Visceral Medicine最新文献

Introduction: Long-term sequelae following acute SARS-CoV-2 infection appear to be common in patients with inflammatory bowel diseases (IBDs).

Methods: We examined the frequency and characteristics of post-COVID-symptoms in patients with IBD (IBD-COVID), comparing them to two control cohorts: infected household members of the IBD-COVID patients without IBD (CONT-COVID) and IBD patients without SARS-COV-2 infection (IBD-no-COVID). A questionnaire for the retrospective documentation of possible post-COVID-19 symptoms was distributed to patients and controls from eight referral centers.

Results: The 319 IBD-COVID, 108 CONT-COVID, and the 221 IBD-no-COVID patients were similar in terms of sex, age, and comorbidities. The occurrence and duration of fatigue in the IBD-COVID cohort correlated with IBD activity. Other complaints such as reduced cognitive performance (p < 0.05) and sleeping disorders (p < 0.05) were even more common in IBD-COVID patients. Persistent hematochezia (p < 0.001), abdominal pain (p < 0.005), diarrhea (p < 0.0001), and anal problems (p < 0.01) were more often in the IBD-COVID patients than in the CONT-COVID cohort. Furthermore, typical IBD-associated symptoms persist for a longer period after an infection. Frequency of post-COVID complaints is higher in IBD patients compared to controls. After infection, the number of outpatient consultations increased in IBD-COVID patients (7.8% vs. 10.9%, p = 0.008).

Conclusion: Fatigue, cognitive impairment, and sleep disturbances are more prevalent among IBD-COVID than CONT-COVID patients. Furthermore, typical IBD-associated symptoms persist for a longer period after an infection. Frequency of post-COVID complaints is higher in IBD patients compared to controls. Tight control of IBD activity could be a suitable tool to avoid post-COVID problems.

Introduction: The development of an intestinal stricture in patients with Crohn's disease represents an important and frequent complication, reflecting the progressive nature of the disease. Depending on the inflammatory and fibrotic composition of the stricture, intensified medical therapy, interventional endoscopy, or surgical intervention is required. However, currently available diagnostic approaches can only assess the level of inflammation, but not the degree of fibrosis, limiting rational therapeutic management of Crohn's disease patients. Recently, prolyl endopeptidase fibroblast activating protein (FAP) has been functionally implicated in fibrotic tissue remodelling, indicating it as a promising target for detection of sites of fibrotic tissue remodelling. Thus, intestinal fibrosis might be visualized using Gallium-68 labelled inhibitors of FAP (FAPI). While F-18-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/CT is a standard diagnostic tool for visualizing inflammatory processes, we combined Ga-68-FAPI-46-PET/CT and F-18-FDG-PET/CT to differentiate predominantly fibrotic or inflammatory areas in Crohn's disease patients with ileo-colonic strictures.

Methods: In our study, we analysed three Crohn's disease patients with anastomotic ileo-colonic strictures who underwent both dynamic Ga-68-FAPI-46-PET/CT and static F-18-FDG-PET/CT imaging to assess the level of visualized fibrotic areas within the stricture and differentiate it from inflammatory ones. PET images were analysed both visually and quantitatively. Furthermore, conventional MR enterography and endoscopy were performed in parallel to correlate observed findings. Two of the included patients underwent surgery and the histological specimen were analysed for the level of inflammation and fibrosis, which results were similarly compared to the findings of the PET imaging procedures.

Results: Different uptake patterns of Ga-68-FAPI-46 could be observed in the anastomotic ileo-colonic strictures of the examined Crohn's disease patients, respectively. Immunohistochemical analyses demonstrated that there was a correlation between the level of Ga-68-FAPI-46 uptake and severity of fibrosis, while FDG uptake correlated with the inflammatory activity in the analysed strictures.

Discussion: The combination with F-18-FDG-PET/CT represents a promising imaging modality to distinguish inflammation from fibrosis and guide subsequent therapy in stricturing Crohn's disease patients, warranting further studies.

Introduction: Inflammatory bowel disease (IBD), encompassing Crohn's disease (CD) and ulcerative colitis (UC), exhibits a multifactorial pathogenesis influenced by genetic and environmental factors. Antibiotic usage has been implicated in modifying the gut microbiome, potentially leading to dysbiosis and contributing to IBD risk. Despite existing literature, the relationship remains inconclusive. This meta-analysis aimed to evaluate the association between prior antibiotic use and the onset of IBD.

Methods: A systematic literature search in PubMed was conducted to identify studies exploring the link between antibiotic use and subsequent IBD diagnosis. Studies reporting CD, UC, or both as primary outcomes were included. The meta-analysis, performed according to PRISMA guidelines, summarized risk estimates, represented as odds ratios (ORs), and corresponding confidence intervals (CIs). Subgroup analyses involved the categorization of antibiotics and the determination of the minimum number of antibiotic therapy courses administered.

Results: Out of 722 publications, 31 studies comprising 102,103 individuals met eligibility criteria. The pooled OR for IBD in those with prior antibiotic exposure was 1.40 (95% CI: 1.25-1.56). Antibiotic use was associated with an increased risk of IBD (OR: 1.52, 95% CI: 1.19-1.94). Notably, this association was confined to CD (OR: 1.50, 95% CI: 1.27-1.77), while no significant association was observed with UC (OR: 1.21, 95% CI: 1.00-1.47). Risk augmentation for IBD correlated positively with the number of antibiotic courses (OR: 1.08, 95% CI: 1.05-1.12).

Conclusion: Previous antibiotic use is associated with the later development of CD. A positive dose-response effect was also observed. Against this background, antibiotics should be used rationally.

Introduction: Ambulatory surgeries are on the rise in recent years and can offer benefits to patients as well as healthcare providers. Laparoscopic cholecystectomy is one of the procedures commonly done in an ambulatory setting, in some European countries. This study aims to gather patients' perceptions towards ambulatory cholecystectomy after undergoing laparoscopic cholecystectomy in an inpatient setting.

Methods: A total of 300 patients from two different hospitals in Germany received a postoperative questionnaire aimed at evaluating their willingness to undergo an ambulatory surgery. Surgeries were performed between January 1, 2017, and July 11, 2018. Operation setting (acute vs. elective), ASA classification, length of hospital stay, age, sex, living situation and location (city vs. rural), as well as status of employment were documented.

Results: Overall, 23% of patients reported considering ambulatory laparoscopic cholecystectomy (ALC), while 77% rejected an ALC. Objections included fear of complications (69%), anticipated pain (65%), concerns about their living situation/home care (21%), other reasons (8%), nausea and vomiting (3.4%). Baseline characteristics of the participants provided no statistical significance on willingness to undergo ALC: acute versus elective (p = 0.22), ASA classification (p = 0.77), age ≥65 years versus <65 years (p = 0.60), gender (p = 0.07), living situation (p = 0.49), location (p = 0.15).

Conclusion: There is a willingness for ALC, albeit still limited. Chosen criteria did not show a significant association for positive perception of ALC.

Background: Achalasia is a motility disorder of the esophagus and depending on its type, esophageal tubular hypo- or hypermotility can cause typical symptoms, such as dysphagia, chest pain, weight loss, or regurgitation. Clinical symptoms during initial diagnosis as well as over the course of therapy can be measured by the Eckardt score. Diagnostics include high-resolution manometry (HR manometry), (timed barium) esophagogram, upper gastrointestinal endoscopy, multiple rapid swallow response, and Endo-FLIP measurement. In this work, we provide a review of the recent literature on surgical treatment of achalasia.

Summary: Besides pharmacological and endoscopic interventions, surgical procedures of laparoscopic/robotic Heller myotomy (LHM/RHM) and 180° anterior Dor's semifundoplication versus 270° dorsal Toupet's fundoplication are primary therapeutic options, especially for type I and II achalasia. Both surgical procedures display little morbidity and mortality. Postsurgical results are comparable between LHM and RHM. RHM allows better angulation during myotomy, lower rates of intraoperative mucosal laceration, and better visualization of the muscles in the lower esophageal sphincter area. Surgery can also be performed safely after failed endoscopic treatments.

Key messages: Surgery in achalasia is especially indicated in patients ≤40 years and also recommended after repeated unsuccessful or complicated endoscopic interventions. In selected patients with end-stage achalasia and sigmoid-shaped megaesophagus, esophagectomy is a reasonable option in order to improve quality of life.

Background: Disorders of the gut-brain axis are public diseases ("Volkskrankheiten") and are among the most frequent reasons to visit a doctor. Despite their great medical and socio-economic importance, patients suffering from these disorders are often not taken seriously and, therefore, do not receive sufficient diagnostic evaluation, or a diagnosis, in conformity with the relevant guidelines. In addition, the inadequate compensation of services makes handling of neurogastroenterological disorders increasingly unattractive. As a result, neurogastroenterology is under-represented in medical curricula, with a decreasing number of scientists in academia who are familiar with this field in Germany.

Summary: The prevalence of neurogastroenterological diseases, which is associated with the need for medical care, should create corresponding care as a "bottom-up" development. However, this is not possible in the German healthcare system, due to the inadequate reimbursement structures. Therefore, a "top-down" strategy must be developed through health policy directives, directing the establishment of neurogastroenterology units based on quality parameters and need. These centers must form comprehensive network structures and share essential information on neurogastroenterological diseases with general practitioners, clinicians, and patients. Appropriate apps that also focus on interdisciplinary care with the involvement of various specialist disciplines (e.g., gastroenterology, neurology, gynecology, urology, psychology, psychosomatics, nutritional medicine) would be helpful for this purpose.

Key messages: Neurogastroenterology units are important and should be interdisciplinary and located in tertiary centers. Due to the lack of incentives in the German healthcare system, they must be instituted through health policy directives from the top down.

Background: The prevalence of neurogastroenterological diseases, i.e., disorders of gut brain interaction, has increased over the last decades. Altered gastrointestinal (GI) motility is a key feature of this group of diseases and is affecting all anatomical segments of the GI tract, ranging from swallowing disorders to fecal incontinence. Considering the ongoing demographic transformation in developed countries worldwide, it is highly relevant to understand the age-dependency of motility disorders per se and its pathophysiological mechanisms with a special focus on neurodegeneration. This review summarizes the most relevant findings and open research questions in the field of age-dependent changes in GI motility with a strong focus on studies performed on humans or with biological material obtained from humans.

Summary: While the basic function of the GI tract including motility in most of its segments is largely unaltered by aging per se, there is clear evidence supporting an age-dependent increase in the prevalence of constipation and fecal incontinence, the latter mainly affecting women. When, however, the large percentage of elderly patients suffering from frequent chronic diseases such as diabetes, Parkinson's disease, or cerebrovascular disease are included, a clear increase in "secondary" motility disorders also affecting the esophagus or the stomach is evident. Studies regarding the pathophysiology of geriatric dysmotility are often limited by the heterogenous clinical history of the studied patients and by coincident impairments of interoceptive sensory function. However, a loss in the number of cholinergic neurons together with changes in the number of interstitial cells of Cajal, certain subtypes of enteric glia, changes in immune cell function, and changes in the endocrine signaling throughout the GI tract have been reported.

Key messages: The overall prevalence of swallowing disorders, impaired gastric emptying, constipation and fecal incontinence is high among elderly patients. The pathophysiology most likely includes a variety of factors ranging from degeneration of enteric neurons and the non-neuronal cell populations involved in GI motility up to age-dependent metabolic and neuroendocrine changes and dietary factors. Deciphering the effects of "healthy aging" but also of the numerous typical chronic diseases of the elderly on GI motility is an ongoing challenge and prerequisite for improving patients' medical care and quality of life.

Background: Gastroesophageal reflux disease (GERD) is common. Management of reflux symptoms includes medical and nonmedical interventions. Proton pump inhibitors (PPIs) continue to be considered first-line agents. Standard investigations to diagnose GERD include upper endoscopy, impedance-pH measurement or capsule-based pH measurements and high-resolution manometry. However, diagnosis can sometimes be difficult in individual cases when measurements yield borderline results. Combination of the three mentioned techniques is considered the diagnostic gold standard now.

Summary: Aside from the current measures considered gold standard, new measurement parameters, mostly focusing on impedance of the esophageal mucosa will help better diagnose GERD. Another promising new modality is the combination of wireless pH measurements and evaluation of esophageal motility and structural abnormalities using the endoscopic functional lumen imaging probe (FLIP). Artificial intelligence may play an increasingly supportive role.

Key messages: GERD needs to be better diagnosed to avoid unnecessary or potentially harmful long-term acid suppression therapy or reflux surgery. A number of tools is under investigation. However, as of now they only have supportive value.

Background: Gastro-oesophageal reflux disease (GORD) is extremely common, with at least 1 in 10 people in the general population reporting heartburn and acid regurgitation on a weekly basis. GORD can also be associated with a variety of atypical symptoms, including chest pain, chronic cough, and laryngopharyngeal symptoms. The causes of GORD are multifactorial, and the severity of symptoms is influenced by peripheral and central factors, including psychosocial stress and anxiety. Therefore, for a variety of reasons, no single investigation provides a definitive diagnosis, and standard treatment with acid suppressants is not always effective.

Summary: This review introduces the Lyon Consensus, now in its second iteration, a classification system that provides a "conclusive" positive or negative diagnosis of GORD by integrating the results of endoscopy, ambulatory reflux monitoring, and high-resolution manometry. Different algorithms are applied to patients with high and low pre-test probability of a causal relationship between reflux episodes and patient symptoms. The results of these studies identify patients with "actionable" results that require escalation, revision, or discontinuation of GORD treatment. Guidance is provided on the range of conservative treatments available for GORD, including dietary and lifestyle advice, antacids and alginates, and drugs that suppress acid secretion.

Key messages: GORD is a common disorder; however, the causes of reflux and symptoms can be complex. As a result, the diagnosis can be missed, and management is sometimes challenging, especially for patients with atypical symptoms. The Lyon classification establishes a conclusive diagnosis of GORD, based on results of endoscopic and physiological investigation. Typical symptoms usually respond to empiric use of alginate-antacid preparations and acid suppression; however, the management of treatment refractory symptoms is tailored to the individual.

Background: Fecal incontinence (FI) is a frequent, often underestimated, health issue in adults. Its treatment is primarily nonsurgical. Only if conservative options fail to result in adequate symptom reduction should surgery be considered. We present an overview of historical and current surgical treatment options.

Summary: Well-known sphincter replacement techniques such as dynamic graciloplasty and the artificial bowel sphincter are no longer used because of their invasiveness and relevant comorbidity. Today, sphincteroplasty and sacral neuromodulation (SNM) are the most common procedures recommended in current guidelines. The therapeutic choice is based on diagnostic findings. Sphincteroplasty is an option only in patients with an anal sphincter lesion and has only moderate long-term success. SNM has become the established first choice in multiple pathophysiological conditions resulting in FI, as it has proved highly successful with minimal invasiveness. Over time, the spectrum of indications has evolved and the technique is now successful in morphological sphincter defects as well.

Key messages: The spectrum of surgical options to treat FI is limited. Owing to its efficacy and low comorbidity, SNM is now considered the gold standard in multiple pathophysiological and morphological conditions, whereas sphincteroplasty remains an option in patients with FI from a defined sphincter lesion.