Saudi Journal of Gastroenterology
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   2018| March-April  | Volume 24 | Issue 2  
    Online since April 6, 2018

 
 
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ORIGINAL ARTICLES
Vitamin D supplementation in adolescents with irritable bowel syndrome: Is it useful? A randomized controlled trial
Doaa El Amrousy, Samir Hassan, Heba El Ashry, Mohamed Yousef, Hossam Hodeib
March-April 2018, 24(2):109-114
DOI:10.4103/sjg.SJG_438_17  PMID:29637918
Background/Aim: Vitamin D deficiency is common in irritable bowel syndrome (IBS). There is growing interest in the role of vitamin D in pediatric IBS. We aimed to evaluate the effect of vitamin D supplementation in adolescents with IBS and vitamin D deficiency. Patients and Methods: One hundred and twelve adolescents with IBS and vitamin D deficiency were randomly divided into two groups of matched age and sex. The first group received oral vitamin D3 2000IU/day for 6 months and the second group received placebo for 6 months. Vitamin D status as well as different IBS score systems (IBS-SSS, IBS-QoL, and total score) were evaluated before and 6 months after treatment. Results: IBS patients who received vitamin D supplementation for 6 months showed significant improvement in IBS-SSS (P < 0.001), IBS-QoL (P < 0.001), and total score (P = 0.02) compared to IBS placebo group. IBS patients treated with vitamin D showed two folds increase in their serum vitamin D levels (from 17.2 ± 1.3 to 39 ± 3.3) ng/ml with P < 0.001. While in the placebo group, their serum vitamin D levels were not significantly changed (P = 0.66). Vitamin D was tolerated well without any recorded adverse effects during the study period. Conclusion: Vitamin D supplementation can be effective in treating adolescents with IBS and vitamin D deficiency.
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SYSTEMATIC REVIEW/META-ANALYSIS
Thiazolidinediones and risk of colorectal cancer in patients with diabetes mellitus: A meta-analysis
Yang Liu, Piao-Piao Jin, Xue-Cheng Sun, Ting-Ting Hu
March-April 2018, 24(2):75-81
DOI:10.4103/sjg.SJG_295_17  PMID:29637913
Background/Aims: A growing body of evidence has suggested that thiazolidinediones (TZDs) potentially reduce the risk of colorectal cancer (CRC). This study aimed to evaluate the effect of TZDs on CRC risk in patients with diabetes mellitus (DM). Patients and Methods: A systematic search of electronic databases was performed for studies evaluating the exposure to TZDs and reporting CRC risk in diabetic patients. Pooled estimates with 95% confidence intervals (CIs) were estimated using fixed or random effects models. Results: A total of 10 observational studies reporting more than 18,972 CRC cases in 2,470,768 DM patients were included. Meta-analysis showed a 9% reduction in CRC risk associated with TZDs use in all studies [relative risk (RR) =0.91, 95% CI = 0.84–0.99, P = 0.03] and cohort studies (RR = 0.89, 95% CI = 0.80–0.99, P = 0.04), respectively. However, such effect was not shown in case–control studies. In subgroup analyses, lower CRC risk was found in Asian population (RR = 0.40, 95% CI = 0.29–0.53, P = 0.00), and a trend toward lower CRC risk was observed in US population (RR = 0.94, 95% CI = 0.88–1.01, P = 0.08). CRC risk was significantly modified with non-pioglitazone TZD use (RR = 0.88, 95% CI = 0.82–0.95, P = 0.00), but not with pioglitazone use (RR = 0.95, 95% CI = 0.89–1.01, P = 0.11). No significant difference was observed with cancer site (colon or rectum). There was considerable inherent heterogeneity across studies, partly explained by study location. Conclusions: This meta-analysis supports a protective association between TZDs use and CRC risk in patients with DM. Future well-designed prospective studies with larger cohorts would be needed to understand this association better.
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ORIGINAL ARTICLES
Immunohistochemical staining of cytokeratin 20 and cytokeratin 7 in colorectal carcinomas: Four different immunostaining profiles
Jaudah Al-Maghrabi, Eman Emam, Wafaey Gomaa
March-April 2018, 24(2):129-134
DOI:10.4103/sjg.SJG_465_17  PMID:29637921
Background/Aim: Aberrant expression of CK20/CK7 is reported in a percentage of colorectal carcinomas (CRC); however, its relation to clinicopathological variables and survival data is still unclear. The objective of this study is to explore patterns of CK20/CK7 immunostaining in CRC and to analyse the diagnostic, prognostic, and predictive role of patterns of CK20/CK7 immunostaining. Materials and Methods: A total of 144 CRC cases were retrieved from the archives at the Department of Pathology, King Abdulaziz University, Jeddah, Saudi Arabia. Immunohistochemistry was performed using antibody to CK7 and CK20. Immunostaining was defined as low and high by using the extent of staining. The association of CK7 and CK20 with clinicopathological characteristics and survival. Results: CK20 was expressed in a higher percentage of CRC and nodal metastasis than CK7. No difference in CK7 and CK20 immunostaining in primary and metastasis carcinomas was found. Four patterns of CK20/CK7 were identified; CK20+/CK7− (60.4%), CK20+/CK7+ (2.1%), CK20−/CK7− (35.4%), and CK20−/CK7+ (2.1%). There was no statistically significant correlation between CK20/CK7 immunohistochemical profile and clinicopathological characteristics, prognosis, and survival was determined. Conclusions: Our results may support the heterogeneity of CRC. CRC showed four different subclasses following patterns of relative CK20/CK7 immunostaining. A considerable number of CRC expressed aberrant immune profile of CK20/CK7, which should be considered during diagnosing CRC in metastatic regions. Further studies on larger cohorts correlating different immunohistochemical cytokeratin profiles to molecular subtypes of CRC are recommended for better understanding of pathogenesis and behaviour of CRC.
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The incidence of and risk factors for inadequate bowel preparation in elderly patients: A prospective observational study
Yuan-Yuan Zhang, Mei'e Niu, Zhen-Yun Wu, Xi-Ya Wang, Yuan-Yuan Zhao, Jie Gu
March-April 2018, 24(2):87-92
DOI:10.4103/sjg.SJG_426_17  PMID:29637915
Background/Aim: We conducted a prospective observational study to identify the incidence of and risk factors for inadequate bowel preparation in elderly Chinese patients. Patients and Methods: We enrolled 240 outpatients over 60 years of age scheduled for elective colonoscopy at our university hospital between November 2016 and April 2017. We recorded patient demographics, bowel preparation data, and clinical characteristics. Factors associated with inadequate bowel preparation were identified by multivariate logistical regression analysis. Results: The rate of inadequate bowel preparation was 34.6%. Factors associated with inadequate bowel preparation were a history of abdominal surgery (OR, 2.617; CI, 1.324–5.174; P = 0.006), chronic constipation (OR, 3.307; CI, 1.551–7.054; P = 0.002), non-compliance with dietary instructions (OR, 2.239; CI, 1.122–4.471; P = 0.022), non-compliance with polyethylene glycol (PEG) dosage (OR, 4.576; CI, 1.855–11.287; P = 0.001), walking <30 minutes during preparation (OR, 2.474; CI, 1.261–4.855; P = 0.008), interval between PEG ingestion and the onset of bowel activity (OR, 1.025; CI, 1.010–1.040; P = 0.001), and a last stool that was not clear and watery (OR, 4.191; CI, 1.529–11.485; P = 0.005). Conclusion: The incidence of adequate bowel preparation in elderly patients is not optimal. Walking <30 minutes during the PEG ingestion period may be a surrogate for bowel preparation failure. Future studies should identify elderly patients at risk for poor bowel preparation and develop interventions to improve outcomes in this population.
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EDITORIALS
Management of distal malignant biliary obstruction
Emad S Aljahdli
March-April 2018, 24(2):71-72
DOI:10.4103/sjg.SJG_611_17  PMID:29637911
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ORIGINAL ARTICLES
Comparison of efficacy and safety between endoscopic submucosal dissection and transanal endoscopic microsurgery for the treatment of rectal tumor
Yun Jung, Jun Lee, Ju Yeon Cho, Young Dae Kim, Chan Guk Park, Man Woo Kim, Kyung Jong Kim, Se Won Kim
March-April 2018, 24(2):115-121
DOI:10.4103/sjg.SJG_440_17  PMID:29637919
Background/Aim: To compare the treatment efficacy and safety between endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) for the treatment of rectal epithelial tumors, including large adenoma, cancer, and subepithelial tumors (SET). Patients and Methods: We conducted a retrospective analysis of the medical records of 71 patients with rectal tumors who were treated with ESD (48 patients) or TEM (23 patients) from January 2013 to December 2015. The patient group comprised 56 patients with epithelial tumors and 15 patients with SET. Treatment efficacy such as en bloc resection, procedure time, local recurrence, hospital stay, additional procedure rate, and safety between the treatment groups were evaluated and analyzed. Results: There were no significant differences in tumor size, location, macroscopic appearance, and histological depth between ESD and TEM groups. For ESD compared to TEM in rectal epithelial tumors, en bloc resection rates were 95% vs. 93.7% and R0 resection rates were 92.5% vs. 87.5% (P = 0.617); in rectal SET, en bloc resection rates were 100% vs. 100% and R0 resection rates were 87% vs. 85% (P = 0.91). The procedure time was 71.5 ± 51.3 min vs. 105.6 ± 28.2 min (P = 0.016) for epithelial tumors and 32.13 ± 13.4 min vs. 80.71 ± 18.35 min (P = 0.00) for SET, respectively. Hospital stay was 4.3 ± 1.2 days vs. 5.8 ± 1.8 days (P = 0.001) for epithelial tumors and 4.1 ± 4.1 days vs. 5.5 ± 2 days (P = 0.42) for rectal SET, respectively. There were no significant differences between recurrence rates, additional procedure rates, and complications in the two groups. Conclusions: ESD and TEM are both effective and safe for the treatment of rectal epithelial tumors and SET because of favorable R0 resection rates and recurrence rates. However, the ESD group showed shorter procedure times and hospital stays than the TEM group. Therefore, ESD should be considered more preferentially than TEM in the treatment of large rectal epithelial tumors and SET.
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Bowel preparation quality between hospitalized patients and outpatient colonoscopies
Majid A Almadi, Othman Alharbi, Nahla Azzam, Mohannad Altayeb, Salem Thaniah, Abdulrahman Aljebreen
March-April 2018, 24(2):93-99
DOI:10.4103/sjg.SJG_485_17  PMID:29637916
Background/Aims: Optimal bowel preparation is essential for a complete high-quality colonoscopy. We sought to determine whether an inpatient, as opposed to an ambulatory setting, would affect the quality of bowel preparation. Patients and Methods: A retrospective chart review was conducted in a tertiary care university hospital. We collected demographic data from consecutive patients who underwent a colonoscopy for any reason between August 2007 and April 2012. Results: A total of 2999 patients were included in the study with a mean age of 50.36 (95%CI; 49.79–50.94). Males comprised 58.12%. Ambulatory patients had a higher rate of good bowel preparations (67.23% vs. 56.64%, P value < 0.01), a lower rate of poor bowel preparations (18.22% vs. 27.14%, P value < 0.01), and a higher rate of colonoscopy completion (86.79% vs. 77.59%, P value < 0.01). There was no difference between the rates of polyps detected (18.90% vs. 20.83%, P value = 0.22). The univariabe modeling factors associated with a sub-optimal bowel preparation were age OR 1.02 (95% CI, 1.01 to 1.02), chronic kidney disease OR 2.34 (95% CI, 1.12 to 4.88), diabetes mellitus OR 2.00 (95% CI, 1.50 to 2.68), hypertension OR 1.48 (95% CI, 1.11 to 1.97), anemia OR 1.81 (95% CI, 1.33 to 2.47), and weight loss OR 1.41 (95% CI, 1.01 to 1.96). Better bowel preparation was associated with colonoscopies performed in the outpatient setting OR 0.63 (95% CI, 0.54 to 0.73). Conclusion: Bowel preparation quality is affected by the setting in which it is performed. This result suggests that, when appropriate, colonoscopies should be performed on an outpatient basis. Further studies are required to replicate this finding.
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EDITORIALS
Bowel preparation: The elderly, the hospitalized, and the colonoscope
Turki AlAmeel
March-April 2018, 24(2):73-74
DOI:10.4103/sjg.SJG_137_18  PMID:29637912
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ORIGINAL ARTICLES
New endoscopic classification of esophageal mucosa in achalasia: A predictor for submucosal fibrosis
Xiuxue Feng, Enqiang Linghu, Ningli Chai, Hui Ding
March-April 2018, 24(2):122-128
DOI:10.4103/sjg.SJG_459_17  PMID:29637920
Background/Aim: In this study, we aim to investigate the predicting ability of one new endoscopic classification of esophageal mucosa in achalasia (EMIA) for submucosal fibrosis (SMF) affecting the success of peroral endoscopic myotomy (POEM). Patients and Methods: The endoscopic and clinical data of achalasia patients undergoing POEM from 2012 to 2016 were investigated retrospectively. According to the endoscopic images or videos, EMIA and SMF grades were recorded. The relation between EMIA and SMF gradings was assessed by Spearman's rank correlation, and the predictive factors of SMF were identified by logistic regression analysis. Results: A total of 568 achalasia patients who underwent POEM were enrolled. For EMIA classification, there were 40 (7.0%), 373 (65.7%), 139 (24.5%), 14 (2.5%), 1 (0.2%), and 1 (0.2%) case (s) for grades a, b, c, d, e1, and f4, respectively. POEM procedures were aborted in 16 patients, and 93.8% (15/16) were due to severe SMF. Because grades e and f were rare and the related SMF was obvious, these two grading cases were excluded from the following analysis. Correlation between EMIA and SMF gradings was significant (Spearman r = 0.62, P < 0.01). Multivariate logistic analysis, including age, sex, disease duration, Ling classification, previous treatment, and EMIA classification, demonstrated that the EMIA classification (grades c to d) was an independent predictor for advanced SMF (odds ratio = 26.547, 95% confidence interval: 15.809–44.578, P < 0.01). Conclusions: The new endoscopic EMIA classification is an independent predictor of advanced SMF during POEM. The classification may be used for assessment of the difficulty and success of POEM.
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CASE REPORT
Candidemia after endoscopic retrograde cholangiopancreatography in an immunocompetent patient: A case report and literature review
Tae Young Park, Young Joo Yang, Suk Pyo Shin, Chang Seok Bang, Ki Tae Suk, Gwang Ho Baik, Dong Joon Kim
March-April 2018, 24(2):135-137
DOI:10.4103/sjg.SJG_536_17  PMID:29637922
Candidemia is a rare adverse event of endoscopic retrograde cholangiopancreatography (ERCP). To date, several case reports of post-ERCP candidemia have been reported. Recently, we experienced a case of disseminated candidemia caused by Candida albicans with secondary complications of acute respiratory distress syndrome, acute kidney injury, and hematogenous candidal endophthalmitis following ERCP in a young healthy patient without well-recognized risk factors for candidemia. After intravenous and intravitreal antifungal therapy and intensive care, the candidemia resolved, and the patient was discharged without further sequela. The present case alerted us to consider candidemia as a rare but potentially fatal adverse event of ERCP, even in an immunocompetent host.
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ORIGINAL ARTICLES
Differences in efficacy of uncovered self-expandable metal stent in relation to placement in the management of malignant distal biliary obstruction
Jin-Xing Zhang, Qing-Quan Zu, Sheng Liu, Chun-Gao Zhou, Jin-Guo Xia, Hai-Bin Shi
March-April 2018, 24(2):82-86
DOI:10.4103/sjg.SJG_326_17  PMID:29637914
Background/Aims: Metal stent insertion is a common palliative treatment for distal malignant biliary obstruction (MBO) but whether placement across the sphincter of Oddi (SO) causes more complications or shorter survival is in question. The aim of this study was to compare the clinical outcomes of percutaneous uncovered self-expandable metal stent placement above and across the SO in patients with distal MBO. Patients and Methods: We retrospectively studied 59 patients who underwent uncovered metal stent placement for distal MBO between January 2012 and March 2016. Stents were placed above the SO for 22 subjects (group A) and across the SO for 37 subjects (group B). Early cholangitis, stent occlusion, and overall survival time were compared between the two groups. Results: Clinical success was 90.9 and 86.5% for groups A and B, respectively. Early cholangitis occurred in 2 patients (9.1%) in group A and in 6 patients (16.2%) in group B (P = 0.645). Median stent patency and median survival time was 105 and 140 days for group A, 120 and 160 days for group B, respectively. The stent occlusion (31.8% in group A and 21.6% in group B, P = 0.454) and the cumulative stent patency times (P = 0.886) did not differ between the two groups. There was no significant difference in cumulative patient survival between the two groups (P = 0.810). Conclusion: Uncovered metal stent placement across the SO did not significantly affect early cholangitis, stent patency, or patient survival.
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Effects of taste stimulation on gastric myoelectrical activity and autonomic balance
Marek Waluga, Krzysztof Jonderko, Ewelina Domosławska, Anna Matwiejszyn, Marek Dzielicki, Beata Krusiec-Świdergoł, Anna Kasicka-Jonderko
March-April 2018, 24(2):100-108
DOI:10.4103/sjg.SJG_419_17  PMID:29637917
Background/Aim: Sham feeding, reproducing the cephalic phase of digestion, and involving combined visual, olfactory, and taste stimulation affects gastrointestinal motility and secretory functions of the digestive system, as well as the sympathetic/parasympathetic balance (SPB). In this study, we aimed to check if taste stimulation with a single flavor affects the gastric myoelectrical activity (GMA) and/or SPB. Materials and Methods: Eighteen healthy volunteers underwent, on four separate days, 30-min electrogastrographic and electrocardiographic recordings: basal, with stimulation – while keeping in the mouth an agar cube with taste-delivering substance, and postexposure. Concentrations of saccharose, NaCl, citric acid, and quinine hydrochloride within the cubes were adjusted to 100-fold the individual taste recognition thresholds. SPB was determined from the heart rate variability (HRV) analysis of the recorded electrocardiograms. Results: A moderate but statistically significant increase in tachygastria and bradygastria percentage time share was observed, regardless of the type of taste applied. Bitter taste elicited a considerable decrease in the normogastria time share (from 82.8 ± 2.5% to 73.5 ± 3.5%, P = 0.00076) and a diminution of the dominant frequency (from 3.07 ± 0.08 to 2.90 ± 0.10 cycles per minute (cpm) postexposure, P = 0.01). Sour taste brought about a drop of the dominant power (from 42.5 ± 1.1 to 40.1 ± 1.4 dB, P = 0.0015). Two tastes hindered propagation of the gastric slow waves – the average percentage of slow wave coupling decreased from 77.9 ± 3.1% to 69.5 ± 3.1% (P = 0.0078) and from 74.6 ± 2.5% to 68.2 ± 2.8% (P = 0.0054) with the bitter and the salty taste, respectively. Stimulation with sweet, salty, or sour taste evoked a significant decrease in the high frequency component of the HRV, whereas bitter taste did not affect the SPB. Conclusions: Oral stimulation with tastes subjectively perceived as unpleasant brings about disturbances of the interdigestive GMA. This, however, does not coincide with its effect upon SPB.
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