Clinical Gastroenterology and Hepatology最新文献

Background & aims: The diagnosis and management of ileocolonic Crohn's disease are well-established. In contrast, standardized guidance pertaining to the diagnosis and management of upper gastrointestinal Crohn's disease (UGICD) is lacking, despite its potentially severe consequences. This comprehensive systematic review describes the prevalence, clinical presentation, and medical and surgical management of involvement of the upper GI tract in adult patients with Crohn's disease.

Methods: A systematic review of available literature was conducted using the search engines Medline, Cochrane, and Embase, with pre-defined search algorithms. Studies published from 1947 to July 2024 were considered. The review included papers describing both clinical characteristics and the effectiveness of medical and interventional procedures in patients with UGICD. All included papers underwent quality appraisal using the Joanna Briggs Institute checklist.

Results: Following screening and full-text review, 47 articles were eligible. The median prevalence of UGICD was found to be 8.7% (interquartile range, 4.74%-24.36%). Over one-third of patients with UGICD are asymptomatic, and abdominal pain was the most frequently reported symptom in symptomatic patients (41%; range, 5%-93%). Endoscopy is the most used diagnostic tool (96%), with the duodenum being the most common disease location (69%). Accepted definitions of UGICD within each diagnostic modality have not been devised. Anti-tumor necrosis factor therapy appears to be efficacious for UGICD (overall clinical response, 81%). The current data are limited by the significant heterogeneity in study design and definitions between studies, particularly inconsistency in diagnosis and outcome measures used.

Conclusions: We highlight the need for the development of standardized guidance in both diagnosing and managing UGICD. This work serves as preparation for an international consensus on the management of UGICD.

Background & aims: Terlipressin is indicated to treat hepatorenal syndrome (HRS)-acute kidney injury (AKI) but is likely used outside this primary indication in clinical practice. We aimed to investigate real-world practice patterns on the use of terlipressin in AKI in cirrhosis.

Methods: International prospective study including patients hospitalized for decompensated cirrhosis. This was a subgroup analysis of patients who received terlipressin to treat AKI. Primary outcome was AKI resolution. Secondary outcomes were respiratory failure and 28-day mortality.

Results: Among 1456 patients with AKI, 243 (17%) received terlipressin. Terlipressin was predominantly administered as a continuous infusion (75%). The AKI phenotype was HRS-AKI in 50%, acute tubular necrosis (ATN) in 17%, hypovolemic in 25%, and other in 8%. AKI resolution occurred in 49% of the patients, and was lowest in ATN (29%), followed by HRS-AKI (51%) and hypovolemic (63%). ATN was independently associated with lack of AKI resolution (odds ratio, 2.77; 95% confidence interval, 1.24-6.54; P = .02). De novo respiratory failure occurred in 20% of patients. There were no significant differences in the amount of albumin received nor acute-on-chronic liver failure grade between those who did and did not develop respiratory failure. The presence of pneumonia independently predicted respiratory failure (odds ratio, 7.80; 95% confidence interval, 2.43-26.95; P < .001). Mortality rate at 28 days was 36%; ATN and hospital-acquired AKI independently predicted 28-day mortality.

Conclusions: Terlipressin is often used for treatment of AKI outside its primary indication of HRS-AKI. Compared with patients with HRS-AKI, response to terlipressin is significantly lower in patients with ATN, in whom the risks may outweigh the benefits. Respiratory failure is common but does not seem to be driven by the amount of albumin received nor acute-on-chronic liver failure grade.

Background & aims: The multicenter, randomized, control trial was conducted to evaluate whether computer-aided diagnosis (CADx) improves the optical diagnosis of gastric neoplasia in nonexpert endoscopists.

Methods: Patients undergoing endoscopy prior to endoscopic resection (ER) of gastric neoplasia or for surveillance after ER were randomized to the CADx-assisted and non-CADx-assisted groups. Endoscopy was performed by a nonexpert endoscopist blinded to the patient information. The CADx system provides a confidence level for gastric neoplasia on a still white light image (WLI) captured during endoscopy and indicates neoplasia if the level is ≥ a 60% cutoff. The targets were lesions diagnosed as neoplasia and those diagnosed as non-neoplasia but requiring biopsy. Endoscopists performed WLI diagnoses to differentiate between neoplasia and non-neoplasia. The accuracy, sensitivity, and specificity in nonexperts have been evaluated using pathology as the gold standard.

Results: A total of 312 patients with 265 gastric neoplasias and 164 non-neoplasias were enrolled. The accuracy, sensitivity, and specificity among nonexperts were 65.3% vs 59.9% (P = .24), 68.6% vs 63.9% (P = .42), and 60.8% vs 53.3% (P = .34) in the CADx-assisted and non-CADx-assisted groups, respectively. Flat or superficially depressed small neoplasias tended to be missed by the CADx.

Conclusions: The present CADx assistance did not improve the nonexpert optical diagnosis of gastric neoplasia. Further improvements of the CADx with WLI are needed by changing the confidence level cutoff and additional training on easily missed neoplasias. Another option is CADx with magnifying narrow band imaging. (Japan Registry of Clinical Trials, number jRCTs032210171).

Background & aims: The study sought to investigate the association between socioeconomic status (SES) and risk of incident irritable bowel syndrome (IBS), and the mediating role of lifestyle factors.

Methods: Participants free of IBS at recruitment were included in this retrospective analysis of a prospectively collected cohort (N = 353,790). SES was assessed through household income, education, and employment status, with different patterns identified through latent class analysis. Healthy lifestyle score was calculated including never smoking, moderate alcohol consumption, healthy diet, regular physical activity, normal body mass index, and healthy sleep duration. The primary endpoint was incident IBS. A Cox proportional hazards model with sequential mediation analysis was used to estimate the association and mediation effect.

Results: During a median follow-up of 14.5 years, 7240 (2.1%) incident IBS cases were identified. Overall, 94,660 (26.7%), 186,317 (52.7%), and 72,813 (20.6%) participants were classified into low, medium, and high SES patterns, respectively. A high SES pattern was associated with lower IBS risk vs a low SES pattern (hazard ratio, 0.61; 95% confidence interval, 0.57-0.66), with 10.2% of effect mediated by a healthy lifestyle score. Similar findings were observed for SES scores. Regarding individual SES items, higher household income and education and employed status were linked to 8%-32% lower IBS risk, with 5.6%-20.8% of mediation proportions. Notably, individuals with high SES pattern and healthy lifestyle score of 5 or 6 had a 55% (hazard ratio, 0.45; 95% confidence interval, 0.39-0.51) reduced IBS risk vs those with a low SES pattern and healthy lifestyle score of 0-2.

Conclusions: Higher SES is associated with reduced risk of incident IBS with mediation effect of healthy lifestyle factors. Interventions targeting both SES inequalities and lifestyle improvements may help reduce IBS burden.

Background & aims: Autoimmune pancreatitis (AIP) could induce peripancreatic vascular involvement, such as portal system stenosis, through inflammatory extension, resulting in the development of collateral vessels. In severe cases, gastric varices may develop, leading to a life-threatening risk of variceal rupture. However, these complications remain underrecognized and are not explicitly addressed in the current clinical guidelines. This study aimed to evaluate the frequency of vascular involvement in AIP, assess therapeutic effects of glucocorticoids, and identify key vessels associated with gastric varices.

Methods: This multicenter retrospective study included 230 patients diagnosed with AIP at 17 institutions in Japan between 2010 and 2021. We analyzed clinical data, contrast-enhanced computed tomography images, and endoscopy findings. All images were evaluated individually by 3 professionals at a central facility. The primary outcome was the frequency of peripancreatic vascular involvement.

Results: At diagnosis, 51.3% of the patients exhibited peripancreatic vascular involvement, primarily in the splenic vein (48.3%), superior mesenteric vein (23.9%), and portal vein (9.6%). Collateral vessel formation was observed in 40.0% of patients, with 24.3% being severe; 2 gastric variceal ruptures occurred prior to therapy. Glucocorticoid therapy significantly improved venous stenosis (response rates: 95.6%, 93.8%, and 93.1% in the splenic, portal, and superior mesenteric veins, respectively). Additionally, 80.9% of patients exhibited collateral vessel improvement. Among 55 patients who underwent upper endoscopy, 10.9% had gastric varices strongly associated with severe splenic vein stenosis.

Conclusions: Peripancreatic vascular involvement represents a common complication of AIP and significantly responds to glucocorticoid therapy, underscoring the importance of careful monitoring to prevent potentially fatal outcomes.

Background & aims: We compared the efficacy of different advanced therapies by disease location in patients with Crohn's disease (CD) through a systematic review and meta-analysis.

Methods: Through a systematic review, we identified 14 randomized controlled trials in 3139 patients with moderate-to-severe CD who were treated with different advanced therapies vs placebo, and reported efficacy in inducing clinical remission, stratified by disease location (isolated colonic vs ileal disease, excluding ileocolonic disease). We grouped advanced therapies based on the primary mechanism of action: anti-interleukins, Janus kinase inhibitors (JAK inhibitors), anti-integrins, and tumor necrosis factor (TNF) antagonists. We calculated treatment efficacy (drug vs placebo), overall and by drug class, for colonic vs ileal disease.

Results: Overall treatment efficacy of advanced therapies vs placebo was higher in patients with colonic (odds ratio [OR], 4.09; 95% confidence interval [CI], 3.02-5.54) vs ileal CD (OR, 1.80; 95% CI, 1.23-2.63; P < .001). By drug class, anti-interleukins demonstrated a higher efficacy in colonic disease (OR, 4.29; 95% CI, 2.77-6.64) vs ileal disease (OR, 2.31; 95% CI, 1.44-3.70; P = .059), whereas no difference in efficacy was observed with anti-integrins (colonic vs ileal: OR, 1.79; 95% CI, 0.55-5.87 vs 2.10; 95% CI, 0.80-5.53; P = .84). For JAK inhibitors, efficacy was observed only in patients with isolated colonic disease (OR, 4.37; 95% CI, 2.67-7.15), but not in ileal disease (OR, 1.01; 95% CI, 0.54-1.89; P < .001). All analyses had minimal to moderate heterogeneity.

Conclusions: The magnitude of efficacy of advanced therapies for ileal CD is generally lower compared with isolated colonic CD, with JAK inhibitors showing particularly limited efficacy for ileal disease. These results may help inform treatment selection.