Hinako Sakurai, Kurato Miyazaki, Atsushi Nakayama
et al.
ABSTRACT Background and Aim Remimazolam is a benzodiazepine receptor agonist intravenous anesthetic. This study aimed to evaluate the efficacy and safety of remimazolam for sedation during gastrointestinal endoscopy using real‐world clinical data. Methods This retrospective observational study included 352 patients who underwent esophagogastroduodenoscopy or colonoscopy sedated with remimazolam between January and February 2024 at our institution. Outcomes included the incidence of awakening during procedures, the sedation completion rate, and the incidence and severity of adverse events. Multivariate logistic regression analyses identified factors associated with hypoxia and hypotension. Results Median patient age was 67 years (IQR: 58–74), and 62.2% were male. Median initial and additional doses were 3 (IQR: 2–3 mg) and 1 mg (IQR: 0–2 mg). Awakening occurred in 19.0% of patients. The sedation completion rate was 100%. Adverse events included hypotension (7.8%), hypoxia (13.1%), and bradycardia (4.0%), and no serious adverse events were observed. The only risk factor for hypoxia was advanced age (Odds ratio 1.04, 95% confidence interval: 1.01–1.08, p = 0.03), and the dose of remimazolam itself was not an independent risk factor for either hypoxia or hypotension. Conclusions Remimazolam usage for gastrointestinal endoscopic sedation showed a favorable safety profile. Advanced age was associated with an increased risk of hypoxia, suggesting that careful monitoring and individualized sedation protocols are especially necessary for elderly patients. On the other hand, there are still issues regarding the duration of sedation. During long procedures, it is necessary to frequently check the depth of sedation to avoid undersedation.
Diseases of the digestive system. Gastroenterology
Background/Aims : Although rectal neuroendocrine tumors (NETs) ≤1 cm in size are generally considered low-risk tumors that are suitable for endoscopic resection, the long-term outcomes after histologically complete resection remain unknown. Methods : We conducted a multicenter retrospective cohort study of patients with rectal NETs who underwent complete endoscopic resection (endoscopic mucosal resection or endoscopic submucosal dissection) between January 2014 and December 2019. A total of 860 patients with ≥6 months of follow-up were included. Recurrence-free survival and its associated risk factors were analyzed using Kaplan-Meier and Cox proportional hazards models. Results : Among 860 patients, the mean age was 47.7 years, and 57.9% of the patients were male. The overall recurrence rate was 1.4% (n=12). Univariate and multivariate analyses identified histological grade 2 (hazard ratio [HR], 19.13; 95% confidence interval [CI], 3.51 to 104.22) and mitotic count 2–20/10 high-power field (HPF) (HR, 20.88; 95% CI, 1.61 to 270.19) as independent predictors of recurrence, while >20/10 HPF (HR, 7.93; 95% CI, 0.90 to 69.87) showed a marginal association. The pathological tumor size, resection method, endoscopic ultrasonography findings, and Charlson Comorbidity Index were not associated with recurrence. The 5-year and 9-year recurrence-free survival rates were 98.4% and 84.7%, respectively. Supplementary analysis excluding patients with missing data confirmed consistent findings. Conclusions : Although recurrence is rare after the complete resection of rectal NETs ≤1 cm in size, patients with grade 2 tumors or a mitotic count ≥2/10 HPF are at increased risk. Risk-adapted follow-up based on histological features should be considered.
Diseases of the digestive system. Gastroenterology
INTRODUCTION: It is unknown how frailty evolves over time in patients with hepatocellular carcinoma who are treated with locoregional therapies (LRTs). METHODS: We conducted a retrospective study of LRT-treated hepatocellular carcinoma patients with Liver Frailty Index (LFI) assessments. Linear mixed-effects modeling was used to assess the impact of time (modeled linearly per month) and other variables on LFI. RESULTS: Of 201 patients enrolled, median baseline LFI was 3.54. LFI did not change significantly over time from study entry (P = 0.93). DISCUSSION: In our study, LFI remained stable over time after LRT, suggesting that LRT is generally well tolerated.
Conclusion: Compared with LSTs without a skirt, the results indicated that LSTs with a skirt are more commonly found in female patients, predominantly has a diameter of ≥ 20 mm, typically presents as a mixed nodular type, is frequently located in the rectum, and is often classified as carcinoma. The presence of rectal lesions and lesion diameter ≥ 20 mm increases the likelihood of skirt features in LSTs. Furthermore, advanced age (≥ 60 years) may elevate the risk of carcinogenesis in LSTs with a skirt, necessitating thorough preoperative assessments and complete resection during endoscopic removal of such lesions.
Diseases of the digestive system. Gastroenterology
Abstract Objective To study the clinical efficacy of infliximab (IFX) in combination with mesalazine in patients with Crohn’s disease (CD). Methods This retrospective analysis study included 197 patients with CD who were treated in Haiyan People's Hospital and Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University our hospital between March 2023 and March 2024, and were divided into two groups according to the different treatments recorded in the electronic medical record system: 82 cases in the control group (mesalazine) and 115 cases in the observation group (IFX combined with mesalazine treatment). The intestinal flora (bifidobacteria, Lactobacillus, Enterococcus, Enterobacteriaceae), serum indicators (tumor necrosis factor-α (TNF-α), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), hemoglobin concentration (HGB), platelets (PLT), Th1, Th2, Th1/Th2), major symptoms and stool status (disappearance of abdominal pain, disappearance of diarrhea, stool frequency and stool normalization), clinical efficacy and complication situation were evaluated. Results The number of bifidobacteria and lactobacilli in the observation group was higher than that in the control group, and the difference was statistically significant (P < 0.05); TNF-α, CRP, ESR, PLT, Th1 and Th1/Th2 were lower than those in the control group, but HGB and Th2 were higher than those in the control group, and the difference was statistically significant (P < 0.05); After treatment, the rate of abdominal pain disappearance, diarrhea disappearance and normal stool rate were higher than that of the control group, and the number of stools was lower than that of the control group, with statistically significant differences (P < 0.05); the total clinical effective rate of the observation group (92.17% vs. 80.49%) was higher than that of the control group, with statistically significant difference (P < 0.05); the overall incidence rate of adverse reactions of the observation group (8.70% vs. 7.32%) was higher than that of the control group, but the difference was not statistically significant (P > 0.05). Conclusion IFX combined with mesalazine demonstrates superior clinical efficacy compared to mesalazine monotherapy in patients with Crohn’s disease. This combination effectively improves intestinal microbiota balance, reduces inflammation, modulates immune responses, and alleviates clinical symptoms without significantly increasing adverse events.
Diseases of the digestive system. Gastroenterology
N. S. Sergeeva, V. I. Ryabtseva, S. S. Pirogov
et al.
Aim: to present current information on serological screening approaches for precancerous gastric diseases and early gastric cancer.Key points. Gastric cancer is one of the most common malignant tumors. Advanced stage of the tumor at the time of diagnosis determines an unfavorable prognosis in a significant proportion of patients. A real strategy for reducing both the incidence of gastric cancer and mortality rate is the introduction of cost-effective screening methods for atrophic gastritis associated with Helicobacter pylori (H. pylori) as a precancerous condition of the stomach. As an alternative to endoscopic examination of the stomach, approaches based on the evaluation of serological markers associated with H. pylori infection and reflecting the state of the gastric mucosa are currently proposed for laboratory screening: serum levels of antibodies to H. pylori, pepsinogen I, pepsinogen II and gastrin 17. Tests combining these markers, GastroPanel®, ABC and New ABC methods, as well as some of their modifications, are currently being widely studied as a tool for atrophic gastritis or gastric cancer risk group selection for further endoscopic examination.Conclusion. An ensemble of serological markers, pepsinogen I, pepsinogen II, gastrin 17, and antibodies to H. pylori, allows for identifying atrophic gastritis with relatively high reliability, and considering additional factors, a high-risk group for the presence of gastric cancer. To achieve optimal medical and economic efficiency, it is necessary to improve the criteria for interpreting test results and including subjects in screening programs.
Diseases of the digestive system. Gastroenterology
Abstract Background The aim was to assess the knowledge, attitudes, and practices (KAPs) of endoscopy among gastroenterologists in the diagnosis and management of IBD in China. Methods A multicenter cross-sectional KAP study was performed. The questionnaire was developed and improved using feedback and opinions from a team of experienced IBD specialist professors and then distributed and collected online. In addition, eight fellow gastroenterologists participated in an IBD endoscopy training program were asked to review endoscopic images, and the consistency of the endoscopic scores before and after training was calculated. Results A total of 193 participants from 12 provincial-level administrative regions encompassing both the Northern and Southern parts of China completed the study questionnaire. The median age of the participants was 40 (36, 45) years, with the majority being female (70.5%). The median professional experience as gastroenterologists was 11 (7, 17) years, while the median experience as endoscopists was 8 (3, 15) years. The median knowledge score was 8 out of 10 points for single-choice questions; however, most gastroenterologists believed that some concepts in these endoscopic indices were vague, including those regarding deep ulcerations, ulcerated surfaces, affected surfaces and narrowing in open-answer questions. The UCEIS and SES-CD were considered most consistent with clinical activity score in the evaluation of UC and CD, respectively. IBD subspecialists and gastroenterologists who had previously received IBD endoscopy screening training were more likely to use endoscopic indices (p<0.001, p = 0.029, respectively). The Rutgeerts score demonstrated the most significant improvement in consistency before and after training, from 0.407 (95% CI: 0.025–0.999) to 0.909 (95% CI: 0.530–1.000). Conclusions We propose the elucidation of ambiguous definitions in endoscopic indices, enhancement of training, and the application of innovative technology to enhance the application of endoscopic evaluation and endoscopic indices in clinical practice.
Diseases of the digestive system. Gastroenterology
Background:
Gastroesophageal reflux (GERD) is a concern after peroral endoscopic myotomy (POEM). Transoral incisionless fundoplication (TIF) has been recently described as a possible therapy for post-POEM GERD in case series.
Methods:
We prospectively enrolled patients undergoing POEM who agreed to participate in objective post-procedure GERD evaluation. Patients with objective evidence of GERD and suitable anatomy were offered TIF vs. proton pump inhibitor (PPI) only. Patients who underwent TIF were compared to those on PPI-only therapy after follow-up.
Results:
Of 21 enrolled POEM patients with objective testing, GERD was found in 11 (52%). Of those eligible for TIF, 4 (40%) opted to pursue TIF and were compared to those on PPI-only therapy (n = 6). Three months post-TIF, 75% of patients had discontinued or significantly decreased PPI. There were no adverse events. GERD health-related quality of life scores were low and comparable between TIF (3.75 ± 6.2) and those who remained on PPI-only therapy (4.1 ± 5).
Conclusion:
In this pilot, patient-driven prospective study, 75% of patients with post-POEM GERD undergoing TIF had stopped or significantly reduced PPI use. Post-POEM TIF is safe and effective and may be a viable alternative to PPI for POEM-related GERD; however, future studies should include a control arm and post-intervention pH monitoring.
Diseases of the digestive system. Gastroenterology
AbstractNon‐alcoholic fatty liver disease (NAFLD) is a significant health burden around the world, affecting approximately 25% of the population. Recent advances in human genetic databases have allowed for the identification of various single nucleotide polymorphisms associated with NAFLD‐related traits. Investigating the functions of these genetic factors provides insight into the pathogenesis of NAFLD and potentially identifies novel therapeutic targets for NAFLD. In this review, we summarized current research on genes with NAFLD‐associated mutations, highlighting phospholipid remodeling and spatially clustered loci as common pathological and genetic features of these mutations. These features suggest a complex yet intriguing mechanism of dissociated steatosis and insulin resistance, which is observed in a subset of patients and may lead to more precise therapy against NAFLD in the future.
Abstract Background To explore the underlying causality between leukocyte telomere length (LTL) and four gastrointestinal diseases, we designed a two-sample bidirectional Mendelian randomization study. Methods Two-sample Mendelian randomization (MR) was used to explore genetic causality between LTL and four gastrointestinal diseases, including irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), gastrointestinal ulcers disease (GUD), and nonalcoholic fatty liver disease (NAFLD). We utilized inverse-variance weighted (IVW) as the primary method for MR analysis. Supplementary analyses were conducted using methods such as MR-Egger regression, weighted-median, Maximum Likelihood (MaxLik), Robust adjusted profile score (MR-RAPS), Contamination mixture (ConMix), and MR-mix. Cochran’s Q was calculated to check for heterogeneity. The MR-Egger regression and MR pleiotropy residual sum and outlier (MR-PRESSO) were detected for pleiotropy. Results The IVW analysis suggests that there may be a potential causal relationship between LTL and two diseases (odds ratio (OR): 1.062; 95% confidence interval (CI): 1.003, 1.124; p = 0.038 for IBS and OR: 0.889; 95% CI: 0.798, 0.990; p = 0.032 for GERD). However, other methods do not entirely align with the results of the IVW analysis. In the reverse MR analysis, we did not find statistically significant associations between LTL and these four diseases. Conclusion The current evidence does not definitively rule out a causal relationship between LTL and these four gastrointestinal diseases but suggests a potential association between LTL and IBS, or LTL and GERD. Exploring the relationship between gastrointestinal diseases and LTL may offer new insights into the onset, progression, and treatment of these diseases.
Diseases of the digestive system. Gastroenterology
Background/Aims The national registry for inflammatory bowel disease (IBD) was designed to study epidemiology and prescribing pattern of treatment of IBD in India. Methods A multicenter, cross-sectional, prospective registry was established across four geographical zones of India. Adult patients with ulcerative colitis (UC) or Crohn’s disease (CD) were enrolled between January 2014 and December 2015. Information related to demographics; disease features; complications; and treatment history were collected and analyzed. Results A total of 3,863 patients (mean age, 36.7 ± 13.6 years; 3,232 UC [83.7%] and 631 CD [16.3%]) were enrolled. The majority of patients with UC (n = 1,870, 57.9%) were from north, CD was more common in south (n = 348, 55.5%). The UC:CD ratio was 5.1:1. There was a male predominance (male:female = 1.6:1). The commonest presentation of UC was moderately severe (n = 1,939, 60%) and E2 disease (n = 1,895, 58.6%). Patients with CD most commonly presented with ileocolonic (n = 229, 36.3%) inflammatory (n = 504, 79.9%) disease. Extraintestinal manifestations were recorded among 13% and 20% of patients in UC and CD respectively. Less than 1% patients from both cohorts developed colon cancer (n = 26, 0.7%). The commonly used drugs were 5-aminosalicylates (99%) in both UC and CD followed by azathioprine (34.4%). Biologics were used in only 1.5% of patients; more commonly for UC in north and CD in south. Conclusions The national IBD registry brings out diversities in the 4 geographical zones of India. This will help in aiding research on IBD and improving quality of patient care.
Medicine, Diseases of the digestive system. Gastroenterology
Our objective was to develop a model of systemic inflammatory response syndrome (SIRS) by chemical induction of colon injury and antibiotic-associated intestinal dysbiosis in rats with primary visceral obesity (PVO) for studies of myocardial resistance to ischemia-reperfusion injury. The experiments were performed with adult Wistar male rats with PVO under improved conditions of a conventional animal clinic. The chemically induced inflammatory colon disease (CIICD) was accomplished by intragastric administration of a mixture of broad-spectrum antimicrobial agents (AMA) for 3 days. Five days later, immunological and biochemical studies were carried out, as follows: composition of the intestinal microbiota in feces and shortchain fatty acids in blood, morphological changes in the structure of the colon, hemodynamic parameters and myocardial stability with modified Langendorff system. In PVO rats, the mass of visceral fat deposits and the content of lipopolysaccharides (LPS) in the blood were significantly increased when giving them fatcarbohydrate diet (FCD). In animals with CIICD, in addition to LPS, there was a significant increase in proinflammatory cytokine concentration (TNF, IL-8, MCP-1), and after oral administration of the AMA mixture, pronounced disturbances of food behavior and evacuatory function of gastrointestinal tract, deep destructive changes in colon, as well as qualitative and quantitative composition of intestinal microbiota with characteristics typical to the first-grade dysbiosis. High levels were shown for IL-8 cytokine only. An increase in acetic and propionic acid concentrations were shown in blood in animals with CIICD, and, to a greater extent, in rats with antibiotic-induced dysbiosis (AID). FCD was followed by significantly reduced levels of lactobacilli and bifidobacteria in colonic contents. CIICD leads to detection of Escherichia coli, and intestinal dysbiosis leads to the manifestation of Proteus. A comorbid combination of pathological changes in the immune and digestive systems caused a significant increase in the area of myocardial necrosis (by 35 percent) in isolated heart by, thus presuming decreased myocardial resistance to ischemia-reperfusion injury (IRI). The SIRS model induced by chemical trauma to large intestine is aggravated by the introduction of AMAs mixture, and it is characterized by a controlled change in inflammatory markers. Deterioration of morphofunctional characteristics in isolated heart included decrease in resistance to IRI seems to correspond to acute inflammatory bowel disease with induced intestinal dysbiosis. This model can be used in experimental medicine in the field of cardiology, endomicroecology, gastroenterology, and immunology.
Intestinal immune homeostasis is maintained by the interplay between microbiota and the mucosal immune system. Changes in gut microbiota have been associated with chronic intestinal conditions, such as inflammatory bowel disease (IBD). The aryl hydrocarbon receptor (AhR) is a transcription factor that is activated by dietary and environmental stimuli to control immune responses in the gut and homeostatic mechanisms at mucosal surfaces. In IBD, AhR expression is downregulated. Major agonists of AhR in the gut include microbial tryptophan metabolites such as indole derivatives, which are decreased in IBD patients. The mechanisms involved in tryptophan metabolism by bacteria and their implications in AhR activation and thus IBD pathogenesis are not well understood. To investigate whether tryptophan metabolism by intestinal bacteria participates in AhR activation and IBD pathogenesis. Microbiota profiles (16S rRNA Illumina) and activation of AhR (luciferase reporter assay) were determined in fecal samples from IBD patients (n=10) and healthy volunteers (n=10). Germ-free C57BL/6 mice were colonized with fecal slurries of 2 healthy subjects and 4 IBD patients (n=4 mice/donor) by oral gavage (humanized-mice). All mice were fed irradiated tryptophan diets with 0.1% or 1% tryptophan content for 14 days. Simultaneously, SPF Mucin 2 (Muc2) deficient mice (C57BL/6 background), which develop colitis spontaneously, were fed tryptophan diets (0.1%, 0.3% and 1% content). Activation of AhR was measured in feces using an AhR luciferase reporter assay. Inflammation was determined by immunohistochemistry and the characterization of immune infiltrate in colon cross-sections. Bacteria from human and mouse fecal samples were isolated and screened for their ability to produce indoles using biochemical reagents. Positive bacteria were identified by colony PCR and 16S rRNA Sanger sequencing. IBD patients had an altered fecal microbiota with a lower capacity to activate AhR compared to healthy subjects. Colonization of mice with microbiota from healthy subjects induced greater activation of AhR compared to mice colonized with microbiota from patients with IBD. Furthermore, increasing dietary tryptophan composition rescued the capacity to activate AhR. In Muc2 deficient mice, dietary tryptophan treatment enhanced AhR activation capacity and reduced infiltration of innate immune cells before the onset of colitis. Several AhR agonist producing bacterial species were identified and will be used in future experiments. Activation of AhR is dependent on the gut microbiota and disease status of the donor. Dietary intervention with tryptophan enhances AhR activation capacity and may be a potential therapeutic avenue in IBD individuals with intestinal dysbiosis. Farncombe Family Digestive Health Research Institute, Biocodex Microbiota Foundation
Cite this article as: Şahin A, Artaş H, Artaş G. An unusual cause of ascites and pleural effusion in an elderly woman: Sarcoidosis presenting with parailiac lymph node involvement. Turk J Gastroenterol 2020; 31(10): 731-3.
Diseases of the digestive system. Gastroenterology