Journal of clinical gastroenterology最新文献

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.

Goals: To assess esophageal cancer (EC) burdens among older adults aged 60+ from 1990 to 2021.

Background: With the aging global population, EC in elderly presents a significant health challenge.

Study: 2021 Global Burden of Disease (GBD) data were used to calculate age-standardized rates (ASRs) for incidence, prevalence, mortality, and disability-adjusted life years (DALYs). Joinpoint regression was used to calculate the average annual percentage change (AAPC) to assess temporal trends. Pearson's correlation analysis investigated the relationship between socio-demographic index (SDI) and the male-to-female ratios of ASRs.

Results: In 2021, there were 421,336 incident cases, 655,313 prevalent cases, 410,902 deaths, and 8,059,156 DALYs due to EC in older adults globally, doubling since 1990. The age-standardized incidence rate, age-standardized mortality rate, and age-standardized DALYs rate exhibited decline from 1990 to 2021, with respective AAPCs of -0.62 (95% CI: -0.76 to -0.48), -0.9 (95% CI: -1.05 to -0.75), and -1.11 (95% CI: -1.25 to -0.97), while age-standardized prevalence rate (AAPC: -0.04, 95% CI: -0.16 to 0.09) remained stable. Western Sub-Saharan Africa experienced the steepest rise in ASRs from 1990 to 2021, while East Asia recorded the highest ASRs in 2021. The male-to-female ratios for all ARSs increased globally from 1990 to 2021, with a significantly positive correlation between the gender ratios and SDI.

Conclusion: EC poses a growing challenge for elderly populations, with clear geographic and gender disparities. Targeted interventions are necessary to mitigate the increasing burden in older adults.

Introduction: Our analysis examines the learning curve of peroral endoscopic myotomy (POEM) training using procedure duration as a key indicator of proficiency.

Methods: We searched PubMed, Embase, Cochrane, and Web of Science from inception until November 2024 for studies evaluating the learning curve of POEM. We divided the data into 0-20, 20-40, and 40-60 cumulative procedure phases of learning. Analysis of variance was performed with Tukey HSD post hoc tests to analyze differences in procedure time between groups. We also calculated means from the pooled data for the number of procedures to achieve proficiency, plateau procedure time postproficiency, plateau myotomy speed, and myotomy length. In addition, an analysis based on an inverse curve regression was also performed to assess the proficiency threshold.

Results: Eleven studies, including 3197 POEM procedures, were included. Mean procedure time for the first, second, and third phases of learning were 99.4±35.2, 87.4±23.1, and 85.4±23.1 minutes, respectively. The 0-20 group had significantly higher mean procedure time than the 20-40 group (P<0.0001) and the 40-60 group (P<0.0001). Mean procedure time was not significantly different between the 20-40 and 40-60 groups (P=0.69). Mean number of procedures to achieve proficiency was 33.29. Mean plateau procedure time following achievement of proficiency was 80.25 minutes. Mean postproficiency plateau myotomy speed was 7.71 minutes per cm of myotomy. Mean length of myotomy was 10.43±1.86 cm.

Conclusion: POEM learners achieved proficiency in procedure speed in the 20-40 learning phase with no significant change with further experience.

Background: The efficacy of nonpharmacological therapies for patients with gastroesophageal reflux disease (GERD) has been progressively proved. However, the specific differences in effectiveness among various nonpharmacological interventions and their combinations with pharmacological interventions remain unclear, and the optimal intervention strategy has yet to be conclusively determined.

Methods: Systematic searches were conducted in PubMed, Web of Science, Embase, Cochrane, and CNKI from inception to November 6, 2024. A network meta-analysis was conducted using a random effects consistency model within a Bayesian framework with lower esophageal sphincter (LES) pressure as the primary outcome indicator.

Result: Thirty-three studies involving 10 nonpharmacological interventions were included. Acupoint stimulation with traditional Chinese medicine (TCM) (SMD=5.83, 95% CI: 1.23 to 10.16), and breathing training with conventional Western medicine (CWM) (SMD=3.88, 95% CI: 0.45 to 7.52) significantly improved LES pressure and reduced esophageal acid exposure time (AET) (SMD=-5.01 to -3.32). In terms of safety, acupoint stimulation with TCM (logOR=-2.51, 95% CI: -5.91 to -0.19) exhibited a significant advantage over CWM. However, acupoint stimulation combined with TCM and breathing training with CWM did not demonstrate a significant improvement in GERD health-related quality of life questionnaire (HRQL) scores.

Conclusion: Acupoint stimulation combined with TCM and breathing training with CWM, when compared with CWM and other nonpharmacological interventions, is considered a potential adjunctive therapeutic approach for GERD, demonstrating both efficacy and safety. However, methodological limitations necessitate cautious interpretation of results.