American Journal of Gastroenterology最新文献

Introduction: Multitarget stool DNA (MT-sDNA) tests (i.e., Cologuard) serve as screening tests for colorectal cancer (CRC) and are recommended by the US Preventive Services Task Force every 1-3 years. In this study, in a primary care setting, our aim was to evaluate the diagnostic performance of MT-sDNA testing and colonoscopy findings after a positive MT-sDNA testing result.

Methods: This was a retrospective cohort study of electronic health record data including all patients who underwent MT-sDNA tests (Cologuard; Exact Sciences, Madison, WI) at 35 network primary care facilities from Winter of 2019 to Spring of 2023. Patients who were at high risk and had a prior colonoscopy or prior negative MT-sDNA test result were excluded. Assessment of pathology was as previously described, including for advanced adenomas and CRC.

Results: Among the 5,827 patients for whom MT-sDNA testing was ordered, 3,119 patients completed the test; 482 (15%) had a positive MT-sDNA test, most of whom were women, had an average age of 65 years, and were predominantly White (Supplemental Figure 1, Table 1). Among these 482 patients, 277 (57%) had a follow-up screening colonoscopy, with 253 patients having complete colonoscopy data. Ten patients (4%) had CRC, 61 (24%) had advanced adenomas, and 184 patients (73%) had neither. The sigmoid colon was the most common site for CRC, with 8 of 10 patients having tumor, node, metastasis stage ≥1 CRC.

Discussion: The rate of colon cancer detection (10/5,827 [0.2%] patients for whom it was ordered and 10/3,119 [0.3%] who completed the test) was lower than expected in a screening cohort. Most patients who completed MT-sDNA testing had a false-positive result for advanced adenomas or CRC (73%). Together, these findings raise questions about the effectiveness of screening based on MT-sDNA testing in an average risk population.

Introduction: The recent US Food and Drug Administration approval of resmetirom for treating metabolic dysfunction-associated steatohepatitis in patients necessitates patient selection for significant fibrosis or higher (≥F2). No existing vibration-controlled transient elastography (VCTE) algorithm targets ≥F2.

Methods: The mAchine Learning ADvanceD fibrosis and rIsk metabolic dysfunction-associated steatohepatitis Novel predictor (ALADDIN) study addressed this gap by introducing a machine-learning-based web calculator that estimates the likelihood of significant fibrosis using routine laboratory parameters with and without VCTE. Our study included a training set of 827 patients, a testing set of 504 patients with biopsy-confirmed metabolic dysfunction-associated steatotic liver disease from 6 centers, and an external validation set of 1,299 patients from 9 centers. Five algorithms were compared using area under the curve (AUC) in the test set: ElasticNet, random forest, gradient boosting machines, XGBoost, and neural networks. The top 3 (random forest, gradient boosting machines, and XGBoost) formed an ensemble model.

Results: In the external validation set, the ALADDIN-F2-VCTE model, using routine laboratory parameters with VCTE (AUC 0.791, 95% confidence interval [CI]: 0.764-0.819), outperformed VCTE alone (0.745, 95% CI 0.717-0.772, P < 0.0001), FibroScan-aspartate aminotransferase (0.710, 0.679-0.748, P < 0.0001), and Agile-3 model (0.740, 0.710-0.770, P < 0.0001) regarding the AUC, decision curve analysis, and calibration. The ALADDIN-F2-Lab model, using routine laboratory parameters without VCTE, achieved an AUC of 0.706 (95% CI: 0.668-0.749) and outperformed Fibrosis-4, steatosis-associated fibrosis estimator, and LiverRisk scores.

Discussion: Along with the steatosis-associated fibrosis estimator model developed to target significant fibrosis or higher, ALADDIN-F2-VCTE ( https://aihepatology.shinyapps.io/ALADDIN1 ) uniquely supports a refined noninvasive approach to patient selection for resmetirom without the need for liver biopsy. In addition, ALADDIN-F2-Lab ( https://aihepatology.shinyapps.io/ALADDIN2 ) offers an effective alternative when VCTE is unavailable.

Barrett esophagus (BE) is the only known histological precursor to esophageal adenocarcinoma (EAC). The incidence of EAC has risen significantly over the past 4 decades in the United States and other Western countries, and the prognosis of EAC remains poor, with over half of individuals diagnosed at a late stage. Despite this, fewer than 1 in 5 eligible individuals undergo endoscopic screening for BE. Current screening practices rely on upper endoscopy, limiting widespread adoption and missing a significant portion of at-risk individuals. Recent technological advancements in minimally invasive screening modalities have the potential to expand screening efforts, improve detection rates, and reduce healthcare resource utilization. This review discusses the conceptual underpinnings and hurdles to successful screening for EAC and BE, evaluates newer technologies for screening, including nonendoscopic cell collection devices, blood-based biomarkers, transnasal endoscopy, and exhaled volatile organic compounds, and examines emerging methods for enhancing detection of dysplasia and intestinal metaplasia, including artificial intelligence and wide area transepithelial sampling. The value of screening in light of a recent randomized trial of surveillance from the United Kingdom, as well as a landmark study on nonendoscopic risk stratification for dysplasia in BE, are considered. While direct evidence linking screening to reduced EAC mortality is lacking, trials highlight promising outcomes in early detection of precancerous and cancerous lesions. Future directions, challenges, and recommendations for optimizing BE screening are discussed.

Introduction: Hepatitis A virus (HAV) is a rare cause of acute liver failure (ALF) that carries a relatively good prognosis for recovery. In recent years, overall numbers of HAV cases have declined, likely because of increased hepatitis A vaccination rates.

Methods and results: We reviewed the Acute Liver Failure Study Group registry for the number HAV-related ALF cases over 24 years.

Discussion: Overall, the number of HAV ALF cases enrolled steeply declined. After 2010, when we began recording acute liver injury (ALI: International normalized ratio ≥ 2 but no encephalopathy), an apparent increase in ALI incidence was noted, despite a near absence of ALF cases.

Introduction: The optimal first-line treatment of pediatric achalasia remains debated. Pneumatic balloon dilation (PD) shows variable success and low complication rates in small cohorts. To evaluate the efficacy and safety of PD as first-line therapy for pediatric achalasia.

Methods: A retrospective review (2011-2022) of patients aged younger than 21 years treated at a single center was conducted. Success was defined as no additional intervention within 12 months.

Results: Of 23 patients (median age 13 years), 78% had success at 12 months; 74% maintained success at 30 months. No major complications occurred.

Discussion: PD is a safe, effective first-line treatment of pediatric achalasia.