Annals of Gastroenterology

Complex cystic liver lesions: classification, diagnosis, and management

Evangelos G. Baltagiannis — 2024-05-30

Cystic liver disease has been increasingly reported in the literature, with a prevalence as high as 15-18%. Hepatic cysts are usually discovered incidentally, while their characterization and classification rely on improved imaging modalities. Complex cystic liver lesions comprise a wide variety of novel, re-introduced, and re-classified clinical entities. This spectrum of disorders ranges from non-neoplastic conditions to benign and malignant tumors. Their
clinicopathological features, prognostic factors, and oncogenic pathways are incompletely understood. Despite representing a heterogeneous group of disorders, they can have similar clinical and imaging characteristics. As a result, the diagnosis and management of complex liver cysts can become quite challenging. Furthermore, inappropriate diagnosis and management can lead to high morbidity and mortality. In this review, we aim to offer up-to-date insight into the diagnosis, classification, and management of the most common complex cystic liver
lesions.

Keywords Complex cystic liver lesion, hepatic mucinous cystic neoplasm, intraductal papillary neoplasm, infectious cyst, hydatid liver disease

Ann Gastroenterol 2024; 37 (3): 255-265

Update in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis

Bálint Gellért — 2024-05-30

Of all the possible complications associated with endoscopic retrograde cholangiopancreatography (ERCP), acute pancreatitis undoubtedly represents the heaviest burden for patients and healthcare professionals. The overall incidence, ranging from 3.5% to around 10%, and annual estimated costs exceeding $150 million in the USA should signal caution for everyone carrying out ERCP. In-depth knowledge of the risk factors and the pharmacological and endoscopic treatment options is required to avoid this adverse event. In this review, we evaluate the relevant data published in the literature since the appearance of the latest recommendations of the leading gastroenterological societies. Thus, we intend to provide a comprehensive and up-to-date overview of the factors to consider and possible interventions applicable before and after the intervention to prevent the development of post-ERCP pancreatitis.

Keywords Post-endoscopic retrograde cholangiopancreatography pancreatitis, prophylaxis, pancreatic stent, nonsteroidal anti-inflammatory drugs, fluid therapy

Ann Gastroenterol 2024; 37 (3): 266-279

Animal studies of sodium-glucose co-transporter 2 inhibitors in nonalcoholic fatty liver disease

Evangelia S. Makri — 2024-05-30

Nonalcoholic fatty liver disease (NAFLD) is considered one of the most common chronic liver diseases. Modern lifestyle, characterized by increasing rates of obesity and type 2 diabetes mellitus (T2DM), has led to a “pandemic” of NAFLD that imposes a personal health and socioeconomic burden. Apart from overnutrition and insulin resistance, various metabolic aberrations, gut microbiota and genetic predispositions are involved in the pathogenesis of the disease. The multifactorial nature of NAFLD’s pathogenesis makes the development of pharmacological therapies for patients with this disease challenging. Sodium-glucose co-transporter 2 inhibitors (SGLT-2i) are antidiabetic agents that reduce blood glucose mainly by increasing its renal excretion. As T2DM is one of the major contributors to NAFLD, SGLT-2i have emerged as promising agents for the management of NAFLD. In this review, we summarize the main animal studies on SGLT-2i in models of NAFLD.

Keywords Fibrosis, nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, pathophysiology, sodium-glucose co-transporter 2

Ann Gastroenterol 2024; 37 (3): 280-290

Endoscopic management of malignant biliary obstructions

Cecilia Binda — 2024-05-30

Malignant biliary obstruction (MBO), both distal and hilar, represents an ensemble of different clinical conditions frequently encountered in everyday practice. Given the frequent unresectability of the disease at presentation and the increasing indications for neoadjuvant chemotherapy, endoscopic biliary drainage is generally required during the course of the disease. With the widespread use of interventional endoscopic ultrasound (EUS) and the introduction of dedicated devices, EUS-guided biliary drainage has rapidly gained acceptance, together with transpapillary endoscopic biliary drainage and the percutaneous approach. This comprehensive review describes
the current role of endoscopy for distal and hilar MBO supported by evidence, with a focus on the current hot topics in this field.

Keywords Malignant biliary obstruction, biliary drainage, endoscopic retrograde cholangiopancreatography, endoscopic ultrasound-guided drainage

Ann Gastroenterol 2024; 37 (3): 291-302

Impact of blood transfusion on mortality and rebleeding in gastrointestinal bleeding: an 8-year cohort from a tertiary care center

Anthony Kerbage — 2024-05-30

Background The aim of this study was to investigate the impact of blood transfusion (BT) on mortality and rebleeding in patients with gastrointestinal bleeding (GIB) and whether BT at a threshold of ≤7 g/dL may improve these outcomes.

Methods A prospective study was conducted in patients admitted with GIB between 2013 and 2021. Antithrombotic (AT) use and clinical outcomes were compared between transfused and nontransfused patients, and between those transfused at a threshold of ≤7 vs. >7 g/dL. Multivariate analysis was performed to identify predictors of mortality and rebleeding.

Results A total of 667 patients, including 383 transfused, were followed up for a median of 56 months. Predictors of end-of-follow-up mortality included: age-adjusted Charlson Comorbidity Index, stigmata of recent hemorrhage (SRH), and being on anticoagulants only upon presentation (P=0.026). SRH was a predictor of end-of-follow-up rebleeding, while having been on only antiplatelet therapy (AP) upon presentation was protective (P˂0.001).
BT was not associated with mortality or rebleeding at 1 month or end of follow up. Among transfused patients, being discharged only on AP protected against mortality (P=0.044). BT at >7 g/dL did not affect the risk of short or long-term rebleeding or mortality compared to BT at ≤7 g/dL.

Conclusions Short- and long-term mortality and rebleeding in GIB were not affected by BT, nor by a transfusion threshold of ≤7 vs. >7 g/dL, but were affected by the use of AT. Further studies that account for AT use are needed to determine the best transfusion strategy in GIB.

Keywords Gastrointestinal bleeding, blood transfusion, mortality, rebleeding

Ann Gastroenterol 2024; 37 (3): 303-312

Pre-left ventricular assist device endoscopic evaluation does not reduce the risk of later gastrointestinal bleeding: a multicenter study

Jiahao Peng — 2024-05-30

Background Gastrointestinal bleeding (GIB) is a common complication after placement of a left ventricular assist device (LVAD). Some institutions attempt to mitigate post-LVAD GIB using preoperative endoscopy. Our study evaluated whether preoperative endoscopy was associated with a lower risk of post-LVAD GIB.

Methods This was a multicenter cohort study of patients who underwent LVAD insertion from 2010-2019 at 3 academic sites. A total of 398 study participants were categorized based on whether they underwent preoperative endoscopy or not. The follow-up period was 1 year and the primary outcome was GIB. Secondary outcomes were severe bleeding and intraprocedural complications.

Results A total of 114 patients experienced GIB within 1 year, with a higher rate in the endoscopy cohort (36.4% vs. 24.8%, P=0.015). After adjusting for covariables, the endoscopy cohort remained at increased risk of GIB (adjusted odds ratio 1.77, 95% confidence interval 1.05-2.976; P=0.032). Severe bleeding was common (47.4%). Arteriovenous malformations (48 cases) and peptic ulcer disease (17 cases) were the most identified sources of GIB. Only 1 minor adverse event occurred during preoperative endoscopy.

Conclusions Our study suggests that pre-LVAD endoscopy is associated with a higher risk of GIB post LVAD, despite controlling for confounders. While this was an observational study and may not have captured all confounders, it appears that endoscopic screening may not be warranted.

Keywords Heart-assist devices, gastrointestinal hemorrhage, endoscopy

Ann Gastroenterol 2024; 37 (3): 313-320

Association of preoperative workup and comorbidities with risk of gastroesophageal surgery failure

Frank Ventura — 2024-05-30

Background While surgical failure rates for fundoplication and hiatal hernia repair are low, there has been no clear evaluation of the preoperative risk factors associated with surgical failure. This study aimed to identify risk factors predisposing patients to surgical failure.

Methods Patients who underwent antireflux surgery during a 3-year period were evaluated for evidence of surgical complications and placed accordingly into the failure or control group. Demographic data, comorbidities, clinical presentation, preoperative evaluation, and surgical data were collected and compared between the groups.

Results In total, 86 patients with failure and 42 controls were identified among our cohort. No significant differences were found between groups based on sex (P=0.640). However, patients with failure were younger than controls (57.0 vs. 64.7 years, P=0.0001). Body mass index, tobacco use and alcohol use did not differ significantly between the groups (P=0.189, P=0.0999, P=0.060). Notably, psychiatric illness was more common in the failure group (P=0.0086). Neither hypertension (P=0.134) nor diabetes (P=0.335) had significant differences between groups. For procedures, no significant differences were found for the frequencies of preoperative imaging (P=0.395) or manometry (P=0.374), but pH/BRAVO studies (P=0.0193) and endoscopy (P<0.001) were both performed more frequently in the failure group.

Conclusions Patients with psychiatric comorbidities are at higher risk of surgical failure. Alcohol use trended toward significance, which warrants further investigation. We also noted an increase in rates of preoperative pH and endoscopy studies, contrary to the prior literature; this is likely due to more complex cases requiring additional workup.

Keywords Gastroenterology, general surgery, fundoplication, hiatal hernia, surgical failure

Ann Gastroenterol 2024; 37 (3): 321-326

Disparities in postoperative outcomes among diverse patient groups with inflammatory bowel disease

Ashley Shustak — 2024-05-30

Background Inflammatory bowel disease (IBD) represents a significant burden in the United States. We aim to evaluate disparities in postoperative outcomes among diverse patients undergoing surgery for IBD.

Methods The National Inpatient Sample (NIS) (2016-2018) was used to calculate national estimates for a number of postoperative complications in patients with IBD. Statistical analyses were performed using SAS survey procedures when calculating the national estimates.

Results A majority of the 107,375 patients (weighted) undergoing surgery for IBD were White (81.7%), rather than Black (10.1%) or Hispanic (8.2%). Black patients had higher rates of postoperative infections compared to White or Hispanic patients (4.2% vs. 3.1% vs. 2.7%, P=0.0137). There was a significant difference in morbidity and mortality, with higher rates in Black patients (20.1% vs. 17.1% vs. 17.9%, P=0.0029). Black patients experienced longer average hospital stays compared to White or Hispanic patients (12.6 vs. 9.6 vs. 11.2 days, P<0.001), despite suffering fewer comorbidities (Modified Charlson Index 1.9 vs. 2.3 vs. 2.0, P<0.001).

Conclusions This study demonstrated racial disparities in postoperative outcomes, with Black patients experiencing significantly higher rates of postoperative infections, overall morbidity and mortality, and length of stay, despite suffering from fewer comorbidities. This suggests an opportunity to improve equity of care for all patients with IBD by further examining social determinants of health that have not been traditionally studied.

Keywords Disparities, postoperative outcomes, inflammatory bowel disease

Ann Gastroenterol 2024; 37 (3): 327-332

Comparison of a selective STAT3 inhibitor with a dual STAT3/STAT1 inhibitor using a dextran sulfate sodium murine colitis model: new insight into the debate on selectivity

Brice Moulari — 2024-05-30

Background Recent advances in the treatment of inflammatory bowel disease include antitumor necrosis factor antibodies and the Janus kinase inhibitor tofacitinib, approved for ulcerative colitis. Janus kinase recruits signal transducers and activators of transcriptions (STAT), which are promising targets in inflammatory bowel diseases. However few inhibitors have been evaluated, and their selectivity with respect to STAT1 and STAT3 remains controversial. Here, we investigated the therapeutic potential of a selective inhibitor vs. a non-selective, closely related compound, in a dextran sulfate sodium (DSS) murine colitis model.

Methods Thirty Swiss/CD-1 male mice were used in this study. They were divided into a healthy control group, a colitis-DSS control group, a compound (cpd) 23-treated group, a cpd 46-treated group and an icariin-treated group. For the coadministration experiment with rutin, the cpd 46-treated group and the icariin-treated group were replaced by the oral rutin-treated group and the coadministration rutin/cpd 23-treated group. The effect of the tested inhibitors was also assessed by quantification of proinflammatory markers.

Results The selective inhibitor had a significantly greater effect than the dual inhibitor on the disease activity index. We also noticed in curative treatment a significant decrease in the most abundant proinflammatory biomarker present in neutrophilic granulocytes, myeloperoxidase and on proinflammatory cytokines, including tumor necrosis factor-α, interferon-γ, interleukins -6 and -23, with a mild synergy with rutin, the glycoside of quercetin.

Conclusion The current study shows how STAT3 selective inhibitors can exert a significant therapeutic effect in the treatment of experimental DSS-colitis.

Keywords Inflammatory bowel disease, ulcerative colitis, signal transducers and activators of transcription 3, dual inhibitor

Ann Gastroenterol 2024; 37 (3): 333-340

Clinical characteristics of symptomatic young patients with colonic adenomas

Mario El Hayek — 2024-05-31

Background The incidence of colonic adenomas and colorectal cancer has been on the rise among young patients. In this study, we aimed to describe the characteristics of young patients (<50 years) with adenomatous polyps and to characterize those polyps. We also aimed to determine appropriate surveillance intervals for young patients.

Methods We performed a retrospective chart review of patients <50 years of age who had polypectomy of 1 or more adenomatous polyps on colonoscopy between 2008 and 2021. Patient demographics, colonoscopy indication and polyp characteristics were obtained from the chart. Timing and findings on surveillance colonoscopies were recorded.

Results A total of 610 patients were included: mean age 42.9±5.9 years, 61% males, body mass index 27.5±4.7 kg/m2, and over 50% smokers. The most common indications were abdominal pain (23.3%), rectal bleeding (22.3%), and change in bowel habits (17.6%). Almost half of the patients who had adenomas (299) were younger than 45 years. Tubular adenoma was the most frequently encountered type of polyp (571; 93.6%). Mean polyp size was 1.1±0.9 cm. The most common location of adenomas was the sigmoid colon (41%). Of patients with adenomas, 156 (26%) had surveillance colonoscopy within 2.9±2.3 years; 74 patients (47.4%) were found to have new adenomas.

Conclusions Patients aged <50 years with colonic adenomas were mostly males, overweight, and smokers. Further adenomas were found in 47% of surveillance colonoscopies, and most were encountered within 5 years. High rates of recurrent adenomas in people ˂50 years of age may warrant frequent surveillance.

Keywords Colon adenoma, young patients, tubular adenoma

Ann Gastroenterol 2024; 37 (3): 341-347

Impact of small intestinal bacterial overgrowth on systemic inflammation, circulatory and renal function, and liver fibrosis in patients with cirrhosis and ascites

Olga Alexiou — 2024-05-31

Background Small intestinal bacterial overgrowth (SIBO) occurs frequently in patients with cirrhosis, particularly in those with ascites, and promotes the translocation of gut-derived bacterial products into the portal and systemic circulation. We investigated the effects of SIBO on systemic inflammatory activity, circulatory and renal function, and the degree of liver fibrosis in patients with cirrhosis and ascites.

Methods Eighty patients with cirrhosis and ascites were prospectively enrolled. SIBO was determined by lactulose breath test. Serum levels of lipopolysaccharide-binding protein (LBP), tumor necrosis factor-α, and interleukin-6, mean arterial pressure (MAP), cardiac output (CO) by echocardiography, systemic vascular resistance (SVR) as MAP/CO ratio, plasma renin activity (PRA), plasma aldosterone, radioisotope-assessed glomerular filtration rate (GFR), and liver stiffness by shear wave elastography were evaluated.

Results SIBO was detected in 58 patients (72.5%). Compared to patients without SIBO, those diagnosed with SIBO had significantly higher LBP levels (P<0.001), significantly lower MAP (P<0.001) and SVR (P<0.001), and significantly higher CO (P=0.002) and PRA (P<0.001). Patients with SIBO had significantly lower GFR (P=0.02) and higher liver stiffness (P=0.04) compared to those without SIBO. The presence of SIBO was independently associated with LBP (P=0.007) and PRA (P=0.01). Among patients with SIBO, peak breath hydrogen concentration was significantly
correlated with serum LBP (P<0.001), MAP (P<0.001), CO (P=0.008), SVR (P=0.001), PRA (P=0.005), plasma aldosterone (P<0.001), GFR (P<0.001), and liver stiffness (P=0.004).

Conclusion SIBO in patients with cirrhosis and ascites may predispose to greater systemic inflammation, circulatory and renal dysfunction, and more advanced liver fibrosis.

Keywords Small intestinal bacterial overgrowth, systemic inflammation, systemic hemodynamics, renal function, liver fibrosis

Ann Gastroenterol 2024; 37 (3): 348-355

Endoscopic ultrasound-guided portal pressure gradient measurement: a systematic review and meta-analysis

Banreet Singh Dhindsa — 2024-05-31

Background Endoscopic ultrasound-guided portal pressure gradient measurement (EUS-PPG) is a new modality where the portal pressure is measured by directly introducing a needle into the hepatic vein and portal vein. This is the first systematic review and meta-analysis to evaluate the efficacy and safety of EUS-PPG.

Methods A comprehensive literature search was performed to identify pertinent studies. The primary outcomes assessed were the technical and clinical success of EUS-PPG. Technical success was defined as successful introduction of the needle into the desired vessel, while clinical success was defined as the correlation of the stage of fibrosis on the liver biopsy to EUS-PPG, or concordance of HVPG and EUS-PPG. The secondary outcomes were pooled rates for total and individual adverse events related to EUS-PPG. Pooled estimates were calculated using randomeffects models with a 95% confidence interval (CI).

Results Eight cohort studies with a total of 178 patients were included in our analysis. The calculated pooled rates of technical success and clinical success were 94.6% (95%CI 88.5-97.6%; P=<0.001; I2=0) and 85.4% (95%CI 51.5-97.0%; P=0.042; I2=70), respectively. The rate of total adverse events was 10.9% (95%CI 6.5-17.7%; P=<0.001; I2=4), and 93.7% of them were mild, as defined by the American Society for Gastrointestinal Endoscopy. Abdominal pain (11%) was the most common adverse event, followed by bleeding (3.6%). There were no cases of perforation or death reported in our study.

Conclusions EUS-PPG is a safe and effective modality for diagnosing portal hypertension. Further randomized controlled trials are needed to validate our findings.

Keywords Endoscopic ultrasound, portal pressure gradient, portal hypertension, cirrhosis

Ann Gastroenterol 2024; 37 (3): 356-361

Equivalent efficacy and safety of plastic stents and lumen-apposing metal stents in the treatment of peripancreatic fluid collections: a prospective cohort study

Kaveh Khodakaram — 2024-05-31

Background Endoscopic ultrasound (EUS)-guided transmural drainage using double pigtail plastic stents (DPPS) has been routine for the treatment of peripancreatic fluid collections (PFC). Lumen-apposing metal stents (LAMS) have since their introduction been the preferred choice; however, their superiority has not been proven. The aim of this study was to compare the efficacy and safety of DPPS and LAMS.

Methods This was a single-center, prospective study that included consecutive patients undergoing EUS-guided drainage between January 2010 and December 2020. The primary endpoints were technical success, clinical success and adverse event rate, while the secondary endpoints included symptomatic relief, length of hospital stay, and need for adjunct drainage. A subgroup analysis of walled-off necrosis (WON) was performed.

Results A total of 89 patients (median age 56 years) underwent EUS-guided transmural drainage (DPPS: n=53; LAMS: n=36) because of a pseudocyst (n=37) or a WON (n=52). Both DPPS and LAMS had a 100% technical success rate and a comparable adverse event rate (4% vs. 6%, P=0.24). In equivalent efficacy was recorded for the drainage of PFC comparing DPPS and LAMS, and no significant statistical difference was recorded in clinical success (DPPS 60% vs. LAMS 61%, P=0.94) or the need for reintervention (DPPS 11% vs. LAMS 13%, P=0.72).

Conclusions In this large, prospective study of EUS-guided drainage of peripancreatic fluid collections, LAMS and DPPS showed equivalent safety, technical success, clinical success and hospital stay. Both techniques were associated with a comparable need for complementary necrosectomy.

Keywords Pancreatic pseudocyst, stents, endoscopic ultrasonography self-expandable metallic stents, drainage

Ann Gastroenterol 2024; 37 (3): 362-370

Comparison of the diagnostic yield of rapid versus non-rapid onsite evaluation in endoscopic ultrasound-guided fine-needle aspiration cytology of solid pancreatic lesions

Rajeeb Jaleel — 2024-05-31

Background The role of rapid on-site evaluation (ROSE) for endoscopic ultrasound-guided fineneedle aspiration (EUS-FNA) of pancreatic lesions is debatable. In this study, we aimed to compare the diagnostic yield of ROSE vs. non-ROSE in solid pancreatic lesions.

Methods This retrospective single-center study included patients undergoing EUS-FNA of solid pancreatic lesions from 2019-2021. Patients with cystic lesions, those undergoing fine-needle core biopsy, those undergoing repeat procedures, and patients with non-diagnostic smears with less than 6-month follow up were excluded. The diagnostic yield, need for repeat procedures and number of passes required with and without ROSE were analyzed in these patients.

Results Of the 111 patients included, 56 underwent ROSE. The majority of lesions were malignant in both groups (79.6% ROSE vs. 75% non-ROSE). The diagnostic yield was 96.4% in the ROSE group and 94.5% in the non-ROSE group. Repeat samples were needed in 1 ROSE and 2 non- ROSE patients. The median number of passes made was significantly fewer in the ROSE group (3.5, interquartile range - 3,4) compared with the non-ROSE group (4, interquartile range - 3,5) P=0.01. However, the frequency of procedure-related complications was similar in both groups.

Conclusion The utilization of ROSE during EUS-FNA of solid pancreatic lesions does not affect the diagnostic yield or the need for repeat samples, but reduces the number of passes needed for acquiring samples.

Keywords Endoscopic ultrasound-guided fine-needle aspiration, rapid on-site evaluation, diagnostic yield, cellularity of smears

Ann Gastroenterol 2024; 37 (3): 371-376

Endoscopic appearance is not sufficient for a diagnosis of segmental colitis associated with diverticulosis

Antonio Tursi — 2024-05-31

Background It has been recently shown that the prevalence of segmental colitis associated with diverticulosis (SCAD) is about 2% of all patients who have colonic diverticulosis. However, sometimes it can be overdiagnosed if only endoscopic criteria are applied. We have recognized endoscopic signs of SCAD (lesions of the interdiverticular mucosa with diverticular and rectal sparing) in patients with a variety of conditions other than SCAD.

Method We reviewed clinical, endoscopic and histologic data from selected patients with endoscopically visualized signs of SCAD.

Results Five patients with endoscopic signs of SCAD were included in this study. SCAD was excluded by the lack of specific biopsy findings, combined with laboratory exams. Final diagnoses were iatrogenic colitis due to immunotherapy (n=1), eosinophilic colitis (n=1), Salmonella typhi (n=1), undetermined inflammatory bowel disease (n=1), and Crohn’s disease (n=1).

Conclusions Lesions of the interdiverticular mucosa with diverticular and rectal sparing are not specific for SCAD, but rather a predictor of disease. In consequence, histology and, if necessary, laboratory analyses are mandatory to support a correct SCAD diagnosis.

Keywords Diverticulosis, endoscopy, histopathology, segmental colitis associated with diverticulosis, treatment

Ann Gastroenterol 2024; 37 (3): 377-380