Algorithm for “Cursed” Dyspepsia

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A recent review (P Koduru et al. Clin Gastroenterol Hepatol 2018; 16: 467-79) provides a good review of dyspepsia and in addition provides some literary perspective.

In their introduction, the authors quote James Joyce in Ulysses: “Tom Rochford split powder from a twisted paper into the water set before him –That cursed dyspepsia, he said before drinking. –Breadsoda is very good Davy.”

After reviewing the definition and the pathophysiology, the authors provide a suggested algorithm (Figure 2).

Initial options:

  • In areas with high H pylori, there is an option of “test and treat” and relying on endoscopy in those who fail to respond
  • Empiric PPI therapy which works best if reflux-type symptoms are present and relying on endoscopy in those who fail to respond
  • Endoscopy without empiric treatment

In those with a negative endoscopy –>functional dyspepsia treatment is driven by symptoms:

  • If pain, the first line option recommended is a tricyclic antidepressant (pain modulator)
  • If nausea, the first line option recommended is an antiemetic
  • If early satiety, the first line option recommended is buspirone

For those with resistant and disabling symptoms, “consider nonpharmacologic approaches, such as psychotherapy or acupuncture.”

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

HBV Reactivation Risk with HCV DAA Therapy and What to Do About It

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A recent prospective study (C-J Liu et al. Gastroenterol 2018; 154: 989-97) provided some reassurance about the likelihood of hepatitis B virus (HBV) reactivation during hepatitis C virus (HCV) treatment with direct-acting antivirals (DAA).

In this study with 111 patients with both HCV and HBV treated with ledpasvir/sofusbuvir, all (100%) of the patients had a sustained virologic response for their HCV infection. Other key findings:

  • Of the 37 patients with baseline HBV DNA < 20 IU.mL, 31 (84%) developed detectable HBV DNA levels through posttreatment week 12.
  • Of the 74 patients with baseline HBV DNA >20 IU/mL, 39 (53%) developed increases in HBV DNA >1 log10 IU/mL through posttreatment week 12.
  • 5 patients developed ALT >2 times ULN and 3 patients were started on HBV therapy.

The associated editorial (pgs 795-8) made the following recommendations:

  • “HBsAg-negative/HBcAb-positive patients should be monitored with ALT alone until SVR12 and should be tested with HBsAg +/- HBV DNA only if ALT increases or fails to normalize on therapy.”
  • “HBsAg-positive patients with undetectable baseline HBV DNA should be considered for preemptive anti-HBV treatment, or monitored with ALT and HBV DNA until SVR12”
  • “HBsAg-positive patients with positive baseline HBV DNA should be started on preemptive anti-HBV treatment until SVR12.”

Using the above management strategy will limit the number of HBV-infected patients who need to be treated.

My take: This study and the associated editorial provide useful information regarding DAA in coinfected HBV/HCV patients; this is important for patients and practitioners, especially given the black box warning on DAA medications.

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Hemospray for GI Bleeding

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From MD Mag: Gastrointestinal Bleeding Spray Gets FDA Marketing Go-Ahead

An excerpt:

 According to Wilson-Cook, Hemospray represents a different approach to treat GI bleeds by reaching hemostasis in patients without the precision or direct visualization required by competing treatments. This makes the device a treatment option for bleeding from damaged tissue where the bleeding source cannot be easily identified.

Hemospray is intended to treat most forms of upper or lower GI bleeding, and is backed by clinical evidence in more than 700 patients.

Its approval was supported by data from clinical studies that consisted of 228 patients with upper and lower GI bleeding, and real-world evidence from medical literature reports that featured another 522 similar patients. According to FDA review, the device stopped GI bleeding in 95% of patients with 5 minutes of its administration. Re-bleeding, as defined by a recurring event from 3-30 days after the use of Hemospray, occurred in 20% of all patients.

Pediatric Experience with Presumed Biliary Dyskinesia

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A recent study (SR Matta et al. JPGN 2018; 66: 808-10) highlights the frequency of cholecystectomies for “presumed biliary dyskinesia” in the United States.

Using a nationwide inpatient database, the authors examined the indication for cholecystectomy in the pediatric population from 2002 to 2011.

Key findings:

  • During the study period, the authors identified 66,380 cholecystectomies in children.  The leading indications were calculus cholecystitis (73.6%), biliary dyskinesia (10.8%), and chronic cholecystitis without calculus.
  • The frequency of biliary dyskinesia as the indication for cholecystectomy jumped significantly during the study period, particularly the first few years: 6.6% (2002), 7.8% (2003), 9.8% (2004), 10.4% (2005 & 2006), 9.9% (2007), 11.8% (2008), 9.6% (2009), 11.9% (2010), and 10.6% (2011).
  • 75% of cases were children >12 years, and 77.5% were females.

The results from the study and the way that biliary dyskinesia is controversial are reviewed in the discussion.

  • A large proportion of biliary dyskinesia patients will develop symptoms suggestive of another functional GI disorder
  • Long-term resolution of symptoms with cholecystectomy is highly variable after surgery and “55-85% of  children with biliary dyskinesia will improve with medical management.”
  • Prospective studies are lacking, but some retrospective studies have recommended using lower cut off values for ejection fraction(eg. <15-% instead of <35%); whereas, other studies have shown no correlation between ejection fraction and outcomes.

My take: Sometimes a ‘quick fix’ is not a fix at all. As this study notes, it is difficult to rely on the diagnosis of biliary dyskinesia.  Many will improve without surgery and many develop divergent symptoms.

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Big Creek Greenway, not far from McFarland

Esophageal Atresia and Barrett’s Esophagus

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Briefly noted: FWT Vergouwe et al. Clin Gastroenterol Hepatol 2018; 16: 513-21.

In this prospective study of adult patients with esophageal atresia (EA) with 151 participants, 6.6% had Barrett’s Esophagus (BE); squamous cell cancer (SCC) was identified in 0.7% (youngest at 42 years).  The authors note that the prevalence of BE and SCC were ~4-fold and ~100-fold higher, respectively, compared to the general population.

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Creek near Chattahoochee River

How Helicobacter pylori Survives in the Stomach

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A recent basic science study (P Morey et al. Gastroenterol 2018; 154: 1391-1404) explains one of the mechanisms whereby Helicobacter pylori survives in the stomach.

The researchers used MKN45 gastric epithelial cells and human gastric cells obtained from patients undergoing gastric resections and exposed them to H pylori strains. They did additional studies in infected mice.

This report has a number of cool figures demonstrating that H pylori blocks the assembly of interferon and other cytokines.  Infected gastric cells were depleted of cholesterol which rendered them unable to respond properly to inflammatory signals from immune cells.  H pylori is able to decrease inflammation at sites of colonization while inducing inflammation in adjacent noninfected epithelium.  The authors note that patients with increased serum cholesterol (especially LDL) are at increased risk for severe H pylori gastritis.

Big Creek Greenway, Alpharetta

Button Battery -Update For Families

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Children’s Healthcare of Atlanta Hope & Will blog: Common Batteries Pose Danger For Kids

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Possible Quality Metric for Fatty Liver Disease: Dyslipidemia

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With nonalcoholic fatty liver disease (NAFLD), it is well-documented that adverse cardiovascular events influence mortality more than any other factor.  Dyslipidemia plays an important role in these outcomes.

A recent study (KE Harlow et al. J Pediatr 2018; article in press. DOI: https://doi.org/10.1016/j.jpeds.2018.02.038) indicates that “clinically actionable dyslipidemia” is present in more than half of pediatric patients with NAFLD.

This multicenter, longitudinal cohort study included children (n=585) with NAFLD enrolled in the National Institute of Diabetes and Digestive and Kidney Diseases Nonalcoholic Steatohepatitis Clinical Research Network.

Key findings:

  • The prevalence of children warranting intervention for low-density lipoprotein cholesterol at baseline was 14%. After 1 year of recommended dietary changes, 51% achieved goal low-density lipoprotein cholesterol, 27% qualified for enhanced dietary and lifestyle modifications, and 22% met criteria for pharmacologic intervention
  • Elevated triglycerides were more prevalent, with 51% meeting criteria for intervention at baseline. At 1 year, 25% achieved goal triglycerides with diet and lifestyle changes, 38% met criteria for advanced dietary modifications, and 37% qualified for antihyperlipidemic medications.

My take: Assessing/managing dyslipidemia is an important component of NAFLD care.

Link to abstract: Clinically Actionable Hypercholesterolemia and Hypertriglyceridemia in Children with Nonalcoholic Fatty Liver Disease

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Saline Shortages

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Two interesting commentaries on the saline shortages:

  • M Mazer-Amirshahi, ER Fox. NEJM 2018; 378: 1472-4.
  • AM Patino et al.  NEJM 2018; 378: 1475-7.

The first explains that large quantities of saline bags are needed each month –more than 40 million bags per month!  While saline is inexpensive, the production requires meticulous care to avoid contamination and there have been supply issues since 2014, prior to Hurricane Maria.  However, the problem has been much worse since Hurricane Maria which damaged Puerto Rico.  Puerto Rico supplies 44% of the IV bags in the U.S.  These fluids are given to virtually all hospitalized patients, either for IV fluids or as a component with medications/flushes.

Other points:

  • “Drug manufacturers are not required to have redundancy in their facilities or even a business contingency plan in case of a disaster.”
  • The  FDA has “recently approved saline products from two additional manufacturers”
  • “To conserve large-volume saline bags, oral hydration is recommended.”

The article by Patino et al provides Brigham and Women’s Hospital Oral Rehydration protocol. Key points:

  • Using their protocol, the volume of IV fluid use decreased over 30% in the first week of implementation
  • The fraction of ED patients using IV fluids dropped by 15% in the first 3 weeks of implementation.
  • Oral hydration protocols are a “rational practice change…even after the current IV-fluid shortage crisis ends.”