Journal of clinical gastroenterology最新文献

Background and aims: Type 2 diabetes (T2DM) and inflammatory bowel disease (IBD) are 2 distinct diseases that share a similar pathophysiology; however, the association between the 2 diseases remains elusive. We aimed to investigate the bidirectional association between T2DM and IBD in a large prospective population cohort.

Methods: Participants were recruited from the prospective cohort of UK Biobank. We included 4921 patients with IBD and 438,948 non-IBD to assess the incident risk of T2DM, and 11,649 patients with T2DM and 438,948 non-T2DM to assess the incident risk of IBD. Multivariable Cox proportional hazards regression model was used to calculate adjusted hazard ratio (HR).

Results: A total of 27,373 incident T2DM and 2696 incident IBD cases were identified during a median of 12.6- and 12.9-years' follow-up, respectively. After adjustment for potential confounders, participants with IBD, UC, or CD showed an excess risk of incident T2DM (HR=1.44, 95% CI: 1.31-1.59 for IBD, HR=1.41, 95% CI: 1.26-1.58 for UC, and HR=1.62, 95% CI: 1.39-1.89 for CD, respectively), compared with non-IBD. By contrast, compared with non-T2DM, participants with T2DM also showed higher risk of incident IBD (HR=1.40, 95% CI: 1.15-1.69), UC (HR=1.41, 95% CI: 1.13-1.76), or CD (HR=1.48, 95% CI: 1.08-2.04). Furthermore, the increased risk of incident T2DM was more evident when accompanied with the severity of IBD, and vice versa. Sensitivity analyses and subgroup analyses according to age, sex, and body mass index demonstrated similar results.

Conclusion: IBD and T2DM are bidirectionally associated with higher comorbidity risks. Further investigations are needed to elucidate the shared pathogenesis underlying these 2 diseases.

Goals: We aimed to examine patients with and without disease activity after induction therapy and the association with several treatment failure endpoints within 2 years.

Background: The efficacy of biological agents is documented for patients with Inflammatory Bowel Disease (IBD). Still, some patients may experience disease activity after induction therapy.

Study: In this Danish cohort study, 2 bio-naive IBD populations were included: (i) the Bio-IBD population with clinical and biochemical data from 2016 to 2019, and (ii) a nationwide register population from 2005 to 2023. Patients with disease activity were compared with patients without disease activity within 120 days after the first maintenance treatment following induction therapy. We used Cox proportional hazard regression models for examining associations.

Results: In total, 9961 patients were included, 762 from the Bio-IBD population, and 9199 from the nationwide population. Within these populations, 253 (33.2%) and 1224 (13.3%) patients had active disease, respectively. The risk for a switch of biological treatment, IBD surgery, IBD hospitalization, corticosteroid usage, or treatment failure (composite endpoint) was statistically significantly increased for patients with active disease compared with patients without disease activity in both study populations. The adjusted hazard ratio for treatment failure was 1.33 (95% CI, 1.07-1.67) and 2.69 (95% CI, 2.50-2.90) in the Bio-IBD and the nationwide population, respectively.

Conclusion: In 2 Danish cohorts of patients with IBD, disease activity after induction therapy with biologics was associated with adverse outcomes (switch of biological treatment, IBD surgery, hospitalization, and corticosteroid usage). Clinicians may use disease activity after induction therapy as a prognostic marker of future adverse outcomes.

Goals: This study aimed to assess perspectives and practices among expert gastroenterologists regarding the screening, diagnosis, and management of BE.

Background: Significant variability in the management of Barrett's esophagus (BE) persists among physicians despite the development and dissemination of several clinical practice guidelines.

Study: An online survey was conducted with 38 expert gastroenterologists specializing in BE management. The 38-question survey evaluated demographics, medical management, and attitudes toward endoscopic treatment, with responses analyzed for trends and variations.

Results: Of the 38 experts, 34 (89%) responded. Respondents were primarily male (85%), with 82% affiliated with academic hospitals and 53% clinically focused on BE. Half discussed BE risks during initial consultations for gastroesophageal reflux disease (GERD). Most (61.8%) agreed BE should be considered in women with chronic GERD, and 88.2% regularly used narrow-band imaging (NBI). However, 44% were neutral or disagreed with diagnosing BE based solely on community gastroenterologist biopsies, and acceptance of Wide-Area Transepithelial Sampling with 3D Analysis (WATS-3D) for Barrett's esophagus diagnosis and surveillance was limited. Fifty-three percent recommended ablation for nondysplastic BE. Fifty-two percent recommended indefinite daily PPI therapy after complete eradication of intestinal metaplasia (CEIM), regardless of symptoms. When encountering cardia intestinal metaplasia after endoscopic eradication, 38% recommended ablation, while 47% continued surveillance.

Conclusion: This study highlights substantial variations in the management of BE among expert gastroenterologists, despite the existence of updated guidelines. Identifying these discrepancies is crucial for optimizing care. Further efforts are needed to standardize practices and enhance the implementation of evidence-based guidelines in clinical settings.

Introduction: The use of multiple biomarkers combined with clinical characteristics is more effective than a single biomarker for the diagnosis of hepatocellular carcinoma (HCC). The present study assessed the performance of ASAP and GALAD scores, 2 novel algorithms for HCC detection in patients with chronic liver diseases (CLDs).

Methods: This case-control study included data from 105 patients with HCC and 104 patients with CLDs without HCC. The performances of serum alpha-fetoprotein (AFP), lens culinaris agglutinin-reactive AFP (AFP-L3), protein induced by vitamin K absence-II (PIVKA-II), the ASAP and GALAD models in identifying patients with HCC were compared using receiver operating characteristic (ROC) curve analysis.

Results: The ASAP model identified patients with all-stage HCC, reflected by a high area under the ROC curve (AUC) of 0.96, similar to the GALAD model (AUC: 0.95; P=0.190). Both models significantly outperformed other individual biomarkers in detecting HCC at any stage, including AFP (AUC: 0.75), AFP-L3 (AUC: 0.73), and PIVKA-II (AUC: 0.85). Furthermore, the ASAP and GALAD scores achieved comparable AUCs (0.91 and 0.90, respectively; P=0.432) for the detection of early-stage HCC.

Conclusions: Compared with the GALAD score, the ASAP score demonstrated strong clinical performance in detecting HCC at any stage, even with one fewer laboratory variable (AFP-L3). Therefore, the ASAP score may serve as a simple and cost-effective tool for the early detection of HCC.

Goals: Colonoscopy is a common gastrointestinal endoscopic procedure for which sedation is frequently used. We investigated whether sedation with >200 mg propofol allows healthy individuals to undergo colonoscopy and drive themselves home.

Methods: This was a prospective study in which healthy subjects (20 to 96 y) who underwent screening, surveillance, or diagnostic colonoscopy with propofol sedation between January 2024 and December 2024, and were allowed to drive themselves home, were enrolled. A nurse using an age-adjusted standard protocol administered the propofol as a bolus injection. Among the enrolled subjects, 300 subjects with >200 mg of propofol sedation received questionnaires asking about the primary outcome measure (the occurrence of adverse events within 24 hr postcolonoscopy) and secondary outcome measures (their overall satisfaction and clinical outcomes).

Results: All 3152 subjects successfully completed their colonoscopy. The mean propofol dose used for colonoscopy was 203 mg (range: 80 to 480 mg), and 1261 (40%) of the subjects received >200 mg propofol. The colorectal polyp removal was successful in 1293 (41%) of subjects. The only adverse event was a transient need for supplemental oxygen, required in 21 subjects (0.7%) during the colonoscopy. The questionnaires revealed that 219 (73%) of the 300 questionnaire respondents were able to drive home or to their office safely 2 hours postcolonoscopy. All 300 subjects had no accidents within 24 hours of their colonoscopy. Most (99%) were willing to have the same procedure again.

Conclusions: Propofol sedation at doses >200 mg allowed healthy individuals to undergo a colonoscopy and drive themselves home safely 2 hours later.

Introduction: Autoimmune factors may be involved in the development of gastroparesis, a subtype known as autoimmune gastrointestinal dysmotility (AGID). Small open label studies in AGID have demonstrated intravenous immunoglobulin (IVIG) therapy may lead to improvement in symptoms and gastric emptying. We aimed to evaluate the effects of IVIG therapy on symptom severity in patients with gastroparesis.

Methods: We conducted a retrospective case series involving patients with AGID through medical chart review. All patients had evidence of delayed gastric emptying through gastric scintigraphy (GES) and had evidence of autoimmune dysfunction through seropositive antibody bloodwork, including glutamic acid decarboxylase (GAD), neuronal voltage-gated calcium channel, acetylcholine receptor, and neuronal voltage gated potassium channel autoantibodies. All patients received at least 12 weeks of IVIG therapy. Gastroparesis Cardinal Symptom Index (GCSI) scores were collected pre-IVIG and post-IVIG treatment.

Results: We analyzed 24 AGID patients. 100% female; 79.2% White; mean age=38.5 (SD=13.7). GAD was the most common serum abnormality (41.7%). Mean 4-hour retention on GES was 42.9%. Following IVIG therapy, mean GCSI scores improved by over 1.5 points (pre-IVIG: 3.64, post-IVIG: 2.01, P<0.001). 67% had an improvement of ≥1 point on the GCSI post-IVIG. Patients who were GAD positive (41.7%) had the most significant symptom improvement (mean change in GCSI: -2.3 compared with -1.1, P=0.02).

Discussion: In this retrospective analysis of a small cohort of patients with AGID, IVIG therapy was associated with symptom improvement, especially in those who were GAD+. Randomized, placebo-controlled trials are needed to understand the effectiveness of IVIG in treating AGID.

Objectives: This systematic review and meta-analysis aimed to evaluate the efficacy and safety of sphingosine-1-phosphate (S1P) receptor modulators for achieving clinical remission and key outcomes in inflammatory bowel disease (IBD) patients and to examine the influence of baseline characteristics.

Methods: MEDLINE (Ovid), PubMed, Web of Science, and Cochrane CENTRAL were searched until January 1, 2024. Randomized controlled trials (RCTs) evaluating S1P receptor modulators in adult IBD patients were included. Meta-analyses used inverse variance random-effects models, with stratified analyses by disease type, prior anti-TNF use, corticosteroid use, disease location, and baseline Mayo score.

Results: Six RCTs involving 1744 patients (male: 58.8%; age: 41.1±13.5 y) were analyzed. S1P modulators significantly improved clinical remission versus placebo in induction (RR: 2.22; 95% CI: 1.30-3.80) and maintenance phases (RR: 2.79; 95% CI: 1.72-4.54). For UC patients, induction remission was notably higher with S1P modulators (RR: 2.69; 95% CI: 1.98-3.65). Stratified analyses indicated consistent efficacy across disease location (P=0.15), corticosteroid use (P=0.20), and Mayo scores (P=0.53). Prior anti-TNF-naive patients experienced greater benefits (P=0.04). Maintenance-phase remission rates favored etrasimod (RR: 4.26; 95% CI: 2.36-7.69) over ozanimod (RR: 2.09; 95% CI: 1.54-2.84; P=0.035). Secondary outcomes, including clinical response, endoscopic and histologic remission, mucosal healing, and corticosteroid-free remission, were also significantly improved. Overall, adverse events were more frequent with S1P modulators (RR: 1.18; 95% CI: 1.07-1.30); serious adverse events, infections, mortality, and cardiac events were comparable.

Conclusions: S1P modulators improved remission rates and secondary outcomes in UC with a generally favorable safety profile. More data on CD are needed.

Background: Repeat colonoscopy ≤1 year after a screening colonoscopy is recommended when bowel preparation is inadequate due to the potential of missed advanced neoplasia. Whether patients whose primary language is not English (NEPL) have a greater risk of repeat colonoscopy ≤1 year after screening colonoscopy than native English speakers (EPL) is unknown. We investigated the primary language in early repeat colonoscopy.

Methods: The TriNetX Research Network database was used to compare rates of repeat colonoscopy ≤1 year between patients with NEPL and EPL. Propensity score matching (PSM) was used to adjust for factors associated with inadequate bowel preparation. Risk of repeat colonoscopy ≤1 year of baseline screening exam, colorectal polyps, and colorectal cancer (CRC) on repeat colonoscopy were expressed as odds ratios (OR) with 95% CI.

Results: Among 611,149 patients undergoing screening colonoscopy (mean age 58.3 y, 63.6% white, 7.1% Hispanic), 31,118 had NEPL and 580,031 had EPL. After PSM, each cohort included 29,446 patients. NEPL patients had higher odds of undergoing repeat colonoscopy within 1 year compared with EPL patients (1.9% vs. 1.3%; OR: 1.49, 95% CI: 1.30-1.69). In the matched cohorts, the rate of polyp detection on repeat colonoscopy was similar, but NEPL patients had higher odds of CRC detection (0.8% vs. 0.6%; OR: 1.4, 95% CI: 1.1-1.7).

Conclusions: NEPL patients had greater odds of early repeat colonoscopy than EPL patients. Although colorectal polyps and CRC were infrequent in both groups, NEPL patients appeared to be at higher risk of CRC detection. Language-tailored interventions may improve bowel preparation quality and reduce repeat procedures.

Goals: To evaluate whether prophylactic antibiotics improve infectious complication rates after endoscopic retrograde cholangiopancreatography (ERCP).

Background: Current guidelines recommend prophylactic antibiotics before ERCP only in cases of anticipated incomplete biliary drainage or severe immunosuppression. A recent randomized controlled trial (RCT) suggested a benefit regardless of drainage status. This systematic review and meta-analysis assess the impact of prophylactic antibiotics on post-ERCP infectious complications.

Study: A systematic search of major databases was conducted through June 2024 for RCTs comparing ERCP outcomes with and without antibiotic prophylaxis. Pooled data were analyzed for the composite outcome of infectious complications, including cholangitis, bacteremia, and sepsis. Mortality and pancreatitis were also analyzed. Publication bias was evaluated using funnel plots and regressions for funnel plot asymmetry. Our analysis implemented a dichotomous regression model with random effects using R software.

Results: Eleven RCTs with 2105 patients were included, with 1086 receiving antibiotics and 1019 serving as controls. Infectious complications were significantly lower in the antibiotic group [risk difference (RD): -0.08, 95% CI: -0.14 to -0.02, P=0.00001, I2: 83%]. Beta-lactam and cephalosporin antibiotics had a greater effect (RD: -0.10, 95% CI: -0.17 to -0.04, P=0.00001, I2: 85%). Bacteremia rates were also reduced (RD: -0.06, 95% CI: -0.11 to -0.01, P=0.01, I2: 58%). No significant differences were found in cholangitis, sepsis, pancreatitis, or mortality. Sensitivity analyses confirmed robustness.

Conclusions: Antibiotic prophylaxis reduces post-ERCP infectious complications and should be considered in all patients with biliary obstruction who are undergoing ERCP.

Background: Variceal upper gastrointestinal bleeding (VUGIB) is associated with significant morbidity and mortality. Historically, patients with human immunodeficiency virus (HIV) infection have experienced worse clinical outcomes compared with HIV-negative individuals. There is a paucity of data on HIV patients suffering from VUGIB.

Aim: Our study aims to investigate the impact of HIV status on VUGIB outcomes.

Methods: We queried the National Inpatient Sample between 2016 and 2022 using the International Classification of Diseases, Tenth revision codes to identify patients admitted with VUGIB. The patients with HIV were stratified into one group, and the remaining patients were in the control group. A 1:10 propensity-score matched analysis was performed to compare in-hospital outcomes of patients with and without HIV suffering from VUGIB.

Results: Our study included 320 HIV patients and 32,320 non-HIV patients who were hospitalized for VUGIB secondary to cirrhosis. After 1:10 propensity-score matching, we had 2760 VUGIB patients without HIV and 300 patients with HIV. All-cause mortality was significantly higher in the HIV group as compared with non-HIV (10% vs. 6%, P<0.01). The median cost of hospital stay was higher in the HIV group, and they were more likely to require ICU and mechanical or NIV. Both groups had similar lengths of stay and comparable use of interventional and diagnostic endoscopy.

Conclusions: HIV increases the risk of poor outcomes and mortality in patients with variceal GI bleed.