Sessile serrated lesion prevalence and factors associated with their detection: a post-hoc analysis of a multinational randomized controlled trial from Asia.

BACKGROUND: Sessile serrated lesions (SSLs) are associated with an increased risk of colorectal cancer. Data on the prevalence of SSLs in Asia are limited. We performed this study to estimate the prevalence of SSLs in Asia and to explore endoscopic factors that are associated with SSL detection. METHODS: This is a post-hoc analysis of a multicenter randomized controlled trial from four Asian countries/regions that compared adenoma detection rates using linked-color imaging (LCI) and white-light imaging. Colonoscopies were performed in an average-risk population for screening, diagnostic examination, or polyp surveillance. Patients with SSLs were compared against those without SSLs to evaluate for possible predictors of SSL detection using Firth's logistic regression. RESULTS: 2898 participants (mean age 64.5 years) were included in the analysis. The estimated prevalence of SSLs was 4.0% (95%CI 3.4%-4.8%), with no sex or age group differences. On multivariable analysis, use of LCI (adjusted odds ratio [aOR] 1.63, 95%CI 1.10-2.41), experienced endoscopists (aOR 1.94, 95%CI 1.25-3.00), use of transparent cap (aOR 1.75, 95%CI 1.09-2.81), and longer withdrawal time (aOR 1.06, 95%CI 1.03-1.10) were independently associated with SSL detection. Synchronous adenoma detection (aOR 1.89, 95%CI 1.20-2.99) was also predictive of SSL detection. CONCLUSION: The prevalence of SSLs in Asia is 4.0%. Use of LCI or a transparent cap, greater endoscopist experience, and longer withdrawal time were all associated with increased SSL detection.

Development of a diagnostic support system for the fibrosis of nonalcoholic fatty liver disease using artificial intelligence and deep learning.

Liver fibrosis is a pathological condition characterized by the abnormal proliferation of liver tissue, subsequently able to progress to cirrhosis or possibly hepatocellular carcinoma. The development of artificial intelligence and deep learning have begun to play a significant role in fibrosis detection. This study aimed to develop SMART AI-PATHO, a fully automated assessment method combining quantification of histopathological architectural features, to analyze steatosis and fibrosis in nonalcoholic fatty liver disease (NAFLD) core biopsies and employ Metavir fibrosis staging as standard references and fat assessment grading measurement for comparison with the pathologist interpretations. There were 146 participants enrolled in our study. The correlation of Metavir scoring system interpretation between pathologists and SMART AI-PATHO was significantly correlated (Agreement = 68%, Kappa = 0.59, p-value <0.001), which subgroup analysis of significant fibrosis (Metavir score F2-F4) and nonsignificant fibrosis (Metavir score F0-F1) demonstrated substantial correlated results (agreement = 80%, kappa = 0.61, p-value <0.001), corresponding with the correlation of advanced fibrosis (Metavir score F3-F4) and nonadvanced fibrosis groups (Metavir score F0-F2), (agreement = 89%, kappa = 0.74, p-value <0.001). SMART AI-PATHO, the first pivotal artificially intelligent diagnostic tool for the color-based NAFLD hepatic tissue staging in Thailand, demonstrated satisfactory performance as a pathologist to provide liver fibrosis scoring and steatosis grading. In the future, developing AI algorithms and reliable testing on a larger scale may increase accuracy and contribute to telemedicine consultations for general pathologists in clinical practice.

Analysis of the Characteristics of Coexisting Lesions in Colorectal Cancer Patients in an International Study: A Subgroup Analysis of the ATLAS Trial.

INTRODUCTION: We investigated coexisting lesion types in patients with invasive colorectal cancer (CRC) in a multinational study for comprehending the adenoma-carcinoma and serrated pathway about the development of CRC. METHODS: We retrospectively reviewed 3,050 patients enrolled in the international randomized controlled trial (ATLAS study) to evaluate the colorectal polyp detection performance of image-enhanced endoscopy in 11 institutions in four Asian countries/regions. In the current study, as a subgroup analysis of the ATLAS study, 92 CRC patients were extracted and compared to 2,958 patients without CRC to examine the effects of age, sex, and coexisting lesion types (high-grade adenoma [HGA], low-grade adenoma with villous component [LGAV], 10 adenomas, adenoma ≥10 mm, sessile serrated lesions [SSLs], and SSLs with dysplasia [SSLD]). Additional analyses of coexisting lesion types were performed according to sex and location of CRC (right- or left-sided). RESULTS: A multivariate analysis showed that HGA (odds ratio [95% confidence interval] 4.29 [2.16-8.18]; p < 0.01), LGAV (3.02 [1.16-7.83], p = 0.02), and age (1.04 [1.01-1.06], p = 0.01) were independently associated with CRC. According to sex, the coexisting lesion types significantly associated with CRC were LGAV (5.58 [1.94-16.0], p < 0.01) and HGA (4.46 [1.95-10.20], p < 0.01) in males and HGA (4.82 [1.47-15.80], p < 0.01) in females. Regarding the location of CRC, SSLD (21.9 [1.31-365.0], p = 0.03) was significant for right-sided CRC, and HGA (5.22 [2.39-11.4], p < 0.01) and LGAV (3.46 [1.13-10.6], p = 0.02) were significant for left-sided CRC. CONCLUSIONS: The significant coexisting lesions in CRC differed according to sex and location. These findings may contribute to comprehending the pathogenesis of CRC.

Linked color imaging improves colorectal lesion detection especially for low performance endoscopists: An international trial in Asia.

BACKGROUND AND AIM: Linked color imaging (LCI) is an image-enhanced endoscopy technique that accentuates the color difference between red and white, potentially improving the adenoma detection rate (ADR). However, it remains unclear whether LCI performance in detecting colorectal lesions differs based on endoscopists' experience levels. We aimed to evaluate the differences in LCI efficacy based on the experience levels of endoscopists by conducting an exploratory analysis. METHODS: In this post hoc analysis of an international randomized controlled trial comparing the detection of adenoma and other lesions using colonoscopy with LCI and high-definition white light imaging (WLI), we included patients from 11 institutions across four countries/regions: Japan, Thailand, Taiwan, and Singapore. We retrospectively reviewed differences in the lesion detection of LCI according to endoscopists' colonoscopy history or ADR. RESULTS: We included 1692 and 1138 patients who underwent colonoscopies performed by 54 experts (experience of ≥ 5000 colonoscopies) and by 43 non-experts (experience of < 5000 colonoscopies), respectively. Both expert and non-expert groups showed a significant improvement in ADR with LCI compared to WLI (expert, 61.7% vs 46.4%; P < 0.001; non-expert, 56.6% vs 46.4%; P < 0.001). LCI had no effect on sessile serrated lesion detection rate in non-experts (3.1% vs 2.5%; P = 0.518). LCI significantly improved detection rates in endoscopists with relatively low detection performance, defined as an ADR < 50%. CONCLUSIONS: This exploratory study analyzed data from a previous trial and revealed that LCI is useful for both experts and non-experts and is even more beneficial for endoscopists with relatively low detection performance using WLI.

Use of virtual reality in patient education program to reduce anxiety in upper gastrointestinal endoscopy: A randomized controlled trial.

Background and Aim: Virtual reality (VR) provides an immersive image-viewing experience that has recently been expanding its use in clinical medicine. We aimed to examine a patient education program by VR to reduce anxiety in patients undergoing esophagogastroduodenoscopy (EGD). Methods: We conducted a randomized controlled trial and consecutively enrolled patients who had an indication for unsedated EGD with topical anesthesia. Patients were randomly assigned to use Oculus GO with three-dimensionally specific software content (a stand-alone VR headset) for patient education or standard patient education using oral information (the control group) before EGD. The primary outcome was the variation in anxiety scores before and after patient education programs. Results: A total of 107 patients underwent EGD and received a VR (n = 58) and control (n = 49) patient education program. The mean anxiety score before starting the patient education program was 41.4 9.6 in the VR group and 41.9 7.7 in the control group. The mean anxiety score after the patient education program was 37.1 10.8 in the VR group and 38.9 8.07 in the control group (P-value = 0.354). The anxiety score in the VR group decreased more than in the control group but was not significant. The recall questionnaire scores were higher in the VR group (4.70.4) than the control group (3.91, P-value 0.001). Conclusion: A virtual reality-assisted patient education program before EGD did not significantly reduce anxiety but may provide more memory and understanding about the procedure to patients who underwent unsedated EGD.

Correlation between neck circumference and hepatic steatosis determined by controlled attenuation parameter.

Neck circumference is an attractive method for determining metabolic profiles and has many advantages over waist circumference. However, the correlation between neck circumference and hepatic fibrosis has not been evaluated. The aim of this study was to evaluate the correlation between neck circumference and hepatic fibrosis and define the optimal cut-off point for neck circumference to determine hepatic fibrosis. A cross-sectional study (n = 333) was conducted among Thai healthcare workers at Phramongkutklao Hospital who received an annual health maintenance program. Neck circumference was measured at the lower margin of the laryngeal prominence. Fibroscan® with a controlled attenuation parameter was used to measure the degree of hepatic fibrosis and steatosis by an experienced, well-trained operator. In the cross-sectional analysis, it was found that the large circumference of the neck was associated with hepatic fibrosis (r = 0.19, p = .001) and hepatic steatosis (r = 0.58, p < .001). Hepatic fibrosis (r = 0.15, p = .004) and steatosis (r = 0.53, p < .001) were also associated with waist circumference. The neck circumferences of 40 and 34 cm were the best cut-offs for male and female participants, respectively.Neck circumference is closely related to hepatic fibrosis and steatosis, which should be promoted and has a better advantage than waist circumference in the screening of hepatic steatosis.

Severity of COVID-19 in Patients with Diarrhoea: A Systematic Review and Meta-Analysis.

COVID-19 patients occasionally present with diarrhoea. Our objective was to estimate the risk of developing the severe disease in COVID-19 patients with and without diarrhoea and to provide a more precise estimate of the prevalence of COVID-19-associated digestive symptoms. A total of 88 studies (n = 67,794) on patients with a COVID-19 infection published between 1 January 2020 and 20 October 2022 were included in this meta-analysis. The overall prevalence of digestive symptoms was 27% (95% confidence interval (CI): 21-34%; I2 = 99%). According to our data, the pooled prevalence of diarrhoea symptoms in the 88 studies analysed was 17% (95% CI: 14-20%; I2 = 98%). The pooled estimate of nausea or vomiting in a total of 60 studies was 12% (95% CI: 8-15%; I2 = 98%). We also analysed 23 studies with eligible individuals (n = 3800) to assess the association between the disease severity and diarrhoea. Individuals who had diarrhoea were more likely to have experienced severe COVID-19 (odds ratio: 1.71; 95% CI: 1.31-2.24; p < 0.0001; I2 = 10%). Gastrointestinal symptoms and diarrhoea are frequently presenting COVID-19 manifestations that physicians should be aware of.

Characteristics of Drug-induced Liver Injury in Chronic Liver Disease: Results from the Thai Association for the Study of the Liver (THASL) DILI Registry.

Background and Aims: The impact of drug-induced liver injury (DILI) on patients with chronic liver disease (CLD) is unclear. There are few reports comparing DILI in CLD and non-CLD patients. In this study, we aimed to determine the incidence and outcomes of DILI in patients with and without CLD. Methods: We collected data on eligible individuals with suspected DILI between 2018 and 2020 who were evaluated systematically for other etiologies, causes, and the severity of DILI. We compared the causative agents, clinical features, and outcomes of DILI among subjects with and without CLD who were enrolled in the Thai Association for the Study of the Liver DILI registry. Subjects with definite, or highly likely DILI were included in the analysis. Results: A total of 200 subjects diagnosed with DILI were found in the registry. Of those, 41 had CLD and 159 had no evidence of CLD in their background. Complementary and alternative medicine (CAM) products were identified as the most common class of DILI agents. Approximately 59% of DILI in the CLD and 40% in non-CLD group were associated with CAM use. Individuals with pre-existing CLD had similar severity including mortality. Twelve patients (6%) developed adverse outcomes related to DILI including seven (3.5%) deaths and five (2.5%) with liver failure. Mortality was 4.88% in CLD and 3.14% in non-CLD subjects over median periods of 58 (8-106) days and 22 (1-65) days, respectively. Conclusions: In this liver disease registry, the causes, clinical presentation, and outcomes of DILI in subjects with CLD and without CLD patients were not different. Further study is required to confirm our findings.

Linked-Color Imaging Detects More Colorectal Adenoma and Serrated Lesions: An International Randomized Controlled Trial.

BACKGROUND & AIMS: Effects of linked-color imaging (LCI) on colorectal lesion detection and colonoscopy quality remain controversial. This study compared the detection rates of adenoma and other precursor lesions using LCI vs white-light imaging (WLI) during screening, diagnostic, and surveillance colonoscopies. METHODS: This randomized controlled trial was performed at 11 institutions in 4 Asian countries/regions. Patients with abdominal symptoms, a primary screening colonoscopy, positive fecal immunochemical test results, or undergoing postpolypectomy surveillance were recruited and randomly assigned in a 1:1 ratio to either the LCI or high-definition WLI group. The primary outcome was adenoma detection rate (ADR). Secondary outcomes were polyp detection rate, advanced ADR, sessile serrated lesion (SSL) detection rate, and the mean number of adenomas per colonoscopy. The recommended surveillance schedule distribution after trial colonoscopy was analyzed. RESULTS: Between November 2020 and January 2022, there were 3050 participants (LCI, n = 1527; WLI, n = 1523) recruited. The LCI group ADR was significantly higher than the WLI group ADR using intention-to-treat (58.7% vs 46.7%; P < .01) and per-protocol analyses (59.6% vs 46.4%; P < .01). The LCI group polyp detection rates (68.6% vs 59.5%; P < .01), SSL detection rates (4.8% vs 2.8%; P < .01), and adenomas per colonoscopy (1.48 vs 1.02; P < .01) also were significantly higher. However, the advanced ADR was not significantly different (13.2% vs 11.0%; P = .06). Significantly more patients in the LCI group had shorter recommended surveillance schedules than the WLI group (P < .01). CONCLUSIONS: Compared with WLI, LCI improved adenoma and other polyp detection rates, including SSLs, resulting in alteration of the recommended surveillance schedule after screening, diagnostic, and postpolypectomy surveillance colonoscopies. TRIAL REGISTRATION NUMBER: UMIN000042432 (https://www.umin.ac.jp/ctr/index.htm).

Validation of prognostic scores predicting mortality in acute liver decompensation or acute-on-chronic liver failure: A Thailand multicenter study.

BACKGROUND & OBJECTIVES: Cirrhosis patients with worsening of the liver function are defined as acute decompensation (AD) and those who develop extrahepatic organ failure are defined as acute-on-chronic liver failure (ACLF). Both AD and ACLF have an extremely poor prognosis. However, information regarding prognostic predictors is still lacking in Asian populations. We aimed to identify prognostic factors for 30-day and 90-day mortality in cirrhosis patients who develop AD with or without ACLF. METHODS: We included 9 tertiary hospitals from Thailand in a retrospective observational study enrolling hospitalized cirrhosis patients with AD. ACLF was diagnosed according to the EASL-CLIF criteria, which defined as AD patients who have kidney failure or a combination of at least two non-kidney organ failure. Outcomes were clinical parameters and prognostic scores associated with mortality evaluated at 30 days and 90 days. RESULTS: Between 2015 and 2020, 602 patients (301 for each group) were included. The 30-day and 90-day mortality rates of ACLF vs. AD were 57.48% vs. 25.50% (p<0.001) and 67.44% vs. 32.78% (p<0.001), respectively. For ACLF patients, logistic regression analysis adjusted for demographic data, and clinical information showed that increasing creatinine was a predictor for 30-day mortality (p = 0.038), while the CLIF-C OF score predicted both 30-day (p = 0.018) and 90-day (p = 0.037) mortalities, achieving the best discriminatory power with AUROCs of 0.705 and 0.709, respectively. For AD patients, none of the parameters was found to be significantly associated with 30-day mortality, while bacterial infection, CLIF-AD score and Child-Turcotte-Pugh score were independent parameters associated with 90-day mortality, with p values of 0.041, 0.024 and 0.024. However, their predictive performance became nonsignificant after adjustment by multivariate regression analysis. CONCLUSIONS: Regarding Thai patients, the CLIF-C OF score was the best predictor for 30-day and 90-day mortalities in ACLF patients, while appropriate prognostic factors for AD patients remained inconclusive.

Hepatitis C prevalence among men who have sex with men attending a gay bathhouse.

Background and Aim: Related research has found that men who visit public sex environments such as a gay bathhouse engage in unprotected anal intercourse and tend to have multiple sexual partners during their visit. We aimed to assess the risk of hepatitis C virus (HCV) transmission among men attending a gay bathhouse. Methods: A prospective study of the prevalence of HCV among men attending a gay bathhouse was conducted in Bangkok, Thailand, from October 2019 to March 2020. HCV risks and risk perceptions were evaluated using a self-administered questionnaire. HCV testing with result notification was provided on site. Results: Of the 40 participants (median age 30 years), one subject (2.5%) was positive for HCV antibody. Bathhouse patrons reported engaging in high-risk sexual behavior, including sexually transmitted infection history and Chemsex experience. The subject tested positive for HCV antibody reported a frequency of attending gay bathhouse of around 2-4 times monthly and had multiple partners while attending a gay bathhouse. Only 15% of subjects realized that hepatitis C can be transmitted through sexual intercourse. Conclusion: Our findings support HCV transmission-reducing guidelines recommending providing selective HCV testing among men who have sex with men (MSM). Bathhouse patrons reported low literacy levels on HCV transmission. Nevertheless, HCV screening should cover a population exhibiting high-risk sexual behaviors such as attending a gay bathhouse.

Acute-on-chronic liver failure: Epidemiology, prognosis, and outcome of a multicenter study in Thai population.

Background and Aim: Acute-on-chronic liver failure (ACLF) leads to multi-organ failure related to high mortality rates. This study aimed to gather epidemiological data and validate a scoring system to predict mortality in ACLF. Methods: This retrospective cohort study collected data from multicenter tertiary care hospitals in Thailand. A total of 638 hospitalized patients (acute decompensated liver disease [ADLD], 292 patients; ACLF, 346 patients) from January 2019 to June 2020 were enrolled in this study. We compared the mortality rate at days 30 and 90 between patients with ADLD and ACLF. Areas under the receiver operating characteristic (AUROC) curves of chronic liver failure-sequential organ failure assessment (CLIF-SOFA) and other existing scoring systems were compared among patients with ACLF. Results: The incidence of patients with ACLF was 54%. The main cause of chronic liver disease was alcohol (38%), with sepsis (50%) as the most common precipitating factor. ACLF with coagulopathy (AUROC 0.58, 95% confidence interval [CI]: 0.52-0.64), metabolic acidosis (AUROC 0.58, 95% CI: 0.52-0.64), and high aspartate aminotransferase (AST) (AUROC 0.59, 95% CI: 0.53-0.66) were associated with high 30-day mortality. The 30-day mortality rate of patients with acute decompensation and patients with ACLF was 46 and 58%, respectively. Respiratory system (P = 0.001) failure was the major end result in ACLF and constituted a significant factor to predict mortality. The AUROC of CLIF-SOFA score was superior to that of the other predicted score (AUROC 0.64, 95% CI: 0.585-0.704). Conclusion: Patients with ACLF with more organ failure and high CLIF-SOFA score were associated with high short-term mortality. Future studies should include an ACLF prospective registry to confirm these finding.

Health care burden and mortality of acute on chronic liver failure in Thailand: a nationwide population-based cohort study.

BACKGROUND: Accurate population-based data are required concerning the rate, economic impact, and long-term outcome from acute on chronic liver failures (ACLF) in hospitalized patients with cirrhosis. We aimed to discover time trends for the epidemiology, economic burden, and mortality of ACLF in Thailand. METHODS: We conducted a nationwide, population-based, cohort study which involved all hospitalized patients with cirrhosis in Thailand during the period between 2009 and 2013, with data from the National Health Security Office. ACLF was defined by two or more extrahepatic organ failures in patients with cirrhosis. Primary outcomes were trends in hospitalizations, hospital costs, together with inpatient mortality. RESULTS: The number of ACLF hospitalizations in Thailand doubled between 3185 in 2009 and 7666 in 2013. The average cost of each ACLF hospitalization was 3.5-fold higher than for cirrhosis ($ 1893 versus $ 519). The hospital is paid using a diagnosis-related group (DRG) payment system that is only 15% of the average treatment costs ($ 286 from $ 1893). The in-hospital fatality rate was 51% for ACLF while the additional fatality rate was 85% up to 1 year. The ACLF organ failure trends indicated sepsis with septic shock and renal failure as the majority proportion. Age, the number and types of organ failure and male sex were predictors of ACLF death. CONCLUSIONS AND RELEVANCE: Cirrhosis and ACLF both represent substantial and increasing health and economic burdens for Thailand. These data can assist national health care policy stakeholders to target high-risk patients with cirrhosis for care.

Virtual reality distraction during upper gastrointestinal endoscopy: a randomized controlled trial.

BACKGROUND AND AIM: Virtual reality (VR) is an established and effective tool in reducing autonomic and somatic pain. We aimed to examine the analgesic effects of VR distraction during esophagogastroduodenoscopy (EGD). METHODS: We conducted a randomized controlled trial and enrolled patients who had indication for unsedated EGD with topical anesthesia. Patients were randomly assigned to use Oculus GO with three-dimensional specific software content (standalone VR headset), sham VR or without VR during EGD. The primary outcome was patient pain scores during EGD. RESULTS: A total of 96 patients undergoing diagnostic EGD were randomized to receive VR (n = 32), sham VR (n = 32), and no VR defined as the control group (n = 32). Patients in all groups reported no statistically different pain during esophageal intubation. The mean pain score was 2.7 ± 2.4 in the VR group, 2.7 ± 2.5 in the sham VR and 2.3 ± 2.3 in the control group, (P value = 0.751). No significant difference was observed in heart rate and blood pressure, and the endoscopists reported higher overall satisfaction scores in VR (4.3 ± 0.5) compared with the control group (4 ± 0.8) but without significance (P value = 0.156). CONCLUSION: Virtual reality-assisted anesthesia during EGD did not significantly reduce patient pain during esophageal intubation. There was no superiority in using VR distraction regarding patient's and endoscopist's satisfaction compared with standard EGD without VR Further studies are required to detect any true clinical advantage of VR distraction during EGD.

Curcuma longa Linn versus omeprazole in treatment of functional dyspepsia: A randomized, double-blind, placebo-controlled trial.

BACKGROUND AND AIMS: Functional dyspepsia (FD) is a common problem in gastroenterology practice. The study aimed to compare the efficacy of Curcuma longa Linn versus omeprazole and placebo among patients diagnosed with FD. METHODS: From November 2017 to November 2018, patients diagnosed with FD according to ROME IV criteria were enrolled. Patients were randomized into curcumin, omeprazole, or placebo groups. The Severity of Dyspepsia Assessment (SODA) was used to evaluate clinical effectiveness after 2 and 4 weeks. Health-related quality of life was assessed using the EuroQol-5 Dimension questionnaire. RESULTS: A total of 132 patients were randomized. Forty-five, 43, and 44 patients were in the curcumin, omeprazole, and placebo groups, respectively. At 4 weeks, the mean SODA score change of pain and non-pain symptoms decreased in the curcumin group compared with the placebo group (pain -16.98 ± 8.09 vs -10.53 ± 4.43; P < 0.001, non-pain -7.96 ± 3.41 vs -6.05 ± 3.03; P < 0.008). No significant difference was observed between curcumin and omeprazole groups (pain -16.98 ± 8.09 vs -14.69 ± 6.41; P = 0.302, non-pain -7.96 ± 3.41 vs -7.07 ± 2.27; P = 0.486). The mean change of the SODA satisfaction score at 4 weeks was higher in the curcumin group compared with the omeprazole group but without statistical significance (9.17 ± 3.88 vs 8.63 ± 3.89, P = 1). The mean change of EQ-5D index at 4 weeks was highest in the curcumin group but not statistically different from other groups (0.12 ± 0.13 vs 0.09 ± 0.10 vs 0.07 ± 0.05; P = 0.055). CONCLUSION: Curcuma longa Linn can improve dyspeptic symptoms, improve quality of life, and provide satisfaction equivalent to omeprazole in treatment of FD.

Thailand guideline 2020 for medical management of gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is one of the most prevalent and bothersome functional gastrointestinal disorders worldwide, including in Thailand. After a decade of the first Thailand GERD guideline, physician and gastroenterologist encountered substantially increase of patients with GERD. Many of them are complicated case and refractory to standard treatment. Concurrently, the evolution of clinical characteristics as well as the progression of investigations and treatment have developed and changed tremendously. As a member of Association of Southeast Asian Nations, which are developing countries, we considered that the counterbalance between advancement and sufficient economy is essential in taking care of patients with GERD. We gather physicians from university hospitals, as well as internist and general practitioners who served in rural area, to make a consensus in this updated version of GERD guideline focusing in medical management of GERD. This clinical practice guideline was constructed adhering with standard procedure. We categorized the guideline in to four parts including definition, investigation, treatment, and long-term follow up. We anticipate that this guideline would improve physicians' proficiency and help direct readers to choose investigations and treatments in patients with GERD wisely. Moreover, we wish that this guideline would be applicable in countries with limited resources as well.

Single dose dexamethasone prophylaxis of postembolisation syndrome after chemoembolisation in hepatocellular carcinoma patient: A randomised, double-blind, placebo-controlled study.

BACKGROUND: Even in the immuno-oncology era, transcatheter arterial chemoembolisation (TACE) is the most effective way to treat intermediate stage hepatocellular carcinoma (HCC). Postembolisation syndrome (PES) is the most common side effect from TACE and there is still no standard prevention guideline. AIM: To evaluate the efficacy of single dose intravenous dexamethasone regimen to prevent PES after TACE among patients with HCC. METHODS: This study enrolled patients with HCC who had eligible indication for TACE without macrovascular invasion/extrahepatic metastasis. Patients were randomly assigned to either an intravenous single dose of dexamethasone 8 mg or placebo one hour before TACE. The primary outcome was a negative result of PES at 48 h after TACE, which was defined as score < 2 of Southwest Oncology Group toxicity coding criteria using fever, nausea, vomiting and pain to calculated. And the secondary end point was duration of admission between two groups. RESULTS: One hundred patients were randomly assigned 1:1. Under intention-to-treat analysis, 49 patients were randomly assigned to the dexamethasone and 51 to the placebo groups. Both groups were similar for baseline characteristics. The negative PES rate was significantly higher in the dexamethasone group than in the placebo group (63.3% vs 29.4%; P = 0.005). Mean Southwest Oncology Group toxicity coding PES was 2.14 (95%CI: 1.41-2.8) vs 3.71 (95%CI: 2.97-4.45) between the dexamethasone and placebo groups, respectively. Cumulative incidence of fever was significantly lower in dexamethasone group with P < 0.001, pain, nausea and vomiting were also lower in the dexamethasone group compared with the placebo group (P = 0.16, P = 0.11, and P = 0.49). The dexamethasone regimen was generally well tolerated by patients with HCC patients including those with hepatitis B virus infection and well-controlled diabetes mellitus. CONCLUSION: Single dose dexamethasone was effective at preventing PES among patients with HCC treated with TACE. The study showed no adverse events of special interest related to dexamethasone.

Safety and efficacy of endoscopic cyanoacrylate injection in the management of gastric varices: A systematic review and meta-analysis.

BACKGROUND AND AIM: Bleeding from gastric varices is a catastrophic event and poses difficulty in management. The efficacy and safety of cyanoacrylate injection remain unclear. We performed a systematic review and meta-analysis to evaluate the effect of endoscopic cyanoacrylate injection in the management of gastric varices. METHODS: We conducted a comprehensive search of MEDLINE, Embase, Web of Science, Scopus databases, and Cochrane Database of Systematic Reviews through November 2020 and manually reviewed the literature. Trial-specific risk ratios (RRs) were estimated and pooled using random-effect model meta-analysis. RESULTS: We included seven randomized controlled trials (six for secondary prophylaxis and one for primary prophylaxis) at low risk of bias in which 126 deaths were reported among 583 patients with gastric varices. All studies reported the use of N-butyl-2-cyanoacrylate glue. Cyanoacrylate use was associated with significantly lower all-cause mortality (RR, 0.59; 95% confidence interval [CI], 0.36-0.98; I2 = 41%) and rebleeding rate after hemostasis (RR, 0.49; 95% CI, 0.35-0.68, I2 = 0%) compared with any other treatment approach not involving cyanoacrylate. When cyanoacrylate was compared with each individual treatment approach (propranolol only, band ligation, sclerotherapy with alcohol or ethanolamine), data comprised sparse limited comparative conclusions. The use of cyanoacrylate injection was not associated with an increase in serious adverse events. The quality of evidence is moderate, graded down due to the small number of events and wide CIs. CONCLUSION: The use of endoscopic cyanoacrylate injection therapy for gastric varices may be associated with lower all-cause mortality and better hemostasis compared with other therapies.

Comparison of aggressive versus standard intravenous hydration for clinical improvement among patients with mild acute pancreatitis: A randomized controlled trial.

BACKGROUND: Controversy remains regarding fluid management strategy, optimal volume and rate of intravenous fluid in mild acute pancreatitis. We performed a randomized controlled trial to compare clinical improvement and inflammatory markers between aggressive and standard fluid management. METHODS: A single center prospective randomized controlled trial was conducted in a tertiary care hospital. We randomized patients with a diagnosis of mild acute pancreatitis using revised Atlanta classification in two groups, the aggressive (20 ml/kg bolus followed by 3 ml/kg/hr) and standard (10 ml/kg bolus followed by 1.5 ml/kg/hr) intravenous hydration with Lactated Ringer's solution. Primary outcome was clinical improvement at 24 and 36 hours. RESULTS: The mean age of patients was 46 years and 34 patients (77%) were male. The average volumes of fluid during the first 24 hours in aggressive and standard groups was 4886 ml (71 ml/kg) and 3985 ml (53 ml/kg), respectively; p-value 0.002. Aggressive intravenous hydration did not significantly improve clinical outcome compared with standard intravenous hydration (45.45% vs. 31.82%, respectively; p-value 0.353). However, subgroup analysis between patients with obese and non-obese status, revealed aggressive intravenous hydration significantly improved clinical outcome within the first 24 hours in obese group. CONCLUSION: Aggressive intravenous hydration with Lactated Ringer's solution did not improve clinical outcome in mild acute pancreatitis but showed statistically significant improvement only in patients with obese status. Future studies should include a larger sample size to confirm these findings.