Journal of clinical gastroenterology最新文献

Objective: This research aimed to review the literature for definitions of moderate Crohn's disease (CD) and ulcerative colitis (UC).

Background: Real-world evidence suggests that biologics may achieve better outcomes in patients with moderate disease than with severe disease; however, research has been hindered by the lack of consensus on the definition of moderate disease.

Study: We conducted a systematic literature review (SLR) of observational and interventional studies published from 2015 onwards, followed by a targeted literature review (TLR) of phase 3 trials of pharmacological therapies from 2000 onwards, to identify definitions of disease severity. A consensus meeting was convened for experts to discuss how to distinguish moderate from mild or severe disease in clinical practice.

Results: The SLR and TLR included 140 and 101 publications, respectively. Six definitions of moderate CD were identified from 7 publications and 16 definitions of moderate UC from 23 publications. Most definitions were based on Crohn's Disease Activity Index (CDAI) or Mayo score (for UC). Three publications defined moderate CD as CDAI of 200 to 450, 220 to 450, or ≤330. Moderate UC was mostly defined as a Mayo score of 6 to 10 but there was overlap with the range used for severe UC. No definition of moderate disease encompassed quality of life or disease course and prognosis, which were considered important by experts in assessments of disease severity in clinical practice.

Conclusion: A comprehensive and clinically relevant definition of moderate disease is needed to identify patients with CD or UC who can benefit from biologics.

Background: Autoimmune gastritis (AIG) is an immune-mediated chronic atrophic gastritis, and anemia is common in AIG. This study aims to investigate the clinical characteristics of AIG patients with and without anemia.

Methods: This was a single-center retrospective study. The diagnosis of AIG was based on endoscopic or pathologic findings combined with antiparietal cell antibody (PCA) and anti-intrinsic factor antibody (IFA) results. Anemia was defined as hemoglobin levels <110 g/L for females or 120 g/L for males.

Results: This study included 117 AIG patients. The median age was 53.6±10.5 years old, and 72.6% were female. Anemia was present in 39.3% patients, with 17.9% iron deficiency anemia (IDA) and 21.4% pernicious anemia (PA). AIG patients with anemia had a higher positive rate of IFA (34.8% vs. 18.3%, P=0.044) and a lower level of pepsinogen I (PG-I) [5.0 (3.3 to 10.4) vs. 8.0 (4.1 to 18.9) ng/mL, P=0.033]. However, no significant differences were observed in the age, sex, PCA positivity, gastrin levels, Helicobacter pylori (H. pylori) infection status or the concomitant diseases between patients with and without anemia. Compared with PA patients, IDA patients had a higher incidence of H. pylori infection (66.7% vs. 28.0%, P=0.009), as well as the levels of PG-I (P=0.001), PG-II (P=0.016) and PG-I/II ratio (P=0.007). Univariate and multivariate analyses revealed that IFA positivity (odds ratio=2.379, P=0.047) was a significant risk factor for anemia in AIG patients.

Conclusions: AIG patients with IFA positivity are more prone to anemia, and IDA maybe associated with H. pylori infection.

Background and aims: Predicting overall survival (OS) in cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) remains challenging due to the complex interdependencies of clinical variables. This study aims to develop and validate a machine learning (ML)-based predictive model using preprocedural clinical variables to improve OS prediction for cirrhotic patients undergoing TIPS.

Methods: This multicenter, retrospective study included 347 cirrhotic patients undergoing TIPS from January 2017 to December 2023. Participants were randomly divided into training (n=243) and validation (n=104) cohorts. Key clinical data, including demographic, biochemical, and procedural variables, were collected. Several ML models, including gradient boosting machine (GBM), random survival forest (RSF), and others, were trained to predict 3-year OS after TIPS. Model performance was evaluated using time-dependent receiver operating characteristic (ROC) curves, area under the curve (AUC), and Harrell C-index. Kaplan-Meier survival analysis was performed to assess risk stratification.

Results: Key prognostic factors identified included cirrhosis etiology, hemoglobin levels, creatinine, and prothrombin time. Among the 5 models, GBM demonstrated the best performance, with higher AUCs and C-indexes in both the training and validation cohorts. RSF also showed strong predictive performance but exhibited slightly inferior calibration compared with GBM. Lasso-Cox, CoxBoost, and SurvivalSVM showed lower predictive accuracy. Kaplan-Meier survival analysis confirmed that the GBM model effectively stratified patients into high-risk and low-risk groups, with significant differences in survival probabilities (P<0.001).

Conclusion: The GBM-based model outperforms other models, which effectively predict OS in cirrhotic patients undergoing TIPS, enabling improved risk stratification and personalized treatment strategies.

Goals: To evaluate the association between multimodal foregut testing, surgical intervention, and outcomes after lung transplantation.

Background: Gastroesophageal reflux and other foregut disorders have been linked to adverse lung transplant outcomes. However, the impact of comprehensive pre- and posttransplant foregut evaluation and targeted intervention remains unclear.

Study: We reviewed lung transplant recipients at a single center from February 2013 to April 2023. Data included demographics, pre- and posttransplant endoscopy, esophageal manometry, pH monitoring, esophagram, gastric emptying studies, and fundoplication status. The primary outcomes were the incidence, timing, and severity of acute cellular rejection, as well as mortality.

Results: Among 197 patients (median age 57 years old; 52% female), foregut testing patterns shifted post-transplant, with esophagram most frequent pre-transplant (44%) and gastric emptying studies most frequent post-transplant (62%). Manometry results were unchanged in 75% of patients, and gastric emptying studies in 27%. Over half developed new delayed gastric emptying posttransplant, including patients after fundoplication. Barrett's esophagus was associated with increased mortality risk. Fundoplication, typically performed in patients with abnormal pH studies, was linked to higher acute rejection incidence but lower severity and reduced mortality.

Conclusions: Comprehensive foregut evaluation before and after lung transplantation reveals high rates of abnormal motility and reflux, dynamic posttransplant physiological changes, and an association between Barrett's esophagus and mortality. Structured foregut testing may help identify high-risk patients and guide timely intervention to improve outcomes.

Background: Hemorrhoidal disease (HD) significantly impairs quality of life, and existing conservative treatments often yield delayed or insufficient relief. This multicentre cohort study evaluated the comparative effectiveness of structured multimodal conservative regimens versus standard conservative care in patients with acute hemorrhoidal disease (AHD).

Methods: This retrospective cohort study, conducted across 5 Italian proctology centres, included 266 patients with AHD (Goligher grades I to III or thrombosed external hemorrhoids) treated between November 2024 and June 2025. Patients were assigned to 3 groups: group A (n=90) received a multimodal approach with phlebotonics, bromelain, and topical lidocaine; group C (n=93) received the same oral regimen with topical nifedipine; and group B (n=83) received conventional conservative therapy. Primary outcomes were changes in the Hemorrhoidal Disease Symptom Score (HDSS) and the visual analog scale (VAS) for pain.

Results: While all treatment strategies yielded significant symptom improvement over time, the lidocaine-based multimodal regimen (group A) was associated with earlier and more pronounced reductions in pain, symptom burden, and impairment in health-related quality of life (SHS-HD), particularly within the first 14 days of treatment (P<0.001 for all comparisons). Patients treated with the lidocaine-based regimen required less rescue systemic analgesia (8.9% vs. 28.9% in group B and 26.9% in group C; P<0.001) and underwent fewer urgent procedural interventions than those receiving standard care. Early resolution of bleeding and perianal oedema was also more frequent in the multimodal arms.

Conclusion: In this multicentre retrospective cohort study, structured multimodal conservative therapy, particularly the lidocaine-based regimen, was associated with faster symptom relief, improved patient-reported quality of life, and a reduced need for urgent procedures compared with standard conservative care for AHD. These findings suggest the need for further prospective evaluation of lidocaine-centred multimodal protocols in the conservative management of AHD.

Background and aims: Upadacitinib, a selective janus kinase 1 (JAK1) inhibitor, and ustekinumab, an interleukin-12/23 inhibitor, are approved for the treatment of moderate-to-severe ulcerative colitis (UC). However, real-world data in patients with anti-tumor necrosis factor (TNF)-exposure are limited.

Methods: We performed a retrospective cohort study in TriNetX US Collaborative Network. Adult patients with UC and prior anti-TNF exposure were identified. Patients who received upadacitinib or ustekinumab between April 2022 and August 2024 were stratified into two cohorts. Patients with Crohn's disease, rheumatoid arthritis, psoriasis and ankylosing spondylitis were excluded. Propensity-score matching was performed to balance comorbidities, medications, and labs between the two cohorts. Study outcomes included rates of corticosteroid use, colectomies, change of therapy, hospital admissions or emergency department visit, and all-cause mortality.

Results: A total of 724 patients in the upadacitinib cohort and 909 in the ustekinumab cohort met the inclusion criteria. After matching, 633 patients remained in each cohort, with balanced baseline characteristics. At 1-year follow-up, the rates of corticosteroid use were 40.1% in the upadacitinib group and 48.5% in the ustekinumab group (aOR= 0.71, 95% CI: 0.69-0.89), mainly driven by differences in oral corticosteroid use (aOR= 0.73, 95% CI: 0.58-0.91). All other outcomes were comparable between the two study groups.

Conclusion: In patients with ulcerative colitis and prior anti-TNF exposure, upadacitinib was associated with lower oral corticosteroid use than ustekinumab over 1 year, with no significant differences in rates of colectomy, ED visits or hospitalizations. These findings suggest a potanial higher effectiveness of upadacitinib compared with ustekinumab and may help inform treatment selection in this population.

Inflammatory bowel diseases (IBD), comprising Crohn's disease and ulcerative colitis, are chronic, relapsing inflammatory disorders increasingly recognized as systemic conditions with significant extraintestinal manifestations. Over the past 3 decades, the prevalence of IBD has risen in parallel with obesity and related metabolic disorders, including type 2 diabetes mellitus (T2DM), cardiovascular disease (CVD), chronic kidney disease (CKD), metabolic dysfunction-associated steatotic liver disease (MASLD), and dyslipidemia. This parallel rise raises the possibility of shared or interacting biological pathways linking metabolic dysfunction and intestinal inflammation. Epidemiologic studies suggest increased risks of metabolic comorbidities in IBD independent of traditional factors, while mechanistic insights implicate systemic meta-inflammation, mesenteric adipose tissue remodeling (creeping fat), gut barrier dysfunction, and altered lipid and glucose metabolism. These pathways perpetuate a cycle of immune dysregulation and metabolic injury, amplifying disease severity and complications. Obesity and insulin resistance further impact IBD outcomes by altering pharmacokinetics and therapeutic response to biologics, with a higher body mass index associated with increased treatment failure, earlier loss of response, and heightened infection risk. Emerging data also suggest potential dual benefits of metabolic-directed therapies, such as glucagon-like peptide-1 receptor agonists, which may improve weight, glycemic control, and inflammatory indices. However, most evidence remains observational, with limited longitudinal or mechanistic studies. This narrative review synthesizes current knowledge at the interface of IBD and metabolic dysfunction, highlighting clinical implications, translational insights, and research gaps. Integrating metabolic screening and multidisciplinary management into IBD care may improve outcomes, while future mechanistic and interventional studies are needed to define therapeutic strategies that address both gut inflammation and systemic metabolic disease.