Introduction

ERCP is a commonly used endoscopic procedure for diagnosing and treating disorders of pancreaticobiliary system. NSAIDs have been proven to minimize the risk of post-ERCP pancreatitis, which occurs in approximately 8% of average-risk procedures (1,2). This study aimed to analyze the occurrence of post-ERCP pancreatitis in patients in whom ERCP was performed for the first time, before and after the use of NSAIDs in routine clinical practice.

Aims & Methods

Between January 2012 and December 2014 and between January 2019 and December 2021, 621 and 664 patients, respectively, were consecutively evaluated. In all those patients therapeutic ERCP procedure with biliary sphyncteroctomy has been done for the first time and the post-procedure complications were consecutively evaluated. NSAIDs were administered in a form of rectal suppositories at least an hour before the procedure. Post-ERCP pancreatitis was defined as an appearance of pain with elevated amylase concentrations at least 3x above the upper limit of normal for more than 24 hours after the procedure. Chi-Square test and Mann-Whitney U tests were used to compare discrete and continuous variables where p<0.05 was considered statistically significant.

Results

A total of 1285 ERCP-naïve patients were analyzed. Patients were split into two groups, one receiving and the other not receiving NSAID prophylaxis (667 vs 618 patients, respectively). Patients who received NSAID prophylaxis showed a significantly lower incidence of post-ERCP pancreatitis (2.9% vs. 7.8%, p<0.05) and transient hyperamylasemia (9.3% vs. 28.2%, p<0.05), as well (Table 1).

Table 1. NSAID non-NSAID

Conclusion

Real-life experience from a single tertiary center demonstrated that including NSAID prophylaxis into standard clinical practice resulted in a considerable reduction in post-ERCP pancreatitis and hyperamylasemia.

References

1. Buxbaum JL, Freeman M, Amateau SK, Chalhoub JM, Coelho-Prabhu N, Desai M, Elhanafi SE, Forbes N, Fujii-Lau LL, Kohli DR, Kwon RS, Machicado JD, Marya NB, Pawa S, Ruan WH, Sheth SG, Thiruvengadam NR, Thosani NC, Qumseya BJ; (ASGE Standards of Practice Committee Chair). American Society for Gastrointestinal Endoscopy guideline on post-ERCP pancreatitis prevention strategies: summary and recommendations. Gastrointest Endosc. 2023 Feb;97(2):153-162. doi: 10.1016/j.gie.2022.10.005. Epub 2022 Dec 12. PMID: 36517310.
2. Pekgöz M. Post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review for prevention and treatment. World J Gastroenterol 2019;25:4019-4042.

Disclosure

no conflict of interest

Introduction

Irritable bowel syndrome (IBS) is a chronic gut-brain disorder that can be responsabil for a variety of uncomfortable gastrointestinal symptoms (laid out in the Rome Criteria) that can reduce quality of life. Although the precise mechanism remains unknown, recent research suggests that an imbalance in intestinal microbiota and a dysfunctional gut-brain axis may be involved in the development of IBS. Because of this, methods to restore the microbiota have been explored as treatment for this condition.

Aims & Methods

Randomized placebo controlled trial 180 patients: active group (probiotic formula, 3g/day- 92, placebo group – 88. men and women aged 24 to 75 who met the Rome IV criteria. One sachet probiotic (3 g) contains 7.5 billion bacteria: Lactobacillus casei W56, Lactococcus lactis W19, Lactobacillus acidophilus W22, Bifidobacterium lactis W52, Lactobacillus paracasei W20 Lactobacillus plantarum W62, Bifidobacterium lactis W51, Bifidobacterium bifidum W23, Lactobacillus salivarius W24. Assessments were made at 4, 8, 12 weeks. All patients agreed to maintain their lifestyle behaviors during their participation in the study. Exclusion criteria: chronic gastrointestinal condition (other than IBS), including inflammatory bowel disease, lactose intolerance, celiac disease, diabetes, neoplasms.Patients have complete weekly data on stool frequency and consistency (Boston scale) and intensity of IBS symptoms (abdominal pain/discomfort, bloating, flatulence/borborygmi, and difficulty defecating) on a Likert scale of 0 (absent) to 7 (severe). Participants completed an IBS-specific quality of life questionnaire (IBS-QoL) at randomization (V1), fallow-up (V2) and at the end of the intervention (V3). Primary endpoint was mean weekly scores of gastrointestinal symptoms. Responders of abdominal pain were defined as subjects who experienced a reduction of at least 30% of the mean daily abdominal score reported at baseline (week 0). Secondary endpoints were the total AUC (W0-W12) of abdominal symptoms (abdominal pain, bloating and flatulence/borborygmi).

Results

​There is a significant reduction in abdominal pain and bloating scores trough all 12 weeks of supplementation versus placebo. A higher overall IBS-QOL score, indicative of better QOL was reported at the end of the intervention (specially for interference with activity P=0.05, body image P=0.040, food avoidance P=0.03)

Conclusion

​The probiotic treatment provides statistically significant and clinically relevant benefits for individuals with IBS. Improves gastrointestinal symptoms and quality of life in IBS patient

References

Rome IV criteria-Rome Foundation

Introduction

Several risk stratification scores have been developed for predicting endoscopic treatment or patient survival in non-variceal upper gastrointestinal bleeding (NVUGIB).

Aims & Methods

Our aim was to compare the performance of some previously described scores such as Canada-United Kingdom-Adelaide score (CANUKA), Glasgow-Blatchford score (GBS), Harbinger score, neutrophil-to-lymphocyte ratio (NLR), red cell distribution width (RDW) and Rockall (pre-endoscopy and complete) scores in predicting with the following outcomes in patients with variceal upper gastrointestinal bleeding (VUGIB): 30-day mortality, in-hospital mortality, need for interventional radiological procedure, need for RBC transfusion and rebleeding. Patients undergoing emergency endoscopy for upper GI bleeding at the Department of Emergency Medicine at Semmelweis University between January 1, 2022 and December 31, 2023 were included in a retrospective cohort analysis. Cases with VUGIB were managed according to the ESGE guideline. Statistical methods included ROC analysis, through which we obtained the AUROC values.

Results

There were 126 patients with VUGIB (79 males, 47 females, mean age 58). In-hospital rebleeding rate was 7.9% (n=10/126) for VUGIB. Second look endoscopy was performed in 30 cases (23.8%). The indication for second look endoscopy was inadequate index endoscopy in 10 cases, suspicion of re-bleeding in 6 cases, control of endoscopic intervention in 12 cases. The 30-day mortality rate was 23.8% (n=30/126). Due to missing data in 5 patients scoring systems were analyzed in 121 patients. Area under receiver operator characteristic curves (AUROC) for predicting various outcomes were as follow: 30-day mortality (HARBINGER: 0.63, CANUKA: 0.75, Rockall (pre-endoscopy): 0.73, Rockall (complete): 0.73, GBS: 0.71, NLR: 0.65, RDW: 0,54); in-hospital mortality (HARBINGER: 0.59, CANUKA: 0.7, Rockall (pre-endoscopy): 0.67, Rockall (complete): 0.67, GBS: 0.65, NLR: 0.63, RDW: 0.56); need for interventional radiological procedure (HARBINGER: 0.62, CANUKA: 0.49, Rockall (pre-endoscopy): 0.56, Rockall (complete): 0.56, GBS: 0.54, NLR: 0.54, RDW: 0.67); need for RBC transfusion (HARBINGER: 0.66, CANUKA: 0.83, Rockall (pre-endoscopy): 0.7, Rockall (complete): 0.7, GBS: 0.78, NLR: 0.65, RDW: 0.63); rebleeding (HARBINGER: 0.45, CANUKA: 0.44, Rockall (pre-endoscopy): 0.42, Rockall (complete): 0.42, GBS: 0.5, NLR: 0.53, RDW: 0.56).

Conclusion

Currently available risk stratification scores developed mainly for NVUGIB, when used for VUGIB have a suboptimal performance (AUROC ≤0.8) in predicting important clinical outcomes as mortality, rebleeding, need for endoscopic or interventional radiological procedure. CANUKA was clinically effective and superior to other scoring systems in estimating the need for RBC transfusion. Further prospective studies on larger patient cohorts are needed to further analyze and improve risk stratification scores for VUGIB.

Disclosure

No Conflict of Interest

Introduction

Acute non-variceal upper gastrointestinal bleeding (NVUGIB) is a common emergency with high morbidity and mortality. Lactate levels and comorbidity indices, such as the Charlson Comorbidity Index (CCI), have shown promise in predicting patient outcomes. While these parameters individually provide valuable prognostic insights, their collective utility in predicting mortality among NVUGIB patients has not been explored.

Aims & Methods

The data for this study were collected from hospital records of patients admitted to Hitit University Hospital with NVUGIB between June 2021 and June 2024.
Demographic information, including age, gender, chronic illnesses, current medications, and history of previous gastrointestinal bleeding, was retrieved from computer database. Clinical data, such as outcomes (discharge or death), reasons for mortality, length of hospital stay were documented. Laboratory parameters, including lactate levels were recorded. Additionally, CCI and Glasgow Blatchford Score (GBS) were calculated for each patient.
Patients were stratified based on mortality status, which was considered the primary outcome. The associations between mortality and potential predictive factors were statistically analyzed. To improve mortality prediction, parameters that were significant in the logistic regression analysis were combined and assessed independently.

Results

A total of 390 patients with acute upper gastrointestinal bleeding were initially assessed. Of these, 180 patients were excluded due to missing data, leaving 210 patients included in the final study cohort. Key variables such as age, CCI, GBS, length of hospital stay, and mortality status were presented. Laboratory findings upon admission and the etiological distribution of gastrointestinal bleeding sources were also detailed.
Variables significantly associated with mortality in the univariate analysis include age, CCI, GBS, urea, aspartate aminotransferase (AST), alanine aminotransferase (ALT) and lactate levels. In the logistic regression analysis, significant predictors of mortality were CCI (OR: 1.318, p=0.001) and lactate levels (OR: 1.575, p=0.003). GBS was not a predictor for mortality (p=0.468). CCI plus lactate levels were significantly higher in deceased patients compared to survivors (12.96 vs.7.31, p<0.001).
The correlation coefficients (r) showed significant positive correlations between the combination of lactate levels and CCI with GBS (r=0.498, p<0.001), length of stay (r=0.213, p=0.014), age (r=0.634, p<0.001) and urea levels (r=0.417, p<0.001). No significant correlation was found with AST or ALT.
ROC curves for lactate levels, CCI and CCI plus lactate levels predicting mortality showed that the area under the curve (AUC) for lactate was 0.704 (95% CI: 0.577–0.830, p=0.002) with a cut-off value of 1.83, yielding a sensitivity of 76% and a specificity of 52%. For CCI, the AUC was 0.769 (95% CI: 0.670–0.869, p<0.001) with a cut-off value of 6.5, showing a sensitivity of 76% and a specificity of 70%. And for the ‘CCI plus lactate’ level, the AUC was higher as 0.799 (95% CI: 0.703–0.895, p<0.001) with a cut-off value of 8.3, showing a sensitivity of 88% and a specificity of 62%.

Conclusion

Both lactate levels and the CCI are valuable tools for predicting mortality in NVUGIB patients. Our findings support the use of these parameters collectively to improve risk stratification. Combining lactate levels and CCI offers the advantage of better predicting mortality and improving sensitivity compared to using lactate levels or CCI alone.

Introduction

Despite its widespread use, the benefit of pre-endoscopic fresh frozen plasma (FFP) transfusion in acute upper gastrointestinal bleeding (AUGIB) with mild to moderate coagulopathy remains unproven. Current guidelines are inconsistent, and indiscriminate use of FFP—particularly in patients with variceal bleeding—may expose patients to harm without improving outcomes.

Aims & Methods

To assess the impact of pre-endoscopic FFP transfusion on clinical outcomes, including 30-day mortality, in patients with AUGIB and an INR between 1.5 and 2.5. We conducted a multicenter retrospective cohort study at one university-affiliated and one tertiary care hospital in Thailand between January 2016 and December 2020. Adult patients with AUGIB and INR 1.5–2.5 were included. Patients were stratified into FFP and non-FFP groups based on transfusion prior to endoscopy. Multivariable logistic regression was performed to adjust for age, comorbidities, bleeding etiology, and hemodynamic parameters. Subgroup analysis was conducted in patients with variceal bleeding.

Results

Among 244 patients (158 FFP; 86 non-FFP), those receiving FFP had significantly higher in-hospital mortality (24.1% vs. 7.0%; p = 0.001), pulmonary edema (23.4% vs. 4.7%; p < 0.001), and longer hospital stay (mean 8.1 vs. 5.8 days; p < 0.001). After adjustment, FFP transfusion remained independently associated with in-hospital mortality (adjusted OR 5.65; 95% CI 2.13–14.99; p < 0.001) and pulmonary edema (adjusted OR 5.56; 95% CI 1.59–19.44; p = 0.007). In patients with variceal bleeding, the adverse effect of FFP was more pronounced. The adjusted 30-day mortality was higher in the FFP group (adjusted OR 2.38; p = 0.075), though this did not reach statistical significance.

Conclusion

Pre-endoscopic FFP transfusion in AUGIB patients with INR 1.5–2.5 is associated with increased risk of in-hospital mortality and volume-related complications, particularly in variceal bleeding. These findings support a more selective and individualized transfusion approach and challenge the routine use of FFP in this population. Prospective studies are warranted to validate these observations and guide evidence-based transfusion thresholds.

References

1. Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol. 2021 May 1;116(5):899-917.
2. Beattie C, Chakravarthy M. Fresh Frozen Plasma. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554919/
3. de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C; Baveno VII Faculty. Baveno VII - Renewing consensus in portal hypertension. J Hepatol. 2022 Apr;76(4):959-974.

Introduction

Individuals with Lynch syndrome (LS) are predisposed to different tumors, including gastric (GC) and duodenal (DC) cancer, especially those with specific mutations or familial aggregation. However, the role of esophagogastroduodenoscopy (EGD) in these patients is still uncertain, with heterogeneous recommendations among different guidelines.

Aims & Methods

To estimate the overall incidence of GC and DC in individuals with LS, to determine the incidence of GC and DC in higher-risk subgroups within these patients, as well as to clarify the usefulness of screening or surveillance by EGD.

Systematic search of Pubmed and Embase for cohort studies and clinical trials from inception to April 2024. Incidences of GC and DC were calculated, as well as the relative risk (RR) and their respective 95% confidence intervals in those studies comparing patients under surveillance with EGD vs without. A meta-analysis was performed using a random-effects model. Heterogeneity was assessed with the I² statistic.

Results

A total of 584 studies were obtained, of which 30 were finally included, with a total of 31264 patients with LS. The overall incidence of GC was 2.04% (95%CI 1.63-2.45). The incidence of GC was 2.60% (95%CI 1.61-3.60) in MLH1 carriers and 2.91% (95%CI 1.63-2.45) in MSH2 carriers. In those with LS and family history, the incidence of GC was 25.94% (95%CI 15.01-36.87). The incidence of DC was 1.61% (95%CI 1.21-2.00).
Only 3 studies compared patients with LS in follow-up with EGD vs those without follow-up, evidencing a protective effect of EGD for GC [RR 0.31 (95%CI 0.14-0.69)], but not for DC [RR 0.65 (95%CI 0.22-1.32)].

Conclusion

The incidence of GC and DC in patients with LS is higher than that of the general population, especially in those patients with MLH1, MSH2 mutations or family aggregation. Surveillance with EGD could help to reduce this incidence through the diagnosis of premalignant lesions.