Annals of Gastroenterology最新文献

Background: Immune checkpoint inhibitors (ICIs) have transformed cancer treatment but are frequently complicated by immune-related adverse events, including immunotherapy-related colitis (irColitis). Early and accurate diagnosis, including endoscopy, is essential for appropriate management, yet the real-world feasibility and clinical impact of early endoscopic evaluation remain unclear.

Methods: We conducted a retrospective analysis of patients who underwent office-based, unsedated flexible sigmoidoscopy between February 2019 and April 2022 as part of the RAPID-GI program at Memorial Sloan Kettering Cancer Center. The program was designed to expedite evaluation of suspected irColitis in ICI-treated patients via rapid GI consultation including sigmoidoscopy. A diagnosis of irColitis was confirmed based on histology review by expert GI pathologists.

Results: irColitis was confirmed in 70% (66/94) of patients. Median time from referral to consultation including sigmoidoscopy was 8 days. Visible inflammation was present in 80% of patients with confirmed irColitis vs. 11% without (P<0.001); all irColitis cases showed histologic inflammation. All procedures were completed without sedation using enemas alone for bowel preparation, and no complications occurred. Findings led to management changes in 89% of irColitis cases, including initiation or adjustment of immunosuppressive therapies. Among patients without irColitis, 79% avoided unnecessary immunosuppression and 57% continued or resumed ICI therapy.

Conclusions: Office-based flexible sigmoidoscopy is a safe, feasible, and high-yield diagnostic tool for suspected irColitis. A rapid access program enables timely diagnosis, guides therapy, minimizes unnecessary immunosuppression, and facilitates ICI continuation. This model may improve outcomes and should be considered for broader adoption among integrated oncology and gastroenterology care teams.

Background: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are associated with gastrointestinal (GI) adverse effects, but real-world evidence about their incidence in patients with functional GI disorders is limited. We examined their prescription and discontinuation patterns in irritable bowel syndrome (IBS) patients.

Methods: In this retrospective analysis of GLP-1RAs prescribed to patients with IBS at our institution from 2013-2023, we assessed the association of IBS subtype- and patient-related (age, race, body mass index, insurance, diabetes, gastroesophageal reflux disease) factors on the number and reasons for agent switches throughout the treatment course.

Results: Of the 256 patients with IBS prescribed >1 GLP-1RAs, 227 (88.7%) patients trialed 2-3 GLP-1RAs, while 29 (11.3%) trialed ≥4 agents. Mixed-type IBS patients showed the highest rates of switching, followed by constipation- and diarrhea-predominant type IBS (21.7%, 11.7% and 2.2%, respectively; P=0.02). Semaglutide had more discontinuations within 6 months of starting the first GLP-1RA, compared to liraglutide (63.4% vs. 43%; P=0.012). Patients aged ≥65 years were more likely to continue the first agent for >6 months compared to those <65 years (65.8% vs. 44%, P=0.014). In successive lines of therapy, treatment-related discontinuations (injection burden, non-response) remained fairly constant (17%, 14%, 14%) but symptom-related (nausea, vomiting, diarrhea, constipation) discontinuations increased steadily from first to third agent (28%, 30%, 48%, respectively). Patients with Medicare/Medicaid were more likely to switch ≥3 therapies, than those with private/self-pay coverage (23% vs. 7.3%; P=0.006).

Conclusion: Our findings highlight the importance of tailoring therapy based on drug-specific and patient-related factors to optimize GLP-1RA use in IBS.

Background: Pancreatic cancer is among the leading causes of cancer-related deaths worldwide. Resectable pancreatic cancer is typically treated with curative resection, often followed by adjuvant therapy. Despite this, recurrence rates remain high after resection. Additionally, micro-metastases may develop during the immediate postoperative period. To address this issue, neoadjuvant therapy has been proposed. This review aimed to assess the effectiveness of neoadjuvant treatment compared to surgery as first approach in resectable pancreatic cancer.

Methods: A comprehensive literature search was conducted up to October 2, 2024, in CENTRAL, PubMed, ProQuest, SAGE and JSTOR. Randomized controlled trials (RCTs) evaluating the effects of neoadjuvant treatment in patients with resectable pancreatic cancer were included.

Results: A total of 5422 articles were identified after duplicate removal. Following the screening process, 8 RCTs were included. No significant difference was observed in the overall survival (OS) among those who received neoadjuvant therapy and those who underwent upfront surgery (hazard ratio [HR] 0.92, 95% confidence interval [CI] 0.72-1.18; P=0.51). Additionally, the groups' disease-free survival (DFS) was comparable (HR 0.98, 95%CI 0.80-1.20; P=0.83). Patients who received neoadjuvant treatment had noticeably higher R0 resection rates compared to the upfront surgery group (risk ratio 1.31, 95%CI 1.11-1.55; P=0.002).

Conclusions: When compared to upfront surgery, neoadjuvant therapy significantly improved the R0 resection rates, but had no significant effect on OS or DFS. More research is required to confirm the potential benefits of neoadjuvant therapy in treating resectable pancreatic cancer.

Background: Diverticular disease (DD) is a common gastrointestinal condition in the United States (US) associated with significant morbidity and mortality. The COVID-19 pandemic posed new challenges that might exacerbate DD-related outcomes. This study analyzed the trends in all-cause, digestive system (DGS), and cardiovascular system (CVS) mortality associated with DD from 1999-2020, focusing on the impact of COVID-19 on age-adjusted mortality rates (AAMRs) and disparities across demographics and geography.

Methods: Data from adults aged ≥25 years were extracted from the Centers for Disease Control WONDER database. AAMRs per 100,000 people were standardized using the 2000 US census. AAMRs were assessed from 1999-2020 for context, while the primary comparative analysis focused on the pre-COVID-19 (2016-2019) and post-COVID-19 (2019-2022) periods using linear regression models. AAMRs were stratified by age, sex, race/ethnicity and geographic region. Note: 2021-2022 trends were extrapolated, as finalized mortality records were not available at the time of analysis.

Results: Between 1999 and 2020, 115,009 DD-related deaths occurred (AAMR 2.4/100,000), including 70,648 DGS-related deaths (AAMR 1.5) and 17,405 CVS-related deaths (AAMR 0.4). Females (AAMR 2.6), elderly individuals (AAMR 11.1), and non-Hispanic whites (AAMR 2.5) had the highest mortality rates. Post-COVID-19, AAMRs increased from 1.8 to 2.0, with significant increases among rural populations. DGS-related deaths were most prevalent, particularly in non-metropolitan areas.

Conclusions: DD-related mortality has increased in the post-COVID-19 period, especially in vulnerable populations, such as the elderly, rural residents and females. These findings highlight the need for equitable healthcare interventions and the continued monitoring of pandemic-era health disparities.

Gastroparesis, a chronic condition with complex etiopathogenesis, is associated with considerable symptom burden and significant morbidity. Dietary modifications and pharmacotherapy exhibit limited long-term efficacy, while surgical interventions are characterized by higher morbidity and variable efficacy. Endoscopic procedures, because of their less invasive nature, have been the focus of past and ongoing research. The majority of endoscopic treatment modalities target the pylorus: e.g., gastric peroral endoscopic pyloromyotomy, botulinum toxin injection, pyloric balloon dilatation, and transpyloric stent placement. Endoscopic feeding tube placement, endoscopic gastric electrical stimulation, and endoscopic ultrasound-guided gastroenterostomy have also been used to treat gastroparesis; however, these procedures are less well-studied. This critical review provides a detailed overview of the available endoscopic procedures for the management of gastroparesis, with emphasis on their pros and cons, quality of data and overall efficacy.

Background: Nurses are essential in the care of patients with inflammatory bowel disease (IBD). However, the competencies of IBD nurses in Italy still need to be studied. This research assessed Italian IBD nurses' fundamental and advanced skills, providing a baseline for future professional development.

Methods: This cross-sectional study used an online survey developed by a multidisciplinary expert panel, including gastroenterologists and IBD nurse specialists. The 53-item survey covered sociodemographics, professional characteristics, institutional context and competencies (fundamental and advanced), assessed via a 5-point Likert scale based on Nurse European Crohn and Colitis Organisation guidelines. Distributed nationwide from June to August 2024, descriptive statistics summarized participants' profiles, while inferential analyses, including Pearson's correlations and ANOVA, explored associations between competencies and variables such as experience, education, and institutional factors.

Results: The study analyzed responses from 50 IBD nurses, predominantly female (92%), with a mean age of 48.38±9.7 years. Fundamental competencies showed consistently higher mean scores compared to advanced competencies. High proficiency was noted in establishing empathetic relationships and recognizing the emotional impact of IBD (mean score: 4.06/5). Advanced competencies with the highest scores included caregiver education and multidisciplinary support (3.56/5 and 3.40/5, respectively). Significant correlations were observed between years of IBD-specific experience and competencies such as therapeutic management and stress handling.

Conclusions: Italian IBD nurses demonstrate fundamental solid and moderate skills in advanced competencies. Enhancing educational programs and multidisciplinary collaboration can improve the quality of care for IBD patients. Future studies should address integrating digital health tools to support self-management and patient outcomes.

Background: Case reports describe the use of oral vancomycin therapy (OVT) in adult patients with concomitant symptomatic inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC). OVT is associated with a higher likelihood of IBD remission in pediatric IBD-PSC patients. However, there are limited data on the association between OVT and IBD disease course in adult IBD-PSC patients.

Methods: We retrospectively evaluated IBD therapy intensification in adults with IBD-PSC prescribed OVT at 2 centers. Subjects were stratified by time "on" and "off" OVT. Only those who spent a minimum of 12 months in each period were included. The primary outcome was the frequency of IBD therapy intensification events.

Results: Of 31 patients initially considered, 22 met the inclusion criteria. Most patients (68.2%) had fewer or no intensification events while "on OVT" compared to those "off OVT". OVT was associated with fewer therapy intensification events (1.7 vs. 6.7, P=0.021) and steroid prescriptions (0.6 vs. 3.2, P=0.013) per 10 person-years.

Conclusions: OVT use is associated with less need for IBD therapy intensification in symptomatic IBD-PSC adult patients. Prospective trials of OVT in such patients are warranted.

The development of clinically significant portal hypertension (CSPH) represents one of the strongest predictive biomarkers for disease progression in patients with compensated advanced chronic liver disease (cACLD). Chronic liver injury triggers both intra- and extrahepatic mechanisms, giving rise to an increasing portal pressure and a self-perpetuating cycle with worsening risks of liver-related complications and mortality. Diagnosing CSPH becomes challenging in patients with advanced but compensated chronic liver disease where CSPH is not apparent clinically. Approximately 60% of patients with cACLD will have CSPH, representing a critical window for intervention to reduce portal pressure and prevent complications. The current gold standard for portal pressure measurement, the hepatic venous pressure gradient, is impractical for widespread use. Emerging diagnostic tools aim to address this limitation. Techniques such as endoscopic ultrasound-guided portal pressure gradient measurement, and noninvasive approaches using imaging methods, elastography (targeting liver and/or spleen) and serum markers, offer alternatives for CSPH detection, and moreover, can guide treatment decisions. Non-selective beta-blockers are known to reduce morbidity and mortality in patients with CSPH. Unfortunately, they remain the only approved therapy for CSPH and they are not effective in reducing portal pressure in all patients, highlighting the urgent need for additional therapeutic options as well as practical methods to evaluate treatment response. Recent innovations and ongoing research are steering the field toward a more personalized approach, where diagnosis, treatment and follow up are tailored to individual patient risk profiles. This evolution holds the potential to improve outcomes in patients with CSPH.

Background: Severe sepsis with septic shock (SSWSS) is a potential and severe complication that can arise among patients hospitalized for acute biliary pancreatitis.

Methods: We queried the 2018-2021 National Inpatient Sample for adults with a primary diagnosis code of acute biliary pancreatitis without necrosis or infection. Baseline characteristics of the patients were studied and multivariate regression models were used to appraise the roles of different factors for events of SSWSS.

Results: We evaluated 136,140 adults who had acute biliary pancreatitis without necrosis or infection on admission; their median age was 57.0 years, and the majority were female (60.6%). Of these, 435 patients developed SSWSS. Higher odds were seen in cases with coexisting chronic kidney disease (P<0.001), liver cirrhosis (P<0.001), and human immunodeficiency virus infection (P<0.001). Races other than White/Black/Hispanics had higher odds (P<0.001) than Whites. Females were less likely to report SSWSS (P<0.001) than males. Moreover, patients from the 26^th-50^th median household quartiles had lower odds of SSWSS than those in the 0-25^th quartiles. Medium (P<0.001) and large (P<0.001) hospitals reported more cases than small hospitals. Admissions in the southern areas of the United States also exhibited higher odds (P=0.026), than Northeast regions. Lower odds were noted in smokers (P<0.001) and cases with dyslipidemia (P=0.048). SSWSS led to higher mortality rates (65.5% vs. 0.4%).

Conclusions: In our nationwide analysis, we found that episodes of SSWSS among patients with acute biliary pancreatitis were influenced by several factors. SSWSS patients also had higher mortality.