Dyspepsia in Montenegrin chronic kidney disease patients undergoing hemodialysis: endoscopic and histopathological features

PURPOSE

The main purpose of this study was to analyze the characteristics of dyspepsia and contributing factors in Montenegrin maintenance hemodialysis patients.

METHODS

The study included 43 patients undergoing hemodialysis with symptoms of dyspepsia and 40 control dyspeptic subjects with preserved kidney function. All subjects underwent an interview about dyspeptic symptoms, physical and biochemical examination, and upper gastrointestinal endoscopy with pathohistological analysis of biopsy specimens.

RESULTS

Early satiety, bloating and heartburn were the most common symptoms in hemodialysis patients but without significant difference in frequency in relation to controls. Chronic kidney disease patients had statistically lower concentration of total proteins and albumin (p < 0.001), as well lower BMI values (p = 0.002). Despite this, no significant correlation of laboratory parameters with dyspeptic symptoms was found. Pathohistological examination indicated that the most common finding in hemodialysis patients was chronic active gastritis (58%), while chronic atrophic gastritis was significantly more common in dialytic patients (p = 0.032). Patients on hemodialysis had more frequently atrophy of corpus mucosa, which was positively related to dialysis duration (p = 0.001) and negatively related to pH values (p = 0.004) and bicarbonate concentration (p = 0.049). Helicobacter pylori was considerably more common in patients who underwent shorter time on hemodialysis (p < 0.001) and had higher values of bicarbonate (p = 0.037).

CONCLUSION

Maintenance hemodialysis patients are at risk for chronic gastric diseases that correlated with both dialysis vintage and duration.

COVID-19 in the endoscopy unit: How likely is transmission of infection? Results from an international, multicenter study

BACKGROUND

Coronavirus disease 2019 (COVID-19) significantly affected endoscopy practice, as gastrointestinal endoscopy is considered a risky procedure for transmission of infection to patients and personnel of endoscopy units (PEU).

AIM

To assess the impact of COVID-19 on endoscopy during the first European lockdown (March-May 2020).

METHODS

Patients undergoing endoscopy in nine endoscopy units across six European countries during the period of the first European lockdown for COVID-19 (March-May 2020) were included. Prior to the endoscopy procedure, participants were stratified as low- or high- risk for potential COVID-19 infection according to the European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) joint statement, and contacted 7-14 d later to assess COVID-19 infection status. PEU were questioned regarding COVID-19 symptoms and/or infection via questionnaire, while information regarding hospitalizations, intensive care unit-admissions and COVID-19-related deaths were collected. The number of weekly endoscopies at each center during the lockdown period was also recorded.

RESULTS

A total of 1267 endoscopies were performed in 1222 individuals across nine European endoscopy departments in six countries. Eighty-seven (7%) were excluded because of initial positive testing. Of the 1135 pre-endoscopy low risk or polymerase chain reaction negative for COVID-19, 254 (22.4%) were tested post endoscopy and 8 were eventually found positive, resulting in an infection rate of 0.7% [(95%CI: 0.2-0.12]. The majority (6 of the 8 patients, 75%) had undergone esophagogastroduodenoscopy. Of the 163 PEU, 5 [3%; (95%CI: 0.4-5.7)] tested positive during the study period. A decrease of 68.7% (95%CI: 64.8-72.7) in the number of weekly endoscopies was recorded in all centers after March 2020. All centers implemented appropriate personal protective measures (PPM) from the initial phases of the lockdown.

CONCLUSION

COVID-19 transmission in endoscopy units is highly unlikely in a lockdown setting, provided endoscopies are restricted to emergency cases and PPM are implemented.

Proton Pump Inhibitors and Radiofrequency Ablation for Treatment of Barrett's Esophagus

Gastroesophageal Reflux Disease (GERD) is characterized by acid and bile reflux in the distal oesophagus, and this may cause the development of reflux esophagitis and Barrett's oesophagus (BE). The natural histological course of untreated BE is non-dysplastic or benign BE (ND), then lowgrade (LGD) and High-Grade Dysplastic (HGD) BE, with the expected increase in malignancy transfer to oesophagal adenocarcinoma (EAC). The gold standard for BE diagnostics involves high-resolution white-light endoscopy, followed by uniform endoscopy findings description (Prague classification) with biopsy performance according to Seattle protocol. The medical treatment of GERD and BE includes the use of proton pump inhibitors (PPIs) regarding symptoms control. It is noteworthy that long-term use of PPIs increases gastrin level, which can contribute to transfer from BE to EAC, as a result of its effects on the proliferation of BE epithelium. Endoscopy treatment includes a wide range of resection and ablative techniques, such as radio-frequency ablation (RFA), often concomitantly used in everyday endoscopy practice (multimodal therapy). RFA promotes mucosal necrosis of treated oesophagal region via high-frequency energy. Laparoscopic surgery, partial or total fundoplication, is reserved for PPIs and endoscopy indolent patients or in those with progressive disease. This review aims to explain distinct effects of PPIs and RFA modalities, illuminate certain aspects of molecular mechanisms involved, as well as the effects of their concomitant use regarding the treatment of BE and prevention of its transfer to EAC.

MDR1 gene polymorphisms are associated with ulcerative colitis in a cohort of Serbian patients with inflammatory bowel disease

Background

Inflammatory bowel disease (IBD) is a chronic disease of unknown etiology in which genetic factors contribute to development of disease. Single nucleotide polymorphisms (SNPs) in multidrug resistance 1 (MDR1) gene encoding transporter P-glycoprotein have been associated with IBD, but their role in disease susceptibility remains unclear. Therefore, the aim of this study was to investigate the association of three MDR1 polymorphisms, C1236T (rs1128503), G2677T/A (rs2032582) and C3435T (rs1045642), with Serbian IBD patients.

Methods

A total of 206 IBD patients, 107 Crohn's disease (CD) and 99 ulcerative colitis (UC), and 255 healthy controls were included in the study. All subjects were genotyped using TaqMan SNP genotyping assays. Comparisons between the groups were performed using the Pearson Chi-square test. False discovery rate according to Benjamini-Hochberg procedure was applied to adjust for multiple comparisons.

Results

Carriers of T allele of all three MDR1 SNPs were more common in UC patients compared to healthy controls, suggesting predisposing role of T allele of these SNPs in UC pathogenesis. Consistently, TT genotype of C1236T and TTT haplotype were also found more frequently in UC patients. On the other hand, C allele and CC genotype of C1236T and C3435T, as well as G allele and GG genotype of G2677T/A were more frequent in healthy subjects, implying protective role of these variants in UC. Likewise, CGC haplotype and CGC/CGC diplotype were more frequent in controls. Contrary to UC, no statistical difference was observed between CD patients and controls in any of the SNPs analyzed.

Conclusion

MDR1 gene variants and haplotypes were associated with UC in Serbian IBD patients, further supporting their potential role in susceptibility to UC.

The Polymorphism rs3024505 (C/T) Downstream of the IL10 Gene Is Associated with Crohn's Disease in Serbian Patients with Inflammatory Bowel Disease

Inflammatory bowel disease (IBD), manifesting as Crohn's disease (CD) and ulcerative colitis (UC), is characterized by recurring episodes of inflammation in gastrointestinal tract, in which aberrant production of regulatory cytokine interleukin-10 (IL-10) presumably plays important role. Single nucleotide polymorphisms (SNPs) that affect IL-10 production, such as rs1800896 (G/A) at position -1082 and rs1800871 (C/T) at position -819 in the promoter region of the IL10 gene, have been associated with CD and/or UC, but the results were inconsistent. Another SNP that may alter IL-10 production, rs3024505 (C/T) located immediately downstream of the IL10 gene has been recently identified. T allele of rs3024505 was associated with both UC and CD in Western populations, but the studies from East European countries are lacking. Therefore, our aim was to assess the association of rs3024505, rs1800896 and rs1800871 with Serbian IBD patients. To this end, 107 CD and 99 UC patients and 255 healthy controls were genotyped. As a result, T allele of rs3024505 was associated with CD at allelic, genotypic (GT genotype) and haplotypic (GCCT haplotype) level, suggesting potential role of this variant in susceptibility to CD. In contrast, CD patients carrying C allele of rs3024505 had significantly increased risk of anemia and stricturing/penetrating behavior. No association was observed between rs3024505 and UC or SNPs in IL10 promoter region and any form of IBD. In conclusion, rs3024505 SNP flanking the IL10 gene is associated with susceptibility and severity of disease in Serbian CD patients, further validating its role as a potential biomarker in IBD.

Manual versus target-controlled infusion of balanced propofol during diagnostic colonoscopy – A prospective randomized controlled trial

INTRODUCTION

There is an increasing interest in balanced propofol sedation (BPS) for colonoscopy in outpatient settings. Propofol is a potent anesthetic agent for this purpose and has a narrow therapeutic range, which increases a risk of cardiovascular and respiratory complications in case of improper administration.

OBJECTIVE

The aim of this study was to compare patients’ safety and comfort of endoscopists in two methods of BPS targeting deep sedation – propofol target-controlled infusion (TCI) and manual intravenous titration technique (MT) – during colonoscopy.

METHODS

This prospective randomized controlled trial included 90 patients (class I or II of the American Society of Anesthesiologists) deeply sedated with propofol, coadministered with small doses of midazolam and fentanyl. Propofol was given by MT technique (45 patients) or by TCI (45 patients). The following adverse effects were recorded: hypotension, hypertension, bradycardia, tachycardia, hypoxemia, bradypnea, apnea, hiccupping, and coughing, as well as endoscopist’s comfort during colonoscopy by means of a questionnaire.

RESULTS

The MT group compared to the TCI group had a lower mean arterial pressure in the 10th minute after the beginning (p = 0.017), and at the end of colonoscopy (p = 0.006), higher oxygen saturation in the fifth minute (p = 0.033), and in the 15th minute (p = 0.008) after the beginning of colonoscopy, and lower heart rate at the beginning of the procedure (p = 0.001). There were no statistically significant differences in adverse events. Endoscopist’s comfort during colonoscopy was high 95.6% in the TCI group vs. 88.9% in the MT group (p = 0.069).

CONCLUSION

MT is clinically as stable as TCI of propofol for deep sedation during colonoscopy, and endoscopists experienced the same comfort during colonoscopy in both groups. Thus, both combinations are suitable for deep sedation during diagnostic colonoscopy.

Therapeutic double-balloon enteroscopy: a binational, three-center experience

BACKGROUND/AIMS

There are few reports focusing on therapeutic small bowel endoscopy. The aim of this study was to analyze the results of therapeutic small bowel endoscopy in a large cohort of patients.

METHODS

A retrospective study of a prospectively collected database comprising all patients undergoing diagnostic and therapeutic small bowel endoscopy in three centers.

RESULTS

A total of 614 double-balloon enteroscopies were performed in 534 patients. The most common pathological findings were angiodysplasias and vascular lesions (n = 98, 18%), mucosal ulcers and erosions (n = 95, 17.8%), polyps and tumors (including patients with familiar polyposis syndrome such as Peutz-Jeghers syndrome, familiar adenomatous polyps syndrome, neurofibromatosis, adenocarcinoma, neuroendocrine tumors and gastrointestinal stromal tumors) (n = 52, 9.7%), and strictures (Crohn's disease, ischemia, tumors) (n = 12, 2.2%). The mean duration of therapeutic small bowel enteroscopy was 67 min (range 30-115) compared to 50 min (range 25-105) for diagnostic procedures (p < 0.05). A therapeutic small bowel endoscopy was performed in 121 patients (22%). Therapeutic procedures included argon plasma coagulation of vascular lesions (n = 73), polypectomy (n = 49), mucosectomy (n = 5), stricture dilation (n = 7), foreign body extraction (n = 7), injection of fibrin glue (n = 10), and clip placement (n = 5). There were a total of 5 complications (0.9%; paralytic ileus, n = 2, pancreatitis, n = 1, bleeding n = 2). No perforations or deaths occurred.

CONCLUSION

Endoscopists performing double-balloon enteroscopy should be trained and prepared to provide therapeutic interventions for small bowel disorders including argon plasma coagulation, injection, hemoclipping, polypectomy, mucosectomy and foreign body extraction. Therapeutic small bowel endoscopy, albeit associated with complications in about 1% of cases, can be considered a relatively safe procedure.

Right liver lobe/albumin ratio: Contribution to non-invasive assessment of portal hypertension

AIM: To study the value of biochemical and ultraso-nographic parameters in prediction of presence and size of esophageal varices.

METHODS: The study includes selected cirrhotic patients who underwent a complete biochemical workup, upper digestive endoscopic and ultrasonographic examinations. Albumin/right liver lobe diameter and platelet count/spleen diameter ratios were calculated. The correlation between calculated ratio and the presence and degree of esophageal varices was evaluated.

RESULTS: Ninety-four subjects (62 males, 32 females), with a mean age of 52.32 ± 13.60 years, were studied. Child-Pugh class A accounted for 42.6%, class B 37.2%, whereas class C 20.2%. Esophageal varices (OE) were not demonstrated by upper digestive endoscopy in 24.5%, while OE gradeIwas found in 22.3% patients, grade II in 33.0%, grade III in 16.0%, and grade IV in 4.3%. The mean value of right liver lobe diameter/albumin ratio was 5.51 ± 1.82 (range from 2.76 to 11.44), while the mean platelet count/spleen diameter ratio was 1017.75 ± 729.36 (range from 117.39 to 3362.50), respectively. Statistically significant correlation was proved by Spearman's test between OE grade and calculated ratios. The P values were 0.481 and -0.686, respectively.

CONCLUSION: The right liver lobe diameter/albumin and platelet count/spleen diameter ratios are non-invasive parameters providing accurate information pertinent to determination of presence of esophageal varices, and their grading in patients with liver cirrhosis.

Renal impairment in patients with inflammatory bowel disease: association with aminosalicylate therapy?

BACKGROUND

In recent years, several case reports have been published suggesting an association between the use of 5-aminosalicylic acid (5-ASA) in patients with inflammatory bowel disease (IBD) and the development of chronic tubulo-interstitial nephritis. Apart from lesions associated to 5-ASA treatment, however, it is clear that IBD itself may also induce renal impairment, albeit the frequency is unknown.

METHODS

During 1 year, all IBD patients seen at the outpatient clinic of 27 European centres of gastro-enterology were registered and screened for renal impairment controlling for a possible association with 5-ASA therapy. Patients were questioned about their medical and drug history and their IBD disease activity. Renal screening (calculated creatinine clearance) was performed at baseline, after 6 and 12 months.

RESULTS

Included patients (n = 1,529) had a mean age of 39 (range 14-98), 56% had Crohn's disease, 42% ulcerative colitis and 2% indeterminate colitis. Half of the patients used 5-ASA during the study period. Decreased creatinine clearance was observed in 34 patients, among them 13 with chronic renal impairment. Comparing patients with and without renal impairment, no difference could be observed in 5-ASA consumption. In contrast, patients with renal impairment were significantly older, had a lower body mass index and showed a higher frequency of male sex, bowel resection and stoma.

CONCLUSION

Although the association between 5-ASA therapy and chronic tubulo-interstitial nephritis is clearly described in several case reports, this prospective study came to the reassuring conclusion that renal impairment in IBD patients is not frequently observed and is rarely associated with 5-ASA therapy.