Small Intestinal Bacterial Overgrowth and Orocecal Transit Time in Patients of Inflammatory Bowel Disease

Background

Inflammatory bowel disease (IBD) consists of Ulcerative colitis (UC) and Crohn’s disease (CD). These two conditions share many common features—diarrhea, bloody stools, weight loss, abdominal pain, fever and fatigue. Small intestinal bacterial overgrowth (SIBO) is frequent in patients with CD but it has not been studied in UC Indian patients.

Aim

The study was planned to measure orocecal transit time (OCTT) and SIBO in UC and CD patients.

Methods

One hundred thirty-seven patients of IBD (95 UC and 42 CD) and 115 healthy controls were enrolled. OCTT and SIBO were measured by lactulose and glucose hydrogen breath test respectively. Concentration of hydrogen and methane were measured by SC microlyser from Quintron, USA.

Results

Mean ± standard deviation (SD) of OCTT in patients of IBD was significantly higher as compared to controls. Furthermore, OCTT was significantly higher in CD patients as compared to UC patients. It was also observed that occurrence of SIBO was significantly higher in IBD patients as compared to controls. The occurrence of SIBO in CD (45.2 %) was significantly higher as compared to patients in UC (17.8 %) group. Percentage of methane positive IBD patients (2.9 %) was significantly lower as compared to methane positive controls (24.4 %).

Conclusion

OCTT was significantly delayed in IBD patients as compared to controls and in CD patients as compared to UC patients. OCTT was significantly higher in SIBO positive IBD patients as compared to SIBO negative patients. Thus, we can suggest that delayed OCTT would have been the cause of increased SIBO in these patients.     

Small Intestinal Bacterial Overgrowth in Gastroparesis

Objective

To determine symptoms of small intestinal bacterial overgrowth (SIBO) in gastroparesis patients.

Methods

Patients undergoing LBT (lactulose breath test) for evaluation of SIBO were included. LBT was considered positive on the basis of three conventional criteria: (1) hydrogen level increase >20 ppm above baseline by 90 min (H2@90min); (2) dual hydrogen peaks (>10 ppm increase over baseline before second peak >20 ppm (DPHBT); and (3) breath methane increase of >20 ppm above baseline by 90 min. Results of gastric emptying scintigraphy (GES) were recorded. Patients completed the Patient Assessment of Upper Gastrointestinal Disorders-Symptom Severity Index.

Results

Of 740 patients who underwent LBT from December 2009 to August 2011, 471 underwent GES, with 201 having delayed GES. Of patients with delayed GES who underwent LBT 87 % were female, 23 % diabetic, 49 % used gastric acid suppressants, 29 % used opiate analgesics, 35 % used pro-motility medications, and 27 % had a history of gastrointestinal surgery. Overall, 79 (39 %) patients with gastroparesis had evidence of SIBO by LBT: 30 (15 %) had positive H2@90min, 53 (26 %) positive DPHBT, and 6 (3 %) positive breath methane test. In gastroparesis patients with positive H2@90min, there was increased severity of bloating (3.80 ± 0.20 vs 3.29 ± 0.12; P = 0.02), early satiety (3.57 ± 0.27 vs 3.05 ± 0.13; P = 0.045), and postprandial fullness (4.20 ± 0.18 vs 3.52 ± 0.12; P < 0.01) compared with negative H2@90min patients. No significant difference in symptom severity was seen between positive and negative DPHBT gastroparesis patients.

Conclusion

In our cohort, 39 % of gastroparesis patients tested positive for SIBO by LBT. Positive H2@90min testing by LBT was associated with increased symptoms of bloating and excessive fullness during and after meals.     

The Impact of Alcohol Consumption and Cholecystectomy on Small Intestinal Bacterial Overgrowth

Background

The etiology of small intestinal bacterial overgrowth (SIBO) is diverse and frequently multi-factorial. SIBO is thought to result from structural changes of the gastrointestinal tract, disordered peristalsis of the stomach and/or small intestine, or a disruption of the normal mucosal defenses of the small intestine. Alcoholics are reported to have higher rates of SIBO, as diagnosed by jejunal aspirate; however, no data are available on the association between moderate alcohol consumption and SIBO.

Aim

To evaluate the association between moderate alcohol consumption and SIBO and identify risk factors for SIBO using the lactulose breath test (LBT).

Methods

A retrospective chart review was completed for 210 consecutive patients who underwent the LBT between 2008 and 2010. We reviewed demographic data, including age, race, body mass index, alcohol and tobacco history, medication use, comorbid medical conditions, and history of abdominal surgery.

Results

The study included 196 patients (68 % female; mean age 55 years), 93 of whom had a positive LBT (47.4 %). Of those patients who consumed a moderate amount of alcohol, 58 % had a positive LBT, compared to 38.9 % of abstainers (P = 0.008). Those with a history of cholecystectomy had significantly lower rates of a positive LBT than those who had not (33.3 vs. 51.7 % respectively; P = 0.031). Neither proton pump inhibitor (PPI) use nor tobacco use was associated with a positive LBT.

Conclusion

In this retrospective review, moderate alcohol consumption was a strong risk factor for SIBO. Cholecystectomy appeared to be protective against SIBO. Neither PPI use nor tobacco use was associated with an increased risk of SIBO.     

Efficacy of Transjugular Intrahepatic Portosystemic Shunt with Adjunctive Embolotherapy with Cyanoacrylate for Esophageal Variceal Bleeding

Background

Transjugular intrahepatic portosystemic shunt (TIPS) with adjunctive embolotherapy has recently been reported to be effective in the prevention of variceal hemorrhage of cirrhotic patients. However, further investigation of its long-term efficacy is still needed.

Aim

To examine the rebleeding, survival, and hepatic encephalopathy (HE) after treatment with TIPS alone and TIPS with adjunctive embolotherapy using cyanoacrylate for esophageal variceal bleeding.

Methods

Patients with refractory to endoscopic therapy for esophageal variceal bleeding were enrolled. TIPS was performed in 101 patients with adjunctive embolotherapy (n = 53) or alone (n = 48) between January 2006 and December 2011. Chart reviews were performed to determine rebleeding, survival rates, and the incidence of HE.

Results

Recurrent hemorrhage occurred in 12 (11.9 %) patients during the mean follow-up periods of 35.8 months. Rebleeding was observed in 9/48 (18.8 %) patients in TIPS alone group and 3/53 (5.7 %) patients in TIPS with adjunctive embolotherapy group (p = 0.042). Death occurred in 30 patients during follow-up (TIPS alone: n = 16, TIPS with adjunctive embolotherapy: n = 14, p = 0.447). Twenty-six episodes of HE occurred in 18 patients in TIPS alone group and 16 episodes occurred in 10 patients in TIPS with embolotherapy group. The probability of HE was significantly higher in TIPS alone group than in TIPS with embolotherapy group (p = 0.019).

Conclusions

TIPS with adjunctive embolotherapy with cyanoacrylate is relatively safe and effective, with a lower rebleeding and HE incidence in comparison of TIPS alone.     

Use of ImPACT to Diagnose Minimal Hepatic Encephalopathy: An Accurate, Practical, User-Friendly Internet-Based Neuropsychological Test Battery

Background and Aims

An effective, user-friendly neurocognitive test to diagnose minimal hepatic encephalopathy (MHE) is needed. Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) is a brief, validated, Web-based, neuropsychological test battery resulting in four composite scores [Verbal Memory (VrbM), Visual Memory, Visual Motor Speed (VMS), Reaction Time (RT)]. We compared ImPACT to traditional paper-and-pencil tests in patients at risk for MHE versus controls.

Methods

Ninety cirrhotic patients with no history of overt hepatic encephalopathy were compared with 131 controls on standard psychometric tests (SPT) [Trail Making Test-A, Trail Making Test-B, Digit Symbol Test], 4 ImPACT composite scores, and the Sickness Impact Profile (SIP). MHE+ was defined by a score 2 SD below the normative mean on at least one of the SPT. ImPACT (ImP+) scores of patients were defined as 2 SD from the control mean.

Results

Cirrhotic patients scored more poorly than controls on 3/4 of ImPACT scores: VrbM (78.88 vs. 71.37, p < 0.001), VMS (26.47 vs. 22.68, p < 0.001) and RT (0.89 vs. 1.00, p < 0.01), as well as on all 3 SPT. Of the 90 cirrhotics, 16 (18 %) were MHE+, who performed more poorly (p < 0.001) than patients without MHE on VrbM (58.13 vs. 74.19), VMS (16.77 vs. 23.95) and RT (1.24 vs. 0.95). Of the 90 cirrhotics, 25 (27.8 %) were ImP+. MHE+ and ImP+ patients had increased SIP scores versus controls (p < 0.001).

Conclusions

Compared to paper-and-pencil testing, ImPACT provides a brief, user-friendly, neuropsychological evaluation of MHE. ImPACT could become a new standard for MHE diagnosis.     

Pulmonary vein re-isolation for atrial fibrillation using duty-cycled phased radiofrequency ablation: safety and efficacy of a primary 2:1 bipolar/unipolar ablation mode

Purpose

Pulmonary vein isolation (PVI) using phased radiofrequency (RF) energy has been shown to be effective in the treatment of paroxysmal atrial fibrillation (AF). We characterize pulmonary vein (PV) conduction at repeat ablation in patients with AF after an initial successful PVI using phased RF technology and analyze the effects of a primary 2:1 ablation mode.

Methods and results

A primary 4:1 bipolar/unipolar mode in group A patients (n = 22) was compared with a primary 2:1 mode in group B (n = 22) acutely and during follow-up. Of all PVs, 81 % showed reconnection(s); 52 % of them had reconnected in all PVs. PVI was achieved in all patients without complications. Procedure and fluoroscopy times were shorter in group B (108 ± 15 vs. 126 ± 24 min and 17 ± 5 vs. 23 ± 7 min, respectively). This was attributed to a significant decrease of early PV reconnections within the first 30 min in 17 % of group B patients vs. 45 % of group A patients (p < 0.001). After 9.5 ± 4 months, recurrence of AF was detected in 5 of 22 patients (22.7 %) in group A vs. 3 of 22 patients (13.6 %) in group B (p = 0.722).

Conclusions

Phased RF energy applied by a 2:1 bipolar/unipolar mode seems safe and effective in redo-PVI procedures, resulting in a mid-term freedom from AF in 86.4%. Significant shorter procedure and fluoroscopy times compared with a primary 4:1 ablation mode during repeat PVI are mainly attributed to a lower incidence of acutely reconnected PVs within the first 30 min.     

Evaluation of Different Bowel Preparations for Small Bowel Capsule Endoscopy: A Prospective, Randomized, Controlled Study

Background and Study Aims

To obtain an adequate view of the whole small intestine during capsule endoscopy (CE) a clear liquid diet and overnight fasting is recommended. However, intestinal content can hamper vision in spite of these measures. Our aim was to evaluate tolerance and degree of intestinal cleanliness during CE following three types of bowel preparation.

Patients and Methods

This was a prospective, multicenter, randomized, controlled study. Two-hundred ninety-one patients underwent one of the following preparations: 4 L of clear liquids (CL) (group A; 92 patients); 90 mL of aqueous sodium phosphate (group B; 89 patients); or 4 L of a polyethylene glycol electrolyte solution (group C; 92 patients). The degree of cleanliness of the small bowel was classified by blinded examiners according to four categories (excellent, good, fair or poor). The degree of patient satisfaction, gastric and small bowel transit times, and diagnostic yield were measured.

Results

The degree of cleanliness did not differ significantly between the groups (P = 0.496). Interobserver concordance was fair (k = 0.38). No significant differences were detected between the diagnostic yields of the CE (P = 0.601). Gastric transit time was 35.7 ± 3.7 min (group A), 46.1 ± 8.6 min (group B) and 34.6 ± 5.0 min (group C) (P = 0.417). Small-intestinal transit time was 276.9 ± 10.7 min (group A), 249.7 ± 13.1 min (group B) and 245.6 ± 11.6 min (group C) (P = 0.120). CL was the best tolerated preparation. Compliance with the bowel preparation regimen was lowest in group C (P = 0.008).

Conclusions

A clear liquid diet and overnight fasting is sufficient to achieve an adequate level of cleanliness and is better tolerated by patients than other forms of preparation.     

Favorable clinical outcome using a covered stent following transjugular intrahepatic portosystemic shunt in patients with portal hypertension

Aims

To compare retrospectively the clinical outcomes in patients treated with transjugular intrahepatic portosystemic shunt (TIPS) using the novel polytetrafluoroethylene-covered stents (Fluency) and bare stents.

Materials and methods

Sixty consecutive patients with portal hypertension treated with TIPS from April 2007 to April 2009 were included. TIPS creation was performed with Fluency stent grafts in 30 patients (group A) and with bare stents in 30 patients (group B). Liver function, TIPS patency and clinical outcomes were evaluated every 3 months after procedures.

Results

During hospitalization, there were no cases of hepatic encephalopathy (HE) and recurrence of variceal bleedings. Acute shunt occlusion was found in one patient in each group. Follow-ups were performed in group A with average time of 6.16 ± 3.89 months and in group B with 8.34 ± 4.42 months. The rates of recurrent bleeding, shunt occlusion, HE and mortality were 0.03, 0.0, 16.7 and 0% in group A, and 20.0, 30.0, 20.0 and 13.3% in group B, respectively. There was no difference of HE between group A and group B. The decrease of portal pressure and portosystemic pressure gradient, and the increase of portal flow were 34.1 and 23.3%, 60.0 and 52.8%, and 189.5 and 111.1% in group A and B, respectively. There were no differences of liver function between group A and B.

Conclusion

The Fluency stent graft is relatively safe and effective in TIPS creation, with a high patency rate compared with bare stents.     

Association Between Small Intestinal Bacterial Overgrowth by Glucose Breath Test and Coronary Artery Disease

Background

A possible role of gut bacteria and their metabolic by-products in the development of coronary artery disease (CAD) is suspected. There is a lack of studies evaluating the association of small intestinal bacterial overgrowth (SIBO) with the development of CAD.

Aim

To evaluate the frequency and risk factors for angiography-confirmed CAD in patients with or without SIBO.

Methods

A total of 1059 patients tested for SIBO using the glucose hydrogen/methane breath test from 2006 to 2014 were evaluated. In total, 160 had coronary artery angiography and were included in the study. SIBO-positive patients were compared to SIBO-negative patients. Demographic, clinical, and laboratory variables and the presence of CAD on coronary angiography were analyzed.

Results

Patients with SIBO had a higher frequency of CAD (78.9 vs. 38.6%, p < 0.001), diabetes mellitus (40.0 vs. 22.9%, p = 0.016), chronic kidney disease (26.7 vs. 12.9%, p = 0.025), use of angiotensin conversion enzyme inhibitor/blocker (45.5 vs. 32.9%, p = 0.008), and statins (75.6 vs. 61.4%, p = 0.004). Patients with SIBO had an increased number of coronary arteries affected compared to SIBO-negative patients (1-vessel disease 67.2 vs. 32.8%, p < 0.001; 2-vessel disease 85.7 vs. 14.3%, p < 0.001; and 3-vessel disease 82.4 vs. 17.6%, p < 0.001, respectively). In the stepwise multivariate logistic regression analysis, SIBO remained an independent risk factor for CAD (odds ratio 7.18, 95% confidence interval 3.09–16.67; p < 0.001).

Conclusion

SIBO was found to be associated with CAD and with the number of coronary arteries involved in this study from a single tertiary center. Further studies are necessary to confirm the association of SIBO with CAD. In the presence of risk factors, patients with SIBO may benefit from assessment for CAD.

     

Which is the best catheter to perform atrial fibrillation ablation? A comparison between standard ThermoCool,SmartTouch, and Surround Flow catheters

Introduction

Catheter ablation (CA) is an established therapy for atrial fibrillation (AF). The SmartTouch catheter (STc) provides information about catheter tip to tissue contact force (CF). The Surround Flow catheter (SFc) provides a uniform cooling of the tip during ablation. We sought to analyze the impact of STc and SFc on CA of paroxysmal AF in terms of feasibility and acute efficacy.

Methods and results

Sixty-three patients (mean age 57.6?±?9.8 years, 53 males) with paroxysmal AF underwent pulmonary veins (PVs) antral isolation, by using standard ThermoCool catheter (TCc) in 21, STc in 21, and SFc in 21. Total procedural, fluoroscopy, and radiofrequency (RF) delivery times; percentage of persistently deconnected PVs after 30 min; and percentage of isolated PVs at the end of the procedure were measured. The use of both STc and SFc obtained a reduction of fluoroscopy time (TCc 34?±?18 min, STc 20?±?10 min, p?<?0.001; SFc 21?±?13 min, p?=?0.02 vs TCc) and RF time (TCc 41?±?13 min, STc 30?±?14 min, p?=?0.013; SFc 30?±?9 min, p?<?0.01 vs TCc). The use of STc resulted in a reduction of procedural time (TCc 181?±?53 min, STc 140?±?53 min, p?<?0.001; SFc 170?±?51 min, p?=?NS vs TCc). The percentage of isolated PVs was comparable between groups (TCc 96 % vs STc 98 % vs SFc 96 %; p?=?NS). The percentage of deconnected PVs at 30 min was lower in TCc (89 %) than in STc (95 %) and in SFc (95 %) group (p?<?0.05).

Conclusions

Both STc and SFc allowed a simplification of CA of paroxysmal AF. In addition, they reduced early PVs reconnection.

Condensed abstract

Sixty-three patients with paroxysmal AF underwent ablation by standard ThermoCool, SmartTouch, or Surround Flow catheter. Both the SmartTouch and the Surround Flow significantly reduced radiofrequency and fluoroscopy times, as well as pulmonary veins reconnection rate at 30 min. Moreover, the SmartTouch reduced overall duration of the procedure.     

Totally laparoscopic resection with natural orifice specimen extraction (NOSE) has more advantages comparing with laparoscopic-assisted resection for selected patients with sigmoid colon or rectal cancer

Purpose

The purposes of this study were to compare the short-term outcomes of natural orifice specimen extraction (NOSE) and laparoscopic-assisted resection for sigmoid colon cancer or rectal cancer and to appraise whether totally laparoscopic resection with NOSE had more advantages compared with conventional laparoscopic-assisted resection.

Methods

Sixty-five patients who underwent totally laparoscopic resection with NOSE were assigned to NOSE group, and 132 patients who underwent laparoscopic-assisted resection were assigned to laparoscopic-assisted (LA) group. Data of all 197 cases were reviewed. Short-term outcomes (including operative outcomes, gastrointestinal recovery, hospital stay, and complication) of the two groups were compared.

Results

Mean numbers of lymph nodes harvested were 17.0?±?8.3 and 18.9?±?11.6 in NOSE group and LA group, respectively, (P?=?0.248); mean operative times were 111.6?±?25.4 min and 115.3?±?23.0 min in the two groups (P?=?0.384); and the mean blood losses in these two groups were 70.2?±?66.1 ml and 126.3?±?58.6 ml, respectively, (P?P?P?=?0.002) in NOSE group and LA group, respectively. Hospital stay in NOSE group were 9.0?±?1.9 and 9.9?±?2.0 days in LA group. Incidences of peri-operative complications were 6.2 and 17.2 % in the two groups, respectively (P?=?0.031).

Conclusions

Without compromising oncologic outcome, totally laparoscopic resection with NOSE had more advantages including less blood loss, less pain, faster recovery of intestinal function and shorter hospital stay compared with laparoscopic-assisted resection for selected patients with sigmoid colon cancer or rectal cancer.     

Genetics correlates with lung function and nocturnal ventilation in myotonic dystrophy

Background

Dystrophia myotonica (DM) is the most frequent adult-onset muscular dystrophy. Type 1 is caused by the cytosine–thymine–guanine (CTG) repeat expansion in the DM protein kinase gene. Respiratory muscle weakness and altered central ventilatory control lead to hypercapnia and lung volume restriction.

Purpose

This study aims to review the respiratory involvement in DM patients and study its relation with genetics.

Methods

Retrospective study of patients with DM referred for respiratory assessment was made. Noninvasive ventilation (NIV) was considered to daytime hypercapnia or symptoms of nocturnal hypoventilation.

Results

Forty-two consecutive patients (37.9?±?13.6 years) were evaluated. Mean CTG length was 642.8?±?439.2 repeats. In the first evaluation, mean forced vital capacity (FVC) was 74.4?±?20.2 %, maximal expiratory pressure (MEP) 35?±?16 %, maximal inspiratory pressure 52?±?23 %, peak cough flow (PCF) 327.3?±?97.7 L/min, arterial pressure of oxygen 79.7?±?11.3 mmHg, arterial pressure of carbon dioxide 45.5?±?6.2 mmHg, overnight minimal peripheral oxygen saturation (SpO₂) 79.6?±?11.6 %, and apnea–hypopnea index 13.9?±?9.9. CTG length was found to be related with MEP (r?=??0.67; p?=?0.001) and SpO₂ (r?=??0.37; p?=?0.039). NIV was started in 25 patients. Ventilated patients had lower FVC (2.19 to 3.21 L; p?<?0.001) and PCF (285.3 to 388.5 L/min; p?=?0.003) and more CTG repeats (826.6 to 388.5 repeats; p?=?0.02). NIV compliance was poor in seven patients (28 %) and related with hypercapnia (r?=?0.87; p?=?0.002) and inspiratory positive airway pressure setting (r?=?0.65; p?=?0.009). Ventilation improved symptoms and nocturnal hypoventilation. Comparing the first and last evaluations, only PCF was significantly lower (275.0 to 310.8 L/min; p?=?0.019).

Conclusions

Ventilatory insufficiency is very common in patients with DM and CTG length may be useful to predict it. Prolonged NIV improves symptoms, nocturnal hypoventilation and maintains daily blood gases. Routine evaluation of PCF should not be forgotten and assisted coughing training provided.     

Clinical outcome of laparoscopic distal pancreatectomy

Background

Few studies have compared laparoscopic distal pancreatectomy (Lap-DP) and open distal pancreatectomy (open-DP). The aim of this study was to evaluate the clinical outcome of Lap-DP and compare it to that of open-DP.

Methods

A total of 37 patients who underwent distal pancreatectomy (Lap-DP, 21 patients; open-DP, 16 patients) between January 2000 and March 2007 were enrolled in this study. Prior to January 2004, open-DP was the standard procedure for patients with a lesion in the distal pancreas without invasive ductal cancer; thereafter, Lap-DP was also an approved procedure. All 16 open-DP procedures were performed prior to January 2004.

Results

The operating times for the Lap-DP and open-DP patients were 308.4 ± 124.6 and 281.5 ± 83.3 min, respectively, and these were not significantly different (P = 0.4635). Blood loss for the Lap-DP group (249.0 ± 239.8 ml) was significantly smaller than that for the open-DP group (714.1 ± 650.4 ml) (P = 0.0055), and none of the patients in the Lap-DP group received transfusions. The frequency of complications for the Lap-DP and open-DP groups was 0 and 18.8%, respectively, which is not significantly different (P = 0.0784). The average hospital stay for the Lap-DP group was significantly shorter than that for the open-DP group (10.0 ± 2.6 vs. 25.8 ± 8.8 days; P < 0.0001).

Conclusion

In pancreatic diseases, other than invasive ductal cancer, arising in the distal pancreas, Lap-DP might be a more feasible and safer than open-DP.     

Endoclip-Assisted Resection of Large Pedunculated Colorectal Polyps: Technical Aspects and Outcome

Background

The most common complication of polypectomy is hemorrhage, and various techniques have been used to prevent this complication.

Aim

This study evaluates the outcomes of endoclip-assisted polypectomy in patients with large pedunculated colorectal polyps, in comparison with a historical control group of patients treated with endoloop-assisted polypectomy.

Methods

Between January and December 2007, 32 patients with 32 large pedunculated polyps (≥15 mm) were treated with endoclip-assisted polypectomy (group A). Between January and December 2006, 35 patients with 35 large pedunculated polyps were treated; 33 with endoloop-assisted polypectomy (control, group B) and two cases with endoclips and needle knife, which were included in group A for the analysis.

Results

The mean (± standard deviation [SD]) size of polyp head was 26.8 ± 8.1 mm (range 15–50) in group A and 22.3 ± 4.1 mm (range 15–30) in group B (P = 0.004). In group A, six polyps had a mean (±SD) head size of 40.8 ± 5.8 mm (range 35–50) and were resected with clips and needle knife. In group A, bleeding occurred in two cases (5.9%), which were associated with the presence of cancer at histology (P = 0.006) and were managed by applying new clips. No bleeding occurred in patients of group B and no perforation and post-polypectomy syndrome occurred in either group. There were three (8.8%) cancerized adenomas in group A and one (3%) in group B. Clip application was possible in all patients, while in two cases, loop placement was impossible.

Conclusions

In our experience, endoclip-assisted resection is a safe alternative to endoloop for the resection of large pedunculated colorectal polyps when endoloop placement is difficult or impossible.     

Effects of 12 weeks’ treatment with a proton pump inhibitor on insulin secretion, glucose metabolism and markers of cardiovascular risk in patients with type 2 diabetes: a randomised double-blind prospective placebo-controlled study

Aims/hypothesis

Recent studies suggest that proton pump inhibitor treatment may increase insulin secretion and improve glucose metabolism in type 2 diabetes. In a randomised double-blind prospective placebo-controlled 2 × 2 factorial study, we examined the effect of esomeprazole on insulin secretion, HbA_1c and cardiovascular risk factors in type 2 diabetes.

Methods

Forty-one patients with type 2 diabetes using dietary control or oral glucose-lowering treatment were randomised to receive add-on esomeprazole 40 mg (n?=?20) or placebo (n?=?21) for 12 weeks. Randomisation was carried out prior to inclusion on the basis of a computer-generated random-number list. The allocation sequence was concealed in sealed envelopes from the researcher enrolling and assessing participants. The study was undertaken at Steno Diabetes Center, Gentofte, Denmark. The primary outcome was change in AUC for insulin levels during a meal test. Secondary outcomes were the levels of HbA_1c and biochemical markers of cardiovascular risk, including lipids, coagulation factors, inflammation markers, markers of endothelial function and 24 h ambulatory BP measurements.

Results

Forty-one participants were analysed. In the esomeprazole-treated group the AUC for insulin did not change (before vs after treatment: 28,049?±?17,659 vs 27,270?±?32,004 pmol/l × min (p?=?0.838). In the placebo group AUC for insulin decreased from 27,392?±?14,348 pmol/l × min to 22,938?±?11,936 pmol/l × min (p?=?0.002). Esomeprazole treatment (n?=?20) caused a ninefold increase in the AUC for gastrin. HbA_1c increased from 7.0?±?0.6% (53?±?5 mmol/mol) to 7.3?±?0.8% (56?±?6 mmol/mol) in the esomeprazole-treated group and from 7.0?±?0.6% (53?±?5 mmol/mol) to 7.4?±?0.8% (57?±?6 mmol/mol) in the placebo group (n?=?21) (p for difference in change >0.05). Except for BP, there were no differences between the groups in the markers of cardiovascular risk (p?>?0.05). Monitoring of 24 h ambulatory BP showed a significant decrease in daytime systolic BP, daytime diastolic BP and 24 h diastolic BP in the placebo group (p?<?0.05). No change in BP was seen in the patients treated with esomeprazole.

Conclusions/interpretation

Treatment with esomeprazole over 12 weeks did not improve insulin secretion, glycaemic control or cardiovascular disease biomarkers in patients with type 2 diabetes.

Trial registration

ClinicalTrials.gov NCT00699426

Funding

The study was funded by Novo Nordisk A/S and Christian Hansen A/S.     

Low Ileocecal Valve Pressure Is Significantly Associated with Small Intestinal Bacterial Overgrowth (SIBO)

Background

Small intestinal bacterial overgrowth (SIBO) is a significant and increasingly recognized syndrome. While the development may be multifactorial, impairment of the ileocecal valve (ICV), small bowel motility, and gastric acid secretion have been hypothesized to be risk factors. ICV dysfunction remains largely unexplored using standard technology. The wireless motility capsule (WMC) that evaluates pressure, pH, and temperature throughout the GI tract provides the ability to assess these parameters.

Aims

The primary aims of this study were to assess the relationship of ICV pressures, small bowel transit time (SBTT) and intestinal pH with lactulose hydrogen breath testing (LBT) results in subjects with suspected SIBO.

Methods

We retrospectively studied consecutive patients referred to our institution for WMC and LBT from 2010–2012. Ileocecal junction pressures (IJP), as a surrogate for ICV pressures, were defined as the highest pressure over a 4-min window prior to the characteristic ileocecal pH drop. SBTT and pH were calculated and compared with LBT results.

Results

Twenty-three patients underwent both WMC and LBT, with positive results observed in 15 (65.2 %). IJP were significantly higher in LBT(?) negative vs. LBT(+) (79.9 vs. 45.1, p < 0.01). SBTT was significantly longer in LBT(+) versus LBT(?) (5.82 vs. 3.81 h, p = 0.05). Among LBT(+) subjects, gastric pH was significantly higher versus LBT(?) subjects (2.76 vs. 1.63, p = 0.01). There was poor correlation between IJP and other parameters (SBTT, small bowel pH, and gastric pH).

Conclusions

Low IJP is significantly associated with SIBO. While this is physiologically plausible, to our knowledge, this is the first study to make this connection. Prolonged SBTT and higher pH are also independently associated with SIBO. Our findings add value of the WMC test as a diagnostic tool in patients with functional gastrointestinal complaints and suggest re-focus of attention on the ileocecal valve as a prominent player in intestinal disorders.     

Robotic ablation of atrial fibrillation with a new remote catheter system

Purpose

Pulmonary vein isolation (PVI) is widely established as a curative treatment option for atrial fibrillation (AF). A wide range of techniques to improve catheter manipulation and steerability has been developed over the past years. A new remote catheter system (RCS) has recently become available (Amigo Remote Catheter System, Catheter Robotics, Budd Lake, NJ, USA). Here, we present a dual-center study on the RCS for left atrial mapping and PVI in patients with paroxysmal AF compared to a control group undergoing conventional PVI.

Methods

One hundred nineteen patients who underwent PVI for paroxysmal AF were studied. Forty patients underwent PVI with the use of the RCS. Seventy-nine patients, who underwent conventional PVI, served as control group. Procedural data were compared between the two groups.

Results

PVI was achieved in all patients. In the RCS group compared to standard ablation group, there were no significant differences in procedure duration (159.1?±?45.4 vs. 146?±?30.1 min, p?=?0.19), total energy delivery (78,146.3?±?26,992.4 vs. 87,963.9?±?79,202.1 Ws, p?=?0.57), and total fluoroscopy time (21.2?±?8.6 vs. 23.9?±?5.4 min, p?=?0.15). Operator fluoroscopy exposure was significantly reduced in the RCS group (13.4?±?6.1 vs. 23.9?±?5.4 min, p?Conclusions These initial results suggest that left atrial mapping and PVI are feasible with the use of the Amigo RCS. Acute procedural efficacy is comparable to the standard approach. The use of the Amigo RCS leads to a significant reduction of operator fluoroscopy exposure.     

Endoscopic ultrasound-guided pelvic and prostatic abscess drainage: Experience in 30 patients

Background

Endoscopic ultrasound (EUS)-guided drainage is an effective treatment for many abscesses in the abdomen. We review our experience with EUS-guided drainage of pelvic abscesses.

Methods

Thirty consecutive patients who underwent EUS-guided pelvic abscess drainage were evaluated after excluding three patients with distance to transducer >2 cm or organized abscess.

Results

Thirty patients (25 male) aged 60?±?4.5 years (mean?±?SD) had 4 prostatic abscesses, 7 perisigmoid abscesses, and 19 perirectal abscesses with mean?±?SD sizes of 2.5?±?0.3, 4.7?±?0.6, and 5.4?±?0.4 cm, respectively. Surgery was the most common predisposing factor (n?=?14, 46.6 %) followed by diverticulitis (n?=?5, 16.6 %). Interventions included aspiration only (2 prostatic and 3 perisigmoid), aspiration and dilatation (2 patients in each group), and dilatation and stenting (2 perisigmoid and 17 perirectal). Five (16.6 %) patients needed re-intervention, and two (6.6 %) needed surgery. There were no recurrences. Technical success of EUS-guided pelvic abscess drainage overall was 90.9 % (30/33) and was 93.3 % (27/30) in patients in whom EUS-guided drainage was attempted, with 16.5 % (n?=?5) re-intervention rate.

Conclusion

EUS-guided drainage has an excellent success rate in drainage of pelvic abscesses.     

Eicosapentaenoic Acid Combined with Optimal Statin Therapy Improves Endothelial Dysfunction in Patients with Coronary Artery Disease

Purpose

Eicosapentaenoic acid (EPA) has been reported to augment endothelial function and improve clinical outcomes in patients with coronary artery disease (CAD). The purpose of this study was to determine whether EPA could improve residual endothelial dysfunction despite adequate lipid-lowering with statin in CAD patients.

Methods

Eighty patients with established CAD, who had been on statin treatment and had serum low-density lipoprotein cholesterol (LDL-C) levels <100 mg/dl, were randomly assigned to receive either 1,800 mg of EPA daily plus statin (EPA group, n?=?40) or statin alone (Control group, n?=?40). Lipid profiles and flow-mediated dilation (FMD) were assessed just before and after more than 3 months of treatment in both groups. Only patients who had impaired FMD (<6 %) before randomization were enrolled.

Results

After treatment for 5.2?±?1.7 months, the EPA group showed a significant increase in the serum concentration of EPA and EPA to arachidonic acid (AA) (EPA/AA) ratio (62.5?±?38.1 to 159.8?±?53.8 μg/ml, 0.45?±?0.34 to 1.20?±?0.55, p?<?0.01 for both). In the EPA group, serum triglycerides significantly decreased (150.7?±?92.9 to 119.3?±?60.7 mg/dl, p?=?0.02), whereas no significant change was seen in the Control group. FMD, the primary study endpoint, showed a significant improvement in the EPA group (2.6?±?1.6 % to 3.2?±?1.6 %, p?=?0.02), whereas no significant change was observed in the Control group (2.7?±?1.6 % to 2.4?±?1.7 %, p?=?0.29).

Conclusions

EPA improved endothelial function and impaired FMD in patients with established CAD who were on optimal statin therapy.     

Entecavir improves the outcome of acute-on-chronic liver failure due to the acute exacerbation of chronic hepatitis B

Background

The mortality of acute-on-chronic hepatitis B liver failure (ACHBLF) from acute exacerbation of chronic hepatitis B is 30–70 % without liver transplant.

Methods

We conducted an open-label, prospective, 48-week study to evaluate the efficacy of entecavir (ETV) in ACHBLF with 110 patients who received either ETV or no treatment. Primary measurements were survival and improvement in disease severity scores.

Results

Of the 110 patients enrolled, 2 withdrew consent, 108 were treated with 53 ETV, and 55 were untreated. When compared to the patients in the untreated group at week 48, a lower cumulative mortality rate in ETV-treated patients was observed [54.7 % (29/53) vs. 78.2 % (43/55), p < 0.01). ETV treatment significantly improved disease severity scores including Child–Turcotte–Pugh (CTP), model for end-stage liver disease (MELD), and MELD sodium (MELD-Na). All ETV-treated subjects achieved an undetectable HBV DNA level (<500 copies/mL; 100 % vs. 7.9 %, p < 0.001). In univariate analysis, predictors of survival at week 48 included baseline age, total bilirubin, international normalized ratio of prothrombin time, albumin, cholesterol, receiving ETV therapy, CTP, MELD, MELD-Na, and sequential organ failure assessment (SOFA) scores. In multivariate analysis, baseline age, total bilirubin, untreated (with ETV), CTP, and SOFA scores were the independent risk factors for mortality.

Conclusions

Entecavir treatment for patients with ACHBLF significantly improves disease severity scores with a marked reduction in mortality and suppression in HBV DNA to undetectable levels at week 48. Patients’ age, total bilirubin, CTP, and SOFA scores at baseline are independent risk factors for higher mortality without liver transplantation.