Journal of clinical gastroenterology最新文献

Introduction and objectives: The portal vein pressure higher than 10 mm Hg in patients with hepatic cirrhosis is more likely to have serious complications and poor prognosis. Nonselective receptor blockers (NSBBs) can reduce the portal vein pressure; however, the efficacy and safety of different NSBBs in reducing portal vein pressure were unconsistent. A systematic review and meta-analysis was conducted to evaluate the efficacy and safety of carvedilol versus propranolol in reducing portal vein pressure in this study.

Materials and methods: We assessed Randomized controlled trials (RCTs) through PubMed, Web of science, Embase, and Cochrane library up to January 2024. Data from eligible studies were pooled in fixed-effect or random-effect meta-analysis models, using RevMan software. Two researchers screened articles, extracted data, and assessed the study quality independently according to the PRISMA guidelines. The primary outcomes were the reduction of hepatic venous pressure gradient (HVPG), the hemodynamic response rate, and the incidence of adverse events. Secondary outcomes were mean artery pressure (MAP) and heart rate (HR).

Results: A total of 7 RCTs, including 351 patients, were included in our meta-analysis. The results indicated that the magnitude of reduction in HVPG was greater in carvedilol compared with propranolol (MD: 1.08; 95% CI: 0.61 to 1.54; I2 =0%, P <0.00001) in short-term follow-up. Carvedilol's hemodynamic response rate was higher than that of propranolol (OR: 0.44; 95% CI: 0.27 to 0.72; I2 =0%, P = 0.001).

Conclusions: Our meta-analysis indicated that compared with propranolol, carvedilol was better in lowering portal hypertensive and had higher response rate in patients with hepatic cirrhosis. There was no obvious difference in safety between the 2 medications.

Background: Several clinical practice guidelines (CPGs) exist for managing Barrett's esophagus (BE). However, the methodological quality of these CPGs is not known. To summarize the methodological quality of CPGs, we performed a critical appraisal of all available CPGs for the management of BE published from January 2018 to February 2023.

Methods: A comprehensive search of EMBASE and PubMed was conducted to identify eligible CPGs published from January 1, 2018, until February 24, 2023, addressing the management of BE. The Canadian Agency for Drugs and Technologies broad filter was also utilized in the search. The quality of the CPGs was independently assessed and evaluated by 2 reviewers using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument, with domain scores showing good quality being >80% and sufficient quality being >60%. The search yielded 652 citations, of which 5 CPGs met eligibility.

Results: Three CPGs were published by gastroenterology societies in the United States and 2 in Europe. The overall median score for the AGREE II domain was 100% for scope and purpose, 93% for stakeholder involvement, 93% for rigor of development, 93% for clarity of presentation, 75% for applicability, and 75% for editorial independence.

Conclusion: The findings from our study show that there is significant variability in the methodological quality of the CPGs for the management of BE across different domains. The application of the AGREE II tool can help CPG developers in improving the methodological rigor and applicability of CPGs.

Introduction: Clostridioides difficile infection (CDI) is a major complication in patients with inflammatory bowel disease (IBD), contributing to increased morbidity, mortality, and health care burden. This study aimed to evaluate national trends and clinical outcomes associated with CDI in hospitalized IBD patients in the United States.

Methods: We conducted a retrospective cohort study using the National Inpatient Sample (NIS) from 2012 to 2021. Adult patients hospitalized with a primary or secondary diagnosis of IBD (Crohn's disease or ulcerative colitis) were stratified into 2 groups by the status of CDI diagnosis (either primary or secondary diagnosis). Demographic characteristics, hospital outcomes, and complications were compared between CDI and non-CDI cohorts. Multivariable logistic regression was used to identify independent predictors of in-hospital mortality, septic shock, and venous thromboembolism (VTE).

Results: Among 4,193,564 hospitalized IBD patients, 534,190 (12.7%) had CDI. CDI patients were older (mean: 68.8 vs 53.3 y, P < 0.001), with higher in-hospital mortality (3.6% vs 2.0%, P < 0.001), VTE (23.7% vs 6.2%, P < 0.001), septic shock (5.4% vs 4.0%, P < 0.001), and mechanical ventilation use (4.2% vs 2.8%, P < 0.001). Ulcerative colitis was more frequently associated with CDI than Crohn's disease (30.3% vs 25.0%, P < 0.001) and independently predicted septic shock (OR: 1.09) and VTE (OR: 1.06) but was associated with lower mortality (OR: 0.81).

Conclusion: The presence of CDI in hospitalized patients with IBD led to significantly worse outcomes. Ulcerative colitis is more commonly associated with CDI and increased risk of complications. These findings highlight the need for early detection, preventive strategies, and tailored management of CDI in the IBD population.

Background: Mastocytic enterocolitis has been proposed as a cause of chronic diarrhea and abdominal pain, characterized by increased mast cells in gastrointestinal mucosal biopsies. However, its clinical significance remains uncertain.

Methods: We present a case report of a patient identified to have high levels of mast cells on gastrointestinal biopsies. We then reviewed cases at Mayo Clinic where patients had >20 mast cells per high-power field (HPF) on gastrointestinal biopsies. Patients with alternative explanations for mast cell elevation, including systemic mastocytosis were excluded. We analyzed demographics, clinical presentations, pathology reports, serum and urine mast cell mediators, inflammatory markers, bone marrow biopsies, motility testing, and treatment responses.

Results: We identified 42 patients (30 female and 12 male) with elevated mast cells on biopsy (mean age: 41 y, range: 17 to 81). Mast cells were quantified using KIT (CD117) staining, with no abnormal clumping or morphology, and CD25 immunostaining was negative in all cases. Eosinophilic infiltration was absent in all but one case. Small intestinal bacterial overgrowth (SIBO) was found in 78% of patients tested. Treatments varied widely, with antihistamines and cromolyn being the most common. Among 21 patients with sufficient follow-up, only 5 (24%) reported partial or complete symptom improvement, while 76% experienced persistent symptoms.

Conclusion: Routine assessment of mast cells on gastrointestinal biopsies is not supported by our findings. Elevated mucosal mast cells, in the absence of systemic mast cell disorders, may not indicate a distinct disease entity. Evaluation should focus on ruling out other inflammatory, allergic, infectious, and motility disorders, as well as SIBO. Further research is needed to determine the clinical significance of increased mucosal mast cells and their role in gastrointestinal symptomatology.

Background: Gastrostomy tube (GT) placement is essential for patients requiring long-term enteral access, but the relative safety of percutaneous endoscopic gastrostomy (PEG), radiologic placement (IR), and surgical gastrostomy across global populations remains uncertain. Previous large-scale studies, such as Kohli and colleagues, demonstrated favorable outcomes for PEG in US cohorts; however, their external validity to international health care systems is unclear.

Materials and methods: We conducted a retrospective cohort study using the TriNetX Global Research Network, including 146 health care organizations worldwide (2005-2024). Hospitalized patients undergoing GT placement through PEG, IR, or surgical techniques were identified using ICD-10-PCS codes. After 1:1 propensity score matching by demographics and comorbidities, outcomes were compared across groups using odds ratios (ORs) with 95% CIs. Primary outcomes included mortality, transfusion, colon perforation, and infection; secondary outcomes included discharge disposition, device-related complications, and SNF/rehab placement.

Results: After matching, PEG was associated with significantly lower odds of transfusion (OR: 0.844, P = 0.001), non-home discharge (OR: 0.514, P < 0.001), and SNF placement (OR: 0.491, P < 0.001) compared with IR, with no significant differences in infection or mortality. Compared with surgical gastrostomy, PEG showed lower risks of colon perforation (OR: 0.144, P < 0.001), transfusion (OR: 0.635, P < 0.001), and mortality (OR: 0.724, P < 0.001), though higher risks of gastrostomy infection (OR: 1.266, P = 0.001) and mechanical complications (OR: 1.129, P = 0.001). IR placement demonstrated lower perforation, transfusion, and mortality risks compared with surgery but higher likelihood of non-home discharge and SNF placement.

Conclusion: In this global cohort, PEG consistently demonstrated superior safety and patient-centered outcomes compared with IR and surgical gastrostomy, supporting its role as the preferred method of GT placement when feasible. These findings reinforce the need for expanded endoscopic infrastructure and training in health care systems worldwide.

Background: Cannabis use (CU) has increased since its legalization, and we are currently assessing its impact on various chronic conditions. The literature supports the anti-inflammatory and antifibrotic effects of cannabidiol in various liver diseases using in vivo and in vitro models. This study explored the role of CU in the outcome of hospitalized patients with metabolic dysfunction-associated steatotic liver disease (MASLD).

Methods: The National Inpatient Sample (NIS) 2016 to 2020 was used to identify adult patients (above 18 y of age) with MASLD using ICD-10 codes. Patients were stratified into 2 groups based on the prevalence of CU. Data were collected on patient demographics, the Elixhauser Comorbidity Index, and comorbidities. A multivariate logistic regression analysis was performed to evaluate the impact of CU on these outcomes.

Results: Of the 3,379,484 patients, CU was identified in 52,315 (1.54%). After adjusting for confounding factors, patients with CU had lower odds of in-hospital mortality (aOR, 0.70; 95% CI: 0.61-0.80; P<0.001), cirrhosis (aOR, 0.72; 95% CI: 0.68-0.76; P<0.001), decompensated cirrhosis (aOR, 0.73; 95% CI: 0.68-0.78; P<0.001), chronic kidney disease (aOR, 0.81; 95% CI: 0.76-0.86; P<0.001), and hepatocellular carcinoma (aOR, 0.71; 95% CI: 0.57-0.89; P=0.003), but higher odds of myocardial infarction (MI) (aOR, 1.42; 95% CI: 1.27-1.83; P<0.001) and stroke (aOR, 1.53; 95% CI: 1.27-1.83; P<0.001).

Discussion: Our study highlights that patients with MASLD have a lower risk of developing liver-related events, but a higher risk of MI and stroke with concomitant CU. Clinical trials involving CU and monitoring of its effects are limited, and further research is needed to elucidate the mechanisms underlying these novel findings.

Background: In adults, the diagnosis of celiac disease (CeD) relies on the presence of disease-specific antibodies and the confirmation of duodenal atrophy. This study aimed to develop a diagnostic model to predict duodenal atrophy in adults, with the goal of assessing the reliability of a non-biopsy diagnostic approach based on serology.

Methods: We conducted a retrospective observational study including consecutive adult patients who attended the Gastroenterology Department of Hospital de Clínicas between 2004 and 2023. Group 1 comprised patients with positive tTG and Marsh 3 lesions, whereas group 2 included patients with normal duodenal biopsies, irrespective of tTG results. Logistic regression models were applied using different tTG cutoff values (dependent variable) to discriminate between "CeD" and "non-CeD".

Results: A total of 211 patients met criteria for group 1 and 267 for group 2. Specificity exceeded 98% at tTG levels ≥2.5 upper the normal level (UNL), with the highest specificity observed at 109 U (5.5 UNL). Model development was restricted to individuals with complete data on all significant variables (n=290; 134 cases, 156 controls). Female sex and folic acid deficiency emerged as significant predictors, increasing sensitivity but not specificity at the 3 and 4 UNL.

Conclusions: In this cohort, a TTG value >5.5 UNL achieved 100% specificity and could potentially obviate the need for diagnostic endoscopy in adults with suspected CeD. Although female sex and folic acid deficiency were independent predictors of CeD, their inclusion did not enhance the predictive performance at a lower tTG cutoffs.

Purpose: The burden of inflammatory bowel disease (IBD) is rising among older adults. We aimed to identify prioritized therapy goals and to evaluate the associations between treatment goal clusters and other factors with well-being in older IBD patients.

Materials and methods: An international survey was conducted by the European Federation of Crohn's and Ulcerative Colitis Associations in IBD patients aged 60 years or older. Participants had to select 3 out of 12 therapy goals. Cluster analysis was performed to identify patterns of therapy goals. was assessed using a 5-point Likert Scale. Ordinal regression models were performed to assess determinants of well-being.

Results: Among 1997 respondents (median age: 66 y; 61% females) from 34 countries, the most frequently selected therapy goals were reducing fatigue (56%) and preserving or restoring a good mood (43%). Six clusters of therapy goals were identified. Lower well-being was associated with clinical disease activity [adjusted odds ratio (aOR): 4.90, 95% CI: 3.89-6.20], risk for frailty (aOR: 2.09, 95% CI: 1.70-2.57), and more than 2 comorbidities (aOR: 2.23, 95% CI: 1.61-3.08), as well as therapy goal clusters focusing on IBD symptom control (aOR: 3.23, 95% CI: 2.16-4.88) and mobility capacity (aOR: 2.21, 95% CI: 1.46-3.37) compared with the activity engagement cluster (prioritizing mobility capacity and social life).

Conclusions: Older patients prioritized therapy goals focusing on symptom management over established therapy goals. Well-being was mainly influenced by clinical disease activity, risk for frailty, and comorbidity. Future research should integrate therapy goals and well-being assessment into routine clinical care.

Background: Early recurrence of intrahepatic cholangiocarcinoma (ICC) is difficult to predict. Traditional machine learning prediction models, characterized by their black-box nature, may be biases or ethical risks.

Methods: The XGBoost algorithm develops the machine learning prediction model. The area under the receiver operating characteristic curve (AUC) served for evaluating model performance. The SHAP algorithm conducts interpretability analysis.

Results: A total of 503 patients with 323 in the training cohort and 180 in the validation cohort. Tumor size, lymph node metastasis, microvascular invasion (MVI), and CA19-9 levels were identified as independent predictors of ICC early recurrence. The predictive model demonstrated the highest discriminative power in both training and validation cohorts (AUC 0.76 vs. 0.72, respectively). SHAP analysis demonstrates the decision-making process of the machine learning model.

Conclusions: The XGBoost model for predicting early recurrence of ICC demonstrates accuracy and reliability. Explainable machine learning models, which balance transparency and accuracy.

Goals: To compare the effectiveness, durability, and safety of vedolizumab and upadacitinib for CD through 52 weeks.

Background: Comparative real-world data for vedolizumab versus upadacitinib in Crohn's disease (CD) are limited.

Study: This retrospective cohort study included 139 adults with active CD who began vedolizumab (n=72) or upadacitinib (n=67) during 2023 at a large academic health system. Co-primary outcomes were steroid-free clinical remission (SFCR) at 12 and 52 weeks and treatment discontinuation within 52 weeks; secondary outcomes included clinical response at 12 and 52 weeks. Inverse probability of treatment weighting balanced relevant confounders. Logistic regression was used for binary outcomes and Cox proportional hazards and competing risks regression were used for treatment discontinuation. Adverse events were ascertained by manual chart review.

Results: After weighting, all covariates were balanced (standardized mean differences <0.10). At 12 weeks, vedolizumab was associated with lower odds of clinical response versus upadacitinib (OR: 0.36; 95% CI: 0.16-0.85). There were no significant differences for SFCR, treatment discontinuation, or other outcomes through 52 weeks. Competing risks regression, accounting for adverse events as competing events, showed a higher incidence of treatment discontinuation due to nonresponse for vedolizumab, but this did not reach statistical significance. Adverse events within 52 weeks were comparable (vedolizumab 33% vs. upadacitinib 39%; P=0.45), and discontinuations due to adverse events were infrequent (3% vs. 6%).

Conclusions: In this tertiary-center cohort, upadacitinib produced faster clinical response at 12 weeks, but SFCR, durability, and safety profiles were similar through 52 weeks.