Proton pump inhibitors as a risk factor for recurrence of Clostridium-difficile-associated diarrhea.

World J Gastroenterol. 2010 Jul 28;16(28):3573-7

Authors: Kim JW, Lee KL, Jeong JB, Kim BG, Shin S, Kim JS, Jung HC, Song IS

To investigate the risk factors for Clostridium-difficile-associated diarrhea (CDAD) recurrence, and its relationship with proton pump inhibitors (PPIs).

PMID: 20653067 [PubMed - indexed for MEDLINE]

[Read more →]

Benefit of combination ?-blocker and endoscopic treatment to prevent variceal rebleeding: A meta-analysis.

World J Gastroenterol. 2010 Dec 21;16(47):5982-92

Authors: Funakoshi N, Ségalas-Largey F, Duny Y, Oberti F, Valats JC, Bismuth M, Daurès JP, Blanc P

To determine whether the association of ?-blockers with endoscopic treatment is superior to endoscopic treatment alone for the secondary prophylaxis of oesophageal variceal bleeding.

PMID: 21157975 [PubMed - in process]

[Read more →]

PPIs are not associated with a lower incidence of portal-hypertension-related bleeding in cirrhosis.

World J Gastroenterol. 2010 Dec 14;16(46):5869-5873

Authors: Garcia-Saenz-de-Sicilia M, Sanchez-Avila F, Chavez-Tapia NC, Lopez-Arce G, Garcia-Osogobio S, Ruiz-Cordero R, Tellez-Avila FI

AIM: To determine if proton pump inhibitor use in cirrhotic patients with endoscopic findings of portal hypertension is associated with a lower frequency of gastrointestinal bleeding. METHODS: Patients with cirrhosis and endoscopic findings related to portal hypertension, receiving or not receiving proton pump inhibitor (PPI) therapy, were included retrospectively. We assigned patients to two groups: group 1 patients underwent PPI therapy and group 2 patients did not undergo PPI therapy. RESULTS: One hundred and five patients with a median age of 58 (26-87) years were included, 57 (54.3%) of which were women. Esophageal varices were found in 82 (78%) patients, portal hypertensive gastropathy in 72 (68.6%) patients, and gastric varices in 15 (14.3%) patients. PPI therapy was used in 45.5% of patients (n = 48). Seventeen (16.1%) patients presented with upper gastrointestinal bleeding; in 14/17 (82.3%) patients, bleeding was secondary to esophageal varices, and in 3/17 patients bleeding was attributed to portal hypertensive gastropathy. Bleeding related to portal hypertension according to PPI therapy occurred in 18.7% (n = 9) of group 1 and in 14% (n = of group 2 (odds ratio: 0.83, 95% confidence interval: 0.5-1.3, P = 0.51). CONCLUSION: Portal hypertension bleeding is not associated with PPI use. These findings do not support the prescription of PPIs in patients with chronic liver disease with no currently accepted indication.

PMID: 21155009 [PubMed - as supplied by publisher]

[Read more →]

Non-steroidal anti-inflammatory drugs: What is the actual risk of liver damage?

World J Gastroenterol. 2010 Dec 7;16(45):5651-61

Authors: Bessone F

Non-steroidal anti-inflammatory drugs (NSAIDs) constitute a family of drugs, which taken as a group, represents one of the most frequently prescribed around the world. Thus, not surprisingly NSAIDs, along with anti-infectious agents, list on the top for causes of Drug-Induced Liver Injury (DILI). The incidence of liver disease induced by NSAIDs reported in clinical studies is fairly uniform ranging from 0.29/100 000 [95% confidence interval (CI): 0.17-051] to 9/100 000 (95% CI: 6-15). However, compared with these results, a higher risk of liver-related hospitalizations was reported (3-23 per 100 000 patients). NSAIDs exhibit a broad spectrum of liver damage ranging from asymptomatic, transient, hyper-transaminasemia to fulminant hepatic failure. However, under-reporting of asymptomatic, mild cases, as well as of those with transient liver-tests alteration, in conjunction with reports non-compliant with pharmacovigilance criteria to ascertain DILI and flawed epidemiological studies, jeopardize the chance to ascertain the actual risk of NSAIDs hepatotoxicity. Several NSAIDs, namely bromfenac, ibufenac and benoxaprofen, have been withdrawn from the market due to hepatotoxicity; others like nimesulide were never marketed in some countries and withdrawn in others. Indeed, the controversy concerning the actual risk of severe liver disease persists within NSAIDs research. The present work intends (1) to provide a critical analysis of the dissimilar results currently available in the literature concerning the epidemiology of NSAIDS hepatotoxicity; and (2) to review the risk of hepatotoxicity for each one of the most commonly employed compounds of the NSAIDs family, based on past and recently published data.

PMID: 21128314 [PubMed - in process]

[Read more →]

Predictors of rebleeding after initial hemostasis with epinephrine injection in high-risk ulcers.

World J Gastroenterol. 2010 Nov 21;16(43):5490-5495

Authors: Hu ML, Wu KL, Chiu KW, Chiu YC, Chou YP, Tai WC, Hu TH, Chiou SS, Chuah SK

AIM: To identify the predictors of rebleeding after initial hemostasis with epinephrine injection (EI) in patients with high-risk ulcers. METHODS: Recent studies have revealed that endoscopic thermocoagulation, or clips alone or combined with EI are superior to EI alone to arrest ulcer bleeding. However, the reality is that EI monotherapy is still common in clinical practice. From October 2006 to April 2008, high-risk ulcer patients in whom hemorrhage was stopped after EI monotherapy were studied using clinical, laboratory and endoscopic variables. The patients were divided into 2 groups: sustained hemostasis and rebleeding. RESULTS: A total of 175 patients (144, sustained hemostasis; 31, rebleeding) were enrolled. Univariate analysis revealed that older age (? 60 years), advanced American Society of Anesthesiology (ASA) status (category III, IV and V), shock, severe anemia (hemoglobin < 80 g/L), EI dose ? 12 mL and severe bleeding signs (SBS) including hematemesis or hematochezia were the factors which predicted rebleeding. However, only older age, severe anemia, high EI dose and SBS were independent predictors. Among 31 rebleeding patients, 10 (32.2%) underwent surgical hemostasis, 15 (48.4%) suffered from delayed hemostasis causing major complications and 13 (41.9%) died of these complications. CONCLUSION: Endoscopic EI monotherapy in patients with high-risk ulcers should be avoided. Initial hemostasis with thermocoagulation, clips or additional hemostasis after EI is mandatory for such patients to ensure better hemostatic status and to prevent subsequent rebleeding, surgery, morbidity and mortality.

PMID: 21086569 [PubMed - as supplied by publisher]

[Read more →]

Terlipressin and hepatorenal syndrome: What is important for nephrologists and hepatologists.

World J Gastroenterol. 2010 Nov 7;16(41):5139-47

Authors: Magan AA, Khalil AA, Ahmed MH

Hepatorenal syndrome (HRS) is a reversible form of functional renal failure that occurs with advanced hepatic cirrhosis and liver failure. Despite mounting research in HRS, its etiology and medical therapy has not been resolved. HRS encompasses 2 distinct types. Type 1 is characterized by the rapid development of renal failure that occurs within 2 wk and involves a doubling of initial serum creatinine. Type 2 has a more insidious onset and is often associated with ascites. Animal studies have shown that both forms, in particular type 1 HRS, are often precipitated by bacterial infections and circulatory changes. The prognosis for HRS remains very poor. Type 1 and 2 both have an expected survival time of 2 wk and 6 mo, respectively. Progression of liver cirrhosis and the resultant portal hypertension leads to the pooling of blood in the splanchnic vascular bed. The ensuing hyperdynamic circulation causes an ineffective circulatory volume which subsequently activates neurohormonal systems. Primarily the sympathetic nervous system and the renin angiotensin system are activated, which, in the early stages of HRS, maintain adequate circulation. Both advanced cirrhosis and prolonged activation of neurohormonal mechanisms result in fatal complications. Locally produced nitric oxide may have the potential to induce a deleterious vasodilatory effect on the splanchnic circulation. Currently medical therapy is aimed at reducing splanchnic vasodilation to resolve the ineffective circulation and maintain good renal perfusion pressure. Terlipressin, a vasopressin analogue, has shown potential benefit in the treatment of HRS. It prolongs both survival time and has the ability to reverse HRS in the majority of patients. In this review we aim to focus on the pathogenesis of HRS and its treatment with terlipressin vs other drugs.

PMID: 21049548 [PubMed - in process]

[Read more →]

Alcoholic hepatitis 2010: A clinician’s guide to diagnosis and therapy.

World J Gastroenterol. 2010 Oct 21;16(39):4905-12

Authors: Amini M, Runyon BA

Alcoholic hepatitis (AH) remains a common and life threatening cause of liver failure, especially when it is severe. Although the adjective “acute” is frequently used to describe this form of liver injury, it is usually subacute and has been developing for weeks to months before it becomes clinically apparent. Patients with this form of alcoholic liver disease usually have a history of drinking heavily for many years. While certain aspects of therapy, mainly nutritional support and abstinence are well established, significant debate has surrounded the pharmacologic treatment of AH, and many institutions practice widely varying treatment protocols. In recent years a significant amount of literature has helped focus on the details of treatment, and more data have accumulated regarding risks and benefits of pharmacologic treatment. In particular, the efficacy of pentoxifylline has become increasingly apparent, and when compared with the risks associated with prednisolone, has brought this drug to the forefront of therapy for severe AH. This review will focus on the clinical and laboratory diagnosis and pharmacologic therapies that should be applied during hospitalization and continued into outpatient management. We conclude that the routine use of glucocorticoids for severe AH poses significant risk with equivocal benefit, and that pentoxifylline is a better, safer and cheaper alternative. While the full details of nutritional support lie beyond the scope of this article, nutrition is a cornerstone of therapy and must be addressed in every patient diagnosed with AH. Finally, while traditional psychosocial techniques play a major role in post-hospitalization care of alcoholics, we hope to make the medical clinician realize his or her role in reducing recidivism rates with early and frequent outpatient visits and with the use of baclofen to reduce alcohol craving.

PMID: 20954276 [PubMed - in process]

[Read more →]

Clostridium difficile infection and inflammatory bowel disease: Understanding the evolving relationship.

World J Gastroenterol. 2010 Oct 21;16(39):4892-904

Authors: Navaneethan U, Venkatesh PG, Shen B

Clostridium difficile (C. difficile) infection (CDI) is the leading identifiable cause of antibiotic-associated diarrhea. While there is an alarming trend of increasing incidence and severity of CDI in the United States and Europe, superimposed CDI in patients with inflammatory bowel disease (IBD) has drawn considerable attention in the gastrointestinal community. The majority of IBD patients appear to contract CDI as outpatients. C. difficile affects disease course of IBD in several ways, including triggering disease flares, sustaining activity, and in some cases, acting as an “innocent” bystander. Despite its wide spectrum of presentations, CDI has been reported to be associated with a longer duration of hospitalization and a higher mortality in IBD patients. IBD patients with restorative proctocolectomy or with diverting ileostomy are not immune to CDI of the small bowel or ileal pouch. Whether immunomodulator or corticosteroid therapy for IBD should be continued in patients with superimposed CDI is controversial. It appears that more adverse outcomes was observed among patients treated by a combination of immunomodulators and antibiotics than those treated by antibiotics alone. The use of biologic agents does not appear to increase the risk of acquisition of CDI. For CDI in the setting of underlying IBD, vancomycin appears to be more efficacious than metronidazole. Randomized controlled trials are required to clearly define the appropriate management for CDI in patients with IBD.

PMID: 20954275 [PubMed - in process]

[Read more →]

Role of endoscopic ultrasound during hospitalization for acute pancreatitis.

World J Gastroenterol. 2010 Oct 21;16(39):4888-91

Authors: Kotwal V, Talukdar R, Levy M, Vege SS

Endoscopic ultrasound (EUS) is often used to detect the cause of acute pancreatitis (AP) after the acute attack has subsided. The limited data on its role during hospitalization for AP are reviewed here. The ability of EUS to visualize the pancreas and bile duct, the sonographic appearance of the pancreas, correlation of such appearance to clinical outcomes and the impact on AP management are analyzed from studies. The most important indication for EUS appears to be for detection of suspected common bile duct and/or gall bladder stones and microlithiasis. Such an approach might avoid diagnostic endoscopic retrograde cholangio-pancreatography with its known complications. The use of EUS during hospitalization for AP still appears to be infrequent but may become more frequent in future.

PMID: 20954274 [PubMed - in process]

[Read more →]

Diagnosis and management of interstitial pneumonitis associated with interferon therapy for chronic hepatitis C.

World J Gastroenterol. 2010 Sep 21;16(35):4394-4399

Authors: Ji FP, Li ZX, Deng H, Xue HA, Liu Y, Li M

Interstitial pneumonitis (IP) is an uncommon pulmonary complication associated with interferon (IFN) therapy for chronic hepatitis C virus (HCV) infection. Pneumonitis can occur at any stage of HCV treatment, ranging from 2 to 48 wk, usually in the first 12 wk. Its most common symptoms are dyspnoea, dry cough, fever, fatigue, arthralgia or myalgia, and anorexia, which are reversible in most cases after cessation of IFN therapy with a mean subsequent recovery time of 7.5 wk. Bronchoalveolar lavage in combination with chest high resolution computed tomography has a high diagnostic value. Prompt discontinuation of medication is the cornerstone, and corticosteroid therapy may not be essential for patients with mild-moderate pulmonary functional impairment. The severity of pulmonary injury is associated with the rapid development of IP. We suggest that methylprednisolone pulse therapy followed by low dose prednisolone for a short term is necessary to minimize the risk of fatal pulmonary damage if signs of significant pulmonary toxicity occur in earlier stage. Clinicians should be aware of the potential pulmonary complication related to the drug, so that an early and opportune diagnosis can be made.

PMID: 20845505 [PubMed - as supplied by publisher]

[Read more →]

ESWL for difficult bile duct stones: A 15-year single centre experience.

World J Gastroenterol. 2010 Sep 7;16(33):4159-63

Authors: Muratori R, Azzaroli F, Buonfiglioli F, Alessandrelli F, Cecinato P, Mazzella G, Roda E

AIM: To evaluate the efficacy of extracorporeal shock wave lithotripsy (ESWL) for the management of refractory bile duct cholelithiasis in a third level referral centre. METHODS: The clinical records of all patients treated with a second generation electromagnetic lithotripter (Lithostar Plus, SIEMENS) from October 1990 to April 2005 were evaluated. All patients were monitored during the procedure and antibiotics were administered in case of cholangitis. The chi(2) test and logistic regression analysis were performed as appropriate. RESULTS: Two hundred and fourteen patients (102 males, 112 females; mean age 74.8 +/- 0.84 years – single stone 97, multiple stones 117) underwent ESWL. The mean number of sessions and shock waves were 3.5 +/- 0.13 and 3477.06 +/- 66.17, respectively. The maximum stone size was 5 cm. Complete stone clearance was achieved in 192 (89.7%) patients. Of the remaining patients 15 required surgery, 2 a palliative stent and in 5 patients stone fragmentation led to effective bile drainage with clinical resolution despite incomplete clearance. Age, sex and stone characteristics were not related to treatment outcome. Major complications occurred in two patients (haemobilia and rectal bleeding) and minor complications in 25 (3 vomiting, 22 arrhythmias). No procedure-related deaths occurred. CONCLUSION: ESWL is a safe and effective technique for clearance of refractory bile duct stones.

PMID: 20806432 [PubMed - in process]

[Read more →]

Use of pre-, pro- and synbiotics in patients with acute pancreatitis: A meta-analysis.

World J Gastroenterol. 2010 Aug 21;16(31):3970-8

Authors: Zhang MM, Cheng JQ, Lu YR, Yi ZH, Yang P, Wu XT

AIM: To assess the clinical outcomes of pre-, pro- and synbiotics therapy in patients with acute pancreatitis. METHODS: The databases including Medline, Embase, the Cochrane Library, Web of Science and Chinese Biomedicine Database were searched for all relevant randomized controlled trials that studied the effects of pre-, pro- or synbiotics in patients with acute pancreatitis. Main outcome measures were postoperative infections, pancreatic infections, multiple organ failure (MOF), systemic inflammatory response syndrome (SIRS), length of hospital stay, antibiotic therapy and mortality. RESULTS: Seven randomized studies with 559 acute pancreatic patients were included. Pre-, pro- or synbiotics treatment showed no influence on the incidence of postoperative infections [odds ratios (OR) 0.30, 95% confidence interval (CI): 0.09-1.02, P = 0.05], pancreatic infection (OR 0.50, 95% CI: 0.12-2.17, P = 0.36), MOF (OR 0.88, 95% CI: 0.35-2.21, P = 0.79) and SIRS (OR 0.78, 95% CI: 0.20-2.98, P = 0.71). There were also no significant differences in the length of antibiotic therapy (OR 0.75, 95% CI: 0.50 – 1.14, P = 0.18) and the mortality (OR 0.75, 95% CI: 0.25-2.24, P = 0.61). However, Pre-, pro- or synbiotics treatment was associated with a reduced length of hospital stay (OR -3.87, 95% CI: -6.20 to -1.54, P = 0.001). When stratifying for the severity of acute pancreatitis, the main results were similar. CONCLUSION: Pre-, pro- or synbiotics treatment shows no significant influence on patients with acute pancreatitis. There is a lack of evidence to support the use of probiotics/synbiotics in this area.

PMID: 20712060 [PubMed - in process]

[Read more →]

Nasogastric or nasointestinal feeding in severe acute pancreatitis.

World J Gastroenterol. 2010 Aug 7;16(29):3692-6

Authors: Piciucchi M, Merola E, Marignani M, Signoretti M, Valente R, Cocomello L, Baccini F, Panzuto F, Capurso G, Delle Fave G

AIM: To assess the rate of spontaneous tube migration and to compare the effects of naso-gastric and naso-intestinal (NI) (beyond the ligament of Treitz) feeding in severe acute pancreatitis (SAP). METHODS: After bedside intragastric insertion, tube position was assessed, and enteral nutrition (EN) started at day 4, irrespective of tube localization. Patients were monitored daily and clinical and laboratory parameters evaluated to compare the outcome of patients with nasogastric (NG) or NI tube. RESULTS: Spontaneous tube migration to a NI site occurred in 10/25 (40%) prospectively enrolled SAP patients, while in 15 (60%) nutrition was started with a NG tube. Groups were similar for demographics and pancreatitis aetiology but computed tomography (CT) severity index was higher in NG tube patients than in NI (mean 6.2 vs 4.7, P = 0.04). The CT index seemed a risk factor for failed obtainment of spontaneous distal migration. EN trough NG or NI tube were similar in terms of tolerability, safety, clinical goals, complications and hospital stay. CONCLUSION: Spontaneous distal tube migration is successful in 40% of SAP patients, with higher CT severity index predicting intragastric retention; in such cases EN by NG tubes seems to provide a pragmatic alternative opportunity with similar outcomes.

PMID: 20677342 [PubMed - in process]

[Read more →]

Changing face of hepatic encephalopathy: Role of inflammation and oxidative stress.

World J Gastroenterol. 2010 Jul 21;16(27):3347-57

Authors: Seyan AS, Hughes RD, Shawcross DL

The face of hepatic encephalopathy (HE) is changing. This review explores how this neurocognitive disorder, which is associated with both acute and chronic liver injury, has grown to become a dynamic syndrome that spans a spectrum of neuropsychological impairment, from normal performance to coma. The central role of ammonia in the pathogenesis of HE remains incontrovertible. However, over the past 10 years, the HE community has begun to characterise the key roles of inflammation, infection, and oxidative/nitrosative stress in modulating the pathophysiological effects of ammonia on the astrocyte. This review explores the current thoughts and evidence base in this area and discusses the potential role of existing and novel therapies that might abrogate the oxidative and nitrosative stresses inflicted on the brain in patients with, or at risk of developing, HE.

PMID: 20632436 [PubMed - in process]

[Read more →]

Endoscopic ultrasound for the diagnosis of chronic pancreatitis.

World J Gastroenterol. 2010 Jun 21;16(23):2841-50

Authors: Stevens T, Parsi MA

Endoscopic ultrasound (EUS) has become a well accepted test for the diagnosis of chronic pancreatitis. Advantages include its ability to detect subtle and severe changes of the pancreatic duct and parenchyma, and its relative safety compared with endoscopic retrograde cholangiopancreatography. Limitations include inter- and intra-observer variability, operator dependence, and an incomplete understanding of its true accuracy. The Rosemont classification has recently been proposed as a weighted, standardized method that may improve EUS chronic pancreatitis scoring. This paper reviews the published evidence regarding the accuracy of EUS in chronic pancreatitis diagnosis, and enumerates the emerging technologies that have been recently studied which may ultimately improve endosonographic imaging of the pancreas.

PMID: 20556829 [PubMed - in process]

[Read more →]