Suspected acute pancreatitis. First-time presentation. Epigastric pain and increased amylase and ... more Suspected acute pancreatitis. First-time presentation. Epigastric pain and increased amylase and lipase. Less than 48 to 72 hours after symptom onset. Initial imaging. Procedure Appropriateness Category Relative Radiation Level US abdomen Usually Appropriate O CT abdomen and pelvis with IV contrast May Be Appropriate ☢☢☢ MRI abdomen without and with IV contrast with MRCP May Be Appropriate O MRI abdomen without IV contrast with MRCP May Be Appropriate O US duplex Doppler abdomen May Be Appropriate O CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢ CT abdomen and pelvis without IV contrast Usually Not Appropriate ☢☢☢ US abdomen with IV contrast Usually Not Appropriate O Variant 2: Suspected acute pancreatitis. Initial presentation with atypical signs and symptoms; including equivocal amylase and lipase values (possibly confounded by acute kidney injury or chronic kidney disease) and when diagnoses other than pancreatitis may be possible (bowel perforation, bowel ischemia, etc). Initial imaging. Procedure Appropriateness Category Relative Radiation Level CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢ MRI abdomen without and with IV contrast with MRCP Usually Appropriate O CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢ MRI abdomen without IV contrast with MRCP May Be Appropriate O US abdomen May Be Appropriate O US duplex Doppler abdomen May Be Appropriate O CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢ US abdomen with IV contrast Usually Not Appropriate O Revised 2019 ACR Appropriateness Criteria ® 2 Acute Pancreatitis Variant 3: Acute pancreatitis. Critically ill, systemic inflammatory response syndrome (SIRS), severe clinical scores (eg, Acute Physiology, Age, and Chronic Health Evaluation [APACHE]-II, Bedside Index for Severity in AP [BISAP], or Marshall). Greater than 48 to 72 hours after onset of symptoms. Procedure Appropriateness Category Relative Radiation Level CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢ MRI abdomen without and with IV contrast with MRCP Usually Appropriate O MRI abdomen without IV contrast with MRCP May Be Appropriate O CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢ US duplex Doppler abdomen May Be Appropriate O CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢ US abdomen Usually Not Appropriate O US abdomen with IV contrast Usually Not Appropriate O Variant 4: Acute pancreatitis. Continued SIRS, severe clinical scores, leukocytosis, and fever. Greater than 7 to 21 days after onset of symptoms. Procedure Appropriateness Category Relative Radiation Level CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢ MRI abdomen without and with IV contrast with MRCP Usually Appropriate O MRI abdomen without IV contrast with MRCP May Be Appropriate O CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢ US abdomen May Be Appropriate O US duplex Doppler abdomen May Be Appropriate O CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢ US abdomen with IV contrast Usually Not Appropriate O Acute Pancreatitis Variant 5: Known necrotizing pancreatitis. Significant deterioration in clinical status, including abrupt decrease in hemoglobin or hematocrit, hypotension, tachycardia, tachypnea, abrupt change in fever curve, or increase in white blood cells. Procedure Appropriateness Category Relative Radiation Level CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢ MRI abdomen without and with IV contrast with MRCP May Be Appropriate O CT abdomen and pelvis without and with IV contrast May Be Appropriate ☢☢☢☢ CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢ MRI abdomen without IV contrast with MRCP May Be Appropriate O US abdomen May Be Appropriate O US duplex Doppler abdomen May Be Appropriate O US abdomen with IV contrast Usually Not Appropriate O Variant 6: Acute pancreatitis. Known pancreatic or peripancreatic fluid collections with continued abdominal pain, early satiety, nausea, vomiting, or signs of infection. Greater than 4 weeks after symptom onset. Procedure Appropriateness Category Relative Radiation Level CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢ MRI abdomen without and with IV contrast with MRCP Usually Appropriate O MRI abdomen without IV contrast with MRCP May Be Appropriate O CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢ US abdomen May Be Appropriate O US duplex Doppler abdomen May Be Appropriate O CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢ US abdomen with IV contrast Usually Not Appropriate O
anastomosis. Bleeding was observed in 1 case and hemostaisis was performed by endoscopic pinpoint... more anastomosis. Bleeding was observed in 1 case and hemostaisis was performed by endoscopic pinpoint coagulation during the same procedure. In 3 other cases, IOCC showed the presence of adenomatous polyps not previously recognized in the preoperative assessment, and permitted to perform endoscopic polypectomy during the same procedure or shortly deferred after surgery. In this group, no postoperative complications were observed. In the control group pneumatic test was positive in only one case that required the recreation of the anastomosis. Early post-operative complications included: two fistulas and a pelvic wall hematoma, all requiring reintervention according to Hartmann procedure. Conclusion: Anastomosis IOCC, when performed by a joint medical-surgical team, appears to be a safe procedure that does not result in increased operative time, nor postoperative mortality/morbility. IOCC can be a more sensitive test than the intraoperative pneumatic test alone, provinding substantial advantages that includes: the possibility of therapeutic endoscopic interventions (e.g., hemostasis, polypectomy), and direct visual examination that, especially in laparoscopy, allows the identification of anastomotic micro-fistulas and/or ischemic stump otherwise unrecognized by the surgeon.
Techniques in Gastrointestinal Endoscopy, Jul 1, 2002
Pancreatic disease commonly involves the distal common bile duct. Pancreatic adenocarcinoma and c... more Pancreatic disease commonly involves the distal common bile duct. Pancreatic adenocarcinoma and chronic pancreatitis are the commonest pancreatic processes resulting in a bile duct stricture. Management of distal common bile duct strictures requires proper diagnosis and appropriate use of both endoscopy and surgery. This article reviews the differential diagnosis and endoscopic management of biliary strictures in pancreatic disease.
Background Among patients undergoing colonoscopy, anticoagulants are usually stopped and are some... more Background Among patients undergoing colonoscopy, anticoagulants are usually stopped and are sometimes substituted by a heparin bridge (hep-bridge). We aimed to assess adverse events associated with hep-bridge compared to temporary cessation of anticoagulants (no-bridge). Methods This was a single-center, retrospective cohort study that included anticoagulated patients undergoing colonoscopy between 2013 and 2016 at a Veterans Affairs Medical Center. In the nobridge cohort, warfarin was stopped for 5 days and novel anticoagulants for 2 days pre-procedure. In the hep-bridge cohort, anticoagulants were stopped and were substituted by subcutaneous enoxaparin. The primary outcome was post-polypectomy bleeding. Secondary outcomes included cardiovascular events, all-cause adverse events and emergency department or unscheduled ambulatory office visits within 30 days. The predictive values of the HAS-BLED and CHADS 2 scores were evaluated. Results A total of 662 patients were included, of whom 551 underwent polypectomy (mean age 68.6 years; 97.6% male). Four hundred seventy colonoscopies were performed with no-bridge and 192 with hep-bridge. Post-polypectomy bleeding occurred in 6.0% of procedures: 5.7% in the no-bridge cohort compared to 13.0% of hep-bridge procedures (P=0.0038). Cardiovascular or thrombotic events occurred after 2.6% of the no-bridge and 5.2% of the hep-bridge procedures (P=0.1176). Emergency department or unscheduled office visits within 30 days were reported after 18.7% of the no-bridge procedures and 29.7% of the hep-bridge procedures (P<0.0001). Neither CHADS 2 nor HASBLED scores predicted bleeding. Conclusion The use of hep-bridge was associated with a greater incidence of post-polypectomy bleeding and more emergency department and unscheduled office visits compared with cessation of all anticoagulants.
Endoscopic submucosal dissection (ESD) is an advanced endoscopic technique pioneered by the Japan... more Endoscopic submucosal dissection (ESD) is an advanced endoscopic technique pioneered by the Japanese, for en bloc removal of large gastrointestinal epithelial lesions. This technique involves injection of a solution into the submucosal layer, followed by dissection around and then under the lesion, with separation of the submucosal layer using an electrocautery knife. ESD technique allows the endoscopist to visualize and control the depth of dissection. Originally described for early gastric cancer, the indications and techniques have evolved to include lesions in most locations and layers of the gastrointestinal wall. Western endoscopists have recently adopted this technique as well. From a practice standpoint, ESD provides the endoscopist with the ability to remove large superficial tumors in a single piece, including ulcerated lesions, lesions with submucosal fibrosis, recurrent neoplasms, non-lifting lesions, and potentially lesions with very early submucosal invasion. En bloc resection and curative resection rates are high in the eastern literature, with bleeding, perforation and strictures, the most frequently reported complications. The procedure is difficult and time consuming, with a steep learning curve and significant complication rates, and therefore requires specialized training.
mall bowel tumors are a rare cause of occult gastrointestinal (GI) bleeding, at times requiring h... more mall bowel tumors are a rare cause of occult gastrointestinal (GI) bleeding, at times requiring hospitalization and blood transfusion. Capsule endoscopy is a commonly used tool for investigation of occult GI bleeding. The risk of capsule retention is rare and not commonly seen when capsule endoscopy is performed for the diagnostic evaluation of occult GI bleeding. We report a case of enteropathy-associated T-cell lymphoma (EATL) discovered via examination for occult GI bleeding requiring hospitalization and subsequent capsule retention that necessitated urgent surgical management secondary to bowel obstruction.
Objectives: Colonoscopy surveillance interval data longer than 5 years are limited. We examined a... more Objectives: Colonoscopy surveillance interval data longer than 5 years are limited. We examined adenoma yield to identify factors that predict appropriate intervals for postpolypectomy surveillance greater than 5 years, including risk of advanced adenoma recurrence. Methods: We identified patients with and without adenomas on an index colonoscopy who returned at 5 to 10 years for a follow-up colonoscopy. Multivariate logistic regression was used to identify variables that predict finding an adenoma on follow-up colonoscopy. Results: Three hundred ninety-nine patients were identified with a follow-up colonoscopy at an interval of >5 years. Irrespective of surveillance interval, adenoma incidence occurred in 116 patients (29.1%) with 25 (6%) having advanced adenomas. Patients with nonadvanced adenomas on index colonoscopy had a similar risk of advanced adenoma on follow-up colonoscopy at 5 years versus 6 to 10 years, 5% versus 6.2% (P=0.39). The risk of advanced adenoma at 5 and 6 to 10 years in patients with a negative index colonoscopy was 7% versus 3.6% (P=0.15). Patients with an advanced adenoma at index colonoscopy had the highest rate of advanced adenoma detection at 5 years at 26%. Proximal polyp location (odds ratio 12.4, confidence interval 2.7-56.7) predicted advanced adenoma occurrence at 5 years. Conclusions: Postpolypectomy colonoscopy intervals can be extended beyond 5 years in patients with nonadvanced adenomas. Our findings also support a rescreening interval of 5 to 10 years in patients with a negative index colonoscopy. Patients with an index advanced adenoma are at highest risk for recurrent advanced adenoma and should have repeat colonoscopy before a 5 years interval.
Background.Pancreatic ductal adenocarcinoma (PDAC) is one of the leading causes of cancer-related... more Background.Pancreatic ductal adenocarcinoma (PDAC) is one of the leading causes of cancer-related deaths in the United States. Although management strategies have evolved, there are continued controversies about the use of neoadjuvant chemotherapy (NAC) and pretreatment biliary drainage (PBD) in patients with resectable and potentially-resectable disease.Aims.We aimed to characterize the practice trends and outcomes for NAC and PBD.Methods.A single-center cohort study was performed. Electronic medical records were reviewed between 2011 and 2019, and 140 patients who had pancreaticoduodenectomy for PDAC were included. Diagnosis, treatment, and outcome data were captured.Results.There were no statistically significant temporal trends relating to the use of chemotherapy and PBD. Overall, 41% of patients received NAC and had improved survival, independent of other factors. Of the 71% who received PBD, only 40% had appropriate indications; 30% experienced post-procedure complications and 34% required reintervention. Factors associated with the application of PBD included preoperative jaundice (OR 70.5, 95% CI 21.4–306.6) and evaluation by non-tertiary therapeutic endoscopists (OR 3.9, 95% CI 1.3–13.6). PBD was associated with a 12-day delay in surgery among those who did not receive NAC (p = 0.005), but there were no differences in surgical complications or mortality.Conclusions.Our findings suggest that (1) NAC may confer a survival benefit and (2) PBD should be reserved for individuals with jaundice requiring NAC. Implementation of guidelines by North American gastroenterology societies, multidisciplinary treatment models, and delivery of care at high-volume tertiary centers may help optimize management.
IntroductionAnal adenocarcinoma is a rare malignancy with a poor prognosis.MethodsWe present a ca... more IntroductionAnal adenocarcinoma is a rare malignancy with a poor prognosis.MethodsWe present a case of rare anal adenocarcinoma in a patient with normal screening colonoscopy. Using the Surveillance, Epidemiology and End Result database between 2000 and 2016, we performed survival analysis among individuals>20 years old comparing anal and rectal cancers.ResultsSurvival analysis showed that anal adenocarcinoma is associated with worse outcomes compared with rectal adenocarcinoma and anal squamous cell carcinoma.DiscussionThis case and survival data illustrate the importance of prompt investigation of symptoms irrespective of colorectal cancer screening status with careful attention to examination of the anal area.
Purpose: Our objective is to investigate the yield of upper and lower gastrointestinal(GI) endosc... more Purpose: Our objective is to investigate the yield of upper and lower gastrointestinal(GI) endoscopic evaluations in anemic patients with serum ferritin levels between 40 and 100 ng/ml. Subjects and Methods: Most practice guidelines recommend endoscopic evaluation of the GI tract in men and post menopausal women with anemia and a serum ferritin level less than 20–40 ng/ml. However, as ferritin is an acute phase reactant, iron deficiency anemia (IDA) can be present with ferritin greater than 40 ng/ml. The diagnostic yield of GI endoscopy in patients with anemia, no GI symptoms or signs, and low normal ferritin. Some patients at the Veterans Affairs (VA) Connecticut Healthcare System undergo endoscopic evaluation as part of their anemia work up even when the ferritin is in the low normal range (40–100 ng/ml). We retrospectively reviewed the data on this population of patients over a 42-month period (1999–2003) to determine the incidence of GI findings. Results: All 522 patients who had undergone endoscopic examination for anemia over a 42 month period were screened. We identified 54 male patients who had a serum ferritin level between 40 and 100 ng/ml, no GI symptoms, and no evidence of GI bleeding. Significant lower GI findings, including large tubular adenomas and arterio-venous malformation (AVM), were identified in 3/53 cases (6.7%). Upper GI findings, including malignancy, peptic ulcers, Helicobacter Pylori gastritis, and AVM, were found in 14/47(30%) of cases. Conclusion: In this retrospective study on male anemic patients with low normal serum ferritin but lack of GI symptoms or known bleeding, the prevalence of upper and lower GI lesions was 30% and 6.7%, respectively. Our study supports a GI endoscopic evaluation in anemic patients with ferritin between 40 to 100 ng/ml, even in the absence of GI symptoms, or evidence for GI bleeding. Table 1: Ferritin, hematocrit (HCT), mean corpuscular volume (MCV) and prevalence of GI lesions in patients with borderline ferritin levels * In the majority of the patients, more than one serum ferritin level was measured, and the one closest to the endoscopic procedure was used. Total number of pateients N=54 Age(YO) 72.4±10.3 Ferritin (ng/ml) 63.6±16.7 HCT(%) 35.5% + 2.4 (range 34–40%) MCV(fL) 85.9±7.6 Upper GI findings 17/47 Lower GI findings 22/53 Table 2: Endoscopic Findings in Anemic Patients with Serum Ferritin Levels between 40–100 ng/mL without significant GI symptoms or signs. LOWER GI FINDINGS Number/percentage TA = tubular adenoma. *In 13/15 cases, TAs were found proximal to the splenic flexure, in 6/15 cases multiple TAs were found. MALIGNANCY 0/53 ADENOMA&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;1CM 2/53 ADENOMA&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;1CM 15/53* EXTENSIVE DIVERTICULOSIS 4/53 ARTERIOVENOUS MALFORMATION 1/53 ULCER 0/53 UPPER GI FINDINGS MALIGNANCY 1/47 ESOPHAGITIS/BARRETT’S ESOPHAGUS 1/47 LARGE HIATAL HERNIAS WITH EROSION 2/47 ESOPHAGEAL VARICES 1/47 CHRONIC ACTIVE GASTRITIS/DUODENITIS, H PYLORI+ 5/47 GASTRIC OR DUODENAL PEPTIC ULCER 5/47 ARTERIOVENOUS MALFORMATION 1/47 ATROPHIC GASTRITIS 1/47
59 Background: 5-Fluorouracil (5-FU) is a component of first-line treatment regimens for metastat... more 59 Background: 5-Fluorouracil (5-FU) is a component of first-line treatment regimens for metastatic colorectal cancer (mCRC). Historically, 5-FU is administered as a bolus followed by an infusion. However, the bolus dose adds substantial toxicity and is often withheld in patients with limited functional status or high-risk comorbidities, but its impact on treatment outcomes remains unclear. Small studies suggest that it may be omitted. The aim of this study was to determine whether omission of the 5-FU bolus is associated with a difference in overall survival (OS). Methods: An electronic health record-derived national multicenter oncology database from Flatiron Health was queried to select patients with mCRC who received a first-line 5-FU-containing regimen. Demographics, relevant labs, treatment details, and survival outcomes were collected. Propensity score (PrS) matching and OS analysis were performed incorporating age, race, sex, ECOG score, combination drug regimen, and baseline creatinine and bilirubin. Variables with p &lt; 0.10 in univariable Cox proportional hazards models were included in the multivariable analysis. Results: We included 9741 patients with mCRC who received 5-FU-based regimens. All individuals received a 5-FU infusion, and 7901 (81%) also received a 5-FU bolus. Among our entire cohort, 43% were female, 23% were &gt; 70 years, 66% were white, and 89% had ECOG ≤ 1. Over a median follow-up time of 19 months, 5847 patients (60%) died. In the unmatched univariable (HR 0.94, 95% CI 0.88-1.00, p = 0.06) and multivariable (aHR 0.85, 95% CI 0.93-1.06, p = 0.85) analyses, there was no association between the use of bolus 5-FU and OS. A number of factors were associated with an increased risk of death, including older age, high ECOG scores, and elevated bilirubin or creatinine levels. Similarly, in our PrS-matched dataset (n = 6126), the use of a 5-FU bolus was not associated with OS (HR 0.98; 95% CI 0.91-1.06; p = 0.64). Conclusions: The findings of our PrS-matched multicenter cohort study indicate that, after adjusting for host and treatment factors, 5-FU bolus dosing was not associated with an overall survival benefit among patients with mCRC. These results suggest that, in mCRC, the addition of a 5-FU bolus does not appear to add efficacy to regimens utilizing infusional 5-FU. Future work is necessary to determine the role of bolus dosing in the adjuvant setting and its impact on other clinically-relevant outcomes.
We report a case of a bleeding duodenal varix demonstrating excellent hemostasis achieved by endo... more We report a case of a bleeding duodenal varix demonstrating excellent hemostasis achieved by endoscopic ultrasound (EUS)-directed placement of an embolization coil followed by cyanoacrylate. A 31-year-old man with decompensated Child's class C cirrhosis presented with hematemesis. An initial endoscopy revealed an actively bleeding duodenal varix. Subsequent attempt at hemostasis with ethanolamine oleate injection failed. A later attempt at hemostasis involving EUS-guided placement of an embolization coil followed by cyanoacrylate injection into the varix was successful. We reviewed the literature involving the treatment of bleeding ectopic varices and conclude that EUS provides a unique and advantageous modality for achieving variceal hemostasis of duodenal varices in patients who are not candidates for transjugular intrahepatic portosystemic shunt.
The American Journal of Gastroenterology, Jul 1, 2016
Concerns about the possible side effects of proton pump inhibitors (PPIs) have been raised since ... more Concerns about the possible side effects of proton pump inhibitors (PPIs) have been raised since their introduction in the 1980s, including gastric carcinoids, gastric carcinoma, decreased absorption of minerals (e.g., iron, calcium) and vitamin B-12, fractures, enteric infections (e.g., C. difficile), pneumonia, hypomagnesemia, and cardiovascular events (1). This year studies reporting associations with chronic kidney disease (CKD) and dementia had widespread media coverage (2, 3), prompting renewed concern and many questions from patients and physicians regarding long-term PPI use.
Suspected acute pancreatitis. First-time presentation. Epigastric pain and increased amylase and ... more Suspected acute pancreatitis. First-time presentation. Epigastric pain and increased amylase and lipase. Less than 48 to 72 hours after symptom onset. Initial imaging. Procedure Appropriateness Category Relative Radiation Level US abdomen Usually Appropriate O CT abdomen and pelvis with IV contrast May Be Appropriate ☢☢☢ MRI abdomen without and with IV contrast with MRCP May Be Appropriate O MRI abdomen without IV contrast with MRCP May Be Appropriate O US duplex Doppler abdomen May Be Appropriate O CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢ CT abdomen and pelvis without IV contrast Usually Not Appropriate ☢☢☢ US abdomen with IV contrast Usually Not Appropriate O Variant 2: Suspected acute pancreatitis. Initial presentation with atypical signs and symptoms; including equivocal amylase and lipase values (possibly confounded by acute kidney injury or chronic kidney disease) and when diagnoses other than pancreatitis may be possible (bowel perforation, bowel ischemia, etc). Initial imaging. Procedure Appropriateness Category Relative Radiation Level CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢ MRI abdomen without and with IV contrast with MRCP Usually Appropriate O CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢ MRI abdomen without IV contrast with MRCP May Be Appropriate O US abdomen May Be Appropriate O US duplex Doppler abdomen May Be Appropriate O CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢ US abdomen with IV contrast Usually Not Appropriate O Revised 2019 ACR Appropriateness Criteria ® 2 Acute Pancreatitis Variant 3: Acute pancreatitis. Critically ill, systemic inflammatory response syndrome (SIRS), severe clinical scores (eg, Acute Physiology, Age, and Chronic Health Evaluation [APACHE]-II, Bedside Index for Severity in AP [BISAP], or Marshall). Greater than 48 to 72 hours after onset of symptoms. Procedure Appropriateness Category Relative Radiation Level CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢ MRI abdomen without and with IV contrast with MRCP Usually Appropriate O MRI abdomen without IV contrast with MRCP May Be Appropriate O CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢ US duplex Doppler abdomen May Be Appropriate O CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢ US abdomen Usually Not Appropriate O US abdomen with IV contrast Usually Not Appropriate O Variant 4: Acute pancreatitis. Continued SIRS, severe clinical scores, leukocytosis, and fever. Greater than 7 to 21 days after onset of symptoms. Procedure Appropriateness Category Relative Radiation Level CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢ MRI abdomen without and with IV contrast with MRCP Usually Appropriate O MRI abdomen without IV contrast with MRCP May Be Appropriate O CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢ US abdomen May Be Appropriate O US duplex Doppler abdomen May Be Appropriate O CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢ US abdomen with IV contrast Usually Not Appropriate O Acute Pancreatitis Variant 5: Known necrotizing pancreatitis. Significant deterioration in clinical status, including abrupt decrease in hemoglobin or hematocrit, hypotension, tachycardia, tachypnea, abrupt change in fever curve, or increase in white blood cells. Procedure Appropriateness Category Relative Radiation Level CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢ MRI abdomen without and with IV contrast with MRCP May Be Appropriate O CT abdomen and pelvis without and with IV contrast May Be Appropriate ☢☢☢☢ CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢ MRI abdomen without IV contrast with MRCP May Be Appropriate O US abdomen May Be Appropriate O US duplex Doppler abdomen May Be Appropriate O US abdomen with IV contrast Usually Not Appropriate O Variant 6: Acute pancreatitis. Known pancreatic or peripancreatic fluid collections with continued abdominal pain, early satiety, nausea, vomiting, or signs of infection. Greater than 4 weeks after symptom onset. Procedure Appropriateness Category Relative Radiation Level CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢ MRI abdomen without and with IV contrast with MRCP Usually Appropriate O MRI abdomen without IV contrast with MRCP May Be Appropriate O CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢ US abdomen May Be Appropriate O US duplex Doppler abdomen May Be Appropriate O CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢ US abdomen with IV contrast Usually Not Appropriate O
anastomosis. Bleeding was observed in 1 case and hemostaisis was performed by endoscopic pinpoint... more anastomosis. Bleeding was observed in 1 case and hemostaisis was performed by endoscopic pinpoint coagulation during the same procedure. In 3 other cases, IOCC showed the presence of adenomatous polyps not previously recognized in the preoperative assessment, and permitted to perform endoscopic polypectomy during the same procedure or shortly deferred after surgery. In this group, no postoperative complications were observed. In the control group pneumatic test was positive in only one case that required the recreation of the anastomosis. Early post-operative complications included: two fistulas and a pelvic wall hematoma, all requiring reintervention according to Hartmann procedure. Conclusion: Anastomosis IOCC, when performed by a joint medical-surgical team, appears to be a safe procedure that does not result in increased operative time, nor postoperative mortality/morbility. IOCC can be a more sensitive test than the intraoperative pneumatic test alone, provinding substantial advantages that includes: the possibility of therapeutic endoscopic interventions (e.g., hemostasis, polypectomy), and direct visual examination that, especially in laparoscopy, allows the identification of anastomotic micro-fistulas and/or ischemic stump otherwise unrecognized by the surgeon.
Techniques in Gastrointestinal Endoscopy, Jul 1, 2002
Pancreatic disease commonly involves the distal common bile duct. Pancreatic adenocarcinoma and c... more Pancreatic disease commonly involves the distal common bile duct. Pancreatic adenocarcinoma and chronic pancreatitis are the commonest pancreatic processes resulting in a bile duct stricture. Management of distal common bile duct strictures requires proper diagnosis and appropriate use of both endoscopy and surgery. This article reviews the differential diagnosis and endoscopic management of biliary strictures in pancreatic disease.
Background Among patients undergoing colonoscopy, anticoagulants are usually stopped and are some... more Background Among patients undergoing colonoscopy, anticoagulants are usually stopped and are sometimes substituted by a heparin bridge (hep-bridge). We aimed to assess adverse events associated with hep-bridge compared to temporary cessation of anticoagulants (no-bridge). Methods This was a single-center, retrospective cohort study that included anticoagulated patients undergoing colonoscopy between 2013 and 2016 at a Veterans Affairs Medical Center. In the nobridge cohort, warfarin was stopped for 5 days and novel anticoagulants for 2 days pre-procedure. In the hep-bridge cohort, anticoagulants were stopped and were substituted by subcutaneous enoxaparin. The primary outcome was post-polypectomy bleeding. Secondary outcomes included cardiovascular events, all-cause adverse events and emergency department or unscheduled ambulatory office visits within 30 days. The predictive values of the HAS-BLED and CHADS 2 scores were evaluated. Results A total of 662 patients were included, of whom 551 underwent polypectomy (mean age 68.6 years; 97.6% male). Four hundred seventy colonoscopies were performed with no-bridge and 192 with hep-bridge. Post-polypectomy bleeding occurred in 6.0% of procedures: 5.7% in the no-bridge cohort compared to 13.0% of hep-bridge procedures (P=0.0038). Cardiovascular or thrombotic events occurred after 2.6% of the no-bridge and 5.2% of the hep-bridge procedures (P=0.1176). Emergency department or unscheduled office visits within 30 days were reported after 18.7% of the no-bridge procedures and 29.7% of the hep-bridge procedures (P<0.0001). Neither CHADS 2 nor HASBLED scores predicted bleeding. Conclusion The use of hep-bridge was associated with a greater incidence of post-polypectomy bleeding and more emergency department and unscheduled office visits compared with cessation of all anticoagulants.
Endoscopic submucosal dissection (ESD) is an advanced endoscopic technique pioneered by the Japan... more Endoscopic submucosal dissection (ESD) is an advanced endoscopic technique pioneered by the Japanese, for en bloc removal of large gastrointestinal epithelial lesions. This technique involves injection of a solution into the submucosal layer, followed by dissection around and then under the lesion, with separation of the submucosal layer using an electrocautery knife. ESD technique allows the endoscopist to visualize and control the depth of dissection. Originally described for early gastric cancer, the indications and techniques have evolved to include lesions in most locations and layers of the gastrointestinal wall. Western endoscopists have recently adopted this technique as well. From a practice standpoint, ESD provides the endoscopist with the ability to remove large superficial tumors in a single piece, including ulcerated lesions, lesions with submucosal fibrosis, recurrent neoplasms, non-lifting lesions, and potentially lesions with very early submucosal invasion. En bloc resection and curative resection rates are high in the eastern literature, with bleeding, perforation and strictures, the most frequently reported complications. The procedure is difficult and time consuming, with a steep learning curve and significant complication rates, and therefore requires specialized training.
mall bowel tumors are a rare cause of occult gastrointestinal (GI) bleeding, at times requiring h... more mall bowel tumors are a rare cause of occult gastrointestinal (GI) bleeding, at times requiring hospitalization and blood transfusion. Capsule endoscopy is a commonly used tool for investigation of occult GI bleeding. The risk of capsule retention is rare and not commonly seen when capsule endoscopy is performed for the diagnostic evaluation of occult GI bleeding. We report a case of enteropathy-associated T-cell lymphoma (EATL) discovered via examination for occult GI bleeding requiring hospitalization and subsequent capsule retention that necessitated urgent surgical management secondary to bowel obstruction.
Objectives: Colonoscopy surveillance interval data longer than 5 years are limited. We examined a... more Objectives: Colonoscopy surveillance interval data longer than 5 years are limited. We examined adenoma yield to identify factors that predict appropriate intervals for postpolypectomy surveillance greater than 5 years, including risk of advanced adenoma recurrence. Methods: We identified patients with and without adenomas on an index colonoscopy who returned at 5 to 10 years for a follow-up colonoscopy. Multivariate logistic regression was used to identify variables that predict finding an adenoma on follow-up colonoscopy. Results: Three hundred ninety-nine patients were identified with a follow-up colonoscopy at an interval of >5 years. Irrespective of surveillance interval, adenoma incidence occurred in 116 patients (29.1%) with 25 (6%) having advanced adenomas. Patients with nonadvanced adenomas on index colonoscopy had a similar risk of advanced adenoma on follow-up colonoscopy at 5 years versus 6 to 10 years, 5% versus 6.2% (P=0.39). The risk of advanced adenoma at 5 and 6 to 10 years in patients with a negative index colonoscopy was 7% versus 3.6% (P=0.15). Patients with an advanced adenoma at index colonoscopy had the highest rate of advanced adenoma detection at 5 years at 26%. Proximal polyp location (odds ratio 12.4, confidence interval 2.7-56.7) predicted advanced adenoma occurrence at 5 years. Conclusions: Postpolypectomy colonoscopy intervals can be extended beyond 5 years in patients with nonadvanced adenomas. Our findings also support a rescreening interval of 5 to 10 years in patients with a negative index colonoscopy. Patients with an index advanced adenoma are at highest risk for recurrent advanced adenoma and should have repeat colonoscopy before a 5 years interval.
Background.Pancreatic ductal adenocarcinoma (PDAC) is one of the leading causes of cancer-related... more Background.Pancreatic ductal adenocarcinoma (PDAC) is one of the leading causes of cancer-related deaths in the United States. Although management strategies have evolved, there are continued controversies about the use of neoadjuvant chemotherapy (NAC) and pretreatment biliary drainage (PBD) in patients with resectable and potentially-resectable disease.Aims.We aimed to characterize the practice trends and outcomes for NAC and PBD.Methods.A single-center cohort study was performed. Electronic medical records were reviewed between 2011 and 2019, and 140 patients who had pancreaticoduodenectomy for PDAC were included. Diagnosis, treatment, and outcome data were captured.Results.There were no statistically significant temporal trends relating to the use of chemotherapy and PBD. Overall, 41% of patients received NAC and had improved survival, independent of other factors. Of the 71% who received PBD, only 40% had appropriate indications; 30% experienced post-procedure complications and 34% required reintervention. Factors associated with the application of PBD included preoperative jaundice (OR 70.5, 95% CI 21.4–306.6) and evaluation by non-tertiary therapeutic endoscopists (OR 3.9, 95% CI 1.3–13.6). PBD was associated with a 12-day delay in surgery among those who did not receive NAC (p = 0.005), but there were no differences in surgical complications or mortality.Conclusions.Our findings suggest that (1) NAC may confer a survival benefit and (2) PBD should be reserved for individuals with jaundice requiring NAC. Implementation of guidelines by North American gastroenterology societies, multidisciplinary treatment models, and delivery of care at high-volume tertiary centers may help optimize management.
IntroductionAnal adenocarcinoma is a rare malignancy with a poor prognosis.MethodsWe present a ca... more IntroductionAnal adenocarcinoma is a rare malignancy with a poor prognosis.MethodsWe present a case of rare anal adenocarcinoma in a patient with normal screening colonoscopy. Using the Surveillance, Epidemiology and End Result database between 2000 and 2016, we performed survival analysis among individuals>20 years old comparing anal and rectal cancers.ResultsSurvival analysis showed that anal adenocarcinoma is associated with worse outcomes compared with rectal adenocarcinoma and anal squamous cell carcinoma.DiscussionThis case and survival data illustrate the importance of prompt investigation of symptoms irrespective of colorectal cancer screening status with careful attention to examination of the anal area.
Purpose: Our objective is to investigate the yield of upper and lower gastrointestinal(GI) endosc... more Purpose: Our objective is to investigate the yield of upper and lower gastrointestinal(GI) endoscopic evaluations in anemic patients with serum ferritin levels between 40 and 100 ng/ml. Subjects and Methods: Most practice guidelines recommend endoscopic evaluation of the GI tract in men and post menopausal women with anemia and a serum ferritin level less than 20–40 ng/ml. However, as ferritin is an acute phase reactant, iron deficiency anemia (IDA) can be present with ferritin greater than 40 ng/ml. The diagnostic yield of GI endoscopy in patients with anemia, no GI symptoms or signs, and low normal ferritin. Some patients at the Veterans Affairs (VA) Connecticut Healthcare System undergo endoscopic evaluation as part of their anemia work up even when the ferritin is in the low normal range (40–100 ng/ml). We retrospectively reviewed the data on this population of patients over a 42-month period (1999–2003) to determine the incidence of GI findings. Results: All 522 patients who had undergone endoscopic examination for anemia over a 42 month period were screened. We identified 54 male patients who had a serum ferritin level between 40 and 100 ng/ml, no GI symptoms, and no evidence of GI bleeding. Significant lower GI findings, including large tubular adenomas and arterio-venous malformation (AVM), were identified in 3/53 cases (6.7%). Upper GI findings, including malignancy, peptic ulcers, Helicobacter Pylori gastritis, and AVM, were found in 14/47(30%) of cases. Conclusion: In this retrospective study on male anemic patients with low normal serum ferritin but lack of GI symptoms or known bleeding, the prevalence of upper and lower GI lesions was 30% and 6.7%, respectively. Our study supports a GI endoscopic evaluation in anemic patients with ferritin between 40 to 100 ng/ml, even in the absence of GI symptoms, or evidence for GI bleeding. Table 1: Ferritin, hematocrit (HCT), mean corpuscular volume (MCV) and prevalence of GI lesions in patients with borderline ferritin levels * In the majority of the patients, more than one serum ferritin level was measured, and the one closest to the endoscopic procedure was used. Total number of pateients N=54 Age(YO) 72.4±10.3 Ferritin (ng/ml) 63.6±16.7 HCT(%) 35.5% + 2.4 (range 34–40%) MCV(fL) 85.9±7.6 Upper GI findings 17/47 Lower GI findings 22/53 Table 2: Endoscopic Findings in Anemic Patients with Serum Ferritin Levels between 40–100 ng/mL without significant GI symptoms or signs. LOWER GI FINDINGS Number/percentage TA = tubular adenoma. *In 13/15 cases, TAs were found proximal to the splenic flexure, in 6/15 cases multiple TAs were found. MALIGNANCY 0/53 ADENOMA&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;1CM 2/53 ADENOMA&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;1CM 15/53* EXTENSIVE DIVERTICULOSIS 4/53 ARTERIOVENOUS MALFORMATION 1/53 ULCER 0/53 UPPER GI FINDINGS MALIGNANCY 1/47 ESOPHAGITIS/BARRETT’S ESOPHAGUS 1/47 LARGE HIATAL HERNIAS WITH EROSION 2/47 ESOPHAGEAL VARICES 1/47 CHRONIC ACTIVE GASTRITIS/DUODENITIS, H PYLORI+ 5/47 GASTRIC OR DUODENAL PEPTIC ULCER 5/47 ARTERIOVENOUS MALFORMATION 1/47 ATROPHIC GASTRITIS 1/47
59 Background: 5-Fluorouracil (5-FU) is a component of first-line treatment regimens for metastat... more 59 Background: 5-Fluorouracil (5-FU) is a component of first-line treatment regimens for metastatic colorectal cancer (mCRC). Historically, 5-FU is administered as a bolus followed by an infusion. However, the bolus dose adds substantial toxicity and is often withheld in patients with limited functional status or high-risk comorbidities, but its impact on treatment outcomes remains unclear. Small studies suggest that it may be omitted. The aim of this study was to determine whether omission of the 5-FU bolus is associated with a difference in overall survival (OS). Methods: An electronic health record-derived national multicenter oncology database from Flatiron Health was queried to select patients with mCRC who received a first-line 5-FU-containing regimen. Demographics, relevant labs, treatment details, and survival outcomes were collected. Propensity score (PrS) matching and OS analysis were performed incorporating age, race, sex, ECOG score, combination drug regimen, and baseline creatinine and bilirubin. Variables with p &lt; 0.10 in univariable Cox proportional hazards models were included in the multivariable analysis. Results: We included 9741 patients with mCRC who received 5-FU-based regimens. All individuals received a 5-FU infusion, and 7901 (81%) also received a 5-FU bolus. Among our entire cohort, 43% were female, 23% were &gt; 70 years, 66% were white, and 89% had ECOG ≤ 1. Over a median follow-up time of 19 months, 5847 patients (60%) died. In the unmatched univariable (HR 0.94, 95% CI 0.88-1.00, p = 0.06) and multivariable (aHR 0.85, 95% CI 0.93-1.06, p = 0.85) analyses, there was no association between the use of bolus 5-FU and OS. A number of factors were associated with an increased risk of death, including older age, high ECOG scores, and elevated bilirubin or creatinine levels. Similarly, in our PrS-matched dataset (n = 6126), the use of a 5-FU bolus was not associated with OS (HR 0.98; 95% CI 0.91-1.06; p = 0.64). Conclusions: The findings of our PrS-matched multicenter cohort study indicate that, after adjusting for host and treatment factors, 5-FU bolus dosing was not associated with an overall survival benefit among patients with mCRC. These results suggest that, in mCRC, the addition of a 5-FU bolus does not appear to add efficacy to regimens utilizing infusional 5-FU. Future work is necessary to determine the role of bolus dosing in the adjuvant setting and its impact on other clinically-relevant outcomes.
We report a case of a bleeding duodenal varix demonstrating excellent hemostasis achieved by endo... more We report a case of a bleeding duodenal varix demonstrating excellent hemostasis achieved by endoscopic ultrasound (EUS)-directed placement of an embolization coil followed by cyanoacrylate. A 31-year-old man with decompensated Child's class C cirrhosis presented with hematemesis. An initial endoscopy revealed an actively bleeding duodenal varix. Subsequent attempt at hemostasis with ethanolamine oleate injection failed. A later attempt at hemostasis involving EUS-guided placement of an embolization coil followed by cyanoacrylate injection into the varix was successful. We reviewed the literature involving the treatment of bleeding ectopic varices and conclude that EUS provides a unique and advantageous modality for achieving variceal hemostasis of duodenal varices in patients who are not candidates for transjugular intrahepatic portosystemic shunt.
The American Journal of Gastroenterology, Jul 1, 2016
Concerns about the possible side effects of proton pump inhibitors (PPIs) have been raised since ... more Concerns about the possible side effects of proton pump inhibitors (PPIs) have been raised since their introduction in the 1980s, including gastric carcinoids, gastric carcinoma, decreased absorption of minerals (e.g., iron, calcium) and vitamin B-12, fractures, enteric infections (e.g., C. difficile), pneumonia, hypomagnesemia, and cardiovascular events (1). This year studies reporting associations with chronic kidney disease (CKD) and dementia had widespread media coverage (2, 3), prompting renewed concern and many questions from patients and physicians regarding long-term PPI use.
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Papers by Anil Nagar