Advances in Digestive Medicine最新文献

Thrombotic thrombocytopenic purpura (TTP) is an unusual disease with a 90% mortality rate without prompt management. The typical clinical manifestations include thrombocytopenia, hemolytic anemia, neurological symptoms, fever, and renal impairment. However, recognizing TTP in its early stages is not always easy due to limited clinical experience and sometimes atypical presentation. We report a 44-year-old male who initially suffered from jaundice and skin purpura, followed by epigastric pain. Acute pancreatitis was first suspected after a computerized tomography (CT) scan in the local medical department, without a definite etiology. He was then transferred to our hospital for further investigation of hemolysis. Transient neurological symptoms occurred 1 week after transferring. TTP was later confirmed based on schistocytes noted in peripheral blood smear and ADAMTS-13 activity = 0%. The patient was discharged successfully after prompt therapeutic plasma exchange and steroid treatment. We present the first case of TTP inducing acute pancreatitis in Asia and remind that acute pancreatitis is a possible cause of abdominal pain, although it's a rare manifestation of TTP.

Increased uptake of hepatitis C virus (HCV) treatment among people who inject drugs (PWID) is critical to achieve HCV elimination goals. This study attempted to observe the influence of different referral strategies among HCV-infected PWID for direct-acting antivirals (DAA). From January 2019 to November 2020, approximately 190 PWID regularly received opioid agonist therapies (OAT) in the drug addiction rehabilitation clinic of our institute. Among these, those with positive anti-HCV were further referred to our hepatology clinics for HCV viremia screening and treatment. According to physician involvement, referral strategies were divided into three models including patient self-intention referral (SR); intensive referral (IR) where patients were referred by clinicians; and fast-intensive referral (FIR) where patients were referred by clinicians with a fast-screening and easy-treatment program. A total of 121 HCV-infected PWID were enrolled and 71 (58.7%) of them received the referrals: 16 (22.5%) in the SR model, 36 (50.7%) in the IR model, and 19 (26.8%) in the FIR model. Monthly average referred patient number was 2.7 people in the SR model, 2.8 people in the IR model, and 4.8 people in the FIR model, respectively. Among the 71 referred patients, 64 (90.1%) had detectable HCV viremia with genotype distributions being genotype 1a (G1a) in 23 patients (35.9%), G1b in 10 (15.6%), G2 in 5 (7.8%), G3 in 6 (9.4%), and G6 in 20 (31.3%). Except for three patients who refused treatment, 61 patients underwent and completed DAA treatment including 35 patients for Maviret, 15 for Epclusa, 9 for Harvoni, and 2 for Zepatier. Excluding three patients who were lost to follow-up and one becoming reinfected, 57 (93.4%) eventually achieved a sustained virologic response. Although HCV treatment uptake among PWID in this hospital-based setting remained suboptimal, the FIR model with a quick-to-screen and easy-to-treat program was proven practicable in the hospital setting. Further innovative strategies are required to reach all HCV-infected PWID receiving OAT.

The prevalence and incidence of Crohn's disease (CD) in Asia is rising, and it is important to know the risk factors of mortality. In our study, CD patients diagnosed and treated in the Chang Gung Memorial Hospital Linkou branch were enrolled from January 1989 to October 2019. The collected data included age, sex, disease duration, location and behavior of the disease, biochemical parameters at admission, medication history, surgical history, and comorbidities. The mean age at diagnosis was 35.7 ± 16.1 years old and the male-to-female ratio was 2.4. The penetrating type of CD was the most common (41.3%) of disease behavior. The ileocolonic area is the most common location of disease involvement (79%). 7.7% of patients had low serum albumin levels (<3 g/dL). 16.8% of patients had hemoglobin levels less than 10 g/dL. Of the patients included, 4 died during the follow-up period. Low serum albumin levels at admission (p = .0307) are an independent predictor for mortality. In conclusion, it is important in perioperative care, especially for CD patients with hypoalbuminemia.

Primary hepatic angiosarcoma (PHA) accounts for 0.5% to 2% of all primary hepatic malignancies, and histopathology findings are required to diagnose PHA accurately. This study investigated 12 patients with PHA at a single medical center in southern Taiwan. We analyzed the clinical characteristics, imaging features, histopathology findings, and survival outcomes of patients with PHA. Of the 12 patients, abdominal pain and fullness were the most common symptoms, and their liver biochemistry data and tumor markers were mostly within the normal limits. The liver tumors tended to present as multifocal or diffuse nodules with bilobar involvement. The median overall survival (OS) of the 12 patients after diagnosis was 9 months. Improved OS was observed in the surgery group compared with the nonsurgery group (15 vs. 2 months, p = .003). The median OS of patients in the surgery ± systemic therapy group was superior to that of patients in the systemic therapy group and in the no-therapy groups (15 vs. 5 vs. 2 months, respectively; p = .012). Complete surgical resection remains the optimal treatment choice, and combined surgery and systemic therapy seem beneficial but require further investigation.

Chronic liver damages may end up with cirrhosis and portal hypertension, featured by splanchnic hyperdynamic circulation, angiogenesis, and collaterals formation. Melatonin is used to improve sleep quality, which exerts anti-inflammatory, anti-angiogenesis, and vascular actions without significant side effects. However, the relevant impacts on aforementioned derangements are unclear. Liver cirrhosis was induced by bile duct ligation in Sprague-Dawley rats. The rats received melatonin (40 mg/kg/day, i.p.) or vehicle for 28 days. Experiments were performed on the 28th day when cirrhosis developed. In cirrhotic rats, melatonin treatment significantly increased superior mesenteric artery resistance and reduced the blood flow. Melatonin enhanced the portosystemic collateral responsiveness to arginine vasopressin, reduced mesenteric vascular area, shunting degree, and down-regulated mesenteric MMP-2 protein expression. Melatonin improved the splanchnic hyperdynamic circulation, portosystemic collateral shunting, and mesenteric angiogenesis in cirrhotic rats. These beneficial effects make melatonin potentially feasible in clinical setting, but further investigation is required.

Chronic hepatitis B (CHB) is a progressive disease and leads to cirrhosis, cirrhotic complications, hepatocellular carcinoma (HCC), and death in a significant proportion of patients. Long-term treatment with nucleos(t)ide analogues (NUCs) significantly reduces the incidences of adverse liver-related events and improves survival in patients with CHB.¹ Although NUC therapy reduces the incidence of HCC, it does not completely eliminate this risk. Entecavir (ETV), tenfovir disoproxil fumarate (TDF), and tenofovir alafenamide are the recommended first-line NUCs for patients with CHB.¹ Whether the effectiveness for preventing HCC differs among these drugs remains unclear. Choi et al.² first reported that TDF treatment was associated with a significantly lower risk of HCC compared with ETV treatment in a population-based cohort, which was validated in a hospital-based cohort. Subsequently, some retrospective observational studies were conducted to compare the risk of HCC between patients treated with TDF versus those treated with ETV but contradictory results have been obtained.^3-7 As such, meta-analyses have been conducted to resolve the discrepancies.^3-7 Despite similar primary studies being included, the statistical significance of the difference between these two drugs varies among these meta-analyses, although more studies reported a lower risk of HCC with TDF treatment.^3-7 Furthermore, whether TDF treatment confers a lower risk of HCC in patients with cirrhosis than ETV treatment remains controversial.^{8, 9} The biological mechanisms underlying this differential effect remain unclear.

In this issue, Lin et al. compared the risk of HCC in a consecutive cohort of patients with hepatitis B virus (HBV)-related liver cirrhosis who received ETV (n = 198) versus TDF (n = 88) treatment.¹⁰ There were no significant differences in demographics or baseline characteristics between the ETV and TDF groups. During a median follow-up of 57.5 months, 25 (12.6%) patients in the ETV group developed HCC compared to 12 (13.6%) patients in the TDF group. The 5-year cumulative incidence of HCC was comparable between the ETV and TDF groups (6.57% vs. 9.09%, p = .242). They further calculated the standardized incidence ratios of HCC in both groups by comparing the observed incidence with that predicted by the REACH-B model. The observed incidence was not significantly different from the predicted incidence in either group. Multivariable Cox regression analysis identified age, male, diabetes, and platelet as the independent predictors for HCC development. They concluded that ETV and TDF provided comparable preventive effects on HCC development in patients with HBV-related liver cirrhosis.

Although ETV and TDF have been shown to reduce the risk of HCC

Proton pump inhibitors (PPIs) have become one of the most commonly prescribed medications worldwide. Although PPIs are generally considered safe and well-tolerated, studies indicate that they may be associated with certain cancer types. This study aimed to examine the association between the use of PPIs and the risk of hepatobiliary cancer using newly available evidence. Effect sizes with their variances and other characteristics were extracted from 10 eligible studies appraised from combined search results published up to September 16, 2022, from PubMed, Cochrane library, and Google Scholar. Sensitivity and trial sequential analyses were also conducted to ensure the robustness of the synthesized results. The estimated pooled relative risk for this study was 1.69 (95% CI 1.44–1.98), and the test result for the overall effect was p < .01 under a zero effect null hypothesis. According to the sensitivity analysis, the results should be robust. A significant association was observed between the use of PPIs and the risk of developing hepatobiliary cancer. The use of PPIs should be determined by prescribers as either absolutely or conditionally necessary, and, when possible, a patient's perspective should be considered in the decision-making process for PPI use.

Gut microbiota (GM) alterations play a key role in the development of hepatocellular carcinoma (HCC); however, little is known about the changes in GM diversity during the progression of HCC. Thus, we analyzed the differences in the fecal microbiota of patients with early-stage and advanced-stage HCC. This cross-sectional study examined stool samples from adults with early-stage HCC (n = 31) and advanced-stage HCC (n = 44). The taxonomic composition of the GM was determined by 16S ribosomal RNA gene sequencing of stool samples. There was no significant difference in the alpha-diversity of the GM between groups; however, beta-diversity was significantly different between the early-stage and advanced-stage groups. Further analysis indicated that the genus Veillonella, family Enterobacteriaceae, order Enterobactriales, and class Gammaproteobacteria were more abundant in the advanced-stage group than the early-stage group. Patients with early-stage and advanced-stage HCC exhibit different patterns of GM diversity. Furthermore, specific taxa—including Veillonella, Enterobacteriaceae, Enterobacteriales, and Gammaproteobacteria—are enriched in patients with advanced-stage HCC.

Medication adherence is crucial in inflammatory bowel disease (IBD). This study aimed to evaluate attitudes to medication and the effects of IBD nursing services in a Taiwanese cohort. Sixty four adult patients with IBD were invited to complete a questionnaire at Changhua Christian Hospital between October 2020 and June 2021. All the patients (32 with Crohn's disease and 32 with ulcerative colitis) completed the questionnaire. Regarding medication adherence, most patients were highly or moderately adherent and reported never or sometimes forgetting to take medication (100% for steroids and 90.7% to 91.2% for other medications). Regarding worries about adverse reactions, 38.8%, 40.3%, 12.8%, and 6.1% of patients never or rarely, sometimes, often, and always felt worried about adverse reactions, respectively. Regarding the usefulness of IBD nursing service for disease education, medication education, and scheduling of an outpatient clinic, approximately 10.9% to 12.5% of patients felt useful, and 78.1% felt very useful. Our study showed a higher adherence rate and lower worries about adverse reactions, which may be the effects of IBD nursing service at our institution.