Yield of alarm features in predicting significant endoscopic findings among hospitalized patients with dyspepsia

BACKGROUND Dyspepsia is a very prevalent upper gastrointestinal tract symptoms complex.Some of these symptoms might arise from serious underlying diseases,so the promotion of evidence-based guidelines could potentially better align evaluation and treatment.AIM To determine the value of alarm features as a predictive factor for significant endoscopic findings(SEFs)among hospitalized patients presenting with dyspepsia.METHODS We conducted a retrospective case-control study including information about 6208 endoscopic procedures performed for hospitalized patients.Patients were divided into two groups,with and without SEFs,and compared to elucidate the ability of the different alarm features to predict SEFs.RESULTS During the study,605 patients fulfilled the inclusion criteria.When the demographics and clinical characteristics of the two groups were compared,tachycardia(P<0.05),normocytic anemia,(P<0.05),leukocytosis(P<0.05),and hypoalbuminemia(P<0.05)documented on admission prior to endoscopy were strong predictors of SEFs.Among the alarm features,upper gastrointestinal bleeding,persistent vomiting,odynophagia[odds ratio(OR)=3.81,P<0.05;OR=1.75,P=0.03;and OR=7.81,P=0.07,respectively]were associated with SEFs.Unexplained weight loss was strongly associated with malignancy as an endoscopic finding(OR=2.05;P<0.05).In addition,long-term use of anti-aggregate medications other than aspirin(P<0.05)was correlated to SEFs.CONCLUSION Novel predictors of SEFs were elucidated in this study.These parameters could be used as an adjunctive in decision making regarding performing upper endoscopy in hospitalized patients with dyspepsia.

Endoscopic ultrasound guided radiofrequency ablation for pancreatic tumors: A critical review focusing on safety, efficacy and controversies

The role of endoscopic ultrasound(EUS)in the last two decades has shifted from a diagnostic tool to an important therapeutic tool treating mainly pancreatobiliary disorders.In recent years,its applications for treating pancreatic diseases have broadened,including the implementation of radiofrequency ablation(RFA),which has been traditionally used for treating solid tumors.In this critical indepth review,we summarized all the papers throughout the literature regarding EUS-RFA for pancreatic neuroendocrine neoplasms,adenocarcinoma,and pancreatic cystic lesions.Overall,for pancreatic neuroendocrine neoplasms we identified 16 papers that reported 96 patients who underwent EUS-RFA,with acceptable adverse events that were rated mild to moderate and a high complete radiological resolution rate of 90%.For pancreatic adenocarcinoma,we identified 8 papers with 121 patients.Adverse events occurred in 13%of patients,mostly rated mild.However,no clear survival benefit was demonstrated.For pancreatic cystic lesions,we identified 4 papers with 38 patients.The adverse events were mostly mild and occurred in 9.1%of patients,and complete or partial radiological resolution of the cysts was reported in 36.8%.Notably,the procedure was technically feasible for most of the patients.Nevertheless,a long road remains before this technique finds its definite place in guidelines due to several controversies.EUS-RFA for pancreatic tumors seems to be safe and effective,especially for pancreatic neuroendocrine neoplasms,but multicenter prospective trials are needed to consider this treatment as a gold standard.

Predictors of recurrent bile duct stone after clearance by endoscopic retrograde cholangiopancreatography:A case-control study

Background:Recurrent common bile duct(CBD)stone is a long-term sequalae among patients who un-derwent endoscopic retrograde cholangiopancreatography(ERCP)with CBD stone extraction.Data regard-ing risk factors for recurrent CBD stone are scarce.We aimed to identify predictors of recurrent CBD stone.Methods:We performed a retrospective case-controlled study from January 2010 to December 2019.In-clusion criteria included patients who had recurrent CBD stone at least 6 months after the index ERCP,in which complete stone extraction was performed and normal cholangiogram was obtained.Overall,457 patients were included.Forty-two patients(9.2%)had recurrent CBD stone,and 415 patients(90.8%)did not have recurrent CBD stone.Results:In univariate analysis,male sex[odds ratio(OR)=0.49,P=0.033]was a protective factor,while endoscopic stone extraction by basket vs.balloon(OR=2.55,P=0.005),older age(OR=1.03,P=0.003),number of CBD stones(OR=1.99,P=0.037),size of CBD stone(OR=4.06,P=0.003)and mechanical lithotripsy(OR=9.22,P=0.004)were risk factors for recurrent CBD stone.In multivariate logistic regression analysis,mechanical lithotripsy[OR=9.73,95%confidence interval(CI):1.69-55.89,P=0.010],basket clearance vs.combined basket and balloon(OR=18.25,95%CI:1.05-318.35,P=0.046)and older age(OR=1.02,95%CI:1.00-1.05,P=0.023)were risk factors,and male sex(OR=0.39,95%CI:0.19-0.81,P=0.012)was a protective factor.

Diagnostic approach to faecal incontinence:What test and when to perform?

Faecal incontinence(FI)is a debilitating common end result of several diseases affecting the quality of life and leading to patient disability,morbidity,and increased societal burden.Given the various causes of FI,it is important to assess and identify the underlying pathomechanisms.Several investigatory tools are available including high-resolution anorectal manometry,transrectal ultrasound,magnetic resonance imaging,and electromyography.This review article provides an overview on the causes and pathophysiology of FI and the author’s perspective of the stepwise investigation of patients with FI based on the available literature.Overall,high-resolution anorectal manometry should be the first investigatory tool for FI,followed by either transrectal ultrasound or magnetic resonance imaging for anal internal sphincter and external anal sphincter injury,respectively.

Predicting common bile duct stones by non-invasive parameters

Background:Common bile duct(CBD)stone affect about 10%of patients with symptomatic cholelithiasis.The American Society for Gastrointestinal Endoscopy(ASGE)published a strategy in 2010 for managing patients with suspected choledocholithiasis.This study aimed to assess the performance of different clinical parameters in predicting CBD stones.Methods:A total of 344 patients suspected to suffer from CBD stone and referred to endoscopic ultrasound(EUS)were included.Parameters were collected and their prediction power for CBD stones was assessed.Results:One hundred and sixty-seven patients without CBD stone according to EUS(group A)were compared to 177 patients with CBD stones(group B).Several predictive factors for CBD stone were identified on univariate analysis.In multivariate regression analysis,CBD width by US(OR=1.224,95%CI:1.073–1.359;P=0.0026),age(OR=1.023,95%CI:1.011–1.035;P=0.0002)and gamma glutamyl transferase(GGT)level(OR=1.001,95%CI:1.000–1.002;P=0.0018)were significantly correlated with CBD stone,with receiver operator characteristics(ROC)of 0.7259.We generated a diagnostic equation[age(yr)×0.1+CBD width(mm)by US×1+GGT(U/L)×0.005]to predict CBD stone with ROC of 0.7287.Conclusions:We suggest this score as a very strong predictor for CBD stones,and to reduce the strength of total bilirubin and transaminases as predictors.

Inflammatory bowel disease patient profiles are related to specific information needs: A nationwide survey

BACKGROUND Inflammatory bowel diseases(IBD) is a heterogenous, lifelong disease, with an unpredictable and potentially progressive course, that may impose negative psychosocial impact on patients.While informed patients with chronic illness have improved adherence and outcomes, previous research showed that the majority of IBD patients receive insufficient information regarding their disease.The large heterogeneity of IBD and the wide range of information topics makes a one-size fits all knowledge resource overwhelming and cumbersome.We hypothesized that different patient profiles may have different and specific information needs, the identification of which will allow building personalized computer-based information resources in the future.AIM To evaluate the scope of disease-related knowledge among IBD patients and determine whether different patient profiles drive unique information needs.METHODS We conducted a nationwide survey addressing hospital-based IBD clinics.A Total of 571 patients completed a 28-item questionnaire, rating the amount of information received at time of diagnosis and the importance of information, as perceived by participants, for a newly diagnosed patient, and for the participants themselves, at current time.We performed an exploratory factor analysis of the crude responses aiming to create a number of representative knowledge domains(factors), and analyzed the responses of a set of 15 real-life patient profiles generated by the study team.RESULTS Participants gave low ratings for the amount of information received at disease onset(averaging 0.9/5) and high ratings for importance, both for the newly diagnosed patients(mean 4.2/5) and for the participants themselves at current time(mean 3.5/5).Factor analysis grouped responses into six informationdomains.The responses of selected profiles, compared with the rest of the participants, yielded significant associations(defined as a difference in rating of >0.5 points with a P < 0.05).Patients with active disease showed a higher interest in work-disability, stress-coping, and therapy-complications.Patients newly diagnosed at age > 50, and patients with long-standing disease(> 10 years)showed less interest in work-disability.Patients in remission with mesalamine or no therapy showed less interest in all domains except for nutrition and long-term complications.CONCLUSION We demonstrate unmet patient information needs.Analysis of various patient profiles revealed associations with specific information topics, paving the way for building patient-tailored information resources.

Azathioprine-induced fever in autoimmune hepatitis

Underdiagnosis of drug-induced fever leads to extensive investigation and prolongation of hospitalization, and may lead to multiple unnecessary invasive procedures and a wrong diagnosis. Azathioprine is a widely used immunosuppressive drug. We report a case of a 53-year-old female patient diagnosed with autoimmune hepatitis treated with azathioprine, who presented to the emergency room with a 6-wk history of fever and chills without other associated symptoms. Since the patient's fever was of unknown origin, she was hospitalized. All treatment was stopped and an extensive workup to explore the source of fever and chills was performed. Results of chest X-ray, viral, urine, and blood cultures, autoimmune serology, transthoracic and transesophageal echocardiography, and abdominal ultrasound revealed no source of infection. A rechallenge test of azathioprine was performed and the fever and chills returned within a few hours. Azathioprine was established as the definite cause following rechallenge. Fever as an adverse drug reaction is often unrecognized. Azathioprine has been reported to cause druginduced fever in patients with inflammatory bowel disease, rheumatoid arthritis, and sarcoidosis. To the bestof our knowledge there have been no previous reports documenting azathioprine-induced fever in patients with autoimmune hepatitis. The occurrence of fever following the readministration of azathioprine suggests the diagnosis of drug-induced fever, particularly after the exclusion of other causes. A careful rechallenge is recommended to confirm the diagnosis.

Hepatitis C infection and lymphoproliferative disease:Accidental comorbidities?

Chronic hepatitis C virus(HCV)infection has been associated with liver cancer and cirrhosis,autoimmune disorders such as thyroiditis and mixed cryoglobulinema,and alterations in immune function and chronic inflammation,both implicated in B cell lymphoproliferative diseases that may progress to non-Hodgkin lymphoma(NHL).HCV bound to B cell surface receptors can induce lymphoproliferation,leading to DNA mutations and/or lower antigen response thresholds.These findings and epidemiological reports suggest an association between HCV infection and NHL.We performed a systematic review of the literature to clarify this potential relationship.We searched the English-language literature utilizing Medline,Embase,Paper First,Web ofScience,Google Scholar,and the Cochrane Database of Systematic Reviews,with search terms broadly defined to capture discussions of HCV and its relationship with NHL and/or lymphoproliferative diseases.References were screened to further identify relevant studies and literature in the basic sciences.A total of 62 reports discussing the relationship between HCV,NHL,and lymphoproliferative diseases were identified.Epidemiological studies suggest that at least a portion of NHL may be etiologically attributable to HCV,particularly in areas with high HCV prevalence.Studies that showed a lack of association between HCV infection and lymphoma may have been influenced by small sample size,short follow-up periods,and database limitations.The association appears strongest with the B-cell lymphomas relative to other lymphoproliferative diseases.Mechanisms by which chronic HCV infection promotes lymphoproliferative disease remains unclear.Lymphomagenesis is a multifactorial process involving genetic,environmental,and infectious factors.HCV most probably have a role in the lymphomagenesis but further study to clarify the association and underlying mechanisms is warranted.

Endoscopic ultrasound role in pancreatic adenocarcinoma treatment:A review focusing on technical success,safety and efficacy

The impressive technological advances in recent years have rapidly translated into the shift of endoscopic ultrasound(EUS)from diagnostic modality into an interventional and therapeutic tool.Despite the great advance in its diagnosis,the majority of pancreatic adenocarcinoma cases are inoperable when diagnosed,thus demanding alternative optional therapies.EUS has emerged as an easy,minimally invasive modality targeting this carcinoma with different interventions that have been reported recently.In this review we summarize the evolving role of interventional therapeutic EUS in pancreatic adenocarcinoma management.

Concise review on the comparative efficacy of endoscopic ultrasound-guided fine-needle aspiration vs core biopsy in pancreatic masses, upper and lower gastrointestinal submucosal tumors

Endoscopic ultrasound(EUS)-guided fine needle aspiration with or without biopsy(FNA/FNB) are the primary diagnostic tools for gastrointestinal submucosal tumors. EUS-guided fine needle aspiration(EUS-FNA) is considered a first line diagnostic method for the characterization of pancreatic and upper gastrointestinal lesions, since it allows for the direct visualization of the collection of specimens for cytopathologic analysis. EUSFNA is most effective and accurate when immediate cytologic assessment is permitted by the presence of a cytopathologist on site. Unfortunately, the accuracy and thus the diagnostic yield of collected specimens suffer without this immediate analysis. Recently, a EUS-FNB needle capable of obtaining core samples(fine needle biopsy, FNB) has been developed and has shown promising results. This new tool adds a new dimension to the diagnostic and therapeutic utility of this technique. The aim of the present review is to compare the efficacy of EUS-FNA to that afforded by EUS-FNB in the characterization of pancreatic masses and of upper and lower gastrointestinal submucosal tumors.

Do inflammatory bowel disease patient preferences from treatment outcomes differ by ethnicity and gender?A cross-sectional observational study

BACKGROUND Inflammatory bowel disease(IBD)patients’expectations of treatment outcomes may differ by ethnicity.AIM To investigate treatment preferences of Jewish and Arabs patients.METHODS This prospective survey ranked outcomes treatment preferences among Arab IBD patients,based on the 10 IBD-disk items compared to historical data of Jews.An anonymous questionnaire in either Arabic or Hebrew was distributed among IBD patients.Patients were required to rank 10 statements describing different aspects of IBD according to their importance to the patients as treatment goals.Answers were compared to the answers of a historical group of Jewish patients.RESULTS IBD-disk items of 121 Arabs were compared to 240 Jewish patients.The Jewish patients included more females,[151(62.9%)vs 52(43.3%);P<0.001],higher education level(P=0.02),more urban residence[188(78.3%)vs 54(45.4%);P<0.001],less unemployment[52(21.7%)vs 41(33.9%);P=0.012],higher income level(P<0.001),and more in a partnership[162(67.8%)vs 55(45.4%);P<0.001].Expectations regarding disease symptoms:abdominal pain,energy,and regular defecation ranked highest for both groups.Arabs gave significantly lower rankings(range 4.29-6.69)than Jewish patients(range 6.25-9.03)regarding all items,except for body image.Compared to Arab women,Jewish women attached higher priority to abdominal pain,energy,education/work,sleep,and joint pain.Multivariable regression analysis revealed that higher patient preferences were associated with Jewish ethnicity(OR 4.77;95%CI 2.36-9.61,P<0.001)and disease activity.The more active the disease,the greater the odds ratio for higher ranking of the questionnaire items(1-2 attacks per year:OR 2.13;95%CI 1.02-4.45,P=0.043;and primarily active disease:OR 5.29;95%CI 2.30-12.18,P<0.001).Factors inversely associated with higher patient preference were male gender(OR 0.5;95%CI 0.271-0.935,P=0.030),UC(OR 0.444;95%CI 0.241-0.819,P=0.009),and above average income level(OR 0.267;95%CI:0.124-0.577,P=0.001).CONCLUSION The highest priority for treatment outcomes was symptom relief.,Patients preferences were impacted by ethnicity,gender,and socio-economic disparity.Understanding patients'priorities may improve communication and enable a personalized approach.

Bedside score predicting retained common bile duct stone in acute biliary pancreatitis

BACKGROUND Retained common bile duct(CBD) stone after an acute episode of biliary pancreatitis is of paramount importance since stone extraction is mandatory.AIM To generate a simple non-invasive score to predict the presence of CBD stone in patients with biliary pancreatitis.METHODS We performed a retrospective study including patients with a diagnosis of biliary pancreatitis. One hundred and fifty-four patients were included. Thirty-three patients(21.5%) were diagnosed with CBD stone by endoscopic ultrasound(US).RESULTS In univariate analysis, age(OR: 1.048, P = 0.0004), aspartate transaminase(OR:1.002, P = 0.0015), alkaline phosphatase(OR: 1.005, P = 0.0005), gamma-glutamyl transferase(OR: 1.003, P = 0.0002) and CBD width by US(OR: 1.187, P = 0.0445)were associated with CBD stone. In multivariate analysis, three parameters were identified to predict CBD stone;age(OR: 1.062, P = 0.0005), gamma-glutamyl transferase level(OR: 1.003, P = 0.0003) and dilated CBD(OR: 3.685, P = 0.027),with area under the curve of 0.8433. We developed a diagnostic score that included the three significant parameters on multivariate analysis, with assignment of weights for each variable according to the co-efficient estimate. A score that ranges from 51.28 to 73.7 has a very high specificity(90%-100%) for CBD stones, while a low score that ranges from 9.16 to 41.04 has a high sensitivity(82%-100%). By performing internal validation, the negative predictive value of the low score group was 93%.CONCLUSION We recommend incorporating this score as an aid for stratifying patients with acute biliary pancreatitis into low or high probability for the presence of CBD stone.

Current and Future Treatment of Hepatocellular Carcinoma:An Updated Comprehensive Review

Hepatocellular carcinoma(HCC)is among the leading causes of cancer-related mortality.The principal treatment is surgical resection or liver transplantation,depending on whether the patient is a suitable transplant candidate.However,in most patients with HCC the diagnosis is often late,thereby excluding the patients from definitive surgical resection.Medical treatment includes sorafenib,which is the most commonly used systemic therapy;although,it has been shown to only minimally impact patient survival by several months.Chemotherapy and radiotherapy are generally ineffective.Due to the poor prognosis of patients with HCC,newer treatments are needed with several being in development,either in preclinical or clinical studies.In this review article,we provide an update on the current and future medical and surgical management of HCC.

Drug Induced Liver Injury: Review with a Focus on Genetic Factors, Tissue Diagnosis, and Treatment Options

Drug-induced liver injury (DILI) is a rare but potentially life threatening adverse drug reaction.DILI may mimic any morphologic characteristic of acute or chronic liver disease,and the histopathologic features of DILI may be indistinguishable from those of other causes of liver injury,such as acute viral hepatitis.In this review article,we provide an update on causative agents,clinical features,pathogenesis,diagnosis modalities,and outcomes of DILI.In addition,we review results of recently reported genetic studies and updates on pharmacological and invasive treatments.

Oral Co-administration of Soy-derived Extracts with Alcohol or with Sugar-sweetened Beverages Exerts Liver and Sugar Protective Effects

Background and Aims:Both alcoholic drinks and high sugar-containing soft drinks cause major health problems worldwide.Oral administration of OS and M1 soy-derived extracts has been shown to alleviate liver injury in animal models.The aim of the present study was to determine the liver-and sugar-protective effect of OS and M1 soy-derived extracts when added to alcohol and sugar-enriched drinks.Methods:Mice were treated with alcohol or high sugarcontaining drinks,with and without administration of a combination of OS and M1 soy extracts.Mice were observed for the effects on liver injury,glucose metabolism,and the immune system.Results:Co-administration of the soy extracts OS and M1 significantly alleviated the liver injury induced by acute alcohol,as evidenced by decreased liver enzymes.These beneficial effects were associated with promotion of subsets of regulatory T lymphocytes and with a trend towards a pro-inflammatory to an anti-inflammatory cytokine shift.Co-administration of OS M1 soy extracts with sugar-sweetened beverages significantly alleviated the increases in serum sugar levels.Conclusion:OS and M1 extracts exert a synergistic hepato-and glucose-protective effect in models of alcohol-induced liver damage and soft drinks-associated increases in serum glucose.These extracts may provide a solution to the two pressing health problems.