Search

Gastrointestinal bleeding is the most frequent major complication of antiplatelet therapy. In patients at low bleeding risk, however, clinically overt gastrointestinal bleeding is relatively uncommon.The authors sought to assess the effects of different antiplatelet regimens on gastrointestinal mucosal injury by means of a novel magnetically controlled capsule endoscopy system in patients at low bleeding risk.Patients (n = 505) undergoing percutaneous coronary intervention in whom capsule endoscopy demonstrated no ulcerations or bleeding (although erosions were permitted) after 6 months of dual antiplatelet therapy (DAPT) were randomly assigned to aspirin plus placebo (n = 168), clopidogrel plus placebo (n = 169), or aspirin plus clopidogrel (n = 168) for an additional 6 months. The primary endpoint was the incidence of gastrointestinal mucosal injury (erosions, ulceration, or bleeding) at 6-month or 12-month capsule endoscopy.Gastrointestinal mucosal injury through 12 months was less with single antiplatelet therapy (SAPT) than with DAPT (94.3% vs 99.2%; P = 0.02). Aspirin and clopidogrel monotherapy had similar effects. Among 68 patients without any gastrointestinal injury at randomization (including no erosions), SAPT compared with DAPT caused less gastrointestinal injury (68.1% vs 95.2%; P = 0.006), including fewer new ulcers (8.5% vs 38.1%; P = 0.009). Clinical gastrointestinal bleeding from 6 to 12 months was less with SAPT than with DAPT (0.6% vs 5.4%; P = 0.001).Despite being at low risk of bleeding, nearly all patients receiving antiplatelet therapy developed gastrointestinal injury, although overt bleeding was infrequent. DAPT for 6 months followed by SAPT with aspirin or clopidogrel from 6 to 12 months resulted in less gastrointestinal mucosal injury and clinical bleeding compared with DAPT through 12 months. (OPT-PEACE [Optimal Antiplatelet Therapy for Prevention of Gastrointestinal Injury Evaluated by Ankon Magnetically Controlled Capsule Endoscopy]; NCT03198741).

Background: Eosinophilic esophagitis (EoE) is an immune-mediated clinicopathological condition characterized by esophageal infiltration with eosinophils resulting in chronic inflammation and stricture. Summary: The recent increase in the incidence of EoE and the characteristic presentation of symptoms with difficulty swallowing and food bolus impaction has raised key concerns of clinicians as well as researchers. EoE often presents with dysphagia, food impaction, nausea, regurgitation or vomiting, and decreased appetite. It is more common in males, affecting both adults and children. The causative manner of this condition is complex and multifactorial. Throughout recent years, researchers have made a significant contribution to understanding the pathogenesis of EoE, genetic background, natural history, work on allergy, and standardization in the evaluation of disease activity. There is relatively high prevalence of EoE among the population, emphasizing the importance of this disease. Key messages: Esophageal involvement with eosinophils may be manifested as isolated or with coexisting conditions and should be taken into consideration in the differential diagnosis. This study aimed to provide gastroenterologists with novel insights into the evaluation of esophageal involvement with eosinophils and to pay special attention to the etiological factors, coexisting clinical diseases, and complications.

POEM is a rescue endoscopic therapy for patients who had previously failed surgical or endoscopic treatment. However, data regarding its effectiveness after failed pneumatic dilation (PD) and its long-term effects are limited. We aimed to retrospectively investigate the long-term outcomes in patients who had undergone POEM after failed PD. Data from 66 achalasia patients with a 2-year follow-up period were analyzed. Intraprocedural events were compared between the first POEM group (patients without prior-endoscopic intervention) and prior PD group (patients who had pre-POEM PD). Symptom evaluation, HRM and 24 h-pH DeMeester scores between the two groups were performed at 2 years after the POEM procedure. Muscularis externa samples were obtained from the lower esophagus using POEM to assess the muscle fibrosis with Azan-Mallory staining. POEM was successfully performed for all achalasia patients. During the 2-year follow-up period, the success rate of POEM was 96.15% (25/26) for patients with prior PD and 95% (38/40) with primary POEM. For patients with type II achalasia and who underwent prior PD, the post-procedure DeMeester score was higher compared to patients who underwent POEM only (P

Background Angiosarcoma is a rare disease with a poor prognosis. Its occurrence in the small intestine is low, and gastrointestinal bleeding caused by small intestinal angiosarcoma is unusual. Case summary Here, we report the case of a 57-year-old man who presented with hematochezia for 1 mo. The patient had a medical history of chronic viral hepatitis B for 15 years. The causes of gastrointestinal bleeding were initially diagnosed as esophagogastric variceal bleeding or portal hypertensive gastropathy before endoscopy. However, after a complicated diagnostic and therapeutic process, including gastroendoscopy, colonoscopy, contrast-enhanced computed tomographic (CT), positron emission computed tomography/CT, capsule endoscopy, and pathological and immunohistochemical examinations, small intestinal angiosarcoma was diagnosed. Arrest of bleeding was achieved after surgical treatment. Furthermore, the patient had lung cancer with bone and adrenal metastases. At the follow-up 10 mo after the operation, the patient was alive. Conclusion Gastroenterologists should maintain strong vigilance to small intestinal angiosarcoma, which is necessary for the early identification of this infrequent but fatal disease.

Colorectal cancer (CRC) is one of the main alimentary tract system malignancies affecting people worldwide. Adenomatous polyps are precursors of CRC, and therefore, preventing the development of these lesions may also prevent subsequent malignancy. However, the adenoma detection rate (ADR), a measure of the ability of a colonoscopist to identify and remove precancerous colorectal polyps, varies significantly among endoscopists. Here, we attempt to use a convolutional neural network (CNN) to generate a unique computer-aided diagnosis (CAD) system by exploring in detail the multiple-scale performance of deep neural networks. We applied this system to 3,375 hand-labeled images from the screening colonoscopies of 1,197 patients; of whom, 3,045 were assigned to the training dataset and 330 to the testing dataset. The images were diagnosed simply as either an adenomatous or non-adenomatous polyp. When applied to the testing dataset, our CNN-CAD system achieved a mean average precision of 89.5%. We conclude that the proposed framework could increase the ADR and decrease the incidence of interval CRCs, although further validation through large multicenter trials is required.

Background Alterations in body compositions are related to poor outcomes and the presence of complications in cirrhosis. However, no predictive tools combining all these anthropometric parameters are applicable in the clinical setting. We aimed to clarify the potential utility of body compositions and develop a nomogram incorporating any independent factor for prognosticating long-term mortality in cirrhosis. Methods A total of 414 patients were randomized into primary (n = 274) and validation (n = 140) cohorts. X-tile was performed to identify optimal cut points for stratifying participants. Multivariate Cox regression was performed, and nomogram incorporating body compositions were generated. The utility of developed models was evaluated by Harrell concordance index (C-index), calibration curve, and decision curve analysis (DCA). Results Stratifying by X-tilederived cut points, low skeletal muscle index (myopenia), high intramuscular adipose tissue content (myosteatosis), and the ratio of high visceral to subcutaneous adipose tissue area (adiposity) was independently associated with 3-year mortality. A sex-stratified nomogram incorporating anthropometric indices and clinical factors resulted in moderate discriminative accuracy, with a C-index of 0.787 (95% CI, 0.736-0.838) and 0.789 (95% CI, 0.727-0.851) in males and females, respectively. The calibration curve showed predictive survival corresponding optimally with the actual outcomes. Our models were feasible in the clinical settings based on DCA. Similar results were observed in the validation cohort. Additionally, participants could be classified into 3 distinct risk groups by the nomogram. Conclusions Our proposed nomogram embedding body compositions rendered an individualized predictive tool for long-term mortality in cirrhosis.

Summary Background Chemoprevention of colorectal adenoma and colorectal cancer remains an important public health goal. The present study aimed to investigate the clinical potential and safety of berberine for prevention of colorectal adenoma recurrence. Methods This double-blind, randomised, placebo-controlled trial was done in seven hospital centres across six provinces in China. Individuals aged 18–75 years who had at least one but no more than six histologically confirmed colorectal adenomas that had undergone complete polypectomy within the 6 months before recruitment were recruited and randomly assigned (1:1) to receive berberine (0·3 g twice daily) or placebo tablets via block randomisation (block size of six). Participants were to undergo a first follow-up colonoscopy 1 year after enrolment, and if no colorectal adenomas were detected, a second follow-up colonoscopy at 2 years was planned. The study continued until the last enrolled participant reached the 2-year follow-up point. All participants, investigators, endoscopists, and pathologists were blinded to treatment assignment. The primary efficacy endpoint was the recurrence of adenomas at any follow-up colonoscopy. Analysis was based on modified intention-to-treat, with the full analysis set including all randomised participants who received at least one dose of study medication and who had available efficacy data. The study is registered with ClinicalTrials.gov , number NCT02226185 ; the trial has ended and this report represents the final analysis. Findings Between Nov 14, 2014, and Dec 30, 2016, 553 participants were randomly assigned to the berberine group and 555 to the placebo group. The full analysis set consisted of 429 participants in the berberine group and 462 in the placebo group. 155 (36%) participants in the berberine group and 216 (47%) in the placebo group were found to have recurrent adenoma during follow-up (unadjusted relative risk ratio for recurrence 0·77, 95% CI 0·66–0·91; p=0·001). No colorectal cancers were detected during follow-up. The most common adverse event was constipation (six [1%] of 446 patients in the berberine group vs one [ Interpretation Berberine 0·3 g twice daily was safe and effective in reducing the risk of recurrence of colorectal adenoma and could be an option for chemoprevention after polypectomy. Funding National Natural Science Foundation of China.

Distal esophageal spasm (DES), a relatively rare condition, is characterized by simultaneous contractions of the distal esophagus and manifested by dysphagia and chest pain. Several treatment options are recommended, such as pharmacological therapy, endoscopic interventions, and surgical myotomy. Recently, per-oral endoscopic myotomy (POEM) has been adopted as an effective and less-invasive treatment due to its excellent short-term clinical outcomes. Nevertheless, few reports describe its long-term effects. A 65-year-old woman complained of chest pain accompanied with dysphagia and weight loss for 4 months. A series of examinations suggested that she was suffering from DES and then POEM was performed. During the 2.5-year follow-up, we observed an exciting long-term outcome. Interestingly, hematoxylin and eosin staining verified a large number of eosinophils in the muscularis externa, which was absent in the mucosa of the esophagus of the patient. We herein report a case of DES who underwent POEM to eliminate persistent esophageal contractions. Eckardt score, esophageal emptying test, and high-resolution manometry were assumed to monitor the efficacy of POEM. During treatment and 2.5 years after operation, esophageal muscle biopsies and/or mucosal tissues were obtained. This case has been presented to describe that POEM could be a strategy for DES with a long-term curative effect and that eosinophils in the muscle layer of the esophagus might be involved in the pathogenesis of DES. What is more, we reviewed literature to find similar cases reported in the past.EINFüHRUNG: Diffuser Ösophagusspasmus (distal esophageal spasm DES) ist ein eher seltenes Krankheitsbild, gekennzeichnet von simultanen Kontraktionen der Muskulatur der distalen Speiseröhre, das Schluckbeschwerden und retrosternale Schmerzen verursacht. Empfohlen werden unterschiedliche Behandlungsmethoden wie medikamentöse Therapie, endoskopische Verfahren und operative Myotomie. Aufgrund der ausgezeichneten Kurzzeitergebnisse im klinischen Umfeld wird seit kurzem die perorale endoskopische Myotomie (POEM) als effektive und wenig invasive Behandlungsmethode angewandt. Es gibt jedoch nur wenige Berichte über die Langzeitergebnisse. FALLBERICHT: Eine 65-jährige Frau gab an, seit 4 Monaten unter Brustschmerzen mit Schluckbeschwerden und Gewichtsverlust zu leiden. Nach mehreren Untersuchungen wurde die Diagnose DES gestellt, woraufhin eine POEM durchgeführt wurde. Innerhalb des 2,5 Jahre langen Follow-up konnten wir ein ausgezeichnetes Langzeitergebnis feststellen. Interessanterweise ergab die Färbung mit Hämatoxylin und Eosin eine große Anzahl an Eosinophilen in der Muskelschicht, jedoch nicht in der Ösophagusschleimhaut der Patientin. SCHLUSSFOLGERUNGEN: Wir berichten hier über einen Fall von DES bei einer Patientin, bei welcher eine POEM durchgeführt wurde, um persistierende Ösophaguskontraktionen zu eliminieren. Die Wirksamkeit des Eingriffs wurde mittels Eckardt-Score, Ösophagus Entleerungstest und hochauflösender Manometrie überwacht. Während der Behandlung und 2,5 Jahre nach dem Eingriff wurden Gewebeproben aus der Muskelschicht und/oder der Ösophagusschleimhaut gewonnen. Dieser Fall wurde vorgestellt, um zu zeigen, dass POEM eine Behandlungsmethode für DES mit dauerhaft heilender Wirkung sein kann und dass Eosinophile in der Muskelschicht des Ösophagus an der Pathogenese von DES beteiligt sein können. Außerdem haben wir eine Literaturübersicht durchgeführt, um ähnliche Fälle in der Vergangenheit zu finden.

Research has shown that maternal sucralose (MS) exposure alters the gut microbiota of offspring at weaning and predisposes the offspring to developing obesity, non-alcoholic fatty liver disease and metabolic syndrome later in life. However, the underlying mechanism remains unclear. Paneth cells are thought to critically influence the gut microbiota. This study aimed to investigate whether MS exposure induced Paneth cell defects and exacerbated gut dysbiosis of offspring. Female C57BL/6 mice were divided into the MS and control (water) groups during pregnancy and lactation. Progeny mice were fed a normal sucralose-free diet after weaning until adulthood. MS inhibited intestinal development and increased the expression of proinflammatory cytokines in the small intestines of 3-week-old progeny mice. MS increased the proportions of abnormal granule secretion by Paneth cells. The number of Paneth cells and mRNA expression of AMPs such as cryptdins and lysozyme were reduced in the MS group. MS disturbed the gut microbiota composition and diversity in the 3-week-old offspring mice. The relative abundances of pro-inflammatory bacteria, such as Desulfovibrionales, Helicobacter, Pasteurellales and Campylobacterales were significantly increased in the MS group, while anti-inflammatory bacteria, including Clostridium XI, were decreased. This dysbiosis continued into adulthood. These findings showed that MS exposure induced Paneth cell defects and exacerbated gut dysbiosis in offspring mice. Sucralose should be consumed with caution, especially during pregnancy and in early life.

Mounting evidence has suggested the clinical significance of body composition abnormalities in the context of cirrhosis. Herein, we aimed to investigate the association between visceral adiposity and malnutrition risk in 176 hospitalized patients with cirrhosis. The adiposity parameters were obtained by computed tomography (CT) as follows: total adipose tissue index (TATI), visceral adipose tissue index (VATI), subcutaneous adipose tissue index (SATI), and visceral to subcutaneous adipose tissue area ratio (VSR). Malnutrition risk was screened using Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT). Visceral adiposity was determined given a higher VSR based on our previously established cutoffs. Multivariate analysis implicated that male gender (OR = 2.884, 95% CI: 1.360–6.115, p = 0.006), BMI (OR = 0.879, 95% CI: 0.812–0.951, P = 0.001), albumin (OR = 0.934, 95% CI: 0.882–0.989, P = 0.019), and visceral adiposity (OR = 3.413, 95% CI: 1.344–8.670, P = 0.010) were independent risk factors of malnutrition risk. No significant difference was observed regarding TATI, SATI, and VATI among patients with low or moderate and high risk of malnutrition. In contrast, the proportion of male patients embracing visceral adiposity was higher in high malnutrition risk group compared with that in low or moderate group (47.27 vs. 17.86%, p = 0.009). Moreover, this disparity was of borderline statistical significance in women (19.05 vs. 5.88%, p = 0.061). Assessing adipose tissue distribution might potentiate the estimation of malnutrition risk in cirrhotics. It is pivotal to recognize visceral adiposity and develop targeted therapeutic strategies.

Both sleep–wake disturbance and malnutrition are common in cirrhosis and might be associated with similar adverse outcomes, such as impaired health-related quality of life, hepatic encephalopathy, and sarcopenia, but there is no study investigating the relationship between these two. We aimed to explore the relationship between sleep–wake disturbance [estimated by the Pittsburgh Sleep Quality Index (PSQI)] and malnutrition risk [estimated by the Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT)]. About 150 patients with cirrhosis were prospectively recruited. The nutritional risk is classified as low (0 points), moderate (1 point), and high (2–7 points) according to the RFH-NPT score. A global PSQI >5 indicated poor sleepers. Furthermore, multivariate linear regression analyses were performed to determine the relationship betweensleep–wakedisturbance and malnutrition. The median PSQI was seven, and RFH-NPT was two in the entire cohort, with 60.67 and 56.67% rated as poor sleep quality and high malnutrition risk, respectively. Patients with cirrhosis with poor sleep quality had significantly higher RFH-NPT score (3 vs. 1,P= 0.007). Our multivariate analyses indicated that male patients (β = 0.279,P< 0.001), ascites (β = 0.210,P= 0.016), and PSQI (β = 0.262,P= 0.001) were independent predictors of malnutrition. In addition, the differences regarding PSQI score were more significant in male patients, as well as those >65 years or with Child-Turcotte-Pugh class A/B (CTP-A/B) or the median model for end-stage liver disease (MELD)

Scope: Gut microbiome-derived metabolites are the major mediators of diet-induced host-microbial interactions. Aryl hydrocarbon receptor (AHR) plays a crucial role in glucose, lipid, and cholesterol metabolism in the liver. In this study, we aimed to investigate the role of indole-3-acetic acid (IAA) and AHR in sulforaphane (SFN) alleviates hepatic steatosis in mice fed on a high-fat diet (HFD).Methods and Results: The HFD-fed male C57BL/6 mice were intervened with SFN for 6 weeks. HFD-mice showed classical pathophysiological characteristics of hepatic steatosis. The results showed that SFN significantly reduced body weight, liver inflammation and hepatic steatosis in HFD-fed mice. SFN reduced hepatic lipogenesis by activating AHR/SREBP-1C pathway, which was confirmed in HepG2 cell experiments. Moreover, SFN increased hepatic antioxidant activity by modulating Nrf-2/NQO1 expression. SFN increased serum and liver IAA level in HFD mice. Notably, SFN manipulated the gut microbiota, resulting in reducing Deferribacteres and proportions of the phylum Firmicutes/Bacteroidetes and increasing the abundance of specific bacteria that produce IAA. Furthermore, SFN upregulated Ahr expression and decreased the expression of inflammatory cytokines in Raw264.7 cells.Conclusions: SFN ameliorated hepatic steatosis not only by modulating lipid metabolism via AHR/SREBP-1C pathway but regulating IAA and gut microbiota in HFD-induced NAFLD mice.

Background: Previous studies have shown that sarcopenia appears to be a significant contributor to physical frailty among outpatients with cirrhosis. However, the evidence is scant regarding the relationship between sarcopenia and multi-dimensional frailty among inpatients. We aimed to investigate the potential contribution of sarcopenia to frailty in hospitalized patients with cirrhosis in a sex-dependent manner. Methods: This cohort enrolled consecutive cirrhotics. Muscle quantity and quality were assessed using the computed tomography-based skeletal muscle index (SMI) and intramuscular adipose tissue content, respectively. Frailty phenotype was clarified by a self-reported Frailty Index. Multiple linear regression determined the association between sarcopenia and frailty phenotype. Results: A total of 202 cirrhotic patients with 48.5% male were included. The median Frailty Index was 0.13, rendering 17.3% subjects as frail. Among the 16 frail men, 68.8% had sarcopenia and 62.5% exhibited myosteatosis. In contrast, among the 19 frail women, 26.3% had sarcopenia and 15.8% exhibited myosteatosis. Frail patients had a significantly lower median SMI (42.80 cm2/m2) compared with those with pre-frailty (48.23 cm2/m2) and with robust status (50.82 cm2/m2) in the male but not the female group. In male patients, multivariate linear regression implicated age (β = 0.330, p Conclusion: Sarcopenia is associated with multi-dimensional frailty in male patients with cirrhosis. It is tempting to incorporate sex-specific intervention with the purpose of mitigating frailty among inpatients.

The aim of this study was to evaluate the short-term complications of submucosal tunneling endoscopic resection (STER) for large submucosal tumors (SMTs) originating from the muscularis propria (MP) layer in the esophagus and gastric cardia. We performed 286 cases of STER from September 2012 to December 2017. The clinical data of patients with SMTs originating from the MP layer of 3.0-7.0 cm, who underwent STER procedure at the endoscopy center of Tianjin Medical University General Hospital, were collected retrospectively. Epidemiological data, tumor location, tumor size, procedure-related parameters, complications, and follow-up were included. A total of 27 (9.4 % [27/286]) patients were large-size SMTs, with a mean age of 51.9 ± 9.4 years. The male/female ratio was 19:8. Of the 27 SMTs, 23 were located in the esophagus and 4 in the gastric cardia. The mean tumor size was 4.0 ± 1.1 cm. The en bloc resection rate was 85.2 % (23/27), and the complete resection rate was 100 % (27/27). Intra-operative perforation occurred in 2 patients (7.4 %) and post-operative perforation occurred in 2 patients (7.4 %). No other complications were observed. The average cost of the procedure was $3357.99 ± $1171.60 per inpatient stay (including both the procedure and an additional inpatient stay). The mean follow-up time was 15 ± 10.1 months. No recurrence and metastasis occurred during the follow-up period. There is low risk of STER for the large-sized SMTs in the esophagus and gastric cardia, and the most common complication occurred during or after the procedure is perforation. Evaluierung der Frühkomplikationen einer STER bei großen SMTs der Tunica muscularis im Ösophagus und der Kardia. Zwischen September 2012 und Dezember 2017 führten wir 286 STER-Eingriffe durch. Die klinischen Daten von Patienten mit SMTs, die aus der MP-Schicht von 3,0–7,0 cm stammen und im Endoskopiezentrum des Tianjin Medical University General Hospital im STER-Verfahren behandelt wurden, wurden retrospektiv erhoben. Epidemiologische Daten, Tumorlage, Tumorgröße, verfahrenstechnische Parameter, Komplikationen und Nachsorge wurden berücksichtigt. Bei insgesamt 27 (9,4 %; 27/286) Patienten handelte es sich um große SMTs; das Durchschnittsalter betrug 51,9 ± 9,4 Jahre. Das Verhältnis Männer/Frauen betrug 19:8. Von den 27 SMTs waren 23 im Ösophagus und 4 in der Kardia lokalisiert. Die Tumorgröße betrug durchschnittlich 4,0 ± 1,1 cm. Die Ratio der En-Bloc-Resektion betrug 85,2 % (23/27), die der vollständigen Resektion betrug 100 % (27/27). Bei zwei Patienten (7,4 %) kam es zu einer intraoperativen Perforation; eine postoperative Perforation trat bei zwei Patienten (7,4 %) auf. Es wurden keine weiteren Komplikationen beobachtet. Die Kosten für den Eingriff betrugen durchschnittlich 3357,99 ± 1171,60 $ für den stationären Aufenthalt (Eingriff und stationärer Aufenthalt). Eine Nachuntersuchung wurde nach durchschnittlich 15 ± 10,1 Monaten durchgeführt. In der Zeit bis zur Nachuntersuchung traten weder Rezidive noch Metastasen auf. Die Submukosale endoskopische Tunnelresektion (STER) bei großen submukösen Tumoren (SMTs) der Tunica muscularis im Ösophagus und der Kardia ist mit einem geringen Risiko verbunden. Die häufigste Komplikation während oder nach dem Eingriff ist eine Perforation.

Background: Immunoglobulin G4-related disease (IgG4-RD) is an autoimmune inflammatory and fibrotic condition. The disease is characterized by tissue infiltration with dense lymphoplasmacytes and IgG4-positive plasma cells. Summary: The aim of this study was to provide gastroenterologists with novel insights into evaluating the gastroesophageal involvement with IgG4-RD or mimickers of this condition and to give special attention to clinicopathological features. A literature review was performed using the PubMed database. A total of 39 studies presenting cases in the form of isolated, typical, and nontypical gastroesophageal involvement with IgG4-RD published between 2010 and 2018 were included. These studies were thoroughly reviewed for symptoms, lesion location, lesion type, lesion size, immune-histopathology, associated diseases, treatment, and follow-up. Of the 39 studies reviewed, 9 were esophageal IgG4-RD lesions, isolated esophageal IgG4-RD 66.66% (6/9), a typical form of esophageal IgG4-RD 11.11% (1/9), and nontypical form esophageal IgG4-RD 22.22% (2/9). The 30 gastric IgG4-RD that include isolated gastric IgG4-RD 46.66% (14/30), typical gastric IgG4-RD 40% (12/30), and nontypical gastric IgG4-RD 13.33% (4/30). The majority of lesions were inflammatory tumors, ulceration, nodular lesions, chronic gastritis, and malignant lesions. Key Messages: IgG4-RD may be manifested by isolated, typical and nontypical forms of gastroesophageal lesions and should be taken into consideration in the differential diagnosis. Corticosteroids may be the sole diagnostic treatment for this condition.

Aim Patients with small serrated adenomas (SAs) ( Method We retrospectively reviewed the data of 638 patients, including 122 cases and 516 controls. Subjects in the case group had small SAs at baseline colonoscopy, including sessile SA/polyps and traditional SAs, while subjects in the control group had negative findings. All patients underwent at least one surveillance colonoscopy during the following 5 years. Results There was no significant difference in the incidence rate of advanced neoplasia between the two groups over a 5-year duration (3.6% vs 2.6%, p=0.455). Moreover, both groups also showed a low prevalence of SA formation over 1–5 years (3.6% vs 1.0%, p=0.145). Patients with baseline SA tended to undergo the first surveillance colonoscopy earlier than those without adenoma (≤1 year vs 1 to ≤3 years). Seventy-one (11.1%) of the total included subjects underwent inadequate initial colonoscopy, and 30 (42.3%) underwent early surveillance of adenoma formation within 1 year. Patients with a family history of colorectal cancer (OR 4.69, 95% CI 1.48 to 14.71, p=0.017) or inadequate baseline colonoscopy (OR 3.17, 95% CI 1.202 to 8.409, p=0.035) were at a higher risk of metachronous adenoma formation during the surveillance period. Conclusion Patients with small SAs at baseline gain little benefit from follow-up of colonoscopy within 5 years after complete polypectomy.

Objectives: To evaluate the safety and efficacy of endoscopic resection and discuss the treatment strategy of small gastric gastrointestinal stromal tumors (GISTs) less than 2 cm.Material and metho...

Background. Patients with prolonged inflammatory bowel disease (IBD) can develop into colorectal cancer (CRC), also called colitis-associated cancer (CAC). Studies have shown the association between gut dysbiosis, abnormal bile acid metabolism, and inflammation process. Here, we aimed to investigate these two factors in the CAC model. Methods. C57BL/6 mice were randomly allocated to two groups: azoxymethane/dextran sodium sulfate (AOM/DSS) and control. The AOM/DSS group received AOM injection followed by DSS drinking water. Intestinal inflammation, mucosal barrier, and bile acid receptors were determined by real-time PCR and immunohistochemistry. Fecal microbiome and bile acids were detected via 16S rRNA sequencing and liquid chromatography-mass spectrometry. Results. The AOM/DSS group exhibited severe mucosal barrier impairment, inflammatory response, and tumor formation. In the CAC model, the richness and biodiversity of gut microbiota were decreased, along with significant alteration of composition. The abundance of pathogens was increased, while the short-chain fatty acids producing bacteria were reduced. Interestingly, Clostridium XlV and Lactobacillus, which might be involved in the bile acid deconjugation, transformation, and desulfation, were significantly decreased. Accordingly, fecal bile acids were decreased, accompanied by reduced transformation of primary to secondary bile acids. Given bile acid receptors, the ileum farnesoid X receptor-fibroblast growth factor 15 (FXR-FGF15) axis was downregulated, while Takeda G-protein receptor 5 (TGR5) was overexpressed in colonic tumor tissues. Conclusion. Gut dysbiosis might alter the metabolism of bile acids and promote CAC, which would provide a potential preventive strategy of CAC by regulating gut microbiota and bile acid metabolism.

BACKGROUND Liver cirrhosis is characterized by immune dysfunction, contributing to malnutrition. We previously revealed neutrophil-to-lymphocyte ratio (NLR) as an indicator of disordered immune system. Herein we aimed to (1) determine the optimal NLR cutoff that best predicts malnutrition risk and (2) clarify the association between NLR and nutrition status. METHODS A total of 135 hospitalized patients with cirrhosis were included. Immune dysfunction was evaluated by levels of serum C-reactive protein (CRP), NLR, and other parameters. Malnutrition was screened by a risk score referring to the Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT). Receiver operating characteristic (ROC) curve was implemented to determine the best NLR cutoff that predicts malnutrition risk. Correlation between NLR and indicators of hepatic and physical function (handgrip strength) were also examined. Multivariable logistic regression was used to assess the association between NLR and malnutrition risk. RESULTS ROC curve revealed that the optimum cutoff to predict malnutrition risk was NLR > 4.2, with a sensitivity of 47.2%, specificity of 81.0%, negative predictive value of 58.0%, and positive predictive value of 74.5%, respectively. Patients with NLR > 4.2 exhibited a higher RFH-NPT score, serum platelet-to-lymphocyte ratio, and CRP. A positive correlation was found between NLR values and Child-Turcotte-Pugh (r = 0.22; P = .010), model for end-stage liver disease (r = 0.36; P < .001), and RFH-NPT scores (r = 0.31; P < .001). NLR was a risk factor for malnutrition independently of alcoholic liver disease and presence of ascites. CONCLUSIONS Immune dysfunction measured by NLR was associated with malnutrition risk estimated by RFH-NPT in cirrhosis.

Background: Most gastric cancer (GC) patients are diagnosed at an advanced stage, which indicates their poor prognosis. We aimed to investigate novel fecal microbial markers for clinical application in the screening and early diagnosis of gastric cancer (GC). Methods: This is an observational study from three cohorts. In discovery cohort, 16S rRNA gene analysis was performed in paired samples (gastric tissues, feces) from GC and CG patients to determine differential microbes. The relative abundances of the differential microbes were detected using qPCR in training cohort. The diagnostic efficacy of fecal marker Sa/Sc was validated in validation cohort. Findings: 575 gastric cancer (GC) patients, 468 chronic gastritis (CG) patients were enrolled from ten hospitals in China. Significant enrichments of Streptococcus anginosus (Sa) and Streptococcus constellatus (Sc) in both cancerous tissues (P < 0·05) and feces ( P < 0·0001) were observed in patients with intraepithelial neoplasia, early and advanced GC. Either the marker parallel test Sa ∪ Sc or single marker Sa/Sc demonstrated superior sensitivity (Sa: 75·6% vs. 72·1%, P

Background: Functional constipation (FC) is an intractable disease that carries large financial burden as well as emotional and physical stress. We aimed to assess the efficacy and safety of the newly developed smartphone-controlled vibrating capsule (VC) in patients with FC. Methods: This was a multicenter, blinded, placebo-controlled randomized trial in six top general hospitals in China focusing on patients aged 18 to 80 with FC. Patients were randomly assigned in a 1:1 ratio to receive VCs or placebo treatment for six weeks (two capsules per week) after two-week baseline period. The primary outcome was the responder rate, defined as the proportion of patients with an increase of at least one complete spontaneous bowel movement (CSBM) per week during treatment compared to baseline in the full analysis set. This trial is registered with ClinicalTrials.gov, number NCT04671264, and is completed. Findings: From December 2018 to February 2020, 107 patients were randomly assigned to receive VCs (n=53) or placebo treatment (n=54). The responder rate in the VC group was significantly higher than that in the placebo group (64·2% vs. 35·8%; difference, 27·7% [95% CI, 10·4% to 45·1%]; P = 0·005). More patients in the VC group reported weekly CSBMs ≥ 1 for at least four weeks during treatment ( P =0·022) and follow-up period ( P =0·041). The mean PAC-SYM and PAC-QoL total scores differed significantly from the baseline in both groups (all P < 0·0001). The most common adverse event associated with VC was abdominal discomfort (3·8%). Interpretation: VCs can greatly promote defecation, as well as ameliorating symptoms and improving the quality of life in patients with FC with sustained efficacy. Funding Statement: The funding source of our work is "One hundred leading scientists for 21st century" of Health Department of Shanghai Municipal Government (to ZL, No.2017BR005). Declaration of Interests: We declare no competing interests. Ethics Approval Statement: The study was approved by the institutional review board at all participating centers. No subsequent amendments of the protocol were made in the process of study implementation. The trial was performed in accordance with the principles of the Declaration of Helsinki and reported in accordance with CONSORT guidelines. An independent Data and safety monitoring committee (DSMC) appointed by the ethics committee and the Shanghai and National Medical Products Administration provided trial regular oversight. Trial Registration: This trial is registered with ClinicalTrials.gov, number NCT04671264, and is completed.

No tailored model incorporating physical frailty for 2-year mortality in cirrhosis is available for practitioners in general practice. Thus we aimed to develop a model based on laboratory results and physical frailty allowing clinicians for stratifying cirrhotics by using individual estimate. One hundred and thirteen cases were assigned to the primary cohort, and all other 76 patients were regarded as the validation cohort. Multivariate Cox regression was performed, and a nomogram including five-meter gait speed (5MGS) were generated. The performance of the proposed model was assessed by C-index, calibration curve, and decision curve analysis (DCA). On multivariate analysis, the Model for End-Stage Liver Disease-Sodium, albumin and 5MGS were independent predictors for 2-year mortality in cirrhosis. A nomogram incorporating all these parameters achieved a C-index of 0.804 (95%CI, 0.731–0.877). The calibration curve implied optimal correspondence between the predicted survival and actual outcomes. Our model is useful in the clinical settings based on DCA. Similar results were observed in the validation cohort with a C-index of 0.796 (95%CI, 0.689–0.899). Moreover, 5MGS, as a surrogate of physical performance, significantly correlated with multiple domains of general frailty according to Frailty Index (our published data), including instrumental activities of daily living, self-reported health, social activity and falls. In conclusion, the nomogram incorporating 5MGS may represent an individualized tool for predicting mortality in cirrhosis for primary care physicians.

Background Osteoporosis is one of the most closely related diseases associated with the elderly. In recent years, the studies found that gut microbiota can cause osteoporosis. We evaluated the role of Bacillus acidophilus in osteoporosis and its roles in proliferation and differentiation. Methods We selected 5 healthy people and 10 osteoporosis patients and analyzed their level of 25‐hydroxyvitamin D and procollagen type I N‐terminal peptide (PINP), the characteristic of gut microbiota. The effect of lactobacillus acidophilus and Lactobacillus rhamnosus supernatant and butanoic acids on proliferation, differentiation, and maturity of osteoblasts MC3T3‐E1 and osteoclasts RAW 264.7 cells and the activity of alkaline phosphatase, concentration of osteocalcin, and the expression of RUNX2, RANK, NFATc1, cathepsin K, DC‐STAMP, OSCAR, WNT2, and CTNNB1 were measured in the above cell lines. Results The diversity of gut microbiota in osteoporosis patients is decreased and imbalanced with lower abundance of lactobacillus and butyric acid bacteria; meanwhile, 25‐hydroxyvitamin D and PINP of osteoporosis patient were significantly lower than the normal group. The proliferation, differentiation, and maturity of MC3T3‐E1 cells were stimulated; the activity of alkaline phosphatase, concentration of osteocalcin, and the expression of RUNX2, NFATc1, cathepsin K, DC‐STAMP, OSCAR, WNT2, and CTNNB1 were improved by supernatant of lactobacillus acidophilus, Lactobacillus rhamnosus and butanoic acids; however, the proliferation, differentiation, maturity, and the expression of RANK, NFATc1, cathepsin K, DC‐STAMP, OSCAR, WNT2, and CTNNB1 in RAW 264.7 cells were suppressed. Conclusions The lactobacillus acidophilus and Lactobacillus rhamnosus supernatant could stimulate the proliferation, differentiation, and maturation of osteoblasts; the production of butyric acid may be the potential mechanism., The diversity of gut microbiota is decreased and imbalance with lower abundance of lactobacillus and butyric acid bacteria in osteoporosis patients. The gut microbiota regulate the proliferation, differentiation, and maturation of osteoblasts, and the production of butyric acid may be the potential mechanism.

The impact of changes in body composition has proved to correlate with outcomes in cirrhosis, however, numerous issues remain elusive. The present study aimed to investigate the prognostic value of myopenic obesity (MO) on long-term mortality in cirrhosis.We retrospectively analyzed 200 patients with cirrhosis. Body composition parameters including skeletal muscle index (SMI) and visceral fat area (VFA) were estimated by computed tomography images at the third lumbar vertebra level. We defined MO as a low SMI (male: SMI 46.96 cmOn the basis of VFA or BMI, the four group comparison demonstrated the prognosis was poor in MO, followed by myopenic/nonobesity (MN), nonmyopenic/obesity and nonmyopenic/nonobesity, in that order (log-rank test). Multivariate Cox analysis identified that MO (HR 2.498; 95% CI, 1.214-5.140; P = 0.013), MN (HR 2.763; 95% CI, 1.244-6.134; P = 0.013), age (HR 3.035; 95% CI, 1.904-4.839; P 0.001), neutrophil-to-lymphocyte ratio (HR 1.142; 95% CI, 1.082-1.207; P 0.001) and MELD (HR 1.140; 95% CI, 1.066-1.219; P = 0.001) were independently associated with 2-year mortality according to VFA classification.MO was an independent predictor of higher long-term mortality in cirrhosis. Prevention strategies by reducing visceral fat obesity rather than BMI should be the optimal target for MO management.

BACKGROUND: To develop a nomogram incorporating indicator of muscle waste to prognosticate long-term mortality in liver cirrhosis (LC), and identify the prognostic impact of psoas muscle index (PMI). METHODS: A total of 251 LC patients who underwent computed tomography were included in this study. Multiple Cox regression was performed, and sex-specific nomogram models incorporating PMI were developed. The utility of the proposed models were evaluated by Harrell’s concordance index (C-index), calibration curve and decision curve analysis. X-tile was used to determine optimal cutpoint for stratifying subjects with distinct outcomes. Subgroup analysis was implemented in terms of age and MELD score. The correlation between PMI and gait speed was also evaluated. RESULTS: On multiple analysis, independent predictors for 3-year all-cause mortality were age, BMI, PMI and MELD for males, and age, PMI and MELD for females. Both nomogram models gave rise to moderately strong discrimination, with a C-index of 0.792 (95% CI: 0.723–0.861) in males and 0.715 (95% CI: 0.637–0.793) in females, respectively. The calibration curve implied predicted survival corresponding optimally with the actual outcomes. The proposed models were feasible in clinical settings based on decision curve analysis. On subgroup analysis, PMI might confer valid predictive value on LC patients with MELD

Colonoscopy is commonly used to screen for colorectal cancer (CRC). We develop a deep learning model called CRCNet for optical diagnosis of CRC by training on 464,105 images from 12,179 patients and test its performance on 2263 patients from three independent datasets. At the patient-level, CRCNet achieves an area under the precision-recall curve (AUPRC) of 0.882 (95% CI: 0.828–0.931), 0.874 (0.820–0.926) and 0.867 (0.795–0.923). CRCNet exceeds average endoscopists performance on recall rate across two test sets (91.3% versus 83.8%; two-sided t-test, p, Colonoscopy is the most commonly used tool to screen for colorectal cancer (CRC). Here, the authors develop a deep learning model to perform optical diagnosis of CRC by training on a large data set of white-light colonoscopy images and achieve endoscopist-level performance on three independent datasets.

Background. To assess the role of endoscopic ultrasound (EUS) in the diagnosis of upper gastrointestinal subepithelial lesions (SELs) and to investigate EUS combined with a grayscale histogram analysis for the differentiation of leiomyomas and gastrointestinal stromal tumors (GISTs). Methods. A retrospective study of 709 patients with upper gastrointestinal SELs was conducted by EUS before endoscopic resection. The EUS findings of SELs and pathological results after endoscopic resection were compared. The EUS images of SELs, particularly, leiomyoma and GIST, were further analyzed via a grayscale histogram to differentiate between the two tumors. Results. Of the 709 patients, 47 cases were pathologically undetermined. The diagnostic consistency of EUS with endoscopic resection was 88.2% (584/662), including 185 muscularis mucosa, 61 submucosa, and 338 muscularis propria, respectively. The diagnostic consistency of EUS with pathology was 80.1% (530/662). The gray value of GISTs was significantly higher than that of leiomyomas (58.9±8.3 vs. 39.5±5.9, t=57.0, P<0.0001). The standard deviation of leiomyomas was significantly lower than that of GISTs (20.6±7.0 vs. 39.8±9.3, t=23.7, P<0.0001). The grayscale histogram analysis of GISTs showed higher echo ultrasound, and the echo of leiomyoma was more uniform. Conclusion. EUS is the preferred procedure for the evaluation of upper gastrointestinal SELs. EUS combined with a grayscale histogram analysis is an effective method for the differentiation of leiomyomas and GISTs.

Background. The enlargement of lymph nodes is a common clinical sign in connective tissue disease (CTD) and viral hepatitis. In this research, we evaluated the incidence of enlarged lymph nodes in autoimmune liver diseases (AILD). Moreover, we identified the clinical significance of abdominal lymph node enlargement in AILD. Methods. The characteristics of abdominal lymph nodes, including their morphology and distribution, were assessed by ultrasonography and computed tomography in 125 patients with AILD, 54 with viral hepatitis, 135 with CTD, and 80 healthy controls. The pathological and laboratory results of 106 AILD patients were collected to analyze the association between lymphadenectasis and disease activity. Results. Enlargement of abdominal lymph nodes was found in 69.6% of patients with AILD, 63% of patients with viral hepatitis, 29.6% of patients with CTD, and 2% of healthy controls. Alkaline phosphatase (ALP), glutamate transpeptidase (GGT), and immunoglobulin M (IgM) levels were significantly increased in AILD patients with lymphadenectasis (LA) in contrast to patients without lymphadenectasis (NLA) (P<0.05). The pathological characteristics of inflammation, cholestasis, and focal necrosis were more common in the LA group than in the NLA group (P<0.05). As shown by multivariate logistic regression analysis, interface hepatitis (OR=3.651, P<0.05), cholestasis (OR=8.137, P<0.05), and focal necrosis (OR=5.212, P<0.05) were related to LA. Conclusions. The percentage of abdominal lymph node enlargement in AILD subjects was significantly higher than that in CTD subjects. Therefore, the enlargement of lymph nodes can represent a noninvasive indicator of histological and biochemical inflammation activity in AILD.

Background: The Rome criteria for functional gastrointestinal diseases (FGIDs) have been updated from Rome III to Rome IV. This study aimed to investigate the impact of the update on patients with ...

PurposeColorectal cancer (CRC) is one of the common causes of cancer death worldwide. Obstructive sleep apnea syndrome (OSAS), sharing many risk factors in common with CRC, is prevalent among CRC patients. OSAS may promote the CRC development independently but the mechanism is still unknown. Intermittent hypoxia (IH) is one of the characteristics of OSAS, and hypoxia may influence the genes associated with CRC. Intestinal microbiota plays important role in CRC carcinogenesis, and OSAS patients have been shown to have intestinal microbiota dysbiosis. We hypothesized that IH and intestinal microbiota dysbiosis may be involved for CRC in patients with OSAS.MethodsWe established precancerous cell models of CRC with Immorto-Min colonic epithelial (IMCE) cells. First, the cells were exposed to IH in a special chamber for 4 h, 8 h, and 12 h. Feces from 6 patients with OSAS and 6 healthy controls were collected and made into sterile fecal fluid for incubation with IMCE cells for 12 h. The cells were then exposed to IH for 4 h, 8 h, and 12 h. After IH exposure, the expressions of genes and inflammation cytokines associated with CRC, such as β-catenin, STAT3, HIF-1α, IL-6, TNF-α, c-myc, and cyclinD1, were tested.ResultsIH activated the expression of HIF-1α and STAT3 both in mRNA and protein level (HIF-1α:P= 0.015 for mRNA level,P= 0.027 for protein level; STAT3:P= 0.023 for mRNA level,P= 0.023 for protein level), and promoted p-STAT3 shifting to the nucleus (P= 0.023). The mRNA of β-catenin (P= 0.022) and cyclinD1 (P= 0.023) was elevated, but there was no change for the β-catenin protein in the nucleus. Gut microbiota of OSAS patients promoted the expression of STAT3 (protein level: 0 h:P= 0.037; 4 h:P= 0.046; 8 h:P= 0.049; 12 h:P= 0.037), promoted p-STAT3 (4 h:P =0.049; 8 h:P =0.046; 12 h:P =0.046) shifting to the nucleus, and also elevated the expression of IL-6 and TNF-α in mRNA level at 4 h (IL-6:P= 0.037, TNF-α:P= 0.037) and 8 h (IL-6:P= 0.037, TNF-α:P= 0.037). The protein of β-catenin in the nucleus was not affected by IH and gut microbiota from OSAS.ConclusionsOur study demonstrated that IH and gut microbiota of patients with OSAS activated HIF-1α expression and STAT3 pathway in IMCE cells, with no influence on β-catenin pathway, which suggested that IH, STAT3 pathway, chronic inflammation, and intestinal microbiota dysbiosis may be involved in CRC carcinogenesis correlated with OSAS These findings must be interpreted cautiously and further research is necessary to clarify the causative steps in CRC development.

AIM The LiFe (liver, injury, failure, evaluation) score, calculated according to arterial lactate, total bilirubin, and international normalized ratio (INR), is a novel score for risk prediction in intensive care unit (ICU) patients with cirrhosis. The present study aimed to externally validate and optimize the LiFe score for predicting outcomes in critically ill cirrhosis patients. METHODS The study used the single-center database Medical Information Mart for Intensive Care-III (MIMIC-III) for analysis. A total of 536 critically ill cirrhosis patients from the MIMIC-III database were analyzed. Routine clinical and laboratory variables were included to compare survivors with non-survivors. The LiFe score was then regraded into three groups to calculate the optimal cut-off values. RESULTS In-ICU mortality occurred in 169 (31.5%) of the patients. Survivor and non-survivor cohorts were similar in age, gender, and etiology of cirrhosis. Multivariate analyses of in-ICU mortality identified four independent variables: total bilirubin, creatinine, INR, and arterial lactate. An external validation of the LiFe score showed good accuracy for predicting in-ICU mortality with an area under the receiver operating characteristic curve of 0.708. In addition, a significant positive correlation exists between LiFe score and acute-on-chronic liver failure grade (r = 0.393, P

BACKGROUND The official guidelines are unclear about whether endoscopic polypectomy should intubate the whole cecum or just intubate the location of the endoscopy inspection. Therefore, the objective of this study was to provide a new perspective of assisting endoscopists make better decisions and decrease the missing detection rate in clinical practice. MATERIAL AND METHODS We retrospectively reviewed records of 8923 patients who underwent endoscopic polypectomy, and 394 participants were included after screening by inclusion and exclusion criteria. We collected and analyzed data on the size, shape, and location of polyps and the clinical experience level of endoscopists in this retrospective study. RESULTS Among the 394 cases, 152 (38.6%) had additional lesions detected through the second endoscopic polypectomy after the first colonoscopy was performed, showing statistically significant differences between the missing group and non-missing group on actual polys (P0.05). No significant differences were detected between the 2 groups (P0.05) in age, sex, withdrawal time, and examination period. Regarding the location, 50.4% of the missing lesions were found on the relatively proximal colon of the detected polyps in the first colonoscopy. In addition, the level of experience of endoscopists was significantly different between the missing group and the non-missing group (P0.05). CONCLUSIONS The characteristics of polyps and the level of endoscopist experience play important roles in the detection of polyps in the colorectum. Moreover, it may be necessary to intubate the cecum to examine the whole colorectum during endoscopic polypectomy.

Background and aim Empirical proton pump inhibitor (PPI) treatment is recommended as a diagnostic indicator for gastroesophageal reflux disease (GERD) and as a therapy for symptomatic control, with responses generally seen within 4 weeks. However, there are no real-world data assessing the effectiveness of short-term empirical treatment with PPIs in patients with GERD in China. Methods The ENLIGHT study was a multicenter, prospective, observational study conducted in China. The primary outcome was the overall response rate after 4 weeks' empirical treatment with PPIs. Adult patients aged between 18 and 65 years of age, with a gastroesophageal reflux disease questionnaire score of ≥ 8, prescribed empirical PPI treatment by their physicians and with no planned endoscopy were eligible to participate. Statistical analyses were primarily descriptive. Results Overall, 987 patients were eligible to participate and were included in the full analysis set (FAS); 707 patients were included in the per protocol set. In the FAS, esomeprazole was received by 57.1% of patients and was the most commonly used PPI. After 4-week treatment, 71.1% (95% confidence interval [CI], 67.9% to 74.2%) of patients were considered responders to PPI. The response rate at the end of 2-week PPI treatment reached 57.0% (95% CI, 52.5% to 61.7%). The median time to response was 13 days (95% CI, 12 to 15). Response rates at 2 and 4 weeks of the per protocol set were similar to those of the FAS. Conclusions Short-term empirical PPI treatment can provide an effective relief of GERD symptoms in most Chinese patients in real-world practice.

Background Neutrophil-to-lymphocyte ratio (NLR) is a marker of systemic inflammation. However, its predictive utility of 30-day mortality remains elusive in decompensated cirrhotics. Aims We aimed to combine NLR and other variables associated with early mortality of cirrhotics with acute insults in to a predictive nomogram. Methods We retrospectively analyzed 352 decompensated cirrhotics. The 30-day mortality was regarded as primary outcome. Multivariate Cox analysis was performed, and a NLR-based nomogram was developed. The performance of nomogram was determined in terms of its calibration, discrimination and clinical usefulness. Serum cytokines were evaluated by Milliplex cytokine assay. Results On multiple analysis, independent factors for early mortality were albumin, MELD and NLR, which were all selected into the nomogram. The nomogram showed good discrimination, with a concordance index of 0.88. Calibration of the nomogram predicted survival corresponding optimally with the actual outcomes. Decision curve analysis indicated our nomogram was useful in clinical practice. Among circulating cytokines we investigated, IL-6 and IL-8 were substantially elevated in cirrhotics compared to healthy subjects. High NLR was positively correlated with the expression of IL-6 and IL-8. Conclusion The proposed nomogram incorporating NLR offered an individualized predictive tool for 30-day mortality in decompensated cirrhotics. The escalating value of NLR likely implicated excessive inflammatory response.

Effect of Lactobacillus rhamnosus GG supernatant on serotonin transporter expression in rats with post-infectious irritable bowel syndrome

Chronic constipation is a prevalent functional gastrointestinal disorder accompanied with intestinal dysbiosis. However, causal relationship between dysbiosis and constipation remains poorly understood. Serotonin transporter (SERT) is a transmembrane transport protein which re-uptakes excessive 5-hydroxytryptamine (5-HT) from effective location to terminate its physiological effects and involves in regulating gastrointestinal motility. In this study, fecal microbiota from patients with constipation and healthy controls were transplanted into the antibiotic depletion mice model. The mice which received fecal microbiota from patients with constipation presented a reducing in intestinal peristalsis and abnormal defecation parameters including the frequency of pellet expulsion, fecal weight and fecal water content. After fecal microbiota transplantation, the SERT expression in the colonic tissue was significantly upregulated, and the content of 5-HT was decreased which negatively correlated with the gastrointestinal transit time. Moverover, fecal microbiota from the mice which received fecal microbiota from patients with constipation also upregulated SERT in Caco-2 cells. Besides, this process accompanied with the decreased abundance of Clostridium, Lactobacillus, Desulfovibrio, and Methylobacterium and an increased tend of Bacteroides and Akkermansia, which also involved in the impairment of intestinal barrier after FMT. Taken together, intestinal dysbiosis may upregulate the SERT expression and contribute to the development of chronic constipation.

Objectives Peroral endoscopic myotomy (POEM) has emerged as an advanced technique for the treatment of achalasia, and defining the learning curve is mandatory. Methods From August 2011 to June 2014, two operators in our institution (A&B) have performed POEM on 35 and 33 consecutive patients, respectively. The moving average and cumulative sum (CUSUM) methods were employed to analyze the POEM learning curve for corrected operative time (cOT), referring to duration of per centimeter myotomy. Additionally, perioperative outcomes were compared among distinct learning curve phases. Results Using the moving average method, cOT reached a plateau at the 29th case and 24th case for operator A and B, respectively. The CUSUM analysis identified three phases: initial learning period (Phase1), efficiency period (Phase 2) and mastery period (Phase3). The relatively smooth state in CUSUM graph occurred at the 26th case and 24th case for operator A and B, respectively. The mean cOT of distinct phases for operator A was 8.32, 5.20 and 3.97 minutes, while being 5.99, 3.06 and 3.75 minutes for operator B, respectively. The Eckardt score and lower esophageal sphincter pressure has significantly decreased during the 1-year follow-up period. Data were comparable regarding patient characteristics and perioperative outcomes. Conclusions This single center study demonstrated that expert endoscopists with experience in esophageal endoscopic submucosal dissection reached a plateau in learning of POEM after around 25 cases. This article is protected by copyright. All rights reserved.

Autoimmune liver diseases (AILDs) often coexist with other extrahepatic autoimmune diseases (EHAIDs). The spectrum of EHAIDs in patients with AILDs is similar, whereas the incidence is different. Notably, autoimmune thyroid disease and Sjogren’s syndrome are the most common EHAIDs. Associated extrahepatic diseases may predate the appearance of AILDs or coincide with their onset. More frequently, they may appear during the course and even occur years after the diagnosis of AILDs. Importantly, associated EHAIDs may influence the natural course and prognosis of AILDs. To date, a definite pathophysiological pathway which contributes to the coexistence of AILDs and EHAIDs is still lacking. The current view of autoimmunity clustering involves a common susceptibility genetic background which applies to related pathologies. Herein, we review the current published researches regarding EHAIDs in patients with AILDs, particularly in relation to their clinical impact and pathophysiology. In managing patients with AILDs, gastroenterologists should be aware of the possibly associated EHAIDs to ensure a prompt diagnosis and better outcome.

Objective. To explore whether pictograms could help people understand reflux symptoms. Methods. Gastroenterologists (n=28), non-GI physicians (n=30), healthy people without medical education (n=34), patients with gastrointestinal reflux disease (GERD) (n=45), and general people (n=100) were included. Pictograms denoting classic reflux symptoms (sour regurgitation, heartburn, retrosternal pain, and regurgitation) were created by the joint efforts of an artist and a gastroenterologist. The subjects were asked to tell the meaning of each card within 30 s. Results. Compared with the physicians, healthy people without medical education tended to make mistakes in the understanding of the terms of reflux symptoms. Among GERD patients, all the terms of reflux symptoms could be understood accurately. Compared with that of non-GI physicians, GI physician had a higher accuracy in the understanding of the term regurgitation (P<0.05). Pictograms denoting reflux symptoms could be understood accurately in all four groups. A sample from the general population showed that the recognition of the pictogram was more accurate than the recognition of the terms. Conclusions. Pictograms could help ordinary people who do not have medical education to understand reflux symptoms more accurately in China. Compared with abstract terms, pictograms could be useful for epidemiological studies and diagnosis of GERD in the community.

Aim It is well known that the use of proton pump inhibitor (PPI) is widespread in patients with liver cirrhosis. PPI counteracts H2 receptor inhibitor (H2 RA) with its strong acid suppression effect. However, there is always a concern that PPI use may increase spontaneous bacteria peritonitis (SBP) development in cirrhotic patients. We aimed to investigate the association between acid suppression therapy (i.e. PPI or H2 RA) and SBP through meta-analysis. Methods We searched PubMed, Medline, Web of Science, Cochrane library, and Embase for relevant studies published up to April 2019. Pooled OR and 95% CI were calculated by a random-effects model. Funnel plots and Egger's tests were performed for the evaluation of publication bias. Non-parametric "trim-and-fill" tests were conducted for sensitivity analysis. Results A total of 20 original articles including 9566 cirrhotic patients were analyzed. The overall meta-analysis highlighted that PPI use was associated with the risk of SBP (pooled OR 1.77, 95% CI 1.49-2.11). The conclusion was irrespective of study methods, whereas the result was inconsistent only in South America. However, the conclusion might not be stable enough and should be extrapolated with caution. Unlike PPI, we found H2 RA was not associated with SBP (pooled OR 1.06, 95% CI 0.75-1.48). Conclusions In conclusion, PPI use, but not H2 RA, will increase the incidence of SBP in cirrhotic patients. In addition, H2 RA might be beneficial for patients who require long-term acid suppression therapy.

An elevated neutrophil-to-lymphocyte ratio (NLR) has received attention as a prognostic surrogate across chronic liver diseases. However, an exact threshold has not been fully elucidated.A total number of 589 patients with cirrhosis (LC) were included. The value of NLR was calculated and its optimal cut-off was initially determined by X-tile program. Independent predictors of 90-day mortality were identified with Cox regression model. The Kaplan-Meier method was used to generate survival curves. To reduce influences of selection bias and possible confounders, a 1:2 propensity score matching (PSM) was performed.The X-tile indicated that the difference in survival was most significant for NLR more than 8.9. Serum NLR 8.9 was an independent indicator in the entire cohort and PSM subset (HR 4.268, 95% CI 2.211-8.238, P .001; HR 4.209, 95% CI 1.448-12.238, P = .008 respectively). Subgroup analysis showed that NLR 8.9 was an independent risk factor of 90-day mortality regardless of age, gender, CTP or MELD score.The value of NLR more than 8.9 is a feasible cut-off across clinical settings among applicable population. The adding of NLR to other conventional predictive systems has the potential to provide incremental value without extra economic cost.

On the basis of lesser rates of major adverse events and a short-term efficacy as Heller's myotomy, there is a growing enthusiasm in favor of peroral endoscopic myotomy (POEM), whereas study comparing POEM and pneumatic dilatation (PD) is quite rare. The aim of this study was to evaluate the efficacy of POEM and PD in Chinese achalasia patients in a retrospectively designed study. Patients with achalasia, who underwent either PD (n = 26) or POEM (n = 40) were retrospectively recruited from September 2010 through March 2016 at a single tertiary center. During the 1-year follow-up, clinical outcome and functional data of lower esophageal sphincter (LES) were recruited. Clinical symptoms were assessed by use of the Eckardt score. The primary outcome was therapeutic success (Eckardt score ≤ 3). Functional data of LES (4-second integrated relaxation pressure [4s-IRP], LES relax rate, and LESP) at baseline and 1 month after treatment were also evaluated. Data was analyzed by SPSS 13.0 version using a significance level of p 0.05. The success rates were 24/26 (92.31 %), 25/26 (96.15 %), and 24/26 (92.31 %), respectively, with POEM, as compared with 35/40 (87.50 %), 29/40 (72.50 %), and 23/40 (57.50 %), respectively, with PD, 1 month, 3 months, and 1 year after treatment. Statistically significant difference was observed between the 2 therapies (at 3 months, Fisher's exact test, p = 0.01; at 1 year, Fisher's exact test, p 0.0001). Compared with PD, the Eckardt score was lower with POEM 1 month, 3 months, and 1 year after treatment. More patients in POEM group reported gastroesophageal reflux symptoms (after 3 months 7/26 (26.92 %) vs. 2/40 (5.00 %), Fisher's exact test, p = 0.01; after 1 year 6/26 (19.23 %) vs. 1/35 (2.86 %), Fisher's exact test, p = 0.02). The postoperative 4s-IRP and LESP were both lower with POEM than with PD, respectively. Type I achalasia had a better response with POEM than with PD. In this retrospective analysis with 1-year follow-up, POEM presents with a higher success rate and more reflux symptoms compared with PD. Change on LES function after treatment may explain the outcome in part. Type I achalasia may respond better to therapies compared with type II. Aufgrund des geringeren Risikos schwerer unerwünschter Ereignisse und der kurzfristigen Wirksamkeit im Vergleich zur Myotomie nach Heller, wird die perorale endoskopische Myotomie (POEM) in letzter Zeit immer beliebter. Dagegen liegen kaum Studien vor, in denen POEM mit Ballon­dilatation verglichen wurde. Ziel der vorliegenden retrospektiven Studie war die Evaluation der Effizienz von POEM und Ballondilatation bei Achalasie-Patienten in China. Von September 2010 bis März 2016 wurden Achalasie-Patienten, die entweder mittels Ballondilatation(n = 26) oder POEM (n = 40) behandelt worden waren, retrospektiv in einem Tertiärzentrum rekrutiert. Während des einjährigen Follow-ups wurden klinisches Outcome und Funktionsdaten des unteren Ösophagussphinkters erhoben. Klinische Symptome wurden mithilfe des Eckardt Scores bewertet. Primäres Outcome war der therapeutische Erfolg (Eckardt Score ≤ 3). Ebenso wurden die Funktionsdaten des unteren Ösophagussphinkters (4s-IRP, LESRR und LESP) an der Baseline und einen Monat nach der Behandlung evaluiert. Die Daten wurden mit dem Statistical Package for Social Sciences (SPSS) Version 13.0 unter Anwendung eines Signifikanzniveaus von P 0,05 analysiert. Die Erfolgsraten betrugen 24/26 (92,31 %), 25/26 (96,15 %) und 24/26 (92,31 %) jeweils bei POEM, im Vergleich zu 35/40 (87,50 %), 29/40 (72,50 %) und 23/40 (57,50 %) jeweils bei Ballondilatation, einen Monat, drei Monate und ein Jahr nach der Behandlung. Es konnte ein statistisch signifikanter Unterschied zwischen den beiden Therapien festgestellt werden (nach drei Monaten, exakter Test nach Fisher, P = 0.01; nach einem Jahr, exakter Test nach Fisher, P 0.0001）. Im Vergleich zur Ballondilatation war der Eckardt Score bei POEM einen Monat, drei Monate und ein Jahr nach der Behandlung niedriger. In der POEM-Gruppe gaben mehr Patienten gastro-ösophageale Refluxsymptome an (nach drei Monaten 7/26 (26.92 %) versus 2/40 (5.00 %), exakter Test nach Fisher, P = 0.01; nach einem Jahr 6/26 (19.23 %) versus 1/35 (2.86 %), exakter Test nach Fisher, P = 0.02). Der postoperative 4s-IRP und LESP waren beide bei POEM niedriger im Vergleich zu den entsprechenden Werten bei Ballondilatation. Typ II Achalasie hatte bei POEM eine bessere Responserate als bei Ballondilatation. In dieser retrospektiven Studie mit einem einjährigen Follow-up zeigte POEM eine höhere Erfolgsrate und mehr Refluxsymptome im Vergleich zur Ballondilatation. Eine veränderte Funktionsweise des unteren Ösophagussphinkters könnte dieses Ergebnis teilweise erklären. Typ I Achalasie spricht möglicherweise besser auf Therapien an als Typ II.

A gastric bezoar is a compact mass of indigestible foreign materials that accumulate and consolidate in the stomach; however, it can be found in other sites of the gastrointestinal tract. The causative manner of this condition is complex and multifactorial. The main purpose of the review was to raise awareness among clinicians, particularly gastroenterologists, that patients with certain risk factors or comorbid conditions are predisposed to gastric bezoar formation. Early diagnosis and prompt intervention are crucial to avoid bezoar-induced complications. Upper gastrointestinal endoscopy is the standard diagnostic and therapeutic method for gastric bezoars. However, for large size bezoars, surgical intervention is needed.

Background: Chemoprevention of colorectal adenoma and cancer remains its importance in public health. The rate of adenoma recurrence in the first year after polypectomy is very high in East Asian populations. We aimed to investigate the clinical potential and safety of Berberine hydrochloride for colorectal adenoma recurrence. Methods: This double-blind, randomised, placebo-controlled clinical trial was done in seven hospital centers across six provinces in China. Patients with recently diagnosed adenomas and after complete polypectomy were recruited and randomized into a BBR group (Berberine hydrochloride 0.3g, twice daily) or a placebo group. They were anticipated for at least one follow-up colonoscopy until a diagnosis of CRA/CRC or the last enrolled patient reached the 2-year follow-up. The primary efficacy endpoint was the recurrence of adenomas at any follow-up colonoscopy. The secondary outcomes were the recurrences of polypoid lesions as well as advanced adenomas or CRC. Findings: Between Nov 14, 2014 and Dec 29, 2018, 1136 patients were screened for eligibility, and 1108 underwent randomization. 553 patients were assigned to receive Berberine hydrochloride and 555 to placebo. An unadjusted RR for recurrent adenomas and all polypoid lesions were 0.77 (95% CI, 0.66 to 0.91) and 0.77 (95% CI, 0.67 to 0.89), representing a decrease of 22.72% and 22.70%, respectively. No CRC occurred during the whole trial. Interaction test showed taking BBR was effective in female with unadjusted RR for recurrent adenomas of 0.58 (95% CI, 0.41 to 0.81); P=0.07 (Alpha = 0.10). No serious adverse events were reported. Interpretation: Although the mechanism has not been fully elucidated yet, Berberine hydrochloride was effective to reduce colorectal adenoma recurrence after polypectomy. Trial Registration: This trial is registered with ClinicalTrials.gov number NCT02226185. Funding Statement: This project was supported by grants from the National Natural Science Foundation of China (81421001, 81530072, 81830081 and 8177100232), the funds from Shanghai Shenkang Center (SHDC12018121), from Shanghai Municipal Key Clinical Specialty, and from Innovative research team of high-level local universities in Shanghai. The project was also partially supported by Top-Notch project of China and Shanghai Municipal Education Commission-Gaofeng Clinical Medicine Grant (20152514). Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: Approval for this study was obtained from the Ethics Committee of Renji Hospital, Shanghai Jiao-Tong University School of Medicine on 13th August 2014. The protocol and informed consent forms were also approved by the institutional ethics committees at each of the participating clinical centers.