European Journal of Gastroenterology & Hepatology最新文献

Background: Completing advanced endoscopic procedures such as endoscopic retrograde cholangiopancreatography (ERCP) under conscious sedation is challenging. International recommendations favor enhanced sedation (e.g. propofol) for ERCP. Conscious sedation can result in sedation-related failure (SRF) and agitation for some patients, limiting therapeutic efficacy.

Aim: The aim of this study is to establish the risk of SRF and the impact on therapeutic success under conscious sedation practice in a single tertiary referral center.

Methods: A retrospective review of a prospectively maintained ERCP database, analyzing sedation, procedural success, and complications.

Results: Over 19 months, 807 conscious sedation ERCPs were recorded. Median midazolam dose was 5 mg (range 1-14 mg) and median fentanyl dose was 75 µg (0-200 µg). Sedation reversal was required in 0.1% of cases (1/807). Overall ductal cannulation rate was 92%. Severe agitation was recorded in 11% (86/807) of conscious sedation ERCP reports with SRF present in 3% (22/807). Patient agitation resulted in significantly lower cannulation (81% vs 92%, P = 0.002) and successful clearance rates (49% vs 85%, P = 0.002) versus non-agitated cases. Complication and pancreatitis rates were unaffected. Highest rates of SRF and agitation were identified in female patients, patients aged <50 years old, and post-operative biliary leak indications.

Conclusion: Over 10% of conscious sedation ERCPs are compromised by sedation issues, resulting in procedure abandonment or significantly diminished therapeutic success. General anesthetic ERCP is beneficial in facilitating biliary access, removing the risk of agitation and providing stability to aid cannulation. Female patients, patients aged <50 years, and post-operative biliary leak ERCPs appear as the priority cases for enhanced sedation support.

Background: The main objective of our study was to assess the frequency of drug-induced liver injury (DILI) patients with coexisting secondary sclerosing cholangitis (SSC) within our center and then analyze clinical features of these patients. SSC has received limited attention in the context of DILI. These changes can be observed on magnetic resonance cholangiopancreatography (MRCP).

Methods: We conducted a single-center retrospective cohort study involving 185 consecutive patients diagnosed with DILI between January 2020 and August 2024. We reviewed MRCP images of 81 available patients.

Results: Among the 185 patients, 81 underwent MRCP and 14 patients (17.3%) were diagnosed with SSC. Nine (64.3%) of 14 were diagnosed with biliary strictures in extrahepatic bile ducts, and 11 of 14 patients (78.6%) displayed segmental distribution. The SSC group showed higher peak alkaline phosphatase (ALP) values (660 vs. 290 U/l, P  = 0.015), longer resolution time (114 vs. 61 days, P  = 0.038), and a higher frequency of chronic injury (35.7% vs. 10.4%, P  = 0.016). Multivariate logistic regression analysis identified peak ALP values as a risk factor for SSC [odds ratio = 1.002 (1.000-1.005), P  = 0.030].

Conclusion: The prevalence of drug-related SSC has noticeably increased in recent years. The higher peak ALP values potentially associated with an increased risk of drug-related SSC onset.

Antitumor necrosis factor (TNF)-alpha (TNFa) drugs are crucial for treating inflammatory bowel disease (IBD) but may increase opportunistic infection risk. Among such infections, sporotrichosis is a chronic granulomatous disease caused by saprophytic dimorphic fungi of the genus Sporothrix, which occurs worldwide. To date, there have been no reports of sporotrichosis in immunosuppressed IBD patients. The main objectives are to discuss clinical, diagnostic, and therapeutic aspects of sporotrichosis in IBD patients on anti-TNF therapy. We describe three patients with IBD on TNFa therapy who contracted cutaneous-disseminated and extracutaneous sporotrichosis and discuss strategies for managing sporotrichosis and IBD therapy in this scenario. The first case is a patient with ulcerative colitis with mild lymphocutaneous sporotrichosis who did not require discontinuation of anti-TNF agents and methotrexate. The other two patients had rapidly progressive extensive lymphocutaneous disease and disseminated sporotrichosis. These patients required hospitalization, a temporary discontinuation of their biological therapy, and a subsequent switch to vedolizumab. In all cases, the sporotrichosis was successfully treated and none of them experienced serious complications. Sporotrichosis should be considered in anti-TNF IBD patients with opportunistic infections. Early diagnosis, infection treatment, education of cat owners, and population control programs are necessary.

Background and aim: Comprehensive exercise rehabilitation has the potential to increase muscle mass and performance by stimulating protein synthesis and accelerating muscle catabolism. We developed the comprehensive exercise rehabilitation intervention (CERI) for elderly patients with cirrhosis, and we aimed to evaluate the safety and efficacy of CERI.

Methods: Eligible were elderly patients with cirrhosis and frailty. Patients were randomized 1 : 1 to 12 weeks of CERI. Physical function were assessed using the gait speed, grip strength, 5 Sit-down Tests, and Balance Test, respectively.

Results: Finally, 58 and 58 completed the study in CERI and SOC arms, respectively. The age range is 60-73. After 12 weeks, gait speed improved from 0.89 to 1.06 in CERI participants (Δgait speed 0.17) and 0.87-0.91 (Δgait speed 0.04) in SOC arm ( P  = 0.001 for Δgait speed difference). Grip strength improved from 15.44 to 15.94 in CERI participants (Δgrip strength 0.50) and 15.52-15.16 (Δgrip strength -0.36) in SOC arm ( P  = 0.044 for Δgrip strength difference). 5 Sit-down Tests Score improved from 16.17 to 15.46 in CERI participants (Δ5 Sit-down Tests 0.71) and 16.78-16.61 (Δ5 Sit-down Tests 0.17) in SOC arm ( P  = 0.037 for Δ5 Sit-down Tests difference). Median Balance Test score improved from 26.11 to 28.82 in CERI participants (ΔBalance Test 2.71) and 25.94-26.13 (ΔBalance Test 0.19) in SOC arm ( P  < 0.001 for ΔBalance Test difference); 92% of CERI participants adhered to the study for 12 weeks. No adverse events were reported by CERI participants.

Conclusion: CERI was safely administered at pilot randomized clinical trial, while all participants showed minimal improvement in gait speed, grip strength, 5 Sit-down Tests, and Balance Test. But multicenter, larger sample clinical trials are needed to track the effects of CERI.

Introduction: Due to the rising incidence of patients with cirrhosis and its accompanied extensive management, there is an increasing burden of cirrhosis patients on healthcare resources and costs. However, exact data on Dutch cirrhosis epidemiology and associated costs are lacking.

Aims and methods: We aimed to determine the year-prevalence of adults (aged ≥18 years) with cirrhosis registered as active patients in Dutch hospitals (2017-2021) using the Dutch hospital claims database. Next, we assessed average reimbursed annual healthcare costs.

Results: The prevalence of patients with cirrhosis registered as an active patient in Dutch hospitals increased by 54% from 48.7 patients per 100 000 in 2017 to 75.2 per 100 000 in 2021. There were regional differences and prevalence for cirrhosis was at highest of 105.6 patients per 100 000. The yearly incidence of patients for which hospitals requested claims was n  = 3725 in 2018, n  = 3840 in 2019 (+3%), n  = 3749 in 2020 (-2%), and n  = 3695 in 2021 (-1%). Total number of hospital admissions increased by 19% from 2443 in 2017 to 2899 in 2021. The annual reported costs for patients with cirrhosis increased by 120% from €35 million in 2017 to €78 million in 2021. Adjusted for inflation this increase was 143% to €85 million.

Conclusion: The prevalence of patients with cirrhosis registered as a patient in Dutch hospitals increased by more than 50 percent from 2017 to 2021, with regional differences. Consequently, total healthcare costs for Dutch patients with cirrhosis more than doubled in less than 5 years.

Objective: Endoscopic and histologic healing in ulcerative colitis (UC) is hypothesized to progress proximally to distally, with healing of the distal rectosigmoid occurring last. However, this has not been empirically verified.

Methods: We performed a prospective cohort study in patients with pancolonic UC commencing treatment with a tumor necrosis factor (TNF) antagonist or vedolizumab. Four biopsies were obtained from each of the five colonic segments at colonoscopy, both at baseline and 16-24 weeks after treatment initiation. Independent, blinded central reading of both endoscopic [modified Mayo Endoscopic Subscore (mMES) (score = 1 excludes any friability), UC Endoscopic Index of Severity (UCEIS)] and histologic disease activity [Robarts Histopathology Index (RHI), Nancy Histological Index (NHI), and Geboes Score] was performed for each colonic segment, and changes per segment were calculated.

Results: A total of eight patients were recruited (five TNF antagonists, three vedolizumab). There was no significant difference in the mean change between colonic segments for any of the endoscopic disease activity indices (P value based on Kruskal-Wallis test for differences between ascending, transverse, descending, sigmoid colon, and rectum: 0.328 for mMES and 0.317 for UCEIS). Similarly, there was no difference in change in histologic activity between colonic segments (P = 0.357 for RHI, P = 0.410 for NHI, P = 0.734 for Geboes score).

Conclusion: We did not observe evidence of an anatomical healing gradient in UC across different colonic segments, nor evidence of delayed distal improvement. Larger studies are required to validate whether the rectum truly does heal last in UC.

Objectives: Opioid administration in acute pancreatitis (AP) exacerbates its severity, prompting concerns regarding the increased requirement for intensive care and its potential impact on patient survival. We aimed to elucidate the influence of analgesic patterns on mortality among patients with AP hospitalized in the ICU.

Methods: We included 784 patients (198 receiving opioid monotherapy and 586 receiving opioid polytherapy) from the Medical Information Mart for Intensive Care database. The primary outcome was in-hospital mortality. Propensity score matching was used to account for baseline differences. We used Kaplan-Meier survival curves and multivariate regression models to indicate survival discrepancies and potential associations.

Results: Polytherapy group exhibited prolonged hospital survival (79.8 vs. 57.3 days, P < 0.001); polytherapy was associated with decreasing in-hospital mortality adjusted for confounders (HR = 0.49, 95% CI: 0.26-0.92; P = 0.027). Stratification analysis indicated that patients receiving adjunctive acetaminophen had prolonged hospital survival (opioid vs. opioid + acetaminophen, P < 0.001; opioid vs. opioid + NSAIDs + acetaminophen, P = 0.026). Opioid polytherapy benefited patients with APACHE III scores >83 and those with mean oral morphine equivalent >60 mg/day (HR = 0.17, 95% CI: 0.1-0.3, P < 0.001 and HR = 0.32, 95% CI: 0.2-0.52, P < 0.001, respectively).

Conclusion: Our findings suggest that an opioid-based analgesic regimen offers a survival advantage for patients with AP, particularly those in critical condition or with concerns about opioid use. This approach provides a viable clinical strategy for pain management. Further randomized clinical trials are warranted to validate these results.

Objective: The diagnosis of inflammatory bowel disease (IBD) associated with high-grade dysplasia (HGD) has a significant impact on clinical management, including colectomy. However, the prognosis of HGD remains unclear due to diagnostic uncertainty and low-quality data on subsequent synchronous and metachronous neoplasia. We aimed to evaluate a diagnostic strategy with dedicated gastrointestinal (GI) pathologist consensus of revised HGD and the impact on synchronous and metachronous neoplasia rates.

Methods: In this retrospective multicenter cohort study, we used the Dutch Nationwide Pathology Databank to identify IBD patients with HGD in seven hospitals. Histopathological specimens of the initial HGD were independently revised by two dedicated GI pathologists. Definitive diagnosis was established in a consensus meeting. Synchronous and metachronous neoplasia incidences were assessed with a competing risk analysis.

Results: We included 54 IBD patients with HGD, of whom 33 (61.1%) with ulcerative colitis and 42 (77.8%) with extensive disease. After consensus, 18 (33.3%) lesions were downgraded to indefinite/low-grade dysplasia, and 6 (11.1%) were revised to colorectal cancer (CRC). Seven patients (13.0%) had synchronous CRC. Patients with downgraded lesions showed a lower cumulative advanced neoplasia (HGD/CRC) incidence compared with confirmed HGD [(Gray's test P < 0.01), 5-year cumulative incidence 0.0% vs. 26.6%].

Conclusions: We demonstrated frequent downgrading of HGD, associated with lower metachronous neoplasia rates. This underlines the potential impact of dedicated GI pathologist consensus meetings. The high and synchronous and metachronous neoplasia rates after HGD underline the need for close surveillance.

Background: The impact of lactate-to-albumin ratio (LAR) on the outcome of acute-on-chronic liver failure (ACLF) is scant.

Aims: To investigate the relationship between LAR and short-term prognosis in patients with COSSH (Chinese Group on the Study of Severe Hepatitis B) ACLF.

Methods: A retrospective cohort study was conducted in patients with COSSH ACLF treated with an artificial liver support system. Restricted cubic splines, linear regression models, and Cox regression models were used to investigate the relationships of LAR with disease severity and 28-day prognosis.

Results: The 28-day transplant-free and overall survival rates in the 258 eligible patients were 76.4% and 82.2%, respectively. The LAR in 28-day transplant-free survivors was lower than that in transplant or death patients [0.74 (0.58-0.98) vs. 1.03 (0.79-1.35), P <  0.001]. The LAR was positively associated with disease severity, 28-day transplant-free survival [adjusted hazard ratio (HR) (95% confidence interval (CI)) for transplant or death: 2.18 (1.37-3.46), P =  0.001], and overall survival [adjusted HR (95% CI) for death: 2.14 (1.21-3.80), P =  0.009]. Compared with patients with LAR < 1.01, patients with LAR ≥ 1.01 had poor 28-day prognosis [all adjusted HR (95% CI) > 1, P  < 0.05]. Lactate was not a potential modifier of the relationship between LAR and short-term prognosis.

Conclusion: LAR was positively associated with disease severity and poor short-term prognosis in patients with COSSH ACLF.