Journal of clinical gastroenterology最新文献

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.

Goals: To investigate the effect of obesity on the stages of fibrosis discordance between FibroScan and liver biopsy.

Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) is the leading cause of liver disease worldwide. Accurate fibrosis assessment is essential in MASLD patients for prognosis and treatment. Vibration-controlled transient elastography using FibroScan can overestimate liver fibrosis in obese patients.

Study: This retrospective study included 245 MASLD patients who underwent FibroScan and liver biopsy. Participants were included with FibroScan controlled attenuation parameter (CAP) 250+, 10 liver stiffness measurements (LSM) with IQR/med ≤30%, and 10+ portal tracts on biopsy. Discordance was defined as a ≥2 stage difference between FibroScan and liver biopsy. Participants were stratified by BMI and obesity class to assess their association with discordance. We conducted a post hoc analysis to determine the implication of discordance on resmetirom eligibility. Data was entered into SPSS v28.

Results: Among 245 patients, 29.4% exhibited a ≥2 stage discordance between FibroScan and biopsy. Class 3 obesity was significantly associated with discordance (38.6%) compared with class 2 obesity (24.6%) and class 0 to 1 obesity (18.4%). FibroScan suggested cirrhosis in 66 (57.9%) participants with class 3 obesity, however, liver biopsy confirmed cirrhosis in only 16 (24.2%) subjects and identified 28 (42.4%) subjects with stages 2 to 3 fibrosis, making them potentially eligible for resmetirom.

Conclusions: FibroScan significantly overestimates advanced fibrosis and cirrhosis in class 3 obesity. A second noninvasive test is warranted for accurate liver-directed therapeutic allocation and to minimize unnecessary biopsies in MASLD management.

Among the various factors implicated in the pathogenesis of gastroesophageal reflux disease (GERD), visceral hypersensitivity and mucosal resistance have been recently re-evaluated in relation to the increasing phenomenon of proton pump inhibitor failure, particularly in patients with nonerosive reflux disease (NERD). Intensive research has allowed us to understand that noxious substances contained in the refluxate are able to interact with esophageal epithelium and to induce the elicitation of symptoms. The frequent evidence of microscopic esophagitis able to increase the permeability of the mucosa, the proximity of sensory afferent nerve fibers to the esophageal lumen favoring the higher sensitivity to noxious substances and the possible activation of inflammatory pathways interacting with sensory nerve endings are pathophysiological alterations confirming that mucosal resistance is impaired in GERD patients. Accordingly, the reinforcement of protective mechanisms of esophageal mucosa by topical therapies has become a novel treatment target. Alginate, the combination of hyaluronic acid+chondroitin sulphate and Poliprotect have been shown to adhere to esophageal mucosa and to have good protective properties. Several placebo-controlled clinical trials have shown that these compounds, given alone or as add-on therapy for short periods, enable to relieve symptoms and to improve the quality of life in NERD patients. Further studies are needed to confirm the above results and to find new mucosal protectants in order to improve the management of NERD patients.

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is indicated for multiple pancreatic and biliary pathologies and carries a heightened risk profile compared with other endoscopic procedures. Considerable research has been directed towards discerning risk factors associated with complications such as post-ERCP pancreatitis and post-ERCP bleeding. Despite this, data on chronic liver disease (CLD) as a risk factor for complications is limited. We aimed to assess the outcomes of patients with CLD who underwent therapeutic or diagnostic ERCP to determine whether these patients had different outcomes relative to patients without CLD.

Methods: We used the National Inpatient Sample (NIS) database to inquire for all adult patients who underwent ERCP between 2016 and 2019 using the International Classification of Disease, Tenth Revision (ICD-10) coding. The group was stratified into 2 groups: patients with CLD and those without. The main outcome we looked at was the rate of post-ERCP pancreatitis, post-ERCP hemorrhage, and perforation between the 2 groups. The secondary outcomes were in-hospital mortality and length of stay. A multivariate regression model was used to estimate the association of CLD with ERCP outcomes.

Results: We identified a total of 883,825 patients who underwent ERCP between 2016 and 2019. Among these, 21,212 (2.4%) had CLD and 862,613 (97.6%) did not have CLD. The mean age for patients in liver disease group was 61.66 years and in group without liver disease was 60.46 years. The predominant ethnicity in both groups was whites. Additional admission-related factors are outlined in Table 1. The rate of post-ERCP pancreatitis (8.8% vs. 6.7%, P < 0.001) with adjusted odds ratio (aOR) 1.3; and post-ERCP hemorrhage (8.8% vs. 6.69%, P < 0.001) with aOR 1.35, was higher in the patient group with CLD. The rate of post-procedure perforation was not significantly different in both groups. For secondary outcomes; the in-hospital mortality (3.03% vs. 1.58%, P < 0.001) and length of stay (7 days vs. 3 days, P < 0.001) were higher in the patients with chronic liver disease. The outcomes are mentioned in Table 2.

Conclusion: Although ERCP is considered a safe procedure, it is one of the endoscopic procedures associated with the highest risk of complications. As a result, risk stratification is crucial. Certain demographics, conditions like end-stage renal disease, liver cirrhosis, and procedural factors have been identified as risk factors for post-ERCP complications. Our study represents newer data, with use of revised ICD codes, to demonstrate increased risk in patients with liver disease. On the basis of these results, ERCP should be used judiciously in this population and further studies are required for identifying reversible risk factors to improve outcomes.

Background: Data regarding the utility of therapeutic drug monitoring with ustekinumab (UST) are sparse. Our aim was to determine the correlation of UST levels with outcomes in a cohort of patients with inflammatory bowel disease (IBD).

Methods: This was a multicenter, retrospective study of all patients with IBD who received UST from January 1, 2014 to March 1, 2022. The primary outcomes were the correlation of UST level with clinical remission (per physician global assessment), endoscopic healing [the absence of ulcers/erosions in Crohn's disease (CD) and Mayo endoscopic score ≤1 for ulcerative colitis (UC)], and normal serum C-reactive protein (CRP) (≤5 mg/L). Secondary outcomes included defining optimal UST trough levels associated with favorable outcomes.

Results: A total of 71 patients (74.6% with CD; 57.7% female) were included. The median age was 39.5 years [interquartile range (IQR): 26 to 52] and 12.6% were on combination therapy with immunomodulators. Median UST trough levels were significantly higher in patients who achieved endoscopic healing at 5.4 µg/mL versus 3.5 µg/mL ( P =0.035) and normal CRP at 5.5 µg/mL versus. 3.1 µg/mL ( P =0.002). A cutoff UST level of 4.8 µg/mL yielded the highest area under the curve (AUC) of 0.73 (95% CI: 0.61-0.80) to predict a normal CRP followed by a cutoff of 3.5 µg/mL which yielded an AUC of 0.66 (95% CI: 0.52-0.81) to predict endoscopic healing.

Conclusions: UST trough levels were significantly higher in patients who achieved a normal CRP and endoscopic healing. A cutoff UST level of 4.8 µg/mL reliably predicted CRP normalization.

Background and aims: Co-axial plastic double pigtail stents (DPSs) are commonly placed through lumen apposing metal stents (LAMS) in patients with pancreatic fluid collections (PFCs) to decrease the risk of adverse events. In this meta-analysis, we have compared the outcomes of LAMS plus co-axial DPS versus LAMS alone in patients with PFCs.

Methods: We reviewed several databases to identify the studies that compared outcomes of LAMS with DPS to LAMS without DPS in the treatment of PFCs. Our outcomes of interest were overall adverse events, clinical success and individual adverse events such as stent (LAMS) migration, stent occlusion, bleeding, and infection. We calculated pooled risk ratios (RR) with 95% confidence intervals (CIs) for the analysis of outcomes. We used a random effects model to analyze the data. Heterogeneity was assessed using the I 2 statistic.

Results: We included 10 studies with 685 patients. Rate of overall adverse events was significantly lower in the LAMS+DPS group compared with LAMS alone, RR (95% CI) 0.58 (0.40, 0.87). There was no significant difference in the rate of clinical success between groups, RR (95% CI) 1.03 (0.94, 1.13). We found no significant difference in rate of stent occlusion between groups. Rate of infection was significantly lower in LAMS+DPS group, RR (95% CI) 0.46 (0.24, 0.85). There was no significant difference in rate of bleeding and stent (LAMS) migration between groups.

Conclusions: Addition of co-axial DPS to LAMS decreases the risk of adverse events in patients with PFCs and should be considered in all patients with PFCs.

Background and objectives: The negative pressure selectable for the wet-suction technique remains uncertain. The aim was to investigate the quality of sampling and diagnostic accuracy with solid lesions by 5 mL and 10 mL negative pressure with wet-suction techniques.

Methods: This is a single-center, crossover, randomized controlled trial conducted with a random sampling technique. In all, 160 patients consecutively undergoing EUS-FNA for solid lesions were randomized in a ratio of 1:1 into 2 groups, the 5 mL and 10 mL negative pressure wet-suction group. The main outcome was to compare the sample quality between the 2 groups. The secondary outcome was to compare the histologic and cytologic diagnostic accuracy of solid lesions.

Results: Pancreatic (n=129) and nonpancreatic (n=27) lesions from 156 lesions were examined. The sample quality concluding cellularity, adequacy, integrity, and blood contamination were comparable between the 2 groups. However, in subgroup analysis, we found 19G FNA provided more integrity of specimen in 5 mL than in 10 mL group (100% vs. 82.9%, P =0.025). In contrast, this benefit was not noteworthy in the 22G FNA subgroup. And there was no statistically significant in histologic (87.82% vs. 87.18%, P =1.000) and cytologic (78.85% vs. 80.77%, P =0.778) accuracy between 5 mL and 10 mL groups.

Conclusion: When using the wet-suction technique, 5 mL and 10 mL negative pressure offer equivalent sample quality and diagnostic accuracy. However, the 19G FNA can obtain better sample quality with 5 mL negative pressure than 10 mL negative pressure.

Objective: Helicobacter pylori ( H. Pylori ) is considered a main causative organism of gastric ulcers, gastric cancer and duodenal ulcers. The current treatment relies on a combination of antimicrobial agents and acid suppressant agents, but the eradication effect is not satisfactory. To clarify the concentration of antibiotics at the lesion site, we investigate the clinical efficacy and drug tissue distribution of the combination therapy of furazolidone and tetracycline in eradicating H. Pylori.

Materials and methods: Patients with H. pylori infection (n = 60) were randomized to either group A or B. Bismuth potassium citrate capsules 220 mg, omeprazole enteric-coated capsules 20 mg, amoxicillin capsules 1000 mg, each twice per day, and furazolidone tablets 500 mg were administered to group A. Group B was treated with bismuth potassium citrate capsules 220 mg, omeprazole enteric-coated capsules 20 mg, amoxicillin capsules 1000 mg, and tetracycline tablets 500 mg each twice per day for 2 weeks. The serum and gastric juice, gastric antrum, gastric horn, and gastric body samples were taken under a gastroscope on the 14th day. The antimicrobial concentrations in serum and tissue samples were determined by high-performance liquid chromatography.

Results: In the negative group of furazolidone, the concentrations of gastric antrum, gastric body, and gastric angle were significantly higher than those in the positive group ( P = 0.017, 0.015, and 0.028). The concentrations of furazolidone in gastric fluid, gastric antrum, gastric angle, and gastric body were ∼421 times, 82 times, 17 times, and 51 times higher than those in serum, respectively. The concentrations of tetracycline in the serum and gastric angle of the tetracycline negative group were significantly higher than those in the positive group ( P = 0.036 and 0.042), and the tetracycline concentrations in the gastric horn and gastric body were about 4 and 6 times higher than those in the serum, respectively. The concentration of amoxicillin in group B was higher than that in group A, especially in serum, gastric juice, gastric angle, and gastric body ( P < 0.05).

Conclusion: Furazolidone is mainly concentrated and sequentially distributed in gastric juice, gastric antrum, and gastric body tissue, and tetracycline is mainly distributed in serum, gastric angle, and gastric body, whereas amoxicillin is mainly distributed in serum, gastric juice, gastric angle, and gastric body. Improving the concentration and tissue distribution of antibacterial drugs in the human gastric mucosa is the key to ensuring the ideal eradication rate of quadruple therapy.