David A. Johnson, MD


June 09, 2011

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DDW 2011: Overview

Hello, I'm Dr. David Johnson, Professor of Medicine and Chief of Gastroenterology, at Eastern Virginia Medical School in Norfolk, Virginia. Digestive Disease Week (DDW) 2011 -- there is always a lot of new information here, and I'll refer to a couple of interviews that I conducted this year while at DDW, with Dr. Phil Katz on esophageal disease (and a special second interview also with Dr. Katz on eosinophilic esophagitis); with Dr. Uma Mahadevan from University of California at San Francisco, on inflammatory bowel disease; and with Dr. Bill Chai on functional bowel disease. These interviews have all been posted on Medscape. So, I'm going to stay away from those areas because they are well-covered during those interviews. Look at Medscape DDW Highlights and you will find those very helpful and insightful. I wanted to cover a couple of other areas that I found particularly useful to my clinical practice and I just want to highlight these for you and, in particular, a couple of snippets on what I also found interesting from DDW 2011 in Chicago.

The Impact of Meditation on Inflammatory Bowel Syndrome Symptoms

Let's start with irritable bowel syndrome (IBS). There was a very interesting abstract that came from Chapel Hill. Dr. Ollie Palsson[3] and his group looked at meditation as it related to improvement in IBS symptoms. This group looked at a composite of 75 patients and they modified a mindfulness training program that they adapted from some Zen meditation, specifically formatted to IBS, where they focused the patients away from their experiences and really focused on the present and using deep breathing exercises. At the end of 8 weeks, they showed a mindfulness specific to present value of things where the patients disassociated from preceding events in their lives. A 20% improvement was seen over the control group in total IBS scores and in abdominal pain, with a significant increase in quality of life as well. So, this may be something to look for as we hear more from this group, whether this is ready for prime time for all patients with IBS. The durability of the effect remains a question, but it's something that certainly has no downside or risks (unlike medications) but may have some upsides and some value as it relates to improvements in quality of life for patients with IBS.

Celiac Disease: How Many Biopsy Specimens for Diagnosis?

The second topic I found very interesting was a study that came from Columbia University[2] in New York from their Celiac Center that looked at the number of biopsies necessary for the diagnosis of celiac disease. Let me first ask a question, when you are performing biopsies for suspected celiac disease, how many biopsies do you perform? This group looked at a large composite of the analysis from the Caris Pathology Database (more than 145,000 specimens) and they found that of these patients being evaluated, only 35% of biopsies submitted included an adequate number, as defined by the American Gastroenterological Association Guidelines for celiac disease. Those guidelines state that 4 or more biopsies are warranted for the diagnosis of celiac disease.

When this group from Columbia looked at this, they found that only 35% of the time were an adequate number of biopsies submitted. This is really a problem because we know that increasing from 2 to 4 takes the sensitivity of detection up from 90% to 100%. The guidelines suggest that you should be taking biopsies from multiple areas of the duodenum, the second and third portions, and probably the duodenal bulb, for the greatest specificity and sensitivity in detection of celiac disease. Biopsy specimens should be taken not only from areas that are obviously scalloping, flattening, or atrophic areas, but also from even normal areas. Increasing the biopsy number from 4 to 6 -- in that range of 4-6 -- is critical. Two biopsy specimens are not acceptable and finding that 35% of biopsy assessments submitted were inadequate speaks to why celiac disease is underrecognized in the United States at present. So, increase your biopsies certainly from 2, but you should be taking multiple biopsy specimens throughout the duodenum, the second and third portions, and also from the duodenal bulb.

Screening for Colorectal Cancer

Next in the area of screening for colon cancer, I found an interesting abstract that was a validation study on metabolomics, which is a new science that looks at the testing of metabolic molecules that are detected and may be applicable to a variety of different cancers. This was a study from Canada,[3] where they were actually using urine metabolomics in patients with adenomatous colon polyps, and testing the sensitivity and specificity of using a urine test in a specimen analysis of about 110 cases. They found a sensitivity of 70% and a specificity of 40%, which is much better than stool testing for polyps. So, more needs to be developed from this, but it is another area to put your ear to the ground and listen for new developments in the science of metabolomics in a variety of gastrointestinal cancers, and now in adenomatous polyp detection.

A couple of other areas that I found of interest were also related to colon polyps. The issue of serrated adenomas continues to be an increasing area of concern as far as our quality colonoscopy and missing lesions that we think may have more biologic risk as far as adverse potentials for high-grade dysplasia in colon cancer. Doug Rex and Charles Kahi[4] actually reported on the sensitivity of detection in normals and they attempted to put a serrated adenoma minimum standard, which we have not had to date, but they set the bar at 5% in men and women. There is a growing concern that we're missing serrated adenomas. We focused on adenomas as average risk, and we set the bar at 25% for men and 15 % in women. Dr. Kahi and Dr. Rex have set the bar for the number that we should be detecting in average risk men and women at 5%. So, maybe this is a new continuous quality improvement monitor for your practice, to start using this serrated adenoma detection rate as a minimum standard, and I will guarantee that you will see this on new standards as we get into the re-evaluation of the colon cancer guidelines. Dr. Rex and I sit on those guideline committees and I promise you that those numbers will emerge as far as minimum standard at some point in the near future.

Another area of concern about serrated adenomas is who is at greatest risk? Dr. Anderson[5] has written a lot about the inference of smoking association with adenomas and colon cancer. Now we find from Dr. Anderson's work, an incremental risk also for serrated adenomas. The odds ratios are increased by 2.8 times in smokers, not only for proximal adenomas, but large adenomas. So in your population of smokers, be especially attuned to the prevalence of adenomas—not only adenomas, colon cancer, but now put serrated adenomas in that list as well.

So, a number of things related to serrated adenomas in colon cancer screening were of interest. One area that I also found of interest was a potential increased uptake of utilization of colon cancer screening in patients with CT colonography (CTC) options. This study comes from The Netherlands,[6] and it's the first study that has really suggested that CTC, as an offer on the menu, might increase compliance with colon cancer screening.

They looked at nearly 5000 patients who were offered colonoscopy and about 1500 patients who were offered CTC, and they found that the decline rate of this offer of screening was lower in the CTC group by a factor of about 12%. This prospective randomized trial suggested a 12% gain in acceptability of colon cancer screening in the CTC group. It suggested there may be some hope for CTC increasing compliance. We are not there yet, by any means. CTC is not covered by standard insurance programs and certainly not by Medicare in the United States for screening, but stay tuned on this.

Therapies for Hepatitis C

Finally, we heard a couple of abstracts on the issues of the protease inhibitors, telaprevir[7] and boceprevir,[8] hot on the heels of US Food and Drug Administration approval of these agents for genotype 1, hepatitis C. It is interesting that there seems to be no difference or predilection as far as advantage in the IL 28 phenotype for either of these agents. This makes sense, however, because the IL 28 phenotype has been a hot topic with respect to its increased potential sensitivity for response to interferon and it wouldn't make sense that it would have an increased benefit in the protease inhibitors. That's very much what we are seeing from the DDW data.

I have tried to give you what I found to be of use in my clinical practice and the highlights in addition to what we covered in the other interviews from DDW with Dr. Chai, Dr. Mahadevan, and Dr. Katz on functional inflammatory bowel disease and esophageal disease. Look at those interviews. I found them very educational from my standpoint. Hopefully, the data that we amplified with this discussion will put some value on things that you may not have seen at DDW, but may be rising areas of interest in the near future in your clinical practice.

I'm Dr. David Johnson. Thanks again, as always, for listening.


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