Scandinavian Journal of Gastroenterology最新文献

Background: The number of patients with cardiac implantable electronic devices (CIEDs) is steadily rising. This population, typically older, comorbid, and often on antiplatelet or anticoagulant therapy, is at increased risk of iron deficiency anaemia (IDA) and gastrointestinal bleeding. Despite the value of video capsule endoscopy (VCE) for panenteric investigation, its use remains limited due to persistent concerns about electromagnetic interference (EMI), which restricts access to this important diagnostic modality.

Aim: To systematically evaluate the safety and diagnostic performance of VCE in patients presenting with anaemia/gastrointestinal bleeding and CIEDs.

Methods: We searched EMBASE, MEDLINE and PubMed. A random-effects meta-analysis of proportions using Freeman-Tukey transformation estimated rates of cardiac events, signal interference and diagnostic yield.

Results: From 275 publications, 18 studies (443 patients) were included. Cardiac device malfunction occurred in 0.9% (4/443) of patients, with no clinically significant events. Pooled malfunction rates were 0% for ICDs and LVADs (95% CI: 0-1%), and 0% for pacemakers (PPMs) (95% CI: 0-6%; I² = 63%). Signal interference occurred in 1.8% (8/443); the pooled rate was 0% (95% CI: 0-2%; I² = 0%), with slightly higher rates in LVADs (1%; 95% CI: 0-6%; I² = 25%). The overall diagnostic yield was 69% (95% CI: 58-80%; I² = 55.5%).

Conclusion: This meta-analysis shows that VCE is safe in patients with CIEDs, with low rates of adverse events and signal interference. Diagnostic performance was not compromised. These findings support revision of current guidance to improve access to CE for patients with anaemia and CIEDs.

Objective: To retrospectively analyze the efficacy and safety of a bismuth-containing quadruple regimen with vonoprazan (VPZ) in the initial eradication of Helicobacter pylori (Hp) infection and to identify influencing factors.

Methods: A total of 1017 treatment-naïve patients with Hp infection, who received a 14-day bismuth-containing quadruple therapy with vonoprazan (VPZ+ bismuth potassium citrate + two antibiotics) between January 2023 and December 2024 at Zhejiang Hospital, were enrolled. Based on actual antibiotic usage, patients were categorized into seven subgroups. Hp eradication rates and influencing factors were analyzed.

Results: The overall treatment success rate of the VPZ-based bismuth quadruple therapy was 90.9% (924/1017). The eradication rates for each subgroup were: Clarithromycin + Amoxicillin 93.3% (714/765), Furazolidone + Amoxicillin 93.5% (87/93), Clarithromycin + Furazolidone 73.7% (42/57), Levofloxacin + Cefuroxime 81.3% (39/48), Clarithromycin + Cefuroxime 100% (24/24), Levofloxacin + Clarithromycin 80.0% (12/15), and Levofloxacin + Furazolidone 40.0% (6/15). Univariate analysis revealed a statistically significant difference in eradication rates among the different treatment regimens (p = 0.002). Binary logistic regression analysis confirmed that the treatment regimen was an independent factor affecting eradication outcome (p = 0.008). Factors such as age, sex, smoking, and alcohol consumption showed no significant correlation with treatment success. All regimens demonstrated good safety profiles, with no reports of severe adverse events, and were well-tolerated, particularly among patients with comorbid gastric or duodenal ulcers.

Conclusion: The vonoprazan-based bismuth-containing quadruple therapy is a highly effective and safe regimen for Hp eradication, achieving a high overall success rate. It represents a preferred strategy for clinical treatment, especially for Hp-infected patients with peptic ulcers.

Introduction: The most important factors for a successful colon capsule endoscopy (CCE) study are the quality of bowel preparation and the capsule excretion during battery life. Incomplete conventional colonoscopy is one of the main indications for CCE. The aim of this study was to analyze clinical and demographic factors for incomplete CCE after an incomplete conventional colonoscopy.

Methods: A retrospective single-center study was conducted including patients who underwent CCE after an incomplete colonoscopy (IC). Complete CCE was defined as capsule excretion or visualization of hemorrhoidal pedicles within battery time. Demographic (gender and age) and clinical data (obesity, smoking history, diabetes mellitus, hypothyroidism, constipation, depression, psychotropic medication use and history of abdominal or pelvic surgery) were collected.

Results: A total of 197 patients were included (mean age 67 ± 10 years; 71.6% female). Complete CCE was achieved in 133 (67.5%) of cases. Adequate bowel preparation was observed in 145 (73.6%) of cases. The most common causes of incomplete conventional colonoscopy were colonic fixed angulation (56.3%) and irreducible loop (42.1%), with no significant difference in capsule completion between these groups (p = 0.770). Obesity (OR 5.328; 95% CI 1.735-16.369; p = 0.003) and constipation (OR 2.999; 95% CI 1.264-7.114; p = 0.013) were independently associated with incomplete CCE.

Conclusions: Obesity and constipation are risk factors for incomplete CCE. Adjustments or intensification of bowel preparation protocols may improve completion rates in these patients.

Objective: To develop and validate the best machine learning model for predicting 28-day mortality in septic patients with alcoholic cirrhosis (AC), leveraging data from the Medical Information Mart for Intensive Care Database, 4th Edition (MIMIC-IV).

Methods: Clinical data of 1958 patients with AC complicated with sepsis were retrospectively extracted. Missing data (<20%) were addressed using Multiple Imputation by Chained Equations (MICE). Key predictors were selected via Least Absolute Shrinkage and Selection Operator (LASSO) regression. Patients were allocated to a training set (n=1268), a testing set (n=318), and a temporal validation set (n=372). Five models were developed and evaluated based on different performance metrics. Decision Curve Analysis (DCA) and SHapley Additive exPlanations (SHAP) were performed to assess clinical applicability and predictor importance.

Results: LASSO regression identified 15 core variables. The eXtreme Gradient Boosting (XGBoost) model achieved the best overall performance, with an area under the ROC curve (AUC) of 0.946 (95%CI [0.932-0.960]) (sensitivity: 0.891) on the training set and an AUC of 0.878 (95% CI [0.838, 0.918]) on the test set, and an AUC of 0.819 on the validation set. The model was well-calibrated and provided a higher net benefit than 'treat-all' or 'treat-none' strategies across wide risk thresholds. SHAP analysis revealed the top 5 predictors to be: Sequential Organ Failure Assessment (SOFA) score, Model for End-Stage Liver Disease (MELD) score, age, temperature, and SPO2.

Conclusion: The XGBoost model had the best predictive performance, providinga robust tool to guide personalized therapy and optimize critical care resource allocation.

Background: Advanced fibrosis is the main risk factor for liver-related complications in patients with metabolic dysfunction-associated steatotic liver disease (MASLD). The first line-test for evaluating presence of advanced fibrosis, Fibrosis-4 index (FIB-4), has limitations. Here, we investigated whether the diagnostic performance of FIB-4 could be improved by incorporating commonly analyzed metabolic biomarkers, including C-reactive protein (CRP), Hemoglobin A1c (HbA1c), the Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), or uric acid.

Methods: This cross-sectional study included 276 adult (≥18 years) patients with MASLD from seven Swedish university hospitals. All patients underwent liver stiffness measurement (LSM) for assessment of advanced fibrosis, defined as LSM ≥12 kPa. The performance of FIB-4, CRP, HbA1c, HOMA-IR, and uric acid, alone and in combination, was assessed using logistic regression models. The area under the curve (AUC) was calculated.

Results: An LSM value of ≥12 kPa was found in 45 patients (16%). Combining FIB-4 with CRP, HbA1c, HOMA-IR, and uric acid yielded the highest AUC (0.810; 95% confidence interval [CI] = 0.732-0.889), which was not significantly better than the AUC for FIB-4 alone (0.774, 95%CI = 0.701-0.847).

Conclusions: Adding CRP, HbA1c, HOMA-IR, or uric acid to FIB-4 did not result in any statistically significant improvement in diagnostic performance, suggesting limited additional value of these biomarkers in identifying advanced fibrosis.

Background: People in prison have a high prevalence of hepatitis C virus (HCV) infection due to the prevalent incarceration of people who inject drugs. The primary aim of the study was to assess the prevalence of HCV infection among people incarcerated in Norwegian prisons with special focus on people who inject drug (PWID).

Methods: Consecutive, newly incarcerated individuals in 6 prisons were offered to participate. Within the first two weeks of incarceration, participants were tested for anti-HCV and the presence of HCV RNA. Demographic, social and behavioral data including drug use was collected.

Results: Among 870 participants the median age was 35 years, 10.3% (90/870) were female and 74.7% were Norwegian citizens. At inclusion, 24.9% (217/870) were on remand awaiting trial and 74.7% (650/870) had been sentenced. Injecting drug use ever was reported by 30.1% (262/870) and 71.4% (187/262) of these had injected within the last 12 months before incarceration. The anti-HCV prevalence and HCV RNA prevalence was 19.7% (171/870) and 9.3% (81/870) in all and among PWID it was 62.6% (164/262) and 30.2% (79/262), respectively. The only independent predictor of being anti-HCV positive was reporting needle sharing (adjusted OR 3.50 (1.57-7.80). HCV test at release was performed in 23 PWID. No incident case of HCV was detected.

Conclusion: One in ten newly incarcerated persons in Norwegian prisons had current HCV infection. Rapid testing and HCV treatment should be readily available in all prisons.

Background: Dubin-Johnson Syndrome (DJS; OMIM 237500) is a rare autosomal recessive disorder caused by pathogenic variants in the ABCC2 gene, encoding for the multidrug resistance protein 2 (MRP2), resulting in impeded biliary excretion of bilirubin metabolites. It is typically characterized by chronic or intermittent jaundice and conjugated hyperbilirubinemia.

Case presentation: We report the case of a 54-year-old male with hyperbilirubinemia (mostly conjugated) and hypertransaminasemia. Hypertransaminasemia was due to presence of Metabolic dysfunction-associated fatty liver disease (MASLD), while whole-genome sequencing revealed a homozygous missense variant affecting ABCC2 (c.3893G > A, p.Gly1298Asp), a previously undescribed variant likely linked to hyperbilirubinemia. It is an extremely rare genetic variant (allele frequency = 6.2 × 10^-7). In silico analyses predicted the variant to be highly pathogenic (CADD score 29; AlphaMissense score 0.978; PhyloP 8.87; DynaMut ΔΔG = -0.765 kcal·mol^-1 and ΔΔSVib = -0.234 kcal·mol^-1·K^-1). Structural modeling suggested no gross conformational changes but potential effects local conformation and overall function of the protein.

Conclusions: We describe a novel ABCC2 mutation associated with Dubin-Johnson Syndrome. This finding expands the spectrum of ABCC2 variants to evaluate in case of hyperbilirubinemia and highlights the importance of genetic testing in unexplained cases of conjugated hyperbilirubinemia.

Introduction: Faecal elastase-1 testing is the most commonly used method for diagnosing pancreatic exocrine insufficiency (PEI), but has poor diagnostic precision and cannot guide titration of pancreatic enzyme replacement therapy (PERT). An alternative is ¹³C-mixed triglyceride breath test. We investigated concordance between breath test and faecal elastase-1, and response to bicarbonate-buffered enzymes.

Methods: In this prospective study, adults with faecal elastase <100 µg/g using PERT performed a baseline breath test without enzyme treatment. Participants with normal baseline exhalation (≥29%) were enrolled in Substudy I, where they discontinued pancreatic enzyme replacement therapy (PERT) and were clinically reassessed after 6 months. Participants with abnormal exhalation (<29%) were enrolled in Substudy II, a three-arm crossover study where breath test was repeated on three separate days while receiving 24,000, 48,000, and 72,000 IU PERT, in random order. Primary outcomes were PERT reinstatement at follow-up (substudy I) and differences in cumulative ¹³CO2 exhalation (substudy II).

Results: Baseline tests where performed in 25 participants. Thirteen participants had normal breath test, 11 agreed to pause PERT, but only five participants did not reinitiate treatment (substudy I). 12 participants were included in substudy II (mean age 65, all males). All had significant breath test improvements on lowest enzyme dose (24,000 IU) versus baseline (mean difference 21.5%, p < 0.001), yet higher enzyme doses did not improve results significantly.

Discussion: About half of participants previously categorised with PEI had normal ¹³C-mixed triglyceride breath test, questioning diagnosis. Most participants demonstrated normal breath test with lowest enzyme dose during standardised test meal. However, this finding may not generalise to habitual meals.

Background: Severe alcohol-associated hepatitis (AH) remains a major challenge in clinical practice due to its limited treatment options and high short-term mortality. Although corticosteroids have long been the mainstay of treatment, their use has been declining because of concerns about side effects and contraindications.

Aim: We aimed to summarize the current standards for corticosteroid use in severe AH, with a specific focus on differentiating absolute from relative contraindications.

Methods: This narrative review integrates evidence from randomized clinical trials, observational cohort studies, and contemporary guideline statements pertaining to corticosteroid therapy in severe alcohol‑associated hepatitis.

Results: The majority of individuals with severe AH present with concomitant complications such as infection, acute kidney injury, or gastrointestinal bleeding. Emerging data indicates that, with the developments in diagnostic methods, treatment strategies, and supportive care, that were previously considered absolute contraindications are now being recognized as relative. Corticosteroid treatment can be administered safely once certain concomitant conditions have been stabilized or resolved. On the other hand, such severe presentations, as identified by markedly elevated Maddrey's discriminant function, MELD score, or acute-on-chronic liver failure (ACLF) grade, determine a poor response to corticosteroid treatment and high risk of complications.

Conclusions: In the setting of severe AH, while certain conditions require a temporary corticosteroid treatment delay, others necessitate alternative approaches. Individuals with a low likelihood of responding, early liver transplantation, extracorporeal therapy, microbiota-based therapeutics, or palliative care should be considered in the earlier settings.

Objectives: The real-world clinical course of hepatocellular carcinoma (HCC) remains poorly understood. We aimed to describe the prognosis of Danish patients with HCC treated with curative-intent resection or ablation strategies.

Methods: This was a population-based, historical cohort study of all patients with HCC within two Danish regions (population 2 million). Information was extracted from patients' medical records. Patients diagnosed with HCC in 2013-2023 and treated first-line with resection/ablation with curative intent were included. We used multistate models, competing risk analyses, and cause-specific Cox models to describe the clinical course and examine risk factors for recurrence.

Results: The cohort comprised 296 patients [79% male; median age 69 years (IQR 62-76); 60% (n = 179) with cirrhosis (alcohol-related, n = 76; viral hepatitis-related, n = 57)] treated first-line with resection (40%; n = 117) or ablation (60%; n = 179). The risk of early recurrence (within 2 years) was 55% (95% CI 50-61) and similar for resection- and ablation-treated patients. Five years post resection/ablation, 10% of patients remained alive and recurrence-free. Alpha-fetoprotein was a strong predictor of recurrence, and a high Child-Pugh score and high comorbidity burden were predictors of death without recurrence. The 10-year probability of receiving systemic treatment was 24%. For the total cohort, the median survival time was 3.5 years (IQR 1.5-5.9) and the median recurrence-free survival time was 1.1 years (IQR 0.5-2.4).

Conclusion: This population-based real-world study demonstrated that current curative-intent treatment strategies for early HCC are insufficient for long-term disease control, and that we need more effective management and follow-up of patients with HCC.