The Contribution of Genetic and Epigenetic Factors: An Emerging Concept in the Assessment and Prognosis of Inflammatory Bowel Diseases.

Inflammatory bowel disease (IBD) represents heterogeneous and relapsing intestinal conditions with a severe impact on the quality of life of individuals and a continuously increasing prevalence. In recent years, the development of sequencing technology has provided new means of exploring the complex pathogenesis of IBD. An ideal solution is represented by the approach of precision medicine that investigates multiple cellular and molecular interactions, which are tools that perform a holistic, systematic, and impartial analysis of the genomic, transcriptomic, proteomic, metabolomic, and microbiomics sets. Hence, it has led to the orientation of current research towards the identification of new biomarkers that could be successfully used in the management of IBD patients. Multi-omics explores the dimension of variation in the characteristics of these diseases, offering the advantage of understanding the cellular and molecular mechanisms that affect intestinal homeostasis for a much better prediction of disease development and choice of treatment. This review focuses on the progress made in the field of prognostic and predictive biomarkers, highlighting the limitations, challenges, and also the opportunities associated with the application of genomics and epigenomics technologies in clinical practice.

Duodenoscope-associated infections: a review.

Flexible digestive endoscopes are used for the management of various conditions with hundreds of thousands of therapeutic procedures performed worldwide each year. Duodenoscopes are indispensable tools for the delivery of minimally invasive vital care of numerous pancreaticobiliary disorders. Despite the fact that nosocomial infections after endoscopic retrograde cholangiopancreatography (ERCP) have always been among the most frequently cited postprocedural complications, recent emergence of duodenoscope-transmitted multiple drug-resistant bacterial infections has led to intense research and debate yet with no clearly delineated solution. Duodenoscope-transmitted nosocomial infections have become one of the most visible topics in the recent literature. Hundreds of high-impact articles have therefore been published in the last decade. This review article discusses how such infections were seen in the past and what is the current situation in both research and practice and thus tries to solve some of the unanswered questions for the future. With the persistence of nosocomial infections despite strict adherence to both manufacturer-issued reprocessing protocols and international guidelines and regulations, an urgent and proper microbiologically driven common action is needed for controlling such nosocomial worldwide threat.

Duodenoscope-Associated Infections beyond the Elevator Channel: Alternative Causes for Difficult Reprocessing.

OBJECTIVES: Duodenoscopes have been widely used for both diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) procedures, but recently, numerous outbreaks of multidrug-resistant organisms (MDRO) infections have been reported which has led to extensive research for their possible causes. Consequently, the aim of this study is to search for possible duodenoscope surface damages that could provide an alternative and plausible source of infections. MATERIALS AND METHODS: In order to assess both outer and inner surfaces, a duodenoscope was dismantled and samples were taken from the outer resin polymer and from the air/water, elevator, and working (biopsy) channels that were characterized by FTIR, DSC, TGA, AFM, SEM techniques and the antimicrobial activity were tested. RESULTS: Alterations were noticed on both the coating and working channel polymers, with external alterations increasing progressively from the proximal sample to the distal sample near the tip of the scope. However, the results showed that the coating surface was still efficient against bacterial adhesion. Changes in surface texture and also morphological changes were shown. CONCLUSIONS: The study describes the impact of routine procedural use and reprocessing cycles on the duodenoscope, showing that these may possibly make it susceptible to bacterial contamination and MDRO biofilm formation due to difficult reprocessing of the altered surfaces.

The Relation between Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis and Different Cannulation Techniques: The Experience of a High-Volume Center from North-Eastern Romania.

BACKGROUND: Despite numerous advances that have aimed to increase the safety of endoscopic retrograde cholangiopancreatography (ERCP), post-ERCP pancreatitis (PEP) still remains a major issue. We aimed to assess the rate of PEP as well as the relation to the cannulation techniques in our unit, a high-volume center in north-eastern Romania. METHODS: ERCPs performed in our unit from March to August 2022 were retrospectively included. Data concerning demographic information, presence of difficult cannulation, the technique used for cannulation, as well as immediate complications, were gathered from the electronic database. RESULTS: 233 ERCPs were included. PEP was diagnosed in 23 (9.9%) of cases. Precut sphincterotomy (PS), transpancreatic sphincterotomy (TPBS), and a combination of TPBS and PS were performed in 6.4%, 10.3%, and 1.7% of cases, respectively, while an Erlangen precut papillotomy was performed in one case. Both in patients with PS and TPBS the rate of PEP was 20%. When the two techniques were associated, the rate of PEP was 25%. TPBS and PS represented risk factors for PEP (OR 1.211 for a CI of 0.946-1.551, p = 0.041, and OR 1.124 for a CI of 0.928-1.361, p = 0.088, respectively). No PEP-associated deaths were found. CONCLUSIONS: Both PS and TPBS presented a similar risk of PEP.

Impaired Intestinal Permeability Assessed by Confocal Laser Endomicroscopy-A New Potential Therapeutic Target in Inflammatory Bowel Disease.

Inflammatory bowel diseases (IBD) represent a global phenomenon, with a continuously rising prevalence. The strategies concerning IBD management are progressing from clinical monitorization to a targeted approach, and current therapies strive to reduce microscopic mucosal inflammation and stimulate repair of the epithelial barrier function. Intestinal permeability has recently been receiving increased attention, as evidence suggests that it could be related to disease activity in IBD. However, most investigations do not successfully provide adequate information regarding the morphological integrity of the intestinal barrier. In this review, we discuss the advantages of confocal laser endomicroscopy (CLE), which allows in vivo visualization of histological abnormalities and targeted optical biopsies in the setting of IBD. Additionally, CLE has been used to assess vascular permeability and epithelial barrier function that could correlate with prolonged clinical remission, increased resection-free survival, and lower hospitalization rates. Moreover, the dynamic evaluation of the functional characteristics of the intestinal barrier presents an advantage over the endoscopic examination as it has the potential to select patients at risk of relapses. Along with mucosal healing, histological or transmural remission, the recovery of the intestinal barrier function emerges as a possible target that could be included in the future therapeutic strategies for IBD.

The Impact of Alcohol Consumption Pattern on Liver Fibrosis in Asymptomatic Patients.

INTRODUCTION: Alcohol consumption (AC) represents a widespread cause of liver diseases affecting 10-20% of the population. The study aimed to evaluate the relationship between advanced liver fibrosis (ALF) measured by transient elastography (TE), laboratory parameters, and the amount of AC depending on non-modifiable risk factors such as age and gender. METHODS: We examined 689 patients with an average age of 49.32 ± 14.31 years, 72.9% males, without liver pathology, who admitted a moderate/high consumption (female ≤ 7 versus > 7 drinks/week; male ≤ 14 versus > 14 drinks/week) for at least five years. The fibrosis level was adjusted according to transaminase levels. Predictive factors were established using univariate regression analysis. RESULTS: ALF (≥F3) was detected in 19.30% of subjects, predominantly males (14.1%) and patients over 55 years (12.5%). Excessive consumption of distilled spirits is associated with ALF in females (OR = 4.5), males (OR = 6.43) and patients over 55 years (OR = 3.73). A particularity highlighted in both genders, regardless of the age group, was the negative correlation between the decrease in the number of platelets, the albumin concentration, and the appearance of AFL. CONCLUSIONS: Screening using TE represents an approach for early detection of ALF in asymptomatic populations and the development of a risk stratification scheme.

Prognostic value of neutrophil-to-lymphocyte ratio in cirrhotic patients with acute-on-chronic liver failure.

BACKGROUND/AIMS: Patients with cirrhosis hospitalized in the intensive care unit (ICU) have a high risk for acute-on-chronic liver failure (ACLF) and short-term mortality. A major factor in the pathogenesis of ACLF is systemic inflammation, the assessment of which includes the use of surrogate markers, such as neutrophil-to-lymphocyte ratio (NLR). This study aimed to assess the accuracy of NLR in predicting the outcome of patients with cirrhosis and ACLF hospitalized in the ICU. MATERIALS AND METHODS: This was a retrospective observational study on patients with cirrhosis with acute decompensation hospitalized in the ICU of a Romanian tertiary care center. ACLF was defined according to the CANONIC criteria, and NLR was calculated by dividing the absolute neutrophil count by the absolute lymphocyte count. RESULTS: A total of 70 patients were included, of whom 70% were men with a mean age of 62±6.2 years. ACLF was diagnosed in 58 (82.9%) patients who presented with higher in-hospital mortality rates than patients without ACLF (84.5% vs. 33.3%, p=0.001). The mean NLR value was 11.7±9.5, higher in non-survivors than in survivors (12.6±9.8 vs. 8.6±7.8, p=0.170). NLR had a poor accuracy in predicting the outcome in patients without ACLF (area under the curve [AUC]=0.611) but a better accuracy in patients with ACLF (AUC=0.776). Patients with cirrhosis and a high NLR had higher levels of bilirubin; higher Child-Turcotte-Pugh score; and higher incidence of ascites, coagulation, and circulatory failure, presenting a poor outcome. Receiver operating characteristic analysis showed a good accuracy for predicting mortality for the Child-Turcotte-Pugh score (AUC= 0.864) and NLR (AUC=0.732). CONCLUSION: NLR is a promising and cost-effective method for the prediction of a poor outcome in critically ill patients with cirrhosis hospitalized in the ICU and shows greater accuracy in those with ACLF.

Idiopathic Cervical Esophageal Webs: A Case Report and Literature Review.

An esophageal web is a thin and smooth extension of normal esophageal tissue consisting of mucosa and submucosa that can occur anywhere along the length of the esophagus but is typically located in the cervical segment. The webs can be congenital or acquired, commonly associated with Plummer-Vinson syndrome and rarely with celiac disease, dermatological disorders or graft-versus-host disease. A 54-year-old man was referred to our hospital with a history of high non-progressive dysphagia to solid food, meat impaction and weight loss over last ten months. His medical history and family history were unremarkable nor was the physical examination. Complete blood count and basic biochemical tests were normal. Antigliadin and antiendomysial antibodies for celiac disease were negative. Barium swallow esophagography and upper endoscopy detected cervical esophageal webs. The treatment consisted of endoscopic balloon dilation. The patient's dysphagia resolved shortly after dilation, and the endoscope passed easily through the esophagus showing normal esophageal, gastric and duodenal mucosa. This report is consistent with a case of esophageal webs rarely documented in males and that is not related with common causes like Plummer-Vinson syndrome. Thus, the pathogenesis and treatment of esophageal webs are evolving.

Anatomy of Major Duodenal Papilla Influences ERCP Outcomes and Complication Rates: A Single Center Prospective Study.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) has been one of the most intensely studied endoscopic procedures due to its overall high complication rates when compared to other digestive endoscopy procedures. The safety and outcome of such procedures have been linked to multiple procedure- or patient-related risk factors. The aim of our study is to evaluate whether the morphology of the major duodenal papilla influences the ERCP outcomes and complication rates. METHODS: A total of 322 patients with a native papilla have been included in the study over an eight month period. Morphology of the papilla has been classified into normal papilla and four anatomical variations (Type I-IV). All patients have been prospectively monitored over a 15 day period after ERCP. Procedural outcomes and complication rates have been registered. RESULTS: Morphology of the papilla influences both overall complication rates (95%CI, p = 0.0066) and post-ERCP pancreatitis rates (95%CI, p = 0.01001) in univariate analysis. Type IV papillae have proven to be independent risk factors for post-ERCP pancreatitis in multivariate analysis (OR = 12.176, 95%CI, p = 0.005). Type I papillae have been significantly linked to difficult cannulation (AUC = 0.591, 95%CI, p = 0.008); Conclusions: In the monitored cohort morphology of the major duodenal papilla has significantly influenced both ERCP outcomes and post-procedural complication rates.

Nonalcoholic Fatty Liver Disease-Related Chronic Kidney Disease.

Nonalcoholic fatty liver disease has become the main concern of hepatologists around the world and the main research topic for identifying effective and safe therapy. Advances in the treatment of chronic viral hepatitis in recent years have opened the way towards reducing mortality in patients with chronic liver disease. This goal has not yet been reached, as the burden of chronic liver disease remains a future major health problem as the incidence of the nonalcoholic fatty liver disease continues to rise. The proportion of patients with liver cirrhosis and those with hepatocellular carcinoma due to nonalcoholic liver disease on the liver transplant waiting list has increased in the last years. The upward trend in the incidence and prevalence of the disease in recent decades raises concern over a possible global epidemic, especially as the disease is still underestimated and underdiagnosed. Chronic kidney disease presented an increase in incidence and prevalence during the last years, and it has been associated not only with increased morbidity and mortality but also with high costs for the health system. During the last decade, several studies have shown the association between nonalcoholic fatty disease and chronic kidney disease, two major worldwide health problems.