Main Gastroenterology, P.C.

UNEVENTFUL COURSE IN IBD PATIENTS DURING SARS-COV-2 OUTBREAK IN NORTHERN ITALY GASTROENTEROLOGY In this study, using a mathematical model applied to the Wuhan region, which estimated 86% undocumented cases, the authors could speculate that in Bergamo province of Italy a total of 46,220 patients were infected by SARS-CoV-2, accounting for 4% of the total population. From this model, the authors estimated that 21 cases in their inflammatory bowel disease (IBD) cohort (N=522) sh...ould have been infected. All patients were counseled to stay on their current therapies, which included salicylates in 59%, immune modulators in 22%, and biologics in 16%. There were no reported cases of COVID-19 in the IBD cohort during that period. AS OF MARCH 23, 2020, NO IBD PATIENTS FROM THE AUTHORS' COHORT WERE AFFECTED BY A COMPLICATED SARS-COV-2RELATED PNEUMONIA. Omar Khan, MD Omar Khan, MD See more

Gastrointestinal Features in COVID-19 and the Possibility of Fecal Transmission Alimentary Pharmacology & Therapeutics This article reviews the gastrointestinal (GI) symptoms of COVID-19 and evaluates the presence of virus particles in the feces as detected by PCR. Diarrhea was the most common GI manifestation of COVID-19 in both children and adults, within an overall wide variety in prevalence of GI manifestations. Fecal PCR was as accurate as respiratory PCR for detecting C...OVID-19. Natasha VonRoenn, MD BACKGROUND There is little published evidence on the gastrointestinal features of COVID-19. AIMS To report on the gastrointestinal manifestations and pathological findings of patients with COVID-19, and to discuss the possibility of faecal transmission. METHODS We have reviewed gastrointestinal features of, and faecal test results in, COVID-19 from case reports and retrospective clinical studies relating to the digestive system published since the outbreak. CONCLUSIONS Gastrointestinal symptoms are common in patients with COVID-19, and had an increased prevalence in the later stage of the recent epidemic in China. SARS-CoV-2 enters gastrointestinal epithelial cells, and the faeces of COVID-19 patients are potentially infectious.

Efficacy of Psychological Therapies for Irritable Bowel Syndrome Gut The authors performed a systematic review and network meta-analysis to try to determine the efficacy of psychological therapies in the management of irritable bowel syndrome. Cognitive behavioral therapy and gut-directed hypnosis had more studies that showed long-term efficacy. Most studies were conducted as refractory therapy.... Use of these techniques as an early intervention may be beneficial. Mukund Venu, MD, FACG OBJECTIVES National guidelines for the management of irritable bowel syndrome (IBS) recommend that psychological therapies should be considered, but their relative efficacy is unknown, because there have been few head-to-head trials. We performed a systematic review and network meta-analysis to try to resolve this uncertainty. DESIGN We searched the medical literature through January 2020 for randomised controlled trials (RCTs) assessing efficacy of psychological therapies for adults with IBS, compared with each other, or a control intervention. Trials reported a dichotomous assessment of symptom status after completion of therapy. We pooled data using a random effects model. Efficacy was reported as a pooled relative risk (RR) of remaining symptomatic, with a 95% CI to summarise efficacy of each comparison tested, and ranked by therapy according to P score. CONCLUSIONS Several psychological therapies are efficacious for IBS, although none were superior to another. CBT-based interventions and gut-directed hypnotherapy had the largest evidence base and were the most efficacious long term.

GLOBAL BURDEN OF IRRITABLE BOWEL SYNDROME NATURE REVIEWS. GASTROENTEROLOGY & HEPATOLOGY This review provides information on the global burden of irritable bowel syndrome (IBS) and the implication of care for people with IBS and identifies key areas for further IBS research. The effect of IBS on management costs and on quality of life appears comparable worldwide.... More rigorous epidemiological studies are needed to determine whether there are differences between country prevalence, along with any possible explanations for these differences. IRRITABLE BOWEL SYNDROME (IBS) IS ONE OF THE MOST COMMON DISORDERS OF GUT-BRAIN INTERACTION WORLDWIDE, DEFINED ACCORDING TO PATTERNS OF GASTROINTESTINAL SYMPTOMS AS DESCRIBED BY THE ROME DIAGNOSTIC CRITERIA. However, these criteria, developed with reference to research conducted largely in Western populations, might be limited in their applicability to other countries and cultures. Epidemiological data show a wide variation in the prevalence of IBS globally and more rigorous studies are needed to accurately determine any differences that might exist between countries as well as the potential explanations. THE EFFECTS OF IBS ON THE INDIVIDUAL, IN TERMS OF THEIR QUALITY OF LIFE, AND ON HEALTH-CARE DELIVERY AND SOCIETY, IN TERMS OF ECONOMIC COSTS, ARE CONSIDERABLE. Although the magnitude of these effects seems to be comparable between nations, their precise nature can vary based on the existence of societal and cultural differences. THE PATHOPHYSIOLOGY OF IBS IS COMPLEX AND INCOMPLETELY UNDERSTOOD; GENETICS, DIET AND THE GUT MICROBIOME ARE ALL RECOGNIZED RISK FACTORS, BUT THE PART THEY PLAY MIGHT BE INFLUENCED BY GEOGRAPHY AND CULTURE, AND HENCE THEIR RELATIVE IMPORTANCE MIGHT VARY BETWEEN COUNTRIES. This Review aims to provide an overview of the burden of IBS in a global context, to discuss future implications for the care of people with IBS worldwide, and to identify key areas for further research.

MANAGEMENT OF CHRONIC ABDOMINAL DISTENSION AND BLOATING CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Abdominal bloating and distension are two of the most commonly reported gastrointestinal symptoms and can develop for multiple reasons. These include food intolerance, a previous infection that perturbed the intestinal microbiota, disordered visceral sensation, delayed intestinal transit, or an abnormal viscerosomatic reflux.... Therapeutic options include dietary changes, probiotics, antibiotics, prokinetic agents, antispasmodics, neuromodulators, and biofeedback. - Omar Khan, MD Abdominal bloating and distension are 2 of the most commonly reported gastrointestinal symptoms. Abdominal bloating is characterized by symptoms of trapped gas, abdominal pressure, and fullness. Abdominal distension is defined as a measurable increase in abdominal girth. These symptoms frequently co-exist, although they can occur separately. Defined by Rome IV criteria, functional abdominal bloating and distension commonly coincide with other functional gastrointestinal disorders, such as functional dyspepsia, irritable bowel syndrome, and functional constipation. Abdominal bloating and distension can develop for multiple reasons, including food intolerances, a previous infection that perturbed the intestinal microbiota, disordered visceral sensation, delayed intestinal transit, or an abnormal viscero-somatic reflux. Treatment can be challenging to patients and providers-no regimen has been consistently successful. Successful treatment involves identifying the etiology, assessing severity, educating and reassuring patients, and setting expectations. Therapeutic options include dietary changes, probiotics, antibiotics, prokinetic agents, antispasmodics, neuromodulators, and biofeedback. We review the epidemiology and effects of chronic bloating and distension and pathophysiology, discuss appropriate diagnostic strategies, and assess available treatment options.

COMPASSIONATE USE OF REMDESIVIR FOR PATIENTS WITH SEVERE COVID-19 THE NEW ENGLAND JOURNAL OF MEDICINE Remdesivir is under investigation as a possible treatment for COVID-19; this observational study presents data on outcomes of patients who received remdesivir on a compassionate-use basis. Included patients were all hospitalized, had a confirmed SARS-CoV-2 infection, and either a need for oxygen support or an oxygen saturation below 94%. All participants received intravenous ...remdesivir over 10 days, with a 200-mg dose on day 1 and 100 mg daily thereafter. The 53 patients included in the analysis were from the US, Europe or Canada, and Japan. Most were receiving oxygen support at baseline, with 57% receiving mechanical ventilation and 8% receiving ECMO. Patients were followed for a median of 18 days. Oxygen-support class improved in 68% of patients during treatment. Of the patients receiving mechanical ventilation, 57% were extubated. Almost half of patients (47%) were discharged, but 13% died. Mortality was 5% and 18% for patients not requiring invasive ventilation and those who did, respectively. This study provides preliminary data suggesting that some patients receiving compassionate-use remdesivir experienced clinical improvement. However, the study did not measure viral loads, and there was no control group. Therefore, further randomized, placebo-controlled trials are critical to better understand the potential role of remdesivir in the treatment of COVID-19. See more

MANAGEMENT OF PATIENTS WITH CROHN’S DISEASE AND ULCERATIVE COLITIS DURING THE COVID-19 PANDEMIC GASTROENTEROLOGY This consensus document discusses the treatment of IBD and the concerns with using immune-modifying therapies to control IBD considering the COVID-19 pandemic. The International Organization for the Study of Inflammatory Bowel Diseases utilized the RAND/UCLA method to address the appropriateness of medical decisions and interventions. THE PANEL AGREED THAT IBD DID ...NOT INCREASE THE RISK OF SARS-COV-2 INFECTION OR DEVELOPING COVID-19 AND THAT IT IS SAFE FOR PATIENTS TO CONTINUE TO ATTEND INFUSION CENTERS AS LONG AS THE CENTER HAS APPROPRIATE SCREENING PROTOCOLS. The group agreed that it is appropriate to decrease or stop prednisone to prevent COVID-19 but not to reduce or stop other IBD therapies. Other scenarios were also presented and voted upon by members. Clinicians should take into consideration these recommendations in developing individual management plans for their patients with IBD. The International Organization for the Study of Inflammatory Bowel Diseases (IOIBD) is the only global organization devoted to the study of and management of the inflammatory bowel diseases (IBDs), Crohn’s disease (CD) and ulcerative colitis (UC). Membership is composed of physician-scientists who have established expertise in these diseases, and the organization hosts an annual meeting and a number of working groups addressing issues of the epidemiology of IBD, diet and nutrition, and the development and utilization of treatments for IBD. There are currently 89 members of IOIBD representing 26 different countries. The organization has taken particular interest in the COVID-19 pandemic and how it may affect the IBD patient population. This document summarizes the results of two recent virtual meetings of the group and subsequent expert guidance for patients and providers.

GASTROINTESTINAL PROCEDURE RECOMMENDATIONS DURING THE COVID-19 PANDEMIC Gastroenterology Gastroenterology COVID-19 can present with gastrointestinal signs. Data from China reported that in COVID-19confirmed infections, 5% OF PATIENTS HAD NAUSEA OR VOMITING AND 3.8% HAD DIARRHEA. A larger meta-analysis of 4243 patients suggests that 17.6% REPORTED VARIOUS GI SYMPTOMS. LIVER INJURY HAS ALSO BEEN REPORTED IN UP TO 20% TO 30% OF PATIENTS. SEVERE HEPATITIS HAS BEEN REPORTED, BUT ...LIVER FAILURE IS RARE. ENDOSCOPY PRESENTS SOME RISK WITH VIRUS AEROSOLIZATION. THIS META-ANALYSIS DISCUSSES IN-DEPTH RECOMMENDATIONS FOR PPE USE DURING THE PROCEDURE. CLINICIANS SHOULD BE AWARE OF THE POTENTIAL FOR PATIENTS PRESENTING WITH COVID-19 AND THE NEED TO PROTECT BOTH PATIENT AND HEALTHCARE WORKERS FROM THE SPREAD OF SARS-COV-2.

CARDIAC COMPLICATIONS OF CHLOROQUINE-BASED THERAPY WRITTEN BY RAYMOND L. WOOSLEY MD, PHD IN the face of a global pandemic, drastic measures and innovative approaches are needed and can be justified. However, recent clinical trials underway with COVID-19 raise concern and require a special caution. The study by Gautret et al and several similar internet communications report encouraging results in treating COVID-19 with hydroxychloroquine, often in combination with azithromyc...Continue reading

COVID-19 A GLIMPSE INTO THE FUTURE WRITTEN BY JONATHAN TEMTE MD, PHD How can we see into the future? The simple answer is that we can’t. We are left only with guesses as to what may be. Some of these are educated and informed; others are wild speculation. It is the former that I will focus on today; informed predictions of what may happen with the global pandemic of COVID-19 in the coming weeks and months. At present, we have no vaccines for SARS-CoV-2 and no evidence-base...Continue reading

SMARTPHONE APPLICATION TO REINFORCE EDUCATION FOR PREPARATION FOR COLORECTAL CANCER SCREENING COLONOSCOPIES Clinical Gastroenterology and Hepatology Clinical Gastroenterology and Hepatology In this randomized trial, patients who received reinforced education on bowel preparation via a smartphone app 3 days prior to colonoscopy procedure were compared with those who received written instructions alone during initial appointment. Boston prep scores were significantly higher in ...the app vs control group (7.6 vs 6.7 P<.0001), and adenoma detection rate was significantly higher in the app group (35% vs 27% P=.0324). Reinforcing bowel prep via smartphone app prior to colonoscopy increases bowel preparedness and adenoma detection rate. Arshish Dua, MD BACKGROUND & AIMS Sufficient bowel preparation is crucial for successful screening and surveillance colonoscopy. However, rates of inadequate preparation are still high. We investigated the effects of reinforced patient education using a smartphone application software (APP) for colonoscopy preparation in participants in a CRC screening program. METHODS We performed a prospective, endoscopist-blinded study of 500 patients undergoing split-dose bowel preparation for CRC screening or surveillance colonoscopies at multiple centers in Germany, from November 2017 through January 2019. Participants (n=500) were given oral and written instructions during their initial appointment and then randomly assigned (1:1) to groups that received reinforced education starting 3 days before the colonoscopy (APP group) or no further education (controls). The primary outcome was quality of bowel preparation according to the Boston bowel preparation scale. Secondary outcomes included polyp and adenoma detection rates, compliance with low-fiber diet, split-dose laxative intake, perceived discomfort from the preparation procedure. CONCLUSIONS In a randomized trial, reinforcing patient education with a smartphone application optimized bowel preparation in the 3 days before colonoscopy, increasing bowel cleanliness, adenoma detection, and compliance in patients undergoing CRC screening or surveillance. ClinicalTrials.gov no: NCT03290157.

PLEASE PAY ATTENTION TO THE NUMBERS TO GET AN IDEA OF HOW FAST THIS INFECTION HAS PROGRESSED JUST IN 4 WEEKS!! THE COVID-19 PANDEMIC IN THE USA: WHAT MIGHT WE EXPECT? The Lancet The Lancet... In this commentary, the authors provide insight into the longevity and likely recurrence and wave-like spreading of COVID-19. The authors emphasize the measures required to keep COVID-19 at bay. Morgan Soffler, MD As of March 19, 2020, 191 127 cases of, including 7807 deaths attributed to, coronavirus disease 2019 (COVID-19) have been reported worldwide. The incidence of reported cases in China has dramatically reduced to tens per day as a result of strict social distancing measures; however, the pandemic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is now generating sustained transmission in many countries including the USA. In The Lancet, Isaac Ghinai, Tristan D McPherson, and colleagues report details of the first known human-to-human transmission of SARS-CoV-2 in the USA, which was identified in late January, 2020. An infected traveller, a woman in her 60s, returned from Wuhan and subsequently became symptomatic and transmitted the infection to her husband with whom she had prolonged and unprotected contact. An investigation of 350 contacts of both patients did not lead to any additional cases. However, we cannot rule out the possibility that some asymptomatic contacts went undetected, because the proportion of asymptomatic COVID-19 cases appears to be large. For example, estimated asymptomatic proportion was 18% for the outbreak on the Diamond Princess cruise ship.

GASTROINTESTINAL PROCEDURE RECOMMENDATIONS DURING THE COVID-19 PANDEMIC Gastroenterology COVID-19 can present with gastrointestinal signs. Data from China reported that in COVID-19confirmed infections, 5% of patients had nausea or vomiting and 3.8% had diarrhea. A larger meta-analysis of 4243 patients suggests that 17.6% reported various GI symptoms. Liver injury has also been reported in up to 20% to 30% of patients. Severe hepatitis has been reported, but liver failure is ...rare. ENDOSCOPY PRESENTS SOME RISK WITH VIRUS AEROSOLIZATION. This meta-analysis discusses in-depth recommendations for PPE use during the procedure. Clinicians should be aware of the potential for patients presenting with COVID-19 and the need to protect both patient and healthcare workers from the spread of SARS-CoV-2.

EVALUATING PATIENTS WHO DISCONTINUE THERAPY FOR IBS-C AND CHRONIC IDIOPATHIC CONSTIPATION The American Journal of Gastroenterology The American Journal of Gastroenterology AMITIZA/LINZESS Lubiprostone and linaclotide are common prescription medications used for chronic constipation and irritable bowel syndrome with constipation (IBS-C). This article provides valuable real-world information for clinicians on reasons why patients discontinue therapy, including efficacy, intoler...ance, and loss of insurance coverage. People are more likely to discontinue medications due to drug intolerance in the first 3 months of treatment. Mukund Venu, MD, FACG INTRODUCTION To inform the patient-centered discussion regarding comparative outcomes with irritable bowel syndrome/chronic idiopathic constipation pharmacotherapy, we evaluated reasons and timing of discontinuation of FDA-approved pharmacotherapy for irritable bowel syndrome and chronic idiopathic constipation in a large observational real-world cohort. METHODS We identified patients initiating lubiprostone or linaclotide within the University of Michigan Electronic Medical Record (2012-2016). Medication start and stop dates were determined in manual chart review including detailed review of all documentation including office notes and telephone encounters. A Cox model was constructed to predict the hazard of discontinuation. RESULTS On multivariate analysis of 1,612 patients, linaclotide users had a lower risk of discontinuing therapy than lubiprostone users for any reason (hazard ratio [HR] = 0.6, 95% confidence interval [CI] 0.5-0.8). At 3 and 12 months, the overall discontinuation rates were 23% and 43% for lubiprostone compared with 14% and 24% for linaclotide. Over the first year of therapy, more than half of discontinuations due to intolerance occurred in the first 3 months for both drugs. Linaclotide users were more likely to discontinue due to intolerance (HR = 1.6 [95% CI, 1.2-2.3]) but less likely to discontinue due to insufficient efficacy of therapy (HR = 0.5 [95% CI, 0.4-0.8]). IBS diagnosis increased the hazard of discontinuation of lubiprostone relative to linactolide (HR = 1.4, 95% CI, 1.1-1.6). Loss of prescription drug coverage remained a common reason for discontinuation over the first year of therapy. DISCUSSION INDIVIDUALS APPEAR MORE LIKELY TO DISCONTINUE LUBIPROSTONE THAN LINACLOTIDE OVERALL, BUT MORE LIKELY TO DISCONTINUE LINACLOTIDE COMPARED WITH LUBIPROSTONE DUE TO INTOLERANCE (MOSTLY DIARRHEA). MOST DISCONTINUATIONS DUE TO INTOLERANCE OCCUR IN THE FIRST 3 MONTHS. THESE RESULTS MAY BE USEFUL IN INDIVIDUALIZED TREATMENT SELECTION AND ENHANCING PATIENT KNOWLEDGE REGARDING LONG-TERM OUTCOMES.