Indian Journal of Gastroenterology最新文献

Sudden and rapid deterioration of hepatic function leading to jaundice, coagulopathy and encephalopathy defines acute liver failure (ALF). Timing of jaundice to encephalopathy classifies ALF into hyperacute, acute and sub-acute liver failure and prognosticates outcome. There exists a significant geographical heterogeneity in the etiology of ALF; paracetamol toxicity is the most common cause in the west, whereas viral hepatitis predominates Asian countries. Hepatitis A is the leading cause for ALF in India. ALF due to yellow phosphorus poisoning is observed commonly in southern India. Clinical outcomes of ALF have improved significantly over the last theee decades and attributed improvement in critical care services, better understanding of the disease and timely initiation of appropriate organ support. Thus, a majority of patients with ALF recover with medical management, in particular hyperacute liver failure. However, patients with seronegative hepatitis, non-paracetamol drug toxicity and sub-acute liver failure are more likely to require liver transplantation (LT). Patients with ALF should be managed in a higher centre with transplant set-up. Emergency LT is a life-saving procedure in ALF, but selection of patients for LT may be a challenge. Various prognostic models have been evaluated to identify those with increased chance of death in the absence of LT. King's College criteria is an extensively studied prognostic model, time tested and used widely across several centres, but has a lower sensitivity missing out on some patients who may benefit from LT. ALF-Early Dynamic (ALFED) being a dynamic model may have better predictability but needs more validation. Timely availability of cadaver organ in ALF patients waitlisted for 'supra-urgent' LT may be an issue. Lower organ donation rates in India and other Asian countries have innovated living donor liver transplantation. Auxiliary partial orthotopic liver transplantation (APOLT) is an exclusive surgical technique in selected patients with ALF allowing regeneration of native liver eliminating the need for long-term immunosuppression. One and five-year survival following LT in ALF patients is around 80% and 70%, respectively, and has significantly improved compared to previous era.

Anemia is a frequent complication in inflammatory bowel disease (IBD) patients. The etiology is multifactorial, with iron deficiency and anemia of chronic disease being the main reasons. Other causes include vitamin B₁₂ and folate deficiency, hemolytic anemia and medications such as azathioprine and sulfasalazine. Apart from physical symptoms, it is associated with several negative outcomes, including poor quality of life, increased risk of hospital admission, increased risk of surgery and higher treatment costs. Diagnostic evaluation aims to identify the underlying cause and severity to determine the appropriate therapeutic strategy. Investigations include a complete blood count, iron indices, inflammatory markers and vitamin B₁₂ and folate levels. Patients with iron deficiency need adequate replacement therapy to improve hemoglobin and replenish iron stores. Those with moderate to severe anemia and/or active disease need intravenous iron, while mild anemia can be treated with oral iron. Multiple parenteral iron formulations are available which differ in dose and frequency of administration. Traditional oral iron supplements are available in ferrous forms, which, although effective, are associated with gastrointestinal side effects. Newer oral iron formulations have helped reduce these adverse effects but are expensive. Anemia of chronic disease is mainly driven by the effects of inflammatory mediators on iron metabolism and erythropoiesis and treatment requires control of disease activity. Relapse of anemia after therapy is frequent; hence, patients need to be closely followed up for early detection and appropriate management. Significant advances have been made in understanding the pathophysiology of anemia in IBD and better and safer iron formulations are available. However, a significant proportion of IBD patients with anemia go undetected or untreated and there is a need for improved recognition and better management practices. This review discusses various aspects of anemia in IBD and the current approach to diagnosis and management.

Colorectal cancer (CRC) is a common malignancy and cause for death around the world. In India, it ranks as the fourth most incident cancer in both sexes, with 64,863 cases and 38,367 deaths in 2022. With such high mortality, CRC survival in India is way lesser than that of developed countries. While western countries are facing an overall decline in CRC incidence, various regions in India are seeing an increasing trend. Within India, urban regions have markedly higher incidence than rural. Risk factors include consumption of red and processed meat, fried and sugary food, smoking and alcohol, comorbidities such as obesity, diabetes and inflammatory bowel disease (IBD), family history of CRC, adenomas and genetic syndromes, radiation exposure, pesticides and asbestos. Consumption of nutrient-rich well-balanced diets abundant in vegetables, dairy products, whole grains, nuts and legumes combined with physical activity are protective against CRC. Besides these, metformin, aspirin and micronutrient supplements were inversely associated with the development of CRC. Since a considerable proportion of CRC burden is attributed to modifiable risk factors, execution of population level preventive strategies is essential to limit the growing burden of CRC. Identifying the necessity, in this review, we explore opportunities for primary prevention and for identifying high-risk populations of CRC to control its burden in the near future.

Background: This systematic review and meta-analysis evaluated the incidence of serious adverse events (SAEs) in patients with Crohn's disease (CD) and ulcerative colitis (UC) treated with upadacitinib and examined secondary adverse events.

Methods: A comprehensive search of PubMed, Embase and Cochrane Library was conducted to identify randomized controlled trials (RCTs) comparing upadacitinib with placebo in adults with inflammatory bowel disease (IBD). The primary outcome was the incidence of SAEs, while secondary outcomes included specific adverse events. Risk ratios (RR) with 95% confidence intervals (CI) were calculated.

Results: Six RCTs, including 2611 patients, were analyzed. The incidence of SAEs did not significantly differ between upadacitinib (6.1%) and placebo (7%) (RR = 0.77; 95% CI: 0.50-1.20; p = 0.25). Secondary outcomes showed no significant differences in serious infections, hepatic disorders, nasopharyngitis or herpes zoster. However, neutropenia (RR = 5.63; 95% CI: 1.90-16.65; p = 0.0002) and creatine kinase elevation (RR = 2.34; 95% CI: 1.22-4.47; p = 0.01) were higher with upadacitinib, while anemia (RR = 0.36; 95% CI: 0.27-0.48; p < 0.00001) and arthralgia (RR = 0.47; 95% CI: 0.30-0.75; p = 0.001) were reduced.

Conclusion: Upadacitinib did not increase the overall risk of SAEs in IBD patients, with a notable reduction in anemia and arthralgia. However, the higher risks of neutropenia and CK elevation underscore the importance of monitoring. Further research is necessary to assess long-term safety, particularly regarding rare but serious events such as thromboembolism.

Background and objective: The epidemiological connections, predisposing factors and clinical outcomes of infections by drug-resistant bacteria in cirrhosis are poorly documented. Thus, this study was conducted to assess the risk factors, complications and patterns of bacterial resistance among these patients.

Methods: This retrospective observational study was conducted from March 1, 2021, to July 31, 2023, at a tertiary care centre in Uttar Pradesh. Patients of cirrhosis aged ≥ 18 years with microbial infection were included in the study. Samples, as indicated, were sent to the microbiology lab for culture and sensitivity. The patient's clinical history, details regarding bacterial culture and antibiotic sensitivity results were extracted from the hospital information system (HIS) and entered into an excel sheet. Univariate analysis of the variables was done and the statistical significance of these variables was determined using the p-value. A p-value of < 0.05 was considered significant.

Results: During the study period, 765 patients were diagnosed with cirrhosis, of which 248 (32%) had a positive bacterial culture report. Among them, 206 (83.1%) patients recovered and were discharged in stable condition. Among the cirrhotic patients, the most common infection was spontaneous bacterial peritonitis (49.5%), followed by bacteremia (39.1%), lower respiratory tract infections (6.4%), urinary tract infections (2.9%) and skin and soft tissue infections (2%). Escherichia coli (28%) was the most common gram-negative bacteria. Multidrug-resistant organism infections were seen in 134 (54%) patients. Multidrug-resistant (MDR) infection (31.4%) and extensively drug-resistant (XDR) infection (22.6%) were significantly associated with poor outcomes among these patients. Carbapenem-resistant organisms (22.6%) were the predominant resistant patterns seen among the gram-negative isolates in cirrhosis patients. The mortality rate among these cirrhotic patients with bacterial infection was 16.9%.

Conclusions: MDR and XDR bacterial infections in cirrhotic patients are an emerging threat that has a detrimental effect on prognosis. Thus, it is critical to assess strategies to prevent the development of antibiotic resistance in cirrhosis.

Background: Celiac disease (CD) is an autoimmune disorder affecting genetically predisposed individuals, causing abnormal immune responses against gluten-containing grains. Celiac disease patients are at risk for health-related problems that affect their nutrition status, mental health and eating behavior. The focus of this study was on mental health aspects, including anxiety, stress and depression as well as eating behaviors among celiac disease patients in Palestine.

Methods: This case-control study compared eating behaviors and psychological status among 226 celiac disease patients and healthy controls. Data was collected using an online questionnaire administrated via Google forms. We used the Eating Behaviors Reference for Adults to assess eating behaviors and the Depression Anxiety and Stress Scale (DASS 21) to assess psychological status. We measured nutritional status using variables such as body mass index (BMI), unintentional weight loss and eating that had stopped or nearly stopped for more than five days.

Results: The study indicated that the case group had a higher mean psychological level as compared to the control group; the mean depression score for the case was 12.94 ± 5.30 for the control (11.35 ± 3.95), p < 0.05. Anxiety levels were higher in the case group (13.72 ± 5.38) compared to the control group (12.25 ± 4.09) (p < 0.05). The case had a higher stress level (15.83 ± 5.58) than the control group (14.23 ± 4.24) (p < 0.05). Results highlighted that mental health association with eating behaviors was found to be significant in the case group, as depression, anxiety and stress were significantly associated with satisfaction responses (r = -.319) (p value ≤ 0.01), (r = .439) (p value ≤ 0.05) and (r = .381) (p value ≤ 0.01) but not in hunger, emotional eating or picky eating. Additionally, with stress was found to be more significant in slow eating (r = .186) (p value ≤ 0.05).

Conclusion: Celiac disease impacts mental health, including depression, stress and anxiety. It also affects eating behaviors such as slow eating, enjoyment and satiety responsiveness. In celiac disease patients, mental health influences eating behaviors such as slow eating and satiety responses.

Selective biliary cannulation is the prerequisite for successful biliary interventions. In the setting of cannulation failure, various rescue cannulation techniques are used for achieving selective biliary access. The various rescue cannulation techniques are (1) free-hand techniques (precut papillotomy and fistulotomy); (2) wire-guided techniques (transpancreatic sphincterotomy [TPS] and double guidewire [DGW]) and (3) endoscopic ultrasound (EUS)-guided technique (EUS-guided rendezvous for biliary access). The morphology of the papilla is the best guide to select the rescue technique. For classic and pendulous down facing papilla, pre-cut fistulotomy is preferable while for irregular ridged type, pre-cut papillotomy is suitable, while for small flat type, a very cautious pre-cut papillotomy may be utilized only by experts in pre-cut techniques. When an inadvertent pancreatic duct cannulation occurs, TPS is the preferred technique for all except small flat type of papilla where DGW is preferable to avoid perforation. We review the literature comparing these techniques to assess their efficacy and safety. Finally, we provide an algorithm that can be used to select the best rescue technique.

Background and objectives: Psychological stress is widely recognized as a key factor that can initiate or aggravate symptoms in patients with inflammatory bowel disease (IBD). This research was aimed at examining the influence of stressors, coping mechanisms and psychological symptoms on disease activity in patients with Crohn's disease (CD) and ulcerative colitis (UC).

Methods: A retrospective case-control research was performed with 138 patients diagnosed with IBD (76 with CD and 62 with UC). The participants were categorized into case groups (active disease: 31 CD, 38 UC) and control groups (inactive disease: 31 CD, 38 UC), with matching on demographic and clinical characteristics. Each participant completed several assessments such as the Simple Clinical Colitis Activity Index (SCCAI), the Harvey-Bradshaw index (HBI), the Life Distress Inventory (LDI), the Symptom Checklist (SCL-25) and the Coping Inventory for Stressful Situations (CISS-21).

Results: Participants experiencing active disease reported higher levels of life stress, with mean scores of 65.42 ± 8.88 in CD and 65.42 ± 8.88 in UC, in comparison with 45.97 ± 13.23 and 41.79 ± 13.49, respectively, in those with inactive disease. Additionally, psychological symptoms were more prevalent in both CD group (57.00 ± 12.71 vs. 47.39 ± 14.65) and the UC group (57.80 ± 9.82 vs. 40.05 ± 11.23) with active disease. Patients with active disease were more likely to employ coping strategies centered on avoidance, emotional responses and tasks than those without disease activity. Logistic regression analysis identified life stress (p < 0.001, 95% CI = [1.06-1.18], B = 1.24) and emotion-focused coping strategies (p < 0.001, 95% CI = [1.26-1.88], B = 1.54) as notable predictors of disease activity, whereas task-focused coping emerged as a protective factor (p < 0.029, 95% CI = [1.68-1.98], B = 1.81).

Conclusion: This research underscores the critical role of managing stress and adopting effective coping mechanisms in reducing the likelihood of disease flare-ups in IBD subjects. Healthcare providers should prioritize integrating these approaches into treatment protocols for IBD management.