Translational gastroenterology and hepatology最新文献

Major advancements in surgery for patients suffering proctocolitis from ulcerative colitis (UC) or selected patients with Crohn's disease (CD) have emerged in a relatively short time. Historically, patients underwent a proctocolectomy with end ileostomy, however, a restorative proctocolectomy with an ileal pouch-anal anastomosis (IPAA) was introduced in the late 1970s in the United Kingdom and gave patients the opportunity to avoid a permanent stoma. Initially designed as a hand-sewn "S" shaped pouch, with the invention of the linear stapler, a "J" shaped pouch was described in Japan, and subsequent advances in the United States largely contributed to the pelvic pouch's evolution to the standard of care in the management of patients with inflammatory bowel disease (IBD). The procedure was then divided into different stages depending on the medical condition of the patient and minimally invasive techniques (laparoscopic & robotic surgery) have continued to advance the success of the operation. Unfortunately, pouch complications occur, and seem to be occurring at an increasing frequency with the adoption of minimally invasive surgery. The field of reoperative pouch surgery has emerged to offer patients the opportunity to restore their quality of life (QOL) without the need for a permanent ostomy. Many patients with signs of pouch failure such as pouchitis, fistulae, pain and obstruction are diagnosed with Crohn's of the pouch, but many have mechanical complications that can be corrected with surgery, rather than offering pouch excision with a permanent ostomy (continent or traditional). Patients with Crohn's may be offered an IPAA but they will not have success if they, like patients with UC, have mechanical complications leading to their pouch failure. Patients who undergo reoperative pouch surgery do well with an acceptable QOL.

Background and objective: Colonoscopy is an ever-growing procedure, being the primary diagnostic and therapeutic modality to manage lower gastrointestinal pathologies. It has a decades-old history with significant successive endoscopic innovations that eventually led to the development of the current colonoscope, as we know it today.

Methods: We reviewed multiple databases in non-systemic fashion using PubMed, Embase and Cochrane library to shed light on historic timeline of advancements and groundbreaking landmark achievements currently underway.

Key content and findings: Initially starting off as a rudimentary rigid, device that utilized candles as a light source, the primitive colonoscope was adapted to a semi-rigid framework to allow better maneuverability. Improved lenses allowed better viewing quality and the development of video capabilities with the capability of performing both diagnostic and therapeutic interventions transformed the colonoscope completely into a modern interventional device. Its utility started gaining attention in the late 90s when multiple guidelines were published, supporting its impact on survival for colorectal screening. Over the years, the therapeutic component of colonoscopy has evolved further allowing it to be used as a treatment modality for several lower gastrointestinal pathologies including control of lower gastrointestinal bleeds, management of large bowel perforation, foreign body removal and dilatation of colonic stenosis. With improving technological advances, success rates of colonoscopic interventions continue to rise and new therapeutic modalities underway further enhancing their role. Multiple developments are underway including use of artificial intelligence (AI) with as endocuff vision, amplify EYE and G-EYE among others that hold great promise for the future of colonoscopy.

Conclusions: With our review, we hope to further the understanding clinicians about the colonoscope and help contribute towards its further developments.

Background: Infection with the SARS-CoV-2 virus, which can result in hepatic inflammation and injury that varies from mild to severe and potentially acute fulminant liver injury, may be associated with poor outcomes. Our aims were to: (I) assess baseline clinical and demographic characteristics in patients with coronavirus disease 2019 (COVID-19) who did and did not have abnormalities in liver chemistries [alkaline phosphatase (ALP), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and total bilirubin (Tbili)] and (II) evaluate associations between abnormalities in liver chemistries and the primary outcomes of in-hospital death, intubation, and hospital length of stay (LOS).

Methods: In this nationwide retrospective cohort study of 14,138 patients, we analyzed associations between abnormalities in liver chemistries (ALT, AST, ALP, and Tbili) and mortality, intubation, and prolonged hospital LOS in patients with laboratory-confirmed COVID-19. We used Pearson's chi-squared tests to detect significant differences in categorical variables for patients with and without abnormal liver chemistries. Welch's two-sample t-tests were used to make comparisons of liver chemistry (ALT, AST, ALP, Tbili) and serum albumin results. All other continuous variables were analyzed using independent samples t-tests. A P value of <0.05 was considered significant.

Results: Propensity score matching demonstrated that abnormalities in liver chemistries at admission are significantly associated with increased risk for mortality (RR 1.70) and intubation (RR 1.44) in patients with COVID-19. Elevated AST is the liver chemistry abnormality associated with the highest risk for mortality (RR 2.27), intubation (RR 2.12), and prolonged hospitalization (RR 1.19). Male gender, pre-existing liver disease, and decreased serum albumin are also significantly associated with severe outcomes and death in COVID-19.

Conclusions: Routine liver chemistry testing should be implemented and used for risk stratification at the time of COVID-19 diagnosis.

Background: Immunoglobulin G4-related sclerosing cholangitis (IgG4-SC) often has a good response to initial steroid therapy, but a high relapse rate during follow-up. Knowledge about the predictors and treatment strategy of relapsing IgG4-SC is of great significance.

Case description: In this paper, we reported that a 57-year-old male was diagnosed with IgG4-SC accompanied by type 1 autoimmune pancreatitis (AIP) at the first onset of his diseases and had a good response to steroid therapy. However, during low-dose steroids maintenance therapy, IgG4-SC relapsed with clinical presentations related to severe bile duct stricture, but improved rapidly after re-administration of full-dose steroids, accompanied by resolution of jaundice, improvement of intrahepatic and extrahepatic bile duct stricture, and gradual recovery of liver function. At the last follow-up in December 2021, he was still stable with methylprednisolone tablets at 4 mg/day.

Conclusions: IgG4-SC is likely to relapse in patients who have high serum IgG4 level at initial onset and receive low-dose steroids maintenance treatment. The predictors of disease relapse also include steroids interruption, more severe bile duct stricture, long duration from diagnosis to treatment, history of allergy, and high serum tumor necrosis factor-alpha (TNF-alpha) and soluble interleukin-2 receptor (sIL-2R) levels. Re-administration or up-dose of steroids, immunosuppressors, and rituximab are effective for treating relapsing disease.

Crohn's disease (CD) in humans and Johne's disease (JD) in ruminants share numerous clinical and pathologic similarities. As Mycobacteria avium subspecies paratuberculosis (MAP) is known to fulfill Koch's postulates as the cause of JD, there has been considerable debate over the past century about whether MAP also plays a role in CD. With recent advances in MAP identification techniques, we can now demonstrate a higher presence of MAP in CD patients compared to the general population. However, it remains unclear if MAP is playing a bystander role or is directly pathogenic in these patients. Studies have shown that there may be an immune response targeting MAP in these patients, which may underlie a pathologic role in CD. Clinical studies have yielded conflicting results as to whether anti-MAP therapy improves clinical outcomes in CD, leading to the lack of its inclusion within evidence-based clinical guidelines. Additionally, many of these studies have been small case series, with only a few randomized controlled trials published to date. In this article, we will discuss the historical context of MAP in CD, review clinical and laboratory data surrounding detection of MAP and possible pathogenesis in human disease, and suggest future directions which may finally provide some clarity to this debate.

Background: Small intestinal Dieulafoy's lesion (DL) is a rare cause of life-threatening gastrointestinal bleeding. Based on previous case reports, the diagnostic approaches for DL located in jejunum and ileum are different. In addition, there is no available consensus regarding the treatment of DL, and previous case reports suggest that surgery is the preferable choice for small intestinal DL compared to endoscopic treatment. Notably, our case report indicates that double-balloon enteroscopy (DBE) should be an effective diagnostic and therapeutic approach for small intestinal DL.

Case description: A 66-year-old female was transferred to the Department of Gastroenterology due to hematochezia and abdominal distension and pain for more than 10 days. She had a history of diabetes, hypertension, coronary heart disease, atrial fibrillation, mitral insufficiency, and acute cerebral infarction. Conventional diagnostic approaches, including gastroduodenoscopy, colonoscopy, and even angiogram, did not show any definite source of bleeding, and then a capsule endoscopy was performed and suggested that the bleeding may be located in ileum. Finally, she was successfully treated by hemostatic clips under DBE via anal route. And there is no recurrence after endoscopic treatment was observed in our case during a 4-month follow-up.

Conclusions: Although small intestinal DL is rare and difficult to be detected by conventional approaches, DL still needs to be considered as a differential diagnosis for gastrointestinal bleeding. In addition, DBE should be considered as a preferred choice for the diagnosis and treatment of small intestinal DL due to lower invasiveness and cost as compared to surgery.

Background and objective: This narrative review discusses Barrett's esophagus management in the context of perceived deficiencies or controversies. Barrett's adenocarcinoma incidence has not clearly been impacted by Barrett's screening and surveillance.

Methods: The following report was derived from articles using PubMed and Google searches. The search was concentrated on Barrett's esophagus screening and management guidelines.

Key content and findings: Comprehensive literature searches that highlight potential deficiencies or controversies regarding the current approach to Barrett's esophagus were employed. Esophageal adenocarcinoma incidence is rapidly increasing and this malignancy usually presents in an advanced and unresectable state. This is despite the significant expenditure of resources and time in endoscopic screening for and surveillance of Barrett's esophagus. Thus, more widespread screening for Barrett's esophagus may be considered. In addition, there are apparent inefficiencies and precision lack in the performance of endoscopic surveillance. This relates mainly to the lack of endoscopic cues for dysplasia. On the other hand, relatively low-risk subjects have frequent screening or surveillance procedures increasing cost. Lastly, endoscopic ablation for Barrett's with dysplasia has moderately good efficacy, especially for eradication of dysplasia, but mandates intensive post-therapy endoscopic surveillance. There is some concern for subsurface development of advanced Barrett's lesions. Fortunately, there is intense research in improving Barrett's esophagus diagnosis and treatment. Our narrative review will delineate deficiencies and potential measures to remedy them.

Conclusions: In conclusion, screening for Barrett's esophagus and surveillance in Barrett's subjects have minimal established benefits, but proposed changes in screening practices and innovations in Barrett's esophagus endoscopic surveillance and dysplasia therapy have great promise.

Background: Hepatic epithelioid hemangioendothelioma (HEHE) is a rare neoplastic disease of varied presentation and unspecific radiological signs in the early stages. The diagnostic delay can lead to metastatic disease, thus increasing the tumor burden and reducing the treatment options. HEHE is usually deemed a slow-growing tumor, but its speed of growth is poorly reported and still unknown.

Case description: In this case report, we documented a HEHE diagnosed in a young woman who had complaints of abdominal pain, weight loss and bloating for a long time. The typical findings observed in histological studies were not promptly recognized in the histological analyzes, even after two laparoscopic-guided liver biopsies, delaying the diagnosis until extrahepatic tumor spreading. Findings observed in computed tomography, magnetic resonance imaging and histological studies are presented. The coalescence of nodules and the rising of giant masses, occupying large parts of the liver in a specific time span, were registered and quantified. As opposed to prior reports, the results show that hepatic HEHE can grow rapidly, reinforcing the need of early diagnosis, thus avoiding the complications presented herein.

Conclusions: The findings observed via radiological and histological imaging that could have avoided the diagnosis delay are depicted and discussed, showing that HEHE can rise faster than previously documented.

Background and objective: Esophageal carcinoma cuniculatum (CC) is a rare variant of a well-differentiated squamous cell carcinoma (SCC). Unlike other forms of esophageal cancers, CC of the esophagus is difficult to diagnose on endoscopic biopsies. This can lead to a delay in the diagnosis and increases morbidity. We reviewed the available literature to shed light on the etiopathogenesis, diagnosis, treatment, and outcomes of this disease. Our aim is to create a better understanding of this rare disease entity and contribute to a timely diagnosis to reduce the associated morbidity and mortality.

Methods: Extensive review of PubMed, Embase, Scopus, Google Scholar was conducted. We identified the published literature on Esophageal CC from inception till date. We report epidemiological trends, clinical presentation, diagnostic and treatment strategies to correctly identify the cases to reduce the likelihood of a missed diagnosis of esophageal CC.

Key content and findings: Associated risk factors for esophageal CC are chronic reflux esophagitis, smoking, alcohol consumption, immunosuppression, and achalasia. Dysphagia is the most common presentation. Primary diagnostic modality is an esophagogastroduodenoscopy (EGD), but diagnosis can be easily missed. To favor an early diagnosis, a histological scoring system has been proposed by Chen et al. where authors describe specific histological features that appear to be common based on the numerous mucosal biopsies examined from patients with CC.

Conclusions: A high clinical suspicion for the disease along with close endoscopic follow-up with repeat biopsies is needed for an early diagnosis. Surgery remains the gold standard for treatment and is associated with a favorable prognosis when the patients are diagnosed early.