Gastroenterology Outpatient Clinic Research Articles

S1036 Cannabidiol (CBD) Use in Inflammatory Bowel Disease

Introduction: Cannabidiol (CBD) is a cannabinoid compound found in cannabis that has been gaining attention over the past few years in the medical community. Unlike tetrahydrocannabinol, also found in cannabis, it does not have psychoactive effects. It is easily obtainable, mixed in an oil or gummy form, and available in different strengths and flavors. CBD is used for pain, anxiety, depression and insomnia. While marijuana use has been widely studied in patients with Inflammatory Bowel Disease (IBD), there are few studies on the use and effects of CBD in this population. The purpose of this survey based study is to determine the number of IBD patients using CBD products, why they use them and if they perceive any benefits. Methods: 229 patients over the age of 18 with a diagnosis of IBD, from two gastroenterology outpatient clinics in Suffolk county, NY were invited to participate in an anonymous survey from June 1st to June 16th, 2022. The survey consisted of 13 questions pertaining to demographics, IBD related history, cancer history and CBD use. The surveys were completed in the office or by telephone. Data was entered into an anonymous database for interpretation. Results: Of the 229 patients, 10.5% used CBD products (n=24). Of the CBD users, more than half (66.7%, n=11) were female, 14 had Crohn’s disease while the rest had Ulcerative colitis, 37.5% (n=9) were on biologic therapy, and 9 (37.5%) had an IBD related surgery. Anxiety (62.5%, n=15), insomnia (54.2%, n=13) and pain (41.7%, n=10) were the most commonly reported reasons for use of CBD. Increase in appetite (25%, n=6) and nausea and vomiting (20.8%, n=5) were also reasons for use but were not reported as frequently. The majority of patients (87.5 %, n=21) felt that CBD helped their symptoms. Conclusion: IBD patients frequently suffer from pain, anxiety, insomnia and depression. There has been a rise in the use of CBD products in patients with various medical conditions. In our small study, we found that only 10.5% of IBD patients use CBD products, mainly for anxiety, insomnia and pain, compared with arthritis where reported use is 50% or more. Patients with IBD who have a complicated disease process often seek alternative therapies and are therefore at risk for substance use. Until there are large clinical trials to assess the role and safety profile of CBD in IBD patients, clinicians should be aware of its use in this population.Figure 1. : Cannabidiol (CBD) use in Inflammatory Bowel Disease Patients

S2527 The Xiphisternum as a Gastric Subepithelial Lesion

Introduction: The xiphisternum, comprised of cartilage surrounding a core of bone, is located inferior to the sternal body and enlarges with age. The process is usually directed anteriorly relative to the sternal body and the abdominal cavity. However, in approximately 10% of individuals the bony structure is angulated more than 10 degrees posterior to the orientation of the sternal body. Although this anatomical variant is typically asymptomatic, it may be encountered during endoscopy. As such, endoscopists should be familiar with its appearance to ensure correct identification. Case Description/Methods: A 66-year-old man presented to an outpatient gastroenterology clinic for assessment of diarrhea and bloating. He had a background medical history significant for colon adenocarcinoma with prior right hemicolectomy, prostate cancer, and B Cell lymphoma. During diagnostic EGD, an incidental medium-sized gastric subepithelial lesion was identified (Figure 1). Biopsy of the lesion demonstrated gastric mucosa with foveolar hyperplasia and minimal chronic inflammation. Endoscopic ultrasound was obtained for further characterization. The lesion was visualized causing indentation on the anterior wall of the gastric body. No mucosal abnormalities were present. With respiration, the stomach “rolled over” this lesion, suggesting that the origin was extramural. Endosonography demonstrated a hyperechoic, multilayered, shadowing lesion external to the stomach. Palpation of the epigastrium resulted in indentation of the stomach just below the lesion. A review of sagittal sections of an abdominal CT, performed for unrelated reasons, clarified the underlying etiology for the lesion identified during endoscopy. Discussion: The CT image demonstrates a posteriorly directed xiphisternum adjacent to the gastric body, causing protrusion of the gastric wall into the stomach which appeared as a subepithelial lesion during endoscopy. Upon visualizing this structure for this patient specifically, it was important to consider lymphoma, or compressive lymphadenopathy, as a differential diagnosis. However, with an intraprocedural examination and information available at the time of the EGD, it is likely that the endoscopic ultrasound could have been avoided. This was likely an incidental finding and not related to his presenting diarrhea and so no intervention was pursued.Figure 1.: Subepithelial gastric lesion identified during endoscopy.

S3275 A Peculiar Case of Limb-Girdle Muscular Dystrophy Masquerading as Elevated Transaminases

Introduction: A disproportional elevation in aspartate transaminase (AST) and alanine transaminase (ALT) is considered a marker of hepatocellular injury. Guidance on the work up of chronically elevated liver chemistry suggests an algorithmic approach to testing of common causes of liver injury based on the degree of elevation and even mentions consideration of nonhepatic etiologies such as skeletal muscle damage. We present a unique case of asymptomatic elevation in liver chemistries as the herald finding in a patient with limb-girdle muscular dystrophy (LGMD). Case Description/Methods: Our patient is a 19-year-old adopted male who was referred to outpatient gastroenterology clinic for asymptomatic elevation in transaminases. AST was 133 IU/L and ALT was 223 IU/L. Total bilirubin and alkaline phosphatase were normal. He denied alcohol use, prescribed medications, herbal supplements, or weightlifting supplements. BMI was normal. Workup for viral hepatitis, hemochromatosis, autoimmune hepatitis, Wilson’s disease, alpha-1 antitrypsin, celiac disease, and thyroid disease were normal. Liver biopsy revealed reticulin collapse with complete regeneration without inflammation. Subsequent follow-up over years demonstrated persistently elevated but stable elevations. At the age of 24, he began to endorse proximal lower extremity muscle pain and weakness. Creatine kinase (CK) was elevated at 11,937 U/L; aldolase was elevated at 31.4 U/L; myositis workup was normal. Right thigh biopsy revealed a myopathic process. Genetic testing confirmed mutation in the CAPN3 gene consistent with calpainopathy, a subtype of LGMD. Discussion: LGMD is a rare, genetic disorder resulting in loss of ambulation within 20 years after disease onset. Concurrent liver disease is rare in LGMD, but elevations in transaminases can be found because of severe elevations in CK. Our patient was found to have calpainopathy, a subtype associated with a recessive mutation in the CAPN3 gene. Our case demonstrates that beyond the recommended algorithmic evaluation of abnormal liver chemistries, inconclusive evaluation of abnormal liver chemistries in children and young adults should include a CK level to further investigate nonhepatic causes, specifically a myopathic process. Although there is no cure for LGMD, interventions focused on muscle conditioning are more beneficial with early detection to mitigate the devastating effects of this disorder.

Impact of a Fellow Created Pre-Visit Patient Questionnaire for GI Fellows’ Clinic

Time constraints during ambulatory visits in subspecialty clinics can lead to abbreviated histories and increased dissatisfaction among fellow trainees. Because outpatient gastroenterology (GI) clinic visits can cover a wide range of digestive complaints, pre-visit questionnaires (PVQ) are sometimes employed to gather information before the start of the visit. The aim of this quality improvement study was to determine if initiation of a PVQ in our fellows’ clinic can increase trainee satisfaction and improve data capture for fellows.

An Asymptomatic Patient with Persistent Anti-HAV IgM and Anti-HAV IgG: A Case Report and Literature Review

<p>?一名61歲女性，因職業為供膳人員而需要每年健檢，2015年於本院健檢時意外發現A型肝炎病毒IgM抗體(anti-HAV IgM)呈現陽性反應，懷疑是急性A型肝炎感染，因而轉至胃腸肝膽科門診檢查。個案本身並無症狀，實驗室報告顯示並無異常。隔年健康檢查仍發現anti-HAV IgM呈現陽性，再次安排實驗室檢查及理學檢查，也無顯示任何異常，隨後入院接受肝臟切片病理檢驗，但報告亦無特異性表現，且個案於住院期間也無任何不適。本次入院前，個案在外院也檢查了A型肝炎病毒IgG抗體(anti-HAV IgG)，發現也呈現陽性反應，且後續追蹤直至2020年期間，個案的anti-HAV IgM及anti-HAV IgG皆持續呈現陽性反應。持續性anti-HAV IgM陽性並不常見，本文針對造成持續性anti-HAV IgM陽性的原因，進行文獻回顧，並分析此案例可能的原因及後續適當之處理程序。</p> <p> </p><p>A 61-year-old female restaurant caterer had received regular annual health examinations. In 2015, hepatitis A virus immunoglobulin M antibody (anti-HAV IgM) was detected, though she showed no symptom or sign of HAV infection. She was then transferred to the gastroenterology (GI) outpatient clinic where she underwent further laboratory tests that revealed no specific findings. Medical certificates were therefore issued and regular follow-ups arranged. However, reactive anti-HAV IgM persisted with reactive result of anti-HAV IgG in 2016, and laboratory tests again showed negative findings. She was accordingly admitted for liver biopsy. Nevertheless, the pathology report also revealed no sign or symptom of infection, and she did not report any symptoms of HAV infection. As a result, she was discharged for annual monitoring. During the period from 2017 to 2020, she had visited our family medicine outpatient clinic for regular follow-ups; anti-HAV IgM and anti-HAV IgG were followed and revealed reactive findings. Persistent anti-HAV IgM is rare in the literature, and concurrent persistent anti-HAV IgG is even more unusual. In this article, we present a rare case of the above condition while the literature of persistent anti-HAV IgM is also reviewed.</p> <p> </p>

Health related quality of life in patients with primary biliary cholangitis

Aim: To assess the health related quality of life (HRQOL) in patients diagnosed with primary biliary cholangitis (PBC). Material and methods: A single-centered, prospective, cross-sectional study was conducted among patients diagnosed with primary biliary cholangitis in the Gastroenterology out-patient clinic at Gazi University Hospital, Ankara. Data was collected using a sociodemographic information form, hospital medical database and a PBC-40 questionnaire. Statistical comparison analysis was performed using Chi-square test for categorical variables and Mann-Whitney U test for continuous variables. P values less than 0.05 were considered significant. Results: A total of 37 PBC patients were included in the study. The mean age of the participants was 54.2±8.6. When evaluating the PBC-40 questionnaire scores from each domain in terms of severity, we found that majority of patients in itch %40.4 (n=19) and social %42,6 (n=20) domains had mild severity, as for fatigue %42.6 (n=20), cognitive %36 (n=17), emotional %40.4 (n=19) and other symptoms %44.7 ((n=21) domains had moderate severity. A statistically significant difference was found between AMA positive and AMA negative patient groups in the itch domain (p=0.007). Discussion: With this study on a Turkish based population using the PBK-40 questionnaire we were able to demonstrate that patients with PBC had a significantly impaired HRQOL and fatigue was the most seen symptom.

The retrospective evaluation of response to adalimumab and infliximab treatment in patients diagnosed with inflammatory bowel disease

Objective: Inflammatory bowel disease encompasses two major form: Crohn's disease and ulcerative colitis. The Crohn's Disease Activity Index is used to determine the severity of disease activity in patients with Crohn's disease. On the other hand, the Truelove-Witts activity index is used to determine the severity of disease activity in patients with ulcerative colitis. Adalimumab and infliximab are biological agents used in the treatment of patients with inflammatory bowel disease. The aim of this study is to conduct a retrospective evaluation regarding the response to adalimumab and infliximab treatment in patients with inflammatory bowel disease. Material and Methods: The data of the patients who were over the age of 18, diagnosed with inflammatory bowel disease, and followed up in the Gastroenterology Clinic and Outpatient Clinic of Firat University Hospital between January 2008-April 2019 were assessed. Eighty patients who received adalimumab and infliximab treatment regularly for at least 4 weeks were included in the study. Results: The Crohn's Disease Activity Index of patients who were diagnosed with Crohn's disease, and received adalimumab and infliximab treatment was compared, and it was found that it was significantly lower after the treatment (p <0.05). Truelove and Witts Activity Index of patients who were diagnosed with Crohn's disease, and received adalimumab and infliximab treatment were compared before and after the treatment, and it was found that it was significantly lower after the treatment (p <0.05). Conclusion: The results showed that the recovery rate was %83,3 in crohn's disease and %84,6 in ulcerative colitis patients. Adalimumab and infliximab treatment was effective on the healing of active disease in patients with inflammatory bowel disease. It was also concluded that although the safety of adalimumab and infliximab was high, but few allergy, lymphadenopathy, and leukopenia side effects were observed.

Short-chain fatty acids in the saliva of patients with gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is a condition characterized by persistent symptoms and complications resulting from reflux of gastric contents into the esophagus. Short-chain fatty acids (SCFAs) are fermentation products of dietary fibres by the gut microbiota and are often studied for their anti-inflammatory and anticancer effects. The presence of SCFAs in the upper gastrointestinal tract, including in patients with GERD, has not been previously studied. The aim of this study was to investigate the relationship between the concentrations of SCFAs in the saliva of different age groups of patients with GERD. The study included 86 patients diagnosed with GERD, divided into two groups according to age: under and over 60 years of age, treated in the Gastroenterology and Hepatology Outpatient Clinic of the University Hospital in Cracow and 39 patients without gastrointestinal tract diseases. After clinical examination, blood was drawn to determine complete blood count, haemoglobin, and CRP. The oral cavity was examined, and unstimulated mixed saliva was collected. The SCFAs analysis was made by liquid chromatography-tandem mass spectrometry after facile derivatization coupled with liquid-liquid extraction. Of the six SCAFs studied, the highest median concentrations of acetic acid and propionic acid were observed in the saliva of patients with GERD and in the control group, in both the younger and older groups of patients. The concentrations of acetic acid and propionic acid were also higher compared with the four other fatty acids in the saliva of patients with GERD and in the control subjects. There were no correlations between salivary SCFAs levels and selected clinical and endoscopic parameters, including chronic inflammatory changes of the esophagus and stomach. In conclusions: SCFAs are present in the saliva of patients with GERD and in the control healthy persons. With the exception of valeric and isovaleric acids, salivary levels of SCFAs were significantly higher in patients with GERD compared to the control group. The highest concentrations of acetic acid and propionic acid were observed in patients with GERD and in both the younger and older patient groups. There were no differences in the concentrations of SCFAs in the saliva of female and male groups. We found no correlations between salivary SCFAs levels and selected clinical, laboratory and endoscopic changes of the oesophagus and stomach.

Three Lumens Full of Blood—An Unusual Case of Gastrointestinal Bleeding

Question: A 58-year-old man was initially referred to our gastroenterology outpatient clinic for investigation of iron-deficiency anemia and positive fecal occult blood test (FOBT). His medical history was significant for simultaneous pancreas-kidney transplants 9 years earlier in the context of type 1 diabetes, for which he remained on triple immunosuppressive therapy with prednisolone, mycophenolate, and tacrolimus. His transplants were complicated by biopsy-proven chronic antibody-mediated rejection 4 years earlier, for which he received 6 months of intravenous immunoglobulin. There was no history of chronic liver disease or nonsteroidal medication use. Investigations demonstrated iron-deficiency anemia with a hemoglobin of 88 g/L, ferritin 14 μg/L, transferring saturation 5%, and a positive FOBT (1 of 3 samples). The patient underwent further evaluation with gastroscopy and colonoscopy, which were both unremarkable and did not identify a cause for iron-deficiency anemia. One month later, the patient re-presented to the emergency department with several days of melena and symptomatic anemia with a hemoglobin of 78 g/L. The patient underwent repeated gastroscopy, which did not reveal a cause for his symptoms. He received a blood transfusion and was referred for outpatient capsule endoscopy. Several weeks later, the patient represented with 3 days of melena and symptomatic anemia with a hemoglobin level of 45 g/L. The patient underwent an urgent push enteroscopy. What are the differential diagnoses of gastrointestinal bleeding in this patient? Look on page 335 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. A pediatric colonoscope was inserted 60 cm beyond the pylorus. There was no evidence of esophageal varices, esophagitis, or gastric varices. There was no ulceration or stigmata of recent hemorrhage found in the stomach or duodenum. At 55 cm distal to the pylorus, the anastomosis of the pancreatic transplant was encountered. It demonstrated a side-to-side duodenojejunostomy with 2 short blind duodenal limbs and the native efferent jejunal limb (Figure A). At the anastomosis, multiple varices were noted, of which one vessel was actively bleeding (Figure B). Hemostasis was achieved with the injection of adrenaline (2 mL, 1:10,000) and 2 through-the-scope hemostatic clips (Figure C). The patient then underwent a computed tomographic scan with pancreas protocol to characterize the anatomy and vasculature at the duodenojejunal anastomosis. Multiple venous varices were identified that communicated with a distended transplant pancreatic vein (Figure D). The transplant pancreatic vein anastomoses with the proximal right common iliac vein, and therefore the varices were not due to portal venous hypertension. There was no anastomotic stenosis, no venous thrombosis, and no arteriovenous fistulae. The hemoglobin remained stable after endoscopy and the patient was discharged home 3 days later. At outpatient follow-up 2 months after discharge, there was no evidence of further gastrointestinal bleeding and the hemoglobin level was stable. The patient will continue to be closely observed in the outpatient setting, with a view to endovascular intervention if further gastrointestinal bleeding occurs. Ectopic variceal bleeding from anastomotic varices between the donor duodenum and recipient small bowel are rare, with only 3 cases reported in the literature.1Gopal J.P. Jackson J.E. Palmer A. Taube D. Rathnasamy Muthusamy A.S. Gastrointestinal bleeding in a pancreas transplant recipient: a case to remember.Am J Case Rep. 2020; 21e923197Crossref PubMed Scopus (3) Google Scholar, 2Rostambeigi N. Shrestha P. Dunn T.B. et al.Recurrent ectopic variceal bleed after pancreas transplantation with no portal hypertension: case report and outcomes of endovascular onyx embolization.Vasc Endovasc Surg. 2019; 53: 415-419Crossref PubMed Scopus (5) Google Scholar, 3Fontana I. Bertocchi M. Di Domenico S. et al.Percutaneous embolization of periduodenal varix due to portal hypertension in a patient with kidney-pancreas transplantation: a case report.Transplant Proc. 2010; 42: 2162-2163Crossref PubMed Scopus (5) Google Scholar The mechanism by which ectopic varices develop after pancreas transplantation are not clear. Potential explanations include portal hypertension secondary to cirrhosis, increased vascular resistance, rejection of pancreatic transplant, and chronic venous obstruction. In our case, the mechanism was not elucidated.

Autoimmune Atrophic Gastritis: The Role of miRNA in Relation to Helicobacter Pylori Infection.

IntroductionMicroRNAs (miRNAs) have been proposed as diagnostic markers, biomarkers of neoplastic progression, and possible therapeutic targets in several immune-mediated diseases. We aimed to analyze the expression profile of selected miRNAs (miR21, miR142, miR223, miR155) in patients with autoimmune atrophic gastritis (AAG), patients with non-autoimmune multifocal atrophic gastritis (MAG), and healthy control subjects (HC).Materials and methodsA total of 103 patients with AAG were consecutively recruited for this study among those attending our gastroenterology outpatient clinic. Participating patients were divided into two groups: primary, not Helicobacter pylori (HP)-associated related AAG (n=57, P-AAG) and HP-associated AAG (n=46, HP-AAG); this subgroup included HP-positive patients, patients with previously reported HP infection, and patients harboring antral atrophy, considered as a stigma of HP infection. We also included 20 sex-age-matched MAG patients and 10 HC. Upper endoscopy with gastric biopsies were performed on each AAG and MAG patient. Circulating levels of miR21-5p, miR142-3p, miR223-3p, and miR155-5p were measured by RT-PCR in all groups.ResultsMiR-21 was over-expressed in P-AAG (p=0.02), HP-AAG (p = 0.04), and MAG (p=0.03) compared with HC. By contrast, miR-142 was more expressed in HC than in HP-AAG (p=0.04) and MAG (p=0.03). MiR-155 showed no significant differences among the four subgroups, while, unexpectedly, miR-223 was overexpressed in HC compared to P-AAG (p=0.01), HP-AAG (p=0.003), and MAG (p<0.001), and was higher in P-AAG than in MAG (p=0.05).ConclusionsMiR-21 was over-expressed in patients with gastric precancerous conditions irrespective of etiology, while in the same subgroups miR-142 and miR-223 were under-expressed compared to healthy controls. Controlling miRNAs up- or downregulation could lead to a breakthrough in treating chronic autoimmune diseases and potentially interfere with the progression to cancer.

Surgical treatment of liver hydatic cyst and evaluation of cystobiliary fistula: experience of two centers

Objective: Intrabiliary rupture or cystobiliary fistula is the most common complication of hepatic hydatid cyst. In this article, our objective is to evaluate the clinical, laboratory, imaging, surgical treatment and results of cystobiliary fistulas, which is the most common complication of hydatid cysts. Material and Method: In our study, patients who underwent open surgery and were followed up and treated for hydatid cyst in the gastroenterology and general surgery outpatient clinic and service between years 2015-2021 were included. The clinical, laboratory, radiological and surgical results of 171 patients with hydatid cysts were retrospectively analyzed. Results: The mean age of 171 patients who underwent surgery for hydatid cyst was 44.8 (18-71), 68 of whom were men and 103 were women. Bile leakage was present in 50 patients (50 (29.23%)). There were 24 (48%) men and 26 (52%) women with bile leakage. The cyst diameter was 74.2 (36-170) mm and the number of cysts was 1.2 (1-2). The cysts were located in the right lobe of the liver in 116 (79%) patients, in the left lobe in 30 (15%) patients, and in both lobes in 25 (6%) patients. Cystobiliary fistula developed more frequently, especially in cysts located in the right lobe(36 (72%)). Cystobiliary fistula was most common in CE3 (Gharbi type 2) type (30 (60%)). Cystectomy+drainage was performed in 137 (80%) patients in all groups. Cystectomy and drainage were the most common surgical procedures. The cyst diameter was 10 cm in the group with cystobiliary fistula and was significant compared to the group without fistula (p&amp;lt;0.001). Aminotransferase (AST and ALT) levels were high in patients with cystobiliary fistula (p=0.012, p=0.054). However, there was no significant difference between the two groups in alkaline phosphatase, total bilirubin, and gamma glutamyl transferase (p=0.231, p=0.097, p=0.544). Conclusion: Liver hydatid cyst is endemic in our country as well as in many other countries in the world. Complicated hepatic hydatid cysts require timely and appropriate treatment because of their life-threatening complications. Cytobiliary fistula is the most common complication. In the surgical treatment of hydatid cyst disease, the earlier the diagnosis of occult cystobiliary fistulas is made (especially in the preoperative or peroperative period), the easier the treatment is, and the risk of bile leakage and consequently the morbidity and mortality decreases. Our results and experience showed that treatment and complications are related to the location and size of the cyst, occult/large cystobiliary fistula, detectability of occult fistulas, experienced center and surgeon.

Only one-third of referrals for fatty liver disease are on time: real-world study reveals opportunities to avoid unnecessary and delayed referrals

Background and aims Fatty liver disease is a global health concern, but in the absence of specific guidelines, current referral patterns differ according to the preferences of the general practitioners. Outpatient Gastroenterology clinics spend futile resources on liver-healthy patients while diagnosing decompensated patients delayed. We aimed to describe referral patterns to a regional outpatient Gastroenterology clinic. Methods We reviewed 9684 referrals from primary care for suspected liver disease in the years 2016–2017, during two years. Data were extracted from the patients’ hospital records to assess the clinical workup and patient outcomes until a mean of 43 months after the time of referral. Referrals were categorized as unnecessary (no signs of liver disease), timely (significant fibrosis/compensated cirrhosis), or delayed (decompensated cirrhosis). Results We included 375 patient referrals from primary care. The main reason for referral was elevated transaminases. More than half (54%) of patients had no signs of liver disease, being unnecessarily referred for evaluation, while 17% had decompensated liver disease and were thus referred too late. Conclusions Only one-third of patients referred on suspicion of liver disease were referred on time, either before presenting with decompensated liver cirrhosis or with some evidence of significant liver disease, e.g., liver fibrosis. There is a huge unmet need for clinical referral pathways in primary care. Strengths and Limitations of this Study A strength of this study is the complete mapping of all potential referrals to the outpatient clinic in the two-year period. Instead of retrieving the historic data by ICD-10 diagnosis codes, and reflecting only those patients where the GP clearly suspects liver disease, we have a strong reliance on our methods. We screened all potentially relevant referrals, e.g., referrals due to weight loss or fatigue, which may reflect symptoms of cirrhosis. Thereby we are confident that we have not missed any patients that originally were referred with unspecific symptoms, but after evaluation are diagnosed with liver disease. Another strength of our study is the long follow-up period, which allows us to fully evaluate the course for the individual patient, and the potential later coming diagnoses. Finally, it is a strength of the study that we were not exclusive to one liver disease etiology, both ALD and NAFLD etiology were included in the study. A limitation of this study is the use of historic data, and the fact that it is a single-center study, showing only the referral patterns in one outpatient Gastroenterology clinic.

The relationship between helicobacter pylori infection and nodular antral gastritis in pediatric patients

Helicobacter pylori (H. pylori) is a spiral-shaped gram-negative bacterium that colonizes the gastric mucosa. It is a common infectious agent in children. In this study, we aim to evaluate the demographic data, and the clinical and histopathological findings of pediatric patients that underwent upper gastrointestinal endoscopy (UGSE) in our clinic. Between July 2017 and February 2019, 636 patients applied to the Selcuk University Faculty of Medicine, Pediatric Gastroenterology outpatient clinic with complaints of epigastric abdominal pain and/or dyspeptic complaints. Patients who underwent upper gastrointestinal endoscopy were evaluated retrospectively. Data on age, gender, family history of peptic ulcer disease, and family history of H. pylori were recorded. Endoscopic and histopathological findings were collected from medical records. 235 (36.9%) of the patients participating in the study were male, and 401 (63.1%) were female. H. pylori infection was detected in 277 (43.6%) patients as a result of histopathological examination of H. Pylori, urea breath tests and H. Pylori antigen tests in the stools of patients are included in the study. Nodular antral gastritis was detected in 282 (44.3%) of our patients endoscopically. H. pylori was detected in 83.7% (n: 236) of the 282 patients with nodular antral gastritis. Nodular antral gastritis was observed to be significantly higher in H. pylori-positive patients than in H. pylori-negative cases (odds ratio (OR), 39.16; 95% confidence interval (CI), 24.88-61.64; p: <0.001). Nodular antral gastritis is caused by chronic H. pylori infection. It is predicted that early detection of H. pylori infection in children is important and may decrease complications later in life. Our study shows that all the markers evaluated are very good predictors of H. pylori infection. Positive significant association was found between the prevalence of H. pylori infection and nodular antral gastritis.

Incidental Finding During Colonoscopy

Question: A 36-year-old man with a past medical history significant for type 2 diabetes mellitus and hyperlipidemia presented to the outpatient gastroenterology clinic due to unintentional 30-pound weight loss and diarrhea for the past year. He noted that his symptoms had been progressive over the last several months occurring on a daily basis. His diabetes had been under tight control with insulin, semaglutide, and metformin. Routine blood work including a complete metabolic panel, complete blood count, and thyroid studies were all within the normal limits. He had a remote history of a prior abnormal colonoscopy, however, a full report was unavailable and he reportedly failed to return for appropriate follow-up. Due to his symptoms, the patient was set up for a repeat colonoscopy. During colonoscopy, several large submucosal polypoid lesions were seen from the hepatic flexure to the proximal ascending colon. Several of the larger lesions were removed with snare to obtain adequate tissue. The endoscopic images can be seen in Figures A, B, and C. Pathology is shown in Figure D. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Pneumatosis Cystoides Intestinalis is a rare disease characterized by gas-filled cysts in the submucosa and/or subserosa tissue. These lesions can be found anywhere in the gastrointestinal tract. Clinical presentation varies, with many patients being asymptomatic. Others may experience diarrhea, constipation, weight loss, and abdominal distention. The pathogenesis is also not clear regarding the disease. Most are thought to be idiopathic, however, there have been some iatrogenic causes that have been linked. These include postsurgical complications, certain medications, diabetes, emphysema, and autoimmune diseases (most notably systemic sclerosis) as some of the potential culprits.1Wang Y.J. Wang Y.M. Zheng Y.M. et al.Pneumatosis cystoides intestinalis: six case reports and a review of the literature.BMC Gastroenterol. 2018; 18: 100Crossref PubMed Scopus (35) Google Scholar Abdominal X-ray and computed tomography abdomen have a utility in establishing the gas pattern in intestines, but endoscopy with ultrasound and/or colonoscopy with biopsy confirms the diagnosis. Treatment for symptomatic patients includes hyperbaric oxygen, antibiotics with probiotics, endoscopic resection, or removal of the offending agent causing the disease.2Azzaroli F. Turco L. Ceroni L. et al.Pneumatosis cystoides intestinalis.World J Gastroenterol. 2011; 17: 4932-4936Crossref PubMed Scopus (51) Google Scholar As for the patient, his symptoms resolved with discontinuation of his semaglutide. He did not require any further treatment for the incidental finding of Pneumatosis Cystoides Intestinalis in his colon.

Evaluation of Patients with Diarrhea Applying to the Outpatient Gastroenterology Clinic of Research Hospital

Objectives: Diarrhea is a common health problem and may occur for many infectious and non-infectious causes. In this study, it was aimed to investigate the causes, methods used in diagnosis and the results obtained in patients who applied to the gastroenterology clinic with the complaint of diarrhea. Materials and methods: 187 patients who presented with diarrhea between 01.11.2019-01.11.2020 were included in this study. Results: Acute diarrhea was detected in 32 (17.1%) out of 187 patients, persistent in 34 (18.2%), and chronic diarrhea in 121 (64.7%). The cause of diarrhea was detected in 148 (79.1%) patients. Infectious cause in 66 (%44.6) patients; inflammatory bowel disease (IBD) in 41 (27.7%) patients; irritable bowel syndrome (IBS) in 22 (14.9%) patients and less frequently as other diagnose were listed. The cause of diarrhea was detected in 73.6% of patients with chronic complaints, and this rate was 87.5% in acute diarrhea; and 91.2% of those presenting with persistent diarrhea (p = 0.04). Lower C reactive protein levels were found in irritable bowel syndrome compared to other diarrheal causes (p&lt;0.001). It was observed that anti-infective treatment was used more frequently in acute and persistent diarrhea compared to chronic diarrhea (p &lt;0.001). Conclusion: Although application to outpatient clinics were more frequent due to chronic diarrhea, acute and persistent diarrhea were also not rare (35.3%). The reason to explain diarrhea has been found in the majority of patients. Infectious induced diarrhea was seen as the most common cause, it was followed by IBD and IBS, respectively. When prescribing anti-infective agents, clinical, laboratory and microbiological results should be considered and inappropriate drug use should be avoided.

Adverse Childhood Experiences and Their Effect on Irritable Bowel Syndrome Among Saudi Arabian Adults.

BackgroundAdverse childhood experiences (ACEs) are traumatic events that occur before 18 years of age. ACEs have been associated with many negative health problems, including the development of chronic diseases, such as irritable bowel syndrome (IBS), a functional gastrointestinal disorder characterized by abdominal pain. We investigated the prevalence of ACEs among patients with IBS, identified the types of ACEs commonly related to patients with IBS, and further assessed the impact of ACEs on IBS severity.MethodologyA cross-sectional study was performed. The study targeted patients with IBS aged ≥ 18 years who were recruited from gastroenterology outpatient clinics at King Abdulaziz University Hospital. Adults were contacted and invited to take part in the study by completing a survey. Data were collected using two validated questionnaires, the ACE questionnaire for adults and the IBS symptom severity scoring system.ResultsThe study included 109 patients with IBS (59.6% females). The prevalence of ACEs (patients with IBS exposed to at least one ACE) was 63.3%. The most prevalent type was emotional abuse (34.9%), followed by both physical abuse and emotional neglect (28.4%). Females reported significantly more ACEs (p = 0.035) than males. The overall IBS symptoms (r = 0.195, p = 0.043) and abdominal pain (r = 0.240, p = 0.012) severity were significantly correlated with total ACEs score.ConclusionsOur findings point to a probable association between ACEs exposure and IBS, demonstrating their long-term impacts on symptoms severity. Further studies are needed to acquire a better understanding of the potential impact of ACEs on IBS.

CLINICAL SPECTRUM OF FUNCTIONAL CONSTIPATION AND BOWEL-HABIT PATTERNS OF SCHOOLCHILDREN RECRUITED FROM TWO ELEMENTARY SCHOOLS AND A SPECIALIZED OUTPATIENT CLINIC.

Early diagnosis of functional constipation is important for reducing its negative consequences on the health of children and adolescents. To describe the clinical spectrum of functional constipation and bowel habit patterns in schoolchildren recruited from two primary schools and patients from a pediatric gastroenterology outpatient clinic. This cross-sectional study included 452 students from two elementary schools in the city of Osasco and 81 patients with functional constipation seen in an outpatient clinic specializing in pediatric gastroenterology. All children were aged between 6 and 12 years. The Rome IV criteria (two features for more than 1 month) and the Bristol scale were used. The prevalence of functional constipation among the elementary school students was 22.3% (n=101). Among the 351 students who did not have functional constipation, 182 (51.9%) had one of the clinical manifestations of the Rome IV criteria. Bristol stool scale types 1 and 2 were observed in 14 (8.3%) of the 169 students without any clinical manifestation of the Rome IV criteria and in 28 (15.4%) of the 182 students who presented one of the Rome IV criteria for functional constipation (P=0.060). A comparison of the clinical manifestations of children with functional constipation identified at school in relation to those seen at the specialized clinic showed the following differences: fewer than two bowel movements per week (21.8% and 54.3%; P<0.001, respectively), one or more episodes of fecal incontinence per week (14.8% and 53.1%; P<0.001), and retentive posturing (70.3% and 40.7%, P<0.001). Only 18 (17.8%) of the 101 students identified at the schools with functional constipation had received any treatment for this disease in the previous 2 months. As expected, the frequency of more severe clinical manifestations was higher in children seen at specialized clinics. Only a small proportion of the children identified with functional constipation at primary schools had undergone any form of treatment in the previous 2 months. More than half of the children without functional constipation in elementary schools reported one of the Rome IV clinical manifestations. Finally, functional constipation has a broad clinical spectrum and also requires attention for the prevention and the management of its early clinical manifestations.

Utilization of Pediatric Psychology Services in Outpatient Pediatric Gastroenterology Within a Rural Health System

Increased utilization of pediatric psychology services has been demonstrated following integration into urban pediatric gastroenterology clinics; however, examination within rural health systems is lacking. Utilization of pediatric psychology services was assessed through a retrospective analysis of Electronic Health Record data contrasting referrals occurring six months pre- and post-integration of pediatric psychology in an outpatient pediatric gastroenterology clinic within a rural setting. Significant increases in the number of referrals to pediatric psychology and number of billed initial visits were observed after integration, as was a significant decrease in time to be seen. Patients with public insurance were 3.1 times more likely to complete a billed initial visit compared with patients with nonpublic insurance. The current findings support the integration of pediatric psychology within rural outpatient pediatric gastroenterology clinics to increase utilization and allow more traditionally underserved families to benefit from these services.

Impact of Telehealth on Medication Adherence in Chronic Gastrointestinal Diseases.

BackgroundWith the COVID-19 pandemic, the demand and availability of telehealth in outpatient care has had exponential growth. Although use of telehealth has been studied and validated for various medical specialties, relatively few studies have looked at its role in gastroenterology.AimTo assess effectiveness of telehealth medicine in gastroenterology by comparing medication adherence rate for patients seen with telehealth and traditional in-person appointment for various gastrointestinal conditions.MethodsRetrospective chart review of patients seen in outpatient gastroenterology clinic was performed to identify patients who were given prescription to fill either through telehealth or in-person appointment. By using provincial pharmacy database, we determined the prescription fill rate.ResultsA total of 206 patients were identified who were provided new prescriptions or prescription renewal at their gastroenterology clinic visit. One hundred and three patients were seen through in-person visit during pre-pandemic period, and 103 patients were seen through telehealth appointment during COVID-19 pandemic. The mean age of patients was 49.2 years (55% female). On average, patients had 4.7 previous visits with their gastroenterologists before their visit. IBD management was the most common reason for visits (37.9% and 46.6% in telehealth and in-person groups, respectively). Prescription fill rate for patients seen through telehealth was 92.2% compared to 81.6% for the in-person group (OR: 2.69, 95% CI: 1.12–6.45; P = 0.023).ConclusionsMedication adherence rate for telehealth visits was higher than for in-patient visits. These findings suggest that telehealth can be an effective method of care delivery, especially for patients with chronic gastrointestinal conditions like IBD.

Self-reported Non-celiac Gluten Sensitivity in the Korean Population: Demographic and Clinical Characteristics.

Background/AimsNon-celiac gluten sensitivity is characterized by intestinal and extra intestinal symptoms associated with the consumption of gluten-containing food. Since biomarkers for non-celiac gluten sensitivity are lacking, its prevalence is estimated based on self-reported symptoms. However, no data exist on self-reported non-celiac gluten sensitivity in the Korean population. Thus, we aim to investigate the prevalence of self-reported non-celiac gluten sensitivity in the Korean population and to determine its demographic and clinical characteristics.MethodsThis study surveyed Korean participants aged 18-80 years who visited gastroenterology outpatient clinics at 9 tertiary hospitals in South Korea from January 2016 to February 2017. They were questioned regarding symptoms related to gluten ingestion degree of discomfort (visual analog scale score), frequency, time of symptom onset, and duration. Abdominal discomfort caused by 11 different kinds of gluten-containing Korean food items was investigated.ResultsMore non-celiac gluten sensitivity self-reporters were identified among those with irritable bowel syndrome (33.6%) than among controls (5.8%). Major gastrointestinal symptoms included bloating (75.0%), abdominal discomfort (71.3%), and belching (45.0%). Common extra-intestinal symptoms included fatigue (20.0%) and headache (13.7%). More than half of those who self-reported non-celiac gluten sensitivity (66.3%) developed symptoms within 1 hour of food ingestion, and symptoms were localized in the upper abdomen (37.5%) and entire abdomen (30.0%).ConclusionOur findings suggest that if there are gluten-related symptoms in irritable bowel syndrome, the possibility of accompanying non-celiac gluten sensitivity should be considered.