Introduction

Patients with type 2 diabetes are prone to the development of dysbiosis, which can manifest as intestinal bacterial overgrowth (SIBO). This may explain the pathomechanism of abdominal symptoms that sometimes affect this group of patients. Disturbances in the composition and quantity of intestinal microbiota translate to impaired production of short-chain fatty acids (SCFA) in the intestinal mucosa. To increase the concentration of butyrate in the lumen of the intestine, oral microencapsulated sodium butyrate supplementation can be proposed. Given the limited research conducted on the topic of the effects of sodium butyrate supplementation in alleviating abdominal symptoms in patients with type 2 diabetes, it became the topic of our interest.

Aims & Methods

The aim of the study was to evaluate the effectiveness of oral sodium butyrate supplementation in the population of patients with type 2 diabetes in alleviating abdominal symptoms and to estimate the incidence of small intestinal bacterial overgrowth in this group. In addition, the impact of the intervention on the carbohydrate metabolism was assessed.A prospective, single-centre, randomized, placebo-controlled study was conducted between October 2022 and April 2023.
52 patients with type 2 diabetes and gastrointestinal symptoms were randomly assigned to one of 2 groups - a group receiving microencapsulated sodium butyrate (Intesta Max) at a dose of 1.5 g/day and a group receiving placebo. As 8 patients (15.3%) were lost to follow-up, for the preliminary analysis 44 patients were included. The study lasted for 6 weeks. Before and after the intervention the presence of abdominal pain, diarrhoea, constipation and flatulence was assessed, laboratory tests and hydrogen breath tests were performed, the HOMA index and body mass index were calculated.

Results

At baseline SIBO was diagnosed in 73.1% of patients in the experimental group and 58.8% of patients in the control group. After 6 weeks of the intervention there was a significant drop in SIBO occurrence in sodium butyrate group – 22.2% (p=0.001). The incidence of SIBO in the control group did not change – 64.7% (p=0.21).All patients included in the study declared abdominal pain before the intervention. After 6 weeks the pain was reported by 42.3% of the patients receiving the sodium butyrate vs. 88.4% of the patients receiving placebo (p=0.002). After the intervention there was a significant difference between the groups regarding diarrhea – 18.5% and 58.8% (p=0.006) in sodium butyrate and placebo groups respectively. A decrease in the incidence of bloating in the sodium butyrate group was observed - 100% before vs. 29,6% after the intervention (p<0.00001). The study also showed a decrease in BMI level, the HOMA index and glycated hemoglobin level after consumption of the sodium butyrate vs. placebo for 6 weeks. These results need confirmation in a larger group.

Conclusion

To our knowledge this is the first study reporting the effectiveness of oral butyric sodium supplementation in relieving abdominal symptoms (abdominal pain, diarrhea, flatulence) in patients with type 2 diabetes. Furthermore, an improvement in carbohydrate metabolism parameters was noted and body weight decrease was observed after the intervention.

Disclosure

Sodium butyrate (Intesta Max) we received from the company that produces it.

Clinical Case Summary

A 62 y/o male complaining from epigastric pain, constipation, vomiting and eructation for two months and CT abd revealed irresectable pancreatic head mass 4.5x4.5 cm encasing PV and SMV with duodenal invasion. Ryle decompression was done before EGD, duodenal obstruction was noted and biopsy showed duodenitis (stasis induced). EUS-FNB confirmed well differentiated AC. Duodenal stenting was successfully performed with improving symptoms.
After one week patient complained from weakness and abnormal gait, examination showed normal vital signs, bilateral lower limb edema and patient was lethargic. Three days after, the patient became confused (GCS 12), so he was admitted to ICU.
CT brain was unremarkable. Lab investigations showed the following:
Na 130, K 4.1, Ca 7.8, Phos 2.8, Mg 2.6, Alb 2.9
Refeeding injury was suspected and TPN was started by the ICU team. No improvement of the consciousness was achieved and patient caught chest infection, developed sepsis and died.
Discussion: Refeeding syndrome is a serious complication that can be easily missed [1] in upper GI malignant obstructions with prolonged decreased oral intake along with the malignancy cachexia status. These obstructions may need surgery or stenting to regain patency and without cautious monitoring of the nutrients repletion rate either enteral or parenteral this will lead to fluid and electrolyte disturbance (Fluid balance abnormalities, Abnormal glucose metabolism, Vitamin deficiency, e.g., vitamin B1 (thiamine), Hypophosphatemia, Hypomagnesaemia and/or Hypokalemia) [2] with symptoms ranging from vague up to life threatening conditions like disturbed conscious level and heart failure. Our patient had high risk of developing refeeding syndrome due to caloric deprivation secondary to duodenal obstruction with development of the symptoms after stenting and restarting oral intake.
Conclusion: Nutritionist counseling after GI stenting of upper GI malignant obstructions is needed to avoid refeeding syndrome.

References

[1] Reber, E., Friedli, N., Vasiloglou, M.F., Schuetz, P. and Stanga, Z., 2019. Management of refeeding syndrome in medical inpatients. Journal of clinical medicine, 8(12), p.2202.
[2] Crook, M.A., Hally, V. and Panteli, J.V., 2001. The importance of the refeeding syndrome. Nutrition, 17(7-8), pp.632-637.

Introduction

Hepatocellular carcinoma (HCC) is the most common form of primary liver cancer, predominantly diagnosed in patients with chronic liver diseases. The absence of specific biomarkers and the typically asymptomatic progression of the disease lead to delayed diagnosis. Patients with liver disease, including HCC, exhibit alterations in the gut microbiome and increased bacterial permeability, factors that may influence disease progression and patient outcomes. In recent years, there has been a growing interest in exploring circulating microbiome signatures as potential indicators of liver disease stutus, providing a new avenue for understanding HCC.

Aims & Methods

Aims: To identify the signatures of the circulating blood microbiome associated with hepatocellular carcinoma, response to treatment and disease prognosis.
Methods: This study conducted a post-hoc analysis of the SORAMIC clinical trial utilizing peripheral blood plasma samples. For this analysis, blood plasma samples from a cohort of 71 patients with HCC were examined (25 treated with Sorafenib and 46 with SIRT/Sorafenib). Peripheral blood samples were collected at two time points: baseline (prior to the initiation of anti-tumor therapy) with all 71 patients included, and post-therapy (7 to 9 weeks after treatment) with 39 patients included. Additionally, peripheral blood samples were obtained from 52 control subjects, who were endoscopically diagnosed with colonic diverticulosis, to compare against the patient group. The composition of the circulating blood microbiome was assessed through 16S rRNA gene sequencing, targeting the V1-V2 hypervariable regions. Subsequent analyses focused on identifying associations with potential novel biomarkers for diagnosis, prognosis, and response to treatment.

Results

Patients with HCC had significantly diminished α-diversity of the circulating blood microbiome as compared to controls. Significant differences were also observed in between microbial communities of these two cohorts based on Bray-Curtis dissimilarity index. Patients with HCC had significantly higher levels of Proteobacteria and Bacteroidetes and lower levels of Firmicutes and Campylobacterota. Differential abundance analysis revealed that families of Gordoniaceae, Cryomorphaceae, Burkholderiaceae, Comamonadaceae, Enterobacteriaceae were significantly enriched in patients with HCC. At the genus level, patients with HCC had higher levels of Gordonia, Fluviicola, Burholderia, Limnohabitans and Escherichia/Shigella and lower levels of Corynebacterium. HCC patients, who responded to treatment with SIRT/Sorafenib showed an increase in blood bacterial diversity, enrichment of families Burkholderiales incertae sedis, Arcobacteraceae, Peptostreptococcaceae, Moraxellaceae, genera Sphaerotilus, Aliacrobacter, Rhodoluna, Giesbergeria, Microbacterium, Romboutsia, Arcicella, Pseudorhodoferax and depletion in families Gordoniaceae, Cryomorphaceae and genera Cloacibacterium, Gordonia, Limnohabitans, Fluviicola after the treatment. Levels of Acinetobacter, Enhydrobacter and Micrococcus in the blood before the HCC treatment were associated with patient prognosis.

Conclusion

Patients with HCC exhibit a unique circulating blood microbiome profile characterized by reduced bacterial diversity. Response to treatment is linked to an increase in α-diversity and changes in the circulating microbiome profile. Specific members of the circulating microbiome show potential prognostic capabilities, suggesting their utility as biomarkers for predicting disease progression and treatment outcomes in HCC.

Introduction

A successful colonoscopy requires ideal stool preparation, yet the percentage of insufficient bowel preparation is still very high. Frequently, the patients use website information on colonoscopy preparation. Conversely, the daily activity of the hospital staff consists of spending time with patients, communicating with them and giving answers to a high number of questions coming from patients regarding the preparation for the procedure or the exam itself. Hence, the idea to adopt a rapid and intuitive patient-oriented digital service to respond to their needs, the virtual assistant Eric.

Aims & Methods

Endo-Chat is an automated online communication platform, powered by AI (Artificial Intelligence) with the use of the Natural Language Processing and Deep Learning technologies, that answers procedure-related questions in real-time. The engine is named ERIC, stands for "Endoscopy Robot for Intelligent Chat" and is an intelligent chatbot, capable of answering autonomously to most of the doubts of a patient who is supposed to undergo an endoscopic examination.

Results

Since the introduction of the conversational artificial intelligence system at the Policlinico Gemelli starting from 24^th of January 2022 to the 16^th of March 2023, Eric has been able to autonomously manage 94% of the questions sent by patients, thus forwarding only the remaining 6% (of the requests) to specialized human operators.
We calculated that in the pre-pilot phase, a large part of the daily activity of nurses was dedicated to communicating with patients, around 40 hours per week, while in the post-pilot phase, the time spent for communication was significantly reduced to 15 hours per week. According to OECD Health Statistics 2022, the average annual salary of a European nurse is 35,300 euros, with an annual hypothetical saving of 22,062 euros, comparable to a part-time contract.
Also, the number of cancelled procedures for poor patient preparation has fallen from 22 to 7 per week, considering a volume of 200 procedures per week.
Regarding patient's experience, users can leave voluntary feedback on their virtual assistant experience directly on the ERIC website, evaluating the quality of the service. Patient service evaluations were enthusiastic till now, as 63% rated the service as excellent.

Conclusion

In our observational pilot study, the first in Europe to our knowledge, we assessed the benefits measurement for patients and Hospital staff. Starting from these preliminary interesting results, we can speculate that the introduction of Endo-Chat in high-volume endoscopy service is feasible and useful not only for patients but also for hospital staff.

Disclosure

The authors declare no conflict of interest