Luckhoff H.K.,Stellenbosch University |
Kruger F.C.,Gastroenterology Unit |
Kotze M.J.,Stellenbosch University
World Journal of Hepatology | Year: 2015
Heterogeneity in clinical presentation, histological severity, prognosis and therapeutic outcomes characteristic of non-alcoholic fatty liver disease (NAFLD) necessitates the development of scientifically sound classification schemes to assist clinicians in stratifying patients into meaningful prognostic subgroups. The need for replacement of invasive liver biopsies as the standard method whereby NAFLD is diagnosed, graded and staged with biomarkers of histological severity injury led to the development of composite prognostic models as potentially viable surrogate alternatives. In the present article, we review existing scoring systems used to (1) confirm the presence of undiagnosed hepatosteatosis; (2) distinguish between simple steatosis and NASH; and (3) predict advanced hepatic fibrosis, with particular emphasis on the role of NAFLD as an independent cardio-metabolic risk factor. In addition, the incorporation of functional genomic markers and application of emerging imaging technologies are discussed as a means to improve the diagnostic accuracy and predictive performance of promising composite models found to be most appropriate for widespread clinical adoption. © 2015 Baishideng Publishing Group Inc.
Koulaouzidis A.,Royal Infirmary |
Rondonotti E.,Gastroenterology Unit |
Karargyris A.,U.S. National Institutes of Health
World Journal of Gastroenterology | Year: 2013
The introduction of capsule endoscopy (CE) in clinical practice increased the interest for the study of the small-bowel. Consequently, in about 10 years, an impressive quantity of literature on indications, diagnostic yield (DY), safety profile and technical evolution of CE has been published as well as several reviews. At present time, there are 5 small-bowel capsule enteroscopy (SBCE) models in the worldwide market. Head-to-head trials have showed in the great majority of studies comparable results in terms of D Y, image quality and completion rate. CE meta-analyses formed the basis of national/international guidelines; these guidelines place CE in a prime position for the diagnostic work-up of patients with obscure gastrointestinal bleeding, known and/or suspected Crohn's disease and possible small-bowel neoplasia. A 2-L polyethylene glycol-based purge, administered the day before the procedure, is the most widely practiced preparation regimen. Whether this regimen can be further improved (i.e., by further decreasing its volume, changing the timing of administration, coupling it with prokinetics and/or other factors) or if it can really affect the D Y, is still under discussion. Faecal calprotectin has been used in SBCE studies in two settings: in patients taking non-steroidal anti-inflammatory drugs, to evaluate the type and extent of mucosal damage and, more importantly from a clinical point of view, in patients with known or suspected Crohn's disease for assessment of inflammation activity. Although there is still a lot of debate around the exact reasons of SBCE poor performance in various small-bowel segments, it is worth to remember that the capsule progress is non-steerable, hence more rapid in the proximal than in lower segments of the small-bowel. Capsule aspiration, a relatively unexpected complication, has been reported with increasing frequency. This is probably related with the increase in the mean age of patients undergoing CE. CE video review is a time-consuming procedure. Therefore, several attempts have been made to develop technical software features, in order to make CE video analysis easier and shorter (without jeopardizing its accuracy). Suspected Blood Indicator, QuickView and Fujinon Intelligent Chromo Endoscopy are some of the software tools that have been checked in various clinical studies to date. © 2013 Baishideng. All rights reserved.
Koulaouzidis A.,Royal Infirmary |
Rondonotti E.,Gastroenterology Unit |
Giannakou A.,University of Bristol |
Plevris J.N.,Royal Infirmary
Gastrointestinal Endoscopy | Year: 2012
Background: Iron-deficiency anemia (IDA) is the most common cause of anemia worldwide. Current guidelines recommend the use of small-bowel capsule endoscopy (SBCE) in IDA. Evidence of the validity of SBCE in patients with IDA alone is still limited. Objective: To assess the diagnostic yield (DY) of SBCE in IDA by pooling data from relevant studies. Design: Systematic review and meta-analysis. Fixed-effects or random-effects models were used as appropriate. Setting: Studies that estimated the DY of SCBE in IDA were identified. Two investigators independently conducted the search and data extraction. Patients: A total of 24 studies enrolling 1960 patients with IDA who underwent SBCE were included. Main Outcome Measurements: Per-patient DY, with 95% confidence intervals. Subgroup analysis was also performed. Results: The pooled DY of SBCE in IDA, evaluated by a random-effects model, was 47% (95% CI, 42%-52%), but there was statistically significant heterogeneity among the included studies (inconsistency index [I2] = 78.8%, P < .0001). The pooled DY of SBCE in studies focused solely on patients with IDA (subset 1, 4 studies) was 66.6% (95% CI, 61.0%-72.3%; I2= 44.3%); conversely, that of studies not focusing only on IDA patients (subset 2, 20 studies) was 44% (95% CI, 39%-48%; I2= 64.9%). In particular, more vascular (31% vs 22.6%, P = .007), inflammatory (17.8% vs 11.3%, P = .009), and mass/tumor (7.95% vs 2.25%, P < .0001) lesions were detected with SBCE in patients participating in the studies in subset 1. Limitations: Heterogeneity of studies, retrospective design, and selection bias. Conclusions: This analysis demonstrates the validity of SBCE in the investigation of patients with IDA and negative findings on a previous diagnostic workup, although certain factors such as heterogeneity and quality of the included studies should be taken into account. Copyright © 2012 by the American Society for Gastrointestinal Endoscopy.
Gisbert J.P.,Hospital Universitario Of La Princesa |
Calvet X.,Gastroenterology Unit
Alimentary Pharmacology and Therapeutics | Year: 2011
Background A decrease in the Helicobacter pylori eradication rate after standard triple therapy has been suggested in recent years. Aim To assess the efficacy of standard triple therapy in the eradication of H. pylori through an epidemiological analysis of all published Spanish trials. A secondary aim was to review the prevalence of clarithromycin resistance in Spain. Methods Articles on H. pylori eradication in Spain published in peer-reviewed journals were identified through MEDLINE searches. Studies that included a triple therapy consisting of any proton pump inhibitor with clarithromycin (500 mg b.d.) and amoxicillin (1 g b.d.) for up to 14 days were selected. Spanish studies evaluating the prevalence of clarithromycin resistance were also reviewed. Meta-analysis was performed using the generic inverse variance method. Results The pooled eradication rates by year from Spanish studies evaluating the efficacy of the standard triple regimen revealed a relatively constant rate over the years. Overall, the analysis of the 32 studies (4727 patients) showed a mean H. pylori cure rate of 80% (95% CI = 77-82%) by intention-to-treat and 83% (81-86%) by per-protocol. When only peptic ulcer disease or 7-day regimens were considered, results were similar. Based on 13 studies (3293 patients), mean clarithromycin resistance rate was 8% (5-10%). Conclusion Although a decrease in the H. pylori eradication rate after triple therapy has been suggested in recent years, cure rates with this regimen did not change in Spain between 1997 and 2008. However, this by no means indicates that the efficacy of standard triple therapy in Spain is acceptable, as it has been calculated to be around only 80%. Therefore, it is evident that new strategies to improve first-line treatment are urgently needed. © 2011 Blackwell Publishing Ltd.
Basilisco G.,Gastroenterology Unit |
Coletta M.,University of Milan
Digestive and Liver Disease | Year: 2013
Chronic constipation is a very common symptom that is rarely associated with life-threatening diseases, but has a substantial impact on patient quality of life and consumption of healthcare resources. Despite the large number of affected patients and the social relevance of the condition, no cost-effectiveness analysis has been made of any diagnostic or therapeutic algorithm, and there are few data comparing different diagnostic and therapeutic approaches in the long term. In this scenario, increasing emphasis has been placed on demonstrating that a number of older and new therapeutic options are effective in treating chronic constipation in well-performed randomised controlled trials, but there is still debate as to when these therapeutic options should be included in diagnostic and therapeutic algorithms. The aim of this review is to perform a critical evaluation of the current diagnostic and therapeutic options available for adult patients with chronic constipation in order to identify a rational patient approach; furthermore we attempt to clarify some of the more controversial points to aid clinicians in managing this symptom in a more efficacious and cost-effective manner. © 2013 Editrice Gastroenterologica Italiana S.r.l.
Ponticelli C.,Scientific Institute Humanitas |
Colombo D.,Ospedale Luigi Marchesi |
Novara M.,Novartis |
Basilisco G.,Gastroenterology Unit
Transplant International | Year: 2010
We assessed patient- and physician-reported prevalence of gastrointestinal symptoms and their impact on quality of life (QOL) in Italian renal transplant recipients with stable graft function. Patients ≥18 years with a renal allograft functioning for ≥6 months and stable serum creatinine levels of <2.5 mgdl were enrolled. Physicians and patients completed an Italian translation of the Gastrointestinal Symptom Rating Scale (GSRS) and Gastrointestinal Quality of Life Index (GIQLI) questionnaires. The average time since transplantation (n = 1130) was 5.9 years. Forty-two immunosuppressant drug regimens were reported. The top three regimens (cyclosporinemycophenolate mofetilsteroids; tacrolimusmycophenolate mofetilsteroids; cyclosporinesteroids) accounted for approximately 40% of patients. In the physician interview, 39.2% of patients had ≥1 gastrointestinal symptom vs. 88.3% of patients in the self-administered questionnaire. The prevalence of GSRS symptoms was similar for each of the most frequently prescribed immunosuppressant drug regimens. GIQLI total score was significantly poorer in patients with versus those without gastrointestinal symptoms (121.8 ± 17.6 vs. 138.4 ± 3.7; P < 0.0001), and there was a strong inverse correlation between GIQLI and patient-reported GSRS scores (Pearson's correlation coefficient -0.816; P < 0.0001). Gastrointestinal symptoms are frequent in renal transplant patients, are under-evaluated by physicians and may adversely impact on patient QOL. © 2010 European Society for Organ Transplantation.
Wiese S.,Center for Functional Imaging and Research |
Hove J.D.,Gastroenterology Unit |
Bendtsen F.,Center for Functional Imaging and Research |
Moller So.,Center for Functional Imaging and Research
Nature Reviews Gastroenterology and Hepatology | Year: 2014
Cirrhosis is known to cause alterations in the systemic haemodynamic system. Cirrhotic cardiomyopathy designates a cardiac dysfunction that includes impaired cardiac contractility with systolic and diastolic dysfunction, as well as electromechanical abnormalities in the absence of other known causes of cardiac disease. This condition is primarily revealed by inducing physical or pharmacological stress, but echocardiography is excellent at revealing diastolic dysfunction and might also be used to detect systolic dysfunction at rest. Furthermore, measurement of circulating levels of cardiac biomarkers could improve the diagnostic assessm+ent. Cirrhotic cardiomyopathy contributes to various complications in cirrhosis, especially as an important factor in the development of hepatic nephropathy. Additionally, cirrhotic cardiomyopathy seems to be associated with the development of heart failure in relation to invasive procedures such as shunt insertion and liver transplantation. Current pharmacological treatment is nonspecific and directed towards left ventricular failure, and liver transplantation is currently the only proven treatment with specific effect on cirrhotic cardiomyopathy. © 2014 Macmillan Publishers Limited. All rights reserved.
Karamanolis G.P.,Gastroenterology Unit |
Tack J.,Catholic University of Leuven
Annals of Gastroenterology | Year: 2012
Functional dyspepsia (FD) is a highly prevalent disease characterized by symptoms originating from the gastroduodenal region in the absence of underlying organic disease. The Rome III consensus made a distinction between meal-induced and meal-unrelated symptoms and proposed subdivision of FD into postprandial distress syndrome and epigastric pain syndrome. The applicability of this subdivision and the impact on management are areas of active research. So far, empirical approaches are still employed for the treatment of FD, although various therapeutic modalities for FD have been explored; acid-suppressive, prokinetic, and fundic relaxant drugs, antidepressants and psychological therapies. FD remains a challenge and presents unmet clinical needs. © 2012 Hellenic Society of Gastroenterology.
Rondonotti E.,Gastroenterology Unit |
Paggi S.,Gastroenterology Unit
Digestive Diseases | Year: 2015
Background: Because of its technical characteristics (i.e. 8-fold magnification, capability to inspect the entire small bowel) and minimal invasiveness, videocapsule endoscopy (VCE) has been proposed as a useful tool for managing patients with celiac disease (CD). Key Messages: Although VCE has been found to be highly sensitive and specific in identifying CD endoscopic markers, it is still inadequate to replace esophagogastroduodenoscopy (EGD) with biopsies in the diagnosis of CD. Nevertheless, it represents a reliable alternative in patients unable or unwilling to undergo EGD. Up to now, available studies have failed to identify any correlation between the length of small bowel involvement and the severity of symptoms. The available evidence on the use of VCE in diagnosing CD in equivocal cases (patients with positive serology and negative or nonspecific histology or those with negative serology and histologically proven villous atrophy) is limited, and its role is still under discussion. In CD patients not improving on gluten-free diet, a complete workup is necessary. In patients with nonresponsive (NRCD) or refractory CD (RCD), VCE has been shown to be able not only to detect significant findings, driving further management, but also to rule out major complications. Nevertheless, in this setting, the inability of VCE to take tissue samples and the risk of capsule retention can represent major limitations. Conclusions: At the present time, for diagnostic purposes, VCE can be proposed only in patients unable or unwilling to undergo EGD, whereas it could be useful in some equivocal cases. Conversely, there is no room for VCE either to estimate the length of the small bowel affected by villous atrophy or to follow up patients improving on gluten-free diet. In patients with NRCD or RCD, VCE can play a role, but it should be combined with other diagnostic techniques. © 2015 S. Karger AG, Basel.
Prantera C.,Gastroenterology Unit |
Scribano M.L.,Gastroenterology Unit
Expert Opinion on Pharmacotherapy | Year: 2014
Budesonide is a corticosteroid characterized by high topical activity and low systemic effect associated with fewer glucocorticoid-related adverse events than conventional steroids. Differently from Crohn's disease, no evidence suggests that oral budesonide is effective for the induction of remission of ulcerative colitis (UC). Budesonide multi-matrix (MMX) system is a new oral preparation that, by employing a MMX, provides the release of the drug throughout the entire colon. Its efficacy in inducing UC remission, at a dose of 9 mg, is based on some recent trials. However, in two studies the absolute differences between budesonide MMX and placebo were much lower than the rate of success reported in previous trials with mesalazines. In addition, the therapeutic advantage of budesonide MMX 9 mg over 5-Aminosalicylic acid (5-ASA) showed by one study, and the advantage of budesonide MMX over budesonide reported in the other study, was only 5.8 and 4.8%, respectively. The evidence supporting the use of budesonide MMX at a dose of 6 mg for maintenance is weak. Therefore, the effective dosage should be 9 mg also in maintenance, but not for > 4-6 months, because a prolonged treatment has showed to increase the rate of side effects. © 2014 Informa UK, Ltd.