Introduction

Metabolic associated steatosis liver disease (MASLD) is the new nomenclature of non-alcoholic fatty liver diseases (NAFLD) which highlights its crucial effect on the cardiometabolic risk factors that lead to the development and progression to liver diseases. Recently SGLT2 inhibitors have been identified to reduce hepatic steatosis in patients with T2DM with MASLD

Aims & Methods

Our aim was to assess the effect of SGLT2 inhibitors on hepatic steatosis in patients with T2DM and MASLD, we enrolled 30 diabetic adults with hepatic steatosis on ultrasound confirmed and quantified by baseline magnetic resonance proton density fat fraction (MRI-PDFF) they started SGLT2 inhibitors added to the standard of care treatment for 6 months and assessment of the percentage change of hepatic steatosis with done by repeat MR-PDFF.

Results

There were statistically significant decreases in the mean body weight and BMI after treatment (86.7Kg, 33.313 Kg/m²) respectively compared to their levels before treatment (90.367kg, 35.144 Kg/m²) respectively, P <0.001. Moreover, the mean serum fasting blood sugar and alanine transaminase decreased significantly after treatment (209.267, 22.633) compared to levels before treatment (220.566, 28.03) (P= 0.017, P=0.03) respectively. Regarding hepatic steatosis there was a statistically significant decrease in the mean MRI-PDFF measurement for hepatic steatosis after treatment (13.297 ±7.15) compared to the mean levels before treatment (15.288 ± 8.72) with a mean difference (-1.9911, P = 0.006) of about 13.16% decrease of steatosis

Conclusion

Addition of SGLT2 inhibitors to the standard treatment in type 2 diabetic patients with MASLD could reduce the hepatic steatosis significantly after 6 months of treatment associated with decrease in body weight, BMI, fasting blood sugar. Thus, the therapeutic use of SGLT2 inhibitors is valuable in type 2 diabetic patients associated with MASLD

Introduction

Informed consent (IC) serves as the ethical foundation for all medical interventions, empowering patients to make informed, autonomous decisions while safeguarding clinicians. Barriers such as limited health literacy and document complexity may hinder comprehension^1,2. This study evaluated the comprehensibility, readability, and effectiveness of the documents provided for IC and instructions for endoscopic procedures.

Aims & Methods

Outpatients undergoing endoscopic procedures completed a questionnaire assessing their understanding of IC, preparation instructions, and adherence to guidelines. Patient confidence and document comprehensibility were assessed through self-reported scales. Readability was assessed using Flesch Reading Ease score adapted for portuguese (FRE-PT)³.

Results

Among 186 participants (mean age: 58.1 ± 16.1 years), 76.9% reported full-extent reading of the provided instructions and IC document. Patients with primary education (≤4th grade) were less likely to read the documents fully (59.2% vs. 83.2%, p < 0.001) and were independently associated with the need for additional assistance (OR 5.65, 95% CI: 1.92 - 16.68, p = 0.002). Full-extent reading was independently associated with greater risk awareness (OR 5.52, 95% CI: 2.37 - 11.55, p < 0.001), reduced need for additional assistance (OR 0.22, 95% CI: 0.09 - 0.51, p < 0.001), and higher compliance with medication guidelines (75.7% vs. 45.8%, OR 3.42, 95% CI: 1.28 - 9.20, p = 0.015). Patients with primary education rated document’s comprehensibility lower (median:8, IQR 7-10) compared to those with higher education (median: 10, IQR 8 - 10, p < 0.001) and reported lower levels of confidence and preparation for the procedure (median: 8, IQR 7 - 10 vs. median: 9, IQR 8 - 10; p = 0.018). Outcomes did not differ significantly between patients aged 65 years or older compared to younger patients. FRE-PT scores classified readability as ‘’very difficult’’ for both upper endoscopy (20.87) and colonoscopy (26.00).

Conclusion

Full-extent reading IC and instruction documents reduces the need for assistance, improves compliance with pre-procedural measures, risk awareness and patient confidence. However, the document’s complexity and difficult readability disproportionately challenge and discourage patients with limited education. Future research should explore strategies to foster more equitable informed decision-making.

References

1. Protheroe J, Rowlands G. Matching clinical information with levels of patient health literacy. Nurs Manag (Harrow). 2013;20(3):20-21. doi:10.7748/nm2013.06.20.3.20.e1095
2. Ley R, Forio T. The use of readability formulas in health care. Psychol Health Med. 1996;1(1):7-28.
3. Martins TBF, Ghiraldelo CM, Nunes MGV, Oliveira Junior ON. Readability formulas applied to textbooks in Brazilian Portuguese. 1996.

Introduction

Alternate day oral iron therapy is better than daily oral iron therapy in Iron deficiency anemia (IDA) as it increases the fractional absorption of iron. In Ulcerative colitis (UC) with IDA increased fractional absorption of iron with alternate day iron may not only be better in improvement of anemia but also results in reduced unabsorbed iron delivery to distal bowel and may hence reduce adverse effects.

Aims & Methods

In a randomized, open label trial, from February 2023 to December 2024 patients of UC in remission (Mayo ≤2 OR partial Mayo ≤1 with fecal calprotectin <150mcg/gm for last 3 months) with IDA (ferritin <30mcg/l, transferrin saturation <20%, Hb 8-12 gm/dl) were randomized to every other day 132mg (EOD group) or daily 66mg (OD group) elemental oral iron given as ferrous fumarate for 8 weeks. Primary outcome was the difference in mean change in Hemoglobin (Hb) at 8 weeks. Secondary outcomes were the difference in mean change in RBC indices, iron indices and adverse events at 8 weeks.

Results

54 patients were randomized between both groups. One patient in EOD and 2 in OD group withdrew before treatment initiation. Eleven patients had disease flare on oral iron therapy (5 in EOD and 6 in OD group) p= 0.62 and two patients in EOD group had intolerance requiring oral iron stoppage. Thirty-eight patients completed treatment. The mean change in Hb at 8 weeks in EOD and OD groups was 2.08±1.0gm/dl and 2.09±1.11gm/dl respectively in per protocol analysis (p=0.797). The mean change in serum ferritin, serum iron, transferrin saturation and total iron binding capacity in both the groups is not significant. Disease flare within 6 months prior to oral iron therapy correlated with increased incidence of flare on oral iron therapy. (P=0.04)

Conclusion

Alternate day oral iron is not better than daily oral iron in improving Hb levels, iron indices and with similar incidence of adverse events in patients of UC in remission. A recent flare has increased chances of disease flare with oral iron therapy

Introduction

ERCP can still represents a challenge for endoscopists. In a variable percentage of cases (about 15%), cannulation of the common bile duct (CBD) is defined as “difficult”. In these cases, various advanced techniques are used to ensure access to the biliary tract. These methods can be summarised as follows: when an accidental cannulation of the pancreatic duct (PD) has occurred, the double guidewire technique (DGW) or the transpancreatic sphincterotomy (TPBS) technique can be performed; when access to the PD has not been achieved, freehand precut (trans papillary or fistulotomy) can be performed.¹
It has been shown that these methods are burdened by higher complication rates (in particular post- ERCP pancreatitis [PEP]) compared to standard cannulation of the CBD.² In particular, TPBS carries a stigma of risk and complexity. The ESGE guidelines propose its use as a second line after failure of DGW technique and only by expert endoscopists.¹ Recent studies have shown a certain distrust among endoscopists towards TPBS.³

Aims & Methods

We conducted a one-year prospective study with the aim of evaluating the efficacy and safety of TPBS in cases of difficult cannulation, comparing it with the DGW technique and trans papillary precut. All patients undergoing ERCP in a secondary centre were enrolled. A total of 169 ERCPs were performed by three endoscopists (two seniors and one junior with experience < 200 ERCPs). The most frequent indication was lithiasis of the CBD (74% of cases). The protocol adopted in case of difficult cannulation was the following: in the case of failed access to the PD, trans papillary precut was attempted. In the case of access to PD, the endoscopist chose at his discretion to perform the DGW technique or TPBS. In the case of PD cannulation, no pancreatic stent placement was performed. Other measures were taken to prevent PEP (rectal indomethacin and intravenous hydration during ERCP). Patients were followed up until discharge and peri- and post-procedural complications were recorded.

Results

The overall cannulation rate for naive papillae was 92.8%. Advanced techniques were used in 19% of the cases to achieve cannulation of the bile duct: 73% were successful. TPBS achieved 100% cannulation of CBP, compared to 66.7% of DWS and 55.6% of pre-cutting, showing a statistically significant better performance (p=0.02). A total of five bleedings, two cholangitis, one cholecystitis and two PEP were recorded. Of all these, only three (respectively one PEP, one bleeding and one cholecystitis) occurred after the above-mentioned advanced CBD cannulation methods were used.

Conclusion

In conclusion, this single-centre prospective observational study, despite its limited sample size, demonstrates that TPBS is a safe and effective method in case of difficult bile duct cannulation when PD cannulation is achieved. In particular TPBS seems to be more efficient than DGW and precut, showing a similar security profile. This technique can also be performed safely by non-expert endoscopists.
Finally, it is important to underline that, despite not placing the pancreatic prosthesis after cannulation of the PD (24 patients) none of them presented PEP.

References

1.Testoni PA, Mariani A, Aabakken L, Arvanitakis M, Bories E, Costamagna G, Devière J, Dinis-Ribeiro M, Dumonceau JM, Giovannini M, Gyokeres T, Hafner M, Halttunen J, Hassan C, Lopes L, Papanikolaou IS, Tham TC, Tringali A, van Hooft J, Williams EJ. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016 Jul;48(7):657-83. doi: 10.1055/s-0042-108641. Epub 2016 Jun 14. PMID: 27299638.
2.Fung BM, tea TCTabibian JH. Difficult Biliary Cannulation in Endoscopic Retrograd2 Cholangiopancreatography: Definitions, Risk Factors, and Implications. Eur Med J Hepatol. 2021 Aug;9(1):64-72. Epub 2021 Aug 5. PMID: 34621527; PMCID: PMC8494185.
3.Kouanda A, Bayudan A, Hussain A, Avila P, Kamal F, Hasan MK, Dai SC, Munroe C, Thiruvengadam N, Arain MA. Current state of biliary cannulation techniques during endoscopic retrograde cholangiopancreatography (ERCP): International survey study. Endosc Int Open. 2023 Jun 21;11(6):E588-E598. doi: 10.1055/a-2085-4565. PMID: 37564727; PMCID: PMC10410689.

Introduction

The available evidence on the epidemiology of acute pancreatitis (AP) is primarily based on older studies conducted in other countries, limiting its applicability to local settings. This study aims to provide updated data on the clinical characteristics and outcomes of patients with AP in our region thereby improving understanding and management of the disease.

Aims & Methods

A retrospective analysis was conducted on a prospective database comprising a cohort of 526 patients with acute pancreatitis (AP), consecutively included between March 2017 and June 2019 at a tertiary care hospital. Systematic laboratory testing was performed at admission and again at 48 hours. Clinical management followed standard practice guidelines, including routine abdominal ultrasound after admission and abdominal CT scan in cases of diagnostic uncertainty, clinical deterioration, or lack of improvement. Diagnosis and classification were based on the revised 2012 Atlanta classification.

Results

The most frequent etiology of AP in our setting was biliary lithiasis (65.9%), followed by idiopathic (15.4%) and alcohol-related causes (8.4%). Severe AP accounted for 9% of cases, while 14.3% were classified as moderately severe. Up to 20.2% of patients developed local complications; however, only 4.9% presented with pancreatic necrosis. SIRS was observed in 18.7% of patients at admission, decreasing to 8.7% at 48 hours. Only 3.7% of patients required ICU admission (Table 1). Factors such as smoking, ERCP, antibiotic therapy, acute cholangitis, and SIRS showed significant differences across different etiological groups.

Conclusion

Acute pancreatitis (AP) is a common condition that imposes a significant healthcare burden. Determining the etiology of AP at admission is important not only from an epidemiological standpoint but also due to its profound implications for patient prognosis.
Contrary to what has been reported in the literature, the second most frequent cause of AP in our cohort was idiopathic, surpassing alcohol-related cases. In line with other studies, we observed significant differences between biliary and alcohol-related etiologies regarding smoking habits, development of acute cholangitis, need for ERCP, and use of antibiotic therapy. Patients with alcohol-related AP were significantly more likely to present with SIRS at admission. However, we did not find statistically significant differences in other key clinical outcomes, although patients with alcohol-related AP appeared to have a higher, but not statistically significant, risk of developing local complications, pancreatic necrosis, and SIRS at 48 hours.
This study highlights the importance of tailoring management strategies according to etiology to optimize clinical outcomes.

References

1. Wang, G. J., Gao, C. F., Wei, D., Wang, C., & Ding, S. Q. (2009). Acute pancreatitis: etiology and common pathogenesis. World journal of gastroenterology, 15(12), 1427–1430.
2. Petrov, M. S., & Yadav, D. (2019). Global epidemiology and holistic prevention of pancreatitis. Nature reviews. Gastroenterology & hepatology, 16(3), 175–184.
3. Iannuzzi, J. P., King, J. A., Leong, J. H., Quan, J., Windsor, J. W., Tanyingoh, D., Coward, S., Forbes, N., Heitman, S. J., Shaheen, A. A., Swain, M., Buie, M., Underwood, F. E., & Kaplan, G. G. (2022). Global Incidence of Acute Pancreatitis Is Increasing Over Time: A Systematic Review and Meta-Analysis. Gastroenterology, 162(1), 122–134.