Annals of Gastroenterology最新文献

Brown bowel syndrome (BBS) is a rare disorder characterized by brown pigmentation of the intestinal wall, thought to be a consequence of lipofuscin accumulation. Celiac disease and vitamin E deficiency have been postulated to be risk factors. We systematically searched PubMed, Embase, Web of Science and Cochrane to identify all case reports and abstracts reporting clinical information on patients with a confirmed diagnosis of BBS. Forty-two studies met our inclusion criteria, including 63 patients with confirmed BBS. The most common symptoms of BBS were diarrhea (50.8%) and malnutrition (50.8%), followed by abdominal pain (39.7%) and vomiting (22.2%). BBS patients with celiac disease who presented with similar symptoms to non-celiac patients were significantly less likely to be hypoalbuminemic (15.4 vs. 45.5%) and showed a non-significant trend towards a higher mortality rate (36.4% vs. 15.4%). Nineteen (31.7%) BBS patients were also vitamin E deficient. The clinical presentation and outcomes in BBS patients with vitamin E deficiency and celiac disease were similar to those without vitamin E deficiency and celiac disease. Further studies are warranted to better define the diagnostic-therapeutic approach to patients with BBS.

Background: Upadacitinib is a selective Janus kinase-1 inhibitor, approved for the management of Crohn's disease (CD) by the United States Food & Drug Administration. In Greece, upadacitinib was initially available through an early-access program. Our goal was to describe the real practice experience.

Methods: This was a multicenter retrospective cohort study of patients with moderate-to-severe CD. The primary endpoint was clinical response, defined as a reduction ≥3 in the Harvey-Bradshaw index. Secondary endpoints included biochemical improvement. Outcomes were assessed at 4, 8 and 12 weeks.

Results: A total of 24 CD patients received upadacitinib and were included in the analysis. Their mean age was 42.2 years (range 24-63). Eleven patients (45.8%) had ileocolonic CD and 5 (20.8%) CD colitis. Fourteen patients had active extraintestinal manifestations. The majority of patients (19/24) had ≥3 failed biologics. All of them had failed treatment with anti-tumor necrosis factor and 19 (79%) with ustekinumab. At 12 weeks, nearly all patients achieved a clinical response (85%). Of 13 patients with C-reactive protein >5 mg/L at baseline, 11 (84.6%) achieved normalization by week 8. Adverse events occurred in 3 patients (14.2%).

Conclusion: In a small cohort of resistant CD patients, the short-term clinical efficacy of upadacitinib was high.

Background: Ileus is a well-known complication of acute pancreatitis (AP). There are limited data on the factors associated with ileus, as well as its impact on AP patients. We aimed to investigate the incidence and clinical predictors of ileus in hospitalized AP patients.

Methods: We queried the 2016-2019 National Inpatient Sample (NIS) database using the International Classification of Diseases (ICD)-10 codes. Adult patients diagnosed with AP (ICD-10 K85) were included, excluding those with chronic pancreatitis. Demographics, comorbidities, complications and interventions were stratified by the presence of ileus. Multivariate analysis identified factors associated with ileus, adjusting for patient and hospital characteristics, comorbidities, and pancreatitis complications.

Results: Among 1,386,390 AP patients, 50,170 (3.6%) developed ileus. Female sex was associated with a lower risk (adjusted odds ratio [aOR] 0.56, 95% confidence interval [CI] 0.53-0.58; P<0.001). Hispanic patients had the lowest risk (aOR 0.82, 95%CI 0.76-0.88), while older age groups had a higher risk. Pseudocysts (P<0.001), sepsis (P<0.001) and portal vein thrombosis (P<0.001) were significant predictors. Pancreatic drainage was associated with ileus (P=0.007), but endoscopic retrograde cholangiopancreatography was not. Patients with ileus had greater mortality (P<0.001), longer hospital stays (+4.9 days, P<0.001), and higher costs ($67,855.91, P<0.001).

Conclusions: This study highlights age, sex and racial disparities in the development of ileus in patients with AP. It also reveals a significant association of ileus with pseudocysts, portal vein thrombosis, and pancreatic drainage. Early recognition and timely enteral feeding are crucial to prevent disease progression and improve outcomes.

Background: Esophageal perforations are managed with endoscopic stenting. However, surgical repair is still employed in many centers, if they lack endoscopic services, or for complex perforations.

Methods: We searched PubMed, Scopus, and Web of Science for relevant clinical trials and observational studies. Quality assessment was evaluated according to GRADE. The studies included were assessed based on the National Heart, Lung, and Blood Institute criteria. We included the following outcomes: leak after primary repair, operative repair after endoscopic therapy, stent migration, length of hospital stay (days), and mortality. We analyzed continuous data using mean differences and 95% confidence intervals (CI), while dichotomous data were analyzed using odds ratios and 95%CI. Statistical heterogeneity was assessed using the I ² statistic.

Results: Eight studies were analyzed and found to include 95 patients with esophageal perforation. Mortality rates decreased over time from 16.3% (Abbas, 2009) to 6.7% (Heel, 2020). Re-operative procedures were highest at 51.4%(D'Cunha, 2011) and lower in later studies. Stent migration rates varied from 16.2-22.3%. Leakage rates ranged from 8.8-16.2%. Hospital stays ranged from 5.0 days (D'Cunha, 2011) to 15.3 days (Law, 2017), with significant variability across studies.

Conclusion: Esophageal stenting is considered an efficient and well-tolerated method for managing esophageal perforation.

Background: Peroral endoscopic myotomy (POEM) is a treatment for esophageal achalasia with 2 variations in myotomy depth: full-thickness myotomy (FTM) and circular myotomy (CM). This systematic review and meta-analysis compares the efficacy and safety of these variations.

Methods: Major health databases and registers, including Embase, MEDLINE and Cochrane were searched systematically. The primary outcome was clinical success, while secondary outcomes included change in achalasia severity scores, post-POEM gastroesophageal reflux disease (GERD) measures, procedural time, and adverse events. Meta-analysis was conducted using random-effects models, with risk ratios (RR) and mean differences (MD) calculated for dichotomous and continuous variables, respectively.

Results: Nine observational studies compared FTM and CM in 1,203 patients. FTM was performed in more severe achalasia and demonstrated similar clinical success to CM (RR 1.01, 95% confidence interval [CI] 0.98-1.04; P=0.55; n=6) and procedural time (MD 3.49 min, 95%CI -2.79-9.78; P=0.28, I ²=66%; n=3). FTM was associated with increased post-POEM GERD outcomes, post-POEM pain (RR 1.94, 95%CI 1.27-2.95; P=0.002; n=2), and length of stay (LOS) (MD 0.85 days, 95%CI 0.11-1.59; P=0.02; I ²=0%; n=2); however, association with esophagitis disappeared when proton pump inhibitors use was accounted for (RR 1.68, 95%CI 0.89-3.16; P=0.11; I ²=23%; n=4). CM was associated with higher rates of subcutaneous emphysema (RR 0.59, 95%CI 0.43-0.81; P=0.001; n=5).

Conclusions: FTM and CM have comparable observed clinical efficacy and procedural time, with minimal differences in complications. FTM may be preferred in more severe achalasia and its association with post-POEM GERD may have been overestimated, but it may increase post-POEM pain and LOS.

Background: We evaluated the efficacy of endoscopic treatment (ET) for gastric neoplastic complications of autoimmune gastritis (AIG). We also assessed the safety of ET and the risk factors for the occurrence of neuroendocrine tumors (NETs) and gastric adenocarcinoma (GA).

Methods: This was a retrospective, single-center, observational study. All patients diagnosed with AIG between 1987 and 2019 and had at least 1 upper endoscopy available were included.

Results: The study population comprised 88 patients (68.2% female). The median follow up was 5 years (range 1-28). A total of 132 NETs were diagnosed in 39/88 patients (44.3%) (median age 50.0 years, range 27.0-85.0 years). The mean lesion size was 7.1 mm (range 1-30); there were 80 G1 NETs and 52 G2 NETs. Among the 132 lesions, 86.3% (114/132) were endoscopically resected, mostly by endoscopic mucosal resection (105/114, 92.1%), without complications. Only 1 patient underwent surgery. Twelve patients (13.6%) (7 females; median age, 76.0 years; range, 53.0-90.0 years) presented with GA. Of these, 66.7% (8/12) needed surgery, while 4 patients underwent exclusive endoscopic resection. Only 2 patients presented with NETs and GA (2.8%). Patients who presented with NETs were significantly younger at AIG diagnosis than patients with GA: 52.0 (18.0-85.0) vs. 67.0 (44.0-81.0) years (P=0.008). Patients who presented with GA were significantly older than those who presented with NETs: 76.0 (53.0-90.0) vs. 50.0 (27.0-85.0) years (P<0.001).

Conclusion: ET of NETs for AIG is effective and safe. GA is rarer, occurs in significantly older patients, and usually requires surgery.

Fontan-associated liver disease (FALD) is a significant complication in patients with Fontan palliation. The improved longevity following Fontan palliation has led to wider recognition of FALD and its association with hepatocellular carcinoma (HCC). This review examines the intricate link between FALD and HCC development, emphasizing the unique hemodynamic changes in Fontan circulation that promote hepatic congestion, fibrosis and cirrhosis, thereby facilitating carcinogenesis. The review comprehensively analyzes the existing literature, highlighting key risk factors, pathophysiological mechanisms, and diagnostic challenges in FALD-related HCC. While HCC incidence in FALD remains relatively low (1.5-5.0%), its higher mortality rate of 29.4% necessitates a thorough understanding of contributing factors and screening requirements. The management of FALD involves multidisciplinary approaches, addressing cardiac and hepatic aspects, with regular surveillance for liver disease progression and HCC using advanced imaging and biomarkers. Therapeutic considerations include interventions to manage hepatic congestion and fibrosis, although balancing these with the unique cardiac needs of Fontan circulation remains challenging. Interestingly, FALD management often mirrors that of other liver diseases, underscoring the need for tailored approaches. In severe cases, combined heart-liver transplantation offers a comprehensive solution for FALD-HCC. This review consolidates current knowledge on the epidemiology, pathogenesis and comprehensive management of HCC in the specific context of FALD, ultimately improving outcomes for this unique patient population.

Background: Patients' and gastroenterologists' views on the relative importance of treatment outcomes and medication attributes for ulcerative colitis (UC) may differ. We aimed to explore which treatment outcomes and medication attributes are considered important by both for therapeutic decisions.

Methods: Eight gastroenterologists and 23 patients with UC in Greece participated in semi-structured interviews and focus groups, respectively. The focus groups and interviews were audio-recorded, transcribed and coded, utilizing thematic analysis until data saturation was achieved.

Results: Themes that were discussed included the impact of UC on daily life, UC-related outcomes, drug-related attributes and the patient-doctor relationship. Within these themes, disparities between the perspectives of gastroenterologists and patients were evident on 2 main issues. Gastroenterologists prioritized clinical remission and emphasized long-term objectives, such as mucosal healing, while patients focused on shorter-term outcomes, such as the early and sustained relief of symptoms. Regarding medication attributes, important factors for patients were primarily those that impacted their daily life, such as route of administration, dosage and the need for hospital visits. In contrast, gastroenterologists were more concerned about potential adverse events and non-responsiveness to treatment. There was a consensus regarding the importance of shared decision-making for UC management, emphasized by both patients and clinicians.

Conclusions: Gastroenterologists mostly prioritize objective measures of remission, while patients mainly focus on factors related to their quality of life and overall well-being. Enhancing communication regarding different goals and expectations may strengthen the physician-patient relationship, ultimately resulting in better shared therapeutic decision-making.

Primary biliary cholangitis (PBC) is a progressive autoimmune liver disease characterized by chronic inflammation and destruction of interlobular bile ducts. Its pathogenesis involves a complex interplay of genetic predisposition, environmental triggers, and immune-mediated mechanisms, particularly T-helper cell activity, leading to bile duct damage. First-line therapy includes ursodeoxycholic acid (UDCA), which improves liver biochemistry and slows disease progression, with obeticholic acid (OCA) as an option for non-responders. Double and/or triple therapy, including UDCA, OCA, and fibrates, appears to be superior in achieving therapeutic benefits in UDCA-nonresponsive PBC patients. Emerging therapies, such as peroxisome proliferator-activated receptor-α agonists, biologics such as dacetuzumab and rituximab, and experimental approaches such as stem-cell therapy, offer promising advances in managing PBC. Liver transplantation remains a final treatment option for advanced cases.

Background: Inflammatory bowel disease (IBD), which includes Crohn's disease and ulcerative colitis, is a multifactorial inflammatory disorder of the gastrointestinal system that impairs the patient's quality of life. Its presentation includes a spectrum of symptoms that may also be secondary to IBD complications, such as malignancy. On the other hand, immunosuppressive treatment to maintain remission also carries a risk of malignancy, which can cause patients distress due to the risk/benefit balance of IBD control and malignancy.

Methods: In this nationwide retrospective study, we aimed to elucidate which patient and treatment factors have the greatest impact on the development of malignancy in IBD patients. Statistical analysis was performed on patient factors, including treatment types, and nominal regression analysis was carried out to assess the effects of multiple risk factors on the incidence of malignancy in patients with IBD.

Results: Age at diagnosis of IBD correlated significantly with malignancy development, as did the diagnosis of ulcerative colitis. IBD patients diagnosed with malignancy had an older age of onset of IBD than those who did not develop malignancy. Sex, treatment type, treatment duration, and extent or location of disease did not correlate significantly with malignancy development.

Conclusion: We conclude that age of onset of IBD plays the greatest role in malignancy development, whilst immunosuppressive treatment is not a significant risk factor.