Prevalence of Small Intestinal Bacterial Overgrowth Syndrome in Patients with Non-Alcoholic Fatty Liver Disease/Non-Alcoholic Steatohepatitis: A Cross-Sectional Study.

INTRODUCTION: Non-alcoholic fatty liver disease (NAFLD) is a multifactorial, wide-spectrum liver disorder. Small intestinal bacterial overgrowth (SIBO) is characterized by an increase in the number and/or type of colonic bacteria in the upper gastrointestinal tract. SIBO, through energy salvage and induction of inflammation, may be a pathophysiological factor for NAFLD development and progression. AIM/METHODS: Consecutive patients with histological, biochemical, or radiological diagnosis of any stage of NAFLD (non-alcoholic fatty liver [NAFL], non-alcoholic steatohepatitis [NASH], cirrhosis) underwent upper gastrointestinal endoscopy. Duodenal fluid (2cc) was aspirated from the 3rd-4th part of duodenum into sterile containers. SIBO was defined as ≥103 aerobic colony-forming units (CFU)/mL of duodenal aspirate and/or the presence of colonic-type bacteria. Patients without any liver disease undergoing gastroscopy due to gastroesophageal reflux disease (GERD) comprised the healthy control (HC) group. Concentrations (pg/mL) of tumor necrosis factor alpha (TNFα), interleukin (IL)-1ß, and IL-6 were also measured in the duodenal fluid. The primary endpoint was to evaluate the prevalence of SIBO in NAFLD patients, while the comparison of SIBO prevalence among NAFLD patients and healthy controls was a secondary endpoint. RESULTS: We enrolled 125 patients (51 NAFL, 27 NASH, 17 cirrhosis, and 30 HC) aged 54 ± 11.9 years and with a weight of 88.3 ± 19.6 kg (NAFLD vs. HC 90.7 ± 19.1 vs. 80.8 ± 19.6 kg, p = 0.02). Overall, SIBO was diagnosed in 23/125 (18.4%) patients, with Gram-negative bacteria being the predominant species (19/23; 82.6%). SIBO prevalence was higher in the NAFLD cohort compared to HC (22/95; 23.2% vs. 1/30; 3.3%, p = 0.014). Patients with NASH had higher SIBO prevalence (6/27; 22.2%) compared to NAFL individuals (8/51; 15.7%), but this difference did not reach statistical significance (p = 0.11). Patients with NASH-associated cirrhosis had a higher SIBO prevalence compared to patients with NAFL (8/17; 47.1% vs. 8/51; 15.7%, p = 0.02), while SIBO prevalence between patients with NASH-associated cirrhosis and NASH was not statistically different (8/17; 47.1% vs. 6/27; 22.2%, p = 0.11). Mean concentration of TNF-α, IL-1ß, and IL-6 did not differ among the different groups. CONCLUSION: The prevalence of SIBO is significantly higher in a cohort of patients with NAFLD compared to healthy controls. Moreover, SIBO is more prevalent in patients with NASH-associated cirrhosis compared to patients with NAFL.

Monitoring of colonoscopy quality indicators in an academic endoscopy facility reveals adherence to international recommendations.

BACKGROUND: We monitor colonoscopy service quality biannually, by measuring sedation administration, colonoscopy completion, adenoma detection and early complications rates (CR). We herein present our audit results for the years 2013 and 2015. METHODS: In our endoscopy facility, five rotating senior gastroenterologists perform colonoscopies, on a daily basis. We measured the quality indicators in three cohorts: A, intention for total colonoscopy cases; B, cohort A excluding bowel obstruction cases; C, colorectal cancer (CRC) screening cases. RESULTS: In 2015, overall sedation administration rate (SAR) was 93.0% (91.6-94.4%), achieving our target to give conscious sedation to >90% of patients undergoing colonoscopy in all three cohorts. Colonoscopy completion rate (CCR) increased significantly (P<0.0001) from 94.8% (93.4-96.2%) to 98.1% (97.3-98.9%) in cohort B and numerically from 96.6% (94.4-98.8%) to 98.6% (97.4-99.7%) in cohort C, at the same periods. In cohort C, adenoma detection rates (ADR) were similar-27.1% (21.7-32.5%) and 27% (22.7-31.3%)-in the two periods. There were only two serious early complications: one cardiorespiratory event and one perforation in 2013 and 2015, respectively. While significant variability regarding SAR (ranging from 80% to 100%) was detected among the participating endoscopists, all but one of them constantly achieved [judged by the lower confidence interval (CI) of the quality indicator] CCRs higher than the recommended by international guidelines. On the contrary ADR was variable among endoscopists during the studied periods. CONCLUSIONS: Although there is certain variability in endoscopists' performance, the overall colonoscopy quality indicators meet or exceed the internationally recommended standards, in our endoscopy facility.

Dislodged biliary stent causes lower gastrointestinal hemorrhage four years postendoscopic retrograde cholangiopancreatography.

Endoscopic biliary stent placement is an efficient method for the decompression of the biliary system in various benign and malignant causes. Dislocation and stent migration is a well-known complication, with most displaced stents passing through the bowel, uneventfully. Rarely, migrated stents can be accounted for potentially life-threatening complications.

Publication dynamics in gastroenterology and hepatology over the last decade in Greece: a SCImago-based study.

BACKGROUND: There is evidence that the financial crisis has deleteriously affected scientific output. We aimed to assess the dynamics of Greek publications in gastroenterology and hepatology over the last ten years. METHODS: Data were collected from SCImago. The average annual growth rate (AAGR) of total and citable documents published in Greece in the field of gastroenterology and hepatology was compared with that of cardiology, surgery, and radiology. In addition, it was compared with the corresponding rates in Belgium, Ireland and Portugal. RESULTS: The annual number of Greek publications (total and citable documents) remained relatively unchanged in the field of gastroenterology and hepatology from 2006-2011. During the following years, we detected a negative AAGR, with values of -12%, -3.3%, -9.5% and -5.4% for gastroenterology-hepatology, cardiology, surgery and radiology, respectively. During the same period, the AAGR of the citable documents of the respective specialties was -8.6%, -3.7%, -9.8%, and -5.1%. Comparison of the 4 European countries in the field of gastroenterology and hepatology revealed that publications from Portugal rose massively (AAGR +24.6% and +20.6% for total and citable documents, respectively), almost reaching the number of Greek publications in 2015. The number of publications from Belgium and Ireland remained essentially unchanged after 2011, with AAGR values of -0.7%, and -2.1% for total and -1.1% and -1.4% for citable documents, respectively. CONCLUSION: The publication output in the field of gastroenterology and hepatology decreased significantly after the outbreak of the financial crisis in Greece, not only in relation to other medical specialties, but also compared to the output of other European countries with or without fiscal austerity measures.

Embolia cutis medicamentosa: an unusual adverse reaction to terlipressin.

Terlipressin is a synthetic long-acting analog of vasopressin widely used to control variceal bleeding by lowering portal venous pressure. We report an unusual adverse reaction to terlipressin in a 78-year-old patient with esophageal variceal bleeding who developed skin necrosis soon after treatment initiation. Skin biopsy revealed embolia cutis medicamentosa.

An unusual cause of acute lower gastrointestinal bleeding: lung adenocarcinoma metastasis to the descending colon.

Lung adenocarcinoma with symptomatic GI metastasis occurs seldom in everyday clinical practice. However, as diagnostic modalities, therapeutic interventions, and supportive care for cancer evolve, it is likely that the clinician might encounter a number of similar cases in the future, and therefore, he should be aware of this rare entity.

Long-term effects of video capsule endoscopy in the management of obscure gastrointestinal bleeding.

Obscure gastrointestinal bleeding (OGIB) accounts for approximately 5% of all gastrointestinal (GI) hemorrhages. It usually arises from a small bowel lesion beyond the reach of conventional endoscopy including esophagogastroduodenoscopy and colonoscopy. Video capsule endoscopy (VCE) revolutionized the evaluation of OGIB patients since it allows reliable and noninvasive visualization of the small bowel mucosal surface. Since 2001, VCE has evolved into an efficient technology integrated in clinical practice. It is the cornerstone in the algorithm of OGIB investigation given its high diagnostic yield, which compares favorably to that of double-balloon enteroscopy (DBE). In terms of outcomes, a positive index VCE examination usually correlates to a high re-bleeding rate, while a negative one provides adequate evidence of low re-bleeding risk, suggesting a wait and watch approach in this subset of patients. Additionally, a variety of factors has been acknowledged as significant predictors of re-bleeding episodes. While research data regarding immediate endoscopic findings have matured, data concerning the clinical utility of VCE in patients with OGIB on the long-term remain sparse. This manuscript reviews the current literature, aiming to highlight the role of VCE in the long-term management of OGIB.

New endoscopes and add-on devices to improve colonoscopy performance.

Colonoscopy is the gold standard for colorectal cancer prevention; however, it is still an imperfect modality. Precancerous lesions can be lost during screening examinations, thus increasing the risk of interval cancer. A variety of factors either patient-, or endoscopist dependent or even the procedure itself may contribute to loss of lesions. Sophisticated modalities including advanced technology endoscopes and add-on devices have been developed in an effort to eliminate colonoscopy's drawbacks and maximize its ability to detect potentially culprit polyps. Novel colonoscopes aim to widen the field of view. They incorporate more than one cameras enabling simultaneous image transmission. In that way the field of view can expand up to 330°. On the other hand a plethora of add-on devices attachable on the standard colonoscope promise to detect lesions in the proximal aspect of colonic folds either by offering a retrograde view of the lumen or by straightening the haustral folds during withdrawal. In this minireview we discuss how these recent advances affect colonoscopy performance by improving its quality indicators (cecal intubation rate, adenoma detection rate) and other metrics (polyp detection rate, adenomas per colonoscopy, polyp/adenoma miss rate) associated with examination's outcomes.

Activation of NLRP3 Inflammasome in Inflammatory Bowel Disease: Differences Between Crohn's Disease and Ulcerative Colitis.

BACKGROUND: NLRP3 inflammasome is a multimolecular cytosol complex that, when activated, contributes to the cleavage of pro-interleukin (IL)-1ß to IL-1ß. AIMS: To investigate NLRP3 inflammasome activation in inflammatory bowel disease. METHODS: Peripheral blood mononuclear cells from Crohn's disease (CD), ulcerative colitis (UC) patients and controls were stimulated with LPS in the absence or presence of MSU. After incubation, concentrations of IL-1ß, IL-6, and TNFα were measured in cell supernatants and concentration of pro-IL-1ß was measured in cell lysates. NLRP3 activation was defined as more than 30% increase in IL-1ß production after MSU addition. In separate experiments, PBMCs were lysed for RNA isolation transcripts of IL-1ß, TNFα, NLRP3, and CASP1 were measured by RT-PCR. DNA was isolated from CD patients for ATG16L1 gene genotyping. RESULTS: NLRP3 inflammasome was activated in 60% of CD patients compared to 28.6% of controls (p = 0.042); no significant difference was detected between UC and controls. Among UC patients, NLRP3 activation was associated (p = 0.008) with long-standing disease (>1.5 years). IL-1ß levels were significantly higher in CD patents in comparison with controls (p = 0.032). No difference was detected in the levels of IL-6, TNFα, pro-IL-1ß and in the numbers IL-1ß, TNFα, NLRP3, and CASP1 transcripts among groups. IL-1ß production was similar between carriers of wild-type and of SNP alleles of the rs2241880. CONCLUSIONS: NLRP3 inflammasome is activated in CD patients and in UC patients with long-standing disease.

Lower adenoma miss rate with FUSE vs. conventional colonoscopy with proximal retroflexion: a randomized back-to-back trial.

Background and study aims Full-spectrum colonoscopy (FSC) promises to increase adenoma detection by providing a wider field of view. The aim of this study was to compare adenoma miss rates of FSC with those of conventional colonoscopy complemented by right-colon re-examination using scope retroflexion (CC/R). Patients and methods At two tertiary endoscopy facilities, patients who were scheduled for colonoscopy for the assessment of symptoms or for colorectal cancer screening/surveillance were randomized (1:1) to undergo same-day, back-to-back colonoscopies (FSC or CC/R first), performed by one of five endoscopists who had documented adenoma detection rates > 35 %. Per-protocol data were analyzed. Results We randomized 220 patients. There were five FSC technical failures (three air pump and two left screen); therefore, 107 and 108 cases were analyzed in the FSC and CC/R index procedure arms, respectively. Withdrawal times were similar for FSC and CC/R (7.7 minutes vs. 7.6 minutes). Overall, we detected 3 cancers and 153 adenomas (FSC = 92; CC/R = 61); 81 were detected in the proximal colon, 3 of which were detected by retroflexed examination. By per-lesion analysis, FSC showed a significantly lower adenoma miss rate compared with CC/R overall (10.9 % [95 % confidence interval (CI) 3.8 to 18.1] vs. 33.7 % [95 %CI 23.4 to 44.1]) and in the proximal colon (13.9 % [95 %CI 2.6 to 25.2] vs. 42.2 % [95 %CI 27.8 to 56.7]). The advanced adenoma miss rate was lower with FSC overall (4.3 % [95 %CI - 4.0 to 12.7] vs. 25.9 % [95 %CI 9.4 to 42.5]). There were no adverse events. Conclusions FSC outperformed conventional colonoscopy with right-colon scope retroflexion in the detection of missed adenomas, both overall and in the proximal colon, even when performed by experienced endoscopists.Trial registered at ClinicalTrials.gov (NCT02117674).

Academic hospital staff compliance with a fecal immunochemical test-based colorectal cancer screening program.

AIM: To measure the compliance of an Academic Hospital staff with a colorectal cancer (CRC) screening program using fecal immunochemical test (FIT). METHODS: All employees of "Attikon" University General Hospital aged over 50 years were thoroughly informed by a team of physicians and medical students about the study aims and they were invited to undergo CRC screening using two rounds of FIT (DyoniFOB(®) Combo H, DyonMed SA, Athens, Greece). The tests were provided for free and subjects tested positive were subsequently referred for colonoscopy. One year after completing the two rounds, participants were asked to be re-screened by means of the same test. RESULTS: Among our target population consisted of 211 employees, 59 (27.9%) consented to participate, but only 41 (19.4%) and 24 (11.4%) completed the first and the second FIT round, respectively. Female gender was significantly associated with higher initial participation (P = 0.005) and test completion - first and second round - (P = 0.004 and P = 0.05) rates, respectively. Physician's (13.5% vs 70.2%, P < 0.0001) participation and test completion rates (7.5% vs 57.6%, P < 0.0001 for the first and 2.3% vs 34%, P < 0.0001 for the second round) were significantly lower compared to those of the administrative/technical staff. Similarly, nurses participated (25.8% vs 70.2%, P = 0.0002) and completed the first test round (19.3% vs 57.6%, P = 0.004) in a significant lower rate than the administrative/technical staff. One test proved false positive. No participant repeated the test one year later. CONCLUSION: Despite the well-organized, guided and supervised provision of the service, the compliance of the Academic Hospital personnel with a FIT-based CRC screening program was suboptimal, especially among physicians.

Endoscopy after bariatric surgery.

Obesity is a global epidemic with significant morbidity and mortality. Weight loss results in reduction of health risks and improvement in quality of life, thus representing a goal of paramount importance. Bariatric surgery is the most efficacious choice compared to conservative alternatives including diet, exercise, drugs and behavioral modification to treat obese patients. Following bariatric operations, patients may present with upper gastrointestinal tract complaints that warrant endoscopic evaluation and the various bariatric surgery types are often linked to complications. A subset of these complications necessitates endoscopic interventions for accurate diagnosis and effective, minimal invasive treatment. This review aims to highlight the role of upper gastrointestinal endoscopy in patients who have undergone bariatric surgery to evaluate and potentially treat surgery-related complications and upper gastrointestinal symptoms.

The association between smoking and psychopathology adjusted for body mass index and gender.

OBJECTIVE: This study examined the correlation between smoking habits and psychopathology status, as well as the impact of confounders such as body mass index and gender. METHOD: A total of 134 non-smokers and 152 smokers were enrolled in this study. We measured psychopathology features using Symptom Checklist 90-Revised. We ran logistic regression models testing the smoking-psychopathology association, controlling for body mass index and gender. RESULTS: Smoking was positively correlated with depression, interpersonal sensitivity, hostility, somatization, paranoid ideation and psychoticism (P<0.05). Adjusting for body mass index and gender, the results remained largely unchanged, with a slight independent effect of body mass index. CONCLUSIONS: Our data suggest that smoking is a stronger predictor of psychopathology than body mass index and gender.

The role of miRNAs and epigenetic mechanisms in primary gastric mucosa-associated lymphoid tissue lymphoma.

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is a rare low-grade B-cell non-Hodgkin lymphoma associated with Helicobacter pylori infection and the subsequent chronic inflammation. Significant progress in understanding the pathogenesis of the disease has already been made. However, the exact molecular pathways of lymphomagenesis remain unclear. Furthermore, difficulties regarding accurate diagnosis of gastric MALT lymphoma and its discrimination from gastritis or other lymphoma subtypes arise. Recent studies evaluate the role of miRNAs and epigenetic alterations on MALT lymphoma pathogenesis and prognosis. This review critically summarizes the most important data on the role of miRNAs and epigenetics in MALT lymphomas pathogenesis, prognosis and treatment.

Long-term patient satisfaction of gastrointestinal endoscopic procedures.

BACKGROUND: We prospectively assessed patient satisfaction in a Greek Academic endoscopy facility. METHODS: Consecutive outpatients filled a satisfaction questionnaire right after their endoscopy (D1), 3 days (D3) and 3 months (M3) later. Overall patient satisfaction was measured by their willingness to repeat endoscopy in our facility and to further recommend it. Participant satisfaction regarding pre-procedural, procedural and post-procedural issues was measured using a five-step Likert scale in 19 items with 4 and 5 scores indicating favorable responses. Pareto analysis was used to determine service issues requiring improvement. Late adverse events were recorded at D3 and M3 assessments. RESULTS: Over six months, 501 patients participated (89.4% and 87.8% response rate at D3 and M3 assessments, respectively). More than 97% of the participants would repeat the procedure in our facility and would recommend our endoscopy service, at all three assessments. Pareto analysis identified waiting time until the appointment and on the day of the examination, discomfort during and after the endoscopy, time to obtain the pathology report and overall management of the patient problems as the issues requiring improvement. No predictor of high satisfaction score has been identified. No serious late adverse events were reported. CONCLUSION: Despite the overall high levels of patient satisfaction, management of patient discomfort and organizational issues need improvement.

Diagnostic yield of scope retroflexion in the right colon: A prospective cohort study.

BACKGROUND: Techniques have been implemented to improve colonoscopy adenoma detection rate (ADR) in the right colon. AIMS & METHODS: We prospectively examined the additional diagnostic yield of right colon examination with colonoscope retroflexion in consecutive, symptomatic and screening-surveillance patients. Right colon was examined in forward-view first and thereafter, retroflexion was performed to re-inspect it. RESULTS: Right colon examination in retroflexion was achieved in 620 (92%) patients. Increased inserted scope length to the cecum (OR: 0.48 [95% CI: 0.27-0.84]) and elderly status (OR: 0.53 [95% CI: 0.430-0.94]) predicted retrofexion failure. Forward-view colonoscopy detected 134 polyps and 112 adenomas in 105 and 85 patients, respectively. Scope retroflexion revealed 7 missed (6 adenomas--2 advanced) polyps in 7 patients; indicating 4.96 (95% CI: 1.37-8.55) % and 5.1 (95% CI: 1.12-9.05) % per-polyp and per-adenoma miss rates, respectively. In ITT analysis, per-patient polyp and adenoma miss rates were 1.041% and 0.89%, respectively. Among screening-surveillance patients, retroflexion detected 3 missed adenomas (2 advanced) in 3 patients, resulting in changed surveillance schedule in 2 of them (5.12 per 1000 screening-surveillance patients). Early study termination was favored by low right colon ADR improvement and lacking substantial surveillance interval change. CONCLUSION: The additional diagnostic yield of scope retroflexion in the right colon is questionable.

Improved bowel preparation increases polyp detection and unmasks significant polyp miss rate.

AIM: To retrospectively compare previous-day vs split-dose preparation in terms of bowel cleanliness and polyp detection in patients referred for polypectomy. METHODS: Fifty patients underwent two colonoscopies: one diagnostic in a private clinic and a second for polypectomy in a University Hospital. The latter procedures were performed within 12 wk of the index ones. Examinations were accomplished by two experienced endoscopists, different in each facility. Twenty-seven patients underwent screening/surveillance colonoscopy, while the rest were symptomatic. Previous day bowel preparation was utilized initially and split-dose for polypectomy. Colon cleansing was evaluated using the Aronchick scale. We measured the number of detected polyps, and the polyp miss rates per-polyp. RESULTS: Excellent/good preparation was reported in 38 cases with previous-day preparation (76%) vs 46 with split-dose (92%), respectively (P = 0.03). One hundred and twenty-six polyps were detected initially and 169 subsequently (P < 0.0001); 88 vs 126 polyps were diminutive (P < 0.0001), 25 vs 29 small (P = 0.048) and 13 vs 14 equal or larger than 10 mm. The miss rates for total, diminutive, small and large polyps were 25.4%, 30.1%, 13.7% and 6.6%, respectively. Multivariate analysis revealed that split-dose preparation was significantly associated (OR, P) with increased number of polyps detected overall (0.869, P < 0.001), in the right (0.418, P = 0.008) and in the left colon (0.452, P = 0.02). CONCLUSION: Split-dose preparation improved colon cleansing, enhanced polyp detection and unmasked significant polyp miss rates.

Is there a role for colon capsule endoscopy beyond colorectal cancer screening? A literature review.

Colon capsule endoscopy is recommended in Europe alternatively to colonoscopy for colorectal cancer screening in average risk individuals. The procedure has also been proposed to complete colon examination in cases of incomplete colonoscopy or when colonoscopy is contraindicated or refused by the patient. As tissue samples cannot be obtained with the current capsule device, colon capsule endoscopy has no place in diagnosing ulcerative colitis or in dysplasia surveillance. Nevertheless, data are accumulating regarding its feasibility to examine ulcerative colitis disease extent and to monitor disease activity and mucosal healing, even though reported results on the capsule's performance in this field vary greatly. In this review we present the currently available evidence for the use of colon capsule endoscopy to complement colonoscopy failure to reach the cecum and its use to evaluate ulcerative colitis disease activity and extent. Moreover, we provide an outlook on issues requiring further investigation before the capsule becomes a mainstream alternative to colonoscopy in such cases.

Percutaneous endoscopic gastrostomy tube replacement unexpected serious events.

Percutaneous endoscopic gastrostomy tubes are replaced due to clogging, breaking, and dislodgement. There are potential complications associated with these procedures, including intraperitoneal placement of the tube and peritonitis, which can occur even in the presence of a well established stoma site. Herein we present a case series of 3 patients with mature gastrocutaneous tracks, who developed peritonitis following tube replacement. In the absence of a consensus or international guidelines regarding the management of patients requiring percoutaneous endoscopic gastrostomy tube replacement, emphasis should be given on prevention of severe adverse events and on early anticipation of their occurrence. Clinical experience indicates that recognition of high-risk procedures, selection of the appropriate replacement method and confirmation of correct tube placement can improve patients' safety and reduce the complications rate.