Journal of clinical gastroenterology最新文献

Introduction: Several factors affect the difficulty, clinical success, and side effects related to endoscopic retrograde cholangiopancreatography (ERCP), of which the endoscopic appearance of the major papilla is one of the most important. This study aimed to investigate the outcomes related to ERCP in relation to major papilla morphology.

Methods: This study was performed prospectively on 581 patients undergoing ERCP. During ERCP, the endoscopist determined the morphology of the major papilla before the cannulation. Primary outcomes included overall operative success rate and post-ERCP pancreatitis (PEP) at 30 days. Secondary outcomes included clinically significant bleeding, perforation, cholangitis or sepsis, difficult cannulation, number of cannulation attempts, and duration of cannulation.

Results: Papilla type 2 (OR=2.36, 95% CI: 1.07-5.20) and type 3b (OR=3.19, 95% CI: 1.16-8.73) were associated with decreased odds of procedure success. PEP was directly associated with type 4 papilla (OR=3.30, 95% CI: 1.21-8.98). There were direct correlation between difficult cannulation and types 3a (OR=1.89, 95% CI: 1.20-2.98) and 3b (OR=5.05, 95% CI: 1.98-12.86), cannulation duration more than 10 minutes and types 2 (OR=2.66, 95% CI: 1.31-5.39), 3a (OR=2.18, 95% CI:1.30-3.64), and 3b (OR=4.97, 95% CI: 1.94-12.71), and attempted cannulation more than 5 times and types 3a (OR=1.64, 95% CI: 1.01-2.69), and 3b (OR=4.40, 95% CI: 1.75-11.09).

Conclusion: The findings of this study showed that ERCP failure is associated with types 2 and 3b papilla, and papilla type 4 is an independent risk factor for PEP.

Introduction: Screening tests like colonoscopy can prevent colorectal cancer (CRC), yet their effectiveness is often questioned. The Nordic-European Initiative on Colorectal Cancer (NordICC) trial demonstrated that colonoscopy significantly reduces CRC incidence and mortality in per-protocol analysis. However, media coverage of the trial often focused on intention-to-screen findings that showed no change in mortality, possibly contributing to public confusion about colonoscopy benefits. This study aimed to assess whether such media articles undermined public perception and intent to undergo colonoscopic screening.

Methods: We recruited a US nationally representative sample of unscreened adults aged 45 to 75 years at average CRC risk. Respondents were randomized 1:1 to read either a low-quality or high-quality article on NordICC, as rated by a panel of gastroenterologists. Before and after reading their article, participants reported whether they plan to be screened for CRC with a colonoscopy. Our primary outcome was a negative change in intent to undergo colonoscopic screening.

Results: Among the 2013 participants who completed the survey, 1531 (76.1%) stated they planned to undergo colonoscopy or were undecided before reading the article. After reading the media report, 90 (12.0%) people in the low-quality article arm no longer planned to undergo colonoscopy versus 73 (9.3%) in the high-quality article arm; the difference was not statistically significant (P=0.08).

Discussion: A widely promulgated article about NordICC rated as low-quality did not differentially impact attitudes towards colonoscopic CRC screening compared with another mainstream article rated as high-quality. Our study provides reassurance that most people will not summarily change health behaviors after reading a single article, regardless of perceived accuracy.

Metabolic dysfunction-associated steatohepatitis (MASH) has become the dominant cause of liver disease in the United States. With the growing burden of this disease in gastroenterology practices, the identification and treatment of those at risk of developing adverse outcomes (cirrhosis, hepatocellular carcinoma, or liver-related death) has become urgent. In recent years, the development of noninvasive tests (NITs) to identify "at-risk MASH" patients have provided cost-effective algorithms to identify these patients. Although treatment has historically been limited to lifestyle modification, recent FDA approval of resmetirom for noncirrhosis MASH with stages 2 and 3 fibrosis has provided a new  opportunity in the United States to provide these patients with novel treatment options. Other new effective treatment regimens are on the horizon. Given that gastroenterology and hepatology practices in the United States heavily rely on advanced practice providers (APPs) to manage patients with MASLD, the APP Committee of the Global NASH/MASH Council has curated the essentials of day-to-day MASH management for our busy gastrohepatology providers and their APP colleagues. The goal of this document is to equip and mobilize more GI providers with the requisite competencies for the management of at-risk MASH, given the rapidly evolving MASH treatment landscape.

Objective: Dyspepsia, a common gastrointestinal issue characterized by upper abdominal discomfort, can be influenced by diet, medication, and lifestyle changes. Ramadan fasting involves refraining from food and drink from dawn to sunset, affecting various physiological processes, including digestion. The fasting period can range from 12 to 18 hours depending on the year, potentially impacting the prevalence of dyspeptic symptoms. This study aimed to assess the effect of fasting on dyspeptic symptoms, taking into account demographic and clinical factors.

Materials and methods: A cohort study examined 1258 clinic patients, with 150 meeting specific inclusion criteria. Dyspepsia was diagnosed using Rome IV criteria, with fasting hours taken into consideration. The relationship between dyspepsia, fasting, Non-Steroidal Anti-Inflammatory Drug use, and demographics was analyzed.

Results: Dyspepsia was more prevalent in females (32%) compared with males (23%), with a higher proportion of non-fasting women among dyspeptic patients. Older patients (>65 y) had a higher prevalence of dyspepsia (P = 0.026). Fasting individuals had a 2.1 times greater likelihood of experiencing dyspeptic symptoms. Although Non-Steroidal Anti-Inflammatory Drug use was lower in fasting patients, no significant association with dyspepsia was observed (P = 0.139).

Conclusion: Ramadan fasting increases the risk of dyspeptic symptoms, particularly in women and older adults. Factors such as medication timing and dietary changes during fasting may contribute to this risk. Highlighting the importance of the pre-dawn meal (Suhoor) in managing dyspeptic symptoms is essential. Tailored guidance should be provided to individuals at higher risk during Ramadan.

Over the past several years, there has been a wealth of new data pertaining to the management of complications of cirrhosis, resulting in several important updates to best practices and consensus guidelines. Despite these advancements and numerous recent targeted quality initiatives, hospitalizations resulting from complications of cirrhosis remain frequent, costly and associated with poor patient outcomes. An emphasis on evidence-based management of hospitalized patients with decompensated cirrhosis has the potential to decrease readmission rates and length of stay while improving overall patient outcomes. Herein, we provide an updated, evidence-based overview of the optimal inpatient management of the most frequently encountered complications associated with cirrhosis.

Background: Swallowed topical corticosteroids (STC) are an effective first-line therapy for patients with eosinophilic esophagitis (EoE), both for induction and maintenance of remission. All interventional trials with STC used twice-daily dosing regimens. However, in other inflammatory gastrointestinal disorders, corticosteroids are given once daily (OD) with equal outcomes and improved compliance.

Goals: To evaluate the effectiveness of topical budesonide maintenance treatment in a once-daily dosing schedule.

Study: Retrospective analysis of confirmed patients with EoE, treated with topical budesonide as maintenance therapy OD, with adequate follow-up available. Patients currently treated with budesonide were contacted to fill out online questionnaires regarding symptoms and health-related quality of life (HRQOL). The primary end point was histologic remission, defined as peak eosinophil count (PEC) <15 eosinophils per high power field (HPF) after >12 weeks of budesonide OD.

Results: We included 29 patients on STC OD (1 mg, N=28; 0.5 mg, N=1), either budesonide orodispersible tablet (BOT, Jorveza, Dr. Falk Pharma; N=12) or budesonide viscous solution (BVS; N=17). After a median follow-up of 767 days on OD dosing (range: 103 to 2396), 86% of patients were in histologic remission. Four patients had histologic disease activity, of which one was treated with BOT. Two patients experienced a slight increase in PEC after dose reduction of BVS to OD (to PEC of 25 and 35/HPF, respectively). However, after switching the formulation to BOT OD they achieved histologic remission.

Conclusions: In this retrospective study, we demonstrated favorable results in the majority of patients treated with budesonide 1 mg OD as maintenance treatment for eosinophilic esophagitis.

Goals: To explore dynamic contrast-enhanced ultrasound (CEUS) parameters in predicting hepatic vein pressure gradient (HVPG) for patients with liver cirrhosis (LC).

Background: Noninvasive diagnosis of HVPG remains a challenge.

Study: This prospective study included patients with LC undergoing hepatic vein catheterization and pressure measurement at the hospital from May 2021 to January 2023. The CEUS images (Mindray Resona R9, 1-6-MHz probe frequency; mechanical index=0.08; image depth=10 cm; focus at the lowest point of the diaphragm; dynamic range=70 dB; optimal gain; single SonoVue bolus injection) were taken for 60 seconds after injection and analyzed using VueBox. HVPG (ie, the gold standard for portal hypertension) was measured routinely by catheterization.

Results: Fifty patients with LC were included in the study. The rise time (r=0.6, P<0.01), the fall time (r=0.7, P<0.01), the peak time (r=0.6, P<0.01), wash-in area under the curve (AUC) (r=0.5, P<0.01), the wash-out phase AUC (r=0.4, P<0.01) and wash-in and wash-out phase AUC (r=0.4, P<0.01) of the dynamic spleen CEUS were positively correlated with HVPG. The optimal fall time cutoff levels to predict HVPG ≥10 mm Hg and ≥12 mm Hg were 27.0 and 36.4 seconds, with the AUC being 0.958 and 0.941, respectively. The optimal area under the wash-in area cutoff level to predict HVPG ≥10 mm Hg and ≥12 mm Hg was 1,658,967.38 (a.u) and 4,244,015.90 (a.u), with the AUC being 0.865 and 0.877, respectively.

Conclusions: The fall time and wash-in AUC obtained by dynamic CEUS may help diagnose HVPG in patients with LC without requiring invasive hepatic vein catheterization.

Background: We aimed to examine the relationship between disease symptoms and disease phenotype in a large Canadian cohort of persons with Crohn's disease (CD).

Methods: Adults (n=1515) with CD from 14 Canadian centers participated in the Mind And Gut Interactions Cohort (MAGIC) between 2018 and 2023. Disease activity was measured using the 24-item IBD Symptom Inventory-Short-Form (IBDSI-SF). We compared the symptoms commonly associated with active versus inactive disease, and explored symptoms patterns in relation to disease phenotype, based on the Montreal Classification. To assess psychological status the Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9 were used.

Results: The mean disease duration was 15.6±11.8 years. The 5 most common symptoms were similar for those with active disease, although at higher prevalence (89% to 98%) versus those with inactive disease (47% to 79%), and included fatigue, diarrhea, gas, bloating, and urgency. The intensity of symptoms was higher in those with active than inactive IBDSI-SF scores. The rank order and relative distribution of the symptoms and intensity of the symptoms reported were similar between those with different disease phenotypes B1, B2, and B3 and L1, L2, and L3. Persons with active IBDSI-SF had a higher prevalence of anxiety (24.6%) and depression (38.2%) versus persons with inactive IBDSI-SF (6.3% and 8%, respectively).

Conclusions: Individuals with CD with active and inactive disease by IBDSI, experience similar symptoms, but the prevalence of symptoms and their intensity is greater in persons with active IBDSI. Persons with inactive IBDSI report many symptoms. There was no difference in symptom reporting by disease behavior or location.

Background: Malnourished patients hospitalized with inflammatory bowel disease (IBD) have a high risk of morbidity and mortality. Risk stratification can help identify patients who are most in need of medical and nutritional intervention.

Goal: This study aimed to develop a machine-learning model that accurately predicts mortality in hospitalized IBD patients with protein-calorie malnutrition (PCM).

Study: Hospitalized adults with IBD and PCM were identified in the 2016 to 2019 National Inpatient Sample (NIS). Random Forest Classifier (RFC) and Extreme Gradient Boosting (XGB) models were constructed using a 70% randomly sampled training set from the years 2016 to 2018, tested using the remaining 30% of 2016 to 2018 data, and externally validated using 2019 data. Patient characteristics were evaluated using weighted estimates that accounted for the complex sampling design of the NIS.

Results: Among 879,730 malnourished patients hospitalized for IBD, 1930 (0.2%) died. Compared with malnourished patients who survived, those who died were generally older, White, had ulcerative colitis with multiple comorbidities, and admitted on the weekend. The accuracy, precision, sensitivity, and specificity for both models were 0.99, 0.98, 0.99, and 0.99, respectively. The area under the receiver operating characteristic curve was 0.91 for both models.

Conclusion: Machine learning models can accurately predict mortality in malnourished patients hospitalized with IBD, while solely relying on readily available clinical data. Further integration of these tools into clinical practice could improve risk stratification of IBD patients with PCM and potentially reduce mortality in this high-risk population by prompting earlier intervention.

Introduction: Thermal ablative methods (such as argon plasma coagulation (APC) and soft tip snare coagulation (STSC) are commonly used to treat polyp margins. We aim to appraise the current literature and compare clinical outcomes between patients with treated (with APC vs. STSC) and non-treated endoscopic mucosal resection (EMR) margins.

Methods: We searched major databases from inception until November 2023 for randomly controlled trials (RCTs) comparing EMR of large non-pedunculated colorectal polyps with and without treated margins. Pooled data were analyzed for the primary outcome of recurrence at first screening colonoscopy, and adverse events. Analysis was performed using a random effects model and data were reported using 95% CIs.

Results: A total of 5 RCT's were found, which included 1020 polyps (577 in treatment and 443 in control groups). Three studies included treatment with STSC and 3 studies used APC as the modality for margin ablation. Of the included patients, 53% were female and the average age was similar between treatment and control groups (65.9 vs. 66.1 y). Seventy-one percent of lesions were proximal to the splenic flexure. The mean follow-up to the first colonoscopy and average polyp size were comparable (6.3 vs. 6.2 mo; 28.2 vs. 28.0 mm, respectively). Pooled analysis showed that margin ablation was associated with significantly lower rates of recurrence [odds ratio (OR) 0.267, 95% CI 0.18-0.4, P<0.001] with low heterogeneity between studies (I2=0%, P=0.47). Pooled analysis showed no significant difference between STSC and APC in terms of recurrence (OR 0.6, 95% CI 0.27-1.7, I2=0%, P=0.3) or adverse events (OR 0.67, 95% CI 0.3-1.6, I2 13%, P=0.46).

Conclusion: Our study shows that ablation of EMR margins is very effective at preventing recurrence at first surveillance colonoscopy. We found no difference between STSC or APC in terms of polyp recurrence or adverse outcomes.