Risk of hepatitis B virus reactivation in hepatitis B virus + hepatitis C virus-co-infected patients with compensated liver cirrhosis treated with ombitasvir, paritaprevir/r + dasabuvir + ribavirin.

Hepatitis B virus may reactivate in patients with chronic hepatitis C treated with direct-acting antivirals. The aim of this study was to investigate the risk of hepatitis B virus (HBV) reactivation in HBV + hepatitis C virus (HCV)-co-infected patients with compensated liver cirrhosis treated with paritaprevir/ombitasvir/ritonavir, dasabuvir with ribavirin. We reviewed prospectively gathered data from a national cohort of 2070 hepatitis C virus patients with compensated liver cirrhosis who received reimbursed paritaprevir/ombitasvir/r, dasabuvir with ribavirin for 12 weeks from the Romanian National Health Agency during 2015-2016. Twenty-five patients in this cohort were HBs antigen positive (1.2%); 15 untreated with nucleotide analogues agreed to enter the study. These patients were followed up: ALT monthly, serology for HBV and DNA viral load at baseline, EOT and SVR at 12 weeks. Hepatitis B virus (HBV)-co-infected patients were all genotype 1b and 52% females, with a median age of 60 years (51 ÷ 74); 76% were pretreated with peginterferon + ribavirin; 72% were with severe necroinflammatory activity on FibroMax assessment; 40% presented comorbidities; and all were HBe antigen negative. Hepatitis C virus (HCV) SVR response rate was 100%. Hepatitis B virus (HBV)-DNA viral load was undetectable in 7/15 (47%) before therapy, and for the other 8 patients, it varied between below 20 and 867 IU/mL. Five patients (33%) presented virological reactivation (>2 log increase in HBV-DNA levels) during therapy. One patient presented with hepatitis associated with HBV reactivation, and two started anti-HBV therapy with entecavir. Hepatitis B virus (HBV) virological reactivation was present in 33% in our patients. Generally, HBV-DNA elevations were mild (<20 000 IU/mL); however, we report one case of hepatitis associated with HBV reactivation.

Preparation regimen is more important than patient-related factors: a randomized trial comparing a standard bowel preparation before colonoscopy with an individualized approach.

BACKGROUND: Optimal bowel preparation is one of the most important factors affecting the quality of colonoscopy. Several patient-related factors are known to influence the quality of bowel cleansing but randomized trials in this area are lacking. We aimed to compare an individualized bowel prep strategy based on patient characteristics to a standard preparation regimen. MATERIAL AND METHODS: We conducted an endoscopist-blinded multicenter randomized control-trial. The Boston Bowel Prep Score (BBPS) was used to assess quality of bowel preparation and a 10 point visual analogue scale to assess patient comfort during bowel prep. Patients were randomised to either the standard regimens of split-dose 4L polyethylene-glycol (group A), split-dose sodium picosulphate/magnesium citrate (group B) or to either of the two depending on their responses to a 3-item questionnaire (individualized preparation, group C). RESULTS: 185 patients were randomized during the study period and 143 patients were included in the final analysis. Patients in the individualized group had a median BBPS of 7 compared to a median of 6 in the standard group (p = 0.7). Also, there was no significant difference in patients' comfort scores, irrespective of study group or laxative regimen. However, on multivariable analysis, a split-dose 4L polyethylene-glycol was an independent predictor for achieving a BBPS>6 (OR 3.7, 95% CI 1.4-9.8), regardless of patient-related factors. CONCLUSION: The choice of laxative seems to be more important than patient-related factors in predicting bowel cleansing. Comfort during bowel prep is not influenced by the type of strategy used.

Rapid Fecal Calprotectin Testing Predicts Mucosal Healing Better than C-reactive Protein and Serum Tumor Necrosis Factor α in Patients with Ulcerative Colitis.

BACKGROUND AND AIMS: Serum and fecal biomarkers have been used as noninvasive methods for assessing disease activity in ulcerative colitis. C-reactive protein, serum tumor necrosis factor-α and fecal calprotectin are among the most promising such biomarkers. However, their role in the management of ulcerative colitis patients remains to be clarified. We aimed to evaluate the accuracy of C-reactive protein, fecal calprotectin and tumor necrosis factor-α in detecting clinical and endoscopic activity and predicting disease outcome. METHODS: A cohort of ulcerative colitis patients was prospectively evaluated for clinical and endoscopic disease activity using the Mayo score. Serum C-reactive protein and tumor necrosis factor-α levels were measured and a point-of-care method was used for determining Calprotectin levels. RESULTS: Fifty-three patients with ulcerative colitis were followed for a median of 12 months. Fecal calprotectin and C-reactive protein levels were significantly higher in patients with clinically active disease at baseline, but only calprotectin levels correlated with endoscopic activity. Calprotectin values over 300 µg/g had 60% sensitivity and 90% specificity for detecting active endoscopic disease and 61% sensitivity and 89% specificity for predicting mucosal healing. CONCLUSION: Rapid calprotectin testing is a better predictor of mucosal healing than serum biomarkers and it could improve the management of ulcerative colitis patients by decreasing the need for invasive investigations.

Novel predictors of intrapulmonary vascular dilatations in cirrhosis: extending the role of pulse oximetry and echocardiography.

BACKGROUND AND STUDY AIMS: Intrapulmonary vascular dilatations (IPVDs) are a criterion for the diagnosis of hepatopulmonary syndrome in patients with liver cirrhosis. We aimed to show that IPVDs are more common than suspected in a heterogenous cirrhotic population and to identify new diagnostic parameters. PATIENTS AND METHODS: Forty-three consecutive patients with cirrhosis admitted to our Gastroenterology department were included in this prospective study. History, physical examination, ECG and, when warranted, pulmonary function tests and chest radiograph were used to exclude patients with significant cardiac or pulmonary disease. Contrast enhanced transthoracic echocardiography (CEE) was used to determine the presence of IPVDs. Pulse oximetry readings were taken in the supine and standing positions. RESULTS: We found 12 patients with IPVDs. Statistical analysis proved the correlation between IPVDs and systolic pulmonary artery pressure (sPAP) (p= .049), right ventricle wall width (RVW) (p = .013) and E/A ratio (p = .034) but not left atrial or ventricular diameter. Orthodeoxia was also present more frequently in patients with positive CEE. The difference between supine and standing oxygen saturation (changeSat) proved a fair diagnostic test for detecting IPVDs, with an area under the receiver operated curve (AUROC) of 0.823. CONCLUSIONS: Our study shows that RVW, sPAP, E/A and orthodeoxia determined by pulse oximetry are valuable novel predictors of IPVDs, encouraging the routine use of pulse oximetry and echocardiography in cirrhotic patients.

Polyp and endoscopist-related factors influencing complication rates in difficult colonic polypectomies: results of a multicenter observational study.

BACKGROUND: Current polypectomy practices are highly variable. Endoscopists report increased size, nonpolypoid lesion type and unfavorable position as characteristic of difficult polypectomies. We studied reported difficult colonic polypectomies to determine polyp-related and operator-dependent factors influencing complication rates. PATIENTS AND METHODS: We conducted an international multicenter observational prospective study of difficult colonic polypectomies. Endoscopists reported difficult cases of colonic polypectomies, techniques and complication rates. Per-polyp and per-endoscopist analyses were performed. RESULTS: Ninety procedures were reported at 4 participating centers by 19 endoscopists. 43% of the lesions were pedunculated, 39% were sessile and 18% were flat. Lesion size ranged between 5-60 mm. Bleeding occurred in 18 out of 90 procedures (17 immediate, 1 delayed); no perforations were reported. Bleeding rate was independent of patient age or sex, polyp type, size and histology or resection method. Procedures were deemed difficult due to polyp size (37/90), unfavorable position (23/90), bleeding risk (12/90), lesion type (12/90) or other reasons (6/90) with no statistically significant difference between expert and beginner endoscopists (p = 0.14). CONCLUSION: Difficult colonic polypectomies are unpredictable with a complication rate independent of polyp type or size. There was no difference between experts and beginners with regard to technical aspects of resection or complication rates.

Th17 and IL-17 immunity in chronic hepatitis C infection.

Hepatitis C virus (HCV) is one of the most important etiologic agents of postransfusional hepatitis and a common cause of chronic hepatitis, cirrhosis and hepatocarcinoma. T helper (Th)17 cells are a newly discovered Th cell subset with implications in both host defense and autoimmunity. Th17 implications in chronic HCV infection are not well characterized. Given the important role in multiple other immune and inflammatory conditions, they are of obvious interest. Specific HCV-Th17 cells are implicated in immune response modulation, correlated with fibrosis severity and intrahepatic inflammatory status. Serum IL-17 levels are higher in chronic HCV infected patients and Th17 cytokines are modulated within the therapeutic response at anti-viral treatment. However, novel intriguing data indicate that Th17 boost could be associated with spontaneous HCV clearance. It is possible that Th17 could play a dual role (both beneficial and harmful) and that an unbalance of regulating factors (chemokines, transcription factors, receptor expression, etc.) rather than the lymphocyte itself could tip the Th17 immune response one way or another. The role of Th17 cells in host anti HCV defense is beginning to emerge and one has to focus upon its potential beneficial aspects and not only on its destructive potential.

Endoscopy: possibilities and limitations in the management of GIST of the upper GI tract.

Gastrointestinal stromal tumors (GISTs) have been a topic of increasing interest since the discovery of their cellular activation pathway via the receptor for tyrosine kinase (KIT) leading to the possibility of targeted molecular therapy in the form of imatinib mesylate. Endoscopic diagnostic and therapeutic possibilities have also been developing at a rapid pace in recent years. Endoscopic ultrasonography (EUS) allows for an accurate assessment of submucosal tumors and can provide tissue samples for diagnostic purposes using fine needle aspiration techniques. Several newer endoscopic techniques, including contrast enhanced EUS and endoscopic submucosal dissection, have also proven useful in the management of GISTs. Although the many recent studies have focused on the role of endoscopy in diagnosing and treating GISTs, we still need better evidence in order to formulate accurate guidelines.

Polypectomy practices in a real life setting. Do we do enough for our patients? A review of 1061 colonoscopies.

UNLABELLED: Endoscopic removal of colon polyps is the main tool in colorectal cancer prevention programs. Although several quality indicators and guidelines have been proposed, polypectomy practices are still subject to great variation among endoscopist and little data is available regarding polypectomy practices in real life settings. METHODS: The records of the 1061 screening colonoscopies performed in 2010 in a tertiary care teaching hospital in Bucharest were reviewed and all colonoscopies where at least one polyp was detected were selected for analysis. The number of detected polyps, the resection rate and method used for polypectomy were studied and compared to colonoscopy quality indicators previously reported in literature. RESULTS: 941 polyps were detected in 395 patients. Invasive colorectal cancer was found in 42 patients. 548 polyps (58.23%) were removed endoscopically, with at least one polyp being resected in 283 patients (71.5%), resulting in a polypectomy rate of 26.67% in the entire study population. Cold forceps resection was the most commonly used method for the resection of polyps less than 5 mm in size, while for larger polyps hot snare was the preferred method. Concomitant invasive carcinoma and a larger number of polyps were predictive of incomplete removal of all detected polyps. CONCLUSION: Most quality indicators were met in our study group, with suboptimal performance regarding histological documentation of detected polyps and establishing a polyp-free colon.

Functional dyspepsia: a pragmatic approach.

Functional dyspepsia includes one or more of four cardinal symptoms: postprandial fullness, early satiety, pain or burning in the epigastrum. According to the Rome III diagnostic criteria for functional dyspepsia, these symptoms must be present for the last 3 months with symptom onset at least 6 months prior to diagnosis. Functional dyspepsia is not the result of an underlying structural abnormality, but rather the consequence of multiple pathophysiological mechanisms such as abnormal gastric motility, gastric and duodenal hypersensitivity to acid, Helicobacter pylori infection. Dyspeptic patients over 50 or those with alarm symptoms should be investigated to detect any structural abnormality such as cancer, peptic ulcer or esophagitis. After structural abnormalities and gastroesophageal reflux disease are excluded the management of functional dyspepsia consists of either a test and treat approach (non invasive detection of Helicobacter pylori infection followed by eradication therapy) or empirical therapy. Although endoscopy was traditionally reserved for those patients without symptom relief after 6-8 weeks of therapy, the significant percentage of patients with functional dyspepsia with symptom breakthrough or relapse after antisecretory or prokinetic therapy discontinuation makes an initial endoscopic study a logical choice. Therapy with proton pump inhibitors yields results especially in those patients with regurgitation and epigastric burning sensation, while prokinetic agents with no extrapyramidal side effects (such as Domperidone and Itopride) alleviate satiation, bloating and nausea by accelerating gastric emptying. Second-line drugs with encouraging results in clinical trials which can be used in functional dyspepsia are low-dose tricyclic antidepressants as well as selective serotonine reuptake inhibitors.