Digestive Diseases and Sciences最新文献

Background: Appropriate prescription of Proton pump inhibitors (PPIs) remains an important concern amid the rising overuse. A gap exists in the literature regarding the benefit of PPI prophylaxis and the consequences of underprescription in patients at risk for upper gastrointestinal bleeding (UGIB).

Aims: This study aims to describe the characteristics of hemorrhage in relation to PPI use in patients experiencing UGIB, with a focus on high-risk individuals requiring gastroprotection.

Methods: Data from a French multicentric cohort of patients experiencing UGIB were analyzed. Patients using PPI were compared to those without PPI considering bleeding etiologies and outcomes of peptic ulcer disease (PUD)-related hemorrhage. The rate of PPI use and its effect on bleeding characteristics in high-risk populations, defined based on international guidelines, were also assessed.

Results: Among 2497 included patients, 31.1% were on PPI at bleeding onset. PPI users exhibited a significantly lower rate of PUD-related bleeding in comparison with those without PPI (24.7 vs 40.8%, respectively, p < 0.0001). Similar difference was observed in high-risk populations, of whom, only 40.3% had gastroprotection with PPI before bleeding onset. PPI prophylaxis, however, did not influence the severity of bleeding in the general study population or in high-risk groups. Multivariate analysis identified age, comorbidities, and having more than two anti-thrombotic agents as predictors of severe bleeding.

Conclusions: PPI users appear to have a lower rate of bleeding ulcers compared to non-users. However, underprescription in high-risk groups raises the need for standardized care to ensure appropriate PPI use.

Background: Most people maintaining a gluten-free diet (GFD) do not have celiac disease (CD). Comorbidities and associated conditions in this population are largely unknown.

Aims: This study identified demographics, dietary patterns, and diagnoses for patients prescribed a GFD during hospitalization and compared patients with CD to those without CD.

Methods: We performed a retrospective cross-sectional study for hospital admissions with a GFD between Jan 1, 2010 and June 30, 2022, while excluding patients missing demographic data (n = 113). We compared patients with and without a CD diagnosis, including multivariable logistic regression to identify characteristics independently associated with a CD diagnosis.

Results: We analyzed 1527 hospitalized patients of all ages. A minority (n = 467, 30.6%) carried a CD diagnosis. Age, sex, body mass index, and Medicare/Medicaid enrollment and additional diagnoses associated with a GFD (e.g., IBS) were not significantly different. The CD cohort was more predominantly white (66.6% vs 58.4%, p = 0.007) and non-Hispanic (62.5% vs. 52.7%, p = 0.001). While hospitalized, patients with CD had fewer additional dietary restrictions (mean 0.33 vs 0.56, p < 0.001) and more frequent micronutrient supplementation (26.6% vs 21.4%, p = 0.03). CD was independently associated with malnutrition (OR 1.86, 95% CI 1.31-2.65) and inversely associated with a vegetarian diet (OR 0.35, 95% CI 0.15-0.81), reduced lactose diet (OR 0.25, 95% CI 0.13-0.50), and Hispanic ethnicity (OR 0.56, 95% CI 0.35-0.90) while controlling for other covariates.

Discussion: Two-thirds of hospitalized patients receiving a GFD do not have a diagnosis of CD. Among GFD inpatients, CD is associated with fewer dietary restrictions and independently associated with malnutrition.

Background and aim: Esophageal duplication cysts (EDCs) are rare congenital malformations, often discovered incidentally during endoscopy or on computed tomography (CT) scans. The role of endoscopic ultrasound (EUS) and CT scan in the diagnosis of these lesions and indications for surgical treatment are underreported. The aim of this study was to investigate these topics in a cohort of patients.

Materials and methods: Between January 2001 and October 2020, 82 patients had a suspicion of esophageal duplication cyst on endoscopic ultrasound. Thirty four of these patients were referred for surgical enucleation of the lesion, but three patients were lost to follow-up. At the end, 31 patients, who underwent surgical treatment for their suspected EDC were included in this study. Clinical features, EUS findings, CT images, surgical treatment, and outcome were collected from hospital health records. CT images were re-evaluated by a chest radiologist. Type of surgery, surgical complications, and final histological diagnosis were reported.

Results and conclusion: The patients referred for surgery were younger (p = 0.0001) and had larger lesions (> 2 cm; p = 0.005) than the patients who had non-operative follow-up. From thirty-one operated patients, eighteen (58%) had post-operative histological diagnosis of duplication cyst. On EUS the final histological diagnosis was correct in 58% (18/31) of all the operated cases and on CT scan 57% (17/30). CT scan misdiagnosed three of the EDCs but found two leiomyomas correctly. None of these patients developed malignancy. According to this study, neither EUS without fine-needle biopsy nor CT scan alone can differentiate EDCs from other mediastinal masses.

Background: In cirrhosis, activation of renin-angiotensin-aldosterone system leads to sodium and water retention causing ascites. Dapagliflozin, a sodium glucose linked transporter-2 inhibitor, induces natriuresis in patients with heart failure. A similar natriuretic effect may improve ascites in patients with cirrhosis. In this pilot study, we evaluated the safety and efficacy of dapagliflozin in patients with cirrhosis and recurrent ascites.

Methods: Forty patients with recurrent ascites and cirrhosis were randomized to 1:1 in a double blinded fashion to receive either dapagliflozin (10 mg/day) with standard medical therapy (Group A) or placebo with standard medical therapy (Group B). The primary outcome was control of ascites at 6 months. Secondary outcomes were urine output, 24-h urinary sodium, Child Turcotte Pugh (CTP), model for end-stage liver disease (MELD) scores, survival at 6 months, incidence of acute kidney injury (AKI) and infections.

Results: The 2 groups were comparable at baseline. Control of ascites at 6 months was significantly better in group A than that in Group B (p = 0.04). Change in urinary sodium was significantly higher in Group A (p < 0.001]. However, there was no difference in change in urine output, CTP or MELD scores and survival (65% vs 72.2%, p = 0.75) between the groups at 6 months. Incidence of AKI (50% vs 15%, p = 0.04) and infections (55% vs 20%, p = 0.04) were significantly higher in Group A.

Conclusion: Significantly better control of ascites and higher natriuresis are observed with dapagliflozin. However, it does not improve disease severity scores or survival, and is associated with increased AKI and infections (NCT05014594).

Background: Patency capsule (PC) ingestion is commonly used to minimize capsule retention in high-risk patients with Crohn's disease (CD). However, false-positive rates remain high, precluding the use of video capsule endoscopy (VCE). We aimed to compare the efficacy of two preparation protocols in reducing failed PC rates in patients with CD.

Methods: This bi-center retrospective case-control study included adult patients with small-bowel CD in clinical remission who underwent PC ingestion. The pro-motility group followed a low-residue diet, then a clear fluid diet, and took bisacodyl after ingestion, while the control group followed only a clear fluid diet. The primary outcome was failed PC, defined as the absence of PC excretion or presence on abdominal X-ray at 30 h post-ingestion. Multivariable logistic regression was used to identify predictors of failed PC.

Results: Among 273 patients (83 in the pro-motility group, 190 controls), the pro-motility group was older (median 36 [27-48] vs. 31 [24-43], p = 0.012) and had a lower rate of B2/3 disease phenotype (32.5 vs. 53.1%, p = 0.002) compared to controls. The pro-motility group also had a lower failed PC rate (12.0 vs. 24.7%, p = 0.023). Longer disease duration (adjusted odds ratio (AOR) 1.053, 95% confidence interval (CI) 1.016-1.091, p = 0.005) increased the odds of failed PC, while the pro-motility protocol was protective (AOR 0.438, 95% CI 0.200-0.956, p = 0.038), outweighing the influence of B2/3 disease phenotype (AOR 1.743, 95% CI 0.912-3.332, p = 0.093).

Conclusions: The pro-motility preparation protocol could substantially improve the success rates of the small-bowel patency test in patients with CD undergoing PC ingestion, potentially reducing the risk of capsule retention and associated complications.

Background: In two-step population screening for colorectal cancer (CRC), a simple non-invasive test, commonly a fecal immunochemical test for hemoglobin (FIT), is first undertaken to predict, based on the fecal hemoglobin concentration (f-Hb), who is more likely to have colorectal neoplasia and needs colonoscopy.

Aim: To evaluate the importance of being able to adjust the f-Hb threshold that triggers follow-up colonoscopy (the "positivity threshold"), we evaluated the predictive value of f-Hb for colorectal neoplasia and its implications for the configuration of new non-invasive tests.

Methods: A literature review was conducted on the use of quantitative FIT to select the positivity threshold, followed by using f-Hb from a large population to model how adjusting the positivity threshold enabled achievement of the desired program outcomes in a feasible manner.

Results: The literature review and the modeling found that while the f-Hb positivity threshold is predictive for colorectal neoplasia across a wide range of f-Hb, there is a complex relationship between program outcomes and f-Hb. The threshold determines not just clinical accuracy (including true- and false-positive results for CRC and/or advanced precursor lesions), but also the colonoscopy workload. A lower f-Hb threshold is associated with a higher sensitivity for neoplasia but a lower specificity and a heavier load of follow-up colonoscopies. Consequently, the threshold determines a program's impact on population CRC mortality and incidence, but also its feasibility and cost-effectiveness within a health-care system.

Discussion: We are entering a new era of non-invasive screening tests, where multiple biomarkers found in biological samples such as blood as well as feces, are being developed and evaluated. These typically specify a non-transparent algorithm, developed with machine learning, to provide a predictive dichotomous positive/negative result with a fixed associated clinical accuracy and colonoscopy workload. This will restrict use of new tests in jurisdictions where the accuracy and workload implications do not match the desired screening program outcomes.

Conclusion: However, similar to flexible FIT positivity thresholds, it would be ideal if new tests also provide capacity for screening program providers to select the positivity threshold that delivers their desired screening outcomes in a feasible manner. How marketing, distribution and reimbursement of non-invasive tests are approved, funded and implemented varies widely across jurisdictions and must be taken into account.

Introduction: In clinical practice, tube feedings have been delayed after the percutaneous endoscopic gastrostomy (PEG) tube placement. Previous studies, including a meta-analysis in 2008, have shown that it is safe to start tube feeding ≤ 4 h of PEG tube placement. However, it is still a common practice to delay the initiation of tube feeding up to 24 h after PEG tube placement. We have performed an updated analysis of studies comparing early versus delayed tube feedings following PEG placement.

Methods: Major databases like PubMed, EMBASE, and Web of Science were searched in June 2022 for randomized controlled trial (RCT) studies reporting on comparative outcomes with early (< or = 4 h) versus delayed (> 4 h) feeding after PEG tube placement in adult patients. The primary outcomes in our study include complication rates and mortality rates within 72 h of the procedure. The outcomes were reported as pooled odds ratio (95% confidence interval (CI) (Moole et al. in Indian J Gastroenterol. 35:323-330, 2016), p value, I² values).

Results: A total of 212 individuals in the early feeding group and 215 individuals in the late feeding group were analyzed from six studies. The pooled odds ratio of total complication events between early and late feed groups was 0.86 (CI 0.51-1.45, p = 0.58). The pooled odds ratio of fever, vomiting, and local infection was 0.94 (CI 0.186-4.74, p = 0.94), 1.0 (CI 0.38-2.65, p = 0.9), and 1.25 (0.36-4.3, p = 0.72), respectively, between early and late feeding post-PEG tube placement. In conclusion, this meta-analysis confirms that early feeding ≤ 4 h after PEG placement does not increase the odds of poor outcomes or mortality, and it is a well-tolerated, safe, and effective alternative to delayed feeding. Furthermore, early feeding may decrease hospital stays and healthcare costs.