Is shorter also better in the treatment of Clostridioides difficile infection?

OBJECTIVES

To assess the effectiveness of shortened regimens of vancomycin or fidaxomicin in the treatment of Clostridioides difficile infection (CDI).

METHODS

Adult patients with CDI hospitalized from January 2022 to May 2023 were included in this observational study. In patients with CDI treated with vancomycin or fidaxomicin, antibiotic treatment was discontinued after either 5 or 7 days of vancomycin or 5 days of fidaxomicin if there was a clinical response and improvement in laboratory parameters. The control cohort was treated with the standard 10 day regimen of either vancomycin or fidaxomicin. The follow-up was 60 days. Causative C. difficile strains were characterized by ribotyping and toxin gene detection when available.

RESULTS

Twenty-five patients (median age 76 years) received shortened treatment with vancomycin (n = 21), or fidaxomicin (n = 4). Five cases fulfilled the criteria for severe CDI. Twenty-three patients completed follow-up; two died from causes other than CDI, and two developed recurrent CDI (8.0%). Ribotypes (RTs) 001 and 014 were the most prevalent with 20% each. In two C. difficile isolates, binary toxin genes were detected (RTs 078 and 023). In the control group of 22 patients recurrent CDI developed in 5 patients (22.7%). No statistically significant differences were found between the groups.

CONCLUSIONS

Shortened treatment regimens for CDI with vancomycin and fidaxomicin were shown to be effective in our cohort of patients compared with 10 days of treatment. The recurrence rate was lower in the study group. A larger, prospective, double-blind, randomized, multicentre study is needed to support our findings.

Diagnostic tools for fecal incontinence: Scoring systems are the crucial first step

The main aim of this editorial is to comment on the recent article published by Garg et al in the World Journal of Gastroenterology 2023; 29: 4593-4603. This original research presents a new scoring system for fecal incontinence. Fecal incontinence is a chronic disease with a severe impact on the quality of life of the patients. Substantial social stigmatization often leads to significant underreporting of the condition even during visits to a specialist and could lead to further mismanagement or non-existent management of the disease. An important fact is that patients are often unable to describe their condition when not asked precisely defined questions. This problem is partially resolved by scoring questionnaires. Several scoring systems are commonly used; however, each of them has their shortcomings. For example, the absence of different kinds of leakage besides flatus and stool could further lead to underscoring the incontinence severity. Therefore, there has long been a call for a more precise scoring system. The correct identification of the presence and severity of fecal incontinence is paramount for further diagnostic approach and for choosing the appropriate therapy option. This editorial describes fecal incontinence, its effect on quality of life in general and further evaluates the diagnostic approach with a particular focus on symptom scoring systems and their implications for clinical practice.

Persistence of Metabolomic Changes in Patients during Post-COVID Phase: A Prospective, Observational Study

Several relatively recently published studies have shown changes in plasma metabolites in various viral diseases such as Zika, Dengue, RSV or SARS-CoV-1. The aim of this study was to analyze the metabolome profile of patients during acute COVID-19 approximately one month after the acute infection and to compare these results with healthy (SARS-CoV-2-negative) controls. The metabolome analysis was performed by NMR spectroscopy from the peripheral blood of patients and controls. The blood samples were collected on 3 different occasions (at admission, during hospitalization and on control visit after discharge from the hospital). When comparing sample groups (based on the date of acquisition) to controls, there is an indicative shift in metabolomics features based on the time passed after the first sample was taken towards controls. Based on the random forest algorithm, there is a strong discriminatory predictive value between controls and different sample groups (AUC equals 1 for controls versus samples taken at admission, Mathew correlation coefficient equals 1). Significant metabolomic changes persist in patients more than a month after acute SARS-CoV-2 infection. The random forest algorithm shows very strong discrimination (almost ideal) when comparing metabolite levels of patients in two various stages of disease and during the recovery period compared to SARS-CoV-2-negative controls.

Phenomenon of hypoglycemia unawareness in patients with insulinoma - single center experience

INTRODUCTION

Insulinomas are rare neuroendocrine tumors of pancreas. Clinical manifestations include various symptoms of hypoglycemia, which is the result of insulin overproduction. Symptoms of hypoglycemia are heterogenous what most probably contributes to diagnostic delay. In this study we retrospectively evaluated clinical features of hypoglycemia. We discovered that a substantial number of patients suffered from hypoglycemia unawareness.

MATERIALS AND METHODS

We performed retrospective analysis of prospectively collected patients with histologically confirmed insulinoma. We evaluated clinical features and signs of hypoglycemia and the duration of symptoms and performed thorough review of the patients' files in order to identify whether patients had been falsely diagnosed previously. Each patient underwent 72 hour fasting test during which levels of immunoreactive insulin (IRI), C-peptide and nadir blood glucose level were obtained. Based on the clinical findings and results of 72 hour fasting test we identified a subgroup of patients with hypoglycemia unawareness. These had an episode of clinically silent hypoglycemia. We compared IRI and C-peptide levels obtained at the time of the fasting test termination in the unawareness group and the group without hypoglycemia unawareness.

RESULTS

Twenty two patients with insulinoma that had been hospitalized in our tertiary center were included in the analysis. Mean age was 51±16.7 years. The most common symptom reported by 63.6% of patients was fatigue, followed by increased appetite with consequent weight gain and the loss of consciousness, both reported by 40.9% of patients. Based on the review of clinical features and the results of the fasting test we identified a group of patients with hypoglycemia unawareness. We labeled the patient accordingly in case of the loss of consciousness in personal history as well as asymptomatic hypoglycemia or severe neuroglycopenic symptoms during the fasting test without any accompanying or preceding clinical signs. There were 7 patients with hypoglycemia unawareness in our cohort (31.8%). Patients with this phenomenon had significantly lower levels of both IRI (2.35±1.25 vs. 5.88±3.92ng/ml, p=0.01) and C-peptide (9.14±7.36 vs. 50±42.8 µU/ml, p=0.01) than the rest of the patients. Nadir blood glucose level during the fasting test showed no significant difference (9.4±8.2 vs. 12.2±8.2 months, p=0.28) in the unawareness group and the rest of the patients, respectively.

CONCLUSION

We described the phenomenon of unawareness to hypoglycemia in the patients with insulinoma. This has not been recognized in insulinoma patients yet since available evidence mostly relates to type I diabetic patients. It might lead to higher morbidity and diagnostic delay. Further studies with prospective evaluation should be performed to further confirm relatively high prevalence in patients with insulinoma.

USB capsule endoscope for retrograde imaging of the esophagus

SIGNIFICANCE

Endoscopes represent electro-optical devices that are used to visualize internal body cavities. The specialized endoscopic procedure of the upper gastrointestinal tract from the esophagus down to the duodenum is called an esophagogastroduodenoscopy.

AIM

We bring our newly developed capsule endoscopy device as a promising alternative diagnostic method for visualization of the upper gastrointestinal tract.

APPROACH

Capsule endoscopy has become an attractive method that uses a tiny wireless camera to take pictures of the digestive tract. Existing esophageal capsule endoscopy does not allow a retrograde view of the esophagus while retrograde scanning can provide information on the esophageal pathology.

RESULTS

In comparison to the existing esophageal capsule endoscopy, our system is much simpler and cheaper due to the need for fewer electronic devices. Moreover, its use is not limited by the capacity of the batteries used by existing capsule endoscopes. The new esophageal endoscopic system was created by combining the universal serial bus (USB) endoscope module with the thin power wires that are routed through the USB port to the computer.

CONCLUSIONS

The endoscope was tested on a volunteer without any side effects such as nausea, belching, and general discomfort. The examination of the patient is performed in a sitting position and the patient discomfort during the examination is minimal so it can be performed without anesthesia.

Comprehensive analysis of acidic pharyngeal reflux before and after proton pump inhibitor treatment in patients with suspected laryngopharyngeal reflux

OBJECTIVES

The usefulness of pharyngeal pH monitoring in patients with symptoms attributed to laryngopharyngeal reflux (LPR) has been questioned. One problem is the uncertainty whether the pharyngeal pH monitoring captures the aspects of LPR which are responsible for symptoms. We aimed to gain more insight into this problem by performing a comprehensive analysis of acidic pharyngeal reflux before and after the treatment with proton pump inhibitors (PPIs) in patients with suspected LPR.

METHODS

We used simultaneous pharyngeal and distal esophageal 24-hour pH/impedance monitoring to establish the gastroesophageal origin of pharyngeal reflux, and an unbiased approach to analysis by evaluating a whole range of pharyngeal reflux acidity (pH < 6, pH < 5.5, pH < 5.0, pH < 4.5 and pH < 4.0).

RESULTS

PPI treatment substantially (by ~50%) improved the symptoms attributed to LPR. In contrast, PPI did not reduce the number of pharyngeal reflux episodes or duration of pharyngeal acid exposure at any pH level. This was also true in a subgroup of patients considered to be good responders to PPI (symptoms improvement by ~75%). Furthermore, good responders did not have more acidic pharyngeal reflux than the patients who were less responsive to PPI.

CONCLUSIONS

PPI treatment did not reduce acidic pharyngeal reflux despite substantially improving the symptoms attributed to LPR. This may be because pharyngeal pH monitoring does not quantitatively capture the aspects of LPR responsible for symptoms or because acid causes the symptoms also by mechanisms other than LPR. Our results argue against the utility of pharyngeal pH monitoring in patients with suspected LPR.

The infusion of menthol into the esophagus evokes cold sensations in healthy subjects but induces heartburn in patients with gastroesophageal reflux disease (GERD)

Recent studies in animal models have reported that some afferent fibers innervating the esophagus express the cold receptor TRPM8. In the somatosensory system the stimulation of TRPM8 leads to cold sensations and in certain circumstances alleviates pain. It is therefore hypothesized in this paper that the esophageal infusion of the TRPM8 activator menthol evokes cold sensations from the esophagus and alleviates heartburn in humans. The esophageal infusion of menthol (3 mM, 20 min) evoked cold sensations in 11 of 12 healthy subjects. In striking contrast, the esophageal infusion of menthol evoked heartburn in 10 of 10 patients with gastroesophageal reflux disease (GERD). In healthy subjects the cold sensation evoked by menthol was perceived only as a minor discomfort as evaluated by the visual analog scale (VAS score 1.9 ± 0.3 on the scale 1-10). However, in patients with GERD the menthol-induced heartburn was perceived as painful (VAS score 5.6 ± 0.6, P < 0.01 compared to healthy subjects). It is concluded that the sensations evoked by esophageal infusion of menthol change from relatively nonpainful cold sensations in healthy subjects to painful heartburn sensations in patients with GERD. These qualitative and quantitative changes indicate substantial alterations in afferent signaling mediating sensations from the esophagus in patients with GERD.

Acidic Pharyngeal Reflux Does Not Correlate with Symptoms and Laryngeal Injury Attributed to Laryngopharyngeal Reflux

BACKGROUND

Laryngopharyngeal reflux (LPR) is suspected when the symptoms are attributed to the penetration of acidic gastroesophageal reflux (GER) into the larynx. However, the relationships between the intensity of LPR and symptoms and laryngeal injury have not been elucidated. Several factors confound the study of LPR, namely pH is monitored in the pharynx (pharyngeal reflux) but the pharyngeal acidity (pH) required to induce laryngeal injury is unknown, the GER origin of pharyngeal acid is not always established, and a recent treatment with proton pump inhibitors (PPI) confounds the analysis.

AIMS

We aimed to limit these confounding factors to analyze the relationship between LPR and symptoms and laryngeal injury.

METHODS

We used dual pharyngeal and distal esophageal 24-h pH/impedance monitoring to establish GER origin of pharyngeal reflux, we used an unbiased approach to analysis by evaluating a whole range of acidity (pH < 6, pH < 5.5, pH < 5.0, pH < 4.5 and pH < 4.0) in patients with suspected LPR without PPI for  > 30 days.

RESULTS

Pharyngeal reflux was (median[IQR]) 14[8-20.5] and 4[1.5-6.5] pharyngeal reflux episodes with pH < 6.0 and pH < 5.5, respectively. Pharyngeal reflux with pH < 5.0 was rare. Comprehensive analysis did not reveal any correlation between symptoms (reflux symptom index) or laryngeal injury (reflux finding score) and the number of pharyngeal reflux episodes or duration of pharyngeal acid exposure at any pH level.

CONCLUSION

Unbiased comprehensive approach did not reveal any relationship between acidic pharyngeal reflux and the symptoms or laryngeal injury attributed to LPR. Limited clinical usefulness of pharyngeal monitoring reported by others is unlikely due to confounding factors.

Idiopathic Pan-Colonic and Small-Intestine Varices

Idiopathic colonic varices represent a rare source of gastrointestinal haemorrhage with a presumed incidence around 0.0007%. Herein, we present a case of idiopathic colonic and small-intestine varices. According to our knowledge, this case report is the first description of both pan-colonic and small-intestine idiopathic varices of this extent. A young male patient without any previous notable medical history was admitted to the hospital because of massive enterorrhagia with haemodynamic instability. Colonoscopy revealed massive pan-colonic varices. After stabilization, numerous diagnostic procedures were performed in order to investigate the aetiology of pan-colonic varices without any explanation of the patient's condition. In addition, capsule endoscopy revealed varices through the whole length of the small intestine. The final diagnosis was idiopathic varices of the colon and small intestine. Because of the rapid clinical stabilization, the single incident of haemorrhage and the extension of the disease, a conservative approach was chosen (venotonics and β-blockers). During the 12-month follow-up period, the patient reported no gastrointestinal haemorrhage.

Studies on the regulation of transient lower esophageal sphincter relaxations (TLESRs) by acid in the esophagus and stomach

Transient lower esophageal sphincter relaxation (TLESR) is the major mechanism of gastroesophageal reflux, but the regulation of TLESR by stimuli in the esophagus is incompletely understood. We have recently reported that acid infusion in the esophagus substantially (by 75%) increased the number of meal-induced TLESR in healthy subjects. We concluded that the TLESR reflex triggered by gastric distention with meal was enhanced by the stimulation of esophageal nerves by acid. However, the possibilities that the acid infused into the esophagus acts after passing though lower esophageal sphincter in stomach to enhance TLESR, or that the acid directly initiates TLESR from the esophagus were not addressed. Here, we evaluated the effect of acid infusion into the proximal stomach on meal-induced TLESR (study 1) and the ability of acid infusion into the esophagus to initiate TLESR without prior meal (study 2). We analyzed TLESRs by using high-resolution manometry in healthy subjects in paired randomized studies. In study 1, we found that acid infusion into the proximal stomach did not affect TLESRs induced by standard meal. The number of meal-induced TLESRs following the acid infusion into the proximal stomach was similar to the number of meal-induced TLESRs following the control infusion. In study 2, we found that acid infusion into the esophagus without prior meal did not initiate TLESRs. We conclude that the increase in the meal-induced TLESRs by acid in the esophagus demonstrated in our previous study is not attributable to the action of acid in the stomach or to direct initiation of TLESR from the esophagus by acid. Our studies are consistent with the concept that the stimuli in the esophagus can influence TLESRs. The enhancement of TLESR by acid in the esophagus may contribute to pathogenesis of gastroesophageal reflux in some patients.