Scandinavian Journal of Gastroenterology最新文献

Introduction: Endoscopic submucosal dissection (ESD) for colonic lesions frequently requires general anaesthesia (GA) or deep sedation to be performed. Saline-immersion/irrigation technique (SITE) improves tolerability as it reduces bowel distension and less stretching of the mesentery. We describe our experience with operator-delivered sedation (OdS) SITE-ESD on a cohort of colonic ESD.

Materials and methods: Retrospective single-centre study of consecutive anonymised patients who underwent SITE-ESD for colonic lesions from Nov-2017 to Feb-2025. Characteristics of patients and lesions, procedure outcomes and adverse events, details of sedation, and hospital admission were recorded.

Results: One-hundred-thirty-eight colonic lesions were included. Median age: 68 (IQR 62-76), ASA II was the most prevalent score (61.1%), the median maximum diameter of lesions was 40 mm (IQR 30-50), and the median resection time was 120 min (IQR 75-180). One-hundred-twenty-seven (127, 92.0%) procedures were performed under OdS with midazolam (median 6 mg; IQR 3.5-7.5) and fentanyl (137.5 mcg; IQR 100-200). No procedure was abandoned due to discomfort. Eighty-one (58.7%) procedures were day cases and of the remaining 57, 46 (80.7%) required less than 48 hrs admission. One case of moderate respiratory failure was recorded (AGREE II).

Discussion: SITE with OdS can be considered for colonic ESD.

Introduction: Self-reported non-coeliac gluten/wheat sensitivity (NCGWS) is triggered by gluten/wheat ingestion in patients without coeliac disease (CD) or wheat allergy. Following the COVID-19 pandemic, diagnoses of NCGWS appear to have declined. A gluten/wheat-free diet (GFD) remains the only management approach, though long-term adherence and outcomes are unclear. This study aimed to evaluate market trends and the long-term GFD adherence in NCGWS. Secondary objectives included evaluating perceived GFD efficacy and the need for further healthcare advice.

Methods: We analyzed UK market data on gluten-free (GF) product sales through September 2024 and shopper insights through July 2021. Additionally, patients with self-reported NCGWS diagnosed between 2006 and 2018 at a tertiary center completed a follow-up questionnaire about their dietary habits and further need of medical advice. GFD adherence was assessed using the Biagi score and compared with a matched cohort of CD patients.

Results: Market analysis showed a continued rise in GF product sales, from £214 m in 2014 to £607 m in 2024. NCGWS patients represented 9.7% of buyers. Of 186 patients, 111 completed the questionnaire. Compared to CD patients, those with NCGWS had significantly lower GFD adherence (Biagi score 0-1: NCGWS 73.9% vs. CD 8.1%; score 3-4: NCGWS 24.3% vs. CD 90.1%; p < 0.05). After discharge, 36% (n = 40) sought further medical advice, with no significant link between GFD adherence and need for intervention.

Conclusions: Although previous data suggests a drop in referrals to secondary care, up to 9.7% of our people are eating GF to treat self-reported NCGWS. The long-term GFD adherence is poor.

Backgrounds and aims: No guidelines exist for gastric acid assessment (GAA) or endoscopic surveillance for patients with Multiple Endocrine Neoplasia Type 1-Zollinger-Ellison Syndrome (MEN1-ZES). We aimed to analyze how GAA via nasogastric tube (NGT) and esophagogastro-duodenoscopy (EGD) altered acid suppression therapy and identify pre-GAA factors associated with post-GAA medication changes to inform which patients benefit from GAAs and/or EGDs for surveillance.

Methods: We assessed the following data from patients at our institution with MEN1-ZES from 2004-2018: 1) pre-GAA gastrointestinal symptoms; 2) serum gastrin levels; 3) gastric acid output (GAO); 4) EGD findings; 5) post-GAA changes in acid suppressing medication. GAO of <10 milliequivalents (mEq) of hydrochloric acid per hour (hr) indicated adequate acid suppression.

Results: Fifty-one patients who underwent 313 EGD/GAAs were identified; 263 EGD/GAAs were included. 51/263 EGD/GAAs (19.4%) led to increased acid suppression medication. Of these, 47.1% had GAO > 10 mEq/hr. Patients who had increases in acid suppression medication had significantly more symptoms, abnormal endoscopic findings, and higher GAOs compared to patients treated with same or decreased dose after endoscopy. All patients without symptoms prior to EGD/GAA were adequately suppressed. 8 NGT/GAAs done in 6 asymptomatic patients demonstrated adequate suppression.

Conclusion: GAA is inadequately sensitive for detecting which patients with MEN1-ZES will benefit from increased acid suppression medication. Patients with symptoms should undergo EGD. A majority of patients without symptoms will not require increased acid suppressing medication following GAA, but a few asymptomatic patients may have endoscopic findings warranting increased therapy. There is no clear clinical benefit for NGT/GAA in asymptomatic patients.

Objectives: Hepatocellular carcinoma (HCC) is a significant global health burden. Examining treatment sequencing before the introduction of immune-based therapies is important for understanding the role and necessity of modern treatment approaches.

Material and methods: This retrospective study analysed 1020 patients with HCC treated at Karolinska University Hospital, Stockholm, between 2010 and 2017 to explore treatment sequencing, and clinical outcomes. Treatment decisions followed a modified Barcelona Clinic Liver Cancer (BCLC) algorithm, and patients were stratified by disease stage and by type of treatment.

Results: Initial treatment strategies included best supportive care (BSC, 32%), ablation (20%), transarterial chemoembolization (TACE, 22%), systemic therapy (12%), resection (12%), and liver transplantation (3%). Median survival ranged from 4.8 years in BCLC 0 to 2.3 months in BCLC D. Curative treatments, particularly liver transplantation, achieved the highest five-year survival (82%), whereas systemic therapy and BSC had the poorest five-year survival (2% and 0%). Despite curative intent, disease recurrence was common, necessitating further treatment in most patients. Treatment sequencing revealed that 37% of patients required a second treatment, and 18% progressed to a third line of therapy.

Conclusions: This study underscores the challenges of managing HCC in a real-world setting, including late diagnosis and high recurrence rates following curative treatments. Real-world treatment deviations from guidelines were observed, often influenced by patient comorbidities, performance status, or other clinical considerations.

Background and aim: Irritable bowel syndrome (IBS) is characterized by abdominal pain and altered bowel habits. Overweight and poor nutrient intake has been described in these patients. The aim of the study was to estimate nutrient intake in IBS, and to relate symptoms with nutrient intake and weight.

Methods: Patients with IBS diagnosed according to Rome IV, without other severe diseases, completed a study questionnaire, IBS-severity scoring system (IBS-SSS), visual analog scale for IBS (VAS-IBS), and food diaries for 3 days. Mean intake of each nutrient per day was calculated. Recommended or adequate intake was a cut off for normal or low/high intake.

Results: In total, 155 patients, 130 (83.9%) women, 42 (32-55) years old, weight 69.2 (63.0-82.9) kg, were included. Fiber intake was low in 91.0% of participants, whereas sodium intake was high in 71.6%. Intakes of vitamin A, vitamin D, riboflavin, vitamin B6, folate, vitamin B12, calcium, vitamin C, calcium, iron, magnesium, potassium, selenium, and zinc were reduced in ≥60% of participants. Half of the participants had a low intake of ≥11 of the 19 micronutrients measured. Most prominently, 85.8% had a low intake of vitamin D and 91.6% of selenium. 50.3% were overweight, and weight correlated with energy intake. Extraintestinal symptoms were associated with weight/BMI but not nutrients.

Conclusions: Patients with IBS are often overweight with a low intake of fiber and several micronutrients but a high intake of sodium. Effects of micronutrient deficiency on gut microbiota, intestinal integrity, and immune system need to be further studied.

Background: Endoscopic retrograde cholangio-pancreatography (ERCP) with plastic stent placement is the standard pertaining preoperative biliary drainage for resectable perihilar cholangiocarcinoma (pCCA). Uncovered self-expanding metal stents (ucSEMS) have shown better outcomes in palliative settings. This pilot study aimed to assess the feasibility and safety of direct ucSEMS placement via ERCP for resectable pCCA.

Materials and methods: In this single-centre pilot study, ten patients with presumed resectable pCCA (without prior drainage) underwent ERCP aiming to place an ucSEMS directly across the papilla into the future liver remnant (FLR). If the opposing liver segment was cannulated or had contrast injected, a stent was placed here too. Primary outcome was feasibility, defined as ucSEMS placement in the targeted liver segment without the need for additional drainage, with adequate bilirubin decrease according to the TOKYO criteria. Secondary outcomes included ERCP adverse events (AE) and successful stent removal during surgery.

Results: In 5 of the 10 included patients, direct ucSEMS placement in the FLR was technically successful, but one required additional intervention, resulting in 40% feasibility. All patients experienced ERCP-AE (five mild, five severe). Only two patients underwent hepatectomy, one after unsuccessful ERCP and one with successful ucSEMS removal during hepatectomy. Other patients did not proceed to hepatectomy due to ERCP-related AE (n = 3), disease progression (n = 2), or unresectability upon staging (n = 3).

Conclusion: Direct placement of ucSEMS for resectable pCCA showed limited feasibility and high AE rates. Its routine use is not justified without further refinement and larger studies to reduce AE and improve outcomes.

Background: The Rockall score (RS) is used to assess the prognosis of patients with nonvariceal upper gastrointestinal bleeding. Aims: To establish the Revised Rockall Score (RRS) that incorporates an assessment of endoscopic treatment results, and analyze the discriminative ability of the RRS for 30-day rebleeding and mortality in patients with nonvariceal upper gastrointestinal bleeding.

Methods: We retrospectively analyzed data from 432 patients between January 2016 and December 2019 (derivation cohort), and further evaluated in an independent population of 290 patients between January 2020 and December 2022 (validation cohort). Clinical records and biological data were collected. The outcome variables were rebleeding and mortality, whereas the explanatory variables were the RS and RRS. The predictive accuracy of the two scoring systems was evaluated using the receiver operating characteristic curve (AUROC).

Results: In the derivation cohort, the RRS achieved a higher area under the AUROC for predicting rebleeding (AUROC: RS, 0.75; RRS, 0.88; p < 0.0001), mortality (AUROC: RS, 0.87; RRS, 0.94; p = 0.001), and rebleeding and/or mortality (AUROC: RS, 0.78; RRS, 0.90; p < 0.0001) than the RS. In the validation cohort, the RRS also achieved a higher AUROC for predicting rebleeding (AUROC: RS, 0.80; RRS, 0.89; p < 0.001), mortality (AUROC: RS, 0.79; RRS, 0.89; p = 0.004), and rebleeding and/or mortality (AUROC: RS, 0.80; RRS, 0.91; p < 0.001) than the RS.

Conclusions: Compared to the RS, the RRS had higher discriminative ability in predicting the risk of rebleeding and mortality.

Objectives: Inflammatory bowel disease (IBD) is a chronic relapsing disease primarily affecting the gastrointestinal tract, comprising mainly of ulcerative colitis and Crohn's disease. Intestinal ultrasound (IUS) evaluates transmural healing, which is associated with better clinical outcomes. The aims of this study were to determine the influence of IUS on clinical management decisions and evaluate cost and carbon emission reductions when colonoscopies and magnetic resonance enterography (MRE) were avoided.

Methods: Eligible patients 18 years and older with established diagnosis of IBD within nine months. Patients seen in IBD outpatient clinics were offered IUS and followed up within two weeks, with evaluation of whether they were in clinical, biochemical and/or transmural remission. We determine clinical, biochemical and sonographic concordance for each IUS assessment and subsequent impact on clinical management.

Results: Out of 60 IUS assessments for 48 unique patients, 38 (63.3%) and 19 (31.7%) were in clinical and transmural remission, respectively. Of the 38 in clinical remission, 18 (47.4%) were in transmural remission. All but one with clinically active disease were not in transmural remission. There was moderate correlation between clinical and transmural remission. Discordant IUS findings were significantly associated with therapy escalation; 63.3 - 65% of patients who underwent IUS avoided endoscopy/MRE. Total cost savings amounted to US$ 92,069; total reduction in carbon emissions was 2752 kg CO₂e.

Conclusion: IUS is a valuable, cost effective and environmentally friendly investigation superior to MRE and endoscopy in evaluating transmural disease and has the potential to alter clinical decisions based on detection of transmural activity.

Background: Though bloating is a common and highly distressing symptom among patients with disorders of gut-brain interaction (DGBI), few targeted treatment options exist. In this study, we examined the use and efficacy of pharmacologic neuromodulators to treat bloating specifically.

Methods: In a retrospective study of consecutively referred patients with a DGBI (N = 77; ages 18-74, 87% female) to a tertiary neurogastroenterology clinic who were prescribed a neuromodulator for a primary complaint of bloating in 2016-2022, the degree of patient-reported bloating response (0-100%) to the maximum dose of a prescribed neuromodulator was examined using multivariable logistic regression, adjusted for key covariates.

Results: Forty-seven (61.0%) patients reported any response (>0%) to neuromodulation and 28 (36.4%) met the a priori responder definition (≥50% improvement). Duloxetine was the most commonly prescribed neuromodulator (n = 52, 67.5%). On multivariable analysis, only younger age was associated with an increased odds of neuromodulator response (OR 1.04, 95% CI [1.08, 1.01]).

Conclusions: Pharmacologic neuromodulators may show promise as a tool for the treatment of bloating, and further research is warranted.

Objectives: The Danish National Patient Registry (NPR) is an obvious source for investigating the period preceding inflammatory bowel disease (IBD). However, accuracy of diagnosis date in the NPR is unknown. Further, assessment of IBD location in the NPR has shown inconsistent results. We identified date of IBD diagnosis in the NPR and captured IBD disease location from the Danish Pathology Registry (DPR) and validated both against the North Denmark IBD cohort (NorDIBD) as the gold standard.

Materials and methods: We identified all patients with incident IBD in NorDIBD between 2000 and 2020. We compared diagnosis date in the NPR with the date in NorDIBD. Next, we inferred disease location from pathology codes in the DPR and compared with disease location in NorDIBD.

Results: We identified 3163 patients with incident IBD. We found a mean of 8 (95% CI -36, 53) and 62 (95% CI 27, 96) days between date of diagnosis in the NPR and NorDIBD for Crohn's disease (CD) and ulcerative colitis (UC), respectively. We could infer disease location from pathology codes in 63% of patients with CD and 56% of UC patients. We found high sensitivity for colonic disease in CD and for ulcerative proctitis in UC.

Conclusion: The date of IBD diagnosis in the NPR showed high validity. IBD location could be inferred via pathology codes for approximately 60% of patients with IBD, with high validity for colonic disease in CD and proctitis in UC. These findings are useful in future epidemiological studies in IBD.