Introduction

Type 2 diabetes mellitus (T2DM) is associated with end-organ injury and is a major risk factor for non-alcoholic fatty liver disease (NAFLD) and advanced liver disease. Despite the high relevance of NAFLD in T2DM, it remains unconsidered in the routine screening of T2DM-related comorbidities in the German diabetes disease management program (DMP).

Aims & Methods

The aim of this prospective cohort study was to assess the prevalence of liver disease from NAFLD and associated clinical risk factors in primary care centers participating in the diabetes DMP in Germany. A total of 175 participants with the diagnosis of T2DM were enrolled in two primary care outpatient centers within the diabetes DMP. The prevalence of steatosis, fibrosis, and cirrhosis was assessed non-invasively using vibration-controlled transient elastography (VCTE). Steatosis was defined as a controlled attenuation parameter (CAP) of ≥ 275 dB/m. Liver fibrosis and cirrhosis were defined as a liver stiffness measurement (LSM) of ≥ 8 kPa and ≥ 15 kPa, respectively. Multivariable logistic regression analysis with stepwise selection was performed to identify clinical predictors of liver fibrosis and cirrhosis.

Results

The majority of participants were male (62%, n = 109), and the median age was 66 years (IQR 59; 71). The median BMI was 31.1 kg/m² (IQR 27.7; 35.3), with 58.9% (n = 103) of the participants being obese. The median HbA1c was 7.0% (IQR 6.5; 7.8). The prevalence of hepatic steatosis, fibrosis, and cirrhosis was 77.1%, 42.3%, and 12%, respectively. NAFLD was identified in the majority of participants (69.9%; n = 121). Obese individuals showed the highest median LSM values (11.3 kPa, IQR 9.4; 16.2). In multivariable logistic regression analysis, obesity was associated with increased odds of hepatic fibrosis (OR = 4.818, 95% CI 2.243-10.350) and cirrhosis (OR = 3.873, 95% CI 1.073-13.977). Although higher blood levels of HbA1c correlated with liver fibrosis, it did not remain an independent predictor.

Conclusion

The prevalence of advanced liver disease is high within the diabetes DMP in Germany. People with T2DM and obesity are at an increased risk to exhibit liver fibrosis, and eventually cirrhosis. Building on VCTE for risk stratification within the DMP would allow identifying the subgroup recommended for intensified management.

Introduction

Data evaluating the utility of Blue light Imaging (BLI) and Linked Color Imaging (LCI) in the diagnosis of gastric intestinal metaplasia (IM) and atrophic gastritis (AG) is limited.

Aims & Methods

We aimed to evaluate and compare the diagnostic accuracy of BLI and LCI without magnification for the detection of IM and AG.
Single centre prospective study involving consecutive patients aged ≥18 years undergoing diagnostic upper gastrointestinal endoscopy (UGIE), endoscopic follow-up of intestinal metaplasia or gastric cancer screening. Exclusion criteria: previous gastrectomy, contraindication to UGIE due to comorbidities, no gastric mucosal biopsies, refusal of consent. Endoscopy was initially performed with white light image (WLI), followed by BLI and LCI. Standardized photodocumentation of stomach was performed with WLI, BLI and LCI. Imaging features suggestive of IM: lavender color sign and whitish flat elevation with LCI, and light blue crest and white opaque substance with BLI. EGGIM and Kimura-Takamoto Classification (KTC) were applied when IM and AG were suspected. Systematic random biopsies of the antrum, incisura angularis and corpus along with targeted biopsies of suspicious gastric mucosal lesions were obtained. Histology was considered gold standard. Performance of endoscopic imaging in the detection of IM, AG and EGC was evaluated.
Initially, 134 patients were evaluated and 64 were excluded: previous gastrectomy-22, pending histology-20, non-BLI imaging-15, intolerance to UGIE-3, refusal of consent-1, esophageal stenosis-1 and contra-indication to biopsies-2. Final sample included 70 patients.
Qualitative data expressed as percentage were compared with Chi-square test. A p value of <0.05 was considered significant.

Results

Median age was 56 (19-86), with 49 (63%) female. There was family history of gastric cancer in 12(15%) and history of smoking in 35 (44%).
Histological AG was found in 15 (19%) and IM in 20 (26%) patients. WLI was suggestive of IM in 14(20%), confirmed histologically in 9 (64%). IM was suspected by LCI and BLI in 24 (34%) and 23 (32%) cases, confirmed by histology in 16 (67%) and 17 (74%), respectively.
WLI classified 56 (71%) as EGGIM 0 and after LCI and BLI, 10 (18%) and 8 (15%) of these cases had EGGIM 1 or 2. In 10 patients, EGGIM 1-2 with WLI, only 1 was upgraded to EGGIM 3-4 with LCI and BLI. In 3 (4%) EGGIM 3-4 with WLI, after LCI and BLI,1 had extensive IM (EGGIM 6). Among 19(24%) patients EGGIM 1-2 with LCI, 3(16%) had EGGIM 0 with BLI.
Atrophy was suspected by WLI and LCI in 9(12%) and 15(21%) patients, confirmed by histology in 6(67%) and 8(53%) cases, respectively. According to KTC, 5 (6%) were classified as C1, 2 (3%) as C2 and 4 (5%) as O3 with WLI. With LCI images, 8 (10%) were classified as C1, 3(4%) as C2 and 4(5%) as O3. The sensitivity (Sens), specificity (Spec), accuracy, positive predictive value (PPV), negative predictive value (NPV) of WLI, BLI and LCI in detecting AG and IM are shown in table 1.


Table 1. Sens, Spec, accuracy, PPV and NPV in detecting AG and IM with WLI, LCI and BLI.

Conclusion

Both BLI and LCI are promising advanced endoscopic imaging techniques with BLI having higher accuracy than LCI in detection of IM.

References

1. Chen H, Liu Y, Lu Y, Lin X, Wu Q, Sun J, et al. Ability of blue laser imaging with magnifying endoscopy for the diagnosis of gastric intestinal metaplasia. Lasers Med Sci. 2018 Nov 1;33(8):1757–62.
2. Ono S, Abiko S, Kato M. Linked color imaging enhances gastric cancer in gastric intestinal metaplasia. Vol. 29, Digestive Endoscopy. Blackwell Publishing; 2017. p. 230–1.
3. Ono S, Kato M, Tsuda M, Miyamoto S, Abiko S, Shimizu Y, et al. Lavender Color in Linked Color Imaging Enables Noninvasive Detection of Gastric Intestinal Metaplasia. Digestion. 2018 Nov 1;98(4):222–30.
4. Zhang G, Zheng J, Zheng L, Yu S, Jiang C, Lin W, et al. Gastric intestinal metaplasia assessment between linked color imaging based on endoscopy and pathology. Scand J Gastroenterol. 2021;56(1):103–10.
5. Shu X, Wu G, Zhang Y, Wang Y, Zheng Y, Guo Q, et al. Diagnostic value of linked color imaging based on endoscopy for gastric intestinal metaplasia: a systematic review and meta-analysis. Ann Transl Med. 2021 Mar;9(6):506–506.
6. Esposito G, Pimentel-Nunes P, Angeletti S, Castro R, Libânio D, Galli G, et al. Endoscopic grading of gastric intestinal metaplasia (EGGIM): A multicenter validation study. Endoscopy. 2019;51(6):515–21.