Gastroenterology Insights

Background and Objectives: Glucose metabolism alterations are very common in solid pancreatic lesions, particularly in pancreatic cancer. Similarly, diabetes and especially new-onset diabetes (NOD) have been associated with the malignant transformation of pancreatic cysts. We aimed to assess the prevalence and relevant associations of glycemic abnormalities in pancreatic cystic lesions (PCLs) in a retrospective analysis. Materials and Methods: We retrospectively recruited all patients who underwent endoscopic ultrasound for a PCL over a period of 36 months (January 2018 to December 2021). Final diagnosis was set by means of tissue acquisition, surgery, follow-up, or board decision. Demographic and clinical data, laboratory workup, and imaging features were extracted from the patients’ charts according to a predefined protocol. We considered fasting blood glucose (FBG) and HbA1c values and stratified the patients as nondiabetic (FBG ≤ 99 mg/dL, HbA1c ≤ 5.6%, no history of glycemic abnormalities), prediabetic (FBG 100–125 mg/dL, HbA1c 5.7–6.4%), or diabetic (long-lasting diabetes or NOD). Results: Altogether, 81 patients were included, with a median age of 66 years, and 54.3% of them were male. The overall prevalence of fasting hyperglycemia was 54.3%, comprising 34.6% prediabetes and 22.2% diabetes, of which 16.7% had NOD. The mean FBG and HbA1c levels were higher in malignant and premalignant PCLs (intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), cystadenocarcinoma, and cystic neuroendocrine tumor) compared to the benign lesions (pseudocysts, walled-off necrosis, and serous cystadenoma): 117.0 mg/dL vs. 108.3 mg/dL and 6.1% vs. 5.5%, respectively. Conclusions: Hyperglycemia and diabetes are common in PCLs, with a high prevalence in premalignant and malignant cysts. Screening and follow-up for glycemic abnormalities should be routinely conducted for PCLs, as they can contribute to a tailored risk assessment of cysts. Full article

Despite the fact that gastric syphilis is considered rare, it is reported as a type of organic involvement that is present in a large proportion of secondary syphilis cases, even though gastritis presenting with symptoms is extremely rare. Clinical, radiological, and endoscopic findings are non-specific and frequently mimic the symptoms of gastric adenocarcinoma or lymphoma, making diagnosis difficult. Immunostaining is required for this diagnosis. We would like to emphasize the importance of being suspicious of GS when a gastric mass exhibits the histologic features of an inflammatory pseudotumor (IPT), as previously reported for nodal IPT caused by luetic infection. We described a 56-year-old man who presented to the oncology department with a 3-month history of anorexia, epigastric pain, nausea, vomiting, and weight loss, as well as an initial radiological and endoscopic suspicion of gastric adenocarcinoma, in which immune staining allowed us to diagnose GS. In addition, we conducted an updated scoping review of the scientific literature to show the clinical, laboratory, and therapeutic findings in GS patients over the last 65 years. Full article

Spontaneous bacterial peritonitis (SBP) is a potentially fatal complication in patients with liver cirrhosis. Early diagnosis and prompt treatment of SBP are vital to shorten hospital stays and reduce mortality. According to society guidelines, patients with cirrhosis and ascites who are admitted to the hospital should have diagnostic paracentesis. However, for various reasons, paracentesis may be delayed or not performed. Therefore, recent research has focused on identifying non-invasive parameters useful in SBP prediction which require urgent antibiotic therapy if rapid and secure paracentesis is not possible or there is insufficient experience with this method. In this review, we discuss the non-invasive methods available to predict SBP. Full article

The outbreak of the coronavirus pandemic in March 2020 has caused unprecedented pressure on public health and healthcare. The spectrum of COVID-19 onset is large, from mild cases with minor symptoms to severe forms with multi-organ dysfunction and death. In COVID-19, multiple organ damage has been described, including lung damage, acute kidney injury, liver damage, stroke, cardiovascular and digestive tract disorders. The aspects of liver injury are different, sometimes presenting with only a slight increase in liver enzymes, but sometimes with severe liver injury, leading to acute liver failure requiring liver transplantation. In patients with chronic liver disease, especially liver cirrhosis, immune dysfunction can increase the risk of infection. Immune dysfunction has a multifactorial physiopathological mechanism, implying a complement system and macrophage activation, lymphocyte and neutrophil activity dysfunction, and intestinal dysbiosis. This review aims to evaluate the most relevant studies published in the last years related to the etiopathogenetic, biochemical, and histological aspects of liver injury in patients diagnosed with COVID-19. Liver damage is more evident in patients with underlying chronic liver disease, with a significantly higher risk of developing severe outcomes of COVID-19 and death. Systemic inflammation, coagulation disorders, endothelial damage, and immune dysfunction explain the pathogenic mechanisms involved in impaired liver function. Although various mechanisms of action of SARS-CoV-2 on the liver cell have been studied, the impact of the direct viral effect on hepatocytes is not yet established. Full article

Background: Upper gastrointestinal (GI) hemorrhage, caused by acute esophageal variceal bleeding, is a common complication and a leading cause of death in patients with cirrhosis. Therefore, predicting the risk in order to employ an active management to prevent rebleeding and death is crucial. Currently, there are many prognostic scoring systems that have been proposed, but research is needed to find a valid score which can be applied in clinical practice in each country and population. Aims: To compare the value of ALBI (Albumin-Bilirubin), PALBI (Platelet Albumin-Bilirubin), AIMS65, model for end-stage liver disease (MELD), and Child–Pugh scores (CPS) approaches in predicting early rebleeding and in-hospital mortality of acute variceal bleeding in patients with cirrhosis. Subjects and methods: We performed a cross-sectional descriptive study on cirrhotic patients with acute variceal bleeding who were being treated at the Department of Gastroenterology, Intensive care unit—Military Hospital 103 and the Institute for Treatment of Digestive Diseases—108 Military Central Hospital from September 2020 to May 2022. We calculated ALBI, PALBI, AIMS65, MELD, Child–Pugh values and compared them with the rates of early rebleeding and in-hospital mortality. Then, determined and compared the prognostic value through an analysis of the area under the curve (AUC). Results: 222 patients with acute esophageal variceal bleeding were eligible for inclusion in the study. The rates of rebleeding and in-hospital mortality were 9.0% and 6.8%, respectively. Regarding the prognosis of early rebleeding, the ALBI and PALBI scores have good prognostic value (AUROC 0.74; 95% CI: 0.63–0.85 and AUROC 0.7; 95% CI: 0.59–0.81; p = 0.004, respectively), while the Child–Pugh, MELD, AIMS65 scores have little prognostic value, with AUROC < 0.70. Regarding prognosis of in-hospital mortality: the ALBI, PALBI, MELD and AIMS65 all have good value in predicting in-hospital mortality, with AUROC of 0.81 (95% CI: 0.68–0.93, respectively; p < 0.001); 0.8 (95% CI: 0.69–0.91; p <0.001); 0.83 (95% CI: 0.72–0.93; p < 0.001); and 0.82 (95% CI: 0.76–0.87, p < 0.001), respectively. While Child–Pugh score only has medium prognostic value, with AUROC 0.79 (95% CI: 0.66–0.92; p < 0.05). However, there was no significant difference between these prognostic scoring systems. Conclusion: the ALBI, PALBI, MELD and AIMS65 scores all had similar good value in predicting in-hospital mortality, but with early rebleeding prognosis, only ALBI and PALBI had good value. CPS does not show prognostic value like other scores, both in predicting early rebleeding and in-hospital mortality. Full article

Foreign bodies in the digestive tract represent a frequent pathology for the emergency service. Foreign bodies are represented by impacted food bolus or voluntarily and involuntarily swallowed objects. Involuntary swallowing of objects occurs most frequently in children, especially between six months and three years of age. Food impaction is mostly encountered among adults with different pathologies. For the removal of swallowed foreign bodies, digestive endoscopy is the gold standard method, being successful in over 95% of cases without significant complications. For the endoscopic management of foreign bodies, it is crucial to be aware of the indications, devices, techniques and patient preparation in order to achieve successful and safe removal from the digestive tract. Recommendations in this article are based on a review of the literature and extensive personal experience. Full article

Introduction. Mirizzi syndrome (MS) represents a rare clinical entity caused by impaction of one or multiple stones in the infundibulum of the gall bladder or the cystic duct resulting in partial or complete obstruction of the common hepatic or common bile duct (CBD). Though described more than a century ago, MS is still one of the most challenging diseases in the spectrum of biliary pathology. In recent years, endoscopic treatment has become an increasingly popular treatment modality. Patients and methods. Three consecutive patients subjected to cholangioscopy-assisted laser lithotripsy (CA-LL) for postocholecystectomy MS (pMS) were retrospectively evaluated. Case reports. Successful clearance of the cystic duct was achieved in all patients in one or two sessions. One complication in the form of mild cholangitis was observed. Clinical success was 100%. Discussion. According to current research, CA-LL achieves a high rate of ductal clearance and acceptable complication rate in patients with pMS. A 250 µm laser fiber seems to be the optimal choice for CA-LL. Our results suggest that procedure duration is closely associated to the stone size and possibly to the operator experience. In our opinion, upon obtainment of successful ductal clearance and drainage, prophylactic stenting does not improve clinical outcome. Conclusions. Our results demonstrate that CA-LL is a safe and effective treatment for pMS. Full article

Serrated lesions in the colorectum include all epithelial neoplastic lesions, which show a sawtooth-like morphology in the epithelial crypts. Classification systems nosologically divide colon serrated polyps into three different categories, primarily emphasizing their micromorphological growth pattern and cytodifferentiation: (1) hyperplastic polyps, (2) sessile serrated adenomas/polyps and (3) traditional serrated adenomas. Overall, 109 patients with serrated lesions of the colon, who underwent endoscopic or surgical polypectomy/tumorectomy during one or multiple endoscopic or surgical interventions, over a four-year period, were analyzed. The average age of patients was 62.8 ± 11.6 years. The frequency of serrated lesions of the colon in male patients was 2.4 times higher than in females (70.6% vs. 29.4%). All sessile serrated lesions without dysplasia were positive for CK7 and statistically significant compared to other serrated lesions, if this positivity was present in the complete crypt (p = 0.005). CK20 positivity, which is limited to the upper half of the crypt, is a special feature of hyperplastic polyps compared to other serrated lesions, which is statistically significant (p = 0.0078). Whereas, CK20 positivity of complete crypts is a statistically significant feature of traditional serrated adenomas (p < 0.01). Differences in the expression pattern of cytokeratin 7 and 20 in different serrated lesions may indicate different pathways of colorectal carcinogenesis, and be diagnostically and prognostically useful. Full article

Introduction: Congenital anomalies (CA’s) of most of the gastrointestinal tract have been linked causally with prenatal or community cannabis exposure. Therefore, we studied this relationship in Europe. Methods: CA data were from Eurocat. Drug-use data were sourced from the European Monitoring Centre for Drugs and Drug Addiction. Income data were taken from the World Bank. Results: When countries with increasing rates of daily cannabis use were compared with those which were not, the overall rate of gastrointestinal CA’s (GCA’s) was higher in the former group (p = 0.0032). The five anomalies which were related to the metrics of cannabis exposure on bivariate analysis were bile duct atresia, Hirschsprungs, digestive disorders, annular pancreas and anorectal stenosis or atresia. The following sequence of GCA’s was significantly linked with cannabis metrics at inverse-probability-weighted-panel modelling, as indicated: esophageal stenosis or atresia, bile duct atresia, small intestinal stenosis or atresia, anorectal stenosis or atresia, Hirschsprungs disease: p = 1.83 × 10⁻⁵, 0.0046, 3.55 × 10⁻¹², 7.35 × 10⁻⁶ and 2.00 × 10⁻¹², respectively. When this GCA series was considered in geospatial modelling, the GCA’s were significantly cannabis-related from p = 0.0003, N.S., 0.0086, 6.652 × 10⁻⁵, 0.0002, 71.4% of 35 E-value estimates and 54.3% minimum E-values (mEVv’s) > 9 (high zone) and 100% and 97.1% > 1.25 (causality threshold). The order of cannabis sensitivity by median mEVv was Hirschsprungs > esophageal atresia > small intestinal atresia > anorectal atresia > bile duct atresia. Conclusions: Seven of eight GCA’s were related to cannabis exposure and fulfilled the quantitative criteria for epidemiologically causal relationships. Penetration of cannabinoids into the community should be carefully scrutinized and controlled to protect against exponential and multigenerational genotoxicity ensuing from multiple cannabinoids. Full article

Background: Interventional inflammatory bowel disease (IIBD) therapies can play a key role in inflammatory bowel disease (IBD) related stricture/fistula/abscess deferring or avoiding invasive surgery. Methods: A total of 112 studies pertaining to IIBD therapy for strictures/fistula/abscess between 2002 and December 2022 were included by searching Pubmed, Medline and Embase with a focus on technical/clinical success, recurrence, re-intervention and complications. Results: IIBD therapy for strictures include endoscopic balloon dilation (EBD), endoscopic stricturotomy (ES) and self-expanding metal stent (SEMS) placement. EBD is the primary therapy for short strictures while ES and SEMS can be used for refractory strictures. ES has higher long-term efficacy than EBD. SEMS is inferior to EBD although it can be useful in long, refractory strictures. Fistula therapy includes endoscopic incision and drainage (perianal fistula)/endoscopic seton (simple, low fistula) and endoscopic ultrasound-guided drainage (pelvic abscess). Fistulotomy can be done for short, superficial, single tract, bowel-bowel fistula. Endoscopic injection of filling agents (fistula plug/glue/stem cell) is feasible although durability is unknown. Endoscopic closure therapies like over-the-scope clips (OTSC), suturing and SEMS should be avoided for de-novo/bowel to hollow organ fistulas. Conclusion: IIBD therapies have the potential to act as a bridge between medical and surgical therapy for properly selected IBD-related stricture/fistula/abscess although future controlled studies are warranted. Full article

We report the case of a 68-year-old man with advanced hepatocellular carcinoma (HCC) with multiple bone metastases (BM) treated with tyrosine kinase inhibitors. Despite an insufficient disease control on BM with a progression free survival (PFS) of 6 months, sorafenib was not discontinued and multiple radiation therapy (RT) sessions with a palliative purpose were performed. Thanks to this aggressive radiotherapy approach in order to control the bone tumor burden, the patient has continued sorafenib for 34.6 months achieving an overall survival (OS) of 41.3 months. This result highlights the importance of a tailored management of patients with advanced HCC and the role of the RT for BM control, even if at lower cumulative radiation dose, for extending patient survival. Full article

This study aimed to assess the relationship between malnutrition and anemia in patients with ulcerative colitis (UC). The cross-sectional retrospective study included 80 patients with UC. Body mass index and total body fat mass were derived retrospectively from bioimpedance measurements. Anemia was diagnosed retrospectively according to WHO criteria. A binary logistic regression was performed to study the relationship between nutritional status parameters and anemia, and adjusted for demographic and disease-associated characteristics. The prevalence of anemia in the study population was 40.0%. Among all included patients, 86.3% had acute disease corresponding to S1–S3 disease behavior. In the adjusted binary logistic model, total serum protein level below 64 g/L and low body fat percentage were associated with high odds for the of development of anemia, with odds ratios of 5.1 (95% CI 1.5; 17.8; p = 0.01) and 8.5 (95% CI 1.1; 63.6; p = 0.037), respectively. The adjusted model included sex, age, disease activity, extent of gut involvement, quantity of relapses from disease onset, and treatment with immunosuppressive drugs as confounders. Hypoproteinemia and low body fat percentage were associated with anemia in patients with UC. These results suggested that undernutrition may be involved as one of the causative factors of anemia in UC. Full article

Inflammatory bowel disease (IBD) refers to chronic conditions with a low mortality but high disability. The multisystemic nature of these diseases can explain the appearance of some extraintestinal manifestations, including liver damage. Abnormal liver biochemical tests can be identified in approximately one third of patients with IBD and chronic liver disease in 5% of them. Among the liver diseases associated with IBD are primary sclerosing cholangitis, cholelithiasis, fatty liver disease, hepatic amyloidosis, granulomatous hepatitis, drug-induced liver injury, venous thromboembolism, primary biliary cholangitis, IgG4-related cholangiopathy, autoimmune hepatitis, liver abscesses or the reactivation of viral hepatitis. The most common disease is primary sclerosing cholangitis, a condition diagnosed especially in patients with ulcerative colitis. The progress registered in recent years in the therapeutic management of IBD has not eliminated the risk of drug-induced liver disease. Additionally, the immunosuppression encountered in these patients increases the risk of opportunistic infections, including the reactivation of viral hepatitis. Currently, one of the concerns consists of establishing an efficiency and safety profile of the use of direct-acting antiviral agents (DAA) among patients with hepatitis C and IBD. Early diagnosis and optimal treatment of liver complications can improve the prognoses of these patients. Full article

Background: Ineffective esophageal motility (IEM) is the most common esophageal motility disorder associated with low-to-moderate amplitude contractions in the distal esophagus in manometric evaluations. Despite recent new conceptions regarding the pathophysiology of esophageal motility and IEM, there are still no effective therapeutic interventions for the treatment of this disorder. This study aimed to investigate the effect of buspirone in the treatment of concomitant IEM and GERD. Methods and Materials: The present study was a randomized clinical trial conducted at the Imam Khomeini Hospital, Tehran. Patients with a history of gastroesophageal reflux disease and dysphagia underwent upper endoscopy to rule out any mechanical obstruction and were diagnosed with an ineffective esophageal motility disorder based on high-resolution manometry. They were given a package containing the desired medication(s); half of the packets contained 10 mg (for 30 days) of buspirone and 40 mg (for 30 days) of pantoprazole, and the other half contained only 40 mg (for 30 days) of pantoprazole. Dysphagia was scored based on the Mayo score, as well as a table of dysphagia severity. Manometric variables were recorded before and after the treatment. Results: Thirty patients (15 pantoprazole and 15 pantoprazole plus buspirone) were included. Females comprised 63.3% of the population, with a mean age of 46.33 ± 11.15. The MAYO score and resting LES pressure significantly changed after treatment. The MAYO and Swallowing Disorder Questionnaire scores significantly decreased after treatment in both groups of patients. Our results revealed that the post-intervention values of manometric variables differed significantly between the two groups after controlling for the baseline values of the variables. This analysis did not demonstrate the superiority of buspirone. Conclusion: Buspirone seems to have no superiority over PPI. Treatment with concomitant IEM and GERD using proton pump inhibitors improves the patient’s clinical condition and quality of life. However, adding buspirone to the treatment regimen did not appear to make a significant difference in patient treatment. Full article

Pancreatitis is the most common complication following endoscopic retrograde cholangio-pancreatography (ERCP). With the progress of research in many drugs and technologies, promising efficacy has been achieved in preventing post-ERCP pancreatitis (PEP). Recently, combined prevention has received more attention in order to further reduce the incidence of PEP. However, there is no review about the combined prevention of PEP. This review summarizes the medication and ERCP techniques that are used to prevent PEP and emphasizes that appropriate combination prevention approaches should be based on risk stratification. Full article

Alcoholic liver disease (ALD) has been a growing concern in developed and developing nations. Oxidative stress and lipid peroxidation are the most common cause of the development and progression of ALD. Due to paucity in the number and efficacy of hepatoprotective drugs currently available, and with the easy availability of natural therapy and herbal medicines, ALD is managed using a combination of pharmaceutical interventions and herbal medications. However, the effectiveness of these hepatoprotectives is controversial. Preclinical and clinical studies have demonstrated that Liv.52 modulates the lipotropic activity of hepatocytes, reduces inflammation, enhances alcohol and acetaldehyde metabolism, and protects the hepatic parenchyma by restoring the antioxidant levels of hepatocytes. Clinical studies further support that there is improvement in the subjective symptoms of patients as well as improvements in liver function test parameters. Studies suggest that Liv.52 is well tolerated and has no reported side effects. Full article

(1) Background: In Vietnam, H. pylori bacteria has a resistance rate of 63% to the antibiotic clarithromycin. The initial therapy of H. pylori eradication with a standard three-drug regimen has low efficacy. Objective: Assess the efficacy of H. pylori eradication therapy which uses a four-drug regimen of rabeprazole–bismuth–tetracycline–tinidazole in patients with duodenal ulcers. (2) Methods: We performed gastrointestinal endoscopy on patients with a diagnosis of duodenal ulcers, gastric mucosa biopsy for a rapid urease test, and histopathology to diagnose H. pylori bacteria before and after treatment. Treatment for eradication of H. pylori bacteria using a rabeprazole–bismuth–tetracycline–tinidazole regimen was prescribed for 14 days. (3) Results: The rate of successful H. pylori eradication treatment according to per protocol (PP) and intention to treat (ITT) was 91.3% (95%CI: 84.8–96.7) and 82.4% (95%CI: 74.5–89.2) respectively. The success rate of H. pylori eradication therapy in males was 96.0% (95%CI: 92–100), higher than in females, which was 70.6% (95%CI: 47.1–88.2), p < 0.01. (4) Conclusions: Treatment of H. pylori with rabeprazole–bismuth–tetracycline–tinidazole regimen is highly effective. Men had higher H. pylori eradication results than women. Full article

Many of the increasing number of community-dwelling older adults will need increased healthcare in the future. By characterising gut health and its association with wellbeing and nutrient intake in this population, we aim to recognise areas along the gut–brain axis through which the health of community-dwelling older adults might be promoted. In this cross-sectional observational study, validated questionnaires were used to assess gut health, nutrient intake, and wellbeing in 241 community-dwelling older adults (≥65 years old). In total, 65% of the participants experienced at least one gastrointestinal symptom, of which females had more abdominal pain and constipation, while the oldest old (i.e., ≥80 years old) had more diarrhoea. Increased gastrointestinal symptoms correlated with more stress, anxiety, depression, and a decreased quality of life, in addition to dyspepsia which correlated with a lower E% of protein. Most of the participants did not reach the recommended intake for protein, fibre and polyunsaturated fats. Males had a lower intake of protein (E%) and fibre (g/MJ) than females, and the oldest old had a lower E% of protein than younger older adults. In conclusion, our results demonstrate that gastrointestinal symptoms are common, and most of the study participants had an imbalanced macronutrient intake, which could be a target for future possible dietary interventions to improve overall health. Full article