Commentary by Milini Sahu, MD Fellow, Division of Gastrotenterology, Gina Sam-DeRiggs, Fellow, Division of Gastroenterology, and Michael Poles MD, Assistant Professor, NYU Division of Gastroenterology and Associate Editor, Clinical Correlations
Close to 17,000 gastroenterologists attended Digestive Disease Week (DDW) from May 19-24 in Washington DC. While I stayed behind (someone has to help with emergency endoscopies), the majority of NYU’s gastroenterology fellows and attendings were there for a week of learning, presenting, and making NYU proud. Two of our fellows, Malini Sahu and Gina Sam-DeRiggs were there and have provided the majority of the information in this update.
As always, there is an immense amount of information presented at this meeting, where the world’s experts in gastroenterology present their most recent observations. A handful of important studies are presented below:
In a study examining the interaction between body weight and erosive esophagitis, Koo et al. performed a cross-sectional study. They enrolled 3801 patients in Korea who had routine EGD, of which 9.9% were found to have esophageal erosions. They found that BMI was higher in patients with esophageal erosions, though the average BMI of each group was less than 25. Waist circumference was also significantly higher in patients with erosive esophagitis. This study therefore suggests that, even in patients with fairly unimpressive BMIs, abdominal obesity is a risk factor for erosive esophagitis
As endoscopists, we are often faced with patients with melena for whom a diagnosis is not revealed by EGD and colonoscopy. A study examined 41 patients who received either capsule endoscopy or mesenteric angiogram as the next step in the diagnostic work-up. The authors showed that capsule endoscopy revealed the likely source of bleeding 55% of the time, while the angiogram only showed the source 9.5% of the time. A drawback of this study was the exclusion of further examination of the upper GI tract using enteroscopy, given that many lesions were found in the stomach (missed with the first endoscopy) and proximal small bowel (potentially within the reach of a longer endoscope). While therapy cannot be rendered with the capsule as opposed to angiography, it appears that it may be a important diagnostic modality in patients with obscure GI bleeding.
Patients who present with severe, steroid refractory ulcerative colitis are commonly considered for emergent surgery. Intravenous cyclosporine, and more recently, infliximab, have shown to be capable of inducing remission in these patients, at least temporarily. A study from Mount Sinai examined whether there is utility in crossing-over to the other agent as salvage therapy if remission is not attained with a trial of cyclosporine or infliximab. They performed a retrospective chart review of 20 patients, noting that crossing-over to the alternate salvage therapy resulted in a 30 % remission rate. It should be noted that equal rates were observed whether cyclosporine or infliximab were used first. While this was a retrospective study with significant variation in treatment lengths/baseline characteristics, it does give some hope for those attempting to avoid colectomy, though past studies suggest that the majority will ultimately require surgery.
Anyone who spends enough time on the VA or BH wards will face a patient with chronic severe abdominal pain due to chronic pancreatitis. While we often resort to narcotics, we are always looking out for non-addictive treatments and adjuncts. In a study from India, we see that vitamins C and E and other antioxidants may be an option for managing abdominal pain in patients suffering from chronic pancreatitis. The study showed that 33% of 127 patients with chronic pancreatitis treated with antioxidant therapy reported no pain after six months, compared with only 13% of patients in a placebo group. Antioxidant therapy was associated with signs of decreased oxidant stress in the periphery. The authors hypothesized that the inflammation produced by oxidative stress may be causing pain, and that antioxidant therapy might relieve that pain. While most preliminary studies using antioxidants for a variety of maladies are eventually found to be negative, we hold out hope that this simple, non-invasive, well-tolerated approach can obviate the need for narcotics.
Additional studies suggest that lubiprostone (Amitiza), a drug used to treat constipation, can be used to treat IBS patients with this condition. Also, the diabetes drug rosiglitazone (Avandia) may be an effective treatment for mild-to-moderate ulcerative colitis. An oral hepatitis C virus protease inhibitor showed early promise as a Hep C treatment. Patients with diverticulosis do not have to forgo the popcorn and peanuts. And my favorite, ingestion of a small, but high-fat appetizer can suppress appetite for the remainder of the meal. Pass the fried calamari.