Gastrointest. Disord., Volume 5, Issue 3 (September 2023) – 11 articles

Background: Neuroendocrine tumors (NET) are a rare group of epithelial neoplasms present in the gastrointestinal tract (GI) (67.5%) and bronchopulmonary tree (25.3–30%), and in 15% of cases, their primary sites cannot be identified. Although endoscopic screening, improvements in pathological techniques, and early detection have shown improvements in NET survival rates, the prognosis of advanced, metastatic, and poorly differentiated NET is very poor. In this study, we aimed to evaluate the effect of gastrointestinal and pancreatic (GEPs) NETs’ grade on overall survival. Method: We searched observational studies describing the overall survival or prognostic factors of primary GEP NETs from May 2011–May 2021 following the PRISMA guidelines. Studies describing the effect of primary grade 3 GEP NETs on overall survival were included. A meta-analysis was performed, and a pooled hazard ratio and their 95% confidence interval (95% CI) were obtained. Forest plots were created using random effects models and a sensitivity analysis was performed to account for the heterogeneity. Results: Seven studies with 7692 confirmed patients were included. In our meta-analysis, grade 3 GEP NETs were associated with higher odds of poor survival (pooled HR: 2.73; 95% CI: 1.36–5.47; p = 0.005), with a 92% heterogeneity between studies (p < 0.0001). To account for this heterogeneity, a sensitivity analysis was performed by removing two outlying studies (Fathi et al. and Foubert et al.) on funnel plots. The results after the sensitivity analysis did not change and still showed a significant association of grade 3 with a poor survival (pooled HR: 4.53; 95% CI: 3.54–5.78; p < 0.00001), with no heterogeneity between studies (p = 0.72; I² = 0%). Conclusions: Our meta-analysis found that grade 3 GEP NETs are associated with poor survival and additional future studies are needed to identify other risk factors associated with poor survival in GEP NETs to improve their mortality. Full article

Background: Anastomotic leakage, which is defined as a defect in the integrity of a surgical join between two hollow viscera leading to communication between the intraluminal and extraluminal compartments, continues to be of high incidence and one of the most feared complications following gastrointestinal surgery, with a significant potential for a fatal outcome. Surgical options for management are limited and carry a high risk of morbidity and mortality; thus, surgeons are urged to look for alternative options which are minimally invasive, repeatable, non-operative, and do not require general anesthesia. Methods: A narrative review of the international literature took place, including PubMed, Scopus, and Google Scholar, utilizing specific search terms such as “Digestive Surgery AND Anastomotic Leakage OR leak OR dehiscence”. Results: In the present review, we try to describe and analyze the pros and cons of the various endoscopic techniques: from the very first (and still available), fibrin gluing, to endoclip and over-the-scope clip positioning, stent insertion, and the latest suturing and endoluminal vacuum devices. Finally, alongside efforts to improve the existing techniques, we consider stem cell application as well as non-endoscopic, and even endoscopic, attempts at intraluminal microbiome modification, which should ultimately intervene pre-emptively, rather than therapeutically, to prevent leaks. Conclusions: In the last three decades, this search for an ideal device for closure, which must be safe, easy to deploy, inexpensive, robust, effect rapid and stable closure of even large defects, and have a low complication rate, has led to the proposal and application of a number of different endoscopic devices and techniques. However, to date, there is no consensus as to the best. The literature contains reports of only small studies and no randomized trials, failing to take into account both the heterogeneity of leaks and their different anatomical sites. Full article

It is estimated that there are about 500,000 Turkish people living in the UK, of whom about 300,000 are of Cypriot origin. A Freedom of Information request was sent to the four NHS Trusts in London which served areas with significant Turkish communities. The request sought information on the total number of patients admitted between 2016 and 2020 with inflammatory bowel disease. Between 2016 and 2020, 1936 patients with inflammatory bowel disease were admitted to North Middlesex University Hospital NHS Trust. Some of these patients will have been readmitted in different years, leading to an inflation of the overall number. The average number of cases admitted each year was approximately 387. The proportion of White British patients with ulcerative colitis was 0.4; for Turkish Cypriots, it was 0.43 and for Turkish patients, 0.45. A z test comparison of these proportions showed that there was no difference between the Turkish communities (z = 0.52 ns) and no overall difference between White British and all Turkish patients (z = −1.5, ns). Between 2016 and 2020, the Homerton Healthcare Foundation Trust admitted 215 English patients with inflammatory bowel disease, of whom 113 had ulcerative colitis. Of the 26 Turkish patients, 4 had ulcerative colitis. The proportion of Turkish patients with Crohn’s disease was significantly greater than that amongst English patients (z = 3.58, p < 0.0003). In the context of the relatively large number of Turkish people with inflammatory bowel disease in both trusts, the absence of published work on the impact of these chronic diseases is of concern. The results from this investigation should prompt specific qualitative research into the Turkish experience in the UK following a diagnosis of inflammatory bowel disease with the intention of developing better patient-centred care. Full article

Approximately 20% of patients with ulcerative colitis (UC) develop acute severe UC (ASUC), for which intravenous systemic steroid therapy and possibly infliximab-based rescue therapy are generally imposed. However, there are no significant guideline recommendations on ASUC regarding vedolizumab as an alternative in this setting. A case report was presented where a patient with steroid-dependent UC developed ASUC induced by second-line chemotherapy. Treatment with intravenous methylprednisolone was imposed, but there was no reduction in bowel movements in the days following admission. Rescue therapy with infliximab was contraindicated because of the oncologic history. Surgical consultation, contraindicated colectomy, and administration of vedolizumab 300 mg were initiated. After infusion with vedolizumab, there was a significant reduction in bowel movements starting the day after infusion until normalisation of bowel movements within three days and the concomitant normalisation of inflammatory indices. The patient is currently in clinical remission, on therapy with vedolizumab 108 mg subcutaneously every two weeks, and is in oncologic follow-up for pulmonary neoplasm. This case highlights the novel potential of vedolizumab as a possible rescue therapy in ASUC, especially in special populations, where it may offer a better safety profile. Although cyclosporine and infliximab still represent the mainstays of salvage therapy for steroid-refractory ASUC, new therapeutic agents may also be effective, such as vedolizumab, ustekinumab, and anti-Janus kinase agents. Full article

Background: Technological advances in pediatric gastrointestinal (GI) endoscopy require highly specialized physicians. Therefore, proper training is fundamental. The aim of this study was to assess the level of competence of pediatric surgery residents to determine areas that should be addressed to design better training programs focused on pediatric GI endoscopy. Methods: An observational study was performed on all Italian pediatric surgery trainees that concluded the training program by the end of 2021, who were asked to answer a questionnaire about the quality of the GI endoscopy education received during their 5 years of residency. Results: 12 out 14 (86%) pediatric surgery trainees answered the questionnaire. A total of 50% (6/12) of the trainees declared they were interested in pediatric GI endoscopy, and 42% (5/12) said that they would be interested in dedicating themselves to this discipline in the future. Only 33% (4/12) of them were in a center equipped with endoscopy simulators. Among them, 17% (2/12) never took part in GI endoscopic procedures while working in centers in which GI endoscopy is performed exclusively by pediatric gastroenterologists, 25% (3/12) had never performed GI endoscopic procedures as a first operator and 17% (2/12) not even as assistant. Overall, 50% (6/12) were not satisfied with the level of education received and only 17% (2/12) declared that they felt confident enough to perform routine endoscopies alone. Conclusions: Our study highlights great inhomogeneity between different schools and some important failings. Better programs should be designed to educate proficient pediatric GI endoscopists. Full article

The COVID-19 pandemic caused by the SARS-CoV-2 virus has led to significant global health implications. Although the respiratory manifestations of COVID-19 are widely recognized, emerging evidence suggests that the disease may also significantly affect the gut microbiota, the intricate community of bacteria that lives within the gastrointestinal system. This extensive article intends to investigate the impact of COVID-19 on the gut microbiota, examining the underlying mechanisms, clinical implications, and potential therapeutic interventions. Understanding the complex interactions between COVID-19 and the gut microbiota will help us to gain valuable insights into the broader consequences of this viral infection on human health. Full article

This study aimed to investigate the relationship between chronic kidney disease (CKD) and different gastric diseases by conducting a population-based retrospective analysis using National Inpatient Sample (NIS) data. A total of 7,159,694 patients diagnosed with gastric diseases with or without CKD were included, and the diagnoses of gastritis, gastric polyps, peptic ulcer disease (PUD), and Helicobacter pylori infection were based on ICD-10-CM codes. The study found a higher prevalence of gastritis and gastric polyps in patients with CKD compared to patients without CKD, especially in the late stages of CKD. After adjustment, patients with CKD also had a higher risk of developing these gastric diseases than patients without CKD. However, there was no significant association between all stages of CKD and PUD or Helicobacter pylori infection. These results underscored the importance of monitoring gastric health in patients with CKD. Full article

Metoclopramide has been the cornerstone of gastroparesis management for the past 40 years as it is the only FDA-approved medication for gastroparesis. Other medications such as erythromycin and domperidone have been used off-label with variable efficacy. Historically, metoclopramide has been used in oral, intravenous, and subcutaneous formulations. It is an antiemetic and prokinetic medication that acts through the inhibition of central (chemoreceptor trigger zone) and peripheral dopaminergic and serotogenic receptors. Due to its antidopaminergic effects, extrapyramidal symptoms have been reported, with the most feared adverse event being tardive dyskinesia. Subsequently, the FDA issued a metoclopramide black box warning label in February 2009 due to its risk of causing tardive dyskinesia, which can be irreversible. The incidence and prevalence of tardive dyskinesia among metoclopramide users have been variable in different studies. However, upon review of the current literature, the true prevalence of tardive dyskinesia seems to be lower than previously thought. This review will focus on metoclopramide and the extrapyramidal symptoms associated with its use. Full article

Alarm symptoms are widely used in pediatric gastroenterology to discern when abdominal pain needs further workup. Despite wide use, the data supporting the validity of these symptoms are not well established. This study explored one alarm symptom—nighttime waking with pain—and its associations with histologic inflammation of the upper gastrointestinal tract, psychological dysfunction, and disordered sleep. This retrospective study evaluated 240 patients with abdominal pain-related disorders of the gut–brain axis (AP-DGBI). Patients underwent questionnaires related to sleep disturbance, behavioral assessment, and gastrointestinal symptoms, including Rome IV criteria for AP-DGBI. Routine upper endoscopy with standardized biopsies was performed in 205 patients. Endoscopy results showed no association between esophageal, gastric, or duodenal histologic inflammation and nighttime waking with pain. Nocturnal pain was associated with increased scores for both psychological and sleep disorders, including social stress, depression, disorders of initiation and maintenance of sleep (DIMS), disorders of daytime somnolence (DOES), and sleep hyperhidrosis (SHY). This study concluded that nocturnal pain is not a reliable predictor of upper gastrointestinal inflammation but may be a prognosticator for psychological distress and sleep disturbances. Full article

Gut dysbiosis presents in many digestive diseases. The aim of this study is to investigate the composition of the gut microbiota and its metabolic activity in patients with diarrhea-predominant irritable bowel syndrome combined with functional dyspepsia (I + D). This study included 60 patients with I + D and 20 healthy controls. Gut microbiota composition was studied using 16S rRNA gene sequencing. The short-chain fatty acids (SCFAs) spectrum was determined via gas–liquid chromatography. Patients with I + D had an increase in the abundance of Holdemanella, Erysipelotrichaceae, Erysipelotrichales, Prevotellaceae, Agathobacter, Slackia, Lactococcus, Pseudomonadaceae, Stenotrophomonas, Xanthomonadaceae, Rhizobiaceae, Erysipelatoclostridiaceae, Lachnospiraceae, and other taxa in addition to a decrease in the abundance of Frisingicoccus, Ralstonia, Burkholderiaceae, Hungatella, Eisenbergiella, Parabacteroides, Peptostreptococcaceae, Merdibacter, Bilophila, Rikenellaceae, Tannerellaceae, Bacteroidaceae, and Flavonifractor in comparison to controls. Patients with I + D showed significantly higher total SCFA content in feces; increased absolute content of acetic acid, propionic acid, butyric acid, and isoacids; and a significant negative shift in the anaerobic index. The relative levels of the main SCFAs and isoacids in the patient group did not differ significantly from those in the control group. The fecal acetate and isoacid levels correlated with the severity of diarrhea. The fecal butyrate level correlated with the severity of flatulence. Full article

Being two immune-mediated diseases (IMIDs), the association between multiple sclerosis (MS) and inflammatory bowel disease (IBD) is plausible, but data in the literature are conflicting. The aim of our study was to evaluate the possible association between IBD and MS in a cohort of patients with IBD. In a retrospective study, we examined the medical records of 5739 patients with a confirmed diagnosis of IBD followed in our clinic between 1978 and 2022. Among these patients, we identified 14 with MS, with a prevalence of 0.24%. The reported prevalence of MS in the general population in Northern Italy in 2021 was 0.18% (p = 0.24). For each of the patients with MS identified, more than ten patients without MS were analyzed. The 14 MS cases were then compared with 342 controls. From the 14 patients with MS, 12 (85.7%) were female and 2 (14.3%) were male, while in the control group, 158 (46.2%) were female and 184 (53.8%) were male (p = 0.004). As for therapy, significant differences were found in mesalazine (5 (41.7%) cases vs. 317 (92.7%) controls, p < 0.0001) and anti-TNF treatment (0% cases vs. 26.6% controls, p = 0.03, respectively) at the time of MS diagnosis. Moreover, a Kaplan–Meier curve analysis showed that the 20-year survival probability was 98.4% for patients with IBD, while for patients diagnosed with MS and IBD it was 82.1% (p = 0.02). In conclusion, patients with IBD have a similar risk of developing MS compared to the general population, but female sex appears to increase the risk. Indeed, life expectancy at 20 years for patients with IBD and MS is lower than for patients with IBD alone. Full article