Scandinavian Journal of Gastroenterology最新文献

Background and aim: Direct oral anticoagulants (DOACs) carry a risk of gastrointestinal bleeding (GIB). We aimed to develop and validate machine learning (ML) models to predict GIB in DOAC users and compare them with conventional risk scores.

Methods: We retrospectively analyzed 4,494 patients aged ≥18 years prescribed DOACs from December 2014 to October 2020. Patients were allocated to the training (n = 3,147), internal (n = 677), and external (n = 670) validation cohorts. Three ML algorithms, Gradient Boosting Machine (GBM), XGBoost, and Generalized Linear Model (GLM), predicted GIB at 12 and 24 months. Performance was assessed using the area under the receiver operating characteristic curve (AUC) and specificity at 100% sensitivity, compared with the HAS-BLED, ATRIA, VTE-BLEED, and ORBIT scores.

Results: At 24 months, XGBoost achieved the AUCs in the training (0.862), internal validation (0.819), and external validation (0.905) sets. At 12 months, XGBoost performed with AUCs of 0.917, 0.839, and 0.948, respectively. XGBoost exceeded the conventional scores, although ORBIT was the best among the latter (AUC 0.780 at 24 months, 0.728 at 12 months). The ML models also achieved higher specificity at 100% sensitivity. At 12 months, XGBoost and GB model demonstrated 79.8% specificity at 100% sensitivity, whereas GLM showed 67.8%. The conventional models were lower, with an ORBIT of 39.8%. By 24 months, GLM and ORBIT specificities were 43.8% and 40.0%, respectively.

Conclusions: ML models, particularly XGBoost, outperformed traditional bleeding risk scores in predicting GIB in DOAC users. However, the performance of the ML models was unsatisfactory. Further research is warranted to achieve a better performance.

Background: Dietary interventions promoting weight loss are central to managing Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD). While short-term benefits of various diets on liver health are well-documented, their long-term effects remain unclear. This study reports one-year follow-up results from a randomized controlled trial of a 12-week diet intervention.

Method: The RCT involved 74 individuals with MASLD, with 64 completing the intervention. One year later, 47 were contacted for follow-up, and 28 attended. Due to restrictions during the Covid-19 pandemic, 17 were could not be included in the one-year follow-up. Liver health was assessed using magnetic resonance spectroscopy and vibration-controlled transient elastography at baseline, 12 weeks, and one-year post-intervention. Dietary habits were evaluated via a food frequency questionnaire and three-day food diary.

Results: One-year post-trial, sustained improvements were observed in key parameters. Compared to baseline, body mass index (30.2 kg/m² [95%CI = 28.4-31.7] vs. 31.5 kg/m² [95%CI = 30.4-32.3], p < 0.001), steatosis (6.8% [95%CI = 3.2-10.5] vs. 10.9% [95%CI = 8.2-16.1], p < 0.001), and liver stiffness (5.5 kPa [95%CI = 4.2-6.0] vs. 6.7 [95%CI = 5.2-9.2], p = 0.001), were significantly reduced. Self-reported dietary habits indicated lower total energy intake, sustained changes in carbohydrate intake, and healthier dietary fat composition one year after baseline. However, the overall dietary quality index showed no long-term improvement.

Conclusion: Short-term dietary interventions yielded significant, sustained improvements in liver health and dietary behaviours after one year. These findings underscore the potential of structured diet programs in MASLD management.

Clinical trial number: Clinicaltrials.gov (NCT03118310).

Background: We aimed to validate the International Classification of Diseases (ICD)-10 codes for alpha-1 antitrypsin deficiency (AATD) (E880A = asymptomatic AATD; E880B = symptomatic AATD) in a large hospital reporting to the Swedish National Patient Register and to ascertain their relation to the protease inhibitor (Pi)*ZZ-phenotype.

Methods: We randomly selected 150 adults and 50 children who visited Karolinska University Hospital (Stockholm, Sweden) between 2014 and 2024 with coding for E880A or E880B (1:1). Positive predictive values (PPVs) of AATD ICD-10 codes were calculated for correctly assigned codes and the Pi*ZZ-phenotype using medical charts as gold standard. Information on smoking status, lung disease, liver disease, and living area, were also retrieved.

Results: The PPV of AATD ICD-10 codes (E880A + E880B) in adults was 99% (95%CI = 95-100%; n = 148/150). The PPV for the Pi*ZZ-phenotype was only 59% (95%CI = 50-67; n = 83/141) but increased to 79% (95%CI = 67-88%; n = 50/63) when only considering outpatients with E880B coding. Of adult participants, 13% had liver disease, 51% had lung disease, and 50% were ever-smokers. In children, the PPV of E880A + E880B was 100% (95%CI = 91-100%; n = 50/50) for any AATD diagnosis and was 88% for the Pi*ZZ-phenotype (95%CI = 75-95%; n = 43/49). Liver or lung disease occurred in 6% of children. Results were consistent across several sensitivity analyses.

Conclusion: In a tertiary care setting, the validity of ICD-10 codes for AATD is excellent. The PPV of these codes for delineating the Pi*ZZ-phenotype is high in children but requires an algorithm in adults with coding for E880B in outpatients.

Background and aims: Patients with Crohn's disease (CD) undergoing ileocolic resection (ICR) develop higher postoperative C-reactive protein (CRP) levels compared to colorectal cancer (CRC) patients, suggesting an increased postoperative inflammatory response. This study investigates whether postoperative C-reactive protein (CRP) levels are associated with endoscopic recurrence (ER) after ICR.

Methods: All CD patients who underwent ICR between 2007 and 2022 at two referral centers were identified from prospectively maintained databases. Those with endoscopic follow-up within 12 months postoperatively were included. ER was defined as modified Rutgeerts score (mRs) ≥i2b. The primary outcome was the association between postoperative CRP levels and ER. Secondary outcomes were the added prognostic value of postoperative CRP levels for predicting ER, adjusted for traditional risk factors.

Results: Among 542 patients, 36% had penetrating disease, 24% were active smokers, and 11% received prophylactic advanced therapies. ER was observed in 243/542 (45%). Patients with ER had higher CRP levels on postoperative day (POD) 2-5, with a significant difference on POD 4 (median CRP, 122 mg/L vs 97 mg/L; adjusted mean difference, 16% [1 to 26%]). After adjusting for traditional risk factors, CRP levels on POD 4 remained an independent predictor of ER (p = 0.022) and improved the AUC of a model with traditional risk factors by 0.04 (95% CI, 0.02-0.09; p = 0.0005).

Conclusion: Elevated CRP levels on POD 4 in CD patients undergoing ICR were associated with an increased risk of ER within 12 months. In combination with other known risk factors, CRP could serve as a marker to identify patients benefitting from closer postoperative monitoring.

Aim: Guidelines advise performing standard 4-5 sites mapping biopsies during the initial endoscopic assessment of gastric cancer risk, which increases the clinical burden. Emerging image-enhanced endoscopy (IEE) has demonstrated high diagnostic accuracy. This study aims to evaluate whether endoscopic evaluation can guide the decision to perform mapping biopsies.

Methods: A prospective cohort of patients underwent gastroscopy screening in a tertiary care setting, with endoscopic evaluation using white light imaging (WLI) and IEE. Mapping biopsies were performed on patients diagnosed with atrophic gastritis to assess the Operative Link on Gastritis Intestinal Metaplasia (OLGIM) staging. Multivariate logistic regression was used to assess the association of OLGIM stage III/IV. The diagnostic performance of intestinal metaplasia (IM) at the lesser curvature for identifying OLGIM stage III/IV was evaluated.

Results: OLGIM staging was completed for 648 patients with atrophic gastritis. Grade 1 and grade 2 IM of the corpus lesser curvature were significantly associated with OLGIM stage III/IV, with odds ratios of 8.17 (95% CI: 3.58-19.95) and 11.56 (95% CI: 3.66-38.94), respectively (both p < 0.001). The negative likelihood ratio (NLR) for IM at the antral lesser curvature was approximately 0.00.

Conclusions: In regions with limited clinical resources, priority should be given to the evaluation of IM at the lesser curvature. Patients with IM at the corpus lesser curvature are suggested to undergo mapping biopsies. In the absence of IM at the antral lesser curvature, mapping biopsies may be safely omitted.

Background: Budesonide is the standard treatment for microscopic colitis (MC), effectively alleviating diarrhoea. However, diarrhoea recurrence upon discontinuation raises ideas about the feasibility of on-demand treatment. While self-management is emphasized in care of chronic diseases, less is known about patients' perspectives on initiating budesonide on-demand.

Method: A qualitative study was conducted using semi-structured interviews with 15 patients diagnosed with MC and previous experience with budesonide treatment. Data were analysed using qualitative content analysis to explore patients' perceptions of on-demand treatment.

Results: Three main categories emerged: (1) Self-management and confidence in handling flares: Patients expressed a strong desire for self-management, valuing the ability to initiate treatment independently during flares. However, some were hesitant due to uncertainty about proper dosing and treatment duration. (2) Perceptions of budesonide and attitudes towards medication: While budesonide was perceived as highly effective, concerns about long-term use, side effects, and potential loss of efficacy influenced adherence. Some adjusted doses based on diarrhoea, while others preferred guidance from their physician before initiating treatment. (3) The role of healthcare in treatment decisions: Patients emphasized the importance of accessible healthcare, clear treatment guidelines, and structured follow-up. Many felt that healthcare providers focused primarily on prescribing medication rather than providing a holistic approach. A model integrating person-centred care with professional guidance was seen as ideal for optimizing treatment outcomes.

Conclusion: On-demand budesonide treatment could provide patients with greater flexibility but requires individualized support. A structured approach that balances self-management with follow-up and person-centred guidance may enhance adherence and improve quality of life in patients with MC.

Objectives: Metabolic dysfunction-associated steatotic liver disease (MASLD) is associated with substantial clinical and economic burden. Fibrosis detection is key to disease management, but biopsy-defined staging is invasive, expensive, and associated with complications. We evaluated healthcare resource utilization (HCRU) and costs by disease stage using biopsy-defined staging and fibrosis-4 (FIB-4; a simple, well-validated, non-invasive tool for assessing fibrosis severity), and compared their utility for predicting long-term outcomes in MASLD.

Methods: This longitudinal observational cohort study included 959 adults with biopsy‑defined MASLD in Swedish medical records (1974-2020) linked to national registers. Patients had a documented fibrosis stage (F0-F4) and age-stratified FIB-4 score (low, indeterminate, high) at baseline. All-cause, liver-, and cardiovascular (CV)-related HCRU/costs were evaluated. The predictive capacity of biopsy and FIB-4 for high HCRU (≥80th percentile of hospitalizations + outpatient visits) was assessed using Harrell's concordance index.

Results: In general, patients with advanced fibrosis had significantly more all-cause and liver-related hospitalizations, longer length of stay, and higher costs than patients with less advanced fibrosis. The number and cost of liver-related outpatient visits increased significantly as fibrosis severity increased, a trend also observed when comparing high and low FIB-4 scores. Other HCRU/cost outcomes were inconsistent between scoring approaches. No association was found between CV-related HCRU and fibrosis severity. Biopsy and FIB-4 demonstrated similar predictive capacity for identifying patients with high HCRU.

Conclusions: These data highlight the positive association between fibrosis severity and HCRU and costs in MASLD, and suggest that FIB-4 may have similar utility to biopsy for evaluating certain HCRU outcomes.

Background and aims: Endoscopic submucosal dissection (ESD) enables en-bloc resection of large (>2cm) colorectal lesions. Despite its proven benefits, ESD remains underutilized in many countries. We evaluated the quality and safety of colorectal ESD resections during the implementation of this technique in a Norwegian endoscopy centre.

Methods: This single centre cohort study included all ESD-procedures performed from March 2021 until March 2025 in a Norwegian community hospital. All data were registered prospectively for quality and safety purposes. Main outcomes were en-bloc and complete (R0) resection rates as well as curative rate and complications. Additional outcomes were dissection time and speed. Outcomes were compared in three equal periods.

Results: In total, 131 procedures were performed, 105 (83%) were outpatient procedures and 123 (94%) were completed. En-bloc resection was achieved in 117 (95%), R0 resections in 98 (80%) and curative resections in 84 (68%). Complications occurred in 19 (15%) patients, intraprocedural in five (4%) and post-procedural in 14 (11%). All intraprocedural perforations (n = 3) were managed endoscopically. One patient (0,7%) had emergency surgery due to a suspicion of perforation (Clavien-Dindo score IIIb). Elective completion surgery was required in 15 patients (11%). Median dissection time was 135 min (interquartile range [IQR]: 100-195) in the first period and 80 min (IQR: 56-110) in the third period. Dissection speed (in mm²/min) increased from 13 (IQR: 10-20) in the first period, to 26 (IQR: 19-38) in the third period.

Conclusion: Colorectal ESD can be safely and effectively implemented in the Nordic setting.

Background and aims: Gallstone disease during pregnancy can have varying consequences, from mild to severe and even life-threatening. The aim was to investigate how gallstone intervention during pregnancy impacts pregnancy, delivery and the newborn child.

Methods: Pregnant patients 18-45 years identified from the Swedish National Register for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) 2009-2016 constituted the intervention group and were cross-linked with the Swedish National Medical Birth Register. A 1:5 matched control group of patients without gallstone intervention during pregnancy was established.

Results: In total, 1620 women were included, and of these, 274 underwent gallstone intervention during pregnancy. Some 221 women underwent cholecystectomy only, and 53 underwent ERCP only or combined with cholecystectomy. The women in the intervention group had a higher BMI at the start of pregnancy (24 vs 28, p < .001) and were more often smokers (21.7% vs. 15.7%, p = .019). Overall, labour started most often spontaneously, (intervention group 67.0% vs. control group 75.3%, p = .004), and elective caesarean section was more common in the intervention group (13.2 vs. 9.0%, p = .034). Premature birth was more common in the intervention group (19 [6.93%] vs. 5 [3.94%], p = .029), with an adjusted odds ratio of 1.8 (CI 1.1-3.3, p < .001). There were no differences in the children's birth weights or APGAR scores.

Conclusions: Caesarean section was more common, and the duration of pregnancy was shorter, including preterm births, in the group with gallstone intervention during pregnancy. However, for the newborn child, birth weight corrected for gestational age and APGAR score was not affected.