Indian Journal of Gastroenterology最新文献

Background: Therapeutic plasma exchange (TPE) has emerged as a promising treatment option for pediatric liver failure (PLF) either as a standalone therapy or as a bridge to liver transplant; however, its precise impact on survival outcomes has not been investigated systematically to date. This meta-analysis aims to evaluate the effect of TPE on survival of pediatric patients with liver failure.  METHODS: PubMed, Scopus and Embase databases were searched to include all studies till August 2024 reporting the effect of TPE on survival of acute and acute-on-chronic liver failure patients of age < 18 years. Primary outcome measures were overall survival (OS) and transplant-free survival (TFS) at Day ≥ 28 in pediatric acute liver failure (PALF) and pediatric acute-on-chronic liver failure (pACLF) patients undergoing TPE. The secondary outcome measure was to determine changes in biochemical parameters (international nrmalized ratio [INR], bilirubin and ammonia) pre and post-TPE in them.

Results: Twelve studies (8 = exclusive PALF cohorts and 4 = combined PALF + pACLF cohorts) comprising 310 patients (273 = PALF and 37 = pACLF) who received TPE were included. Pooled OS at Day ≥ 28 for PLF after TPE is 61% (95% CI: 55-66%, p = 0.03, I² = 49%). The estimated pooled TFS in them was 35% (95% CI: 29-41%, p = < 0.01, I² = 84%). On sub-group analysis, the standard-volume TPE group had both higher OS and TFS in comparison to the high-volume sub-group. There was a significant improvement in all three biochemical parameters post-TPE compared to pre-TPE values. None of the included studies reported any TPE-related mortality or potentially fatal side effects.

Conclusion: TPE shows the potential to improve overall survival in pediatric liver failure, mostly acting as a bridge to liver transplant or native liver recovery. Further, well-designed, adequately powered, randomized-controlled trials are needed to confirm TPE's survival benefit in PLF.

Introduction: Gastrointestinal (GI) bleeding is a common and potentially life-threatening medical emergency. Despite advancements in therapy, mortality rates associated with GI bleeding remain high (2.4% to 11%). Tranexamic acid (TXA) has been proposed as a treatment. However, the HALT-IT trial questioned its efficacy and safety, showing no significant reduction in death and potential thrombotic complications. This meta-analysis aims to evaluate the effectiveness and safety of TXA in treating acute GI bleeding.

Methods: This systematic review and meta-analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. In October 2024 a comprehensive literature search was conducted using relevant MeSh terms and keywords in 11 databases. We included patients with acute GI bleeding treated with TXA and compared it with either a placebo or standard treatment. Outcomes such as mortality, need for blood transfusion, surgery and thrombotic events were studied.

Results: The search identified 6810 articles. After screening, 23 studies were included, encompassing 2,061,231 participants. Our meta-analysis demonstrated that TXA significantly reduced rebleeding rates overall (RR: 0.81, 95% CI: 0.87-0.97). This effect was even more pronounced in studies with a lower risk of bias. Additionally, TXA use was associated with a mortality reduction when administered through both oral and intravenous routes (RR: 0.56, 95% CI: 0.35-0.89) and in cases of upper GI bleeding (RR: 0.72, 95% CI: 0.59-0.87). However, TXA was linked to a significant increase in mortality in patients with lower GI bleeding (RR: 1.67, 95% CI: 1.44-1.93) and overall reduction when only randomized controlled trials (RCTs) were included (RR:0.83, 95% CI; 0.70 to 0,97, I2=0%). Other variables, such as the overall need for blood transfusions (RR: 1.03, 95% CI: 0.80-1.32), thrombotic events (RR: 1.30, 95% CI: 0.75-2.23) and the need for surgical intervention (RR: 0.78, 95% CI: 0.57-1.09), did not reach statistical significance. However, when considering only low risk of bias studies the need for surgical interventions was significantly reduced (RR: 0.85, 95% CI: 0.75 to 0.97, I2=0%).

Conclusions: Our findings suggest that TXA significantly reduces rebleeding in patients, particularly in upper gastrointestinal bleeding (UGIB) and reduces need for surgical intervention when excluding high risk of bias studies. The findings also demonstrated a significant reduction in mortality, particularly in certain sub-groups. There was no definitive evidence that its use is associated with thromboembolictic events. These results highlight the potential benefit of TXA without dismissing the need for cautious interpretation and individualized patient management when considering TXA for GI bleeding.

Background and objectives: The ageing population is increasing in India and there is hardly any information on outcomes of acute pancreatitis (AP) in the elderly in India. Hence we studied the comprehensive clinical characteristics and outcomes of AP in elderly patients.

Methods: This study included patients admitted with AP to a tertiary care centre from October 2018 to October 2022. Patients with the first episode of AP presenting within 14 days of disease onset were eligible for inclusion. The elderly population was defined as age ≥ 60 years. Recurrent AP, chronic pancreatitis and AP presenting after 14 days of disease onset were excluded. Propensity score matching was performed based on etiology and severity to compare elderly and non-elderly groups. Primary outcome was serious adverse outcome (SAO: in-hospital mortality or discharge in critical state). Secondary outcomes included organ failures, local complications, necrosis, mesenteric vascular thrombosis (MVT), length of hospital stay, intensive care unit (ICU) admission and infections.

Results: Of 630 eligible patients, 120 were > 60 years of age. Among the elderly, 72 (60%) were males. The median age was 68 (IQR 63-74) years. The most common etiology was biliary 76 (63.3%) followed by idiopathic 25 (20.8%) and alcohol eight (6.7%). Mild AP was seen in 72 (60%), while 21 (17.5%) had moderately severe and 27 (22.5%) had severe AP. Organ failures occurred in 27.5%, necrotizing pancreatitis in 15.2%, local complications in 27.6% and MVT in 3.3%. Infections affected 28.3%. Median hospital stay was four days (IQR 1-28), with 12.5% requiring ICU admission. SAO occurred in 8.3% of elderly patients, comparable to 11.4% in the non-elderly (p = 0.334). Bedside index for severity in acute pancreatitis (BISAP) score (adjusted OR 2.7, 95% CI 1.05-6.96, p = 0.04) and Charlson comorbidity index (without age) (adjusted OR 1.94, 95% CI 1.07-3.51, p = 0.03) independently predicted SAO in the elderly.

Conclusion: The outcomes of AP in the elderly in India are similar to patients < 60 years. Charlson comorbidity index and BISAP score predicted serious adverse outcomes in the elderly.

Background: Elobixibat is a locally acting ileal bile acid transporter (IBAT) inhibitor that relieves functional constipation in patients by accelerating colonic transit. In this study, we aimed at determining the efficacy and safety of elobixibat for short-term treatment (two weeks) of chronic constipation in Indian patients.

Methods: The present study was a randomized, double-blind, parallel-group, placebo-controlled, phase III study to evaluate efficacy and safety of elobixibat. The study planned to enroll patients with chronic constipation of at least six months' duration, satisfying Rome IV criteria for functional constipation. Following a run-in of approximately 14 days to confirm eligibility and determine baseline frequency of spontaneous bowel movements (SBMs), eligible patients were randomized 1:1 either to elobixibat or to placebo groups. The change in weekly frequency of spontaneous bowel movements (SBMs) at the end of treatment (week two) over baseline was the primary efficacy endpoint in this trial. Primary efficacy analyses were based on the modified intention-to-treat (mITT) population. This trial is registered at CTRI (Clinical Trial Registry of India).

Results: Between April 2023 and December 2023, 150 patients were randomized into the two-week trial. In mITT population (n = 146 [elobixibat = 75 and placebo = 71]), the least square mean (LSM) difference between elobixibat (3.83) and placebo (2.68) was 1.15 (95% CI, 0.31, 1.99) demonstrating a statistically significant improvement (p = 0.008) in weekly frequency of SBMs (week two over baseline) with the use of elobixibat. The proportions of patients with a complete spontaneous bowel movement (CSBM) "response" was significantly higher with elobixibat (49.33%) compared to the placebo (26.76%) treatment (difference 22.57% [95% CI, 8.36%, 36.78%] [p = 0.005]). The most common adverse event (AE) was abdominal pain (elobixibat = 6 patients [7.89%] vs. placebo = 3 patients [4.05%]).

Conclusions: Elobixibat was well tolerated and improved bowel movement frequency within two weeks of treatment in Indian patient population with chronic constipation.

Clinical trial registry number: CTRI/2022/10/046690.

The Indian Society of Gastroenterology has developed an evidence-based practice guideline for the management of caustic ingestion-related gastrointestinal (GI) injuries. A modified Delphi process was used to arrive at this consensus containing 41 statements. These statements were generated after two rounds of electronic voting, one round of physical meeting, and extensive review of the available literature. The exact prevalence of caustic injury and ingestion in developing countries is not known, though it appears to be of significant magnitude to pose a public health problem. The extent and severity of this preventable injury to the GI tract determine the short and long-term outcomes. Esophagogastroduodenoscopy is the preferred initial approach for the evaluation of injury and contrast-enhanced computed tomography is reserved only for specific situations. Low-grade injuries (Zargar grade ≤ 2a) have shown better outcomes with early oral feeding and discharge from hospital. However, patients with high-grade injury (Zargar grade ≥ 2b) require hospitalization as they are at a higher risk for both short and long-term complications, including luminal narrowing. These strictures can be managed endoscopically or surgically depending on the anatomy and extent of stricture, expertise available and patients' preferences. Nutritional support all along is crucial for all these patients until nutritional autonomy is established.

Introduction: Endoscopic ultrasound-guided tissue acquisition (EUS TA) has become the mainstay for tissue diagnosis of abdominal mass lesions. Two widely used and accepted methods for obtaining diagnostic material, namely fine needle aspiration cytology (EUS FNAC) and needle core biopsy (EUS FNB), have distinct advantages and disadvantages. We compared the diagnostic accuracy of EUS FNAC without on-site pathology and EUS FNB taken within the same endoscopic session in evaluation of intra-abdominal masses.

Methods: In this prospective observational study, we included patients undergoing EUS FNAC and EUS FNB for the diagnosis of solid intra-abdominal masses. Sample size was calculated based on the available literature. Location, origin, dimensions of the intra-abdominal masses and number of passes taken were recorded. EUS-guided FNAC followed by EUS-guided FNB was done back-to-back during the same endoscopic session. FNAC smears were prepared and air dried and alcohol-fixed slides were prepared. Adequacy of the FNB specimen was judged visually. The diagnostic accuracy of FNA and FNB specimens was then calculated based on the final diagnosis and compared.

Results: Of the 58 patients included, 50% of patients were females with a mean age of 53.91 ± 17.16 years. Nineteen pancreatic masses (32.7%), three gastric mass lesions (5.1%), one adrenal mass (1.7%), one liver mass (1.7%), three gallbladder masses (5.1%) and 31 lymph nodal masses (53.4%) were sampled. With EUS FNB, malignancy was diagnosed in 38/58 (65.5%), benign diseases in 19/58 (32.7%) and 1/58 (1.7%) was inconclusive. Number of passes was more in the EUS FNAC group compared to EUS FNB, but not statistically significant. Sensitivity and specificity of EUS FNAC without rapid on-site evaluation (ROSE) were found to be 92.4% and 100%, respectively. Diagnostic accuracy of EUS FNAC was 93.1% and when compared with EUS FNB with macroscopic on-site evaluation (MOSE), no statistically significant difference was noted.

Conclusion: EUS FNAC and EUS FNB are comparable for the diagnosis of intra-abdominal masses in terms of diagnostic accuracy, sample adequacy, number of passes and safety. In resource-constraint settings, either EUS FNAC or EUS FNB alone may be sufficient for diagnosis with EUS FNB being preferred in select cases where maintained tissue architecture is needed.