Annals of Gastroenterology最新文献

Background: Meandering main pancreatic duct (MMPD) refers to an uncommon ductal variant of the normal smooth curvilinear course of the pancreatic duct. More specifically, MMPD is characterized by a hairpin (reverse Z-type) or loop (loop-type) turn in the pancreatic head. It has been suggested as a predisposing factor for the development of pancreatitis. Studies regarding treatment are scarce.

Methods: We conducted a narrative review of the current literature regarding MMPD. Additionally, we present a cohort of 9 symptomatic patients treated endoscopically at our tertiary center.

Results: Seven retrospective cohort studies and 4 case reports were included in our review. Only 1 study focuses on the clinical significance of MMPD and describes a positive association between MMPD and the onset of pancreatitis, especially recurrent acute pancreatitis. Only 1 case reports an endoscopic treatment. In our cohort of 9 MMPD patients, 7 did indeed present with recurrent acute pancreatitis. Endotherapy provided substantial regression of symptoms in 6 patients, all of whom had signs of ductal hypertension.

Conclusions: Our review shows the scarcity of data regarding MMPD, especially concerning treatment, in the current literature. With our cohort, we not only hope to raise awareness of this often-neglected entity of recurrent acute pancreatitis, but also support the case for endotherapy for the first time in 9 symptomatic MMPD patients, especially in the presence of ductal hypertension.

Background: This study evaluated the technical and clinical outcomes of transcatheter arterial embolization (TAE) in patients with acute small-bowel bleeding (SBB) and aimed to identify potential risk factors for early recurrent bleeding after TAE.

Methods: Thirty-one patients with SBB managed with TAE between January 2006 and December 2021 were included. Technical and clinical success was defined as angiographic occlusion of the bleeding artery and disappearance of clinical or laboratory signs of persistent bleeding without major complications. Complications were classified according to the Society of Interventional Radiology's guidelines. Kaplan-Meier estimates assessed overall survival, and logistic regression models determined risk factors for clinical success and early rebleeding.

Results: Technical and clinical success were achieved in 30/31 (97%) and 19 (61%), respectively. Early recurrent bleeding was present in 9 (29%) patients, and was treated by repeat embolization in 4 patients, conversion to surgery in 4, and comfort therapy in 1 patient. TAE-related small bowel ischemia requiring surgery was found in 2 (6.5%) patients. Thirty-day and in-hospital mortality were 19% (6/31) and 23% (7/31), respectively; overall 5-year estimated survival was 60%. Thrombocytopenia and elevated prothrombin time (PT)/activated partial thromboplastin time (aPTT) levels prior to TAE were identified as risk factors for clinical failure (P=0.0026 and P=0.027, respectively), and for residual or early recurrent bleeding (P<0.001 and P=0.01, respectively).

Conclusions: TAE is safe and effective for managing severe SBB; however, early recurrent bleeding was found in nearly one third of patients. Thrombocytopenia and elevated PT/aPTT levels were risk factors for early recurrent bleeding.

Background: Malignant distal biliary obstruction (MDBO) is a challenging clinical condition commonly managed with endoscopic retrograde cholangiopancreatography (ERCP). However, endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an alternative, especially in complex cases where ERCP fails or is deemed risky. This study aimed to compare the efficacy, safety and cost-effectiveness of EUS-BD vs. ERCP in the palliation of MDBO.

Methods: We conducted a systematic review and meta-analysis, following PRISMA guidelines. Three databases were searched up to December 2023, including MEDLINE/PubMed, OVID and the Cochrane Central Register of Controlled Trials, for studies comparing EUS-BD with ERCP. Primary outcomes were technical and clinical success rates, while secondary outcomes included procedural times, hospital stay duration, 30-day mortality, reintervention rates, and adverse events such as pancreatitis.

Results: Seven studies involving 1245 patients met the inclusion criteria. The meta-analysis revealed that EUS-BD had a technical success rate of 92%, compared to 85% for ERCP. Clinical success rates were similar for both EUS-BD and ERCP, at approximately 89%. EUS-BD was associated with a significantly lower incidence of pancreatitis (2% vs. 10% for ERCP).

Conclusions: EUS-BD offers a viable and potentially superior alternative to ERCP for the primary palliation of MDBO, particularly in terms of technical success and a lower risk of pancreatitis. These findings support the adoption of EUS-BD in clinical settings equipped to perform this technique, though future research should focus on long-term outcomes and further economic analysis to solidify these recommendations.

Background: The epidemiology of inflammatory bowel disease (IBD) has changed rapidly in recent years. Objective data concerning the IBD burden in the Middle East and North Africa (MENA) region is limited. We aimed to provide a systematic report on the IBD burden in the MENA region. Additionally, we aimed to study the age- and sex-specific trends in IBD incidence, prevalence and mortality rates from 1990-2019.

Methods: Using the Global Burden of Disease (GBD) 2019 Study Database, we investigated the changes in incidence, prevalence and mortality rate, and disability-adjusted life-years (DALYs), at a regional and country level between 1990 and 2019.

Results: In 2019, there were 282,534 cases (95% confidence interval [CI] 239,506-334,478) of IBD in the MENA region (50.5% male). There was an overall increase in the incidence and prevalence rates of IBD in the MENA region from 1990 to 2019, while a simultaneous decrease in overall mortality rates was identified. Incidence rates were highest in Jordan, at 6.9 (95%CI 5.8-8.1) per 100,000, and lowest in Morocco, at 1.6 (95%CI 1.4-2) per 100,000. From 1990-2019, the incidence was found increased in males at a higher rate than in females. The age-standardized mortality rate decreased for both sexes by 24% from 1990-2019.

Conclusion: The trends and geographic variations in IBD within the MENA region provide policymakers with vital information for making informed decisions in policy, research, and investment, thereby enabling the development of more effective strategies and better allocation of resources.

Background: In view of the growing complexity of managing anticoagulation for patients undergoing gastrointestinal (GI) procedures, this study evaluated ChatGPT-4's ability to provide accurate medical guidance, comparing it with its prior artificial intelligence (AI) models (ChatGPT-3.5) and the retrieval-augmented generation (RAG)-supported model (ChatGPT4-RAG).

Methods: Thirty-six anticoagulation-related questions, based on professional guidelines, were answered by ChatGPT-4. Nine gastroenterologists assessed these responses for accuracy and relevance. ChatGPT-4's performance was also compared to that of ChatGPT-3.5 and ChatGPT4-RAG. Additionally, a survey was conducted to understand gastroenterologists' perceptions of ChatGPT-4.

Results: ChatGPT-4's responses showed significantly better accuracy and coherence compared to ChatGPT-3.5, with 30.5% of responses fully accurate and 47.2% generally accurate. ChatGPT4-RAG demonstrated a higher ability to integrate current information, achieving 75% full accuracy. Notably, for diagnostic and therapeutic esophagogastroduodenoscopy, 51.8% of responses were fully accurate; for endoscopic retrograde cholangiopancreatography with and without stent placement, 42.8% were fully accurate; and for diagnostic and therapeutic colonoscopy, 50% were fully accurate.

Conclusions: ChatGPT4-RAG significantly advances anticoagulation management in endoscopic procedures, offering reliable and precise medical guidance. However, medicolegal considerations mean that a 75% full accuracy rate remains inadequate for independent clinical decision-making. AI may be more appropriately utilized to support and confirm clinicians' decisions, rather than replace them. Further evaluation is essential to maintain patient confidentiality and the integrity of the physician-patient relationship.

Background: The recommended duration of vasoactive drugs in esophageal variceal bleeding (EVB) spans 2-5 days. Prior meta-analyses of randomized trials include only a few studies that compared short vs. long vasoactive drug durations approximating this time range, including older management techniques, and only assessed variceal rebleeding at 5 days. We identified several additional randomized controlled trials (RCTs) assessing rebleeding at various durations, with updated management of EVB.

Methods: We performed an updated systematic review and meta-analysis assessing the effect of shortening the vasoactive drug duration by 48-72 h. The primary outcome was rebleeding within 5 days. Secondary outcomes included rebleeding, mortality due to rebleeding, and all-cause mortality within 4-6 weeks (extended period) with subgroup analysis by vasoactive drug and type of endoscopic therapy. Length of stay, blood transfusion requirements and terlipressin-related adverse events were additional secondary outcomes.

Results: Our comprehensive search strategy and screening process yielded 14 RCTs with 1060 patients (75.1% male): 7 trials used terlipressin, 4 octreotide, and 3 somatostatin. Shortened durations combined with band ligation led to similar rebleeding, with a trend towards less rebleeding when populations with more severe liver disease were excluded. There was greater rebleeding and mortality over an extended period when shorter durations were combined with sclerotherapy. Longer durations were associated with a longer hospital stay and, for terlipressin, more adverse events.

Conclusions: Shorter vasoactive drug durations combined with band ligation in selected populations appear safe. Higher powered RCTs are needed, involving patients with different degrees of severity of EVB and liver disease.

Background: Silent chronic pancreatitis (SCP) is a poorly understood subtype of chronic pancreatitis (CP) in which individuals describe little to no abdominal pain. The risk factors for SCP are unclear, and it is unknown whether there are differences in the clinical outcomes of SCP and painful CP. We set out to investigate the clinical features of SCP and the risk factors associated with this condition.

Methods: This was a retrospective cohort study using data from the Penn State Milton S. Hershey Medical Center from 2019-2022. Two patient groups, the SCP cohort (23 patients) and the painful CP cohort (94 patients), were identified from consecutive clinics. Descriptive statistics and bivariate and logistic regression analyses (including variables with a P-value <0.1 on bivariate analysis) were performed to characterize the study cohort and to evaluate for independent associations with SCP.

Results: SCP was independently associated with older age (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.01-1.11; P=0.03) and male sex (OR 5.38, 95%CI 1.38-20.96; P=0.02), and inversely associated with current opioid use (OR 0.18, 95%CI 0.03-0.96; P=0.04). There was no association between SCP and current pain medication or diabetes mellitus.

Conclusions: Our study adds to the growing body of literature describing SCP as a condition associated with older age and male sex, and inversely associated with opioid use. We found no greater association of diabetes with SCP. Future larger longitudinal studies are needed to gain a better understanding of SCP.

Background: The controlled attenuation parameter (CAP) enables the noninvasive assessment of liver steatosis. We performed a systematic review and meta-analysis to evaluate the diagnostic accuracy of CAP for identifying liver steatosis in patients at risk for metabolic dysfunction-associated steatotic liver disease (MASLD), using magnetic resonance imaging proton density fat fraction (MRI-PDFF) as the reference standard.

Methods: We searched Medline, Embase, Cochrane Library and gray literature sources up to March 2024. We defined MASLD as MRI-PDFF ≥5%. We also assessed the accuracy of CAP for identifying patients with MRI-PDFF ≥10%. We calculated pooled sensitivity and specificity estimates using hierarchical random-effects models. We assessed the risk of bias using the Quality Assessment of Diagnostic Accuracy Studies 2 tool, and the certainty in meta-analysis estimates using the Grading of Recommendations Assessment, Development and Evaluation framework.

Results: We included 8 studies with 1116 participants. The prevalence of MASLD ranged from 65.2-93.9%. Pooled sensitivity and specificity of CAP for MRI-PDFF ≥5% were 0.84 (95% confidence interval [CI] 0.79-0.88) and 0.77 (95%CI 0.68-0.84), respectively, with an area under the receiver operating characteristic curve (AUROC) of 0.88. The pooled sensitivity and specificity for MRI-PDFF ≥10% were 0.83 (95%CI 0.80-0.87) and 0.72 (95%CI 0.59-0.82), with an AUROC of 0.85. The certainty in our estimates was low to very low because of the high risk of bias, inconsistency and imprecision.

Conclusions: CAP has acceptable diagnostic accuracy for both MRI-PDFF ≥5% and MRI-PDFF ≥10%. Adequately powered and rigorously conducted diagnostic accuracy studies are warranted to establish the optimal CAP thresholds.

Background: Crohn's disease (CD) predisposes patients to intestinal obstruction (IO), a severe complication. This study examined the outcomes and healthcare utilization of patients with CD and IO using data from the National Inpatient Sample (NIS).

Methods: This retrospective analysis of NIS data from 2016-2020 compared hospitalized adult CD patients with and without IO. Outcomes studied include in-hospital mortality, length of stay (LOS), hospitalization charges, and the requirement for intervention, using regression models for adjustment.

Results: Among the 304,149 CD patients, 27,024 had IO. These patients experienced higher in-hospital mortality (3.9% vs. 1.8% for non-IO, adjusted odds ratio [aOR] 1.78, 95% confidence interval [CI] 1.09-2.89; P=0.02), longer mean LOS (7.23 vs. 4.53 days for non-IO, P<0.001), and higher average hospitalization charges ($71,775 vs. $43,717 for non-IO, P<0.001). Additionally, they had higher odds of requiring admission to the intensive care unit (aOR 1.99, 95%CI 1.45-2.73; P<0.001), intubation (aOR 2.53, 95%CI 1.74-3.68; P<0.001), balloon dilation (aOR 1.50, 95%CI 1.132-1.98; P=0.005), or intestinal resection (aOR 2.29, 95%CI 2.11-2.49; P<0.001).

Conclusions: CD patients with IO face considerable challenges, including greater mortality, longer hospital stays, and higher hospitalization costs. The need for intensive care and surgical interventions highlights the urgent need for improved management and treatment strategies to enhance outcomes for these patients.

Background: Autonomic neuropathy (AN) in cirrhotic patients has been linked to a higher risk of cirrhosis-related complications and worse outcomes before, during or after liver transplantation (LT). However, only a few studies exist with inconsistent results.

Methods: We searched for all articles published until September 2023 that described a diagnosis of AN based on cardiovascular autonomic reflex tests (CARTs), assessment of the rate-corrected QT interval (QTc), heart rate variability (HRV), and baroreflex sensitivity (BRS) tests, in order to evaluate the predictive role of AN in cirrhosis and/or peri-/post-LT prognosis.

Results: Twenty-five studies were included: 5, 12, 9, and 1 study, respectively, assessed the predictive role of CARTs, prolonged QTc, HRV indices, and BRS in cirrhosis or peri-/post-LT prognosis. In CARTs-based analysis, the pre-LT pooled mortality rate was significantly higher in cirrhotics with AN compared to those without AN (20% vs. 6%; P=0.01). However, no difference was found between patients with and without pre-LT prolonged QTc in the pre-LT pooled mortality rates (41% vs. 18%; P=0.08), pooled peri-transplant risk of major complications (29% vs. 17%; P=0.08) or post-LT pooled mortality rates (15% vs. 12%; P=0.36). In HRV-based analysis, the standard deviation of normal-to-normal intervals was significantly lower in non-survivors, compared to survivors with cirrhosis: standardized mean difference -2.59, 95% confidence interval -4.75 to -0.43; P=0.04.

Conclusions: The presence of CARTs- and HRV-based AN was a good predictor of mortality in the pre-LT setting. Preoperative prolonged QTc did not seem to be associated with the outcome before or after LT.