 60 pg/mL; P=0.001). Simple linear regression showed a correlation between serum gastrin levels and gender (P=0.0008) as well as PPI exposure in mg/kg (P=0.0001) and mg/m2 (P=0.0001). Multiple linear regression analysis showed that PPI exposure, both in mg/kg (β=0.95 [CI=0.4-1.5]; P=0.001) and mg/m2 (β=0.02 [CI=0.0-0.0]; P=0.0015) along with female gender (β=0.2 [CI=0.0-0.4]; P=0.02) predicted higher gastrin values. Conclusions: Dosage and female gender seem to play an important role in the development of gastrin elevation on PPI therapy. A significant correlation was found between fasting serum gastrin and dosage of PPIs over weight and body surface area.

Does Helicobacter pylori Eradication Reduce the Incidence of Metachronous Gastric Cancer After Curative Endoscopic Resection of Early Gastric Cancer: A Systematic Review and Meta-Analysis Background: Whether Helicobacter pylori eradication could reduce the risk of metachronous gastric cancer remain controversial. In the present study, we performed a systematic review and meta-analysis to evaluate the preventive effect of H. pylori eradication on the occurrence of metachronous gastric cancer after curative endoscopic resection of early gastric cancer. Methods: The related studies were identified by searching PubMed and Embase databases. According to the H. pylori infection status and subsequent treatment, all patients were classified into H. pylori negative group, H. pylori eradication group and noneradication group. The relevant data were extracted and pooled effect size was assessed using a fixed effect model or a random effect model. Results: A total of 11 retrospective cohort studies and 3 randomized controlled trials were included in this meta-analysis. The results based on the cohort studies indicated that the risk of metachronous gastric cancer was significantly lower in H. pylori eradication group than in noneradication group (hazard ratios: 0.65, 95% confidence interval: 0.50-0.86, P=0.002; I2=0%). The pooled result of 2 randomized controlled trials demonstrated that the patients receiving anti-H. pylori treatment had a lower risk of metachronous gastric cancer than those who did not receive H. pylori eradication treatment (hazard ratios: 0.43, 95% confidence interval: 0.26-0.70, P=0.001; I2=0%). In addition, the occurrence of metachronous gastric cancer in H. pylori eradication group was not significantly different from that in H. pylori negative group. Conclusions: Successful H. pylori eradication may be useful for the prevention of metachronous gastric cancer after curative endoscopic resection of early gastric cancer. Thus, anti-H. pylori treatment should be considered for those patients with H. pylori infection after curative endoscopic resection.

Patterns of Marijuana Use Among Patients With Celiac Disease in the United States: A Population-based Analysis of the NHANES Survey Background: Marijuana use has been assessed in patients with chronic gastrointestinal disorders and may contribute to either symptoms or palliation. Use in those with celiac disease (CD) has not been assessed. Our aim was to evaluate patterns of marijuana use in a large population-based survey among patients with CD, people who avoid gluten (PWAG), and controls. Study: We analyzed data from the National Health and Nutrition Examination Survey from 2009 to 2014. χ2 tests and multivariable logistic regression were used to compare participants with CD and PWAG to controls regarding the use of marijuana. Results: Among respondents who reported ever using marijuana (overall 59.1%), routine (at-least monthly) marijuana use was reported by 46% of controls versus 6% of participants with diagnosed CD (P=0.005) and 66% undiagnosed CD as identified on serology (P=0.098) and 51% of PWAG (P=0.536). Subjects with diagnosed CD had lower odds of routine marijuana use compared with controls (odds ratio, 0.08; 95% confidence interval, 0.01-0.73), whereas participants with undiagnosed CD had increased odds of routine use (odds ratio, 2.26; 95% confidence interval, 0.83-6.13), which remained elevated even after adjusting for age, sex, race/ethnicity, health insurance status, alcohol, tobacco use, educational level, and poverty/income ratio. Conclusions: In all groups, marijuana use was high. Although there were no differences among subjects with CD, PWAG, and controls who ever used marijuana, subjects with diagnosed CD appear to have decreased routine use of marijuana when compared with controls and PWAG. Those with undiagnosed CD have significantly higher rates of regular use. Future research should focus on the utilization of marijuana as it may contribute to further understanding of symptoms and treatments.

Nationwide Analysis of Resource Utilization and In-Hospital Outcomes in the Obese Patients With Lower Gastrointestinal Hemorrhage Goals: The goal of this study was to evaluate the impact of obesity on the outcomes of patients with lower gastrointestinal hemorrhage (LGIH). Background: Obesity is considered as an independent risk factor for LGIH. We sought to analyze in-hospital outcomes and characteristics of nonobese and obese patients who presented with LGIH, and further, identify resource utilization during their hospital stay. Materials and Methods: With the use of National Inpatient Sample from January 2005 through December 2014, LGIH-related hospitalizations (age≥18 y) were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic codes. Patients were stratified into the nonobese and obese groups depending on their body mass index (>30 kg/m2). The statistical analyses were performed using SAS 9.4. Results: Of the total 482,711 patients with LGIH-related hospitalizations, 38,592 patients were found to be obese. In a propensity-matched analysis, the in-hospital mortality was higher in the nonobese patients (4.2% vs. 3.8%, P=0.004), however, the mean length of hospital stay and mean cost was higher in the obese group which could be due to a higher number of comorbidities in the obese group. Secondary outcomes such as the need for mechanical ventilation vasopressor use and colonoscopy was significantly higher in the obese group. Conclusions: The study results demonstrate that ‘obesity paradox’ do exist for LGIH-related hospitalizations for mortality. LGIH hospitalizations in the obese patients are associated with higher resource utilization as evidenced by the longer length of stay and higher cost of hospitalizations as compared with the nonobese patients.

Thromboelastography-guided Blood Product Transfusion in Cirrhosis Patients With Variceal Bleeding: A Randomized Controlled Trial Goals: The aim of this study was to assess the use of thromboelastography (TEG)-directed blood product transfusion in cirrhotic patients with acute variceal bleeding compared with conventional transfusion for correction of coagulopathy. Background: Coagulopathy is common in patients with cirrhosis. Recommendations for correction of conventional parameters of coagulation—platelets and the international normalized ratio before endoscopy in patients with acute variceal bleeding—need more validation. Study: In this randomized controlled trial, cirrhotic patients with severe coagulopathy and acute variceal bleeding were randomized to either TEG-guided blood product transfusion or conventional transfusion from March 2017 to December 2017. The primary outcome was the difference in the amount of fresh frozen plasma and platelet units transfused between the groups. Secondary outcomes were rebleeding at 5 days and 42 days, and 6-week mortality. Results: Of the 60 recruited patients, 30 each were randomized to the TEG and conventional transfusion groups. There were no differences in baseline characteristic and endoscopic findings between the 2 groups. Four subjects in the TEG group received blood product transfusions versus all in the conventional transfusion group (13.3% vs. 100%; P<0.001). The control of bleeding on initial endoscopy was similar in the 2 groups. Rebleeding in the TEG and conventional transfusion groups at 5 days was similar [1 (3.3%) vs. 4 (13.3%), P=0.167], whereas it was significantly less in the TEG group at 42 days [3 (10%) vs. 11 (36.7%), P=0.012]. Mortality at 6 weeks was seen in 4 (13.3%) in the TEG group and in 8 (26.7%) patients in the conventional transfusion group (P=0.176). Conclusions: TEG-guided strategy was associated with reduced blood product transfusion to correct coagulopathy without compromising hemostasis in cirrhotic patients (Clinical trial ID: CTRI/2017/02/007864).