Journal of clinical gastroenterology最新文献

This paper assesses the existing literature to explore the association between obstructive sleep apnea (OSA) and cirrhosis. While OSA's impact on metabolic dysfunction-associated steatotic liver disease (MASLD) is well-established, limited data exists for other causes of chronic liver disease. The review examines OSA's role in cirrhosis, emphasizing its potential influence on liver disease progression and laying the groundwork for future studies. Current data indicates a greater likelihood of liver disease in individuals with OSA, with continuous positive airway pressure (CPAP) treatment potentially slowing liver disease advancement. Undiagnosed OSA exacerbates liver disease progression, underscoring the urgency of identifying and managing sleep disturbances in patients with liver disease. Patients with a BMI over 30 and liver disease should be screened for sleep disturbances. Addressing sleep issues and OSA could enhance well-being and liver disease management in these patients.

Background: EUS-guided gastroenterostomy (EUS-GE) is a minimally invasive therapy for the management of gastric outlet obstruction (GOO). EUS-GE has demonstrated excellent short-term efficacy without the risks of surgical bypass. However, there is limited data on follow-up outcomes. In this study, we collected 6-month follow-up data on patients who underwent EUS-GE for benign and malignant etiologies, to aim to show the shift in paradigm in their management algorithm.

Methods: This was a retrospective multicenter study across 7 international centers of consecutive patients undergoing EUS-GE over a 4-year period who were entered in a dedicated registry. Demographic characteristics, procedure-related information, and follow-up data were collected. Primary outcome was the 6-month data on clinical resolution of GOO.

Results: Ninety-one patients were included (71 malignant and 20 benign cases). Technical success was 99% due to high expertise and volume. Clinical success at 48 hours was 97% (88/90) with an average procedure time of 47 minutes and length of stay of 5.86 days. At 3 months, 87 (95.6%) patients had achieved clinical resolution. At 6 months, 48 (53%) subjects were alive, 40 (44%) were deceased, 3 were lost to follow-up (3.3%) and 1 (1%) had a recurrence of GOO. Clinical success at 6 months follow-up was 98% (47/48).

Conclusions: The majority of patients with GOO who undergo EUS-GE showed clinical resolution at 6-month follow-up. Patients with malignant etiology are appropriately palliated during their life span. Further prospective studies are necessary to obtain long-term data regarding EUS-GE for benign etiologies.

Goals: To test the efficacy of a self-help cognitive behavioral therapy (CBT) for irritable bowel syndrome (IBS) app compared with an active control app.

Background: IBS is a disorder of gut-brain interaction that can result in significant distress, disability, and psychiatric co-morbidity. CBT is an effective treatment for IBS. Self-help CBT apps can increase accessibility but should be tested against active controls.

Methods: This randomized controlled trial (NCT04665271) compared a CBT for IBS self-help app (Zemedy) to an active education, lifestyle management, relaxation, and mindfulness control app. A total of 453 individuals were screened in and offered allocation to treatment. Participants who actually downloaded their assigned app (N=267) were evenly split between the CBT app (N=136) and the active control (N=131). Follow-up data (CBT N=74, control N=82) were collected immediately post-treatment, at which point the control group was offered crossover to CBT. Follow-up data were collected at 3 (N=65) and 6 (N=32) months. Primary outcomes included IBS symptom severity and IBS quality of life. Secondary outcomes included catastrophizing, visceral anxiety, fear of food, and depression.

Results: At post-treatment, the CBT group improved significantly across all outcomes. The control group also improved on all outcomes except fear of food. In the intent-to-treat analysis the CBT group improved significantly more than the control group on both primary and secondary outcomes except depression. Gains were maintained at 3 and 6 months, although attrition was considerable.

Conclusion: Self-help CBT for IBS may be effective and can be delivered successfully through apps, although we did not have data on engagement. Psychoeducation about symptom management strategies, relaxation, and mindfulness are active treatment components, but CBT is better at addressing underlying maintaining factors like catastrophizing, visceral anxiety, and fear of food.

Background and goals: Endoscopic biliary stenting is a standard palliative procedure to improve the quality of life in patients with unresectable malignant distal biliary obstruction (MDBO). Self-expandable metallic stents (SEMS) are preferred for their longer patency than plastic stents. However, cholecystitis can complicate SEMS placement by obstructing the cystic duct. This meta-analysis aims to identify risk factors for cholecystitis after SEMS placement for MDBO.

Study: We conducted a comprehensive database search to identify published studies. Only full-text articles using multivariate models to assess risk factors were included. Pooled adjusted odds ratios (OR) with 95% CIs were obtained.

Results: Eleven retrospective cohort studies (4291 patients who underwent SEMS placement for MDBO) were included, analyzing 8 unique risk factors. Predictors of cholecystitis after SEMS placement for MDBO included tumor involvement of the cystic duct take-off (OR 5.61, 95% CI 3.36-9.36, P< 0.001; I²=65%), SEMS placement across the orifice of the cystic duct (OR 1.97, 95% CI 1.27-3.07, P=0.003; I²=0%), gallstones presence (OR 2.56, 95% CI 1.65-3.98, P< 0.001; I²=0%), flow of contrast agent into gallbladder (OR 3.91, 95% CI 1.11-13.79, P=0.03; I²=75%), and use of covered metal stent (OR 2.77, 95% CI 1.42-5.43, P=0.003; I²=0%). Prior biliary drainage, tumor invasion to the feeding artery, and stent length ≤60 mm were not associated with an increased cholecystitis risk.

Conclusions: Our meta-analysis examined adjusted risk factors to reliably estimate the main risk factors associated with cholecystitis after SEMS placement for MDBO. Integrating our findings into a prediction model may help identify high-risk individuals.

Chronic liver disease (CLD) is increasing in prevalence worldwide. CLD has significant associated morbidity and mortality, including a negative impact on health-related quality of life (HRQOL), progression to cirrhosis, development of hepatocellular carcinoma (HCC), and need for liver transplantation. CLD disproportionately impacts racial, ethnic, sexual, and gender minorities. CLD is also more prevalent in populations experiencing challenging social determinants of health (SDOH) factors. Health disparities are prevalent across various forms of CLD, reflected in higher disease prevalence and severity, premature or excess adverse clinical outcomes and worse patient-reported outcomes. In this review, we highlight current epidemiology and health disparities across major forms of CLD, including metabolic dysfunction-associated steatotic liver disease (MASLD), alcohol-associated liver disease (ALD), viral hepatitis, and autoimmune liver disease. Herein we discuss challenges with respect to disparities in screening, diagnosis, noninvasive testing for risk stratification, treatment, and rates of clinical outcomes. We outline actionable interventions from a broad public health level to the individual patient level with the goal of moving towards health equity. Lastly, we highlight areas in need of future research that can inform future interventions to achieve health equity.

Goals: Assess the safety and effectiveness of upadacitinib in patients with prior tofacitinib failure.

Background: Patients with severe, refractory Crohn's disease (CD) or ulcerative colitis (UC) and inadequate response to medical therapy have a high risk of complications. A better understanding of treatment response in the setting of prior failure may improve disease control in high-risk patients. Currently, the response to a subsequent Janus Kinase (JAK) inhibitor after prior JAK failure is poorly understood.

Study: We retrospectively assessed the safety and effectiveness of upadacitinib in patients with prior tofacitinib failure.

Results: We report on 26 patients (10 UC, 16 CD) treated with upadacitinib after tofacitinib failure. Mean age 40.2 years, mean disease duration 14.4 years (range 2 to 33), and previously failed a median of 5 advanced therapies. The mean upadacitinib treatment duration was 13.9 months (SD 4.5). On upadacitinib, 83.3% (n=10/12) of patients achieved clinical response, 66.7% (n=8/12) clinical remission, 71.4% (n=10/14) endoscopic improvement, 57.1% (n=8/14) endoscopic remission, and 35.7% (n=5/14) endoscopic healing. The mean Simple Endoscopic Score in CD decreased from 14.3 (SD: 8.3) to 8.6 (SD: 9.0) (P=0.24). The mean Mayo Endoscopic Subscore significantly decreased from 2.7 (SD 0.8) to 0.9 (SD 1.2) (P=0.006). 73.1% of patients on upadacitinib reported adverse events, most commonly minor infections and acne. No serious adverse events, major cardiovascular events, malignancies, or Shingles were observed.

Conclusions: Upadacitinib was tolerated in most patients and resulted in clinical and endoscopic improvement in the majority of patients with severe, refractory CD or UC with prior tofacitinib failure, regardless of previous clinical response to tofacitinib. Further studies would define the long-term safety, efficacy, and predictors of response after previous JAK exposure.

Background: Necrotizing pancreatitis (NP), a severe form of pancreatitis characterized by necrosis of pancreatic tissue, is associated with a significant health care burden worldwide. In this study, we assess early readmissions of NP in the US.

Methods: The National Readmission Database from 2016 to 2020 was utilized to identify all index and 30-day readmissions of NP in the US. Hospitalization characteristics, readmission rates, clinical outcomes, predictors of readmissions, and health care burden were assessed. P-values <0.05 were statistically significant.

Results: From 2016 to 2020, 43,968 index admissions for NP were identified. Of which, 18.6% were readmitted within 30 days. There was a higher proportion of males on index and 30-day readmission. On readmission, NP was identified as the admitting diagnosis in only 27.64% of the patients, followed by pancreatitis without necrosis (17.7%), sepsis (8.8%), pancreatic pseudocyst (6.85%), and chronic pancreatitis (2.5%). Biliary pancreatitis (aHR 1.46, 95% CI 1.30-1.65, P<0.001), idiopathic pancreatitis (aHR 1.45, 95% CI 1.33-1.57, P<0.001), and other etiologies of pancreatitis (aHR 1.74, 95% CI 1.46-2.06, P<0.001) had a higher risk of 30-day readmission compared with alcohol-induced pancreatitis. We noted lower inpatient mortality (2.11 vs. 2.97%, aOR:0.65, 95% CI 0.50-0.83, P=0.001), mean length of stay (7.36 vs. 10.97 days, mean difference 3.86, 95% CI 4.25-3.48, P<0.001), and total hospitalization charges ($75,282 vs. $125,480, mean difference $53,979, 95% CI $59,417-$48,541, P<0.001) for 30-day readmissions compared with index NP hospitalizations.

Conclusion: About one-fifth of NP patients were readmitted within 30 days. However, these patients had lower mortality and health care burden compared with index hospitalization.

Goals: To assess the feasibility and safety of endoscopic ultrasound-guided laser ablation (EUS-LA) of retroperitoneal lymph node (RPLN) metastasis.

Background: RPLN metastasis is challenging to treat, partly due to hazardous location. EUS-LA is a new attractive option for lesions in high-risk or percutaneous difficult-to-reach locations. Here, we reported the initial experience with EUS-LA of RPLN metastases.

Study: From November 2016 through July 2023, patients with oligometastatic RPLN metastases who were not eligible or refused surgery were prospectively enrolled. EUS-LA was performed using a neodymium: yttrium-aluminum-garnet (Nd: YAG) laser beam fiber ablation system. The technical success rate, focal control rate, visual analog scale (VAS) scores, and adverse events were assessed.

Results: Nineteen patients with 25 RPLN metastases were included in the study. EUS-LA was performed successfully in all patients. The 3-month, 6-month, and 12-month focal control rates were 96.0%, 86.4%, and 76.5%, respectively. During a median follow-up of 24 months (3 to 46 mo), the median diameter of the RPLN metastases changed from 22 mm (12 to 44 mm) at baseline to 8.5 mm (6 to 39 mm) at the final follow-up. After ablation, the VAS scores decreased significantly in all patients with pain. Two patients experienced self-limited abdominal pain, and no moderate or severe adverse events were reported.

Conclusions: EUS-LA showed high technical feasibility and an acceptable safety profile in the treatment of oligometastatic RPLN metastases. In patients at high surgical risk, EUS-LA can be considered as an alternative therapeutic modality, which warrants a long-term follow-up study to verify the efficacy.