American Gastroenterological Association Medical Position Research Articles

Understanding Compliance, Practice Patterns, and Barriers Among Gastroenterologists and Primary Care Providers Is Crucial for Developing Strategies to Improve Screening for Barrett’s Esophagus

Understanding Compliance, Practice Patterns, and Barriers Among Gastroenterologists and Primary Care Providers Is Crucial for Developing Strategies to Improve Screening for Barrett’s Esophagus

High-resolution anorectal manometry: An expensive hobby or worth every penny?

Introduced approximately 10years ago, high-resolution manometry catheters have fostered interest in anorectal manometry. This review, which accompanies two articles in this issue of Neurogastroenterology and Motility, reviews the methods, clinical indications, utility, and pitfalls of anorectal manometry and revisits the American Gastroenterological Association (AGA) Medical Position Statement on Anorectal Testing Techniques, which was last published in 1999. High-resolution manometry provides a refined assessment of the anorectal pressure profile, obviates the need for station pull-through maneuvers, and minimizes movement artifacts. In selected cases, this refined assessment may be useful for identifying structural abnormalities or anal weakness. However, many manometry patterns that were previously regarded as abnormal are also observed in a majority of healthy patients, which substantially limits the utility of manometry for identifying defecatory disorders. It is our impression that most conclusions of the AGA medical position statement from 1999 remain valid today. High-resolution techniques have not substantially affected the number of publications on or management of anorectal disorders. The ongoing efforts of an international working group to standardize techniques for anorectal manometry are welcome. Although high-resolution manometry is more than an expensive hobby, improvements in catheter design and further research to rigorously define and evaluate these techniques are necessary to determine if they are worth every penny.

Adherence to the 2011 American Gastroenterological Association medical position statement for the diagnosis and management of Barrett's esophagus.

Considerable variability exists in adherence to practice guidelines for Barrett's esophagus (BE). Rapid advances in management approaches to BE led to a new American Gastroenterological Association (AGA) medical position statement in 2011. Our aim was to assess how well members of the AGA Clinical Practice section adhered to these guidelines. A self-administered survey incorporating questions on diagnostic criteria, cancer risk estimates, screening, surveillance, and therapeutics for BE was distributed electronically to 5850 North American members of the AGA Clinical Practice section. The response rate was 470 of 2040 opened e-mails (23%). Intestinal metaplasia was required for diagnosis of BE by 90%, but the Prague classification was used by only 53% of those aware of it. The annual risk of progression to esophageal adenocarcinoma was reported as 0.1-0.5% by 76%. Screening practices were variable, with 35% screening all patients with chronic gastroesophageal reflux disease and 15% repeating endoscopy in patients with gastroesophageal reflux disease following a negative screening. Surveillance guidelines were followed by 79% for nondysplastic BE and 86% for low-grade dysplasia, with expert pathology confirmation of dysplasia reported by 86%. Proton pump inhibitor dosing was variable, with 18% administering twice-daily doses and 30% titrating dose to symptoms. Ablation therapy was recommended by 6% for nondysplastic BE, 38% for low-grade dysplasia, and 52% for high-grade dysplasia. There is satisfactory adherence to the new AGA guidelines with respect to diagnosis, cancer risk estimates, and surveillance intervals in a select group of respondents. However, adherence continues to be variable in the use of the Prague classification, screening, and dosing of antisecretory therapy. Use of ablation therapy increases with grade of dysplasia. The reason for continued variability in adherence to BE practice guidelines remains unclear, and more evidence-based guidance is required to enhance clinical practice.

End treatment response and sustained viral response in hepatitis C virus genotype 3 among Pakistani population

BACKGROUND AND OBJECTIVESThis study aimed to determine the end treatment response (ETR) and sustained viral response (SVR) to interferon (IFN) and ribavirin in hepatitis C virus (HCV) genotype 3 in the Pakistani population.DESIGN AND SETTINGSThis is an interventional study conducted from January 2010 to December 2012 in Lyari General Hospital and Abbasi Shaheed Hospital, Karachi, outpatients department.METHODSAll patients with chronic hepatitis C genotype 3 infections were included. Patients with decompensated chronic liver disease, or having coexisting hepatitis B virus/human immunodeficiency virus were excluded. All patients received IFN alpha, 3 million international units (MIU), subcutaneously 3 times weekly and ribavirin >800 mg/d for a period of 6 months. Outcome parameters included ETR (negative polymerase chain reaction [PCR] at the end of therapy), SVR (negative PCR both at the end of treatment and 6 months later), and relapse (PCR negative at the end of treatment but positive 6 months later) were determined.RESULTSA total of 1170 patients were included with a female to male ratio of 1.64:1 and a mean age of 31.6 (8.4) years. Among 1170 patients, 985 completed the therapy as per the protocol, 119 were defaulted (treatment abandoned before completion), and 66 had to stop treatment due to side effects. ETR was 74.1%, SVR was 98%, relapse rate was 1.5%, and 10.1% were nonresponders. SVR was seen only in patients who had achieved an ETR (n=867). SVR was achieved in 848 patients (out of 867) (98%), relapse was seen in 13 (1.5%), and 6 (0.7%) patients lost follow-up after stopping treatment. Patients achieving ETR and SVR had a mean serum alanine aminotransferase of 71.3 (57.1) and 71.0 (56.5), respectively, which is approximately twice the upper normal limit.CONCLUSIONThe conventional IFN and ribavirin therapy in genotype 3 chronic HCV-infected patients gives an ETR and SVR of 74.1% and 98%, respectively.

Presentation, Diagnosis, and Management of Achalasia

Presentation, Diagnosis, and Management of Achalasia

ColoSeq Provides Comprehensive Lynch and Polyposis Syndrome Mutational Analysis Using Massively Parallel Sequencing

Lynch syndrome (hereditary nonpolyposis colon cancer) and adenomatous polyposis syndromes frequently have overlapping clinical features. Current approaches for molecular genetic testing are often stepwise, taking a best-candidate gene approach with testing of additional genes if initial results are negative. We report a comprehensive assay called ColoSeq that detects all classes of mutations in Lynch and polyposis syndrome genes using targeted capture and massively parallel next-generation sequencing on the Illumina HiSeq2000 instrument. In blinded specimens and colon cancer cell lines with defined mutations, ColoSeq correctly identified 28/28 (100%) pathogenic mutations in MLH1, MSH2, MSH6, PMS2, EPCAM, APC, and MUTYH, including single nucleotide variants (SNVs), small insertions and deletions, and large copy number variants. There was 100% reproducibility of detection mutation between independent runs. The assay correctly identified 222 of 224 heterozygous SNVs (99.4%) in HapMap samples, demonstrating high sensitivity of calling all variants across each captured gene. Average coverage was greater than 320 reads per base pair when the maximum of 96 index samples with barcodes were pooled. In a specificity study of 19 control patients without cancer from different ethnic backgrounds, we did not find any pathogenic mutations but detected two variants of uncertain significance. ColoSeq offers a powerful, cost-effective means of genetic testing for Lynch and polyposis syndromes that eliminates the need for stepwise testing and multiple follow-up clinical visits.

American Gastroenterological Association Medical Position Statement on the Management of Barrett's Esophagus

American Gastroenterological Association Medical Position Statement on the Management of Barrett's Esophagus

American Gastroenterological Association Medical Position Statement on the Management of Barrett's Esophagus

American Gastroenterological Association Medical Position Statement on the Management of Barrett's Esophagus

American Gastroenterological Association Medical Position Statement on the Management of Barrett's Esophagus

American Gastroenterological Association Medical Position Statement on the Management of Barrett's Esophagus

American Gastroenterological Association Medical Position Statement on the Management of Gastroesophageal Reflux Disease

The American Gastroenterological Association (AGA) Institute Medical Position Panel consisted of the authors of the technical review, a community-based gastroenterologist (Stephen W. Hiltz, MD, MBA, AGAF), an insurance provider representative (Edgar Black, MD, Medical Director, Policy Resources Technology Evaluation Center, BlueCross BlueShield Association), a general surgeon (Irvin M. Modlin, MD), a patient advocate (Gregory Lane), a primary care physician (Steve P. Johnson, MD), a gastroenterologist with expertise in health services research (Philip S. Schoenfeld, MD), the Chair of the AGA Institute Clinical Practice and Quality Management Committee (John Allen, MD, MBA, AGAF), and the Chair of the AGA Institute Practice Management and Economics Committee and the AGA Institute CPT Advisor (Joel V. Brill, MD, AGAF).

Peginterferon Alfa-2a and Ribavirin for 24 Weeks in Hepatitis C Type 1 and 4 Patients With Rapid Virological Response

This analysis reports the rate of sustained virological response (SVR) in patients infected with hepatitis C virus (HCV) genotype 1 or 4 who were assigned to 24 weeks of treatment with pegylated interferon (peginterferon) alfa-2a 180 mug/wk plus ribavirin 1000/1200 mg/day after achieving a rapid virological response (RVR; HCV RNA level <50 IU/mL) at week 4 in a prospective trial investigating response-guided therapy. Non-RVR patients with an early virological response were randomized to 48 or 72 weeks of therapy (this is a still-ongoing trial). A total of 150 of 516 patients (29%) had an RVR, 143 of whom completed 24 weeks of treatment. Younger patients, leaner patients, and those with an HCV RNA level </=400,000 IU/mL and HCV genotype 4 infection were more likely to achieve an RVR; however, among patients with an RVR, no baseline factor predicted SVR. The SVR rate was 80.4% (115/143; 95% confidence interval [CI], 72.9-86.6) in patients who completed 24 weeks of treatment. The SVR rate was 86.7% (26/30; 95% CI, 69.3%-96.2%) in patients infected with genotype 4 and 78.8% in those infected with genotype 1 (89/113; 95% CI, 70.1%-85.9%; intent to treat: 89/120; 74.2%; 65.4-81.7%). Treatment was well tolerated. This prospective study confirms that a 24-week regimen of peginterferon alfa-2a plus ribavirin 1000/1200 mg/day is appropriate in genotype 1 and 4 patients with a low baseline HCV RNA level who achieve an RVR by week 4 of therapy.

Prevalence of Elevated Alanine Aminotransferase Among US Adolescents and Associated Factors: NHANES 1999–2004

Nonalcoholic fatty liver disease (NAFLD) is a common cause of liver disease in children and adolescents. The majority of studies of NAFLD in children have been in select populations of the clinically obese. Study aims were to estimate the prevalence of elevated alanine aminotransferase (ALT, as a marker of NAFLD) in a general contemporary adolescent population and to identify leading risk factors for ALT elevation (>30 U/L). We analyzed data of adolescent participants (aged 12-19 years; N = 5586) in the National Health and Nutrition Examination Survey 1999-2004, a representative sample of the civilian noninstitutionalized US population. The prevalence of elevated ALT levels (>30 U/L) was 7.4% among white adolescents, 11.5% among Mexican American adolescents, and 6.0% among black adolescents. Elevated ALT levels were prevalent in 12.4% of male subjects compared with 3.5% of female subjects. Multivariable associations with elevated ALT levels were found for sex (odds ratio [OR] male vs female, 7.7; 95% confidence interval [CI], 3.9-15.1), ethnicity (OR black vs white, 0.6; 95% CI, 0.3-1.3; OR Mexican American vs white, 1.6; 95% CI, 1.0-2.6), waist circumference (OR per 1 SD, 1.4; 95% CI, 1.0-2.0), and fasting insulin level (OR per 1 SD, 1.6; 95% CI, 1.2-2.1). Age, C-reactive protein levels, and triglyceride levels were also positively and socioeconomic position inversely associated with elevated ALT levels. The magnitude of associations were similar across ethnic groups. ALT level is associated with waist circumference and insulin resistance even in a young population. These characteristics could be utilized to identify adolescents who may benefit from screening for NAFLD, offering an opportunity to prevent disease progression at an early age.

American Gastroenterological Association Medical Position Statement on the Management of Hepatitis C

American Gastroenterological Association Medical Position Statement on the Management of Hepatitis C

American Gastroenterological Association Medical Position Statement: Evaluation of Dyspepsia

American Gastroenterological Association Medical Position Statement: Evaluation of Dyspepsia

American Gastroenterological Association Medical Position Statement: Role of the Gastroenterologist in the Management of Esophageal Carcinoma

American Gastroenterological Association Medical Position Statement: Role of the Gastroenterologist in the Management of Esophageal Carcinoma

Follow-up of patients with celiac disease: Achieving compliance with treatment

Celiac disease is the only autoimmune condition for which we know the environmental trigger: gluten. Complete removal of gluten from the diet in a patient with celiac disease should result in symptomatic, serologic, and histologic remission. However, compliance with the gluten-free diet, especially in the United States, is extremely challenging. Compliance can be measured both noninvasively, by dietary history and measurement of serum antibodies, and invasively, by using endoscopic and histologic criteria. The advantages and disadvantages of these various modalities are discussed. The highest rates of compliance are reported in patients who are diagnosed as young children, whereas adolescents and those diagnosed via mass serologic screening have the most transgressions. Barriers to compliance include the poor palatability of gluten-free foods, confusing food-labeling practices, and common comorbid psychologic burdens such as anxiety and depression. Because celiac disease is a multisystemic disorder, physicians need to be aware of the potential autoimmune, nutritional, and malignant complications. An algorithm for the follow-up and management of the newly diagnosed celiac disease patient is presented, which includes regular follow-up; measurement of serum antibodies; eliciting a detailed dietary history; and examination for signs and symptoms of nutritional deficiencies, malignancy, and other autoimmune diseases. Ideally, a team approach to the follow-up of the newly diagnosed patient should include regular supervision by an interested physician, medical nutritional counseling by a registered dietician, and access to local and national support groups knowledgeable about this condition.

American Gastroenterological Association medical position statement: Clinical use of esophageal manometry

This document presents the official recommendations of the American Gastroenterological Association (AGA) on Clinical Use of Esophageal Manometry. It was approved by the Clinical Practice Committee on October 2, 2004, and by the AGA Governing Board on November 7, 2004. This document presents the official recommendations of the American Gastroenterological Association (AGA) on Clinical Use of Esophageal Manometry. It was approved by the Clinical Practice Committee on October 2, 2004, and by the AGA Governing Board on November 7, 2004. The following recommendations were developed to assist physicians in the appropriate use of esophageal manometry in patient care. These recommendations are an update from previous recommendations published in 1994 and represent the results of meticulous research into areas of controversy from the previous policy statement. In addition, new techniques have evolved that may improve and complement manometric diagnosis. Thus, these recommendations also take into account how these new technologies may alter clinical practice (Table 1).Table 1Summary of the Recommendations for the Clinical Use of Esophageal ManometryManometry indicatedManometry possibly indicatedManometry not indicatedTo establish the diagnosis of dysphagia when obstruction (eg, a stricture) cannot be found. Particularly important if achalasia is suspected.For the preoperative assessment of peristaltic function in patients being considered for antireflux surgery.For making or confirming a suspected diagnosis of gastroesophageal reflux disease.For placement of intraluminal devices (eg, pH probes) when positioning depends on the relationship to functional landmarks, such as the lower esophageal sphincter.For evaluation of dysphagia in patients who have undergone either antireflux surgery or treatment for achalasia.As the initial test for chest pain or other esophageal symptoms because of the low specificity of the findings and the low likelihood of detecting a clinically significant motility disorder.For the preoperative assessment of patients being considered for antireflux surgery if there is any question of an alternative diagnosis, especially achalasia. Open table in a new tab 1Manometry is indicated to establish the diagnosis of dysphagia in instances in which a mechanical obstruction (eg, stricture) cannot be found. This is particularly important if a diagnosis of achalasia is suspected. However, given the low prevalence of achalasia in patients with esophageal symptoms, more common esophageal disorders should be excluded with barium radiographs or endoscopy before manometric evaluation.2Manometric techniques are indicated for placement of intraluminal devices (eg, pH probes) when positioning is dependent on the relationship to functional landmarks, such as the lower esophageal sphincter.3Manometry is indicated for the preoperative assessment of patients being considered for antireflux surgery if there is any question of an alternative diagnosis, especially achalasia. 1Manometry is possibly indicated for the preoperative assessment of peristaltic function in patients being considered for antireflux surgery.2Manometry is possibly indicated to assess symptoms of dysphagia in patients who have undergone either antireflux surgery or treatment for achalasia. 1Manometry is not indicated for making or confirming a suspected diagnosis of gastroesophageal reflux disease.2Manometry should not be routinely used as the initial test for chest pain or other esophageal symptoms because of the low specificity of the findings and the low likelihood of detecting a clinically significant motility disorder.

AGA technical review on the clinical use of esophageal manometry

AGA technical review on the clinical use of esophageal manometry

American Gastroenterological Association medical position statement: Diagnosis and treatment of gastroparesis

This document presents the official recommendations of the American Gastroenterological Association (AGA) on Diagnosis and Treatment of Gastroparesis. It was approved by the Clinical Practice Committee on May 16, 2004, and by the AGA Governing Board on September 23, 2004.

American Gastroenterological Association medical position statement: Diagnosis and treatment of hemorrhoids

This document presents the official recommendations of the American Gastroenterological Association (AGA) on Hemorrhoids. It was approved by the Clinical Practice Committee on January 8, 2004, and by the AGA Governing Board on February 13, 2004.