Journal of clinical gastroenterology最新文献

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.

Background: Per-oral endoscopic myotomy (POEM) is an effective option for treating achalasia. Despite its high efficacy, a fraction of patients remain symptomatic after POEM, and the data on the optimal management of these patients is limited. Few studies have evaluated the effectiveness of repeat POEM after a failed POEM.

Aim: To evaluate the efficacy and safety of repeat POEM for persistent symptoms after the initial POEM.

Methods: We searched major databases from inception to April 2024 to identify studies evaluating the efficacy and safety of repeat POEM after failed POEM in patients with achalasia. Our outcomes of interest were clinical success (a reduction in the Eckardt score to ≤3 after the procedure), adverse events, and differences in pre-procedure and post-procedure Eckardt scores. Using the random effects model, we calculated pooled rates with 95% CI for categorical variables and mean difference (MD) with 95% CI for continuous variables.

Results: We included 6 observational studies with 123 patients. The mean time between myotomies ranged from 12.2 to 13.5 months. The pooled rate (95% CI) of clinical success was 82.69% (95% CI; 69.65%-93.06%). The pooled rate (95% CI) of adverse events was 17.97% (95% CI: 5.08%-35.15%). The pooled mean±SD post-procedure Eckardt score was 1.63±1.93. The mean post-procedure Eckardt score was significantly lower than the re-procedure Eckardt score, MD (95% CI): 3.68 (2.58, 4.78).

Conclusion: Repeated POEM is an effective option for persistent symptoms of achalasia after initial POEM; however, it is associated with nontrivial adverse events.

Background and aim: The laryngeal cognitive-affective tool (LCAT) was recently validated in the US to assess laryngeal-specific hypervigilance and anxiety. The aim of this study was to examine LCAT validity in the Taiwanese population.

Methods: This prospective single-center study enrolled adults from Hualien Tzu Chi Hospital with laryngeal symptoms for >6 months.

Results: One hundred four patients included: mean age 49.5 years (SD 13.3), 69% female, mean BMI 25.3 kg/m2 (5.8), and mean LCAT 25.9 (15.2). The LCAT had excellent internal consistency (α=0.969) and split-half reliability (Guttman=0.925).

Conclusions: The LCAT is newly validated in the Taiwanese population and assesses laryngeal-specific cognitive-affective processes in patients with chronic laryngeal symptoms.

Goals: To identify the association between infliximab trough levels (ITL) and treatment outcomes in small bowel Crohn's disease (SB-CD).

Background: Higher ITL are associated with favorable treatment outcomes in CD. However, the association between ITL and SB-CD treatment outcomes are rarely studied.

Study: This was a retrospective cross-sectional study. Patients with SB-CD who received maintenance infliximab therapy were recruited, and treatment efficacy was evaluated through double balloon endoscopy. Serum samples were collected to test ITL. The primary outcome was endoscopic remission (ER), which is defined as a Simple Endoscopic Score of Crohn's disease (SES-CD) of <3. The secondary outcome was mucosal healing (MH) (SES-CD: 0) and endoscopic response (SES-CD decreased by 50% from baseline). The factors associated with ER were also explored through logistic regression analysis.

Results: In total, 111 patients with SB-CD were enrolled. Forty-seven patients (42.3%) achieved ER. Median ITL was significantly higher in patients with ER than patients without ER (2.74 vs. 1.12 µg/mL, P<0.01). In a multivariate model, an elevated ITL was the only independent factor associated with an increased probability of ER [odds ratio (OR): 1.24, 95% CI: 1.08-1.43, P=0.003]. The cutoff level of ITL used to predict ER with a specificity of >80% was 3.45 µg/mL, and the area under the curve (AUC) was 0.790. Meanwhile, the AUC cutoff to predict MH and endoscopic responses was 0.767 and 0.759, respectively.

Conclusions: There was a significant association between higher ITL and favorable SB-CD treatment outcomes.