Endoscopic resection of polypoid solitary rectal ulcer: A novel first-line therapeutic strategy using snare-assisted mucosal and fibrosis resection

Objectives

To propose a novel first-line endoscopic therapy for treating polypoid lesions in solitary rectal ulcer syndrome (P-SRUS), the rarest and most challenging subtype of SRUS, which encompasses various endoscopic findings including mucosal erythema, superficial or deep ulcers, and polypoid lesions.

Methods

A prospective, single-arm study was conducted on 56 patients with histologically confirmed SRUS and broad-based polypoid lesions in the rectum and anal canal. These patients were referred to the Department of Motility Disorders of the Lower Gastrointestinal Tract. The lesions were removed using snare-assisted mucosal and fibrosis resection. Patients were monitored for clinical and endoscopic responses at 1, 3, 6, and 12 months post-treatment.

Results

The study observed improvement in clinical symptoms, a complete endoscopic response, and the absence of late complications following endoscopic resection. Endoscopic evaluations revealed no recurrence of lesions in the follow-up period.

Conclusion

Endoscopic resection using the snare-assisted mucosal and fibrosis resection method appears to be an effective and safe treatment option for polypoid SRUS. (Clinical Trial Registration Number: IRCT20211101052935N2).

Integrative review of the gut microbiome’s role in pain management for orthopaedic conditions

The gut microbiome, a complex ecosystem of microorganisms, has a significant role in modulating pain, particularly within orthopaedic conditions. Its impact on immune and neurological functions is underscored by the gut-brain axis, which influences inflammation, pain perception, and systemic immune responses. This integrative review examines current research on how gut dysbiosis is associated with various pain pathways, notably nociceptive and neuroinflammatory mechanisms linked to central sensitization. We highlight advancements in meta-omics technologies, such as metagenomics and metaproteomics, which deepen our understanding of microbiome-host interactions and their implications in pain. Recent studies emphasize that gut-derived short-chain fatty acids and microbial metabolites play roles in modulating neuroinflammation and nociception, contributing to pain management. Probiotics, prebiotics, synbiotics, and faecal microbiome transplants are explored as potential therapeutic strategies to alleviate pain through gut microbiome modulation, offering an adjunct or alternative to opioids. However, variability in individual microbiomes poses challenges to standardizing these treatments, necessitating further rigorous clinical trials. A multidisciplinary approach combining microbiology, immunology, neurology, and orthopaedics is essential to develop innovative, personalized pain management strategies rooted in gut health, with potential to transform orthopaedic pain care.

Breaking the cycle: Psychological and social dimensions of pediatric functional gastrointestinal disorders

BACKGROUND

Functional gastrointestinal disorders (FGIDs) in children present with chronic symptoms like abdominal pain, diarrhea, and constipation without identifiable structural abnormalities. These disorders are closely linked to gut-brain axis dysfunction, altered gut microbiota, and psychosocial stress, leading to psychiatric comorbidities such as anxiety, depression, and behavioral issues. Understanding this bidirectional relationship is crucial for developing effective, holistic management strategies that address physical and mental health.

AIM

To examine the psychiatric impacts of FGIDs in children, focusing on anxiety and depression and their association with other neurodevelopmental disorders of childhood, such as attention-deficit/hyperactivity disorder, emphasizing the role of the gut-brain axis, emotional dysregulation, and psychosocial stress. Key mechanisms explored include neurotransmitter dysregulation, microbiota imbalance, central sensitization, heightening stress reactivity, emotional dysregulation, and symptom perception. The review also evaluates the role of family dynamics and coping strategies in exacerbating FGID symptoms and contributing to psychiatric conditions.

METHODS

A narrative review was conducted using 328 studies sourced from PubMed, Scopus, and Google Scholar, covering research published over the past 20 years. Inclusion criteria focused on studies examining FGID diagnosis, gut-brain mechanisms, psychiatric comorbidities, and psychosocial factors in pediatric populations. FGIDs commonly affecting children, including functional constipation, abdominal pain, irritable bowel syndrome, gastroesophageal reflux, and cyclic vomiting syndrome, were analyzed concerning their psychological impacts.

RESULTS

The review highlights a strong connection between FGIDs and psychiatric symptoms, mediated by gut-brain axis dysfunction, dysregulated microbiota, and central sensitization. These physiological disruptions increase children’s vulnerability to anxiety and depression, while psychosocial factors - such as chronic stress, early-life trauma, maladaptive family dynamics, and ineffective coping strategies - intensify the cycle of gastrointestinal and emotional distress.

CONCLUSION

Effective management of FGIDs requires a biopsychosocial approach integrating medical, psychological, and dietary interventions. Parental education, early intervention, and multidisciplinary care coordination are critical in mitigating long-term psychological impacts and improving both gastrointestinal and mental health outcomes in children with FGIDs.

A case report of fatal splenic rupture caused by multiple organ infection following foreign body ingestion in a detainee

Among forensic and clinical cases, infections caused by the ingestion of foreign bodies are common. In general, timely removal of the foreign body and appropriate treatment prevent serious consequences. We herein report a rare case of death due to massive bleeding caused by splenic rupture following foreign body ingestion. To our knowledge, no similar cases have been reported in the Chinese or international literature, making this case particularly noteworthy. In this instance, the decedent was in a detention centre for a criminal offence and swallowed a wire unnoticed. The wire remained in his stomach for >50 days, leading to a severe suppurative infection in the gastric tissue. This resulted in suppurative inflammation affecting multiple organs, including the liver, pancreas, and spleen. The condition ultimately led to the rupture of splenic vessels and the formation of a rare, massive haematoma beneath the splenic capsule. Based on medical records and histopathological findings, we infer that the wire had remained in the stomach for ~50 days, triggering severe suppurative infections in multiple organs. The spleen eventually ruptured, and the victim died of massive haemorrhage.

Clinical Trial: A Multicentre Randomised Controlled Trial of Carvedilol Versus Variceal Band Ligation in Primary Prevention of Variceal Bleeding in Liver Cirrhosis (CALIBRE Trial)

BACKGROUND

The superior efficacy of non-selective beta-blockers (NSBB) compared with variceal band ligation (VBL) in the primary prevention of variceal bleeding is uncertain.

AIM

To compare carvedilol versus VBL for primary prevention of variceal bleeding.

METHODS

CALIBRE was an investigator-initiated, multicentre, randomised, controlled, open-label trial. Participants were randomly assigned to 12.5 mg carvedilol once daily or VBL. Inclusion criteria were cirrhosis and medium to large oesophageal varices that had not bled. The primary outcome is any variceal bleeding within 1 year of randomisation. Secondary outcomes include survival, other complications of cirrhosis, quality of life, cost-effectiveness and adverse events. Recruitment closed early, mainly due to the impact of the pandemic.

RESULTS

265 participants (10% of the intended sample size) from 52 sites were randomised to carvedilol (n = 133) or VBL (n = 132) between 22 January 2019 and 31 August 2022. 5/133 participants (3.8%) in the carvedilol arm vs. 10/132 participants (7.6%) in the VBL arm experienced variceal bleeding (risk ratio 0.50 (95% confidence interval [CI]; 0.17-1.41); risk difference - 0.038 (95% CI; -0.094-0.017)). Serious adverse events occurred in one participant in each treatment arm, with no treatment-related deaths. Of the secondary outcomes, there were no statistically significant differences. Carvedilol was cheaper and resulted in slightly more quality-adjusted life years than VBL.

CONCLUSIONS

The early terminated and, thus, underpowered CALIBRE trial showed no difference between carvedilol and VBL in the primary prevention of variceal bleeding in patients with cirrhosis and medium-to large-sized oesophageal varices. No untoward safety concerns were noted.

TRIAL REGISTRATION

ISRCTN73887615.

Safety of Anticoagulant Treatment in Patients With Splanchnic Vein Thrombosis and History of Portal Hypertension-Related Bleeding

Splanchnic vein thrombosis (SVT) can be associated with liver cirrhosis or prothrombotic conditions, including myeloproliferative disorders, intra-abdominal inflammation, solid cancers or surgery. While anticoagulation therapy improves outcomes in noncirrhotic patients and reduces all-cause mortality in cirrhotic populations, its safety in patients with a history of portal hypertension (PH)-related bleeding is less clear. This systematic review examines the impact of anticoagulant therapy on rebleeding risk in SVT patients with a history of PH-related bleeding. A systematic review and meta-analysis were conducted according to PRISMA guidelines. A comprehensive search of PubMed, Web of Science and Scopus was performed for studies published up to September 2024. Studies were included if they compared SVT patients with a history of PH-related bleeding receiving anticoagulant therapy versus those not receiving anticoagulants. The primary outcome was the cumulative incidence of PH-related rebleedings. Of 2853 identified studies, five (186 participants) met the inclusion criteria: two randomised controlled trials (RCTs) and three observational studies. The cumulative incidence of PH-related rebleeding was significantly lower in the anticoagulant group at 17.10% [95% CI 17.02, 17.19] compared to the control group at 40.00% [95% CI 39.90, 40.09]. The overall odds ratio (OR) from observational studies was 0.15 [95% CI 0.04, 0.52], indicating a reduced bleeding risk, while the OR from RCTs was 0.84 [95% CI 0.31, 2.32], showing a nonsignificant trend. Anticoagulant therapy may reduce rebleeding risk in SVT patients with a history of PH-related bleeding, but further high-quality studies are needed.

Multisystem hemodynamic effects of terlipressin in cirrhosis: A scoping review

INTRODUCTION

Hepatorenal syndrome (HRS-AKI) is a serious complication of advanced liver disease. Pharmacologic options are limited in effectiveness, therefore liver transplantation is the definitive therapy. Early investigation into terlipressin as a first-line therapy for HRS-AKI has been promising but expected hemodynamic changes across organ systems in patients with cirrhosis have not been thoroughly examined.

METHODS

We conducted a scoping review of the literature including adult patients with cirrhosis who received terlipressin and hemodynamic parameters were recorded. Non-human studies, case reports, conference abstracts, and review articles were excluded. Searches were performed up to December 2024 in the following databases: MEDLINE, Embase, Cochrane Library, Scopus, Web of Science, and CINAHL.

RESULTS

Of 2022 studies retrieved, 56 studies met inclusion criteria. Heart rate, mean arterial pressure, and cardiac output were the most reported parameters. Pulmonary arterial pressure and wedge pressure were the next most common. Systemic vascular resistance, hepatic and renal measures such as resistive indices and portal pressure gradients had fewer studies. Studies reported decreased heart rate, increased mean arterial pressure, decreased cardiac output/index, and increased systemic vascular resistance. Other hemodynamic outcomes were more varied across studies.

CONCLUSIONS

Terlipressin exerts a variety of hemodynamic effects across organ systems and vascular beds. More studies are required to understand if any hemodynamic parameters might predict terlipressin response or adverse events.

The Impact of Pediatric Disorders of Gut-Brain Interaction on the Family: The Mediating Role of Child Somatic Symptoms

BACKGROUND

It is important to identify modifiable factors to reduce the negative impact of pediatric disorders of gut-brain interaction (DGBIs) on the family. The current study examined whether child somatic symptoms and caregiver mental health negatively influenced caregiver and family functioning.

METHODS

Participants were 84 children (8-17 years old) with DGBI symptoms and their caregivers presenting to a specialty DGBI clinic. Participants completed measures assessing demographics, child somatic symptoms, caregiver anxiety and depressive symptoms, and the impact of the child's illness on the family. Regression analyses examined if child somatic symptoms and caregiver and mental health were associated with family outcomes (i.e., Caregiver Health-Related Quality of Life [HRQoL], Family Functioning, Total Family Impact). Mediation analyses examined if child somatic symptoms mediated the association between caregiver mental health and Total Family Impact.

KEY RESULTS

Child somatic symptoms (self- and caregiver-report) were negatively related to Caregiver HRQoL, Family Functioning, and Total Family Impact (ps < 0.01). Caregiver anxiety was related to poorer Caregiver HRQoL (p < 0.001) and Total Family Impact (p = 0.01), while caregiver depression was negatively related to Family Functioning (p = 0.01). Self-report of child somatic symptoms partially mediated the association between caregiver anxiety and depressive symptoms and the Total Family Impact.

CONCLUSIONS AND INFERENCES

Findings indicate that child somatic symptoms are one pathway by which caregiver mental health may amplify the impact of pediatric DGBIs on the family. This highlights the importance of screening for child somatic symptoms and caregiver mental health in pediatric DGBI treatment.

Predictive Analysis of Dental Caries Risk via Rapid Urease Activity Evaluation in Saliva Using a ZIF-8 Nanoporous Membrane

Despite a decrease in the incidence of dental caries over the past four decades, it remains a widespread public health concern. The multifactorial etiology of dental caries complicates effective prevention and early intervention efforts, underscoring the need for the development of rapid predictive methods that account for multiple factors. In this study, we selected the activity of urease secreted by Streptococcus salivarius as a metabolic marker for dental caries. This activity was quantified by measuring the diffusion of hydroxide ions generated from the urease catalytic reaction on urea across a ZIF-8-modified nanoporous membrane. The choice of ZIF-8 was based on its preference in transporting hydroxide ions, enabling the accurate detection of urease activity at concentrations as low as 1 CFU/mL. Subsequently, we collected 287 saliva samples to determine the Michaelis constant (Km) of urease using this method. Logistic regression analysis revealed that both the Km of urease and the frequency of sugar intake are significant factors influencing the development of dental caries. Furthermore, we developed a machine learning methodology for identifying dental caries, achieving an accuracy rate of 81%. It is expected that increasing the sample size will further enhance the predictive accuracy of the model. This innovative approach provides valuable insights into early intervention strategies in the fight against dental caries.

Endoscopy-Related Musculoskeletal Injuries: A Systematic Review and Meta-Analysis on Prevalence, Risk Factors and Prevention

BACKGROUND

Endoscopy-related musculoskeletal injuries (ERIs) are a major occupational hazard, impacting career longevity and personal well-being.

OBJECTIVE

This systematic review and meta-analysis aimed to update and expand on previous findings by assessing prevalence, risk factors and management of ERIs among endoscopists.

METHODS

Following PRISMA guidelines, we systematically searched MEDLINE, Web of Science and Scopus for relevant studies published since the last comprehensive review. A manual search of the references of relevant manuscripts was also performed. Outcomes of interest included the prevalence of ERIs, common pain syndromes, risk factors, and preventive or treatment strategies. Studies' quality was assessed using the National Institutes of Health (NIH) Quality Assessment Tool.

RESULTS

Thirty studies were included, incorporating data from 7646 gastrointestinal endoscopists. The pooled career-long prevalence of overall ERI was 62.5% (CI 52.6-71.8, I2 = 98%), including pain (67.5%; CI 46.4%-85.6%; I2 = 98%) and numbness (12.4%; 95% CI 6.6%-19.7%; I2 = 98%) syndromes. Among pain syndromes, the most affected areas were the hand (28.2%; CI 19.2%-38.2%; I2 = 99%), lower back (27.3%; CI 20.1%-35.2%; I2 = 97%), thumb (27.1%; CI 18.9%-37.7%; I2 = 99%) and neck (25.7%; CI 19.3%-32.7%; I2 = 98%). Higher procedural volume, years in practice and female gender were consistently reported as risk factors for ERIs. Concerning therapy, 41.8% of endoscopists used medications (CI 31.2%-52.8%; I2 = 94%), while 28.2% engaged in physical therapy (CI 18.2%-39.5%; I2 = 96%). Sick leave was reported by 13.8% of endoscopists (CI 7.9%-20.9%; I2 = 94%). Practice modifications to manage ERIs included adjusting monitor (45.5%, CI 22.2%-69.9%; I2 = 96%) and table (32.4%, CI 14.5%-53.5%; I2 = 97%) height, but also reducing the number of cases per endoscopy session (14.6%; CI 10.4%-19.4%; I2 = 72%).

CONCLUSION

ERIs are highly prevalent among international gastrointestinal endoscopists, and are linked to procedural volume, years in practice, and gender. Ergonomic training and workplace adaptations are essential to mitigate risks and support career sustainability.

TRIAL REGISTRATION

PROSPERO Registration: CRD42024534349.

Impact of hepatitis C virus genotype on the efficacy of the direct-acting antivirals in chronic kidney disease patients in West Bengal, India

BACKGROUND

Hepatitis C virus (HCV) infection increases the risk of mortality and morbidity among chronic kidney disease (CKD) patients. However, the advancement of HCV treatment has made this viral infection curable. Thus, the main objective of this study was to comprehend the HCV genotype (GT) distribution and the efficacy of direct-acting antivirals (DAAs) among CKD patients in West Bengal.

METHODS

Over five years (January 2017 to December 2021), 310 HCV sero-reactive patients were enrolled in this observational prospective study. HCV RNA was quantified using qRT-PCR. The partial amplification of the core (405 bp) and NS5B (389 bp) region was performed by nested RT-PCR followed by Sanger sequencing for HCV genotype analysis using the NCBI genotyping tool. The phylogenetic tree was constructed using the MEGA-X tool.

RESULTS

The occurrence of HCV RNA positivity was 50.64% (n = 157), and of these 157 patients, 141 (89.81%) completed the DAAs treatment. The most important observation of the study was the prevalence of uncommon HCV genotype GT-1c (67.52%) followed by 1a, 4a, 3a, 1b, and 3b among CKD patients. The overall DAAs efficacy between January 2017 and December 2018 was ~ 97%, and in January 2019 and December 2021, ~ 95% among CKD patients. At the same time, in these two phases, DAAs efficacy among GT-1c-infected CKD patients was ˜ 96% and ˜ 93%, respectively.

CONCLUSIONS

The prevalence of GT-1c among CKD patients was unusual in this geographic region. The overall efficacy of DAAs among the CKD population was encouraging. However, the downtrend of the DAAs efficacy in GT-1c may increase concern among this high-risk group in the future.

CLINICAL TRIAL

Not applicable.

Comparative evaluation of mitochondrial gene markers for molecular diagnosis of Echinococcus granulosus sensu lato in clinical samples

Cystic echinococcosis (CE), caused by Echinococcus granulosus sensu lato (s.l.), remains a significant public health concern, particularly in regions reliant on livestock farming. Early and accurate diagnosis is essential for effective disease management, yet traditional diagnostic methods such as imaging and serological assays often lack specificity and sensitivity. Molecular diagnostics, particularly polymerase chain reaction (PCR), offer a promising alternative by enabling the direct detection of E. granulosus s.l. DNA in clinical samples. This study evaluates the diagnostic performance of four primer sets targeting mitochondrial genes-Cytochrome c oxidase subunit 1 (Cox1), Mitochondrial NADH dehydrogenase subunit 1 (NAD1) and Mitochondrial 12s ribosomal RNA (12s rRNA). All primer sets achieved 100% positivity in hydatid cyst fluids and tissues, confirming their utility in detecting E. granulosus s.l. DNA. However, specificity varied, with NAD1 and 12S rRNA primers demonstrating excellent specificity, while Cox1.1 and Cox1.2 exhibited cross-reactivity with Taenia solium and Dirofilaria spp., respectively. Sensitivity analysis revealed NAD1 as the most sensitive marker, detecting as little as 305 fg/µl of parasite DNA. These findings underscore the importance of genetic marker selection in optimizing PCR-based diagnostics. While NAD1 and 12S rRNA primers showed strong potential for clinical application, further refinement of Cox1 primers is necessary to minimize false positives. Our study highlights the power of molecular diagnostics in improving CE detection and emphasizes the need for continuous assay optimization to ensure accurate and reliable parasite identification in endemic settings.

Bee products in the fight against Helicobacter pylori and molecular interactions

Gastric or duodenal ulcers can lead to upper gastrointestinal (GI) bleeding. Infection with Helicobacter pylori (H. pylori) is one of the most common infections in the world and can cause both gastric ulcers and gastric cancer. The treatment aims to eradicate H. pylori and treatment with antibiotics has made it possible to cure gastric ulcers. The most common complication of untreated peptic ulcer disease is bleeding (hematemesis, melena, and anemia), while perforation occurs in a smaller proportion of patients. In some individuals, the infection causes mucosal changes with increasing age that lead to atrophy and intestinal metaplasia. It is believed that atrophy and especially intestinal metaplasia are a prerequisite for the most common form of gastric cancer, adenocarcinoma. There is presently a demand for an alternate treatment devoid of the current strategies drawbacks including recurrence, resistance and antibiotic abuse. The current workhighlights the possibility of bee product-based treatments for preventing and eliminating H. pylori infestation. Sci-finder, Google Scholar, PubMed, ScienceDirect, Web of Science, and Scopus were used for literature screening. Terms and keywords, i.e. "helicobacter pylori", "epidemiology", "chemotherapy", "honey", "propolis", "bee venom", "bioactive compounds", and "mechanism of action" were used in the search. Bee products are important alternatives that have been utilized for treating many ailments due to their diverse biochemical and biological characteristics. Various mechanisms, such as direct antibacterial, antioxidant, anti-inflammatory, and wound healing capacities, are proposed to explain the potential effect of bee products against H. pylori. The bee product's metabolites have a role in the adherence of H. pylori to stomach epithelial cells. The disruption of bacterial cell membranes and the inhibition of virulence factors are the two mechanisms behind the bee product's promising therapeutic applications against H. pylori.

EASL Clinical Practice Guidelines on extrahepatic abdominal surgery in patients with cirrhosis and advanced chronic liver disease

Extrahepatic surgery in patients with cirrhosis of the liver represents a growing clinical challenge due to the increasing prevalence of chronic liver disease and improved long-term survival of these patients. The presence of cirrhosis significantly increases the risk of perioperative morbidity and mortality following abdominal surgery. Advances in preoperative risk stratification, surgical techniques, and perioperative care have led to better outcomes, yet integration of these improvements into routine clinical practice is needed. These clinical practice guidelines provide comprehensive recommendations for the assessment and perioperative management of patients with cirrhosis undergoing extrahepatic surgery. An individualised patient-centred risk assessment by a multidisciplinary team including hepatologists, surgeons, anaesthesiologists, and other support teams is essential.

Correlation of electrogastrography and bioelectric impedance techniques for the gastric motility assessment

OBJECTIVES

The electrical bioimpedance (EBI) technique has been used to measure gastric motility and emptying parameters. A well-known technique for this purpose is electrogastrography (EGG). No correlation between EGG signal and mechanical motility has been reported. In this study, a direct data comparison of these two techniques was performed.

METHODS

23 volunteers underwent simultaneous gastric monitoring using EGG and EBI. Signal processing was performed to isolate the slow waves of 0.5-9 cpm. The parameters obtained from 70 % overlapped time slots of 3.5 min, included the dominant frequency and power of the normo-gastric region and the percentage of brady-, normo-, and tachy-gastric slow waves.

RESULTS

The EGG showed slightly higher values in dominant frequencies, whereas EBI displayed higher variability. High-frequency features were more significant in the EBI, with lower variability, and correlations were found in approximately half of the frequency spectra. Slow waves exhibited poor correlation, but were significant at 95 % of the timeslots.

CONCLUSIONS

Comparing EBI and EGG, global parameters in the normogastric region had slight variances, which may not significantly impact clinical findings. The sensitivity of the EBI to higher frequencies is evident.

The Impact of Alpha-Neurofeedback Training on Gastric Slow Wave Activity and Heart Rate Variability in Humans

INTRODUCTION

Neuromodulation of cortical brain regions associated with the gut-brain axis may have the potential to modulate gastric function. Previous studies have shown phase-amplitude coupling between the electroencephalogram (EEG) alpha band frequency of the insula (Ins) and gastric slow wave (GSW) activity. This study investigated the first evidence of alpha band EEG-neurofeedback (EEG-NF) training to explore its effects on GSW activity and heart rate variability (HRV).

METHODS

A randomized crossover design was employed with 20 healthy participants attending two separate sessions [active-training: uptraining left posterior Insula (LPIns) and active-control: uptraining primary visual cortex (PVC Brodmann area 17)] following the baseline recording period. A 5-min water loading test (5WLT) was conducted following the EEG-NF sessions. Finally, a post EEG-NF/5WL period was also recorded. Participants were blinded to the training program, and the sessions were randomized and conducted at least 48 h apart. Electrocardiogram (ECG), EEG, and electrogastrogram (EGG) data were recorded throughout theexperiment. In addition, the duration of successful NF training was also extracted. Correlation analysis was performed to assess the relationships between outcome variables.

RESULTS

Pearson correlation coefficient analysis revealed a significant relationship between the duration of successful NF training and HRV metrics (RMSSD: r = 0.59; p = 0.005, SI: r = -0.59; p = 0.006) in the LPIns training group and EGG-gastric rhythm index (r = -0.40; p = 0.028) in the PVC training group. Moreover, the duration of successful LPIns NF correlated with EEG activity of the infraslow band over the left anterior Ins (r = 0.45; p = 0.043), slow band over the right posterior Ins (r = -0.5; p = 0.022), and beta band over the left (r = 0.44; p = 0.04) and right anterior Ins (r = 0.45; p = 0.04). Significant correlations were also observed between LPIns NF duration and connectivity in the beta and gamma bands between cortical regions of interest.

CONCLUSION

The alpha band EEG-NF training of LPIns demonstrated significant association with HRV, and EEG (activity and functional connectivity)measures and did not show a negative correlation with Gastric Alimetry Rhythm Index (GA-RI) following the 5WLT as in the PVC training group. These findings underscore the importance of considering the duration of successful NF as an important variable when evaluating NF training efficacy in future studies.

Recurrent Abdominal Pain in a Child - Evaluation and Management

Recurrent abdominal pain (RAP) is defined as the presence of at least 3 episodes of abdominal pain for 3 mo duration, including both organic and functional etiology. Up to 95% of the causes of RAP are due to functional abdominal pain disorders (FAPD). Peptic ulcer disease, cholelithiasis, chronic pancreatitis, abdominal tuberculosis, inflammatory bowel diseases (IBD), parasitic infection, and urinary tract infection (UTI) are prominent organic causes of RAP. The published data from developed countries reported pooled prevalence of FAPD in children is 13.5%, in which irritable bowel syndrome (IBS) is the most common sub-type. The evaluation includes history taking regarding pain characteristics, associated symptoms, and the presence of stressors. A detailed history and examination are required to assess for alarm symptoms and signs. The presence of alarm symptoms increases the chances of organic etiology for RAP. Basic work-ups such as complete blood counts, stool and urine examinations, serum albumin, and inflammatory markers may be required to look for chronic organic etiologies. Fecal calprotectin (FCP) is a highly sensitive tool to differentiate IBD from IBS. Ultrasound abdomen (USG) helps in the evaluation of cholelithiasis, biliary obstruction, chronic pancreatitis, malrotation, and bowel thickening. Endoscopies are useful for peptic ulcer disease, inflammatory bowel diseases, abdominal tuberculosis, Helicobacter pylori infection, etc. Organic causes need specific management. FAPD requires patient counselling and medications. Cognitive behavioral therapy, hypnotherapy, yoga, and percutaneous electrical superficial nerve stimulation are indicated for refractory cases.

Endoscopic Glue Injection vs Glue Plus BRTO or TIPSS for Preventing Gastric Variceal Bleeding: A Randomized Controlled Trial

BACKGROUND AND AIMS

The study sought to compare the efficacy of endoscopic injection sclerotherapy with cyanoacrylate glue (EIS-CYA) vs EIS-CYA plus a radiologic intervention (RI) (either transjugular intrahepatic portosystemic shunt or balloon-occluded retrograde transvenous obliteration) for secondary prophylaxis in patients with liver cirrhosis who presented with acute variceal bleeding from cardiofundal varices. Primary outcome measure was gastric varix (GV) rebleed rates at 1 year.

METHODS

Consecutive cirrhosis patients with acute variceal bleeding from cardiofundal varices were randomized into 2 arms (45 in each) after primary hemostasis by EIS-CYA. In the endoscopic intervention (EI) arm, EIS-CYA was repeated at regular intervals (1, 3, 6, and 12 months), while in the RI arm, patients underwent transjugular intrahepatic portosystemic shunt or balloon-occluded retrograde transvenous obliteration followed by endoscopic surveillance.

RESULTS

GV rebleed rates at 1 year were higher in the EI arm compared with the RI arm: 11 (24.4%; 95% confidence interval [CI], 12.9%-39.5%) vs 1 (2.2%; 95% CI, 0.1%-11.8%) (P = .004; absolute risk difference: 22.2%; 95% CI, 8.4%-36.6%). GV rebleed-related mortality in the EI arm (8 [17.8%; 95% CI, 8.0%-32.1%]) was significantly higher than in the RI arm (1 [2.2%; 0.1%-11.8%]) (P = .030; absolute risk difference: 15.6; 95% CI, 2.9%-29.2%); however, there was no difference in all-cause mortality between the 2 groups (12 [26.7%; 95% CI, 14.6%-41.9%] vs 7 [15.6%; 95% CI, 6.5%-29.5%]). The number needed to treat to prevent 1 GV-related rebleed at 1 year was 4.5.

CONCLUSIONS

RI for secondary prophylaxis reduces rebleeding from GV and GV rebleeding-related mortality in patients with GV hemorrhage. (CTRI/2021/02/031396).

A Randomized Study of Consolidation Chemoradiotherapy Versus Observation After First-line Chemotherapy in Advanced Gallbladder Cancers: RACE-GB study

PURPOSE

Chemotherapy (CT) is the standard of care for patients presenting with unresectable advanced gallbladder carcinoma (GBC) but their prognosis remains poor. The value of consolidation CT and radiation therapy (RT) after initial CT is uncertain. We, therefore, conducted a single-center open-label randomized trial evaluating consolidation CTRT versus observation after 4 cycles of CT in patients whose disease did not progress during CT (partial responders/stable disease).

METHODS AND MATERIALS

Responders to 4 cycles of CT were randomized (1:1) to CTRT versus observation (n = 135). CTRT was delivered using 3-dimensional-conformal RT (Field in the field when required) along with concurrent capecitabine. The dose of RT was 45 Gy in 25 fractions to GBC and lymphatics followed by a boost of 9 Gy in 5 fractions to the GBC. The primary endpoint was overall survival (OS) which was calculated from the date of randomization.

RESULTS

A total of 67 patients were randomized to observation and 68 to CTRT. Consolidation CTRT led to an improvement in median OS from 4 to 10 months (hazard ratio, 0.43; 95% CI, 0.32-0.62; P < .001). The actual median OS from accrual was 7 months (95% CI, 6.114-7.88 months) versus 13 months (95% CI, 11.13 -14.84 months). Adverse events (grade 3 or higher) because of CTRT were nausea (3%), anemia (9%), gastrointestinal bleeding (5.8%), and hepatotoxicity (13%). Functional Assessment of Cancer Therapy-General score and the Functional Assessment of Cancer Therapy-Hepatobiliary score did not deteriorate because of CTRT compared with observation (P values, .053 and .097).

CONCLUSIONS

To our knowledge, this is the first-ever randomized study in a low-middle-income country setting to demonstrate that consolidation CTRT significantly prolonged OS without deterioration in quality of life and should be the alternative standard of care in advanced unresectable GBC.

Fecal Secretory Immunoglobulin A and Lactate Level as a Biomarker of Mucosal Immune Dysfunction in Horses With Colic

BACKGROUND

Colic-related obstructions can reduced intestinal mucosa function and cause dysbiosis in horses, but it is unclear how defense barrier and secretory immunoglobulin A (SIgA) secretion is disrupted.

OBJECTIVES

The aim of the study is to evaluate the effect of severity of colic signs and treatments on fecal SIgA and fecal lactate in horses.

ANIMALS

Sixty-two client owned hospitalised horses with colic and eight healthy horses.

METHODS

Prospective clinical trial. Fecal samples were taken daily for 7 days. SIgA was analyzed using ELISA, and D/L-lactate measured with a commercial kit.

RESULTS

At Day 0, SIgA values in the colic medical and colic surgical groups were significantly higher than in the control stable group (U = 126.0, p = 0.099, Cliff's ∆ = 0.58 and U = 248.0, p = 0.005, Cliff's ∆ = 0.72, respectively). We found significant correlation between fecal SIgA and fecal lactate level in D0 (rs = 0.421, p = 0.038).

CONCLUSIONS

This study demonstrates the feasibility of using fecal samples to identify biomarkers of colic in horses. An increase in fecal SIgA in horses with colic might suggest the presence of inflammation within the intestines and disruption of the mucosal barrier. These data highlight changes in gastrointestinal barrier and immune function and the intestinal microbiota's metabolic activity in horses with colic.

Global prevalence and risk factors of irritable bowel syndrome from 2006 to 2024 using the Rome III and IV criteria: a meta-analysis

Functional gastrointestinal disorders impact 40% of the global population, with irritable bowel syndrome (IBS) standing out due to its complexity, quality-of-life effects, and economic impact. Our meta-analysis explored the global prevalence of IBS, considering diagnostic criteria, subtypes, sampling methods, geographical variations, and risk factors. The literature search used databases like PubMed and Cochrane Library, focusing on IBS studies from 2006 to June 2024. Eligibility criteria included studies on individuals aged ≥18, based on Rome III/IV criteria, using random or convenience sampling. Data on IBS prevalence, subtypes, and sampling methods were extracted, and statistical analysis was performed using Open MetaAnalyst and the review manager. The study reviewed 96 articles on IBS prevalence using Rome III and IV criteria across 52 countries, revealing a global prevalence of 14.1%. Prevalence varied by subtype: IBS-C (26.1%), IBS-D (26.5%), IBS-M (31.4%), and IBS-U (8.3%). IBS-D was more prevalent under Rome III (26.2%), while IBS-C was more common under Rome IV (34.2%). First-world countries like the UK, China, and Japan had the highest prevalence. Females [odds ratios (OR): 1.49], stress (OR: 2.47), anxiety (OR: 2.93), and depression (OR: 2.24) were significantly more prevalent in IBS patients, while no significant differences were found in smoking, alcohol use, or education levels. This meta-analysis reveals regional and subtype variations in IBS prevalence, with psychological factors significantly impacting its development. The influence of sampling techniques and Rome III/IV criteria on prevalence estimates highlights the need for a multidisciplinary treatment approach, with important implications for IBS management.

Endoscopic variceal ligation combined with carvedilol versus endoscopic variceal ligation combined with propranolol for the treatment of oesophageal variceal bleeding in cirrhosis: study protocol for a multicentre, randomised controlled trial

INTRODUCTION

Liver cirrhosis and its severe complication, oesophageal variceal bleeding (EVB), pose significant health risks. Standard treatment for EVB combines non-selective beta-blockers (NSBB) with endoscopic variceal ligation (EVL). Carvedilol, an NSBB with additional benefits, is preferred for compensated cirrhosis. However, no randomised controlled trial (RCT) has compared carvedilol with propranolol, a conventional NSBB, in combination with EVL for secondary prophylaxis. This study aims to compare the effectiveness and safety of these treatments in preventing variceal rebleeding or death in patients with cirrhosis and EVB.

METHODS AND ANALYSIS

This multicentre, RCT is scheduled to begin in December 2024, with recruitment and follow-up continuing until December 2026. Eligible participants are patients with liver cirrhosis and EVB. Participants are randomly assigned in a 1:1 ratio to receive EVL combined with either carvedilol or propranolol. The primary endpoint is the incidence of variceal rebleeding or all-cause death. Secondary endpoints include all-cause death, liver-related death, each of the complications of portal hypertension (overt ascites, overt hepatic encephalopathy, spontaneous bacterial peritonitis, hepatorenal syndrome, portal vein thrombosis), hepatocellular carcinoma, changes in liver function (assessed by Child-Pugh and Model for End-Stage Liver Disease scores), changes in liver stiffness, changes in spleen stiffness, and adverse events. Subgroup and sensitivity analyses will be conducted to evaluate the consistency and robustness of the treatment effects. A total sample size of 524 patients (262 per group) is required to detect a significant difference between the treatment arms.

ETHICS AND DISSEMINATION

The study protocol has been approved by the ethics committee of the First Hospital of China Medical University (No. 2024-656-2). The study will follow the Declaration of Helsinki and Good Clinical Practice guidelines. The findings of this trial will be disseminated through peer-reviewed publications, conference presentations and healthcare professionals to guide future clinical practice.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (Registration number: ChiCTR2400089692).

Clinical Features of Anti-Tuberculosis Drug-Induced Liver Injury and Risk Factors for Severe Cases: A Retrospective Study in China

Background

Anti-tuberculosis drug-induced liver injury (ATB-DILI) is a common adverse reaction associated with tuberculosis (TB) treatment, significantly impacting treatment adherence and therapeutic outcomes. However, large-scale studies on hospitalized patients in China remain limited.

Purpose

To characterize the clinical features and liver injury patterns in hospitalized TB patients with ATB-DILI and to identify risk factors associated with severe ATB-DILI.

Methods

We retrospectively reviewed 28,753 hospitalized TB patients at Beijing Chest Hospital from 2014 to 2023. ATB-DILI was diagnosed in 567 patients (2.0%) based on serum biochemical criteria and causality assessment. Demographic, clinical, and laboratory data were analyzed to characterize liver injury types and identify risk factors for severe cases. Subgroup analyses based on liver injury patterns were performed to further evaluate the association between age and severe ATB-DILI.

Results

Overall, 567 cases with ATB-DILI (2.0%) were analyzed. Hepatocellular injury was the most common type (71.4%), followed by cholestatic (13.8%) and mixed (14.8%) injury patterns. Most patients (68.4%) were asymptomatic and diagnosed via routine biochemical monitoring; jaundice occurred in 18.2%. Patients with hepatocellular damage were significantly younger, while those with cholestatic injury were older (p < 0.001). Severe ATB-DILI occurred in 46 patients (8.1%), with advanced age (≥60 years) identified as an independent risk factor (OR = 2.45, 95% CI: 1.33-4.52, p = 0.004). Subgroup analysis showed that this association between age and severe ATB-DILI was significant in the hepatocellular injury type (unadjusted OR = 3.59, 95% CI: 1.61-8.02, p = 0.002), while no statistically significant association was observed in cholestatic or mixed types, which may reflect limited statistical power in these subgroups.

Conclusion

Routine liver function monitoring and age-specific risk assessment are essential for early identification and management of ATB-DILI in hospitalized TB patients.

Fecal Arachidonic Acid: A Potential Biomarker for Inflammatory Bowel Disease Severity

Arachidonic acid levels are elevated in the colonic mucosa of patients with inflammatory bowel disease (IBD). Fecal metabolites are emerging as valuable diagnostic tools for IBD. This study aimed to investigate associations between 31 fecal fatty acids, including arachidonic acid, to identify potential correlations with disease severity. Among the 31 fatty acids analyzed in feces, dihomo-γ-linolenic acid, arachidonic acid, and adrenic acid were significantly increased in patients with IBD compared to controls. In contrast, levels of linoleic acid and γ-linolenic acid, the precursors of arachidonic acid, were similar between both groups. No significant differences in fatty acid levels were observed between patients with Crohn's disease and ulcerative colitis. Arachidonic acid and adrenic acid levels positively correlated with fecal calprotectin, a clinically established marker of IBD severity, but showed no association with stool consistency or the Gastrointestinal Symptom Rating Scale. This suggests that these fatty acids are linked to disease severity rather than disease-related symptoms. Current IBD-specific medications had no significant impact on the fecal levels of any of the 31 fatty acids. In summary, this study demonstrates elevated fecal levels of dihomo-γ-linolenic acid, arachidonic acid, and adrenic acid in IBD patients. Normal levels of precursor fatty acids suggest that impaired downstream metabolism may contribute to the accumulation of these n-6 polyunsaturated fatty acids.

A rare case of upper gastrointestinal hemorrhage due to tuberculous lymphadenitis fistulized in the duodenum

INTRODUCTION

Abdominal tuberculosis is less prevalent than pulmonary tuberculosis. Tuberculous lymphadenitis accounts for fewer than 5% of abdominal cases. An unusual complication is the fistulization of a tuberculous lymph node into the digestive tract, with an even rarer association with upper gastrointestinal bleeding.

CASE REPORT

A 63-year-old male with a history of rectal adenocarcinoma surgery presented with severe gastrointestinal bleeding that required multiple transfusions. Endoscopic attempts failed to locate the bleeding source, but CT angiogram revealed a hemorrhagic necrotic mesenteric lymph node with a fistula to the second part of the duodenum. The patient underwent surgery, which involved resecting the lymph nodes and disconnecting the fistula. Histopathological findings confirmed tuberculous mesenteric lymphadenitis, and the patient was subsequently started on HRZE therapy. Six months postoperatively, there was no recurrence of bleeding.

DISCUSSION

Gastroduodenal tuberculosis is infrequent due to factors such as the high acidity of the gastric environment and limited lymphoid tissue. Symptoms may mimic other abdominal conditions, making diagnosis challenging. Common complications include gastric outlet obstruction and perforation, while gastrointestinal bleeding is rare. This case of hemorrhagic tuberculous lymphadenitis with fistulization highlights the need for a high index of suspicion and the role of imaging in diagnosing uncommon bleeding sources. While anti-tuberculosis therapy remains the primary treatment, surgery is warranted in cases involving refractory bleeding or fistulization.

CONCLUSION

This case emphasizes the importance of a multidisciplinary approach to abdominal tuberculosis with atypical presentations. Awareness of rare complications is essential for prompt diagnosis and management.

Prevalence and short-term outcomes of acute complications of tuberculosis: a cross-sectional, monocentre, Italian study

BACKGROUND

Tuberculosis (TB) is a major cause of morbidity and mortality worldwide. Acute complications may impact on disease progression but their prevalence is unclear and prognostic outcomes of complicated patients have been poorly studied. The aim of the study was to estimate the prevalence of acute complications of TB at the time of diagnosis. Short-term outcomes were also evaluated.

METHODS

A cross-sectional study was carried out in Milan (Italy), from January 2018 to December 2023.

RESULTS

201 patients with TB were recruited. 88 complications were recorded in 65 (32.3%) patients. Disseminated TB was the most frequent complication (30, 34.1%) followed by acute respiratory failure (23, 26.1%) and pleural empyema (6, 6.8%). In-hospital and 30-days mortality in complicated patients were 9/65 (13.8%) and 10/65 (15.4%), respectively. In-hospital mortality was significantly higher in patients with > 1 versus (VS) 1 complication (6, 31.6% VS 3, 6.5%, p = 0.02) without any difference in 1-month mortality (6, 31.6% VS 4, 9.8%, p = 0.06) between subgroups. Acute respiratory failure was the most lethal complication.

CONCLUSIONS

The study shows a substantial rate of complications in patients with a new diagnosis of TB associated to a significant short-term mortality. A prompt screen of complications at diagnosis is needed to improve short-term outcomes of these patients.

Carvedilol and traditional nonselective beta blockers for the secondary prophylaxis of variceal hemorrhage and portal hypertension related complications among patients with decompensated cirrhosis: a systematic review and network meta-analysis

BACKGROUND

Carvedilol has limited research on decompensated cirrhosis. This study compared the effects of carvedilol, traditional nonselective beta blockers (NSBBs), including propranolol and nadolol, and other interventions in patients using carvedilol or traditional NSBBs for secondary prophylaxis of variceal hemorrhage (VH) and portal hypertension (PH)-related complications.

METHODS

A systematic search of databases, including PubMed, Embase, Cochrane Library, and Scopus, was conducted through October 2023. Randomized controlled trials (RCTs) evaluating carvedilol or traditional NSBBs for secondary prophylaxis of VH were included. The outcomes were the occurrence of VH and portal PH-related complications, including new or worsening ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, and hepatorenal syndrome. A network meta-analysis was performed using a random-effects model.

RESULTS

A total of 60 RCTs involving 5,600 patients with a median Child Pugh score of 8.0 (range 6.8-10) were included. The risk of carvedilol plus variceal band ligation (VBL) on VH was lower than placebo (relative risk (RR) 0.24; 95% confidence interval (CI): 0.10-0.57), and the risk of carvedilol on new or worsening ascites was lower than placebo (RR = 0.10, 95%CI; 0.01-0.93). Traditional NSBBs plus VBL also had preventive effects on VH compared to placebo (RR = 0.31, 95%CI; 0.18-0.54). However, there were no differences between carvedilol and traditional NSBBs in other outcomes.

CONCLUSION

Carvedilol can prevent PH-related complications, including VH and new or worsening ascites, in cirrhosis patients with a history of VH. No significant differences were observed between the effects of carvedilol and traditional NSBBs, both combined with VBL.

The association between migraine and gut microbiota: a systematic review

INTRODUCTION

Recent studies suggest a link between gut microbiota and neurological diseases, implicating the microbiome's role in neurological health. However, the specific alterations in the microbiome associated with migraine remain underexplored. This study aims to systematically review the existing literature to determine whether migraine patients are associated with changes in gut microbiota composition.

METHODS

A systematic review was conducted in accordance with the PRISMA statement. We included original empirical studies investigating the microbiome in migraine patients. Data extracted included study design, participant demographics, microbiome differences at various taxonomic levels, and measures of microbial diversity (alpha and beta diversity). The search and selection process involved four independent reviewers who assessed abstracts and full texts to ensure eligibility. The gut microbiota was evaluated using relative abundance and diversity indices.

RESULTS

Six studies, encompassing various regions including China, Korea, and Italy, were included in the analysis. The results indicated significant differences in gut microbiota between migraine patients and controls. Key findings include a reduction in Faecalibacterium, a genus known for its anti-inflammatory properties, in migraine patients, including those with chronic migraine. Conversely, Veillonella exhibited elevated abundance compared to controls. Other taxa, such as Prevotella and Parabacteroides, showed variable associations with migraine across different studies, suggesting a dysbiotic gut environment in migraine patients.

CONCLUSION

This review highlights that migraines are associated with specific alterations in gut microbiota, including decreased microbial diversity and changes in the abundance of key taxa. These findings suggest that gut microbiota dysbiosis may play a role in migraine pathophysiology. Further research is needed to explore the potential causal relationships and therapeutic implications, particularly targeting the microbiome in migraine management.

Advances in imaging-Elastography

Chronic liver disease affects over a billion people worldwide. Liver fibrosis is the key driver of liver-related complications and mortality. Elastography has been a transformative tool in hepatology, allowing for the diagnosis and staging of liver fibrosis noninvasively, and is evolving beyond these purposes into a prognostication tool. By measuring tissue stiffness, elastography techniques such as shear-wave and magnetic resonance elastography offer critical insights into liver fibrosis, portal hypertension, and the progression of disease. Magnetic resonance elastography stands out for its reliability across fibrosis stages and robustness in obese patients affected by metabolic liver disease. Spleen stiffness measurement complements liver assessments, enhancing the identification of portal hypertension and refining patient risk stratification. This review covers current clinical applications but also anticipates future innovations such as artificial intelligence-based algorithms that could expand elastography's clinical impact, thereby improving patient outcomes.

Preventing the progression of cirrhosis to decompensation and death

Two main stages are differentiated in patients with advanced chronic liver disease (ACLD), one compensated (cACLD) with an excellent prognosis, and the other decompensated (dACLD), defined by the appearance of complications (ascites, variceal bleeding and hepatic encephalopathy) and associated with high mortality. Preventing the progression to dACLD might dramatically improve prognosis and reduce the burden of care associated with ACLD. Portal hypertension is a major driver of the transition from cACLD to dACLD, and a portal pressure of ≥10 mmHg defines clinically significant portal hypertension (CSPH) as the threshold from which decompensating events may occur. In recent years, innovative studies have provided evidence supporting new strategies to prevent decompensation in cACLD. These studies have yielded major advances, including the development of noninvasive tests (NITs) to identify patients with CSPH with reasonable confidence, the demonstration that aetiological therapies can prevent disease progression and even achieve regression of cirrhosis, and the finding that non-selective β-blockers can effectively prevent decompensation in patients with cACLD and CSPH, mainly by reducing the risk of ascites, the most frequent decompensating event. Here, we review the evidence supporting new strategies to manage cACLD to prevent decompensation and the caveats for their implementation, from patient selection using NITs to ancillary therapies.

An indication-based analysis of the yield and findings of esophageal high-resolution manometry

BACKGROUND

High-resolution manometry (HRM) is the gold standard for the diagnosis of esophageal motility disorders. While studies have previously reported on HRM findings in patients with dysphagia and/or chest pain, we sought to compare the yield and findings of HRM based on different indications for motility testing.

METHODS

A retrospective study was performed including all successful HRM studies performed at two tertiary medical centers between 2018 and 2023. The indication was categorized as either: (1) dysphagia; (2) GERD evaluation; (3) non-cardiac chest pain; (4) epigastric pain; (5) regurgitation/vomiting; or (6) prior to esophageal surgery. Motility disorders were diagnosed as per the Chicago Classification, version 4.0.

RESULTS

A total of 768 patients were included (mean age 55.5 +/- 17.3; 56.2% female). The most common indications were dysphagia (368, 47.9%) and prior to reflux testing (267, 34.8%). Normal motility was found in 417 (54.3%) patients while a motility disorder was diagnosed in 351 (45.7%) subjects. A major motility disorder was found in 178 (23.2%) cases, with achalasia in 82 (10.7%) patients. HRM diagnoses significantly differed based on the indication for testing (p < 0.001), with major motility disorders and achalasia being most commonly diagnosed when performed for dysphagia and recurrent regurgitation/vomiting. The indication affected the likelihood of having any motility disorder (p = 0.010), a major motility disorder (p < 0.001), a disorder of EGJ Outflow (p < 0.001), and achalasia (p < 0.001).

CONCLUSIONS

The indication for HRM testing affects the likelihood of having a motility disorder including achalasia. The highest yield is in patients being evaluated for dysphagia and regurgitation/vomiting.

The current applications and future directions of terlipressin

Terlipressin is a vasopressin analog with potent splanchnic vasoconstrictor properties. It has an established role in managing portal hypertensive bleeding and hepatorenal syndrome-acute kidney injury, with a growing body of evidence demonstrating improved safety and efficacy with continuous infusion-based administration compared to bolus dosing. We discuss previously reported adverse effects of terlipressin and evidence-based strategies to maximize the safety of administration. We also review the literature surrounding emerging indications for terlipressin in decompensated cirrhosis, particularly in the management of refractory ascites. Furthermore, we present data on novel ambulatory programs utilizing long-term continuous terlipressin infusion as bridging therapy for liver transplant candidates with recurrent hepatorenal syndrome-acute kidney injury, diuretic-refractory ascites, or hydrothorax.

Exploring the Relationship Between NOD2 Risk Variants and First Decompensation Events in Cirrhotic Patients With Varices

BACKGROUND AND AIMS

NOD2 mutations are associated with impaired gut mucosal barrier function. According to the systemic inflammation hypothesis, bacterial translocation is central in the development of decompensation. The aim was to evaluate whether the presence of NOD2 variants is associated with the development of first decompensation.

METHOD

Secondary analysis of prospectively collected consecutive patients with compensated cirrhosis, who were screened between 2014 and 2018. Patients with and without NOD2 variants were compared and stratified analysis according to the presence of varices was performed.

RESULTS

360 patients [239 (66%) men, median age 61 (53-69) years, 70 (19%) with NOD2 variants, 90 (25%) with varices] were followed for a median of 9 (4-16) months. Similar baseline characteristics were observed across NOD2 status groups, except for beta-blocker use (45% vs. 32% amongst variant carriers vs. non-carriers, p = 0.05). During follow-up, 34 patients (12%) developed their first decompensation, with no differences according to NOD2 status [HR 1.75 (95% CI 0.84-3.67)]. On multivariate analysis, only MELD remained an independent predictor of decompensation. Amongst patients with varices (n = 90), 18 (24.4%) carried a NOD2 variants, with a higher incidence of first decompensation [HR 3.00 (95% CI 1.08-8.32)], primarily due to ascites [HR 3.32 (95% CI 1.07-10.32)]. In this subgroup, MELD [HR 1.18 (95% CI 1.06-1.32)] and NOD2 variants [HR 2.91 (95% CI 0.95-8.89)] were determined to be independent predictors of decompensation.

CONCLUSIONS

The presence of NOD2 risk variants leads to a greater incidence of first decompensation only in compensated patients with varices.

Design and evaluation of new user control devices for improved ergonomics in flexible robotic endoscopy

Background

The ergonomics of flexible endoscopes require improvement as the current design carries a high risk of musculoskeletal injury for endoscopists. Robotic systems offer a solution by separating the endoscope from the control handle, allowing a focus on ergonomics and usability. Despite the increasing interest in this field, little attention has been paid towards developing ergonomic human input devices. This study addresses two key questions: How can handheld control devices for flexible robotic endoscopy be designed to prioritize ergonomics and usability? And, how effective are these new devices in a simulated clinical environment?

Methods

Addressing this gap, the study proposes two handheld input device models for controlling a flexible endoscope in four degrees of freedom (DOFs) and an endoscopic instrument in three DOFs. A two-stage evaluation was conducted with six endoscopists evaluating the physical ergonomics and a final clinical user evaluation with seven endoscopists using a virtual colonoscopy simulator with proportional velocity and position mapping.

Results and discussion

Both models demonstrated clinical suitability, with the first model scoring 4.8 and the second model scoring 5.2 out of 6 in the final evaluation. In sum, the study presents two designs of ergonomic control devices for robotic colonoscopy, which have the potential to reduce endoscopy-related injuries. Furthermore, the proposed colonoscopy simulator is useful to evaluate the benefits of different mapping modes. This could help to optimize the design and control mechanism of future control devices.

Recurrent Anemia Due To Mucosal Prolapse Syndrome

Mucosal prolapse syndrome is a rare group of benign disorders mainly in the rectum. It often causes rectal bleeding, abdominal pain, and anaemia. We report a case of severe anaemia due to mucosal prolapse syndrome requiring blood transfusion. A 36-year-old man was referred for further evaluation of recurrent iron deficiency anaemia. Initial examinations, including esophagogastroduodenoscopy, colonoscopy, and capsule endoscopy, revealed no significant abnormalities other than rectal mucosal prolapse syndrome without notable bleeding. Nine months later, despite oral iron therapy, the patient developed bloody stools and severe anaemia (haemoglobin 6.2 g/dl), requiring a transfusion. Colonoscopy showed an enlarged mucosal prolapse, which was strongly suspected as the cause of the anaemia, leading to a transanal lumpectomy. Postoperatively, the patient has remained symptom-free, with no recurrence of anaemia or bloody stools. While mucosal prolapse syndrome is an rare condition, clinicians should remain vigilant about its potential to cause severe anaemia requiring blood transfusion.

LEARNING POINTS

Mucosal prolapse syndrome (MPS) is a benign group of conditions associated with mucosal prolapse and can appear in a variety of forms, mainly in the rectum.Although MPS is rare, clinicians should remain vigilant as it can lead to severe anaemia requiring blood transfusions.

Management of gastrointestinal bleed in the intensive care setting, an updated literature review

Gastrointestinal (GI) bleeding is a critical and potentially life-threatening condition frequently observed in the intensive care unit (ICU). This literature review consolidates current insights on the epidemiology, etiology, management, and outcomes of GI bleeding in critically ill patients. GI bleeding remains a significant concern, especially among patients with underlying risk factors such as coagulopathy, mechanical ventilation, and renal failure. Managing GI bleeding in the ICU requires a multidisciplinary approach, including resuscitation, endoscopic intervention, pharmacologic therapy, and sometimes surgical procedures. Even with enhanced management strategies, GI bleeding in the ICU is associated with considerable morbidity and mortality, particularly when complicated by multi-organ failure. This review reiterates the need for adequate resuscitation and interventions in managing GI bleeding in critically ill patients, aiming to enhance survival rates and improve the quality of care within the ICU setting.

Cefdinir-Induced Liver Injury: A Case Report

Cephalosporins are very rarely known to cause drug-induced liver injury (DILI). We present the case of a healthy 40-year-old female who developed DILI after completing a course of cefdinir, a third-generation cephalosporin, to treat a urinary tract infection. A 40-year-old female with no past medical history presented to the emergency department with a chief complaint of epigastric pain and jaundice for the last four days. A workup at an urgent care revealed hyperbilirubinemia and elevated liver enzymes, prompting this visit. She had completed a five-day course of cefdinir for a urinary tract infection three weeks prior to her visit. Physical examination revealed a vitally stable patient with scleral icterus and no other positive findings. Laboratory workup was significant for total bilirubin 4.3 mg/dL, direct bilirubin 0.7 mg/dL, ALP 130 unit/L, ALT 546 unit/L, and AST 213 unit/L. Serum hepatitis panel, ferritin, ceruloplasmin, alpha-1 antitrypsin, and autoimmune workup were within normal limits. Ultrasound and CT of the abdomen and magnetic resonance cholangiopancreatography did not reveal any pathology. Liver biopsy demonstrated hepatocellular adaptive changes and mild bile duct epithelial damage, suggestive of DILI. This case highlights the importance of obtaining a thorough medical history, including recent medication use, drug dose, and time of symptom onset, for a patient presenting with elevated liver enzymes. This case also emphasizes keeping a broad list of differential diagnoses when managing patients with elevated liver enzymes.

Optimizing achalasia diagnosis in the era of high-resolution manometry: A Pakistani perspective

Background

High-resolution manometry (HRM) is a gold standard for diagnosing achalasia and identification of its subtypes, but data regarding its correlation with clinical, endoscopic, and radiological features in low-resource settings like Pakistan are limited. This study aims to identify and compare manometric parameters with other diagnostic parameters among achalasia subtypes in Pakistani population.

Methodology

A retrospective analysis of clinical, endoscopic, and radiological features of 381 patients who underwent HRM at Center for Liver and Digestive Diseases, Holy Family Hospital, Rawalpindi, Pakistan, from December 2015 to February 2024 was performed. Based on the HRM criterion, 213 patients were identified and categorized into subtypes: 132 cases for type I and 64 and 17 for type II and III, respectively.

Results

Patient demographics were similar across subtypes except for sex (male-dominant in types I and II, female-dominant in type III). Symptom duration was longest in type III (8 years vs. 4.1 years). Almost all patients had dysphagia; 83% reported regurgitation/weight loss, 71% chest pain, and 64% vomiting. The endoscopy results were normal in 40% of patients, and barium swallow was inconclusive in just 13% of achalasia patients. Type III exhibited the highest EGJ relaxation pressure and lowest LES pressure. Notably, all subtypes displayed elevated IRP, with type I showing highest value.

Conclusion

This study identified type I achalasia as the most prevalent subtype. While barium swallow and endoscopy showed limited diagnostic accuracy, HRM confirmed subtypes in all patients. Despite challenges with GERD-like symptoms and inconclusive findings, further research is warranted to investigate specific clinical features of each subtype, potentially attributing to personalized treatment strategies.

Abbreviated Duration of Vasoactive Agents Has Similar Outcomes as Standard Duration of Therapy in Patients with Liver Cirrhosis and Variceal Bleeding: An Individual Patient Data Meta-Analysis

BACKGROUND

This two-stage individual patient data meta-analysis (IPD-MA) compared the efficacy of a shorter duration (≤ 2 days) of vasoactive (VA) drug therapy to standard duration (3-5 days) after acute variceal bleeding (AVB) in patients with liver cirrhosis.

PATIENTS AND METHODS

Randomized clinical trials on patients with cirrhosis and AVB undergoing endoscopic band ligation which compared a short duration versus the standard duration of VA therapy were included. The primary outcome was 5-day rebleeding rate. Secondary outcomes included 5-day and 42-day mortality, 42-day rebleeding rate, and length of hospital stay in patients receiving short duration of therapy as compared to those receiving standard duration. Aggregate data meta-analysis and IPD-MA of trials were performed for these outcomes and comparisons in patients with different severities of liver disease.

RESULTS

Out of 11 eligible trials, 542 IPD data sets were available from 6 trials. Two hundred and seventy-nine patients received short duration and 263 received standard duration VA therapy. Two-stage IPD-MA revealed no significant differences in the 5-day rebleeding rate (HR = 0.59, 95%CI: 0.19-1.81, p = 0.66), 5-day mortality (HR = 1.12, 95%CI: 0.18-6.63, p = 0.44), 42-day rebleeding rate (HR = 0.95, 95%CI: 0.47-1.90, p = 0.90) and 42-day mortality (HR = 1.05, 95% CI: 0.43-2.56, p = 0.34) between the two groups. One-stage IPD-MA revealed no significant differences in the outcomes across Child-Pugh classes, with shorter hospital stay in short duration group.

CONCLUSIONS

Short duration VA therapy has similar outcomes to standard duration in patients with liver cirrhosis presenting with AVB, irrespective of severity of liver disease.

Exploring algorithms to select candidates for non-selective beta-blockers in cirrhosis: A post hoc analysis of the PREDESCI trial

BACKGROUND & AIMS

Whether non-invasive tests (NITs) can accurately select patients with cirrhosis requiring non-selective beta-blockers (NSBBs) for clinically significant portal hypertension (CSPH) and prevention of decompensation is unclear. Our aim was to test the performance of NIT-based algorithms for CSPH diagnosis using the prospective PREDESCI cohort. We investigated whether a new algorithm combining NITs with endoscopy could improve performance.

METHODS

We included patients with compensated cirrhosis and available liver elastography who were screened during the trial. The performance of models based on liver stiffness measurement (LSM) and platelet count was evaluated. An algorithm considering endoscopy for patients with inconclusive results (the "grey zone") was then developed and validated in an independent cohort of 195 patients in whom spleen stiffness was also available.

RESULTS

We included 170 patients from the PREDESCI cohort. An LSM ≥25 kPa alone (Baveno VII criteria) or combined with an LSM >20 kPa plus thrombocytopenia (AASLD criteria) ruled-in CSPH with positive predictive values of 88% and 89%, respectively. However, 37%-47% patients fell into the grey zone while at high risk of decompensation or death. Performing endoscopy in inconclusive cases identified patients with varices that, when reclassified as high-risk for CSPH, significantly reduced the grey zone to 22%. In this algorithm, 86% of patients with CSPH were correctly classified as high risk. The diagnostic performance was confirmed in the external validation cohort, where combining Baveno VII criteria with spleen stiffness showed similar accuracy to the model using endoscopy.

CONCLUSIONS

Algorithms based only on LSM and platelet count are suboptimal to identify NSBB treatment candidates. Performing endoscopy in patients with indeterminate findings from NITs improved diagnostic performance and risk stratification. Endoscopy may be substituted by spleen stiffness for stratifying risk in the grey zone.

IMPACT AND IMPLICATIONS

The PREDESCI trial demonstrated that non-selective beta-blockers prevent decompensation in patients with clinically significant portal hypertension (CSPH). Still, it is unclear whether we can select treatment candidates using non-invasive tests to assess the presence of CSPH without measuring HVPG (hepatic venous pressure gradient). In the prospective cohort of patients screened during the PREDESCI trial, we showed that algorithms based on liver stiffness and platelet count had suboptimal performance, mainly due to a high rate of indeterminate results. Performing endoscopy on patients in the grey zone significantly increased the number correctly characterized as having CSPH and improved the risk stratification for decompensation or death on long-term follow-up. These findings were validated in an independent cohort. In addition, a model using spleen stiffness instead of endoscopy showed similar diagnostic performance in the external validation cohort, suggesting that adequate risk stratification to select treatment candidates can be achieved with a fully non-invasive algorithm.

A new human autologous hepatocyte/macrophage co-culture system that mimics drug-induced liver injury-like inflammation

The development of in vitro hepatocyte cell culture systems is crucial for investigating drug-induced liver injury (DILI). One prerequisite for monitoring DILI related immunologic reactions is the extension of primary human hepatocyte (PHH) cultures towards the inclusion of macrophages. Therefore, we developed and characterized an autologous co-culture system of PHH and primary human hepatic macrophages (hepM) (CoC1). We compared CoC1 with a co-culture of the same PHH batch + M0 macrophages derived from THP1 cells (CoC2) in order to represent a donor independent macrophage reaction. Then, we treated the mono- and co-cultures with drugs that cause DILI-menadione (MEN, 1 or 10 µM, 3 h), diclofenac (DIC, 0.5 or 5 mM, 6 h), or acetaminophen (APAP, 0.5 or 5 mM, 6 h)-and assessed culture stability, cell activity, macrophage differentiation, cytokine production and cell viability. Without drug treatment, CoC1 was the most stable over a culture time of up to 60 h. Cytokine array analysis revealed a proinflammatory profile of PHH mono-cultures due to isolation stress but showed different influences of hepM and M0 on the cytokine profile in the co-cultures. MEN, DIC and APAP treatment led to donor-dependent signs of cell stress and toxicity. HepM can either promote or reduce the DILI effects donor dependently in CoC1. CoC2 are slightly less sensitive than CoC1 in representing DILI. In summary, we present a new autologous co-culture system that can mimic DILI in a donor-dependent manner. This cellular system could be useful for new drug testing strategies and reducing animal testing.

Autologous macrophage therapy for liver cirrhosis: a phase 2 open-label randomized controlled trial

Cirrhosis is a major cause of morbidity and mortality; however, there are no approved therapies except orthotopic liver transplantation. Preclinical studies showed that bone-marrow-derived macrophage injections reduce inflammation, resolve fibrosis and stimulate liver regeneration. In a multicenter, open-label, parallel-group, phase 2 randomized controlled trial ( ISRCTN10368050 ) in n = 51 adult patients with compensated cirrhosis and Model for End-Stage Liver Disease (MELD) score ≥10 and ≤17, we evaluated the efficacy of autologous monocyte-derived macrophage therapy (n = 27) compared to standard medical care (n = 24). The primary endpoint was the difference in baseline to day 90 change in MELD score (ΔMELD) between treatment and control groups (ΔΔMELD). Secondary endpoints included adverse clinical outcomes, non-invasive fibrosis biomarkers and health-related quality of life (HRQoL) at 90 d, 180 d and 360 d. The ΔΔMELD between day 0 and day 90 in the treatment group compared to controls was -0.87 (95% confidence interval: -1.79, 0.0; P = 0.06); therefore, the primary endpoint was not met. During 360-d follow-up, five of 24 participants in the control group developed a total of 10 severe adverse events, four of which were liver related, and three deaths (two liver related), whereas no liver-related severe adverse events or deaths occurred in the treatment group. Although no differences were observed in biomarkers or HRQoL, exploratory analysis showed anti-inflammatory serum cytokine profiles after macrophage infusion. This study reinforces the safety and potential efficacy of macrophage therapy in cirrhosis, supporting further investigation.

Noninvasive assessment of hepatic decompensation

Noninvasive tests (NITs) are used in all aspects of liver disease management. Their most prominent break-through since the millennium has been in advancing early detection of liver fibrosis, but their use is not limited to this. In contrast to the symptom-driven assessment of decompensation in patients with cirrhosis, NITs provide not only opportunities for earlier diagnoses but also accurate prognostication, targeted treatment decisions, and a means of monitoring disease. NITs can inform disease management and decision-making based on validated cutoffs and standardized interpretations as a valuable supplement to clinical acumen. The Baveno VI and VII consensus meetings resulted in tangible improvements to pathways of care for patients with compensated and decompensated advanced chronic liver disease, including the combination of platelet count and transient elastography to diagnose clinically significant portal hypertension. Furthermore, circulating NITs will play increasingly important roles in assessing the response to interventions against ascites, variceal bleeding, HE, acute kidney injury, and infections. However, due to NITs' wide availability, there is a risk of inaccurate use, leading to a waste of resources and flawed decisions. In this review, we describe the uses and pitfalls of NITs for hepatic decompensation, from risk stratification in primary care to treatment decisions in outpatient clinics, as well as for the in-hospital management of patients with acute-on-chronic liver failure. We summarize which NITs to use when, for what indications, and how to maximize the potential of NITs for improved patient management.

The Dutch Gastrointestinal Symptom Tracker for People With Cystic Fibrosis: Associations With Anxiety, Depression, and Health-Related Quality of Life

BACKGROUND

People with CF (pwCF) frequently have gastrointestinal symptoms (GI), including abdominal pain and irregular bowel movements. These are often embarrassing, difficult to report, and frequently missed. Thus, a GI Symptom Tracker was created and validated in the USA and translated and validated in Dutch. This questionnaire consists of four subscales: Eating Challenges, Stools, Adherence Challenges, and Abdominal Symptoms. The aim of this study was to investigate the relationship between GI symptoms, anxiety/depression, and health-related quality of life (HRQoL) in Dutch pwCF.

METHODS

In this prospective, cross-sectional single-center pilot study, pwCF completed the Dutch GI Symptom Tracker, GAD-7 (anxiety), PHQ-9 (depression), and CFQ-R (HRQoL) from September 2021 to June 2022. Regression analyses were used to analyze the univariable associations between GI symptoms, anxiety/depression, and HRQoL.

RESULTS

A total of 51 pwCF were enrolled consecutively (n = 41 adults, 66% female, mean age (y) [range] = 32.7 [19-71] and n = 10 adolescents, 70% female, mean age (y) [range] = 14.2 [12-17]). Elevated levels of anxiety (scores ≥ 10 on GAD-7) were found in 17% of adults and 0% of adolescents. Elevated depression scores (≥ 10 on PHQ-9) were found in 9% of adults and 20% of adolescents. GI scales "Abdominal Symptoms" and "Stools" were significantly, positively associated with elevated symptoms of anxiety and depression. Most GI scales were associated with lower HRQoL.

CONCLUSION

This is the first study investigating the link between GI symptoms assessed by the Dutch GI Symptom Tracker and anxiety/depression and HRQoL in Dutch pwCF. More GI symptoms were associated with higher anxiety and depression scores and worse HRQoL. Additional research is needed to better understand how mental and physical health are linked in GI symptoms in CF.

Ergonomic endoscopy - Fundamentals of ergonomics and interventions for endoscopy-related musculoskeletal disorders

Recently, musculoskeletal disorders (MSDs) among endoscopists have attracted considerable attention. MSDs are caused by prolonged static postures, forceful manual exertions, and repetitive twisting maneuvers. Basic knowledge of ergonomics is useful for improving the posture, movements, and work environment of endoscopists, as well as developing equipment to prevent MSDs. This review discusses problematic endoscopic tasks from an ergonomic perspective, issues with MSD definitions, the prevalence of MSDs, local site interpretations, risk factors including working time and environment, and ergonomic evaluations. The evidence highlights the importance of multifaceted strategies for risk avoidance using the Hierarchy of Controls. Additionally, this review summarizes global trends and introduces the Ergonomic Endoscopy 7 Tips for MSD prevention, emphasizing a systems approach through collaboration with various stakeholders. Thus, it may serve as a guide for gastroenterologists and staff engaged in endoscopic procedures for prolonged periods.

Pregnancy and the liver

Some of the physiological changes that occur in pregnancy manifest in the liver. These alterations might exacerbate or improve some pre-existent liver diseases, while many conditions remain unaffected. Some hepatic manifestations during pregnancy are secondary to disorders unique to pregnancy. Due to improved management of chronic conditions and assisted conception methods, pregnancies in people with cirrhosis or after liver transplantation are increasingly common. With pregnancy also becoming more common in older people and with the rising prevalence of comorbidities, such as obesity, diabetes, and metabolic syndrome, hypertensive disorders of pregnancy and gestational diabetes are increasing in prevalance. Thus, a broad range of specialists might encounter liver abnormalities in pregnancy, necessitating an understanding of how the liver changes during pregnancy and the importance of multi-disciplinary input to mitigate maternal-fetal risks. From a global health perspective, pregnancy also offers a unique opportunity to influence disease management and initiate interventions that might influence the life course of pregnant people and their families. In this Review, we describe the challenges of diagnosing, risk stratifying, and managing liver disease in pregnancy, and explore factors that might affect future maternal health.