gastroendonews.com
The Independent Monthly Newspaper for Gastroenterologists
Volume 66, Number 1 • January 2015
Real-World Data Mimic Trial Findings For HCV Treatment BOSTON—Drugs often fall short of the expectations set in clinical trials, because the trials often exclude patients with various comorbidities and the sickest of the sick. This does not seem to be the case with the latest generation of medications to treat hepatitis C virus (HCV) infection, which so far are meeting the high bar they set in pre-approval trials. see Real World, page 26
‘Normal’ Stomach On Endoscopy May Be Anything But Precautionary biopsies make sense PHILADELPHIA A—Nearly 30% of stomachs that appear to be normal during endoscopy in fact may have significant gastric pathology, according to a new study, which suggests that endoscopists may want to consider taking more biopsies as a precaution. see Biopsy, page 34
Falling Through the Cracks: Mothers With Hepatitis B Receive Inadequate Treatment, Follow-up
M
ore than on ne-third of women with the hepatitis B virus (HBV) are initially diagnoosed with the infection at their first prenatal care visit, but they do not receive follow-up care for the infection after their pregnaancy, researchers have found. The retrospective stud dy examined the medical records of 243 women with HBV who receiveed prenatal care at facilities under th he umbrella of Massachusetts Gen neral Hospital (MGH). “It’s clear from the data that these women are getting lostt to followup or not getting ap ppropriate care to begin with,” saaid Ruma Rajbhandari, MD, MPH, a gastroenterology and hepatology fellow at MGH H, in Boston, who led the sttudy. “It’s a real shame. It is siimilar to getting diagnosed with HIV and not receiving any follow-up care for it.”
The researchers presented theeir findings at the 2014 Liver Meetin ng of the American Association for th he Study of Liver Diseases (AAS SLD), in Boston (abstract 1552). In 1990, the Centers for Disease Control and Prevention created the U.S. Perinatal Hep patitis B Prevention Program (P PHBPP) in an effort too reduce perinatal trransmission of the disease. Under the PHBPP, pregnant women are rroutinely screened for HBV H and their inffants are treated an nd monitored approopriately. The prograam has resulted in a sharp reduction of p perinatal infections with HBV. see Hep B, page 32
I N S I D E
Are We There Yet? Women still feel gender disparities in pediatric gastroenterology
W
hen it comes to compensation, mentoring and promotions, women in pediatric gastroenterology believe they continue to lag behind their male peers, a new survey has found. see Disparities, page 22
BEST OF ACG 2014: PART 2 EXPERTS’ PICKS More of the Best of the American College of Gastroenterology annual meeting .................... page 14
Gary Lichtenstein, MD
Peter Higgins, MD
Rajiv Chhabra, MD
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Hemorrhoids: Evaluation and Management for the Office-based Clinician ERIC FONTENOT, MD
STEPHEN W. LANDRENEAU, MD
Louisiana State University School of Medicine Department of Medicine Section of Gastroenterology New Orleans, Louisiana
Louisiana State University School of Medicine Department of Medicine Section of Gastroenterology New Orleans, Louisiana
The authors report no relevant financial conflicts of interest.
T
Hemorrhoids: Evaluation and Management for the Office-based Clinician
he medical literature on hemorrhoidal disease dates back at least as far
as Hippocrates, who described techniques that will be familiar to practitioners even today. This article will cover the epidemiology,
Internal hemorrhoidal plexus
normal anatomy and physiology, pathophysiology, and classification of
Dentate line
hemorrhoids, with a particular focus
External hemorrhoidal plexus
on the office-based physician. Epidemiology Hemorrhoids are a common problem, estimated in a large epidemiologic study to have an overall prevalence of as much as 4.4% in the United States.1 Both sexes demonstrate a peak prevalence in the age range of 45 to 65 years, with increased rates associated with higher socioeconomic status.1 However, the true prevalence of hemorrhoidal disease may be underestimated because many patients do not seek medical attention, or overestimated because some patients erroneously attribute any anorectal problem to “hemorrhoids.”2
Anatomy The anal canal (Figure 1) consists of the approximately 4 cm between the distal rectum and the anal verge. In the approximate midpoint of the canal is the dentate line, an important anatomic landmark in the
Figure 1. Normal anorectal anatomy. Courtesy of Iain Cleator MD, Vancouver, BC, Canada
evaluation and treatment of hemorrhoidal disease. The dentate line represents the junction between the embryologic endoderm and ectoderm and is the point that the mucosa of the anal canal changes from the insensitive columnar epithelium of the rectum to the highly sensitive squamous epithelium of the anoderm. Found proximally to the dentate line, the internal hemorrhoids are a specialized collection of 3 fibrovascular “cushions” arranged in a left lateral, right anterior, and right posterior configuration.3 They are composed of an arteriovenous plexus where branches of the superior, middle, and, to a lesser extent, inferior hemorrhoidal
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