Metataxonomic Analysis Demonstrates a Shift in Duodenal Microbiota in Patients with Obstructive Jaundice.

The human gastrointestinal tract (GIT) is home to an abundance of diverse microorganisms, and the balance of this microbiome plays a vital role in maintaining a healthy GIT. The obstruction of the flow of bile into the duodenum, resulting in obstructive jaundice (OJ), has a major impact on the health of the affected individual. This study sought to identify changes in the duodenal microbiota in South African patients with OJ compared to those without this disorder. Mucosal biopsies were taken from the duodenum of nineteen jaundiced patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and nineteen control participants (non-jaundiced patients) undergoing gastroscopy. DNA extracted from the samples was subjected to 16S rRNA amplicon sequencing using the Ion S5 TM sequencing platform. Diversity metrics and statistical correlation analyses with the clinical data were performed to compare duodenal microbial communities in both groups. Differences in the mean distribution of the microbial communities in the jaundiced and non-jaundiced samples were observed; however, this difference did not reach statistical significance. Of note, there was a statistically significant difference between the mean distributions of bacteria comparing jaundiced patients with cholangitis to those without (p = 0.0026). On further subset analysis, a significant difference was observed between patients with benign (Cholelithiasis) and malignant disease, namely, head of pancreas (HOP) mass (p = 0.01). Beta diversity analyses further revealed a significant difference between patients with stone and non-stone related disease when factoring in the Campylobacter-Like Organisms (CLO) test status (p = 0.048). This study demonstrated a shift in the microbiota in jaundiced patients, especially considering some underlying conditions of the upper GI tract. Future studies should aim to verify these findings in a larger cohort.

Endoscopic capacity in West Africa.

BACKGROUND: Levels of endoscopic demand and capacity in West Africa are unclear. OBJECTIVES: This paper aims to: 1. describe the current labor and endoscopic capacity, 2. quantify the impact of a mixed-methods endoscopy course on healthcare professionals in West Africa, and 3. quantify the types of diagnoses encountered. METHODS: In a three-day course, healthcare professionals were surveyed on endoscopic resources and capacity and were taught through active observation of live cases, case discussion, simulator experience and didactics. Before and after didactics, multiple-choice exams as well as questionnaires were administered to assess for course efficacy. Also, a case series of 23 patients needing upper GI endoscopy was done. RESULTS: In surveying physicians, less than half had resources to perform an EGD and none could perform an ERCP, while waiting time for emergency endoscopy in urban populations was at least one day. In assessing improvement in medical knowledge among participants after didactics, objective data paired with subjective responses was more useful than either alone. Of 23 patients who received endoscopy, 7 required endoscopic intervention with 6 having gastric or esophageal varices. Currently the endoscopic capacity in West Africa is not sufficient. A formal GI course with simulation and didactics improves gastrointestinal knowledge amongst participants.

Antibiotic prophylaxis for patients undergoing elective endoscopic retrograde cholangiopancreatography.

BACKGROUND: The use of prophylactic antibiotics before endoscopic retrograde cholangiopancreatography (ERCP) is recommended by all major international gastroenterological societies, especially in the presence of an obstructed biliary system. Their use is intended to decrease or eliminate the incidence of complications following the procedure, namely cholangitis, cholecystitis, septicaemia, and pancreatitis. OBJECTIVES: To assess the benefits and harms of antibiotics before elective ERCP in patients without evidence of acute or chronic cholecystitis, or acute or chronic cholangitis, or severe acute pancreatitis. SEARCH STRATEGY: We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and LILACS until March 2010. Relevant medical and surgical international conference proceedings were also searched. SELECTION CRITERIA: Only randomised clinical trials were included in the analyses, irrespective of blinding, language, or publication status. Participants were patients that underwent elective ERCP that were not on antibiotics, without evidence of acute or chronic cholecystitis, cholangitis, or severe acute pancreatitis before the procedure. We compared patients that received prophylactic antibiotics before the procedure with patients that were given placebo or no intervention before the procedure. DATA COLLECTION AND ANALYSIS: The review was conducted according to the recommendations of The Cochrane Collaboration as well as the Cochrane Hepato-Biliary Group. Review Manager 5 was used employing fixed-effect and random-effects models meta-analyses. MAIN RESULTS: Nine randomised clinical trials (1573 patients) were included in the analyses. The majority of the trials had risks of bias. When all patients providing data for a certain outcome were included, the fixed-effect meta-analyses significantly favoured the use of prophylactic antibiotics in preventing cholangitis (relative risk (RR) 0.54, 95% CI 0.33 to 0.91), septicaemia (RR 0.35, 95% CI 0.11 to 1.11), bacteriaemia (RR 0.50, 95% CI 0.33 to 0.78), and pancreatitis (RR 0.54, 95% CI 0.29 to 1.00). In random-effects meta-analyses, only the effect on bacteriaemia remained significant. Overall mortality was not reduced (RR 1.33, 95% CI 0.32 to 5.44). If one selects patients in whom the ERCP resolved the biliary obstruction at the first procedure, there seem to be no significant benefit in using prophylactic antibiotics to prevent cholangitis (RR 0.98, 95% CI 0.35 to 2.69, only three trials). AUTHORS' CONCLUSIONS: Prophylactic antibiotics reduce bacteriaemia and seem to prevent cholangitis and septicaemia in patients undergoing elective ERCP. In the subgroup of patients with uncomplicated ERCP, the effect of antibiotics may be less evident. Further research is required to determine whether antibiotics can be given during or after an ERCP if it becomes apparent that biliary obstruction cannot be relieved during that procedure.

Antibiotic prophylaxis for patients undergoing elective endoscopic retrograde cholangiopancreatography. A survey of South African endoscopists and review of the literature.

BACKGROUND: Antibiotic prophylaxis for endoscopic retrograde cholangiopancreatography (ERCP) is controversial. We set out to assess the current antibiotic prescribing practice among South African endoscopists who perform ERCPs, and then reviewed international guidelines and relevant studies. METHODS: Our audit of South African endoscopists who perform ERCPs took the form of a questionnaire. For the literature review a Pubmed search was performed from 1978 to March 2008, and these findings were compared with the current practice in South Africa. RESULTS: No specific protocols were being implemented widely in South Africa, and there was a marked difference in the practice between surgical and medical gastroenterologists, with surgeons using antibiotics more often. There was also a wide spectrum of antibiotic types that were being used. The Pubmed search revealed only 7 randomised controlled trials, with little consensus between them as to the absolute indications for prophylactic antibiotics in ERCP. CONCLUSIONS: Guidelines on antibiotic prophylaxis for ERCP are based on poor evidence. Varied opinions on its indications in South Africa may reflect the situation in other countries as well.

Preliminary report on the effect of brachytherapy on expression of p53, bc1-2 and apoptosis in squamous cell carcinoma of the oesophagus.

Pre-brachytherapy biopsies and post-brachytherapy oesophagectomy specimens of 10 patients with early squamous cell carcinoma of the middle third of the oesophagus were examined for the expression of p53, bcl-2 and apoptosis using immunohistochemical markers. There was no expression of p53 in one patient in both pre- and post-brachytherapy specimens. In 8 patients, p53 staining was strongly positive (3+) with approximately 50% or more cells, and with diffuse and no specific pattern in the pre-brachytherapy biopsies. The tumour areas of the post-brachytherapy specimens of this group showed strong 3+ positivity with p53 (10-50% positive cell count), with the pattern being focal and peripheral in the tumour islands. The centre of the tumour islands showed necrosis and/or keratinisation. In one patient, the pre-brachytherapy biopsy showed expression of p53 while the post-brachytherapy specimen was negative. bcl-2 expression in both pre- and post-brachytherapy was equivocal and inconclusive in both the pre- and post-brachytherapy specimens. Apoptosis was negative in all the pre- and post-brachytherapy tissue sections in the presence of positive controls. Brachytherapy does not cause cell death by apoptosis but by necrosis and maturation of the cells into better differentiated cells, which is caused by OH free radical, and induction of the keratin gene respectively. It is possible that brachytherapy may cause destruction of cells containing wild-type p53, while mutant p53 in cells located at the tumour periphery escape the effect of brachytherapy. This may be responsible for the high incidence of local recurrence and distant metastasis in oesophageal cancer treated with radiotherapy. There is no effect of brachytherapy on bcl-2 expression in oesophageal cancer.