Any prognosis of gastrointestinal (GI) cancer is closely related to the stage of the disease at diagnosis.Endoscopic submucosal dissection (ESD) and en bloc endoscopic mucosal resection (EMR) have been performed as cu...Any prognosis of gastrointestinal (GI) cancer is closely related to the stage of the disease at diagnosis.Endoscopic submucosal dissection (ESD) and en bloc endoscopic mucosal resection (EMR) have been performed as curative treatments for many early-stage GI lesions in recent years.The technologies have been widely accepted in many Asian countries because they are minimally invasive and supply thorough histopathologic evaluation of the specimens.However,before engaging in endoscopic therapy,an accurate diagnosis is a precondition to effecting the complete cure of the underlying malignancy or carcinoma in situ.For the past few years,many new types of endoscopic techniques,including magnifying endoscopy with narrow-band imaging (MENBI),have emerged in many countries because these methods provide a strong indication of early lesions and are very useful in determining treatment options before ESD or EMR.However,to date,there is no comparable classification equivalent to "Kudo's Pit Pattern Classification in the colon",for the upper GI,there is still no clear internationally accepted classification system of magnifying endoscopy.Therefore,in order to help unify some viewpoints,here we will review the defining optical imaging characteristics and the current representative classifications of microvascular and microsurface patterns in the upper GI tract under ME-NBI,describe the accurate relationship between them and the pathological diagnosis,and their clinical applications prior to ESD or en bloc EMR.We will also discuss assessing the differentiation and depth of invasion,defying the lateral spread of involvement and targeting biopsy in real time.展开更多
Since its advent in 1980,the scope of endoscopic ultrasound(EUS)has grown to include a wide range of indications,and it is now being incorporated as an integral part of everyday practice in the field of gastroenterolo...Since its advent in 1980,the scope of endoscopic ultrasound(EUS)has grown to include a wide range of indications,and it is now being incorporated as an integral part of everyday practice in the field of gastroenterology.Its use is extending from an adjuvant imaging aid to utilization as a therapeutic tool for various gastrointestinal disorders.EUS was first used to visualize remote organs,such as the pancreas and abdominal lymph nodes.When fine needle aspiration was introduced,the indications for EUS expanded to include tissue sampling for diagnostic purposes.At the same time,the needle can be used to convey a potential therapy to the internal organs,allowing access to remote sites.In this review,we aim to highlight the expanding spectrum of EUS indications and uses in the field of gastroenterology.展开更多
AIM: To systematically review economic evaluations in gastroenterology, relating to Brazil, published between 1980 and 2013. METHODS: We selected full and partial economic evaluations from among those retrieved by sea...AIM: To systematically review economic evaluations in gastroenterology, relating to Brazil, published between 1980 and 2013. METHODS: We selected full and partial economic evaluations from among those retrieved by searching the following databases: MEDLINE(PubM ed); Excerpta Medica; the Latin American and Caribbean Health Sciences Literature database; the Scientific Electronic Library Online; the database of the Centre for Reviews and Dissemination; the National Health Service(NHS) Economic Evaluation Database; the NHS Health Technology Assessment database; the Health Economics database of the Brazilian Virtual Library of Health; Scopus; Web of Science; and the Brazilian Network for the Evaluation of Health Technologies. Two researchers, working independently, selected the studies and extracted the data. RESULTS: We ide nt if ie d 535 he alt h e c onomic evaluations relating to Brazil and published in the 1980-2013 period. Of those 535 articles, only 40 dealt with gastroenterology. Full and partial economic evaluations respectively accounted for 23(57.5%) and 17(42.5%) of the 40 studies included. Among the 23 full economic evaluations, there were 11 cost-utility analyses, seven cost-effectiveness analyses, four costconsequence analyses, and one cost-minimization analysis. Of the 40 studies, 25(62.5%) evaluated medications; 7(17.5%) evaluated procedures; and 3(7.5%) evaluated equipment. Most(55%) of the studies were related to viral hepatitis, and most(63.4%) were published after 2010. Other topics included gastrointestinal cancer, liver transplantation, digestive diseases and hernias. Over the 33-year period examined, the number of such economic evaluations relating to Brazil, especially of those evaluating medications for the treatment of hepatitis, increased considerably. CONCLUSION: Further studies are needed in order to ensure that expenditures on health care in Brazil are made as fairly and efficiently as possible.展开更多
We write a letter to the editor commenting the article“Who to screen and how to screen for celiac disease”.We discuss the present literature on cirrhosis and celiac disease(CD)and recommend screening and treating CD...We write a letter to the editor commenting the article“Who to screen and how to screen for celiac disease”.We discuss the present literature on cirrhosis and celiac disease(CD)and recommend screening and treating CD in individuals with cryptogenic cirrhosis.展开更多
Celiac disease(CD)is a chronic inflammatory intestinal disorder mediated by the ingestion of gluten in genetically susceptible individuals.Liver involvement in CD has been widely described,and active screening for CD ...Celiac disease(CD)is a chronic inflammatory intestinal disorder mediated by the ingestion of gluten in genetically susceptible individuals.Liver involvement in CD has been widely described,and active screening for CD is recommended in patients with liver diseases,particularly in those with autoimmune disorders,fatty liver in the absence of metabolic syndrome,noncirrhotic intrahepatic portal hypertension,cryptogenic cirrhosis,and in the context of liver transplantation.Non-alcoholic fatty liver disease is estimated to affect approximately 25%of the world’s adult population and is the world’s leading cause of chronic liver disease.In view of both diseases’global significance,and to their correlation,this study reviews the available literature on fatty liver and CD and verifies particularities of the clinical setting.展开更多
Due to the high risk of morbidity and mortality associated with surgical resection in this tract,endoscopic resection(ER)has taken the place of surgical resection as the first line treatment for non-ampullary duodenal...Due to the high risk of morbidity and mortality associated with surgical resection in this tract,endoscopic resection(ER)has taken the place of surgical resection as the first line treatment for non-ampullary duodenal adenomas.However,due to the anatomical characteristics of this area,which enhance the risk of post-ER problems,ER in the duodenum is particularly difficult.Due to a lack of data,no ER technique for superficial non-ampullary duodenal epithelial tumours(SNADETs)has yet been backed by strong,high-quality evidence;yet,traditional hot snare-based techniques are still regarded as the standard treatment.Despite having a favourable efficiency profile,adverse events during duodenal hot snare polypectomy(HSP)and hot endoscopic mucosal resection,such as delayed bleeding and perforation,have been reported to be frequent.These events are primarily caused by electrocautery-induced damage.Thus,ER techniques with a better safety profile are needed to overcome these shortcomings.Cold snare polypectomy,which has already been shown as a safer,equally effective pro-cedure compared to HSP for treatment of small colorectal polyps,is being increasingly evaluated as a potential therapeutic option for non-ampullary duodenal adenomas.The aim of this review is to report and discuss the early outcomes of the first experiences with cold snaring for SNADETs.展开更多
AIM: To assess the safety of bismuth used in Helico- bacter pylori (H pylori) eradication therapy regimens. METHODS: We conducted a systematic review and meta-analysis. MEDLINE and EMBASE were searched (up to October ...AIM: To assess the safety of bismuth used in Helico- bacter pylori (H pylori) eradication therapy regimens. METHODS: We conducted a systematic review and meta-analysis. MEDLINE and EMBASE were searched (up to October 2007) to identify randomised controlled tri- als comparing bismuth with placebo or no treatment, or bismuth salts in combination with antibiotics as part of eradication therapy with the same dose and duration of antibiotics alone or, in combination, with acid suppres- sion. Total numbers of adverse events were recorded. Data were pooled and expressed as relative risks with 95% confidence intervals (CI). RESULTS: We identified 35 randomised controlled tri- als containing 4763 patients. There were no serious adverse events occurring with bismuth therapy. There was no statistically significant difference detected in total adverse events with bismuth [relative risk (RR) = 1.01; 95% CI: 0.87-1.16], specific individual adverse events, with the exception of dark stools (RR = 5.06; 95% CI: 1.59-16.12), or adverse events leading to withdrawal of therapy (RR = 0.86; 95% CI: 0.54-1.37). CONCLUSION: Bismuth for the treatment of H pylori is safe and well-tolerated. The only adverse event oc- curring significantly more commonly was dark stools.展开更多
Ulcerative colitis(UC) is a chronic inflammatory disease, whose etiology is still unclear. Its pathogenesis involves an interaction between genetic factors, immune response and the "forgotten organ", Gut Mic...Ulcerative colitis(UC) is a chronic inflammatory disease, whose etiology is still unclear. Its pathogenesis involves an interaction between genetic factors, immune response and the "forgotten organ", Gut Microbiota. Several studies have been conducted to assess the role of antibiotics and probiotics as additional or alternative therapies for Ulcerative Colitis. Escherichia coli Nissle(Ec N) is a nonpathogenic Gram-negative strain isolated in 1917 by Alfred Nissle and it is the active component of microbial drug Mutaflor®(Ardeypharm Gmb H, Herdecke, Germany and Ec N, Cadigroup, In Italy) used in many gastrointestinal disorder including diarrhea, uncomplicated diverticular disease and UC. It is the only probiotic recommended in ECCO guidelines as effective alternative to mesalazine in maintenance of remission in UC patients. In this review we propose an update on the role of Ec N 1917 in maintenance of remission in UC patients, including data about efficacy and safety. Further studies may be helpful for this subject to further the full use of potential of Ec N.展开更多
Drug-induced liver injury is a significant and still unresolved clinical problem.Limitations to knowledge about the mechanisms of toxicity render incomplete the detection of hepatotoxic potential during preclinical de...Drug-induced liver injury is a significant and still unresolved clinical problem.Limitations to knowledge about the mechanisms of toxicity render incomplete the detection of hepatotoxic potential during preclinical development.Several xenobiotics are lipophilic substances and their transformation into hydrophilic compounds by the cytochrome P-450 system results in production of toxic metabolites.Aging,preexisting liver disease,enzyme induction or inhibition,genetic variances,local O2 supply and,above all,the intrinsic molecular properties of the drug may affect this process.Necrotic death follows antioxidant consumption and oxidation of intracellular proteins,which determine increased permeability of mitochondrial membranes,loss of potential,decreased ATP synthesis,inhibition of Ca2+-dependent ATPase,reduced capability to sequester Ca2+ within mitochondria,and membrane bleb formation.Conversely,activation of nucleases and energetic participation of mitochondria are the main intracellular mechanisms that lead to apoptosis.Non-parenchymal hepatic cells are inducers of hepatocellular injury and targets for damage.Activation of the immune system promotes idiosyncratic reactions that result in hepatic necrosis or cholestasis,in which different HLA genotypes might play a major role.This review focuses on current knowledge of the mechanisms of drug-induced liver injury and recent advances on newly discovered mechanisms of liver damage.Future perspectives including new frontiers for research are discussed.展开更多
Non-organ-specific autoantibodies and thyroid autoantibodies have been frequently found in chronic carriers of hepatitis C virus(HCV). With respect to endomysial antibodies and tissue transglutaminase, it is controver...Non-organ-specific autoantibodies and thyroid autoantibodies have been frequently found in chronic carriers of hepatitis C virus(HCV). With respect to endomysial antibodies and tissue transglutaminase, it is controversial whether the prevalence of glutenrelated seromarkers is higher in patients with HCV. In such cases, in addition to acknowledging any currently existing autoimmune disease, recognizing the risk of the patient developing an autoimmune disease during interferon(IFN)-based treatment must be a principle concern. From a clinical point-of-view, the presence of autoantibodies arouses suspicion that an autoimmunedisease may be present or may be precipitated by IFNbased HCV treatment. In this paper, we review the prevalence of autoantibodies in individuals with hepatitis C, the clinical significance of these autoantibodies, and the approach recommended for such situations.展开更多
Gastric sleeve gastrectomy has become a frequent bariatric procedure. Its apparent simplicity hides a number of serious,sometimes fatal,complications. This is more important in the absence of an internationally adopte...Gastric sleeve gastrectomy has become a frequent bariatric procedure. Its apparent simplicity hides a number of serious,sometimes fatal,complications. This is more important in the absence of an internationally adopted algorithm for the management of the leaks complicating this operation. The debates exist even regarding the definition of a leak,with several classification systems that can be used to predict the cause of the leak,and also to determine the treatment plan. Causes of leak are classified as mechanical,technical and ischemic causes. After defining the possible causes,authors went into suggesting a number of preventive measures to decrease the leak rate,including gentle handling of tissues,staple line reinforcement,larger bougie size and routine use of methylene blue test per operatively. In our review,we noticed that the most important clinical sign or symptom in patients with gastric leaks are fever and tachycardia,which mandate the use of an abdominal computed tomography,associated with an upper gastrointrstinal series and/or gastroscopy if no leak was detected. After diagnosis,the management of leak depends mainly on the clinical condition of the patient and the onset time of leak. It varies between prompt surgical intervention in unstable patients and conservative management in stable ones in whom leaks present lately. The management options include also endoscopic interventions with closure techniques or more commonly exclusion techniques with an endoprosthesis. The aim of this review was to highlight the causes and thus the prevention modalities and find a standardized algorithm to deal with gastric leaks post sleeve gastrectomy.展开更多
AIM: The purpose of this review is to describe the variousaspects of primary gastric lymphoma and the treatmentoptions currently available. METHODS: After a systematic search of Pubmed, Medscape and MDconsult, we revi...AIM: The purpose of this review is to describe the variousaspects of primary gastric lymphoma and the treatmentoptions currently available. METHODS: After a systematic search of Pubmed, Medscape and MDconsult, we reviewed and retrieved literature regarding gastric lymphoma. RESULTS: Primary gastric lymphoma is rare however, the incidence of this malignancy is increasing. Chronic gastritis secondary to Helicobacterpylori(H pylon) infection has been considered a major predisposing factor for MALT lymphoma.Immune histochemical marker studies and molecular biology utilizing polymerase chain reaction have facilitated appropriate diagnosis and abolished the need for diagnostic surgical resection. Advances in imaging techniques including Magnetic Resonance Imaging (MRI) and Endoscopic UItrasonography (EUS) have helped evaluation of tumor extension and invasion.The clinical course and prognosis of this disease is dependent on histopathological sub-type and stage at the time of diagnosis. Controversy remains regarding the best treatment for early stages of this disease. Chemotherapy, surgery and combination have been studied and shared almost comparable results with survival rate of 70-90%. However, chemotherapy possesses the advantage of preserving gastric anatomy.Radiotherapy alone has been tried and showed good results.Stage ⅢE, IVE disease treatment is solely by chemotherapy and surgical resection has been a remote consideration. CONCLUSION: We conclude that methods of diagnosis and staging of the primary gastric lymphoma have dramatically improved. The modalities of treatment are many and probably chemotherapy is superior because of high success rate,preservation of stomach and tolerable complications.展开更多
Assessment of liver fibrosis in chronic hepatitis C virus(HCV)infection is considered a relevant part of patient care and key for decision making.Although liver biopsy has been considered the gold standard for staging...Assessment of liver fibrosis in chronic hepatitis C virus(HCV)infection is considered a relevant part of patient care and key for decision making.Although liver biopsy has been considered the gold standard for staging liver fibrosis,it is an invasive technique and subject to sampling errors and significant intra-and inter-observer variability.Over the last decade,several noninvasive markers were proposed for liver fibrosis diagnosis in chronic HCV infection,with variable performance.Besides the clear advantage of being noninvasive,a more objective interpretation of test results may overcome the mentioned intra-and inter-observer variability of liver biopsy.In addition,these tests can theoretically offer a more accurate view of fibrogenic events occurring in the entire liver with the advantage of providing frequent fibrosis evaluation without additional risk.However,in general,these tests show low accuracy in discriminating between intermediate stages of fibrosis and may be influenced by several hepatic and extrahepatic conditions.These methods are either serum markers(usually combined in a mathematical model)or imaging modalities that can be used separately or combined in algorithms to improve accuracy.In this review we will discuss the different noninvasive methods that are currently available for the evaluation of liver fibrosis in chronic hepatitis C,their advantages,limitations and application in clinical practice.展开更多
AIM:To evaluate the effectiveness of hepatic arterial infusion chemotherapy(HAIC) for advanced hepatocellular carcinoma(HCC) resistant to transarterial chemoembolization(TACE).METHODS:This study was conducted on 42 pa...AIM:To evaluate the effectiveness of hepatic arterial infusion chemotherapy(HAIC) for advanced hepatocellular carcinoma(HCC) resistant to transarterial chemoembolization(TACE).METHODS:This study was conducted on 42 patients who received HAIC for advanced HCC between 2001and 2010 at our hospital.5-fluorouracil(5-FU) was administered continuously for 24 h from day 1 to day 5 every 2-4 wk via an injection reservoir.Intra-arterial cisplatin or subcutaneous interferon was administered in combination with the 5-FU.The patients enrolled in this retrospective study were divided into two groups according to whether or not they fulfilled the criteria for resistance to TACE proposed by the Japan Society of Hepatology in 2010(written in Japanese);one group of patients who did not fulfill the criteria for TACE resistance(group A,n = 23),and another group who fulfilled the criteria for TACE resistance(group B,n = 19).We compared the outcomes in terms of the response and survival rates between the two groups.RESULTS:Both the response rate and tumor suppression rate following HAIC were significantly superior in group A than in group B(response rate:48% vs 16%,P = 0.028,tumor suppression rate:87% vs 53%,P = 0.014).Furthermore,both the progression-free survival rate and survival time were significantly superior in group A than in group B(3-,6-,12-,and 24-mo = 83%,70%,29% and 20% vs 63%,42%,16% and 0%,respectively,P = 0.040,and 9.8 mo vs 6.2 mo,P = 0.040).A multivariate analysis(Cox proportional hazards regression model) showed that resistance to TACE was an independent predictor of poor survival(P = 0.007).CONCLUSION:HAIC administrating 5-FU was not effective against advanced HCC resistant to TACE.Other tools for treatment,i.e.,molecular-targeting agents may be considered for these cases.展开更多
The Epstein-Barr virus(EBV)has an important and multifaceted role in liver pathology.As a member of the herpes virus family,EBV establishes a persistent infection in more than 90%of adults.Besides acute hepatitis duri...The Epstein-Barr virus(EBV)has an important and multifaceted role in liver pathology.As a member of the herpes virus family,EBV establishes a persistent infection in more than 90%of adults.Besides acute hepatitis during primary infection,many clinical syndromes of interest for the hepatologist are associated with EBV infection.The role of EBV in the evolution of chronic hepatitis from hepatotropic viruses is considered.Chronic EBVassociated hepatitis is suspected in immunocompetent adults with compatible serology,suggestive histology and detection of the viral genome in the liver and/or increase of specific circulating cytotoxic T-lymphocytes.EBV is the main cause of post-transplant lymphoproliferative disorders which occur in up to 30%of cases.EBV-driven lymphoproliferative diseases are also recognized in non-immunocompromised patients and liver is involved in up to a third of the cases.Directly implicated in the pathogenesis of different tumors,EBV has a disputable role in hepatocellular carcinoma carcinogenesis.Further research is required in order to establish or reject the role of EBV in human liver cancer.This paper attempts to discuss the range of EBV-associated chronic liver diseases in immunocompetent patients,from mild,self-limiting mononuclear hepatitis to liver cancer.展开更多
Forty-four different animal biles obtained from both invertebrates and vertebrates(including human bile)have been used for centuries for a host of maladies in traditional Chinese medicine(TCM)beginning with dog,ox and...Forty-four different animal biles obtained from both invertebrates and vertebrates(including human bile)have been used for centuries for a host of maladies in traditional Chinese medicine(TCM)beginning with dog,ox and common carp biles approximately in the Zhou dynasty(c.1046-256 BCE).Overall,different animal biles were prescribed principally for the treatment of liver,biliary,skin(including burns),gynecological and heart diseases,as well as diseases of the eyes,ears,nose,mouth and throat.We present an informed opinion of the clinical efficacy of the medicinal uses of the different animal biles based on their presently known principal chemical components which are mostly steroidal detergent-like molecules and the membrane lipids such as unesterified cholesterol and mixed phosphatidylcholines and sometimes sphingomyelin,as well as containing lipopigments derived from heme principally bilirubin glucuronides.All of the available information on the ethnopharmacological uses of biles in TCM were collated from the rich collection of ancient Chinese books on materia medica held in libraries in China and United States and the composition of various animal biles was based on rigorous separatory and advanced chemical identification techniques published since the mid-20th century collected via library(Harvard’s Countway Library)and electronic searches(PubMed and Google Scholar).Our analysis of ethnomedical data and information on biliary chemistry shows that specific bile salts,as well as the common bile pigment bilirubin and its glucuronides plus the minor components of bile such as vitamins A,D,E,K,as well as melatonin(N-acetyl-5-methoxytryptamine)are salutary in improving liver function,dissolving gallstones,inhibiting bacterial and viral multiplication,promoting cardiac chronotropsim,as well as exhibiting anti-inflammatory,anti-pyretic,anti-oxidant,sedative,anti-convulsive,anti-allergic,anti-congestive,anti-diabetic and anti-spasmodic effects.Pig,wild boar and human biles diluted with alcohol were shown to form an artificial skin for burns and wounds one thousand years ago in the Tang dynasty(618-907 CE).Although various animal biles exhibit several generic effects in common,a number of biles appear to be advantageous for specific therapeutic indications.We attempt to understand these effects based on the pharmacology of individual components of bile as well as attempting to identify a variety of future research needs.展开更多
AIM: To present our experience with pregnant patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) without using radiation, and to evaluate the acceptability of this alternative therapeutic path...AIM: To present our experience with pregnant patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) without using radiation, and to evaluate the acceptability of this alternative therapeutic pathway for ERCP during pregnancy. METHODS: Between 2000 and 2008, six pregnant women underwent seven ERCP procedures. ERCP was performed under mild sedoanalgesia induced with pethidine HCl and midazolam. The bile duct was cannulated with a guidewire through the papilla. A catheter was slid over the guidewire and bile aspiration and/or visualization of the bile oozing around the guidewire was used to confirm correct cannulation. Following sphincterotomy, the bile duct was cleared by balloon sweeping. When indicated, stents were placed. Confirmation of successful biliary cannulation and stone extraction was made by laboratory, radiological and clinical improvement. Neither fluoroscopy nor spot radiography was used during the procedure. RESULTS: The mean age of the patients was 28 years (range, 21-33 years). The mean gestational age for the fetus was 23 wk (range, 14-34 wk). Five patients underwent ERCP because of choledocholithiasis and/orcholedocholithiasis-induced acute cholangitis. In one case, a stone was extracted after precut papillotomy with a needle-knife, since the stone was impacted. One patient had ERCP because of persistent biliary fistula after hepatic hydatid disease surgery. Following sphincterotomy, scoleces were removed from the common bile duct. Two weeks later, because of the absence of fistula closure, repeat ERCP was performed and a stent was placed. The fistula was closed after stent placement. Neither post-ERCP complications nor premature birth or abortion was seen. CONCLUSION: Non-radiation ERCP in experienced hands can be performed during pregnancy. Stent placement should be considered in cases for which complete common bile duct clearance is dubious because of a lack of visualization of the biliary tree.展开更多
Eosinophilic esophagitis is a newly diagnosed esophageal disease in adult and children. The clinical and pathological characteristics of this disease have been established and were recently summarized in the expert cl...Eosinophilic esophagitis is a newly diagnosed esophageal disease in adult and children. The clinical and pathological characteristics of this disease have been established and were recently summarized in the expert clinical guideline published in 2011. In spite of the wide knowledge accumulated on this disease, there are many areas where scientific data are missing, especially in regard to the disease's pathophysiology. Recent publications have suggested that other confounding factors modify the disease and may affect its clinicalphenotypic presentation. Those factors may include place of living, air pollution, race, genetic factors and other. In the present report we discussed and review those confounding factors, the new developments, and what direction we should go to further advance our knowledge of this disease.展开更多
Many diagnostic and screening colonoscopies are performed on very elderly patients.Although colonoscopic yield increases with age,the potential benefits in such patients decrease because of shorter life expectancy and...Many diagnostic and screening colonoscopies are performed on very elderly patients.Although colonoscopic yield increases with age,the potential benefits in such patients decrease because of shorter life expectancy and more frequent comorbidities.Colonoscopy in very elderly patients carries a greater risk of complications and morbidity than in younger patients,and is associated with lower completion rates and higher likelihood of poor bowel preparation.Thus,screening colonoscopy in very elderly patients should be performed only after careful consideration of potential benefits,risks and patient preferences.On the other hand,diagnostic and therapeutic colonoscopy are more likely to benefit even very elderly patients,and in most cases should be performed if indicated.展开更多
Clinical manifestations of inflammatory bowel disease(IBD) are not locally restricted to the gastrointestinal tract, and a significant portion of patients have involvement of other organs and systems. The visual syste...Clinical manifestations of inflammatory bowel disease(IBD) are not locally restricted to the gastrointestinal tract, and a significant portion of patients have involvement of other organs and systems. The visual system is one of the most frequently affected, mainly by inflammatory disorders such as episcleritis, uveitis and scleritis. A critical review of available literature concerning ocular involvement in IBD, as it appears in Pub Med, was performed. Episcleritis, the most common ocular extraintestinal manifestation(EIM), seems to be more associated with IBD activity when compared with other ocular EIMs. In IBD patients, anterior uveitis has an insidious onset, it is longstanding and bilateral, and not related to the intestinal disease activity. Systemic steroids or immunosuppressants may be necessary in severe ocular inflammation cases, and control of the underlying bowel disease is important to prevent recurrence. Our review revealed that ocular involvement is more prevalent in Crohn's disease than ulcerative colitis, in active IBD, mainly in the presence of other EIMs. The ophthalmic symptoms in IBD are mainly nonspecific and their relevance may not be recognized by the clinician; most ophthalmic manifestations are treatable, and resolve without sequel upon prompt treatment. A collaborative clinical care team for management of IBD that includes ophthalmologists is central for improvement of quality care for these patients, and it is also cost-effective.展开更多
基金Supported by The fund of National Natural Science Foundation Financial of China,No. 81072913
文摘Any prognosis of gastrointestinal (GI) cancer is closely related to the stage of the disease at diagnosis.Endoscopic submucosal dissection (ESD) and en bloc endoscopic mucosal resection (EMR) have been performed as curative treatments for many early-stage GI lesions in recent years.The technologies have been widely accepted in many Asian countries because they are minimally invasive and supply thorough histopathologic evaluation of the specimens.However,before engaging in endoscopic therapy,an accurate diagnosis is a precondition to effecting the complete cure of the underlying malignancy or carcinoma in situ.For the past few years,many new types of endoscopic techniques,including magnifying endoscopy with narrow-band imaging (MENBI),have emerged in many countries because these methods provide a strong indication of early lesions and are very useful in determining treatment options before ESD or EMR.However,to date,there is no comparable classification equivalent to "Kudo's Pit Pattern Classification in the colon",for the upper GI,there is still no clear internationally accepted classification system of magnifying endoscopy.Therefore,in order to help unify some viewpoints,here we will review the defining optical imaging characteristics and the current representative classifications of microvascular and microsurface patterns in the upper GI tract under ME-NBI,describe the accurate relationship between them and the pathological diagnosis,and their clinical applications prior to ESD or en bloc EMR.We will also discuss assessing the differentiation and depth of invasion,defying the lateral spread of involvement and targeting biopsy in real time.
文摘Since its advent in 1980,the scope of endoscopic ultrasound(EUS)has grown to include a wide range of indications,and it is now being incorporated as an integral part of everyday practice in the field of gastroenterology.Its use is extending from an adjuvant imaging aid to utilization as a therapeutic tool for various gastrointestinal disorders.EUS was first used to visualize remote organs,such as the pancreas and abdominal lymph nodes.When fine needle aspiration was introduced,the indications for EUS expanded to include tissue sampling for diagnostic purposes.At the same time,the needle can be used to convey a potential therapy to the internal organs,allowing access to remote sites.In this review,we aim to highlight the expanding spectrum of EUS indications and uses in the field of gastroenterology.
基金Supported by The Funda??o de AmparoàPesquisa do Estado de S?o Paulo(FAPESP,S?o Paulo Research Foundation)as part of a larger project entitled "Systematic review of health economic evaluations conducted in Brazil,1980-2013"carried out under the leadership of Professor Patricia Coelho de Soárez,No.2012/22126-3
文摘AIM: To systematically review economic evaluations in gastroenterology, relating to Brazil, published between 1980 and 2013. METHODS: We selected full and partial economic evaluations from among those retrieved by searching the following databases: MEDLINE(PubM ed); Excerpta Medica; the Latin American and Caribbean Health Sciences Literature database; the Scientific Electronic Library Online; the database of the Centre for Reviews and Dissemination; the National Health Service(NHS) Economic Evaluation Database; the NHS Health Technology Assessment database; the Health Economics database of the Brazilian Virtual Library of Health; Scopus; Web of Science; and the Brazilian Network for the Evaluation of Health Technologies. Two researchers, working independently, selected the studies and extracted the data. RESULTS: We ide nt if ie d 535 he alt h e c onomic evaluations relating to Brazil and published in the 1980-2013 period. Of those 535 articles, only 40 dealt with gastroenterology. Full and partial economic evaluations respectively accounted for 23(57.5%) and 17(42.5%) of the 40 studies included. Among the 23 full economic evaluations, there were 11 cost-utility analyses, seven cost-effectiveness analyses, four costconsequence analyses, and one cost-minimization analysis. Of the 40 studies, 25(62.5%) evaluated medications; 7(17.5%) evaluated procedures; and 3(7.5%) evaluated equipment. Most(55%) of the studies were related to viral hepatitis, and most(63.4%) were published after 2010. Other topics included gastrointestinal cancer, liver transplantation, digestive diseases and hernias. Over the 33-year period examined, the number of such economic evaluations relating to Brazil, especially of those evaluating medications for the treatment of hepatitis, increased considerably. CONCLUSION: Further studies are needed in order to ensure that expenditures on health care in Brazil are made as fairly and efficiently as possible.
文摘We write a letter to the editor commenting the article“Who to screen and how to screen for celiac disease”.We discuss the present literature on cirrhosis and celiac disease(CD)and recommend screening and treating CD in individuals with cryptogenic cirrhosis.
文摘Celiac disease(CD)is a chronic inflammatory intestinal disorder mediated by the ingestion of gluten in genetically susceptible individuals.Liver involvement in CD has been widely described,and active screening for CD is recommended in patients with liver diseases,particularly in those with autoimmune disorders,fatty liver in the absence of metabolic syndrome,noncirrhotic intrahepatic portal hypertension,cryptogenic cirrhosis,and in the context of liver transplantation.Non-alcoholic fatty liver disease is estimated to affect approximately 25%of the world’s adult population and is the world’s leading cause of chronic liver disease.In view of both diseases’global significance,and to their correlation,this study reviews the available literature on fatty liver and CD and verifies particularities of the clinical setting.
文摘Due to the high risk of morbidity and mortality associated with surgical resection in this tract,endoscopic resection(ER)has taken the place of surgical resection as the first line treatment for non-ampullary duodenal adenomas.However,due to the anatomical characteristics of this area,which enhance the risk of post-ER problems,ER in the duodenum is particularly difficult.Due to a lack of data,no ER technique for superficial non-ampullary duodenal epithelial tumours(SNADETs)has yet been backed by strong,high-quality evidence;yet,traditional hot snare-based techniques are still regarded as the standard treatment.Despite having a favourable efficiency profile,adverse events during duodenal hot snare polypectomy(HSP)and hot endoscopic mucosal resection,such as delayed bleeding and perforation,have been reported to be frequent.These events are primarily caused by electrocautery-induced damage.Thus,ER techniques with a better safety profile are needed to overcome these shortcomings.Cold snare polypectomy,which has already been shown as a safer,equally effective pro-cedure compared to HSP for treatment of small colorectal polyps,is being increasingly evaluated as a potential therapeutic option for non-ampullary duodenal adenomas.The aim of this review is to report and discuss the early outcomes of the first experiences with cold snaring for SNADETs.
文摘AIM: To assess the safety of bismuth used in Helico- bacter pylori (H pylori) eradication therapy regimens. METHODS: We conducted a systematic review and meta-analysis. MEDLINE and EMBASE were searched (up to October 2007) to identify randomised controlled tri- als comparing bismuth with placebo or no treatment, or bismuth salts in combination with antibiotics as part of eradication therapy with the same dose and duration of antibiotics alone or, in combination, with acid suppres- sion. Total numbers of adverse events were recorded. Data were pooled and expressed as relative risks with 95% confidence intervals (CI). RESULTS: We identified 35 randomised controlled tri- als containing 4763 patients. There were no serious adverse events occurring with bismuth therapy. There was no statistically significant difference detected in total adverse events with bismuth [relative risk (RR) = 1.01; 95% CI: 0.87-1.16], specific individual adverse events, with the exception of dark stools (RR = 5.06; 95% CI: 1.59-16.12), or adverse events leading to withdrawal of therapy (RR = 0.86; 95% CI: 0.54-1.37). CONCLUSION: Bismuth for the treatment of H pylori is safe and well-tolerated. The only adverse event oc- curring significantly more commonly was dark stools.
文摘Ulcerative colitis(UC) is a chronic inflammatory disease, whose etiology is still unclear. Its pathogenesis involves an interaction between genetic factors, immune response and the "forgotten organ", Gut Microbiota. Several studies have been conducted to assess the role of antibiotics and probiotics as additional or alternative therapies for Ulcerative Colitis. Escherichia coli Nissle(Ec N) is a nonpathogenic Gram-negative strain isolated in 1917 by Alfred Nissle and it is the active component of microbial drug Mutaflor®(Ardeypharm Gmb H, Herdecke, Germany and Ec N, Cadigroup, In Italy) used in many gastrointestinal disorder including diarrhea, uncomplicated diverticular disease and UC. It is the only probiotic recommended in ECCO guidelines as effective alternative to mesalazine in maintenance of remission in UC patients. In this review we propose an update on the role of Ec N 1917 in maintenance of remission in UC patients, including data about efficacy and safety. Further studies may be helpful for this subject to further the full use of potential of Ec N.
文摘Drug-induced liver injury is a significant and still unresolved clinical problem.Limitations to knowledge about the mechanisms of toxicity render incomplete the detection of hepatotoxic potential during preclinical development.Several xenobiotics are lipophilic substances and their transformation into hydrophilic compounds by the cytochrome P-450 system results in production of toxic metabolites.Aging,preexisting liver disease,enzyme induction or inhibition,genetic variances,local O2 supply and,above all,the intrinsic molecular properties of the drug may affect this process.Necrotic death follows antioxidant consumption and oxidation of intracellular proteins,which determine increased permeability of mitochondrial membranes,loss of potential,decreased ATP synthesis,inhibition of Ca2+-dependent ATPase,reduced capability to sequester Ca2+ within mitochondria,and membrane bleb formation.Conversely,activation of nucleases and energetic participation of mitochondria are the main intracellular mechanisms that lead to apoptosis.Non-parenchymal hepatic cells are inducers of hepatocellular injury and targets for damage.Activation of the immune system promotes idiosyncratic reactions that result in hepatic necrosis or cholestasis,in which different HLA genotypes might play a major role.This review focuses on current knowledge of the mechanisms of drug-induced liver injury and recent advances on newly discovered mechanisms of liver damage.Future perspectives including new frontiers for research are discussed.
文摘Non-organ-specific autoantibodies and thyroid autoantibodies have been frequently found in chronic carriers of hepatitis C virus(HCV). With respect to endomysial antibodies and tissue transglutaminase, it is controversial whether the prevalence of glutenrelated seromarkers is higher in patients with HCV. In such cases, in addition to acknowledging any currently existing autoimmune disease, recognizing the risk of the patient developing an autoimmune disease during interferon(IFN)-based treatment must be a principle concern. From a clinical point-of-view, the presence of autoantibodies arouses suspicion that an autoimmunedisease may be present or may be precipitated by IFNbased HCV treatment. In this paper, we review the prevalence of autoantibodies in individuals with hepatitis C, the clinical significance of these autoantibodies, and the approach recommended for such situations.
文摘Gastric sleeve gastrectomy has become a frequent bariatric procedure. Its apparent simplicity hides a number of serious,sometimes fatal,complications. This is more important in the absence of an internationally adopted algorithm for the management of the leaks complicating this operation. The debates exist even regarding the definition of a leak,with several classification systems that can be used to predict the cause of the leak,and also to determine the treatment plan. Causes of leak are classified as mechanical,technical and ischemic causes. After defining the possible causes,authors went into suggesting a number of preventive measures to decrease the leak rate,including gentle handling of tissues,staple line reinforcement,larger bougie size and routine use of methylene blue test per operatively. In our review,we noticed that the most important clinical sign or symptom in patients with gastric leaks are fever and tachycardia,which mandate the use of an abdominal computed tomography,associated with an upper gastrointrstinal series and/or gastroscopy if no leak was detected. After diagnosis,the management of leak depends mainly on the clinical condition of the patient and the onset time of leak. It varies between prompt surgical intervention in unstable patients and conservative management in stable ones in whom leaks present lately. The management options include also endoscopic interventions with closure techniques or more commonly exclusion techniques with an endoprosthesis. The aim of this review was to highlight the causes and thus the prevention modalities and find a standardized algorithm to deal with gastric leaks post sleeve gastrectomy.
文摘AIM: The purpose of this review is to describe the variousaspects of primary gastric lymphoma and the treatmentoptions currently available. METHODS: After a systematic search of Pubmed, Medscape and MDconsult, we reviewed and retrieved literature regarding gastric lymphoma. RESULTS: Primary gastric lymphoma is rare however, the incidence of this malignancy is increasing. Chronic gastritis secondary to Helicobacterpylori(H pylon) infection has been considered a major predisposing factor for MALT lymphoma.Immune histochemical marker studies and molecular biology utilizing polymerase chain reaction have facilitated appropriate diagnosis and abolished the need for diagnostic surgical resection. Advances in imaging techniques including Magnetic Resonance Imaging (MRI) and Endoscopic UItrasonography (EUS) have helped evaluation of tumor extension and invasion.The clinical course and prognosis of this disease is dependent on histopathological sub-type and stage at the time of diagnosis. Controversy remains regarding the best treatment for early stages of this disease. Chemotherapy, surgery and combination have been studied and shared almost comparable results with survival rate of 70-90%. However, chemotherapy possesses the advantage of preserving gastric anatomy.Radiotherapy alone has been tried and showed good results.Stage ⅢE, IVE disease treatment is solely by chemotherapy and surgical resection has been a remote consideration. CONCLUSION: We conclude that methods of diagnosis and staging of the primary gastric lymphoma have dramatically improved. The modalities of treatment are many and probably chemotherapy is superior because of high success rate,preservation of stomach and tolerable complications.
文摘Assessment of liver fibrosis in chronic hepatitis C virus(HCV)infection is considered a relevant part of patient care and key for decision making.Although liver biopsy has been considered the gold standard for staging liver fibrosis,it is an invasive technique and subject to sampling errors and significant intra-and inter-observer variability.Over the last decade,several noninvasive markers were proposed for liver fibrosis diagnosis in chronic HCV infection,with variable performance.Besides the clear advantage of being noninvasive,a more objective interpretation of test results may overcome the mentioned intra-and inter-observer variability of liver biopsy.In addition,these tests can theoretically offer a more accurate view of fibrogenic events occurring in the entire liver with the advantage of providing frequent fibrosis evaluation without additional risk.However,in general,these tests show low accuracy in discriminating between intermediate stages of fibrosis and may be influenced by several hepatic and extrahepatic conditions.These methods are either serum markers(usually combined in a mathematical model)or imaging modalities that can be used separately or combined in algorithms to improve accuracy.In this review we will discuss the different noninvasive methods that are currently available for the evaluation of liver fibrosis in chronic hepatitis C,their advantages,limitations and application in clinical practice.
基金Supported by A Grant-in-Aid for research on the Third Term Comprehensive Control Research for Cancer from the Ministry on Health,Labour and Welfare,Japan,to Atsushi Nakajimaa grant from the National Institute of Biomedical Innovation (NBIO) to Atsushi Nakajima+1 种基金a grant from the Ministry of Education,Culture,Sports,Science and Technology,Japan(KIBAN-B), to Atsushi Nakajima,(KIBAN-C),to Satoru Saitothe grant program,"Collaborative Development of Innovative Seeds," from the Japan Science and Technology Agency(JST)
文摘AIM:To evaluate the effectiveness of hepatic arterial infusion chemotherapy(HAIC) for advanced hepatocellular carcinoma(HCC) resistant to transarterial chemoembolization(TACE).METHODS:This study was conducted on 42 patients who received HAIC for advanced HCC between 2001and 2010 at our hospital.5-fluorouracil(5-FU) was administered continuously for 24 h from day 1 to day 5 every 2-4 wk via an injection reservoir.Intra-arterial cisplatin or subcutaneous interferon was administered in combination with the 5-FU.The patients enrolled in this retrospective study were divided into two groups according to whether or not they fulfilled the criteria for resistance to TACE proposed by the Japan Society of Hepatology in 2010(written in Japanese);one group of patients who did not fulfill the criteria for TACE resistance(group A,n = 23),and another group who fulfilled the criteria for TACE resistance(group B,n = 19).We compared the outcomes in terms of the response and survival rates between the two groups.RESULTS:Both the response rate and tumor suppression rate following HAIC were significantly superior in group A than in group B(response rate:48% vs 16%,P = 0.028,tumor suppression rate:87% vs 53%,P = 0.014).Furthermore,both the progression-free survival rate and survival time were significantly superior in group A than in group B(3-,6-,12-,and 24-mo = 83%,70%,29% and 20% vs 63%,42%,16% and 0%,respectively,P = 0.040,and 9.8 mo vs 6.2 mo,P = 0.040).A multivariate analysis(Cox proportional hazards regression model) showed that resistance to TACE was an independent predictor of poor survival(P = 0.007).CONCLUSION:HAIC administrating 5-FU was not effective against advanced HCC resistant to TACE.Other tools for treatment,i.e.,molecular-targeting agents may be considered for these cases.
文摘The Epstein-Barr virus(EBV)has an important and multifaceted role in liver pathology.As a member of the herpes virus family,EBV establishes a persistent infection in more than 90%of adults.Besides acute hepatitis during primary infection,many clinical syndromes of interest for the hepatologist are associated with EBV infection.The role of EBV in the evolution of chronic hepatitis from hepatotropic viruses is considered.Chronic EBVassociated hepatitis is suspected in immunocompetent adults with compatible serology,suggestive histology and detection of the viral genome in the liver and/or increase of specific circulating cytotoxic T-lymphocytes.EBV is the main cause of post-transplant lymphoproliferative disorders which occur in up to 30%of cases.EBV-driven lymphoproliferative diseases are also recognized in non-immunocompromised patients and liver is involved in up to a third of the cases.Directly implicated in the pathogenesis of different tumors,EBV has a disputable role in hepatocellular carcinoma carcinogenesis.Further research is required in order to establish or reject the role of EBV in human liver cancer.This paper attempts to discuss the range of EBV-associated chronic liver diseases in immunocompetent patients,from mild,self-limiting mononuclear hepatitis to liver cancer.
基金Supported by Grants DK54012,DK73917,to Wang DQ-HDK36588,DK34854,and DK73687,to Carey MCall from the National Institutes of Health(US Public Health Service)
文摘Forty-four different animal biles obtained from both invertebrates and vertebrates(including human bile)have been used for centuries for a host of maladies in traditional Chinese medicine(TCM)beginning with dog,ox and common carp biles approximately in the Zhou dynasty(c.1046-256 BCE).Overall,different animal biles were prescribed principally for the treatment of liver,biliary,skin(including burns),gynecological and heart diseases,as well as diseases of the eyes,ears,nose,mouth and throat.We present an informed opinion of the clinical efficacy of the medicinal uses of the different animal biles based on their presently known principal chemical components which are mostly steroidal detergent-like molecules and the membrane lipids such as unesterified cholesterol and mixed phosphatidylcholines and sometimes sphingomyelin,as well as containing lipopigments derived from heme principally bilirubin glucuronides.All of the available information on the ethnopharmacological uses of biles in TCM were collated from the rich collection of ancient Chinese books on materia medica held in libraries in China and United States and the composition of various animal biles was based on rigorous separatory and advanced chemical identification techniques published since the mid-20th century collected via library(Harvard’s Countway Library)and electronic searches(PubMed and Google Scholar).Our analysis of ethnomedical data and information on biliary chemistry shows that specific bile salts,as well as the common bile pigment bilirubin and its glucuronides plus the minor components of bile such as vitamins A,D,E,K,as well as melatonin(N-acetyl-5-methoxytryptamine)are salutary in improving liver function,dissolving gallstones,inhibiting bacterial and viral multiplication,promoting cardiac chronotropsim,as well as exhibiting anti-inflammatory,anti-pyretic,anti-oxidant,sedative,anti-convulsive,anti-allergic,anti-congestive,anti-diabetic and anti-spasmodic effects.Pig,wild boar and human biles diluted with alcohol were shown to form an artificial skin for burns and wounds one thousand years ago in the Tang dynasty(618-907 CE).Although various animal biles exhibit several generic effects in common,a number of biles appear to be advantageous for specific therapeutic indications.We attempt to understand these effects based on the pharmacology of individual components of bile as well as attempting to identify a variety of future research needs.
文摘AIM: To present our experience with pregnant patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) without using radiation, and to evaluate the acceptability of this alternative therapeutic pathway for ERCP during pregnancy. METHODS: Between 2000 and 2008, six pregnant women underwent seven ERCP procedures. ERCP was performed under mild sedoanalgesia induced with pethidine HCl and midazolam. The bile duct was cannulated with a guidewire through the papilla. A catheter was slid over the guidewire and bile aspiration and/or visualization of the bile oozing around the guidewire was used to confirm correct cannulation. Following sphincterotomy, the bile duct was cleared by balloon sweeping. When indicated, stents were placed. Confirmation of successful biliary cannulation and stone extraction was made by laboratory, radiological and clinical improvement. Neither fluoroscopy nor spot radiography was used during the procedure. RESULTS: The mean age of the patients was 28 years (range, 21-33 years). The mean gestational age for the fetus was 23 wk (range, 14-34 wk). Five patients underwent ERCP because of choledocholithiasis and/orcholedocholithiasis-induced acute cholangitis. In one case, a stone was extracted after precut papillotomy with a needle-knife, since the stone was impacted. One patient had ERCP because of persistent biliary fistula after hepatic hydatid disease surgery. Following sphincterotomy, scoleces were removed from the common bile duct. Two weeks later, because of the absence of fistula closure, repeat ERCP was performed and a stent was placed. The fistula was closed after stent placement. Neither post-ERCP complications nor premature birth or abortion was seen. CONCLUSION: Non-radiation ERCP in experienced hands can be performed during pregnancy. Stent placement should be considered in cases for which complete common bile duct clearance is dubious because of a lack of visualization of the biliary tree.
文摘Eosinophilic esophagitis is a newly diagnosed esophageal disease in adult and children. The clinical and pathological characteristics of this disease have been established and were recently summarized in the expert clinical guideline published in 2011. In spite of the wide knowledge accumulated on this disease, there are many areas where scientific data are missing, especially in regard to the disease's pathophysiology. Recent publications have suggested that other confounding factors modify the disease and may affect its clinicalphenotypic presentation. Those factors may include place of living, air pollution, race, genetic factors and other. In the present report we discussed and review those confounding factors, the new developments, and what direction we should go to further advance our knowledge of this disease.
文摘Many diagnostic and screening colonoscopies are performed on very elderly patients.Although colonoscopic yield increases with age,the potential benefits in such patients decrease because of shorter life expectancy and more frequent comorbidities.Colonoscopy in very elderly patients carries a greater risk of complications and morbidity than in younger patients,and is associated with lower completion rates and higher likelihood of poor bowel preparation.Thus,screening colonoscopy in very elderly patients should be performed only after careful consideration of potential benefits,risks and patient preferences.On the other hand,diagnostic and therapeutic colonoscopy are more likely to benefit even very elderly patients,and in most cases should be performed if indicated.
文摘Clinical manifestations of inflammatory bowel disease(IBD) are not locally restricted to the gastrointestinal tract, and a significant portion of patients have involvement of other organs and systems. The visual system is one of the most frequently affected, mainly by inflammatory disorders such as episcleritis, uveitis and scleritis. A critical review of available literature concerning ocular involvement in IBD, as it appears in Pub Med, was performed. Episcleritis, the most common ocular extraintestinal manifestation(EIM), seems to be more associated with IBD activity when compared with other ocular EIMs. In IBD patients, anterior uveitis has an insidious onset, it is longstanding and bilateral, and not related to the intestinal disease activity. Systemic steroids or immunosuppressants may be necessary in severe ocular inflammation cases, and control of the underlying bowel disease is important to prevent recurrence. Our review revealed that ocular involvement is more prevalent in Crohn's disease than ulcerative colitis, in active IBD, mainly in the presence of other EIMs. The ophthalmic symptoms in IBD are mainly nonspecific and their relevance may not be recognized by the clinician; most ophthalmic manifestations are treatable, and resolve without sequel upon prompt treatment. A collaborative clinical care team for management of IBD that includes ophthalmologists is central for improvement of quality care for these patients, and it is also cost-effective.
