Effect of oral erythromycin on gastric and small bowel transit time of capsule endoscopy

AIM: To determine the effect of oral erythromycin on gastric and small bowel transit time of capsule endoscopy.METHODS: Consecutive patients who underwent capsule endoscopy du ring the 16-mo study period were either given 250 mg oral erythromycin, 1 h prior to swallowing the capsule endoscope or nothing. The gastric and small bowel transit time, and the small bowel image quality were compared.RESULTS: Twenty-four patients received oral erythromycin whereas 14 patients were not given any prokinetic agent.Patients who received erythromycin had a significantly lower gastric transit time than control (16 min vs70 min, P= 0.005),whereas the small bowel transit time was comparable between the two groups (227 min vs183 min, P = 0.18).Incomplete small bowel examination was found in three patients of the control group and in one patient of the erythromycin group. There was no significant difference in the overall quality of small bowel images between the two groups. A marked reduction in gastric transit time was noted in two patients who had repeat capsule endoscopy after oral erythromycin.CONCLUSION: Use of oral erythromycin significantly reduces the gastric transit time of capsule endoscopy.

Key factors in developing the trinitrobenzene sulfonic acid-induced post-inflammatory irritable bowel syndrome model in rats

AIM:To investigate the key factors in developing the trinitrobenzene sulfonic acid(TNBS)-induced postinflammatory irritable bowel syndrome(PI-IBS)model in rats. METHODS:TNBS was administered to rats at the following conditions:(1)with different doses(20,10,5 mg/0.8 mL per rat);(2)with same dose in different concentrations(20 mg/rat,25,50 mg/mL);(3)in different ethanol percentage(25%,50%);and(4)at depth either 4 cm or 8 cm from anus.At 5 d and 4 wk after TNBS administration,inflammation severity and inflammation resolution were evaluated.At 4 and 8 wk after TNBS application,visceral hyperalgesia and enterochromaffin(EC)cell hyperplasia were assayed by abdominal withdrawal reflex test,silver staining and capillary electrophoresis. RESULTS:Our results showed that:(1)TNBS induced dose-dependent acute inflammation and inflammation resolution.At 5 d post TNBS,the pathological score and myeloperoxidase(MPO)activity in all TNBS treated rats were significantly elevated compared to that of the control(9.48±1.86,8.18±0.67,5.78± 0.77 vs 0,and 3.55±1.11,1.80±0.82,0.97±0.08 unit/mg vs 0.14±0.01 unit/mg,P<0.05).At 4 wk post TNBS,the pathological score in high and median dose TNBS-treated rats were still significantly higher than that of the control(1.52±0.38 and 0.80±0.35 vs 0,P<0.05);(2)Intracolonic TNBS administration position affected the persistence of visceral hyperalgesia.At 4 wk post TNBS,abdominal withdrawal reflex (AWR)threshold pressure in all TNBS-treated groups were decreased compared to that of the control(21.52 ±1.73 and 27.10±1.94 mmHg vs 34.44±1.89 mmHg,P<0.05).At 8 wk post TNBS,AWR threshold pressure in 8 cm administration group was still significantly decreased(23.33±1.33 mmHg vs 36.79±2.29 mmHg,P<0.05);(3)Ethanol percentage affected the TNBS-induced inflammation severity and visceral hyperalgesia.In TNBS-25%ethanol-treated group,the pathological score and MPO activity were significantly lowered compared to that of the TNBS-50%ethanoltreated group,while AWR threshold pressure were significantly elevated(36.33±0.61 mmHg vs 23.33±1.33 mmHg,P<0.05);and(4)TNBS(5 mg/0.8 mL per rat, in 50%ethanol,8 cm from anus)-treated rats recovered completely from the inflammation with acquired visceral hyperalgesia and EC cell hyperplasia at 4 wk after TNBS administration.CONCLUSION:TNBS dosage,concentration,intraco-lonic administration position,and ethanol percentage play important roles in developing visceral hyperalgesia and EC cell hyperplasia of TNBS-induced PI-IBS rats.

Dieulafoy's lesion:A case series study

AIM: Dieulafoy's lesion (DL) accounts for 1-5.8% of cases of acute upper gastrointestinal bleeding (GIB). Its mortality is high, approaching 20%, despite recent advances in endoscopic therapy. We aimed to report our experience in the treatment of DL.METHODS: A retrospective case study of all patients with DL between January 1993 and January 2003 was done. Characteristics, treatment methods, success rates and 30-d mortality of the patients were analyzed. RESULTS: Thirty-six patients were noted to have DL in the study period. Thirty-three records were available for assessment in which 35 DL were identified. The median age of the patients was 67 years with male to female ratio of 5.6:1. Significant comorbidities existed in 69% of the patients. Eighty-nine percent of the DL was found at first endoscopy, three DL at laparotomy. Significant coexistent endoscopic findings existed in 23%. Hemostasis was achieved in 88% by using adrenaline injection, or in combination with heater probe application at first endoscopy. Four cases had re-bleeding, all were successfully treated endoscopically. The 30-d mortality rate was 23%.CONCLUSION: Successful endoscopic hemostasis could be achieved in 100% of cases of DL. The overall mortality may still remain high, mainly due to the comorbidities and age of these patients.

Correlation and prognostic significance of beta-galactoside alpha-2,6-sialyltransferase and serum monosialylated alpha-fetoprotein in hepatocellular carcinoma

AIM: To investigate the correlation between tissue ST6Gal I and serum msAFP in HCC patients, and to investigate their prognostic significance.METHODS: Preoperative sera,paired tumorous and non-tumorous tissues were collected from 19 consecutive patients who had undergone surgical resection of HCC.ST6Gal T activities in the tissues were measured by an in vitro microsomal enzyme activity assay. The percentages of tumor-specific msAFP in the sera were also estimated by an isoelectric focusing-immunoblotting assay.RESULTS: The tumor ST6Gal I activity was negatively correlated with serum msAFP percentage (r = -0.53,P = 0.019). Both decreased tumor ST6Gal I activity andincreased serum msAFP percentage were associatedwith poor tumor cell differentiation. Univariate analyses showed that both decreased tumor ST6Gal T activity (P = 0.028), increased serum msAFP percentage (P = 0.034) and poor tumor cell differentiation (P = 0.031)were associated with shorter overall survival. Multivariate analysis using the Cox regression model showed that the preoperative serum msAFP percentage (P = 0.022)and tumor cell differentiation status (P = 0.048) were independent prognostic indicators for patient overall survival.CONCLUSION: Our results indicate that the presence of msAFP in blood circulation is associated with a decreased activity of ST6Gal I activity in HCC. Both tissue ST6Gal I and serum msAFP are potential prognostic markers for patients with operable HCC.

Evaluation of the string test for the detection of Helicobacter pylori

AIM: Helicobacter pylori can be diagnosed by invasive ornon-invasive tests but to obtain bacteria for culture andantibiotic susceptibility testing, an upper GI endoscopy isoften required. The string test may be a minimally-invasivealternative method of obtaining H. pylori samples. This studyevaluates the sensitivity and specificity of the string test inthe diagnosis of H. pylori in comparison with endoscopicmeans of diagnosis.METHODS: This was a prospective open comparative studyof patients with dyspepsia with endoscopy-based tests asgold standard (defined as a positive CLO test and antralhistology). Fasting patients swallowed the encapsulated-string(Entero-test Hp), which was withdrawn after 1 hour. Thegastric juice from the string was plated onto H. pylori-selectivemedia for culture. Helicobacter pylori was identified by typicalcolony morphology, gram stain and biochemical test results.RESULTS: Thirty dyspeptic patients were recruited of whom21 (70 %) were positive for H. pylori according to the goldstandard. The sensitivity, specificity, positive predictive value,and negative predictive value for the string test were 38 %,100 %, 100 % and 41% respectively, and for endoscopicbiopsies 81%, 100 %, 100 %, 69 % respectively (P=0.004).Logistic regression showed that only abundant growthdensity from endoscopic biopsy cultures to be a predictor ofa positive string test (P=0.018).CONCLUSION: The string test is an alternative method toendoscopy in obtaining H. pylori but has a low sensitivitycompared to endoscopic biopsies.

Virtual colonoscopy-induced perforation in a patient with Crohn's disease

We report a case of sigmoid colon perforation in a patient with Crohn's disease undergoing computed-tomographic (CT) colonography. A 70-year-old patient with Crohn's disease with terminal ileitis and sigmoid stricture underwent CT colonography after incomplete conventional colonoscopy. During the procedure, the colon was inflated by air insufflation and the patient developed abdominal pain with radiological evidence of retroperitoneal and intraperitoneal free gas. Hartmann's operation was performed. This case highlights that CT colonography is not risk-free. The risk of perforation may be higher in patients with inflammatory bowel disease.

Analgesic effects of JCM-16021 on neonatal maternal separation-induced visceral pain in rats

AIM:To investigate the pharmacological effect of JCM-16021,a Chinese herbal formula,and its underlying mechanisms.METHODS:JCM-16021 is composed of seven herbal plant materials.All raw materials of the formula were examined according to the quality control criteria listed in the Chinese Pharmacopeia(2005).In a neonatal maternal separation(NMS)model,male SpragueDawley rats were submitted to daily maternal separation from postnatal day 2 to day 14,or no specific handling(NH).Starting from postnatal day 60,rats were administered JCM-16021(2,4,8 g/kg per day)orally twice a day for 28 d.Pain threshold pressure and electromyographic activities of external oblique muscles in response to colorectal distention recorded with a Power Lab System(AD Instruments International),were tested as pain indices.Changes in serotonin(5-HT)and 5-hydroxyindoleacetic acid(5-HIAA)concentrations in the colon of rats were analyzed;the enterochromaffin cell numbers and serotonin transporter in the colon of rats were also evaluated with an immunohistochemistry method.RESULTS:NMS treatment significantly reduced pain threshold pressure(37.4±1.4 mmHg),as compared to that of NH rats(57.7±1.9 mmHg,P<0.05).After JCM-16021 treatment,the pain threshold pressure significantly increased when compared to that before treatment(34.2±0.9 mmHg vs 52.8±2.3 mmHg in the high dose group,40.2±1.6 mmHg vs 46.5±1.3 mmHg in the middle dose group,and 39.3±0.7 mmHg vs 46.5±1.6 mmHg in the low dose group,P<0.05).Also JCM-16021 significantly and dose-dependently decreased electromyographic activity to the graded colorectal distension(CRD),(the meanΔAUC values were:0.17±0.03,0.53±0.15,1.06±0.18,1.22±0.24 in the high dose group;0.23±0.04,0.68±0.17,1.27 ±0.26,1.8±0.3 in the middle dose group;and 0.29 ±0.06,0.8±0.16,1.53±0.24,2.1±0.21 in the low dose group for the pressures 20,40,60,80 mmHg),as compared to the NMS vehicle group.The meanΔAUC values were:0.57±0.12,1.33±0.18,2.57±0.37,3.08±0.37 for the pressures 20,40,60,80 mmHg(P <0.05).JCM-16021 treatment significantly reduced the 5-HT concentrations(from high,middle and low dosage groups:60.25±5.98 ng/100 mg,60.32±4.22 ng/100 mg,73.31±7.65 ng/100 mg),as compared to the NMS vehicle groups(93.11±9.85 ng/100 mg,P<0.05);and increased the 5-HIAA concentrations(after treatment,from high,middle and low dosage groups:54.24±3.27 ng/100 mg,50.34±1.26 ng/100 mg,51.37±2.13 ng/100 mg)when compared to that in the NMS vehicle group(51.75±1.98 ng/100 mg,P <0.05);but did not change the enterochromaffin cell numbers in the colon of rats.In addition,NMS rats had higher SERT expression(n=10)than NH rats(n=8,P<0.05).JCM-16021 treatment significantly decreased SERT expression when compared to the NMS group(P <0.01-0.001).CONCLUSION:JCM-16021 can attenuate visceral hypersensitivity,and this analgesic effect may be mediated through the serotonin signaling pathway in the colon of rats.

Proteome profiling of spinal cord and dorsal root ganglia in rats with trinitrobenzene sulfonic acid-induced colitis

AIM: To investigate proteomic changes in spinal cord and dorsal root ganglia (DRG) of rats with trinitrobenzene sulfonic acid (TNBS)-induced colitis. METHODS: The colonic myeloperoxidase (MPO) activity and tumor necrosis factor-(TNF- ) level were determined. A two-dimensional electrophoresis (2-DE)-based proteomic technique was used to profile the global protein expression changes in the DRG and spinal cord of the rats with acute colitis induced by intracolonic injection of TNBS. RESULTS: TNBS group showed significantly elevated colonic MPO activity and increased TNF-level. The proteins derived from lumbosacral enlargement of the spinal cord and DRG were resolved by 2-DE; and 26 and 19 proteins that displayed significantly different expression levels in the DRG and spinal cord were identified respectively. Altered proteins were found to be involved in a number of biological functions, such as inflammation/immunity, cell signaling, redox regulation, sulfate transport and cellular metabolism. The over-expression of the protein similar to potassium channel tetramerisation domain containing protein 12 (Kctd 12) and low expression of proteasome subunit type-1 (psma) were validated by Western blotting analysis. CONCLUSION: TNBS-induced colitis has a profound impact on protein profiling in the nervous system. This result helps understand the neurological pathogenesis of inflammatory bowel disease.

COVID-19 risk prediction scores for mortality:A validation study from the National Registry of COVID-19 in China

To the Editor:Coronavirus disease 2019(COVID-19)has evolved into a global pandemic,with over 700 million confirmed cases worldwide and still mounting.^([1])The clinical impact of this pandemic is immense,given the wide spectrum of disease manifestation,ranging from mild respiratory symptoms to severe pulmonary infections.Identifying high-risk individuals,especially during their initial encounters in clinics and hospital emergency services,is crucial to provide timely effective treatment.Therefore,the timely risk stratification of COVID-19 patients in the emergency room can greatly benefit both infected individuals and healthcare professionals.^([2])This study aims to identify features of serious COVID-19 infection at presentation that may lead to mortality of the patients.

The combined role of MRI prostate and prostate health index in improving detection of significant prostate cancer in a screening population of Chinese men

Using prostate-specific antigen(PSA)for prostate cancer(PCa)screening led to overinvestigation and overdiagnosis of indolent PCa.We aimed to investigate the value of prostate health index(PHI)and magnetic resonance imaging(MRI)prostate in an Asian PCa screening program.Men aged 50–75 years were prospectively recruited from a community-based PSA screening program.Men with PSA 4.0–10.0 ng ml^(−1) had PHI result analyzed.MRI prostate was offered to men with PSA 4.0–50.0 ng ml−1.A systematic prostate biopsy was offered to men with PSA 4.0–9.9 ng ml^(−1) and PHI≥35,or PSA 10.0–50.0 ng ml^(−1).Additional targeted prostate biopsy was offered if they had PI-RADS score≥3.Clinically significant PCa(csPCa)was defined as the International Society of Urological Pathology(ISUP)grade group(GG)≥2 or ISUP GG 1 with involvement of≥30%of total systematic cores.In total,12.8%(196/1536)men had PSA≥4.0 ng ml^(−1).Among 194 men with PSA 4.0–50.0 ng ml^(−1),187(96.4%)received MRI prostate.Among them,28.3%(53/187)had PI-RADS≥3 lesions.Moreover,7.0%(107/1536)men were indicated for biopsy and 94.4%(101/107)men received biopsy.Among the men received biopsy,PCa,ISUP GG≥2 PCa,and csPCa was diagnosed in 42(41.6%),24(23.8%),and 34(33.7%)men,respectively.Compared with PSA/PHI pathway in men with PSA 4.0–50.0 ng ml^(−1),additional MRI increased diagnoses of PCa,ISUP GG≥2 PCa,and csPCa by 21.2%(from 33 to 40),22.2%(from 18 to 22),and 18.5%(from 27 to 32),respectively.The benefit of additional MRI was only observed in PSA 4.0–10.0 ng ml^(−1),and the number of MRI needed to diagnose one additional ISUP GG≥2 PCa was 20 in PHI≥35 and 94 in PHI<35.Among them,45.4%(89/196)men with PSA≥4.0 ng ml^(−1) avoided unnecessary biopsy with the use of PHI and MRI.A screening algorithm with PSA,PHI,and MRI could effectively diagnose csPCa while reducing unnecessary biopsies.The benefit of MRI prostate was mainly observed in PSA 4.0–9.9 ng ml^(−1) and PHI≥35 group.PHI was an important risk stratification step for PCa screening.

Artificial intelligence in gastroenterology:where are we heading?

Artificial intelligence(AI)is coming to medicine in a big wave.From making diagnosis in various medical conditions,following the latest advancements in scientific literature,suggesting appropriate therapies,to predicting prognosis and outcome of diseases and conditions,AI is offering unprecedented possibilities to improve care for patients.Gastroenterology is a field that AI can make a significant impact.This is partly because the diagnosis of gastrointestinal conditions relies a lot on image-based investigations and procedures(endoscopy and radiology).AI-assisted image analysis can make accurate assessment and provide more information than conventional analysis.AI integration of genomic,epigenetic,and metagenomic data may offer new classifications of gastrointestinal cancers and suggest optimal personalized treatments.In managing relapsing and remitting diseases such as inflammatory bowel disease,irritable bowel syndrome,and peptic ulcer bleeding,convoluted neural network may formulate models to predict disease outcome,enhancing treatment efficacy.AI and surgical robots can also assist surgeons in conducting gastrointestinal operations.While the advancement and new opportunities are exciting,the responsibility and liability issues of AI-assisted diagnosis and management need much deliberations.