Clinical and Translational Gastroenterology最新文献

Introduction: Gastrointestinal graft-versus-host disease (GI-GVHD) is a serious complication of hematopoietic stem cell transplantation, with diagnosis reliant on results of endoscopic biopsy. Optimal endoscopic approaches based on symptoms remain unclear.

Methods: We conducted a retrospective cohort study of 75 adult hematopoietic stem cell transplantation recipients with GVHD and GI symptoms undergoing endoscopic biopsy at Montefiore Medical Center (2015-2023). We assessed correlations between presenting upper (UGI) or lower GI (LGI) symptoms and biopsy-proven GVHD. Statistical analyses included χ 2 tests, phi coefficients, and logistic regression adjusting for demographic confounders. A subgroup analysis compared the diagnostic yield of flexible sigmoidoscopy vs full colonoscopy.

Results: Biopsy positivity strongly correlated with symptom location: 89.5% of patients with UGI symptoms had positive upper GI biopsies, and 100% with LGI symptoms had positive lower GI biopsies. χ 2 tests showed significant associations between symptoms and biopsy positivity ( P < 0.001), with phi coefficients indicating strong correlations ( r = 0.79 UGI; r = 0.82 LGI). Logistic regression confirmed symptom location as an independent predictor of biopsy results. Among 37 patients undergoing full colonoscopy, rectosigmoid biopsies showed perfect correlation with a diagnosis of GVHD ( r = 1.0, P < 0.001) when compared with other anatomic colon biopsy sites, suggesting flexible sigmoidoscopy is a cost-effective alternative for LGI symptoms.

Discussion: Symptom-guided endoscopic evaluation in GI-GVHD yields high diagnostic accuracy. Flexible sigmoidoscopy with targeted biopsies should be considered for patients with LGI symptoms because it may reduce procedural burden and health care costs without compromising diagnostic yield. These findings support symptom-directed, anatomically targeted approaches to improve patient care and resource utilization.

Introduction: We aimed to map the distribution of patients with inflammatory bowel disease (IBD) and gastroenterologists throughout the United States and identify local-level and state-level variations in the availability of specialist care.

Methods: For each first 3-digit ZIP code tabulation area (ZCTA) and state in the United States, we calculated the density of patients with IBD (Crohn's disease or ulcerative colitis) per 100,000 population, gastroenterologists per 100,000 population, and gastroenterologists per 100 patients with IBD. We used 2022 claims data to identify patients with IBD, the 2022 National Provider Identifier registry for provider details, and the 2020 US Census for area-level variables.

Results: Overall, 520,020 patients with IBD and 21,611 gastroenterologists were identified. Patient density varied across states, from 58.2 (New Mexico) to 337.1 (Maine). On average, there were 4.2 (ranging from 1.4 in Kansas to 9.8 in Hawaii) gastroenterologists/100 patients with IBD. The Midwest and the Southwest Border regions had the lowest density of gastroenterologists. Across the United States, 130 3-digit ZIP code tabulation areas (ZCTA) had zero gastroenterologists/100 patients; 62% of these ZIP codes were in rural areas, and 25% had household income <150% of the poverty line. ZIP codes with ≥5 gastroenterologists/100,000 population tended to have lower poverty rates and were more urban than those with 1 to <5 gastroenterologists/100,000 population.

Discussion: Geographic disparities in the availability of gastroenterologist care exist at the state and local levels. This disparity was highlighted for patients with IBD and populations living in rural and high-poverty areas.

Introduction: Endoscopic removal of a bony foreign body is accompanied by risks, such as perforation. The use of a transparent cap attached to the tip of the endoscope has become an increasingly recommended technique for removing esophageal foreign bodies. However, its effectiveness specifically for bony foreign bodies remains uncertain, as does the optimal timing for cap application. This study aimed to investigate the effectiveness and the optimal timing of a transparent cap.

Methods: From January 1, 2010-May 30, 2025, patients with reported bony esophageal foreign body for endoscopic removal were retrospectively analyzed. The primary outcome was the technical failure rate of endoscopic removal of a bony foreign body.

Results: A total of 595 patients with bony esophageal foreign bodies underwent endoscopic removal during the study period: 216 underwent the transparent cap-assisted method and 379 underwent the conventional method. Among these foreign bodies, fish bones accounted for the majority (91.4%). The endoscopic failure rate of bony foreign body removal was lower in the cap-assisted group than in the conventional group (3.2% vs 7.9%, P = 0.022). Subgroup analysis demonstrated the incidence of esophageal erosions and ulcerations was higher in patients who underwent endoscopy withdrawal for capping than in those who received capping before the examination (58.5% vs 32.8%, P < 0.001).

Discussion: The use of a transparent cap is an effective method to reduce the technical failure rate for endoscopic removal of an esophageal bony foreign body. Applying the transparent cap before the start of the endoscopic examination reduced the complication rates.

Introduction: Evidence on the comparative real-world effectiveness of terlipressin vs midodrine plus octreotide (MO) for hepatorenal syndrome-acute kidney injury (HRS-AKI) in the United Kingdom and the United States is limited.

Methods: Using individual-level chart review data for patients across the United Kingdom (2013-2017) and the United States (2016-2019), an indirect treatment comparison was conducted comparing the efficacy of terlipressin (UK cohort) with MO (US cohort). Covariate balancing propensity scoring matched the cohorts on baseline serum creatinine (SCr), presence of encephalopathy and/or ascites, albumin use and duration, age, and sex. The primary endpoint was HRS reversal, defined as achieving SCr ≤1.5 mg/dL by the last day of treatment.

Results: At treatment initiation, 90.2% of UK patients received terlipressin (194/215), while 89.2% of US patients received MO (140/157). Concomitant albumin was administered in 67.9% of UK and 98.7% of US patients. In a covariate balancing propensity score-adjusted cohort, HRS reversal was achieved in 53.2% of terlipressin-treated patients (the United Kingdom, weighted effective sample size of 75) compared with 16.9% of MO-treated patients (the United States, n = 89) (adjusted mean difference (95% CI) 36.3% (22.4, 50.2), P < 0.0001). In adjusted analysis, individuals treated with terlipressin experienced an overall reduction in SCr at completion of treatment (SCr decrease 1.00 mg/dL vs increase of 0.08 mg/dL for MO-treated patients, P < 0.0001).

Discussion: HRS-AKI treatment and outcomes differ between the United Kingdom and the United States, attributed to the historical standard of care MO in the United States. In adjusted analyses, real-world use of terlipressin was more effective than MO at improving kidney function and achieving HRS-AKI reversal.

Introduction: The liver clock of hepatocytes is actively involved in regulating their proliferation, metabolism, oxidative stress response, and chronic liver disease (CLD) progression. However, the relationship between circadian rhythms and CLD remains poorly understood. This study aimed to examine the associations of circadian rhythms with metabolic dysfunction-associated steatotic liver disease, cirrhosis, and hepatocellular carcinoma.

Methods: This study included 94,006 participants from the UK Biobank. Circadian rhythms were assessed by a 7-day accelerometer by relative amplitude (RA), which indicates the difference between the most and least active periods. Cox regression and restricted cubic splines were used to evaluate the associations between circadian rhythms and CLD. Liver fat content and hepatic inflammation were additionally assessed using magnetic resonance imaging-measured proton density fat fraction and corrected T1 scores.

Results: During the follow-up of 9.8 years, individuals in the lowest quartile of RA had higher hazard ratios of 1.54 (95% CI: 1.32-1.78) for metabolic dysfunction-associated steatotic liver disease, 1.79 (95% CI: 1.38-2.32) for cirrhosis, and 1.65 (95% CI: 1.02-2.76) for hepatocellular carcinoma than those in the highest third quartile did. A dose‒response relationship between RA and CLD was observed ( P < 0.001). Furthermore, there was a joint and independent relationship between polygenic risk scores, RA, and the CLD. RA was negatively correlated with proton density fat fraction and corrected T1 scores, demonstrating a dose‒response pattern ( P < 0.001).

Discussion: Abnormal circadian rhythm is significantly associated with the risk of CLD, potentially due to increased liver fat content and hepatic inflammation. Therefore, disrupted circadian rhythms may be a risk factor for liver disease and represent a potential target for intervention.

Introduction: Biliary strictures present diagnostic challenges, necessitating early differentiation between benign and malignant cases. This study evaluates the diagnostic value of biliary and serum carcinoembryonic antigen (SCEA, BCEA) and carbohydrate antigen 19-9 (BCA19-9, SCA19-9) to enhance diagnostic accuracy.

Methods: A single-center retrospective cohort study enrolled 268 endoscopic retrograde cholangiopancreatography-treated patients, divided into training (n = 160) and validation (n = 108) sets. Levels of SCEA/SCA19-9 and BCEA/BCA19-9 were measured, and a combined diagnostic model was developed using receiver operating characteristic analysis and logistic regression. A meta-analysis of 7 studies assessed pooled odds ratios and heterogeneity in marker detection.

Results: BCEA and BCA19-9 levels significantly exceeded serum levels, with the combined model achieving an area under the curve of 0.921 (training) and 0.911 (validation), sensitivity 85.0%-83.3%, and specificity 83.7%-87.0%. Meta-analysis demonstrated a pooled odds ratio of 25.65, sensitivity of 95.0%, and specificity of 83.7%. CA19-9 cutoff variations had an insignificant impact, and the model improved pre-endoscopic retrograde cholangiopancreatography diagnostic accuracy by 20.7%.

Discussion: BCEA and BCA19-9 exhibit superior expression levels and diagnostic efficacy in distinguishing benign and malignant biliary strictures. The multimarker model enhances diagnostic performance, suggesting the relevance of integrating serum and biliary markers for accurate differentiation. Future studies should focus on optimizing cutoff values for enhanced diagnostic precision.

Introduction: Sound speed correction endoscopic ultrasound (SSC-EUS) is a novel imaging technique with limited previous validation. The aim of this study was to evaluate the diagnostic efficacy of SSC-EUS for solid pancreatic lesions (SPL) and compare it with B-mode endoscopic ultrasound (B-EUS), elastography endoscopic ultrasound (EG-EUS), and contrast-enhanced endoscopic ultrasound (CE-EUS).

Methods: A prospective, single-blind, randomized trial included 240 patients with computed tomography/magnetic resonance imaging-confirmed SPL (solid portion >80% of lesion volume). Participants were equally divided into 4 groups (B-EUS, EG-EUS, CE-EUS, and SSC-EUS). Diagnostic thresholds were determined through receiver operating characteristic curves. Subgroup analyses assessed the impact of lesion location (head/body/tail), tumor size (≤3 vs >3 cm), and cancer stage (I/II vs III/IV). Statistical analysis used SPSS 23.0 and GraphPad Prism 8.

Results: Among 240 patients, 138 (57.5%) had malignant lesions. SSC-EUS achieved optimal diagnostic performance at a cutoff sound speed of 1,563 m/s (area under the receiver operating characteristic curve = 0.822, sensitivity = 82.8%, specificity = 78.9%, accuracy = 81.7%). CE-EUS demonstrated the highest overall efficacy (sensitivity = 90.3%, specificity = 82.8%, accuracy = 86.7%), followed by SSC-EUS and EG-EUS, both outperforming B-EUS (accuracy = 70.0%). Subgroup analysis revealed superior sensitivity for pancreatic body lesions (SSC-EUS: 87.5%; CE-EUS: 90.0%), tumors >3 cm (SSC-EUS: 84.2%; CE-EUS: 90.0%), and stage III/IV cancers (SSC-EUS: 81.8%; CE-EUS: 90.9%). EG-EUS strain ratio (cutoff = 4.44) showed limited accuracy (61.7%), whereas elastic strain value A (cutoff = 0.065%) exhibited moderate utility (accuracy = 75.0%).

Discussion: CE-EUS remains the most effective imaging modality for SPL diagnosis. SSC-EUS demonstrates comparable accuracy with EG-EUS and is particularly advantageous for larger tumors (>3 cm) and advanced-stage malignancies. EG-EUS strain ratio lacks clinical robustness, whereas elastic strain value A warrants further validation. Tailoring imaging method selection to lesion characteristics (location, size, and stage) may optimize diagnostic outcomes.

Introduction: Few studies have examined outcomes of laparoscopic cholecystectomy for acute cholecystitis in patients with heart failure (HF). This study was to assess the impact of HF on cholecystectomy outcomes.

Methods: Data from the United States Nationwide Inpatient Sample (NIS) from 2016 to 2020 were examined. Adults 20 years and older diagnosed with acute cholecystitis who underwent laparoscopic cholecystectomy were included. Patients were categorized into groups with and without pre-existing HF.

Results: Outcomes assessed included inhospital mortality, nonroutine discharge, length of hospital stay, total hospital cost, and complications. Propensity score matching at a 1:1 ratio was conducted to balance between-group characteristics. Associations between HF and the outcomes were determined using univariate and multivariable regression analyses. After propensity score matching, 11,646 patients were included in the analysis: 5,823 with HF and 5,823 without. Patients with HF had significantly elevated risks of inhospital mortality (adjusted odds ratio [aOR] = 2.14, 95% confidence interval [CI]: 1.44-3.17), nonroutine discharge (aOR = 1.80, 95% CI: 1.61-2.01), and complications (aOR = 1.51, 95% CI: 1.40-1.63). Patients with HF also had longer length of hospital stay (1.52 days, 95% CI: 1.45-1.60) and higher total hospital costs (16.64 thousand USD, 95% CI: 15.58-17.70). The outcomes of patients with HF were seen in those with HF reduced ejection fraction and HF with preserved ejection fraction.

Discussion: Patients with HF, either HF reduced ejection fraction or HF with preserved ejection fraction, have increased risk of adverse inpatient outcomes after laparoscopic cholecystectomy for acute cholecystitis. This emphasizes the importance of tailored perioperative care to optimize patient outcomes.

Introduction: Despite the growing recognition of autoimmune hepatitis (AIH)-metabolic dysfunction-associated steatotic liver disease (MASLD) overlap, studies today are limited by small sample sizes. The aim of this study was to investigate the impact of MASLD on the outcomes of patients with AIH using large-scale real world data.

Methods: This cohort study used the TriNetX research network to identify US adults (≥18 years) with AIH. Patients were stratified into those with MASLD (AIH-MASLD cohort) and controls (AIH without MASLD). Propensity score matching (1:1) between AIH-MASLD and controls accounted for demographics, comorbidities, and treatments. Outcomes were classified as short-term (within 1 year after diagnosis) or long-term (within 10 years) outcomes.

Results: Among 4,798 records with AIH, 1,440 AIH-MASLD patients were propensity matched with 1,440 controls. AIH-MASLD patients demonstrated reduced 1-year risks of all-cause mortality (hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.44-0.98) and immunosuppressive medication use (HR 0.69, 95% CI 0.63-0.76), along with increased 10-year risks of cirrhosis (HR 1.22, 95% CI 1.06-1.40) and hepatocellular carcinoma (HR 2.03, 95% CI 1.09-3.78) compared with controls.

Discussion: In summary, our study using real-world evidence showed a significant association between MASLD and worse clinical outcomes in patients with AIH. Future efforts should be targeted toward facilitating early detection and management of MASLD in patients with AIH.

Introduction: Glucagon-like peptide-1 receptor agonists (GLP-1RA) are increasingly used for managing diabetes and obesity. Although they improve glycemic control, they also delay gastrointestinal motility, potentially leading to inadequate bowel preparation for colonoscopy, which can increase the risk of missed lesions. This study aimed to evaluate the impact of GLP-1RA use on the quality of bowel preparation and on adenomas and sessile serrated polyp (SSP) detection.

Methods: We conducted a retrospective cohort study of outpatient screening and surveillance colonoscopies at a tertiary academic medical center. Adults who used a GLP-1RA within 1 week of their colonoscopy formed the treatment group; patients not on GLP-1RA (nonusers) who never used GLP-1RA served as controls. Propensity score weighting was applied for age, sex, BMI, race, diabetes status, and relevant medications. The subgroup analysis was stratified based on diabetes status and GLP-1RA use.

Results: Among 49,987 patients (4,269 GLP-1RA users, 45,718 nonusers), GLP-1RA use was associated with increased odds of inadequate bowel preparation (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.04-1.46). No significant difference in SSP and adenoma detection was observed. In subgroup analysis, GLP-1RA users with diabetes had the highest odds of inadequate preparation (OR 1.88, 95% CI 1.59-2.24) and the lowest odds of SSP detection (OR 0.71, 95% CI 0.57-0.89).

Discussion: GLP-1RA use, particularly among patients with diabetes, is associated with higher odds of inadequate bowel preparation and lower SSP detection, whereas adenoma detection was unaffected. Tailored bowel-prep protocols for GLP-1RA users with diabetes should be evaluated prospectively.