Mortality From Acute Upper Gastrointestinal Bleeding in the United Kingdom: Does It Display a “Weekend Effect”?
Am J Gastroenterol. 2011 May 24;
Authors: Jairath V, Kahan BC, Logan RF, Hearnshaw SA, Travis SP, Murphy MF, Palme…

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Proton Pump Inhibitors and Risk of Fracture: A Systematic Review and Meta-Analysis of Observational Studies.
Am J Gastroenterol. 2011 Apr 12;
Authors: Ngamruengphong S, Leontiadis GI, Radhi S, Dentino A, Nugent K
OBJEC…

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Enteral Feeding in the Critically Ill: The Role of the Gastroenterologist.
Am J Gastroenterol. 2011 Apr 5;
Authors: Fang JC, Delegge MH
Expertise in enteral nutrition (EN) is an important aspect of the skill set of the…

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Antibiotic Therapy in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis.
Am J Gastroenterol. 2011 Mar 15;
Authors: Khan KJ, Ullman TA, Ford AC, Abreu MT, Abadir A, Marshall JK, Talley NJ, Moayyedi P
The…

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Efficacy of Biological Therapies in Inflammatory Bowel Disease: Systematic Review and Meta-Analysis.
Am J Gastroenterol. 2011 Mar 15;
Authors: Ford AC, Sandborn WJ, Khan KJ, Hanauer SB, Talley NJ, Moayyedi P
OBJECTIVES…

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Glucocorticosteroid Therapy in Inflammatory Bowel Disease: Systematic Review and Meta-Analysis.
Am J Gastroenterol. 2011 Mar 15;
Authors: Ford AC, Bernstein CN, Khan KJ, Abreu MT, Marshall JK, Talley NJ, Moayyedi P
OBJ…

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Venous Thromboembolism in Inflammatory Bowel Disease: An Epidemiological Review.
Am J Gastroenterol. 2011 Mar 15;
Authors: Murthy SK, Nguyen GC
OBJECTIVES:This article aims to review the evidence implicating inflammato…

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Editorial: rifaximin and minimal hepatic encephalopathy.

Am J Gastroenterol. 2011 Feb;106(2):317-8

Authors: Butterworth RF

Minimal hepatic encephalopathy (MHE) occurs in up to 70% of patients with cirrhosis and has a clear impact on health-related quality of life (HRQOL) in these patients. Antibiotics leading to reductions in circulating ammonia have been used in the past for the treatment of MHE. However, serious adverse effects such as nephrotoxicity, ototoxicity, and peripheral neuropathy limit their use to relatively short time periods. In this issue of the American Journal of Gastroenterology, an article by Sidhu et al. demonstrates unequivocally that the antibiotic rifaximin, a minimally absorbed antibiotic with broad spectrum activity, improves psychometric test performance scores and concomitantly improves HRQOL in patients with MHE (the RIME Trial). Rifaximin was well tolerated. Results of the RIME Trial represent an important step in the establishment of this antibiotic as an effective and safe treatment for MHE.

PMID: 21301455 [PubMed - in process]

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Prospective assessment of inpatient gastrointestinal consultation requests in an academic teaching hospital.

Am J Gastroenterol. 2010 Mar;105(3):484-9

Authors: Day LW, Cello JP, Madden E, Segal M

OBJECTIVES:To assess the completeness of gastrointestinal (GI) inpatient consultations at an academic teaching hospital.METHODS:We conducted a prospective, cross-sectional study of 278 inpatient GI consultation requests evaluated from 1 July 2005 to 31 May 2007. A questionnaire assessing multiple aspects of the requesting health-care providers' knowledge and documentation of patient information was completed by first-year GI fellows. Completeness of the consultation was evaluated by the GI consultation attending physician.RESULTS:The most frequent consultation requests pertained to patients with GI hemorrhage (52.5%) and were made by first-year residents (56.8%). In 15% of requests, health-care providers lacked basic knowledge about the patients for whom consultations were sought. Conversely, in 17% of consultations, pertinent information could not be located in patients' paper medical chart/electronic medical record. The strongest predictors for a complete consultation were requesters' knowledge of patients' past medical history (P < 0.001), documentation of patients' current illness (P < 0.001), and presence of the providers' admission note in the paper medical chart (P = 0.002). Consultations requested between 5 and 10 PM were assessed to be more complete (P = 0.02), and more incomplete consultations occurred in the first 3 months of the academic year (P = 0.04).CONCLUSIONS:In 16% of inpatient GI consultation requests analyzed, crucial patient data were missing or were unknown by the requesting provider. Several aspects of requesting providers' knowledge and documentation of patient information were strongly associated with completeness of inpatient GI consultations.

PMID: 20203634 [PubMed - indexed for MEDLINE]

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Increased prevalence of and associated mortality with methicillin-resistant Staphylococcus aureus among hospitalized IBD patients.

Am J Gastroenterol. 2010 Feb;105(2):371-7

Authors: Nguyen GC, Patel H, Chong RY

OBJECTIVES: Methicillin-resistant Staphylococcus aureus (MRSA) infection has become increasingly prevalent in US hospitals, and the impact of MRSA on hospitalized inflammatory bowel disease (IBD) patients is unknown. METHODS: We used the Nationwide Inpatient Sample to identify admissions for IBD (n=116,842) between 1998 and 2004. We compared prevalence and in-hospital mortality of MRSA among IBD, non-IBD gastrointestinal (GI), and general medical inpatients. RESULTS: MRSA prevalence increased from 4.5/10,000 to 19.0/10,000 over the 7-year period (P<0.0001). After adjustment for confounders, IBD inpatients were at increased risk of MRSA compared with the non-IBD GI (adjusted odds ratio (aOR) 1.61; 95% confidence interval (CI): 1.33-1.96) and general medical (aOR 1.36; 95% CI: 1.11-1.66) groups. Of those with MRSA, catheter-related infections were specifically more common among IBD compared with non-IBD GI and general inpatients (28.8% vs. 11.0% and 8.5%, respectively, P<0.0002). Bowel surgery, parenteral nutrition, and health insurance were predictors of MRSA infection, but the first two became insignificant after controlling for length of stay (LOS). Compared with LOS < or = 7 days, MRSA was more likely among those hospitalized 8-21 days (aOR 7.40; 95% CI: 4.68-11.7) and >21 days (aOR 58.6; 95% CI: 36.0-95.3). MRSA infection was associated with sevenfold increase in mortality (aOR 7.61; 95% CI: 3.33-17.4). CONCLUSIONS: Hospitalized IBD patients are at increased risk of MRSA compared with non-IBD GI and general medical inpatients. Increased mortality in the IBD population associated with MRSA reinforces the importance of measures to prevent nosocomial infection and to reduce length of hospitalization.

PMID: 19809406 [PubMed - indexed for MEDLINE]

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Clostridium difficile is associated with poor outcomes in patients with cirrhosis: A national and tertiary center perspective.

Am J Gastroenterol. 2010 Jan;105(1):106-13

Authors: Bajaj JS, Ananthakrishnan AN, Hafeezullah M, Zadvornova Y, Dye A, McGinley EL, Saeian K, Heuman D, Sanyal AJ, Hoffmann RG

OBJECTIVES: Clostridium difficile-associated disease (CDAD) is associated with antibiotic use, acid suppression, and hospitalization, all of which occur frequently in cirrhosis. The aim was to define the effect of CDAD on outcomes and identify risk factors for its development in cirrhosis. METHODS: Case-control studies using the de-identified national (Nationwide Inpatient Sample, NIS) and an identified liver transplant center database of hospitalized cirrhotics with and without CDAD were performed. The NIS 2005 was queried for mortality, charges, and length of stay (LOS) in cirrhotics with/without CDAD. Outcomes of cirrhosis and infections were also analyzed. In the transplant center database, risk factors for CDAD were defined in hospitalized cirrhotics with/without CDAD who were age matched in a 1:2 ratio. RESULTS: The NIS 2005 included 1,165 cirrhotics with and 82,065 without CDAD. Cirrhotics with CDAD had a significantly higher mortality (13.8% vs. 8.2%, P<0.001), LOS (14.4 days vs. 6.7 days, P<0.001), and charges ($79,351 vs. $35,686, P<0.001) compared with those without CDAD. On multivariate analysis, CDAD was associated with higher mortality (odds ratio (OR) 1.55, 95% confidence interval (CI) 1.29-1.85), charges, and LOS despite controlling for cirrhosis complications and infections. In the transplant center database, 54 cirrhotics with and 108 cirrhotics without CDAD were included. Outpatient spontaneous bacterial peritonitis prophylaxis (35% vs. 13%, P=0.01), inpatient antibiotic (63% vs. 35%, P=0.0001), and proton pump inhibitor (PPI) use (74% vs. 31%, P=0.0001) were significantly higher in those with CDAD. CONCLUSIONS: Cirrhotics with CDAD have a higher mortality, LOS, and charges on the NIS 2005 compared with those without CDAD. Antibiotic and PPI use are risk factors for CDAD development in hospitalized cirrhotics.

PMID: 19844204 [PubMed - indexed for MEDLINE]

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Management of anticoagulation before and after gastrointestinal endoscopy.

Am J Gastroenterol. 2009 Dec;104(12):3085-97; quiz 3098

Authors: Kwok A, Faigel DO

The management of anticoagulants and antiplatelet agents in patients undergoing gastrointestinal endoscopic procedures is a common clinical problem. Although guidelines have been published, they are supported by little prospective or randomized trial data, but are primarily based on observational studies, expert opinion, and best clinical practices. As a general principle, the risks of thromboembolism need to be balanced against the risks of bleeding during the endoscopic procedure. By understanding these risks, management plans for individual cases may be made. This article reviews the current data and guidelines on the management of anticoagulants, antiplatelet agents, use of reversal agents, and the role and risks of concomitant proton pump inhibitors.

PMID: 19672250 [PubMed - indexed for MEDLINE]

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Management and treatment of patients with cirrhosis and portal hypertension: recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program.

Am J Gastroenterol. 2009 Jul;104(7):1802-29

Authors: Garcia-Tsao G, Lim JK, Lim J,

Cirrhosis represents the end stage of any chronic liver disease. Hepatitis C and alcohol are currently the main causes of cirrhosis in the United States. Although initially cirrhosis is compensated, it eventually becomes decompensated, as defined by the presence of ascites, variceal hemorrhage, encephalopathy, and/or jaundice. These management recommendations are divided according to the status, compensated or decompensated, of the cirrhotic patient, with a separate section for the screening, diagnosis, and management of hepatocellular carcinoma (HCC), as this applies to patients with both compensated and decompensated cirrhosis. In the compensated patient, the main objective is to prevent variceal hemorrhage and any practice that could lead to decompensation. In the decompensated patient, acute variceal hemorrhage and spontaneous bacterial peritonitis are severe complications that require hospitalization. Hepatorenal syndrome is also a severe complication of cirrhosis but one that usually occurs in patients who are already in the hospital and, as it represents an extreme of the hemodynamic alterations that lead to ascites formation, it is placed under treatment of ascites. Recent advances in the pathophysiology of the complications of cirrhosis have allowed for a more rational management of cirrhosis and also for the stratification of patients into different risk groups that require different management. These recommendations are based on evidence in the literature, mainly from randomized clinical trials and meta-analyses of these trials. When few or no data exist from well-designed prospective trials, emphasis is given to results from large series and consensus conferences with involvement of recognized experts. A rational management of cirrhosis will result in improvements in quality of life, treatment adherence, and, ultimately, in outcomes.

PMID: 19455106 [PubMed - indexed for MEDLINE]

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Hyponatremia in hepatic encephalopathy: an accomplice or innocent bystander?

Am J Gastroenterol. 2009 Jun;104(6):1390-1

Authors: Yun BC, Kim WR

Hyponatremia, a common complication inpatients with advanced liver disease and impaired free water clearance, has been shown to be an important predictor of short-term mortality. Hepatic encephalopathy, also a late complication of end-stage liver disease, has been associated with low-grade cerebral edema as a result of swelling of astrocytes. Guevara et al. hypothesized that hyponatremia and the resultant depletion of organic osmolytes (e.g.,myo-inositol) from brain cells contribute to brain edema, playing an important role in the pathogenesis of hepatic encephalopathy. Using a multivariable analysis, they demonstrated that hyponatremia increased the risk of hepatic encephalopathy more than eightfold, after adjustment for serum bilirubin and creatinine concentrations and previous history of encephalopathy. Their magnetic resonance spectroscopy data correlated low brain concentrations of myoinositol with hepatic encephalopathy. As both hyponatremia and encephalopathy occur in patients with advanced liver disease, it has been difficult to implicate hyponatremia independently in the pathogenesis of hepatic encephalopathy. Guevara’s data do suggest that hyponatremia is more likely an accomplice than an innocent bystander.

PMID: 19455127 [PubMed - indexed for MEDLINE]

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Hypertriglyceridemic pancreatitis: presentation and management.

Am J Gastroenterol. 2009 Apr;104(4):984-91

Authors: Tsuang W, Navaneethan U, Ruiz L, Palascak JB, Gelrud A

Hypertriglyceridemia (HTG) is reported to cause 1-4% of acute pancreatitis (AP) episodes. HTG is also implicated in more than half of gestational pancreatitis cases. Disorders of lipoprotein metabolism are conventionally divided into primary (genetic) and secondary causes, including diabetes, hypothyroidism, and obesity. Serum triglyceride (TG) levels above 1,000 mg/dl are usually considered necessary to ascribe causation for AP. The mechanism for hypertriglyceridemic pancreatitis (HTGP) is postulated to involve hydrolysis of TG by pancreatic lipase and release of free fatty acids that induce free radical damage. Multiple small studies on HTGP management have evaluated the use of insulin, heparin, or both. Many series have also reported use of apheresis to reduce TG levels. Subsequent control of HTG with dietary restrictions, antihyperlipidemic agents, and even regular apheresis has been shown anecdotally in case series to prevent future episodes of AP. However, large multicenter studies are needed to optimize future management guidelines for patients with HTGP.

PMID: 19293788 [PubMed - indexed for MEDLINE]

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