AGA Clinical Practice Guideline on Endoscopic Eradication Therapy of Barrett's Esophagus and Related Neoplasia.

BACKGROUND & AIMS: Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Endoscopic eradication therapy (EET) can be effective in eradicating BE and related neoplasia and has greater risk of harms and resource use than surveillance endoscopy. This clinical practice guideline aims to inform clinicians and patients by providing evidence-based practice recommendations for the use of EET in BE and related neoplasia. METHODS: The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess evidence and make recommendations. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients, conducted an evidence review, and used the Evidence-to-Decision Framework to develop recommendations regarding the use of EET in patients with BE under the following scenarios: presence of (1) high-grade dysplasia, (2) low-grade dysplasia, (3) no dysplasia, and (4) choice of stepwise endoscopic mucosal resection (EMR) or focal EMR plus ablation, and (5) endoscopic submucosal dissection vs EMR. Clinical recommendations were based on the balance between desirable and undesirable effects, patient values, costs, and health equity considerations. RESULTS: The panel agreed on 5 recommendations for the use of EET in BE and related neoplasia. Based on the available evidence, the panel made a strong recommendation in favor of EET in patients with BE high-grade dysplasia and conditional recommendation against EET in BE without dysplasia. The panel made a conditional recommendation in favor of EET in BE low-grade dysplasia; patients with BE low-grade dysplasia who place a higher value on the potential harms and lower value on the benefits (which are uncertain) regarding reduction of esophageal cancer mortality could reasonably select surveillance endoscopy. In patients with visible lesions, a conditional recommendation was made in favor of focal EMR plus ablation over stepwise EMR. In patients with visible neoplastic lesions undergoing resection, the use of either endoscopic mucosal resection or endoscopic submucosal dissection was suggested based on lesion characteristics. CONCLUSIONS: This document provides a comprehensive outline of the indications for EET in the management of BE and related neoplasia. Guidance is also provided regarding the considerations surrounding implementation of EET. Providers should engage in shared decision making based on patient preferences. Limitations and gaps in the evidence are highlighted to guide future research opportunities.

Why MASLD Lags Behind MAFLD: A Critical Analysis of Diagnostic Criteria Evolution in Metabolic Dysfunction-Associated Liver Diseases.

Emerging in the 1800s under the label "fat in the liver" and later gaining prominence in the 1980 as non-alcoholic fatty liver disease (NAFLD), the disease predominantly attributed to metabolic dysfunction presents a formidable health issue marked by substantial morbidity and mortality. It was 2020 when a change of one letter "NAFLD" to metabolic dysfunction-associated fatty liver disease "MAFLD" linked with the change in the definition and diagnostic criteria began a new controversy around the globe. Metabolic dysfunction-associated fatty liver disease (MAFLD) criteria represent a substantial departure from previous diagnostic measures of NAFLD, and provide the first set of positive criteria for diagnosis of the disease in adults and children that emphasise the key attribute of metabolic dysfunction in the pathogenesis, and acknowledges that the disease is a continuum across the life span. In 2023, an adapted version of the diagnostic criteria of MAFLD was proposed to define a slightly modified term; metabolic dysfunction-associated steatotic liver disease (MASLD). The MASLD criteria did not provide any conceptual advantage, and emerging evidence suggests that it actually performs worse than the MAFLD criteria. This raises the intriguing question of why MASLD was unable to take advantage of being second? In this review, we will explore the possible reasons for this unique case and highlight the current evidence supporting the use of MAFLD instead of MASLD in defining metabolic dysfunction-associated fatty liver diseases.

Efficacy of routine second-look endoscopy after endoscopic hemostasis in patients with acute peptic ulcer bleeding: systematic review and meta-analysis.

OBJECTIVE: To evaluate the efficacy of scheduled second-look endoscopy in patients with acute peptic ulcer bleeding (PUB). MATERIALS AND METHODS: We systematically search in four databases for randomized controlled trials (RCTs) that evaluated the usefulness of scheduled second-look endoscopy vs. single endoscopy in patients with PUB. Our primary outcome was rebleeding. Secondary outcomes were surgery, mortality, and the number of units of blood transfused (NUBT). All meta-analyses were performed using a random-effects model. Pooled risk ratio (RR) and mean difference (MD), with their 95% confidence intervals (CIs) were calculated for categorical and continuous outcomes, respectively. The risk of bias was assessed using the Cochrane RoB 2.0 tool, and the quality of evidence (QoE) was rated with the GRADE approach. RESULTS: Eight full-text RCTs and two RCT abstracts were included (n=1513). We did not find differences in rebleeding (RR, 0.78; 95% CI, 0.53-1.14, moderate QoE), surgery (RR, 0.58; 95% CI, 0.29-1.15, moderate QoE), mortality (RR, 0.89; 95% CI, 0.46-1.71, moderate QoE) or NUBT (MD, -0.01 units; 95% CI, -0.3 to 0.28, low QoE) between second-look and single endoscopy. Sensitivity analyses had similar results to the main analyses. CONCLUSIONS: Routine second-look endoscopy was not more efficacious than single endoscopy in patients with PUB.

Vegetarian diets on anthropometric, metabolic and blood pressure outcomes in people with overweight and obesity: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: It is unknown whether vegetarian diets (VDs) may improve outcomes in people with overweight and obesity. OBJECTIVE: To systematically assess the effects of VDs vs. omnivore diets on anthropometric, metabolic, and blood pressure outcomes in people with overweight and obesity. METHODS: We searched for randomized controlled trials (RCTs) in EMBASE, PubMed, Web of Science, and Scopus until February 2, 2022. Primary outcomes were anthropometric risk factors (weight, body mass index [BMI], waist circumference [WC], hip circumference [HC], and body fat percentage). Secondary outcomes were metabolic risk factors (fasting serum glucose, HbA1c, insulin levels) and blood pressure (systolic blood pressure [SBP], diastolic blood pressure [DBP]). Random-effects meta-analyses were performed and effects were expressed as mean difference (MD) and their 95% confidence intervals (CI). The quality of evidence was assessed using GRADE methods. RESULTS: Nine RCTs (n = 1628) were included. VDs decreased weight (MD -3.60 kg, 95%CI -4.75 to -2.46) and glucose (MD -10.64 mg/dL, 95%CI -15.77 to -5.51), but did not decrease WC (MD -3.00 cm, 95%CI -6.20 to 0.20), BMI (MD -0.87 kg/m2, 95%CI -1.80 to 0.06), or HC (MD: -0.86 cm, 95%CI -3.46 to 1.74). VDs did not decrease HbA1c (MD -0.40%, 95%CI -0.89 to 0.10), insulin (MD -3.83 mU/L, 95%CI -8.06 to 0.40), SBP (MD -0.25 mmHg, 95%CI -2.58 to 2.07), or DBP (MD -1.57 mmHg, 95%CI -3.93 to 0.78). Subgroup analyses by type of VD (four RCTs evaluated lacto-ovo-vegetarian diets and five RCTs vegan diets) showed similar results to the main analyses. QoE was very low for most of the outcomes. CONCLUSIONS: In comparison to an omnivorous diet, VDs may reduce weight and glucose, but not blood pressure or other metabolic or anthropometric outcomes. However, the QoE was mostly very low. Larger RCTs are still needed to evaluate the effects of VD on anthropometric, metabolic factors, and blood pressure in people with overweight and obesity.

Helicobacter pylori World Gastroenterology Organization Global Guideline.

Helicobacter pylori remains a major health problem worldwide, causing considerable morbidity and mortality due to peptic ulcer disease and gastric cancer. The burden of disease falls disproportionally on less well-resourced populations. As with most infectious diseases, the largest impact on reducing this burden comes from improvement in socioeconomic status, which interrupts transmission. This has been observed in many regions of the world, but the prevalence of infection remains high in many regions where improvements in living standards are slow to occur. Meanwhile, the optimal clinical management and treatment pathways remain unsettled and are evolving with changing antimicrobial resistance patterns. Despite decades of research and clinical practice, major challenges remain. The quest for the most effective, safe, and simple therapy remains the major issue for clinicians. The search for an effective vaccine appears to be elusive still. Clinical guidelines do not infrequently proffer discordant advice. A major challenge for guidelines is for relevance across a variety of populations with a varying spectrum of disease, antimicrobial resistance rates, and vastly different resources. As local factors are central to determining the impact and management strategies for H. pylori infection, it is important that pathways are based on the best available local knowledge rather than solely extrapolating from guidelines formulated in other regions, which may be less applicable. To this end, this revision of the World Gastroenterology Organisation (WGO) H. pylori guideline uses a "Cascades" approach that seeks to summarize the principles of management and offer advice for pragmatic, relevant and achievable diagnostic and treatment pathways based on established key treatment principles and using local knowledge and available resources to guide regional practice.

Endoscopic submucosal dissection versus surgery for patients with undifferentiated early gastric cancer.

BACKGROUND AND AIMS: endoscopic submucosal dissection (ESD) is the standard treatment for differentiated early gastric cancer (EGC). However, its expanded indication for undifferentiated EGC is controversial. In this study, the efficacy and safety of ESD versus surgery in patients with undifferentiated EGC were compared. METHODS: four databases were searched until February 24, 2022, for studies assessing patients with undifferentiated EGC that met an expanded indication for endoscopic resection and who were treated with ESD or surgery. Primary outcomes were all-cause mortality and any recurrence. Secondary outcomes were complete histological resection, local recurrence, metachronous recurrence, synchronous recurrence, distant metastasis, overall complication, and bleeding. All meta-analyses were performed using a random-effects models. Unadjusted (risk ratio [RR]) and adjusted (aRR and hazard ratio [aHR]) estimates with 95 % confidence interval (CI) were calculated. RESULTS: seven cohort studies were included (n = 2637). The use of ESD was significantly associated with higher all-cause mortality compared to surgery (RR, 2.17; 95 % CI, 1.24-3.81); adjusted all-cause mortality effects were not significant (aRR, 2.28; 95 % CI, 0.95-5.47 and aHR, 1.97; 95 % CI, 0.85-4.53). ESD was associated with a higher risk of any recurrence using unadjusted (RR, 5.24; 95 % CI, 1.49-18.46) and adjusted (aRR, 7.89; 95 % CI, 1.52-40.95 and aHR, 3.73; 95 % CI, 1.17-11.90) estimates. The risk of local recurrence, synchronous recurrence and bleeding were significantly higher for ESD versus surgery. No significant differences were found for other secondary outcomes. CONCLUSIONS: although ESD is associated with a higher risk of any recurrence, adjusted all-cause mortality is similar during follow-up. Overall complications were similar between ESD and surgery.

Utility of YouTube online learning for junior gastrointestinal endoscopists: A rewarding or deterring practice?

Endoscopy is a competitive field in clinical practice, in which skilled endoscopists are in high demand. The learning process for Junior Gastrointestinal Endoscopists (JGEs) is difficult, quite long, and technically demanding. This directs JGEs to seek additive learning sources, including online sources. The purpose of this study was to determine the frequency, context, attitudes, perceived benefits, drawbacks, and recommendations for using YouTube videos as an educational platform among JGEs from the uses'prespective. We disseminated a cross-sectional online questionnaire from January 15th to March 17th, 2022, and recruited 166 JGE from 39 different countries. The majority of surveyed JGEs (138, 85.2%) were already using YouTube as a learning tool. The majority of JGEs (97, 59.8%) reported gaining knowledge and applying it in their clinical practice, but 56 (34.6 %) reported gaining knowledge without application in real practice. Most participants (124, 76.5 %) reported missing procedure details in YouTube endoscopy videos. The majority of JGEs (110, 80.9%) reported that YouTube videos are provided by endoscopy specialists. Only one participant, 0.6% out of the 166 JGEs surveyed, disliked video records, including YouTube as a source of learning. Based on their experience, 106 (65.4%) of participants recommended YouTube as an educational tool for the coming generation of JGEs. We consider that YouTube represents a potentially useful tool for JGEs, supplying them with both knowledge and clinical practice tricks. However, many drawbacks could make the experience misleading and time-consuming. Consequently, we encourage educational providers on YouTube and other platforms to upload well-constructed, peerreviewed, interactive educational endoscopy videos.

Ivermectin for the Treatment of Coronavirus Disease 2019: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: We systematically assessed benefits and harms of the use of ivermectin (IVM) in patients with coronavirus disease 2019 (COVID-19). METHODS: Published and preprint randomized controlled trials (RCTs) assessing the effects of IVM on adult patients with COVID-19 were searched until 22 March 2021 in 5 engines. Primary outcomes were all-cause mortality rate, length of hospital stay (LOS), and adverse events (AEs). Secondary outcomes included viral clearance and severe AEs (SAEs). The risk of bias (RoB) was evaluated using the Cochrane Risk of Bias 2.0 tool. Inverse variance random effect meta-analyses were performed, with quality of evidence (QoE) evaluated using GRADE methods. RESULTS: Ten RCTs (n = 1173) were included. The controls were the standard of care in 5 RCTs and placebo in 5. COVID-19 disease severity was mild in 8 RCTs, moderate in 1, and mild and moderate in 1. IVM did not reduce all-cause mortality rates compared with controls (relative risk [RR], 0.37 [95% confidence interval, .12-1.13]; very low QoE) or LOS compared with controls (mean difference, 0.72 days [95% confidence interval, -.86 to 2.29 days]; very low QoE). AEs, SAEs, and viral clearance were similar between IVM and control groups (low QoE for all outcomes). Subgroups by severity of COVID-19 or RoB were mostly consistent with main analyses; all-cause mortality rates in 3 RCTs at high RoB were reduced with IVM. CONCLUSIONS: Compared with the standard of care or placebo, IVM did not reduce all-cause mortality, LOS, or viral clearance in RCTs in patients with mostly mild COVID-19. IVM did not have an effect on AEs or SAEs and is not a viable option to treat patients with COVID-19.

Uniting the Global Gastroenterology Community to Meet the Challenge of Climate Change and Nonrecyclable Waste.

Climate change has been described as the greatest public health threat of the 21st century. It has significant implications for digestive health. A multinational team with representation from all continents, excluding Antarctica and covering 18 countries, has formulated a commentary which outlines both the implications for digestive health and ways in which this challenge can be faced.

[Clinical practice guidelines for the diagnosis and management chronic infection of hepatitis viral C of the Peruvian Health Social Security (EsSalud)]. / Guía de práctica clínica para el diagnóstico y tratamiento de la infección crónica por el virus de hepatitis C en el Seguro Social de Salud del Perú (EsSalud).

INTRODUCTION: This article summarizes the clinical practice guidelines (CPG) for the diagnosis and treatment of chronic infection of hepatitis viral C of the Peruvian Health Social Security (EsSalud). OBJECTIVE: To provide clinical recommendations based on evidence for the diagnosis and treatment of chronic infection of hepatitis viral C in EsSalud. METHODS: A guideline development group (GDG) was established, including medical specialists and methodologists. The GDG formulated 4 clinical questions to be answered in this CPG. Systematic searches of systematic reviews and primary studies (when pertinent) were conducted in PubMed, and Central (Cochrane) during 2019. The evidence was selected to answer each of the clinical questions. The accuracy of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work meetings, the GEG used the GRADE methodology to review the evidence and formulate the recommendations, the points of good clinical practice and the treatment flowchart. Finally, the CPG was approved with Resolution No. 151-IETSIESSALUD-2019. RESULTS: The present CPG addressed 4 clinical questions of four topics: screening, diagnosis, staging and treatment. Based on these questions, 13 recommendations (8 strong recommendations and 5 weak recommendations), 27 points of good clinical practice, and 1 flowchart were formulated. CONCLUSION: This paper summarizes the methodology and evidencebased conclusions from the CPG for for the diagnosis and treatment of chronic infection of hepatitis viral C of the EsSalud.

Colorectal cancer screening: a South American perspective.

Colorectal cancer (CRC) occupies the first places of cancer incidence and mortality worldwide. There are screening guidelines that must be adapted to the available resources. South America (SA) is a region with characteristics that influences in the behavior of diseases. MATERIALS AND METHODS: A bibliographic review focused on publications originating in SA in the last 10 years was performed by two independents reviewers using Medline, EMBASE and LILACS platforms. RESULTS: Forty-seven publications were included. There is an increase in the incidence of CRC, mortality and years of life lost. Higher mortality is observed in indigenous populations, older adults, and low socioeconomic strata. Many barriers in the access to screening were observed (lack of knowledge about screening in the population and health professionals, insufficient technical resources). Prevention of CRC is a health challenge where improvement in living conditions is a central part. SA is taking its first steps in the prevention of CRC and the path must contemplate elements inherent of the region. A central point in the development of effective screening strategies is to increase research and scientific production. We consider useful for each country, to evaluate its screening actions taking into account the incidence (high, average or low) to determine if it is convenient to develop structured or opportunistic programs but always starting from the premise that the awareness of the population is essential. CONCLUSIONS: The great challenge to achieve effective CRC prevention can be summed up in the concept of equity. CRC screening in SA requires leadership, creativity, and the ability to craft responses tailored to each local setting.

[Performance of the FIB-4 index in esophageal varices screening in patients with the diagnosis of liver cirrhosis]. / Desempeñ o del índice FIB-4 en el despistaje de vá rices esofá gicas en pacientes con el diagnóstico de cirrosis hepá tica.

INTRODUCTION: The diagnosis of esophageal varices in cirrhotic patients is made by the upper gastrointestinal endoscopy. Multiple non-invasive predictors have been studied for the diag-nosis of esophageal varices. The objective of this study is to testthe FIB4 index as screening of esophageal varices in patients with liver cirrhosis. MATERIALS AND METHODS: A cross-sectional analytic study was developed in four national hospital using hepatic cirrhosis patient's medi-cal files. We assessed the information using univariate and bivariate analysis, sensitivity, speci-ficity, predictive positive and negative value, the positive and negative likelihood ratio calcu-lation of the esophageal varices screening and its size. We built ROC curve for every analysis group. RESULTS: The study included 289 liver cirrhosis patients. Most of the patients were male (54.33%). 77.85% patients had esophageal varices. The distribution of varices was 19.03%, 35.99% and 22.84% for large, medium and small varices, respectively. In the FIB-4 index analysis for the presence of varices, it was found a sensitivity of 81.3%, specificity of 37.5% (AUC: 0.57). The calculation for variceal size showed a sensitivity of 81.8%, specificity of 23.9% (AUC: 0.50). In the analysis of FIB-4 index for prophylaxis groups was found a sensitivity of 81.8% and a specificity of 28.5% (AUC: 0.54). CONCLUSIONS: The FIB-4 index has no good performance in the screening for the presence of esophageal varices and its size in liver cirrhosis patients.

[Recommendations of the Society of Gastroenterology of Peru to avoid the spread of SARS-CoV-2 through digestive endoscopy procedures]. / Recomendaciones de la Sociedad de Gastroenterología del Perú para evitar la propagación del SARS-CoV-2 a través de procedimientos de endoscopía digestiva.

The SARS-CoV-2 coronavirus produces the disease called COVID-19, currently spreading in a rapidly evolving pandemic. It can be transmitted by contact, drops and aerosols, and has been isolated from gastrointestinal secretions and faeces. During digestive endoscopy, transmission by any of these mechanisms could occur. It is recommended to limit digestive endoscopy to cases of digestive bleeding, severe dysphagia, foreign body in the digestive tract, biliary obstruction with intractable pain or cholangitis, pseudocyst or complicated encapsulated pancreatic necrosis, gastrointestinal obstruction, and cases at risk of deterioration over time. It is recommended to screen patients based on temperature, symptoms, and epidemiological factors to classify them according to their risk of infection. For procedures in low risk patients, personnel must wear a disposable gown, gloves, eye or face shield, standard surgical mask, disposable hat, disposable shoe covers. In cases of intermediate or high risk, or confirmed COVID-19, protection should be increased using disposable waterproof gown, N95 respirator or similar, and double glove. In case of shortage it may be necessary to reuse N95 respirators for up to 5 uses, following CDC recommendations for donning, removing and storing to prevent secondary contact contamination. Likewise, all protective equipment should be put on and removed according to CDC recommendations. The presence of personnel in endoscopy should be limited to the bare minimum. Said personnel must have daily temperature control and if it is above 37.3ºC, the corresponding evaluation must be carried out. After each procedure, the stretcher and room surfaces should be properly disinfected. High-level disinfection of endoscopes eliminates SARS-CoV-2.

[Primary intestinal lymphangiectasia: first case report in Peru]. / Linfangiectasia intestinal primaria: primer reporte de caso en Perú.

Primary intestinal lymphangiectasia is a rare clinical condition of unknown etiology. The common age of presentation is during the first 3 years of life, but cases in adults have also been reported. It has a variable symptomatology, but the main clinical manifestation is edema, also diarrhea and weight loss can occur. The loss of lymph fluid into the gastrointestinal tract also leads to hypoproteinemia and lymphopenia. Diagnosis is based on clinical manifestations, laboratory and endoscopic findings, and is confirmed on histopathological examination of biopsy. The main treatment is a protein rich, low in fat and medium chain triglyceride diet. We present the case of a 1-year-old male patient who presents with generalized edema, predominantly in lower limbs, and diarrhea. Laboratory findings show the presence of marked hypoproteinemia. Then an endoscopy and a duodenal biopsy are performed, and the histopathological study confirms the diagnosis of primary intestinal lymphangiectasia. The patient is treated and after a satisfactory evolution, is discharged.

[Primary gastric choriocarcinoma: case report]. / Coriocarcinoma gástrico primario: reporte de caso.

Primary gastric choriocarcinoma (PGC) is an extremely rare and highly invasive tumor with rapid hematogenous spread. We present the case of a 57-year-old female patient who started with hematemesis and progressive episodes of melena, weight loss and epigastralgia. It is derived from the National Institute of Neoplastic Diseases where gastroscopy and biopsy are performed. Histological analysis reported pattern suggestive of PGC; that was confirmed by immunohistochemical analysis for human chorionic gonadotrophin and fetal alpha protein. Subsequently, the patient underwent a radical D2 gastrectomy with splenic preservation and tail of the pancreas preservation. Unfortunately, her evolution was not favorable and died due to the progression of the disease.

[Clinical practice guideline for the evaluation and management of upper gastrointestinal bleeding for the Peruvian Social Security (EsSalud)]. / Guía de práctica clínica para la evaluación y el manejo de la hemorragia digestiva alta en el Seguro Social del Perú (EsSalud).

OBJECTIVE: To provide evidence-based clinical recommendations for the evaluation and management of patients with upper gastrointestinal bleeding (UGB) in the Peruvian Social Security (EsSalud). MATERIALS AND METHODS: A local guideline development group (local GDG) was established, including specialists in gastroenterology and methodologists. The local GDG formulated 11 clinical questions to be answered by this clinical practice guide (CPG). We searched and selected CPG of UGB published from 2012, which answered the posed questions and obtained a score higher than 60% in domains 1 and 3 of the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool. During September 2017, bibliographic searches were conducted in Pubmed, to update 9 clinical questions of the preselected CPGs, and to answer 2 de novo questions. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work meetings, the local GDG reviewed the evidence and formulated the recommendations, points of good clinical practice and the flowchart of evaluation and management, using the GRADE methodology Lastly, the CPG was approved with Resolución N° 80-IETSI-ESSALUD-2017. RESULTS: This CPG addressed 11 clinical questions, divided into four themes: risk assessment, initial management, management of non-variceal UGB, and management of variceal UGB. Based on these questions, 10 recommendations (7 strong recommendations and 3 weak recommendations), 24 points of good clinical practice, and 2 flow charts were formulated. CONCLUSION: This article is the summary of the EsSalud' CPG, where the available scientific evidence on evaluation and management of UGB was evaluated.