Page 43 – Practical Gastro

Guidelines For Authors

August 2020 • Volume XLIV, Issue 8

Practical Gastroenterology publishes articles for the primary care physician, and your article should therefore have a nuts-and-bolts slant. We urge you to keep the nonspecialist in mind as you write your article. We cannot stress strongly enough the importance of focusing your article on information that will be useful and instructive to the primary care physician. In this regard, it would be helpful for you to emphasize prevention and cost (of tests, drugs, surgery, hospital stay, procedures, techniques, etc.) whenever and wherever possible.

We offer the following list to help you conform to our mechanical requirements:

1. Please submit one copy of your manuscript as a Microsoft Word file, typed on 8½″ × 11″ pages with 1″ margins, double-spaced throughout, including references, tables and figure legends. Ideally, the length of the manuscript should be 2000–2500 words (10–13 pages). Manuscripts should be submitted via e-mail to: PracticalGastro@aol.com

2. Manuscripts must be submitted as Microsoft Word files without automatic footnoting and as final format documents (without indications of markup).

3. Tables should be submitted with titles. If the table has been previously published, identify the source and provide all information that would be included in a standard reference list (see below), along with indication that permission to republish has been obtained. It is your responsibility to obtain permission.

4. Figures and illustrations (photographs, drawings, charts) help explain the text, add to the visual appeal of the published article, and are very welcome. Each table should have a title, and each figure should have an accompanying legend. If figures and illustrations have been previously published, you should identify the source and provide all information that would be included in a standard reference list (see below), along with indication that permission to republish has been obtained. It is your responsibility to obtain permission. All figures and illustrations must be supplied in JPEG format and must be identified as Figure 1, Figure 2, etc. When e-mailing figures and illustrations, do not embed them into a text document. Each JPEG should be sent as a separate document attached to the e-mail. Tables, figures and Illustrations should not be submitted as Excel spreadsheets or in Power Point.

5. The title page should include the names, addresses, phone numbers, complete titles and affiliations of all authors.

6. A color head-shot photograph of each author should accompany the manuscript. These will be published with your article. These must be submitted as JPEG files.

7. An abstract of 125–150 words should also accompany your paper. This will be published at the beginning of your article. Please do not exceed the 150-word limit.

8. References should be used sparingly and cited in the body of the paper using consecutive superscript (raised) numbers. The references section should be numbered consecutively in the order in which the references are cited in the text. References should follow AMA style, and journal names should be abbreviated according to Index Medicus practice. Inclusive page ranges should be indicated. The following references illustrate AMA style:

Jacobson IM, McHutchison JG, Dusheiko GM, et al. Telaprevir for previously untreated chronic
hepatitis C virus infection. N Engl J Med. 2011;364:2405–2416.
Bernatsky S, Clarke AE, Suissa S. Hematologic malignant neoplasms after drug exposure in rheumatoid arthritis. Arch Intern Med. 2008;168:378-81.

9. Articles will be copyrighted upon publication by Practical Gastroenterology Publishing, Inc. The manuscript must not have been published previously. Each article we publish is subject to review by members of our Editorial Board. Articles are also subject to final editing.

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FRONTIERS IN ENDOSCOPY, SERIES #57

Needle Knife Sphincterotomy for ERCP: A Review of Techniques and Outcomes

December 2019 • Volume XLIII, Issue 12

Taylor Frost,

Douglas G. Adler

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INTRODUCTION
Successful biliary interventions during endoscopic retrograde cholangiopancreatography (ERCP) rely upon selective and timely access to the biliary tree. Despite advances in ERCP techniques and accessories common bile duct cannulation may be unsuccessful in up to 5-15% of cases.25 Several advanced techniques for difficult biliary cannulation exist and are best utilized by experienced endoscopists in instances where standard biliary cannulation has failed. Advanced techniques such as needle-knife sphincterotomy, pre-cut fistulotomy, and transpancreatic pre-cut sphincterotomy have all been utilized for difficult biliary cannulation with varying rates of success. This review aims to present and compare some of the techniques that can be used when difficult biliary cannulation is experienced but will primarily focus on needle-knife sphincterotomy.

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FROM THE LITERATURE

Efficacy of Treatment for HCV Virus Infection Post Treatment Failure

January 2020 • Volume XLIV, Issue 1

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After treatment failure on sofosbuvir plus an NS5A inhibitor, treatment options are limited. A randomized trial of the safety and efficacy of 12 and 16 weeks of glecaprevir and pibrentasvir (G/P), was evaluated, performing a randomized trial in patients with genotype 1 infection. A phase 3B, open-label study of those who received previous treatment with sofosbuvir plus an NS5A inhibitor was carried out. Patients without cirrhosis were randomly assigned to groups that received G/P for 12 weeks or 16 weeks (78 group A, 49 group B). Patients with compensated cirrhosis were randomly assigned to groups that received G/P and ribavirin for 12 weeks or G/P for 16 weeks. The primary endpoint was an SVR 12 weeks after treatment.

Samples collected at baseline and at time of treatment failure were sequenced for resistantassociated substitutions in NS3 and NS5A. In the 171 patients, 81% were men, 79% had HCV genotype 1A infection and 44% were black. Proportion of patients with SVR 12 weeks after treatment in group A, B, C and D were 90%, 94%, 86% and 97%, respectively. The treatment failed in 13 (7.3%) of patients with HCV genotype 1A infection, 6 (7.9%) in group A, 3 (6.1%) in group B, 3 (6.1%) in group C, and 1 in group B.

Most patients had baseline resistanceassociated substitutions in NS5A treatment. Emerged resistance-associated substitutions in NS3 and NS5A were observed in 9 and 10 patients for treatment failure, respectively. G/P was well tolerated. Ribavirin increased adverse events, but did not increase efficacy.

It was concluded in a randomized study of patients with chronic HCV genotype 1 infection who received previous treatment with sofosbuvir plus an NS5A inhibitor, 16 weeks treatment with G/P produces same, but produced SVR 12 weeks after treatment with greater than 90% of patients, including those with compensated cirrhosis.

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MEDICAL BULLETIN BOARD

Three Pioneering Physician Scientists Awarded 2019 Sherman Prizes for Focusing on Critical Unmet Needs in Inflammatory Bowel Diseases

December 2019 • Volume XLIII, Issue 12

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Honorees Recognized for Building MultiDisciplinary IBD Centers, Driving Innovative Research on Environmental Triggers and Novel Therapies, Enabling a Treatment Revolution and Tackling One of IBD’s Most Difficult Complications

NAPLES, Florida – The Bruce and Cynthia Sherman Charitable Foundation announced the recipients of the 2019 Sherman Prizes, recognizing outstanding achievements in the fight to overcome Crohn’s disease and ulcerative colitis, also known as the inflammatory bowel diseases (IBD).

Maria T. Abreu, MD, Professor of Medicine, Professor of Microbiology and Immunology, University of Miami Miller School of Medicine; Director, Crohn’s & Colitis Center, University of Miami Health System, Miami, FL, is a champion for patients, particularly those in underserved communities. She is awarded a $100,000 Sherman Prize for identifying an epidemic of IBD in Miami’s Hispanic community; advancing novel research to understand environmental triggers for IBD and exploring ways to optimize treatment; and mentoring junior colleagues in advancing their own innovative research. Dr. Abreu is beloved by her patients and is a relentless advocate, running marathons and triathlons in her spare time to raise money and awareness for IBD.

William J. Sandborn, MD, Chief, Division of Gastroenterology and Director, Inflammatory Bowel Disease Center, UC San Diego Health; Professor of Medicine, UC San Diego School of Medicine, San Diego, CA, is awarded a $100,000 Sherman Prize for his groundbreaking work in IBD clinical trial design that enabled a revolution in treatment that set the standard for clinical care; leading the development of innovative medicines to provide patients with much-needed options; and helping to establish holistic care models that have improved patient care and outcomes. Dr. Sandborn is a sought-after clinician who has improved the quality of life for patients who feel they have run out of options, and a mentor to colleagues and students who have gone on to run major IBD centers

Florian Rieder, MD, Assistant Professor, Department of Inflammation and Immunity; Clinical Staff, Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH, is awarded the $25,000 Sherman Emerging Leader Prize for his key role in advancing the development of novel therapies to treat fibrostenosis, a common and potentially devastating complication of IBD. Dr. Rieder is a respected early-career clinician, researcher and educator who devotes considerable energy to supporting junior talent and creating opportunities for others to make an impact for patients

“In the fourth year of the Sherman Prize, we’re proud to honor Drs. Abreu, Sandborn and Rieder, visionaries who share a deep commitment to addressing the unmet challenges of IBD,” said Prize founders Bruce and Cynthia Sherman. “The holistic care they provide and the rigorous scientific research they lead is improving the quality of life for people with IBD today, and laying the foundation for greater discoveries in the future.”

Millions of people worldwide suffer from Crohn’s disease and ulcerative colitis, which are chronic, inflammatory diseases that damage the gastrointestinal tract. While there are effective treatments, there is no cure and available medicines do not work for everyone. The Bruce and Cynthia Sherman Charitable Foundation established the Sherman Prize to recognize and reward talented individuals for their pioneering achievements in improving outcomes for people living with these diseases. Through this first-of-its-kind Prize, the Shermans aim to create a ripple effect, spreading awareness of excellence and inspiring others to continue innovating.

“IBD can be devastating, disrupting people’s lives and livelihoods,” said Dr. Dermot P.B. McGovern, Sherman Prize Selection Committee Chair and the Joshua L. and Lisa Z. Greer Endowed Chair in Inflammatory Bowel Disease Genetics at Cedars-Sinai. “Not only have these Sherman Prize honorees made incredible contributions to improving treatment and care, they are exceptional teachers, mentoring the next generation of physician scientists to ensure continued advances in the field.”

The Sherman Prizes were presented on December 12th at the Advances in Inflammatory Bowel Diseases conference in Orlando, Florida.

About the Sherman Prize

Every year, two $100,000 Sherman Prizes are awarded to individuals with extraordinary track records of achievement making exceptional and pioneering contributions, transforming IBD care and inspiring tomorrow’s innovators. A $25,000 Sherman Emerging Leader Prize is awarded to an individual making impressive contributions early in his or her career and showing great promise for significant contributions in the future. Sherman Prize honorees are selected by the Sherman Prize Board of Directors, with guidance from a nationally renowned group of IBD experts who comprise the Sherman Prize Selection Committee. Nominations for the 2020 Sherman Prizes may be submitted at ShermanPrize.org beginning in March 2020.

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NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #192

Fiber and Ileostomies: Does it Help or Hurt?

November 2019 • Volume XLIII, Issue 11

Brian J. Wentworth

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Patients may receive an ileostomy as either destination therapy (such as in proctocolectomy) or as a temporary diversion prior to anastomosis. While the formation of an ileostomy is often quite beneficial for the patient, it can be complicated by dehydration, electrolyte losses, malnutrition, and undesirable stool consistency. To combat these issues, physicians and nutritionists alike employ a variety of measures. One of the more controversial strategies utilized is fiber supplementation with an intention to increase ileostomy effluent viscosity, slow transit time, and reduce water and micronutrient losses. Despite its commonality, there is surprisingly minimal literature on this topic. Nonetheless, the predicted physiologic benefits of fiber in patients with an ileostomy are not matched in both observational studies and randomized controlled clinical trials.

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INFLAMMATORY BOWEL DISEASE: A PRACTICAL APPROACH, SERIES #108

Primary Sclerosing Cholangitis and Inflammatory Bowel Disease

November 2019 • Volume XLIII, Issue 11

Akash Singh,

David Bernstein

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Primary sclerosing cholangitis (PSC) is an immune mediated, chronic, cholestatic liver disease causing inflammation and fibrosis of the intrahepatic and extrahepatic biliary tree. PSC is strongly associated with inflammatory bowel disease, especially ulcerative colitis, predominantly affects males and can lead to the development of portal hypertension, cirrhosis and its complications and cholangiocarcinoma. Patients are usually asymptomatic and present with abnormal liver chemistries in a cholestatic pattern with abnormal imaging of the biliary tree. Currently there are no effective medical therapies to prevent disease progression and treatment is primarily for symptomatic relief. Advanced liver disease is treated with liver transplantation. Due to the high risk of the development of cholangiocarcinoma in patients with PSC, screening of the biliary tract and evaluation of suspicious findings should be performed regularly.

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A CASE REPORT

Deep Rectal Ulcer as a Result of Argon Plasma Coagulation Therapy for Radiation Proctopathy

November 2019 • Volume XLIII, Issue 11

David Pineles,Cristina Hajdu,David M. Poppers

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Globally, prostate cancer is the most commonly diagnosed cancer in men.1 Radiation therapy remains a mainstay in the treatment of this disease. Radiation proctopathy is a common side effect of this treatment modality with an incidence in patients treated with brachytherapy alone estimated to range from 8 to 13%, and up to 21% in combination with other modalities.2 Radiation proctopathy typically presents with diarrhea, mucoid discharge, urgency, tenesmus, and bleeding. Argon plasma coagulation (APC) has become the primary therapeutic modality in the management of radiation injury. It is essential that physicians of all specialties (as well as others who care for these patients) be aware of the multiple complications of this therapy. More severe adverse events, notably rectal ulcers following APC therapy are not uncommon, with an incidence ranging from 3 to 16%.2

Case

A sixty seven year old man with a history of prostate cancer treated with radiation therapy one year prior presented with intermittent rectal bleeding for one and a half months. Colonoscopy revealed a small area near the dentate line characterized by slightly oozing, neovascularized tissue consistent with radiation proctopathy (Image 1). This area was treated with APC with good effect. Biopsies of this area revealed hyperplastic crypts, lamina propria fibrosis, and vascular ectasias compatible with radiation injury. Three months following treatment, the patient developed recurrent rectal bleeding. A flexible sigmoidoscopy revealed a deep, non-bleeding ulcer in the rectum (Image 3). Subsequent computed tomography enterographyand magnetic resonance imaging of the pelvis demonstrated a deep rectal ulcer with abutment of a 1.5 cm peri-prostatic abscess. The patient was followed closely over the next several months, in conjunction with colorectal surgery, with serial imaging and subsequent resolution of the periprostatic abscess and cessation of rectal bleeding.

Discussion

As more patients with prostate cancer are treated with radiation therapy the incidence of radiation proctopathy is increasing.3,4 Although argon plasma coagulation has been shown to be an effective therapy for this issue, providers must consider and discuss with patients the potential complications of this otherwise effective and generally welltolerated mode of treatment

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DISPATCHES FROM THE GUILD CONFERENCE, SERIES #26

Medical Management of Post-Operative Crohn’s Disease

November 2019 • Volume XLIII, Issue 11

Abhik Bhattacharya,

Miguel Regueiro

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Nearly one million people in the United States suffer from Crohn’s disease (CD), with studies showing increase in the rate of prevalence of CD from 214 per 100,000 people in 2004-2005, to 236 per 100,000 people in 2008-2009.1,2 Crohn’s disease (CD) is a chronic immune mediated inflammatory disorder of the gastrointestinal system that can involve anywhere from the mouth to the anus. Over one-half of patients with CD will have an intestinal complication of strictures, fistulas and abscesses3 and nearly 70% require surgical resections by 15 years.4 Surgery can induce remission but is not curative, as most patients undergoing an ileo-cecal resection will develop endoscopic recurrence one year after surgery.5 More importantly, these patients do not manifest symptoms (i.e. they are clinically “silent”) until another complication presents and surgery is required. Primary care physicians will often see these patients and it is important to understand the natural course and management of postoperative Crohn’s disease.

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NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #191

Author Addendum/Correction

November 2019 • Volume XLIII, Issue 11

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Carol Rees Parrish, MS, RDN, Series Editor

Diet in Non-Alcoholic Fatty Liver Disease

by Jennifer B. Miller, Zachary Henry

We regret the following oversight in our article,“Diet in Non-Alcoholic Fatty Liver Disease”, by Jennifer B. Miller and Zachary Henry, that appeared in our October 2019 issue (Volume XLIII No. 10, pp. 24-27).

Specifically, the last two bullet points on Table 1 were incorrect. Please see the corrected Table 1. Download the PDF below.

The Editors

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FRONTIERS IN ENDOSCOPY, SERIES #56

A Common Bile Duct Bump

November 2019 • Volume XLIII, Issue 11

Moamen Gabr,

Pradeep Yarra,

Douglas Pleskow

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We present a 36-year-old woman with right upper quadrant pain, nausea, vomiting and anorexia. Significant past medical history includes morbid obesity, status post laparoscopic sleeve gastrectomy (14 months ago) with an accompanying 70 pounds weight loss. The postoperative course was complicated by a portal vein thrombosis, which was treated with Apixaban for 3 months. She was non-complaint in her followup. The patient now presents 6 months later with these symptoms. On examination, right upper quadrant tenderness was present with negative murphy sign, Patient had normal white blood count and liver function tests. Initial evaluation included a right upper quadrant ultrasound, which showed cholelithiasis without gallbladder wall edema or pericholecystic fluid. The surgical consult agreed that there were no signs of acute cholecystitis. Computed tomography (CT) demonstrated no acute abdominal process. Cavernous transformation of the main portal vein with numerous abdominal varices was seen. Additional findings included mild splenomegaly and cholelithiasis without evidence of cholecystitis. (Figure 1) A Magnetic Resonance Venography (MRV) was performed which revealed Cavernous transformation of the main portal vein with multiple collateral vessels as well as multiple portosystemic collateral vessels within the anterior abdomen and anterior body wall. Given a suspicion for a biliary process as a source of her right upper quadrant pain, she was referred for an endoscopic retrograde cholangiopancreatography (ERCP). ERCP was performed and revealed smooth narrowing of the common bile duct on the cholangiogram (Figure 2). In order to more fully characterize the stricture a cholangioscopy was performed. Cholangioscopy revealed a smooth extrinsic compressible common bile duct mass consistent with intraductal varix (Figure 3). The decision was made to perform intraductal endoscopic ultrasound (IDUS) using the ultrasound probe. The probe was advanced in the bile duct under fluoroscopic and endoscopic guidance and revealed periductal dilated intravascular spaces compressing the distal common bile duct. (Figure 4) The patient was referred to IR for a trial of portal vein recanalization that was not successful, the patient then underwent a successful Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure. This case also showed extensive involvement of the pericholecystic, peripancreatic, intra and extra hepatic venous system causing the cavernous transformation.

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