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August 5th, 2012

PPIs: Are the risk issues being overplayed?

 I have been using PPIs to manage GERD and acid-sensitive dyspepsia since omeprazole first became available in 1989. Although no drug class is absolutely safe, there is, as yet, not a single case report of a death related to this drug class, despite hundreds of millions of patient-years of exposure. Despite this remarkable safety profile, much attention has focused recently on the overall safety of PPIs, as they have been associated with enteric infections (e.g., c. difficile), decreased bone density, electrolyte abnormalities (e.g., low magnesium), etc. However, most of these risks have been described in epidemiological studies that can establish association but not causation, and we learned an important lesson about interpreting such results with caution after authors and the FDA sent a message about the so-called interaction between PPIs and clopidogrel that turned out to be clinically irrelevant.

Despite the benefits of PPIs, increased scrutiny of the safety of this drug class has led a number of my patients to question recommendations about trying or continuing PPI therapy. I think that patients are wise to ask about the relevant side effects of any drug, but I have had trouble giving much in the way of advice or information about PPI risks, given the lack of credible evidence of cause and effect.

So, what do you tell your patients about risks when you start them on a PPI therapy?

What do you tell patients on long-term PPI therapy?

Do you use drug holidays?

Do you do bone-density studies earlier or more often in patients on PPIs?

Do you monitor magnesium levels?

Do you have patients stop therapy if they at risk for enteric infections (e.g., from hospital antibiotic exposure, travel to developing nations, etc.)?

I am looking forward to your insightful comments.

 

July 8th, 2012

Gluten: How often is it the culprit?

All gastroenterologists are very familiar with celiac disease, including its characteristic findings on small bowel biopsy and the treatment with a gluten-free diet. But I have noticed that we as gastroenterologists approach the possibility of sprue, or those suspected of having gluten sensitivity without sprue, with extraordinary variability. For instance, a negative screening tissue transglutaminase (TTG) has greater than a 99% negative predictive value (essentially excluding celiac disease), but a positive TTG has only a 25% to 35% positive predictive value, meaning that most patients who test positive do not have celiac disease.

So, first, here are some questions:

1) Do you still take biopsies in some patients with a negative TTG, and, if so, how do you decide which patients should undergo biopsy?

2) Do you take biopsies in all patients with positive TTG screens? If not, do you put these patients on a gluten-free diet as a trial?

3) Where and how many biopsies do you take to diagnose sprue? Do you always take biopsies in the duodenal bulb?

4) If you take duodenal biopsies, how long do you want the patient on gluten prior to the exam?

Now, let’s talk about gluten sensitivity:

1) If you take biopsies in patients with symptoms suggestive of sprue, and the biopsies are normal, but the patiens are improved on a gluten-free diet, what do you tell these patients? That they are sprue-variant? That they do not have sprue, but they are gluten sensitive?

2) Do you prescribe the same diet to these patients?

Please weigh in. I look forward to seeing your responses.

April 29th, 2012

How do you treat eosinophilic esophagitis?

We all are seeing this disease more often than in the past. Whereas the diagnostic criteria now seem firmly entrenched, the optimal treatment strategy remains to be determined. Treatments have included food avoidance, anti-secretory drugs, topical steroids, immunomodulators, and combinations of these approaches.

So I am interested in how you treat eosinophilic esophagitis.

What is your first line therapy?

Do you put every patient on a PPI?

Do you use food avoidance, and, if so, is it directed empirically or by allergy testing?

Which topical steroid do you use?

Do you treat before dilating?

How long do you treat, or do you maintain patients on therapy?

Let’s get the conversation rolling!

April 2nd, 2012

Screening for hepatocellular cancer: Recommended, but should we do it?

Most gastroenterologists are aware of the increasing incidence of hepatocellular cancer (HCC) in patients with cirrhosis. Most are also aware of the updated 2011 guidelines from the American Association for Study of Liver Diseases that recommend screening many patients with cirrhosis for HCC with every 6-month ultrasound examinations. These guidelines are based largely on a cost-effectiveness analysis showing that, at a certain threshold, incidence of HCC screening would be cost-effective in various cirrhotic states. However, there is a lack of data from prospective trials showing that screening is effective in preventing death from HCC and almost no data on the efficacy of such an intervention in the U.S.

1. Do you think we should screen patients with cirrhosis for HCC?

2. How effective do you think such screening is?

3. How would you screen (ultrasound, CT, MRI, alpha fetoprotein)?

4. What frequency intervals should be used?

5. If you do not screen, what data would compel you to begin screening?

I look forward to the discussion.

February 20th, 2012

Fecal transplants: The new cure-all?

The importance of our normal gut flora becomes apparent when antibiotics wipe out a portion of it and give Clostridium difficile a niche to reside in, which can lead to severe colitis. Relapse of the colitis is the rule until the normal gut flora is reestablished, and treatment of relapsing C. difficile colitis has usually involved trials of antibiotics and toxin binding agents. 

More recently, fecal transplants have been reported as both first-line and relapse treatment for C. diff. The effect seems to be far superior to that from traditional approaches and is being touted as a treatment for other GI and nonGI diseases as well.

Have you used fecal transplants?

If not, what would it take for you to start using them? 

If yes, how do you a) prepare them and b) deliver them (e.g., through the scope or by oral capsule delivery)?

What diseases do you screen the donor for? 

What success rate have you observed? 

How much does the treatment cost?

I look forward to hearing what your experiences have been.

January 19th, 2012

Stewardship in medicine: Is it time to stop sending small polyps to the pathologist?

The American Society for Gastrointestinal Endoscopy has stated: “In order for colorectal polyps <5 mm in size to be resected and discarded without pathologic assessment, endoscopic technology (when used with high confidence) used to determine histology of polyps <5 mm in size, when combined with the histopathologic assessment of polyps >5 mm in size, should provide a >90% agreement in assignment of post-polypectomy surveillance intervals when compared to decisions based on pathology assessment of all identified polyps.”*

 How many of us heed this guidance? We do have technologies that in some of our hands exceed the threshold established here for identifying polyp histology >90% of the time (narrow band imaging, confocal microscopy, etc.). But are we teaching, learning, and implementing these technologies to save the patient and payer the substantial pathology charges arising from resecting the many thousands of these diminutive lesions?

 So my questions to you are:

1. Do you ever use real-time histology technology to assess colon polyps?

2. Which one do you use and in what circumstance (small vs. large polyps, all polyps, etc.)?

3. Do you make clinical decisions based on that assessment?

4. If you do not use the technology to make clinical decisions, what accuracy will it take to allow you to “resect and discard” these small polyps?

 * Rex, et al. The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps (Gastrointest Endosc 2011; 73:419).

November 15th, 2011

Water-aided colonoscopy: Does the temperature matter?

  • Many, if not most, colonoscopists are now convinced that using water infusion during scope insertion leads to less patient discomfort and lower sedation needs. What is often used in this situation is water that has been warmed under the assumption that warm is better (i.e., causing less spasm). However, using warm water out of the tap or warmed to a specific temperature in a bath has not been demonstrated to improve outcomes of colonoscopy.

What I am interested in hearing about from you is:

1)       Do you routinely use water infusion during colonoscopy?

2)       If yes, what temperature do you use?

3)       If you use warm water, in what manner do you think it further improves colonoscopy versus room-temperature water, and what specific temperature do you warm it to?

I look forward to hearing from you.

October 24th, 2011

Is it time to stop surveying Barrett esophagus?

One area of gastroenterology that is guided more by dogma than evidence regards surveillance of nondysplastic Barrett esophagus (BE). Surveillance of BE lesions is widely practiced, despite a large body of evidence that the practice is not cost-effective, the cancer risk from BE is very low, and the life expectancy of BE patients is normal. Even guidelines of professional societies (the AGA, ASGE, and ACG) do not endorse such surveillance, but instead view it as an optional strategy.

Now, a new study shows that cancer risk from BE is much lower than the already low rate we had been estimating  (see summary in Journal Watch Gastroenterology).

Based on these emerging facts, I’d like to generate a discussion regarding these questions:
1. Should we be screening for BE, and, if so, in whom?
2. In patients discovered to have nondysplastic BE, should we be doing surveillance?
3. If we do surveillance, how often should it be done?
4. If we recommend no surveillance, what should we be telling these patients?

I look forward to your discussion.

September 19th, 2011

Is it time to make a U-turn in the right colon during colonoscopy?

The right side of the colon seems to be the Achilles heel of colonoscopy because polyps there tend to be flat and harder to find, and we confer the least protection from later colon cancer in that zone.

A recent article summary in Journal Watch Gastroenterology concludes that when we see a right-sided colon polyp, we may have missed another, so we should go back and look again.

This provocative recommendation represents a major change in the way we normally perform colonoscopy. But the issue is, and always has been, how to identify and remove all polyps from the colon.

So the questions I have for you are:

1) Should we routinely reexamine the right colon in everyone, only those with a polyp, or no one?

2) Have you already changed the way you inspect the right colon, or will you now?

3) If you do inspect the right colon differently, do you use retroflexion, repeat examination, narrow-band imaging?

I look forward to your response.

August 7th, 2011

Ablating short-segment Barrett esophagus: What’s your weapon of choice?

The first cases of Barrett esophagus (BE) ablation in the late 1980s used YAG and Argon laser. Since then, a myriad of ablation techniques have been described, including multipolar electrocautery (MPEC), argon plasma coagulation (APC), cryotherapy, radiofrequency ablation (RFA), and endoscopic mucosal resection (EMR). Each technique has had its advocates, and some of the techniques appear to have certain advantages in certain types of BE: e.g., long segment, nodular, etc.

Most cases of BE are short segment, and most neoplastic cases do not have nodules or erosions. So the question I would like to see discussed is: In a patient with 1–2 cm of otherwise featureless flat but neoplastic BE:

What ablation technique would you use, and what do you feel makes this technique advantageous?

What would be your second option, and when would you employ it?

Do you use more than one technique, and, if so, which ones do you use and why?

What are the most common complications you see with BE ablation?

What is your overall success at complete BE elimination?

We look forward to your comments.

Gastroenterology Research: Author M. Brian Fennerty, M.D.

M. Brian Fennerty, MD

Editor-in-Chief

NEJM Journal Watch Gastroenterology

Biography | Disclosures | Summaries

Learn more about Gut Check on Gastroenterology.