Journal of gastrointestinal and liver diseases : JGLD最新文献

Overlapping primary biliary cholangitis (PBC) and autoimmune hepatitis (AIH) represents a distinctive autoimmune phenotype characterized by concurrent cholestatic and hepatocellular damage, culminating in a more aggressive disease course if not recognized. This review synthesizes the existing evidence concerning epidemiology, pathophysiology, and diagnostic criteria, with particular emphasis on histopathology, serological markers, and established scoring systems, including the Paris criteria and the International Autoimmune Hepatitis Group (IAIHG) scoring scheme. We highlight the clinical relevance of combined therapies, typically comprising ursodeoxycholic acid and immunosuppressants, in effectively controlling both components of the disorder and halting fibrosis progression. Additionally, we discuss emerging data regarding second-line agents such as obeticholic acid and innovative immunomodulatory approaches aimed at refining patient outcomes. Special attention is dedicated to pediatric and pregnant populations, in whom disease manifestation and therapeutic responses may differ. Ongoing evaluations of noninvasive biomarkers and imaging modalities, including transient elastography, promise improved monitoring and individualized management strategies. Notably, relevant outcome measures, including quality of life and the burden of pruritus, are paramount for comprehensive patient care. Collectively, these advances hold promise for improved long-term patient survival by enabling more precise diagnostic pathways, targeted therapeutic regimens, and closer surveillance.

Neurogastroenterology disorders, also known as "Disorders of Gut-Brain Interaction" are gastrointestinal disorders that comprise a wide range of symptoms such as dysphagia, chest pain, heartburn, abdominal pain, nausea and vomiting, bloating, constipation, diarrhea or stool discharge. Scarcity of recognition, knowledge and training leading to the underdiagnosis of these conditions is associated with increased referrals to gastroenterologists or emergency room visits, along with a dramatic rise in healthcare costs and impaired quality of life. Despite advances in endoscopy and radiology, motility and pH impedance procedures remain the cornerstone of an accurate "Disorders of Gut-Brain Interaction" diagnosis, but these procedures need to be performed by well-trained personnel in a dedicated motility unit, with high-performance equipment. The primary motility procedures include high-resolution esophageal manometry and pH monitoring for esophageal function, high-resolution anorectal manometry and balloon expulsion tests for anorectal function, as well as hydrogen/methane breath tests for identifying dysbiosis and food intolerances. The purpose of this article is to highlight the importance of establishing a Neurogastroenterology and Motility Unit, and to provide an up-to-date overview on the main issues encountered when setting up a motility laboratory in the community or academic practice, including considerations for personnel training, equipment, and commonly performed motility procedures and their clinical usefulness.

Background and aims: Lichenoid esophagitis (LichE) is rarely encountered by gastrointestinal endoscopists. Using a large nationwide database of clinicopathological records, the demographic and clinical characteristics of patients with LichE were compared to patients with lymphocytic esophagitis (LyE) and eosinophilic esophagitis (EoE).

Methods: In a case-control study, cases with a diagnosis of LichE, LyE, or EoE were compared to a control population of all patients without these 3 conditions. In addition to histopathology, patients' demographics, clinical presentation, and gastrointestinal comorbidities were considered. Statistical significance was assessed using odds ratios (OR) and 95% confidence intervals (95%CI).

Results: Among 967,773 unique patients with esophageal biopsies, LichE was found in 511 (0.05%), LyE in 1,786 (0.18%), EoE in 56,474 (5.84%), and none of these 3 diagnoses in a control population of 909,002 patients. LichE patients were significantly older, and EoE patients were significantly younger than the control population (p<0.0001). LichE and LyE significantly prevailed in females (OR=1.69; 95%CI: 1.40-2.04 and 1.34; 1.22-1.47, respectively). EoE was significantly less common in females (OR=0.49; 95%CI: 0.48-0.49). All 3 types of esophagitis were significantly less common among Hispanics, with their respective ORs of 0.70 (95%CI: 0.50-0.98), 0.83 (95%CI: 0.70-0.98), and 0.55 (95%CI: 0.53-0.57). EoE was also less common in persons of East and South Asian ancestry, with respective ORs of 0.52 (95%CI: 0.47-0.56) and 0.66 (95%CI: 0.56-0.76).

Conclusions: Increasing clinical awareness of LichE may enhance its clinico-pathological recognition, clarify its natural history, and ultimately lead to more effective clinical management.

Background and aims: Endoscopic procedures prioritization is an important tool for defining healthcare resources distribution in a daily practice and more important in times of limited resources such as the COVID 19 pandemic. We assessed the completion rate of endoscopic procedures that were canceled by the patients themself, based on the prioritization strategy recommended by the European Society of Gastrointestinal Endoscopy (ESGE) and examine what were the outcomes of the procedures' cancellation according to the endoscopic different indications.

Methods: Retrospective analysis of all the self-cancelled procedures during March 2020 at our tertiary endoscopic referral center. The completion rate was estimated until July 2021. The procedure's primary indications were classified according to the ESGE position statement ("always perform/high priority" vs. "low-priority/postpone always"); Endoscopic findings were classified as "significant", defined as advanced neoplasia/ a clinically significant intervention, or "other".

Results: We included 194 patients (mean age 60.4±15.3 years old; 44.8% females, 90.7% colonoscopies, 20.1% classified as "always perform/ high priority"). The completion rate in the "perform always/high priority" groups versus the "low-priority/postpone always" groups was 51.3% versus 70.3%, (p=0.024). In contrast, the rate of significant endoscopic findings in the "perform always/high priority" groups versus the "low-priority/postpone always" groups was 40.0% versus 7.3%, (p<0.001).

Conclusions: Patients who are prioritized according to the ESGE classification have a higher rate of significant findings but a lower likelihood of completing the procedure. This highlights the need for improving implementation of prioritization strategy based on the ESGE classification.

Background and aims: Hepatocellular carcinoma (HCC) is currently the third leading cause of cancer-related mortality, a figure that is on the rise. The shared hallmark of different etiologies, progression, and HCC survival is chronic inflammation, making it a significant field of interest for prognostic and therapeutic strategies. We aimed to evaluate the prognostic accuracy of several inflammation-based scores in HCC.

Methods: A consecutive series of patients at their first HCC diagnosis were enrolled during a 5-year timespan in a prospectively maintained multicentric database. Demographic, clinical, biological, and imagistic data were collected. Representative inflammation-based prognostic scores, including the platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), systemic immune inflammation index (SII), prognostic nutritional index (PNI), albumin-to-bilirubin index (ALBI), platelet-albumin-bilirubin-index (PALBI), AST-to-lymphocyte ratio (ALRI), AST/ALT, AST-to-platelet ratio (APRI) were assessed for prediction of overall survival (OS) in a scenario-based setting, using Kaplan-Meier curves, univariate and multivariate analyses.

Results: A total of 467 patients from five tertiary-care hospitals were enrolled in this study. The median age was 64.94 years, and the most frequent etiology of the liver disease was hepatitis C (50%). During a median of 14.85 (35) months of follow-up, the cumulative mortality was 84.8%. In the univariate analysis, PNI (HR=2.414; p=0.021), ALBI grade (HR=2.023; p<0.001), and PALBI grade (HR=2.022; p<0.001) demonstrated the highest prognostic accuracies for OS in HCC, regardless of the clinical scenario. Moreover, PLR (HR=1.635; p=0.002), ALRI (HR=1.555; p<0.001), NLR (HR=1.461; p=0.007), AST/ALT (HR=1.420; p=0.012), and APRI (HR=1.356; p=0.009) were also significant prognostic factors for OS. The multivariate analysis showed that only ALBI grade (HR=1.974; p<0.001), SII (HR=1.487; p=0.009), and PLR (HR=1.647; p=0.014) were independently associated with OS.

Conclusions: Inflammation-based scores allow for an accurate prediction of survival in HCC. Their ability to predict the response to treatment and complications merits further investigation.

Background and aims: This study aimed to evaluate the efficacy and safety of transpapillary simultaneous side-by-side (SBS) stenting using uncovered self-expandable metal stents (UCSEMSs) at the initial endoscopic retrograde cholangiopancreatography (ERCP) for unresectable malignant hilar biliary obstruction (UMHBO).

Methods: A total of 67 patients with UMHBO who underwent simultaneous SBS stenting at our institution were retrospectively divided into two groups: the SBS stenting at the initial ERCP group (n=13) and the SBS stenting at the subsequent ERCP group (n=54). Clinical outcomes were compared between the groups.

Results: There were no significant differences between the SBS stenting at the initial ERCP group and the SBS stenting at the subsequent ERCP group in procedural time (median: 50 vs. 40 minutes, p=0.31), functional success rate (69.2% vs. 83.3%, p=0.25), adverse event rate (30.8% vs. 14.8%, p=0.18), recurrent biliary obstruction (RBO) rate (23.1% vs. 38.9%, p=0.29), technical success rate of re-intervention (100% vs. 90.5%, p=0.58), cumulative time to RBO (not reached vs. 252 days, p=0.80), or median overall survival (73 vs. 212 days, p=0.12).

Conclusions: Simultaneous SBS stenting using UCSEMSs at the initial ERCP is a safe and effective strategy for managing UMHBO, with outcomes comparable to those of SBS stenting performed at the subsequent ERCP.

In the past, advanced chronic liver disease was considered irreversible, but with better understanding and improved treatments, it is now recognized that fibrosis is a dynamic process that can regress even when it has reached the stage of cirrhosis. We present the case of a 60-year-old male patient with advanced chronic liver disease due to chronic hepatitis B, whose follow-up liver biopsy revealed significant fibrosis regression after successful antiviral therapy. We confirmed the predominantly regressive pattern using the P-I-R classification, a new histological classification that defines the tissue features as predominantly "Progressive, Intermediate or Regressive" by comparing stroma to parenchymal ratios. Furthermore, we also point out the prognostic value of P-I-R classification, as the patient has remained free of decompensation over time. In this clinical case, we highlight important aspects of the pathophysiology and histopathology of cirrhosis regression, emphasizing its critical prognostic significance. Finally, familiarizing clinicians and pathologists with the application of the P-I-R classification may improve prognostication based on histology in patients with advanced liver disease.