Immune Checkpoint Inhibitor Colitis, a Rising Issue in Targeted Cancer Therapy Era: A Literature Review

Research advances in the oncology treatment field have led to the widespread use of immunotherapy. The usage of immune checkpoint inhibitor (ICI) has improved the survival of cancer patients with metastases. This has also led to the rapidly expanding indications for ICI use. However, ICI usage may lead to toxicity, which may be immune-related, in different organ-specific targets. The immune-related adverse events (irAEs) of ICI may lead to increased morbidity, decreased quality of life, and early termination of ICI. The clinical manifestations of irAEs in the gastrointestinal system are variable, ranging from self-limited to life-threatening or fatal events. In this review article, we would like to focus on discussing ICI-induced colitis, which is one of the most common ICI irAEs in the gastrointestinal tract.

Needs assessment of basic gastrointestinal endoscopy training: A qualitative study in Indonesia

Background and Aim

Gastointestinal endoscopy is a complex practical skill, and training and experience are required to ensure the accuracy and safety of the procedures. Therefore, proper endoscopy training is needed to provide highly skilled endoscopists. This study explores the learning experience and assesses the need for endoscopy training in Indonesia from an endoscopy trainee's point of view. Limitations from the current training model and the trainees' suggestions hopefully will become a foundation for the future endoscopy training model in Indonesia.

Methods

A total of 132 current endoscopy trainees and graduates of endoscopy training from various centers in Indonesia completed an online qualitative survey regarding their endoscopy training experience, their satisfaction with the current training method, barriers to achieving competency, and their suggestions for future training. Data were subjected to descriptive and qualitative analysis using content analysis.

Results

We found variations in the trainee's learning experience regarding the training supervision, feedback, and assessment methods. The most common endoscopy training methods were observation and direct practice with supervision. There was only a low proportion of simulator use (25%). The most found concept in barriers to achieving competency was "insufficient number of patients." Meanwhile, the most found concept in suggestions for future training methods was "increasing the variety of cases and procedures."

Conclusion

Our findings suggest that there are still variations in endoscopy training methods in Indonesia. Therefore, we propose to design a standardized endoscopy training program to ensure the competence of endoscopy trainees and better care for endoscopic patients. Simulators might be used to increase the trainees' competence in settings with low numbers of patients or cases.

Diagnostic accuracy of gastroesophageal reflux disease questionnaire for gastroesophageal reflux disease: A systematic review and meta-analysis

BACKGROUND

The use of a symptom-based gastroesophageal reflux disease (GERD) questionnaire (GerdQ) for GERD diagnosis has gained interest due to its greater efficacy and ease of use than other available questionnaires. However, different guidelines have given inconsistent recommendations regarding using GerdQ as a diagnostic test. This meta-analysis summarized the diagnostic accuracy of GerdQ for diagnosing GERD.

METHODS

Studies published up to April 12, 2023, and indexed in MEDLINE, EMBASE, SCOPUS, Web of Science, and the Cochrane Library were searched. Diagnostic test accuracy studies comparing GerdQ with upper endoscopy and/or pH-metry for GERD diagnosis in adult patients with symptoms suggestive of GERD were included. The study quality was assessed using the QUADAS-2 tool. Meta-analysis using bivariate (Reitsma) analysis was done to summarize the overall sensitivity, specificity, likelihood ratios (LRs), and diagnostic odds ratio (DOR). The summary receiver operating characteristics (SROC) curve was visualized, and the area under the ROC (AUC) was calculated.

KEY RESULTS

A total of 13 studies with 11,166 participants were included in the meta-analysis. The pooled sensitivity, specificity, positive LR, negative LR, and DOR for GerdQ (cut-off value of ≥8) were 66.9% (95% CI 56.4%-73.1%), 65.2% (95% CI 56.4%-73.1%), 1.93 (95% CI 1.55-2.42), 0.51 (95% CI 0.38-0.66), and 3.89 (95% CI 2.44-5.89), respectively. The overall AUC from the SROC was 0.705. The subgroup analysis showed similar pooled sensitivity, specificity, and DOR between Asian and non-Asian studies.

CONCLUSIONS & INFERENCES

GerdQ had moderate sensitivity and specificity for GERD diagnosis. GerdQ can still be recommended as a diagnostic tool for GERD, especially when the PPI test is unavailable or contraindicated.

The Impact of Artificial Intelligence in Improving Polyp and Adenoma Detection Rate During Colonoscopy: Systematic-Review and Meta-Analysis

INTRODUCTION

Colonoscopy may detect colorectal polyp and facilitate its removal in order to prevent colorectal cancer. However, substantial miss rate for colorectal adenomas detection still occurred during screening colonoscopy procedure. Nowadays, artificial intelligence (AI) have been employed in trials to improve polyp detection rate (PDR) and adenoma detection rate (ADR). Therefore, we would like to determine the impact of AI in increasing PDR and ADR.

METHODS

The present study adhered to the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 (PRISMA 2020) statement. To identify relevant literature, comprehensive searches were conducted on major scientific databases, including Pubmed, EBSCO-host, and Proquest. The search was limited to articles published up to November 30, 2022. Inclusion criteria for the study encompassed full-text accessibility, articles written in the English language, and randomized controlled trials (RCTs) that reported both ADR and PDR values, comparing conventional diagnostic methods with AI-aided approaches. To synthesize the data, we computed the combined pooled odds ratio (OR) using a random-effects model. This model was chosen due to the expectation of considerable heterogeneity among the selected studies. To evaluate potential publication bias, the Begg's funnel diagram was employed.

RESULTS

A total of 13 studies were included in this study. Colonoscopy with AI had significantly higher PDR compared to without AI (pooled OR 1.46, 95% CI 1.13-1.89, p = 0.003) and higher ADR (pooled OR 1.58, 95% CI 1.37-1.82, p < 0.00001). PDR analysis showed moderate heterogeneity between included studies (p = 0.004; I2=63%). Furthermore, ADR analysis showed moderate heterogeneity (p < 0.007; I2 = 57%). Additionally, the funnels plot of ADR and PDR analysis showed an asymmetry plot and low publication bias.

CONCLUSION

AI may improve colonoscopy result quality through improving PDR and ADR.

Left lateral decubitus sleeping position is associated with improved gastroesophageal reflux disease symptoms: A systematic review and meta-analysis

BACKGROUND

A limited number of studies have demonstrated that sleeping in the left lateral decubitus (LLD) decreases nocturnal reflux in patients with gastroesophageal reflux disease (GERD) compared to right lateral decubitus (RLD) and supine.

AIM

This systematic review summarizes the association between sleeping in the LLD position and nocturnal reflux in patients with GERD.

METHODS

Studies published up to July 17, 2023, in MEDLINE, EMBASE, and CENTRAL were searched. Eligible studies were randomized and nonrandomized studies assessing the effect of sleeping in LLD compared to RLD and supine in reducing nocturnal reflux in GERD patients. Outcomes include the acid exposure time (AET) (% time in pH<4), acid clearance time (ACT) (in sec/episode), number of reflux episodes, and improvement in N-GSSIQ scores.

RESULTS

Two nonrandomized studies showed decreased AET and ACT in LLD sleep position in comparison to RLD (mean difference [MD] -2.03 [95%CI: -3.62 to -0.45]; -81.84 [95%CI: -127.48 to -36.20], respectively) and supine position (MD -2.71 [95%CI: -4.34 to -1.09]; -74.47 [95%CI: -116.26 to -32.69], respectively). There was no difference in AET and ACT between RLD sleep position and supine. Furthermore, one randomized controlled trial investigating the use of electronic sleep positional therapy, which increased the duration of LLD sleep and decreased the duration of RLD sleep compared to sham, showed nocturnal symptoms improvement (improved N-GSSIQ score, increased reflux-free nights, and resolution of nocturnal reflux symptoms).

CONCLUSION

Current evidence suggests that sleeping on the left side could reduce nocturnal reflux and improve GERD-related quality of life, therefore warranting interventions that promote LLD sleep position.

Assessment of Circulating Tumor Cells in Colorectal Cancer as an Adjunctive Non-invasive Diagnostic Method

BACKGROUND

Colorectal cancer (CRC) is a significant contributor to cancer-related morbidity and mortality. Biopsy remains the gold standard for CRC diagnosis, but invasive testing may not be preferred as an initial diagnostic procedure. Therefore, alternative non-invasive approaches are needed. Circulating tumor cells (CTC) present in the bloodstream have great potential as a non-invasive diagnostic marker for CRC patients. This study aimed to assess the diagnostic potential of CTC in CRC as an adjunctive diagnostic method using a subjective manual identification method and laser capture microdissection at 40x magnification.

METHODS

A cross-sectional study was conducted on adult patients suspected to have CRC at Dr. Cipto Mangunkusumo National General Hospital, Jakarta, between November 2020 and March 2021. CTC analysis was performed using the negative selection immunomagnetic method with Easysep™ and the CD44 mesenchymal tumor marker. The identification and quantification of CTC were conducted manually and subjectively, with three repetitions of cell counting per field of view at 40x magnification.

RESULTS

Of 80 subjects, 77.5% were diagnosed with CRC, while 7.5% and 15% exhibited adenomatous polyps and inflammatory/hyperplastic polyps, respectively. The diagnostic analysis of CTC for detecting CRC (compared to polyps) using a CTC cutoff point of >1.5 cells/mL suggested sensitivity, specificity, and positive predictive value (PPV) of 50%, 88.89%, and 93.94%. Additionally, the negative predictive value (NPV), as well as the positive and negative likelihood ratio (PLR and NLR) were 34.04%, 4.5, and 0.56, respectively. The subjective manual identification and quantification of CTC were performed at 40x magnification using laser capture microdissection.

CONCLUSION

This study assessed the diagnostic potential of CTC examination in CRC as an adjunctive diagnostic method using the subjective manual identification method and laser capture microdissection at 40x magnification. Despite the limitations associated with subjective cell counting, the results showed 50% sensitivity and 88.89% specificity in diagnosing CRC. Further studies are needed to optimize the manual identification process and validate the clinical utility of CTC analysis in CRC patients.

The Gut Microbiota Profile in Heart Failure Patients: A Systematic Review

BACKGROUND AND AIMS

Traditional cardiovascular risk factors are established predictors of heart failure (HF). However, the human gut microbiota is suggested to potentially interact with the cardiovascular system through the "gut-heart axis", which induces inflammation and contributes to HF pathogenesis. This systematic review aims to confirm the interconnection between the gut microbiome in HF patients.

METHODS

Peer-reviewed human studies comparing the gut microbiota profile in adult patients with HF and healthy controls (HCs) up to April 18, 2022, were searched in Ovid MEDLINE, Ovid EMBASE, SCOPUS, and the Cochrane Library. The quality of the included studies was assessed using the Newcastle-Ottawa Scale (NOS).

RESULTS

A total of nine studies, including 317 HF patients and 510 HCs, were included in the review. Decreased gut microbiota richness and similar microbial diversity (alpha diversity), and significantly different gut microbiota composition (beta diversity) were observed between HF patients and HCs. In comparison to HCs, HF patients had a greater abundance of Actinobacteria, Proteobacteria, and Synergistetes phyla; Enterococcus, Escherichia, Klebsiella, Lactobacillus, Streptococcus, and Veilonella genera and Ruminococcus gnavus, Streptococcus sp., and Veilonella sp. species. In contrast, there was decreased abundance of Firmicutes phylum; Blautia, Eubacterium, Faecalibacterium, and Lachnospiraceae FCS020 genera; and Dorea longicatena, Eubacterium rectale, Faecalibacterium prausnitzii, Oscillibacter sp., and Sutterella wadsworthensis species in HF patients.

CONCLUSIONS

Gut microbiota diversity, richness, and composition in HF patients differ significantly from the healthy population. Overall, short-chain fatty acid (SCFA)-producing gut microbiota was depleted in HF patients. However, different underlying comorbidities, environments, lifestyles, and dietary choices could affect gut microbiota heterogeneity.

A systematic review of gut microbiota profile in COVID-19 and among those who have recovered from COVID-19 patients

BACKGROUND AND AIMS

Given the scale and persistence of COVID-19, significant attention has been given to understanding the relationship between human gut microbiota and COVID-19. This systematic review aims to comprehensively assess the gut microbiota composition in COVID-19 and recovered COVID-19 patients in comparison to healthy controls (HCs).

METHODS

Peer-reviewed articles and preprints published up to September 1, 2022, were searched in Ovid MEDLINE, Ovid EMBASE, and SCOPUS. Observational studies reporting the gut microbiota profile in adult (≥18 years old) COVID-19 patients or recovered COVID-19 patients compared to HCs were eligible for inclusion in this systematic review. The quality assessment of studies was performed using the Newcastle-Ottawa Scale.

RESULT

We identified 27 studies comprising 18 that compared COVID-19 patients and six studies that compared recovered COVID-19 patients to HCs, while three studies compared both COVID-19 and recovered COVID-19 patients to HCs. Compared to HCs, decreased gut microbial diversity and richness and a distinctive microbial composition were reported in COVID-19 patients and recovered COVID-19 patients. In COVID-19 patients, Bacteroidetes were found to be enriched, and Firmicutes depleted. Decreased SCFA-producing bacteria such as Faecalibacterium, Ruminococcus, and Bifidobacterium, among others, were also observed in COVID-19 patients, which were not restored to normal levels in those who recovered.

CONCLUSION

Gut dysbiosis was evident in COVID-19, and available data suggested that dysbiosis persisted even in recovered COVID-19 patients, with decreased Firmicutes and SCFA-producing bacteria.

Management of dyspepsia and Helicobacter pylori infection: the 2022 Indonesian Consensus Report

Dyspepsia still becomes a major challenge in upper gastrointestinal disease in Indonesia. This disease often correlated with Helicobacter pylori infection. However, the prevalence of this bacterium is generally low in Indonesia. Therefore, several considerations should be taken into consideration during the management of dyspepsia and H. pylori infection. "Management of dyspepsia and H. pylori infection in Indonesia: The Indonesian consensus report" comprises information gathered from 22 gastroenterology centers across Indonesia. The experts gathered to evolve a consensus, that consists of the statements, grades of recommendations, evidence levels, and rationales for the dyspepsia and H. pylori infection management for daily clinical practice. The report explains several aspects from the updated epidemiology information to comprehensive management therapy. After the experts worked together on all statements in the recommendations, the results are presented with the final agreement as a consensus to help clinicians in understanding, diagnosing, and treating dyspepsia and H. pylori infection patients in daily clinical practice in Indonesia.

Gastrointestinal Symptoms of Monkeypox Infection: A systematic review and meta-analysis

BACKGROUND

Since early May 2022, outbreaks of Monkeypox (Mpox) cases have emerged and become a global concern. Studies exploring the gastrointestinal symptoms and/or liver injury of Mpox are still very limited. This systematic review and meta-analysis is the first to summarize the gastrointestinal symptoms reported by Mpox patients.

METHODS

We searched for Mpox studies published until October 21, 2022, in MEDLINE, EMBASE, SCOPUS, and organization websites. Mpox studies were observational studies that reported at least one of either gastrointestinal symptoms and/or liver injury in Mpox patients. Meta-analysis was done to obtain the pooled prevalence of gastrointestinal symptoms in Mpox patients. Subgroup analyses were done based on the study location, age groups, and Mpox clades. The quality of included studies was assessed using the NIH Quality Assessment Tool.

RESULTS

Overall, 31 studies that reported gastrointestinal symptoms and/or liver injury in Mpox patients were included. The reported gastrointestinal symptoms were abdominal pain, anorexia, diarrhea, nausea, and vomiting. There is a lack of reporting for liver injury. The most prevalent gastrointestinal symptoms in Mpox patients were anorexia (47%; 95%CI 41-53%), followed by vomiting (12%; 95%CI 11-13%), nausea (10%; 95%CI 9-11%), abdominal pain (9%; 95%CI 8-10%), and diarrhea (5%; 95%CI 4-6%). Additionally, the prevalence of proctitis, rectal/anal pain, and rectal bleeding were 11% (95%CI 11-12%), 25% (95%CI-24-27%), and 12% (95%CI 11-13%), respectively.

CONCLUSION

Anorexia was the most frequently reported gastrointestinal symptom in Mpox patients, followed by vomiting, nausea, abdominal pain, and diarrhea. Proctitis is a novel presentation of Mpox in the 2022 outbreak. This article is protected by copyright. All rights reserved.

The Expressions of NF−κB, COX−2, Sp1, and c−Jun in Pancreatic Ductal Adenocarcinoma and Their Associations with Patient Survival

Chronic inflammation is a crucial driver of carcinogenesis in pancreatic ductal adenocarcinoma (PDAC). Several studies have investigated the prognostic significance of cyclooxygenase−2 (COX−2) expression in PDAC patients, obtaining conflicting results. Nuclear factor kappa−B (NF−κB), specificity protein 1 (Sp1), and c−Jun are known as the transcription factors of the COX2 gene. This exploratory observational study investigated the association of the NF−κB, COX−2, Sp1, and c−Jun expressions with patient survival in PDAC. We used the immunohistochemical method to detect the PDAC tissue expressions of NF−κB (RelA/p65), COX−2, Sp1, and c−Jun. The expressions of these proteins were correlated with the overall survival (OS) and other clinicopathological characteristics of PDAC patients. We obtained 53 PDAC specimens from resections and biopsies. There were significant correlations between the four proteins’ expressions in the PDAC tissues. The expression of the cytoplasmic (aHR = 0.31; 95% CI 0.11–0.90; p = 0.032) or nuclear NF−κB (aHR = 0.22; 95% CI 0.07–0.66; p = 0.007) was independently associated with a better prognosis in the PDAC patients. COX−2, Sp1, and c−Jun showed no significant association with a prognosis in the PDAC patients. The PDAC patients who expressed NF−κB had a better prognosis than the other patients, which suggests that the role of inflammation in PDAC is more complex than previously thought.

Role of interventional endoscopic ultrasound in a developing country

BACKGROUND/AIMS

Endoscopic ultrasound (EUS) has become an essential diagnostic and therapeutic tool. EUS was introduced in 2013 in Indonesia and is considered relatively new. This study aimed to describe the current role of interventional EUS at our hospital as a part of the Indonesian tertiary health center experience.

METHODS

This retrospective study included all patients who underwent interventional EUS (n=94) at our center between January 2015 and December 2020. Patient characteristics, technical success, clinical success, and adverse events associated with each type of interventional EUS procedure were evaluated.

RESULTS

Altogether, 94 interventional EUS procedures were performed at our center between 2015 and 2020 including 75 cases of EUS-guided biliary drainage (EUS-BD), 14 cases of EUS-guided pancreatic fluid drainage, and five cases of EUS-guided celiac plexus neurolysis. The technical and clinical success rates of EUS-BD were 98.6% and 52%, respectively. The technical success rate was 100% for both EUS-guided pancreatic fluid drainage and EUS-guided celiac plexus neurolysis. The adverse event rates were 10.6% and 7.1% for EUS-BD and EUS-guided pancreatic fluid drainage, respectively.

CONCLUSION

EUS is an effective and safe tool for the treatment of gastrointestinal and biliary diseases. It has a low rate of adverse events, even in developing countries.

A systematic review and meta-analysis of the relationship between advanced glycation end products ceceptor (RAGE) gene polymorphisms and the risk of inflammatory bowel disease

Background

In the pathogenesis of inflammatory bowel disease (IBD), the advanced glycation end product receptor (RAGE) has been involved. IBD is classified into Chron's disease (CD) and ulcerative colitis (UC). The promoter gene of the RAGE gene was discovered to have had unique polymorphisms that increased its transcriptional activity. This study, therefore, used a systematic review and meta-analysis to examine the relationship between the RAGE gene polymorphism and the risk of IBD.

Methods

Databases such as PubMed, Scopus, and Cochrane library were searched to identify the relationship between RAGE gene polymorphisms and IBD susceptibility. We identified three Single Nucleotide Polymorphism (SNPs) (RAGE-429T/C, 374T/A, and G82S). The data were analyzed by RevMan 5.4.

Results

Four studies (932 cases/1366 controls) were included. The findings showed no relationship between RAGE -429T/C and -G82S polymorphisms and the risk of IBD in all genetic models significantly. TT genotype of RAGE -374T/A polymorphisms was related to increased CD risk (OR=1.37; 95%CI=1.04-1.81; P=0.02), while TA genotype was determined to be a protective factor (OR=0.75; 95%CI=0.57-0.99; P=0.04). In UC, A allele of RAGE -374T/A was related to increase risk (OR=1.26; 95%CI=1.04-1.53; P=0.02), while T allele was determined to decrease risk (OR=0.79; 95%CI= 0.65-0.96; P=0.02).

Conclusions

Our findings demonstrated that TT genotype and A allele of RAGE -374T/A polymorphisms were related to CD and UC risks, respectively, while the TA genotype and T allele possibly had a protective effect. RAGE -429T/C and RAGE -G82S polymorphisms were not related to increased IBD risk.

Screening of pancreatic cancer: Target population, optimal timing and how?

Pancreatic cancer patients usually present at a late stage due to subtle clinical manifestations. One of the most predictive prognostic factors in pancreatic cancer is the pancreatic cancer stage at diagnosis; therefore, early diagnosis is essential. Until now, pancreatic cancer screening has not become a standard practice for the general population due to the low incidence. In current circumstances, targeting individuals with a high risk of pancreatic cancer may be more rational. Several screening modalities for pancreatic cancer have also become debatable topics. Therefore, this article will review current evidence and recommendations regarding pancreatic screening cancer protocol in general and in high-risk populations.

Role of thigh circumference, calf circumference, subjective global assessment, and handgrip strength as diagnostic modalities of sarcopenia in women inflammatory bowel disease patients

Background and Aim

Sarcopenia is a problem affecting inflammatory bowel disease (IBD) outcome and should be evaluated by measuring muscle mass (using dual‐energy X‐ray absorptiometry [DXA]), muscle strength, and physical performance. DXA has drawbacks as it is expensive, not covered by a national program, and requires a technician. Other inexpensive and simple examinations are needed. The objective is to explore cutoff point and diagnostic accuracy of thigh circumference (TC), calf circumference (CC), subjective global assessment (SGA), and handgrip strength (HGS) to identify sarcopenia in IBD patients.

Methods

The study was conducted in Cipto Mangunkusumo Hospital during November 2020–June 2021. Analysis was performed to discover the cutoff point and diagnostic accuracy of TC, CC, SGA, and HGS to identify sarcopenia.

Results

As assessed by DXA, 7 of 60 women (11.7%) with IBD had sarcopenia. Using CC cutoff ≤31 cm, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ration (PLR), and negative likelihood ratio (NLR) were 100%, 60.38%, 25%, 100%, 2.52, and 0, respectively. Using TC cutoff ≤50 cm, the sensitivity, specificity, PPV, NPV, PLR, and NLR were 100%, 83.02%, 43.75%, 100%, 5.90, and 0, respectively. SGA has sensitivity, specificity, PPV, NPV, PLR, and NLR of 42.86%, 84.91%, 27.27%, 91.84%, 2.84, and 0.67, respectively. The area under curve of HGS was 33.3%.

Conclusion

In this survey of Indonesian women with IBD, the frequency of sarcopenia was 11.7%. When compared with DXA, TC and CC values over 50 cm and 31 cm, respectively, were helpful to exclude the diagnosis of sarcopenia. SGA and HGS were of lesser value for the identification of a decrease in muscle mass.

Global Hospitalization Trends for Crohn's Disease and Ulcerative Colitis in the 21st Century: A Systematic Review With Temporal Analyses

BACKGROUND & AIMS

The evolving epidemiologic patterns of inflammatory bowel disease (IBD) throughout the world, in conjunction with advances in therapeutic treatments, may influence hospitalization rates of IBD. We performed a systematic review with temporal analysis of hospitalization rates for IBD across the world in the 21st century.

METHODS

We systematically reviewed Medline and Embase for population-based studies reporting hospitalization rates for IBD, Crohn's disease (CD), or ulcerative colitis (UC) in the 21st century. Log-linear models were used to calculate the average annual percentage change (AAPC) with associated 95% confidence intervals (95% CIs). Random-effects meta-analysis pooled country-level AAPCs. Data were stratified by the epidemiologic stage of a region: compounding prevalence (stage 3) in North America, Western Europe, and Oceania vs acceleration of incidence (stage 2) in Asia, Eastern Europe, and Latin America vs emergence (stage 1) in developing countries.

RESULTS

Hospitalization rates for a primary diagnosis of IBD were stable in countries in stage 3 (AAPC, -0.13%; 95% CI, -0.72 to 0.97), CD (AAPC, 0.20%; 95% CI, -1.78 to 2.17), and UC (AAPC, 0.02%; 95% CI, -0.91 to 0.94). In contrast, hospitalization rates for a primary diagnosis were increasing in countries in stage 2 for IBD (AAPC, 4.44%; 95% CI, 2.75 to 6.14), CD (AAPC, 8.34%; 95% CI, 4.38 to 12.29), and UC (AAPC, 3.90; 95% CI, 1.29 to 6.52). No population-based studies were available for developing regions in stage 1 (emergence).

CONCLUSIONS

Hospitalization rates for IBD are stabilizing in countries in stage 3, whereas newly industrialized countries in stage 2 have rapidly increasing hospitalization rates, contributing to an increasing burden on global health care systems.

Recent advances in the diagnosis of intestinal tuberculosis

BACKGROUND

Intestinal tuberculosis still has a high incidence, especially in developing countries. The biggest challenge of this disease is the establishment of the diagnosis because the clinical features are not typical. Investigations such as culture, acid-fast bacilli (AFB) staining, and histopathology have low sensitivity, so other investigations are needed. Latest molecular-based diagnostic modalities such as GeneXpert, interferon-gamma (IFN-γ) release assays (IGRA), polymerase chain reaction (PCR), multiplex-PCR, and immunological markers are expected to help diagnose intestinal tuberculosis. This article review will examine the latest diagnostic modalities that can be used as a tool in establishing the diagnosis of intestinal tuberculosis.

RESULTS

Through a literature search, we were able to review the diagnostic values of various available diagnostic modalities as the appropriate additional test in intestinal tuberculosis. Culture as a gold standard has a sensitivity and specificity value of 9.3% and 100% with the MGIT BACTEC system as the most recommended medium. The sensitivity values of AFB staining, histopathology examination, GeneXpert, IGRA, PCR, multiplex-PCR and, immunological markers were ranged between 17.3 and 31%; 68%; 81-95.7%; 74-88%; 21.6-65%; 75.7-93.1%; and 52-87%, respectively. Meanwhile the specificity values were 100%; 77.1%; 91-100%; 74-87%; 93-100%; 96.4-100%; and 70-95%, respectively.

CONCLUSION

The combination of clinical examination, conventional examination, and the latest molecular-based examination is the best choice for establishing the diagnosis of intestinal tuberculosis. Most recent modalities such as multiplex PCR and immunological marker examinations are diagnostic tools that deserve to be used in diagnosing intestinal tuberculosis as their sensitivity and specificity values are quite high and more evidences are expected to support the application of these examinations shortly soon.

Clinical teachers' professional identity formation: an exploratory study using the 4S transition framework

OBJECTIVES

The aim of this study was to explore factors that may influence the formation of professional identity in clinical teachers, specifically during the transition period from practitioner to teacher.

METHODS

This was a descriptive qualitative study. We used Schlossberg's 4S framework to explore influential factors comprised of the following: situation, self, support, and strategies. This study was conducted in teaching hospitals of a relatively new private medical school in Bali, a province in Indonesia. The participants were 30 clinical teachers who were selected using a maximum variation sampling strategy based on length of work experience, gender, specific educational roles as coordinators, and clinical specialty. Data were derived from three focus-group discussions and 13 in-depth interviews. A thematic analysis method was used to analyse the data.

RESULTS

The thematic analysis revealed that 12 subthemes related to the 4S framework influenced the development of clinical teachers' identity. It was also shown that reflective ability and community of practice, which was included in the self and strategy factors, respectively, were the two most important factors during the transition period in the development of professional identity.

CONCLUSIONS

Factors, both within and outside the self, can either support or hinder the formation of professional identity in clinical teachers. We suggest that when faculty development programs are designed, these factors should be incorporated, such as including a community of practice as part of the formal faculty development programs and the development of a teaching portfolio that nurtures reflective practice.

Colorectal cancer patients in a tertiary hospital in Indonesia: Prevalence of the younger population and associated factors

BACKGROUND

An increasing trend in colorectal cancer (CRC) occurring at younger ages has been observed worldwide, even though incidence is declining in the general population. Most currently available guidelines still recommend CRC screening for older populations, despite an alarming rise in early-onset CRC incidence. Risk stratification is necessary to further determine the population most at risk for early-onset CRC. However, epidemiological data on related clinical characteristics and potential risk factors, especially in developing countries, have not been widely reported.

AIM

To investigate the prevalence, demographics, clinicopathologic features, and associated factors of young-onset CRC patients in a tertiary hospital in Indonesia.

METHODS

Patients undergoing colonoscopy examination between 2008 and 2019, yielding a diagnosis of CRC were identified from medical records. The subjects were classified into two groups according to their age at diagnosis, namely early-onset (18-49 years old) and late-onset (≥ 50-years-old). Demographic data, characteristics, and risk factors of both onset age groups were evaluated using the chi-square and Fisher’s exact test.

RESULTS

Among 495 CRC patients confirmed by histopathology, 205 (41.4%) were classified as early-onset and 290 (58.6%) as late-onset. Most subjects in the early-onset CRC group were male (53.7%), with 89.8% displaying adenocarcinoma histopathology. A majority (78%) of the early-onset CRC patients had left-sided tumors, with the rectum (41%) and rectosigmoid (17.6%) being the most common sites. Abdominal pain was the most frequent symptom in the early-onset CRC patients (55.6%), which was significantly higher than that in the late-onset CRC patients (43.8%, P < 0.05). Early-onset CRC cases were more likely to be underweight (34.6% vs 20.0%, P < 0.001) compared to late-onset CRC cases. The proportion of subjects with suspected hereditary nonpolyposis colorectal cancer (HNPCC) was also higher in the early-onset CRC group than in the late-onset age group (9.3% vs 4.1%, P < 0.05). However, no difference was observed in the parental or family histories of CRC cases.

CONCLUSION

Early-onset CRC patients were more likely to have abdominal pain, underweight status, and HNPCC suspicion than late-onset CRC patients.

Prognostic Value of COX-2, NF-κB, and Sp1 Tissue Expressions in Pancreatic Ductal Adenocarcinoma: A Systematic Review and Meta-analysis

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is deadly cancer with a poor prognosis. Molecular prognostic markers are needed to predict the patient's survival. The cyclooxygenase-2 enzyme (COX-2) and its 2 major transcription factors--nuclear factorkappa B (NF-κB) and specificity protein 1 (Sp1)--are activated during inflammation caused by neoplasia. Several studies have investigated the association between the COX-2, NF-κB, and Sp1 tissue expressions with the patient's overall survival. Therefore, we conducted this systematic review and meta-analysis to evaluate those studies.

METHODS

We searched for relevant articles from the MEDLINE database through June 2020. Studies were eligible if they included dichotomized tissue protein expression status and the overall survival as the outcome. We used RevMan and ProMeta programs to perform the meta-analysis.

RESULTS

We identified 11 eligible studies. The meta-analysis showed that COX-2 tissue expression was associated with decreased overall survival (crude HR = 1.35; 95% CI, 1.05-1.74), although the result was not significant when controlling for other covariates. The NF-κB tissue expression was associated with decreased overall survival (crude HR = 2.18; 95% CI, 1.49-3.18), although it was not significant when controlling for other covariates. The Sp1 tissue expression showed significantly decreased overall survival even when adjusted with other covariates (aHR = 3.47; 95% CI, 1.52-7.94). The limitations included searching only for English publications and the substantial heterogeneity among the studies.

CONCLUSION

COX-2, NF-κB, and Sp1 tissue expressions have the potential to be used as prognostic markers in PDAC. Further studies are still needed to clarify the associations.

Physician Perceptions on the Use of Antibiotics and Probiotics in Adults: An International Survey in the Asia-Pacific Area

Background and Aims

The over-prescription of antibiotics is thought to represent a major threat to public health worldwide and is more frequently observed in some low- and middle-income countries. In the Asia-Pacific region, economic development, health care organization and population demographics are very heterogenous. The objective of this survey was to investigate antibiotic use and probiotic co-prescription among adult patients in this area.

Methods

An online survey of physicians from seven countries of the Asia-Pacific region (Australia, Japan, Indonesia, India, China, Singapore and South Korea) was performed in 2018. The questionnaire explored current practices of physicians concerning antibiotics and probiotics and factors related to prescribing decisions.

Results

A total of 387 general practitioners and 350 gastroenterologists completed the questionnaire. Physicians in Australia, Japan and South-Korea were low prescribers of antibiotics (11% to 19% of visits resulted in an antibiotic prescription), while physicians in Indonesia, India, China and Singapore were high prescribers (41% to 61%). A large majority (85%) of physicians agreed that antibiotics disrupted intestinal microbiota. The rates of co-prescription of probiotics varied from 16% in Japan to 39% in Singapore (overall, 27%). Conditions considered by physicians to be prevented by probiotics were mostly antibiotic-associated diarrhea (62%) and Clostridium difficile colitis (43%).

Conclusions

Rates of probiotic co-prescription remain low in many countries although the negative effects of antibiotics on the gut microbiota and the benefits of co-prescribing probiotics are generally known.

Anemia in Inflammatory Bowel Disease: A Neglected Issue in Comprehensive Inflammatory Bowel Disease Management

Anemia is the most common extraintestinal inflammatory bowel disease (IBD) manifestations and is significantly correlated with several adverse impacts such as higher hospitalization rate, relapse rate, surgical intervention requirement, and low quality of life. The prevalence of anemia in IBD patients is greatly varied between reports, which is estimated between 8.8% to 74%. However, studies showed there were still gaps in the screening protocol and anemia treatment in daily practice. Anemia in IBD tends to be an overlooked IBD complication yet significant and must be adequately addressed. Anemia in IBD may be caused by several factors that interplayed, with iron deficiency anemia being the most common etiology. Comprehensive management of anemia in IBD should consist of active screening, evaluation of the etiology, holistic treatment, and follow-up monitoring. Optimization of IBD therapy should be emphasized because it also may improve the anemic condition. A multidisciplinary approach and collaboration are needed to ensure better IBD care.

Increased serum amylase and/or lipase in coronavirus disease 2019 (COVID-19) patients: Is it really pancreatic injury?

Coronavirus disease 2019 (COVID-19) is a novel disorder caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although it mainly affects the respiratory system, the pancreas could also become the virus' target. The issue regarding pancreatic involvement in COVID-19 has been raised by several researchers. They found increased serum amylase and/or lipase in COVID-19 patients, which suggested pancreatic injury. We aimed to critically review the evidence to provide insights and to answer the very question of the possibility of pancreatic injury. Current evidence shows that increased amylase and/or lipase is not necessarily a pancreatic injury in COVID-19 patients. Those increased enzymes might also be found in other clinical conditions.

Impact of COVID-19 on the Gut: A Review of the Manifestations, Pathology, Management, and Challenges

SARS-CoV-2 is a virus that can enter its hosts through the Angiotensin Converting Enzyme-2 (ACE2) receptor. ACE2 is mainly expressed in cells of the gastrointestinal tract, such as the esophageal epithelium and enterocytes from the ileum-colon. Coronavirus Disease 2019 (COVID-19) has varying clinical symptoms and presents differently in individuals, ranging from asymptomatic carriers to moderate clinical spectrum with mild pneumonia clinical features, and to a severe clinical presentation with dyspnea and hypoxia, leading to death due to respiratory or multi-organ failure. COVID-19 infection can also manifest themselves in the form of gastrointestinal symptoms such as diarrhea, vomiting, nausea, and abdominal pain. Severe complications of gastrointestinal COVID-19 infections include hemorrhage or perforation of the gastrointestinal tract and severe inflammation, which can adversely affect the intestinal immune system, and therefore the systemic immune system of the host. Furthermore, COVID-19 has also shown to affect microbiota homeostasis in the digestive tract. To date, no clear explanation is available regarding the pathophysiology of gastrointestinal SARS-CoV-2 infection, fecal RNA detection, and the possibility of fecal-oral transmission of SARS-CoV-2. This review aims to discuss the effects of SARS-CoV-2 infection on the digestive tract, microbiota, and lung, and the possibility of fecal-oral transmission in COVID-19.

Risk Assessment in Hereditary Colorectal Cancer Family by Using APC and MSH2 mRNA Gene Expression and Bayesian Analysis

BACKGROUND: Some of colorectal cancers (CRCs) are familial, however, heterozygote relatives have approximately 80% lifetime risk of cancer. Risk assessment of CRC’s family could be calculated by direct measurement of mRNA gene expression and Bayesian theorem which is modifying initial background of pedigree risk with additional conditional information. This application has not been reported.METHODS: The cross-sectional translational sequential studies were performed: (1) adenomatous polyposis coli (APC) and MutS homolog (MSH)2 mRNA quantitative RT PCR gene expressions in tissue and whole blood CRC patients; (2) gene expression was determined in matched controls; and (3) pedigree and Bayesian analysis was calculated in the patient’s family of Proband.RESULTS: Fourty CRC and 31 control subjects were enrolled. The mean blood APC level control’s group was 13,261±670 fold-change (fc) and blood MSH2 level was 12,219±756 fc. The cut-off points for hereditary APC was 12,195 fc and MSH2 was 11,059 fc. The mean APC blood level in CRC subject was 11,578±2,638 fc and MSH2 blood level was 11,411±2,912 fc. There were significant differences APC and MSH level between tissue and blood level in CRC. Eight of 40 CRC subjects had a history of familial CRC. Four patients and 10 Probands were available for recurrence risk evaluation of pedigree analysis, RNA PCR quantitative and Bayesian calculation.CONCLUSION: There was determined a cut-off point of hereditary mRNA quantitative expression. The APC and MSH2 levels in CRC subjects were significantly lower than controls. Bayesian analysis allowed for the calculation of relative risk in CRC family members and considered in clinical practice.KEYWORDS: hereditary CRC, APC gene, MSH gene, Bayesian analysis

A Clinical and Procedural Guideline for Gastrointestinal Endoscopy Units during COVID-19 Pandemic Era

The World Health Organization (WHO) has declared COVID-19 as global pandemic since there are tremendous growing numbers of confirmed cases for SARS-C0V-2 infection, the number of affected countries and high mortality rate. The global COVID-19 pandemic also will affect various aspects of health care including endoscopic service. The Indonesian Society for Digestive Endoscopy (ISDE), which provides a scope for doctors who perform endoscopic procedures, has developed a clinical and procedural guideline that may serve as a reference for doctors performing gastrointestinal endoscopy in Indonesia.

Correlation of gut Firmicutes/Bacteroidetes ratio with fibrosis and steatosis stratified by body mass index in patients with non-alcoholic fatty liver disease

We investigated the gut microbiota in patients with non-alcoholic fatty liver disease (NAFLD) and its correlation with fibrosis and steatosis stratified by body mass index, as reflected in the controlled attenuation parameter and transient elastography values. A cross-sectional study was performed on 37 patients with NAFLD at Cipto Mangunkusumo National General Hospital from December 2018 to March 2019. The gut microbiota was investigated in fecal samples with 16S RNA sequencing using the MiSeq next-generation sequencing platform (Illumina). NAFLD was more common in patients with metabolic syndrome. Firmicutes, Bacteroidetes, and Proteobacteria were the predominant phyla. Bacteroides was more dominant than Prevotella, contrary to the results of previous studies on healthy populations in Indonesia. Microbiota dysbiosis was observed in most samples. The gastrointestinal microbiota diversity was significantly decreased in patients with NAFLD, high triglyceride levels, and central obesity. The Firmicutes/Bacteroidetes ratio correlated with steatosis and obesity, whereas some of the other species in lower taxonomy levels were mostly associated with steatosis and obesity without fibrosis. Proteobacteria was the only phylum strongly correlated with fibrosis in patients with an average body mass index. The gut microbiota diversity was decreased in patients with NAFLD, high triglyceride levels, and central obesity, and certain gut microbes were correlated with fibrosis and steatosis.

Asian Pacific Association of Gastroenterology (APAGE) Inflammatory Bowel Disease (IBD) Working Party guidelines on IBD management during the COVID-19 pandemic

The COVID-19 pandemic, secondary to SARS-CoV-2, has resulted in high mortality and morbidity worldwide. As inflammatory bowel disease (IBD) is a chronic disease, and most patients are on long-term immunosuppressive agents, there is understandable concern, particularly in terms of therapy. In view of this, experts in IBD across the Asia Pacific region were invited to put together recommendations based on their experience and the currently available data. In general, most IBD therapies (with a few exceptions) can be continued safely, and the general consensus is that maintaining disease control should remain the main principle of management. In addition, social distancing measures and the appropriate use of personal protective equipment should be strictly adhered to. During the current pandemic, face-to-face clinic follow ups and non-urgent procedures should be kept to a minimum.

Comparison of 10-Day Course of Triple Therapy Versus 14-Day Course for Eradication of Helicobacter pylori Infection in an Indonesian Population: Double-Blinded Randomized Clinical Trial

Objective:

The aim of this study was to compare the effectiveness of 10-day course of triple therapy versus a 14-day course in the treatment of H.pylori infection in an Indonesian population.

Methods:

A double-blinded randomized clinical trial was included patients, Indonesian population, with H.pylori infection conducted in Cipto Mangunkusumo Hospital, Jakarta; Cilincing District General Hospital, Jakarta; and West Nusa Tenggara General Hospital, Mataram, during October 2016 - April 2017. Patients were randomized to be given triple therapy as Rabeprazole 20 mg, Amoxicillin 1,000 mg, and Clarithromycin 500 mg twice daily, for 14 days or 10 days plus 4 days placebo. Eradication was evaluated with UBT at least 4 weeks after completion the therapy.

Results:

A total of 75 patients (38 in the 14-day group and 37 in the 10-day group) were included to the study. In the intention-to-threat analysis, eradication rate was 67.6% (95% CI. 52.5%-82.6%) for the 10-day group versus 86.8% (95% CI. 76.0%-97.5%) for the 14-day group (p = 0.046), whereas per protocol analysis obtained 73.5% (95% CI. 58.6%-88.3%) for the 10-day versus 91.9% (95% CI. 84.1%-99.6%) in the 14-day group (p = 0.039). Adverse events were not significantly different between the two groups.

Conclusion:

A 14-day course was more effective than 10-day course of triple therapy as first-line for eradication of H.pylori infection in an Indonesian population.

Best practices on immunomodulators and biologic agents for ulcerative colitis and Crohn's disease in Asia

The Asia-Pacific Working Group on Inflammatory Bowel Disease was established in Cebu, Philippines, under the auspices of the Asia-Pacific Association of Gastroenterology with the goal of improving inflammatory bowel disease care in Asia. This consensus is carried out in collaboration with Asian Organization for Crohn's and Colitis. With biologic agents and biosimilars becoming more established, it is necessary to conduct a review on existing literature and establish a consensus on when and how to introduce biologic agents and biosimilars in conjunction with conventional treatments for ulcerative colitis and Crohn's disease in Asia. These statements also address how pharmacogenetics influences the treatments of ulcerative colitis and Crohn's disease and provides guidance on response monitoring and strategies to restore loss of response. Finally, the review includes statements on how to manage treatment alongside possible hepatitis B and tuberculosis infections, both common in Asia. These statements have been prepared and voted upon by members of inflammatory bowel disease workgroup employing the modified Delphi process. These statements do not intend to be all-encompassing, and future revisions are likely as new data continue to emerge.

Best practices on immunomodulators and biologic agents for ulcerative colitis and Crohn's disease in Asia

The Asia-Pacific Working Group on inflammatory bowel disease (IBD) was established in Cebu, Philippines, under the auspices of the Asian Pacific Association of Gastroenterology with the goal of improving IBD care in Asia. This consensus is carried out in collaboration with Asian Organization for Crohn’s and Colitis. With biologic agents and biosimilars becoming more established, it is necessary to conduct a review on existing literature and establish a consensus on when and how to introduce biologic agents and biosimilars in the conjunction with conventional treatments for ulcerative colitis (UC) and Crohn’s disease (CD) in Asia. These statements also address how pharmacogenetics influence the treatments of UC and CD and provide guidance on response monitoring and strategies to restore loss of response. Finally, the review includes statements on how to manage treatment alongside possible hepatitis B and tuberculosis infections, both common in Asia. These statements have been prepared and voted upon by members of IBD workgroup employing the modified Delphi process. These statements do not intend to be all-encompassing and future revisions are likely as new data continue to emerge.

Visceral fat thickness of erosive and non-erosive reflux disease subjects in Indonesia's tertiary referral hospital

BACKGROUND

There has been an increasing number of reports regarding the correlation between obesity and gastroesophageal reflux disease (GERD). Visceral fat thickness is thought to be a risk factor for GERD and its severity. Several studies have conflicting results, so this study aimed to determine visceral fat thickness difference between erosive and non-erosive reflux disease.

METHODS

A cross-sectional study of 56 adult subjects with GERD symptoms was held at Cipto Mangunkusumo National General Hospital between April and November 2018. Gastroesophageal Reflux Disease Questionnaires (GERDQ) were utilized to determine the presence of GERD. Ultrasonography was used to determine visceral fat thickness. Esophageal erosions were diagnosed using upper gastrointestinal endoscopy. The difference in visceral fat thickness between esophagitis and non-esophagitis group was analysed using T-test.

RESULTS

From 56 total subjects, 55.4% have erosive reflux disease (ERD), in which were dominated by subjects with grade A esophagitis (64.5%) based on Los Angeles Classification of Esophagitis (LA classifications). There was no significant difference of visceral fat thickness between non-erosive reflux disease (NERD) and ERD (p = 0,831). There was, however, an increasing trend of visceral fat thickness with the advancing severity of esophagitis, although statistical significance was not reached.

CONCLUSION

Visceral fat thickness as measured by ultrasonography has no significant difference between NERD and ERD.

The role of Small Intestinal Bacterial Overgrowth (SIBO) in Non-alcoholic Fatty Liver Disease (NAFLD) patients evaluated using Controlled Attenuation Parameter (CAP) Transient Elastography (TE): a tertiary referral center experience

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is an emerging disease, where it can progress to non-alcoholic steatohepatitis (NASH) and lead to liver cirrhosis or liver cancer. Small intestinal bacterial overgrowth (SIBO) has been hypothesized to play an important role in NAFLD development and progression, however, there is still conflicting data about this phenomenon. Transient Elastography (TE) examination using controlled attenuation parameter (CAP) has been validated for liver disease progression assessment in NAFLD. It is non-invasive method and easy to perform in clinical practice. Therefore, we would like to know the role of SIBO in NAFLD and its possible impact on disease progression.

METHODS

A cross-sectional design study performed at outpatient's Hepatobiliary clinic at tertiary referral university hospital in Jakarta. All recruited study subjects based on inclusions criteria underwent laboratory examination, transabdominal ultrasound examination, CAP-TE 502 (by Echosens, France), and glucose hydrogen breath test (GHBT) using portable hydrogen breath test apparatus (Gastro+™ Gastrolyzer by Bedfont Scientific Ltd). Stool sample examination was performed using RT-PCR.

RESULTS

This study recruited 160 subjects with median age of 58 (22-78) years and 108 (67.5%) of them are female. SIBO (65,5%), DM (70.8%), dyslipidemia (75.2%), obesity (76.6%), and metabolic syndrome (73%) were more prevalent in NAFLD than non-NAFLD population. Bivariate analysis showed no significant association between SIBO and NAFLD development (p = 0.191; PR 0.871; CI 95% [0.306-1.269]). SIBO was also not associated with significant hepatic steatosis (p = 0.951; PR = 0.951; CI 95% [0.452-2.239]) and fibrosis (p = 0.371; PR = 1.369; CI 95% [0.608-3.772]). However, the presence of central obesity has significantly associated with the presence of SIBO (p = 0.001; PR = 0.378; CI 95% [0.021-0.478]). Based on stool sample analysis from 60 NAFLD patients, there is a significant correlation using Spearmen test between the presence of Bacteroides and the stage of fibrosis (p .037). Further analysis between obese NAFLD patients and non-obese NAFLD patients showing that there is a significant decrease of Bifidobacteria (p .047) and Lactobacillus (p .038) in obese NAFLD patients and a tendency of increase Bacteroides in obese NAFLD patients (p .572).

CONCLUSIONS

SIBO is not associated with NAFLD development and progression.

The effect of breakfast with different macronutrient composition on PYY, ghrelin, and ad libitum intake 4 h after breakfast in Indonesian obese women

OBJECTIVES

Gut hormones, such as PYY and ghrelin, are associated with appetite control and obesity. Protein is thought to be the most satiating nutrient and could affect the production of several gut hormones. The purpose of the current study was to find the effect of breakfast with different protein composition on PYY, ghrelin, and ad libitum intake 4 h after breakfast.

RESULTS

This clinical trial involves 22 obese women participants. Subjects were given three types of breakfast: low protein consumption (12.4% protein), medium protein (23.5% protein), and high protein (40.6% protein). PYY and ghrelin levels were measured at 0, 15, 60, 120, and 180 min after breakfast. Ad libitum meal was given 4 h after breakfast and measured after. This study found that there is no significant difference in PYY and ghrelin level at each measurement time between different type of breakfast. This study also found no significant difference of ad libitum energy intake between different type of breakfast. Trial registration ClinicalTrials.gov NCT03697486, 3 December 2018. Retrospectively registered.

Consensus and contentious statements on the use of probiotics in clinical practice: A south east Asian gastro-neuro motility association working team report

The concept of consuming microorganisms in the treatment of a medical condition and in health maintenance has gained much attraction, giving rise to an abundance of medical claims and of health supplements. This study identified relevant clinical questions on the therapeutic use of probiotics and reviewed the literature in irritable bowel syndrome, inflammatory bowel disease, impaired intestinal immunity, liver disease, intestinal infections, and common childhood digestive disorders. Statements were developed to address these clinical questions. A panel of experienced clinicians was tasked to critically evaluate and debate the available data. Both consensus and contentious statements are presented to provide to clinicians a perspective on the potential of probiotics and importantly their limitations.

Insulin Resistance in Gastroesophageal Reflux Disease

Insulin resistance is the disturbance of glucose regulation characterized by higher insulin level. In clinical context, insulin resistance can manifest as abnormalities that are related with cardiovascular event risk, known as metabolic syndrome. Several studies had reported that insulin resistance was associated with erosive esophagitis in patients with gastroesophageal reflux disease (GERD).

The association between new generation oral contraceptive pill and the development of inflammatory bowel diseases

Background/Aims

To examine the association between use of oral contraceptive pills (OCPs) and the risk of developing inflammatory bowel diseases (IBD), in a modern cohort.

Methods

A prospective nested case-control study across sites in the Asia-Pacific region was conducted; involving female IBD cases and asymptomatic controls. Subjects completed a questionnaire addressing questions related to OCP use. Primary outcome was the risk of development of IBD of those exposed to OCP versus non-exposure. Secondary outcomes were development of Crohn's disease (CD) versus ulcerative colitis (UC), and whether age of first use of OCP use may be associated with risk of IBD.

Results

Three hundred and forty-eight female IBD cases (41% CD, median age: 43 years) and 590 female age-matched controls were recruited. No significant association was found between OCP use and the risk of IBD (odds ratio [OR], 1.65; 95% confidence interval, 0.77-3.13; P=0.22), CD (OR, 1.55) or UC (OR, 1.01). The lack of association persisted when results were adjusted for age and smoking. IBD cases commenced OCP use at a younger age than controls (18 years vs. 20 years, P=0.049).

Conclusions

In this large cohort of subjects from the Asia-Pacific region, we found a modest but not significantly increased risk of developing IBD amongst OCP users.

The role of the microbiome and the use of probiotics in gastrointestinal disorders in adults in the Asia-Pacific region - background and recommendations of a regional consensus meeting

The Asia-Pacific region is diverse, with regard to ethnicity, culture, and economic development incorporating some of the world's least and most developed nations. Gastrointestinal diseases are common in the Asia-Pacific region, and their prevalence, presentation, and management vary considerably within the region. There is growing evidence for an important role for the human gut microbiota in gastrointestinal health. As a consequence, geographic variations in the composition of the gut microbiota may contribute to variations in both the prevalence and response to therapy of specific diseases. Probiotics have been proposed as a valuable option in the prevention and treatment of a number of gastrointestinal illnesses, but the quality of available evidence to support their efficacy is variable. A meeting of international experts in adult and pediatric gastroenterology was held at the Sorbonne University, Paris, France, on April 11 and 12, 2016, to discuss current evidence supporting the use of probiotics in gastrointestinal disorders in the Asia-Pacific region. This article provides an overview of the discussions held at this meeting and recommends the formation of an Asia-Pacific Consortium on Gut Microbiota similar to those established in Europe and North America.

Endoscopic and Histological Mucosal Healing in Ulcerative Colitis in the First Year of Diagnosis: Results from a Population-based Inception Cohort from Six Countries in Asia

BACKGROUND AND AIMS

Mucosal healing is associated with improved long-term clinical outcomes in patients with ulcerative colitis. This population-based study assessed endoscopic and histological mucosal healing within the first year of diagnosis.

METHODS

Consecutive patients diagnosed with ulcerative colitis from six countries in Asia were prospectively enrolled. Clinical demographics, blood markers and inflammatory activity were assessed at baseline. Mayo score and Nancy index were used to assess endoscopic and histological activities, respectively. Clinical, endoscopic and histological evaluations were repeated at 1 year. Logistic regression was performed to identify predictors of mucosal healing.

RESULTS

Of 433 ulcerative colitis patients, 202 [46.7%] underwent colonoscopy at 1 year. In total, 68 [38.2%] achieved endoscopic mucosal healing and 35 [23.1%] achieved histological mucosal healing. On multivariate analysis, an elevated erythrocyte sedimentation rate [ESR] at diagnosis (odds ratio [OR], 0.332; 95% confidence interval (CI), 0.133-0.830; p = 0.018) was a significant negative predictor of endoscopic mucosal healing at 1 year, while histological features of ulceration [OR, 0.156; 95% CI, 0.028-0.862; p = 0.033] and being an ex-smoker [OR, 0.067; 95% CI, 0.005-0.965; p = 0.047] were significant negative predictors of histological healing at 1 year. Both endoscopic and histological mucosal healing were associated with less steroid use [p < 0.001 and p = 0.001, respectively] and hospitalization [p = 0.002 and p = 0.01, respectively].

CONCLUSIONS

Mucosal healing was achieved in fewer than half of patients with ulcerative colitis in the first year of diagnosis. An elevated ESR predicted less likelihood of endoscopic mucosal healing, while histological features of ulceration and being an ex-smoker at diagnosis predicted less likelihood of histological healing.

Efficacy of Curcumin as Adjuvant Therapy to Induce or Maintain Remission in Ulcerative Colitis Patients: an Evidence-based Clinical Review

BACKGROUND

treatment guidelines for ulcerative colitis (UC) not yet established. Currently, mesalazine, corticosteroids, and immunomodulators are treatment options for UC. However, they are known to have unpleaseant side effects such as nausea, vomiting, headaches, hepatitis, and male infertility. Curcumin is found in Turmeric plants (Curcuma longa L.), which possesses both anti-inflammatory and antioxidant properties. This study aimed to determine whether curcumin as adjuvant therapy can induce or maintain remission in UC patients.

METHODS

structured search in three database (Cochrane, PubMed, Proquest) using "Curcumin", "remission" and "Ulcerative Colitis" as keywords. Inclusion criteria is randomized controlled trials (RCTs), meta-analysis, or systematic review using curcumin as adjuvant therapy in adult UC patients.

RESULTS

we found 49 articles. After exclusion, three RCTs were reviewed; two examined curcumin efficacy to induce remission and one for remision maintenance in UC. Curcumin was significantly more effective than placebo in all RCTs. The efficacy of curcumin could be explained by its anti-inflammatory properties, which inhibit NF-kB pathway. Regulation of oxidant/anti-oxidant balance can modify the release of cytokines. However, methods varied between RCTs. Therefore, they cannot be compared objectively. Futhermore, the sample size were small (n= 50, 45, 89) therefore the statistical power was not enough to generate representative results in all UC patients.

CONCLUSION

Available evidence showed that curcumin has the potential to induce and maintain remission in UC patients with no serious side effects. However, further studies with larger sample size are needed to recommend it as adjuvant therapy of ulcerative colitis.

Current Issues of Gastroenterology in Indonesia

Indonesia is one of the most populous developing countries in the world. Similar with other developing countries, Indonesia has been suffered from the high incidence of gastroenterology diseases that mainly due to infection. In the recent years, Indonesia had also increased number of non-infectious gastroenterology diseases cases such as inflammatory bowel disease, gastroesophageal reflux disease, and colorectal cancer. Nevertheless, the developments of diagnostic and therapeutic modality along with the cooperation between sectors have undergone rapid progress as an effort in improving digestive health in Indonesia.

National Consensus on Management of Dyspepsia and Helicobacter pylori Infection

Dyspepsia is one of numerous general complaints, which is commonly encountered by doctors of various disciplines. In daily practice, the complaint is not only limited for gastroenterologists. Knowledge on pathophysiology of dyspepsia have been developing continuously since a scientific investigation has been started in 1980's, which considers Helicobacter pylori as one of key factor in managing dyspepsia, either it is associated with ulcer or non-ulcer. The management of dyspepsia cannot be separated from the management of H. pylori and there is an additional new knowledge associated with definition, pathophysiology, diagnosis and treatment of both dyspepsia and H. pylori infection.This consensus document on the management of dyspepsia and H. pylori infection in Indonesia has been developed using the evidence-based medicine principles; therefore, it can be used as a reference for doctors in dealing with dyspepsia and H. pylori infection cases in their daily practice. It is expected that with the new consensus, doctors can provide greater service to their patients who have dyspepsia and H. pylori infection.

The Validity and Reliability Test of the Indonesian Version of Gastroesophageal Reflux Disease Quality of Life (GERD-QOL) Questionnaire

AIM

to obtain a valid and reliable GERD-QOL questionnaire for Indonesian application.

METHODS

at the initial stage, the GERD-QOL questionnaire was first translated into Indonesian language and the translated questionnaire was subsequently translated back into the original language (back-to-back translation). The results were evaluated by the researcher team and therefore, an Indonesian version of GERD-QOL questionnaire was developed. Ninety-one patients who had been clinically diagnosed with GERD based on the Montreal criteria were interviewed using the Indonesian version of GERD-QOL questionnaire and the SF 36 questionnaire. The validity was evaluated using a method of construct validity and external validity, and reliability can be tested by the method of internal consistency and test retest.

RESULTS

the Indonesian version of GERD-QOL questionnaire had a good internal consistency reliability with a Cronbach Alpha of 0.687-0.842 and a good test retest reliability with an intra-class correlation coefficient of 0.756-0.936; p<0.05). The questionnaire had also been demonstrated to have a good validity with a proven high correlation to each question of SF-36 (p<0.05).

CONCLUSION

the Indonesian version of GERD-QOL questionnaire has been proven valid and reliable to evaluate the quality of life of GERD patients.

Mortality-related Factors in Patients with Malignant Obstructive Jaundice

AIM

to obtain survival rate and mortality-related factors of malignant obstructive jaundice patients.

METHODS

all medical records of obstructive jaundice inpatient at Cipto Mangunkusumo Hospital, Jakarta from January 2010 to December 2013 were reviewed retrospectively. The following factors were analyzed in terms of mortality: age, gender, sepsis, hypoalbumin, serum bilirubin level, serum CA 19-9 level, billiary drainage, non-ampulla Vateri carcinoma, and comorbid factors.

RESULTS

total 181 out of 402 patients were enrolled in this study with male proportion was 58.6%, and patients aged 50 years or above was 57.5%. Multivariate analysis showed that only sepsis, unsuccessful or no prior biliary drainage and Charlson comorbid score ≥4 were independent predictors of mortality. Patients with significant prognostic factors had median survival 14 days compared with overall median survival 26 days. Score ≥2 identified as the highest prognostic score threshold with sensitivity 68%, specificity 75%, and AUC on ROC curve 0.769.

CONCLUSION

sepsis, unsuccessful or no prior bilirary drainage, and Charlson comorbid score ≥4 are factors significantly associated with shortened survival in malignant obstructive jaundice patients. Prognostic score  ≥2 was determined to classify patients into high risk mortality group. Mortality of patients with those significant prognostic factors can be predicted in 76.9%.

Early Course of Inflammatory Bowel Disease in a Population-Based Inception Cohort Study From 8 Countries in Asia and Australia

BACKGROUND & AIMS

The incidence of inflammatory bowel disease (IBD) is increasing in Asia, but little is known about disease progression in this region. The Asia-Pacific Crohn's and Colitis Epidemiology Study was initiated in 2011, enrolling subjects from 8 countries in Asia (China, Hong Kong, Indonesia, Sri Lanka, Macau, Malaysia, Singapore, and Thailand) and Australia. We present data from this ongoing study.

METHODS

We collected data on 413 patients diagnosed with IBD (222 with ulcerative colitis [UC], 181 with Crohn's disease [CD], 10 with IBD unclassified; median age, 37 y) from 2011 through 2013. We analyzed the disease course and severity and mortality. Risks for medical and surgical therapies were assessed using Kaplan-Meier analysis.

RESULTS

The cumulative probability that CD would change from inflammatory to stricturing or penetrating disease was 19.6%. The cumulative probabilities for use of immunosuppressants or anti-tumor necrosis factor agents were 58.9% and 12.0% for patients with CD, and 12.7% and 0.9% for patients with UC, respectively. Perianal CD was associated with an increased risk of anti-tumor necrosis factor therapy within 1 year of its diagnosis (hazard ratio, 2.97; 95% confidence interval, 1.09-8.09). The cumulative probabilities for surgery 1 year after diagnosis were 9.1% for patients with CD and 0.9% for patients with UC. Patients with CD and penetrating disease had a 7-fold increase for risk of surgery, compared with patients with inflammatory disease (hazard ratio, 7.67; 95% confidence interval, 3.93-14.96). The overall mortality for patients with IBD was 0.7%.

CONCLUSIONS

In a prospective population-based study, we found that the early course of disease in patients with IBD in Asia was comparable with that of the West. Patients with CD frequently progress to complicated disease and have accelerated use of immunosuppressants. Few patients with early stage UC undergo surgery in Asia. Increasing our understanding of IBD progression in different populations can help optimize therapy and improve outcomes.

Environmental risk factors in inflammatory bowel disease: a population-based case-control study in Asia-Pacific

OBJECTIVE

The rising incidence of inflammatory bowel disease in Asia supports the importance of environmental risk factors in disease aetiology. This prospective population-based case-control study in Asia-Pacific examined risk factors prior to patients developing IBD.

DESIGN

442 incident cases (186 Crohn's disease (CD); 256 UC; 374 Asians) diagnosed between 2011 and 2013 from eight countries in Asia and Australia and 940 controls (frequency-matched by sex, age and geographical location; 789 Asians) completed an environmental factor questionnaire at diagnosis. Unconditional logistic regression models were used to estimate adjusted ORs (aOR) and 95% CIs.

RESULTS

In multivariate model, being breast fed >12 months (aOR 0.10; 95% CI 0.04 to 0.30), antibiotic use (aOR 0.19; 0.07 to 0.52), having dogs (aOR 0.54; 0.35 to 0.83), daily tea consumption (aOR 0.62; 0.43 to 0.91) and daily physical activity (aOR 0.58; 0.35 to 0.96) decreased the odds for CD in Asians. In UC, being breast fed >12 months (aOR 0.16; 0.08 to 0.31), antibiotic use (aOR 0.48; 0.27 to 0.87), daily tea (aOR 0.63; 0.46 to 0.86) or coffee consumption (aOR 0.51; 0.36 to 0.72), presence of hot water tap (aOR 0.65; 0.46 to 0.91) and flush toilet in childhood (aOR 0.71; 0.51 to 0.98) were protective for UC development whereas ex-smoking (aOR 2.02; 1.22 to 3.35) increased the risk of UC.

CONCLUSIONS

This first population-based study of IBD risk factors in Asia-Pacific supports the importance of childhood immunological, hygiene and dietary factors in the development of IBD, suggesting that markers of altered intestinal microbiota may modulate risk of IBD later in life.

New insights on the pathomechanisms of inflammatory bowel disease

Pathogenesis of inflammatory bowel disease (IBD) remains an enigma on whether germs, genes or a combination of these two with excessive immune responses to gut-associated bacteria explicates its pathomechanisms. The incidence of IBD is 0.76747 per 100,000 in Central Indonesia, as shown in the Project Indonesian IBD ACCESS 2012 progress report. This result, together with other epidemiological studies in Asia, may conclusively reflect increased rates of the disease, while its pathogenesis still undoubtedly obscured. However, knowledge of the pathophysiology of IBD is rapidly growing, abreast with new developments. A series of recent updates in core pathomechanisms such as bacterial, endoplasmic reticulum stress, new immune cell populations, T-cell differentiation and function, mucosal immune defenses and oxidative stress are relevant pathomechanism keypoints in IBD.

New insights on the pathomechanisms of inflammatory bowel disease

Pathogenesis of inflammatory bowel disease (IBD) remains an enigma on whether germs, genes or a combination of these two with excessive immune responses to gut-associated bacteria explicates its pathomechanisms. The incidence of IBD is 0.76747 per 100,000 in Central Indonesia, as shown in the Project Indonesian IBD ACCESS 2012 progress report. This result, together with other epidemiological studies in Asia, may conclusively reflect increased rates of the disease, while its pathogenesis still undoubtedly obscured. However, knowledge of the pathophysiology of IBD is rapidly growing, abreast with new developments. A series of recent updates in core pathomechanisms such as bacterial, endoplasmic reticulum stress, new immune cell populations, T-cell differentiation and function, mucosal immune defenses and oxidative stress are relevant pathomechanism keypoints in IBD.