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Cirrhosis is a prevalent and expensive condition. With an increasing emphasis on quality in health care and recognition of inconsistencies in the management of patients with cirrhosis, we established a set of explicit quality indicators (QIs) for their treatment.

Background & Aims - Whipple's disease is a chronic infection caused by the actinomycete Tropheryma whipplei. We conducted a randomized controlled trial of the efficacy of antimicrobials that are able to cross the blood-brain barrier and to which T whipplei is susceptible. Methods - Patients from central Europe with previously untreated Whipple's disease (n = 40) were assigned randomly to groups given daily infusions of either ceftriaxone (1 × 2 g, 20 patients) or meropenem (3 × 1 g, 20 patients) for 14 days, followed by oral trimethoprim–sulfamethoxazole for 12 months. The primary outcome measured was maintenance of remission for 3 years, determined by a composite index of clinical and laboratory data as well as histology. Results - All patients were observed for the entire follow-up period (median, 89 mo; range, 71–128 mo); all achieved clinical and laboratory remission. Remission was maintained in all patients during the time of observation, except for 2 who died from unrelated causes. A single patient with asymptomatic cerebrospinal infection who was resistant to both treatments responded to chloroquine and minocycline. The odds ratio for the end point (remission for at least 3 years) was 0.95 (95% confidence interval, 0.05–16.29; P = 1.0). Conclusions - This was a randomized controlled trial to show that treatment with ceftriaxone or meropenem, followed by trimethoprim–sulfamethoxazole, cures patients with Whipple's disease. One asymptomatic individual with infection of the cerebrospinal fluid required additional therapy.

Background & Aims Data on the benefit of selective serotonin reuptake inhibitors (SSRIs) in irritable bowel syndrome (IBS) are conflicting. The longitudinal relationship between clinical symptoms and sensitivity to barostat-mediated rectal distension in IBS remains unclear. We assessed the benefit of citalopram and explored the relationships between symptoms, quality of life (QOL), and rectal sensitivity to barostat distension in non-depressed IBS patients. Methods Patients from primary, secondary, and tertiary care settings were randomly assigned to receive citalopram (20 mg/day for 4 weeks, then 40 mg/day for 4 weeks) or placebo in a study with double-masking and concealed allocation. Symptoms were assessed weekly, and IBS-QOL and rectal sensation by barostat were assessed at the beginning and end of the study. Results Patients receiving citalopram did not achieve a higher rate of adequate relief of IBS symptoms than patients receiving placebo (12/27 [44%] vs 15/27 [56%]; P = .59), regardless of IBS subtype. The odds ratio for weekly response with citalopram vs placebo was 0.80 (95% confidence interval, 0.61–1.04). Improvements in specific symptom and IBS-QOL scores were not superior for citalopram. Changes in IBS-QOL score and pressure eliciting pain showed a modest correlation (r = 0.33; 95% confidence interval, 0.03–0.57), but changes in symptoms and IBS-QOL scores or rectal sensitivity were not correlated substantially. Conclusions Citalopram was not superior to placebo in treating non-depressed IBS patients. Changes in symptoms were not substantially correlated with changes in rectal sensation assessed by barostat. Any benefit of citalopram in non-depressed IBS patients is likely to be modest at best.

Background & Aims Achalasia is treated with pneumatic dilation or Heller myotomy, but studies suggest poor long-term outcomes. We analyzed long-term outcomes after initial pneumatic dilation and studied factors associated with failure. Methods A total of 209 patients (111 men; mean age, 51.2 ± 1.4 years) with achalasia who were treated with pneumatic dilation between 1992 and 2002 were followed. Outcomes were correlated with demographics, presenting symptoms, manometric features, and treatment variables by using χ2 and Student t tests. Results All patients were initially treated with consecutive esophageal dilations up to balloon diameters of 3.0 (26%), 3.5 (41%), or 4.0 cm (33%). After dilations, mean lower esophageal sphincter (LES) pressure had decreased from 31.3 ± 1.3 to 14.0 ± 0.7 mm Hg (P < .0001); dysphagia decreased from 96% to 26%; and 49% had gained an average of 4.6 ± 0.5 kg (weight loss at presentation was 10.6 ± 0.7 kg in 39%). During follow-up, 66% required no additional treatment, whereas 23% underwent repeat dilations after 79 ± 8 months. Patients without recurrence were older (41.2 ± 2.1 vs 56.6 ± 1.6 years; P < .0001) and had lower post-treatment LES pressure (17.8 ± 1.2 vs 12.9 ± 0.6 mm Hg; P < .005). After 70-month follow-up, balloon dilation yielded good or excellent outcomes in 72% of patients. In nonresponders, rescue surgery yielded higher success rates than botulinum toxin therapy (84% vs 44%). Patient satisfaction ranged from good to excellent in 81% of patients. Conclusions Treating achalasia with initial dilation and then surgery for short-term failures yielded good long-term results in more than 70% and treatment satisfaction in more than 80% of patients. Management of dilation failures is more problematic.

Background & Aims Small intestinal bacterial overgrowth (SIBO) has been proposed as an etiologic factor in irritable bowel syndrome (IBS), but evidence is conflicting. We conducted a systematic review and meta-analysis of the prevalence of SIBO in IBS. Methods MEDLINE and EMBASE were searched up to November 2008. Case series and case-control studies applying diagnostic tests for SIBO in unselected adults meeting diagnostic criteria for IBS were eligible. Prevalence of a positive test for SIBO was extracted and pooled for all studies, and compared between cases and controls using an odds ratio and 95% confidence interval (CI). Results Twelve studies were identified containing 1921 subjects meeting criteria for IBS. Pooled prevalence of a positive lactulose or glucose hydrogen breath test was 54% (95% CI, 32%–76%) and 31% (95% CI, 14%–50%), respectively, with statistically significant heterogeneity between study results. Prevalence of a positive jejunal aspirate and culture was 4% (95% CI, 2%–9%). The pooled odds ratio for any positive test for SIBO in cases compared with healthy asymptomatic controls was 3.45 (95% CI, 0.9–12.7) or 4.7 (95% CI, 1.7–12.95), depending on the criteria used to define a positive test, with statistically significant heterogeneity for both. Conclusions Prevalence of SIBO in individuals meeting diagnostic criteria for IBS was highest with breath testing. The prevalence in cases with IBS compared with controls varied according to criteria used to define a positive test. The role of testing for SIBO in individuals with suspected IBS remains unclear.

Background & Aims There has been no prospective, community-based study to track changes in adenoma detection by individual physicians over time and to determine the effectiveness of targeted educational interventions. Methods We prospectively collected information on 47,253 screening colonoscopies in average-risk individuals 50 years and older performed by a community-based practice in the Twin Cities of Minnesota. During a period of 3 years, 5 specific interventions were implemented; each was designed to improve adenoma detection rates. Controlling for patient-related and procedure-related factors, rates of adenoma detection and 3-year trends for individual physicians were plotted, and intraclass correlation coefficients were calculated. Generalized estimating equations were used to identify factors associated with detection of adenomas and polyps. Results At least 1 polyp and 1 adenoma were found in 36% and 22% of examinations, respectively. Adenoma detection rates by endoscopists ranged from 10%–39%. There was no significant improvement during the study period despite planned, systematic interventions. Factors associated with adenoma detection included age of the patient (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.02–1.02), male sex (OR, 1.53; 95% CI, 1.34–1.74), and adequate preparation quality (OR, 2.26; 95% CI, 1.64–3.12).  Conclusions The detection of adenomas by individual physicians during a 3-year period varied and did not appear to change between individual endoscopists, despite planned, systematic interventions. This indicates that other targeted interventions might be required to improve adenoma detection rates among experienced, community gastroenterologists.

Background & Aims There have been few clinical studies of systemic inflammatory response syndrome (SIRS) in patients with acute pancreatitis. The aim of this study was to evaluate the role of SIRS in assessing severity of acute pancreatitis. Methods We prospectively enrolled 252 consecutive patients with acute pancreatitis who were admitted directly to our institution between 2005–2007. The incidence and duration of SIRS (transient ≤48 hours vs persistent >48 hours) during the first 7 days of hospitalization, and the number of SIRS criteria (0–4) on the first day of hospitalization (day 1) were evaluated with individual markers of severity, including persistent organ failure, pancreatic necrosis, need for intensive care unit, and mortality.  Results SIRS occurred in 155/252 patients (62%) on day 1. SIRS on day 1 predicted severe disease with high sensitivity (85%–100%). The absence of SIRS on day 1 was associated with a high negative predictive value (98%–100%). Patients with a higher number of systemic inflammatory response (SIR) criteria on day 1 and persistent SIRS had an increased risk for severe disease (P < .01). Conclusions The majority of patients hospitalized with acute pancreatitis have SIRS on day 1. The severity of acute pancreatitis is greater among patients with SIRS on day 1 and, in particular, among those with 3 or 4 SIRS criteria, compared with those without SIRS on day 1.

Background & Aims One objective of colonoscopy is to identify and remove polyps—this process requires attention to detail and prolonged concentration. Providers are predisposed to cognitive errors because the procedure is often performed repetitively throughout the day. We measured the adjusted relationship between colonoscopy start time and polyp yield.  Methods We performed a prospective study of 477 patients that received screening, surveillance, or diagnostic colonoscopies at a Veteran's Administration (VA) teaching hospital. The primary outcome measure was polyp yield. We collected data on colonoscopy start times, which were analyzed both as a dichotomous time period (“early-morning case” vs “later case”) and as a continuous variable (start time). We identified significant risk factors using univariate analysis and performed Poisson multivariable regression to measure the independent effect of colonoscopy start time on polyp yield. We evaluated evidence of decreasing polyp yield as the day progressed throughout pre-specified time intervals. Results In univariate analysis, early-morning cases yielded 27% more polyps per patient than later cases (95% confidence interval, 11%–45%; P < .001). The total numbers of, hyperplastic and adenomatous polyps found decreased hour-by-hour as the day progressed. Multivariable analysis demonstrated that early-morning cases yielded 20% more polyps per patient than later cases (95% confidence interval, 5%–38%; P = .007).  Conclusions At a VA medical center, more polyps were detected in patients that received colonoscopies early in the morning compared with later in the day. Moreover, adenoma detection reduced as the day progressed. Providers might be most adept at detecting polyps at the beginning of the day; further validation in other practice settings is required.

Background & Aims - Nighttime symptoms of gastroesophageal reflux disease (GERD) are prevalent and have negative effects on sleep quality. We quantified the effects of GERD symptoms on sleep difficulties and their effects on outcomes. Methods - Data were obtained from a patient-reported survey conducted in 2006 among the general US population. Respondents who had experienced GERD symptoms at least twice during the past month were categorized as GERD patients and were subclassified into groups on the basis of nighttime symptoms and sleep difficulties. Outcomes included health care resource use in past 6 months, work productivity and activity impairment (WPAI), and health-related quality of life (HRQOL) based on results of the Short-Form Health Survey (SF-8). Regression analysis was used to adjust for demographics and clinical characteristics. Results - Of 11,685 survey respondents with GERD, 88.9% experienced nighttime symptoms, 68.3% sleep difficulties, 49.1% difficulty initiating asleep (induction symptoms), and 58.3% difficulty maintaining sleep (maintenance symptoms). Respondents with nighttime GERD symptoms were more likely to experience sleep difficulties (odds ratio, 1.53) and difficulties with induction (odds ratio, 1.43) and maintenance (odds ratio, 1.56) of sleep (P < .001 for all). Sleep difficulties were associated with 0.9 additional provider visits, a 5.5% increase in overall work impairment, a 10.9% increase in activity impairment, and reductions of 3.1 and 3.6 points in SF-8 physical and mental summary scores, respectively. Conclusions - Nighttime GERD symptoms are associated with interruption of sleep induction and maintenance and result in considerable economic burden and reduction in HRQOL.

Background & Aims - Nighttime symptoms of gastroesophageal reflux disease (GERD) are prevalent and have negative effects on sleep quality. We quantified the effects of GERD symptoms on sleep difficulties and their effects on outcomes.  Methods - Data were obtained from a patient-reported survey conducted in 2006 among the general US population. Respondents who had experienced GERD symptoms at least twice during the past month were categorized as GERD patients and were subclassified into groups on the basis of nighttime symptoms and sleep difficulties. Outcomes included health care resource use in past 6 months, work productivity and activity impairment (WPAI), and health-related quality of life (HRQOL) based on results of the Short-Form Health Survey (SF-8). Regression analysis was used to adjust for demographics and clinical characteristics. Results - Of 11,685 survey respondents with GERD, 88.9% experienced nighttime symptoms, 68.3% sleep difficulties, 49.1% difficulty initiating asleep (induction symptoms), and 58.3% difficulty maintaining sleep (maintenance symptoms). Respondents with nighttime GERD symptoms were more likely to experience sleep difficulties (odds ratio, 1.53) and difficulties with induction (odds ratio, 1.43) and maintenance (odds ratio, 1.56) of sleep (P < .001 for all). Sleep difficulties were associated with 0.9 additional provider visits, a 5.5% increase in overall work impairment, a 10.9% increase in activity impairment, and reductions of 3.1 and 3.6 points in SF-8 physical and mental summary scores, respectively.  Conclusions - Nighttime GERD symptoms are associated with interruption of sleep induction and maintenance and result in considerable economic burden and reduction in HRQOL.

Background & Aims - Endoscopic ultrasound is a clinically valuable endoscopic platform, although a potential barrier to its widespread use is the modest reimbursement to the hospital, compared with that of standard endoscopy. However, the downstream procedures generated by endoscopic ultrasound findings might offset its modest procedural reimbursement for a hospital or health care system. We compared the number of hospital procedures that resulted from endoscopic ultrasound findings with those from colonoscopy findings and also compared the downstream hospital charges generated by endoscopic ultrasounds with those from colonoscopies. Methods - We retrospectively reviewed data from 920 consecutive endoscopic ultrasounds and 920 consecutive colonoscopies performed at University Hospital in Cincinnati, Ohio to determine the downstream procedures generated within 18 months of the index procedure. Total hospital charges were determined for the index procedures, as well as all downstream surgeries, endoscopic procedures, and radiation therapy, chemotherapy, and interventional radiology procedures. Results - Endoscopic ultrasounds led to a greater number of downstream procedures than colonoscopies (198 vs 34). Hospital charges for downstream procedures that arose from endoscopic ultrasounds were 2.63-fold greater than those of colonoscopies ($4,068,115 vs $1,546,291). Hospital charges that resulted from the 920 index endoscopic ultrasounds were 1.34-fold greater than those of the index colonoscopies ($3,194,715 vs $2,381,745). Thus, the total hospital charges (index procedures plus downstream procedures) that arose from endoscopic ultrasounds were 1.85-fold greater than those of colonoscopies ($7,262,830 vs $3,928,036). Conclusions - Endoscopic ultrasounds generate greater downstream hospital charges than colonoscopies. These downstream charges attenuate the higher procedure-related charges of colonoscopy for a hospital.

Background & Aims - Fundic gland polyps (FGPs), the most common type of gastric polyps, have been associated with prolonged proton pump inhibitor therapy and an increased risk of colon cancer. The presence of FGPs has been inversely correlated with Helicobacter pylori infection. We evaluated the prevalence of H pylori-associated gastritis, colonic polyps, and carcinomas in subjects with and without FGPs.  Methods - We analyzed data collected from community-based endoscopy centers in 36 states (plus Washington DC and Puerto Rico) on patients who underwent esophagogastroduodenoscopy (EGD) and colonoscopy between April 2007 and March 2008. Of the 103,385 patients who underwent EGD during this time period, gastric biopsy samples were collected from 78,801 and colonic biopsies from 26,017. Slides of samples from Helicobacter-infected FGPs and FGPs with dysplasia were reviewed.  Results - FGPs were detected in 6081 patients (67.8% women). Helicobacter infection was present in less than 0.5% patients with FGPs and 13.0% of those without FGPs (odds ratio [OR], 29.05; 95% confidence interval [CI], 20.4–41.4; P < .0001). Colonic adenomas were detected in 42.3% of women with FGPs and 33.8% of those without (OR, 1.43; 95% CI, 1.26–1.63; P < .001); there was no significant difference in colonic adenomas between men with and without FGPs.  Conclusions - Women had a higher prevalence of FGPs. FGPs were associated with gastroesophageal reflux disease symptoms, gastric heterotopia, hyperplastic colonic polyps (only in men), and colonic adenomas (only in women, especially those over 60 years of age). The presence of FGPs was inversely correlated with H pylori infection, active gastritis, and gastric neoplasia.

Background & Aims Only severe acute pancreatitis requires treatment, according to the principles of intensive care medicine in an intensive care or intermediate care unit. The aim of the study was to define and evaluate a simple clinical algorithm for rapid initial identification of patients with a first attack of acute pancreatitis who do not require intensive care. Methods This prospective study included 394 patients who were admitted to the Municipal Clinic of Lüneburg, Germany, between 1987 and 2003. From a number of parameters of disease severity on admission, 3 parameters that showed the strongest prediction of a nonsevere course (no rebound tenderness and/or guarding, normal hematocrit level, and normal serum creatinine level) were combined to form the harmless acute pancreatitis score (HAPS). The score then was validated in a German multicenter study including 452 patients between 2004 and 2006. Results In both the initial and the validation set, the HAPS correlated with a nonsevere course of the disease (P < .0001). The score correctly identified a harmless course in 200 (98%) of 204 patients. Conclusions The HAPS enables identification, within approximately 30 minutes after admission, of patients with acute pancreatitis whose disease will run a mild course. The high level of accuracy of this test (98%) will allow physicians to identify patients quickly who do not require intensive care, and potentially those who will not require inpatient treatment at all. Thus, the HAPS may save substantial hospital costs.

To summarize and compare the safety and efficacy of endoscopic and surgical treatments for esophageal achalasia.

The hepatitis B virus (HBV) causes chronic infection in approximately 400 million people in the world. Most carriers of chronic HBV, including Asians, Africans, and a proportion of persons in Mediterranean countries, acquire the infection at birth or within the first 1 to 2 years after birth.1 It is estimated that 50% of male carriers and 14% of female carriers will eventually die of the complications of cirrhosis and hepatocellular carcinoma.