Andrew W. Dupont

Systematic review of randomized controlled trials of probiotics, prebiotics, and synbiotics in inflammatory bowel disease

Background Probiotics are microorganisms that are ingested either in combination or as a single organism in an effort to normalize intestinal microbiota and potentially improve intestinal barrier function. Recent evidence has suggested that inflammatory bowel disease (IBD) may result from an inappropriate immunologic response to intestinal bacteria and a disruption in the balance of the gastrointestinal microbiota in genetically susceptible individuals. Prebiotics, synbiotics, and probiotics have all been studied with growing interest as adjuncts to standard therapies for IBD. In general, probiotics have been shown to be well-tolerated with few side effects, making them a potential attractive treatment option in the management of IBD. Aim To perform a systematic review of randomized controlled trials on the use of probiotics, prebiotics, and synbiotics in IBD. Results In our systematic review we found 14 studies in patients with Crohn’s disease (CD), 21 studies in patients with ulcerative colitis (UC), and five studies in patients with pouchitis. These were randomized controlled trials using probiotics, prebiotics, and/or synbiotics. In patients with CD, multiple studies comparing probiotics and placebo showed no significant difference in clinical outcomes. Adding a probiotic to conventional treatment improved the overall induction of remission rates among patients with UC. There was also a similar benefit in maintaining remission in UC. Probiotics have also shown some efficacy in the treatment of pouchitis after antibiotic-induced remission. Conclusions To date, there is insufficient data to recommend probiotics for use in CD. There is evidence to support the use of probiotics for induction and maintenance of remission in UC and pouchitis. Future quality studies are needed to confirm whether probiotics, prebiotics, and synbiotics have a definite role in induction or maintenance of remission in CD, UC, and pouchitis. Similar to probiotics, fecal microbiota transplantation provides an alternate modality of therapy to treat IBD by influencing the intestinal flora.

Surgery or Endoscopy for Palliation of Biliary Obstruction Due to Metastatic Pancreatic Cancer

BACKGROUND AND AIMS:Both endoscopic and surgical drainage procedures are effective palliative methods for malignant biliary obstruction. Surgical drainage is still preferred in developing countries due to the high cost of procuring metal biliary stents. The aim of this study was to evaluate the quality of life and the cost of care in patients with metastatic pancreatic cancer after endoscopic biliary drainage and surgical drainage.PATIENTS AND METHODS:This is a prospective, randomized controlled trial conducted in a tertiary referral center in Brazil. Patients with biliary obstruction due to metastatic pancreatic cancer and liver metastasis, but without gastric outlet obstruction, were included in the study. Endoscopic biliary drainage with the insertion of a metal stent into the bile duct was compared with the surgical drainage procedure (choledochojejunostomy and gastrojejunostomy). Quality of life was assessed before, and 30 days, 60 days, and 120 days after the drainage procedure. The cost of drainage procedure, cost during the first 30 days and the total cost from drainage procedure to death were calculated.RESULTS:Of the 273 patients with pancreatic malignancy seen at our hospital between July 2001 and October 2004, 35 patients were eligible for the study, and 30 agreed to participate in the study. Both surgical and endoscopic drainage procedures were successful, without any mortality in the first 30 days. The cost of biliary drainage procedure (US

Where do ERCP, endoscopic ultrasound, magnetic resonance cholangiopancreatography, and intraoperative cholangiography fit in the management of acute biliary pancreatitis? A decision analysis model

2,832 ± 519 vs 3,821 ± 1,181, p = 0.031), the cost of care during the first 30 days after drainage (US

Postinfectious irritable bowel syndrome.

3,122 ± 877 vs 6,591 ± 711, p = 0.001), and the overall total cost of care that included initial care and subsequent interventions and hospitalizations until death (US

Motility Abnormalities in Irritable Bowel Syndrome

4,271 ± 2,411 vs 8,321 ± 1,821, p = 0.0013) were lower in the endoscopy group compared with the surgical group. In addition, the quality of life scores were better in the endoscopy group at 30 days (p = 0.042) and 60 days (p = 0.05). There was no difference between the two groups in complication rate, readmissions for complications, and duration of survival.CONCLUSIONS:Endoscopic biliary drainage is cheaper and provides better quality of life in patients with biliary obstruction and metastatic pancreatic cancer.

Randomised clinical trial: faecal microbiota transplantation for recurrent Clostridum difficile infection – fresh, or frozen, or lyophilised microbiota from a small pool of healthy donors delivered by colonoscopy

OBJECTIVES:The role of ERCP in acute biliary pancreatitis (ABP) is controversial. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) are modalities for bile duct visualization that could lower costs and prevent ERCP-related complications. We analyzed costs and examined the cost-effectiveness of these modalities to define their role in ABP.METHODS:A decision analysis model of ABP was constructed. The strategies evaluated were 1) ERCP, 2) MRCP followed by ERCP if positive for common bile duct stones (CBDS) or if biliary sepsis ensued, 3) EUS followed by ERCP if positive or if biliary sepsis ensued, and 4) observation with intraoperative cholangiography at the time of cholecystectomy with ERCP only if biliary sepsis ensued. We compared costs and performed cost-effectiveness analysis between strategies at probabilities of CBDS ranging from 0% to 100%. The outcome measures were total costs and costs per ABP death prevented.RESULTS:At probabilities of CBDS < 15%, observation with intraoperative cholangiography is the least expensive strategy, whereas EUS and ERCP are the least expensive strategies at probabilities of 15–58% and >58%, respectively. In terms of cost-effectiveness, at probabilities of CBDS of 7–45%, EUS is the most cost-effective alternative, and at a probability of >45% ERCP is the most cost-effective option.CONCLUSIONS:Total costs and cost-effectiveness ratios of these strategies in patients with ABP are highly dependent on the probability of CBDS.

Aspirin chemoprevention in patients with increased risk for colorectal cancer: a cost-effectiveness analysis.

After acute bacterial gastroenteritis, up to one-third of patients will have prolonged gastrointestinal complaints, and a portion of those affected will meet the diagnostic criteria for postinfectious irritable bowel syndrome. After resolution of the acute infection, patients with postinfectious irritable bowel syndrome appear to have chronic mucosal immunologic dysregulation with altered intestinal permeability and motility that can lead to persistent intestinal symptoms. Both host- and pathogen-related factors, such as preexisting psychological disorders and duration of initial infection, have been associated with an increased risk for the development of postinfectious irritable bowel syndrome. Current treatments for postinfectious irritable bowel syndrome are typically targeted at specific symptoms, although studies evaluating therapies directed at preventing or reducing the duration of the initial infection are ongoing.

Cost-effectiveness of hepatic venous pressure gradient measurements for prophylaxis of variceal re-bleeding

Background/Aims: The intestinal pathophysiology in irritable bowel syndrome (IBS) is largely unknown. The lactulose breath test has been used to identify small bowel bacterial overgrowth in these patients. Methods: We studied intestinal transit in patients with IBS using of the SmartPill® (SP) wireless pH/pressure recording capsule and performed lactulose breath tests to look for physiologic abnormalities. Results: A total of 35/46 (76%) of the IBS patients had prolonged gastric emptying times. Constipation-predominant disease was associated with prolonged gut transit times. The mean hours ± SD for colonic transit time in the constipation group was 71.7 ± 61.1 (n = 13) compared with 22.5 ± 14.9 (n = 14) for diarrhea-predominant and 26.4 ± 21.5 (n = 20) for mixed clinical subtype (p = 0.0010). No correlation between small bowel transit time and abnormal breath hydrogen or methane excretion in the 46 combined patients with IBS was seen. Conclusions: Delayed gastric emptying was identified in IBS and in some patients may contribute to at least a component of their symptoms. Constipation-predominant IBS is associated with prolonged gut transit times. Otherwise, transit abnormalities do not appear to be important in IBS. Intestinal transit did not correlate with breath test results.

In vivo analysis of mucosal lipids reveals histological disease activity in ulcerative colitis using endoscope-coupled Raman spectroscopy

Faecal microbiota transplantation (FMT) has become routine in managing recurrent C. difficile infection (CDI) refractory to antibiotics.

Recent Advances in the Diagnosis and Treatment of Clostridium Difficile Infection.

Background  Aspirin chemoprevention combined with colonoscopy screening is not cost‐effective for the general population. However, the cost‐effectiveness of aspirin in individuals with prior adenoma resection has not been evaluated.