Subclinical hepatitis E virus genotype 1 infection: The concept of “dynamic human reservoir”

Hepatitis E virus (HEV) is hyperendemic in South Asia and Africa accounting for half of total Global HEV burden. There are eight genotypes of HEV. Among them, the four common ones known to infect humans, genotypes 1 and 2 are prevalent in the developing world and genotypes 3 and 4 are causing challenge in the industrialized world. Asymptomatic HEV viremia in the general population, especially among blood donors, has been reported in the literature worldwide. The clinical implications related to this asymptomatic viremia are unclear and need further exploration. Detection of viremia due to HEV genotype 1 infection, apparently among healthy blood donors is also reported without much knowledge about its infection rate. Similarly, while HEV genotype 3 is known to be transmitted via blood transfusion in humans and has been subjected to screening in many European nations, instances of transmission have also been documented albeit without significant clinical consequences. Epidemiology of HEV genotype 1 in endemic areas often show waxing and waning pattern. Occasional sporadic occurrence of HEV infection interrupted by outbreaks have been frequently seen. In absence of known animal reservoir, where HEV exists in between outbreak is a mystery that needs further exploration. However, occurrence of asymptomatic HEV viremia due to HEV genotype 1 during epidemiologically quiescent period may explain that this phenomenon may act as a dynamic reservoir. Since HEV genotype 1 infection cannot cause chronicity, subclinical transient infection and transmission of virus might be the reason it sustains in interepidemic period. This might be the similar phenomenon with SARS COVID-19 corona virus infection which is circulating worldwide in distinct phases with peaks and plateaus despite vaccination against it. In view of existing evidence, we propose the concept of “Dynamic Human Reservoir.” Quiescent subclinical infection of HEV without any clinical consequences and subsequent transmission may contribute to the existence of the virus in a community. The potential for transmitting HEV infection by asymptomatic HEV infected individuals by fecal shedding of virus has not been reported in literature. This missing link may be a key to Pandora's box in understanding epidemiology of HEV infection in genotype 1 predominant region.

Experience of diet in patients with inflammatory bowel disease: A thematic synthesis of qualitative studies

AIM

To synthesise the dietary expesriences of patients with inflammatory bowel disease by reviewing relevant qualitative studies.

BACKGROUND

Diet plays a crucial role in the development and progression of inflammatory bowel disease (IBD). There is no specific diet that can be recommended for all patients. We conducted a synthesis of qualitative studies to gain a comprehensive understanding of the dietary management experience of patients with IBD, aiming to provide better dietary guidance in the future.

DESIGN

A qualitative synthesis was conducted following the Thomas and Harden method and reported following the ENTREQ statement.

METHODS

Qualitative studies were systematically searched in five electronic databases: PubMed, PsycINFO, Embase, CINAHL, and Web of Science. There was no time limit for publication, and all database searches were up to 10 May, 2023. The Joanna Briggs Institute Qualitative Assessment and Review Instrument was utilised to appraise the quality of the included studies. Data for inclusion in articles were extracted and analysed using a thematic synthesis method.

RESULTS

Six studies involving 119 patients were eventually included. The studies were conducted in six different countries. Four major themes were identified: the diet of patients with IBD is completely different from the normal one; manage symptoms and live with the disease by modifying diet; psychological adjustment to eating (be frustrated; worried and afraid; feel ashamed; growth and resilience); barriers and challenges (barriers from perceived social support; conflicts between diet and nutrition; challenges from food hedonism and cravings).

CONCLUSIONS

Patients with IBD highlighted the distinction between their diet and the normal diet. Dietary modifications were used as a way to manage symptoms and live with the disease. In addition to physical symptoms, patients experienced diet-related psychological changes. Dietary modifications in patients with IBD encounters difficulties and challenges, necessitating prompt guidance and intervention. (1) The implementation of dietary modifications in patients with IBD encounters numerous obstacles and complexities, necessitating prompt guidance and intervention.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

REGISTRATION

The protocol was registered with PROSPERO (CRD42023391545).

Management of Anticoagulant and Antiplatelet Agents in Acute Gastrointestinal Bleeding and Prevention of Gastrointestinal Bleeding

Managing gastrointestinal bleeding in patients using antithrombotic agents remains challenging in clinical practice. This review article provides a comprehensive and evidence-based approach to managing acute antithrombotic-related gastrointestinal bleeding, focusing on the triage of patients, appropriate resuscitation, and timely endoscopy. The latest clinical practice guidelines are highlighted to guide decisions concerning the use of reversal agents, temporary interruption, and resumption of antithrombotic drugs. Additionally, preventive measures are discussed to lower the risk of future bleeding and minimize complications among patients prescribed antithrombotic drugs.

Percutaneous drainage and combined praziquantel-albendazole therapy: a novel approach for the treatment of simple echinococcal liver cysts

Cystic echinococcosis (CE) is a worldwide helminthic zoonosis causing serious disease in humans. The WHO Informal Working Group on Echinococcosis recommends a stage-specific treatment approach of hepatic CE that facilitates the decision on what therapy option is most appropriate. Percutaneous aspiration, instillation of a scolicide, e.g., ethanol or hypertonic saline, and subsequent re-aspiration (PAIR) have been advocated for treating medium-size unilocular WHO-stage CE1 cysts. PAIR can pose a risk of toxic cholangitis because of spillage of ethanol in the case of a cysto-biliary fistula or of life-threatening hypernatriaemia when hypertonic saline is used. The purpose of our study is to develop an alternative, safe, minimally invasive method to treat CE1 cysts, avoiding the use of toxic topic scolicides.We opt for percutaneous drainage (PD) in four patients: the intrahepatic drainage catheter is placed under CT-fluoroscopy, intracystic fluid is aspirated, and the viability of intracystic echinococcal protoscolices is assessed microscopically. Oral praziquantel (PZQ) is added to albendazole (ABZ) instead of using topical scolicidals.Protoscolices degenerate within 5 to 10 days after PZQ co-medication at a cumulative dosage of 250 to 335 mg/kg, and the cysts collapse. The cysts degenerate, and no sign of spillage nor relapse is observed in the follow-up time of up to 24 months post-intervention.In conclusion, PD combined with oral PZQ under ABZ coverage is preferable to PAIR in patients with unilocular echinococcal cysts.

Influence of Helicobacter pylori Infection and Eradication on Small Intestinal Bacterial Overgrowth and Abdominal Symptoms

BACKGROUND

The relationship between Helicobacter pylori (H. pylori) infection and small intestinal bacterial overgrowth (SIBO) has attracted attention recently.

AIMS

To analyze the influence of H. pylori infection and eradication on SIBO, IMO, and abdominal symptoms.

METHODS

Patients with gastrointestinal symptoms were tested for 13C urea breath test and if positive, treated with bismuth-based quadruple therapy. Lactulose hydrogen methane breath test (HMBT) was performed and symptoms were assessed using gastrointestinal symptom rating scale (GSRS) before and 6 weeks after eradication.

RESULTS

Of the 102 subjects, 53 were H. pylori positive. The prevalence of SIBO and IMO were higher in patients with H. pylori infection than in those without infection (49.1% vs 24.5%, P = 0.019 for SIBO; 24.5% vs 8.2%, P = 0.027 for IMO). GSRS scores were similar between H. pylori-infected and uninfected patients (2 (IQR: 1;3) vs 2 (IQR: 1;2), P = 0.211). Patients with SIBO or IMO presented higher GSRS scores than patients with both SIBO and IMO negative (2 (IQR: 2;3), 2 (IQR: 2;3) vs 2 (IQR: 1;2), P = 0.011, 0.001, respectively). For the 50 patients who successfully eradicated H. pylori, the response rates for SIBO and IMO were 66.7% and 76.9%, respectively. GSRS scores also significantly decreased (2 (IQR: 1;3) to 0 (IQR: 0;1), P < 0.001) after eradication.

CONCLUSION

Helicobacter pylori infection was associated with higher prevalence of SIBO and IMO, both of which led to more pronounced abdominal symptoms. H. pylori eradication also achieved therapeutic effects on SIBO and IMO, accompanied by relief of abdominal symptoms.

Endoscopic sphincterotomy for adults with biliary sphincter of Oddi dysfunction

BACKGROUND

The sphincter of Oddi comprises a muscular complex encircling the distal part of the common bile duct and the pancreatic duct regulating the outflow from these ducts. Sphincter of Oddi dysfunction refers to the abnormal opening and closing of the muscular valve, which impairs the circulation of bile and pancreatic juices.

OBJECTIVES

To evaluate the benefits and harms of any type of endoscopic sphincterotomy compared with a placebo drug, sham operation, or any pharmaceutical treatment, administered orally or endoscopically, alone or in combination, or a different type of endoscopic sphincterotomy in adults with biliary sphincter of Oddi dysfunction.

SEARCH METHODS

We used extensive Cochrane search methods. The latest search date was 16 May 2023.

SELECTION CRITERIA

We included randomised clinical trials assessing any type of endoscopic sphincterotomy versus placebo drug, sham operation, or any pharmaceutical treatment, alone or in combination, or a different type of endoscopic sphincterotomy in adults diagnosed with sphincter of Oddi dysfunction, irrespective of year, language of publication, format, or outcomes reported.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods and Review Manager to prepare the review. Our primary outcomes were: proportion of participants without successful treatment; proportion of participants with one or more serious adverse events; and health-related quality of life. Our secondary outcomes were: all-cause mortality; proportion of participants with one or more non-serious adverse events; length of hospital stay; and proportion of participants without improvement in liver function tests. We used the outcome data at the longest follow-up and the random-effects model for our primary analyses. We assessed the risk of bias of the included trials using RoB 2 and the certainty of evidence using GRADE. We planned to present the results of time-to-event outcomes as hazard ratios (HR). We presented dichotomous outcomes as risk ratios (RR) and continuous outcomes as mean difference (MD) with their 95% confidence intervals (CI).

MAIN RESULTS

We included four randomised clinical trials, including 433 participants. Trials were published between 1989 and 2015. The trial participants had sphincter of Oddi dysfunction. Two trials were conducted in the USA, one in Australia, and one in Japan. One was a multicentre trial conducted in seven US centres, and the remaining three were single-centre trials. One trial used a two-stage randomisation, resulting in two comparisons. The number of participants in the four trials ranged from 47 to 214 (median 86), with a median age of 45 years, and the mean proportion of males was 49%. The follow-up duration ranged from one year to four years after the end of treatment. All trials assessed one or more outcomes of interest to our review. The trials provided data for the comparisons and outcomes below, in conformity with our review protocol. The certainty of evidence for all the outcomes was very low. Endoscopic sphincterotomy versus sham Endoscopic sphincterotomy versus sham may have little to no effect on treatment success (RR 1.05, 95% CI 0.66 to 1.66; 3 trials, 340 participants; follow-up range 1 to 4 years); serious adverse events (RR 0.71, 95% CI 0.34 to 1.46; 1 trial, 214 participants; follow-up 1 year), health-related quality of life (Physical scale) (MD -1.00, 95% CI -3.84 to 1.84; 1 trial, 214 participants; follow-up 1 year), health-related quality of life (Mental scale) (MD -1.00, 95% CI -4.16 to 2.16; 1 trial, 214 participants; follow-up 1 year), and no improvement in liver function test (RR 0.89, 95% CI 0.35 to 2.26; 1 trial, 47 participants; follow-up 1 year), but the evidence is very uncertain. Endoscopic sphincterotomy versus endoscopic papillary balloon dilation Endoscopic sphincterotomy versus endoscopic papillary balloon dilationmay have little to no effect on serious adverse events (RR 0.34, 95% CI 0.04 to 3.15; 1 trial, 91 participants; follow-up 1 year), but the evidence is very uncertain. Endoscopic sphincterotomy versus dual endoscopic sphincterotomy Endoscopic sphincterotomy versus dual endoscopic sphincterotomy may have little to no effect on treatment success (RR 0.65, 95% CI 0.32 to 1.31; 1 trial, 99 participants; follow-up 1 year), but the evidence is very uncertain. Funding One trial did not provide any information on sponsorship; one trial was funded by a foundation (the National Institutes of Diabetes and Digestive and Kidney Diseases, NIDDK), and two trials seemed to be funded by the local health institutes or universities where the investigators worked. We did not identify any ongoing randomised clinical trials.

AUTHORS' CONCLUSIONS

Based on very low-certainty evidence from the trials included in this review, we do not know if endoscopic sphincterotomy versus sham or versus dual endoscopic sphincterotomy increases, reduces, or makes no difference to the number of people with treatment success; if endoscopic sphincterotomy versus sham or versus endoscopic papillary balloon dilation increases, reduces, or makes no difference to serious adverse events; or if endoscopic sphincterotomy versus sham improves, worsens, or makes no difference to health-related quality of life and liver function tests in adults with biliary sphincter of Oddi dysfunction. Evidence on the effect of endoscopic sphincterotomy compared with sham, endoscopic papillary balloon dilation,or dual endoscopic sphincterotomyon all-cause mortality, non-serious adverse events, and length of hospital stay is lacking. We found no trials comparing endoscopic sphincterotomy versus a placebo drug or versus any other pharmaceutical treatment, alone or in combination. All four trials were underpowered and lacked trial data on clinically important outcomes. We lack randomised clinical trials assessing clinically and patient-relevant outcomes to demonstrate the effects of endoscopic sphincterotomy in adults with biliary sphincter of Oddi dysfunction.

Minimal endoscopic sphincterotomy followed by papillary balloon dilation to relieve choledocholithiasis in a 6-year-old girl with hereditary spherocytosis

A 6-year-old girl previously diagnosed with hereditary spherocytosis was admitted to our hospital with gallstones and cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, and fluoroscopy revealed a dilated common bile duct (CBD) without evident stones, possibly due to spontaneous excretion through the papilla of Vater. A 7-French plastic stent was inserted into the CBD. After the procedure, a marked increase in pancreatic enzyme levels was observed, and she was diagnosed with post-ERCP pancreatitis (PEP). Stent placement could have been a cause of pancreatitis; therefore, we removed the stent. Subsequently, recovery from pancreatitis was confirmed, although she suddenly complained of abdominal pain and was diagnosed with choledocholithiasis recurrence. ERCP was repeated, and fluoroscopy revealed a dilated CBD with a stone. A minimal endoscopic sphincterotomy (EST) was performed to reduce the risk of PEP, and a biliary dilation balloon placed across the papilla was gradually inflated until the waist of the balloon disappeared. Stones were extracted using a retrieval balloon catheter. The abdominal pain resolved immediately, and the patient recovered without developing PEP. To our knowledge, this is the first case report of a pediatric patient treated with minimal EST followed by papillary balloon dilation for choledocholithiasis.

BRAZILIAN CLINICAL GUIDELINE FOR THE THERAPEUTIC MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE (BRAZILIAN FEDERATION OF GASTROENTEROLOGY, FBG)

BACKGROUND

Gastroesophageal Reflux Disease (GERD) is a prevalent condition in Brazil, affecting 12% to 20% of the urban population, with significant implications for patient quality of life and potential for complications.

OBJECTIVE

This paper focuses on the recent update of the Brazilian guidelines for GERD, a necessary revision due to advancements in knowledge and practice since the last publication over a decade ago. The update pays particular attention to the role and safety of proton pump inhibitors (PPIs), acknowledging the growing concerns about their long-term use, adverse events, and overprescription.

METHODS

The methodology of the guideline update involved an extensive literature review in multiple languages (English, French, Italian, Spanish, and Portuguese), drawing from major databases such as Medline, Embase, and SciELO-Lilacs.

RESULTS

This comprehensive approach resulted in a carefully curated selection of studies, systematic reviews, and meta-analyses, specifically focusing on PPIs and other therapeutic strategies for GERD. The updated guidelines are presented in a user-friendly question-and-answer format, adhering to the PICO system (Population, Intervention, Comparison, Outcomes) for clarity and ease of interpretation. The recommendations are supported by robust scientific evidence and expert opinions, enhancing their practical applicability in clinical settings. To ensure the reliability and clarity of the recommendations, the GRADE system (Grading of Recommendations Assessment, Development, and Evaluation) was employed. This system categorizes the strength of recommendations as strong, weak, or conditional and classifies evidence quality as high, moderate, low, or very low. These classifications provide insight into the confidence level of each recommendation and the likelihood of future research impacting these guidelines.

CONCLUSION

The primary aim of these updated guidelines is to offer practical, evidence-based advice for the management of GERD in Brazil, ensuring that healthcare professionals are equipped with the latest knowledge and tools to deliver optimal patient care.

BACKGROUND

•Gastrointestinal specialists rely heavily on guidelines to manage digestive pathologies effectively. The Brazilian clinical guideline for therapeutic management of gastroesophageal reflux disease (GERD) is an invaluable tool for these specialists.

BACKGROUND

•It critically analyzes practical aspects of therapy through 12 questions covering a wide range of topics, from behavioral measures to surgical and endoscopic indications.

BACKGROUND

•The recommendations in this guideline are justified using the GRADE system (Grading of Recommendations Assessment, Development, and Evaluation), and experienced experts provide comments and suggestions at the end of each question.

Increase in acute pancreatitis, especially gallstone related, as the cause for emergency admissions: Temporal trend from Kashmir, India

BACKGROUND

The incidence of acute pancreatitis is increasing globally. Gallstones (GS) and ascariasis are the major causes for acute pancreatitis in the Kashmiri population. In recent years, we have observed an increase in the admission rate of acute pancreatitis. Many patients who present first time as gallstone pancreatitis have asymptomatic gallstones. We aimed at studying the etiology and yearly admission rate of acute pancreatitis with main focus on gallstone pancreatitis and the contribution of asymptomatic gallstones.

METHODS

This was a hospital-based, prospective, observational study from January 2015 to December 2019 for a period of five years. Patients of acute pancreatitis were evaluated for etiology and yearly admission rate. Patients of gallstone pancreatitis were evaluated in terms of clinical profile, risk factors, nature (symptomatic/asymptomatic, known/unknown gallstones), size of stones, treatment and outcome in terms of severity and mortality. The data was analyzed by Statistical Package for the Social Sciences (SPSS) version 20.0, as mean (SD), frequencies and percentages.

RESULTS

As many as 702 (8.5%) patients of acute pancreatitis were admitted among 8245 gastrointestinal emergencies in five years. The yearly admission rate of acute pancreatitis was 5.6%, 7.3%, 8.7%, 9.5% and 10.3%, respectively (p = 0.013). Gallstones, Ascariasis, alcohol and idiopathic acute pancreatitis were 47.7%, 6.9%, 1.2% and 33.7%, respectively. Gallstone pancreatitis increased from 31% in 2015 to 52.4% in 2019 (p = 0.045) and ascariasis-related acute pancreatitis declined from 14.4% to 1.6% (p = 0.034). Asymptomatic gallstones constituted 87.7% of cases. Known/unknown asymptomatic gallstones and symptomatic gallstones were 24.4%, 63.2% and 12.2%, respectively. Gallstones < 5 mm and > 5 mm were76.1% and 23.8% respectively (p = 0.027). Cholecystectomy rate in index admission was 4.7%. Mild, moderate and severe gallstone pancreatitis was 60.2%, 18.8% and 20.8%, respectively. Mortality in gallstone pancreatitis was 10.4%.

CONCLUSION

The incidence of acute pancreatitis is increasing due to gallstone pancreatitis. Ascariasis-related acute pancreatitis has declined. There is significant contribution of asymptomatic gallstones in patients who present for the first time as acute pancreatitis. Small gallstones < 5 mm are likely to be the risk factors for gallstone pancreatitis.

The Role of Imaging for GI Bleeding: ACG and SAR Consensus Recommendations

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high health care utilization and costs. Radiologic techniques including CT angiography, catheter angiography, CT enterography, MR enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist, which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided. © Radiological Society of North America and the American College of Gastroenterology, 2024. Supplemental material is available for this article. This article is being published concurrently in American Journal of Gastroenterology and Radiology. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Citations from either journal can be used when citing this article. See also the editorial by Lockhart in this issue.

Correlation Between Hypothyroidism and Gallstone Disease in Central India

Introduction The decreased thyroid-stimulating hormone (TSH) levels affect almost every nucleated cell in our body, which directly affects the basal metabolic rate (BMR). It tends to affect multiple organ systems in the human body. In recent times, there have been changes in lifestyle and the consumption of processed foods has increased. Thus, cholelithiasis and hypothyroidism are being encountered frequently, even in rural populations. In recent times, the overt clinical presentation of hypothyroidism is rare due to early diagnosis and treatment of the subclinical hypothyroidism state itself. Aim The aim is to determine the correlation between cholelithiasis and hypothyroidism. Methods This was a cross-sectional study done on the patients presenting to the surgical department at Acharya Vinoba Bhave Rural Hospital affiliated to Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, India between the duration from December 2020 to December 2022, having gallstone disease or with symptoms suggestive of gall bladder stones. The admitted patients were then evaluated for hypothyroidism by thyroid profile tests, and the results were documented. Using the collected data, factors such as clinical spectrum, correlation between cholelithiasis and hypothyroidism, relation with the demographic data, and body mass index (BMI) were studied. Results A total of 52 gallstone patients were included in the study. A greater number of patients were found to be above the age of 40 years (82.7%), with female preponderance (61.5%). More patients with cholelithiasis were from the group with having BMI more than normal (57.6%). More patients having both cholelithiasis and hypothyroidism were also from the group with having BMI more than normal. Most symptomatic patients complained of pain in the right hypochondriac region (88.5%). Of these 52 patients, nine (17.3%) were found to have hypothyroidism (seven were subclinical, two patients had overt clinical symptoms and signs) and the remaining 43 patients were euthyroid. Conclusions Our study supports that there is a correlation between cholelithiasis and hypothyroidism. Out of all the 52 patients, nine had hypothyroidism, seven were subclinical, and two had overt symptoms. Thus, we conclude that there is a correlation between cholelithiasis and hypothyroidism.

Novel choledochojejunostomy technique "T-shaped anastomosis" for preventing the development of postoperative cholangitis in pancreatoduodenectomy: A propensity score matching analysis

Background

There have been few studies of countermeasures against postoperative cholangitis, a serious complication after pancreaticoduodenectomy (PD) that impairs quality of life.

Objective

To evaluate our recently developed, novel method of choledochojejunostomy with a larger anastomotic diameter, the "T-shaped anastomosis."

Methods

The study included 261 cases of PD. The T-shaped choledochojejunostomy technique was performed with an additional incision for a distance greater than half the diameter of the bile duct at the anterior wall of the bile duct and the anterior wall of the elevated jejunum. To compensate for potential confounding biases between the standard anastomosis group (n = 206) and the T-shaped anastomosis group (n = 55), we performed propensity score matching (PSM). The primary endpoint was the incidence of medium-term postoperative cholangitis adjusted for PSM.

Results

In the PSM analysis, 54 patients in each group were matched, and the median bile duct diameter measured by preoperative CT was 8.8 mm versus 9.3 mm, the rate of preoperative biliary drainage was 31% versus 37%, the incidence of cholangitis within 1 month before surgery was 9% versus 13%, and the incidence of postoperative bile leakage was 2% versus 2%, with no significant differences. The incidence of medium-term postoperative cholangitis was 15% versus 4%, and multivariate logistic regression revealed that T-shaped choledochojejunostomy was an independent predictor of a reduced incidence of cholangitis (odds ratio, 0.17, 95% CI 0.02-0.81; p = 0.024).

Conclusions

The T-shaped choledochojejunostomy technique was shown to be effective with a significant reduction in the incidence of medium-term postoperative cholangitis. Clinical trial identification: UMIN000050990.

Biliary complications after adult-to-adult living-donor liver transplantation: An international multicenter study of 3633 cases

In living-donor liver transplantation, biliary complications including bile leaks and biliary anastomotic strictures remain significant challenges, with incidences varying across different centers. This multicentric retrospective study (2016-2020) included 3633 adult patients from 18 centers and aimed to identify risk factors for these biliary complications and their impact on patient survival. Incidences of bile leaks and biliary strictures were 11.4% and 20.6%, respectively. Key risk factors for bile leaks included multiple bile duct anastomoses (odds ratio, [OR] 1.8), Roux-en-Y hepaticojejunostomy (OR, 1.4), and a history of major abdominal surgery (OR, 1.4). For biliary anastomotic strictures, risk factors were ABO incompatibility (OR, 1.4), blood loss >1 L (OR, 1.4), and previous abdominal surgery (OR, 1.7). Patients experiencing biliary complications had extended hospital stays, increased incidence of major complications, and higher comprehensive complication index scores. The impact on graft survival became evident after accounting for immortal time bias using time-dependent covariate survival analysis. Bile leaks and biliary anastomotic strictures were associated with adjusted hazard ratios of 1.7 and 1.8 for graft survival, respectively. The study underscores the importance of minimizing these risks through careful donor selection and preoperative planning, as biliary complications significantly affect graft survival, despite the availability of effective treatments.

Clinical profile of 1208 newly diagnosed colorectal cancer patients in Tamil Nadu-A multi-centric survey

BACKGROUND

An increasing incidence of colorectal cancer (CRC) is being reported in developing countries, including India. Most Indian studies on CRC are retrospective and single-centered. The present study is an attempt to understand the current clinical profile and stage of newly diagnosed CRCs across multiple centers in Tamil Nadu, India.

METHODS

A multi-centric observational survey was conducted between September 1, 2021, and August 31, 2022, under the aegis of the Indian Society of Gastroenterology - Tamil Nadu chapter. Patients 18 years of age and older with a recent diagnosis of CRC fulfilling the inclusion criteria were prospectively recruited at the participating centers. Their demographic, clinical, biochemical, endoscopic, histopathologic, radiologic and risk factor details were systematically collected and analyzed.

RESULTS

Across 23 centers in Tamil Nadu, 1208 patients were recruited. The male:female ratio was 1.49:1, while mean (SD) age was 57.7 (13.5) years. A majority (81.9%) were Tamils and 78.5% belonged to lower socioeconomic classes. The predominant symptoms were hematochezia (30.2%) and a change in bowel habits (27.5%). The most common locations were the rectum (34.3%) and rectosigmoid (15.1%). Synchronous CRCs were seen in 3.3% and synchronous colorectal polyps in 12.8%. Predisposing factors for CRC were seen in 2%. A past history of any cancer among CRC patients was obtained in 3.1% and a family history of any cancer was found in 7.6%. Patients who were either overweight or obese constituted 46.4% of the study population. At presentation, the predominant stages were stage III (44.7%) and stage IV (20.8%).

CONCLUSIONS

A majority of patients with newly diagnosed CRC in Tamil Nadu belonged to the lower socioeconomic classes. About 60% had CRCs located within the reach of the flexible sigmoidoscope. Two-thirds of the patients exceeded stage II disease at presentation.

TRIAL REGISTRATION

Not applicable.

Laboratory Assessment of Molluscicidal Activities of Cannabis sativa, Acacia nilotica, and Tinospora cordifolia Against Snail Host of Fasciola spp

Background: The potential molluscicidal extracts, obtained from indigenous plants Cannabis sativa, Acacia nilotica, and Tinospora cordifolia, were tested for toxicity against freshwater pulmonate snail Lymnaea acuminata, an intermediate host of Fasciola hepatica. The organic extracts had a significant effect on young snails. Materials and Methods: All organic extracts and column-purified fractions gave median lethal concentrations (19-100.05 mg/L; 24 h) that fell well within the threshold level of 100 mg/L, set for a potential molluscicide by the World Health Organization. Results: The toxicity of T. cordifolia stem acetone extract (96 h LC50: 16.08 mg/L) was more pronounced compared with C. sativa leaf ethanol extract (96 h LC50: 16.32 mg/L) and A. nilotica leaf ethanol extract (96 h LC50: 24.78 mg/L). β-caryophyllene, gallic acid, and berberine were characterized and identified as active molluscicidal components. Co-migration of β-caryophyllene (retardation factor [Rf] 0.95), gallic acid (Rf 0.30), and berberine (Rf 0.23) with column-purified parts of Cannabis sativa, Acacia nilotica, and Tinospora cordifolia on thin-layer chromatography demonstrates same Rf value, that is, 0.95, 0.30, and 0.23, respectively. Conclusion: This study indicates that these extracts thus represent potential plant-derived molluscicides that are worthy of further investigations.

Wake up to gastro-oesophageal reflux disease: The interplay between arousal and night-time reflux

This review examines the temporal association between nocturnal gastro-oesophageal reflux and sleep-arousal cycles. Most nocturnal gastro-oesophageal reflux events occur during the awake cycle, and arousals precede most nocturnal gastro-oesophageal reflux events, indicating that arousal from sleep predisposes to nocturnal gastro-oesophageal reflux. This sheds light on the complex relationship between nocturnal gastro-oesophageal reflux and sleep, and has implications for managing nocturnal gastro-oesophageal reflux symptoms. The appearance of symptoms and the pathophysiology of nocturnal gastro-oesophageal reflux are influenced by sleep hygiene, sleep disturbances and the misalignment of circadian rhythms. Nocturnal gastro-oesophageal reflux and its related sleep disorders are prevalent and negatively impact the quality of life. There is conflicting evidence on whether nocturnal gastro-oesophageal reflux and sleep disturbances are causally linked, and whether sleep disturbances drive nocturnal gastro-oesophageal reflux. Poor sleep quality increases oesophageal hypersensitivity and overall acid exposure. The nocturnal gastro-oesophageal reflux is linked to the more severe forms of gastro-oesophageal reflux disease, especially with atypical/extra-oesophageal manifestations and complications of mucosal damage such as oesophagitis and stricture, Barret's oesophagus, and oesophageal adenocarcinoma. This review highlights the role of sleep problems in presenting nocturnal gastro-oesophageal reflux, and the potential benefits of treating sleep disturbances in enhancing patient care and quality of life.

Endoscopic full-thickness plication for the treatment of gastroesophageal reflux disease: A systematic review and meta-analysis

Background and study aims Gastroesophageal reflux disease (GERD) is a widespread chronic gastrointestinal condition with an increasing worldwide prevalence. This research was a systematic review and meta-analysis evaluating the efficacy, safety, and long-term outcomes of endoscopic full-thickness plication (EFTP) for the treatment of GERD. Methods A comprehensive search of databases was conducted for studies published up to April 2023. We included randomized controlled trials (RCTs) and prospective observational studies that examined the use of EFTP in treating GERD among adult patients. We calculated pooled effect estimates using a random-effects model. Results EFTP significantly improved GERD Health-Related Quality of Life (GERD-HRQL) scores at 3-, 6-, and 12-month follow-up intervals. A considerable proportion of patients discontinued proton pump inhibitors, with cessation rates of 59% (95% confidence interval [CI]: 0.47-0.71), 68% (95% CI: 0.58-0.78), and 67% (95% CI: 0.46-0.89,) at 3, 6, and 12 months, respectively. At 3 and 6 months, 61% (95% CI: 0.54-0.68) and 66% (95% CI: 0.56-0.76) of patients experienced ≥50% improvement in GERD-HRQL scores. EFTP demonstrated a favorable safety profile, with a low rate of severe adverse events. We observed a 6.76% reduction (95% CI: -14.53-1.02) in the percentage of time with esophageal pH <4, a decrease in DeMeester scores, and fewer total reflux episodes. The average procedure time was 22.75 minutes (95% CI: 22.03-23.48). Subgroup analyses suggest that both the GERDx system and the NDO Plicator are effective and safe in treating GERD. Conclusions The findings from our study reveal that EFTP is a safe and effective treatment for GERD patients who have not responded adequately to conventional therapies. Given its minimally invasive nature, effectiveness, and limited adverse effects, EFTP emerges as a compelling alternative to conventional surgical procedures.

Refractory Gastroesophageal Reflux Disease: Diagnosis and Management

Gastroesophageal reflux disease (GERD) is common, with increasing worldwide disease prevalence and high economic burden. A significant number of patients will remain symptomatic following an empiric proton pump inhibitor (PPI) trial. Persistent symptoms despite PPI therapy are often mislabeled as refractory GERD. For patients with no prior GERD evidence (unproven GERD), testing is performed off antisecretory therapy to identify objective evidence of pathologic reflux using criteria outlined by the Lyon consensus. In proven GERD, differentiation between refractory symptoms (persisting symptoms despite optimized antisecretory therapy) and refractory GERD (abnormal reflux metrics on ambulatory pH impedance monitoring and/or persistent erosive esophagitis on endoscopy while on optimized PPI therapy) can direct subsequent management. While refractory symptoms may arise from esophageal hypersensitivity or functional heartburn, proven refractory GERD requires personalization of the management approach, tapping from an array of non-pharmacologic, pharmacologic, endoscopic, and surgical interventions. Proper diagnosis and management of refractory GERD is critical to mitigate undesirable long-term complications such as strictures, Barrett's esophagus, and esophageal adenocarcinoma. This review outlines the diagnostic workup of patients presenting with refractory GERD symptoms, describes the distinction between unproven and proven GERD, and provides a comprehensive review of the current treatment strategies available for the management of refractory GERD.

Coconut Water Induces Clinical Remission in Mild to Moderate Ulcerative Colitis: Double-blind Placebo-controlled Trial

BACKGROUND & AIMS

Coconut water (CW) is anti-inflammatory, can manipulate the gut microbiome, and is a rich source of potassium. Gut microbiome modulation improves outcomes in ulcerative colitis (UC), and potassium possesses in vitro anti-inflammatory property. We evaluated the effect of CW as an adjunct therapy for patients with mild-moderate UC.

METHODS

This single-center, double-blind, placebo-controlled trial randomized patients with mild to moderate (Simple Clinical Colitis Activity Index [SCCAI] :3-9) endoscopically active UC (Ulcerative Colitis Endoscopic Index of Severity [UCEIS] >1) in 1:1 ratio to CW + standard medical therapy (SMT) vs placebo + SMT. Four hundred mL of CW was administered for 8 weeks. Primary outcome measure was clinical remission (SCCAI ≤2), and secondary outcome measures were clinical response (SCCAI decline ≥3) and adverse events at 8 weeks. Microbiome was analyzed at baseline and 8 weeks.

RESULTS

Of 121 patients screened, 95 were included for modified intention to treat analysis (CW, n = 49; placebo, n = 46) (mean age, 37.2 ± 1.2 years; males, 54.1%; disease duration, 48 months [interquartile range (IQR), 24-90 months]; pancolitis, 26.1%; SCCAI, 5 [IQR, 4-6]; UCEIS, 4 [IQR, 3-5]). Clinical response (57.1% vs 28.3%; odds ratio [OR], 3.4; 95% confidence interval [CI], 1.4-7.9; P = .01), remission (53.1% vs 28.3%; OR, 2.9; 95% CI, 1.2-6.7; P = .02), and proportion of patients with fecal calprotectin (FCP) <150 μg/g (30.6% vs 6.5%; OR, 6.3; 95% CI, 1.7-23.6; P = .003) were significantly higher in CW. The relative abundance of bacterial taxa that had a significant or trend towards negative correlation with SCCAI, UCEIS, or FCP increased at 8 weeks in CW, and this effect was independent of disease activity and dietary fiber. Adverse events were comparable, and no patient developed hyperkalemia.

CONCLUSIONS

CW was more effective than placebo for induction of clinical remission in patients with mild to moderate UC. The trial was prospectively registered on Clinical Trials Registry of India (No: CTRI/2019/03/01827).

Helicobacter pylori infection in humans and phytotherapy, probiotics, and emerging therapeutic interventions: a review

The global prevalence of Helicobacter pylori (H. pylori) infection remains high, indicating a persistent presence of this pathogenic bacterium capable of infecting humans. This review summarizes the population demographics, transmission routes, as well as conventional and novel therapeutic approaches for H. pylori infection. The prevalence of H. pylori infection exceeds 30% in numerous countries worldwide and can be transmitted through interpersonal and zoonotic routes. Cytotoxin-related gene A (CagA) and vacuolar cytotoxin A (VacA) are the main virulence factors of H. pylori, contributing to its steep global infection rate. Preventative measures should be taken from people's living habits and dietary factors to reduce H. pylori infection. Phytotherapy, probiotics therapies and some emerging therapies have emerged as alternative treatments for H. pylori infection, addressing the issue of elevated antibiotic resistance rates. Plant extracts primarily target urease activity and adhesion activity to treat H. pylori, while probiotics prevent H. pylori infection through both immune and non-immune pathways. In the future, the primary research focus will be on combining multiple treatment methods to effectively eradicate H. pylori infection.

Management advice for patients with reflux-like symptoms: an evidence-based consensus

Patients with reflux-like symptoms (heartburn and regurgitation) are often not well advised on implementing individualised strategies to help control their symptoms using dietary changes, lifestyle modifications, behavioural changes or fast-acting rescue therapies. One reason for this may be the lack of emphasis in management guidelines owing to 'low-quality' evidence and a paucity of interventional studies. Thus, a panel of 11 gastroenterologists and primary care doctors used the Delphi method to develop consolidated advice for patients based on expert consensus. A steering committee selected topics for literature searches using the PubMed database, and a modified Delphi process including two online meetings and two rounds of voting was conducted to generate consensus statements based on prespecified criteria (67% voting 'strongly agree' or 'agree with minor reservation'). After expert discussion and two rounds of voting, 21 consensus statements were generated, and assigned strength of evidence and Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) rating. Eleven statements achieved the strongest (100%) agreement: five are related to diet and include identification and avoidance of dietary triggers, limiting alcohol, coffee and carbonated beverages, and advising patients troubled by postprandial symptoms not to overeat; the remaining six statements concern advice around smoking cessation, weight loss, raising the head-of-the-bed, avoiding recumbency after meals, stress reduction and alginate use. The aim of developing the consensus statements is that they may serve as a foundation for tools and advice that can routinely help patients with reflux-like symptoms better understand the causes of their symptoms and manage their individual risk factors and triggers.

Leveraging the Multidimensional Poverty Index to estimate Helicobacter pylori prevalence in districts in Karnataka, India

The prevalence of Helicobacter pylori (Hp) in India is approximately 64%. However, substantial regional variations necessitate high-fidelity, locality-specific studies to characterise its population distribution in India. We conducted a cross-sectional study including 2998 dyspeptic patients at a tertiary care centre in Karnataka and investigated the relationship between Hp prevalence and the Multidimensional Poverty Index (MPI) by district. Helicobacter pylori prevalence in our population was 43.2% with a significant correlation between district-specific Hp prevalence and MPI. This data can be leveraged for evaluating local Hp infection control strategies, planning interventions for Hp hotspots in Karnataka and predicting a dyspeptic patient's risk of Hp infection.

Non-Traumatic Hepatobiliary Emergencies

Hepatobiliary emergencies typically present with a constellation of different symptoms including abdominal pain, fevers, nausea, vomiting, jaundice, coagulopathy, and in some instances, encephalopathy. The differential can be broad and may include infectious, inflammatory, and even iatrogenic etiologies. Workup with appropriate lab and imaging studies can help discern between different pathologies and thus guide their management. Interventions can range broadly from conservative management with medical therapy to endoscopic options or surgery. This article explores the diagnostic workup and evaluation as well as the current therapeutic interventions for a variety of these nontraumatic hepatobiliary emergencies based on the most current literature.

Validation of Urdu Version of the Low Anterior Resection Syndrome (LARS) Score

Patients subjected to low anterior resection for rectal cancers experience a constellation of symptoms of disordered bowel function which leads to a detriment in the quality of life. The LAR syndrome (LARS) score is a self-administered questionnaire to identify and assess disordered bowel function after resective surgery. The objective of this study was to validate the Urdu version of the LARS score. The translation process was carried out in a fashion outlined by the original authors of the LARS score after obtaining proper permission. The validation of the translated version included the assessment of its reliability, convergent and discriminant validities, internal consistency, and confirmatory analyses. A total of 60 patients were enrolled in the study with a 95% power of study. The translated questionnaire was initially administered to a random subgroup of patients to verify the adequacy and degree of comprehension of questions. Then reproducibility was investigated by a test-retest procedure. An analysis was then done to determine the correlation between Urdu LARS score and a quality of life related question that was included along with the questionnaire. The Urdu version of the LARS score demonstrates a high convergent validity in terms of its correlation with self-reported quality of life. It also demonstrated its efficacy to discriminate between clinical variables expected to differ with regards to LARS. There was almost perfect agreement in the test and retest values demonstrating good reliability across all instruments. The Urdu version of the LARS score has proven to be a reliable and a valid tool for measuring LARS in the Urdu speaking population of the Indian subcontinent.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-023-01801-0.

Risk of avoidant/restrictive food intake disorder in patients with inflammatory bowel disease: predictive value of disease phenotype, disease activity and food literacy

BACKGROUND

Avoidant/Restrictive Food Intake Disorder (ARFID) is a newly described eating disorder. Adequate levels of food literacy allow individuals to have adequate food choices. This study aimed to assess the prevalence of ARFID and the level of food literacy in patients with inflammatory bowel disease (IBD) and to analyse the correlation between ARFID and food literacy.

METHOD

This cross-sectional study screened for ARFID and assessed food literacy levels in patients with IBD attending four tertiary hospitals in China. ARFID risk was measured using the Nine Item Avoidant/Restrictive Food Intake Disorder Screen (NIAS). Food literacy was assessed using the Food Literacy Evaluation Questionnaire (Chinese version, FLEQ-Ch).The relationship between individual NIAS scores and food literacy variables was analysed to assess which food literacy aspect is positively or negatively associated with NIAS scores. Stepwise linear regression analysis was performed to identify the possible predictors of NIAS scores in patients with IBD.

RESULT

A total of 372 IBD subjects completed the NIAS and FLEQ-Ch. The overall mean NIAS scores for the IBD cohort was 28.16 ± 8.03 (p < 0.01), and of the 372 participants, 123 (32.5%) had positive ARFID risk scores (≥ 10 NIAS-picky eating, ≥ 9 NIAS-poor appetite, and ≥ 10 NIAS-fear of negative consequences).The NIAS scores were inversely associated with food literacy levels (β =  - 0.299; p < 0.01).Disease phenotype, disease activity, and food literacy in patients with IBD provided valuable predictive insights for avoiding positive outcomes in ARFID.

CONCLUSION

This study shows that the risk of ARFID in the cohort of patients with IBD is associated with their inadequate food literacy levels. Therefore, this study supports the notion that patients with IBD should be assessed for food literacy regardless of whether they are currently diagnosed with ARFID. Specifically, for early identification of those at risk for ARFID in IBD, disease phenotype, disease activity, and food literacy should be routinely considered in clinical practice.The food literacy awareness of patients must be investigated and improved to predict the risk occurrence of ARFID and encourage healthy eating behaviour.

Indications, success, and adverse event rates of pediatric endoscopic retrograde cholangiopancreatography (ERCP): a systematic review and meta-analysis

BACKGROUND

To improve knowledge on endoscopic retrograde cholangiopancreatography (ERCP) in children, we aimed to study the proportion of indications, success rate and complication of ERCP.

METHODS

We performed a systematic search of all articles published up to December 2022 in the following databases: Cochrane Library, PubMed (MEDLINE) and Scopus. The meta-analysis was performed using a random-effects model. Heterogeneity was determined by the I2 statistics and the Cochrane Q test. The included data were analyzed to identify the proportion of indications, success rate and complications of ERCP in children.

RESULTS

Based on data from 52 studies with a total of 5624 participants, the most common indications for ERCP in children were biliary [48% (95% CI: 0.40 - 0.57; I2 = 98.17%, P < 0.001)] and both biliary and pancreatic [41% (95% CI: 0.33 - 0.49; I2 = 98.27%, P < 0.001)]. The success rate of ERCP was 95% (95% CI: 0.94 - 0.96; I2 = 82.53%, P < 0.001) with the overall complication rate of 7% (95% CI: 0.05 - 0.09; I2 = 82.06%, P < 0.001). The pooled estimate for the incidence of post ERCP pancreatitis was 4% (95% CI: 0.03 - 0.06; I2 = 85.46%, P < 0.001) and the bleeding was 0% (95% CI: 0.0 - 0.0; I2 = 28.21%, P = 0.03).

CONCLUSIONS

ERCP appears to be performed safely in children with a similar success rate as in the adult population.

My 40-Year Encounter with ERCP: A Saga of Service, Syndromes, and Solutions

Endoscopic retrograde cholangiopancreatography (ERCP) has been a significant development in gastrointestinal endoscopy. I did my first ERCP at SKIMS on December 5, 1982, and over the last 40 years, I have performed 10,100 ERCP procedures, including 600 Sphincter of Oddi manometries (SOM), and 3200 therapeutic ERCPs. We were confronted with many clinical challenges that needed answers by applying ERCP as a primary diagnostic tool. These studies gave birth to and/or recognition of several clinical syndromes. The hepatobiliary and pancreatic ascariasis (HBPA) as a clinical disease was recognized in 1985. The nematode, Ascaris lumbricoides, was the most common cause of hepatobiliary and pancreatic diseases in Kashmir, and its impact on healthcare, clinical profile, management policies, and control measures was identified. Kashmir was recognized as an endemic zone for recurrent pyogenic cholangitis (RPC), which constituted 12.5% of all biliary diseases. RPC in this population was found essentially to be an aftermath of HBPA. A subset of patients with hepatic hydatidosis with rupture into the biliary tract was recognized at ERCP and primarily treated by endotherapy. Cholangiographic abnormalities in children with portal cavernoma evolved into the recognition of portal biliopathy. Extensive studies of the sphincter of Oddi manometry in patients with unexplained biliary and/or pancreatic pain following cholecystectomy identified the entity of the sphincter of Oddi dyskinesia (SOD). In a cross-over trial, Nifedipine, compared with a placebo, showed a significant clinical response in 20 of 28 such patients. ERCP studies done in patients with tropical calcific pancreatitis showed an anomalous union of bile and pancreatic ducts. Forty of the 220 patients with liver transplantation had biliary complications namely biliary leaks, bile duct strictures, SOD, and recurrence of underlying primary biliary cholangitis. Biliary complications caused considerable morbidity and mortality in patients with liver transplantation.

Portosystemic Shunt Surgery for Extrahepatic Portal Venous Obstruction Beyond Endoscopic Variceal Eradication: Two Decades of Pediatric Surgical Experience

Background

This exclusively surgical series on pediatric extrahepatic portal venous obstruction (EHPVO) defines surgical indications beyond endoscopic eradication of esophageal varices (EEEV), the selection of an appropriate surgical procedure, and the long-term post-surgical outcome.

Methods

EHPVO management protocol at the reporting institute has been endotherapy until esophageal variceal eradication and surgery for select adverse sequelae manifesting after EEEV.

Results

One hundred and thirty-nine EHPVO cases underwent surgery for the following indications in combination: i) massive splenomegaly with severe hypersplenism (n = 132, 95%); ii) growth retardation (GR, n = 95, 68%); iii) isolated gastric (IGV) and ectopic varices (n = 49, 35%); iv) Portal cavernoma cholangiopathy (PCC) (n = 07, 5%). A portosystemic shunt (PSS) was performed in 119 (86%) cases. Types of PSS performed were as follows: central end-to-side splenorenal shunt with splenectomy (n = 104); side-to-side splenorenal shunt (n = 4); mesocaval shunt (n = 1); inferior mesenteric vein (IMV) to left renal vein shunt (n = 2); IMV to inferior vena cava shunt (n = 3); H-graft interposition splenorenal shunt (n = 1); spleno-adrenal shunt (n = 3); makeshift shunt (n = 1). Esophagogastric devascularization (n = 20, 14%) was opted for only for non-shuntable anatomy. At a median follow-up (FU) of 41 (range: 6-228) months, PSS block was detected in 13 (11%) cases, with recurrent variceal bleeding in 4 cases. PCC-related cholestasis regressed in 5 of 7 cases. Issues of splenomegaly were resolved, and growth z-scores improved significantly.

Conclusions

Endotherapy for secondary prophylaxis until EEEV has resulted in a shift in surgical indications for EHPVO. Beyond EEEV, surgery was indicated predominantly for non-variceal sequelae, namely massive splenomegaly with severe hypersplenism, GR, and PCC. Varices warranted surgery infrequently but more often from sites less amenable to endotherapy, i.e., IGV and ectopic varices. The selection of PSS was tailored to anatomy and surgical indications. On long-term FU post surgery, PSS block was detected in 13% of patients. PCC-related cholestasis regressed in 71%, and issues of splenomegaly resolved with significantly improved growth Z scores.

Prevesical hydatid cyst: A case report

Hydatid cyst is a zoonotic disease caused by a tapeworm of the genus Echinococcus granulosus either in its adult or larval forms. Original pelvic cysts are rare; however, the majority of abdominal and pelvic hydatid cysts are believed to result from inadvertent surgical inoculation or spontaneous rupture from a primary hepatic focus. We present a 35-year-old female patient who visited our facility complaining of lower abdominal pain that had persisted for the last 5 months.

Endoscopic retrograde cholangiopancreatography for diagnosing and treating pediatric biliary and pancreatic diseases

BACKGROUND

This study evaluated the safety and effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) in pediatric patients with biliary and pancreatic diseases. A retrospective analysis was conducted on 57 ERCP procedures performed in 41 children, primarily for treating pancreatic diseases. The overall success rate was 91.2%, with no major complications observed. Post-ERCP pancreatitis (PEP) occurred in 8.8% of cases. Follow-up examinations over one year showed no recurrence of biliary or pancreatic diseases. Notably, endoscopic treatment led to a significant increase in body mass index (BMI). These findings demonstrate the valuable role of ERCP in managing such conditions.

AIM

To evaluate the safety and efficacy of ERCP for the management of biliary and pancreatic diseases in pediatric patients.

METHODS

We conducted a retrospective analysis of data from children aged 1-18 years who underwent ERCP for biliary and pancreatic diseases at Beijing Children's Hospital between January 2021 and December 2022. The collected data included procedure time, endoscopic treatment, success rate, and postoperative complications.

RESULTS

Forty-one children underwent 57 ERCP procedures, including 14 with biliary duct disease and 27 with pancreatic disease. The mean age of the patients was 7.48 ± 3.48 years. Biliary duct-related treatments were performed 18 times, and pancreatic disease treatments were performed 39 times. ERCP was primarily used to treat pediatric pancreatic diseases [68.4% (39/57) of the procedures]. The overall success rate was 91.2% (52/57 patients). PEP was noted in five patients (8.8%, 5/57), and no instances of bleeding, perforation, or cholangitis were observed. The patients were followed up for over one year, and no recurrence of biliary or pancreatic diseases was detected. Importantly, BMI significantly increased after endoscopic treatment compared to that before treatment (P = 0.001).

CONCLUSION

The high success rate and lack of major complications support the valuable role of ERCP in the management of pediatric biliary and pancreatic diseases in the pediatric population.

Left lateral decubitus sleeping position is associated with improved gastroesophageal reflux disease symptoms: A systematic review and meta-analysis

BACKGROUND

A limited number of studies have demonstrated that sleeping in the left lateral decubitus (LLD) decreases nocturnal reflux in patients with gastroesophageal reflux disease (GERD) compared to right lateral decubitus (RLD) and supine.

AIM

This systematic review summarizes the association between sleeping in the LLD position and nocturnal reflux in patients with GERD.

METHODS

Studies published up to July 17, 2023, in MEDLINE, EMBASE, and CENTRAL were searched. Eligible studies were randomized and nonrandomized studies assessing the effect of sleeping in LLD compared to RLD and supine in reducing nocturnal reflux in GERD patients. Outcomes include the acid exposure time (AET) (% time in pH<4), acid clearance time (ACT) (in sec/episode), number of reflux episodes, and improvement in N-GSSIQ scores.

RESULTS

Two nonrandomized studies showed decreased AET and ACT in LLD sleep position in comparison to RLD (mean difference [MD] -2.03 [95%CI: -3.62 to -0.45]; -81.84 [95%CI: -127.48 to -36.20], respectively) and supine position (MD -2.71 [95%CI: -4.34 to -1.09]; -74.47 [95%CI: -116.26 to -32.69], respectively). There was no difference in AET and ACT between RLD sleep position and supine. Furthermore, one randomized controlled trial investigating the use of electronic sleep positional therapy, which increased the duration of LLD sleep and decreased the duration of RLD sleep compared to sham, showed nocturnal symptoms improvement (improved N-GSSIQ score, increased reflux-free nights, and resolution of nocturnal reflux symptoms).

CONCLUSION

Current evidence suggests that sleeping on the left side could reduce nocturnal reflux and improve GERD-related quality of life, therefore warranting interventions that promote LLD sleep position.

Magnetic resonance imaging for acute pancreatitis in type 2 diabetes patients

Type 2 diabetes mellitus (T2DM) and its complications have significantly increased the burden of mortality and disability globally, making diabetes one of the most dangerous and prevalent chronic diseases. Acute pancreatitis (AP) is one of the most frequent gastrointestinal causes for hospital admission, which is a common exocrine pancreatic inflammatory disease that can cause severe abdominal pain and multiple organ dysfunction. There is an inseparable relationship between AP and diabetes. Diabetes is a high risk factor of AP, and patients with AP can develop pancreatogenic diabetes. In T2DM patients, the incidence rate of AP is significantly higher than that of the general population, and the clinical symptoms are more severe, with the majority of cases being moderate to severe AP. This review briefly introduces the pathogenesis and clinical features of AP in T2DM patients, focusing on the magnetic resonance imaging (MRI) manifestations of AP in T2DM patients. Our aim is to evaluate the severity of AP in patients with T2DM by MRI, so as to help clinicians assess the patient's condition and prognosis.

Current complementary and alternative therapy forgastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a widely prevalent gastrointestinal disorder, affecting ∼13.3% of the global population. There are shortages and limitations of current GERD treatment modalities, and complementary and alternative therapy (CAT) is a promising option to fill in the gap. Dietary and lifestyle modifications might play an important and complementary role in alleviating GERD symptoms. Traditional Chinese medicine and brain-gut behavior therapy, particularly transcutaneous electrical acustimulation and diaphragmatic breathing therapy were shown to be useful adjuncts or alternatives in treating GERD. CAT may help to relieve GERD symptoms, minimize medication dosage, and slow the demand for surgery. The aim of this review was to summarize the existing evidence of some common CATs in treating symptomatic GERD, including dietary modification, lifestyle change, traditional Chinese medicine, and brain-gut behavior therapy.

Hydatid Disease of the Liver

Background

Echinococcosis also known as hydatid disease is a zoonotic parasitic disease caused by a tapeworm. It has a worldwide distribution. For long, it was thought to be a problem of the poorly sanitized "third world" and not given the importance it deserved. However, its occurrence in countries like Australia and New Zealand and recently in countries in Central Europe has meant that it is included in a WHO list of neglected diseases, has recently been the subject of extensive epidemiological studies, and has been the recipient of increased research funding.

Summary

The diagnosis is still based on clinical presentation in an endemic area corroborated with typical findings on imaging which routinely include ultrasound and CT scan. Serological tests have been used in some centers to support the diagnosis. Treatment depends on the site of involvement and can vary from wait and watch to extensive radical surgical procedures. The common element of all treatments is the addition of albendazole which forms an essential cornerstone of all treatment protocols. Inspite having been used for a fairly long time, there is still no consensus on the dose, duration, and timing of therapy with albendazole.

Key Message

Hydatid disease continues to be a significant global health problem inspite of a good understanding of its life cycle and rising standards of public sanitation. Though diagnosis is straightforward and not expensive, treatment can sometimes be complicated. The addition of albendazole to all treatment protocols is an important advance, but firm guidelines on duration of its use are still awaited.

Guidelines on optimizing the use of proton pump inhibitors: PPI stewardship

Proton pump inhibitors (PPIs) have been available for over three decades and are among the most commonly prescribed medications. They are effective in treating a variety of gastric acid-related disorders. They are freely available and based on current evidence, use of PPIs for inappropriate indications and duration appears to be common. Over the years, concerns have been raised on the safety of PPIs as they have been associated with several adverse effects. Hence, there is a need for PPI stewardship to promote the use of PPIs for appropriate indication and duration. With this objective, the Indian Society of Gastroenterology has formulated guidelines on the rational use of PPIs. The guidelines were developed using a modified Delphi process. This paper presents these guidelines in detail, including the statements, review of literature, level of evidence and recommendations. This would help the clinicians in optimizing the use of PPIs in their practice and promote PPI stewardship.

Percutaneous treatment of liver hydatid cysts: to PAIR or not to PAIR

PURPOSE OF REVIEW

The aim is to review recent literature for percutaneous treatment of liver hydatid cysts (cystic echinococcosis: CE) via different techniques such as PAIR (puncture, aspiration, injection, and reaspiration), standard catheterization, and modified catheterization technique (MoCaT).

RECENT FINDINGS

PAIR is an established technique and considered to be safe and effective for CE1 and CE3a as it is associated with lower morbidity, mortality, recurrence, and shorter hospital stay as compared with surgery. Standard catheterization is also dedicated for the treatment of CE1 and CE3a. PAIR should be preferred for treatment of liver CE1 and CE3a cysts, since PAIR is associated with lower major complication rates and shorter hospital stay. However, standard catheterization technique is indicated when cysto-biliary fistula develops or any technical difficulty arises during the PAIR. In these cases it is needed to switch PAIR to standard catheterization to complete the procedure.

SUMMARY

For CE1 and CE3a cysts, PAIR and standard catheterization are the choice for percutaneous treatments, while MoCaT is a treatment option for CE2 and CE3b cysts.

ULTRASOUND-GUIDED PERCUTANEOUS TREATMENT OF HEPATIC HYDATIDOSIS IN TWO RED-SHANKED DOUC LANGURS (PYGATHRIX NEMAEUS)

Hydatid disease caused by Echinococcus ortleppi is a major cause of morbidity and mortality for critically endangered captive langurs in northern Vietnam. The most common sites for hydatid cyst development are the liver and the lungs. Chemotherapy trials with albendazole alone or in combination with praziquantel in these langurs had varying results and in most cases were ineffective. Ultrasound-guided percutaneous aspiration of cystic fluid followed by instillation and re-aspiration of a scolicidal agent (PAIR technique), has gained importance in the treatment of active hepatic cysts in humans and in many cases is preferred over surgical and endoscopic approaches. The PAIR technique was used in two red-shanked douc langurs (Pygathrix nemaeus) for the treatment of unilocular active hepatic cysts. The technique was found to be fairly easy to perform, safe, and effective and should be a useful treatment tool for hepatic hydatidosis in langurs and other nonhuman primate species.

Hydatid cyst of the hepatopancreatic groove - A case report

INTRODUCTION AND IMPORTANCE

Hydatid cysts are zoonoses caused by Echinococcus granulosus. It can affect any part of the body. The most common sites are the liver and lungs. Hydatid cyst of the hepatopancreatic groove is rare and to the best of our knowledge, this has not been reported in the literature before.

CASE PRESENTATION

We present a case of a young male patient who presented with abdomimal pain and jaundice. His workup revealed a hydatid cyst in the hepatopancreatic groove. Surgery for the hydatid cyst was done and the postoperative course was uneventful.

CLINICAL DISCUSSION

Hepatopancreatic groove is an atypical site for a hydatid cyst. The main symptoms of a patient include vomiting, discomfort as well as pain in the epigastrium. The diagnostic imaging techniques include an ultrasound, CT scan as well as an MRI. Definitive treatment includes the cyst to be surgically removed.

CONCLUSION

Hydatid cyst of the hepatopancreatic groove is rare. The diagnosis is usually not very easy and imaging can help in this regard. Surgery is the treatment modality of choice.

Survey of dietary beliefs and habits of inflammatory bowel disease patients

BACKGROUND & AIMS

It is presumed that diet plays a role in the prevention and pathogenesis of inflammatory bowel disease (IBD). Patients with Crohn's disease (CD) and ulcerative colitis (UC) often report a link between their disease and diet. However, studies evaluating patient perceptions on diet in IBD are lacking. This study aimed to assess patient beliefs on the role of diet in IBD and the adequacy of dietary advice they received.

METHODS

A self-administered questionnaire was offered to consecutive patients attending two IBD centers in Switzerland. Data were collected regarding patient dietary beliefs and behaviors and whether they received medical advice on their diet.

RESULTS

Of 210 questionnaires distributed, 171 were completed. Participants were mainly female (53%), young (median age 38 years) with either CD (66%) or UC (34%). Most patients believed that diet plays a role in their disease (74%), whereas only 15% believed that diet could be the trigger of their disease. Since their IBD diagnosis, more than half of patients (56%) modified their diet, and 39% did not receive dietary advice from their physicians or a dietician. Most patients (91-95%) ingested gluten, lactose, red and white meat. 20% of patients practiced intermittent fasting and only a minority had previously tried a low-FODMAP (9%) diet or probiotics supplementation (16%).

CONCLUSION

The majority of IBD patients believe that diet plays a role in their disease but have never received dietary advice from their doctor or a dietician. This highlights a need for more information for IBD patients on dietary advice from the medical profession.

'Eating is like experiencing a gamble': A qualitative study exploring the dietary decision-making process in adults with inflammatory bowel disease

BACKGROUND

For adults with inflammatory bowel disease (IBD), they experience many challenges in dietary decision-making. Thus, this study examined the perspective and experiences of adults with IBD in dietary decision-making.

OBJECTIVE

This study aimed to explore the perception and consideration of people with IBD in their daily dietary decisions through monitoring, interpretation and action during the decision-making process.

DESIGN

A qualitative study of individuals affected by IBD was conducted through semistructured interviews.

RESULTS

Twenty patients were recruited from four tertiary hospitals in Nanjing, China, and each participant completed a semistructured interview. The majority of participants reported on the process and experience of dietary decision-making. Key themes were categorised into three stages: (1) assessing needs, preferences and food cues (monitor); (2) moving from experience to expertise (interpret) and (3) balancing expectations amidst limitations (act). The majority of participants reported that their decisions were shaped by assessing current disease status and food cues. Those interviewed with IBD were willing to make tradeoffs for bowel stability, but their decisions were also influenced by past dietary experiences and traditional Chinese beliefs. The lack of awareness of dietary guidelines was a significant barrier to healthy eating decisions. Positive or negative feelings accompanied dietary decisions.

CONCLUSION

Although most people with IBD change their diet after diagnosis, the changes made are often inconsistent with existing dietary recommendations. Several factors can influence the dietary decision-making process. This study will help assess the experiences of people with IBD in dietary decision-making to encourage the formation of targeted dietary health and well-being interventions. Knowledge of nutrition and diet should be provided in education and training programmes for IBD management.

PATIENT OR PUBLIC CONTRIBUTION

The first three authors of this paper were the lead researchers in this study's design. These authors were mentored by patient researchers who also contributed to the manuscript, and the research process was co-lead and directed by other patient participants and consultants. The results of this paper were directly obtained from patient participants.

Percutaneous Treatment of Giant Hydatid Cysts and Cystobiliary Fistula Management

RATIONALE AND OBJECTIVES

To investigate the efficacy and safety of percutaneous treatment in cystic echinococcosis (CE) type 1 and 3a giant cysts (with at least one diameter>10 cm) according to the World Health Organization classification and to evaluate the management of complications, especially cystobiliary fistulas (CBFs).

MATERIALS AND METHODS

This retrospective study included 66 patients with 68 CE1 and CE3a giant cysts treated with percutaneous catheterization between January 2016 and December 2021. The characteristics of the cysts, major and minor complications, time to catheter removal, and length of hospital stay were recorded.

RESULTS

Among the 68 cysts, CBFs occurred in 35 (51.5%), cavity infections in 11 (16.1%), recollection in five (7.4%), and anaphylaxis in three (4.5%). There was no mortality. Biliary drainage was observed intraoperatively in 20 (29.4%) and only postoperatively in 15 (22.1%) of the 35 cysts with CBFs. A plastic biliary stent was placed in 18 (51.5%) of the 35 cysts with CBFs. The patients with CBFs had a longer hospital stay and time to catheter removal than those without fistulas (15.3 ± 10.9 vs. 6.1 ± 2.6 days and 32.7 ± 51.8 vs. 6.2 ± 3.1 days, respectively; P < 0.001). Of the patients who developed recollection, three were treated with secondary catheterization, and two underwent surgery. In total, three patients underwent surgery. The rate of clinical success was 95.4%. All cysts were followed up for an average of 19.1 (range, 12-60) months, and there was an average 88.8% reduction in cyst volume compared to the initial evaluation.

CONCLUSION

CE1 and CE3a giant cysts can be treated effectively and safely with high clinical success using the catheterization technique. Contrary to what has previously been reported for these patients, the rate of CBFs is high, but these patients can successfully be treated with percutaneous drainage and/or endoscopic retrograde cholangiopancreatography without the requirement of surgery.

EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy

Liver diseases in pregnancy comprise both gestational liver disorders and acute and chronic hepatic disorders occurring coincidentally in pregnancy. Whether related to pregnancy or pre-existing, liver diseases in pregnancy are associated with a significant risk of maternal and fetal morbidity and mortality. Thus, the European Association for the Study of Liver Disease invited a panel of experts to develop clinical practice guidelines aimed at providing recommendations, based on the best available evidence, for the management of liver disease in pregnancy for hepatologists, gastroenterologists, obstetric physicians, general physicians, obstetricians, specialists in training and other healthcare professionals who provide care for this patient population.

Analysis of Risk Factors for Cholelithiasis: A Single-Center Retrospective Study

Objectives Cholelithiasis poses a considerable medical burden worldwide. While its pathogenesis is multifactorial, identifying the key risk factors is essential for understanding the disease and improving patient care. This study aims to investigate the potential associations between demographic, clinical, and laboratory variables and the development of cholelithiasis. Methods This single-center retrospective study was conducted at Malla Reddy Institute of Medical Sciences, Hyderabad, India, over one month. A total of 200 patients diagnosed with cholelithiasis were included. Data were extracted from electronic health records and the patients using a questionnaire, including demographic information (age, gender), clinical data including body mass index (BMI), and comorbidities. Statistical analyses were conducted to determine the associations between risk factors and cholelithiasis. Results The frequency of cholelithiasis is found to be higher in the female gender and patients with obesity, sedentary lifestyle and hypertension as compared to male patients, and the risk of cholelithiasis also increases with age. Females demonstrated a higher prevalence of cholelithiasis, with an odds ratio (OR) and confidence interval (CI) of 1.4, 95% CI [1.1, 1.7], p < 0.05). Obese individuals (BMI ≥ 30) had 2.2 times higher odds of cholelithiasis compared to those with normal BMI (< 24.9) (OR = 2.2, 95% CI [1.7, 2.9], p < 0.001). The presence of diabetes significantly increased the odds of cholelithiasis by 1.6 times (OR = 1.6, 95% CI [1.2, 2.1], p < 0.01). Overweight individuals (BMI: 25-29.9) were associated with 1.4 times higher odds of cholelithiasis (OR = 1.4, 95% CI [1.1, 1.9], p < 0.05). Conclusion Our study identified age, gender, BMI, diabetes, and obesity as significant risk factors for cholelithiasis. These findings underscore the importance of targeted interventions and lifestyle modifications to mitigate cholelithiasis risk and improve patient outcomes. Further research, including prospective multicentric studies, must validate these findings and explore potential underlying mechanisms.

Echinococcal Disease of the Fallopian Tube as a Rare Cause of Primary Subfertility

Echinococcosis is a significant zoonotic infection caused by Echinococcus granulosus, which has a worldwide distribution. In India, the annual incidence varies from one to 200 in 100,000 people. The liver and lungs are often affected, making diagnosis difficult when infections occur in uncommon areas. We report a case of a hydatid cyst in the fallopian tube, which presented as subfertility and was confirmed by radiological imaging.

Discovery of Hepatitis E and Its Impact on Global Health: A Journey of 44 Years about an Incredible Human-Interest Story

The story of the discovery of hepatitis E originated in the late 1970s with my extreme belief that there was a hidden saga in the relationship between jaundice and pregnancy in developing countries and the opportunity for a massive epidemic of viral hepatitis, which hit the Gulmarg Kashmir region in November 1978. Based on data collected from a door-to-door survey, the existence of a new disease, epidemic non-A, non-B hepatitis, caused by a hitherto unknown hepatitis virus, was announced. This news was received by the world community with hype and skepticism. In the early 1980s, the world watched in awe as an extreme example of human self-experimentation led to the identification of VLP. In 1990, a cDNA clone from the virus responsible for epidemic non-A, non-B hepatitis was isolated. Over the years, we traversed three eras of ambiguity, hope, and hype of hepatitis E research and conducted several seminal studies to understand the biology of HEV and manifestations of hepatitis E. Many milestones have been reached on the long and winding road of hepatitis E research to understand the structure, biology, and diversity of the agent, changing the behavior of the pathogen in developed countries, and the discovery of a highly effective vaccine.

Dysfunction of Biliary Sphincter of Oddi-Clinical, Diagnostic and Treatment Challenges

Biliary Sphincter of Oddi dysfunction (SOD) is one of the main causes of post-cholecystectomy pain. In this review, we aimed to provide an update on the current knowledge on biliary SOD, with an emphasis on diagnostics and therapy. Overall, current but scarce data support biliary sphincterotomy for patients with type 1 and 2 SOD, but not for type 3. However, sphincterotomy is associated with post-treatment pancreatitis rates of from 10% to 15%, thus calling for improved diagnostics, patient selection and treatment modalities for SOD. The role of pharmacologic therapy for patients with SOD is poorly explored and only two randomized controlled trials are available. Currently, studies comparing treatment outcomes are few. There is an unmet need for randomized sham/placebo-controlled clinical trials related to both pharmacological and non-pharmacological treatments of SOD.

Complementary and alternative medicine mention and recommendations in inflammatory bowel disease guidelines: systematic review and assessment using AGREE II

BACKGROUND

Many patients with inflammatory bowel disease (IBD) use complementary and alternative medicine (CAM) for disease management. There is, however, a communication gap between patients and healthcare professionals regarding CAM use, where patients are hesitant to disclose CAM use to providers. The purpose of this study was to identify the quantity and assess the quality of CAM recommendations in IBD clinical practice guidelines (CPGs) using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

METHODS

MEDLINE, EMBASE, and CINAHL were systematically searched from 2011 to 2022 to find CPGs for the treatment and/or management of IBD. The Guidelines International Network (GIN) and National Center for Complementary and Integrative Health (NCCIH) websites were also searched. Eligible CPGs were assessed using the AGREE II instrument.

RESULTS

Nineteen CPGs made CAM recommendations for IBD and were included in this review. Average scaled domain percentages of CPGs were as follows (overall CPG, CAM section): scope and purpose (91.5%, 91.5%), clarity of presentation (90.3%, 64.0%), editorial independence (57.0%, 57.0%), stakeholder involvement (56.7%, 27.8%), rigour of development (54.7%, 45.9%), and applicability (14.6%, 2.1%).

CONCLUSIONS

The majority of CPGs with CAM recommendations were of low quality and their CAM sections scored substantially lower relative to other therapies in the overall CPG. In future updates, CPGs with low scaled-domain percentages could be improved in accordance with AGREE II and other guideline development resources. Further research investigating how CAM therapies can best be incorporated into IBD CPGs is warranted.