Gianluca Bersani

Nutrient intake in Italian obese patients: Relationships with insulin resistance and markers of non-alcoholic fatty liver disease

OBJECTIVE We investigated the prevalence of insulin resistance, elevated liver enzymes, and Non-Alcoholic Fatty Liver Disease Fibrosis Score (NFS) in obese and severely obese patients. Relations between inadequate nutrient intakes and the markers of metabolic and hepatic disorders were evaluated. METHODS From January to September 2009, 63 consecutive obese patients (21 men and 42 women, 19-68 y old) were admitted to the study. According to the World Health Organization obesity classification, patients were categorized into three subgroups (classes I, II, and III). NFS scores lower than -1.455 were defined as NFS(-); higher scores were positive (NFS(+)). Insulin resistance (IR) was assessed by the homeostasis model assessment. Nutrient intakes and their potential role as risk factors for IR and liver damage were determined. RESULTS Body mass index ranged from 30.9 to 73.7 kg/m(2) and most patients (54%) were in class III (body mass index ≥40 kg/m(2)). Homeostasis model assessment of IR (>2.5) was recorded in 63.5%. The prevalence of NFS(+) was significantly higher in class III than in classes II and I. Excessive nutrient and energy intake prevalence showed significant differences for protein, fat, and carbohydrate among the obesity classes. Animal protein (odds ratio 3.43, 95% confidence interval 1.15-10.20) and carbohydrate (odds ratio 3.83, 95% confidence interval 1.33-10.94) intakes were the risk factors for IR and NFS(+). CONCLUSION Non-normal alanine aminotransferase and γ-glutamyltranspeptidase values were observed in less than one-third of patients, whereas NFS(+) and IR were significantly prevalent, suggesting a close relation between the progression of liver fibrosis and metabolic derangement. An excessive intake of animal protein is associated with an increased risk of IR. Carbohydrate intake, albeit at the highest limit of the recommended dietary allowance range, is associated with an increased risk of liver fibrosis.

Comparison between the Two Systems to Evaluate the Appropriateness of Endoscopy of the Upper Digestive Tract

OBJECTIVES:The aim of this study was to compare the diagnostic performance of the two systems for the evaluation of the appropriateness of upper digestive endoscopy suggested by the American Society of Gastrointestinal Endoscopy (ASGE) and by the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE).METHODS:Patients referred for the upper digestive endoscopy (EGD) to a University Outpatients Clinic of Northeastern Italy were consecutively included in this prospective observational study. Before the EGD, the endoscopist assigned the patients to one of the ASGE appropriateness classes; another endoscopist then identified the detailed clinical scenario for the patients, which corresponds to scenarios examined by EPAGE by using a nine-point scale: 1–3 inappropriate; 4–6 uncertain; and 7–9 appropriate. The relationship between the appropriateness of use and the presence of relevant endoscopic lesions (neoplasms, ulcers, esophagitis, erosive gastritis/duodenitis, stenosis, and varices) was assessed, calculating the sensitivity and the specificity for each of the ASGE criteria, and each of the EPAGE scores, and plotting them to form a receiver operating characteristic (ROC) curve. The area under the ROC curve (AUC) provides a summary measure of test performance, and can vary from a minimum of 0.5 to a maximum of 1.0. We compared the AUC of the ROC curve derived from the ASGE criteria against that derived from the EPAGE criteria.RESULTS:A total of 2,300 consecutive patients were included in the study (42% men; mean age: 57.3; range: 12–99); comparison of appropriateness criteria according to the ASGE and EPAGE could be made for 2,000 patients. The AUC of the ROC curve derived from the ASGE criteria was 0.553 (95% CI: 0.527–0.579), significantly higher than the AUC of the ROC curve derived from the EPAGE score: 0.523 (95% CI: 0.497–0.549; p < 0.05).CONCLUSIONS:We suggest that the diagnostic yield for relevant endoscopic findings obtained by both the systems (ASGE and EPAGE) is low; slightly better results could be accomplished by the ASGE criteria.

Appropriateness guidelines and predictive rules to select patients for upper endoscopy: A nationwide multicenter study

OBJECTIVES:Selecting patients appropriately for upper endoscopy (EGD) is crucial for efficient use of endoscopy. The objective of this study was to compare different clinical strategies and statistical methods to select patients for EGD, namely appropriateness guidelines, age and/or alarm features, and multivariate and artificial neural network (ANN) models.METHODS:A nationwide, multicenter, prospective study was undertaken in which consecutive patients referred for EGD during a 1-month period were enrolled. Before EGD, the endoscopist assessed referral appropriateness according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines, also collecting clinical and demographic variables. Outcomes of the study were detection of relevant findings and new diagnosis of malignancy at EGD. The accuracy of the following clinical strategies and predictive rules was compared: (i) ASGE appropriateness guidelines (indicated vs. not indicated), (ii) simplified rule (≥45 years or alarm features vs. <45 years without alarm features), (iii) logistic regression model, and (iv) ANN models.RESULTS:A total of 8,252 patients were enrolled in 57 centers. Overall, 3,803 (46%) relevant findings and 132 (1.6%) new malignancies were detected. Sensitivity, specificity, and area under the receiver-operating characteristic curve (AUC) of the simplified rule were similar to that of the ASGE guidelines for both relevant findings (82%/26%/0.55 vs. 88%/27%/0.52) and cancer (97%/22%/0.58 vs. 98%/20%/0.58). Both logistic regression and ANN models seemed to be substantially more accurate in predicting new cases of malignancy, with an AUC of 0.82 and 0.87, respectively.CONCLUSIONS:A simple predictive rule based on age and alarm features is similarly effective to the more complex ASGE guidelines in selecting patients for EGD. Regression and ANN models may be useful in identifying a relatively small subgroup of patients at higher risk of cancer.

24-h pH-metry and Multichannel Intraluminal Impedance Monitoring in Obese Patients with and without Gastroesophageal Reflux Disease Symptoms

BackgroundThe 24-h ambulatory pH-metry with multichannel intraluminal impedance monitoring (24-h pH-metry+MII) allows the simultaneous assessment of chemical and physical properties of esophageal refluxes and the detection of its proximal migration.MethodsGastroesophageal reflux (GER) was investigated in obese symptomatic (obese gastroesophageal reflux disease, GERD) and asymptomatic (obese non-GERD) patients. The data were compared with those obtained from non-obese GERD patients and a control group. Thirty-five (20 non-GERD, 15 GERD) obese patients and 15 non-obese GERD were investigated with 24-h pH-metry+MII. Ten normal weight subjects with normal 24-h pH-metry+MII were used as control group.ResultsThe percent time acid exposure was significantly higher in obese non-GERD than controls (p = 0.007). Acid reflux episodes were increased vs. controls in obese non-GERD (p = 0.005) and obese GERD (p = 0.034). Upright position showed a significant increase of reflux episodes in non-obese GERD (p = 0.034) and in obese non-GERD (p = 0.027) vs. controls. Recumbent position showed reflux episodes significantly increased vs. controls in obese non-GERD (p = 0.002), obese GERD (p = 0.021), and non-obese GERD (p = 0.033). In obese non-GERD, waist circumference (WC) correlated negatively with upright position episodes (r = −0.53; p = 0.043) and with proximal migration episodes, i.e., total (r = −0.60; p = 0.018), acid (r = −0.55; p = 0.033), and weakly acidic refluxes (r = −0.56; p = 0.031).ConclusionsObese patients showed an increased number of refluxes with acid content. Refluxes with proximal extent were significantly higher in obese non-GERD than in controls and non-obese GERD patients. No difference was observed between the two obese patient groups. In asymptomatic obese patients, the WC correlated with proximal extent episodes.

How to predict a high rate of inappropriateness for upper endoscopy in an endoscopic centre

BACKGROUND Inappropriateness of upper endoscopy (EGD) indication causes decreased diagnostic yield. Our aim of was to identify predictors of appropriateness rate for EGD among endoscopic centres. METHODS A post-hoc analysis of two multicentre cross-sectional studies, including 6270 and 8252 patients consecutively referred to EGD in 44 (group A) and 55 (group B) endoscopic Italian centres in 2003 and 2007, respectively, was performed. A multiple forward stepwise regression was applied to group A, and independently validated in group B. A <70% threshold was adopted to define inadequate appropriateness rate clustered by centre. RESULTS discrete variability of clustered appropriateness rates among the 44 group A centres was observed (median: 77%; range: 41-97%), and a <70% appropriateness rate was detected in 11 (25%). Independent predictors of centre appropriateness rate were: percentage of patients referred by general practitioners (GP), rate of urgent examinations, prevalence of relevant diseases, and academic status. For group B, sensitivity, specificity and area under receiver operating characteristic curve of the model in detecting centres with a <70% appropriateness rate were 54%, 93% and 0.72, respectively. CONCLUSIONS A simple predictive rule, based on rate of patients referred by GPs, rate of urgent examinations, prevalence of relevant diseases and academic status, identified a small subset of centres characterised by a high rate of inappropriateness. These centres may be presumed to obtain the largest benefit from targeted educational programs.

4725 Preneoplastic gastric lesions in a population with high incidence of gastric cancer: a cross-sectional study.

Background: High incidence rates of gastric cancer are associated with high incidence of so called pre-neoplastic lesions (chronic atrophic gastritis CAG, Intestinal Metaplasia IM and gastric epithelial dysplasia GED). However a reliable estimation of these values is lacking from many countries even those plagued by gastric cancer. Aim: To estimate, by a cross-sectional study, the incidence of CAG, IM and GED in a rural area of Northern Italy characterized by high incidence of gastric cancer. Subjects and Methods: 2792 subjects (77% of total) attending for Esophago-gastro-duodenoscopy (EGDS) in a 2 and half years period, underwent multiple biopsies from antrum-angulus, body and fundus; the percentage of cases affected by CAG, IM and GED was calculated (with 95% CI) globally and for different age classes and Helicobacter Pylori (HP) infection. Differences between percentages were considered significant at 0.05 if 95%CI did not overlap. Results: 134 cases of GED (4.8% of total EGDS), 472 of CAG (16.9%) and 1065 of IM (39.2%) were identified. These lesions were significantly more frequent in older patients (≥ 60 yrs) compared with younger ones: 8% vs 2.8% for GED; 25.8% vs 10.8% for CAG; 58% vs 25% for IM; p

Non-cirrhotic extrahepatic portal vein thrombosis: a 6-year long case history

In the absence of liver cirrhosis or cancer, splanchnic vein thrombosis is rare. Additional risk factors are neoplasia, abdominal inflammatory disease, and inherited and acquired thrombophilia as reported in chronic myeloproliferative disorders (CMPD), i.e. polycythemia vera and essential thrombocythemia [1, 2]. The Janus kinase-2 somatic mutation (JAK2V617F) represents a risk factor for myeloproliferative diseases and is helpful in laboratory tests for the evaluation of unexplained abdominal vein thrombosis [3–5]. A 47-year-old man was referred (November 2007) to our gastroenterology unit for further investigations regarding complications related to portal hypertension. Extrahepatic portal vein thrombosis (EHPVT) was diagnosed in another Hospital 6 years before (November 2001) after the onset of acute abdominal pain. Basic investigations were performed in order to diagnose liver cirrhosis as the main cause of splanchnic vein thrombosis. Neither ascites nor encephalopathy was present at the time of EHPVT diagnosis. Computed tomography showed thrombosis of the portal, splenic, and mesenteric veins, without alterations in hepatic pattern. Collateral vessels and portal cavernoma, as well as splenomegaly, were also reported. The patient developed significant portal hypertension with portosystemic collaterals that caused a serious episode of esophageal variceal bleeding in June 2007. Further abdominal ultrasound investigations, confirming the EHPVT, showed a significant enlargement of the spleen (16–17 cm) with signs of portal hypertension. The liver appeared to be slightly enlarged with a normal echo-pattern and regular borders. A splenoportography confirmed the presence of spleno-portal axis thrombosis. Liver biopsy excluded cirrhosis and showed mild portal inflammation with fibrosis confined to portal tracts. In November 2007, when he was referred to our gastroenterology unit, and additional causes of non-cirrhotic EHPVT were investigated (Table 1). Liver routine laboratory examinations did not show any significant alteration. However, despite the considerable splenomegaly (18 cm at abdominal US), platelet count was higher than normal (449 9 10/l). The review of previous clinical and laboratory files showed increased platelet counts ranging from 900 to 449 9 10/l from the first (November 2001) to the last investigation. This feature was never highlighted before our case investigation. We suspected that the normal and sometimes increased platelet count might mask CMPD. A search for the molecular marker, JAK2V617F, was performed by means of PCR assay and was positive in our patient. A bone marrow biopsy showed CMPD with prevalence of megakaryocytes, as well as myelofibrosis, consistent with ‘essential thrombocythemia’. The patient started treatment with acetylsalicylic acid (75 mg/day) and hydroxycarbamide (500 mg/day). Non-cirrhotic EHPVT is quite a rare event [1, 2]. In our patient from the EHPVT onset (6 years before) onwards, despite increasing splenomegaly, platelet counts were observed at the upper level of normal range and sometimes higher than normal. However, they were never investigated until the last admission to our hospital. It could be argued that a myeloproliferative disease was already present at the time of EHPVT diagnosis. Bone marrow biopsy showed an G. Ricci (&) F. Pigo V. Alvisi Department of Clinical and Experimental Medicine, Gastroenterology, University of Ferrara, Via Savonarola 9, 44100 Ferrara, Italy e-mail: giorgio.ricci@unife.it

For the appropriate use of upper digestive endoscopy are ASGE criteria more accurate than EPAGE method

For the appropriate use of upper digestive endoscopy are ASGE criteria more accurate than EPAGE method?

Polyamines and ornithine decarboxylase activity in intestinal metaplasia and dysplasia of gastric mucosa

Polyamines and ornithine decarboxylase activity in intestinal metaplasia and dysplasia of gastric mucosa

Endoscopic esophagitis: prevalence and association with gastritis, hiatal hernia and Helicobacter pylori (HP) infection

Endoscopic esophagitis: prevalence and association with gastritis, hiatal hernia and Helicobacter pylori (HP) infection