Publications by authors named "Nayantara Coelho-Prabhu"

30 Publications

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Does Size Really Matter?

Am J Gastroenterol 2021 01;116(1):84-85

Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.

Abstract: Ileocolonoscopy remains the mainstay of objective disease assessment in Crohn's Disease, and various validated indices are used to grade severity of the disease. The most commonly used indices are the Simple Endoscopic Score for Crohn's Disease (including the size of ulcers) and the Crohn's Disease Endoscopic Index of Severity (including the depth of ulcers). These measurements are highly subjective, especially the depth of an ulcer, and are based solely on the discretion of the endoscopist coupled with the imaging capabilities of the colonoscope and adequacy of the bowel prep. Narula et al. undertook a post hoc analysis of baseline predictors of endoscopic remission (ER) at week 26 in a subset (172 of 508) of moderate-severe Crohn's disease patients participating in the SONIC trial. The authors found no significant differences in the odds of achieving ER when comparing overall or segmental severe inflammation (high Simple Endoscopic Score for Crohn's Disease [>16 overall or >3 per segment] or Crohn's Disease Endoscopic Index of Severity [>12 overall or >3 per segment] scores) with moderate inflammation. The number of affected segments involved also did not impact the likelihood of achieving week 26 ER. The authors then found a potentially synergistic effect with large and deep ulcers in the ileum and rectum. The optimal time to assess whether ulcers ultimately heal or not is unknown, but waiting longer than 26 weeks may negate any lead time bias regarding ulcer size. Therefore, similar to many areas of life, it is likely that size ultimately does not matter, but instead location, location, and location.
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http://dx.doi.org/10.14309/ajg.0000000000001057DOI Listing
January 2021

Jejunal Polyps out of Place: A Case of Gastric Heterotopia of the Jejunum.

Case Rep Gastrointest Med 2020 20;2020:8822019. Epub 2020 Aug 20.

Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.

Heterotopia is the presence of normal physiologic tissue in an atypical location. Gastric heterotopia has been described in various locations throughout the gastrointestinal tract, including the small intestine. Gastric heterotopia of the small intestine typically is asymptomatic but may present in several ways with symptoms of obstruction, bleeding, perforation, intussusception, or pain. However, gastric heterotopia is rare beyond the duodenum except for its frequent association with Meckel's diverticulum. This entity should be considered in the differential diagnosis of polypoid lesions presenting with symptoms of bleeding or obstruction especially in younger patients. We present a case of gastric heterotopia of the jejunum in a patient with a prior history of Meckel's diverticulectomy after he presented with obstructive symptoms. His symptoms improved following resection of two jejunal polyps via antegrade double-balloon assisted enteroscopy with fluoroscopy. On histopathlogical examination, findings were consistent with gastric heterotopia. This case highlights the importance of considering gastric heterotopia in the differential diagnosis of polypoid lesions located beyond the ligament of Treitz in younger patients presenting with obstructive symptoms.
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http://dx.doi.org/10.1155/2020/8822019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7455846PMC
August 2020

A 1-Year Cross-sectional Inflammatory Bowel Disease Surveillance Colonoscopy Cohort Comparing High-definition White Light Endoscopy and Chromoendoscopy.

Inflamm Bowel Dis 2020 Jun 12. Epub 2020 Jun 12.

Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Minnesota, USA.

Background: We sought to compare the dysplasia detection rate of high-definition white light endoscopy (HDWLE) with that of chromoendoscopy in patients with long-standing inflammatory bowel disease (IBD).

Methods: This is a retrospective observational cohort of patients with IBD who underwent surveillance colonoscopy between October 1, 2016 and September 30, 2017. We assessed the association between dysplasia detection and multiple variables.

Results: A total of 808 unique colonoscopies were performed, of which 150 (18.6%) included chromoendoscopy. Primary sclerosing cholangitis was a comorbid diagnosis in 24.5% of patients. The performing endoscopist was an IBD specialist with 37.1% of patients and had >10 years' experience with 64.9% of patients. Prior dysplasia had been seen in 245 (30.3%) patients: 102 (68.0%) and 143 (22.0%) among patients who had chromoendoscopy and HDWLE, respectively. Dysplasia in polyps was found in 129 procedures (15.1%). Among patients who had chromoendoscopy and HDWLE, polypoid dysplasia was identified in 50 (33.0%) and 79 (12.0%) patients, respectively, P < 0.01. Dysplasia in random biopsies was found in 39 patients (4.8%): 15 (10%) who had chromoendoscopy and 24 (3.6%) who had HDWLE (P < 0.001). On multivariate analysis, patient and disease characteristics significantly associated with an increased odds for polypoid dysplasia included older age at diagnosis (odds ratio [OR] = 1.3 per 10 years; 95% confidence interval [CI], 1.07-1.60), having an IBD physician endoscopist (OR = 1.6; 95% CI, 1.01-2.67), having an endoscopist with less than 10 years' experience (OR = 1.8; 95% CI (1.16-2.89), and prior random dysplasia (OR = 4.2; 95% CI (1.93-9.17). Concomitant primary sclerosing cholangitis was significantly associated with random dysplasia (OR = 2.3; 95% CI, 1.02-5.07). After multivariate analysis adjusting for these variables, chromoendoscopy was no more likely to identify dysplasia than was HDWLE.

Conclusions: Chromoendoscopy and HDWLE had a similar diagnostic yield for dysplasia detection in patients with chronic IBD-colitis after adjusting for multiple known risk factors.
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http://dx.doi.org/10.1093/ibd/izaa146DOI Listing
June 2020

Celiac Disease: A Subtle Clue for a Common Disease.

Am J Med 2020 12 4;133(12):e722-e723. Epub 2020 Jun 4.

Division of Gastroenterology and Hepatology. Electronic address:

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http://dx.doi.org/10.1016/j.amjmed.2020.04.041DOI Listing
December 2020

Combination Biologic Therapy in Inflammatory Bowel Disease: Experience From a Tertiary Care Center.

Clin Gastroenterol Hepatol 2021 Mar 14;19(3):616-617. Epub 2020 Feb 14.

Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.

The global incidence of inflammatory bowel disease (IBD) has increased considerably during the past few decades. IBDs, composed of Crohn's disease (CD) and ulcerative colitis (UC), are characterized by heterogeneous presentation and widely variable clinical course. The therapeutic goals are to induce and maintain remission. Despite the current treatments available, many patients do not achieve this goal.
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http://dx.doi.org/10.1016/j.cgh.2020.02.017DOI Listing
March 2021

Practical guidelines on endoscopic treatment for Crohn's disease strictures: a consensus statement from the Global Interventional Inflammatory Bowel Disease Group.

Lancet Gastroenterol Hepatol 2020 04 16;5(4):393-405. Epub 2020 Jan 16.

Department of Gastroenterology, University of California San Diego Medical Center, San Diego, CA, USA.

Stricture formation is a common complication of Crohn's disease, resulting from the disease process, surgery, or drugs. Endoscopic balloon dilation has an important role in the management of strictures, with emerging techniques, such as endoscopic electroincision and stenting, showing promising results. The underlying disease process, altered bowel anatomy from disease or surgery, and concurrent use of immunosuppressive drugs can make endoscopic procedures more challenging. There is an urgent need for the standardisation of endoscopic procedures and peri-procedural management strategies. On the basis of an extensive literature review and the clinical experience of the consensus group, which consisted of representatives from the Interventional Inflammatory Bowel Disease Group, we propose detailed guidance on all aspects of the principles and techniques for endoscopic procedures in the treatment of inflammatory bowel disease-associated strictures.
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http://dx.doi.org/10.1016/S2468-1253(19)30366-8DOI Listing
April 2020

Outcome of endoscopic resection of colonic polyps larger than 10 mm in patients with inflammatory bowel disease.

Endosc Int Open 2019 Aug 8;7(8):E994-E1001. Epub 2019 Aug 8.

Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Minnesota, United States.

 There are limited published data on endoscopic removal of colorectal polyps by endoscopic mucosal resection (EMR) and endoscopic mucosal dissection (ESD) in patients with inflammatory bowel disease (IBD).  We performed a retrospective review of patients with colonic IBD and colonic polyps >10mm who underwent EMR and/or ESD at our institution between January 1, 2012 and June 31, 2016.  Ninety-seven patients with pathology-confirmed IBD (median disease duration 16 years) were included. Mild or moderate active colitis (in background biopsies) was seen in 85 %. Of the total 124 polyps, location was ascending colon in 44 %, transverse in 15 % and sigmoid in 18.5 %; of the total, 55 % were < 20 mm and 45 % were ≥20mm in maximal diameter. Using the Paris classification, 56 % of polyps were polypoid sessile (Is) polyps, while 38 % were non-polypoid (IIa, IIb, IIc). EMR was used in 118 polyps, three required ESD, and three by combined EMR-ESD. Seventy-two percent were resected en-bloc; 28 % underwent piecemeal resection. Histology included low-grade dysplasia in 75, serrated adenoma in 31, and tubular adenoma in 14 polyps. Chromoendoscopy was used in 33 (26.6 %). Adverse events occurred in three patients. Colectomy was performed in 11 patients within 12 months. Recurrence was seen in 20 polyps, 11 of which were successfully resected en-bloc using EMR. Polyps ≥ 20 mm and polyps treated with APC were found to have a statistically significantly higher risk of recurrence.  This study demonstrates the efficacy and safety of endoscopic resection of large polyps in patients with IBD, making them effective alternatives to colectomy.
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http://dx.doi.org/10.1055/a-0953-2021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6687483PMC
August 2019

The Combination of Patient-Reported Clinical Symptoms and an Endoscopic Score Correlates Well with Health-Related Quality of Life in Patients with Ulcerative Colitis.

J Clin Med 2019 Aug 5;8(8). Epub 2019 Aug 5.

Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA.

Background And Aims: Patient-reported outcomes (PROs) will become increasingly important as primary endpoints in future clinical trials. We aimed to evaluate the relationship between health-related quality of life (HRQoL) and the combination of patient-reported clinical symptoms (ClinPRO2) and Mayo endoscopic subscore (MES) in patients with ulcerative colitis (UC).

Methods: We conducted a prospective cross-sectional study of 90 consecutive UC patients who were scheduled for sigmoidoscopy or colonoscopy. All patients completed the following questionnaires: (1) self-rated rectal bleeding and stool frequency (ClinPRO2); (2) Short Inflammatory Bowel Disease Questionnaire (SIBDQ); (3) European Quality of Life 5-Dimensions 3-Level (EQ5D3L); (4) Work Productivity and Activity Impairment questionnaire (WPAI); (5) Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F); and (6) Hospital Anxiety and Depression Scale (HADS). The endoscopic images were graded according to the MES. "No symptoms" was defined as a symptom score of 0, and "mucosal healing" was defined as MES score of 0-1. Correlations between the combined ClinPRO2 and MES with HRQoL were assessed using Spearman's correlation coefficients.

Results: The combination of the ClinPRO2 and MES was well correlated to SIBDQ ( = -0.70), EQ5D3L ( = -0.51), WPAI ( = 0.62), FACIT-F ( = -0.58), and HADS-depression ( = 0.45). SIBDQ scores had strong correlations with FACIT-F ( = 0.86), WPAI ( = -0.80), and HADS-depression ( = -0.75) ( < 0.05 for all correlations). Patients with no symptoms reported the greatest all HRQoL scores.

Conclusions: In patients with ulcerative colitis, the combination of a ClinPRO2 and the MES had good correlation with the SIBDQ. In addition, SIBDQ was well correlated to the various HRQoL.
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http://dx.doi.org/10.3390/jcm8081171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6723355PMC
August 2019

Small bowel bleeding in patients with left ventricular assist device: outcomes of conservative therapy versus balloon-assisted enteroscopy.

Ann Gastroenterol 2018 Nov-Dec;31(6):692-697. Epub 2018 Sep 26.

Division of Gastroenterology and Hepatology (Badr Al-Bawardy, Emmanuel Gorospe, Louis M. Wong Kee Song, Jeffrey A. Alexander, David H. Bruining, Nayantara Coelho-Prabhu, Elizabeth Rajan).

Background: Small bowel bleeding (SBB) accounts for 30% of gastrointestinal bleeding (GIB) episodes in patients with a left ventricular assist device (LVAD). The aim of this study was to determine the outcomes of conservative therapy (CT) compared to balloon-assisted enteroscopy (BAE) in the management of SBB in LVAD patients.

Methods: A retrospective review was performed of a prospectively maintained LVAD database from January 2003 to July 2015. LVAD patients with SBB were classified into a BAE group or a CT group according to whether they did or did not undergo BAE.

Results: Forty-two patients (22 BAE, 20 CT) with mean age 66±9.3 years (79% male) were included. The yield of BAE was 64% without reported complications. Overt re-bleeding occurred in 40% of the BAE group compared to 22% of the CT group. The BAE group had a higher mean number of GIB hospitalizations per month compared to the CT group (0.07 vs. 0.03; incidence rate ratio [IRR] 2.72, 95% CI 1.06-6.98; P=0.04). There was no significant difference between the BAE and the CT groups in the number of packed red blood cell (pRBC) transfusions per month (0.42 vs. 0.18; IRR 2.31, 95% CI 0.88-6.04; P=0.09) or all-cause mortality (61% in the CT group and 42% in the BAE group; P=0.90).

Conclusion: BAE is safe in LVAD patients and has a moderate therapeutic yield. In our cohort of patients, BAE did not appear to improve re-bleeding rate, GIB-related hospitalizations, pRBC transfusions or mortality compared to CT. However, future prospective trials with larger sample sizes are needed to confirm these findings.
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http://dx.doi.org/10.20524/aog.2018.0316DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6191869PMC
September 2018

Outcomes of repeat balloon assisted enteroscopy in small-bowel bleeding.

Endosc Int Open 2018 Jun 25;6(6):E694-E699. Epub 2018 May 25.

Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.

Background/aims:  The rate of recurrent small-bowel bleeding (SBB) remains high despite the advent of balloon assisted enteroscopy (BAE). The study aims were to determine: (1) the diagnostic and therapeutic yields, and adverse event rate of repeat BAE in SBB, and (2) the predictors of a positive repeat BAE.

Methods:  A retrospective review of a BAE database was conducted. Patients who had > 1 BAE for SBB were included. Primary outcomes were diagnostic yield, therapeutic yield, and adverse events of repeat BAE. Secondary outcomes were predictors of a positive repeat BAE.

Results:  A total of 175 patients (55 % men; mean age 64.1 ± 16.3 years) were included. The diagnostic and therapeutic yields of repeat BAE were 55 % and 42 %, respectively. Repeat BAE adverse events occurred in 5 % with self-limited abdominal pain being most common. Patients with a positive repeat BAE were significantly older than the negative group (68.6 ± 13.9 vs. 60.9 ± 17.1;  = 0.001) and were more likely to have cardiac comorbidities (OR 2.4, 95 %CI: 1.3 - 4.6;  = 0.01), chronic kidney disease (OR 2.3, 95 %CI: 1.1 - 4.9;  = 0.04), chronic obstructive pulmonary disease (OR 3.3, 95 %CI: 1.3 - 8.1;  = 0.01), positive initial BAE (OR 3.6, 95 %CI: 1.9 - 6.8;  < 0.001), and antegrade procedure (OR 3.3, 95 %CI: 1.7 - 6.1;  < 0.001). On multivariate analysis, a positive initial BAE and antegrade route were the only significant predictive factors.

Conclusions:  Performing a repeat BAE for SBB appears safe and provided modest yields. A positive initial BAE and antegrade route were predictive of a positive repeat BAE.
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http://dx.doi.org/10.1055/a-0599-6085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5979197PMC
June 2018

Clinical Benefit of Capsule Endoscopy in Crohn's Disease: Impact on Patient Management and Prevalence of Proximal Small Bowel Involvement.

Inflamm Bowel Dis 2018 06;24(7):1582-1588

Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.

Background: Ileocolonoscopy and computed tomography (CT) or magnetic resonance (MR) enterography (CTE/MRE) are utilized to evaluate patients with small bowel (SB) Crohn's disease (CD). The purpose of our study was to estimate the impact of capsule endoscopy (CE) on patient management after clinical assessment, ileocolonoscopy, and CTE/MRE.

Methods: We prospectively analyzed 50 adult CD patients without strictures at clinically indicated ileocolonoscopy and CTE/MRE exams. Providers completed pre- and post-CE clinical management questionnaires. Pre-CE questionnaire assessed likelihood of active SBCD and management plan using a 5-point level of confidence (LOC) scales. Post-CE questionnaire assessed alteration in management plans and contribution of CE findings to these changes. A change of ≥2 on LOC scale was considered clinically meaningful.

Results: Of the 50 patients evaluated (60% females), median age was 38 years, median disease duration was 3 years, and median Crohn's Disease Activity Index (CDAI) score was 238 points. All CTE/MRE studies were negative for proximal disease. CE detected proximal disease in 14 patients (28%) with a median Lewis score of 215 points. CE findings altered management in 17 cases (34%). The most frequent provider-perceived benefits of CE were addition of new medication (29%) and exclusion of active SB mucosal disease (24%).

Conclusion: CE is a safe imaging modality that alters clinical management in patients with established SBCD by adding incremental information not available at ileocolonoscopy and cross-sectional enterography.
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http://dx.doi.org/10.1093/ibd/izy050DOI Listing
June 2018

Outcomes of Endoscopic Therapy for Luminal Strictures in Crohn's Disease.

Inflamm Bowel Dis 2018 06;24(7):1575-1581

Divisions of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota.

Backgrounds: We sought to describe the outcomes of endoscopic therapy of luminal strictures in patients with Crohn's disease (CD) at a large tertiary referral center.

Methods: All patients who had undergone endoscopic dilation of CD strictures between January 1, 1990 and November 30, 2013 were identified. Demographics, disease characteristics including medication use and history of surgeries, details of endoscopic procedures, and long-term outcomes were analyzed. A successful procedure was defined as ability of the endoscope to pass through the stricture after dilation or effacement of the dilating balloon under fluoroscopy. Kaplan-Meier and Cox proportional hazards analysis were used.

Results: For this study 286 index procedures for CD-related stricture dilation were performed in 273 patients (53.8% women) with median age of 45.9 years (range, 14.9-92.2). The most common stricture locations were ileocolonic anastomosis (36.4%) and colon (13.9%). One hundred fourteen (41.8%) patients had a second dilation. The cumulative probability of need for a second dilation following the index procedure was 33.6% at 1 year (95% CI, 25.9%-38.7%), 53.9% at 3 years (45.9%-61.2%), and 60.2% at 5 years (51.4%-67.5%). Six adverse events occurred after the first procedure: 4 perforations, 1 patient with bleeding, and 1 patient with abdominal pain requiring hospitalization. A total of 82 (30%) patients required surgery for their stricture.

Conclusions: In a large cohort, endoscopic stricture dilation in CD was safe and effective. About 33% of patients required a second dilation at 1 year after the initial dilation; younger age and smaller inner diameter of the index stricture predicted need for a second dilation. 10.1093/ibd/izy049_video1izy049.video15794820307001.
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http://dx.doi.org/10.1093/ibd/izy049DOI Listing
June 2018

Assessment of multi-modality evaluations of obscure gastrointestinal bleeding.

World J Gastroenterol 2017 Jan;23(4):614-621

Ryan Law, Jithinraj E Varayil, Louis M WongKeeSong, Jeffrey Alexander, Elizabeth Rajan, Stephanie Hansel, Brenda Becker, David H Bruining, Nayantara Coelho-Prabhu, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States.

Aim: To determine the frequency of bleeding source detection in patients with obscure gastrointestinal bleeding (OGIB) who underwent double balloon enteroscopy (DBE) after pre-procedure imaging [multiphase computed tomography enterography (MPCTE), video capsule endoscopy (VCE), or both] and assess the impact of imaging on DBE diagnostic yield.

Methods: Retrospective cohort study using a prospectively maintained database of all adult patients presenting with OGIB who underwent DBE from September 1, 2002 to June 30, 2013 at a single tertiary center.

Results: Four hundred and ninety five patients (52% females; median age 68 years) underwent DBE for OGIB. AVCE and/or MPCTE performed within 1 year prior to DBE (in 441 patients) increased the diagnostic yield of DBE (67.1% with preceding imaging 59.5% without). Using DBE as the gold standard, VCE and MPCTE had a diagnostic yield of 72.7% and 32.5% respectively. There were no increased odds of finding a bleeding site at DBE compared to VCE (OR = 1.3, = 0.150). There were increased odds of finding a bleeding site at DBE compared to MPCTE (OR = 5.9, < 0.001). In inpatients with overt OGIB, diagnostic yield of DBE was not affected by preceding imaging.

Conclusion: DBE is a safe and well-tolerated procedure for the diagnosis and treatment of OGIB, with a diagnostic yield that may be increased after obtaining a preceding VCE or MPCTE. However, inpatients with active ongoing bleeding may benefit from proceeding directly to antegrade DBE.
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http://dx.doi.org/10.3748/wjg.v23.i4.614DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5292334PMC
January 2017

Dilation of Strictures in Patients with Inflammatory Bowel Disease: Who, When and How.

Gastrointest Endosc Clin N Am 2016 Oct;26(4):739-59

Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA. Electronic address:

Stricture formation occurs in up to 40% of patients with inflammatory bowel disease (IBD). Patients are often symptomatic, resulting in significant morbidity, hospitalizations, and loss of productivity. Strictures can be managed endoscopically in addition to traditional surgical management (sphincteroplasty or resection of the affected bowel segments). About 3% to 5% patients with IBD develop primary sclerosing cholangitis (PSC), which results in stricture formation in the biliary tree, managed for the most part by endoscopic therapies. In this article, we discuss endoscopic management of strictures both in the alimentary tract and biliary tree in patients with IBD and/or PSC.
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http://dx.doi.org/10.1016/j.giec.2016.06.011DOI Listing
October 2016

Outcomes of double-balloon enteroscopy-assisted direct percutaneous endoscopic jejunostomy tube placement.

Endoscopy 2016 Jun 10;48(6):552-6. Epub 2016 Mar 10.

Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.

Background And Study Aims: In a large series, conventional direct percutaneous endoscopic jejunostomy (DPEJ) tube placement with push endoscopes failed in approximately one-third of patients. In a pilot study, double-balloon enteroscopy (DBE)-assisted DPEJ tube placement was successful in all patients in whom attempted conventional DPEJ had failed. The study aim was to assess the technical success of and adverse events related to DBE-DPEJ tube placement in a large cohort of patients.

Patients And Methods: The medical records of all patients who underwent DBE-DPEJ tube placement between July 2010 and November 2013 were reviewed using a prospectively maintained electronic database. Data were abstracted for patient demographics, indications for DPEJ, gut anatomy, technical success rate, causes of failure, and adverse events.

Results: The study comprised a total of 94 patients (39 men; mean age 56 years; body mass index [BMI] 23 ± 6.4 kg/m(2)). The most common indication for DPEJ was gastroparesis (n = 29). Altered gut anatomy was present in 36 patients (38 %). DBE-DPEJ tube placement was technically successful in 87 patients (93 %). The mean procedure duration was 33 minutes (range 15 - 88). DBE-DPEJ tube placement failed in seven patients (7 %), primarily because of limited instrument advancement in the setting of presumed surgical adhesions. Post-procedural adverse events occurred in eight patients (9 %), with one serious adverse event, which was a gastric interposition requiring surgical repair.

Conclusions: Compared with the published outcomes of DPEJ by conventional endoscopy, DBE-DPEJ tube placement was technically successful in a high proportion of patients (93 %) and with a relatively low rate of significant adverse events.
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http://dx.doi.org/10.1055/s-0042-101853DOI Listing
June 2016

An Assessment of the AGA and CCFA Quality Indicators in a Sample of Patients Diagnosed with Inflammatory Bowel Disease.

J Manag Care Spec Pharm 2015 Nov;21(11):1064-76

Health Analytics, 9200 Rumsey Rd., Ste. 215, Columbia, MD 21045.

Background: Inflammatory bowel disease (IBD) is a chronic relapsing disease characterized by activation of the mucosal immune system and inflammation of the gastrointestinal tract. Management of IBD places a significant burden on the health care system because of the complexity of treatment, variability in patient outcomes, and chronic nature of the disease. 

Objective: To investigate the American Gastroenterological Association (AGA) and Crohn's and Colitis Foundation of America's (CCFA) quality measurement sets in a sample of IBD patients.

Methods: Fourteen quality measures were restated for application to a claims database and calculated using Optum Clinformatics DataMart database. Selected measures were calculated over calendar year 2011.

Results: Performance measures ranged from 0.4% for AGA measure 9, prophylaxis for venous thromboembolism, to 66.9% for AGA measure 8, testing for Clostridium difficile. CCFA outcome measures ranged from 0.6% qualifying for CCFA O10, report of fecal incontinence, to 32.9% for CCFA O1, prednisone usage. In addition to Clostridium difficile testing, the use of appropriate corticosteroid-sparing therapy (51.1%) and testing for latent tuberculosis before initiating anti-tumor necrosis factor therapy (45.0%) were the highest achieved measures.

Conclusions: This is the first examination of IBD quality measures using administrative claims. Rates of achievement across measures were variable and likely affected by the ability to calculate certain measures with claims data. Future studies should further examine measurement of IBD quality indicators in claims data to assess the validity of claims-based analyses and to ascertain whether measure attainment translates into better overall health or IBD-related outcomes.
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http://dx.doi.org/10.18553/jmcp.2015.21.11.1064DOI Listing
November 2015

Achieving hemostasis and the risks associated with therapy.

Gastrointest Endosc Clin N Am 2015 Jan;25(1):123-45

Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA. Electronic address:

Acute gastrointestinal bleeding is a common cause for hospitalization. Endoscopic hemostasis plays a central role in the management of lesions with active bleeding or high-risk stigmata for rebleeding. The efficacy and safety of endoscopic hemostasis rely on the identification of lesions suitable for endoscopic therapy, selection of the appropriate hemostatic devices, attention to technique, and prompt recognition and management of procedure-related adverse events. In this article, practical applications of hemostatic devices and pitfalls related to endoscopic hemostasis are discussed.
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http://dx.doi.org/10.1016/j.giec.2014.09.012DOI Listing
January 2015

Mucormycosis in patients with inflammatory bowel disease: case series and review of the literature.

Case Rep Med 2014 27;2014:637492. Epub 2014 Apr 27.

Division of Infectious Diseases, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55902, USA.

Mucormycosis is a rare and often fatal invasive fungal infection mostly seen in immune-compromised individuals. A high index of clinical suspicion is necessary, so that effective preemptive therapy can be started, as timely intervention is crucial. In this series we present three cases of invasive mucormycosis in patients with underlying inflammatory bowel disease that had received therapy with immunomodulators prior to the infection. All three had varied clinical manifestations. We also review the literature of invasive mucormycosis in patients with inflammatory bowel disease.
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http://dx.doi.org/10.1155/2014/637492DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4020554PMC
May 2014

Cytomegalovirus infection of the ileoanal pouch: clinical characteristics and outcomes.

Inflamm Bowel Dis 2013 Oct;19(11):2394-9

Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.

Background: Up to 30% of cases of pouchitis are felt to have a secondary cause. Cytomegalovirus (CMV) may represent a possible etiopathological agent. Here, we report our experience with CMV involvement of the pouch, including risk factors, clinical features, and pouch outcomes in patients with inflammatory bowel disease after proctocolectomy with ileal pouch-anal anastomosis.

Methods: The pathology database at Mayo Clinic in Rochester was searched between January 1995 and October 2012 for patients with a tissue diagnosis of CMV of the pouch following ileal pouch-anal anastomosis.

Results: Seven patients with CMV inclusions of the pouch were identified. The median age was 35 (range, 10-53) years, and the majority were female (71%). Five patients (71%) were on immunosuppressive medications including 4 who had undergone orthotopic liver transplantation for primary sclerosing cholangitis. The clinical presentation was similar among all patients: the majority had diarrhea (86%), fever (71%), and abdominal pain (57%). All had mucosal inflammation, with 71% having focal ulcerations in the pouch and 60% having inflammatory changes in the prepouch ileum. All patients improved with ganciclovir. None required pouch excision or had recurrent CMV infection. Three patients had recurrent nonspecific pouchitis.

Conclusions: A high index of suspicion is needed to diagnose CMV of the pouch. An increase in stool frequency and fever in patients on immune suppression or in those who have failed empiric antibiotics should prompt assessment for CMV infection. Antiviral therapy seems to be effective, and postinfection pouch outcomes seem favorable, particularly in those presenting with their first episode of pouchitis.
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http://dx.doi.org/10.1097/MIB.0b013e3182a52553DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4085480PMC
October 2013

Endoscopic retrograde cholangiopancreatography: utilisation and outcomes in a 10-year population-based cohort.

BMJ Open 2013 May 31;3(5). Epub 2013 May 31.

Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.

Objective: To determine utilisation of endoscopic retrograde cholangiopancreatography (ERCP); incidence of inpatient admissions for complications occurring within 30 days of ERCP and risk factors for procedural-related complications, in a population-based study.

Design: Retrospective cohort study.

Setting: Olmsted County, Minnesota.

Participants: All adult residents of Olmsted County, Minnesota, who underwent ERCP from 1997 to 2006.

Interventions: Diagnostic and therapeutic ERCPs were assessed.

Primary And Secondary Outcome Measures: Patient and procedural characteristics and complications within 30 days; and rates of ERCP utilisation and unplanned admissions and risk factors for admissions.

Results: In 10 years, 1072 ERCPs were performed on 827 individual patients. Average utilisation of ERCP was 83.1 ERCPs/100 000 persons/year, with an increase from 58 to 104.8 ERCPs/100 000 persons/year over time, driven by increases in therapeutic procedures. Within 30 days after 236 procedures, 62 admissions were definitely related to the index ERCP. The complication rate was 5.3%, including pancreatitis (26, 2.4%), infection/cholangitis (16, 1.5%), bleeding (15, 1.4%) and perforation (4, 0.37%). 30-day mortality was 2.4%, none of which was directly related to the ERCP or complications thereof. Risk factors identified through multivariate analysis to be associated with adverse events included: age <45 years (p=0.0498); body mass index ≥35 (p=0.0024); pancreatic duct cannulation (p=0.0026); outpatient procedure (p<0.0001); intraprocedure sphincterotomy bleeding (p<0.0001); difficulty grade (p=0.115) and patient's first ERCP (p=0.0394).

Limitations: Retrospective study.

Conclusions: Population utilisation of ERCP rose during the study period, specifically in therapeutic procedures. Admissions within 30 days of ERCP are common but often unrelated. Complications of ERCP remain infrequent and deaths quite unusual.
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http://dx.doi.org/10.1136/bmjopen-2013-002689DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4387279PMC
May 2013

Increased risk of prosthetic joint infection associated with esophago-gastro-duodenoscopy with biopsy.

Acta Orthop 2013 Feb 25;84(1):82-6. Epub 2013 Jan 25.

Division of Gastroenterology, Mayo Clinic, Rochester, MN, USA.

Background: There are no prospective data regarding the risk of prosthetic joint infection following routine gastrointestinal endoscopic procedures. We wanted to determine the risk of prosthetic hip or knee infection following gastrointestinal endoscopic procedures in patients with joint arthroplasty.

Methods: We conducted a prospective, single-center, case-control study at a single, tertiary-care referral center. Cases were defined as adult patients hospitalized for prosthetic joint infection of the hip or knee between December 1, 2001 and May 31, 2006. Controls were adult patients with hip or knee arthroplasties but without a diagnosis of joint infection, hospitalized during the same time period at the same orthopedic hospital. The main outcome measure was the odds ratio (OR) of prosthetic joint infection after gastrointestinal endoscopic procedures performed within 2 years before admission.

Results: 339 cases and 339 controls were included in the study. Of these, 70 cases (21%) cases and 82 controls (24%) had undergone a gastrointestinal endoscopic procedure in the preceding 2 years. Among gastrointestinal procedures that were assessed, esophago-gastro-duodenoscopy (EGD) with biopsy was associated with an increased risk of prosthetic joint infection (OR = 3, 95% CI: 1.1-7). In a multivariable analysis adjusting for sex, age, joint age, immunosuppression, BMI, presence of wound drain, prior arthroplasty, malignancy, ASA score, and prothrombin time, the OR for infection after EGD with biopsy was 4 (95% CI: 1.5-10).

Interpretation: EGD with biopsy was associated with an increased risk of prosthetic joint infection in patients with hip or knee arthroplasties. This association will need to be confirmed in other epidemiological studies and adequately powered prospective clinical trials prior to recommending antibiotic prophylaxis in these patients.
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http://dx.doi.org/10.3109/17453674.2013.769079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584609PMC
February 2013

ERCP for the treatment of bile leak after partial hepatectomy and fenestration for symptomatic polycystic liver disease.

World J Gastroenterol 2012 Jul;18(28):3705-9

Mayo Clinic College of Medicine, Rochester, MN 55905, USA.

Aim: To describe endoscopic treatment of bile leaks in these patients and to identify risk factors in these patients which can predict the development of bile leaks.

Methods: Retrospective case-control study examining consecutive patients who underwent partial hepatectomy for polycystic liver disease (PLD) and developed a postoperative bile leak managed endoscopically over a ten year period. Each case was matched with two controls with PLD who did not develop a postoperative bile leak.

Results: Ten cases underwent partial hepatectomy with fenestration for symptoms including abdominal distention, pain and nausea. Endoscopic retrograde cholangiopancreatography (ERCP) showed anatomic abnormalities in 1 case. A biliary sphincterotomy was performed in 4 cases. A plastic biliary stent was placed with the proximal end at the site of the leak in 9 cases; in 1 case two stents were placed. The overall success rate of ERCP to manage the leak was 90%. There were no significant differences in age, gender, comorbidities, duration of symptoms, history of previous surgery or type of surgery performed between cases and controls.

Conclusion: ERCP with stent placement is safe and effective for management of post-hepatectomy bile leak in patients with PLD.
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http://dx.doi.org/10.3748/wjg.v18.i28.3705DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3406422PMC
July 2012

Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter U.S. series.

Gastrointest Endosc 2011 Apr 14;73(4):718-26. Epub 2011 Jan 14.

Section of Gastroenterology and Hepatology, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.

Background: Direct endoscopic necrosectomy (DEN) for treatment of walled-off pancreatic necrosis (WOPN) has been performed as an alternative to operative or percutaneous therapy.

Objective: To report the largest combined experience of DEN performed for WOPN.

Design: Retrospective chart review.

Setting: Six U.S. tertiary medical centers.

Patients: A total of 104 patients with a history of acute pancreatitis and symptomatic WOPN since 2003.

Interventions: DEN for WOPN.

Main Outcome Measurements: Resolution or near-resolution of WOPN without the need for surgical or percutaneous intervention and procedural complications.

Results: Successful resolution was achieved in 95 of 104 patients (91%). Of the patients in whom it failed, 5 died during follow-up before resolution, 2 underwent operative drainage for persistent WOPN, 1 required surgery for massive bleeding on fistula tract dilation, and 1 died periprocedurally. The mean time to resolution from the initial DEN was 4.1 months. The first débridement was performed a mean of 63 days after the initial onset of acute pancreatitis. In 73%, the entry was transgastric with median tract dilation diameter of 18 mm. The median number of procedures was 3 with 2 débridements. Complications occurred in approximately 14% and included 5 retrogastric perforations/pneumoperitoneum, which were managed nonoperatively. Univariate analysis identified a body mass index >32 as a risk factor for failed DEN.

Limitations: Retrospective, highly specialized centers.

Conclusions: This large, multicenter series demonstrates that transmural, minimally invasive endoscopic débridement of WOPN performed in the United States is an efficacious and reproducible technique with an acceptable safety profile.
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http://dx.doi.org/10.1016/j.gie.2010.10.053DOI Listing
April 2011

Endoscopic retrograde cholangiopancreatography in the diagnosis and management of cholangiocarcinoma.

Clin Liver Dis 2010 May;14(2):333-48

Mayo Clinic Rochester, MN 55905, USA.

Cholangiocarcinomas (CCAs) are rare malignancies that arise from the biliary epithelium. Intrahepatic CCAs usually present as mass lesions that are asymptomatic or cause nonspecific systemic symptoms such as fatigue, fever, and weight loss. Hilar and extrahepatic tumors most commonly present with jaundice, though cholangitis also can be seen. Tumor markers such as carbohydrate antigen 19-9 and carcinoembryonic antigen have been used to diagnose CCA, but these are nonspecific and may be elevated in infection, inflammation, or any obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) has been used for the diagnosis and management of CCA for many years. This article summarizes the data regarding the application of ERCP in the diagnosis and management of CCA.
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http://dx.doi.org/10.1016/j.cld.2010.03.011DOI Listing
May 2010

Current staging and diagnosis of gastroesophageal varices.

Clin Liver Dis 2010 May;14(2):195-208

Mayo Clinic Rochester, MN 55905, USA.

Portal hypertension is defined as an increase in hepatic sinusoidal pressure to 6 mm Hg or higher. Cirrhosis is the most common cause of portal hypertension in the western world and results from increased resistance to blood flow at the hepatic sinusoidal level.
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http://dx.doi.org/10.1016/j.cld.2010.03.006DOI Listing
May 2010

Endoscopic gallbladder drainage for management of acute cholecystitis.

Gastrointest Endosc 2010 May;71(6):1038-45

Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan.

Background: Nonoperative gallbladder drainage methods for acute cholecystitis include percutaneous transhepatic gallbladder drainage and percutaneous transhepatic gallbladder aspiration, endoscopic nasogallbladder drainage and gallbladder stenting via a transpapillary endoscopic approach, and EUS-guided nasogallbladder drainage and gallbladder stenting via a transmural endoscopic approach.

Objective: A systematic review was performed to evaluate the current potential role of each gallbladder drainage technique for acute cholecystitis.

Design: MEDLINE, EMBASE, and manual searches were performed to identify pertinent English-language articles.

Results: The technical success rate, clinical success rate, and the frequency of adverse events in percutaneous transhepatic gallbladder aspiration (n = 122) and percutaneous transhepatic gallbladder drainage (n = 246) were 93% and 98%, 83% and 90%, and 0.8% and 3.7%, respectively. In contrast, the technical success rate, clinical success rate, and the frequency of adverse events in endoscopic nasogallbladder drainage (n = 194) and endoscopic gallbladder stenting (n = 127) were 81% and 96%, 75% and 88%, and 3.6% (n = 7) and 6.3% (n = 8), respectively. Although there have been 2 small case series of successful EUS-guided transmural nasogallbladder drainage (total n = 12), the procedure was technically and clinically successful in all of the patients with 2 adverse events. Only 1 case of successful EUS-guided gallbladder stent placement without any procedure-related adverse events has been reported.

Limitations: Retrospective studies, small number of patients, and lack of randomized, controlled trials.

Conclusions: Although prospective evaluation of the feasibility, safety, and efficacy of these various approaches will help identify the most suitable therapeutic modality for patients with acute cholecystitis, endoscopic gallbladder drainage may have a high potential as an alternative drainage method in acute cholecystitis.
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http://dx.doi.org/10.1016/j.gie.2010.01.026DOI Listing
May 2010

Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors.

Gastrointest Endosc 2010 Mar;71(3):560-72

Department of Medicine, Weill Medical College of Cornell University, New York, New York, USA.

Background: Self-expandable metal stents (SEMSs) are used for colonic obstruction palliatively and preoperatively.

Objective: Determine long-term efficacy, incidence of complications, and risk factors of SEMS placement for colonic obstruction.

Design: Retrospective review of SEMSs placed for malignant colorectal obstruction from 1999 to 2008.

Setting: Tertiary-care center.

Patients: This study involved 168 patients who underwent SEMS placement for palliation and 65 patients who underwent SEMS placement as a "bridge to surgery."

Intervention: Colonic SEMS placement.

Main Outcome Measurements: Stricture location, stent-induced complications, time to adverse events, need for reintervention.

Results: Technical and immediate clinical success rates were 96% and 99% in the palliative group and 95% and 98% in the preoperative group. Forty-one patients (24.4%) in the palliative group had complications including perforation (9%), occlusion (9%), migration (5%), and erosion/ulcer (2%). Mean stent patency was 145 days in the palliative group. One hundred eight of 122 patients (88.5%) were free of obstruction from implantation until death. Preoperatively placed stents remained in situ for a mean of 25.4 days and remained patent until surgery in 73.8% of patients. Complications were present preoperatively in 23.1% of patients; 94% underwent elective colectomy. Univariate analysis identified males, complete obstruction, stent diameter < or = 22 mm, stricture dilation during SEMS insertion, and operator experience as significant risk factors for complication. In the palliative group, intraluminal lesions (27% vs 19%), bevacizumab (35% vs 23%), and distal colon placement of the stent (27% vs 13%) were also associated with higher complication rates as compared to extraluminal lesions, patients not treated with bevacizumab, and stents in the proximal colon, respectively. Bevacizumab therapy nearly tripled the risk of perforation.

Limitations: Retrospective analysis, single institution.

Conclusion: Colorectal SEMS placement is relatively safe and effective but with a complication rate of nearly 25%. Patient characteristics and technical variables appear to affect the outcome of SEMS therapy.
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http://dx.doi.org/10.1016/j.gie.2009.10.012DOI Listing
March 2010

Dysphagia and weight loss in an elderly person. Dysphagia aortica.

Gastroenterology 2009 Nov 2;137(5):e1-2. Epub 2009 Oct 2.

Miles and Shirley Fiterman Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.

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http://dx.doi.org/10.1053/j.gastro.2009.02.011DOI Listing
November 2009

Assessment of need for repeat ERCP during biliary stent removal after clinical resolution of postcholecystectomy bile leak.

Am J Gastroenterol 2010 Jan 22;105(1):100-5. Epub 2009 Sep 22.

Mayo Clinic Rochester, Minnesota 55905, USA.

Objectives: In patients who have undergone endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement for postcholecystectomy bile leak there is limited evidence to support the repeat ERCP at the time of stent removal. Esophagogastroduodenoscopy (EGD) with biliary stent removal may suffice. The aim of this study was to describe the clinical course of patients who underwent biliary stent placement for a postcholecystectomy bile leak and determine whether repeat ERCP is necessary.

Methods: We identified all adult patients who underwent biliary stent placement for postcholecystectomy bile leak from 1 January 1996 to 31 October 2008. Demographic data, cholecystectomy details, and procedural data were collected, specifically focusing on closure of the bile leak. Time to resolution of leak was calculated, up to either the date of the first repeat ERCP that demonstrated no persistent leak or the date of removal of any radiologically placed percutaneous drain, whichever came first.

Results: Sixty-four patients underwent repeat ERCP with biliary stent removal. The median time to repeat ERCP was 36 days (interquartile range (IQR) 26-48). Fifty-seven (89%) patients had resolved the leak by time of repeat ERCP. Of those in whom the leak had not resolved, 6 had a repeat exam within 14 days of stent placement; 4 of these resolved the leak by day 39. There were no procedure-related complications in the ERCP group. Thirteen patients underwent EGD with stent removal after a median of 29 days (IQR 23-38). None had adverse events, with a median follow-up of 38 months. Overall, the median time to resolution of biliary leak was 33 days (IQR 22-44). Importantly, repeat ERCP altered the management in only one patient in whom bile duct stones were found.

Conclusions: Patients with uncomplicated postcholecystectomy bile leak who have clinically resolved their leak do not require cholangiography at the time of stent removal. In these patients, EGD with stent removal at 4-6 weeks seems to be sufficient and significantly less expensive.
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http://dx.doi.org/10.1038/ajg.2009.546DOI Listing
January 2010

Successful transgastric drainage of a large mucinous adenocarcinoma of the stomach for palliation of malignant gastric luminal obstruction.

Gastrointest Endosc 2009 Apr 18;69(4):e23-5. Epub 2009 Jan 18.

Miles and Shirley Fiterman Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA.

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http://dx.doi.org/10.1016/j.gie.2008.08.003DOI Listing
April 2009