Journal of clinical gastroenterology最新文献

Over the past several years, there has been a wealth of new data pertaining to the management of complications of cirrhosis, resulting in several important updates to best practices and consensus guidelines. Despite these advancements and numerous recent targeted quality initiatives, hospitalizations resulting from complications of cirrhosis remain frequent, costly and associated with poor patient outcomes. An emphasis on evidence-based management of hospitalized patients with decompensated cirrhosis has the potential to decrease readmission rates and length of stay while improving overall patient outcomes. Herein, we provide an updated, evidence-based overview of the optimal inpatient management of the most frequently encountered complications associated with cirrhosis.

Background: Swallowed topical corticosteroids (STC) are an effective first-line therapy for patients with eosinophilic esophagitis (EoE), both for induction and maintenance of remission. All interventional trials with STC used twice-daily dosing regimens. However, in other inflammatory gastrointestinal disorders, corticosteroids are given once daily (OD) with equal outcomes and improved compliance.

Goals: To evaluate the effectiveness of topical budesonide maintenance treatment in a once-daily dosing schedule.

Study: Retrospective analysis of confirmed patients with EoE, treated with topical budesonide as maintenance therapy OD, with adequate follow-up available. Patients currently treated with budesonide were contacted to fill out online questionnaires regarding symptoms and health-related quality of life (HRQOL). The primary end point was histologic remission, defined as peak eosinophil count (PEC) <15 eosinophils per high power field (HPF) after >12 weeks of budesonide OD.

Results: We included 29 patients on STC OD (1 mg, N=28; 0.5 mg, N=1), either budesonide orodispersible tablet (BOT, Jorveza, Dr. Falk Pharma; N=12) or budesonide viscous solution (BVS; N=17). After a median follow-up of 767 days on OD dosing (range: 103 to 2396), 86% of patients were in histologic remission. Four patients had histologic disease activity, of which one was treated with BOT. Two patients experienced a slight increase in PEC after dose reduction of BVS to OD (to PEC of 25 and 35/HPF, respectively). However, after switching the formulation to BOT OD they achieved histologic remission.

Conclusions: In this retrospective study, we demonstrated favorable results in the majority of patients treated with budesonide 1 mg OD as maintenance treatment for eosinophilic esophagitis.

Goals: To explore dynamic contrast-enhanced ultrasound (CEUS) parameters in predicting hepatic vein pressure gradient (HVPG) for patients with liver cirrhosis (LC).

Background: Noninvasive diagnosis of HVPG remains a challenge.

Study: This prospective study included patients with LC undergoing hepatic vein catheterization and pressure measurement at the hospital from May 2021 to January 2023. The CEUS images (Mindray Resona R9, 1-6-MHz probe frequency; mechanical index=0.08; image depth=10 cm; focus at the lowest point of the diaphragm; dynamic range=70 dB; optimal gain; single SonoVue bolus injection) were taken for 60 seconds after injection and analyzed using VueBox. HVPG (ie, the gold standard for portal hypertension) was measured routinely by catheterization.

Results: Fifty patients with LC were included in the study. The rise time (r=0.6, P<0.01), the fall time (r=0.7, P<0.01), the peak time (r=0.6, P<0.01), wash-in area under the curve (AUC) (r=0.5, P<0.01), the wash-out phase AUC (r=0.4, P<0.01) and wash-in and wash-out phase AUC (r=0.4, P<0.01) of the dynamic spleen CEUS were positively correlated with HVPG. The optimal fall time cutoff levels to predict HVPG ≥10 mm Hg and ≥12 mm Hg were 27.0 and 36.4 seconds, with the AUC being 0.958 and 0.941, respectively. The optimal area under the wash-in area cutoff level to predict HVPG ≥10 mm Hg and ≥12 mm Hg was 1,658,967.38 (a.u) and 4,244,015.90 (a.u), with the AUC being 0.865 and 0.877, respectively.

Conclusions: The fall time and wash-in AUC obtained by dynamic CEUS may help diagnose HVPG in patients with LC without requiring invasive hepatic vein catheterization.

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.

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.