Intravenous metoclopramide for increasing endoscopic mucosal visualization in patients with acute upper gastrointestinal bleeding: a multicenter, randomized, double-blind, controlled trial

Acute upper gastrointestinal hemorrhage (UGIH) is the most common emergency condition that requires rapid endoscopic treatment. This study aimed to evaluate the effects of pre-endoscopic intravenous metoclopramide on endoscopic mucosal visualization (EMV) in patients with acute UGIH. This was a multicenter, randomized, double-blind controlled trial of participants diagnosed with acute UGIH. All participants underwent esophagogastroduodenoscopy within 24 h. Participants were assigned to either the metoclopramide or placebo group. Modified Avgerinos scores were evaluated during endoscopy. In total, 284 out of 300 patients completed the per-protocol procedure. The mean age was 62.8 ± 14.3 years, and 67.6% were men. Metoclopramide group achieved a higher total EMV and gastric body EMV score than the other group (7.34 ± 1.1 vs 6.94 ± 1.6; P = 0.017 and 1.80 ± 0.4 vs 1.64 ± 0.6; P = 0.006, respectively). Success in identifying lesions was not different between the groups (96.5% in metoclopramide and 93.6% in placebo group; P = 0.26). In the metoclopramide group, those with active variceal bleeding compared with the control group demonstrated substantial improvements in gastric EMV (1.83 ± 0.4 vs 1.28 ± 0.8, P = 0.004), antral EMV (1.96 ± 0.2 vs 1.56 ± 0.6, P = 0.003), and total EMV score (7.48 ± 1.1 vs 6.2 ± 2.3, P = 0.02). Pre-endoscopic intravenous metoclopramide improved the quality of EMV in variceal etiologies of UGIH, which was especially prominent in those who had signs of active bleeding based on nasogastric tube assessment.Trial Registration: Trial was registered in Clinical Trials: TCTR 20210708004 (08/07/2021).

Nonvitamin K oral anticoagulants with proton pump inhibitor cotherapy ameliorated the risk of upper gastrointestinal bleeding

Proton pump inhibitors (PPIs) can reduce the risk of upper gastrointestinal bleeding (UGIB) in patients who are taking oral anticoagulants. This study aimed to identify the association between NOACs with PPI cotherapy and UGIB. This retrospective cohort analysis included patients over the age of 18 years who were using NOACs between 2013 and 2020. NOAC categories, concomitant medications, endoscopic findings, the HAS-BLED score and the Charlson Comorbidity Index score were recorded. Using Poisson regression models, the relationship between UGIB events and risk factors was analyzed. Throughout a mean follow-up of 29.5 months, 14 (5.1%) individuals experienced UGIB. The incidence of UGIB was greater in patients receiving NOACs without PPIs (2.7 [1.26-5.60] per 1000) than in those receiving NOACs with PPIs (1.3 [0.61-2.67] per 1000). Patients receiving NOACs with PPIs had a 79.2% lower incidence of UGIB than patients receiving NOAC monotherapy (RR 0.208, 95% CI 0.061-0.706; p = 0.012). Female sex and the HAS-BLED score were associated with UGIB (RR 5.043; 95% CI 1.096-23.20; p = 0.038; RR 2.024; 95% CI 1.095-3.743; p = 0.024, respectively). Patients receiving NOAC and PPI cotherapy had a lower incidence of UGIB than those receiving NOACs alone, and female sex was a risk factor for UGIB in NOAC-treated patients.

Thailand guideline 2020 for medical management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is one of the most prevalent and bothersome functional gastrointestinal disorders worldwide, including in Thailand. After a decade of the first Thailand GERD guideline, physician and gastroenterologist encountered substantially increase of patients with GERD. Many of them are complicated case and refractory to standard treatment. Concurrently, the evolution of clinical characteristics as well as the progression of investigations and treatment have developed and changed tremendously. As a member of Association of Southeast Asian Nations, which are developing countries, we considered that the counterbalance between advancement and sufficient economy is essential in taking care of patients with GERD. We gather physicians from university hospitals, as well as internist and general practitioners who served in rural area, to make a consensus in this updated version of GERD guideline focusing in medical management of GERD. This clinical practice guideline was constructed adhering with standard procedure. We categorized the guideline in to four parts including definition, investigation, treatment, and long-term follow up. We anticipate that this guideline would improve physicians' proficiency and help direct readers to choose investigations and treatments in patients with GERD wisely. Moreover, we wish that this guideline would be applicable in countries with limited resources as well.

Efficacy and safety of EUS-guided hepaticoesophagostomy (EUS-HES) for malignant biliary obstruction: the first case series

BACKGROUND

EUS-guided hepaticoesophagostomy (EUS-HES) was reported as an alternative procedure when puncture through the esophagus was inevitable. However, the existing data is very limited. We aimed to evaluate the efficacy and safety of EUS-HES in patients with difficult malignant biliary obstruction.

METHODS

All cases who underwent EUS-HES at our institute were retrospectively reviewed.

RESULTS

A total of 11 patients underwent EUS-HES from January 2011 to December 2017. Five were male, and the mean age was 57.9 ± 6.3 years. The majority of the patients (8 out of 11 patients) had a biliary obstruction caused by cholangiocarcinoma. The technical success was 100%. The mean procedure time was 73.2 ± 37.6 min. The main reason for EUS-HES was the improper alignment of the bile duct due to left lobe hypertrophy. The clinical success was 90.9%. The mean overall survival was 97.8 ± 68.5 days. No major procedure-related complication, particularly pneumomediastinum, occurred.

CONCLUSIONS

EUS-HES is a technically feasible and safe procedure to provide biliary drainage, especially in patients with left hepatic lobe hypertrophy. Using a bougie dilator instead of balloon dilation can avoid previously reported complications.

Comparison between disease free survival of hepatocellular carcinoma after hepatic resection in chronic hepatitis B patients with or without cirrhosis

BACKGROUND

Hepatocellular carcinoma (HCC) in chronic hepatitis B (CHB) patients can develop in those with cirrhotic and non-cirrhotic liver Not only impairment of liver status, but also the extension of tumor and difference of pathogenesis may also affect characteristics of patient and tumor including survival and recurrence.

OBJECTIVE

To evaluate the disease free survival, prognostic factors and features of HCC after hepatic resection in CHB patients with and without cirrhosis.

MATERIAL AND METHOD

Two hundred fifteen HBV-related HCC patients underwent hepatic resection and were analyzed. Cirrhotic and non-cirrhotic groups were compared for differences inpatient and tumor characteristics, disease-free survival including prognostic factors.

RESULTS

In comparison with cirrhotic patients, non-cirrhotic patients had more family history of HCC, more preserved liver function, were less HBeAg positive, and had lower HBV viral load. HCC characteristics in non-cirrhotic groups showed significantly larger (5.8 ± 3.7 vs. 4.9 ± 3.9 cm, p = 0.036) and operative data revealed that non-cirrhotic patients underwent more major surgery (50.7 vs. 18.3%, p < 0.001), and had shorter hospital stay (10.8 ± 8.9 vs. 8.1 ± 4.3 days, p = 0.006) than cirrhotic ones. Operative time, blood loss and requirement of PRC transfusion were similar in both groups. Pathological profiles of HCC and liver parenchyma were comparable in both cirrhotic and non-cirrhotic patients. The disease-free survival of non-cirrhotic patients was longer than cirrhotic patients (Median disease free survival were 21 and 11 months respectively, p = 0.022). The independent predictive factor of lower disease-free survival of non-cirrhotic CHB patients who underwent hepatic resection was lymph node involvement (Hazard ratio (HR), 4.598. 95% confidence interval (CI), 1.1-19.212; p = 0.037) while of cirrhotic patients, factors were age > 50 years old (HR, 2.998; 95% CI, 1.298-6.925; p = 0.01), multifocal tumor (HR, 5.835; 95% CI, 1.122-30.342; p = 0.036) andportal vein involvement (HR, 3.722; 95% CI, 1.121-12.353; p = 0.032). HBV treatment after HCC diagnosis was a significant predictor in the cirrhotic group by univariate analysis (p = 0.04).

CONCLUSION

Imaging and histological findings of HCC in cirrhotic and non-cirrhotic CHB patients were not different, except for larger tumor size in non-cirrhotic patients. Lymph node involvement is the predictor of HCC recurrence in non- cirrhotic CHB patients. Age > 50 year old and multifocal tumor and portal vein involvement are the predictors of HCC recurrence in cirrhotic CHB patients. These groups may need surveillance that is more intensive after hepatic resection. Antiviral therapy may lower the risk of HCC recurrence among CHB cirrhotic patients.