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The Effect of Bariatric Surgery and Endoscopic Procedures on Gastroesophageal Reflux Disease

Fass, Ofer Z; Mashimo, Hiroshi
Obesity is a global epidemic posing a significant burden on patients and healthcare systems. Gastroesophageal reflux disease is associated with obesity and its prevalence is also growing worldwide. Numerous bariatric surgeries and endoscopic procedures have arisen to assist with weight loss and management of obesity-related conditions. However, the effect of these interventions on reflux is variable and the evidence is often conflicting. To date, Roux-en-Y gastric bypass remains the gold-standard for attaining both reflux and weight loss management, however novel endoscopic techniques are quickly becoming more prevalent as an alternative to surgery. This review aims to summarize currently available endoscopic and surgical weight loss procedures and their impact on reflux symptoms while emphasizing areas requiring additional investigation.
PMCID:7786084
PMID: 33380553
ISSN: 2093-0879
CID: 4774102

Primary gastric tuberculosis in a patient with new human immunodeficiency virus [Meeting Abstract]

Fass, O; Ramprasad, C; Teperman, J; Wilcox, T
INTRODUCTION: Mycobacterium tuberculosis is a common and challenging-to-treat infectious organism affecting more than 1.7 billion people globally. While primarily a respiratory illness, it can spread to other parts of the body, including the gastrointestinal tract. Abdominal tuberculosis (TB) is rare, accounting for 5% of all TB cases worldwide, of which only 1-2% involve the stomach. Most gastric cases are secondary to pulmonary infections, however primary gastric TB can arise following ingestion of the organism.We describe a case of primary gastric TB in a patient with newly diagnosed human immunodeficiency virus (HIV). CASE DESCRIPTION/METHODS: A 40-year-old man visiting from Ecuador with no prior medical history presented to the emergency room with one month of abdominal bloating and decreased oral intake. Physical examination was notable for cachexia and oral thrush; however, the abdomen was soft, nontender and nondistended. Blood work was positive for HIV with a CD4 count of 34 cells/mm3. An abdominal CT revealed an ill-defined soft tissue mass along the lesser curvature of the stomach with numerous enlarged adjacent lymph nodes. Subsequent upper endoscopy showed a friable gastric mass within the cardia and an erosion in the lesser body. Biopsies were obtained and pathology was notable for numerous acid-fast bacilli. Neither H. pylori nor carcinoma was identified. PCR analysis of tissue was positive for M. tuberculosis. Evaluation for pulmonary TB was unremarkable with a normal chest x-ray and negative sputum acid fast stains. The patient was ultimately discharged on anti-TB therapy with a plan to initiate antiretroviral therapy the following week. DISCUSSION: Primary gastric TB is exceedingly rare and is generally observed in patients with immunosuppression secondary to HIV, cirrhosis, diabetes, or treatment with anti-tumor necrosis factor agents. Abdominal TB primarily arises via reactivation of a latent infection, however primary cases may arise from ingestion of unpasteurized milk or undercooked meat. The rarity of gastric TB has been attributed to the low density of lymphoid tissue, acidic pH, and rapid emptying of stomach contents. Typical sites of involvement include the antrum and pre-pyloric area with lesions typically being ulcerative. Treatment is similar as to pulmonary TB with prolonged antibiotic therapy, however symptoms of perforation, abscess bleeding, or obstruction may require surgery. (Figure Presented)
EMBASE:633657589
ISSN: 1572-0241
CID: 4720542

New onset esophagitis and ulcerative duodenitis in a patient with acute SARS-COV-2 infection [Meeting Abstract]

Fass, O; Offerman, E; Vargas, A
INTRODUCTION: The novel coronavirus SARS-CoV-2 has infected nearly 6 million people globally and resulted in over 350,000 deaths thus far. While primarily a respiratory illness, gastrointestinal (GI) manifestations have been described in up to 50.5% of patients. In a subgroup of patients, GI symptoms may be the only evidence of infection. Understanding the full spectrum of GI manifestations is crucial for recognizing affected patients and maintaining the safety of both clinicians and the public. CASE DESCRIPTION/METHODS: A 27-year-old woman with lupus presented to the emergency room with three days of abdominal pain and three weeks of cough, fevers, and malaise. Physical examination was notable for severe pain with epigastric palpation but without rebound or guarding. An abdominal CT revealed segments of small bowel wall thickening concerning for possible ischemia. An abdominal angiogram showed no evidence of mesenteric ischemia, however, exhibited small bowel inflammation. An esophagogastroduodenoscopy found atrophic, friable esophagus and circumferential ulceration of the distal duodenum. Biopsies revealed fibrin-rich thrombi within the lamina propria, and submucosa associated with mucosal necrosis. No cellular infiltration was observed to suggest vasculitis. SARS-CoV-2 nasopharyngeal PCR from admission returned positive. Rheumatology was consulted and determined that the patient's lupus was not clinically active and that microthrombi were likely related to the SARS-CoV-2 infection. The patient was discharged home on pantoprazole and apixaban with GI follow-up and instructions to self-isolate. DISCUSSION: This is the first case to date describing ulceration of the GI tract in the setting of acute SARS-CoV-2 infection. Pathology suggests the mechanism of injury to be microthrombi causing mucosal necrosis. Autopsies of recently deceased patients have similarly revealed microthrombi affecting the pulmonary and renal vasculature and it is hypothesized to be the mechanism of organ damage. Optimal medical management for hypercoagulability in the setting of SARS-CoV-2 infection remains unclear. Some authors recommend anticoagulation for 3-6 months only if venous thromboembolism (VTE) is present, while others endorse a prophylactic strategy by discharging all patients on 4-6 weeks of treatment. As SARS-CoV-2 becomes increasingly prevalent, it should be considered in the differential diagnosis of patients presenting with new onset ulcerative esophagitis or duodenitis. (Figure Presented)
EMBASE:633656241
ISSN: 1572-0241
CID: 4720612

Esophageal motility disorders and gerd in patients with bronchiectasis [Meeting Abstract]

Fass, O; Krishna, M; Kamelhar, D; Addrizzo-Harris, D; Segal, L; Khan, A; Knotts, R M
INTRODUCTION: Bronchiectasis is a common chronic pulmonary condition characterized by inflammation and recurrent infections. There is evidence that gastroesophageal reflux disease (GERD) is associated with bronchiectasis and can increase the severity of pulmonary disease. Data regarding esophageal function in this population is sparse. We aimed to assess whether patients with bronchiectasis have an increased prevalence of esophageal motility disturbances and GERD.
METHOD(S): We conducted a single-center matched cohort study of all adult patients with confirmed bronchiectasis who underwent esophageal high-resolution manometry (HRM) between 11/ 2014-3/2018. All cases were randomly matched with a control by age (65 years) and sex. Chicago Classification 3.0 was used to characterize HRM findings. Combined multichannel intraluminal impedance-pH (pH-MII) was utilized to assess reflux burden. Statistical relationships between proportions were evaluated by Chi-square or Fisher's exact test and continuous variables were compared using t-test or rank sum test.
RESULT(S): 63 bronchiectasis patients underwent HRM, of which 54 underwent pH-MII. Of the controls, 63 underwent HRM, of which 39 underwent pH-MII. Baseline characteristics between cases and controls were similar. Mean age of bronchiectasis patients was 65 (SD 12.73), mean body mass index was 25.51 (SD 8.50), 70% were female, and 48% had a smoking history (Table). HRM did not demonstrate any significant differences between cases and controls. pH-MII trended towards a greater reflux burden among controls. However, nearly half of cases had conclusive evidence of pathologic reflux by esophageal acid exposure on pH-MII. On endoscopy, no significant differences were noted.
CONCLUSION(S): Esophageal motility and acid exposure did not significantly differ among patients with bronchiectasis and controls, which may indicate that esophageal physiology in bronchiectasis is not unique. Nevertheless, more than half of the bronchiectasis group had evidence of abnormal esophageal motility and almost half of patients had conclusive evidence of pathologic reflux. Small differences are likely due to the high prevalence of GERD and associated motility disorders in the control group. Larger studies are warranted to further characterize esophageal physiology in these patients and the potential impact on pulmonary pathology. (Table Presented)
EMBASE:633655604
ISSN: 1572-0241
CID: 4720662

Demographics Predict Stage III/IV Colorectal Cancer in Individuals Under Age 50

Fass, Ofer Z; Poels, Kamrine E; Qian, Yingzhi; Zhong, Hua; Liang, Peter S
GOALS/OBJECTIVE:The goal of this study was to quantify the association between demographic factors and advanced colorectal cancer (CRC) in patients under age 50. BACKGROUND:CRC incidence in the United States has declined in older individuals but increased in those under age 50 (early-onset). More than 60% of early-onset CRC patients present with advanced disease (stage III/IV), but predictors of stage in this population are poorly defined. STUDY/METHODS:We analyzed CRC cases diagnosed between age 20 and 49 in the United States Surveillance, Epidemiology, and End Results (SEER) 18 database during 2004 to 2015. Logistic regression models were fit to assess the impact of age, sex, race, ethnicity, marital status, and cancer site on the probability of advanced disease. RESULTS:The analysis included 37,044 cases. On multivariable regression, age was inversely associated with advanced disease. Relative to 45 to 49-year-olds, 40 to 44-year-olds had 8% greater odds of having advanced CRC, and 20 to 24-year-olds had 53% greater odds. Asians, blacks, and Pacific Islanders had 10%, 12%, and 45% greater odds of advanced disease compared with whites. Compared with nonpartnered individuals, those with partners had 11% lower odds of advanced CRC. Both right-sided and left-sided colon cancer were more likely to be diagnosed at stage IV compared with rectal cancer. CONCLUSIONS:Among individuals with early-onset CRC, younger age, Asian, black, or Pacific Islander race, and being nonpartnered were predictors of advanced disease at presentation. Colon cancer was more likely to be diagnosed at stage IV than rectal cancer. Patient characteristics associated with advanced CRC may indicate both differences in tumor biology and disparities in health care access.
PMID: 32520886
ISSN: 1539-2031
CID: 4489632

National Trends for Medicare Prescriptions of Antireflux Medications

Fass, Ofer Z; Poels, Kamrine E
PMID: 32222398
ISSN: 1528-0012
CID: 4506162

National trends in medicare opiate prescriptions: The role of physicians and non-physician providers [Meeting Abstract]

Fass, O Z; Beccarino, N J; Hosseini, S A A K
BACKGROUND: The opiate epidemic remains a major public health crisiswith approximately 50,000 overdose deaths annually. This epidemic stems in part from over prescription of opiates and is therefore linked to physician prescribing habits. In recent years, non-physician providers such as physician assistants and nurse practitioners have become increasingly vital in the provision of care, supplying up to 25%of primary care in certain areas. In this study, we used theMedicare Provider Utilization and Payment Data: Part D Prescriber Public Use File (PDPPUF) to evaluate changes in opioid prescribing habits of physician specialties and nonphysician providers.
METHOD(S): We searched the Medicare PDPPUF for opiate prescriptions reimbursed from 2013 to 2017. Opiates queried included codeine, fentanyl, methadone, morphine, oxycodone, and tramadol. Prescribing trends evaluated included Medicare claims by specialty and total number of Medicare claims. Chi-squared goodness-of-fit tests were used to calculate differences in prescribing trends between years.
RESULT(S): The majority of reimbursement requests for opiates were filed by internal medicine/primary care providers, accounting for 61.6% of all prescriptions in 2013. From 2013 to 2017, the number of opiates prescribed by internal medicine/primary care physicians decreased by 14.5% (P < .001). Non-internal medicine physicians similarly decreased prescriptions by 12.2% (P < .001). However, non-physician providers increased prescriptions by 30.8% (P < .001). By 2017, non-physician providers grew to account for 25.1% of all Medicare opiate prescriptions. Overall number of opiate prescriptions decreased 6% (P < .001), with significant increases noted between 2013 and 2015 for codeine, fentanyl, morphine, oxycodone, and tramadol (P < .001).
CONCLUSION(S): The number of opiate reimbursement requests by internal medicine/primary care and non- internal medicine physicians significantly decreased between 2013 and 2017 while the overall number of opiate prescriptions decreased only slightly. This disconnect appears to be driven by increasing opiate prescription by non-physician providers. Recent data has shown that targeting specific providers with educationbased interventions can decrease opiate prescription by greater than 50%. Non-physician providers are vital for expanding the provision of primary care; however, the observed trends suggest that interventions targeting the prescribing habits of these providers may be effective in decreasing total opiate prescriptions and overdose deaths
EMBASE:633957389
ISSN: 1525-1497
CID: 4805292

Functional esophgeal chest pain, functional heartburn and reflux hypersensitivity

Chapter by: Fass, Ofer; Nyabanga, Custon; Smukalla, Scott; Khan, Abraham
in: Clinical and basic neurogastroenterology and motility by Rao, Satish S; Yeh, Yeong; Ghoshal, Uday C (Eds)
London : Academic Press, c2020
pp. 247-262
ISBN: 0128130377
CID: 4306222

NATIONAL TRENDS IN MEDICARE PRESCRIPTIONS OF ANTI-REFLUX MEDICATIONS FROM 2013 TO 2017-THE TIDE HAS TURNED [Meeting Abstract]

Fass, Ofer; Poels, Kamrine
ISI:000540349500083
ISSN: 0016-5085
CID: 4506242

Functional dysphagia

Chapter by: Fass, Ofer Z.; Fass, Ronnie
in: Evaluation and Management of Dysphagia: An Evidence-Based Approach by
[S.l.] : Springer International Publishing, 2019
pp. 201-218
ISBN: 9783030265533
CID: 4508582