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BACKGROUND AND AIMS: Dysphagia is the hallmark symptom in eosinophilic esophagitis (EoE). However, data are limited regarding the overall prevalence and potential implications of atypical symptoms like odynophagia and retrosternal pain. METHODS: Patients enrolled into the Swiss EoE cohort study (SEECS) were analyzed regarding the presence of odynophagia and retrosternal pain. Demographics, other EoE-related symptoms, histologic and endoscopic activity were compared between EoE-patients with vs. without odynophagia and/or retrosternal pain. RESULTS: 474 patients (75.2% male) were analyzed. In their individual course of disease 110 (23.2%) patients stated to have ever experienced odynophagia and 64 (13.5%) retrosternal pain independent of food intake, 24 (5%) patients complained about both symptoms. Patients with odynophagia consistently scored higher in symptom severity (p < 0.001), EREFS score (median 3.0 vs. 2.0, p = 0.006), histologic activity and a lower quality of life (p = 0.001) compared to patients without odynophagia. Sex, age at diagnosis, EoE-specific treatment, complications such as candida or viral esophagitis and disease duration were similar in patients with vs. without odynophagia. Also patients with retrosternal pain scored higher in symptom severity (2.0 vs. 1.0, p = 0.001 and 2.0 vs. 1.0, p < 0.001 in physician and patient questionnaire assessment, respectively). However, there was neither a difference in endoscopic/histologic disease activity nor in quality of life according to presence or absence of retrosternal pain. Due to logistic reasons, a stratification regarding the presence of concomitant dysphagia was not possible. CONCLUSION: Odynophagia and swallowing-independent retrosternal pain are common symptoms in patients with EoE, associate with an overall higher EoE-related symptom severity and for the case of odynophagia lower quality of life. However, the influence of concomitant dysphagia and its severity remains unclear and needs to be included in future analyses.
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Background and Objectives: Patients with perianal Crohn's (CD) fistula often need repetitive surgeries and none of the established techniques was shown to be superior or preferable. Furthermore, the long-term outcome of fistula Seton drainage is not well described. The aims of this study were to analyze the long-term healing and recurrence rate of CD perianal fistulas in a large patient cohort. Materials and Methods: Database analysis of the Swiss IBD (Inflammatory Bowel Disease) cohort study. Results: 365 perianal fistula patients with 576 surgical interventions and a median follow-up of 7.5 years (0-12.6) were analyzed. 39.7% of patients required more than one procedure. The first surgical interventions were fistulectomies ± mucosal sliding flap (59.2%), Seton drainage (29.6%), fistula plugs or fibrin glue installations (2.5%) and combined procedures (8.8%). Fistulectomy patients required no more surgery in 69%, one additional surgery in 25% and more than one additional surgery in 6%, with closure rates at 7.5 years follow-up of 77.1%, 74.1% and 66.7%, respectively. In patients with Seton drainage as index surgery, 52% required no more surgery, and over 75% achieved fistula closure after 10 years. Conclusions: First-line fistulectomies, when feasible, achieved the highest healing rates, but one-third of patients required additional surgeries, and one-fourth of patients will remain with a fistula at 10 years. Initial Seton drainage and concurrent medical therapy can achieve fistula closure in 75%. However, in 50% of patients, more surgeries are needed, and fistula closure is achieved in only two-thirds of patients.
Subject(s)
Crohn Disease , Rectal Fistula , Humans , Crohn Disease/surgery , Crohn Disease/complications , Male , Female , Rectal Fistula/surgery , Rectal Fistula/etiology , Adult , Treatment Outcome , Middle Aged , Cohort Studies , Drainage/methods , Switzerland , Recurrence , AgedABSTRACT
Edema, rings, exudates, furrows, and strictures (EREFS) represent the major endoscopic features of eosinophilic esophagitis (EoE). The Endoscopic Reference System (EREFS) grading system is easy to learn and apply during daily clinical practice in the diagnosis and follow-up of EoE patients. When endoscopy is performed by an EoE-experienced physician, the EREFS criteria will identify the majority of EoE patients. The EREFS score from the area of greatest involvement of the esophagus should be reported. The EREFS grading system was formally validated as an endoscopy score and several randomized placebo-controlled trials have shown responsiveness of the EREFS score to therapeutic interventions.
Subject(s)
Eosinophilic Esophagitis , Humans , Eosinophilic Esophagitis/diagnosis , Eosinophilic Esophagitis/therapy , Esophagoscopy , Severity of Illness Index , Randomized Controlled Trials as TopicABSTRACT
BACKGROUND AND AIMS: Eosinophilic oesophagitis (EoE) is characterised by symptoms of esophageal dysfunction and oesinophil tissue infiltration. The EoE Diagnostic Panel (EDP) can distinguish between active and non-active EoE using a set of 77 genes. Recently, the existence of distinct EoE variants featuring symptoms similar to EoE, such as oesophageal dysfunction but lacking eosinophil infiltration, had been determined. METHODS: We used oesophageal biopsies from patients with histologically active (n=10) and non-active EoE (n=9) as well as from healthy oesophageal controls (n=5) participating in the Swiss Eosinophilic Esophagitis Cohort Study (SEECS) and analysed the gene expression profile in these biopsies by total RNA-sequencing (RNA-seq). Moreover, we employed the publicly accessible RNA-seq dataset (series GSE148381) as reported by Greuter et al, encompassing a comprehensive genomic profile of patients presenting with EoE variants. RESULTS: A novel, diagnostic gene expression panel that can effectively distinguish patients with histologically active conventional EoE from patients with EoE in histological remission and control individuals, and from three newly discovered EoE variants was identified. Histologically Active EoE Diagnostic Panel (HAEDP) consists of 53 genes that were identified based on differential expression between histologically active EoE, histological remission and controls (p≤0.05). By combining the HAEDP with EDP, we expanded our knowledge about factors that may contribute to the inflammation in EoE and improved our understanding of the underlying mechanisms of the disease. Conversely, we suggested a compact group of genes common to both HAEDP and EDP to create a reliable diagnostic tool that might enhance the accuracy of EoE diagnosis. CONCLUSION: We identified a novel set of 53 dysregulated genes that are closely associated with the histological inflammatory activity of EoE. In combination with EDP, our new panel might be a valuable tool for the accurate diagnosis of patients with EoE as well as for monitoring their disease course.
Subject(s)
Eosinophilic Esophagitis , Transcriptome , Eosinophilic Esophagitis/genetics , Eosinophilic Esophagitis/pathology , Eosinophilic Esophagitis/diagnosis , Humans , Female , Male , Adult , Biopsy , Middle Aged , Adolescent , Esophagus/pathology , Gene Expression Profiling/methods , Case-Control Studies , Young AdultABSTRACT
INTRODUCTION: Given the lack of data, we aimed to explore which therapeutic endpoints pediatric patients with eosinophilic esophagitis (EoE) and their parents consider to be relevant. METHODS: We created an educational brochure on EoE and a questionnaire, both of which were content-validated by pediatric patients and parents. Validated documents were sent to 112 patients and parents. They ranked the importance (5 levels) of short (during next 3 months) and long-term (≥1 year) treatment effect on symptoms, quality of life, endoscopic inflammation, stricture formation, histological inflammation, and fibrosis. RESULTS: A total of 45 parents and 30 pediatric patients ≥11 years completed the questionnaires. Pediatric patients identified improvement in the following domains as most important in the short- and long-term, respectively: symptoms (73% vs. 77%), QoL (53% vs. 57%), histologic inflammation (47% vs. 50%), histologic fibrosis (40% vs. 33%), endoscopic inflammation (47% vs. 40%), and strictures (33% vs. 40%). Parents of children ≥11 years old classified improvement in the following domains as most important in the short- and long-term, respectively: symptoms (70% vs. 83%), QoL (63% vs. 80%), histologic inflammation (67% vs. 77%), histologic fibrosis (47% vs. 63%), endoscopic inflammation (77% vs. 80%), and strictures (40% vs. 53%). Agreement between caregiver and children on the short-term importance of treatment outcomes was as follows: symptoms (77%), QoL (40%), histologic inflammation and fibrosis (47% and 43%), endoscopic inflammation and strictures (50% and 40%). CONCLUSION: Pediatric patients and parents attributed most importance to improvement in symptoms and QoL. Agreement between parents and patients regarding therapy goals is limited.
Subject(s)
Eosinophilic Esophagitis , Parents , Quality of Life , Humans , Eosinophilic Esophagitis/therapy , Eosinophilic Esophagitis/diagnosis , Parents/psychology , Child , Surveys and Questionnaires , Male , Female , Treatment Outcome , Adolescent , Child, PreschoolABSTRACT
INTRODUCTION: Eosinophilic esophagitis (EoE) variants have been recently characterized as conditions with symptoms of esophageal dysfunction resembling EoE, but absence of significant esophageal eosinophilia. Their disease course and severity have yet to be determined. METHODS: Patients from 6 EoE centers with symptoms of esophageal dysfunction, but peak eosinophil counts of <15/hpf in esophageal biopsies and absence of gastroesophageal reflux disease with at least one follow-up visit were included. Clinical, (immuno)histological, and molecular features were determined and compared with EoE and healthy controls. RESULTS: We included 54 patients with EoE variants (EoE-like esophagitis 53.7%; lymphocytic esophagitis 13.0%; and nonspecific esophagitis 33.3%). In 8 EoE-like esophagitis patients, EoE developed after a median of 14 months (interquartile range 3.6-37.6). Such progression increased over time (17.6% year 1, 32.0% year 3, and 62.2% year 6). Sequential RNA sequencing analyses revealed only 7 genes associated with this progression (with TSG6 and ALOX15 among the top 3 upregulated genes) with upregulation of a previously attenuated Th2 pathway. Immunostaining confirmed the involvement of eosinophil-associated proteins (TSG6 and ALOX15) and revealed a significantly increased number of GATA3-positive cells during progression, indicating a Th1/Th2 switch. Transition from one EoE variant (baseline) to another variant (during follow-up) was seen in 35.2% (median observation time of 17.3 months). DISCUSSION: Transition of EoE variants to EoE suggests the presence of a disease spectrum. Few genes seem to be associated with the progression to EoE with upregulation of a previously attenuated Th2 signal. These genes, including GATA3 as a Th1/Th2 switch regulator, may represent potential therapeutic targets in early disease pathogenesis.
Subject(s)
Disease Progression , Eosinophilic Esophagitis , Esophagus , Humans , Eosinophilic Esophagitis/genetics , Eosinophilic Esophagitis/pathology , Eosinophilic Esophagitis/diagnosis , Female , Male , Adult , Esophagus/pathology , Arachidonate 15-Lipoxygenase/genetics , Arachidonate 15-Lipoxygenase/metabolism , Adolescent , Eosinophils/pathology , Eosinophils/immunology , Young Adult , GATA3 Transcription Factor/genetics , Cell Adhesion Molecules/genetics , Cell Adhesion Molecules/metabolism , Child , Biopsy , Th2 Cells/immunology , Middle Aged , Case-Control Studies , Leukocyte CountABSTRACT
2023 has been marked by numerous advancements in the fields of hepatology, liver transplantation, gastroenterology, and interventional endoscopy. These developments hold the promise of changing our daily practice while enhancing the diagnosis and treatment of various hepatic and gastroenterological conditions. Additionally, the European Association for the Study of the Liver (EASL) has issued recommendations for the management of hepatitis delta, acute-on-chronic liver failure, liver diseases of pregnancy, and intrahepatic cholangiocarcinoma. Risankizumab was approved by Swiss Authorities for patients with Crohn's disease and dupilumab was approved for patients with eosinophilic esophagitis. The European Society of Gastrointestinal Endoscopy (ESGE) has revised its recommendations regarding Barrett's esophagus.
2023 a été marquée par de nombreuses avancées dans le domaine de l'hépatologie, de la transplantation hépatique, de la gastroentérologie et de l'endoscopie interventionnelle. Ces développements promettent de changer notre pratique quotidienne dans le but d'améliorer le diagnostic et le traitement de nombreuses affections hépatiques et gastroentérologiques. En outre, la Société européenne d'hépatologie (EASL) a émis des recommandations pour la prise en charge de l'hépatite delta, de l'insuffisance hépatique aiguë sur chronique, des complications hépatiques de la grossesse et du cholangiocarcinome intrahépatique. Le risankizumab a été approuvé par Swissmedic pour le traitement de la maladie de Crohn et le dupilumab pour les patients avec Åsophagite à éosinophiles. La Société européenne d'endoscopie a mis à jour ses recommandations concernant l'Åsophage de Barrett.
Subject(s)
Acute-On-Chronic Liver Failure , Bile Duct Neoplasms , Gastroenterology , Female , Pregnancy , Humans , Bile Ducts, IntrahepaticABSTRACT
INTRODUCTION: It is still unknown whether eosinophilic esophagitis (EoE) patients with localized disease are different from those with extended disease. METHODS: We evaluated prospectively included patients in the Swiss EoE cohort. Data on all patients with active disease at baseline, no concomitant gastroesophageal reflux disease, no strictures at baseline, and at least one follow-up visit were analyzed. We compared patients with histologically localized proximal versus distal versus extended (=proximal and distal) disease with regard to patient, disease characteristics, disease presentation, and development of complications. RESULTS: We included 124 patients with a median of 2.5 years of follow-up (73.4% males, median age 35.0 years). Ten patients had proximal (8.1%), 46 patients had distal (37.1%), and 68 patients had extended disease (54.8%). Patients with proximal disease were significantly more often females (80%) compared with patients with distal (26.1%, p = 0.002) or extended disease (19.1%, p < 0.001) and reported less severe symptoms (VAS 0 vs. VAS 1, p = 0.001). Endoscopic and histological disease was less pronounced in the proximal esophagus of proximal EoE compared to extended disease (EREFS 1.0 vs. 3.0, p = 0.001; 27.0 eos/hpf vs. 52.5 eos/hpf, p = 0.008). Patients with proximal disease were less likely to undergo dilation compared to patients with distal disease in the follow-up (3.3% vs. 23.3%, p = 0.010). In a multivariate Cox regression model, proximal eosinophilia was less likely to be associated with treatment failure compared to distal eosinophilia. CONCLUSION: Although isolated proximal EoE is infrequent, it is associated with less severe disease and better disease outcome. Proximal disease appears to present a unique EoE phenotype.
Subject(s)
Enteritis , Eosinophilia , Eosinophilic Esophagitis , Gastritis , Male , Female , Humans , Adult , Eosinophilic Esophagitis/diagnosis , Eosinophilic Esophagitis/epidemiology , Eosinophilic Esophagitis/therapy , Endoscopy , PhenotypeABSTRACT
Although mostly accentuated in the distal esophagus, distribution of esophageal eosinophilia in eosinophilic esophagitis (EoE) seems to be nonuniform.1 Disease extent has been associated with disease severity and disease progression in inflammatory bowel disease.2,3 Whether the same holds true for EoE remains largely unknown. One recent EoE study looked at the distribution of eosinophilia, but without analyzing its potential association with treatment outcomes.4 Here, we characterize the different inflammatory patterns of EoE and investigate their impact on disease presentation and disease outcome, with a particular focus on therapeutic response.
Subject(s)
Eosinophilic Esophagitis , Eosinophils , Eosinophilic Esophagitis/therapy , Humans , Treatment Outcome , MaleABSTRACT
INTRODUCTION: Faecal microbiota transplantation (FMT) is an established therapy for recurrent C. difficile infection, and recent studies have reported encouraging results of FMT in patients with ulcerative colitis. Few international consensus guidelines exist for this therapy, and thus FMT policies and practices differ among European countries. As of 2019, stool transplants are considered a non-standardised medicinal product in Switzerland, and a standardised production process requires authorisation by the Swiss Agency for Therapeutic Products. This authorisation leads to prolonged administrative procedures and increasing costs, which reduces treatment accessibility. In particular, patients with ulcerative colitis in Switzerland can only benefit from FMT off-label, even though it is a valid therapeutic option. Therefore, this study summarised the available data on FMT and established a framework for the standardised use of FMT. METHODS: A panel of Swiss gastroenterologists with a special interest in inflammatory bowel disease was established to identify the current key issues of FMT. After a comprehensive review of the literature, statements were formulated about FMT indications, donor screening, stool transplant preparation and administration, and safety aspects. The panel then voted on the statements following the Delphi process; the statements were reformulated and revoted until a consensus was reached. The manuscript was then reviewed by an infectiologist (the head of Lausanne's FMT centre). RESULTS: The established statements are summarised in the supplementary tables in the appendix to this paper. The working group hopes these will help standardise FMT practice in Switzerland and contribute to making faecal microbiota transplantation a safe and accessible treatment for patients with recurrent C. difficile infections and selected patients with ulcerative colitis, as well as other indications in the future.
Subject(s)
Clostridioides difficile , Clostridium Infections , Colitis, Ulcerative , Fecal Microbiota Transplantation , Humans , Clostridium Infections/microbiology , Clostridium Infections/therapy , Colitis, Ulcerative/etiology , Colitis, Ulcerative/therapy , Fecal Microbiota Transplantation/adverse effects , Fecal Microbiota Transplantation/methods , Inflammatory Bowel Diseases/therapy , Switzerland , Treatment OutcomeABSTRACT
Functional dyspepsia is defined by epigastric pain/burning, postprandial fullness and/or early satiety that have been present for at least six months before diagnosis, including three consecutive months, without evidence of an organic cause likely to explain these symptoms. The pathogenesis is complex and incompletely understood. The initial assessment includes a thorough history, physical examination, blood work, celiac disease serology and ruling out Helicobacter pylori infection. Most patients will undergo upper gastrointestinal endoscopy and abdominal ultrasound to exclude organic differential diagnoses. The therapy is multi-facetted and includes, among others, proton pump inhibitors, Helicobacter pylori eradication, herbal agents, and neuromodulators.
La dyspepsie fonctionnelle est définie par la présence d'un ou plusieurs des symptômes suivants : douleur/brûlure épigastrique, plénitude postprandiale, satiété précoce qui doivent être présents depuis au moins six mois avant le diagnostic, dont trois mois consécutifs, sans qu'il y ait de preuve d'une cause organique. La physiopathologie est complexe et mal comprise. Le bilan initial comprend une anamnèse approfondie, un examen physique, un bilan sanguin, une sérologie de la maladie cÅliaque et écarter une infection à Helicobacter pylori. Une gastroscopie et un ultrason abdominal sont indiqués chez la majorité des patients afin d'exclure les diagnostics différentiels organiques. Le traitement est multiple et comprend les inhibiteurs de la pompe à proton, l'éradication d'Helicobacter pylori, la phytothérapie et les neuromodulateurs.
Subject(s)
Celiac Disease , Dyspepsia , Helicobacter Infections , Helicobacter pylori , Humans , Dyspepsia/diagnosis , Dyspepsia/etiology , Dyspepsia/therapy , Helicobacter Infections/complications , Helicobacter Infections/diagnosis , Helicobacter Infections/drug therapy , Abdominal PainABSTRACT
INTRODUCTION: There is a complex interrelationship between gastroesophageal reflux disease (GERD) and eosinophilic esophagitis (EoE) potentially promoting the occurrence and modulating severity of each other reciprocally. Presence of Barrett's esophagus (BE) is a defining factor for the diagnosis of GERD. While several studies investigated the potential impact of concomitant GERD on the presentation and course of EoE, little was known with regards to BE in EoE patients. METHODS: We analyzed prospectively collected clinical, endoscopic, and histological data from patients enrolled in the Swiss Eosinophilic Esophagitis Cohort Study (SEECS) regarding differences between EoE patients with (EoE/BE+) versus without BE (EoE/BE-) and determined the prevalence of BE in EoE patients. RESULTS: Among a total of 509 EoE patients included in our analysis, 24 (4.7%) had concomitant BE with a high male preponderance (EoE/BE+ 83.3% vs. EoE/BE- 74.4%). While there were no differences in dysphagia, odynophagia was significantly (12.5 vs. 3.1%, p = 0.047) more common in EoE/BE+ versus EoE/BE-. General well-being at last follow-up was significantly lower in EoE/BE+. Endoscopically, we observed an increased incidence of fixed rings in the proximal esophagus in EoE/BE+ (70.8 vs. 46.3% in EoE/BE-, p = 0.019) and a higher fraction of patients with a severe fibrosis in the proximal histological specimen (8.7 vs. 1.6% in EoE/BE, p = 0.017). CONCLUSION: Our study reveals that BE is twice as frequent in EoE patients compared to general population. Despite many similarities between EoE patients with and without BE, the finding of a more pronounced remodeling in EoE patients with Barrett is noteworthy.
Subject(s)
Barrett Esophagus , Deglutition Disorders , Eosinophilic Esophagitis , Gastroesophageal Reflux , Humans , Male , Barrett Esophagus/complications , Barrett Esophagus/epidemiology , Barrett Esophagus/diagnosis , Eosinophilic Esophagitis/complications , Eosinophilic Esophagitis/epidemiology , Eosinophilic Esophagitis/diagnosis , Cohort Studies , Switzerland/epidemiology , Gastroesophageal Reflux/diagnosis , Deglutition Disorders/complicationsABSTRACT
Frequent Gastro-Intestinal Disorders: Management of Functional Dyspepsia and Irritable Bowel Syndrome in Clinical Practice Abstract: Functional dyspepsia (FD) and irritable bowel syndrome (IBS), two common gastrointestinal entities with overlapping symptoms, should be diagnosed according to Rome IV criteria. This includes one or more of the following symptoms: in FD, postprandial fullness, early satiation, epigastric pain or burning; in IBS, recurrent abdominal pain associated with defecation, change in frequency of stool or form of stool. To exclude structural diseases, attention should be paid to alarm symptoms. As far as treatment is concerned, a stepwise scheme proves to be effective for both diseases. Step 1: doctor-patient discussion with explanation of diagnosis and prognosis as well as clarification of therapy goals; lifestyle adaptations; use of phytotherapeutics; step 2: symptom-oriented medication: for FD, PPIs or prokinetics; for IBS, antispasmodics, secretagogues, laxatives, bile acid sequestrants, antidiarrheals, antibiotics, probiotics; step 3: visceral analgesics (antidepressants).
Subject(s)
Dyspepsia , Gastrointestinal Diseases , Irritable Bowel Syndrome , Humans , Dyspepsia/complications , Dyspepsia/diagnosis , Prevalence , Gastrointestinal Diseases/complications , Gastrointestinal Diseases/diagnosis , Abdominal PainABSTRACT
Having long been considered the mainstay in eosinophilic esophagitis (EoE) diagnosis and pathogenesis, the role of eosinophils has been questioned and might be less important than previously thought. It is well known now that EoE is a Th2-mediated disease with many more disease features than eosinophilic infiltration. With more knowledge on EoE, less pronounced phenotypes or nuances of the disease have become apparent. In fact, EoE might be only the tip of the iceberg (and the most extreme phenotype) with several variant forms, at least three, lying on a disease spectrum. Although a common (food induced) pathogenesis has yet to be confirmed, gastroenterologists and allergologists should be aware of these new phenomena in order to further characterize these patients. In the following review, we discuss the pathogenesis of EoE, particularly those mechanisms beyond eosinophilic infiltration of the esophageal mucosa, non-eosinophilic inflammatory cell populations, the new disease entity EoE-like disease, variant forms of EoE, and the recently coined term mast cell esophagitis.
Subject(s)
Enteritis , Eosinophilic Esophagitis , Gastritis , Humans , Eosinophilic Esophagitis/diagnosis , Eosinophils/pathology , Enteritis/complications , Enteritis/pathology , Gastritis/complicationsABSTRACT
The field of gastroenterology and hepatology is evolving constantly. In 2022, numerous landmark studies have been published in all its subspecialities including hepatology, functional diseases, interventional endoscopy, and inflammatory bowel disease. Among the most significant advances are the antiviral treatment for hepatitis D, the new Chicago classification version 4 for esophageal motility disorders, the first biological treatment for eosinophilic esophagitis, a randomized controlled trial about the efficacy of screening colonoscopy, novel endoscopic techniques such as G-POEM or endoscopic sleeve gastrectomy, and emerging IBD therapies such as ozanimod, upadacitinib or anti-IL23 antibodies.
La gastroentérologie et l'hépatologie sont des disciplines variées et en pleine évolution. Durant l'année 2022, plusieurs études marquantes ont été publiées dans les domaines de l'hépatologie, des maladies fonctionnelles, de l'endoscopie et des maladies inflammatoires chroniques de l'intestin (MICI). Les avancées les plus importantes sont le traitement antiviral contre l'hépatite D, la nouvelle classification de Chicago version 4 pour les troubles moteurs Åsophagiens, le traitement biologique de l'Åsophagite à éosinophiles, l'efficacité de la coloscopie de dépistage, de nouvelles techniques endoscopiques comme le G-POEM ou la gastrectomie endoscopique et des nouveaux médicaments pour les MICI comme l'ozanimod, l'upadacitinib ou les anticorps anti-IL-23.
Subject(s)
Gastroenterology , Inflammatory Bowel Diseases , Humans , Gastroenterology/methods , Inflammatory Bowel Diseases/therapy , ColonoscopyABSTRACT
BACKGROUND: The impact of hiatal hernia (HH) on oncologic outcomes of patients with esophageal adenocarcinoma (AC) remains unclear. The aim of this study was to assess the effect of pre-existing HH (≥3 cm) on histologic response after neoadjuvant treatment (NAT), overall (OS) and disease-free survival (DFS). METHODS: All consecutive patients with oncological esophagectomy for AC from 2012 to 2018 in our center were eligible for assessment. Categorical variables were compared with the X2 or Fisher's test, continuous ones with the Mann-Whitney-U test, and survival with the Kaplan-Meier and log-rank test. RESULTS: Overall, 101 patients were included; 33 (32.7%) had a pre-existing HH. There were no baseline differences between HH and non-HH patients. NAT was used in 81.8% HH and 80.9% non-HH patients (p = 0.910), most often chemoradiation (63.6% and 57.4% respectively, p = 0.423). Good response to NAT (TRG 1-2) was observed in 36.4% of HH versus 32.4% of non-HH patients (p = 0.297), whereas R0 resection was achieved in 90.9% versus 94.1% respectively (p = 0.551). Three-year OS was comparable for the two groups (52.4% in HH, 56.5% in non-HH patients, p = 0.765), as was 3-year DFS (32.7% for HH versus 45.6% for non-HH patients, p = 0.283). CONCLUSION: HH ≥ 3 cm are common in patients with esophageal AC, concerning 32.7% of all patients in this series. However, its presence was neither associated with more advanced disease upon diagnosis, worse response to NAT, nor overall and disease-free survival. Therefore, such HH should not be considered as risk factor that negatively affects oncological outcome after multimodal treatment of esophageal AC.
Subject(s)
Adenocarcinoma , Esophageal Neoplasms , Hernia, Hiatal , Humans , Hernia, Hiatal/complications , Hernia, Hiatal/surgery , Retrospective Studies , Adenocarcinoma/complications , Adenocarcinoma/surgery , Esophageal Neoplasms/complications , Esophageal Neoplasms/surgery , Esophagectomy , Neoadjuvant TherapyABSTRACT
BACKGROUND & AIMS: There are no studies or recommendations on optimal monitoring strategies for patients with eosinophilic esophagitis (EoE). Our objective was to develop guidance on how to monitor patients with EoE in routine clinical practice, on the basis of available clinical evidence and expert opinion. METHODS: A multidisciplinary, international group of EoE experts identified the following important 3 questions during several consensus meetings: why, by what means, and when to monitor patients with EoE. A steering committee was named, and 3 teams were formed to review literature and to formulate statements for each topic. In a Delphi survey, a level of agreement of ≥75% was defined as threshold value for acceptance. In a final conference, results were presented, critical points and comments on the statements were discussed, and statements were rephrased/rewritten if necessary. RESULTS: Eighteen EoE experts (14 adult and pediatric gastroenterologists, 2 pathologists and 2 allergists) with a median of 21.7 years in clinical practice, mostly academic or university-based, completed the Delphi survey, which included 11 statements and a proposed algorithm for monitoring patients with EoE. Each statement attained ≥75% agreement. Participants discussed and debated mostly about the statement concerning surveillance intervals for EoE patients with stable disease. CONCLUSIONS: It was concluded that effective maintenance treatment probably reduces the development of EoE complications, and regular, structured, and, under certain conditions, individualized clinical follow-up is recommended to assess disease activity while opening a window to monitoring side effects, adjusting therapy, and encouraging adherence to treatment. Follow-up should comprise symptom assessment and periodic or repeated endoscopy with histological assessment in specific EoE settings.
Subject(s)
Drug-Related Side Effects and Adverse Reactions , Eosinophilic Esophagitis , Adult , Child , Humans , Eosinophilic Esophagitis/therapy , Eosinophilic Esophagitis/drug therapy , Endoscopy, Gastrointestinal , AlgorithmsABSTRACT
Upper gastrointestinal bleeding (UGIB) presents a high incidence in an emergency department (ED) and requires careful evaluation of the patient's risk level to ensure optimal management. The primary aim of this study was to externally validate and compare the performance of the Rockall score, Glasgow-Blatchford score (GBS), modified GBS and AIMS65 score to predict death and the need for an intervention among patients with UGIB. This was a cross-sectional observational study of patients consulting the ED of a Swiss tertiary care hospital with UGIB. Primary outcomes were the inhospital need for an intervention, including transfusion, or an endoscopic procedure or surgery or inhospital death. The secondary outcome was inhospital death. We included 1521 patients with UGIB, median age, 68 (52-81) years; 940 (62%) were men. Melena or hematemesis were the most common complaints in 1020 (73%) patients. Among 422 (28%) patients who needed an intervention or died, 76 (5%) died in the hospital. Accuracy of the scoring systems assessed by receiver operating characteristic curves showed that the Glasgow-Blatchford bleeding and modified GBSs had the highest discriminatory capacity to determine inhospital death or the need of an intervention [AUC, 0.77 (95% CI, 0.75-0.80) and 0.78 (95% CI, 0.76-0.81), respectively]. AIMS65 and the pre-endoscopic Rockall score showed a lower discrimination [AUC, 0.68 (95% CI, 0.66-0.71) and 0.65 (95% CI, 0.62-0.68), respectively]. For a GBS of 0, only one patient (0.8%) needed an endoscopic intervention. The modified Glasgow-Blatchford and Glasgow-Blatchford bleeding scores appear to be the most accurate scores to predict the need for intervention or inhospital death.
Subject(s)
Gastrointestinal Hemorrhage , Hospitals , Male , Humans , Aged , Female , Switzerland , Cross-Sectional Studies , Gastrointestinal Hemorrhage/diagnosis , Gastrointestinal Hemorrhage/therapy , Gastrointestinal Hemorrhage/etiology , ROC Curve , Risk Assessment/methods , Severity of Illness Index , PrognosisABSTRACT
OBJECTIVES OF THE STUDY: There is little guidance regarding the impact of alcohol and cannabis on the clinical course of inflammatory bowel disease. The aim of this study was to assess the prevalence, sociodemographic characteristics and impact of alcohol and cannabis use on the clinical course of the disease. METHODS: We performed an analysis of prospectively collected data within the Swiss Inflammatory Bowel Disease Cohort Study with yearly follow-ups and substance-specific questionnaires. We analyzed the prevalence of use, the profile of users at risk for addiction and the impact of alcohol and cannabis on the course of the disease. RESULTS: We collected data of 2828 patients included between 2006 and 2018 and analyzed it according to their completion of specific surveys on alcohol and cannabis use. The prevalence of patient-reported active use was 41.3% for alcohol and 6% for cannabis. Heavy drinkers were over-represented among retired, married smokers receiving mostly aminosalicylates and less immunosuppression. In ulcerative colitis patients, low-to-moderate drinking was associated with less extensive disease. Cannabis users were often students with ileal Crohn's disease. CONCLUSION: A significant proportion of patients with inflammatory bowel disease consume alcohol or cannabis. Heavy alcohol consumption is most likely in male smokers >50 years, whereas young men with ileal disease rather use cannabis.