United European Gastroenterology Journal最新文献

Introduction: Perianal Crohn's disease (CD) remains challenging to treat despite the increasing number of advanced therapies. Advanced dual-targeted therapy has emerged as a new treatment option in CD, but no data are available for perianal CD. The aim of this study was to evaluate the effectiveness and safety of advanced dual-targeted therapy for anoperineal fistulas (APFs) in CD patients.

Materials and methods: We prospectively included all consecutive patients receiving an advanced dual-targeted therapy for APFs from August 2019 to December 2023 in a single tertiary perianal CD centre. The primary outcome was clinical effectiveness. Secondary outcomes were patients' treatment perception, radiological effectiveness, luminal disease effectiveness, impact on extra-intestinal manifestations, and safety. Factors associated with complete clinical remission of APFs were identified using logistic regression.

Results: A total of 33 patients were included. The most frequently used advanced dual-targeted therapy was a combination of infliximab and ustekinumab (75.8%). After a median follow-up of 27.4 months, 48.5% and 97.0% of patients were in complete clinical remission and reported a perceived improvement, respectively. Complete radiological remission was achieved in 24.2% of the patients. A concomitant improvement in luminal intestinal involvement was observed in 46.1% of cases, and in extra-digestive manifestations in 45.8% of cases. Treatment tolerance was considered good or very good in 90.9% of cases. Associated anal ulcers and long-term exposure to antibiotics were associated with a lower likelihood of complete clinical remission for fistulas.

Conclusion: These findings suggest that advanced dual-targeted therapy is a valid option with a good safety profile for the treatment of refractory APFs. Larger studies are required to identify the most effective combination.

Background and aims: Dye-based chromoendoscopy (DCE) has been the preferred method for colonoscopy surveillance in patients with inflammatory bowel disease (IBD). However, with advances in endoscopy, virtual chromoendoscopy (VCE) techniques have emerged. This network meta-analysis evaluates the effectiveness of different endoscopy techniques for IBD patient surveillance.

Methods: Sixteen randomized controlled trials involving 2514 patients were included in the analysis, comparing endoscopy techniques in IBD patient surveillance: DCE, high-definition white light endoscopy (WLE), standard-definition WLE, i-scan, narrow band imaging (NBI), flexible spectral imaging color enhancement (FICE), and autofluorescence imaging (AFI). We assessed the per patient neoplasia detection rate, positive predictive value (PPV), and withdrawal time between different endoscopy techniques. Moreover, subgroup analysis was conducted to investigate the neoplasia detection rate according to endoscopy techniques using various biopsy protocols.

Results: Comparing neoplasia detection rates revealed that only DCE (OR: 2.56 [1.17-5.59]) significantly increased the neoplasia detection rate compared with standard-definition WLE. The subsequent rankings were high-definition WLE, NBI, FICE, i-scan, and AFI. Moreover, the PPVs of DCE, VCE, and high-definition WLE showed no significant difference compared with that of standard-definition WLE. However, DCE required a significantly longer withdrawal time. Subgroup analysis showed that DCE with random biopsy or target biopsy and high-definition WLE with target biopsy had superior neoplasia detection rates than standard-definition WLE with random biopsy.

Conclusion: DCE significantly outperforms standard-definition WLE in neoplasia detection rates, with random biopsy providing additional benefits. Although DCE does not lower PPV, it requires more withdrawal time. If DCE-based surveillance is not feasible, high-definition WLE with targeted biopsy should be considered as other VCE techniques offer no significant advantages.

Introduction: United European Gastroenterology (UEG) Guidelines on immunoglobulin G4 (IgG4)-related digestive disease provides evidence-based recommendations for the diagnosis and management of IgG4-related digestive disease. The aim of this study is to evaluate the adherence to recommendations of this IgG4 guideline across centers in Europe.

Patients and methods: Questionnaire-based data related to organ involvement, diagnosis, treatment and follow-up of newly diagnosed patients with IgG4-related digestive diseases over a 3-year period, were collected from 14 centers in 11 European countries.

Results: One hundred and ninety-nine patients (76% males) were included. Median age at diagnosis was 64 years. Most of the patients had concomitant pancreatic and biliary tree involvement (46%), followed by isolated pancreatic involvement (33.5%), isolated biliary tree involvement (18.5%), esophageal involvement (1.5%) or bowel (0.5%) involvement. Most of the patients (64%) underwent a combination of computed tomography and magnetic resonance imaging at diagnosis. Among the 158 autoimmune pancreatitis patients with or without concomitant bile duct involvement, treatment was performed according to guidelines in 115 patients (73%; moderate adherence). Follow-up assessment was performed between 2 and 4 weeks in 75 patients (47%, partial adherence). Among 37 patients with liver- or biliary tree involvement, 29 patients were treated according to guidelines (78%; full adherence). In the follow-up of patients with isolated liver- or biliary tree involvement, we observed moderate adherence in 21 (57%). Disease monitoring for activity and damage using the IgG4 responder activity index was utilized in only 3/14 centers (poor adherence).

Conclusions: IgG4-related digestive disease is restricted to the pancreas and bile ducts in the majority of patients. Even in specialist centers with an interest in IgG4-related digestive disease, UEG guideline treatment adherence was moderate, follow-up at 2-4 weeks was only partial, and monitoring for disease activity was poor. These findings highlight the need for ongoing education and improved adherence to monitoring among healthcare providers.

Microscopic colitis is an inflammatory bowel disease (IBD) comprising two clinically undiscernible entities: collagenous colitis and lymphocytic colitis. Collagenous colitis associates with HLA genes and displays a Th1/Tc1-Th17/Tc17 profile with pericryptal myofibroblast activity, water malabsorption and secondary fluid loss due to altered osmoregulation. Conversely, lymphocytic colitis lacks genetic associations and displays a Th1/Th2 profile and paracellular/transcellular permeability. Lymphocytic colitis subclassifies into channelopathic lymphocytic colitis due to unique alteration of ion and organic acid transport that could result from drug exposure, and inflammatory lymphocytic colitis due to the involvement of moderate immune responses compared to collagenous colitis. As microscopic colitis mucosa remains intact and immune cells seem to stay inactive, microscopic colitis is an ideal model to explore early stages of IBD if collagenous colitis and lymphocytic colitis are studied as distinct entities. Exploiting multiomic approaches and established biobanks will ensure validation of microscopic colitis patient stratification, and deepening into pathomechanisms which could enable precision medicine.

Background: Upper gastrointestinal (UGI) endoscopy lacks established key performance indicators. Up to three-fold variation in post endoscopy upper gastrointestinal cancer rates has been observed among endoscopy providers in England, highlighting the need for standardisation of UGI endoscopy practices.

Objective: We aimed to achieve consensus on evidence-based key performance indicators to reduce post endoscopy upper gastrointestinal cancer.

Methods: Modified nominal group technique was employed in two consensus workshops, with representation from clinicians, patients and relatives, moderated by James Lind Alliance facilitators. Potential indicators were identified from the umbrella systematic review, English provider post endoscopy upper gastrointestinal cancer rates, and differences in endoscopy practices from the National Endoscopy Database between providers with the highest (worst) and lowest (best) post endoscopy upper gastrointestinal cancer rates. KPIs were categorised as provider or endoscopist/procedure related and ranked as of major or minor importance. Minimum standards were proposed where possible.

Results: Participants included 14 clinicians (gastroenterologists and UGI surgeons), 3 nurse endoscopists, 2 UGI cancer nurse specialists, 14 patients, their relatives and representatives from patient support groups and four observers. Endoscopy provider related major key performance indicators and proposed standards included monitoring post endoscopy upper gastrointestinal cancer rates (minimum standard ≤ 7%); less intense endoscopy lists (maximum 10 'points' per list [one point is equivalent to 15 min]); endoscopy provider accreditation (all providers); and premalignant condition surveillance on dedicated lists by endoscopists with adequate training (> 90% surveillance endoscopies). Endoscopist/procedure related major key performance indicators included: examination time ≥ 7 min; training in early UGI neoplasia recognition (all endoscopists); mucosal view quality recorded and cleansing agents used if not excellent (> 90% endoscopies); intravenous sedation offered to all appropriate patients; recommended number of biopsies from cancer associated or premalignant lesions (> 90% endoscopy where such lesions identified); and endoscopists' annual UGI endoscopy volume > 100 (all endoscopists).

Conclusion: This study offers a consensus on the key performance indicators and minimum standards that should be used to improve UGI endoscopy quality and reduce post endoscopy upper gastrointestinal cancer.

Background: Current trends in complications and mortality among individuals with chronic liver disease and cirrhosis are largely unknown.

Objective: To explore changes in mortality trends among patients with cirrhosis and chronic liver disease based on etiology in the Veneto Region (Italy), to differentiate mortality between liver-related and non-liver-related causes before and during the COVID-19 pandemic, and to determine trends in the development of cirrhosis complications.

Methods: Three subsequent population-based cohorts of individuals with chronic liver disease/cirrhosis were identified in Veneto (North-eastern Italy, 4.9 million residents): the first enrolled before introduction of direct-acting antivirals (DAA); the second corresponding to full availability of DAA treatment; and the last enrolled at the beginning of the pandemic. Risks of liver decompensation and death-liver and non-liver related-were recorded for each cohort during a 3-year follow-up. Changes in the risk of death across cohorts were measured by risk ratios (RR) obtained through Poisson regression models with robust error variance.

Results: Across the cohorts spanning over 10 years, we found that the number of individuals with CLD and cirrhosis remained stable at about 40,000 and 10,000, respectively. The 3-year risk of ascites, hepatic encephalopathy, and hepatocellular carcinoma decreased across the study period, largely due to individuals with HCV-related liver disease. The overall 3-year mortality risk declined by 14% (liver cirrhosis, subjects enrolled in 2020 vs. 2013: RR = 0.86, 95% CI 0.83-0.89), especially among those with viral etiology. In contrast, mortality due to alcohol-related chronic liver disease/cirrhosis was stable or increasing during the COVID-19 pandemic, especially for non-liver causes of death.

Conclusions: Despite increased awareness and proactive enrollment into patient care, chronic liver disease and cirrhosis remain significant health-challenges. The reduction in HCV-related mortality underscores the impact of antiviral treatments, while the persistently high mortality risk of alcohol-related disease highlights the need for targeted interventions.

Inflammatory Bowel Disease (IBD) has become a global disease. The increasing incidence of inflammatory bowel disease across the world is challenging the traditional view of IBD as a western disease and represents a unique opportunity to gain an understanding of the disease in diverse ethnic groups and in different socio-economical and geographical environments. However, the continued growth in prevalence in developing countries in the coming years will lead to increased use of health-care resources due to IBD-related complications, costs of drugs and indirect health costs. Here we analyze the challenges and opportunities that this situation represents and suggest actions and potential solutions to improve the quality of IBD care globally.