Vittorio Alvisi

ASGE guidelines for the appropriate use of upper endoscopy: Association with endoscopic findings

BACKGROUNDnThis prospective study examined the appropriate use of EGD in an open-access system with the American Society for Gastrointestinal Endoscopy (ASGE) guidelines and determined whether the ASGE guidelines were associated with relevant endoscopic findings.nnnMETHODSnIn a cohort of 1777 consecutive patients referred for open-access EGD, the proportion of patients who underwent EGD for appropriate indications was prospectively assessed. The relationship between appropriateness and the presence of clinically relevant endoscopic diagnoses was assessed by calculating (1) the likelihood ratio, positive and negative, of the indications; and (2) the change in the probability of relevant endoscopic diagnoses in the presence of the ASGE criteria.nnnRESULTSnThe rate for EGDs generally not indicated was 15.6%. Relevant endoscopic diagnoses were present in 47.4% of cases with ASGE indications versus 28.8% of patients without appropriate indications as defined by the ASGE criteria (OR: 2.23; 99% CI [1.55, 3.22]; p < 0.01). A similar difference was observed for erosive gastritis (OR: 1.86; 99% CI [1.17, 2.95]; p < 0.01), erosive esophagitis (OR: 1.48; 99% CI [0.87, 2.52]; p < 0.05), and Barretts esophagus (OR: 9.76; 99% CI [0.72, 132]; p < 0.05). The pretest probability of finding a relevant endoscopic diagnosis was modified slightly when an ASGE indication(s) was present and decreased markedly when ASGE criteria were absent.nnnCONCLUSIONSnThe use of the ASGE guideline for appropriate indications for EGD can improve patient selection for the procedure. However, to avoid missed diagnoses of serious disease, use of the guidelines must be tailored to the specific clinical setting.

Short-term low-dose triple therapy with azithromycin, metronidazole and lansoprazole appears highly effective for the eradication of Helicobacter pylori

Background: Although the OCN (omeprazole, clarithromycin and nitroimidazoles) shortterm low‐dose regimens are regarded as ‘the standard’ in the treatment of Helicobacter pylori infection, azithromycin is a new‐generation, acid‐stable macrolide which may prove particularly useful for a new short‐term low‐dose triple therapy regimen. Objective: To further improve OCN eradication treatments by reducing both the number of pills and the total cost. Methods: A new short‐term low‐dose triple therapy (LAM) using lansoprazole 30mg once a day for 1 week, azithromycin 500 mg once a day for 3 days, and metronidazole 250mg twice a day for the same 3 days, was administrated to 60 patients presenting with H. pylori‐positive gastritis with or without peptic ulcer, and compared with the classic ‘Bazzoli regimen’ (OCT: omeprazole, clarithromycin, tinidazole) in 60 matched patients. H. pylori infection before and after therapy was evaluated by a rapid urease test, conventional histology and toluidine‐stained semi‐thin sections. Three biopsies from the corpus and three from the antrum were taken during endoscopical examination before and 7‐8 weeks after discontinuation of the treatment. Patient compliance, drug tolerance and drug costs were also taken into consideration. Results: H. pylori infection was eradicated 7‐8 weeks after treatment in 56 of the 60 patients in the LAM group (93.3%), and in 52 of the 57 patients in the OCT group who completed the treatment (91.2%), with no statistical difference. When gastric or duodenal ulceration was present, ulcer healing was observed in all cases. Conclusion: The new proposed short‐term low‐dose triple therapy (LAM) appears to be as effective as the OCT for the eradication of H. pylori infection. The new treatment, however, seems to have advantages in terms of drug tolerance, patient compliance and therapy cost.

Bariatric Therapy with Intragastric Balloon Improves Liver Dysfunction and Insulin Resistance in Obese Patients

BackgroundObesity is often associated with fatty liver (FL). In most cases, bright liver at ultrasound (US) and increased alanine aminotransferase (ALT) and gamma-glutamyltranspeptidase (GGT) levels are considered the hallmarks of nonalcoholic fatty liver disease (NAFLD). Insulin resistance (IR) is the main link between obesity and NAFLD. The use of the Bioenterics® intragastric balloon (BIB) is a safe procedure either for inducing a sustained weight loss with diet support or for preparing those patients who are candidates for bariatric surgery. The aim of the study was to investigate whether the weight loss induced by intragastric balloon might improve IR and liver enzymes. The presence or absence of FL at US and the influence of a body mass index (BMI) decrease ≥10% after BIB (ΔBMIu2009≥u200910%) were also considered.MethodsOne hundred and three consecutive obese (BMIu2009>u200930xa0kg/m2) patients (38 males/65 females; mean age 41.3, range 20–63xa0years) underwent BIB insertion under endoscopic control. The BIB was removed 6xa0months later. US, clinical, and routine laboratory investigations were performed before and after BIB. IR was calculated by the homeostasis model assessment (HOMA-IRu2009>u20092.5). Exclusion criteria were hepatitis B virus positive, hepatitis C virus positive, alcohol consumption >30xa0g/day, history of hepato-steatogenic drugs, and type 1 diabetes.ResultsNinety-three patients were eligible for the study. The BMI significantly decreased in all investigated patients, and it was ≥10% in 59% of the patients. FL was seen at US in 70%, impaired fasting blood glucose was present in 13%, ALT exceeded the normal limit in 30.1%, GGT exceeded the normal limit in 15%, and HOMA-IR was >2.5 in 85%. Median HOMA-IR decreased significantly in FL (4.71 vs 3.10; pu2009<u20090.05) and non-FL (3.72 vs 2.81; pu2009<u20090.01) groups. Median ALT decreased significantly in the FL group (31.5 vs 24; pu2009<u20090.001) and GGT significantly decreased in the FL group (31 vs 23.5; pu2009<u20090.05). In the FL group with ΔBMIu2009≥u200910%, the median values of HOMA-IR (4.95 vs 2.69; pu2009<u20090.05), ALT (30 vs 23; pu2009<u20090.01), and GGT (28 vs 20; pu2009<u20090.001) significantly decreased after BIB. In the non-FL group, HOMA-IR values significantly decreased (4.07 vs 2.36; pu2009<u20090.01) in patients with a ΔBMIu2009≥u200910%; ALT and GGT did not significantly decrease.ConclusionsWeight loss induced by intragrastric balloon reduces IR. The ALT and GGT decrease suggests an improvement in hepatic damage. The benefit depends on the decrease of BMI higher than 10%.

“Cervia Working Group Report”: Guidelines on the diagnosis and treatment of Helicobacter pylori infection

Different national attitudes exist between countries in Europe concerning eradication of Helicobacter pylori infection due to the wide differences in Helicobacter pylori prevalence, gastric cancer risk, bacterial resistance to antibiotics, health care systems and financial resources. The Cervia Working Group Report has been established in order to fill the gap in the absence of National Guidelines in Italy concerning the diagnosis and treatment of Helicobacter pylori infection. The recommendations made are, by and large, similar to the European Guidelines but differ slightly with regard to the test-and-treat approach to young dyspeptics without sinister symptoms. In the absence of a national validation of this strategy a case-by-case assessment of dyspepsia has been promoted, both at primary care and specialist level. Another area of partial disagreement concerns the eradication of Helicobacter pylori in patients undergoing long-term proton pump inhibitor treatment which has not been generally recommended as scientific evidence in support of this policy is at present rather weak.

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

OBJECTIVEnWe 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.nnnMETHODSnFrom 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.nnnRESULTSnBody 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(+).nnnCONCLUSIONnNon-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.

Risk factors for the development of gallstone recurrence following medical dissolution

Objective To assess risk factors for gallstone recurrence following non‐surgical treatment. Design A prospective follow‐up of a multicentre cohort of post‐dissolution gallstone patients. Setting Six gastroenterology units in the UK and Italy. Participants One hundred and sixty‐three patients with confirmed gallstone dissolution following non‐surgical therapy (bile acids or lithotripsy plus bile acids), followed up by ultrasound scan and clinical assessment at 6‐monthly intervals for up to 6 years (median, 25 months; range, 6‐70 months). Outcome measures Subject‐related variables (sex, age, height, weight, body mass index), gallstone‐related variables (number, diameter, presence of symptoms, months to complete stone clearance), treatment modalities (bile acid therapy, extracorporeal shock wave lithotripsy) and follow‐up related variables (weight change, use of non‐steroidal anti‐inflammatory agents, statins, pregnancies and/or use of oestrogens) were assessed by univariate and multivariate analysis as putative risk factors for gallstone recurrence. Results Forty‐five gallstone recurrences were observed during the follow‐up period. Multiple primary gallstones and length of time to achieve gallstone dissolution were the only variables associated with a significant increase in the recurrence rate. Appearance of biliary sludge during follow‐up was also significantly related to development of gallstone recurrence. Use of statins or non‐steroidal antiinflammatory agents did not confer protection against recurrence. Conclusions Patients with primary single stones are the best candidates for non‐surgical treatment of gallstones, because of a low risk of gallstone recurrence. The positive association of recurrence with biliary sludge formation and time to dissolution of primary stones may provide indirect confirmation for the role of impaired gallbladder motility in the pathogenesis of this condition. Eur J Gastroenterol Hepatol 12:695‐700

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.

Repeated bile acid therapy for the long-term management of cholesterol gallstones.

BACKGROUND/AIMSnFollowing non-surgical treatment, cholesterol gallstones recur in a high proportion of patients, and recurrence cannot be predicted nor effectively prevented. Our aim was to test prospectively the viability and the efficacy of repeated bile acid therapy, in which recurrent stones are diagnosed at an early stage by regular ultrasound monitoring and promptly retreated, as a strategy for the management of these patients in clinical practice.nnnMETHODSnOne hundred and seventy-two consecutive patients were recruited upon achieving complete gallstone dissolution using non-surgical therapy (bile acids or lithotripsy plus bile acids), and followed up at 6-monthly intervals by ultrasound scan. Gallstone recurrence was promptly treated by a combination of ursodeoxycholic acid plus chenodeoxycholic acid (5 mg/kg per day each) for a period of 2 years, or less if complete redissolution was achieved. Median follow-up period was 34 months (range 6-70).nnnRESULTSnForty-five patients had gallstone recurrence; of these, 39 underwent one or more repeated courses of bile acid therapy (follow-up data available in 27). Gallstone recurrence rate was 15% at 1 year and 47% at 5 years. Average annual redissolution rate of recurrent gallstones (intention to treat) was 41%. The proportion of gallstone-free patients in the whole population was 88%, 84%, 77%, 78%, 75% at 1-5 years, respectively, and rose to > 90% at 3 years onwards in patients with single primary stones.nnnCONCLUSIONSnWe conclude that repeated bile acid therapy maintains the majority of patients gallstone free, and is therefore an effective long-term management strategy, especially in patients with primary single gallstones.

Appropriateness of Upper Gastrointestinal Endoscopy: A Hospital-Based Study

Aims of this study were to evaluate: (1) whether upper gastrointestinal endoscopy (UGE) is used appropriately according to the American Society for Gastrointestinal Endoscopy (ASGE) and British Society of Gastroenterology (BSG) guidelines in a hospital setting and (2) whether there is any relationship between appropriateness of UGE and the presence of lesions detected by endoscopy. %Indications and endoscopic findings for 734 consecutive UGE performed in 697 inpatients were retrospectively evaluated using ASGE and BSG guidelines to determine appropriateness of referrals. UGE showing endoscopic findings that had direct therapeutic or prognostic consequences were classified as “positive”; the other UGEs were classified as “negative.” In all, 46% of UGEs were “positive,” 54% “negative,” and 61.7% and 23.2% of UGEs were inappropriate according to ASGE and BSG guidelines, respectively (P < 0.001). The probability of finding a positive endoscopy was significantly higher in UGE rated as appropriate than in those rated as inappropriate on the basis of ASGE guidelines (P < 0.001), but not on the basis of BSG guidelines. Endoscopies rated as inappropriate according to ASGE and BSG criteria showed a positive finding in 37.3% and 42.3% of cases, respectively (not significant difference). Multivariate analysis showed that the positive finding is directly related to age (P < 0.05), male gender (P < 0.001), prior UGE (P < 0.05), hematemesis (P < 0.001), and inversely related with upper abdominal pain (P < 0.01) and dyspepsia (P < 0.05). In hospitalized patients, UGE is frequently used for inappropriate indications, according to both ASGE and BSG guidelines. However, the actual clinical usefulness of appropriateness criteria, such as those proposed by ASGE and BSG, is questionable, as their strict observance could lead to missing a large number of significant endoscopic findings.

Ornithine decarboxylase in colonic mucosa from patients with moderate or severe Crohn's disease and ulcerative colitis.

Polyamines, as well as ornithine decarboxylase (ODC), the enzyme involved in their synthesis, were reported to be closely related to cell proliferation. In Crohns disease and ulcerative colitis, cell destruction and proliferation increase in the active stage. The aim of the present study was to determine the ODC in both involved and uninvolved areas of the colonic mucosa of active Crohns disease and ulcerative colitis patients. The patients were divided in two groups, owing to the different level of activity (severe or moderate), by means of clinical endoscopy, laboratory, and histology evaluations. Subjects with suspected disease, but endoscopically unconfirmed, were used as controls. In all ulcerative colitis and Crohns disease patients the ODC values both in involved and uninvolved mucosa were significantly lower than in controls. In severe Crohns disease ODC was significantly reduced versus moderate Crohns disease only in affected tissues. In all ulcerative colitis patients (moderate or severe) the ODC was significantly decreased in involved mucosa compared with uninvolved mucosa. Severe ulcerative colitis showed the significantly lowest ODC. We suggest that the significant decrease of ODC in the bowel mucosa is closely related to the severity of the disease. The highest decrease of ODC in ulcerative colitis patients would be due both to the enhanced cell destruction, and to the feed-back from exogenous increased polyamine production (bowel bacteria, cell desquamation). Therefore ODC would be considered a sensitive index of the inflammatory derangement of the mucosa, especially in acute ulcerative colitis. We conclude that this behaviour may result in an enhanced risk of neoplasia.