Liver injury has been described with COVID-19, and early reports suggested 2%-11% of patients had chronic liver disease (CLD). In this multicentre retrospective study, we evaluated hospitalized adults with laboratory-confirmed COVID-19 and the impact of CLD on relevant clinical outcomes. Of 363 patients included, 19% had CLD, including 15.2% with NAFLD. Patients with CLD had longer length of stay. After controlling for age, gender, obesity, cardiac diseases, hypertension, hyperlipidaemia, diabetes and pulmonary disorders, CLD and NAFLD were independently associated with ICU admission ([aOR 1.77, 95% CI 1.03-3.04] and [aOR 2.30, 95% CI 1.27-4.17]) and mechanical ventilation ([aOR 2.08, 95% CI 1.20-3.60] and [aOR 2.15, 95% CI 1.18-3.91]). Presence of cirrhosis was an independent predictor of mortality (aOR 12.5, 95% CI 2.16-72.5). Overall, nearly one-fifth of hospitalized COVID-19 patients had CLD, which was associated with more critical illness. Future studies are needed to identify interventions to improve clinical outcomes.

BACKGROUND: Weight regain (WR) after gastric bypass is thought to be multifactorial in etiology with behavioral, neurohormonal, and anatomic features playing a role. A significant proportion of patients complain of dysphagia after Roux-en-Y gastric bypass (RYGB) and may have difficulty tolerating solid foods. Our observations suggest that this subgroup of patients compensate for esophageal symptoms by increasing their intake of calorie-dense liquid and soft foods, which can precipitate WR.

OBJECTIVES: We hypothesize that dysphagia predisposes to greater WR than seen in individuals without swallowing symptoms.

SETTING: Single tertiary care referral center.

METHODS: This was a matched-cohort study analysis of prospectively collected data on RYGB patients. All individuals who underwent high-resolution manometry after RYGB were enrolled. Controls were identified via a retrospective analysis of a prospective institutional database. Patients who developed dysphagia were matched with controls, from a subset of 450 eligible controls. Each patient with dysphagia was matched with 4 control patients based on age, body mass index, and time since surgery. WR was defined as an increase of ≥15% from nadir. Χ2 and t test (or Wilcoxon rank sum, if applicable) were used for bivariable analysis. Multiple logistic and linear regression were used for multivariable calculations.

RESULTS: Forty-nine patients with dysphagia were included. After matching, there were 196 RYGB controls that did not have swallowing or esophageal symptoms. Controls had similar baseline demographic characteristics and initial weight loss compared with dysphagia cases. WR was common in both groups; however, total WR in those with dysphagia was greater than controls (15.7 versus 11.4 kg, respectively; P = .02). In addition, percent WR in those with dysphagia exceeded that seen in controls (mean 37% versus 25%, P = .003), and more individuals regained 15% of nadir weight (55% of dysphagia cases versus 38% of controls, P = .03) when adjusting for baseline body mass index, age at surgery, and race. Dietary histories suggested that, among those with dysphagia, patients with partial or complete conversion to soft or liquid calories had greater WR than those who adhered to the solid food diet.

CONCLUSIONS: Dysphagia is a risk factor for WR post-RYGB. This is likely due to increased intake of soft or liquid foods that are tolerable in these patients but lead to a positive energy balance and accelerated WR. More than half of patients with dysphagia after RYGB regain significant weight. Screening for and aggressively managing dysphagia in patients before or after RYGB may be warranted to prevent significant WR.

BACKGROUND: Traditionally, small intestinal bacterial overgrowth (SIBO) is diagnosed when there is an early peak in breath hydrogen or methane. Given unclear intestinal transit time in Roux-en-Y gastric bypass (RYGB) patients, it is unknown if the traditional approach at diagnosing SIBO is adequate in this patient population.

AIM: To assess oral-cecal transit time (OCTT) and its impact on the interpretation of breath tests in the diagnosis of SIBO in patients with RYGB.

METHODS: This study was a retrospective review of prospectively collected data on RYGB patients who underwent testing for SIBO using lactulose breath test (LBT) with or without small bowel follow-through (SBFT) to assess OCTT. Outcomes of SIBO test based on LBT alone versus LBT with OCTT were compared using a chi-squared test.

RESULTS: Sixty-two of the 151 RYGB patients who underwent LBT underwent an additional SBFT to assess OCTT. Median OCTT was 60 min. Of these, 59.7% had OCTT shorter than 90 min. Based on LBT alone, 36/62 patients (58.1%) were classified as positive SIBO. When LBT results were combined with OCTT, 26/36 patients (72.2%) had hydrogen or methane rise within OCTT, suggesting 27.8% false positive rate. Patients with true positive SIBO based on LBT and OCTT had a higher response rate to antibiotics compared to those with false positive SIBO (78.3% vs. 33.3%, p = 0.03).

CONCLUSION: A personalized approach of combining LBT with SBFT to assess OCTT may improve the accuracy of SIBO testing and enhance clinical outcomes in patients with RYGB.

BACKGROUND: Laryngopharyngeal reflux (LPR) is commonly treated with empiric acid suppression. More evidence points to pepsin in the pathophysiology of LPR. Previous studies have evaluated esophageal impedance in patients who had previously failed high dose proton pump inhibitor (PPI) using older catheters without proximal esophageal (just under the upper esophageal sphincter) and pharyngeal impedance sensors. The aim of this study was to compare what traditional diagnostic tools, used for esophageal reflux, would detect and diagnose compared with what a combined hypopharyngeal-esophageal MII catheter with dual pH (HEMII-pH) can detect in the esophagus and pharynx in patients with suspected LPR.

METHODS: Forty-two subjects with presumed LPR were referred for HEMII-pH testing. The number of distal and proximal esophageal impedance events, number of pharyngeal impedance events, symptom correlation, and event acidity were recorded. Previous normative values (>1 pharyngeal impedance events every 24 hours) were used to designate what was pathological LPR on HEMII-pH.

RESULTS: Forty-two total subjects had pharyngeal impedance sensor data recorded. Twelve (28.6%) of the subjects were tested while taking high-dose PPI therapy. The mean number of proximal esophageal events was 23.3. The mean number of pharyngeal impedance events was 10. Thirty-four subjects (81%) tested positive for pharyngeal reflux. All patients who tested positive using traditional proximal impedance criteria also tested positive using pharyngeal criteria. Of patients who tested negative using traditional criteria, 72% were positive based on pharyngeal criteria.

CONCLUSIONS: HEMII-pH catheters should be considered in patients with LPR symptoms. Traditional criteria used for diagnosing esophageal reflux may not translate into LPR.

BACKGROUND: Patients often look to social media as an important tool to gather information about institutions and professionals. Since 1990, United States News and World Report (USNWR) has published annual rankings of hospitals and subspecialty divisions. It remains unknown if social media presence is associated with the USNWR gastroenterology and gastrointestinal (GI) surgery divisional rankings, or how changes in online presence over time affects division ranking.

OBJECTIVE: The objective of this study was to determine if social media presence is associated with USNWR gastroenterology and GI surgery divisional rankings and to ascertain how changes in online presence over time affect division rankings.

METHODS: Social media presence among the top 30 institutions listed in the 2014 USNWR gastroenterology and GI surgery divisional rankings were assessed using Pearson's correlation coefficients and multivariate analysis, controlling for covariates. Linear and logistic regression using data from 2014 and 2016 USNWR rankings were then used to assess the association between institutional ranking or reputation score with any potential changes in numbers of followers over time. Sensitivity analysis was performed by assessing the area under the receiver operating characteristic curve to determine the follower threshold associated with improved or maintained ranking, which was done by dichotomizing changes in followers at values between the 7000 and 12,000 follower mark.

RESULTS: Twitter follower count was an independent predictor of divisional ranking (β=.00004; P<.001) and reputation score (β=-.00002; P=.03) in 2014. Academic affiliation also independently predicted USNWR division ranking (β=5.3; P=.04) and reputation score (β=-7.3; P=.03). Between 2014 and 2016, Twitter followers remained significantly associated with improved or maintained rankings (OR 14.63; 95% CI 1.08-197.81; P=.04). On sensitivity analysis, an 8000 person increase in Twitter followers significantly predicted improved or maintained rankings compared to other cutoffs.

CONCLUSIONS: Institutional social media presence is independently associated with USNWR divisional ranking and reputation score. Improvement in social media following was also independently associated with improved or maintained divisional ranking and reputation score, with a threshold of 8000 additional followers as the best predictor of improved or stable ranking.

BACKGROUND: Fecal microbiota transplantation (FMT) is a promising therapy for recurrent Clostridioides difficile infection (CDI). Many patients report altered bowel habits including constipation, bloating, gas and loose stool post-FMT despite resolution of CDI, and the etiology remains unclear.

METHODS: This was a prospective cohort study of adult patients with recurrent CDI who underwent FMT (1) via colonoscopy with patient-selected donor stool, (2) via colonoscopy from a universal stool bank donor, or (3) via capsules from a universal stool bank. Reassessment occurred 8 weeks post-FMT. Those cured were assessed for gastrointestinal symptoms (bloating, loose stools, constipation). Multivariate logistic regression was performed to assess predictors of post-FMT gastrointestinal symptoms.

RESULTS: A total of 150 subjects underwent FMT for recurrent CDI, of which 68.7% (103) were female, mean age was 61.5 years±18.1 and 31 patients (20.7%) had preexisting irritable bowel syndrome. Thirty-six had FMT via colonoscopy with a patient-selected donor, 67 via colonoscopy with stool bank donors, and 47 via FMT capsules from stool bank donors. Among those cured, 41 (31.2%) had gastrointestinal symptoms post-FMT. The factors associated with symptoms included younger age (57.2 vs. 64.1 y, P=0.03), a baseline history of irritable bowel syndrome (36.6% vs. 13.3%, P=0.002) and preexisting inflammatory bowel disease (31.7% vs. 10%, P=0.002). Small bowel exposure to donor stool was not related to symptoms (63.4% vs. 62.2%, P=0.89).

CONCLUSIONS: Altered bowel habits are a consequence of CDI and are common after FMT. This study suggests that donor type and FMT delivery modality are not related to the presence of irregular gastrointestinal symptoms after FMT.

Background and study aims  Although endoscopic retrograde cholangiopancreatography (ERCP) is standard of care for malignant biliary obstruction, endoscopic ultrasound-guided biliary drainage (EUS-BD) as a primary treatment has become increasingly utilized. The aim of this study was to perform a systematic review and meta-analysis to evaluate the effectiveness and safety of EUS-BD for primary treatment of malignant biliary obstruction and comparison to traditional ERCP. Methods  Individualized search strategies were developed through November 2018 using PRISMA and MOOSE guidelines. A cumulative meta-analysis was performed by calculating pooled proportions. Subgroup analysis was performed for studies comparing EUS-BD versus ERCP. Heterogeneity was assessed with Cochran Q test or I 2 statistics, and publication bias by funnel plot and Egger's tests. Results  Seven studies (n = 193 patients; 57.5 % males) evaluating primary EUS-BD for malignant biliary obstruction were included. Mean age was 67.4 years (2.3) followed an average of 5.4 months (1.0). For primary EUS-BD, pooled technical success, clinical success, and adverse event (AE) rates were 95 % (95 % CI 91 - 98), 97 % (95 % CI 93 - 100), and 19 % (95 % CI 11 - 29), respectively. Among EUS-BD and ERCP comparator studies, technical and clinical success, and total AEs were not different with lower rates of post-ERCP pancreatitis and reintervention among the EUS-BD group. Conclusion  Primary EUS-BD is an effective treatment with few AE. Comparing EUS-BD versus ERCP, EUS-BD has comparable efficacy and improved safety as a primary treatment for malignant biliary obstruction. Further randomized trials should be performed to identify patient populations and clinical scenarios in which primary EUS-BD would be most appropriate.

Esophageal symptoms can arise from gastroesophageal reflux disease (GERD) as well as other mucosal and motor processes, structural disease, and functional esophageal syndromes. GERD is the most common esophageal disorder, but diagnosis may not be straightforward when symptoms persist despite empiric acid suppressive therapy and when mucosal erosions are not seen on endoscopy (as for nonerosive reflux disease, NERD). Esophageal physiological tests (ambulatory pH or pH-impedance monitoring and manometry) can be of value in defining abnormal reflux burden and reflux-symptom association. NERD diagnosed on the basis of abnormal reflux burden on ambulatory reflux monitoring is associated with similar symptom response from antireflux therapy for erosive esophagitis. Acid suppression is the mainstay of therapy, and antireflux surgery has a definitive role in the management of persisting symptoms attributed to NERD, especially when the esophagogastric junction is compromised. Adjunctive approaches and complementary therapy may be of additional value in management. In this review, we describe the evaluation, diagnosis, differential diagnosis, and management of NERD.

BACKGROUND: Type 2 diabetes mellitus (T2DM) resolves in >80% of patients after Roux-en-Y gastric bypass (RYGB). It has been hypothesized that foregut exclusion is mechanistically important to this observation. This study aimed to determine whether gastrogastric (GG) fistula, with a loss of foregut exclusion, is associated with T2DM relapse, and to assess whether closure of GG fistula is associated with T2DM resolution.

STUDY DESIGN: A matched cohort study of patients who experienced T2DM remission after RYGB. Cases (patients with GG fistula) were matched to controls (patients without GG fistula) based on age, BMI, weight regain, and duration from RYGB. Primary end point was T2DM relapse. Time-to-event analysis was performed to identify an association between GG fistula and time to T2DM resolution.

RESULTS: One hundred and twenty-six patients (42 cases and 84 controls) were included. Cases experienced a higher rate of T2DM relapse than controls (48% vs 13%; odds ratio 18; p < 0.0001). On multivariable analysis, GG fistula remained a significant predictor of T2DM relapse after controlling for sex and insulin use (odds ratio 6.3; p = 0.02). Of the 42 cases, 20 experienced T2DM relapse, with 1 spontaneous resolution. Of 19, thirteen underwent fistula revision and experienced a higher rate of T2DM resolution than the nonrevision group (69% vs 0%; odds ratio 27; p = 0.036). Time to T2DM resolution was shorter in the revision group compared with the nonrevision group (p = 0.006).

CONCLUSIONS: The RYGB patients with GG fistula have a higher rate of T2DM relapse, compared with those without GG fistula with similar BMI and weight regain. Successful fistula revision is associated with resolution of T2DM.

BACKGROUND/AIMS: Liver biopsy has traditionally been used for determining the degree of fibrosis, however there are several limitations. Endoscopic ultrasound (EUS) real-time elastography (RTE) is a novel technology that uses image enhancement to display differences in tissue compressibility. We sought to assess whether liver fibrosis index (LFI) can distinguish normal, fatty, and cirrhotic liver tissue.

METHODS: A total of 50 patients undergoing EUS were prospectively enrolled. RTE of the liver was performed to synthesize the LFI in each patient. Univariate and multivariable analyses were performed. Chi-square and t-tests were performed for categorical and continuous variables, respectively. A p-value of <0.05 was considered significant.

RESULTS: Abdominal imaging prior to endoscopic evaluation suggested normal tissue, fatty liver, and cirrhosis in 26, 16, and 8 patients, respectively. Patients with cirrhosis had significantly increased mean LFI compared to the fatty liver (3.2 vs. 1.7, p<0.001) and normal (3.2 vs. 0.8, p<0.001) groups. The fatty liver group showed significantly increased LFI compared to the normal group (3.8 vs. 1.4, p<0.001). Multivariable regression analysis suggested that LFI was an independent predictor of group features (p<0.001).

CONCLUSIONS: LFI computed from RTE images significantly correlates with abdominal imaging and can distinguish normal, fatty, and cirrhotic-appearing livers; therefore, LFI may play an important role in patients with chronic liver disease.