Normal Endoscopic Findings Research Articles

Correlation between Clinical and Endoscopic Findings in Patients with Dyspepsia at a Tertiary-Care Hospital of Bangladesh

Background: Dyspepsia is a prevalent symptom worldwide, affecting 7%-34.2% of populations, and has a significant impact on patients and healthcare systems. The study aimed to investigate the relationship between clinical and endoscopic findings to improve cost-effectiveness in endoscopy. Materials and methods: This observational study was conducted at the Department of Gastroenterology, Chattagram Maa-O-Shishu Hospital Medical College (CMOSHMC) over a period of 34 months from January 2020 to October 2022. Study population was patients aged 18 years and above with dyspepsia symptoms referred from various departments of this hospital for upper gastrointestinal tract endoscopy. Results: The study involved 705 patients, with the largest age group experiencing dyspepsia symptoms being 28-37 years old (25.5%). Dyspepsia was more prevalent in patients below 57 years old (83.1%) compared to those above 57 years old (16.8%). Females had a higher incidence of dyspepsia than males, with a ratio of 1.9:1. Abdominal pain was the most common symptom (43.96%). Endoscopic findings included peptic ulcers (14.6%), gastric ulcer (8.36%), duodenal ulcer (6.24%), gastritis (32.48%), oesophagitis (13.33%), gastric carcinoma (1.84%), and normal results (34.60%). Female gender was associated with normal endoscopic findings (p<0.05). Conclusion: The study concludes that both uninvestigated and functional dyspepsia was more prevalent in females. Abdominal pain was the most common complaint followed by abdominal burning. The study also revealed that prevalence of functional dyspepsia decreases with age, giving way to organic lesions. Gastritis was a frequent endoscopic finding; however, its clinical relevance is uncertain><0.05). Conclusion: The study concludes that both uninvestigated and functional dyspepsia was more prevalent in females. Abdominal pain was the most common complaint followed by abdominal burning. The study also revealed that prevalence of functional dyspepsia decreases with age, giving way to organic lesions. Gastritis was a frequent endoscopic finding; however, its clinical relevance is uncertain. Chatt Maa Shi Hosp Med Coll J; Vol.22 (2); July 2023; Page 31-35

Prevalence of Helicobacter Pylori Infection Among Dyspepsia Patients in a Tertiary Care Hospital of Puducherry

Background: Dyspepsia is a relatively common clinical condition characterized by chronic / recurrent upper abdominal pain or discomfort. Dyspeptic individuals were found to be infected with H-pylori than asymptomatic individuals. Though most individuals are asymptomatic, H. pylori plays a key role in the etiology of many upper gastrointestinal disorder. Materials and Methods: This cross-sectional prospective analytical study was done in Department of General surgery, IGMCRI Pondicherry from February 2022 to June 2022. Both male and female patients attending surgery OPD of age 20 to 60 years with upper gastrointestinal symptoms like dyspepsia and epigastric pain were subjected to upper gastrointestinal endoscopy and scopy findings noted and a Rapid urease test done for them. Results: The prevalence of H-Pylori was found to be 53%. Gender wise distribution shows more prevalence among females (61%) compared to males (44%). Of the total patients, 72% presented with abdominal pain, 34% presented with associated nausea, vomiting and 50% presented with regurgitation, 47% presented with bloating sensation. 11% present with other associated symptoms like malena and dysphagia. 9 patients with dyspepsia had ulcers in the antral wall and duodenum with 33% RUT positivity. 11 of them presented with pangastritis with 72% RUT positivity, 47 of them had antral gastritis with 66% RUT positivity, and 15 of them were found to have normal endoscopic findings with 33% RUT positivity.47% of the patients with esophageal varices and 20% of the patients with ulceroproliferative growth showed RUT positivity. Conclusion: This study validates that more than half the patients with dyspepsia in our population are H-pylori positive. Early referral for Upper GI endoscopy can help diagnose the same and associated clinical condition and initiate an early anti-H. Pylori regimen to achieve quicker symptom relief in these patients.

Impact of Esophageal Motility on Microbiome Alterations in Symptomatic Gastroesophageal Reflux Disease Patients With Negative Endoscopy: Exploring the Role of Ineffective Esophageal Motility and Contraction Reserve.

Ineffective esophageal motility (IEM) is common in patients with gastroesophageal reflux disease (GERD) and can be associated with poor esophageal contraction reserve on multiple rapid swallows. Alterations in the esophageal microbiome have been reported in GERD, but the relationship to presence or absence of contraction reserve in IEM patients has not been evaluated. We aim to investigate whether contraction reserve influences esophageal microbiome alterations in patients with GERD and IEM. We prospectively enrolled GERD patients with normal endoscopy and evaluated esophageal motility and contraction reserve with multiple rapid swallows during high-resolution manometry. The esophageal mucosa was biopsied for DNA extraction and 16S ribosomal RNA gene V3-V4 (Illumina)/full-length (Pacbio) amplicon sequencing analysis. Among the 56 recruited patients, 20 had normal motility (NM), 19 had IEM with contraction reserve (IEM-R), and 17 had IEM without contraction reserve (IEM-NR). Esophageal microbiome analysis showed a significant decrease in microbial richness in patients with IEM-NR when compared to NM. The beta diversity revealed different microbiome profiles between patients with NM or IEM-R and IEM-NR (P = 0.037). Several esophageal bacterial taxa were characteristic in patients with IEM-NR, including reduced Prevotella spp. and Veillonella dispar, and enriched Fusobacterium nucleatum. In a microbiome-based random forest model for predicting IEM-NR, an area under the receiver operating characteristic curve of 0.81 was yielded. In symptomatic GERD patients with normal endoscopic findings, the esophageal microbiome differs based on contraction reserve among IEM. Absent contraction reserve appears to alter the physiology and microbiota of the esophagus.

Unraveling the Mind-Gut Connection: Investigating Anxiety and Depression in Functional Dyspepsia

Psychological association with functional dyspepsia underscores the importance of a holistic approach to its management, addressing both physical and psychological aspects of the condition. Objective: To determine the relationship of anxiety and depression with severity of dyspepsia. Methods: A prospective cross sectional study was carried out in the Endoscopy Unit, Department of Gastroenterology, Baqai Medical Institute. All patients fulfilling the Rome III criteria for functional dyspepsia with normal endoscopy findings were included in the study, Pregnant females, patients with known diabetes, chronic kidney disease, chronic liver disease and known psychiatric illness, history of peptic ulcer disease and use of NSAIDs, steroids or alternative medicine were excluded. Severity of dyspepsia was assessed by Short Form Leeds Dyspepsia Questionnaire (SF-LDQ). Whereas hospital anxiety and depression scale (HADS) was used to assess the psychological factors. Results: A total of 223 participants were included in the study. Out of 223 participants, majority 55.6% (124) had moderate dyspepsia, followed by severe dyspepsia 26.9% (60), mild dyspepsia 12.6% (28) and very mild dyspepsia 4.9% (11). Using Hospital Anxiety And Depression Scale (HAD-S), we found that out of 223 participants, 56.5% (126) had moderate to severe anxiety and depression while 29.1% (65) had mild anxiety and depression. Conclusions: It was concluded that functional dyspepsia is clearly associated with common psychological disorders like depression and anxiety. Early recognition and timely linkage to care in such cases can considerably improve the health-related quality of life and hence decrease the global burden of this common disorder.

The relationship between peritoneal membrane permeability and dyspepsia in peritoneal dialysis patients.

The aim of this study is to determine whether there is a relationship between peritoneal membrane permeability and dyspepsia in peritoneal dialysis patients. This study included 95 peritoneal dialysis patients aged 18 and older. The presence of dyspepsia in patients was recorded according to the 2016 ROME-IV Functional Dyspepsia Diagnostic Criteria. Subsequently, the Glasgow Dyspepsia Severity Score questionnaire was administered to assess the severity of dyspepsia. Endoscopy was performed for those who agreed to exclude organic pathology, or the results of endoscopy conducted within the last 2years were recorded. Furthermore, stool samples were examined for H. pylori to exclude organic causes of dyspepsia. PET (peritoneal equilibration test) and Kt/V values of patients were calculated using the "PD Adequest" computer software. PET values were categorized as low and low-normal for low permeability and high and high-normal for high permeability. Dyspepsia was detected in 51.6% of all peritoneal dialysis patients. H. pylori was found positive in 11.6% of all patients and 12.2% of those with dyspeptic symptoms. There was no significant difference in the rate of H. pylori occurrence between low and high permeability groups. The Glasgow Dyspepsia Severity Score did not differ significantly between H. pylori-positive and -negative patients. Dyspepsia was more frequent and severe in the low permeability group. Dyspepsia in the low permeability group was mostly considered as functional dyspepsia due to the predominance of normal endoscopic findings. Dyspepsia is a common health problem in approximately half of peritoneal dialysis patients. Dyspepsia observed in those with low peritoneal membrane permeability is generally of functional origin. Furthermore, the frequency and severity of dyspepsia are higher in individuals with low permeability. When planning peritoneal dialysis for these patients, the current status should be taken into consideration, and patients should be informed about necessary precautions and recommendations.

Esophageal Lichen Planus: A Descriptive Multicenter Report.

To better understand the characteristics, treatment approaches, and outcomes of patients with esophageal lichen planus (ELP). ELP is a rare, often unrecognized and misdiagnosed disorder. Data on this unique patient population are currently limited to small, single-center series. A multicenter, retrospective descriptive study was conducted of adults diagnosed with ELP over a 5-year period, between January 1, 2015, and October 10, 2020, from 7 centers across the United States. Seventy-eight patients (average age 65y, 86% female, 90% Caucasian) were included. Over half had at least 1 extraesophageal manifestation. Esophageal strictures (54%) and abnormal mucosa (50%) were frequent endoscopic findings, with the proximal esophagus the most common site of stricture. Approximately 20% had normal endoscopic findings. Topical steroids (64%) and/or proton pump inhibitors (74%) dominated management; endoscopic response favored steroids (43% vs. 29% respectively). Almost half of the patients required switching treatment modalities during the study period. Adjunctive therapies varied significantly between centers. Given its at times subtle clinical and endoscopic signs, a high index of suspicion and biopsy will improve ELP diagnosis, especially in those with extraesophageal manifestations. Effective therapies are lacking and vary significantly. Prospective investigations into optimal treatment regimens are necessary.

S1754 The Efficacy and Yield of Routine Duodenal Biopsy for the Diagnostic Evaluation of Celiac Disease in Patients With Normal Endoscopic Findings

S1754 The Efficacy and Yield of Routine Duodenal Biopsy for the Diagnostic Evaluation of Celiac Disease in Patients With Normal Endoscopic Findings

Discrepancy between Abdominal Symptoms and Endoscopic Findings in Patients with Gastro-duodenal Eosinophilia: A Case Series.

Some patients present gastro-duodenal eosinophilia without abdominal symptoms. Nine cases with gastro-duodenal eosinophilia were seen at the Tohoku University Hospital between January 2011 and June 2022. Seven (78%) patients had a background of allergic or hyper-eosinophilic disease. Esophagogastroduodenoscopy showed erosions (n=6), discoloration (n=4), ulcers (n=3), erythema (n=3), muskmelon-like appearance (n=2), and cracks (n=1). Two cases were asymptomatic with eosinophilic gastroenteritis (EGE)-like endoscopic findings, and two were symptomatic with normal endoscopic findings. The discrepancy between the abdominal symptoms and esophagogastroduodenoscopy findings suggests that clinicians should assess patients for background allergic disease, regardless of abdominal symptoms.

Topic: Education/Training Abstract ID: 18 The Efficacy and Yield of Routine Duodenal Biopsy Sampling and Histopathological Analysis Versus Endoscopic Gestalt for the Diagnostic Evaluation of Celiac Disease in Patients With Normal Endoscopic Findings: An Experience at a Tertiary Care Center

Topic: Education/Training Abstract ID: 18 The Efficacy and Yield of Routine Duodenal Biopsy Sampling and Histopathological Analysis Versus Endoscopic Gestalt for the Diagnostic Evaluation of Celiac Disease in Patients With Normal Endoscopic Findings: An Experience at a Tertiary Care Center

A survey of flexible bronchoscopy practice at Kenyatta National Hospital, Kenya

Objectives: Flexible bronchoscopy (FB) is an essential diagnostic and therapeutic tool for managing respiratory diseases, and an audit of its practice is important; it enhances standardization of practice and improves outcomes and patient safety. This study aimed to describe the FB practice at Kenyatta National Hospital (KNH) regarding indications, peri-procedure practice, gross and histologic findings, and safety. Materials and Methods: This study was a quantitative and retrospective chart review of files of 282 patients who underwent flexible bronchoscopies over 5 years in KNH. Results: We reviewed 282 flexible bronchoscopies done between January 2016 and December 2020. There was a significant documentation gap (22%); 54 out of the 282 cases audited had incomplete documentation. The male-to-female ratio was 1:1, with a median age of 51 years. Most (58.2%) of the patients were residents of counties outside Nairobi. Despite a lack of evidence for routine evaluation, we noted significant rates (75.9%) of routine laboratory evaluations (International normalized ratio (INR), platelet count). The most common indication of bronchoscopy was the evaluation of a lung mass (100) 35.7%, pulmonary infiltrate 53 (18.9%), and assessment for interstitial lung disease 39 (13.9%). The most common gross bronchoscopic findings were visible tumors at 38.5% (107) and normal endoscopic findings at 29.5% (82). The practice was safe, with a complication rate of 3.2%. The most common diagnostic outcome was lung cancer (40.1%), with adenocarcinoma being the most common (45.1%) histologic subtype. The diagnostic yield for malignancy where there was a visible tumor was 87.2%. Conclusion: Our study showed that FB practice at KNH is safe and provides a good diagnostic yield, but a significant documentation gap and record keeping exist. Adenocarcinoma was the most predominant lung cancer histologic subtype among the mostly non-smoker population.

Quality of life and severity of symptoms among patients with various degrees of reflux esophagitis: a prospective study

Gastro-esophageal reflux disease (GERD) can cause erosive esophagitis (EE) and compromise the quality of life (QoL). We examined differences in symptom severity and QoL according to EE severity grade. A follow-up study was conducted among GERD patients at the Nazareth Hospital in Israel. Patients underwent a baseline gastroscopy in 2014–2020 during which the EE grade was determined using the Los Angeles classification. Follow-up telephone interviews were conducted during 2019–2020 with a mean time interval of 18.9 months (SD = 14.9) after the baseline gastroscopy to assess GERD symptoms using the Reflux disease questionnaire (RDQ) and QoL using the GERD QoL questionnaire. The patients were interviewed in their native language (Arabic or Hebrew). Overall, 149 (66.4% males) patients were included; 50 had EE grades C/D and 99 had grades A/B. The mean age at baseline and follow-up was 44.6 years (SD = 15.1) and 46.2 years (SD = 14.9), respectively. Cronbach’s alpha was 0.928 and 0.855 for the RDQ and QoL questionnaires, respectively. Patients with EE C/D grades had more severe symptoms than patients with EE A/B grades (P = 0.05), especially in regurgitation scores (P = 0.03). Females had more severe symptoms (overall) than males (adjusted OR = 2.34; 95% CI 1.12–4.90). Patients with the more severe esophagitis EE C/D group (adjusted OR = 1.98; 95% CI 0.93–4.24) and those who used PPIs treatment (adjusted OR = 2.19; 95% CI 0.95–5.01) reported more severe GERD symptoms. The number of schooling years was significantly associated with better QoL score (beta coefficient 1.33, P = 0.005) but not EE grade or GERD symptoms. Follow-up endoscopy conducted among 22 patients with EE grades C/D showed that 13 (59.1%) of these patients had normal endoscopic findings, 6 patients (27.3%) had a grade A EE, 1 patient (4.5%) had grade B, and 2 (9.1%) remained with grade C EE. The Arabic and Hebrew versions of the RDQ and QoL questionnaires were highly reliable. GERD symptoms severity was more profound among patients with more severe esophagitis. No significant association between EE grade and QoL; this negative result might be due to the improvement in esophagitis endoscopic findings among patients with C/D grade.

Clinical features of upper gastrointestinal endoscopy in 3146 patients: a 9-year retrospective cohort study in Zanzibar Archipelago, Tanzania.

To investigate the demographic features, primary endoscopic findings, and the status of Helicobacter Pylori (H. pylori) infection of the enrolled subjects who underwent upper gastrointestinal endoscopy (UGIE) in the Zanzibar Archipelago, Tanzania. Between December 2013 and October 2021, a total of 3146 eligible participants were finally recruited in present retrospective cohort. Demographic information and endoscopic findings of each participant was retrieved. H. pylori infection was confirmed by rapid-urease test of gastric antral and body biopsies at endoscopy. Among the recruited subjects, 1691 (53.76%) are females, remaining 1455 (46.24%) are males. The median age of this retrospective cohort was 40 years ranging from 8 to 97 years. The common identified endoscopic findings included gastro-duodenitis, normal endoscopic finding, peptic ulcer disease (PUD), esophagitis, esophagogastric varices, esophageal and gastric cancer, respectively. After adjustment for sex and age, a significant risk of gastric and/or duodenal ulcer (OR, 2.51; 95% CI, 1.82-3.48, P<0.001) and gastric cancer (OR, 3.49; 95% CI, 1.27-9.58, P=0.015) in H. pylori positive group was observed. Stratified analysis indicated a significant relationship between duodenal ulcer with younger age (adjusted OR, 0.98; 95% CI, 0.97-0.99, p = 0.002), and the presence of H. pylori (OR, 2.01; 95% CI, 1.12-3.91, p= 0.021). The present study revealed that gastro-duodenitis, PUD, and normal finding are the most common endoscopic diagnoses in Zanzibar. The presence of H. pylori is significantly associated with duodenal ulcer and gastric cancer.

Reflux definitions in esophageal multi-channel intraluminal impedance.

In this study, we aim to propose consensus-based interpretations to enhance both automatic, and manual analysis and then present our recommendations about reflux-related variables to enhance Multichannel Intraluminal (MII) measurements. Multichannel Intraluminal Impedance-pH (MII-pH) monitoring is the most sensible option to evaluate Gastroesophageal Reflux Disease (GERD), specifically for the patients with normal endoscopy findings, and persistent symptoms without response to Proton Pomp Inhibitor therapy. There were only a few studies on the interpretation of reflux events in MII tracings. Several 200 episodes of reflux events were reviewed during several meetings in five steps, to discuss and categorize unresolved issues within existing interpretations, and propose technical principles for accurate characterization of reflux events. In this study, we show that baseline impedance is determined using a moving average procedure to the impedance data of each channel with a time window of 60 seconds based on this finding; a liquid reflux event is defined as a retrograde 50% drop in baseline impedance, gas reflux event is defined as a rapid increase in impedance greater than 5 kΩ, Mixed liquid-gas reflux is defined as gas reflux occurring immediately before or during liquid reflux. The reliability of final diagnosis is significantly dependent on the accurate detection of reflux events, which is currently confronting technical limitations. A pathological reflux event propagates to at least three of the impedance sites, according to the literature. We think that taking three impedance locations into account might be too strict.

Is mastocytic colitis a specific clinical-pathological entity?

The number of intestinal mast cells (MC) is increased in several types of colitis, but the mucosa of patients with chronic non-bloody diarrhea has not been studied. The current study sought to determine the relationship between MC counts and degranulation and the severity of symptoms in patients with chronic loose stools. Following a negative laboratory workup for the most common causes of chronic diarrhea, patients with chronic non-bloody loose stools were included in the study. Patients with macroscopic evidence of inflammation or organic disease were excluded after endoscopy with biopsies. Biopsies from the 179 patients in the study were stained with hematoxylin and eosin and anti-CD117 c-kit antibodies. Immunohistochemistry was used to assess the degree of MC degranulation. Out of the 179 patients, 128 had normal histologic findings suggestive of irritable bowel syndrome and were used as controls. Twenty-four presented with abnormally high MC counts (≥40 MC x HPF), 23 with ≥20 intraepithelial lymphocytes x HPF suggesting lymphocytic colitis, and 4 had both (≥40 MC and ≥20 intraepithelial lymphocytes x HPF). In the patients with high MC counts, figures were significantly higher in the right colon versus the left colon (p=0.016), but degranulation did not differ in the right versus the left colon (p=0.125). No age or sex-related difference was observed (p=0.527 and p=0.859 respectively). The prevalence of abdominal pain and bloating did not differ in the three groups (p=0.959 and p=0.140, respectively). Patients with lymphocytic colitis (p=0.008) and those with high MC counts (p=0.025) had significantly higher evacuation rates compared to controls. There was no difference between these two groups (p=0.831). Mast cell degranulation was not associated with the number of evacuations, abdominal pain, or bloating (p=0.51; p=0.41; p=0.42, respectively). The finding that a significantly higher number of evacuations was linked to increased MC in the colonic mucosa of a subset of patients with otherwise normal laboratory and endoscopic findings suggests that "mastocytic colitis" may be a new clinical-pathological entity responsible for chronic non-bloody diarrhea. Prospective studies with a larger number of patients, as well as endoscopic and histological follow-up, are needed to confirm this hypothesis.

Clinical presentation and endoscopic findings in adult patients with eosinophilic esophagitis

Background/Aim: The frequency of eosinophilic esophagitis has been rising over the last decades. It is diagnosed primarily based on symptoms and endoscopic and histopathological examination findings. Although eosinophilic esophagitis is not associated with malignancy, it remains an important condition affecting both children and adults, as it is associated with morbidity such as dysphagia, food impaction, and esophageal strictures. This study aimed to define clinical and endoscopic characteristics of adult patients diagnosed with eosinophilic esophagitis based on recently recommended histopathological criteria. Methods: This retrospective cross-sectional descriptive study included 54 adult patients (mean age: 33.6 yr, range: 16–61 yr) who underwent upper gastrointestinal system endoscopy for dyspeptic complaints (epigastric pain, reflux, dysphagia, or food impaction) and diagnosed with eosinophilic esophagitis based on the latest histopathological criteria (≥15 eosinophils per high-power field). Patients with a history of malignancy were excluded. Patients’ clinical, endoscopic, and histopathological data were examined. Results: In patients diagnosed with eosinophilic esophagitis, the most common presenting complaint was dysphagia (61.1%), followed by dyspepsia (24.0%), regurgitation (16.6%), chest pain (16.6%), epigastric pain (12.9%), food impaction (11.1%), and halitosis (3.7%), without any age predilection for the complaints. White papules and linear furrow were the most frequent findings on endoscopic examination (35.1% each), followed by circular rings (24.0%), paleness (22.2%), normal endoscopic finding (20.3%), and small-caliber esophagus (11.1%). Conclusion: The diagnosis of eosinophilic esophagitis remains challenging due to considerable variations in definitions and in the relative frequencies of endoscopic findings. Therefore, we recommend combining clinical, endoscopic, and histologic criteria to establish diagnosis. The identification of standards for diagnosis in future studies is warranted.

Endoscopic Findings in Patient with Dyspepsia in Al- Ramadi General Hospital

This study including upper gastro - intestinal endoscopic findings of 1998 patients complaining from dyspepsia, 803 (40%) of them were found to have normal endoscopic findings and 1195 (60%) found to have upper gastro - intestinal abnormalities. Duodenal ulcer represents the highest frequency (24%) of these abnormalities followed by gastritis (13%), duodenitis (7%), gastro duodenitis (4.4%), hiatus hernia &amp; prolapse gastropathy (3.9%), reflux esophagitis (3.1%), gastric tumor (1.7%), gastric ulcer (1.3%), gastric outlet obstruction (1.2%) while tumor of esophagus found to be the lowest value (0.4%).Of the all examined cases as well as cases with abnormal endoscopy (1195 case), the highest number of referred cases were from the age group 21-30year, and the lowest was from the age group 81-90years. Also, we found that when the age is more than 60years of age, more than 79% of their endoscopic findings were abnormal.There were no significant sex differences among all studied cases except for tumor of esophagus and hiatus hernia as showed male predominance.

S3450 Atypical Endoscopic and Clinical Presentation of Strongyloidiasis

Introduction: Strongyloidiasis is a helminthic parasitic infection caused by the nematode Strongyloides stercoralis. Due to its replication cycle within the human host, acute infection classically presents sequentially with skin irritation, dry cough, and then non-specific gastrointestinal (GI) symptoms. Mild GI and dermatologic symptoms appear to be more prevalent in chronic infections. Here we present a case of strongyloidiasis manifesting in atypical symptoms with normal endoscopic findings. Case Description/Methods: An 81-year-old female with a medical history of diverticulosis, hypertension, type 2 diabetes mellitus, hypercholesterolemia, and chronic kidney disease was admitted to the hospital for anorexia, abdominal pain, and unintentional 26-pound weight loss over 6 months. Computed tomography of chest, abdomen, and pelvis revealed a moderate left-sided pleural effusion and uncomplicated sigmoid diverticulitis. Pleural fluid studies showed exudative features, with negative cultures and cytology. She was started on ciprofloxacin and metronidazole for diverticulitis. The patient also had a chronic iron deficiency anemia with an average hemoglobin of 7.4 g/dL. Absolute eosinophil count, total IgE, sedimentation rate, and c-reactive protein were elevated. Enteroscopy up to the mid jejunum appeared normal except for a 4 cm hiatal hernia. Random duodenal biopsies showed chronic active duodenitis with several eosinophils and parasitic organisms (Figure). Colonoscopy was deferred due to acute diverticulitis. Strongyloides serum antibodies were positive. Stool studies were not analyzed due to lab errors. The patient was treated with oral ivermectin 200 mcg/kg/day for 14 days due to concern for disseminated infection and scheduled for an outpatient endoscopy and colonoscopy. Discussion: This case highlights the need to keep parasitic infections on the differential when patients present with symptoms concerning for malignancy, such as weight loss, anemia, abnormal laboratory markers, and new pleural effusions. While S. stercoralis has been found to mimic inflammatory bowel disease, it has not been associated with diverticulitis thus far. In addition, typical endoscopic findings include edematous and erythematous mucosa with white villi, however, this patient had normal endoscopic findings despite the extent of her infection. The duodenal biopsies aided in making the diagnosis for this case and should be considered in patients with similar presentations.Figure 1.: Duodenal biopsies showing chronic active duodenitis with several eosinophils and parasitic organisms.

Clinical characteristics and outcomes of tyrosine kinase inhibitor-related lower GI adverse effects.

A variety of tyrosine kinase inhibitors (TKIs) are currently approved for the treatment of solid tumors and hematological cancers. However, TKIs are often associated with gastrointestinal (GI) adverse effects (AEs), especially diarrhea. Therefore, in the present study, we aimed to describe the clinical features and outcomes of TKI-associated lower GI AEs. This was a retrospective single-center cohort study of patients with cancer treated with TKIs from March 2016 to September 2020 who experienced diarrhea without other identifiable causes. Basic and GI AE-related characteristics and outcomes were compared using χ2 and Mann-Whitney U tests. Of 2172 patients who received TKIs over the study period, we included 228 in the final analysis. Of these, 166 (72.8%) had hematological cancers. Besides diarrhea, GI symptoms included nausea (36.4%), vomiting (21.9%), abdominal pain (15.4%), and bleeding (3.1%). Symptoms were typically mild, with 209 patients (91.7%) presenting with Common Terminology Criteria for Adverse Events grade 1-2 diarrhea. Only 5 patients (2.2%) received immunosuppressants for diarrhea treatment, 83 (36.4%) received no treatment, 29 (12.7%) received antibiotics, 101 (44.3%) received supportive antidiarrheal medications, and 17 patients (7.5%) needed TKI dose reduction or cessation of TKI use. When compared with patients with hematological cancers, those with solid tumors had a higher rate of hospitalization (29.0% vs. 7.2%; p < 0.001) and mortality (75.8% vs. 43.4%; p < 0.001) but a lower rate of recurrence of GI AEs (21.0% vs. 42.8%; p = 0.003. Only 15 patients (6.6%) underwent colonoscopy, with normal endoscopic findings in 8 patients (53.3%) and nonulcerative inflammation in 5 patients (33.3%). The inflammation universally involved the left colon. Twelve of the 15 patients who underwent colonoscopy had active colitis. In the hematological cancer group, patients with acute myeloid leukemia had a lower GI AE recurrence rate than did patients with other hematological cancers (7.2% vs. 30.1%; p = 0.001). Ten percent of cancer patients receiving TKIs experienced lower GI AEs, which were usually mild. Symptoms TKI-related GI adverse effects were nonspecific, often overlapping those of other cancer therapy-related GI AEs. Treatment of GI AEs was largely supportive, with limited roles for antibiotics and immunosuppressants.

Seronegative Celiac Disease in Patients with Isolated Refractory Dyspepsia and Gastroesophageal Reflux Disease.

Background/AimsTo investigate the presence of seronegative celiac disease in patients with isolated refractory dyspepsia and gastroesophageal reflux disease (GERD)-related complaints.MethodsThis was a single-center, prospective study performed at a tertiary care referral hospital. Among 968 consecutive patients, 129 seronegative patients with tissue damage consistent with Marsh IIIa classification or above were included. The patients were divided into two groups dyspepsia (n=78) and GERD (n=51). Biopsies were taken from the duodenum regardless of endoscopic appearance, and patients with Marsh IIIa or above damage were advised to consume a gluten-free diet. The Glasgow Dyspepsia Severity (GDS) score, Reflux Symptom Index (RSI), and Biagi score were calculated at baseline and every 3 months. Control endoscopy was performed every 6 months during follow-up.ResultsThe median follow-up time was 19.9 months (range, 6 to 24 months) in the dyspepsia group and 19.2 months (range, 6 to 24 months) in the GERD group. All the patients were positive for the HLA-DQ2 and DQ8 haplotypes. The differences between the mean GDS scores (14.3±2.1 vs 1.1±0.2, respectively, p<0.05), RSI scores (6.3±0.8 vs 0.7±0.1, respectively, p<0.05), and Biagi scores (3.1±0.4 vs 0.7±0.3 in the dyspepsia group and 2.5±0.4 vs 0.5±0.2 in GERD group) before and after implementation of the gluten-free diet were statistically significant. The decreases in the scores were consistent with improvements in the histological findings. There was no significant correlation between endoscopic appearance and histological examination results (p=0.487).ConclusionsSeronegative celiac disease may be considered in this group of patients. Even if a patient is seronegative and has normal endoscopic findings, duodenal biopsy should be considered.

UTILITY OF SERUM FERRITIN AS A PREDICTOR OF COLORECTAL CANCER IN ELDERLY PATIENTS

Objective: Ferritin is an indicator of iron deficiency. Colorectal cancer is an important cause of morbidity and mortality in older subjects. The aim of this study was to determine the value of serum ferritin and ferritin-transferrin saturation in the diagnosis of colorectal cancer in older subjects. Material and Methods: 600 older patients who had undergone upper and lower gastrointestinal endoscopic examination were included into the study. Serum iron profile and C-reactive protein were also recorded. Patients were then evaluated by three different ferritin levels according to their iron profiles: method 1: ferritin < 50 µg/L; method 2: ferritin < 100 µg/L; method 3: ferritin+transferrin saturation index. The relationship between existence of colorectal cancer and serum ferritin level was investigated. Results: 528 patients had normal upper and lower endoscopic findings. 72 patients had colorectal carcinoma with normal upper gastrointestinal findings. Method 1 (ferritin<50 µg/L) predicted 58.4% of patients with colorectal carcinoma with a sensitivity and specificity of 63% (95% CI:52-74) and 53% (95% CI: 48-57) respectively. However, sensitivity [91% (95% CI:82-96)] of method 3 was greater than method 1 and 2 with a AUROC value of 70.4%. There was no difference by means of median ferritin levels. Median transferrin saturation index was significantly higher in group I (Normal subjects) compared to patients in group II (Colorectal cancer patients) (17.5 vs 8%, p<0.001). Conclusion: Serum ferritin <50 μg/L and <100 μg/L have rather low diagnostic yield in the decision making of colonscopic examination for colorectal carcinoma. However, ferritin <100 μg/L and TSI <16% values can be more useful in selecting older patients for colonoscopic examination.