Impact of the COVID-19 pandemic on the time to emergency endoscopy and clinical outcomes in patients with upper gastrointestinal bleeding

Objectives

To investigate endoscopic management and clinical outcomes in patients with non-variceal upper gastrointestinal (GI) bleeding during the coronavirus disease 2019 pandemic.

Methods

We retrospectively analyzed the data of 332 patients with non-variceal upper GI bleeding who underwent emergency upper GI endoscopy at three hospitals during the pandemic (April 2020-June 2021) and before the pandemic (January 2019-March 2020). The number of emergency upper GI endoscopies, time from hospital arrival to endoscopy, mortality within 30 days, rebleeding within 30 days, interventional radiology (IVR)/surgery requirement, composite outcome, rates of endoscopic hemostasis procedures, and second-look endoscopy were investigated using logistic regression.

Results

Overall, 152 and 180 patients underwent emergency upper GI endoscopies during and before the pandemic, respectively. The mean time from arrival to endoscopy was longer during the pandemic than before it (11.7 vs. 6.1 h, p < 0.01). Multivariate analysis revealed that mortality within 30 days (odds ratio [OR]: 2.27, p = 0.26), rebleeding within 30 days (OR: 0.43, p = 0.17), IVR/surgery requirement (OR: 1.79, p = 0.33), and composite outcome (OR: 0.98, p = 0.96) did not differ significantly between the periods; conversely, endoscopic hemostasis procedures (OR: 0.38, p < 0.01) and second-look endoscopies (OR: 0.04, p < 0.01) were less likely to be performed during the pandemic than before it.

Conclusions

Although the time from arrival to endoscopy was significantly longer during the pandemic, it did not affect mortality and rebleeding.

Healthcare professionals knowledge, attitude, practices, and perspectives providing care to Muslims in Western countries who fast during Ramadan: a scoping review

The practice of fasting during the month of Ramadan is an obligation for healthy Muslims and involves abstaining from food and drinks from dawn to dusk for 29-30 consecutive days annually. With changes in dietary and lifestyle patterns, healthcare professionals (HCPs) play a significant role in supporting Muslims health during Ramadan. In this scoping review, we employed a systematic approach to map existing literature on HCPs' knowledge, attitude, practices, and perspectives working with Muslims who fast during Ramadan in Western countries. Our aim was to identify research gaps and opportunities for improving healthcare services for Muslims during Ramadan. Literature searches were generated through multiple scientific literature databases, including Web of Science, Ovid MEDLINE, CINAHL, and Embase and reviewed following The Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews guidelines. From the eight sources included in this review, it was found that HCPs' knowledge of Ramadan fasting practices vary, with many lacking adequate knowledge. While HCPs recognize potential health complications, adjustments to medications for fasting patients, especially those with diabetes, are often neglected. Challenges in care included language barriers, limited cultural training, and resource awareness. Strategies identified to address barriers include reducing language barriers, providing resources in relevant languages, and enhancing cultural competence training. Further research is required on HCPs' knowledge providing care to Muslims during Ramadan, cultural competency training impact, and diverse healthcare interventions for fasting Muslims. Addressing these gaps may enhance culturally safe care and improve patient outcomes.

Pleural migration of biliary stent 10 years following treatment of hepatic hydatic echinococcosis: A case report

INTRODUCTION

Echinococcosis, caused by larval stages of taeniid cestodes, primarily affects the liver and is commonly treated surgically. However, a complication post-treatment is biliary fistula, necessitating interventions like biliary stents. While stent complications are recognized, proximal migration leading to pneumonia is exceptionally rare. This case report details an unusual occurrence of biliary stent migration years after hepatic hydatid echinococcosis treatment.

CASE PRESENTATION

A 42-year-old patient underwent 2014 surgery for a large hydatid cyst, resulting in a biliary fistula. Endoscopic sphincterotomy and biliary stent placement led to a successful outcome. Lost to follow-up, the patient reappeared in 2022 with basithoracic pain, fever, and a thoracic CT scan revealing transdiaphragmatic stent migration causing basal pneumonitis. Antibiotic therapy and endoscopic stent removal ensued with an uncomplicated recovery.

CLINICAL DISCUSSION

This report emphasizes a rare complication that is proximal migration of a biliary stent 10 years post-initial placement for biliary fistula management. Despite the absence of typical risk factors. We managed a successful endoscopic retrieval. This highlights the importance of vigilance and follow-up for potential complications associated with biliary stent. Unusual presentations, like pneumonitis, underscore the need for awareness and a cautious approach.

CONCLUSION

The primary complication following surgical intervention for hepatic hydatid cysts is the development of an external biliary fistula, necessitating the use of biliary stents for treatment. Given the rarity of complications observed in our case, the removal of stents post-treatment for biliary fistula becomes crucial, underscoring the significance of vigilant follow-up care.

Comparison of miRNA profiles in the immune response of pediatric acute appendicitis and pediatric enterobiasis patients caused by Enterobius vermicularis

BACKGROUND

The aim of this study was to determine and compare the miRNA profile in the immune response with the parasite in pediatric patients with acute appendicitis caused by Enterobius vermicularis and in pediatric patients with enterobiasis.

METHODS

A total of 30 tissue samples, which were operated with the diagnosis of pediatric acute appendicitis in the last 10 y and Enterobius vermicularis was detected by histopathological findings, were analyzed. In addition, blood samples were taken from 30 pediatric patients diagnosed with enterobiasis for this study. The miRNAs that activate T and B cells were evaluated by a quantitative real-time PCR, statistically calculated within ΔΔCt values, and fold changes were evaluated by Welch's T test, in which p<0.5 was considered to be significant.

RESULTS

It was found that 48 out of 136 (35.3%) miRNAs differed between the pediatric patient and healthy control groups. It was determined that 22 (57.9%) of the different miRNAs were T cell activating miRNAs and 26 (68.4%) were B cell activating miRNAs. While there was a significant difference in miRNA values activating T cells in two patient groups (p<0.01), there was no significant difference in miRNA values activating B cells (p>0.01).

CONCLUSIONS

In the study, although Enterobius vermicularis was the causative agent in both patient groups, it was revealed that the immune response of patients with acute appendicitis was more affected than enterobiasis patients.

Consensus recommendations on fasting during Ramadan for patients with kidney disease: review of available evidence and a call for action (RaK Initiative)

Ramadan fasting (RF) involves abstaining from food and drink during daylight hours; it is obligatory for all healthy Muslims from the age of puberty. Although sick individuals are exempt from fasting, many will fast anyway. This article explores the impact of RF on individuals with kidney diseases through a comprehensive review of existing literature and consensus recommendations. This study was conducted by a multidisciplinary panel of experts.The recommendations aim to provide a structured approach to assess and manage fasting during Ramadan for patients with kidney diseases, empowering both healthcare providers and patients to make informed decisions while considering their unique circumstances.

H. Pylori Treatment in the COVID-19 Era. What Have We Learned So Far?

PURPOSE OF REVIEW

CoronaVirus Disease of 2019 (COVID-19) has negatively influenced the management of multiple conditions in regards to the gastroenterology patient. An equivalent change in the management of Helicobacter pylori (H. pylori)-related diseases was reported, as practically no eradication treatment was offered during most of the pandemic. Given the scarcity of published data, we performed a literature review trying to elucidate the effect of COVID-19 on H. pylori treatment.

RECENT FINDINGS

COVID-19 has produced more questions than answers as to the outcome of COVID-19 in H. Pylori infected patients, post-COVID-19 patients treated for H. pylori, acid suppression and COVID-19 incidence and outcomes, and H. pylori eradication treatment in patients having recovered from COVID-19. We strongly believe that this scientific uncertainty produced by the COVID-19 pandemic has set up the stage for an incremental change in H. pylori treatment as COVID-19 has offered us the chance to speed up how we will, in the near future, approach patients with a possible Η. pylori infection.

Endoscopic Management of Difficult Biliary Stones: An Evergreen Issue

Choledocholithiasis is one of the most common indications for endoscopic retrograde cholangiopancreatography (ERCP) in daily practice. Although the majority of stones are small and can be easily removed in a single endoscopy session, approximately 10-15% of patients have complex biliary stones, requiring additional procedures for an optimum clinical outcome. A plethora of endoscopic methods is available for the removal of difficult biliary stones, including papillary large balloon dilation, mechanical lithotripsy, and electrohydraulic and laser lithotripsy. In-depth knowledge of these techniques and the emerging literature on them is required to yield the most optimal therapeutic effects. This narrative review aims to describe the definition of difficult bile duct stones based on certain characteristics and streamline their endoscopic retrieval using various modalities to achieve higher clearance rates.

Telehealth-Enabled In-Home Elbow Rehabilitation for Brachial Plexus Injuries Using Deep-Reinforcement-Learning-Assisted Telepresence Robots

Due to damage to the network of nerves that regulate the muscles and feeling in the shoulder, arm, and forearm, brachial plexus injuries (BPIs) are known to significantly reduce the function and quality of life of affected persons. According to the World Health Organization (WHO), a considerable share of global disability-adjusted life years (DALYs) is attributable to upper limb injuries, including BPIs. Telehealth can improve access concerns for patients with BPIs, particularly in lower-middle-income nations. This study used deep reinforcement learning (DRL)-assisted telepresence robots, specifically the deep deterministic policy gradient (DDPG) algorithm, to provide in-home elbow rehabilitation with elbow flexion exercises for BPI patients. The telepresence robots were used for a six-month deployment period, and DDPG drove the DRL architecture to maximize patient-centric exercises with its robotic arm. Compared to conventional rehabilitation techniques, patients demonstrated an average increase of 4.7% in force exertion and a 5.2% improvement in range of motion (ROM) with the assistance of the telepresence robot arm. According to the findings of this study, telepresence robots are a valuable and practical method for BPI patients' at-home rehabilitation. This technology paves the way for further research and development in telerehabilitation and can be crucial in addressing broader physical rehabilitation challenges.

The need for a risk-assessment tool among patients with chronic liver diseases interested in intermittent fasting: Ramadan model

Liver diseases, especially the chronic type, are a global concern. There is a growing interest in the intermittent fasting model due to its presumed health benefits. Ramadan fasting, although religious fasting, is one of the best examples of intermittent fasting, with some differences, and is observed by more than 1 billion Muslims around the world. This month follows the Arabic Hijri calendar, which is 12 days shorter than the Gregorian calendar; hence, this entire month of fasting may occur in any season of the year. There is evidence that many patients with chronic liver disease are prone to adverse events upon observing this month of continuous intermittent fasting, particularly during the hot summer with prolonged hours of fasting, if they are not adequately addressed and prevented from fasting. There is a need to sound the alarm to develop a risk-assessment tool to omit vulnerable patients with chronic liver disease-who are exempted on religious grounds from observing this pattern of fasting.

Role of probiotics in managing various human diseases, from oral pathology to cancer and gastrointestinal diseases

The imbalance of microbial composition and diversity in favor of pathogenic microorganisms combined with a loss of beneficial gut microbiota taxa results from factors such as age, diet, antimicrobial administration for different infections, other underlying medical conditions, etc. Probiotics are known for their capacity to improve health by stimulating the indigenous gut microbiota, enhancing host immunity resistance to infection, helping digestion, and carrying out various other functions. Concurrently, the metabolites produced by these microorganisms, termed postbiotics, which include compounds like bacteriocins, lactic acid, and hydrogen peroxide, contribute to inhibiting a wide range of pathogenic bacteria. This review presents an update on using probiotics in managing and treating various human diseases, including complications that may emerge during or after a COVID-19 infection.

Impact of IL-10 gene promoter polymorphisms on treatment response in HCV patients: A systematic review, a meta-analysis, and a meta-regression

The impact of interleukin-10 (IL-10) gene promoter polymorphisms (SNPs) on treatment response in HCV patients was dissimilarly estimated. Hence, the aim of this meta-analysis was to robustly assess the effect of IL-10 SNPs on treatment response in HCV patients. An electronic literature search was carried out through PubMed, EMBASE, Web of science, and Scopus databases. Studies assessing the association between IL-10 polymorphisms and treatment response in HCV patients were included. Studies were excluded if genotype frequencies are not consistent with the Hardy-Weinberg Equilibrium (HWE) or in case of including patients with hepatitis B virus coinfection. Risk of bias in included studies was assessed using the Newcastle-Ottawa Scale. Meta-analyses were performed for the influence of IL-10 gene promoter SNPs (rs1800896 (-1082 A/G), rs1800871 (-819 C/T), and rs1800872 (-592 C/T)) and haplotypes on treatment response in HCV patients. Subgroup analyses, meta-regressions, publication bias assessment, and sensitivity analyses were also conducted. Overall, 32 studies with a total of 5943 HCV cases and 2697 controls were included in the present study. The -1082*G allele was significantly associated with increased risk of non-response (NR) to treatment, OR [95% CI] = 1.29 [1.1-1.51], p = .002. Besides, the rs1800872 -592*C allele was significantly associated with increased NR risk, OR [95% CI] = 1.22 [1.02-1.46], p = .03. Subgroup analysis showed that this association remained significant only in patients treated with PEG-IFN alone, p = .01. The -1082*G/-819*C/-592*C (GCC) haplotype was significantly associated with increased NR risk, OR [95% CI] = 1.62 [1.13-2.23], p = .009. Our results suggest that the IL-10 rs1800896 was associated with NR risk especially in North-African and Asian populations. Moreover, the IL-10 gene promoter -1082*G/-819*C/-592*C (GCC) haplotype which has been associated with higher production of IL-10, was significantly associated with increased NR risk.

Bowel Obstruction From Biliary Stent Migration: An Unusual Case of Abdominal Pain

Endoscopic biliary stent placement is an important procedure that is commonly done in patients with malignant obstruction of the biliary tree. However, it can also be done to relieve non-maligant obstructions short term until more curative surgical interventions can be performed. There are two main types of stents used for these procedures: self-expanding metal stents (SEMSs) and plastic stents. Each of these stent types has different indications, and determining the correct stent for each individual patient is important. Here, we present a case of a 73-year-old female who presented with abdominal pain due to small bowel obstruction caused by a dislodged biliary duct stent. We hope to promote more focus on selecting the right stent type for each patient and encouraging follow-up visits after placement, especially for those with a history of medical noncompliance.

Post-cholecystectomy iatrogenic bile duct injuries: Emerging role for endoscopic management

Post-cholecystectomy iatrogenic bile duct injuries (IBDIs), are not uncommon and although the frequency of IBDIs vary across the literature, the rates following the procedure of laparoscopic cholecystectomy are much higher than open cholecystectomy. These injuries caries a great burden on the patients, physicians and the health care systems and sometime are life-threatening. IBDIs are associated with different manifestations that are not limited to abdominal pain, bile leaks from the surgical drains, peritonitis with fever and sometimes jaundice. Such injuries if not witnessed during the surgery, can be diagnosed by combining clinical manifestations, biochemical tests and imaging techniques. Among such techniques abdominal US is usually the first choice while Magnetic Resonance Cholangio-Pancreatography seems the most appropriate. Surgical approach was the ideal approach for such cases, however the introduction of Endoscopic Retrograde Cholangio-Pancreatography (ERCP) was a paradigm shift in the management of such injuries due to accepted success rates, lower cost and lower rates of associated morbidity and mortality. However, the literature lacks consensus for the optimal timing of ERCP intervention in the management of IBDIs. ERCP management of IBDIs can be tailored according to the nature of the underlying injury. For the subgroup of patients with complete bile duct ligation and lost ductal continuity, transfer to surgery is indicated without delay. Those patients will not benefit from endoscopy and hence should not do unnecessary ERCP. For low-flow leaks e.g. gallbladder bed leaks, conservative management for 1-2 wk prior to ERCP is advised, in contrary to high-flow leaks e.g. cystic duct leaks and stricture lesions in whom early ERCP is encouraged. Sphincterotomy plus stenting is the ideal management line for cases of IBDIs. Interventional radiologic techniques are promising options especially for cases of failed endoscopic repair and also for cases with altered anatomy. Future studies will solve many unsolved issues in the management of IBDIs.

Probiotic containing Lactobacillus reuteri DSM 17648 as an adjunct treatment for Helicobacter pylori infection: A randomized, double-blind, placebo-controlled trial

BACKGROUND

Despite multiple therapy regimens, the decline in the Helicobacter pylori eradication rate poses a significant challenge to the medical community. Adding Lactobacillus reuteri probiotic as an adjunct treatment has shown some promising results. This study aims to investigate the efficacy of Lactobacillus reuteri DSM 17648 in H. pylori eradication and its effect in ameliorating gastrointestinal symptoms and adverse treatment effects.

MATERIALS AND METHODS

This randomized, double-blinded, placebo-controlled trial involved treatment-naïve H. pylori-positive patients. Ninety patients received standard triple therapy for 2 weeks before receiving either a probiotic or placebo for 4 weeks. The posttreatment eradication rate was assessed via a 14 C urea breath test in Week 8. The Gastrointestinal Symptom Rating Scale (GSRS) questionnaire and an interview on treatment adverse effects were conducted during this study.

RESULTS

The eradication rate was higher in the probiotic group than in the placebo group, with a 22.2% difference in the intention-to-treat analysis (91.1% vs. 68.9%; p = 0.007) and 24.3% difference in the per-protocol analysis (93.2% vs. 68.9%; p = 0.007). The probiotic group showed significant pre- to post-treatment reductions in indigestion, constipation, abdominal pain, and total GSRS scores. The probiotic group showed significantly greater reductions in GSRS scores than the placebo group: indigestion (4.34 ± 5.00 vs. 1.78 ± 5.64; p = 0.026), abdominal pain (2.64 ± 2.88 vs. 0.89 ± 3.11; p = 0.007), constipation (2.34 ± 3.91 vs. 0.64 ± 2.92; p = 0.023), and total score (12.41 ± 12.19 vs. 4.24 ± 13.72; p = 0.004). The probiotic group reported significantly fewer adverse headache (0% vs. 15.6%; p = 0.012) and abdominal pain (0% vs. 13.3%; p = 0.026) effects.

CONCLUSIONS

There was a significant increase in H. pylori eradication rate and attenuation of symptoms and adverse treatment effects when L. reuteri was given as an adjunct treatment.

CT imaging features of bile duct stent complications

Biliary stents have been widely used to treat both malignant and benign biliary obstruction. Biliary stenting serves as a temporary measure to maintain ductal patency and promote bile drainage. Biliary decompression can help relieve clinical symptoms of pain, obstructive jaundice, pruritis, fat malabsorption, and failure to thrive and prevent disease progression, such as secondary biliary cirrhosis and end-stage liver failure. Endoscopic placement of biliary endoprosthesis is a minimally invasive procedure well tolerated by most patients but is not without problems. Multiple early and late complications have been reported in the literature and Computed Tomography (CT) is the most used modality to assess normal positions and evaluate patients suspected of stent complications. The aim of this article is to provide a review various of biliary stent related complications, as seen on CT. Current literature on risk factors, diagnosis and management is also discussed.

Favorable impact of a novel endoscopic auxiliary system (NEAS) on fluoroscopy-guided lithotripsy for difficult bile duct stones: A pilot study

OBJECTIVES

Laser lithotripsy under fluoroscopic guidance is difficult to perform and risky due to its invisibility. In this study we aimed to investigate the efficacy and safety of a novel endoscopic auxiliary system (NEAS)-assisted lithotripsy under fluoroscopy for treating difficult common bile duct (CBD) stones.

METHODS

Patients with difficult CBD stones who were treated with NEAS-assisted laser lithotripsy (NEAS group) or conventional mechanical lithotripsy (ML) under fluoroscopy (ML group) were retrospectively evaluated. The primary outcome was the complete stone clearance rate and the secondary outcomes included operation time, complications, and medical cost.

RESULTS

Seventeen patients were treated with NEAS-assisted laser lithotripsy and 144 patients underwent ML. Using the propensity score matching analysis, 17 pairs of cases treated with NEAS-assisted lithotripsy and ML were included. Patients in the NEAS group showed a higher stone clearance rate than the ML group (94.1% vs 58.8%, P = 0.039), as well as shorter operation time (41.9 min vs 49.4 min, P < 0.001) and lower medical cost (USD 4607 vs USD 5014, P < 0.001). There was no significant difference in the complication rate between the two groups (5.9% vs 17.6%, P = 0.601).

CONCLUSION

NEAS-assisted fluoroscopy-guided laser lithotripsy is feasible and safe, which may be a promising technique in fluoroscopy-guided laser lithotripsy for difficult CBD stones.

Impact of the Coronavirus Disease 2019 Pandemic on Pediatric Gastrointestinal Endoscopy: A Questionnaire-based Internet Survey of 162 Institutional Experiences in Asia Pacific

Purpose

The impact of coronavirus 2019 (COVID-19) on gastrointestinal (GI) endoscopy procedures in adults has been reported, with a drastic reduction in the number of procedures. However, there are no sufficient data regarding the impact on pediatric GI endoscopy. Here, we aimed to report that impact in the Asia-Pacific region.

Methods

A questionnaire-based internet survey was conducted from June to November 2021 among pediatric endoscopy institutions in the Asia-Pacific region, with each institution providing a single response. Overall, 25 questions focused on the impact of the number of procedures conducted, the usage of personal protective equipment (PPE), and endoscopy training programs during the pandemic.

Results

A total of 162 institutions across 13 countries in the Asia-Pacific region participated in the study, and 133 (82.1%) institutions underwent procedure changes since the emergence of COVID-19. The number of esophagogastroduodenoscopy and ileocolonoscopy procedures decreased in 118/133 (88.7%) and 112/133 (84.2%) institutions, respectively. Endoscopy for patient with positive COVID-19 in an emergency or urgent cases still carried out in 102/162 (62.9%) institutions. Screening of COVID-19 for all patients before endoscopy was done across 110/162 (67.9%) institutions. PPE recommendations varied among institutions. Pediatric gastrointestinal endoscopy training programs were discontinued in 127/162 (78.4%) institutions.

Conclusion

This study reports the impact of the COVID-19 pandemic on pediatric gastrointestinal endoscopy in the Asia-Pacific region. There has been a significant reduction in the number of endoscopic procedures and relevant training programs.

A Review of Helicobacter pylori Diagnostics in Africa : From the Bedside to the Laboratory

Helicobacter pylori (H. pylori) is endemic in Africa with a prevalence estimate of 79.1%. In addition, there is a significant community burden of dyspepsia in Africa, similar to other western countries. However, the majority of infected persons do not manifest the disease. In Africa, for instance, peptic ulcer disease is prevalent, whereas gastric cancer has reportedly low incidence. Therefore, it is important that testing is focused, targeting individuals most likely to benefit from treatment. In Africa, there are currently no guidelines for H. pylori testing and treatment. Empirical treatment is common due to variable access to diagnostics and health care. To assess the spectrum of H. pylori testing in Africa, we performed a literature search in PubMed over the past 10 years, 2013 to 2023. Histology was the most widely used modality in 16 out of 18 countries. Capacity for culture was shown in 11 studies, importantly across regions of Africa. H. pylori serology was demonstrated in 8 countries, although it has limited sensitivity in identifying active infection. H. pylori test-and-treat strategy has been shown to be cost-effective. Particularly in a region with high antibiotic resistance, adopting this strategy ensures that only confirmed positive patients are treated. Furthermore, test-of-cure ought to be mandatory to guide future therapies. Health authorities can leverage polymerase chain reaction facilities, left behind by the coronavirus disease 2019 pandemic, to make molecular susceptibility testing available in the near future. A systematic approach to testing incorporating indication for endoscopy and medication use is recommended.

Predicting Factors of Clinical Outcomes in Patients Hospitalized after Esophageal Foreign Body or Caustic Injuries: The Experience of a Tertiary Center

Ingestion of foreign bodies (IFB) and ingestion of caustic agents are frequent non-hemorrhagic causes of endoscopic urgencies, with the potential for severe complications. This study aimed to evaluate the predicting factors of the clinical outcomes of patients hospitalized as a result of IFB or ingestion of caustics (IC). This was a retrospective single-center study of patients admitted for IFB or IC between 2000 and 2019 at a tertiary center. Demographic and clinical data, as well as preliminary exams, were evaluated. Also, variables of the clinical outcomes, including the length of stay (LS) and other inpatient complications, were assessed. Sixty-six patients were included (44 IFB and 22 IC). The median LS was 7 days, with no differences between the groups (p = 0.07). The values of C-reactive protein (CRP) upon admission correlated with the LS in the IFB group (p < 0.01) but not with that of those admitted after IC. In the IFB patients, a diagnosis of perforation on both an endoscopy (p = 0.02) and CT scan (p < 0.01) was correlated with the LS. The Zargar classification was not correlated with the LS in the IC patients (p = 0.36). However, it was correlated with antibiotics, nosocomial pneumonia and an increased need for intensive care treatment. CT assessment of the severity of the caustic lesions did not correlate with the LS. In patients admitted for IFB, CRP values may help stratify the probability of complications. In patients admitted due to IC, the Zargar classification may help to predict inpatient complications, but it does not correlate with the LS.

Cholangioscopy-guided salvage retrieval of a migrated stent at a hepaticojejunostomy anastomosis using a colonoscope

Video 1Cholangioscopy-guided retrieval of a migrated biliary stent at the hepaticojejunostomy anastomosis.

Predictive value of liver and spleen stiffness measurement based on two-dimensional shear wave elastography for the portal vein pressure in patients with compensatory viral cirrhosis

Objective

This study aimed to explore the predictive value of liver and spleen stiffness measurement based on two-dimensional shear wave elastography for the portal vein pressure in patients with compensatory viral cirrhosis.

Methods

From January 2017 to August 2019, 107 patients with compensatory viral cirrhosis and 76 patients with viral hepatitis were enrolled as cirrhosis group and hepatitis group, respectively. Patient data were obtained during admission, and this study was a review and analysis of patient data. Liver stiffness measurement (LSM), spleen stiffness measurement (SSM), portal vein diameter and spleen thickness were compared between the two groups, and their diagnostic value for compensatory viral cirrhosis was analyzed. According to the hepatic vein pressure, the cirrhosis group patients were divided into non-hypertensive group (no portal hypertension, hepatic venous pressure gradient (HVPG) < 5 mmHg), mild group (mild portal hypertension, 5 mmHg ≤ HVPG ≤ 10 mmHg) and severe group (clinically significant portal hypertension group, HVPG > 10 mmHg). LSM, SSM, portal vein diameter and spleen thickness of the three groups were compared, and the correlation between SSM and hepatic vein pressure was analyzed.

Results

LSM, SSM, portal vein diameter and spleen thickness in the cirrhosis group were higher than those in hepatitis group (all P < 0.05). The area under the curve (AUC) of combined detection was larger than that of LSM, SSM and spleen thickness detection alone in liver cirrhosis diagnosis (all P < 0.05). LSM, SSM, portal vein diameter and spleen thickness increased with the increase of hepatic vein pressure in patients with liver cirrhosis (all P < 0.05). LSM, SSM, portal vein diameter and spleen thickness were all positively correlated with hepatic vein pressure (P < 0.05). ROC curve showed that AUC of combined detection was greater than that of LSM, SSM, portal vein diameter and spleen thickness alone detection in the diagnosis of clinically significant portal hypertension (all P < 0.05). The increase of LSM, SSM, portal vein diameter and spleen thickness were the influencing factors for hepatic vein pressure rising (all P < 0.05).

Conclusion

There was an increase of LSM and SSM in patients with compensatory viral cirrhosis, which were positively correlated with hepatic venous pressure, and combined index detection has diagnostic and predictive value for the change of portal venous pressure.

Multidisciplinary Inflammatory Bowel Disease Conference: The Impact of the Expert Pathologist on Patient Care

BACKGROUND

Multidisciplinary teams (MDT) aid the diagnosis and management of patients with inflammatory bowel disease (IBD) and improve patient outcomes. The direct impact of a gastrointestinal expert pathologist on MDT care of IBD patients is unknown.

METHODS

A retrospective chart review was conducted evaluating all cases (N = 289) discussed at the IBD MDT conference at Carilion Roanoke Memorial Hospital from June 1, 2013, through December 31, 2019. Cases were discussed between 1 and 6 times at the conference. Data collected included demographics, diagnosis before and after conference, reason for diagnostic change, endoscopy findings, medications, surgeries, and clinical follow-up.

RESULTS

Approximately 15% to 42% of patients had a change in diagnosis after the first 3 conferences. The majority of diagnostic changes after the first (84%), second (73%), and third (67%) conferences were due to expert pathologist interpretation. Indeterminate colitis was the most frequently changed diagnosis, and Crohn's disease was the most common new diagnosis after conference. Among patients with a diagnostic change, 28.6% to 38.5% of patients had a change in their IBD medication regimen, and 7.7% to 10.9% had a surgical intervention after the first 2 conferences. Approximately 54.2% to 60% of patients reported clinical improvement or remission within 6 months of the first 3 conferences.

CONCLUSION

The majority of diagnostic changes made at the multidisciplinary IBD conference were due to histopathologic re-interpretation. A change in diagnosis at times led to significant modifications in medical or surgical management. An expert gastrointestinal pathologist is an essential MDT member for IBD management.

Frequency and risk factors of H. pylori infection among dental students: an observational cross-sectional study

Despite Helicobacter pylori infection remains asymptomatic in most people, it is associated with an increased risk of gastric cancer. Considering Egypt had the highest prevalence of H. pylori in healthy asymptomatic population in adults and pediatric age in past studies and currently salivary ELISA could be used for diagnosis of Oral H. pylori infection. Moreover, some researchers speculated that dentists and dental students might be at a higher risk for oral H. pylori infection because they are the most frequently exposed ones to saliva and dental plaque. This study aimed to determine risk factors associated with frequency of H. pylori among a sample of dental students for better management of the disease. 83 participants, with age (21-25 years), attending Faculty of Dentistry, Fayoum University were recruited. A structured questionnaire was used to collect information on sociodemographic parameters and risk factors for H. pylori. Direct inquiry about dyspeptic symptoms were done. Saliva samples were collected and tested for H. pylori antibodies. Overall seroprevalence was 22.9%. Participants in internship were more prone to be positive (p = 0.005). 32.6% of urban residents versus 10.8% of rural were H. pylori positive (p = 0.019). 75.0% of previous history of H. pylori infection versus 14.1% of those with no history were H. pylori positive p < 0.001. 70% of positive H. pylori participants reported positive clinical symptoms that were statistically significant. This study suggests that middle income, previous history of H. pylori and clinical symptoms of dyspepsia are risk factors of oral H. pylori with a decline in its prevalence in Egypt.

Efficacy of Fasting in Type 1 and Type 2 Diabetes Mellitus: A Narrative Review

Over the last decade, studies suggested that dietary behavior modification, including fasting, can improve metabolic and cardiovascular markers as well as body composition. Given the increasing prevalence of people with type 1 (T1DM) and type 2 diabetes mellitus (T2DM) and the increasing obesity (also in combination with diabetes), nutritional therapies are gaining importance, besides pharmaceutical interventions. Fasting has demonstrated beneficial effects for both healthy individuals and those with metabolic diseases, leading to increased research interest in its impact on glycemia and associated short- and long-term complications. Therefore, this review aimed to investigate whether fasting can be used safely and effectively in addition to medications to support the therapy in T1DM and T2DM. A literature search on fasting and its interaction with diabetes was conducted via PubMed in September 2022. Fasting has the potential to minimize the risk of hypoglycemia in T1DM, lower glycaemic variability, and improve fat metabolism in T1DM and T2DM. It also increases insulin sensitivity, reduces endogenous glucose production in diabetes, lowers body weight, and improves body composition. To conclude, fasting is efficient for therapy management for both people with T1DM and T2DM and can be safely performed, when necessary, with the support of health care professionals.

Diagnostic Accuracy of Portal Vein Flow Velocity for Esophageal Varices in Cirrhotic Patients

Background Variceal bleeding is a life-threatening complication of cirrhosis. Traditionally, endoscopy has been utilized as a preferred modality for the detection and grading of esophageal varices. However, endoscopy is an invasive procedure and may not be readily available in resource-limited settings. To overcome this limitation, various non-invasive tests, including Doppler ultrasonography (DUS) with portal vein (PV) velocity measurement, have been investigated to predict the presence of esophageal varices (EV). This study aimed to evaluate the potential utility of portal vein flow velocity (PVFV) as a non-invasive alternative to endoscopic screening for predicting the presence of esophageal varices among cirrhotic patients. Methodology This validation cross-sectional study was carried out at the Department of Gastroenterology and Hepatology, Pakistan Kidney and Liver Institute & Research Centre (PKLI&RC), Lahore, Pakistan from June 8, 2022, to March 8, 2023. Cirrhotic patients were enrolled based on clinical, laboratory, and radiological assessments. Doppler ultrasonography was performed to measure portal vein flow velocity along other relevant indices. Subsequently, all patients underwent endoscopic evaluation to screen and grade the esophageal varices. Univariate and multivariate logistic regression analyses were performed to identify significant clinical predictors of EV based on the results of the independent sample t-tests or Mann-Whitney U tests. Receiver operating characteristic (ROC) curves were employed to determine the optimal cut-off value for portal vein flow velocity (PVFV). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated based on the identified cut-off value. A p-value ≤ 0.05 was considered statistically significant. Results A cohort of 137 cirrhotic patients was enrolled. The study population consisted of 92 males (67.2%) and 45 females (32.8%). Endoscopic screening confirmed the presence of esophageal varices in 81 patients (59.91%). A multivariate analysis revealed that aspartate aminotransferase to platelet ratio index (APRI) (p=0.008) and portal vein flow velocity (p=0.001) were significant factors associated with esophageal varices and were used for receiver operating characteristic (ROC) analysis. The area under the curve (AUC) for PVFV was 0.981, and for APRI, it was 0.711. At a cut-off value of 18 cm/sec for PVFV, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy for esophageal varices were found to be 93.83%, 92.86%, 95%, 91.23%, and 93.43%, respectively. Conclusion Measurement of portal vein flow velocity using Doppler ultrasonography (DUS) is a reliable screening method for predicting the presence of esophageal varices (EV) in patients with liver cirrhosis. DUS offers several advantages, including its non-invasive nature, cost-effectiveness, and widespread availability, making it a recommended approach due to its high diagnostic accuracy.

Prevalence of occult hepatitis B virus infection in Egypt: a systematic review with meta-analysis

BACKGROUND

Occult hepatitis B virus (HBV) infection (OBI) is a major public health problem. The clinical importance of OBI stems from the fact that it can be transmitted to healthy individuals at extremely low viral load levels. Additionally, immunosuppression has the potential to trigger viral replication, which can result in life-threatening liver decompensation. Despite several studies examining the prevalence of OBI, the pooled prevalence of OBI in Egypt remains unknown, particularly among blood donors and high-risk individuals, to whom intervention should be targeted.

METHODS

A comprehensive literature search of the following databases was conducted from inception to October 2022 using the following keywords: occult hepatitis B virus infection or occult HBV infection or OBI and Egypt in MEDLINE [PubMed], Scopus, Google Scholar, and Web of Science. The review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. I-squared and Cochran's Q were used to measure the heterogeneity between the studies, and based on the random effects model, results were reported as proportions (%) with a 95% confidence interval (CI). Analyses of subgroup analyses were conducted based on the target population. Sensitivity analyses were conducted using the leave-one-out approach to test the robustness of the results.

RESULTS

A total of 50 studies with 62 estimations of OBI were included, 19 in patients who were HBsAg-negative and anti-HBc-positive and 43 in patients who were HBsAg-negative. The highest prevalence (41%) was among multi-transfused patients according to  studies that report occult hepatitis B virus prevalence in an HBsAg-negative population, while the pooled prevalence of OBI among patients on hemodialysis, patients with chronic hepatitis C infection, patients with hepatocellular carcinoma (HCC), and patients with liver cirrhosis was 17%, 10%, 24%, and 13%, respectively. On the other hand, among studies that report OBI prevalence in HBsAg-negative and anti-HBc-positive individuals, the pooled prevalence of OBI among blood donors, patients with chronic hepatitis C infection, and patients with HCC was 12%, 15%, and 31%, respectively. Also, the majority of studies examining the genetic background of OBI have found that genotype D is the most prevalent.

CONCLUSION

 This study highlights the high prevalence in OBI among blood donors and high-risk populations in Egypt. The implementation of HBV nucleic acid amplification testing (NAT) may increase the safety of blood transfusions by excluding all HBV DNA-positive donations. However, the cost-effectiveness of these tests should be investigated.

Schistosomal (bilharzial) polyps: Travel through the colon and beyond

Schistosomiasis (bilharziasis) is a major neglected tropical disease. It is endemic in many tropical and subtropical communities. Schistosomal polyps (S. polyps) are not uncommon presentation of this infection. Although the colon is the most commonly affected organ, many other organs are affected. S. polyps are associated with a variable range of morbidity independent of the Schistosomal infection. S. polyps are frequently described in endemic areas and increasingly reported in non-endemic areas mainly among immigrants and visitors to the endemic areas. This review aimed to increase awareness of practitioners, especially gastroenterologists, for this peculiar type of polyps caused by this neglected infection hence improving patient outcomes. Web-based search of different databases was conducted for the literature focusing the development of S. polyps in the colon and other organs with analysis of the clinical manifestations, diagnosis and treatment. The following key words were used in the search, “Schistosomiasis” OR “Bilharziasis” AND “Polyps” OR “Polyp” AND “Colon” OR “Small intestine” OR “ Duodenum” OR “ Stomach” OR “Esophagus” OR ” Gallbladder” OR” Pharynx” OR “Larynx” OR “Trachea” OR ”Urinary bladder” OR “ Ureter” OR “Renal Pelvis” OR “Urethra”. All publication types including case reports, case series, original research, and review articles were retrieved and analyzed. S. polyps are not infrequent presentation of acute or chronic Schistosomal infection. S. polyps are described in many organs including the bowel, genitourinary tract, skin, gallbladder and the larynx. Presentation of S. polyps is variable and depends on the site, number as well as the polyp size. The relationship of S. polyps to malignant transformation is a matter of discussion. Presence of S. polyps is sometimes the only manifestation of Schistosomiasis. Small polyps can be treated medically with praziquantel, while large accessible polyps are amendable for endoscopic excision through different polyp resection techniques. However, huge, complicated, non-accessible and suspicious polyps are indicated for surgical management or advanced endoscopic resection when appropriate. Clinicians and endoscopists should be aware about these facts when treating patients living in, immigrated from or visiting endemic areas.

Helicobacter pylori Infection: Antibiotic Resistance and Solutions for Effective Management in Africa

Helicobacter pylori (H. pylori) infection is ubiquitous worldwide, with prevalence rates of greater than 70% in Africa. Symptomatic patients present with foregut gastrointestinal symptoms which can be readily diagnosed with standardized non-invasive or invasive tests. The biggest challenge, however, is in the management of this condition with rising antimicrobial resistance rates to most of the antibiotics recommended for therapy. This is a problem worldwide, but more specifically in Africa, where the socio-economic and political climate is such that eradication of this organism seems impossible. Furthermore, the recommended antimicrobial susceptibility testing for drug resistance is not widely available in Africa due to the lack of infrastructural as well as human resources. With the widespread unregulated use of antibiotics in some parts of Africa, the figures of antimicrobial resistance are likely to soar. In the face of these significant challenges, this 'perspectives' article aims to address the issue of antimicrobial resistance in Africa, by providing achievable and targeted goals to curb the spread of infection and rising antimicrobial resistance.

Susceptibility patterns and virulence genotypes of Helicobacter pylori affecting eradication therapy outcomes among Egyptian patients with gastroduodenal diseases

BACKGROUND

Helicobacter pylori (H. pylori) is a significant human pathogen that is responsible for a variety of illnesses, including mucosa-associated lymphoid tissue lymphoma, gastric cancer, peptic ulcers, and gastritis.

AIM

To investigate the frequency of H. pylori infection and its resistance patterns among Egyptian patients and to determine the influence of H. pylori virulence genetic determinants on the eradication success of 14-d triple therapy regimen.

METHODS

H. pylori infections were investigated in 72 patients with gastroduodenal complications suggestive of H. pylori infection. The cagA and vacA genotypes of cultured strains were studied using polymerase chain reaction. The patients underwent 14 d of triple-therapy treatment. The treatment response was examined using histology and a rapid urease test 6 wk after therapy discontinuation.

RESULTS

The intention-to-treat eradication rate was 59.2% (95%CI: 48.2%–70.3%). Rates of H. pylori resistance to clarithromycin, amoxicillin, and metronidazole were 52.8%, 81.9%, and 100%, respectively. Successful eradication of H. pylori was more significantly associated with vacA s1-positive strains [adjusted odds ratio (aOR) = 0.507, 95%CI: 0.175–0.822]. A significant association was found between failed eradication rate and H. pylori strains resistant to clarithromycin (aOR = 0.204, 95%CI: –0.005 to 0.412) and amoxicillin (aOR = 0.223, 95%CI: 0.026–0.537).

CONCLUSION

This study’s low H. pylori eradication rate following 14-d triple therapy is concerning and worrying. H. pylori pan-resistance to metronidazole followed by the high resistance to ciprofloxacin, amoxicillin, and clarithromycin in this research is challenging and of great concern.

Comparative effectiveness of different probiotics supplements for triple helicobacter pylori eradication: a network meta-analysis

Background

Probiotics has been reported as an effective supplement for Helicobacter pylori eradication. However, knowledge of their comparative efficacy is still lacking.

Aim

In this study, we used network meta-analysis of current probiotics supplement used in standard triple therapy to assess and rank their comparative effectiveness.

Methods

All randomized controlled trials from three main databases (PubMed, Embase and Cochrane Library) up to April 2022 were collected and filtered to meet our criterion. We used Bayesian network meta-analysis to evaluate the eligible randomized controlled trials and gave a rank for the efficiency and incidence of side effects of each probiotics supplement. The ranking probability for each therapy was assessed by means of surfaces under cumulative ranking values. Subgroup analysis was conducted to evaluate other possible influencing factors.

Results

34 eligible randomized controlled trials entered the following meta-analysis, including 9,004 patients randomized to 10 kinds of therapies. Result showed that most probiotics added therapies had better outcomes than triple therapy, among which Bifidobacterium-Lactobacillus and Bifidobacterium-Lactobacillus-Saccharomyces adjuvant therapy could obtain comprehensive benefit with high eradication rate (78.3% and 88.2% respectively), and cause few side effects. Combination of different probiotics, adding probiotics before or after triple therapy and longer duration of probiotics can improve therapeutic effect in H.pylori infected individuals.

Conclusion

For triple therapy of H.pylori infection, adding probiotics can increase eradication rate and bring protective effect. Considering the overall influence, Bifidobacterium-Lactobacillus or Bifidobacterium-Lactobacillus-Saccharomyces therapy can be a better choice in improving H.pylori eradication process.

Gallbladder Wall Thickness as a Non-Invasive Marker for Esophageal Varices: A Systematic Review and Meta-Analysis

Background

The early detection of esophageal varices (EV) is important in patients with chronic liver disease (CLD). Non-invasive diagnostic markers are preferred to avoid the cost and potential complications associated with endoscopy. The gallbladder venous blood is drained via small veins which terminate in the portal venous circulation. Therefore, the gallbladder wall thickness (GBWT) can be affected by portal hypertension. We conducted the present study to evaluate the diagnostic and predictive utility of ultrasound GBWT measurement in patients with EV.

Methods

We searched PubMed, Scopus, Web of Science and Embase for relevant studies up to March 15, 2022, using the keywords "varix", "varices", and "gallbladder" to search the databases by title and abstract. Our meta-analysis was performed using the "meta" package of R software version 4.1.0 and meta-disc for diagnostic test accuracy (DTA).

Results

We included 12 studies in our review (N = 1343 participants). The gallbladder thickness was significantly larger in patients with EV compared with the control group (MD = 1.86 mm; 95% CI, 1.36-2.36). The DTA analysis and summary ROC plot showed an AUC of 86% and Q∗ = 0.80. The pooled sensitivity was 73% and the specificity was 86.

Conclusions

Our analysis shows that GBWT measurement is a promising predictor of esophageal varices in chronic liver disease patients.

Salvage endoscopic ultrasound-guided gastrojejunostomy as a bridge to definitive surgical therapy for duodenal adenocarcinoma presenting with duodenal stent obstruction

The utilization of endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) in the setting of an obstructed (ingrown) duodenal stent as a bridge to pancreaticoduodenectomy (PD) remains undescribed. Herein, we report a case study of a 51-year-old patient who underwent EUS-GJ using lumen apposing metal stent (LAMS) for an obstructed duodenal stent during neoadjuvant treatment for duodenal adenocarcinoma. The patient ultimately underwent surgical resection by a classic PD 14 weeks after LAMS placement. EUS-GJ using LAMS represents a potential option as a salvage bridge to surgery for duodenal obstruction in the setting of an obstructed duodenal stent.

The Pierced Colon: When Biliary Stents Go the Wrong Way

Bowel perforation of biliary stents is a rare complication of biliary stenting. We report the successful endoscopic treatment of a 78-year-old man with a straight biliary plastic stent perforating the ascending colon without underlying structural abnormality in the affected segment. Perforation was detected incidentally during computed tomography; the patient had been under continued antibiotic therapy for liver abscess. Stent extraction was performed by using an endoscopic snare; the site of perforation was closed with through-the-scope clips. The patient remained asymptomatic. In addition, we reviewed published cases of perforated biliary stents and outlined that most perforations are caused by straight plastic stents.

Regulatory B cells (Bregs) in Helicobacter pylori chronic infection

BACKGROUND

Helicobacter pylori (H. pylori) infection is linked with a wide variety of diseases and was reported in more than half of the world's population. Chronic H. pylori infection and its final clinical outcome depend mainly on the bacterial virulence factors and its ability to manipulate and adapt to human immune responses. Bregs blood levels have been correlated with increased bacterial load and infection chronicity, especially Gram-negative bacterial infection. This study aimed to identify prevalence and virulence factors of chronic H. pylori infection among symptomatic Egyptian patients and to examine its possible correlation to levels of regulatory B cells (Bregs) in blood.

MATERIALS AND METHODS

Gastric biopsies and blood samples from each of 113 adult patients, who underwent upper endoscopy, were examined for the detection of H. pylori by culture and PCR methods. Conventional PCR was used to determine various virulent genes prevalence and association to clinical outcome. Flow cytometry was used to evaluate Bregs levels.

RESULTS

Helicobacter pylori prevalence was 49.1% (55/112). Regarding virulence genes incidence, flaA gene was detected in 73% (40/55), vir B11 in 56.4% (31/55), hopZ1 in 34.5% (19/55), hopZ2 in 89% (49/55), babA2 in 52.7% (29/55), dupA jhp917 in 61.8% (34/55), vacA m1/m2 in 70.9% (39/55), and vacA s1/s2 in 69% (38/55) strains. Bregs levels were significantly lower in H. pylori-infected patients (p = 0.013), while total leukocyte count (TLC) showed no significant differences.

CONCLUSION

Helicobacter pylori infection prevalence was almost 49%, and the infection was found to be related to inflammatory conditions as gastritis and ulcers rather than malignant transformations. Also, we found that CD24⁺ CD38⁺ B cells were downregulated in H. pylori-infected patients.

A Rare Case of Huge Schistosomiasis-Associated Cecal Polyp Mimicking Colon Carcinoma

Schistosomiasis is a parasitic infection caused by Schistosoma species, commonly found in tropical and subtropical regions. It affects millions of people worldwide and can lead to different clinical presentations like abdominal pain, weight loss, anemia, and chronic colonic schistosomiasis. In rare cases, chronic infection can result in the development of polyps, which can mimic colon carcinoma, posing a diagnostic challenge. Here, we present a rare case of a huge Schistosomiasis-associated cecal polyp in a patient initially suspected to have colon cancer. The patient's clinical history and the histopathological analysis confirmed the diagnosis, emphasizing the importance of considering parasitic infections in the differential diagnosis of gastrointestinal polyps in Schistosomiasis-endemic areas. This case report highlights the need for increased awareness among healthcare professionals of the potential for Schistosomiasis-associated polyps and the importance of multidisciplinary management in such cases.

Current Status of Management of Hepatocellular Carcinoma in The Gulf Region: Challenges and Recommendations

The burden of hepatocellular carcinoma (HCC) is on the rise in the Gulf region, with most patients being diagnosed in the intermediate or advanced stages. Surgery is a treatment option for only a few, and the majority of patients receive either locoregional treatment (percutaneous ethanol injection, radiofrequency ablation, transarterial chemoembolization [TACE], radioembolization, radiotherapy, or transarterial radioembolization) or systemic therapy (for those ineligible for locoregional treatments or who do not benefit from TACE). The recent emergence of novel immunotherapies such as immune checkpoint inhibitors has begun to change the landscape of systemic HCC treatment in the Gulf. The combination of atezolizumab and bevacizumab is currently the preferred first-line therapy in patients not at risk of bleeding. Additionally, the HIMALAYA trial has demonstrated the superiority of the durvalumab plus tremelimumab combination (STRIDE regimen) therapy in efficacy and safety compared with sorafenib in patients with unresectable HCC. However, there is a lack of data on post-progression treatment after first-line therapy with either atezolizumab plus bevacizumab or durvalumab plus tremelimumab regimens, highlighting the need for better-designed studies for improved management of patients with unresectable HCC in the Gulf region.

Outcomes in Patients Admitted for Upper Gastrointestinal Bleeding and COVID-19 Infection: A Study of Two Years of the Pandemic

Upper gastrointestinal bleeding (UGIB) represents a major emergency, and patient management requires endoscopic assessment to ensure appropriate treatment. The impact of COVID-19 on patient mortality in UGIB may be related to the combination of respiratory failure and severe bleeding and indirectly to delayed admissions or a reduction in endoscopic procedures. Methods: We conducted a retrospective study involving patients admitted between March 2020 and December 2021 with UGIB and confirmed. Our objective was to compare these types of patients with those negative for SARS-CoV-2 infection, as well as with a pre-pandemic group of patients admitted between May 2018 and December 2019. Results: Thirty-nine patients (4.7%) with UGIB had an active COVID-19 infection. A higher mortality rate (58.97%) and a high risk of death (OR 9.04, p < 0.0001) were noted in the COVID-19 pandemic, mostly because of respiratory failure; endoscopy was not performed in half of the cases. Admissions for UGIB have decreased by 23.7% during the pandemic. Conclusions: COVID-19 infection in patients admitted for UGIB was associated with a higher mortality rate because of respiratory failure and possible delays in or contraindications of treatment.

Associations of gallbladder and gallstone parameters with clinical outcomes in patients with cirrhosis

Background

Morphologic changes in the gallbladder and gallstones are common in cirrhotic patients, but their associations with outcomes of cirrhotic patients are unclear.

Methods

We retrospectively enrolled 206 cirrhotic patients and measured their gallbladder length and width, gallbladder wall thickness, presence of gallstones, and gallstones’ length and width in axial contrast-enhanced computed tomography (CT) images. X-tile software was utilized to calculate the optimal cutoff values of these parameters for evaluating survival and hepatic decompensation events in the cirrhosis group. Their associations with survival were explored by Cox regression analyses and Kaplan–Meier curve analyses. Their associations with hepatic decompensation events were evaluated by competing risk analyses and Nelson-Aalen cumulative risk curve analyses where death was a competing event.

Results

Cirrhotic patients with gallbladder length < 72 mm had a significantly higher cumulative survival rate than those with a length of ≥ 72 mm (P = 0.049 by log-rank test), but gallbladder width, gallbladder wall thickness, presence of gallstones, and gallstones’ length and width were not significantly associated with survival (P = 0.10, P = 0.14, P = 0.97, P = 0.73, and P = 0.73 by log-rank tests, respectively). Cirrhotic patients with gallbladder wall thickness < 3.4 mm had a significantly lower cumulative rate of hepatic decompensation events than those with a wall thickness of ≥ 3.4 mm (P = 0.02 by Gray’s test), but gallbladder length and width, presence of gallstones, and gallstones’ length and width were not significantly associated with hepatic decompensation events (P = 0.15, P = 0.15, P = 0.54, P = 0.76, and P = 0.54 by Gray’s tests, respectively).

Conclusion

Changes in gallbladder length and gallbladder wall thickness, rather than gallstone parameters, may be in parallel with the long-term outcomes of cirrhotic patients.

Underwater versus conventional EMR for nonpedunculated colorectal lesions: a randomized clinical trial

BACKGROUND AND AIMS

Conventional endoscopic mucosal resection (CEMR) is the standard modality for removing nonpedunculated colorectal lesions. Underwater endoscopic mucosal resection (UEMR) has emerged as an alternative method. There are few comparative studies between these techniques, especially evaluating recurrence. Therefore, the purpose of this trial was to compare CEMR and UEMR for the resection of colorectal lesions with respect to efficacy, safety, and recurrence rate.

METHODS

This was a randomized controlled trial of UEMR versus CEMR for naïve and nonpedunculated lesions measuring between 10 and 40 mm. The primary outcome was adenoma recurrence at 6 months after the resection. Secondary outcomes were rates of technical success, en bloc resection, and adverse events. Block randomization was used to assign patients. Tattooing was performed to facilitate localization of the scars and eventual recurrences. Endoscopic follow-up was scheduled at 6 months after the procedure. The sites of resections were examined with white-light imaging, narrow-band imaging (NBI), and conventional chromoscopy with indigo carmine followed by biopsies.

RESULTS

One hundred five patients with 120 lesions were included, with a mean size of 17.5 ± 7.1 (SD) mm. Sixty-one lesions were resected by UEMR and 59 by CEMR. The groups were similar at baseline regarding age, sex, average size, and histologic type. Lesions in the proximal colon in the CEMR group corresponded to 83% and in the UEMR group to 67.8% (P = .073). There was no difference between groups regarding success rate (1 failure in each group) and en bloc resection rate (60.6% UEMR vs 54.2% CEMR, P = .48). Intraprocedural bleeding was observed in 5 CEMRs (8.5%) and 2 UEMRs (3.3%) (P = .27). There was no perforation or delayed hemorrhage in either groups. Recurrence rate was higher in the CEMR arm (15%) than in the UEMR arm (2%) (P = .031). Therefore, the relative risk of 6-month recurrence rate in the CEMR group was 7.5-fold higher (95% CI, 0.98-58.20), with a number needed to treat of 7.7 (95% CI, 40.33-4.22). The higher recurrence rate in the CEMR group persisted only for lesions measuring 21 to 40 mm (35.7% vs 0%; P = .04).

CONCLUSION

This study demonstrated that UEMR was associated with a lower adenoma recurrence rate than was CEMR. Both endoscopic techniques were effective and had similar rates of adverse events for the treatment of nonpedunculated colorectal lesions.

Gallbladder wall thickness adversely impacts the surgical outcome

Backgrounds/Aims

To evaluate surgical outcomes of patients with gallbladder wall thickness (GBWT) > 5 mm.

Methods

Patients who underwent cholecystectomy were classified into two groups according to their GBWT status (GBWT+ vs. GBWT-).

Results

Among 1,211 patients who underwent cholecystectomy, GBWT+ was seen in 177 (14.6%). The GBWT+ group was significantly older with more males, higher ASA score, higher alkaline phosphatase level, higher international normalized ratio, and lower albumin level than the GBWT- group. On ultrasound, GBWT+ patients had larger stone size, more pericholecystic fluid, more common bile duct stone, and more biliary pancreatitis. Compared with the GBWT- group, the GBWT+ group had more urgent surgeries (12.4% vs. 3.2%, p = 0.001), higher conversion rate (4.5% vs. 0.3%, p = 0.001), prolonged operative time (67 ± 38 vs. 54 ± 29 min; p = 0.001), more bleeding (3.4% vs. 0.5%, p = 0.002), and more need of drain (21.5% vs. 10.5%, p = 0.001). By multivariate analysis, factors associated with increased length of hospital stay were GBWT+ (HR: 1.97, 95% CI: 1.19-3.25, p = 0.008), urgent surgery (HR: 10.2, 95% CI: 4.07-25.92, p = 0.001), prolonged surgery (HR: 1.01, 95% CI: 1.0-1.02, p = 0.001), and postoperative drain (HR: 11.3, 95% CI: 6.40-20.0, p = 0.001).

Conclusions

Variables such as GBWT ≥ 5 mm, urgent prolonged operation, and postoperative drains are independent predictors of extended hospital stay. GBWT+ patients are twice likely to stay in hospital for more than 72 hours and more prone to develop complications than GBWT- patients.

COVID-19 associated ketosis and diabetic ketoacidosis: A rapid review

SARS-CoV-2 infection could disrupt the endocrine system directly or indirectly, which could result in endocrine dysfunction and glycaemic dysregulation, triggering transient or persistent diabetes mellitus. The literature on the complex relationship between COVID-19 and endocrine dysfunctions is still evolving and remains incompletely understood. Thus, we conducted a review on all literature to date involving COVID-19 associated ketosis or diabetic ketoacidosis (DKA). In total, 27 publications were included and analysed quantitatively and qualitatively. Studies included patients with DKA with existing or new onset diabetes. While the number of case and cohort studies was limited, DKA in the setting of COVID-19 seemed to increase risk of death, particularly in patients with new onset diabetes. Future studies with more specific variables and larger sample sizes are needed to draw better conclusions.

Sonographic gallbladder wall thickness measurement and the prediction of esophageal varices among cirrhotics

Acute variceal bleeding in patients with liver cirrhosis and portal hypertension (PHT) is the most serious emergency complication among those patients and could have catastrophic ‎outcomes if not timely managed. ‎Early screening by esophago-gastro-duodenoscopy (EGD) for the presence of esophageal varices (EVs) is ‎‎currently recommended by the practice guidelines for all cirrhotic patients. Meanwhile, EGD is not readily accepted or preferred by many patients. The literature is rich in ‎studies to investigate and validate ‎ non-invasive markers of EVs prediction aiming at reducing the unneeded endoscopic procedures. Gallbladder (GB) wall thickness (GBWT) ‎measurement has been found promising in many published research ‎articles. We aim to highlight the validity of sonographic GBWT measurement in the ‎prediction of EVs based on the available evidence.‎ We searched databases including Cochrane library, PubMed, Web of Science and many others for relevant articles. GBWT is associated with the presence of EVs in cirrhotic patients with PHT of different etiologies. The cut-off of GBWT that can predict the presence of EVs varied in the literature and ranges from 3.1 mm to 4.35 mm with variable sensitivities of 46%-90.9% and lower cut-offs in viral cirrhosis compared to non-viral, however GBWT > 4 mm in many studies is associated with acceptable sensitivity up to 90%. Furthermore, a relation was also noticed with the degree of varices and portal hypertensive gastropathy. Among cirrhotics, GBWT > 3.5 mm predicts the presence of advanced (grade III-IV) EVs with a sensitivity of 45%, the sensitivity increased to 92% when a cut-off ≥ 3.95 mm was used in another cohort. Analysis of these results should carefully be revised in the context of ascites, hypoalbuminemia and other intrinsic GB diseases among cirrhotic patients. The sensitivity for prediction of EVs improved upon combining GBWT measurement with other non-invasive predictors, e.g., platelets/GBWT.

Lacticaseibacillus casei T1 attenuates Helicobacter pylori-induced inflammation and gut microbiota disorders in mice

Probiotics are defined as live microbial food elements that are beneficial to human health. Lacticaseibacillus casei T1 was considered to have potential as a bioactive ingredient in functional foods, which was isolated from kurut. Previous research by our group proved that L. casei T1 could prevent inflammatory responses caused by Helicobacter pylori. This study aimed to investigate whether treatment with L. casei T1 resulted in a suppressive effect on H. pylori-induced oxidative stress and inflammatory responses. The results showed that treatment with L. casei T1 could relieve H. pylori-induced overexpression of inflammatory cytokines in GES-1 cells. Experiments in animals suggested that taking long-term L. casei T1 could reduce oxidative stress and inflammatory cytokines and improve H. pylori-induced gastric mucosal damage. Furthermore, taking L. casei T1 could increase the relative abundance of beneficial intestinal bacterium (Lachnospiraceae and Odoribacter) of H. pylori-infected mice and help in maintaining the balance of intestinal microflora.Collectively, L. casei T1 had certain degrees of therapeutic effect against H. pylori. In the future, it combined with antibiotics for H. pylori eradication deserves further study.

Evaluation of guidelines for diagnosis and treatment of Helicobacter pylori infection

BACKGROUND

To systematically evaluate the quality of the guidelines for the diagnosis and treatment of Helicobacter pylori infection and to analyze the differences and reasons for the key recommendations in the guidelines.

METHODS

Databases and websites were systematically searched to obtain guidelines for the diagnosis and treatment of Helicobacter pylori infection. Four independent reviewers used the Guideline Evaluation Tool (AGREE II) to evaluate the included guidelines. The intraclass correlation coefficient (ICC) and Fleiss' kappa coefficient were used to measure the consistency of evaluation guidelines between guide reviewers. Differences between guidelines and the reasons for the differences were analyzed by comparing the recommendations of different guidelines and the evidence supporting the recommendations.

RESULTS

A total of 17 guidelines for Helicobacter pylori infection were included in this study. The AGREE II scores of these guidelines were low overall, with 4 of them had a score of over 60%, which indicates that the guidelines are recommended, and 13 of them having a score ranging from 30 to 60%, which indicates that the guidelines are recommended but need to be revised, while no guideline had a score of 30% or less, which indicates that they were not recommended. The analysis of these guidelines found that there were some differences in the main recommendations. Not all guidelines recommend sequential therapy as the recommended therapy. Whether bismuth quadruple therapy should be used as the recommended first-line therapy is unclear. The antibiotic resistance rate is different in different regions. Combined with the local antibiotic sensitivity test, the eradication rate of Helicobacter pylori can be improved.

CONCLUSION

There are significant differences in the quality of Helicobacter pylori infection guidelines and the key recommendations. Improving the deficiencies of existing guidelines is an effective way to develop high-quality guidelines and make reasonable recommendations for the treatment of Helicobacter pylori infection in the future.

Helicobacter pylori eradication rates using clarithromycin and levofloxacin-based regimens in patients with previous COVID-19 treatment: a randomized clinical trial

BACKGROUND

Helicobacter pylori (H. pylori) is affecting half of the globe. It is considered a main causative organism of chronic gastritis, peptic ulcer disease, and different gastric maliganacies. It has been also correlated to extraintestinal diseases, including refractory iron deficiency anaemia, vitamin B12 deficiency, and immune thrombocytopenic purpura. The misuse of antibiotics during the coronavirus diseases 2019 (COVID-19) pandemic time can affect H. pylori eradication rates. Our aim was to compare the efficacy of clarithromycin versus levofloxacin-based regimens for H. pylori treatment in naïve patients after the COVID-19 pandemic misuse of antibiotics.

METHODS

A total of 270 naïve H. pylori infected patients with previous treatment for COVID-19 more than 3 months before enrolment were recruited. Patients were randomized to receive either clarithromycin, esomeprazole, and amoxicillin, or levofloxacin, esomeprazole, and amoxicillin.

RESULTS

A total of 270 naïve H. pylori infected patients with previous treatment for COVID-19 more than 3 months before enrolment were included, 135 in each arm. In total, 19 patients in the clarithromycin group and 18 patients in the levofloxacin group stopped treatment after 2-4 days because of side effects or were lost for follow-up. Finally, 116 subjects in the clarithromycin group and 117 in the levofloxacin group were assessed. The eradication rates in intention to treat (ITT) and per protocol (PP) analyses were: group I, 55.56% and 64.66%; and Group II, 64.44% and 74.36% respectively (p = 0.11).

CONCLUSION

As COVID-19 pandemic has moved forward fast, high resistance rates of H. pylori to both clarithromycin and levofloxacin were developed after less than two years from the start of the pandemic. Molecular & genetic testing is highly recommended to identify antimicrobial resistance patterns. Strategies to prevent antibiotic misuse in the treatment of COVID-19 are needed to prevent more antibiotic resistance.

TRIAL REGISTRATION

The trial was registered on Clinicaltrials.gov NCT05035186. Date of registration is 2-09-2021.

Epidemiology of Inflammatory Bowel Diseases: A Population Study in a Healthcare District of North-West Italy

The burden of inflammatory bowel diseases (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), is increasing worldwide. The aim of the present study was to investigate the clinical characteristics and the changing in epidemiology of IBD in the Healthcare District Bra, an area of North-West Italy accounting for 57,615 inhabitants as of 31 December 2021. Clinical and demographic data were retrieved from administrative databases and the medical records of general practitioners (n = 39) at Verduno Hospital. Prevalence and incidence rates were calculated for the time span 2016-2021 and compared to the 2001-2006 period. IBD prevalence was 321.2 per 100,000 population in 2021 and, compared with 2006 (200 per 100,000 population), the prevalence has increased at a rate of +46%. Similarly, the average incidence has increased from the period 2001-2006 (6.7 per 100,000 population/year) to the period 2016-2021 (18.0 per 100,000 population/year) at a rate of +169%; such an increase was greater for CD than UC. In the 2016-2021 period, the mean age at diagnosis was 42.0 ± 17.4 years and 30.9% required at least one hospitalization, while 10.9% of patients underwent at least one surgery. In conclusion, the prevalence and incidence of IBD distinctly increased over a two decade period in the Healthcare District Bra paralleling the results of previous surveys from other Italian regions. These data warrant specific interventions to improve patients' management and resources' allocation.

Assessing Radiation Dosage in Pediatric Head and Neck Computed Tomography Examinations During COVID-19 in a Tertiary Hospital in Saudi Arabia, Jeddah

This study aimed to assess the practice of imaging and optimization of the radiation dose in pediatric head and neck computed tomography (CT) examinations during the coronavirus disease of 2019 (COVID-19) period. This study is based on a retrospective analysis of pediatric head CT records, conducted in the Radiology Department of the King Abdulaziz University Hospital in Jeddah, Saudi Arabia. We examined the data of all pediatric patients between 0 and 14 years of age who underwent head CT scans between March and September in both 2019 (before the COVID-19 pandemic) and 2020 (during the COVID-19 pandemic). In total, we analyzed 1005 scans; 531 (52.8%) were performed before and 474 (47.2%) during COVID-19. The dose parameters were similar; however, the exposure time was significantly lower during COVID-19 (5432 ms vs. 5811 before; p < 0.001). In contrast, the mean total CTDI_vol and dose-length product (DLP) were slightly higher during COVID-19 than those before (23.34 mGy vs. 22.04 mGy (p-value=0.565) and 577.36 mGy*cm vs. 518.93 mGy*cm (p-value=0.193) respectively). These changes could be attributed to the desire to limit the contact between technicians and patients. The limitation of contact with the patient allows the technicians to be independent during the scan, possibly accounting for this slight decrease.