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Long X, Zhang Y, Liu M, Liu Z, Xia L, Xu X, Wu M. Causality of genetically determined blood metabolites on inflammatory bowel disease: a two-sample Mendelian randomization study. Sci Rep 2024; 14:16361. [PMID: 39014047 PMCID: PMC11252329 DOI: 10.1038/s41598-024-67376-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 07/10/2024] [Indexed: 07/18/2024] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic and recurrent inflammatory disease of the gastrointestinal tract, including two subtypes: Crohn's disease (CD) and ulcerative colitis (UC). Metabolic disorders are important factors in the development of IBD. However, the evidence for the causal relationship between blood metabolites and IBD remains limited. A two-sample MR analysis was applied to evaluate relationships between 486 blood metabolites and IBD. The inverse variance weighted method was chosen as the primary MR analysis method. False discovery rate correction was used to control for false positives in multiple testing. Following complementary and sensitivity analyses were conducted using methods such as weight median, MR-egger, weighted mode, simple mode, Cochran Q test, and MR-PRESSO. Moreover, we performed replication, meta-analysis, Steiger test, and linkage disequilibrium score regression to enhance the robustness of the results. Additionally, we performed metabolic pathway analysis to identify potential metabolic pathways. As a result, we identified four significant causal associations between four blood metabolites and two IBD subtypes. Specifically, one metabolite was identified as being associated with the development of CD (mannose: odds ratio (OR) = 0.19, 95% confidence interval (CI) 0.08-0.43, P = 8.54 × 10-5). Three metabolites were identified as being associated with the development of UC (arachidonate (20:4n6): OR = 0.18, 95% CI 0.11-0.30, P = 2.09 × 10-11; 1, 5-anhydroglucitol: OR = 2.21, 95% CI 1.47-3.34, P = 1.50 × 10-4; 2-stearoylglycerophosphocholine: OR = 2.66, 95% CI 1.53-4.63, P = 5.30 × 10-4). The findings of our study suggested that the identified metabolites and metabolic pathways can be considered as useful circulating metabolic biomarkers for the screening and prevention of IBD in clinical practice, as well as candidate molecules for future mechanism exploration and drug target selection.
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Affiliation(s)
- Xiongquan Long
- Department of Gastroenterology, The First Affiliated Hospital of Hunan Normal University, Hunan Provincial People's Hospital, Changsha, 410005, Hunan, China
- Central Laboratory of Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005, Hunan, China
| | - Yuyang Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Hunan Normal University, Hunan Provincial People's Hospital, Changsha, 410005, Hunan, China
- Central Laboratory of Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005, Hunan, China
| | - Mingzhu Liu
- Department of Gastroenterology, The First Affiliated Hospital of Hunan Normal University, Hunan Provincial People's Hospital, Changsha, 410005, Hunan, China
- Central Laboratory of Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005, Hunan, China
| | - Zihao Liu
- Department of Endoscopic Diagnosis and Treatment Center, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410005, Hunan, China
| | - Lvzhou Xia
- Department of Gastroenterology, The First Affiliated Hospital of Hunan Normal University, Hunan Provincial People's Hospital, Changsha, 410005, Hunan, China
- Central Laboratory of Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005, Hunan, China
| | - Xiaoping Xu
- Department of Gastroenterology, The First Affiliated Hospital of Hunan Normal University, Hunan Provincial People's Hospital, Changsha, 410005, Hunan, China.
- Central Laboratory of Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005, Hunan, China.
| | - Minghao Wu
- Department of Gastroenterology, The First Affiliated Hospital of Hunan Normal University, Hunan Provincial People's Hospital, Changsha, 410005, Hunan, China.
- Central Laboratory of Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005, Hunan, China.
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Uchino M, Ikeuchi H, Noguchi T, Okabayashi K, Futami K, Tanaka S, Ohge H, Watanabe K, Itabashi M, Okamoto K, Okita Y, Mizushima T, Mizuuchi Y, Yamada K, Shimada Y, Sato Y, Kimura H, Takahashi K, Hida K, Kinugasa Y, Okuda J, Daito K, Koyama F, Ueno H, Yamamoto T, Hanai T, Kono T, Kobayashi H, Ajioka Y, Sugihara K, Ishihara S. Histological differentiation between sporadic and colitis-associated intestinal cancer in a nationwide study: A propensity-score-matched analysis. J Gastroenterol Hepatol 2024; 39:893-901. [PMID: 38273469 DOI: 10.1111/jgh.16496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/05/2023] [Accepted: 01/07/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND AND AIM Colitis-associated intestinal cancer (CAC) can develop in patients with inflammatory bowel disease; however, the malignant grade of CAC may differ from that of sporadic colorectal cancer (CRC). Therefore, we compared histological findings distinct from cancer stage between CAC and sporadic CRC to evaluate the features of CAC. METHODS We reviewed the clinical and histological data collected from a nationwide database in Japan between 1983 and 2020. Patient characteristics were compared to distinguish ulcerative colitis (UC), Crohn's disease (CD), and sporadic CRC. Comparisons were performed by using all collected data and propensity score-matched data. RESULTS A total of 1077 patients with UC-CAC, 297 with CD-CAC, and 136 927 with sporadic CRC were included. Although the prevalence of well or moderately differentiated adenocarcinoma (Tub1 and Tub2) decreased according to tumor progression for all diseases (P < 0.01), the prevalence of other histological findings, including signet ring cell carcinoma, mucinous carcinoma, poorly differentiated adenocarcinoma, or squamous cell carcinoma, was significantly higher in CAC than in sporadic CRC. Based on propensity score-matched data for 982 patients with UC and 268 with CD, the prevalence of histological findings other than Tub1 and Tub2 was also significantly higher in those with CAC. At pT4, mucinous carcinoma occurred at a significantly higher rate in patients with CD (45/86 [52.3%]) than in those with sporadic CRC (13/88 [14.8%]) (P < 0.01). CONCLUSION CAC, including early-stage CAC, has a higher malignant grade than sporadic CRC, and this difference increases in significance with tumor progression.
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MESH Headings
- Humans
- Propensity Score
- Male
- Female
- Middle Aged
- Colitis, Ulcerative/pathology
- Colitis, Ulcerative/complications
- Colitis, Ulcerative/epidemiology
- Aged
- Japan/epidemiology
- Crohn Disease/pathology
- Crohn Disease/epidemiology
- Crohn Disease/complications
- Colitis-Associated Neoplasms/pathology
- Colitis-Associated Neoplasms/etiology
- Colitis-Associated Neoplasms/epidemiology
- Colorectal Neoplasms/pathology
- Colorectal Neoplasms/epidemiology
- Colorectal Neoplasms/etiology
- Adult
- Adenocarcinoma/pathology
- Adenocarcinoma/epidemiology
- Adenocarcinoma/etiology
- Neoplasm Staging
- Neoplasm Grading
- Adenocarcinoma, Mucinous/pathology
- Adenocarcinoma, Mucinous/epidemiology
- Adenocarcinoma, Mucinous/etiology
- Carcinoma, Signet Ring Cell/pathology
- Carcinoma, Signet Ring Cell/epidemiology
- Carcinoma, Squamous Cell/pathology
- Carcinoma, Squamous Cell/epidemiology
- Carcinoma, Squamous Cell/etiology
- Diagnosis, Differential
- Prevalence
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Affiliation(s)
- Motoi Uchino
- Department of Gastroenterological Surgery, Division of Inflammatory Bowel Disease, Hyogo Medical University, Nishinomiya, Japan
| | - Hiroki Ikeuchi
- Department of Gastroenterological Surgery, Division of Inflammatory Bowel Disease, Hyogo Medical University, Nishinomiya, Japan
| | - Tatsuki Noguchi
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Koji Okabayashi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kitaro Futami
- Department of Surgery, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Hiroki Ohge
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazuhiro Watanabe
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michio Itabashi
- Department of Surgery, Division of Inflammatory Bowel Disease Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Kinya Okamoto
- Department of Coloproctology, Tokyo Yamate Medical Center, Tokyo, Japan
| | - Yoshiki Okita
- Department of Gastrointestinal and Pediatric Surgery, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu, Japan
| | - Tsunekazu Mizushima
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yusuke Mizuuchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazutaka Yamada
- Department of Surgery, Coloproctology Center Takano Hospital, Kumamoto, Japan
| | - Yoshifumi Shimada
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Yu Sato
- Department of Surgery, Toho University Sakura Medical Center, Chiba, Japan
| | - Hideaki Kimura
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Kenichi Takahashi
- Department of Colorectal Surgery, Tohoku Rosai Hospital, Sendai, Japan
| | - Koya Hida
- Department of Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Yusuke Kinugasa
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Junji Okuda
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Koji Daito
- Department of Surgery, Kindai University, Faculty of Medicine, Osaka, Japan
| | - Fumikazu Koyama
- Department of Surgery, Nara Medical University, Kashihara, Japan
| | - Hideki Ueno
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Takayuki Yamamoto
- Inflammatory Bowel Disease Center, Yokkaichi Hazu Medical Center, Yokkaichi, Japan
| | - Tsunekazu Hanai
- Department of Surgery, School of Medicine, Fujita Health University, Toyoake, Japan
| | - Toru Kono
- Advanced Surgery Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Hirotoshi Kobayashi
- Department of Surgery, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Yoichi Ajioka
- Division of Molecular and Diagnostic Pathology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | | | - Soichiro Ishihara
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
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Nishizaki D, Eskander RN. Targeted Therapies, Biologics, and Immunotherapy in the Neoadjuvant and Adjuvant Settings: Perioperative Risks. Surg Oncol Clin N Am 2024; 33:279-291. [PMID: 38401910 DOI: 10.1016/j.soc.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2024]
Abstract
Cancer therapeutics has been revolutionized by the introduction of molecularly targeted therapies and immune checkpoint inhibitors (ICIs). The paradigm of neoadjuvant therapy is commonly employed across multiple solid tumors, exhibiting significant clinical benefit as exemplified with ICIs in melanoma and non-small-cell lung cancer. However, neoadjuvant therapy can be associated with treatment-related adverse events. As the incorporation of these novel therapies in the preoperative space expands, it is crucial for surgical oncologists to understand the potential perioperative implications of these treatments. This article focuses on surgical considerations tied to these treatments, highlighting potential drug-surgery interactions and complications.
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Affiliation(s)
- Daisuke Nishizaki
- Division of Hematology and Oncology, Department of Medicine, Center for Personalized Cancer Therapy, University of California San Diego, Moores Cancer Center, 3855 Health Sciences Drive, La Jolla, CA 92037, USA.
| | - Ramez N Eskander
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, Center for Personalized Cancer Therapy, University of California San Diego, Moores Cancer Center, La Jolla, CA, USA
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Mao YQ, Sun SP, Lv B, Fan YH. Progress in understanding of relationship between use of biological agents and risk of malignant tumors in patients with inflammatory bowel disease. WORLD CHINESE JOURNAL OF DIGESTOLOGY 2024; 32:221-227. [DOI: 10.11569/wcjd.v32.i3.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/29/2024]
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Andrew B, Trinh S, Zhou A, Vasudevan A, Srinivasan A. Anal Cancer in Crohn's Disease: The Need to Optimize Treatment and Improve Surveillance. Am J Gastroenterol 2024; 119:390-391. [PMID: 38305248 DOI: 10.14309/ajg.0000000000002469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Affiliation(s)
- Bridgette Andrew
- Department of Gastroenterology, Eastern Health, Melbourne, Australia
| | - Steven Trinh
- Department of Gastroenterology, Eastern Health, Melbourne, Australia
| | - Annie Zhou
- Department of Gastroenterology, Eastern Health, Melbourne, Australia
| | - Abhinav Vasudevan
- Department of Gastroenterology, Eastern Health, Melbourne, Australia
- Monash University, Melbourne, Australia
| | - Ashish Srinivasan
- Department of Gastroenterology, Eastern Health, Melbourne, Australia
- Monash University, Melbourne, Australia
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6
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Parigi TL, Allocca M, Furfaro F, D’Amico F, Zilli A, Dal Buono A, Gabbiadini R, Bonovas S, Armuzzi A, Danese S, Fiorino G. Treat-to-Target and Regular Surveillance of Inflammatory Bowel Disease Are Associated with Low Incidence and Early-Stage Detection of Malignancies: A Retrospective Cohort Study. Cancers (Basel) 2023; 15:5754. [PMID: 38136300 PMCID: PMC10742048 DOI: 10.3390/cancers15245754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/02/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
Inflammatory bowel diseases (IBD), including ulcerative colitis (UC) and Crohn's disease (CD), increase the risk of malignancies, particularly colorectal cancer (CRC). We aimed to assess the incidence of malignancies in IBD patients managed using a treat-to-target approach and recommended surveillance. We retrospectively searched the electronic databases of two tertiary IBD centers in Milan from 2010 to 2019 for new diagnoses of malignancy in patients with pre-existing IBD. A total of 5239 patients with a follow-up of 19,820 years were included. In total, 71 malignancies were diagnosed in 70 patients (38 CD, 32 UC) with a mean age of 52.9 years, of whom 64% were former or active smokers. The annual incidence of all malignancies was 358 per 100,000 patient years (95% CI 275-444), and the standardized incidence rate (SIR) was 0.93 (95% CI 0.73-1.16). Gastrointestinal cancers were the most frequent (n = 17, 23.9%), in particular, CRC (n = 9), with an incidence of 45 per 100,000 (95% CI 15-74) and an SIR of 1.18 (95% CI 0.54-2.09). CRC occurred mainly in UC patients (6/8), while small bowel cancer was seen in CD patients (5/9). Melanoma and breast cancer (n = 8 each) were the most common non-GI cancers. No significant difference in incidence was found between CD or UC. Death occurred in nine patients (11%) and was due to cancer in eight of these cases, two of which were IBD-related. Most malignancies included in the surveillance were diagnosed at early (I-II) stages (20 vs. 4, p < 0.05). In patients with IBD, treat-to-target and strict surveillance were associated with a low incidence of cancer, similar to that of the general population, and the detection of malignancies at an early stage.
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Affiliation(s)
- Tommaso Lorenzo Parigi
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, 20132 Milan, Italy (M.A.); (F.F.); (F.D.); (A.Z.)
- Division of Immunology, Transplantation and Infectious Disease, Università Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Mariangela Allocca
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, 20132 Milan, Italy (M.A.); (F.F.); (F.D.); (A.Z.)
| | - Federica Furfaro
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, 20132 Milan, Italy (M.A.); (F.F.); (F.D.); (A.Z.)
| | - Ferdinando D’Amico
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, 20132 Milan, Italy (M.A.); (F.F.); (F.D.); (A.Z.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
| | - Alessandra Zilli
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, 20132 Milan, Italy (M.A.); (F.F.); (F.D.); (A.Z.)
| | - Arianna Dal Buono
- IBD Center, Department of Gastroenterology, Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (A.D.B.)
| | - Roberto Gabbiadini
- IBD Center, Department of Gastroenterology, Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (A.D.B.)
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
| | - Alessandro Armuzzi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- IBD Center, Department of Gastroenterology, Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (A.D.B.)
| | - Silvio Danese
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, 20132 Milan, Italy (M.A.); (F.F.); (F.D.); (A.Z.)
- Division of Immunology, Transplantation and Infectious Disease, Università Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Gionata Fiorino
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, 20132 Milan, Italy (M.A.); (F.F.); (F.D.); (A.Z.)
- IBD Unit, Department of Gastroenterology and Digestive Endoscopy, San Camillo-Forlanini Hospital, 00152 Rome, Italy
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7
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Awadhi SA, Alboraie M, Albaba EA, Almutairdi A, Alsaad M, Azzam N, Barakat H, D’Amico F, Danese S, El Kady M, Ghoneim H, Hamoudi W, Jazzar A, Mosli M, Shehab H, Sneineh AA. Treatment of Patients with Mild to Moderate Ulcerative Colitis: A Middle East Expert Consensus. J Clin Med 2023; 12:6929. [PMID: 37959394 PMCID: PMC10650478 DOI: 10.3390/jcm12216929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 10/29/2023] [Accepted: 11/02/2023] [Indexed: 11/15/2023] Open
Abstract
The prevalence of ulcerative colitis (UC) in the Middle East is increasing, impacting the economic and healthcare burden. The management of patients with mild to moderate UC is still a challenge as several factors can affect optimal care, including drug choice, induction and maintenance dose, treatment optimization and de-escalation, therapy duration, monitoring, and safety profile. We conducted an expert consensus to standardize the management of patients with mild to moderate UC. Sixteen experts in inflammatory bowel diseases, through a well-established and accepted Delphi methodology, voted and approved eight statements in order to provide practical guidance to clinicians in the Middle East.
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Affiliation(s)
- Sameer Al Awadhi
- Digestive Diseases Unit, Rashid Hospital, Dubai 003206, United Arab Emirates
| | - Mohamed Alboraie
- Department of Internal Medicine, Al-Azhar University, Cairo 11884, Egypt;
| | - Emad Aldin Albaba
- Department of Medicine, Almana General Hospital, Alkhobar 31952, Saudi Arabia;
| | - Abdulelah Almutairdi
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia;
| | - Monther Alsaad
- Al Madar Medical Centre, Sharjah P.O. Box 80789, United Arab Emirates;
| | - Nahla Azzam
- Division of Gastroenterology, Department of Medicine, College of Medicine, King Saud University, Riyadh 11451, Saudi Arabia;
| | - Husam Barakat
- Department of Gastroenterology, Yarmouk University, Irbid 21163, Jordan;
| | - Ferdinando D’Amico
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, 20132 Milan, Italy; (F.D.); (S.D.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20132 Milan, Italy
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, 20132 Milan, Italy; (F.D.); (S.D.)
| | - Mohamed El Kady
- Department of Medical Pharmacology, Faculty of Medicine, Cairo University, Cairo 11559, Egypt;
| | - Hossam Ghoneim
- Immunology and Allergy Department, Medical Research Institute, Alexandria University, Alexandria 5424041, Egypt;
| | - Waseem Hamoudi
- Internal Medicine Department, Al-Bashir Hospital, Amman 11151, Jordan;
| | - Ahmad Jazzar
- Gastroenterology Division, Sheikh Khalifa Medical City, Abu Dhabi 51900, United Arab Emirates;
| | - Mahmoud Mosli
- Department of Medicine, King Abdulaziz University Hospital, Jeddah 21589, Saudi Arabia;
| | - Hany Shehab
- Integrated Clinical and Research Center for Intestinal Disorders (ICRID), Gastroenterology Division, Endemic Medicine Department, Cairo University, Cairo 3725121, Egypt;
| | - Awni Abu Sneineh
- Gastroenterology and Hepatology, University of Jordan, Amman 11942, Jordan;
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