Journal of clinical gastroenterology最新文献

Goals: To compare clinical outcomes of terlipressin as continuous versus bolus infusion for the management of acute variceal hemorrhage.

Background: Terlipressin is commonly used in the management of acute variceal bleeding, but evidence on the optimal method of administration-continuous infusion versus intermittent bolus-is limited.

Study: Patients presented with acute variceal bleeding were randomized into 2 arms: the intervention arm and the control arm received continuous and bolus infusion of terlipressin, respectively. Clinical endpoints included in-hospital mortality, 6-week mortality, the length of hospital stay, rebleeding and transfusion rates, and adverse events. Hemodynamic outcomes included were stability of heart rate, systolic, diastolic, and mean arterial blood pressures.

Results: A total of 128 patients were analysed. In-hospital mortality was none in both arms (P=0.490). Mean length of stay for the intervention arm was 60.56±30.87 hours and the control arm was 57.80±33.35 hours (P=0.569). Rebleeding was reported in 2 patients in each arm (P=0.569). Packed cell transfusion rates were, 2.47±1.59 versus 2.17±0.98 units in intervention and control arm, respectively (P=0.256). The 6-week mortality was 7 in the intervention and 12 in the control arms (P=0.220). Bolus administration led to a greater reduction in heart rate at 4, 8, and post-20 hours (P<0.05). Systolic blood pressure improved at 16 and 24 hours in the intervention arm (P=0.02).

Conclusions: There was no difference in length of hospital stay, packed cell volume, rebleeding, and mortality between both modes of terlipressin administration. Somewhat better improvement in systolic blood pressure was observed in patients who received a continuous infusion of terlipressin without any impact on clinical outcomes.

Goals: To compare the interobserver variability of the American Foregut Society (AFS) endoscopic classification of esophago-gastric junction (EGJ) integrity with the Hill classification among endoscopists with varying expertise, assessing reproducibility in real-world clinical settings.

Background: Gastroesophageal reflux disease (GERD) is a common indication for esophagogastroduodenoscopy (EGD), yet endoscopic EGJ assessment often lacks standardization. The Hill classification, traditionally used, has limitations, including vague grade distinctions and poor interobserver reliability. The AFS classification, incorporating axial hiatal hernia length (L), hiatal aperture diameter (D), and gastroesophageal flap valve presence (F), offers a standardized protocol to improve consistency and stratification of EGJ disruption.

Study: This multicenter, prospective, blinded study involved 21 endoscopists (10 gastroenterologists, 11 surgeons) evaluating 48 deidentified EGJ video clips using both Hill and AFS classifications. Participants, with varied experience levels, graded EGJ integrity independently. Interobserver agreement was assessed using the Intraclass Correlation Coefficient (ICC) and Fleiss' Kappa (κ) for overall and individual components.

Results: The AFS classification demonstrated superior interobserver agreement (ICC=0.749) compared with the Hill classification (ICC=0.651) (P=0.002). AFS grade 4 showed the highest concordance (κ=0.730), while Hill grade 2 had the lowest (κ=0.239). Agreement was excellent among experienced AFS users (ICC=0.813) and good for first-time users (ICC=0.709) (P=0.003). Interobserver variability of the AFS classification among first-time users was significantly lower than the Hill classification variability (P=0.025). L and D components showed good agreement (ICC=0.729, 0.686), while F had moderate agreement (ICC=0.441). No significant specialty-based differences were observed (P=0.516).

Conclusions: The AFS classification offers lower interobserver variability and greater reproducibility than the Hill classification, enhancing diagnostic consistency in GERD evaluation across expertise levels and specialties.

Background and aims: Mucosal integrity testing (MI) is a diagnostic modality for gastroesophageal reflux disease (GERD). The aim of this study was to evaluate whether MI predicted long-term improvement in reflux symptoms and the ability to discontinue proton pump inhibitors (PPIs).

Methods: Patients with suspected GERD who underwent MI with (N=86) or without (N=25) wireless pH capsule placement were studied. The GERD-questionnaire (GERD-Q) and GERD health-related quality of life (GERD-HRQL) were administered at follow-up. Logistic regression models were used to estimate the predicted probability of reflux resolution and PPI discontinuation.

Key results: Complete resolution (CR) occurred in 73% (81/111), while reflux remained partially resolved (PR) in 27% (30/111) at a median follow-up of 2.5 years. In the CR group, 33% (27/81) no longer required PPI therapy compared with 13% (4/30) in the PR group. Median (IQR) MI patterns of change over distance from the squamocolumnar junction differed in the 2 groups with the CR group having a higher intercept (4130 Ω vs. 3045 Ω, P<0.01) and flatter slope (71 Ω/cm vs. 224 Ω/cm, P<0.01). MI (C-index 0.71) was better than pH (C-index 0.49) at predicting long-term resolution of reflux in this cohort.

Conclusions and inferences: This is the first outcome-based study to show that changes in MI can predict long-term outcomes. One in 3 patients with higher mucosal impedance (suggesting normal mucosal integrity) can discontinue PPIs long-term.

Background: Gastric peroral endoscopic myotomy (G-POEM) is an emerging endoscopic approach to treat refractory gastroparesis (GP). Previous studies have shown short-term benefits, but the long-term outcomes are unclear. This analysis evaluated the short- and long-term efficacy of G-POEM compared with standard medical treatment for adults with refractory GP.

Methods: We performed a systematic review and meta-analysis of studies that evaluated G-POEM for refractory GP. Clinical success was defined variably across studies, most commonly as a ≥50% reduction in Gastroparesis Cardinal Symptom Index (GCSI) scores or combined symptoms and gastric emptying improvement. Pooled estimates for clinical success, GCSI scores, and gastric emptying scintigraphy (GES) were calculated using a random effects model. Adverse events and predictors of long-term outcomes were assessed.

Results: This meta-analysis included 23 studies involving 871 patients who underwent G-POEM. The clinical response rates remained consistently above 70% during the first year, peaked at 79% at 24 months, and reached 81% at 60 months. G-POEM was associated with significant and durable reductions in GCSI scores at 1 month (SMD -2.68, 95% CI: -3.58 to -1.78), 12 months (SMD -2.12, 95% CI: -2.73 to -1.50), and 60 months (SMD -2.55, 95% CI: -4.88 to -0.23), as well as sustained improvements in gastric emptying at 12 months (SMD -33.60%, P <0.05) and 24 months (SMD -36.17%, P <0.05). Adverse events occurred in 7% of the cases. Predictors of long-term clinical success included idiopathic etiology (P=0.04), shorter disease duration (P=0.04), prior botulinum toxin injection (P=0.02), and higher baseline symptom severity (P <0.05).

Conclusions: G-POEM may offer sustained symptoms and gastric emptying improvement in refractory GP, but findings should be interpreted cautiously given reliance on observational data, variable success definitions, lack of sham-controlled evidence, and the absence of a standard effective medical comparator. Careful patient selection remains essential, and randomized trials are needed to confirm its long-term efficacy.

Goals: To investigate the feasibility and effectiveness of an 8-week multimodal physical therapy program for adults with constipation.

Background: Constipation is a common multifactorial digestive disease in adults. A multimodal intervention program may better improve pelvic floor muscle (PFM) function and alleviate symptoms.

Study: This pilot randomized controlled trial was conducted at a Tertiary Medical Center in Taiwan. Adults with functional constipation were recruited and randomly assigned to either the intervention group (IG) or the control group (CG). The IG received a multimodal physical therapy intervention, including therapist-guided lifestyle modification education, twice-weekly physical exercise, and pelvic floor muscle training for 8 weeks. The CG received only 1 session of lifestyle modification education after baseline assessment. Assessments were conducted at baseline and after the 8-week program. Primary outcomes included feasibility measures. Secondary outcomes comprised symptom severity, PFM function, health-related quality of life (HRQOL), and physical activity levels.

Results: A total of 27 participants were recruited (IG: n=14, CG: n=13). The consent rate was 65.2%, with an overall withdrawal rate of 14.8%. No adverse events were reported, and treatment satisfaction was moderate to high. After the 8-week intervention, significant improvements were observed in symptom severity (P=0.003), PFM coordination (P=0.011), PFM strength (P=0.007), HRQOL (P=0.013), and physical activity levels (P=0.037) in the IG, whereas no significant changes were observed in the CG.

Conclusions: An 8-week multimodal physical therapy intervention program appears feasible and potentially effective in improving constipation symptoms, PFM function, HRQOL, and physical activity levels in adults with constipation.

Goals: In this study, we investigate clinical outcomes of inflammatory bowel disease (IBD) patients prescribed opioids after discharge from the hospital or emergency department (ED).

Background: IBD is commonly associated with abdominal pain. Opioids are frequently prescribed to address pain in IBD patients. Importantly, however, there is limited evidence of analgesic benefit. In addition, there are significant safety concerns about opioid use in this setting.

Study: This retrospective study utilized Merative MarketScan claims databases to identify IBD patients who had a hospital or ED visit between 2017 and 2021. Two patient groups were formed based on whether they received an opioid prescription within 7 days of discharge or not. Demographics and baseline clinical features were evaluated. Using χ2 tests and logistic regression, clinical outcomes were compared between groups at 3 time points (1, 3, and 6 mo) starting 7 days after discharge.

Results: Thirty-five thousand eight hundred ninety IBD patients were included in the analysis, with 7892 (22.0%) patients in the opioid prescription group. Using logistic regression analysis, IBD opioid users were found to be significantly more likely to experience repeat ED visits, hospitalizations and opioid prescriptions at multiple time points. IBD opioid users were also more likely to receive corticosteroids and undergo medication escalation during follow-up. Ulcerative colitis opioid users also trended toward being more likely to undergo IBD-associated surgery 6 months after discharge.

Conclusions: Patients who are prescribed opioids after acute hospital care are more likely to have poor clinical outcomes. Physicians should avoid prescribing opioids to IBD patients at discharge from the ED or hospital.

Introduction: Perianal fistulizing Crohn's disease (PFCD) is known to impact patients' quality of life (QoL). However, the interactions between PFCD activity itself with patients' psychosocial well-being and social determinants of health (SDOH) are not fully understood.

Methods: We conducted a survey study of adult patients with clinically active and inactive PFCD defined by the presence or absence of perianal pain and/or drainage between July 2023 and April 2024. The survey included the Crohn's anal fistula quality of life (CAF-QoL) scale, PROMIS scale, IBD Internalized Stigma Scale (modified), Everyday discrimination scale, Health Leads screening tool for SDOH, and Cantril ladder for life satisfaction.

Results: The study included 97 patients with active and 31 with inactive PFCD. Patients with active PFCD reported lower QoL (P<0.001), higher rates of anxiety and depression (P<0.001), decreased life satisfaction (P<0.001), and higher internalized stigma (P<0.001) than patients with inactive PFCD. Lower QoL was associated with lower annual household income (P<0.004) and elevated internalized stigma (P=0.001). Nonwhite patients with active PFCD reported higher internalized stigma related to discrimination experiences (P=0.006). Patients with active PFCD were more likely to report social isolation compared with inactive patients (23.7% vs. 0.0%, P=0.001).

Conclusion: Internalized stigma, nonwhite race, financial resource strain, and social isolation negatively impact patients with PFCD, with those having symptomatic PFCD more affected than those with inactive perianal disease. Providers should screen for these factors to identify vulnerable patients who would benefit from psychosocial care and patient navigation.

Introduction: The ideal resection strategy for rectal neoplasms extending to the dentate line (RNDLs) remains unclear. Transanal surgical approaches and endoscopic mucosal resection (EMR) have their limitations related to inadequate visualization, device maneuverability, and securing an adequate margin on the anal side. Endoscopic submucosal dissection (ESD) appears to overcome some of the limitations of transanal surgical and snare-based endoscopic techniques. Therefore, we evaluated the safety and efficacy of ESD for resection of distal rectal lesions within 2 cm of the dentate line.

Methods: This is a large-scale multicenter retrospective study of patients who underwent ESD for RNDLs between 2015 and 2023. The primary outcomes were the rates of R0 and en bloc resection. Secondary outcomes were immediate and delayed adverse events.

Results: A total of 255 patients across 20 institutions were included (mean age 63.60, women 52.20%). The median lesion size was 40 mm (IQR: 30 to 55), and the median resection time was 110 minutes (IQR: 81 to 169). The en bloc resection rate was 93.70% (n=236), and the rate of R0 resection was 85.40% (n=216). The rate of overall adverse events was 8.70% (n=22, 95% CI: 5.22% to 12.17%), with 13 cases of bleeding (5.10%), 4 cases of full-thickness perforation, and 1 case of postprocedural pain requiring intervention. All AEs were managed conservatively without the need for subsequent surgical or endoscopic interventions.

Conclusions: ESD is safe and effective for resecting RNDLs with high en bloc and R0 resection rates, offering the potential for complete resection with minimal morbidity. It offers advantages over TEN, TAMIS, and other forms of transanal surgery due to the anatomy being less conducive to the equipment required for these techniques, lower cost, and lower rates of complications. However, careful patient selection, meticulous procedural planning, and close follow-up are essential to ensure optimal outcomes and minimize the risk of complications. Long-term follow-up studies and additional prospective controlled trials are warranted.

Goals: To evaluate whether low-volume bowel preparation achieved similar rates of bowel cleansing as standard volume bowel preparations among hospitalized patients and assess the tolerability and safety of their use in this population.

Background: The use of low-volume bowel preparations for colonoscopy preparation is understudied in the inpatient setting, where standard volume preparations remain the standard of care.

Methods: We conducted a multicenter, randomized, single-blind, noninferiority trial. Hospitalized adult patients were randomized to receive low volume (2 L polyethylene glycol and ascorbic acid, 2L PEG+ASC) or standard volume bowel preparation (4 L polyethylene glycol and electrolyte lavage solution, 4L PEG-ELS) before colonoscopy. The primary outcome was noninferiority with respect to the achievement of adequate bowel preparation. Secondary outcomes included rates of electrolyte derangements, acute kidney injury, and patient tolerability.

Results: Five hundred twenty patients were randomized to 2L PEG+ASC (n=257) and 4L PEG-ELS (n=263). In per-protocol analysis, 2L PEG+ASC was noninferior to 4L PEG-ELS for achievement of adequate bowel preparation (55.0% vs. 52.9%, P =0.007). No significant difference was detected with regard to hyponatremia (1.6% vs. 3.3%, P =0.50), hypokalemia (5.3% vs. 8.7%, P =0.27), hyperkalemia (1.1% vs. 0.0% P =0.24), or acute kidney injury (4.3% vs. 3.3%, P =0.73). More 2L PEG+ASC patients found the preparation to be "easy" to tolerate compared with 4L PEG-ELS patients (29.0% vs. 13.1%, P <0.001).

Conclusions: Among hospitalized patients, 2L PEG+ASC was noninferior to 4L PEG-ELS for achieving bowel cleanliness with similar rates of electrolyte disturbance and acute kidney injury and with higher tolerability (ClinicalTrials.gov number, NCT05054036).