Journal of clinical gastroenterology最新文献

Goals: To determine long-term efficacy and safety of tCS for treatment of EoE.

Background: Maintenance therapy with topical corticosteroids (tCS) is recommended for eosinophilic esophagitis (EoE), but data for long-term use are still needed.

Study: This retrospective cohort study assessed newly diagnosed patients with EoE who were treated with a tCS and had a follow-up endoscopy with biopsy after at least 5 years. Histologic symptomatic and endoscopic responses were extracted from medical records. Patients who did and did not have long-term tCS treatment were compared at baseline, and outcomes for patients were assessed at their last endoscopy while on tCS.

Results: Of 431 patients with EoE treated with tCS, 104 met inclusion criteria for long-term use. For patients with long-term tCS use, the median time (IQR) on tCS was 6.5 years (5.4 to 8.8 y). At the last endoscopy, 54% had histologic response (<15 eos/hpf), but those with excellent adherence had a histologic response of 64%. Endoscopic severity also decreased with improved adherence which was strongly associated with EREFS (1.7 vs. 2.8 vs. 4.0 for excellent, good, and poor adherence; P<0.001). Symptomatic response was 68% overall, but only 40% in those with poor adherence (P=0.07). Complications of taking tCS were uncommon (adrenal insufficiency: 1%; osteopenia: 1%; and esophageal candidiasis: 4% at final endoscopy).

Conclusions: Long-term tCS (median 6.5 y) were generally effective, especially with better adherence, and also safe, with only rare serious complications. These data can be used to help patients make clinical decisions about chronic tCS use in EoE.

Objective: Endoscopic ultrasound (EUS) is routinely used for fiducial marker placement (FMP) to guide stereotactic radiation of pancreatic tumors, but EUS-FMP explicitly to guide surgery has not been studied in a prospective, controlled manner. Multipurpose EUS systems have been developed that facilitate simultaneous EUS-FMP at the time of biopsy. We aimed to evaluate the feasibility of EUS-FMP to guide pancreatic resection.

Methods: In this prospective trial, we enrolled patients with resectable pancreas masses undergoing tissue sampling and placed preloaded fiducials immediately after biopsy. Intraprocedure confirmation of carcinoma, neuroendocrine, and nonlymphomatous neoplasia by rapid on-site evaluation and lesion size <4 cm was required. The main outcomes were the feasibility and ease of preoperative placement and intraoperative detection of the markers using predefined Likert scales.

Results: In 20 patients, EUS-FMP was successful before planned surgery and placement was technically straightforward (Likert Scale: 9.1 ± 1.3; range: 1, most challenging to 10, most facile). Intraoperative detection was feasible and improved when compared with a pre-established comparator of 5 representing an equivalent lesion without a marker (Likert Scale: 7.8 ± 2.2; range: 1, most difficult to 10, most facile; P = 0.011). The mean tumor size on EUS was 1.7 ± 0.9 (range: 0.5 to 3.6) cm.

Conclusion: EUS-FMP is feasible and safe for resectable pancreatic tumors before surgery and may assist in perioperative detection. Preloaded fiducials may be considered for placement at the time of initial referral for EUS-fine needle biopsy.

Objective: Functional dyspepsia (FD) is a gastrointestinal functional disorder of the upper gastrointestinal tract that affects the quality of life of patients and poses a significant economic burden. It has been proposed that the local inflammatory immune response at the duodenum is associated with an increase in intestinal permeability, favoring the recruitment of Th2 cells and granulocyte degranulation. Moreover, systemic immune response could also be related to the symptoms of FD. The objective of this study was to evaluate the systemic immune response in Uruguayan patients with FD by analyzing the cytokine levels in plasma and the frequency of circulating T cells associated with duodenal recruitment.

Patients and methods: An analytic and cross-sectional study in 30 patients with FD and 15 healthy controls (HCs) was carried out. Patients were diagnosed with FD according to the Roma IV Committee definition. Cytokine levels were measured in plasma by a specific assay. Expression of α4β7 and CC chemokine receptor9 in circulating T cells was evaluated by flow cytometry.

Results: Higher levels of interleukin (IL)-5, IL-13, and IL-8 and lower levels of IL-10 and IL-12p70 were detected in patients with FD than in HC. Furthermore, a positive linear correlation between IL-13 and the severity of FD symptoms was found. CD4 + T cells from patients with FD expressed higher levels of α4β7 and CC chemokine receptor9 than those from HC.

Conclusions: An increase of Th2-like cytokines and a positive correlation between the levels of plasma IL-13 and the severity of symptoms in patients with FD from Uruguay were detected.

Background and goals: The Fibrosis-4 Index (FIB-4) has demonstrated a strong association with severe liver disease (SLD) outcomes in primary care, but previous studies have only evaluated this relationship using 1 or 2 FIB-4 scores. In this study, we determined the association of FIB-4 as a time-varying covariate with SLD risk using time-dependent Cox regression models.

Study: This retrospective cohort study included primary care patients with at least 2 FIB-4 scores between 2012 and 2021. The outcome was the occurrence of an SLD event, a composite of cirrhosis, complications of cirrhosis, hepatocellular carcinoma, and liver transplantation. The primary predictor was FIB-4 advanced fibrosis risk, categorized as low-(<1.3), indeterminate-(1.3≤FIB to 4<2.67), and high-risk (≥2.67). FIB-4 scores were calculated and the index, last, and maximum FIB-4s were identified. Time-dependent Cox regression models were used to estimate hazard ratios (HR) and their corresponding 95% CI with adjustment for potentially confounding covariates.

Results: In the cohort, 20,828 patients had a median of 5 (IQR: 3 to 11) FIB-4 scores each and 3% (n=667) suffered an SLD outcome during follow-up. Maximum FIB-4 scores were indeterminate-risk for 34% (7149) and high-risk for 24% (4971) of the sample, and 32% (6692) of patients had an increase in fibrosis risk category compared with their index value. The adjusted Cox regression model demonstrated an association between indeterminate- (hazard ratio 3.21; 95% CI 2.33-4.42) and high-risk (hazard ratio 20.36; 95% CI 15.03-27.57) FIB-4 scores with SLD outcomes.

Conclusions: Multiple FIB-4 values per patient are accessible in primary care, FIB-4 fibrosis risk assessments change over time, and high-risk FIB-4 scores (≥2.67) are strongly associated with severe liver disease outcomes when accounting for FIB-4 as a time-varying variable.

Background and aims: IgG4 pancreaticobilliary disease (IgG4-PBD) typically shows a rapid improvement with glucocorticoid treatment, yet most patients experience a recurrence. Rituximab (RTX) has emerged as a hopeful approach to prevent relapses in IgG4-PBD. Nevertheless, there is a lack of data on the efficacy and safety of RTX in IgG4-PBD. In this study, we aim to perform a systematic review and meta-analysis to study the pooled efficacy of RTX in this patient population.

Methods: Multiple databases, including MEDLINE, SCOPUS, and Embase, were searched (in March 2024) using specific terms for studies evaluating the efficacy and safety of RTX in IgG4 pancreatic biliary disease. Outcomes of interest were relapse, remission, partial remission rates, and adverse events. Standard meta-analysis methods were used using the random-effects model. I2% heterogeneity was used to assess the heterogeneity.

Results: Twelve studies were included in the study (257 patients). The pooled rate of complete remission was 68% (54% to 80%), I2 =53%, respectively. The pooled relapse rate was 23% (13% to 36%), I2=64%. The pooled rate of total adverse events was 21% (12% to 35%), I2=52%. The pooled partial remission rate is 16% (7% to 32%), I2=25%. The pooled rate of complete and partial remission was 81% (66% to 90%), I2=75%. The pooled infusion reaction and infection were 12% (7% to 18%), I2=0% and 14% (8% to 22%), I2=16%, respectively.

Conclusion: RTX therapy appears effective in inducing and maintaining remission of pancreaticobiliary disease with a low rate of side effects. RTX presents as a promising treatment option for patients grappling with recurrent or unresponsive IgG4-related ailments. In addition, RTX emerges as an attractive alternative for individuals intolerant to steroids or experiencing IgG4-related disease relapses. Future studies comparing RTX with other immunomodulators will offer deeper insights into relapse factors and elucidate the appropriateness of utilizing this maintenance treatment following the initial flare.

Objective: We aimed to assess the hospital frailty risk score on the inpatient mortality, morbidity, and health care resource utilization among endoscopic retrograde cholangiopancreatography (ERCP)-related hospitalizations.

Background: Data regarding the inpatient mortality, morbidity, and health care resource utilization of ERCP among frail individuals remain limited.

Materials and methods: Using the Nationwide Inpatient Sample, we compared the odds of inpatient mortality and morbidity of ERCP-related hospitalizations among individuals with low frailty scores, intermediate frailty scores (IFSs), and high frailty scores (HFSs).

Results: Overall, 776,025 ERCP-related hospitalizations were recorded from 2016 to 2020. 552,045 had a low frailty score, whereas 217,875 had an IFS, and 6105 had an HFS. Frail individuals had a 5-fold increase in mortality [IFS: adjusted odds ratio (aOR) = 4.81, 95% CI: 3.77-6.14; HFS: aOR = 4.62, 95% CI: 2.48-8.63]. An IFS was associated with a 24% increase in post-ERCP pancreatitis (aOR = 1.25, 95% CI: 1.11-1.41), a 3-fold increase in post-ERCP bleeding (aOR = 2.59, 95% CI: 1.82-3.67), and a 2-fold increase in post-ERCP duct perforation (aOR = 1.91, 95% CI: 1.38-2.64). Frail individuals experienced higher odds of in-hospital morbidity, including secondary sepsis, respiratory failure, acute kidney injury, cerebrovascular accidents, deep vein thrombosis, and pulmonary embolism.

Conclusions: In summary, our study presents strong evidence in support of using the hospital frailty risk score as an index to predict mortality and morbidity during ERCP-related hospitalizations. Additional caution is warranted in the management of frail individuals undergoing ERCP.

Background and objectives: Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a viable alternative in cases with failed ERCP transpapillary drainage (ERCP-TPD). This systematic review and meta-analysis aimed to compare the efficacy and safety of EUS-BD and ERCP-TPD for primary biliary drainage in patients with distal malignant biliary obstruction (DMBO).

Methods: We searched Embase, PubMed, and Medline databases for studies comparing EUS-BD and ERCP-TPD in DMBO, from inception until September 2023. The primary endpoint was clinical success and secondary endpoints included technical success, procedure duration, and adverse events.

Results: Eight studies (815 patients, 56.1% male) were included in this analysis. Indications for biliary drainage were pancreatic carcinoma (75.1%), followed by cholangiocarcinoma (10.1%). Clinical success was comparable between EUS-BD and ERCP-TPD groups (OR 1.34; 95% CI, 0.75-2.40; P=0.32). Technical success was similar between the 2 groups (OR 2.09; 95% CI, 0.83-5.25; P=0.12). There was a trend toward fewer adverse events in the EUS-BD group (OR 0.65; 95% CI, 0.40-1.07; P=0.09), with significantly lower odds of post-procedure pancreatitis (OR 0.17; 95% CI, 0.06-0.50; P=0.001).

Conclusion: EUS-BD is comparable to ERCP for primary biliary drainage in DMBO patients with shorter procedural time and a significantly reduced risk of post-procedure pancreatitis.

Background: Question prompt lists (QPLs) are structured sets of disease-specific questions intended to encourage question-asking by patients and enhance patient-physician communication. To date, an EoE-specific QPL has not been developed for EoE patients.

Aim: To develop a preliminary QPL specific to adults with EoE by incorporating input from international esophageal experts.

Methods: Sixteen experts were invited to generate QPL content through a modified Delphi (RAND/University of California, Los Angeles, CA) method consisting of 2 rounds of independent ratings. In round 1, experts provided 5 answers to the prompts "what general questions should patients ask when being seen for EoE?" and "what questions do I not hear patients asking but given my experience, I believe they should be asking?" In round 2, experts rated each question on a 5-point Likert scale, and responses rated as "essential" or "important" (determined by an a priori median threshold of ≥ 4.0) were accepted for the EoE QPL.

Results: Ten esophageal experts participated in both rounds. Round 1 generated 100 questions. Questions were combined and modified to reduce redundancy, yielding 57 questions. After round 2, 51 questions (85%) were accepted for inclusion (median value ≥ 4.0) in the final QPL. Questions were then divided into 4 themes based on disease domains: (1) "What is EoE?," (2) "Treatment Options," (3) "Follow-up Surveillance and Long-term Risks," and (4) "Allergy and Genetic Testing." The largest number of questions covered was "What is EoE?" (16/51 or 31%). Questions with the highest agreement median (5.0) included examples such as "what should I do if I get a food impaction?" and "what are the treatment options?"

Conclusion: This is the first preliminary EoE QPL developed in the field of medicine. We hope implementation enhances effective patient-physician communication by encouraging patients to ask relevant questions that experts prioritized. Future studies will aim to modify this communication tool by incorporating patient perspectives.

Objective: Gastric antral vascular ectasia (GAVE) is characterized by vascular ectasias accounting for 4% of nonvariceal upper gastrointestinal bleeds, which can range from occult bleeds to severe acute upper gastrointestinal bleeding. In turn, GAVE can lead to severe morbidity and recurrent hospitalization. Current endoscopic treatments for GAVE include argon plasma coagulation (APC), endoscopic band ligation (EBL), and radiofrequency ablation. With this significant burden in mind, a systematic review and network meta-analysis were conducted to compare the efficacy and safety of various modalities in the treatment of GAVE.

Methods: All studies that involved adults and children with endoscopic characteristics of GAVE undergoing treatment with APC, EBL, radiofrequency ablation, or a combination of 2 treatment modalities were included.

Results: There was no statistical difference in the rate of adverse events and the number of red blood cell transfusions across all 3 groups (APC, EBL, and APC + EBL). However, statistical differences were noted for outcomes of bleeding recurrence, length of hospitalization, and change in hemoglobin status. EBL exhibited a significant decrease in bleeding recurrence when compared with APC. Moreover, shorter hospitalization stays were seen in APC + EBL and EBL groups compared with APC, and a beneficial change in hemoglobin status was also more often seen in APC + EBL and EBL groups compared with APC.

Conclusions: Based on this study, EBL was found to have superior efficacy when compared with APC for the treatment of GAVE; however, there was no significant difference in rates of adverse events between APC, EBL, and combination therapy.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) are interventions used to relieve biliary obstruction. The utility of ERCP compared with PTBD is not fully understood from a utilization outcome standpoint. Our study compares readmission rates and hospitalization outcomes in ERCP and PTBD.

Methods: Using the National Readmission Database (NRD) 2016 to 2020, we identified all patients with an ERCP or PTBD completed during admission. The study cohort was first analyzed by 3 weighted study arms including those admitted with cholangitis, biliary/pancreatic malignancy, and choledocholithiasis. Second, we analyzed the cohort by a 1:1, unweighted propensity match. The primary outcome was 30 day, 90 day, and 6 month readmission. Secondary outcomes were readmission/overall mortality, cost, and length of stay. Outcomes were analyzed using multivariate analysis.

Results: A total of 621,735 admissions were identified associated with 589,796 ERCP and 31,939 PTBD. In the propensity matched cohort, PTBD had a higher readmission rate at 30 days (20.38% vs. 13.71% P<0.0001), 90 days (14.63% vs. 13.14%, P<0.0001) but lower rate at 6 months (8.50% vs. 9.67%, P=0.0003). Secondary outcomes included increased PTBD-associated hospital length of stay (9.01 d vs. 6.74 d, P<0.0001), hospitalization cost ($106,947.97 vs. $97,602.25, P<0.0001), and overall mortality (6.86% vs. 4.35%, P<0.0001). No major differences were found for mortality among readmissions at 30 days (7.19% vs. 6.88%, P=0.5382), 90 day (6.82% vs. 6.51%, P=0.5612), and 6 months (5.08% vs. 5.91%, P=0.1744).

Conclusions: ERCP demonstrated superior results compared with PTBD for readmission rates, length of stay and overall mortality. For failed ERCP cases, emerging data for Endoscopic ultrasound guided-biliary drainage (EUS-BD) offers potential over PTBD and may provide additional options for the future in tertiary referral centers with experience.