Burden and Cost of Gastrointestinal, Liver, and Pancreatic Diseases in the United States: Update 2018

Computed Tomography Imaging for Suspected Gastrointestinal Bleeding and Bowel Ischemia

Computed tomography (CT) is one of the main diagnostic methods for assessing both acute gastrointestinal bleeding (GIB) and bowel ischemia due to its widespread availability, excellent spatial resolution, and high accuracy. While endoscopy is the preferred diagnostic tool for workup of upper GIB, CT is used in select instances as a complementary modality or when endoscopy is impractical. For lower GIB, CT is one of the first-line imaging tools. Mesenteric ischemia is primarily diagnosed with CT, which can exquisitely assess the vasculature and demonstrate bowel findings of ischemia or infarction.

Evaluating Accountable Care Organizations impact on gastrointestinal cancer care: are they falling short on health outcomes?

BACKGROUND

Accountable Care Organizations (ACOs) have emerged as a value-based care model. However, the effect on gastrointestinal (GI) cancer care remains poorly defined. Therefore, the current study aimed to investigate the effect of hospital ACO participation on surgical and financial outcomes.

METHODS

Patients who underwent GI cancer surgery between 2016 and 2020 were identified from the Medicare Standard Analytic Files. Difference-in-differences (DID) analysis was performed to examine the effect of hospital ACO participation on surgical outcomes and healthcare expenditures.

RESULTS

A total of 23,357 beneficiaries underwent GI cancer surgery at 2180 hospitals (ACO participating: 57 [2.7%]). The median patient age was 75 years (IQR, 71-81). Moreover, most patients were female (12,207 [52.3%]) and had a Charlson Comorbidity Index score of >2 (14,067 [54.3%]). On DID analysis, after adjusting for patient and hospital baseline characteristics, ACO participation was not associated with a reduced risk of complications during the index hospitalization (RRR [relative risk ratio], 1.03 [95% CI, 0.90-1.18]; P =.71), extended length of stay (RRR, 1.04 [95% CI, 0.92-1.67]; P =.52), 30-day complication (RRR, 1.96 [95% CI, 0.72-1.27]; P =.77), 30-day readmission (RRR, 1.07 [95% CI, 0.92-1.25]; P =.96), or 30-day mortality (RRR, 0.96 [95% CI, 0.77-1.21]; P =.74). Moreover, ACO participation was not associated with reduced healthcare costs.

CONCLUSION

Hospital participation in ACOs was not associated with improved surgical outcomes or reduced healthcare costs. There is a need for nuanced, targeted interventions within the ACO framework that address the unique needs of complex surgical patients.

Diagnosis and management of gastrointestinal hemorrhage: What you need to know

ABSTRACT

Acute gastrointestinal (GI) hemorrhage is a common cause for hospital admission that requires prompt diagnosis and multidisciplinary management to optimize clinical outcomes. Acute gastrointestinal bleeding (GIB) includes both upper and lower GI tract sources with an extensive list of differential pathologies. This review provides a systematic approach to both upper and lower GIB management, emphasizing initial resuscitation, stabilization, diagnostic evaluation to identify the source, and treatment modalities. Endoscopy remains the cornerstone for diagnostic and interventional purposes, significantly reducing the need for surgical procedures. However, lower GIB and severe or refractory cases may necessitate additional imaging and interventions, including surgical management. Integrating clinical guidelines, evidence-based strategies, and individualized care, this review delineates what you need to know to diagnose and manage acute GI hemorrhage.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Mutant KRAS and CK2 Cooperatively Stimulate SLC16A3 Activity to Drive Intrahepatic Cholangiocarcinoma Progression

Intrahepatic cholangiocarcinoma (iCCA) is a lethal malignancy affecting the liver and biliary system. Enhanced understanding of the pathogenic mechanisms underlying iCCA tumorigenesis and the discovery of appropriate therapeutic targets are imperative to improve patient outcomes. In this study, we investigated the functions and regulations of solute carrier family 16 member 3 (SLC16A3), which has been reported to be a biomarker of poor prognosis in iCCA. High SLC16A3 expression was enriched in KRAS viral oncogene homolog-mutated iCCA tumors, and mutant KRAS elevated SLC16A3 expression via the PI3K-AKT-mTORC1-HIF1α pathway. SLC16A3 not only enhanced glycolysis but also induced epigenetic reprogramming to regulate iCCA progression. Phosphorylation of SLC16A3 at S436 was vital for its oncogenic function and was linked to iCCA progression. Casein kinase 2 (CK2) directly phosphorylated SLC16A3 at S436, and CK2 inhibition with CX-4945 (silmitasertib) reduced the growth of KRAS-mutated iCCA tumor xenografts and patient-derived organoids. Together, this study provides valuable insights into the diverse functions of SLC16A3 in iCCA and comprehensively elucidates the upstream regulatory mechanisms, providing potential therapeutic strategies for patients with iCCA with KRAS mutations. Significance: Characterization of the oncogenic function and regulators of SLC16A3 in intrahepatic cholangiocarcinogenesis revealed the potential of CK2 inhibitors as a promising treatment for KRAS-mutated tumors.

Food Insecurity Is Increasing and Is More Common Among Persons with Chronic Liver Disease

BACKGROUND

Effective interventions for metabolic liver disease include optimized nutritional intake. It is increasingly clear, however, that many patients with metabolic liver disease lack the resources to execute nutritional advice. Data on the trends of food insecurity are needed to prioritize public health strategies to address the burden of liver disease.

METHODS

Cross-sectional analysis of six waves of data from 24,847 adults aged > 20 years from the 2017-2018 National Health and Nutrition Examination Survey. Food security was measured using the US Department of Agriculture's Core Food Security Module. Liver disease was defined as elevated liver enzymes and a risk factor: elevated BMI, diabetes, and/or excess alcohol consumption. Advanced liver disease was estimated using FIB-4 > 2.67.Additional covariates included age, sex, race/ethnicity, education, marital status, poverty-income ratio, alcohol intake, body mass index, diabetes, and participation in the Supplemental Nutrition Assistance Program (SNAP).

RESULTS

The overall prevalence of liver disease was 24.6%, ranging from 21.1% (2017-2018) to 28.3% (2015-2016) (P-trend = 0.85). 3.4% of participants had possible advanced liver disease, ranging from 1.9% (2007-2008) to 4.2% (2015-2016)(P-trend = 0.07). Among those with liver disease, the prevalence of food insecurity was 13.6% in 2007-2008, which rose steadily to 21.6% in 2015-2016, before declining to 18.0% in 2017-2018 (P-trend = 0.0004). Food insecurity rose more sharply for adults aged < 50 years (2007-2008: 17.6%, 2015-2016: 28.0%, P-trend = 0.004) compared to adults aged ≥ 50 years (2007-2008: 9.5%, 2015-2016: 16.5%, P-trend < 0.0001). Similarly among those with liver disease, significant predictors of food insecurity included Hispanic ethnicity, low educational attainment, and participating in SNAP.

CONCLUSION

Food insecurity is increasingly common among those with liver disease.

Incidence Trends in Upper Gastrointestinal Cancer in Young Adults: A Nationwide Time-Trend Analysis Using 2001-2019 US Cancer Statistics Databases

INTRODUCTION

Upper gastrointestinal (UGI) cancers, comprising malignancies of the esophagus, stomach, duodenum, pancreas, liver, biliary tract, and gallbladder, are the second leading cause of cancer-related mortality in the United States and are associated with significant comorbidities. Recent studies show a disproportionate rise in pancreatic and stomach cancer among young adults. This study aims to use a nationwide, population-based cohort to (i) evaluate the trend of all UGI cancer as an aggregate and (ii) examine the role of demographics, histology, and tumor stage in UGI cancer incidence among young adults.

METHODS

Individuals diagnosed with UGI cancer in the United States from 2001 to 2019 were identified and obtained from the Surveillance, Epidemiology, and End Results-National Program of Cancer Registries database. The primary outcomes were incidence rates of UGI cancer (calculated per 100,000, age-adjusted to the year 2000 US population), stratified by sex and age (< 55 years for young adults and ≥ 55 years for older adults). Trends, annual percentage change, and average annual percentage change were calculated using the parametric method. Sensitivity analysis was performed according to primary site and histology; further analysis examining race and cancer stage was performed in the young adult subgroup.

RESULTS

A total of 2,333,161 patients with UGI cancer were identified. Most cases were male, and 14.3% were < 55 years of age. Incidence of UGI cancer increased most in women younger than 55 years, driven primarily by pancreatic and stomach cancers, as well as neuroendocrine tumor and gastrointestinal stromal tumor histology. African American race and localized tumors and malignancy with distant spread are also contributing to the disparate increase among young women. UGI mortality rates have not changed significantly in young adults.

DISCUSSION

The overall incidence rate of upper gastrointestinal cancer is increasing significantly in young women compared with men. Increased endoscopic procedures and disparate exposure to risk factors are likely contributing to these trends.

The use of endoscopic ultrasound in tandem with endoscopic retrograde cholangiopancreatography in the 2019 American Society for Gastrointestinal Endoscopy guideline for patients at high risk of choledocholithiasis can help to avoid diagnostic endoscopic retrograde cholangiopancreatography in individuals without ascending cholangitis

Objectives

Choledocholithiasis is the leading cause of biliary pancreatitis and biliary sepsis. Endoscopic retrograde cholangiopancreatography (ERCP) is considered a minimally invasive treatment for choledocholithiasis. However, diagnostic ERCP should be avoided. We conducted a prospective trial in high-risk choledocholithiasis patients based on the American Society for Gastrointestinal Endoscopy (ASGE) 2019 criteria to investigate the diagnostic accuracy of the current guideline.

Methods

This multicenter, prospective cohort study included 240 consecutive patients. The primary outcome was the performance of the criteria in predicting choledocholithiasis. The secondary outcome was a percentage reduction in diagnostic ERCP when endoscopic ultrasound was used in tandem with ERCP in individuals without ascending cholangitis.

Results

The overall criteria revealed a positive common bile duct (CBD) stone in 87.1% of patients. Regarding the diagnostic performance of each criterion, ascending cholangitis had a specificity of 67.7% and a positive predictive value (PPV) of 90.2%; total bilirubin >4 mg/dL and dilated CBD had a specificity of 74.2% and a PPV of 55.6%; and CBD stone on ultrasound/cross-sectional imaging had a specificity of 58.1% and a PPV of 89.2%. Of the 138 patients without ascending cholangitis who met the other two high-risk criteria and were sent for EUS first, 21 cases (15.2%) were able to avoid a diagnostic ERCP.

Conclusions

The current ASGE 2019 criteria yield acceptable choledocholithiasis diagnostic accuracy. Using endoscopic ultrasound to confirm CBD stones before ERCP can help almost half of patients with the specific condition of total bilirubin >4 mg/dL and dilated CBD to avoid diagnostic ERCP.

Comparison of acute pancreatitis and acute on chronic pancreatitis: a retrospective cohort study

BACKGROUND

Acute on chronic pancreatitis (ACP) shares a similar clinical presentation with acute pancreatitis (AP) and is often diagnosed and treated in the same way. However, these two conditions may have distinct clinical risk profiles and prognoses. There is currently limited evidence available regarding the specific characteristics of ACP.

METHODS

This retrospective cohort study included all adult patients admitted with a diagnosis of AP or ACP between 2017 and 2019 at two tertiary referral centers. The primary outcome was disease severity as defined by the Atlanta classification. Secondary outcomes included the presence of local and systemic complications, organ failure, ICU admission, and mortality. Differences in outcomes between ACP and AP were compared using multivariate logistic regression models, with results presented as odds ratios (ORs).

RESULTS

We included 1163 patients, 90% of whom had AP and 10% had ACP. ACP patients were predominantly male (81 vs. 46%; P  < 0.001), whereas AP patients were older (mean age 62.6 vs. 56.5 years, P  < 0.001). ACP patients had lower amylase and lipase levels ( P  < 0.001). Multivariate analysis showed no difference in the risk of moderate or severe pancreatitis (OR, 1.15; 95% CI, 0.66-1.98; P  = 0.615). ACP patients had a higher risk of local complications (predominantly pseudocysts) (OR, 1.71; 95% CI, 1.00-2.92; P  = 0.049) and a lower risk of organ failure ( P  = 0.019) and ICU admission ( P  = 0.005).

CONCLUSION

Our study confirms previous observations that ACP has a more favorable in-hospital prognosis than AP and extends these findings to a modern European setting.

A novel network-level fused deep learning architecture with shallow neural network classifier for gastrointestinal cancer classification from wireless capsule endoscopy images

Deep learning has significantly contributed to medical imaging and computer-aided diagnosis (CAD), providing accurate disease classification and diagnosis. However, challenges such as inter- and intra-class similarities, class imbalance, and computational inefficiencies due to numerous hyperparameters persist. This study aims to address these challenges by presenting a novel deep-learning framework for classifying and localizing gastrointestinal (GI) diseases from wireless capsule endoscopy (WCE) images. The proposed framework begins with dataset augmentation to enhance training robustness. Two novel architectures, Sparse Convolutional DenseNet201 with Self-Attention (SC-DSAN) and CNN-GRU, are fused at the network level using a depth concatenation layer, avoiding the computational costs of feature-level fusion. Bayesian Optimization (BO) is employed for dynamic hyperparameter tuning, and an Entropy-controlled Marine Predators Algorithm (EMPA) selects optimal features. These features are classified using a Shallow Wide Neural Network (SWNN) and traditional classifiers. Experimental evaluations on the Kvasir-V1 and Kvasir-V2 datasets demonstrate superior performance, achieving accuracies of 99.60% and 95.10%, respectively. The proposed framework offers improved accuracy, precision, and computational efficiency compared to state-of-the-art models. The proposed framework addresses key challenges in GI disease diagnosis, demonstrating its potential for accurate and efficient clinical applications. Future work will explore its adaptability to additional datasets and optimize its computational complexity for broader deployment.

Decoding Abdominal Pain in Constipation-predominant Irritable Bowel Syndrome and Functional Constipation: Mechanisms and Managements

PURPOSE OF REVIEW

Abdominal pain in constipation-predominant irritable bowel syndrome (IBS-C) and functional constipation (FC) remains a difficult clinical challenge due to unclear pathophysiological mechanisms and limited pain-targeted treatments. This review critically evaluates the evidence on the underlying pain mechanisms in IBS-C and/or FC and explores management strategies, their limitations, and future directions.

RECENT FINDINGS

Most research on constipation-related pain is based on IBS-C patients or animal models, with limited studies focusing on FC. Visceral hypersensitivity, serotonin dysregulation, gut-brain axis dysfunction, and central/peripheral nervous system alterations are implicated in IBS-C pain, while FC pain is less studied and may be primarily linked to colonic distension and motility dysfunction. Management strategies include 5-HT4 agonists, GC-C agonists, chloride channel activators, psychological therapies, probiotics and complementary medicine. Despite available treatment options, managing abdominal pain in IBS-C and FC remains challenging due to heterogeneous pathophysiology and limited targeted therapies. While some interventions provide symptomatic relief, there is no universally effective treatment for abdominal pain across all patients. Future research should focus on identifying pain-specific biomarkers, refining diagnostic criteria, and integrating multi-omics data and neuroimaging techniques to better distinguish pain mechanisms in IBS-C versus FC and develop more precise, patient-centered interventions.

High Rates of Dysplasia in a Population-based Analysis of "Incidental" Barrett's Esophagus

BACKGROUND AND AIMS

Current screening and surveillance in Barrett's esophagus (BE) identifies only a minority of esophageal adenocarcinomas. Novel testing modalities may allow broadening of indications for BE screening. Whether such efforts are warranted depends on the characteristics of additional BE cases discovered, and their risk of progression. This study used national benchmarking data to characterize "incidental" BE.

METHODS

Upper endoscopies with BE in GI Quality Improvement Consortium (GIQuIC) Registry from January 2015 to July 2022 were categorized by indication: BE screening, surveillance, or non-BE-related ("incidental"). Demographics, disease-specific characteristics, and dysplasia detection rate (DDR: low and high-grade dysplasia) were compared, as well as adherence to quality indicators.

RESULTS

Of 88,370 cases (67.3% male; 74.0% white) with histologically confirmed intestinal metaplasia, 88.1% were nondysplastic (NDBE). Most cases were performed for BE surveillance (65.0%). Incidental BE (16.4%) occurred almost as frequently as BE found in screening exams (18.6%). The mean BE segment length was longer in incidental BE (2.9 cm) than BE screening (2.6 cm) or surveillance (2.8 cm; P < .001). DDR was actually highest in incidental BE (3.8%), compared with surveillance or screening exams (2.5% and 3.3%; P < .0001). Adherence to appropriate surveillance was similar in incidental and screening (54.5% and 51.9%), with higher adherence in the surveillance group (73.6%; P < .0001).

CONCLUSION

BE is found incidentally at rates approaching those seen in dedicated screening exams. Incidental BE is not only common but has similar or worse high-risk features as BE in traditional screening and surveillance populations, given segment length and dysplasia yield. Refinement of BE screening programs could yield cases of similar risk of progression as traditional programs.

Genistein alleviates colitis by suppressing inflammation and modulating colonic Marvinbryantia formatexigens abundance and metabolites

As an active ingredient of leguminous plants, genistein is extremely important for alleviating various human diseases. However, the regulatory effect of genistein on intestinal microbiota in alleviating enteritis is still unclear. In this study, the effect of genistein in alleviating dextran sodium sulfate (DSS)-induced colitis and the potential microbial metabolic regulation mechanism were explored. First, the effect of genistein on DSS-induced colitis was studied in mice. Then antibiotics were used to inhibit intestinal bacteria to verify that intestinal microorganisms play an important role in alleviating colitis of genistein. Finally, mice were administrated with live differential bacterium to confirm that genistein can regulate intestinal microorganisms to treat colitis. The results indicated that genistein alleviated DSS-induced colonic inflammation by inhibiting the Nuclear factor kappa-B and Cyclooxygenase-2/Prostaglandin E2 pathway. Genistein alleviated DSS-induced intestinal injury and decreased Mucin 2 secretion. Supplementation with genistein attenuated the DSS-induced decrease in the alpha diversity of gut bacteria. Genistein increased the abundance of Lachnospiraceae and Marvinbryantia formatexigens, increased the concentration of short chain fatty acids in colitis. After antibiotics depleted the intestinal bacteria, genistein lost the effect of relieving colitis, indicating that genistein must relieve colitis through the intestinal bacteria. Mice fed with living Marvinbryantia formatexigens increased short-chain fatty acids and relieved colitis. The present study demonstrates that genistein alleviated colonic inflammation by regulating intestinal bacterium of Marvinbryantia formatexigens and increasing short-chain fatty acid production.

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

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

Decreased Life Expectancy in Patients with Acute and Chronic Pancreatitis

BACKGROUND AND AIMS

Population-based data on the life expectancy and mortality for acute (AP) and chronic pancreatitis (CP) in the United States are limited. This study evaluates the life expectancy, mortality rates and the cause of death in AP and CP patients.

METHODS

Using the nationwide Veterans Administration database from 1999 to 2015, we identified AP and CP patients (using ICD-9 codes) and non-pancreatitis patients (controls). Age at the time of death was used as a surrogate indicator of life expectancy. Life expectancy in AP and CP patients was compared with the controls, using Cox-proportional hazards model. The mortality rates and cause of death for AP, CP, and controls were also assessed.

RESULTS

Overall, we selected 35,550 AP and 12,545 CP patients and 100,000 controls. The life expectancy was significantly lower for both AP (69 years) and CP (71 years) patients compared to the controls (81 years, p < 0.001). The risk of mortality was higher for AP (adjusted hazard ratio (aHR) 1.61, 95% CI 1.58-1.65, p < 0.001) and CP (aHR 1.64, 95% CI 1.59-1.68, p < 0.001) than in controls. Approximately forty-two percent of all patients died during the follow-up (AP-44.3%, CP-52.1% and controls-39.7%). Circulatory disorders, neoplasms, and respiratory disorders were the leading causes of death in AP and CP patients.

CONCLUSIONS

Acute and chronic pancreatitis are associated with decreased life span and higher mortality emphasizing their clinical importance. Although the deaths due to gastrointestinal/digestive system disorders were significantly higher, most of the deaths in AP and CP patients were primarily due to non-gastrointestinal causes.

Both general and central obesity are associated with increased risk of irritable bowel syndrome: A large-scale prospective cohort study

BACKGROUND

Obesity has emerged as a major public health concern worldwide. However, the relationship between obesity and irritable bowel syndrome (IBS) remains unclear.

OBJECTIVES

We aimed to systematically examine the association of both general and central obesity measures with risk of incident IBS in a large population-based cohort.

METHODS

Participants free of IBS, celiac disease, inflammatory bowel disease, and any cancer at baseline were included. Obesity was assessed using various measures of general and central obesity [i.e., Body mass index (BMI in kg/m2), waist circumference, etc.]. The primary outcome was incident IBS. The Cox proportional hazard model was conducted to estimate the association.

RESULTS

Among 416,124 participants (mean age 56.2 y), 133,775 (32.1%), 178,283 (42.8%) and 102,139 (24.5%) were BMI-defined normal, overweight and obesity at baseline. During a median of 14.6-y follow-up, 8744 (2.1%) incident IBS were identified. After multiple adjustments, individuals with obesity had a 7% higher risk of developing IBS than those with normal BMI [hazard ratio (HR): 1.07; 95% confidence interval (CI): 1.01, 1.13]. As for central obesity, individuals with the highest quartiles of waist circumference (HR: 1.14; 95% CI: 1.06, 1.27) and visceral adipose tissue volume (HR: 1.35; 95% CI: 1.04, 1.75) had a 14% and 35% greater risk of IBS compared with the lowest quartiles. A similar positive association was observed in other general and central obesity measures, with an 8-35% higher risk of IBS occurrence in the highest quartile compared with the reference group. Further sensitivity analyses and subgroup analyses demonstrated similar results.

CONCLUSIONS

Both general and central obesity are associated with an increased risk of developing IBS, suggesting the importance of obesity management.

Efficacy and Safety of Remimazolam in Short Endoscopic Procedures: A Systematic Review and Meta-Analysis

Background and Objectives: Appropriate sedation and anesthesia are crucial for ensuring comfortable endoscopic procedures. Propofol is one of the most often used sedatives. However, its safety and adverse effects restrict its usage. Remimazolam is a relatively new intravenous benzodiazepine that offers many benefits. Our analysis aims to evaluate the effectiveness and safety of remimazolam during short endoscopic procedures. Materials and Methods: We conducted a comprehensive search of the PubMed, Web of Science, ClinicalTrials.gov, and Turning Research Into Practice databases up to 31 December 2023, for randomized controlled trials published in English. Statistical analyses were performed using Cochrane Review Manager 5.4.1 and Stata Software/MP. Results: The success rate of sedation with remimazolam was slightly lower than that with propofol (RR: 0.99, 95% CI: 0.98~1.00; p = 0.004; I2 = 42%). As for anesthetic effect-related outcomes, remimazolam did not show advantages in onset time (MD = 12.72, 95% CI: 6.53~18.90, p < 0.001, I2 = 94%), recovery time (MD = 0.86, 95% CI: -0.55~2.27, p = 0.23, I2 = 98%), or intraoperative body movement (RR: 1.18, 95% CI: 0.60~2.32, p = 0.62, I2 = 87%). However, compared to propofol, remimazolam significantly reduced the incidence of several adverse events, including injection pain (RR: 0.07, 95% CI: 0.03~0.14, p < 0.001, I2 = 69%), intraoperative hypotension (RR: 0.38, 95% CI: 0.31~0.47, p < 0.001, I2 = 65%), bradycardia (RR: 0.25, 95% CI: 0.15~0.45, p < 0.001, I2 = 0%), and respiratory depression (RR: 0.34, 95% CI: 0.25~0.46, p < 0.001, I2 = 50%). The incidence of postoperative nausea and vomiting (PONV) was slightly higher with remimazolam (RD: 0.01, 95% CI: 0.00~0.03, p = 0.04, I2 = 33%). Conclusions: Remimazolam is a promising sedative for short endoscopic procedures due to its superior safety profile despite a slightly lower sedation success rate compared to propofol.

Economic and treatment burden among newly diagnosed patients with erosive esophagitis in the US: a national retrospective cohort study

Erosive esophagitis (EE) is a common complication of gastroesophageal reflux disease. Guidelines support long-term proton pump inhibitor (PPI) therapy to relieve symptoms and maintain healing of EE. Ideally, patients remain on their first line of therapy (LOT) with an effective PPI. We aimed to measure how often patients receive PPI, persistence and cycling among LOTs, and resulting healthcare resource utilization and costs. We assessed administrative claims data of patients diagnosed with EE between 0 October 2016 and 31 December 2020 using the Optum Research Database. We assessed prescribing rates of the first PPI, persistence, and rate of cycling among LOTs, health care resource utilization, and overall costs. Of 281,087 patients with EE, 178,789 had endoscopy. Overall, 27% of EE-diagnosed patients and 21% of patients in the endoscopy subgroup did not receive a PPI prescription. Among patients that did receive PPI, cycling and switching among PPIs was common, with over 50% of those patients switching to another PPI or back to a previously-used PPI after a lapse in therapy. Average total all-cause costs per patient among endoscopy patients (including patients with no record of PPI fills) were $58,692.46, and average total EE-related costs were $4304.88. Patients with EE frequently cycle and switch among PPIs. About one-fifth of patients who underwent endoscopy did not receive prescription PPI. Health care resource utilization and costs in patients with EE are substantial. PPI cycling and high discontinuation rates to PPI therapy contribute to costs associated with EE and potential delays in effective therapy.

Traditional Chinese medicine Chaiqinchengqi decoction for patients with acute pancreatitis: A randomized clinical trial

BACKGROUND

Chaiqinchengqi decoction, a traditional Chinese medicine, has shown promising effects in in vitro, animal and preliminary small human studies for acute pancreatitis, but evidence of clinical practice is limited.

PURPOSE

To investigate whether Chaiqinchengqi decoction could improve clinical outcomes in patients with acute pancreatitis.

STUDY DESIGN

Prospective, pragmatic, randomized controlled trial. (Chictr.org.cn registration number: ChiCTR2000034325) METHODS: This trial was conducted at West China Hospital of Sichuan University, China. Patients with acute pancreatitis were randomly assigned to receive either Chaiqinchengqi decoction or placebo by oral and rectal enemas in addition to guideline-directed administrations using a 1:1 ratio. The intervention of Chaiqinchengqi and placebo was determined by the grading of acute gastrointestinal injury. Patients were assessed within 24 and 48 hours, and on 3, 5, and 7 days after admission, or organ failure normalized. Survivors were followed up at 1, 3, and 6 months after discharge. Primary outcome was the duration of respiratory failure to 28 days after enrollment. Secondary outcomes included other organ failure, local complications, 6-month all-cause mortality, inflammatory indicators, and related interventions.

RESULTS

Among 248 patients enrolled, Chaiqinchengqi decoction shortened the duration of respiratory failure compared with the placebo (median [IQR], 1.0 [0.0 to 5.0] vs 3.0 [1.0-8.0] days; median difference, -1.0; 95% CI, -2.0 to 0.0, P=.001). There were significant differences in the duration of circulatory failure, the incidence of new-onset respiratory and cardiovascular and failure, the incidence of new organ failure, severity, intensive care unit need, pain visual analogue scale, pancreatitis activity scoring system, and EQ-5D-5L.

CONCLUSION

Chaiqinchengqi decoction as an adjunctive therapy significantly reduced the duration of respiratory failure and improved 6-month clinical outcomes of acute pancreatitis in addition to guideline-directed treatments. Further study is needed to elucidate the mechanism of action.

The development and evaluation of nine obesity-based indices for gallstones in U.S. adults

OBJECTIVE

Gallstones have gradually become a highly prevalent digestive disease worldwide. This study aimed to investigate the association of nine different obesity-related indicators (BRI, RFM, BMI, WC, LAP, CMI, VAI, AIP, TyG) with gallstones and to compare their predictive properties for screening gallstones.

METHODS

Data for this study were obtained from the National Health and Nutrition Examination Survey (NHANES) for the 2017-2020 cycle, and weighted logistic regression analyses with multi-model adjustment were conducted to explore the association of the nine indicators with gallstones. Subject working curves were analyzed to assess the screening ability of the nine indicators. In addition, the association between the most predictive indicator and gallstones was investigated with smooth curve fitting, and differences in risk across populations were explored with subgroup analyses.

RESULTS

In total, 3654 participants were involved in the final analysis and 383 (10.48%) carried gallstones. The results of weighted multifactorial logistic regression analysis indicated that BRI, RFM, BMI, WC, LAP, and CMI were independent risk factors for gallstones. The ORs for the highest quartile were 4.13 for RFM, 3.13 for BRI, 2.85 for BMI, 2.86 for WC, 2.45 for LAP, and 1.49 for CMI. The area under the ROC curve for RFM was 0.70. The Delong test compared the performance of different ROCs and revealed that the difference between the area under the curve of RFM and the other metrics was significant ( P < 0.05). Smooth curve fitting suggested a linear positive correlation between RFM and gallstones (LLR > 0.05), especially in women, non-Hispanic White, insufficient physical activity, hypertensive, and diabetic populations.

CONCLUSION

RFM, BRI, BMI, WC, LAP, and CMI were essential indicators for recognizing gallstones. By comparison, we realized that RFM was a better predictor of gallstones.

Intra-abdominal Hypertension Is a Strong Predictor of Mortality and Poor Clinical Outcome in Severe Acute Pancreatitis

BACKGROUND

Acute pancreatitis is one of the leading causes of mortality and morbidity. Most acute pancreatitis scoring systems have no pathophysiologic basis when evaluating severity. Such a limitation led to an interest in measuring intra-abdominal pressure (IAP) as a method to predict outcomes in patients with acute pancreatitis.

AIMS

Investigate the predictive impact of intra-abdominal hypertension (IAH) on mortality and clinical outcomes in a patient hospitalized with severe acute pancreatitis.

METHODS

We conducted a systematic search of the PubMed, Embase, and Cochrane databases from inception through November 2021 for studies evaluating the effect of IAH on acute pancreatitis. Relevant data were extracted and analyzed using STATA 17 software. A random-effects model was used for all variables. Publication bias was assessed using Egger's test.

RESULTS

Fourteen studies investigating 1197 patients were included. Mortality, multiorgan dysfunction syndrome, pancreatic necrosis, renal, respiratory, and cardiovascular failure were more likely in the IAH group. However, infected necrosis and surgical intervention were not statistically significant between the two groups. After excluding abdominal compartment syndrome patients, mortality and respiratory failure were the only outcomes, which remained statistically significant.

CONCLUSIONS

Patients admitted to the hospital with severe acute pancreatitis have higher odds for mortality, multiorgan dysfunction syndrome, renal, respiratory, and cardiovascular failure if they developed IAH. IAH remained a strong predictor of mortality and respiratory failure even in the absence of abdominal compartment syndrome. Therefore, the development of IAH is a strong predictor of mortality and poor clinical outcome in such a population.

Inpatient Outcomes of Gastrointestinal Bleeding in Advanced CKD and Kidney Transplant Recipients: A National Analysis 2016-2019

Key Points

Advanced CKD and ESKD are independent risk factors for gastrointestinal bleeding hospitalizations, angiodysplasia bleeding, and in-hospital mortality. Patients with ESKD with gastrointestinal bleeding exhibit significantly higher rates of adverse outcomes compared with those without CKD. Patients with advanced CKD and ESKD had lower rates of early endoscopy and higher rates of delayed endoscopy, with delayed endoscopy linked to increased mortality.

Background

Patients with kidney disease are at increased risk for gastrointestinal bleeding (GIB). This study aimed to investigate the incidence, causes, interventions, and inpatient outcomes of GIB in patients with advanced CKD (ACKD), ESKD, and kidney transplant (KT) recipients, compared with those without CKD (NCKD).

Methods

This retrospective study used the Nationwide Inpatient Sample database to identify adult patients admitted nonelectively with GIB from 2016 to 2019. Patients were stratified into five groups: ACKD (CKD stages 4 or 5), ESKD, KT, NCKD, and others (including CKD stages 1–3 and unspecified CKD). We compared outcomes across these groups and conducted subgroup analyses within the ACKD and ESKD groups to explore the association between mortality and the timing of endoscopic evaluation. Multivariate logistic regression (for binary outcomes) and linear regression (for continuous outcomes) models were used to analyze the dependent variables.

Results

A total of 2,163,929 patients were included. The incidence of GIB hospitalizations was higher in the ACKD (3.2%) and ESKD (3.4%) groups and lower in the KT group (2.1%) compared with the NCKD group (2.2%). All-cause in-hospital mortality was increased in ACKD, ESKD, and KT (3.0%, 3.1%, and 2.0%, respectively) compared with NCKD (1.7%). ESKD patients had higher rates of mechanical ventilation, vasopressor support, and blood transfusion, along with prolonged and costly hospitalizations (P < 0.001). ACKD and ESKD groups had lower rates of early endoscopy (<24 hours) and higher rates of delayed endoscopy (>48 hours), with delayed endoscopy linked to increased mortality. ACKD and ESKD were independent risk factors for angiodysplasia bleeding, while KT was a risk factor for diverticular and esophageal bleeding.

Conclusions

ACKD and ESKD are independent risk factors for GIB hospitalizations and in-hospital mortality, with delayed endoscopy further worsening outcomes. Tailored treatment plans are essential to improve outcomes in this complex population.

Mapping training programs for endoscopy nurses in gastroenterology: a scoping review

OBJECTIVE

Given the significant differences in the scope of practice for endoscopy nurses across various countries and due to the heterogeneity in training required to become an endoscopy nurse, this study aims to map the existing training programs designed for endoscopy nurse in gastroenterology and examine the influence of such educational programs on clinical practice and patient care outcomes.

METHODS

A scoping review was conducted using the Arksey and O'Malley framework. We identified studies relevant to endoscopy nurse training across databases including PubMed, Embase, Web of Science, SCOPUS, and CINAHL. Eligible studies focused on training programs for endoscopy nurses and were subjected to a two-stage screening process. Data extraction focused on program characteristics, skill development, and clinical outcomes.

RESULTS

Of 4834 records, 12 studies were included in the final analysis. These studies detailed diverse training programs ranging from 1-day workshops to 2-year extensive programs. Key skills developed included sedation administration, airway management, handling endoscopy equipment, and interpreting capsule endoscopy images. Nontechnical skills, such as communication, teamwork, and crisis management, were also emphasized. Training programs demonstrated a positive impact on clinical and organizational outcomes, reducing adverse events and improving procedural efficiency. Endoscopy nurses also reported higher job satisfaction following training.

CONCLUSION

Training programs for endoscopy nurses play a vital role in improving both technical and nontechnical competencies, enhancing clinical practice and patient safety. However, significant variability exists in the content and duration of these programs. Standardizing training practices could further optimize nurse performance and patient outcomes in gastroenterology endoscopy.

QRNet: A Quaternion-Based Retinex Framework for Enhanced Wireless Capsule Endoscopy Image Quality

Wireless capsule endoscopy (WCE) offers a non-invasive diagnostic alternative for the gastrointestinal tract using a battery-powered capsule. Despite advantages, WCE encounters issues with video quality and diagnostic accuracy, often resulting in missing rates of 1-20%. These challenges stem from weak texture characteristics due to non-Lambertian tissue reflections, uneven illumination, and the necessity of color fidelity. Traditional Retinex-based methods used for image enhancement are suboptimal for endoscopy, as they frequently compromise anatomical detail while distorting color. To address these limitations, we introduce QRNet, a novel quaternion-based Retinex framework. QRNet performs image decomposition into reflectance and illumination components within hypercomplex space, maintaining inter-channel relationships that preserve color fidelity. A quaternion wavelet attention mechanism refines essential features while suppressing noise, balancing enhancement and fidelity through an innovative loss function. Experiments on Kvasir-Capsule and Red Lesion Endoscopy datasets demonstrate notable improvements in metrics such as PSNR (+2.3 dB), SSIM (+0.089), and LPIPS (-0.126). Moreover, lesion segmentation accuracy increases by up to 5%, indicating the framework's potential for improving early-stage lesion detection. Ablation studies highlight the quaternion representation's pivotal role in maintaining color consistency, confirming the promise of this advanced approach for clinical settings.

Supportive care for systemic amyloidosis: International Society of Amyloidosis (ISA) expert panel guidelines

Systemic amyloidosis refers to a group of protein misfolding disorders resulting in organ deposition with amyloid, leading to organ dysfunction, ultimately resulting in organ failure and death if not successfully treated. Treatment is type-specific and aimed at the underlying source of the misfolded protein. In the past decades, treatments have become increasingly available across the various amyloidosis types with improved response rates and longer survival. Supportive care measures are an integral part of care for patients with systemic amyloidosis to improve symptom burden and quality of life, reduce healthcare costs, and potentially prolong survival while type-directed therapy takes effect. In these guidelines, we provide supportive care recommendations across eight areas of interest in systemic amyloidosis: cardiology, nephrology, peripheral neuropathy, central nervous system involvement, autonomic neuropathy, gastroenterology, coagulopathy and bleeding, nutrition and hematology. These guidelines were developed on behalf of the International Society of Amyloidosis (ISA) by experts in the above fields and provide the best available evidence and expertise for supportive care in these rare disorders.

Examining the relationship between secondhand smoke and non-malignant digestive system diseases: Mendelian randomization evidence

INTRODUCTION

Secondhand smoke (SHS) may exacerbate the global disease burden, particularly in workplace settings. Observational studies have implicated SHS as a risk factor for various non-malignant digestive system diseases (NMDSD), yet establishing a causal relationship remains challenging. Therefore, we conducted a Mendelian randomization (MR) study to explore whether workplace exposure to SHS is associated with NMDSD.

METHODS

This study utilized a secondary dataset analysis based on Genome-Wide association study (GWAS) summary data. Genetic variants associated with exposure to SHS in the workplace were used as instrumental variables. Genome-wide association study (GWAS) summary data for SHS were obtained from the UK Biobank. GWAS summary data for NMDSD were sourced from the FinnGen study, the International Inflammatory Bowel Disease Genetics Consortium (IIBDGC), and a large-scale study conducted in Japan. We employed inverse variance-weighted (IVW), MR-Egger, and weighted median methods for MR analysis. Additionally, sensitivity analyses were conducted to ensure the robustness of our findings.

RESULTS

According to the IVW model, SHS in the workplace was positively associated with ulcerative colitis (UC) (OR=2.03; 95% CI: 1.03-4.05; p=0.04). There was no evidence of horizontal pleiotropy biasing causality (p>0.05), and leave-one-out analysis confirmed the stability and robustness of this association.

CONCLUSIONS

Our study identifies an association between regular exposure to SHS in the workplace and an increased risk of ulcerative colitis. However, the potential influence of active smoking or exposure to SHS from other sources cannot be excluded. Further research is needed to confirm these findings.

Life's Simple 7 and its impact on chronic bowel disorders: a study on constipation and diarrhea in the U.S. adult population

Background

Chronic gastrointestinal disorders, such as chronic constipation and diarrhea, pose significant public health challenges, affecting quality of life and healthcare costs. Life's Simple 7 (LS7), established by the American Heart Association, encompasses essential health behaviors that may influence bowel health.

Methods

We utilized data from the National Health and Nutrition Examination Survey (NHANES) conducted between 2005 and 2010, focusing on adults aged 20 years and older. A total of 12,912 participants were included in the analysis. Bowel health was assessed through self-reported questionnaires, while LS7 was evaluated based on seven components: smoking status, physical activity, dietary quality, BMI, blood pressure, blood glucose, and blood cholesterol. Survey-weighted logistic regression models were employed to assess the associations between LS7 and chronic constipation and diarrhea, adjusting for various demographic and health-related covariates.

Results

Our findings revealed a significant inverse association between LS7 adherence and the prevalence of chronic constipation (OR: 0.914, 95% CI: 0.864-0.966, p = 0.003) and chronic diarrhea (OR: 0.883, 95% CI: 0.856-0.912, p < 0.0001). The protective effect of LS7 was more pronounced among males and individuals with a BMI under 30 kg/m2 for chronic constipation, and among younger adults and those without hypertension for chronic diarrhea. Restricted cubic spline analyses indicated a dose-response relationship, particularly for chronic diarrhea.

Conclusion

This study highlights the protective role of LS7 in promoting bowel health and preventing chronic constipation and diarrhea. Tailoring public health interventions based on demographic and health characteristics may enhance the effectiveness of strategies aimed at improving gastrointestinal health outcomes.

Burden and Cost of Gastrointestinal, Liver, and Pancreatic Diseases in the United States: Update 2024

BACKGROUND & AIMS

A contemporary report describing the burden and expenditures of gastrointestinal (GI) diseases can be helpful for policy makers, administrators, and researchers. Using the most recent data, we estimated the burden and costs associated with GI diseases in the United States.

METHODS

We generated estimates using data from the Rome Foundation Global Epidemiology Study 2017-2018 (symptoms), National Ambulatory Medical Care Survey 2019 and National Hospital Ambulatory Medical Care Survey 2019 (ambulatory visits), Nationwide Emergency Department Sample 2021 (emergency department visits), National Inpatient Sample 2021 (admissions), Kids' Inpatient Database 2019 (admissions), National Program of Cancer Registries 2001-2021 (cancer incidence), National Center for Health Statistics 2001-2021 (cancer mortality), Centers for Disease Control Wide-ranging Online Data for Epidemiologic Research 2021 (non-cancer mortality), MarketScan Commercial Claims and Encounters data 2002-2021 (endoscopy), MarketScan Medicare Supplemental data 2002-2021 (endoscopy), United Network for Organ Sharing Registry 2023 (transplant), Medical Expenditure Panel Survey 2021 (expenditures), and National Institutes of Health (NIH) 2012-2025 (research).

RESULTS

In 2021, GI health care expenditures totaled $111.8 billion. A GI diagnosis or symptom led to 14.5 million emergency department visits and 2.9 million hospital admissions. There were 315,065 new GI cancers diagnosed. GI diseases caused 281,413 deaths. In 2022, an estimated 23.5 million GI endoscopies were performed. In 2023, the NIH supported $3.6 billion for GI research, which represents 7.4% of the NIH budget.

CONCLUSION

GI diseases are responsible for a considerable and growing burden of health care use and costs. Funding innovative GI science and supporting the practice of GI medicine are critical to meeting the burden of GI illness.

Unveiling the Puzzle: Reactivated Epstein-Barr Virus-Associated Pancreatitis in a Young Adult

Epstein-Barr virus (EBV) is a rare cause of acute pancreatitis, with only 17 cases reported in the literature. We describe a 25-year-old male patient with recurrent pancreatitis, ultimately attributed to EBV reactivation. The initial presentation included severe epigastric pain, elevated lipase levels, and unremarkable imaging. A subsequent episode revealed diffuse pancreatic inflammation on MRI and positive Epstein-Barr nuclear antigen, confirming the diagnosis. Other common etiologies, including alcohol use, gallstones, and genetic predisposition, were ruled out. The patient was successfully managed with supportive care. This case highlights the diagnostic challenges of EBV-related pancreatitis and underscores the importance of considering viral etiologies in recurrent pancreatitis cases.

Outcomes of percutaneous endoscopic versus endoscopic transmural necrosectomy for necrotizing pancreatitis: A propensity score-matched study

BACKGROUND

Few published studies exist that compare the outcomes of different endoscopic necrosectomy methods for necrotizing pancreatitis (NP). We compared the safety and efficacy of percutaneous versus transmural endoscopic necrosectomy for NP patients.

METHODS

In this retrospective cohort study, we analyzed adult NP patients who underwent either percutaneous endoscopic necrosectomy (PEN) or endoscopic transmural necrosectomy (ETN), and compared safety and efficacy between the two groups. Propensity score-matched analysis and multivariable logistic regression analysis were conducted.

RESULTS

A total of 280 patients were enrolled, among which 142 underwent PEN and 138 underwent ETN. There were differences in baseline characteristics between the two groups, including body mass index, C-reactive protein, systemic inflammatory response syndrome score. The incidences of sepsis, respiratory failure, and intensive care unit stay were higher among patients who underwent PEN than those who underwent ETN (all P < 0.01). Ninety-one pairs were matched with comparable baseline characteristics and severity. The incidence of postoperative complications, open surgery, clinical success, radiological success, collection recurrence, and reintervention were not significantly different between the ETN group and PEN group (all P > 0.05). Multivariate analysis also showed that the approaches (PEN vs ETN) was not associated with postoperative complications or mortality.

CONCLUSIONS

In real world setting, sicker patients tend to be more effectively managed through PEN compared to ETN. PEN demonstrates comparable efficacy and safety to ETN in the treatment of NP patients.

Outcomes of Acute Pancreatitis in Patients With and Without Liver Cirrhosis: A Retrospective Analysis

Background Acute pancreatitis (AP) is a common cause of hospitalization in the United States. Our study aimed to investigate the impact of liver cirrhosis (LC) on the outcomes of AP in adult patients hospitalized with AP. Methods We performed a retrospective study of adult patients with AP utilizing the Nationwide Inpatient Sample (NIS) database from 2020 to 2022. We compared AP outcomes in patients with and without LC. The primary outcome was all-cause inpatient mortality. Secondary outcomes were the length of stay (LOS), healthcare cost utilization adjusted to 2022, the incidence of acute renal failure (ARF), sepsis, shock, venous thromboembolism (VTE), and the need for intensive care unit (ICU) admission. Statistical analyses were performed using STATA, version 16.1 (StataCorp., College Station, Texas, USA). A multivariate logistic regression analysis was conducted to assess if gender was an independent predictor for these outcomes and to adjust for any confounders. Results From 2020 to 2022, 738,139 adult patients underwent AP admissions. Among the patients, 723,959 had AP without LC, and 14,180 had AP with LC. The mean age for patients with and without LC was the same, 50.9 years. Patients without LC had a higher prevalence of cerebrovascular accident (CVA) and obesity. Patients with LC had a higher prevalence of congestive heart failure (CHF), diabetes mellitus type 2 (DM2), diabetes mellitus type 1 (DM1), chronic kidney disease (CKD), and smoking/tobacco use. We found that AP patients with LC had a significantly higher likelihood of in-hospital mortality (aOR: 1.74, 95% CI: 1.22-2.42, P < 0.01), longer LOS (+ 0.46 days, 95% CI: 0.26-0.67, P < 0.01), higher healthcare utilization cost (+ $4163, 95% CI: $1530.9-$6796.0, P < 0.01), shock (aOR: 1.87, 95% CI: 1.42-2.46, P < 0.01), ARF (aOR: 1.44, 95% CI: 1.30-1.59, P < 0.01), ICU admission (aOR: 1.67, 95% CI: 1.38-1.91, P < 0.01), and acute VTE (aOR: 1.65, 95% CI: 1.30-2.11, P < 0.01).  Conclusions We found that patients with AP who concomitantly had LC had significantly poor clinical outcomes, including higher mortality, ARF, shock, ICU admission, VTE, LOS, and total hospitalization charges as compared to AP patients who did not have LC. Our study highlights that cirrhotic patients with AP have poor inpatient hospital outcomes and need aggressive treatment to prevent morbidity and mortality.

Efficacy of Amitriptyline in Irritable Bowel Syndrome: A Systematic Review and Meta-analysis

Background/Aims

Amitriptyline is prescribed off-label for irritable bowel syndrome (IBS). We conducted a meta-analysis to assess its efficacy.

Methods

A systematic literature review was conducted until November 10, 2023, using MEDLINE, Embase, Cochrane Library, and Web of Science to study the efficacy of amitriptyline in patients with IBS. We included all randomized controlled trials that compared amitriptyline to placebo. Revised Cochrane risk-of-bias tool was used to assess the quality of studies. Meta-analyses were performed using a bivariate random-effects model. Statistical analyses were performed using R Software 4.2.3 and heterogeneity was assessed with I2 statistics.

Results

Seven trials were included with 796 patients (61% female). Amitriptyline was associated with better treatment response (OR, 5.30; 95% CI, 2.47 to 11.39; P < 0.001), reduced Irritable Bowel Syndrome Symptom Severity Scores (MD, -50.72; 95% CI, -94.23 to -7.20; P = 0.020) and improved diarrhea (OR, 10.55; 95% CI, 2.90 to 38.41; P < 0.001). No significant difference between the 2 groups regarding the adverse effects was observed. Three trials showed an overall low risk of bias, 2 trials showed an overall high risk of bias due to randomization and missing data, and 2 trials had some concerns regarding missing data.

Conclusions

Amitriptyline was found to be well-tolerated and effective in treating IBS compared to placebo. These findings support the use of amitriptyline for the management of IBS, particularly among patients with the IBS diarrhea subtype. Future research should focus on the dose-dependent effects of amitriptyline in IBS to better guide clinicians in personalized titration regimens.

Risk factors for inflammatory bowel disease: an umbrella review

Introduction

Inflammatory bowel disease (IBD) represents a cluster of chronic idiopathic inflammatory disorders situated at the nexus of intricate interplays. The primary aim of the present investigation is to perform an umbrella review of metaanalyses, systematically offering a comprehensive overview of the evidence concerning risk factors for IBD.

Methods

To achieve this, we searched reputable databases, including PubMed, Embase, Web of Science, and the Cochrane Database of Systematic Reviews, from inception through April 2023. Two authors independently assessed the methodological quality of each metaanalysis using the AMSTAR tool and adhered to evidence classification criteria.

Results

In total, we extracted 191 unique risk factors in meta-analyses, including 92 significantly associated risk factors. The top ten risk factors were human cytomegalovirus (HCMV) infection, IBD family history, periodontal disease, poliomyelitis, campylobacter species infection, hidradenitis suppurativa, psoriasis, use of proton pump inhibitors, chronic obstructive pulmonary disease, and western dietary pattern.

Discussion

In conclusion, this umbrella review extracted 62 risk factors and 30 protective factors, most of which were related to underlying diseases, personal lifestyle and environmental factors. The findings in this paper help to develop better prevention and treatment measures to reduce the incidence of IBD, delay its progression, and reduce the burden of IBD-related disease worldwide.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023417175.

Effects of air pollution on the development and progression of digestive diseases: an umbrella review of systematic reviews and meta-analyses

Air pollution, especially particulate matter (PM), is one of the most common risk factors for global burden of disease. However, its effect on the risk of digestive diseases is unclear. Herein, we attempt to explore this issue by reviewing the existing evidence from published meta-analyses. We conducted a systematic literature search to identify all relevant meta-analyses regarding the association of air pollution with digestive diseases, and summarize their major findings. We assessed the methodological quality and evidence quality of the included meta-analyses using the AMSTAR-2 and GRADE tools, respectively, and the overlap of primary studies was assessed by the GROOVE tool. Nine meta-analyses were included in our analysis, containing 43 primary studies with high overlap. In the included meta-analyses, the methodological quality was from critically low to moderate, and the evidence quality was from very low to moderate. The exposure was primarily PM2.5. Seven, four, and one meta-analysis investigated the effect of air pollution on liver diseases, gastrointestinal diseases, and pancreatic diseases, respectively. PM2.5 exposure was significantly associated with liver dysfunction, chronic liver diseases, liver cancer, and colorectal cancer, but not oesophagus cancer, gastric cancer, or pancreatic cancer. Based on very low to moderate quality evidence from meta-analyses, PM2.5 exposure may contribute to the development of some digestive diseases, especially liver diseases.

Comparing the efficacy of different proton pump inhibitor dosing regimens for the treatment of gastroesophageal reflux disease: a systematic review and meta-analysis

Several proton pump inhibitor (PPI) dosing regimens that vary by strength and frequency (once [Qday] or twice [BID] daily) are available to treat gastroesophageal reflux disease (GERD). We performed an updated systematic review and meta-analysis of randomized controlled trials (RCTs) assessing the impact of various PPI regimens on esophageal healing and GERD and heartburn symptoms. To identify relevant studies, we searched EMBASE and PubMed in January 2023, which yielded 1381 records. Eligible RCTs included those that enrolled adults diagnosed with GERD and compared different dosing regimens within the same PPI. The outcomes were esophageal healing and resolution of GERD and heartburn symptoms within 12 weeks (i.e. short-term) and > 12 weeks (i.e. long-term). Meta-analysis pooling of the odds ratios with 95% confidence intervals were estimated using the random-effects inverse-variance model. Overall, a total of 38 RCTs across 20 countries (N = 15,540 patients, mean age 50 years, 55% male) were included. Most PPI trials compared half standard dose Qday versus standard dose Qday or standard dose Qday versus double standard dose Qday. In general, when considering daily dosing, higher PPI strength significantly improved esophageal healing and relief of GERD symptoms both in the short- and long-term. Fewer trials compared Qday versus BID dosing; the impact of BID dosing on outcomes was inconsistent across the different PPI strength comparisons. In conclusion, this meta-analysis revealed that increasing PPI Qday dosages led to improved GERD outcomes. However, few studies compared Qday to BID dosing; as twice daily PPI usage is common in clinical practice, further studies are warranted to determine whether such dosing improves clinical outcomes.

Efficacy and Safety of a Combination of Enteral and Parenteral Nutrition Support in the Postoperative Period for Patients with Gastrointestinal Cancer: A Systematic Review and Meta-Analysis

Background

Postoperative nutritional support in gastrointestinal cancer, including enteral nutrition (EN), parenteral nutrition (PN), and combined nutrition strategies, is vital for enhancing recovery and patient outcomes.

Aims

We aimed to comprehensively evaluate the impact of postoperative EN, PN, and EN + PN in patients with gastrointestinal cancer.

Methods

PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wan Fang, and VIP were searched from conception until January 2, 2024. Randomized controlled trials (RCTs) that compared different postoperative nutritional support (EN, PN, or EN + PN) in patients with gastrointestinal cancer were included. The Cochrane Risk of Bias Assessment tool was used to assess the quality of the RCTs. Fixed- and random-effects models were chosen according to the heterogeneity of variables for the synthesis of results. Continuous and categorical variables were analyzed using the weighted mean difference or relative risk (RR) and 95% confidence interval (CI).

Results

In this meta-analysis, 11 RCTs were included. The PN + EN group exhibited significantly improved postoperative recovery, nutritional function, and immune indicators than the PN and EN groups (p < 0.05). Additionally, a higher incidence of postoperative complications such as abdominal distension (RR: 2.53; 95% CI: 1.17-5.49), nausea/vomiting (RR: 2.01; 95% CI: 1.09-3.71), and diarrhea (RR: 3.17; 95% CI: 1.41-7.10) was observed in the EN group than in the PN + EN group.

Conclusion

Combining supplemental PN with enteral support improves energy intake and prognosis in gastrointestinal cancer, though limited studies restrict publication bias evaluation.

Upper Gastrointestinal Bleeding: A Retrospective, Single-Center Experience on the Role of Endoscopy and Outcomes

Background

Upper gastrointestinal bleeding (UGIB) is a common and potentially fatal medical emergency. This study aimed to investigate the frequency, causes, outcomes, and efficacy of endoscopy in the treatment of UGIB at King Fahad Central Hospital in Jazan, Saudi Arabia.

Methods

Between January 2017 and December 2023, a retrospective study was performed including all hospitalized patients with UGIB. This research investigated sociodemographic characteristics, clinical history, endoscopic findings, treatment options, and results using statistical analysis, which included both descriptive and inferential approaches.

Results

The study included 483 patients (of which 74.1% men), with a mean age of 53.9 ± 19.5 years. Hematemesis was observed in 67.5% of the patients, whereas melena occurred in 49.7% of the cases. Two-hundred sixty-two (54.2%) patients underwent endoscopy within the first 24 h from presentation. The most frequent endoscopic findings were esophageal varices (52.2%) and duodenal ulcers (21.7%). Bandings accounted for 48.0% of all endoscopic procedures, whereas 36.9% of the patients received epinephrine injections along with endoclips. Medical therapy mostly consisted of a mix of proton pump inhibitors (PPIs) and octreotide. A significant minority (43.5%) of the patients stayed in the hospital for 1 - 3 days, while 59.6% did not need blood transfusions. During the first 3 days, 7% of patients experienced rebleeding, with a 6% mortality rate. Using multivariate regression analysis, rebleeding was strongly associated with initial presentation with shock (P < 0.001), renal disease (P = 0.01), and increased transfusion requirement (P = 0.001). Mortality was strongly associated with steroid usage (P = 0.007), increasing transfusion requirements (P < 0.0001), and rebleeding (P = 0.002).

Conclusions

Timely endoscopy and proper treatment dramatically improved UGIB results. Identifying those who are at high risk and acting swiftly is a critical step in reducing the likelihood of recurrent bleeding and fatality.

Economic and equity evaluation of age restrictions on over-the-counter diet pills and muscle-building supplements

Over-the-counter diet pills and muscle-building supplements are linked to increased eating disorder diagnoses, especially among youth. With limited regulatory oversight, minors may unknowingly consume harmful substances leading to other adverse effects. Massachusetts has proposed restricting sales to individuals under 18 years. However, concerns about health equity and unintended consequences arise when proposing new policies. We conducted a cost-effectiveness analysis of the proposed age-restriction policy compared to the status quo, focusing on 2 closed cohorts of males and females aged 0-17 years in Massachusetts over a 30-year time horizon. We evaluated the impact from both societal and health systems' perspectives and further assessed equity implications by modeling 3 racial/ethnic subgroups. The policy is projected to prevent 57 034 eating disorder cases and over 46 000 additional adverse medical events (eg, liver injuries). It would yield 51 749 quality-adjusted life years and generate healthcare savings of $14 million and societal savings of $30 million annually. The Latine subpopulation would see the highest per capita health benefits followed by Black and White residents, respectively. Restricting the sale of these supplements to minors offers both health and economic benefits. These findings underscore the policy's effectiveness, fiscal responsibility, and positive equity impacts, providing confidence for policymakers and the public.

Gastric Ultrasound in the Management of Emergency Department Patients with Upper Gastrointestinal Bleeding: A Case Series and Sonographic Technique

BACKGROUND

Gastrointestinal bleeding (GIB) is a common condition in the emergency department (ED) with high incidence and mortality.

OBJECTIVES

Very early risk stratification of GIB patients can sometimes be a challenge. The decision to intubate these patients is multifactorial and requires careful consideration.

DISCUSSION

Gastric ultrasound (GUS) is an adjunct tool that may help make such decisions and is supported by anesthesiology society guidelines to assess aspiration risk.

CONCLUSION

In this manuscript, we present a case series of ED patients with upper GIB in whom emergency physicians (2 fellowship-trained attendings and 2 senior residents facile with point-of-care ultrasound) performed GUS. As a supplement to the clinical examination, this sonographic "lavage" (i.e., using GUS in patients with upper GIB) helped predict aspiration risk, support diagnostic reasoning, and expedite early goal-directed management and appropriate disposition. We also provide a step-by-step tutorial using high-quality media, as well as a novel algorithm for translation of this technique to the bedside for emergency physicians.

Risk Factors of Acute Pancreatitis in Young Adults: A Nationwide Population-Based Cohort Study in South Korea

OBJECTIVES

This study aimed to identify the risk factors for acute pancreatitis (AP) in young adults in their 20s based on data from the nationwide cohort in South Korea.

MATERIALS AND METHODS

From the 2009 national health examination database of South Korea, a total of 471,098 individuals between the ages of 20 and 29 were analyzed. To identify the newly developed AP, the linked claims database was used.

RESULTS

The incidence rates of AP were 18.8 and 9.8 per 100,000 person-years in male and female participants, respectively. Alcohol consumption and smoking were associated with the heightened risk of AP. The risk of AP development was increased as daily alcohol consumption increased. In addition, ex-smokers and current smokers showed higher AP risk than never smokers. Hypertriglyceridemia and obesity were associated with the increased AP risk as well. Compared with female participants, male participants showed a higher risk of AP in univariate analysis but showed a lower risk of AP in multivariate analysis.

CONCLUSIONS

In the young adult population, alcohol consumption, smoking, hypertriglyceridemia, and obesity were associated with an elevated risk of developing AP. It is important to identify and manage the modifiable AP risk factors in young adults to minimize the socioeconomic burden of AP.

Laparoscopic Versus Robotic Elective Sigmoid Resection for Complicated Diverticulitis

Objective

Minimally invasive surgical techniques for colorectal surgery have continued to grow in prevalence with robotic surgery potentially providing advantages in complex pelvic operations. We sought to examine the outcomes of laparoscopic versus robotic elective sigmoid colon resection for complicated diverticulitis.

Methods

We performed a retrospective review of patients at an academic tertiary care center from 2018-2023 who underwent elective minimally invasive sigmoid colon resections for complicated diverticulitis. Multiple regression analysis was performed with primary outcomes being reoperation within 30 days and overall complications. Secondary outcomes included conversion to open, estimated blood loss, operative time, days until return of bowel function, and length of stay.

Results

In this cohort of 131 patients, 38 underwent laparoscopic colectomy and 93 patients underwent robotic colectomy. There were no significant differences between rate of reoperation (7.7% vs 2.1%, P = .42), complications (5.1% vs 8.4%, P = .52), conversion to open (5.1% vs 2.1%, P = .25), days until return of bowel function (1.87 vs 2.01, P = .41), or length of stay (5.2 vs 5.2, P = .92). There were significant differences in operative time and estimated blood loss. Robotic approach was 128.11 minutes longer (β = 128.11, SE = 12, p < .001) and had 33.4 cc less estimated blood loss (β = -33.4, SE = 16.6, P = .046), when adjusting for other confounders.

Conclusion

Robotic sigmoid colectomy for complicated diverticulitis had mostly equivalent outcomes at this institution. There was some decrease in estimated blood loss, however, operative time was increased in the robotic group.

A network dynamic nomogram for predicting overall survival and cancer-specific survival in patients with breast cancer liver metastases: an analysis based on the SEER database

The liver stands out as one of the most frequent sites for distant metastasis in breast cancer cases. However, effective risk stratification tools for patients with breast cancer liver metastases (BCLM) are still lacking. We identified BCLM patients from the SEER database spanning from 2010 to 2016. After meticulously filtering out cases with incomplete data, a total of 3179 patients were enrolled and randomly divided into training and validation cohorts at a ratio of 2:1. Leveraging comprehensive patient data, we constructed a nomogram through rigorous evaluation of a Cox regression model. Validation of the nomogram was conducted using a range of statistical measures, including the concordance index (C-index), calibration curves, time-dependent receiver operating characteristic curves, and decision curve analysis (DCA). Both univariable and multivariable analyses revealed significant associations between OS and CSS in BCLM patients and 14 variables, including age, race, and tumor stage, among others. Utilizing these pertinent variables, we formulated nomograms for OS and CSS prediction. Subsequent validation involved rigorous assessment using time-dependent ROC curves, decision curve analysis, C-index evaluations, and calibration curves. Our web-based dynamic nomogram represents a valuable tool for efficiently analyzing the clinical profiles of BCLM patients, thereby aiding in informed clinical decision-making processes.

Physical activity and risk of cholelithiasis: a narrative review

Cholelithiasis, commonly known as gallstone disease, poses a significant public health concern globally, with a myriad of risk factors contributing to its development. Among these, lifestyle factors, particularly physical activity, have garnered considerable attention for their potential role in modulating the risk of gallstone formation. This review aims to synthesize the current landscape of physical activity and the risk of developing cholelithiasis and identify knowledge gaps. To identify relevant articles, an independent author conducted a literature search using the PubMed database including keywords "cholelithiasis," "gallstones," and "physical activity" with no restriction on publication date. Cohort studies or Mendelian randomization analyses that reported physical activity and risk of gallstone disease were included in the current review. 15 articles were included in this review. The review highlights evidence suggesting a protective effect of regular physical activity against the development of gallstones. Results of Mendelian randomization analyses similarly demonstrated that physical activity remains independently causally associated with cholelithiasis. This review underscores the potential of physical activity as a modifiable risk factor for cholelithiasis, advocating for further research to establish definitive guidelines for prevention through lifestyle modification.

Xuebijing and somatostatin against acute pancreatitis: A systematic review and network pharmacology

BACKGROUND

Acute pancreatitis (AP) is a common pancreatic disease. Xuebijing injection (XBJ) combined with somatostatin in the treatment of AP is frequently used in clinical practice. There is, however, a lack of high-quality evidence-based evidence and network pharmacology to regard the therapeutic efficacy and pharmacological mechanisms.

PURPOSE

The purpose of this study is to investigate the potential therapeutic targets and pharmacological mechanism of XBJ in AP using integrating evidence-based medicine and network pharmacology.

METHODS

PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Weipu, and Wanfang databases were searched. Randomized controlled trials of XBJ combined with somatostatin (experimental group) versus somatostatin alone (control group) in the treatment of AP were collected. After extracting data from the literature that meets the inclusion criteria, and using the Cochrane Scale to evaluate the quality of the literature, we used Rev Man 5.3.0 statistical software to perform meta-analysis of the effective rate, the disappearance time of abdominal pain and bloating, the recovery of gastrointestinal motility, serum-related indicators, inflammatory factors, ventilator evacuation time, and hospitalization time. A network pharmacology is used to analyze the potential active ingredients and related crucial targets of the XBJ in the treatment of AP, and we explored key regulatory pathways and potential biomarkers related to XBJ for AP with integrated bioinformatics analysis.

RESULTS

It was significant that the total effective rate in the study group was higher than that in the control group (P < .05). The time of recovery of gastrointestinal motility, serum-related indicators, inflammatory factors, ventilator withdrawal time, and hospitalization time were significantly lower than that of the control group. The differences were statistically significant (P < .05). Signal transducer and activator of transcription 3, tumor protein P53, interleukin 6, tumor necrosis factor, Jun Proto-Oncogene, SRC Proto-Oncogene, Heat Shock Protein 90 Alpha Family Class A Member 1, Vascular Endothelial Growth Factor A, Epidermal Growth Factor Receptor, and Mitogen-Activated Protein Kinase 1 were identified as the key hub of the protein-protein interaction network according to an analysis of network centrality. According to the Kyoto Encyclopedia of Genes and Genomes pathway analysis, the main pathways are involved in PI3K-Akt signaling pathway, HIF-1 signaling pathway, and tumor necrosis factor signaling pathway.

CONCLUSIONS

The effectiveness of combination therapy of XBJ and somatostatin on AP is likely to be better than somatostatin. In addition, XBJ and somatostatin synergistically treated AP through a multi-pathway network.

Acupuncture reduces sedative and anaesthetic consumption and improves pain tolerance in patients undergoing colonoscopy: a Meta-analysis

OBJECTIVE

To evaluate the effects of acupuncture anesthesia on the consumption of sedatives and anesthetics, pain, and time consumption in patients undergoing colonoscopy, thus providing evidence that acupuncture anesthesia should be extended to endoscopists and anesthetists.

METHODS

Four English and four Chinese databases were searched for randomised controlled trials of acupuncture anaesthesia in patients undergoing colonoscopy, published from database inception to 1 March 2023. Outcomes were consumption of sedatives and anaesthetics, pain tolerance, visual analog scale (VAS) score, the meantime consumption of examination, satisfaction, and adverse reactions.

RESULTS

Thirty-one randomized controlled trials with a total of 4790 participants were included. Results showed that acupuncture anaesthesia significantly reduced consumption of sedatives and anaesthetics [9 studies, n = 944, standardized mean difference (SMD) = －0.82, 95% CI (－1.31, －0.33), P = 0.001], VAS score [9 studies, n = 1790, mean difference (MD) = －1.13, 95% CI (－1.70, －0.57), P < 0.001], meantime consumption [21 studies, n = 3799, MD = －2.09, 95% CI (－3.15, －1.03), P<0.001] and adverse reactions of colonoscopy [7 studies, n = 738, odds ratio (OR) = 0.17, 95% CI (0.10, 0.28), P<0.001]. Acupuncture also significantly improved pain tolerance [14 studies, n = 1661, OR = 7.05, 95% CI (3.79, 13.12), P<0.001], while no beneficial effects were found for satisfaction [7 studies, n = 843, SMD = 0.02, 95% CI (－0.38, 0.43), P = 0.91].

CONCLUSION

Acupuncture has beneficial effects on patients undergoing colonoscopy, particularly in reducing consumption of sedatives and anaesthetics, alleviating pain, shortening the time consumption of examination and preventing adverse events. As an alternative, effective, inexpensive, and accessible approach, acupuncture anaesthesia should be extended to endoscopists and anaesthesiologists.

Unveiling the applicability of the Brussels Infant and Toddler Stool Scale for hard stool in young children: A South Asian perspective

BACKGROUND AND AIM

The Rome IV criteria, the standard for diagnosing functional constipation (FC), deem the Bristol Stool Scale (BSS) unsuitable for assessing stool consistency in young children. Hence, the Brussels Infant and Toddler Stool Scale (BITSS) was developed. We aimed to validate and test the reliability of BITSS for hard stools and FC among infants and toddlers, where there is limited evidence in Asian populations.

METHODS

The research evaluated FC in children aged 0-48 months who came for medical examination using Rome IV criteria. Stool properties provided by caregivers were assessed sequentially through three methods: the BSS, the BITSS, and caregiver reports.

RESULTS

A total of 370 responses were received, with an average age of 26.2 months. Substantial agreement was observed between the BITSS and caregiver reports for hard stools (concordance rate: 91.9%, κ = 0.75), while near-perfect agreement was found between BITSS and BSS (concordance rate: 93.5%, κ = 0.81). The BITSS exhibited higher sensitivity than the BSS in assessing hard stools (95.3% vs 87.5%, P < 0.001). And the BITSS (23.5%) identified the highest prevalence of FC than the BSS (20.5%) and caregiver report (18.7%), with near-perfect agreement. Moderate agreement was reported when evaluating the test-retest reliability between BITSS and caregiver reports (concordance rate: 86.2%, κ = 0.44).

CONCLUSIONS

The BITSS, more sensitive than the BSS in identifying abnormal, especially hard stools, aids in early FC detection in young children. These findings support using BITSS over BSS for evaluating hard stools in infants and toddlers, both in Vietnam and globally.