Annals of Gastroenterology最新文献

Background: Ulcerative colitis (UC) is a chronic inflammatory disease affecting ~1.5 million individuals, causing significant impairment in quality of life, psychological well-being, and healthcare burden. Using indirect meta-analysis, this study compared the efficacy and safety of anti-interleukin (IL)-12/23 and IL-23 agents vs. placebo and each other, during induction and maintenance in moderate-to-severe UC.

Methods: A systematic search of PubMed, Cochrane, Scopus, Web of Science, and ClinicalTrials. gov was conducted on October 1, 2024. The randomized controlled trials (RCTs) included evaluated ustekinumab, mirikizumab, risankizumab, and guselkumab. The primary outcomes were clinical remission and endoscopic improvement at both induction and maintenance endpoints. Odds ratios (ORs) with 95% confidence intervals (CIs) and surface under the cumulative ranking (SUCRA) values were used to rank treatment efficacy.

Results: Six RCTs (n=3808) were analyzed for induction and 5 RCTs (n=1697) for maintenance. During induction, risankizumab demonstrated the highest clinical remission rates (OR 3.89, 95%CI 2.24-6.75; SUCRA 80.7%) and endoscopic improvement rates (OR 4.21, 95%CI 2.12-8.35; SUCRA 87.6%) compared to placebo. In maintenance, guselkumab showed the highest clinical remission (OR 4.28, 95%CI 1.58-11.59; SUCRA 81.6%) and endoscopic improvement (OR 4.21, 95%CI 2.12-8.35; SUCRA 93.1%), and was superior to risankizumab (OR 2.05, 95%CI 1.09-3.84) for endoscopic outcomes.

Conclusions: Risankizumab was most effective in induction, while guselkumab was more effective in maintenance. Head-to-head trials are warranted.

Background: Esophageal submucosal tumors (ESTs) were typically managed through surveillance, but there is now a shift towards endoscopic resection. Endoscopic submucosal dissection (ESD) and submucosal tumor endoscopic resection (STER) appear to be safe and effective treatment options; however, evidence from non-East Asian centers is limited.

Methods: This retrospective multicenter study included 97 patients from 15 centers across 9 countries who underwent endoscopic resection of ESTs via ESD or STER. Demographics, tumor characteristics, procedural details, adverse events and follow-up outcomes were recorded and analyzed.

Results: Of the 97 patients, 48 underwent ESD and 49 STER. Most lesions were located in the lower esophagus and originated from the muscularis propria. En bloc resection was achieved in 95% of cases, with no significant difference between techniques (STER: 92% vs. ESD: 98%, P=0.18). The most common histologic diagnosis was leiomyoma (52%), followed by granular cell tumors (22%) and gastrointestinal stromal tumors (6%). Adverse events were infrequent: 9 cases of perforation were recorded, with only 4 being unintentional and all managed endoscopically. Follow-up data revealed only 1 case of local recurrence in a patient with a 50 mm lesion treated by STER. Hospital stay was longer after STER than ESD (3 vs. 2 days, P<0.001).

Conclusions: ESD and STER are effective and safe for ESTs, with high en bloc resection rates, minimal adverse events and very low recurrence during short-term follow up. These findings support the broader adoption of advanced endoscopic resection, which is transforming the management of ESTs from surgical to endoscopic treatment.

Background: Endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) with a lumen-apposing metal stent has been proposed as a treatment for patients with gastric outlet obstruction (GOO). We performed a systematic review and meta-analysis to compute the technical success, clinical success and complication rates of EUS-GE in treating GOO due to either neoplastic or benign diseases.

Methods: The literature search was conducted in PubMed, EMBASE and the Cochrane Central Register of Controlled Trials, from inception until January 23, 2025, according to the PRISMA and MOOSE statement guidelines. The primary objective was to assess both technical and clinical success. A secondary outcome was to rate the adverse events.

Results: Data from 39 studies involving 2845 patients were analyzed. The pooled technical success rate was 95.1%, and the procedure was successful in 95.3% and 95.1% of patients with malignant or benign diseases, respectively. Clinical success was achieved in 93.5% of all patients where the procedure had technical success, and in 93.1% and 94.4% of those treated for malignant and benign conditions, respectively. The overall rate of adverse events was 18.5%, including perforation (4.4%), bleeding (2.7%), stent migration (1.4%), stent closure (3.3%), infection (4.4%), and fistula (2.3%). The procedure-related mortality was 1.4%.

Conclusion: EUS-GE appears to be a viable approach for the treatment of GOO patients, for both malignant and benign diseases, with favorable outcomes and an acceptable safety profile.

Crohn's disease (CD) and ulcerative colitis (UC), known as inflammatory bowel disease (IBD), are characterized by immune system dysregulation. The spleen holds a primary role in systemic inflammation and immune responses. Splenic involvement or splenomegaly in IBD patients may result from secondary causes, such as portal hypertension, myeloproliferative diseases, amyloidosis, splenic abscesses or granulomas. Current research on the direct association between IBD and spleen volume (SV) has expanded significantly. In CD, SV is predominantly increased, and is associated with worsen clinical outcomes. Successful treatment with infliximab often leads to a reduction in the elevated SV. Patients with UC often present spleens with invariant SV, or smaller spleens than those observed in CD, as UC typically affects a more limited part of the gastrointestinal tract compared to CD. However, reduction of SV in UC can also indicate relapsing pancolitis. Recent genetic data also suggest that an increased SV serves as a potential risk factor for the development of IBD, emphasizing the possible bidirectional causal relationship between IBD and SV. Shared pathogenic pathways, including intestinal immune activation, tumor necrosis factor-α activation, bowel toxin absorption and lymphatic tissue involvement, might explain the splenic and intestinal immune dysfunction. Thus, the measurement of SV and its adjustment for body mass index or weight, factors that affect the spleen size, may serve as a potential indicator for IBD monitoring, predicting disease-related flares and complications, and evaluating the response to current biologics. Nonetheless, further insights into the underlying pathogenic pathways linking SV and IBD are considered imperative.

Background: Hepatogenous diabetes (HD) is common in advanced cirrhosis. The oral glucose tolerant test (OGTT) is frequently diagnostic, as fasting blood glucose (FBG) may be normal. We investigated the impact of FBG- and OGTT-diagnosed HD, and metformin treatment, on circulatory function, renal function and perfusion, and inflammatory activity in patients with cirrhosis and ascites. Also, long-term prognosis of HD under metformin/metformin-based treatment was assessed.

Methods: Mean arterial pressure (MAP), cardiac output (CO), systemic vascular resistance (SVR) as MAP/CO ratio, plasma renin activity (PRA), plasma aldosterone, glomerular filtration rate (GFR), renal blood flow (RBF), and plasma levels of lipopolysaccharide-binding protein (LBP), tumor-necrosis factor-α (TNF-α) and interleukin-6 were evaluated at baseline in patients with and without HD, and after 6 months of metformin treatment for newly diagnosed HD.

Results: Compared to OGTT-HD (n=34) and no-HD (n=37), FBG-HD patients (n=35; newly-diagnosed, n=13) had significantly lower SVR (P=0.02/P=0.01), GFR (P=0.01/P=0.008) and RBF (P=0.02/P=0.01), and significantly higher CO (P=0.04/P=0.03), PRA (P=0.009/P=0.006), and levels of LBP (P=0.01/P=0.008) and TNF-α (P=0.03/P=0.02). Initiation of metformin in OGTT-HD and FBG-HD patients induced significant increases in SVR (P=0.02/P=0.04), GFR (P=0.02/P=0.04) and RBF (P=0.04/P=0.05), and significant decreases in PRA (P=0.02/P=0.03) and LBP (P=0.02/P=0.04). Three-year survival in OGTT-HD was significantly higher than in FBG-HD (75.3% vs. 55.3%; P=0.03) and similar to no-HD (81.7%).

Conclusions: Circulatory function and renal function and perfusion are aggravated by FBG-HD compared to OGTT-HD or no-HD, possibly because of greater inflammatory activity, while they improve significantly after metformin treatment. Early treatment of HD with metformin may improve prognosis.

Background: We investigated the short-term diuretic and natriuretic effect of empagliflozin, a sodium-glucose linked transporter 2 inhibitor, in patients with cirrhosis and type 2 diabetes mellitus (T2DM).

Methods: This was a prospective, single-arm study including 30 patients with T2DM and cirrhosis (Child-Pugh class A/B). Participants received empagliflozin 10 mg for 15 days while continuing their standard treatment. Clinical and biochemical parameters, and urinary samples, using 24-h urine collection, were recorded before and after treatment. Twenty-seven patients continued empagliflozin for 6 months and were assessed for glycemic control and renal function.

Results: Empagliflozin increased median daily urine volume by 475 mL (P=0.010) and fractional sodium excretion (FE_Na) by 16% at day 15 (P=0.030), but the 8 mmol/L increase in 24-h sodium excretion was not significant. Empagliflozin also reduced body weight (-0.8 kg, P<0.001) and systolic blood pressure (-4 mmHg, P=0.029). Glycemic control remained unremarkable at day 15, but improved at 6 months (baseline vs. 6 months: fasting glucose 146 vs. 116 mg/dL, P=0.016; glycosylated hemoglobin 6.2% vs. 6%, P=0.011). Compared to baseline (89.1±20.6 mL/min/1.73m², estimated glomerular filtration rate declined numerically but not statistically significantly at day 15 (85.2±21.8, P=0.056 and at 6 months (82.8±23.7, P=0.035. No serious adverse events were noticed.

Conclusions: Up to 6 months' empagliflozin administration in patients with cirrhosis and T2DM seems safe and increases urine output and FE_Na, but its impact on renal function requires further investigation. Larger randomized controlled trials are needed to confirm its long-term efficacy and safety in this setting.

Background: Small bowel capsule endoscopy (SBCE) is a critical tool in the evaluation of small bowel bleeding, detection of small bowel neoplasms and diagnosing Crohn's disease. The object of this study was to examine device failures (DF) and patient-related adverse events (PRAE) in SBCE, including those involving the patency capsule system, using user-generated reports from the US Food and Drug Administration's (FDA) Manufacturer and User facility Device Experience (MAUDE) database.

Method: We analyzed post marketing surveillance data for SBCE data for all of the SBCE systems from the FDA's MAUDE database from January 2000 until December 2023.

Results: A total of 352 reports were obtained during the study period, pertaining to the following SBCE systems, in descending order of frequency: Pillcam SB^® system, Pillcam^® Patency Capsule, Endocapsule^®, CapsoCam^® and MiroCam^®. The vast majority pertained to the Pillcam^® and Pillcam^® Patency system: a total of 307 medical device reports with 398 DFs and 569 PRAEs. The most reported DFs were entrapment of the device (n=212, 53.2%), failure to transmit record (n=38, 9.5%), and failure to record (n=35, 8.7%). The most commonly reported PRAEs were a foreign body retained in the patient (n=140, 24.6%), unintentional exposure to radiation (n=104, 18.2%), and unintended exposure to anesthesia (n=58, 10.2%).

Conclusions: Findings from the MAUDE database regarding SBCE devices provide valuable information on DFs and PRAEs. This knowledge can help operators optimize patient selection and reduce patient risk.

Background: Upadacitinib, a selective Janus kinase (JAK) inhibitor, is a recently approved therapy for moderate-to-severe ulcerative colitis (UC). Limited data are available on its efficacy in patients previously exposed to tofacitinib, a non-selective JAK inhibitor. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy of upadacitinib in UC patients with prior tofacitinib treatment.

Methods: PubMed, Embase, Web of Science, and Cochrane Library were queried for studies evaluating the effectiveness of upadacitinib in UC patients with prior tofacitinib treatment. Primary outcomes included clinical remission, steroid-free clinical remission (SFCR), and clinical response. Secondary outcomes were the mean decrease in fecal calprotectin, and adverse events. Statistical analyses were performed using R, calculating pooled proportions with 95% confidence intervals (CI) for dichotomous outcomes and mean differences with 95%CI for continuous outcomes using a random-effects model.

Results: Five studies, with 127 patients, were included in the final analysis. Upadacitinib increased pooled clinical remission rates by 57% (95%CI 0.32-0.80), SFCR rates by 52% (95%CI 0.26-0.78), and clinical response rates by 75% (95%CI 0.44-0.96). Upadacitinib reduced mean fecal calprotectin levels by 597.59% (95%CI 350.94-844.324). Adverse events, such as headache, acne vulgaris, rash, nasopharyngitis and infections, were reported in 34% of patients (95%CI 0.11-0.62).

Conclusions: Our meta-analysis indicates that upadacitinib may be an effective treatment for patients with prior tofacitinib exposure, demonstrating significant clinical remission, SFCR, and clinical response. Larger clinical trials are needed to establish long-term outcomes.