A low FODMAP diet plus traditional dietary advice versus a low-carbohydrate diet versus pharmacological treatment in irritable bowel syndrome (CARBIS): a single-centre, single-blind, randomised controlled trial

BACKGROUND

Dietary advice and medical treatments are recommended to patients with irritable bowel syndrome (IBS). Studies have not yet compared the efficacy of dietary treatment with pharmacological treatment targeting the predominant IBS symptom. We therefore aimed to compare the effects of two restrictive dietary treatment options versus optimised medical treatment in people with IBS.

METHODS

This single-centre, single-blind, randomised controlled trial was conducted in a specialised outpatient clinic at the Sahlgrenska University Hospital, Gothenburg, Sweden. Participants (aged ≥18 years) with moderate-to-severe IBS (Rome IV; IBS Severity Scoring System [IBS-SSS] ≥175) and no other serious diseases or food allergies were randomly assigned (1:1:1) by web-based randomisation to receive a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) plus traditional IBS dietary advice recommended by the UK National Institute for Health and Care Excellence (hereafter the LFTD diet), a fibre-optimised diet low in total carbohydrates and high in protein and fat (hereafter the low-carbohydrate diet), or optimised medical treatment based on predominant IBS symptom. Participants were masked to the names of the diets, but the pharmacological treatment was open-label. The intervention lasted 4 weeks, after which time participants in the dietary interventions were unmasked to their diets and encouraged to continue during 6 months' follow-up, participants in the LFTD group were instructed on how to reintroduce FODMAPs, and participants receiving pharmacological treatment were offered diet counselling and to continue with their medication. The primary endpoint was the proportion of participants who responded to the 4-week intervention, defined as a reduction of 50 or more in IBS-SSS relative to baseline, and was analysed per modified intention-to-treat (ie, all participants who started the intervention). Safety was analysed in the modified intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT02970591, and is complete.

FINDINGS

Between Jan 24, 2017, and Sept 2, 2021, 1104 participants were assessed for eligibility and 304 were randomly assigned. Ten participants did not receive their intervention after randomisation and thus 294 participants were included in the modified intention-to-treat population (96 assigned to the LFTD diet, 97 to the low-carbohydrate diet, and 101 to optimised medical treatment). 241 (82%) of 294 participants were women and 53 (18%) were men and the mean age was 38 (SD 13). After 4 weeks, 73 (76%) of 96 participants in the LFTD diet group, 69 (71%) of 97 participants in the low-carbohydrate diet group, and 59 (58%) of 101 participants in the optimised medical treatment group had a reduction of 50 or more in IBS-SSS compared with baseline, with a significant difference between the groups (p=0·023). 91 (95%) of 96 participants completed 4 weeks in the LFTD group, 92 (95%) of 97 completed 4 weeks in the low-carbohydrate group, and 91 (90%) of 101 completed 4 weeks in the optimised medical treatment group. Two individuals in each of the intervention groups stated that adverse events were the reason for discontinuing the 4-week intervention. Five (5%) of 91 participants in the optimised medical treatment group stopped treatment prematurely due to side-effects. No serious adverse events or treatment-related deaths occurred.

INTERPRETATION

Two 4-week dietary interventions and optimised medical treatment reduced the severity of IBS symptoms, with a larger effect size in the diet groups. Dietary interventions might be considered as an initial treatment for patients with IBS. Research is needed to enable personalised treatment strategies.

FUNDING

The Healthcare Board Region Västra Götaland, the Swedish Research Council, the Swedish Research Council for Health, Working Life and Welfare, AFA Insurance, grants from the Swedish state, the Wilhelm and Martina Lundgren Science Foundation, Skandia, the Dietary Science Foundation, and the Nanna Swartz Foundation.

Development of severe alcohol related liver disease over four decades in Iceland: impact of increased access and use of alcohol

OBJECTIVE

Limited data exist on the association between per capita alcohol consumption and incidence of alcohol related liver disease (ARLD). The aims were to analyse this relationship and assess prevalence of ARLD in Iceland and among patients treated for alcohol use disorder (AUD) and its impact on outcomes.

METHODS

A retrospective study on all patients diagnosed with severe ARLD: alcohol related cirrhosis (ARC) and alcohol related hepatitis (ARH) in Iceland 1984-2020. Medical records were scrutinized for clinical features, severity of ARLD, proportion undergoing treatment for AUD, data on abstinence and long-term outcomes.

RESULTS

A total of 314 patients, males 76%, median age 56 years, fulfilled the predetermined criteria for ARLD. Median MELD was 17, 73% with Child-Pugh B/C and 70/314 (22%) who had ARH. Incidence of ARLD increased from 0.77 cases per 100 000 inhabitants annually 1984-2000 to 6.1 per 100 000 in 2016-2020. Per capita alcohol consumption increased from 4.3 Liters to 7.5 L in in the same time periods. Overall 220/314 (70%) with ARLD had undergone treatment for AUD. Of all individuals who had AUD treatment during the study period (n = 21.845), 1% were diagnosed with ARLD. Patients who underwent treatment for AUD after the ARLD diagnosis had better prognosis than those who had treatment prior to ARLD diagnosis (hazard ratio 2.5 [95% CI 1.3-5.0]).

CONCLUSIONS

The incidence of ARLD increased 8-fold during the study period coinciding with 74% increase in per capita alcohol consumption. Patients with prior diagnosis of AUD had worse prognosis that needs special attention.

Face-to-face interviews versus Internet surveys: Comparison of two data collection methods in the Rome foundation global epidemiology study: Implications for population-based research

BACKGROUND AND AIMS

The Rome Foundation Global Epidemiology Study (RFGES) assessed the prevalence, burden, and associated factors of Disorders of Gut-Brain Interaction (DGBI) in 33 countries around the world. Achieving worldwide sampling necessitated use of two different surveying methods: In-person household interviews (9 countries) and Internet surveys (26 countries). Two countries, China and Turkey, were surveyed with both methods. This paper examines the differences in the survey results with the two methods, as well as likely reasons for those differences.

METHODS

The two RFGES survey methods are described in detail, and differences in DGBI findings summarized for household versus Internet surveys globally, and in more detail for China and Turkey. Logistic regression analysis was used to elucidate factors contributing to these differences.

RESULTS

Overall, DGBI were only half as prevalent when assessed with household vs Internet surveys. Similar patterns of methodology-related DGBI differences were seen within both China and Turkey, but prevalence differences between the survey methods were dramatically larger in Turkey. No clear reasons for outcome differences by survey method were identified, although greater relative reduction in bowel and anorectal versus upper gastrointestinal disorders when household versus Internet surveying was used suggests an inhibiting influence of social sensitivity.

CONCLUSIONS

The findings strongly indicate that besides affecting data quality, manpower needs and data collection time and costs, the choice of survey method is a substantial determinant of symptom reporting and DGBI prevalence outcomes. This has important implications for future DGBI research and epidemiological research more broadly.

A comparative study of disorders of gut-brain interaction in Western Europe and Asia based on the Rome foundation global epidemiology study

OBJECTIVE

Many studies have been published on disorders of the gut-brain interaction (DGBI) in Asia and Western Europe, but no previous study has directly assessed the difference between the two regions. The aim was to compare the prevalence of DGBI in Asia and Western Europe.

METHODS

We used data collected in a population-based Internet survey, the Rome Foundation Global Epidemiology Study, from countries in Western Europe (Belgium, France, Germany, Netherlands, Italy, Spain, Sweden, and the United Kingdom) and Asia (China, Japan, South Korea, and Singapore). We assessed DGBI diagnoses (Rome IV Adult Diagnostic Questionnaire), anxiety/depression (Patient Health Questionnaire-4, PHQ-4), non-GI somatic symptoms (PHQ-12), and access to and personal costs of doctor visits.

RESULTS

The study included 9487 subjects in Asia and 16,314 in Western Europe. Overall, 38.0% had at least one DGBI; younger age, female sex, and higher scores on PHQ4 and PHQ12 were all associated with DGBI. The prevalence of having at least one DGBI was higher in Western Europe than in Asia (39.1% vs 36.1%, OR 1.14 [95% CI 1.08-1.20]). This difference was also observed for DGBI by anatomical regions, most prominently esophageal DGBI (OR 1.67 [1.48-1.88]). After adjustment, the difference in DGBI prevalence diminished and psychological (PHQ-4) and non-GI somatic symptoms (PHQ-12) had the greatest effect on the odds ratio estimates.

CONCLUSION

The prevalence of DGBI is generally higher in Western Europe compared to Asia. A considerable portion of the observed difference in prevalence rates seems to be explained by more severe psychological and non-GI somatic symptoms in Western Europe.

Warfarin Is Associated With Higher Rates of Upper But Not Lower Gastrointestinal Bleeding Compared with Direct Oral Anticoagulants: A Population-Based Propensity-Weighted Cohort Study

BACKGROUND AND AIMS

While overall gastrointestinal bleeding (GIB) rates have been extensively compared between warfarin and direct oral anticoagulants (DOACs), it is still unclear whether upper and lower GIB rates differ between these types of drugs. This study aimed to compare upper and lower GIB rates between warfarin and DOACs in a nationwide cohort.

METHODS

Data on all patients in Iceland who received a prescription for oral anticoagulation from 2014 to 2019 were collected and their personal identification numbers linked to the electronic medical record system of the National University Hospital of Iceland and the 4 regional hospitals in Iceland. Inverse probability weighting was used to yield balanced study groups and rates of overall, major, upper, and lower GIB were compared using Cox regression. All GIB events were manually confirmed by chart review.

RESULTS

Warfarin was associated with higher rates of upper GIB (1.7 events per 100 person-years vs 0.8 events per 100 person-years; hazard ratio [HR], 2.12; 95% confidence interval [CI], 1.26-3.59) but similar rates of lower GIB compared with DOACs. Specifically, warfarin was associated with higher rates of upper GIB compared with apixaban (HR, 2.63; 95% CI, 1.35-5.13), dabigatran (5.47; 95% CI, 1.87-16.05), and rivaroxaban (HR, 1.74; 95% CI, 1.00-3.05). Warfarin was associated with higher rates of major GIB compared with apixaban (2.3 events per 100 person-years vs 1.5 events per 100 person-years; HR, 1.79; 95% CI, 1.06-3.05), but otherwise overall and major GIB rates were similar in warfarin and DOAC users.

CONCLUSIONS

Warfarin was associated with higher rates of upper but not overall or lower GIB compared with DOACs. Warfarin was associated with higher rates of major GIB compared with apixaban.

Randomised clinical trial and meta-analysis: mesalazine treatment in irritable bowel syndrome-effects on gastrointestinal symptoms and rectal biomarkers of immune activity

BACKGROUND

Low-grade immune activation in the gut is a potential treatment target in irritable bowel syndrome (IBS).

AIMS

To determine improvement in IBS symptoms after mesalazine treatment, and the utility of measures of immune activity in the rectal mucosa METHODS: This was a randomised, double-blind, placebo-controlled, parallel-arm, multicentre trial in subjects with IBS (Rome III criteria), with an eight-week treatment period of mesalazine 2400 mg or plcebo once-daily. The primary endpoint was the global assessment of satisfactory relief of IBS symptoms in ≥50% of weeks during intervention. IBS symptoms were also measured with the IBS severity scoring system; immune activity was measured by mucosal patch technology. A post hoc meta-analysis of randomised placebo-controlled trials of mesalazine in IBS was added.

RESULTS

Of 181 included patients, 91 received mesalazine and 90 received placebo. The primary endpoint was met by 32 (36%) patients after mesalazine and 27 (30%) after placebo (p = 0.40). There were no differences in response rates related to IBS subtype or post-infection symptom onset. More reduction of abdominal bloating was noted in the mesalazine group (p = 0.02). The meta-analysis showed no effect of mesalazine on IBS symptoms. No mucosal patch technology measure could predict response to mesalazine, and found no differences in the effects of intervention on levels of immune markers.

CONCLUSIONS

Mesalazine is ineffective in reducing IBS symptoms. Rectal measures of immune activity by the mucosal patch technology cannot predict a higher chance of response to mesalazine.

Warfarin is associated with higher rates of epistaxis compared to direct oral anticoagulants: A nationwide propensity score-weighted study

BACKGROUND

Although epistaxis is one of the most common side effects of oral anticoagulation, it is unclear whether epistaxis rates vary between different oral anticoagulants (OAC).

OBJECTIVE

To compare rates of clinically relevant epistaxis between OAC.

METHODS

Epistaxis event rates were compared between new users of apixaban, dabigatran, rivaroxaban, and warfarin in a nationwide population-based cohort study over a 5-year study period, 2014-2019. Data was collected from the Icelandic Medicine Registry and the five major hospitals in Iceland. Inverse probability weighting (IPW) was used to yield balanced baseline characteristics, and epistaxis rates were compared using Kaplan-Meier survival estimates and Cox regression.

RESULTS

During the study period, 2098 patients received apixaban, 474 dabigatran, 3106 rivaroxaban, and 1403 warfarin. In total, 93 patients presented with clinically relevant epistaxis, including 11 (12%) major epistaxis events and one fatal epistaxis episode. Furthermore, seven patients (9%) with non-major epistaxis later presented with major bleeding during the follow-up period. Warfarin use was associated with higher rates of epistaxis compared to apixaban (2.2 events per 100-person years (events/100-py) vs. 0.6 events/100-py, hazard ratio [HR] 4.22, 95% confidence interval [CI] 2.08-8.59, p < 0.001), rivaroxaban (2.2 events/100-py vs. 1.0 events/100-py, HR 2.26, 95% CI 1.28-4.01, p = 0.005), and dabigatran (2.2 events/100-py vs. no events, HR n/a, p < 0.001).

CONCLUSION

Warfarin treatment was associated with higher rates of clinically relevant epistaxis compared to direct oral anticoagulants.

Acute gastrointestinal bleeding among patients on antiplatelet and anticoagulant therapy after percutaneous coronary intervention

BACKGROUND

Patients undergoing percutaneous coronary intervention (PCI) require dual antiplatelet therapy and some require additional anticoagulation. We aimed to investigate the incidence of acute gastrointestinal bleeding (AGIB) among PCI patients receiving antiplatelet and anticoagulant therapy.

METHODS

A population-based study that included all patients undergoing PCI during 2008-2016 in Iceland. Data from the Icelandic Medicines Registry were obtained on all outpatient prescriptions 1 year after first PCI. Patients receiving single or dual-antiplatelet therapy with or without anticoagulation cotherapy were analyzed. Rehospitalization for AGIB and endoscopic data were obtained within the 12-month follow-up period.

RESULTS

A total of 5166 patients (male 75%) underwent PCI during the study period. The incidence of AGIB was 1% (54/5166) per year. The mean age among non-bleeders 65 (±11) years was lower than among bleeders 69 (±9) years (p = .002). The proportion of acute upper GIB (AUGIB) was 56%, whereas lower GIB occurred in 44%. Overall, 41% with AUGIB had PPIs compared to 39% of non-bleeders (NS). The incidence of AGIB among patients on single antiplatelet therapy combined with an anticoagulant was 2.5% compared to 0.9% among those on single antiplatelet treatment alone (p = .028). The number needed to harm (NNH) for treatment with single antiplatelet therapy and anticoagulant therapy compared to single antiplatelet therapy was 62 but no deaths related to AGIB.

CONCLUSIONS

The 1-year incidence of AGIB was low with no mortality. Bleeding risk was found to be higher among patients on single antiplatelet therapy combined with anticoagulant therapy compared to patients on single antiplatelet therapy alone.

Acute upper gastrointestinal bleeding: a population-based, five-year follow-up study

OBJECTIVE

Data on long-term rebleeding risk and mortality in acute upper gastrointestinal bleeding (AUGIB) patients are scarce and comparison to controls are lacking. Aimsof the study were to assess long-term prognosis of AUGIB patients and compare to controls.

METHODS

A population-based retrospective case-control study conducted at the National University Hospital of Iceland and included all patients who underwent endoscopy in 2010-2011. AUGIB was defined as haematemesis or coffee ground vomiting leading to hospitalization or occurring in a hospitalized patient. Controls underwent endoscopy in 2010-2011, matched for sex/age. Rebleeding was defined as AUGIB >14 days up to five years after index bleeding.

RESULTS

Overall, 303 patients had AUGIB, mean age 67 (±18), controls66 years (±19), females, 51 and 46%, respectively. The five-year rebleeding rate for AUGIB patients was 13% (95%CI 9-17%), higher than the rate of bleeding events in controls, 3% (95%CI 1-5%; log-rank <0.001), hazard ratio (HR) 6.0 (95%CI 2.4-15) when correcting for comorbidities, NSAID's, PPI's and antithrombotics. The mortality of AUGIB patients at end of follow-up was higher when compared to controls, 39% (95%CI 49-33%) vs. 26% (95%CI 30-21%), log-rank <0.001, comorbidity-adjusted HR 1.4 (1.1-1.9). A subanalysis of non-variceal AUGIB yielded similar results in regard to rebleeding and mortality rates.

CONCLUSIONS

AUGIB patients were at 6-fold risk of rebleeding compared to bleeding events in controls at five years of follow-up. Five-year mortality was higher in AUGIB patients when compared to controls even when correcting for age and comorbidities, suggesting that an episode of AUGIB indicates serious frailty.

Acute lower gastrointestinal bleeding: A population-based five-year follow-up study

Background

Data on the natural history of acute lower gastrointestinal bleeding (ALGIB) are lacking. We evaluated five-year bleeding risk and mortality in ALGIB patients and controls. Furthermore, we aimed to find predictors of rebleeding.

Methods

This was a population-based retrospective case-control study conducted at the National University Hospital of Iceland, and included every individual who underwent endoscopy in 2010-2011. ALGIB was defined as rectal bleeding leading to hospitalisation or occurring in a hospitalised patient. Controls were randomly selected from those who underwent endoscopy in the same time period but who did not have GIB, and were matched for sex and age. Patients were followed up five years after index bleeding. Rebleeding was defined as ALGIB >14 days after index bleeding.

Results

In total, 2294 patients underwent 2602 colonoscopies in 2010-2011. Of those, 319 (14%) had ALGIB. The mean age for cases and controls was 64 and 65 years (±19.3-20.7), respectively, and females accounted for 51-52% of the study population. For ALGIB patients, the five-year risk of a bleeding was 20% (95% confidence interval (CI) 15-24%) compared to 3% (95% CI 1-5%) in controls (log rank < 0.0001; co-morbidity-adjusted hazard ratio (HR) 6.9 (95% CI 3.4-14)). Only 37% of bleeders had the same cause of index bleeding and rebleeding. In ALGIB patients, age and inflammatory bowel disease (IBD) were predictors of rebleeding, with odds ratios per 10 years of 1.3 (95% CI 1.1-1.6) and 4.3 (95% CI 1.5-12), respectively. Bleeders did not have a higher risk of five-year mortality compared to controls (HR = 1.2; 95% CI 0.87-1.6).

Conclusions

One fifth of ALGIB patients had rebleeding during follow-up. Age and IBD were independent predictors of rebleeding. ALGIB was not associated with lower five-year survival.

Incidence of diverticular bleeding: a population-based study

OBJECTIVE

To determine the incidence of diverticular bleeding (DB) and examine the time trend of the incidence. Furthermore to study prognosis with regard to therapy and rebleeding.

METHODS

A retrospective, population-based study of patients with DB in a National University Hospital from 2006 to 2016. Patients were identified in an electronically stored colonoscopy database. Definite diverticular bleeding was defined as active bleeding, a nonbleeding visible vessel or adherent clot. Presumptive diverticular bleeding was defined as acute painless rectal bleeding leading to hospitalization with visible diverticula but no evidence of bleeding and no other colonic lesions or bleeding sites identified on endoscopy. A 30-day re-bleeding was determined after discharge.

RESULTS

A total of 3683 colonoscopy reports were reviewed, including 345 patients (males 51%) with presumptive 95% (n = 327) or definitive 5% (n = 18) diverticular bleeding. Overall 96% were treated conservatively, 3% endoscopically and 0.3% surgically. Only 5.8% of patients had a 30-day rebleed. After exclusion, 315 patients were included in the incidence calculations. The mean cumulative incidence of diverticular bleeding was 14/100,000 inhabitants per year. A time trend analysis of the incidence of DB revealed no significant change in incidence during the study period.

CONCLUSIONS

The mean incidence of colonic diverticular bleeding was found to be approximately 14 cases per 100,000 inhabitants and year. The incidence does not seem to have changed in the past decade. The vast majority of patients with diverticular bleeding did not require endoscopic therapy and could be managed with conservative treatment.

The SHA2PE score: a new score for lower gastrointestinal bleeding that predicts low-risk of hospital-based intervention

OBJECTIVES

Lower gastrointestinal bleeding (LGIB) risk scores have mainly focused on identifying high-risk patients. A risk score aimed at predicting which patients will not require hospital-based intervention may reduce unnecessary hospital admissions. The aim of the current study was to develop such a risk score.

MATERIAL AND METHODS

A retrospective, population-based study that included patients presenting to the emergency room (ER) with LGIB from 2010 to 2013. Hospital-based intervention was defined as blood transfusion, endoscopic hemostasis, arterial embolization or surgery. The study cohort was split into train (70%) and test (30%) data. Train data were used to produce a multiple logistic regression model and a risk score that was validated on the test data.

RESULTS

Overall, 581 patients presented 625 times to the ER, mean age 61 (±22), males 49%. Of train data patients, 72% did not require hospital-based intervention. Independent predictors of low-risk patients (did not require hospital-based intervention) were systolic pressure ≥100mmHg (Odds ratio [OR] 4.9), hemoglobin >12g/dL (OR 103), hemoglobin 10.5-12.0g/dL (OR 19), no antiplatelets (OR 3.7), no anticoagulants (OR 2.2), pulse ≤100 (OR 2.9), and visible bleeding in the ER (OR 3.8). When validating the score on the test data, only 2% were wrongly predicted to be low-risk, the negative predictive value was 96% and the area under curve was 0.83.

CONCLUSIONS

A new risk score has been developed for LGIB that may help identify low-risk patients in the ER that can be managed in an outpatient setting, thereby lowering unnecessary hospital admissions.

The incidence and outcome of ischemic colitis in a population-based setting

OBJECTIVE

Population-based studies on patients with ischemic colitis (IC) are limited. We aimed to determine the incidence, risk factors and outcome of patients with IC.

METHODS

A retrospective nationwide study was conducted on adult patients with histologically confirmed IC in 2009-2013 in Iceland. IC patients were matched for age and gender with patients hospitalized with lower gastrointestinal bleeding. Data were collected on clinical presentation, comorbidities, smoking habits, management and outcome.

RESULTS

Eighty-nine patients, 61 (69%) females and mean age of 65 years (±17), fulfilled the predetermined criteria. Females were older than males, 68 years (±14) vs. 59 years (±20) (p = .0170). The mean cumulative incidence was 7.3 cases per 100,000 inhabitants. A total of 57 (64%) patients presented with abdominal pain, hematochezia and diarrhea. IC was localized in the left colon in 78 (88%) patients. Overall, 62 (70%) patients had cardiovascular disease vs. 53 (60%) of control group (NS) and 55 (62%) had a history of smoking vs. 53 (60%) in control group (NS). Ten (11%) patients required surgery and/or died within 30-days from hospital admission. At the end of follow-up, 7 (9%) patients had experienced recurrence of IC with an estimated 3-year recurrence rate of 15%.

CONCLUSIONS

IC is a common clinical phenomenon that affects a wide range of age groups, but is most prominent among elderly women. It typically presents with a clinical triad of abdominal pain, hematochezia and diarrhea. Most cases are mild and self-limiting with a good prognosis.

Helicobacter pylori infection in Icelandic children

OBJECTIVE

The prevalence of Helicobacter pylori (HP) infection is decreasing in the western world. The seroprevalence among 25-50-year-old Icelandic adults was recently shown to be 30-40%. Information on the seroprevalence in Nordic children is limited. We aimed at ascertaining the infection prevalence among healthy Icelandic children.

METHODS

The infection status in stored frozen blood samples from two cross-sectional studies on the health of 7-9-year-old children (n = 125) and 16-18-year-old adolescents (n = 80) was determined by enzyme-linked immunosorbent assay (ELISA). Information on family demographics and GI symptoms was obtained by standardized questionnaires.

RESULTS

Overall, 3.4% (7/205) of the children were infected with H. pylori. The prevalence was 2.6% (5/190), missing data n = 3, among children with both parents born in a low prevalence country compared to 17% (2/12) among those with at least one parent born in a high prevalence area (p = .026). When at least one parent was born in a high prevalence country, the odds ratio for being H. pylori seropositive was 2.2 (95% CI, 1.02-54.67), when adjusted for the educational status of the mother. There was no significant association between H. pylori infection and gastrointestinal symptoms.

CONCLUSION

Prevalence of H. pylori infection in Iceland has become very low, suggesting a great reduction in transmission from older generations. There was an association between H. pylori infection and origin from high prevalence areas but not with gastrointestinal symptoms. The results mirror recent studies of children of Scandinavian ancestry.

The Association of Drugs With Severity and Specific Causes of Acute Lower Gastrointestinal Bleeding: A Prospective Study

OBJECTIVES

Studies on the association of acute lower gastrointestinal bleeding (ALGIB) and drugs are scarce. We aimed to investigate the association of drugs and ALGIB, especially regarding specific causes of ALGIB, and their role in the severity of ALGIB.

MATERIALS AND METHODS

The study was prospective and included all patients undergoing colonoscopy in 2010 and 2013 at the National University Hospital of Iceland. Use of nonsteroidal anti-inflammatory drugs (NSAIDs), low-dose aspirin (LDA), and warfarin before ALGIB was registered. Clinically significant bleeding was defined as: hemoglobin <100 g/L, hemodynamic instability, blood transfusion, surgery, or death.

RESULTS

Overall, 2392 patients underwent 2751 colonoscopies, of those, 325 (14%) had ALGIB, mean age 64 years (±20). The commonest diagnoses were diverticulosis (22%) and ischemic colitis (14%). In multivariate analysis, NSAIDs, LDA, and warfarin use was associated with ALGIB, odds ratio (OR) 3.3 [95% confidence interval (95% CI), 1.99-5.82], OR 1.5 (95% CI, 1.01-2.13), and OR 2.7 (95% CI, 1.61-4.57), respectively. Clinically significant bleeders were more likely than nonclinically significant bleeders to use NSAIDs or LDA+warfarin, OR 2.3 (95% CI, 1.26-3.76) and OR 33.0 (95% CI, 6.74-595), respectively. Patients with diverticular bleeding had greater odds than controls of NSAID, LDA, and warfarin use, OR 8.3 (95% CI, 3.8-18.3), OR 2.1 (95% CI, 1.15-3.67), and OR 2.6 (95% CI, 1.24-5.56), respectively. Patients with ischemic colitis were more likely than controls to use LDA, OR 2.3 (95% CI, 1.14-4.45).

CONCLUSIONS

NSAIDs, LDA, and warfarin were associated with ALGIB and diverticular bleeding. These drugs may have a role in other etiologies of ALGIB and seem to increase the risk of clinically significant bleeding.

The outcome and role of drugs in patients with unexplained gastrointestinal bleeding

OBJECTIVE

Studies on unexplained gastrointestinal bleeding (GIB) are lacking. We aimed to study the clinical outcomes of patients with unexplained GIB and to determine the incidence of obscure GIB.

MATERIAL AND METHODS

A population-based study on all patients undergoing endoscopy at the National University Hospital of Iceland in 2010. Indications, results of endoscopies and drug history were prospectively registered with a follow-up of 3 years. A national pharmaceutical database containing prescription data was utilized. Patients were categorized into unexplained overt and occult GIB and obscure GIB. Patients undergoing endoscopy and without GIB acted as controls.

RESULTS

Of 2471 patients undergoing endoscopy, 11% had unexplained GIB. Of those, 46% had unexplained overt GIB, 44% had unexplained occult GIB and 11% had obscure GIB. Multivariate analysis showed that patients with unexplained GIB and unexplained overt GIB had greater odds of NSAID use than controls, OR 1.8 (CI 1.03-3.03) and OR 2.0 (CI 1.01-3.77), respectively. Warfarin was strongly associated with all bleeder groups, OR 4-4.8. The incidence of obscure GIB was 10/100,000 inhabitants annually. Two (0.8%) patients were diagnosed with colon cancer 16 and 30 months after the index colonoscopy. Of patients with unexplained overt, unexplained occult GIB and controls, 5%, 6% and 3.5% (NS) had another overt bleeding episode, during the study period.

CONCLUSIONS

NSAIDs and warfarin seem to play an important role in unexplained GIB. The incidence of obscure GIB is low and missed cancers are very rare. The probability of a repeat bleeding episode is similar to that of controls.

The risk of colorectal cancer after an attack of uncomplicated diverticulitis

OBJECTIVE

According to clinical guidelines, a colonoscopy is recommended after an attack of diverticulitis in order to exclude colorectal cancer (CRC). This is based on studies prior to the use of computerized tomography (CT) for confirmation of the diagnosis. We aimed to investigate the findings of a subsequent colonoscopy after an attack of uncomplicated diverticulitis.

MATERIAL AND METHODS

The study cohort consisted of all patients with the diagnosis of uncomplicated diverticulitis, who underwent a subsequent colonoscopy 6-8 weeks later during a 6-years period in the National University Hospital of Iceland. The diagnosis of diverticulitis was based on clinical symptoms verified with a CT of the abdomen. Relevant clinical information was obtained from medical records and from the Icelandic Cancer Registry.

RESULTS

A total of 282 patients had uncomplicated diverticulitis and 199 patients underwent endoscopy. Two patients had CRC (0.7%), diagnosed with diverticulitis but did not recover clinically. All other patients recovered clinically. Colonic polyps were found in 33 of 195 (17%) cases. In 19/33 (58%) cases the histology demonstrated hyperplastic polyps, and in 13/33 (39%) adenoma with mild dysplasia. Only 1/33 (3%) of the colonic polyps were >1 cm in size.

CONCLUSIONS

Among patients experiencing an attack of uncomplicated diverticulitis the frequency of CRC was equal to what might be expected compared to the average risk in the population. In these patients a routine colonoscopy in the absence of other clinical signs of CRC seems hardly necessary, if the clinical course is uneventful and the patient recovers.

Bleeding-related symptoms in colorectal cancer: a 4-year nationwide population-based study

BACKGROUND

Little is known about the major presenting features of patients with colorectal cancer (CRC) in a population-based setting, especially regarding bleeding-related symptoms.

AIM

To determine the proportion of CRC patients presenting with bleeding-related symptoms, to compare bleeders and nonbleeders and to explore the role of anticoagulants in bleeders.

METHODS

This was a nationwide, population-based, retrospective study, investigating all patients diagnosed with CRC in Iceland from 2008 to 2011. Bleeding-related symptoms were defined as overt bleeding, iron deficiency anaemia or a positive faecal occult blood test. Obstructive symptoms were defined as a confirmed diagnosis of ileus or dilated intestines on imaging.

RESULTS

Data were available for 472/496 (95%) patients, males 51%, mean age 69 (±13) years. In all, 348 (74%) patients had bleeding-related symptoms; of these 348 patients, 61% had overt bleeding. Bleeders were less likely than nonbleeders to have metastases at diagnosis, 19% vs. 34% (P < 0.001). Overt bleeders were less likely than nonbleeders to have obstructive symptoms, 2% vs. 16% respectively (P < 0.0001). Occult bleeders were more likely to have proximal cancer (69%) than both overt (17%) and nonbleeders (44%) (P < 0.0001); however, they were less likely than nonbleeders to have metastases (22% vs. 35%, P < 0.05). Bleeders were more likely to use warfarin than nonbleeders (9% vs. 3%, P < 0.05); the use of low-dose aspirin was the same (24%).

CONCLUSIONS

The majority of patients with CRC present with bleeding-related symptoms. Bleeders with CRC present earlier than nonbleeders. Warfarin use may induce bleeding in some patients, resulting in an earlier diagnosis.