Journal of clinical gastroenterology最新文献

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.

Goals: To evaluate the efficacy and safety of standard triple therapy (STT) in Latin America.

Background: Helicobacter pylori infection affects more than 50% of the Latin Americans and leads to gastric mucosa damage. Scarce data on effective therapeutic approaches in the region underscores the need for comprehensive information.

Study: The analysis included Randomized Controlled Trials published up to the year 2020, comparing STT with other treatments. Cumulative relative risks (RR) were estimated, with 95% CI, according to intention-to-treat (ITT) and per protocol (PP) analysis.

Results: Eleven studies (clinical trials conducted between 1995 and 2013), revealed cumulative eradication rates of 78.31-90.63% (ITT) and 76.71-93.55% (PP). The eradication with the STT was superior to sequential therapy (ITT-RR: 10.6, 95% CI: 1.01 to 1.12) (PP-RR: 10.6, 95% CI: 1.02-1.11) and dual therapy (ITT-RR: 1.61, 95% CI: 1.13-2.30) (PP-RR: 1.72, 95% CI: 1.25-2.37), but is less effective than other triple therapies (PP-RR: 0.85, 95% CI: 0.78-092). Regarding adverse effects, diarrhea, metallic taste, nausea, vomiting, and headache were the most common symptoms across treatments. Abdominal pain was associated with STT (ITT-RR: 1.75, 95% CI: 1.07-2.86).

Conclusion: STT was a safe regimen but with acceptable efficacy (most eradication rates <90%). Due to rising clarithromycin resistance, the study suggests avoiding STT as a first-line treatment. These results must be considered with caution due to the low representativeness of several Latin American countries and the lack of recent high-quality randomized studies.

Background: There is limited evidence that histologic remission improves outcomes in Crohn's disease (CD). We aimed to characterize a cohort of patients with CD in endoscopic remission and explore factors associated with subsequent loss of remission (LOR).

Methods: In total, 4474 patients were enrolled in TARGET-IBD, a longitudinal, observational cohort study. Patients with a normal steroid-free colonoscopy (index) were defined as "in endoscopic remission" and were followed for LOR, defined as presence of inflammation, erosion, ulceration, or stricturing on a subsequent colonoscopy or commencement of steroids. Histologic activity was dichotomized using standard of care reports for active inflammation. Unadjusted and multivariable-adjusted Cox proportional hazards regression models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) of LOR in relation to independent variables.

Results: Of 658 patients with CD with steroid-free endoscopic remission, the majority were female (57%), white (83%), non-Hispanic (93%); 20% had ileal and 20% isolated colonic disease. Inflammatory (B1) disease was the most common phenotype (43%). Of these 658 patients, 257 (39%) had histologic inflammation on index colonoscopy. Histologic inflammation at index colonoscopy was associated with nearly twice the LOR risk (HR 1.96, 95% CI: 1.50-2.57) with median time to relapse of 1.20 years. Biologic use at index was associated with lower LOR risk (monotherapy, HR 0.61, 95% CI: 0.45-0.82; combination therapy, HR 0.43, 95% CI: 0.28-0.66).

Conclusions: Active histologic inflammation despite endoscopic remission, and lack of biologic use were independently associated with risk of subsequent LOR, providing evidence that histologic remission may impart improved outcomes in patients with CD.

Introduction and aim: Unresectable malignant distal biliary obstruction is a condition that should be treated with drainage and clearance of the biliary duct. self-expanded metal stents (SEMS) are known to be better and more effective than plastic stents because the patency is longer. The actual evidence is insufficient to recommend if it is better the use of SEMSu over SEMSc or vice versa for the drainage of the malignant distal biliary obstruction during ERCP. We performed a systematic review and meta-analyses to demonstrate if exists superiority between one or other type of SEMS performed by ERCP.

Materials and methods: We conducted a systematic review in different databases, such as PubMed, Cochrane, Medline, and OVID database. A search was made of all studies published up to May 2023.

Results: Seven studies were analyzed. A total of 1070 patients were included. Of the total of patients, 48.9% were male. The cumulative stent patency, the failure rate, the survival probably and the adverse events rate, were similar between SEMSc and SEMSu groups. The stent migration rate was higher in the SEMSc group (RR=2.34 [95% CI: 1.35-4.08]). The tumor overgrowth was higher in the SEMSc group (RR=2.05 [95% CI: 1.13-3.72]). The tumor ingrowth was higher in the SEMSu group (RR=0.25 [95% CI: 0.11-0.61]).

Conclusions: The conclusions of our study show that there are no differences between the use of uncovered SEMS and covered SEMS for palliative treatment of distal biliopancreatic obstructions, and it has no impact on mortality or patient survival. New functional studies regarding the type of stent cover, radial force or length thereof are required.

Goals: We aimed to determine if the use of a web-based digital tool could improve methodology and reporting of breath tests (BT).

Background: Although BT represent a noninvasive and low-cost tool for the diagnosis of small intestinal bacterial overgrowth (SIBO), lack of standardization and poor test performance have been described.

Methods: We performed a retrospective analysis of a consecutive series of BT reports from 8 different gastroenterology units during the period April 2024 to July 2024. Data from the BT reports was extracted, masked, and uploaded in a digital tool that supports the entire breath test process and creates a report. Three experts in SIBO who were blinded for the test interpretation determined a diagnosis for each patient and delineated a total of 12 quality items that considered relevant to be included in a BT report. The main outcomes of the study were accuracy (ie, proportion of correct diagnoses) and quality of BT reports.

Results: A total of 210 BT were analyzed; the type of substrate was informed in 187 (89.0%) BT and lactulose was used in most of the studies (162/187, 86.6%). Most tests measured only hydrogen (89.5%) and 38 (18.1%) extended the BT for <90 minutes. SIBO was diagnosed in 92 (43.8%) and 79 (37.6%) patients in the original BT report and the digital tool report, respectively. As compared with the diagnosis by the expert gastroenterologists and current guidelines, the original report was accurate in 182 (86.6%) patients and the digital tool report in 210 (100%) patients (P<0.0001). Regarding quality of reporting, the original BT report had a median of 5 (3 to 8) items included and the digital tool report described a median of 9 (7 to 11) items (P<0.0001).

Conclusions: Breath tests methodology and interpretation for the diagnosis of SIBO are heterogenous and do not comply with current guidelines. The use of a web-based digital tool specifically developed to assist the entire BT process appears to improve accuracy and quality of reports.

Objective: Gastroesophageal reflux (GER) is often reported in barium studies (GERB). We aimed to evaluate whether GERB associates with parameters defining conclusive reflux using Lyon criteria on esophageal physiological testing (GERpH).

Methods: Adults who underwent both ambulatory reflux monitoring off antisecretory therapy and barium esophagogram between 2018 and 2023 were eligible for inclusion in this retrospective study. All reflux monitoring studies were independently reviewed to extract acid exposure time (AET) and number of reflux episodes. GERpH was diagnosed based on Lyon consensus criteria, and compared with GERB reported on barium esophagogram. Performance characteristics of GERB in predicting AET >6% and GERpH by Lyon criteria were calculated.

Results: Of 182 patients (median age: 55.0 y, 69.8% females, median body mass index: 29.8 kg/m2), 61 had GERB and 101 had GERpH, whereas 58 had neither GERB nor GERpH. AET >6% was seen in 39.3% with GERB, and never with GERB without GERpH. The sensitivity and specificity of GERB in predicting AET >6% were 31.6% and 65.1%; corresponding values in predicting conclusive gastroesophageal reflux disease were 37.6% and 71.6%, respectively. A hiatus hernia (HH) was seen in 46.8% with GERB and was associated with higher median AET (6.0% vs 3.8% without HH, P = 0.003) and higher frequency of AET >6% (50.6% vs 32.5%, P = 0.032), but not higher reflux episodes (P ≥ 0.51).

Conclusions: In patients with symptoms suspicious of reflux disease, reflux seen on a barium esophagogram has suboptimal performance characteristics in predicting conclusive gastroesophageal reflux disease. HH identified on barium esophagography is associated with a higher reflux burden on reflux monitoring.

Goals: This study aimed to assess the seroprevalence of celiac disease in Mexican patients with autoimmune thyroid diseases, hypothesizing that prevalence would align with rates observed in other populations.

Background: The association between celiac disease and autoimmune thyroid diseases has been documented globally, with varying seroprevalence rates. Historically, Mexican Mestizos were considered at low risk for celiac disease, yet recent findings suggest similar prevalence to other regions. However, data regarding Hispanic patients with autoimmune thyroid diseases are limited.

Study: This observational, descriptive, cross-sectional study involved 170 Mexican Mestizo patients diagnosed with autoimmune thyroid diseases, specifically Hashimoto thyroiditis or Graves' disease. Data on demographics, disease history, and symptoms were collected. Celiac disease seroprevalence was assessed using immunoglobulin A anti-tissue transglutaminase, immunoglobulin A deamidated gliadin peptide, and immunoglobulin G deamidated gliadin peptide antibodies, with values above a specified threshold considered positive.

Results: Among the participants, 92.4% were female, with a mean age of 45.4 years. Hashimoto thyroiditis was present in 80.6% of cases, whereas Graves disease accounted for 19.4%. The overall celiac disease seroprevalence was 8.8% (95% CI; 5.4-14.1). All individuals with positive serology had Hashimoto thyroiditis, and although no gastrointestinal symptoms were linked to seropositivity, anemia was more common in celiac-positive subjects.

Conclusions: Celiac disease seroprevalence among Mexican Mestizo patients with autoimmune thyroid diseases aligns with other populations. Serological screening for celiac disease is recommended, even in the absence of gastrointestinal symptoms. Further biopsy-confirmed studies are necessary.

Colonoscopy is a crucial tool for evaluating lower gastrointestinal disease, monitoring high-risk patients for colorectal neoplasia, and screening for colorectal cancer. In the United States, over 14 million colonoscopies are performed annually, with a significant portion dedicated to post-polypectomy follow-up. Accurate measurement of colorectal polyp size during colonoscopy is essential, as it influences patient management, including the determination of surveillance intervals, resection strategies, and the assessment of malignancy risk. Despite its importance, many endoscopists typically rely on visual estimation alone, which is often imprecise due to technological and human biases, frequently leading to overestimations of polyp size and unnecessarily shortened surveillance intervals. To address these challenges, multiple tools and technologies have been developed to enhance the accuracy of polyp size estimation. The review examines the evolution of polyp measurement techniques, ranging from through-the-scope tools to computer-based and artificial intelligence-assisted technologies.

Background and aim: The "July effect" refers to increased morbidity and mortality observed when new medical trainees start at teaching hospitals in July. This phenomenon has been noted in various conditions but has not been extensively studied in lower gastrointestinal bleeding (LGIB). LGIB accounts for 20% to 30% of major gastrointestinal bleeding admissions, with a mortality rate of 2% to 4%. This study aimed to assess the impact of the "July effect" on clinical outcomes for patients with LGIB admitted to teaching hospitals in the United States from 2016 to 2020.

Methods: This retrospective cohort study analyzed data from the Nationwide Inpatient Sample (2016 to 2020). The primary outcomes were inpatient mortality, hospital length of stay (LOS), and delays in early colonoscopy, defined as more than 24 hours from admission. The key variable was the month of admission, categorized into pre-July (May and June) and July effect (July and August) periods. Survey-weighted multivariable logistic and Poisson regression models were used to evaluate the month of admission's impact on outcomes.

Results: The study included 27,425 admissions, with 13,746 (50.1%) in May and June and 13,679 (49.9%) in July and August. Less than two-thirds (59.2%) of LGIB admissions received a colonoscopy during hospitalization. Among the 15,708 patients who underwent colonoscopy within 7 days of admission, 40.8% had an early colonoscopy (within 24 h). The overall mean hospital LOS was 4.4 days, with an in-hospital mortality rate of 1%. There was no significant "July effect" on delays in early colonoscopy [adjusted odds ratio (aOR) 1.06, 95% CI (0.99, 1.13)], hospital LOS [adjusted incidence rate ratio (aIRR) 1.02, 95% CI (1.00, 1.04)], or in-hospital mortality [aOR 1.17, 95% CI (0.91, 1.50)].

Conclusion: The study found no evidence of a "July effect" on in-hospital mortality, LOS, or delays in early colonoscopy for LGIB patients. Despite the influx of new trainees in July, patient care for LGIB in teaching hospitals seems consistent, indicating that current protocols and supervision effectively mitigate risks. Further research is needed to explore other factors influencing LGIB outcomes and overall patient care during this period.