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Journal: Journal of gastroenterology and hepatology

151

Lymph node metastasis is a major prognostic factor for perihilar cholangiocarcinoma (PHC). However, prognostic significance of extent of node dissection, lymph node ratio (LNR), number and location of positive nodes remain unclear. We aimed to evaluate whether node status, LNR, number or location of positive nodes are independent factors for staging in PHC, and to determine the minimum requirements for node examination.

Concepts: Cancer, Lung cancer, Lymph node, Lymphadenectomy

28

Development of hepatic cirrhosis involves oxidative stress, inflammation, hepatic stellate cells (HSC)s activation and fibrosis. On the other hand, quercetin, a natural flavonoid is a potent antioxidant and activator of superoxide dismutase and catalase. The aim was to determinate the effect of quercetin on HSCs and development of hepatic fibrosis.

Concepts: Enzyme, Antioxidant, Oxidative stress, Superoxide dismutase, Cirrhosis, Vitamin C, Superoxide, Hepatic stellate cell

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BACKGROUND AND AIM: Proton pump inhibitors (PPI) and H(2) -receptor antagonists (H(2) RA) are frequently prescribed in hospitalized patients with cirrhosis. There are conflicting reports regarding the role of acid suppressive therapy in predisposing hospitalized patients with cirrhosis to spontaneous bacterial peritonitis (SBP).The aim of this meta-analysis was to evaluate the association between acid-suppressive therapy and the risk of SBP in hospitalized patients with cirrhosis. METHODS: We searched MEDLINE and 4 other databases for subject headings and text words related to SBP and acid-suppressive therapy. All observational studies that investigated the risk of SBP associated with PPI/H2RA therapy and utilized SBP as an endpoint were considered eligible. Data from the identified studies were combined by means of a random-effects model and odds ratios (ORs) were calculated. RESULTS: Eight studies (n=3,815 patients) met inclusion criteria. The risk of hospitalized cirrhotic patients developing SBP increased when using acid-suppressive therapy. The risk was greater with PPI therapy (n= 3,815; OR 3.15, 95% CI 2.09-4.74) as compared to those on H2RA therapy (n=562; OR 1.71, 95% CI 0.97- 3.01). CONCLUSIONS: Pharmacologic acid-suppression was associated with a greater risk of SBP in hospitalized patients with cirrhosis. Cirrhotic patients receiving a PPI have approximately 3 times the risk of developing SBP compared to those not receiving this medication. Prospective studies may help clarify this relationship and shed light on the mechanism(s) by which acid-suppressive therapy increases the risk of SBP in hospitalized patients with cirrhosis.

Concepts: Observational study, Proton, Cirrhosis, Ascites, Gastroenterology, Peritonitis, Hepatic encephalopathy, Spontaneous bacterial peritonitis

28

Recently, it has been suggested that single nucleotide polymorphisms (SNPs) in some cytokine genes may influence the production of the associated cytokines that affect the host immune response to pegylated interferon-α (Peg-IFN-α) with ribavirin (RBV) in hepatitis C virus (HCV) patients. The aim of the present study was to investigate the possible role of the SNPs of IL-10 and Il-28B and their serum levels in predicting the response to treatment of HCV-4.

Concepts: Antibody, DNA, Gene, Interferon, Interleukin, Hepatitis C, Hepatitis B, Hepatitis A

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BACKGROUND & AIMS: Belching is a common disorder with undetermined pathogenesis. With the combined multichannel intraluminal pH impedance (MII-pH) monitoring, two different models of belching have been defined: gastric belching (GB) and supragastric belching (SB). The aim of this study was to assess whether supragastric belching (SB) was associated with air swallowing as compared to gastric belching (GB) or healthy volunteers based on Rome III Criteria. METHODS: Consecutive patients who presented with troublesome repetitive belching were recruited. Both upper endoscopy and multichannel intraluminal pH impedance (MII-pH) monitoring were performed. Patients were divided into 2 groups: SB and GB groups according to the percentage of the predominant belching types. Twenty volunteers were enrolled as healthy controls. The number of air swallowing, regular swallowing and gastroesophageal reflux (GER) profile were compared among the three groups. RESULTS: Thirty-seven patients were included in the study: 25 in the SB group and 12 in GB group. SB patients presented more belching events than GB patients (p<0.05). There were no significant differences among the SB, GB patients and healthy volunteers concerning the episodes of air swallowing and regular swallowing (p>0.05). No significant difference was found among the three groups in regard with the reflux parameters (p>0.05). The number of gas-containing reflux episodes were 33.0 [20.0-48.0], 39.5 [29.5-47.5] and 30.5 [27.0-41.8] among SB, GB and healthy volunteers (p=0.383) respectively. CONCLUSIONS: SB patients presented with more belching events, compared with GB patients. However, air swallowing and reflux profile were similar among the SB, GB patients and normal controls.

Concepts: Blood, Statistical significance, Difference, Gastroesophageal reflux disease, Endoscopy, Barrett's esophagus, Belching, Aerophagia

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BACKGROUND AND AIM: Spiral enteroscopy is a novel technique for small bowel exploration. The aim of this study is to compare double balloon and spiral enteroscopy in patients with suspected small bowel lesions. METHODS: Patients with suspected small bowel lesion diagnosed by capsule endoscopy were prospectively included between September 2009 and December 2010 in five tertiary-care academic medical centres. RESULTS: After capsule endoscopy, 191 double balloon enteroscopy and 50 spiral enteroscopies were performed. Indications were obscure gastro-intestinal bleeding in 194 (80%) of cases. Lesions detected by capsule endoscopy were mainly angioectasia. Double balloon and spiral enteroscopy resulted in finding one or more lesions in 70% and 75% of cases, respectively. The mean diagnosis procedure time and the average small bowel explored length during double balloon and spiral enteroscopy were respectively 60 minutes (45-80) and 55 minutes (45-80) (p=0.74), and 200 cm (150-300) and 220 cm (200-300) (p=0.13). Treatment during double balloon and spiral enteroscopy was possible in 66% and 70% of cases, respectively. There was no significant major procedure-related complication. CONCLUSION: Spiral enteroscopy appears as safe as double balloon enteroscopy for small bowel exploration with a similar diagnostic and therapeutic yield. Comparison between the two procedures, in terms of duration and length of small bowel explored, is slightly in favor of SE but not significantly.

Concepts: Diagnosis, Gastroenterology, Arithmetic mean, Ablative brain surgery, Endoscopy, Enteroscopy, Double-balloon enteroscopy, Hironori Yamamoto

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BACKGROUND AND AIM: Evidence suggests probiotics reduce certain constipation-related symptoms. Lactobacillus casei strain Shirota has never been tested as treatment for functional constipation in otherwise-healthy subjects. We aimed to evaluate the efficacy of this probiotic among adults with functional constipation. METHODS: Subjects with functional constipation (Rome II-defined) were randomized to intake Lactobacillus casei strain Shirota fermented milk or placebo once daily for 4 weeks under double-blind condition. Primary outcomes were constipation severity and stool frequency; secondary outcomes were stool consistency and quantity. RESULTS: In intent-to-treat population, compared to baseline, constipation severity and stool frequency improved in both probiotic (n=47) and control groups (n=43) but improvements were comparable in both groups at Week 4 (α=5% level). In probiotic group, stool consistency and quantity at Week 4 improved significantly vs. baseline but not vs. control. Considering the study agent is non-pharmaceutical and purpose of supplementation is for long term effect, re-evaluation at α=10% was conducted which showed significant improvement in constipation severity at Week 4 (P=0.058). Magnitude of the probiotic effect on stool consistency was small but grew over time, d=0.19, 95% CI 0.00-0.35 (Week 4), d=0.29, 95% CI 0.11-0.52 (post-intervention). Post-hoc exploratory analysis suggests incomplete evacuation may decrease with probiotic intake. CONCLUSIONS: Four week administration of Lactobacillus casei strain Shirota did not alleviate constipation severity or stool frequency, consistency and quantity when compared to control. With re-evaluation at α=10% level, improvement in constipation severity was significant at Week 4. To obtain conclusive results, further studies with longer intervention are warranted.

Concepts: Gut flora, Improve, Microbiology, Feces, Probiotic, Lactobacillus, Lactobacillus casei, Yakult

27

BACKGROUND AND AIM: The Blatchford score is based on clinical and laboratory variables to predict need for clinical interventions in upper gastrointestinal bleeding (UGIB). The primary object was to evaluate the Blatchford score with clinical and full Rockall scores in patients with active cancer presenting to emergency department (ED) with UGIB. The secondary object was to assess the accuracy of the Blatchford score at different source of UGIB; cancer bleeding vs. non-malignant lesions METHODS: We reviewed and extracted data form electronic medical record on patients with active cancer presenting to ED from January 2009 to December 2011. Clinical interventions included blood transfusion, therapeutic endoscopy, angiographic intervention and surgery. RESULTS: Of the 225 patients included, 197 (87.6%) received interventions. Comparing the area under receiver-operator curves, the Blatchford score (0.86, 95% CI 0.77 - 0.95) was superior to clinical Rockall (0.67, 95% CI 0.55 - 0.79) and full Rockall score (0.72, 95% CI 0.61 - 0.83) in predicting interventions. When the score of 2 or less is counted as negative, sensitivity of 0.99 and specificity of 0.54 were calculated. When the patients were separated according to the source of UGIB, sensitivity and specificity were not changed. CONCLUSIONS: The Blatchford score outperformed both Rockall scoring system in predicting intervention in patients with active cancer. The source of bleeding was not important factor in the score performance. The Blatchford score has a very good sensitivity. However, suboptimal specificity limits its role as sole means of decision making in cancer patient with UGIB.

Concepts: Sensitivity and specificity, Gastroenterology, Upper gastrointestinal bleeding, Glasgow-Blatchford

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BACKGROUND: Hepatic steatosis is an important parameter to assess in chronic liver disease patients. The Controlled Attenuation Parameter (CAP) assesses liver steatosis using transient elastography. AIM: To determine the accuracy of CAP for evaluation of hepatic steatosis in chronic hepatitis B virus (CHBV) infected, chronic hepatitis C virus (CHCV) infected and non alcoholic fatty liver disease (NAFLD) patients and to determine the influence of aetiology on the diagnostic accuracy of CAP. METHODS: 146 CHBV patients, 108 CHCV infected patients and 63 patients with NAFLD, who underwent both liver biopsy and successful CAP measurements within the study period, were assessed. Area under the Receiver Operating Characteristic (AUROC) was used to evaluate performance of CAP for diagnosing steatosis compared with biopsy. RESULTS: Multivariate analysis found that CAP correlated with BMI [ OR , 95% CI=4.09 (1.2-6.8) for CHBV ; 4.7 (1.1-8.4) for CHCV and 16.2(9.1-24.5) for NAFLD patients respectively] and hepatic steatosis score on biopsy [ OR , 95% CI=30.7 (19.2-42.2]) for CHBV ; 24.2 (11.5-37.3) for CHCV and 21.8(10.1-45.0)16.2(9.1-24.5) for NAFLD patients respectively]. AUROC for CAP was 0.683 (0.601-0.757) for steatosis (S) ≥6 %, 0.793 (0.718-0.856) for S>33% and 0.841 (0.771-0.896) for S > 66% respectively for CHBV infected patients. There was no difference in accuracy of CAP for assessing liver fat among CHBV, CHCV and NAFLD patients. CONCLUSIONS: CAP is a novel, noninvasive tool that can detect and quantify steatosis accurately among CHBV, CHCV and NAFLD patients, the accuracy being similar for all the three groups of patients.

Concepts: Cirrhosis, Hepatitis, Hepatitis C, Hepatitis B, Hepatitis A, Non-alcoholic fatty liver disease, Fatty liver, Steatosis

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BACKGROUND AND AIM: TRIM28 is a multi-domain nuclear protein with pleotropic effects in both normal and tumor cells. In this study, we investigate TRIM28 expression in epithelial and stromal tumor microenvironment and its prognostic role in colorectal cancer. METHODS: Immunohistological staining of TRIM28 was evaluated in tissue microarrays constructed from 137 colorectal cancer patients. The correlations of TRIM28 expression with clinicopathologic features and p53 expression were studied. Kaplan-Meier analysis and Cox proportional hazard modeling were used to assess overall survival (OS) and recurrence-free survival (RFS). RESULTS: Strong epithelial TRIM28 expression was found in 42% of colorectal cancer tissues. TRIM28 expression correlated significantly with p53 expression in matched cases (P = 0.0168, Spearman rank test). A high epithelial to stromal TRIM28 expression ratio was associated with shorter OS (P = 0.033; log-rank test) and RFS (P = 0.043; log-rank test). Multivariate analysis showed that the epithelial to stromal TRIM28 expression ratio was an independent predictor of OS (hazard ratio (HR) = 2.136; 95% confidence interval (CI) 1.015-4.498, P = 0.046) and RFS (HR = 2.100; CI 1.052-4.191, P = 0.035). CONCLUSION: A high TRIM28 expression ratio between stromal and epithelial compartments in colorectal cancer tissue is an independent predictor of poor prognosis. The pathophysiological role of TRIM28 in carcinogenesis may be dependent on expression levels and cell type within the tumor microenvironment.

Concepts: Gene expression, Cell, Cancer, Oncology, Statistics, Spearman's rank correlation coefficient, Correlation and dependence, Pearson product-moment correlation coefficient