Category Archives: Disorders

Diabetes Mellitus and Metabolic Syndrome—Independent Risk Factors for Hepatocellular Carcinoma

At the annual American College of Gastroenterology (ACG) meeting in 2015, Allison Kasmari, M.D., internal medicine resident, Penn State Health Milton S. Hershey Medical Center, presented findings on behalf of a group of researchers, including Amy Welch, M.D., Thomas Riley, M.D., and Thomas McGarrity, M.D., demonstrating a significantly increased risk (35 percent) of hepatocellular carcinoma (HCC) among individuals with type II diabetes mellitus (DM) and hypertension (23 percent). Based on a retrospective review (2008-2012) of 7,473 patients with HCC using MarketScan, a U.S. insurance claims database, the largest increase in HCC risk (458 percent) was seen among patients with the triple combination of DM, hypertension and hepatitis C virus (HCV), compared to age-matched controls without such diseases (Table). The abstract findings were ranked among the top 10 from a total of more than 2,500 abstracts presented at the ACG meeting and were also featured on Medscape and in an ACG SmartBrief. Continue reading

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Pelvic Floor Disorders: Common, Undetected Problems

Pelvic floor disorders are the “Don’t Ask, Don’t Tell” of gastroenterology, colorectal surgery and urogynecology. “Patients don’t volunteer information about urinary incontinence, fecal or anal incontinence, or constipation.

Likewise, most physicians don’t ask the detailed questions needed to make the correct diagnosis,” says Deborah Bethards, M.D., of Penn State Hershey Gastroenterology and Hepatology. Bethards says, “These disorders are seen even among active younger women. A recent study showed that over one-third of female triathletes had at least one pelvic floor disorder symptom.”

According to this report, 37 percent of the women experienced anal incontinence.1 These data indicate that physicians should have pelvic floor problems high on their radar. To increase detection, Bethards stresses the importance of asking the appropriate questions. “A complaint of ‘constipation’ is an opportunity to ask about chronicity, frequency, stool characteristics, whether they strain or sit for a long time, and if they feel incomplete evacuation. Different symptoms point to distinctly different problems such as dyssynergic defecation, which can be found in up to 50 percent of patients referred to tertiary care centers for chronic constipation.2 These are problems that a change in diet or even medication won’t really address,” says Bethards. Continue reading

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Surgical Diverticulitis Associated with TNFSF15 Gene Single Nucleotide Polymorphism rs7848647

Diverticular disease is a common gastrointestinal disorder seen in over half of all United States adults over the age of sixty years, with approximately 5 percent of the population requiring surgery. According to Walter Koltun, M.D., F.A.C.S, F.A.S.C.R.S., chief, division of colon and rectal surgery at Penn State Hershey Medical Center, “We’re beginning to understand that diverticulitis is caused by a mix of genetic and environmental factors. A strong genetic component for diverticular disease was demonstrated in twin studies done in Europe, showing that about 50 percent of diverticular disease susceptibility is genetically based. We also know genetic influence is complex, and related to multiple genes.” The overall mix of genetic and environmental factors associated with the development of diverticular disease helps to explain the wide phenotypic variation physicians observe clinically, ranging from asymptomatic to life-threatening. Continue reading

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The CHARM Trial: CHemotherapy for Ablation and Resolution of Mucinous Pancreatic Cysts

CHARM image 1

76-year-old female with a 4.2cm mucinous (premalignant type) pancreatic cyst (white arrow) prior to EUS-guided chemoablation in the Penn State CHARM trial.

Pancreatic cysts are incidentally detected in 5-20 percent of patients over the age of sixty-five who undergo CT or MRI imaging, and the majority of these cysts are comprised of premalignant type mucinous cysts. While their detection may lead to early treatment or prevention of pancreatic cancer, effective and safe management poses a challenge. “Current guidelines,” explains Matthew T. Moyer, M.D., of Penn State Hershey Gastroenterology and Hepatology, “call for ongoing radiographic surveillance or surgical resection of these premalignant lesions; however, both options have significant limitations, risks, and costs.” Pancreatic surgical resection is associated with a 2 percent risk of mortality and an estimated 30 percent risk of serious complications. Continue reading

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Interferon-Free Regimens Offer the Potential of Hepatitis C Cure

For a quarter century, hepatitis C was a dreaded diagnosis, linked to long, grueling treatment regimens and poor outcomes. Dramatic gains, however, have been witnessed since the approval in 2011 of the protease inhibitors boceprevir and telaprevir – the first of the “directly acting antiviral agents.”

“With the addition of boceprevir or telaprevir to interferon and ribavirin, cure rates of about 70 percent were seen after only six months of treatment,” says Ian Schreibman, M.D., of Penn State Hershey Gastroenterology and Heptology. The fast pace of successful drug development has not slowed, and now interferon-free regimens are being studied, with cure rates of more than 90 percent. “We’ve turned the tables on hepatitis C. The potential to completely eliminate it is now on the horizon, similar to what occurred with polio during the twentieth century,” says Schreibman. Continue reading

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Advances in Treating Esophageal Perforation

Decisions regarding the treatment of patients with an esophageal perforation or spontaneous rupture are usually tackled in the emergency care setting. In recent years, the viable treatment options for patients with such life-threatening problems have expanded with development of new techniques and more widespread use of collaborative care.

As an example, in a case of Boerhaave syndrome (emetogenic esophageal rupture) recently encountered at Penn State Hershey Medical Center, a middle-aged woman presented to the emergency department medical team with unrelenting, severe, upper abdominal and pleuritic lower chest pain after a long night of emesis. Contrast radiography and computed tomography revealed a distal esophageal perforation, a complex pleural effusion, and associated mediastinal air (Figure 1), prompting emergent consults to gastroenterology and thoracic surgery. Medical Center surgeons and gastroenterologists chose to deploy a removable, fully covered, self-expanding metal esophageal stent across the esophageal disruption (Figure 2). This was positioned to arrest mediastinal contamination due to leakage of esophageal contents into the pleural space and periesophageal tissues. The stent type, diameter and length are individualized to each patient; getting the right “fit” is critical to exclude the lesion and achieve stable placement.

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