Introduction

Standard treatment of autoimmune hepatitis (AIH) typically includes a combination of azathioprine and corticosteroids. However, approximately 20% of patients do not respond well to this conventional therapy. In this scenario, mycophenolate mofetil (MMF) may be used as an alternative treatment for patients with intolerance or non-response to first-line options.

Aims & Methods

This study aims to evaluate the performance of MMF in intolerant or non-responders patients with AIH previously treated with conventional therapy. We performed a systematic review in PubMed, Embase, and Cochrane databases. We analyzed overall remission, remission at AZA intolerance, and remission at AZA non-response. We also compared the outcome of overall remission in patients with AZA intolerance vs. AZA non-response. Statistical analyses were performed using R language 4.3.1.

Results

21 studies and 646 patients were included. The pooled overall remission rate was 62.21 (95% CI 54.31, 70.10). We found an overall remission rate of 66.74 (95% CI 57.48, 76.00) in patients intolerant to AZA, and 27.80 (95% CI 11.56, 44.04) in AZA non-responders. The comparison of overall remission in both groups favored the intolerance group (OR 4.98; 95% CI 1.69, 14.72; p = 0.004).

Conclusion

MMF is effective in inducing remission in patients with AIH who failed the first-line treatment. The overall effect is more prominent in patients who failed conventional therapy due to intolerance. Non-response to AZA may be correlated to suboptimal response to MMF as well.

Introduction

The prevalence of musculoskeletal disorders (MSD) among gastroenterologists is estimated between 39 to 89%. Factors associated with MSDs among endoscopists include a high number of procedures (over 20/week), prolonged procedure times (over 16 hours/week), the age of the endoscopist (> 40 years vs ≤ 40 years), and female sex.
This study aimed to evaluate the prevalence of MSD among French gastroenterologists and identify risk factors of MSD

Aims & Methods

A computerized, anonymized questionnaire was e-mailed to all members of French society of endoscopy (SFED) over a one-month period. Demographic data were collected, as well as the level of endoscopic activity performed, the quantity and volume of endoscopies performed per week, the presence of pain associated with the practice of endoscopy, and an assessment of stress.

Results

485 gastroenterologists responded to the questionnaires, the majority were male (55%), with a median age of 48 years (IQR 37–60), and 45.6% practiced endoscopy for more than 20 years. 74.3% of respondents worked full-time, mostly in private practice (47% in private practice, 13% in mixed public-private practice). Endoscopy was performed for a median of 15 hours per week (IQR 10–18.8), with 24 procedures per week (IQR 15–30).
76.3% of participants had already experienced joint and/or musculoskeletal pain related to work. Pain complaints mainly concerned the lower back (55%), shoulders (36% left, 37% right%), neck (50%), and wrists (30% both side). More than half of the participants (55.9%) reported that the pain persisted after procedures, with 17.8% experiencing nocturnal pain and about a quarter reporting pain lasting more than 3 months.
The impact of MSD on workload was evaluated. 5.1% of the gastroenterologists reported loss of efficiency, 3,8% adapted their job, 2.4% decreased their activity, and 2.1% had work stoppage. 35% declared to have management of their MSD (28.1% painkiller, 23.2% reeducation, 3.5% surgery). To reduce discomfort, 74.7% of respondents reported using an adjustable-height examination table, and half adjusted the height and distance of the screen.
In multivariate analysis, factors associated with MSD were, femal sexe (OR 1.85 (1.15-3.01) p = 0.012, number of endoscopy (OR 1.05 (1.01-1.11) p=0.03, activity > 20 years (OR 2.42 (0.89, 6.47) p=0.079.) The risk of MSD was higher after 16.5 hours of endoscopy/ week (Se 35%, Sp 83%).

Conclusion

Musculoskeletal pain among French gastroenterologists is common and concerning. Therefore, it is essential to develop preventive programs to support their health and ensure the quality and safety of care.

Introduction

Esophageal varices (EV) are a critical complication of portal hypertension in patients with cirrhosis, and early detection is essential to prevent potentially life-threatening hemorrhage. The Baveno VII consensus recommends performing endoscopy in patients with transient elastography (TE) values exceeding 20 kPa and platelet counts below 150,000/mm³. While endoscopy remains the gold standard for diagnosis, non-invasive tests are gaining importance as a promising alternative for predicting EV(1) .The objective of our study is to predict the grade of varices in cirrhotic patients using a score derived from both their biological blood test results and clinical parameters.

Aims & Methods

The objective of our study was to predict the grade of varices in cirrhotic patients using a score derived from their biological blood test results and clinical parameters. This retrospective study involved patients recruited from Hôtel-Dieu de France, with data collected a few months prior to their gastroscopy for esophageal varices detection.
We calculated the ALBI-PLT score based on the method described by Inoue-Yuri et al.(2). The modified ALBI-PLT (mALBI-PLT) score was derived from the mALBI grade, assigning 1 point for grades 1 or 2a, and 2 points for grades 2b or 3. It also incorporated platelet counts, awarding 1 point for counts greater than 150,000/μL and 2 points for counts of 150,000/μL or lower. In addition to the mALBI-PLT score, we considered various variables, including blood test results and established predictive scores such as Child-Pugh, MELD-Na, FIB-4, and APRI.

Results

This study analyzed 108 cirrhotic patients (mean age: 63.94 years, 64.8% men, 33.03% had hepatocellular carcinoma (HCC)) out of 115 recruited, excluding cases with missing data. Key predictors of varice grades included lymphocyte count (L, β = −0.43, p = 0.011) and sodium (Na^10, β = −3.22 × 10^−22, p = 0.005) as significant negative associations. Positive associations were observed for the modified ALBI-platelet score (β = 0.43, p < 0.001), HCC (β = 0.51, p = 0.005), and gastrointestinal (GI) bleeding (β = 0.48, p = 0.013).
A derived formula for predicting varice grades is: VariceGrade = 3.49 − 0.43×ln(L) + 0.43×mALBI-PLT score − 3.22×10^−22×Na^10 + 0.51×HCC + 0.48×GI Bleeding.
The model showed strong specificity (94.5%) for identifying varices when the score was ≥ 1 and high sensitivity (97.8%) for excluding grade 3 varices when the score was ≤ 2.

Conclusion

This study introduces a non-invasive scoring system to accurately stratify esophageal varices severity, optimizing clinical decision-making and endoscopic screening in cirrhotic patients.

References

(1) 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;76:959–974. doi: 10.1016/j.jhep.2021.12.022.
(2) Inoue-Yuri M, Enomoto H, Wakabayashi I, Yuri Y, Aizawa N, Ikeda N, Takashima T, Fujiwara A, Yoshioka R, Kawata S, Yoshihara K, Ota S, Nakano R, Shiomi H, Nishimura T, Nishiguchi S, Iijima H. Modification of the ALBI-PLT Score for the Prediction of High-risk Varices. In Vivo. 2022 May-Jun;36(3):1360-1366. doi: 10.21873/invivo.12839. PMID: 35478164; PMCID: PMC9087093.

Introduction

​​​​​PSC is chronic infammatory disease of bile ducts leading to strictures of bile duct and eventually to liver cirrhosis. Chronic inflammation is associated with markedly increased risk of cholangiocancer (CCA). In addition, gall bladder abnormalities are common in patients with PSC¹ such as cholecystitis, gallstones, polys and gallbladder carcinoma (GBCA). Increased fasting gallbladder volume has been reported with normal gallbladder emptying². Due to the increased risk of GBCA³ cholecystectomy is recommended in PSC with gallbladder polyps ≥8 mm and smaller polyps growing⁴. However, cholecystectomy has been associated with impaired PSC outcome. A study consisting of 11 PSC patients with cholecystectomy suggested protective role of gallbladder based on MRCP changes and elevated AST levels in patients with cholecystectomy. No significant difference in serum bile acids was observed in patients with or w/o cholecystectomy⁵. Another small study including five PSC patients with cholecystectomy showed that cholecystectomy was associated with worse Mayo scores and an elevated FIB4⁶. More than 50% of PSC have enlarged gallbladder which is suspected to be caused by hyperpressure in the biliary tract⁵. Cholecystectomy may thus eliminate this reserve function and lead to progression of bile duct strictures.

Aims & Methods

To evaluate the impact of cholecystectomy on liver enzyme levels, biliary bile acid composition, bile duct disease progression, and overall outcomes in a large PSC patient cohort, we analyzed data from 1,009 individuals enrolled in the prospective Helsinki PSC registry. Of these, 114 patients (11.3%) had undergone cholecystectomy—34 prior to and 80 following the PSC diagnosis. Patients with gallbladder cancer were excluded. Clinical and laboratory parameters were collected, along with data on disease progression based on sequential ERC examinations scored by the Helsinki ERC score⁷. Additionally, bile composition was analyzed in a subgroup of 157 patients receiving UDCA therapy, 32 of whom had undergone cholecystectomy.

Results

Demographics, liver function tests, and outcomes stratified by cholecystectomy, are presented in the table. We found no differences between the three groups (no cholecystectomy, cholecystectomy done prior or after PSC dg) regarding the progression of bile duct disease or its severity, liver function tests, development of biliary dysplasia or need for dilatation, Mayo- and MELD-scores. The cumulative incidence of the composite end point (= transplantation, liver related death, HCC or CCA) did not differ between groups. The molar-% of phospholipids were lower and cholic acid and deoxycholic acid (mg) elevated in bile in patients with cholecystectomy, whereas no differences were found in UDCA content.

Conclusion

In this large study investigating the impact of cholecystectomy on PSC outcomes, we found no effect on liver enzyme levels, prognostic indices, bile duct disease progression, or overall prognosis, regardless of whether the procedure was performed before or after the PSC diagnosis.

References

1. Said K, eta al. Journal of Hepatology 2008; 48:598–605
2. Said K, et al. World J Gastroenterol 2009; 15: 3498-3503
3. van Erp LW, et al. Liver Int 2020; 40:382–92.
4. Chazouilleres O et al. EASL Clinical Practice Guidelines on sclerosing cholangitis. J Hepatol 2022; 77:761–806
5. Cazzagon N, et al. JHEP Reports 2023. https://doi.org/10.1016/j.jhepr.2022.100649
6. Miyake N, et al. Cureus 17(3): e80184. DOI 10.7759/cureus.80184
7. Boyd S, et al. Endoscopy. 2016;48:432-9.

Introduction

Gender diversity in scientific authorship is a progress indicator in various medical fields, including gastrointestinal (GI) endoscopy. The representation of women in academia reflects broader changes in professional roles and leadership. This study aims at analyzing trends in gender representation among authors of randomised controlled trials (RCTs) in GI endoscopy from the 1960s to the present, providing insights into the progression of gender equity in academic gastroenterology.

Aims & Methods

A PubMed search using the terms "digestive endoscopy" and "gastrointestinal endoscopy" was conducted on April 1st, 2024, yielding 5,944 studies filtered for RCTs. After excluding non-English articles, those unrelated to endoscopy, and studies without identifiable first authors, 4,357 RCTs were included. First and last authors' genders were identified using Genderize.io with ≥90% certainty. Descriptive and inferential statistics, including chi-squared tests, were used to analyze trends in gender representation over time.

Results

In total, there were 967 female first authors (21.7%), 3,415 male first authors (77.0%), and 57 unclassified first authors (1.3%). Out of 4173 last authors, 637 were female (15.3%), 3,203 were male (76.7%), and 333 were unclassified (8.0%) (p < 0.001). Female representation among last authors increased from 0% to approximately 20%, while first authors rose from 0% in the 1970s to about 30% by 2024 (p<0.05 for both trends). Multivariate regression confirmed that the increase in female first authorship was more significant compared to last authorship (p<0.001, R-square 0.90).Regarding specific topics, “non-IBD-related diagnostic lower GI endoscopy” showed the highest representation for female first authors at 25.5%, while “Obesity” and “Artificial Intelligence” had the lowest at 1.4% and 1.7%, respectively. For the last authorship, “non-IBD-related diagnostic lower GI endoscopy” led at 22.1%, followed by “Diagnostic upper GI endoscopy” at 14.0%. The lowest percentages among the last authors were “Obesity” at 1.4% and “Artificial Intelligence” at 0.6%. Statistical analysis revealed significant differences in gender representation across topics (p < 0.0001).Regional differences were noted, with female first authors more prevalent in Europe (36.2%) and Asia (31.0%), while female last authors were more common in Europe (34.2%) and North America (30.8%, p = 0.032), highlighting variations in gender dynamics within endoscopy research.

Conclusion

This study demonstrates a progressive increase in female representation in digestive endoscopy RCTs, particularly among first authors. However, gender disparities persist in senior roles, underscoring the need for continued efforts to support gender equity, especially in leadership positions within academic gastroenterology.

References

Liu CS et al. Am J Gastroenterol. 2024 Oct 1;119(10):2103-2106.
Genderize Data Roskilde, Denmark. Genderize.io (last access Nov 1st, 2024