Foreign body and caustic ingestions in children: A clinical practice guideline

Foreign body and caustic ingestions in children are usually the most common clinical challenges for emergency physicians, general pediatricians and pediatric gastroenterologists. Management of these conditions often requires different levels of expertise and competence. Endoscopy is often necessary but there is a high risk of misusing this tool with incorrect timing and indications. The imprecise clinical history frequently leaves clinicians uncertain about timing and nature of the ingestion. Few clinical guidelines regarding management of these ingestions in children have been published, none of which from the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP). An expert panel of Italian endoscopists was convened by the SIGENP Endoscopy Working Group to produce the present article that outlines practical clinical approaches to the pediatric patient with a variety of foreign body and caustic ingestions. The Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) has also endorsed the project since many adult endoscopists usually manage children with these conditions. Differently from the other published guidelines, the proposed one focuses on the role of the endoscopists (regardless of whether they are adult or pediatric gastroenterologists) in the diagnostic process of children with foreign body and caustic ingestions.

Prognostic effect of a novel long noncoding RNA signature and comparison with clinical staging systems for patients with hepatitis B virus-related hepatocellular carcinoma after hepatectomy

OBJECTIVES

We aimed to establish a novel prognostic long noncoding RNA (lncRNA) signature for hepatitis B virus-related hepatocellular carcinoma (HBV-HCC) patients after hepatectomy and to validate its prognostic efficacy compared with other clinical staging systems.

METHODS

Expression data of 374 HCC samples were retrieved from The Cancer Genome Atlas (TCGA) database. Cox regression analyses were performed to develop the lncRNA model. The expression levels of lncRNAs were detected by qualitative real-time polymerase chain reaction (qRT-PCR) in HBV-HCC. Then the qRT-PCR-based signature and nomogram were constructed and compared with those of other clinical staging systems in a clinical cohort and qRT-PCR, RNA fluorescent in situ hybridization and comprehensive bioinformatics analyses were conducted.

RESULTS

The signature containing five lncRNAs was constructed through TCGA. This model showed the highest predictive efficacy in patients with HBV-HCC. Compared with normal liver tissues, all lncRNAs were highly expressed in HBV-HCC. A four-lncRNA signature containing LINC01116, DDX11-AS1, LUCAT1 and FIRRE was developed based on the qRT-PCR data in a clinical HBV-HCC patient cohort. A Kaplan-Meier analysis indicated that the low-risk group had significantly longer overall survival than the high-risk group. Additionally, the qRT-PCR-based four-lncRNA formula was an independent prognostic factor and had better predictive efficacy for survival (area under the receiver operating characteristic curve 0.875) compared with other clinical staging systems in HBV-HCC. The lncRNA-mRNA co-expression and enrichment analyses revealed the potential regulatory mechanisms of the lncRNA identified.

CONCLUSION

The four-lncRNA model may be an effective prognostic signature and provides potential prognostic biomarkers and therapeutic targets for HBV-HCC.

Endogenous ethanol produced by intestinal bacteria induces mitochondrial dysfunction in non-alcoholic fatty liver disease

BACKGROUND AND AIM

A causal relationship between changes of the gut microbiome and non-alcoholic fatty liver disease (NAFLD) remains unclear. We demonstrated that endogenous ethanol (EnEth) produced by intestinal microbiota is likely a causative agent of NAFLD.

METHODS

Two mutants with different alcohol-producing abilities, namely, W14-adh and W14Δadh, were constructed using the clinical high alcohol-producing (HiAlc) Klebsiella pneumoniae strain W14 as a parent. Damage to hepatocytes caused by bacteria with different alcohol-producing capacities was evaluated (EtOH group as positive control). The ultrastructural changes of mitochondria were assessed via transmission electron microscopy (TEM). Hepatic levels of mitochondrial reactive oxygen species (ROS), DNA damage, and adenosine triphosphate were examined.

RESULTS

The results illustrated that steatosis was most severe in the W14-adh group, followed by the W14 group, whereas the W14Δadh group had few fatty droplets. TEM and examination of related protein expression revealed that the mitochondrial integrity of HepG2 hepatocytes was considerably damaged in the EtOH and bacteria treatment groups. The impaired mitochondrial function in HepG2 hepatocytes was evidenced by reduced adenosine triphosphate content and increased mitochondrial ROS accumulation and DNA damage in the EtOH and bacteria treatment groups, especially the W14-adh group. Meanwhile, liver injury and mitochondrial damage were observed in the hepatocytes of mice. The livers of mice in the W14-adh group, which had the highest ethanol production, exhibited the most serious damage, similar to that in the EtOH group.

CONCLUSIONS

EnEth produced by HiAlc bacteria induces mitochondrial dysfunction in NAFLD.

Gastrointestinal fistula endoscopic closure techniques

With the improvement in flexible endoscopic technology and the availability of new endoscopic devices, current endoscopic therapies spare many patients who would otherwise undergo surgical repair of gastrointestinal fistulas. These endoscopic techniques include gastrointestinal stents, endoscopic suturing, cardiac septal occluders, endo-sponge, vacuum therapy and others. This review elaborates on the indications, evidence, procedural details, efficacy, and complications of various endoscopic techniques for the management of gastrointestinal fistulas.

Clinical heterogeneity in patients with non-alcoholic fatty liver disease-associated hepatocellular carcinoma

INTRODUCTION

The indisputable increase in nonalcoholic Fatty Liver Disease (NAFLD) prevalence (25% of population) has consequently led to an increase in Hepatocellular Carcinoma (HCC) and liver-related mortality worldwide. The characteristics of patients with HCC, secondary to NAFLD, are older age, large tumors due to late diagnosis, often without cirrhosis and high prevalence of the metabolic syndrome components, leading to an increased mortality rate. Although the mechanisms of disease remain partially obscure, insulin resistance, oxidative stress, apoptosis, iron overload, and excessive local and systemic inflammation are identified as culprits for hepatocarcinogenesis in the presence of NAFLD.

AREA COVERED

In this review, the authors report that there are no uniform guidelines for surveillance and early diagnosis in this patient group. Barcelona Clinic Liver Cancer staging is generally applicable to HCC due to NAFLD and management depends on liver function, tumor characteristics, and cardiovascular comorbidity. Evidence suggests that HCC due to NAFLD can be associated with worse survival due to late diagnosis.

EXPERT OPINION

The need for effective early diagnosis and management of NAFLD is urgent, considering the galloping incidence of the obesity and the fact that liver cirrhosis and HCC due to NAFLD will become the first indication for liver transplantation in foreseeable future.

Rebleeding and mortality risk are increased by ACLF but reduced by pre-emptive TIPS

BACKGROUND & AIMS

The relationship between acute-on-chronic liver failure (ACLF) and acute variceal bleeding (AVB) is poorly understood. Specifically, the prevalence and prognosis of ACLF in the context of AVB is unclear, while the role of transjugular intrahepatic portosystemic shunt (TIPS) in the management in patients with ACLF has not been described to date.

METHODS

A multicenter, international, observational study was conducted in 2,138 patients from 34 centers between 2011 and 2015. ACLF was defined and graded according to the EASL-CLIF consortium definition. Placement of pre-emptive TIPS (pTIPS) was based on individual center policy. Patients were followed-up for 1 year, until death or liver transplantation. Cox regression and competing risk models (Gray's test) were used to identify independent predictors of rebleeding or mortality.

RESULTS

At admission, 380/2,138 (17.8%) patients had ACLF according to EASL-CLIF criteria (grade 1: 38.7%; grade 2: 39.2%; grade 3: 22.1%). The 42-day rebleeding (19% vs. 10%; p <0.001) and mortality (47% vs. 10%; p <0.001) rates were higher in patients with ACLF and increased with ACLF grades. Of note, the presence of ACLF was independently associated with rebleeding and mortality. pTIPS placement improved survival in patients with ACLF at 42 days and 1 year. This effect was also observed in propensity score matching analysis of 66 patients with ACLF, of whom 44 received pTIPs and 22 did not.

CONCLUSIONS

This large multicenter international real-life study identified ACLF at admission as an independent predictor of rebleeding and mortality in patients with AVB. Moreover, pTIPS was associated with improved survival in patients with ACLF and AVB.

LAY SUMMARY

Acute variceal bleeding is a deadly complication of liver cirrhosis that results from severe portal hypertension. This study demonstrates that the presence of acute-on-chronic liver failure (ACLF) is the strongest predictor of mortality in patients with acute variceal bleeding. Importantly, patients with ACLF and acute variceal (re)bleeding benefit from pre-emptive (early) placement of a transjugular intrahepatic portosystemic shunt.

Hyponatremia in Cirrhosis: An Update

Hyponatremia is frequently seen in patients with ascites secondary to advanced cirrhosis and portal hypertension. Although not apparent in the early stages of cirrhosis, the progression of cirrhosis and portal hypertension leads to splanchnic vasodilation, and this leads to the activation of compensatory mechanisms such as renin-angiotensin-aldosterone system (RAAS), sympathetic nervous system, and antidiuretic hormone (ADH) to ameliorate low circulatory volume. The net effect is the avid retention of sodium and water to compensate for the low effective circulatory volume, resulting in the development of ascites. These compensatory mechanisms lead to impairment of the kidneys to eliminate solute-free water in decompensated cirrhosis. Nonosmotic secretion of antidiuretic hormone (ADH), also known as arginine vasopressin, further worsens excess water retention and thereby hyponatremia. The management of hyponatremia in this setting is a challenge as conventional therapies for hyponatremia including fluid restriction and correction of hypokalemia are frequently inefficacious. In this review, we discuss the pathophysiology, complications, and various treatment modalities, including albumin infusion, selective vasopressin receptor antagonists, or hypertonic saline for patients with severe hyponatremia and those awaiting liver transplantation.

The interplay between the gut microbiota and NLRP3 activation affects the severity of acute pancreatitis in mice

Early dysbiosis of the gut microbiota is associated with the severity of acute pancreatitis (AP), although the underlying mechanism is unclear. Here, we investigated the role of crosstalk between NLRP3 and the gut microbiota in the development of AP utilizing gut microbiota deficient mice, as well as NLRP3 knockout (KO) mouse models. Pancreatic damage and systemic inflammation were improved in antibiotic-treated (Abx) and germ-free (GF) mice, accompanied by weakened activity of the intestinal NLRP3 inflammasome. Interestingly, fecal microbiota transplantation (FMT) reactivated the intestinal NLRP3 inflammasome and exacerbated the disease in Abx and GF mice. Although the gut barrier in GF and Abx mice was disrupted, gut microbiota deficiency ameliorated the severity of AP, probably due to the reduction in bacterial translocation from the gut to the pancreas. The composition of the gut microbiota was significantly different between NLRP3 KO mice and wild-type (WT) mice at baseline, and there were alterations in response to the induction of AP. While a dramatic shift in the gut microbiota with overgrowth of Escherichia-Shigella was observed in WT mice suffering from AP, there was no significant change in NLRP3 KO mice with or without AP, suggesting that NLRP3 deficiency counteracts AP-induced microbial disturbance. With a strengthened gut barrier and decreased systemic inflammation, NLRP3 KO mice showed less severe AP, as revealed by reduced pancreatic neutrophilic infiltration and necrosis. Taken together, these results identified the bidirectional modulation between the gut microbiota and NLRP3 in the progression of AP, which suggests the interplay of the host and microbiome during AP.

Present and future management of viral hepatitis B and C in children

Having a hepatitis B virus (HBV) or hepatitis C virus (HCV) infection places a child at higher risk for subsequent chronic hepatitis B (CHB) or chronic hepatitis C (CHC) infection. The risk of mother-to-child transmission is higher for HBV (20% to 90%) than for HCV (<5%). Perinatal HBV infection generally causes CHB infection while perinatal HCV infection has a certain rate of spontaneous viral clearance (around 20% to 30%). Of the two, only HBV infection can benefit from passive/active perinatal immunoprophylaxis. The risk of CHB in children with HBV horizontal transmission decreases with age, whereas HCV transmission among teenagers commonly results into a long-life infection and CHC infection. Children with CHB or CHC should be carefully assessed for the need for antiviral treatment. When treatment cannot be deferred, pediatric CHB infection has different first-line treatment options: standard interferon (for children aged≥1 year), pegylated interferon (for children aged≥3 years), and the oral nucleotide analogues entecavir (for children aged≥2 years) and tenofovir (for children aged≥12 years). The choice of treatment depends on the child's age, virus genotypes, previous treatment failure and presence of contraindications. Expected responsiveness rate is 25% of hepatitis B e-antigen clearance, with both standard interferon and nucleotide analogues. Direct antiviral agents are first-line treatment for CHC infection in children aged 3 years or older. Hepatitis C virus sustained virus response is as high as 97%. Therefore, if direct antiviral agents can be proven to be safe and well tolerated in very young children, HCV eradication could be planned after the first screening.

Pancreatobiliary Endoscopic Interventions for Pediatric Pancreatic Pathology

Despite the increased global recognition of pediatric pancreatic diseases, there are limited data on the utility of sophisticated endoscopic procedures such as endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) in their management. Promising results of recent studies have highlighted the emerging therapeutic utility of EUS and ERCP in children. With these latest developments in mind, this article reviews the current literature regarding diagnostic and therapeutic uses, benefits, limitations, and clinical outcomes of EUS and ERCP in pediatric pancreatology.

Impact of a simulation-based ergonomics training curriculum on work-related musculoskeletal injury risk in colonoscopy

BACKGROUND AND AIMS

Endoscopists are at risk of developing musculoskeletal injuries (MSIs), and few receive training on ergonomics. The aim of this study was to determine the impact of a simulation-based ergonomics training curriculum (ETC) on work-related MSI risk during clinical colonoscopy.

METHODS

Novice endoscopists underwent a simulation-based ETC and were compared with an historical control group who received simulation-based training without ergonomics training. The ETC included a didactic lecture and video on ergonomics in colonoscopy, feedback from supervisors on ergonomics, and an ergonomics checklist to augment feedback and promote self-reflection. Participants were assessed using the rapid entire body assessment (REBA) and rapid upper limb assessment (RULA). The primary outcome was participants' REBA scores during 2 clinical colonoscopies 4 to 6 weeks after training.

RESULTS

In clinical colonoscopy, the ETC group had superior REBA scores (clinical procedure 1: median score, 6 vs 11; P < .001; clinical procedure 2: median score, 6 vs 10; P < .001). In a simulated colonoscopy, the ETC group did not have significantly different REBA or RULA scores between baseline, immediately after training, and 4 to 6 weeks after (REBA: median scores of 5, 5, and 5, respectively; P > .05; RULA: median scores of 6, 6, and 6, respectively; P > .05). The control group had worsening REBA and RULA scores during the study timeline (REBA: median scores of 5 at baseline, 9 immediately after training, and 9 at 4-6 weeks after training; P < .001; RULA: median scores of 6, 7, and 7, respectively; P = .04) during simulated procedures.

CONCLUSIONS

A simulation-based ETC is associated with reduced risk of MSI during endoscopy. Although the REBA score was improved, the intervention group was still within the medium-risk range.

The status of training in new technologies in advanced endoscopy: from defining competence to credentialing and privileging

The landscape of advanced endoscopy continues to evolve as new technologies and techniques become available. Although postgraduate advanced endoscopy fellowships have traditionally centered on ERCP and diagnostic EUS, the breadth of training has increased over the years in response to the ever-growing demand for therapeutic endoscopy. The increasing diversity and complexity of emerging endoscopic techniques accompanied by the shift in focus toward competency-based medical education requires innovative changes to the curriculum that will ensure adequate training yet without compromising best patient practices. The purpose of this review is to highlight the expansive array of advanced endoscopic procedures and the challenges of both defining and measuring competence during training. All authors are interventional endoscopists at their respective institutions performing these complex procedures, as well as training fellows in these techniques. We share our perspectives based on our experience navigating through these issues at our institutions and discuss strategies to standardize training and how to potentially incorporate these measures in the process of credentialing and privileging in endoscopy.

Nonalcoholic Fatty Liver Disease and Estimated Insulin Resistance in Obese Youth: A Mendelian Randomization Analysis

CONTEXT

Nonalcoholic fatty liver disease (NAFLD) is associated with insulin resistance (IR) and predicts type 2 diabetes. Currently, it is uncertain whether NAFLD may directly cause IR or vice versa.

OBJECTIVE

To test the hypothesis that NAFLD is causally related to IR.

DESIGN AND METHODS

We performed a Mendelian randomization (MR) in 904 obese children/adolescents using an NAFLD-related genetic risk score (GRS) as an instrumental variable. We assessed NAFLD by ultrasonography and IR by homeostasis model assessment (HOMA-IR). We also interrogated the MAGIC Consortium dataset of 46 186 adults to assess the association between PNPLA3 rs738409 (ie, the most robust NAFLD-related polymorphism) and HOMA-IR, and we performed a 2-sample MR with 2 large datasets to test reverse causation (HOMA-IR increasing the risk of NAFLD).

RESULTS

Nonalcoholic fatty liver disease prevalence increased by 20% for every increase in the GRS (β-coefficient = 0.20, P < 0.001), and NAFLD was associated with ln-HOMA-IR (β-coefficient = 0.28, P < 0.001). Thus, the expected increase in ln-HOMA-IR for every increase in the GRS (expected β-coefficient) was 0.056 (0.28*0.20) in the case of complete NAFLD-HOMA-IR causal association, and 0.042 in the case of 75% causality. In our cohort, the GRS did not predict ln-HOMA-IR (β-coefficient = 0.007, P = 0.75). In the MAGIC cohort, the PNPLA3 rs738409 did not associate with ln-HOMA-IR. The 2-sample MR failed to show a causal association between ln-HOMA-IR and NAFLD.

CONCLUSIONS

Our study shows that genetically-influenced NAFLD does not increase HOMA-IR, and genetically-influenced HOMA-IR does not increase the risk of NAFLD. Shared pathogenic pathways or NAFLD subtypes not "captured" by our MR design might underpin the association between NAFLD and HOMA-IR.

The micro-structural analysis of lumbar vertebrae in alcoholic liver cirrhosis

Although vertebral fracture is more common among alcoholic liver cirrhosis patients when compared to general population, current data on three-dimensional micro-architecture are scarce. Our study showed significant trabecular deterioration in lumbar vertebrae obtained from alcoholic liver cirrhosis donors, suggesting that they should be advised to undergo early-stage screening for osteoporosis.

PURPOSE

Recent studies showed an increased incidence of vertebral fractures in alcoholic liver cirrhosis (ALC) patients, while data about vertebral micro-structure are still limited. The aim of this study was to compare trabecular and cortical micro-architecture of lumbar vertebrae between ALC patients and healthy age- and sex-matched controls.

METHODS

Our study included lumbar vertebral samples of male cadaveric donors, divided into ALC (n = 20, age: 59 ± 6 years) and control group (n = 20, age: 59 ± 8 years). Following pathohistological verification of liver cirrhosis, trabecular and cortical bone micro-architecture was analyzed by micro-computed tomography (micro-CT).

RESULTS

Micro-CT evaluation of the trabecular bone in lumbar vertebrae showed a significant decrease in bone volume fraction, trabecular thickness, trabecular number, and connectivity (p < 0.01). In contrast to trabecular deterioration, prominent alteration in cortical parameters was not observed in lumbar vertebrae of ALC patients (p > 0.05).

CONCLUSIONS

Our data indicate that susceptibility to non-traumatic fractures in ALC patients could be explained by alterations in trabecular bone micro-architecture. Thus, we genuinely recommend osteological screening of the lumbar spine for all ALC patients in order to evaluate individual fracture risk. Graphical abstract.

Polypectomy Techniques

Polyps in the upper and lower gastrointestinal tract can be premalignant or malignant lesions that can be treated endoscopically in early stages to prevent morbidity and more invasive procedures. This article critically reviews the techniques available and provides recommendations for endoscopic polypectomy.

S-adenosyl-L-methionine (SAMe) halts the autoimmune response in patients with primary biliary cholangitis (PBC) via antioxidant and S-glutathionylation processes in cholangiocytes

S-adenosyl-L-methionine is an endogenous molecule with hepato-protective properties linked to redox regulation and methylation. Here, the potential therapeutic value of SAMe was tested in 17 patients with PBC, a cholestatic disease with autoimmune phenomena targeting small bile ducts. Nine patients responded to SAMe (SAMe responders) with increased serum protein S-glutathionylation. That posttranslational protein modification was associated with reduction of serum anti-mitochondrial autoantibodies (AMA-M2) titers and improvement of liver biochemistry. Clinically, SAMe responders were younger at diagnosis, had longer duration of the disease and lower level of serum S-glutathionylated proteins at entry. SAMe treatment was associated with negative correlation between protein S-glutathionylation and TNFα. Furthermore, AMA-M2 titers correlated positively with INFγ and FGF-19 while negatively with TGFβ. Additionally, cirrhotic PBC livers showed reduced levels of glutathionylated proteins, glutaredoxine-1 (Grx-1) and GSH synthase (GS). The effect of SAMe was also analyzed in vitro. In human cholangiocytes overexpressing miR-506, which induces PBC-like features, SAMe increased total protein S-glutathionylation and the level of γ-glutamylcysteine ligase (GCLC), whereas reduced Grx-1 level. Moreover, SAMe protected primary human cholangiocytes against mitochondrial oxidative stress induced by tBHQ (tert-Butylhydroquinone) via raising the level of Nrf2 and HO-1. Finally, SAMe reduced apoptosis (cleaved-caspase3) and PDC-E2 (antigen responsible of the AMA-M2) induced experimentally by glycochenodeoxycholic acid (GCDC). These data suggest that SAMe may inhibit autoimmune events in patients with PBC via its antioxidant and S-glutathionylation properties. These findings provide new insights into the molecular events promoting progression of PBC and suggest potential therapeutic application of SAMe in PBC.

Effect on Bleeding Prevention of an Intravenous Proton Pump Inhibitor During the Fasting Period After Endoscopic Submucosal Dissection: a Prospective, Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

No consensus has been achieved on optimal perioperative strategies for patients undergoing endoscopic submucosal dissection (ESD). The aim of this study was to investigate the effects of an intravenous (IV) proton pump inhibitor (PPI) given during the fasting period after ESD on delayed bleeding following ESD.

METHODS

This study was designed as a prospective, randomized, double-blind, placebo-controlled trial in a single center. A total of 235 patients who underwent ESD for adenoma and early gastric cancer between March 2016 and September 2018 were randomized into a PPI group and placebo group. Patients were administrated intravenous pantoprazole 40 mg daily (PPI group) or placebo (placebo group) during the fasting period 48 h after ESD (from the day of ESD to the following day, 48 h). After oral feeding (48 h after ESD), oral PPI was given to both groups for 8 weeks.

RESULTS

Among 235 patients in the intention-to-treat (ITT) and 195 in the per-protocol (PP) analysis, there was no significant difference between the PPI and control groups in major bleeding (PPI vs. placebo; 3.3% vs. 1.7%, p = 0.27) or minor bleeding (PPI vs. placebo; 7.6% vs. 4.3%, p = 0.41) after ESD. There was no significant difference in age (p = 0.28), histology (p = 0.75), tumor size (p = 0.48), or procedure time (p = 0.49) between the two groups. The only independent risk factor for major delayed bleeding was the combined use of aspirin and antiplatelet agent (OR; 12.25, 95% CI; 1.06-141.19, p = 0.04).

CONCLUSIONS

Administration of routine IV PPI during the fasting period 48 h after ESD does not reduce delayed post-ESD bleeding.

P53 Activated by ER Stress Aggravates Caerulein-Induced Acute Pancreatitis Progression by Inducing Acinar Cell Apoptosis

BACKGROUND AND AIMS

Acute pancreatitis (AP) is a severe pancreatic disorder that remains associated with high mortality due to a lack of effective drugs and management strategies. This study aimed to investigate the molecular pathogenic mechanisms of AP involving p53 and endoplasmic reticulum (ER) stress pathways.

METHODS

Expression of PRSS1 and p53 in human AP tissues was detected by immunohistochemistry and Western blotting. AP was induced with caerulein in humanized PRSS1 transgenic mice, and its severity was verified by histological imaging, evaluation of edema, serum amylase, and trypsin activity assays. A transferase-mediated d-UTP nick end-labeling assay was performed to evaluate acinar cell apoptosis associated with AP. The expression of ER stress genes was assessed by quantitative RT-PCR (qRT-PCR) and Western blotting.

RESULTS

PRSS1 and p53 were highly expressed in human AP tissues. Expression of human PRSS1 in caerulein-treated mice induced significant acinar cell apoptosis and AP progression. P53 knockout significantly suppressed AP progression in humanized PRSS1 transgenic mice. The ER stress pathway was activated by PRSS1 and mediated the progression of AP in mouse pancreatic tissues. Application of a p53 inhibitor effectively ameliorated caerulein-induced AP in PRSS1 transgenic mice, while a p53 activator promoted the progression of AP.

CONCLUSION

P53, which was activated by the ER stress pathway, promoted the progression of AP in mice expressing PRSS1 by inducing acinar cell apoptosis.

Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection

Therapeutic endoscopy is an emerging field within general surgery. This article explores the evidence for and usage of endoscopic mucosal resection and endoscopic submucosal dissection throughout the gastrointestinal tract. We aim to educate surgeons and provide an understanding of these techniques. With education and appropriate training, the surgeon will gain confidence and hopefully adopt these tools into their daily practice.

DNA Methyltransferases as Potential Biomarkers for HCV Related Hepatocellular Carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is a major health concern in many countries including Egypt. The alteration in DNA methylation that was observed in HCC patients suggests a possible role of DNA methyltransferases (DNMTs) in the disease pathogenesis in addition to potential role as a disease biomarker.

AIM

To study the change in DNMTs expression in chronic HCV infected patients as potential non- invasive biomarker for diagnosis of hepatocellular carcinoma.

METHODS

26 patients with HCC, 45 patients with liver cirrhosis, 20 chronic HCV patients and 20 apparently healthy individuals as a control group were enrolled in this study. Real-Time Quantitative Reverse Transcription PCR (qRT-PCR) was performed for all study participants.

RESULTS

A significant difference in DNMTs expression was observed among the studied groups. Receiver operating characteristics (ROC) curve analysis revealed that with a cutoff value of 3.16 for DNMT 3A expression, sensitivity and specificity were 80.8 and 95.6% respectively and area under curve (AUC) was 0.958, p < 0.001 for discriminating hepatocellular carcinoma among post hepatitis C cirrhotic patients. Besides DNMT 3B relative expression cutoff value of 3.10 showed 84.6% sensitivity and 77.8% specificity and AUC was 0.888, p < 0.001. On the other hand, cutoff value 0.65 for DNMT1 relative expression showed 92.3% sensitivity and 44.4% specificity and AUC was 0.72, p= 0.002. DNMT1, DNMT 3A and DNMT 3B have significant positive correlation with the level of AFP (p-value = 0.003, 0.004 and 0.008 respectively). The relative expression of DNMT3B was significantly correlated to focal lesion size (p-value = 0.015). High DNMTs expression was significantly associated with the presence of multiple focal lesions but not with the Child Pugh grade (p> 0.05).

CONCLUSION

The mRNA levels of DNMTs could be a potential biomarker for early detection of HCC development.<br />.

Low Fermentable Oligo- Di- and Mono-Saccharides and Polyols (FODMAPs) or Gluten Free Diet: What Is Best for Irritable Bowel Syndrome?

Irritable Bowel Syndrome (IBS) is a very common functional gastrointestinal disease. Its pathogenesis is multifactorial and not yet clearly defined, and hence, its therapy mainly relies on symptomatic treatments. Changes in lifestyle and dietary behavior are usually the first step, but unfortunately, there is little high-quality scientific evidence regarding a dietary approach. This is due to the difficulty in setting up randomized double-blind controlled trials which objectively evaluate efficacy without the risk of a placebo effect. However, a Low Fermentable Oligo-, Di- and Mono-saccharides And Polyols (FODMAP) Diet (LFD) and Gluten Free Diet (GFD) are among the most frequently suggested diets. This paper aims to evaluate their possible role in IBS management. A GFD is less restrictive and easier to implement in everyday life and can be suggested for patients who clearly recognize gluten as a trigger of their symptoms. An LFD, being more restrictive and less easy to learn and to follow, needs the close supervision of a skilled nutritionist and should be reserved for patients who recognize that the trigger of their symptoms is not, or not only, gluten. Even if the evidence is of very low-quality for both diets, the LFD is the most effective among the dietary interventions suggested for treating IBS, and it is included in the most updated guidelines.

Flavonoids from Barnebydendron riedelii leaf extract mitigate thioacetamide-induced hepatic encephalopathy in rats: The interplay of NF-κB/IL-6 and Nrf2/HO-1 signaling pathways

Phytochemical investigation of the butanol fraction (BUF) derived from the 70% aqueous methanolic leaf extract of Barnebydendron riedelii led to the isolation of three flavonoid glycosides; kaempferol-3-O-α-l-rhamnopyranosyl-(1 → 6)-β-d-glucopyranoside, quercetin-3-O-α-l-rhamnopyranosyl-(1 → 6)-β-d-galactopyranoside and quercetin-3-O-α-l-rhamnopyranosyl-(1 → 6)-β-d-glucopyranoside. Docking studies were fulfilled to validate the possible bio-properties of BUF toward nuclear factorkappa B (NF-κB) and nuclear factor erythroid 2-related factor 2 (Nrf2). The protective role of BUF against behavioral, biochemical, molecular, histopathological and immunohistochemical alterations in thioacetamide (TAA)-induced hepatic encephalopathy in rats was investigated. The toxicological studies indicated that BUF was safe up to 2000 mg/kg bw. Prior to TAA intoxication, rats were orally treated with either BUF at multiple doses (70, 140 and 280 mg/kg bw) or lactulose (8 mL/kg bw) for 14 consecutive days. On the 13th and the 14th day, TAA (200 mg/kg bw/day) was intraperitoneally injected. The BUF significantly improved motor impairment, ameliorated cognitive deficits and attenuated TAA-induced hepatotoxicity. Moreover, BUF controlled the inflammatory processes by suppressing the hepatic inflammatory cytokine; interleukin-6 (IL-6) as well as its pro-inflammatory mediator; NF-κB supporting the molecular docking assessment. The brain neurotransmitters; dopamine, serotonin and noradrenaline, as well as ammonia levels were improved in BUF-treated TAA-intoxicated animals in a dose-dependent manner. Furthermore, BUF administration to TAA-intoxicated rats modulated the Nrf2 and heme oxygenase 1 (HO-1) genes expression in liver and brain tissues. The histological evaluation showed that pretreatment of TAA-intoxicated rats with BUF ameliorated the degenerative effects of TAA on liver and brain tissues as well as reduced the activation of cellular apoptotic marker; caspase-3 and glial fibrillary acidic protein (GFAP⁺) astrocytes. In conclusion, the observed hepato-neuroprotective effect of BUF is attributed to its flavonoidal content through its modulatory effects on of NF-κB/IL-6 and Nrf2/HO-1 signaling pathways.

Effects of Fluid Resuscitation on the Occurrence of Organ Failure and Mortality in Patients With Acute Pancreatitis

OBJECTIVES

Acute pancreatitis (AP) is a serious gastroenterological condition requiring urgent fluid resuscitation and emergent intensive care. However, the benefit of fluid resuscitation is inconsistent. Therefore, this study aimed to examine the effects of fluid resuscitation on the occurrence of organ failure and mortality in patients with AP.

METHODS

The data were retrospectively extracted from the Medical Information Mart for Intensive Care III 2002-2012 database. The fluid resuscitation and fluid balance were calculated at 12, 24, 36, and 48 hours after intensive care unit admission. Multivariate analysis models were used.

RESULTS

A total of 317 patients with AP were included. Odds of organ failure increased significantly with increased fluid input at 0 to 12 hours [adjusted odds ratio (aOR), 1.124; 95% confidence interval (CI), 1.015-1.244] and with increased fluid balance at 36 to 48 hours (aOR, 1.184; 95% CI, 1.009-1.389). Odds of in-hospital mortality increased significantly with increased fluid balance at 24 to 36 hours (aOR, 1.201; 95% CI, 1.052-1.371). Odds of 30-day mortality increased significantly with increased fluid balance at 24 to 36 hours (aOR, 1.189; 95% CI, 1.039-1.361).

CONCLUSIONS

Increased fluid balance was associated with increased risk of organ failure and mortality. Increased fluid output may decrease mortality.

Early Experience With Transanal Total Mesorectal Excision Compared With Laparoscopic Total Mesorectal Excision for Rectal Cancer: A Propensity Score-Matched Analysis

BACKGROUND

Laparoscopic total mesorectal excision is widely used for rectal cancers; however, it is sometimes challenging, especially in obese patients with low tumors, particularly after chemoradiotherapy. Transanal total mesorectal excision was developed to overcome these limitations in terms of visualization, dissection, and stapling.

OBJECTIVE

The purpose of this study was to compare the pathologic and early oncologic outcomes of the laparoscopic and transanal approaches.

DESIGN

This was a retrospective comparative study using propensity score-matched analysis.

SETTING

The study was conducted at a tertiary hospital specializing in oncology.

PATIENTS

In total, 722 inpatients who underwent total mesorectal excision for rectal cancer from January 2014 to December 2017 were included.

INTERVENTIONS

Laparoscopic (N = 514) and transanal (N = 208) total mesorectal excision were performed.

MAIN OUTCOME MEASURES

The primary outcome was pathologic outcome including circumferential and distal resection margin involvement. The secondary outcomes were intraoperative and postoperative complications and overall survival, recurrence-free survival, and local recurrence rates.

RESULTS

The 2 groups of the cohort had several differences; thus, we performed propensity score matching. The circumferential resection margin was involved in 13.4% and 12.9% of the laparoscopic and transanal groups (p = 0.88). The distal resection margin was involved in 1% and 3% of the laparoscopic and transanal groups (p = 0.28). Complete or nearly complete total mesorectal excision was 98.0% and 96.5% in the laparoscopic and transanal groups (p = 0.41). Postoperative complications with Clavien-Dindo grade III or higher did not differ significantly between groups (p = 0.54) but were significantly higher in patients with tumors <5 cm from the anal verge who underwent laparoscopy (laparoscopic group = 11.9%; transanal group = 1.7%; p = 0.04). There were no statistical differences in the 3-year overall survival, recurrence-free survival, or local recurrence rates between groups.

LIMITATIONS

This was a retrospective study design with a short follow-up period.

CONCLUSIONS

Early experience with the transanal approach showed similar pathologic outcomes as those of conventional laparoscopy; hence, it should be considered as a surgical option for lower rectal cancer. See Video Abstract at http://links.lww.com/DCR/B352. EXPERIENCIA TEMPRANA CON LA ESCISIÓN MESORRECTAL TOTAL TRANSANAL EN COMPARACIÓN CON LA ESCISIÓN MESORRECTAL TOTAL LAPAROSCÓPICA PARA EL CÁNCER DE RECTO: UN ANÁLISIS DE PUNTUACIÓN DE PROPENSIÓN: La escisión mesorrectal total laparoscópica se usa ampliamente para los cánceres rectales; Sin embargo, a veces es un desafío, especialmente en pacientes obesos con tumores bajos, particularmente después de la quimiorradioterapia. La escisión mesorrectal total transanal se desarrolló para superar estas limitaciones en términos de visualización, disección y grapado.Comparar los resultados patológicos y oncológicos precoces de los enfoques laparoscópico y transanal.estudio comparativo retrospectivo con puntaje de propensión-análisis emparejadoHospital terciario especializado en oncología.En total, se incluyeron 722 pacientes hospitalizados que se sometieron a una escisión mesorrectal total por cáncer rectal desde Enero de 2014 hasta Diciembre de 2017.Se realizó escisión mesorrectal total laparoscópica (n = 514) y transanal (n = 208).El resultado primario fue el resultado patológico, incluyendo el involucramiento del margen de resección circunferencial y distal. Los resultados secundarios fueron complicaciones intraoperatorias, postoperatorias y supervivencia general, supervivencia libre de recurrencia y tasas de recurrencia local.Los dos grupos de la cohorte tuvieron varias diferencias; así, realizamos un emparejamiento de puntuación de propensión. El margen de resección circunferencial estuvo involucrado en 13.4% y 12.9% de los grupos laparoscópico y transanal, respectivamente (p = 0.88). El margen de resección distal estuvo involucrado en 1% y 3% de los grupos laparoscópico y transanal, respectivamente (p = 0.28). La escisión mesorrectal total completa o casi completa fue de 98.0% y 96.5% en los grupos laparoscópico y transanal, respectivamente (p = 0.41). Las complicaciones postoperatorias con Clavien-Dindo grado ≥ III no difirieron significativamente entre los grupos (p = 0,54), pero fueron significativamente mayores en pacientes con tumores de < 5 cm del borde anal que se sometieron a laparoscopia (grupo laparoscópico, 11,9%; grupo transanal, 1,7%; p = 0,04). No hubo diferencias estadísticas en la supervivencia general a 3 años, la supervivencia libre de recurrencia y las tasas de recurrencia local entre los grupos.Diseño de estudio retrospectivo, corto período de seguimiento.La experiencia temprana con el enfoque transanal mostró resultados patológicos similares a los de la laparoscopia convencional; por lo tanto, debe considerarse como una opción quirúrgica para el cáncer rectal mas bajo. Consulte Video Resumen en http://links.lww.com/DCR/B352. (Traducción-Dr Yesenia Rojas-Khalil).

Ischemic Cholangiopathy Following Transcatheter Arterial Chemoembolization for Recurrent Hepatocellular Carcinoma After Hepatectomy: an Underestimated and Devastating Complication

BACKGROUND

Ischemic cholangiopathy (IC) has a known poor prognosis. However, the risks and outcomes of this complication after transcatheter arterial chemoembolization (TACE) in hepatectomized patients are poorly documented. This study aimed to evaluate the incidence of and to identify the predictive factors for IC following TACE for recurrent hepatocellular carcinoma (HCC) after hepatectomy.

METHOD

From a cohort with a total of 486 patients who underwent resection for HCC, we included all consecutive patients who were treated with TACE for recurrent HCC after hepatectomy between 2000 and 2017. IC was defined by the coexistence of biological cholestasis and morphological lesions.

RESULTS

A total of 156 patients underwent TACE for the treatment of HCC recurrence after hepatectomy. Of them, eight (5.1%) developed IC. Their prognosis was poor compared with patients without IC (3-year survival 23.4% vs 76.2%; P = 0.008). Two factors, namely, time between hepatectomy and TACE (4.8 months vs. 16.0 months, P = 0.001) and TACE for a remnant liver mobilized during hepatectomy (P = 0.001), were associated with IC. Receiver operating characteristic (ROC) curve analysis showed that 7 months was the more discriminant cutoff for the time period. IC occurred in 33.3% of the patients with the two factors, in 5.0% of those with one factor, and 0% in the absence of any factors.

CONCLUSION

TACE for treating HCC recurrence carries a high risk of IC when performed early after hepatectomy in a previously mobilized liver. Our results might aid in identifying candidates for TACE for recurrent HCC, considering the major effect on patient outcomes.

Levels of Anti-Citrullinated Protein Antibodies and Rheumatoid Factor, Including IgA Isotypes, and Articular Manifestations in Ulcerative Colitis and Crohn's Disease

Systemic presence of arthritis autoantibodies (AAb) is specific for rheumatoid arthritis (RA). AAb initiation might be triggered by chronic mucosal inflammation, such as in inflammatory bowel disease (IBD). We assessed the prevalence of anti-citrullinated protein antibodies (ACPA) and rheumatoid factor (RF) in ulcerative colitis (UC) and Crohn’s disease (CD) patients, with regard to the prevalence of joint complaints in AAb+ versus AAb− IBD patients. RA patients and healthy subjects (HC) served as controls. Serum was collected from 226 UC, 165 CD and 86 RA patients, and 36 HCs. One-hundred-and-ten UC (48.7%) and 76 CD (46.1%) patients were seropositive for at least one autoantibody, compared to 4 (13.9%) HCs and 81 (94.2%) RA patients. Eighty-three (37%) UC and 52 (32%) CD patients were seropositive for the anti-cyclic citrullinated protein antibody (anti-CCP2) of the immunoglobulin A type (IgA anti-CCP2), compared to 1 (2.8%) HC and 64 (74%) RA patients. RF of the immunoglobulin G type (IgG RF) and IgA RF seropositivity in UC and CD patients was comparable to HCs and low compared to RA patients. Arthralgia was reported by 34 (18.7%) UC and 50 (33.1%) CD patients, but presence of arthralgia was not increased in AAb+ patients. AAbs are frequently present in IBD patients, supporting the hypothesis that inflammation of intestinal mucosa induces low systemic levels of ACPA.

Hiatal Hernia Evaluation Before Bariatric Surgery: Should It Be Routinely Done?

PURPOSE

The necessity of routine preoperative esophagogastroduodenoscopy (EGD) and upper gastrointestinal series (UGIS) in the evaluation of hiatal hernia (HH) among bariatric surgery candidates is controversial since most are detected during surgery, regardless of the preoperative work-up. The aim is to determine the accuracy of preoperative EGD and UGIS for HH diagnosis among bariatric surgery candidates.

MATERIAL AND METHODS

The records of bariatric surgery patients between 2011 and 2015 were reviewed. Patients underwent routine UGIS and/or EGD before the surgery. The positive and negative predictive values (PPV, NPV) for each study were calculated based on operative findings.

RESULTS

A total of 463 patients were included in the study. Mean age was 44.34 ± 12.99 years. Mean preoperative body mass index (BMI) was 42.7 ± 5.15 kg/m². A total of 450 patients (97.2%) had a UGIS, 263 patients underwent EGD (56.8%), and 258 (55.7%) patients had both tests. HH was diagnosed in 26 (5.8%), 60 (13%), and 72 (27.8%) patients, respectively. HH was found intra-operatively in 53 patients (11.4%). It was associated with heartburn (P = 0.005) and previous bariatric surgery (P = 0.008). EGD had a greater sensitivity than UGIS (47.4% vs. 30.2%) and a lower specificity (81.4% vs. 97.5%). PPV and NPV for UGIS and EGD were 61.5% and 91.3% vs. 30% and 90.2%, respectively. The sensitivity of both tests when combined together reached 60.5%.

CONCLUSIONS

Both EGD and UGIS, whether solely performed or combined, have low sensitivity for diagnosis of HH and can probably be omitted from the preoperative evaluation, except for high-risk patients.

Sporadic pyloric gland adenoma associated with a large fundic gland polyp: genetic evidence for stepwise progression

Pyloric gland adenoma (PGA) is an uncommon variant of gastric adenoma exhibiting pyloric gland/mucous neck cell differentiation. We present a sporadic PGA associated with a large fundic gland polyp (FGP) in a woman in her 40 s without Helicobacter pylori infection. The polyp, measuring 25 mm in size, was located in the middle gastric body and was removed by endoscopic submucosal dissection. Histological examination revealed three morphologically distinct components: FGP, FGP with large cysts, and PGA. A genetic analysis identified a truncating APC mutation in all the three components, supporting their histogenetic relationship. Additionally, a GNAS mutation was detected in two components, FGP with large cysts and PGA, whereas a KRAS mutation was exclusively found in the PGA component. Thus, despite the unusual presentation, the PGA component harbored prototypical genetic alterations. The differential genetic alterations observed in the three components imply that they represent stepwise progression from FGP to PGA.

Multichannel intraluminal impedance-pH and psychometric properties in gastroesophageal reflux: systematic review

OBJECTIVE

Systematically assess studies that have analyzed the psychometric properties of multichannel intraluminal impedance-pH for the diagnosis of gastroesophageal reflux. Systematically verify studies that have analyzed the psychometric properties of multichannel intraluminal impedance-pH regarding the diagnosis of gastroesophageal reflux disease in pediatric patients.

METHODS

Systematic review considering specific descriptors (children and adolescents, gastroesophageal reflux disease and multichannel intraluminal impedance-pH) and their synonyms. The systematic search was carried out in the MEDLINE/Ovid, Scopus, and Embase databases, considering the period from October 2017 to December 2018. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), which was used for study selection. The psychometric properties described in the studies were: sensitivity, specificity, accuracy, and reproducibility.

RESULTS

Sensitivity was discussed in most studies, with a result of more than 70% in four of them. Specificity was assessed only in conjunction with sensitivity, with values from 23% to 25% in two studies, and it reached 80% in a single study. Accuracy was assessed higher than 76% in one of the selected articles. The methodological quality of the studies demonstrated low risk of bias, and there was no significant concern related to applicability of the studies.

CONCLUSIONS

According to the selected studies, multichannel intraluminal impedance-pH was considered a safe and effective tool, presenting higher sensitivity values than pHmetry regarding the diagnosis of gastroesophageal reflux disease.

Pediatric liver transplantation in severe hepatopulmonary syndrome and use of inhaled nitric oxide for post-transplant hypoxemia-a single center experience

Data on pediatric patients with HPS undergoing LT are limited. Our aim was to study the spectrum and outcomes of pediatric patients with HPS undergoing LDLT. The role ofiNO for post-LDLT refractory hypoxemia was also assessed. Patients (aged < 18 years) undergoing LT were retrospectively studied. HPS was diagnosed based on European Respiratory Society Taskforce 2004 criteria. HPS was graded based on oxygenation criteria and contrast-enhanced echocardiogram. Post-operative course was studied. Refractory post-operative hypoxemia was treated with iNO by institutionally developed protocol. 23/150 pediatric patients undergoing LDLT had HPS. BA was the most common underlying cause (52.2%). By oxygenation criteria, 6 (26.1%) had VS-HPS. VS-HPS was associated with longer LOS (p = .031) and prolonged oxygen requirement (p = .001) compared with other HPS patients. 4/6 patients with VS-HPS had pO2 < 45 mm Hg. Among these, 2 developed ICH post-operatively and 1 died. 3 developed refractory post-operative hypoxemia, successfully treated with iNO. Mean duration of iNO was 26.3 days. In the group of patients with HPS, the incidence of HAT and portal vein thrombosis was 17.3% and 4.3%, respectively. One year post-LDLT survival of patients with HPS was similar to non-HPS patients (86.9% vs 94.4%; p = .88). We concluded that, pediatric patients with VS-HPS, especially those with pre-operative pO2 < 45 mm Hg, have long and difficult post-LT course. Refractory postoperative hypoxemia can be successfully overcome with strategic use of iNO. Vigilant monitoring and good intensive care support are essential.

Pancreatic Diseases and Microbiota: A Literature Review and Future Perspectives

Gut microbiota represent an interesting worldwide research area. Several studies confirm that microbiota has a key role in human diseases, both intestinal (such as inflammatory bowel disease, celiac disease, intestinal infectious diseases, irritable bowel syndrome) and extra intestinal disorders (such as autism, multiple sclerosis, rheumatologic diseases). Nowadays, it is possible to manipulate microbiota by administering prebiotics, probiotics or synbiotics, through fecal microbiota transplantation in selected cases. In this scenario, pancreatic disorders might be influenced by gut microbiota and this relationship could be an innovative and inspiring field of research. However, data are still scarce and controversial. Microbiota manipulation could represent an important therapeutic strategy in the pancreatic diseases, in addition to standard therapies. In this review, we analyze current knowledge about correlation between gut microbiota and pancreatic diseases, by discussing on the one hand existing data and on the other hand future possible perspectives.