The Benefits of Neuromuscular Electrical Stimulation in the Muscular and Functional Capacity of Patients With Liver Cirrhosis: Protocol for a Randomized Clinical Trial

Cirrhosis causes systemic and metabolic changes that culminate in various complications, such as compromised pulmonary function, ascites, hepatic encephalopathy, weight loss, and muscle weakness with significant physical function limitations. Our aim is to evaluate the effects of training with neuromuscular electrical stimulation (NMES) on the muscular and functional capacity of patients with cirrhosis classified as Child-Pugh B and C. A total of 72 patients diagnosed with cirrhosis will be recruited and randomized to perform an NMES protocol for 50 minutes, 3 times a week, for 4 weeks. The evaluations will be performed at the beginning and after 12 sessions, and patients will be submitted to a pulmonary function test, an ultrasound evaluation of the rectus femoris, an evaluation of peripheral muscle strength, a submaximal exercise capacity test associated with an evaluation of peripheral tissue oxygenation, a quality of life evaluation, and orientation about monitoring daily physical activities. The evaluators and patients will be blinded to the allocation of the groups. Training Group will be treated with the following parameters: frequency of 50 Hz, pulse width of 400 μs, rise and fall times of 2 s, and on:off 1:1; Sham Group: 5 Hz, 100 μs, on:off 1:3. The data will be analyzed using the principles of the intention to treat. This study provides health professionals with information on the benefits of this intervention. In this way, we believe that the results of this study could stimulate the use of NMES as a way of rehabilitating patients with more severe cirrhosis, with the objective of improving these patients’ functional independence.

Biodegradable Stents in Resistant Peptic Oesophageal Stricture: Is It the Right Way to Go?

Peptic oesophageal stricture can be considered as the end result of prolonged gastro-oesophageal reflux. The ‘gold standard’ treatment for peptic stricture is endoscopic dilatation with balloon or bougie. It is predicted that up to 40% of patients remain symptomatic with dysphagia due to refractory (resistant to treatment) or recurrent strictures, needing frequent interventions at short intervals. Such patients have poor nutritional status due to the primary disease and are susceptible to complications related to repeated endoscopic dilatation such as bleeding and perforation. This general review aims to analyse existing published evidence and address the role of biodegradable stents in resistant peptic strictures as an alternative treatment to provide long-term dysphagia-free intervals.

Esophageal Adenocarcinoma: Opportunities for Targeted Prevention in Ohio

Objective: The incidence of esophageal adenocarcinoma, one of the most lethal gastroenterological diseases, has been increasing since the 1960s. Prevention of esophageal adenocarcinoma is important because no early detection screening programs have been shown to reduce mortality. Obesity, gastroesophageal reflux disease, and tobacco smoking are risk factors for esophageal adenocarcinoma. Due to the high prevalence in Ohio of obesity (32.6%) and cigarette smoking (21.0%), this study sought to identify trends and patterns of these risk factors and esophageal adenocarcinoma in Ohio as compared with the United States. Methods: Data from the Ohio Cancer Incidence Surveillance System, Surveillance Epidemiology and End Results Program (SEER), and Behavioral Risk Factor Surveillance System were used. Incidence rates overall, by demographics and by county, as well as trends in incidence of esophageal adenocarcinoma and the percent of esophageal adenocarcinoma among esophageal cancers were examined. Trends in obesity and cigarette smoking in Ohio, and the prevalence of each by county, were reported. Results: There was an increasing trend in esophageal adenocarcinoma incidence in Ohio. Ohio’s average annual esophageal adenocarcinoma incidence rate was higher than the SEER rate overall and for each sex, race, and age group in 2009 to 2013. There was also an increasing prevalence of obesity in Ohio. Although the prevalence of cigarette smoking has been stable, it was high in Ohio compared with the United States. Conclusions: Health care providers and researchers should be aware of the esophageal adenocarcinoma incidence rates and risk factor patterns and tailor interventions for areas and populations at higher risk.

Orbital Inflammatory Complications of Crohn’s Disease: A Rare Case Series

Orbital inflammatory disease is a rare ophthalmic manifestation of Crohn’s disease. Inflammation is characteristically nonspecific, involving one or multiple structures of the orbit. Mechanisms of disease and optimal methods of treatment are poorly understood. The aim of this report is to present 3 cases of orbital involvement in Crohn’s disease. A retrospective case note review of patients with orbital inflammatory disease and Crohn’s disease was performed at our academic center to determine the clinical, imaging, and histopathologic features of this condition and its relationship to intestinal Crohn’s disease. Three patients were identified with orbital inflammatory manifestations complicating Crohn’s disease. All patients described were women with active intestinal disease and had a history of treatment with immunosuppressive therapies. Similarities were observed in clinical presentations with variance noted in radiologic and histopathologic findings. In all cases, symptoms improved with oral corticosteroids or nonsteroidal drugs in combination with anti-tumor necrosis factor agents. Inflammatory bowel disease–related orbital complications are rare but potentially vision-threatening. It is important to consider mimics of orbital inflammatory disease such as systemic inflammatory disease, malignancy, congenital malformations, infection, and trauma when formulating a comprehensive differential diagnosis. Therapeutic intervention is directed toward preservation of vision and orbital function and reducing the acute inflammatory process. Corticosteroids are typically the initial treatment of choice for moderate-to-severe disease, although several classes of immunomodulatory agents have been variably useful in treating this condition. Heightened awareness and close cooperation between gastroenterologists and ophthalmologists are mandatory.

Plasma-Free Amino Acid Profiles in Crohn’s Disease: Relationship With the Crohn Disease Activity Index

We aimed to clarify the relationship between plasma-free amino acid (PFAA) profiles and the Crohn’s disease (CD) activity index (CDAI) in patients with CD. Methods: We measured fasting PFAA concentrations in 29 patients with CD and their correlation with disease activity. Results: In all patients, significant correlations were noted between CDAI and concentrations of valine, methionine, leucine, histidine, tryptophan, alanine, tyrosine, total amino acids (TAAs), nonessential amino acids (NEAAs), essential amino acids (EAAs), and branched-chain amino acids (BCAAs). In patients with the ileo-colonic type of CD, significant correlations were noted between CDAI and valine, histidine, tryptophan, glutamine, TAA, NEAA, EAA, and BCAA. In ileal type, significant correlations were observed between CDAI and threonine, valine, histidine, serine, and glycine. In colonic type, significant correlations were noted between CDAI and valine, histidine, tryptophan, TAA, NEAA, EAA, and BCAA. Conclusions: In patients with CD, plasma amino acids appear to be associated with disease activity.

Gastroduodenal Tuberculosis: A Case Series and Review of Literature

Gastroduodenal tuberculosis is infrequently seen in day-to-day clinical practice with few cases reported in the literature. It is usually associated with features of gastric outlet obstruction. This is a case series of 4 patients with 2 of them having associated lower gastrointestinal involvement. One of them resembled a growth in the cardia of the stomach which responded to antitubercular drugs. Another had duodenal erosions with portal lymph node enlargement which responded to antitubercular drug treatment. None of the patients required surgical management. Gastroduodenal tuberculosis should be considered with a high degree of suspicion when patients present with gastric outlet obstruction or with endoscopic evidence of ulceronodular disease in areas endemic for tuberculosis.

Gastrointestinal Lesions in African American Patients With Iron Deficiency Anemia

Background: Iron deficiency anemia (IDA) is a frequent disorder that is associated with many serious diseases. However, the findings of an evaluation of IDA-associated gastrointestinal disorders are lacking among African American patients. Aim: To determine the most prevalent gastrointestinal lesions among African American patients with IDA especially in young men. Methods: We reviewed medical records (n = 422) of patients referred for evaluation of IDA from 2008 to 2012. Iron deficiency anemia was diagnosed using clinical laboratory tests. The results of esophagogastroduodenoscopy, colonoscopy, and pathology specimens along with demographic data were abstracted and analyzed using Stata. Results: The mean age was 61.9 years, and 50.5% were women. In total, 189 patients (45%) had gross gastrointestinal (GI) bleeding. The most frequent diagnoses were gastritis (40%), benign colonic lesions (13%), esophagitis (9%), gastric ulcer (6%), and duodenitis (6%). GI bleeding was significantly more frequent in men ( P = 0.001). Benign and malignant colonic lesions were significantly more present among older patients: 16% vs 6% ( P = .005) and 5% vs 0% ( P = .008), respectively. Colitis was more prevalent in younger patients (⩽50): 11% vs 2% ( P = .001). In patients with gross lower GI bleeding, the top diagnoses were gastritis (25%), benign colon tumors (10%), and duodenitis (6%). Colon cancer was diagnosed among 15 patients, and all these patients were older than 50 years of age. Conclusions: Gastritis and colonic lesions are most common associated lesions with IDA among African Americans. So bidirectional endoscopy is required for unrevealing of the cause of IDA in asymptomatic patients.

Impact of Video Aid on Quality of Bowel Preparation Among Patients Undergoing Outpatient Screening Colonoscopy

Aim: To investigate the effect of video aid on quality of bowel preparation. Study: A retrospective study was done on patients undergoing outpatient screening colonoscopy. All subjects received educational video prior to colonoscopy in addition to the standard counseling. Patient charts were reviewed to collect data regarding quality of bowel preparation (adequate or inadequate). The study population was stratified into four groups according to viewing status: Group I 0% (control group), Group II <50%, Group III >50% to <75%, and Group IV watched ⩾75% of the video. Results: A total of 338 patients with an average age of 59.1 years and 60.3% females were included in the final study cohort. Of the patients in Groups I, II, III, and IV, 94.3%, 90.9%, 100%, and 91.7%, respectively, had adequate preparation ( P value = .827). Adenoma detection rate (ADR) for Groups I, II, III, and IV was 28.8%, 50%, 50%, and 22.6%, respectively ( P value = .305). The mean cecal intubation time was 20.7, 16.4, 16.57, and 17 minutes for Groups I, II, III, and IV, respectively ( P value = .041). Conclusions: Video aid use for patients undergoing screening colonoscopy lacked a statistically significant impact on the quality of bowel preparation, ADR, and advanced adenoma detection rate when compared with standard practice.

Understanding Therapeutic Concepts in Crohn’s Disease

For more than a decade, the therapeutic focus for Crohn’s disease has remained fixed at temporary arrestment of symptomology. The Centers for Disease Control and Prevention (CDC) lists Crohn’s disease as a disease entity without current cure. Biologics in combination with antibiotics can frequently achieve remissions. Without ongoing drug administration, these remissions tend to be of limited duration. Conceptual advancements in understanding the pathogenesis of Crohn’s disease have identified treatment approaches, the focus of which goes beyond temporary remission. Concepts derived from Infectious Diseases Inc.’s 17 years of research with Mycobacterium avium subspecies paratuberculosis delineate how new knowledge can be integrated to achieve more sustained remissions.

Melanosis Coli: A Helpful Contrast Effect or a Harmful Pigmentation?

Background: Melanosis coli, a brown discoloration of colonic mucosa, is considered as a benign condition mainly observed in patients under chronic anthranoid laxatives. Recent data link this condition with an increased adenoma detection rate. Moreover, its tumorigenic potential and possible association with the development of colorectal cancer remains uncertain. We conducted this study to compare the polyp detection rate and colorectal cancer diagnosis in patients with melanosis against matched control group without melanosis. Patients and methods: A retrospective single-center study. Patients diagnosed with melanosis coli on colonoscopy over a 15-year period were included. Each melanosis coli patient was matched with three controls by age, gender, setting (inpatient/outpatient), and procedure’s indication. Polyp detection rate and diagnosis of colorectal cancer were recorded and compared between the groups before and after adjustment for bowel preparation. Results: A cohort of 718 patients with melanosis and 2154 controls were included. The polyp detection rates were 33.4% and 21.8% of melanosis and control groups, respectively ( P < .001). Melanosis coli, however, was associated with less diagnosis of colorectal cancer than controls (0.3% vs 3.9%; P < .001). In multivariate analysis, melanosis diagnosis on endoscopy was significantly associated with higher polyp detection rate (odds ratio [OR] = 1.986, 95% confidence interval [CI]: 1.626-2.425; P value < .01). Conclusions: Melanosis coli is not associated with increased diagnosis of colorectal cancer. It is associated, however, with enhanced polyp detection likely due to chromo-endoscopy-like effect.