BMJ Open Gastroenterology最新文献

Objective: Approximately 30% of the 700 000 US Gulf War Veterans (GWVs) report symptoms collectively termed Gulf War Illness (GWI), a multisymptom illness of uncertain pathophysiology. Prior studies in GWI focus on overlap with irritable bowel syndrome. This study examines the associations between upper gastrointestinal (UGI) symptoms, GWI and specialty GI care.

Methods: This cross-sectional study analysed GWVs referred to a Veterans Health Administration clinical War-Related Illness and Injury Study Center (2008-2020). Symptoms, demographics, military service and clinical history were obtained from self-reported intake packets. GWI was defined by the Centers for Disease Control and Prevention criteria requiring moderate-to-severe symptoms in at least two of three domains: fatigue, musculoskeletal and mood cognition. UGI symptoms were analysed individually as a composite variable and additively (0-5). Logistic regression models estimated ORs for associations between UGI symptoms, GWI and GI specialty care.

Results: The cohort included 596 GWVs (mean age 49.3 years, 88% men). Most (93.5%) reported at least one UGI symptom, with a mean of 2.8 symptoms. GWI was identified in 413 (69%). Veterans with GWI were more likely to report UGI symptoms (98.3% vs 82.5%) and had a higher mean symptom count (3.1 vs 2.1). Adjusted ORs for UGI symptoms in GWI ranged from 1.79 (dysphagia) to 3.57 (nausea/vomiting).

Conclusion: UGI symptoms are common among GWVs and strongly associated with GWI. Clinicians should screen for UGI symptoms and follow standard protocols for treatment and referral.

Objective: Bothersome ulcerative colitis (UC) symptoms include stool frequency (SF), rectal bleeding (RB), abdominal pain and bowel urgency; symptomatic relief is a key treatment goal. Etrasimod is an oral, once-daily (QD), selective sphingosine 1-phosphate_1,4,5 receptor modulator for the treatment of moderately to severely active UC. We assessed outcomes related to symptomatic relief among patients with moderately to severely active UC in the phase III ELEVATE UC clinical programme.

Methods: In both ELEVATE UC 52 and ELEVATE UC 12, adults were randomly assigned (2:1) to etrasimod 2 mg QD or placebo. Symptomatic remission, symptomatic response, complete symptomatic remission, SF and RB were evaluated at each trial visit. Bowel urgency and abdominal pain were also assessed (weeks 12 and 52).

Results: Significantly more patients receiving etrasimod were in symptomatic remission and symptomatic response at weeks 12 and 52 versus placebo (all p<0.001). Improvements from baseline in RB and SF subscores were significantly greater in those receiving etrasimod versus placebo from weeks 2 (ELEVATE UC 12) and 4 (ELEVATE UC 52). Similarly, a significantly greater number of patients in the etrasimod versus placebo group were in complete symptomatic remission. At weeks 12 and 52, the number of patients achieving clinically meaningful improvements in bowel urgency, bowel urgency remission and abdominal pain remission was significantly greater for etrasimod versus placebo (all p<0.05).

Conclusion: Etrasimod was efficacious in improving symptoms of UC from week 2; improvements were maintained through week 52.

Trial registration number: ClinicalTrials.gov: NCT03945188; NCT03996369.

Objective: To establish patients' perceptions of decision-making and prioritisation of test attributes when considering a colonic investigation.

Methods: National Health Service Highland patients on the waiting list for a colon capsule endoscopy (CCE) and colonoscopy were invited to undergo a semistructured qualitative telephone interview. A diverse sample was sought using a purposive sampling strategy, aiming for differences in age, gender and test awaited between participants. An interview guide was developed using an iterative approach and published data on patients' experience of colonic investigations. Data were analysed using phenomenological approach and thematic analysis.

Results: Between 12 June 2022 and 02 August 2022, 12 patients underwent telephone interviews. Nine of those patients were on the waiting list for colonoscopy and three were waiting for a CCE. Patients described a mixed level of involvement in the decision-making process for a colonic investigation; some were not involved in the process at all, while others were guided by their clinician. The most important test aspect reported by patients was diagnostic quality, focused on getting a diagnosis, ruling out cancer or the diagnostic accuracy of the test. The importance of the waiting time for the test, the amount of pain or discomfort experienced during the test and the invasiveness of the test were also discussed by patients.

Conclusion: Through qualitative interviews, we have identified patients' priorities for colonic investigations, which should be further explored to quantify the value patients place on these aspects of the test. Areas of improvement in the decision-making process have been reported, which could be addressed to improve patient care.

Trial registration number: NCT05391529.

Objective: Appendiceal adenocarcinoma is a rare cancer with very limited therapeutic options. We aimed to determine whether molecular profiling of advanced appendiceal adenocancer can identify actionable therapeutic alterations.

Methods: We retrospectively analysed cohorts from two large German precision oncology programmes. Patient records and pathology reports from 19 patients with advanced appendiceal adenocarcinoma who were enrolled between 2015 and 2021 were included in this study. We report the molecular features, the resulting molecular tumour board recommendations and their clinical implementation.

Results: In 95% of the tumours, at least one potentially actionable alteration was identified, including mutations in ATM, PIK3CA and AKT1. An elevated tumour mutational burden was identified in 26% of the tumours. A total of 74% of all patients received a molecularly driven treatment recommendation, of which 2 (11%) received the recommended therapy.

Conclusion: Molecular profiling of appendiceal adenocarcinomas revealed potentially actionable alterations in a number of cases.

Objective: Intestinal failure in advanced malignancy is most commonly due to mechanical bowel obstruction. Palliative home parenteral nutrition (HPN) is an option for such patients to meet their nutritional needs. However, there are limited data on overall survival and predictive factors. This study aimed to evaluate the survival of patients receiving palliative HPN and the impact of patient factors on survival.

Methods: This is a single-centre retrospective observational study of patients referred for palliative HPN from 1 January 2020 to 19 November 2024 at the Cambridge University Hospitals NHS Foundation Trust. Demographic, nutritional and medical data were analysed. Survival rates were compared using Kaplan-Meier curves and Cox regression.

Results: 84 patients were referred and 77 were discharged with HPN (median age was 60.9 years (IQR: 51.3-70.4), female 77%). 78% of the underlying primary malignancies were gynaecological and gastrointestinal. Malignant bowel obstruction was the main indication for HPN (86%). Eastern Cooperative Oncology Group performance status (PS) scores were ≤2 in 82% of patients and 75% had an estimated prognosis of >3 months. Median survival was 58 days (IQR 31-108) with a 3-month mortality of 69%. There was no statistical difference in survival by PS, estimated prognosis, underlying malignancy or modified Glasgow Prognostic Score (mGPS).

Conclusions: The overall survival in our study is modest. PS, prognosis, mGPS or tumour type did not show a significant impact on survival. This highlights the challenges in artificial nutrition and emphasises the role of a multidisciplinary team in the care of these patients.

Objective: Deficiencies have been highlighted in acute hospital care for alcohol-related liver disease (ARLD). Such problems may be worse at weekends (WEs). Increased 30-day mortality for WE admissions has been reported for several acute conditions, but data for ARLD are limited. We aimed to compare patient and pathway characteristics between WE and weekday (WD) admissions and investigate the 'weekend effect' on mortality.

Methods: Retrospective cohort study (2008-2018) using linked electronic databases (Hospital Episode Statistics-Clinical Practice Research Datalink and death registration) including 17 575 first emergency admissions identified using the Liverpool ARLD algorithm.

Exposure: WE admission (Saturday or Sunday).

Main outcome: all-cause death within 30 days. Covariates included socio-demographic characteristics, pathway characteristics (pre-admission contacts and admission method) and markers of severity (recorded stage of liver disease, ascites and varices, comorbidity). Alternative risk-adjustment methods were used, including standard regression and propensity-weighted analysis (Inverse Probability of Treatment Weighting).

Results: 3249 admissions (18.5%) were at WE. Unadjusted 30-day mortality was significantly higher for WE versus WD (17.1% vs 15.5%, p=0.018). All models demonstrated increased odds of death for WE admissions with adjusted ORs ranging from 1.15 to 1.23 (relative risk of 1.12-1.19). Causes of death did not vary by admission day and effect was consistent across subgroups. Findings were robust to sensitivity analyses restricting the cohort to patients admitted directly from Accident and Emergency department (A&E), or cirrhosis or ascites but not varices.

Conclusion: First ARLD admissions at the WE experienced a 12-19% increase in 30-day mortality risk compared with WD. Although residual confounding cannot be excluded, this suggests the possibility of avoidable mortality among those hospitalised at WEs. Services should be alert to risks of WE effects when planning care.

Objective: Current patient-reported outcome measures (PROMs) for chronic constipation (CC) have been predominantly developed for Western populations, often neglecting cultural factors critical to Asian contexts. This study aimed to psychometrically validate the Asian Constipation Assessment Initiative Questionnaire (ACAIQ), codesigned with patients experiencing CC and clinicians in Singapore, and examine the effect of constipation awareness on symptom reporting.

Methods: A cross-sectional study enrolled 259 participants with CC (Rome IV criteria) and 153 healthy controls between 9 December 2022 and 19 March 2024. Participants completed the ACAIQ alongside established PROMs. Structural validity, internal consistency, test-retest reliability and criterion validity were evaluated following Consensus-based Standards for the Selection of Health Measurement Instruments guidelines. The influence of constipation awareness on symptom reporting and Rome IV criteria was analysed using non-parametric statistical tests.

Results: ACAIQ-SYM (symptom severity scale) demonstrated strong structural validity (comparative fit index=0.968, Tucker-Lewis Index=0.958, root mean square error of approximation=0.06), internal consistency and reproducibility (α=0.88, intraclass correlation coefficient≥0.70). However, the ACAIQ-QoL (quality of life scale) exhibited structural inconsistencies, necessitating further refinement. Aware participants reported more severe symptoms than unaware and controls (p<0.05). Notably, 71.4% of participants with CC were unaware of their condition, underscoring the importance of constipation awareness in symptom perception and reporting.

Conclusion: ACAIQ-SYM is a valid tool for assessing constipation symptoms in Asian populations. The significant impact of awareness on symptom reporting highlights the need for patient education. Further refinement of ACAIQ-QoL is necessary to ensure a comprehensive evaluation of QoL. Once optimised, ACAIQ could improve digital health platforms, patient-clinician engagement and personalised CC management strategies.

Objective: This study aimed to explore the lived experiences and coping strategies of patients with short bowel syndrome (SBS) prescribed teduglutide and weaning off home parenteral nutrition (HPN), and to compare the quality of life (QOL) of these patients to patients with SBS but not prescribed teduglutide.

Methods: A qualitative study was conducted, with patients recruited from a specialist HPN clinic. Participants completed handwritten semi-structured daily diaries for 6 weeks and a validated Home Parenteral Nutrition-Quality of Life (HPN-QOL) paper-based questionnaire as part of what aimed to be a mixed methods cross-tracks study. Participants were age-matched with patients with SBS receiving HPN but not prescribed teduglutide, and these 'controls' also completed the HPN-QOL questionnaire. Data analysis involved qualitative analysis of diary entries using grounded theory methodology and descriptive analysis of HPN-QOL questionnaire responses.

Results: Five participants completed the study and were matched with four 'controls'. All participants and 'controls' reported a high QOL with no differences observed between patients prescribed and not prescribed teduglutide. Qualitative analysis revealed that participants engaged in iterative cycles of problem-focused action and emotion-focused coping strategies to manage their condition and wean off parenteral nutrition (PN). Key subthemes included polyphagia and pleomorphism in diet, fatigue-related emotional distress and positive reframing using an objective scientific lens. Decisional regret was absent, participants agreed that treatment with teduglutide was the right choice for them, despite its challenges. Their goal of independence from PN was the main motivating factor.

Conclusion: This study provides valuable insights into the lived experiences and coping strategies of patients with SBS prescribed teduglutide to wean off PN. The findings underscore the importance of healthcare teams understanding these everyday challenges to facilitate shared decision-making and tailor care plans. Further research is needed to explore the long-term impact of teduglutide on QOL, including the validation of tools to screen for fatigue-related emotional distress and the development of targeted interventions to support patients during the weaning process.

Objective: Fontan-associated liver disease (FALD) results from haemodynamic changes following the Fontan procedure for congenital heart disease and is associated with poorer outcomes. The prevalence of Fontan is rising due to improved survival; however, little is known about predictors of advanced liver fibrosis in adult patients. This study aimed to determine the accuracy of non-invasive fibrosis assessment tools (NIT) in predicting histologically confirmed advanced liver fibrosis in an adult Fontan cohort attending Mater Misericordiae University Hospital.

Methods: Patient demographics, congenital cardiac variables and fibrosis biomarkers were recorded including liver stiffness measurement (LSM) via transient elastography, Fibrosis-4 (FIB-4) and Aspartate aminotransferase-to-Platelet Ratio Index (APRI) scores. Biopsies, taken between 2017 and 2024, were staged using the congestive hepatic fibrosis score. Analysis was performed using SPSS.

Results: 71 patients (58% male) were included. The median age was 25 years. 62% had histological advanced fibrosis. There were no significant bleeding events post biopsy. Overall, advanced fibrosis was associated with a closed Fontan fenestration (p=0.022) and higher LSM, although with a weak correlation (p=0.04, r=0.25, area under the curve (AUC) 0.65), but not with APRI or FIB-4. There was no difference in rates of advanced fibrosis between sex (p=0.84). In females, higher APRI was associated with advanced fibrosis (p=0.045, r=0.41, AUC 0.73).

Conclusions: The majority of Fontan patients have advanced liver fibrosis in their third decade. A patent Fontan fenestration appears to reduce the risk of advanced fibrosis. Despite an association with higher LSM, there was no cut-off which could negate the need for biopsy in a significant population. Our data suggest that the discriminatory ability of NIT may vary according to sex. Liver biopsy is safe and remains the only method of reliably diagnosing advanced fibrosis in FALD.

Objective: Recent evidence supports diagnosing coeliac disease without biopsy in patients with significantly elevated tissue transglutaminase (IgA-tTG) antibodies. However, the implementation of this no-biopsy approach relies on accurate and consistent serological testing across laboratories. In this nationwide survey, we aimed to evaluate the availability and variability of coeliac disease testing across the UK.

Methods: We conducted a cross-sectional telephone survey of biomedical scientists and laboratory managers from National Health Service trusts and health boards across England, Wales, Scotland, and Northern Ireland. Data collected included assay types, reporting methods, upper limit of normal (ULN) thresholds, turnaround times, total IgA testing, and anti-endomysial antibodies (EMAs) availability.

Results: A total of 356 sites were approached, with a 96% response rate (n=342). Of responding sites, 177 performed coeliac serology tests in-house, while 165 transferred samples externally. Among sites performing tests, 12 different IgA-tTG assays were identified, with considerable variability in ULN thresholds ranging from 3 to 30 IU/mL, even within laboratories using the same assays. The median turnaround time for IgA-tTG results was 7 days (range 1-21 days). Only 43% of laboratories routinely measured total IgA when IgA-tTG was requested. EMA testing was available in 83% of laboratories.

Conclusion: Significant variability exists in coeliac serology testing across UK laboratories which poses a challenge for the implementation of the no-biopsy approach in clinical practice. Efforts to standardise serological testing are urgently needed. Until such standardisation is achieved, local assay validation remains critical.