Saudi Journal of Gastroenterology
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   Table of Contents - Current issue
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November-December 2020
Volume 26 | Issue 6
Page Nos. 287-350

Online since Friday, November 27, 2020

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EDITORIAL  

Nonresponse to intramuscular vaccination: An unmet need in hepatitis B vaccination p. 287
Sara Manti, Giuseppe F Parisi, Salvatore Leonardi
DOI:10.4103/sjg.SJG_472_20  PMID:33078721
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REVIEW ARTICLE Top

Nutrition and the gut microbiome during critical illness: A new insight of nutritional therapy p. 290
Sara Zaher
DOI:10.4103/sjg.SJG_352_20  PMID:33208559
Changes in the microbiome in response to environmental influences can affect the overall health. Critical illness is considered one of the major environmental factors that can potentially influence the normal gut homeostasis. It is associated with pathophysiological effects causing damage to the intestinal microbiome. Alteration of intestinal microbial composition during critical illness may subsequently compromise the integrity of the intestinal epithelial barrier and intestinal mucosa absorptive function. Many factors can impact the microbiome of critically ill patients including ischemia, hypoxia and hypotension along with the iatrogenic effects of therapeutic agents and the lack of enteral feeds. Factors related to disease state and medication are inevitable and they are part of the intensive care unit (ICU) exposure. However, a nutritional intervention targeting gut microbiota might have the potential to improve clinical outcomes in the critically ill population given the extensive vascular and lymphatic links between the intestines and other organs. Although nutrition is considered an integral part of the treatment plan of critically ill patients, still the role of nutritional intervention is restricted to improve nitrogen balance. What is dismissed is whether the nutrients we provide are adequate and how they are processed and utilised by the host and the microbiota. Therefore, the goal of nutrition therapy during critical illness should be extended to provide good quality feeds with balanced macronutrient content to feed up the entire body including the microbiota and host cells. The main aim of this review is to examine the current literature on the effect of critical illness on the gut microbiome and to highlight the role of nutrition as a factor affecting the intestinal microbiome-host relationship during critical illness.
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SYSTEMATIC REVIEW/META-ANALYSIS Top

Nonclostridium difficile enteric infection and the risk of developing inflammatory bowel disease: A systematic review and meta-analysis p. 299
Cong Dai, Yu-Hong Huang, Min Jiang, Ming-Jun Sun
DOI:10.4103/sjg.SJG_231_20  PMID:33154203
Background: Inflammatory bowel disease (IBD) is a chronic inflammatory intestinal disorder. Some studies have investigated the association between non-Clostridium difficile infection (CDI) enteric infection and the risk of developing IBD with conflicting conclusions. The objective of our study was to perform a meta-analysis of available studies evaluating the possible association between non-CDI enteric infection and the risk of developing IBD. Methods: We performed a systematic literature search of multiple online electronic databases. Inclusion criteria entailed studies about non-CDI enteric infection and IBD; A meta-analysis was conducted to evaluate relative risk (RR) and 95% confidence intervals (CIs) of combined studies for the association between non-CDI enteric infection and the risk of developing IBD. Publication bias was assessed by funnel plot analysis. Results: Eight studies comprising 345,490 enteric infected patients, 3223 ulcerative colitis (UC) patients, and 2133 CD patients were included in the meta-analysis. Meta-analysis showed a significantly higher risk of UC in patients with enteric infection compared with noninfected patients (RR, 2.28; 95% CI, 1.85–2.8) (I2 = 91.3%, P < 0.001). It also showed a significantly higher risk of CD in patients with enteric infection compared with noninfected patients (RR, 1.88; 95% CI, 1.66–2.14) (I2 = 49%, P = 0.024). Conclusion: Our meta-analysis has found that patients with non-CDI enteric infection were associated with an increased risk of IBD. Future studies are needed to determine the association between non-CDI enteric infection and the risk of developing IBD and elucidate the potential underlying mechanisms.
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ORIGINAL ARTICLES Top

Successful response of intradermal hepatitis B vaccine in nonresponders of intramuscular hepatitis B vaccine in general and hemodialysis population p. 306
Farina M Hanif, Nasir Mehmood, Zain Majid, Nasir H Luck, S Mudassir Laeeq, Abbas A Tasneem, Muhammad Manzoor ul Haque
DOI:10.4103/sjg.SJG_300_20  PMID:33154204
Background: Hepatitis B infection is one of the most common infections worldwide, with its vaccination being an effective preventive measure. Nonresponse to hepatitis B vaccination increases population susceptibility to virus dissemination along with detrimental complications. Despite twice intramuscular vaccination series, 14.3% in the general population and 50% in hemodialysis patients fail to mount a response against hepatitis B. We aimed to evaluate the effectiveness of intradermal (ID) vaccination in the nonresponders amongst the general and hemodialysis population. Methods: A total of 5 doses of 10 μg of hepatitis B vaccine was given intradermally, 2 weeks apart, to both the study groups: patients who were on hemodialysis and the general population group who previously had failed to achieve satisfactory antibody titers with the IM administration of the vaccine. A hepatitis B surface antibody (HBsAb) titer of ≥10 IU/mL and ≥100 IU/mL were considered “responder” and “good responder,” respectively. Results: Out of a total of 95 participants, 49 (51.6%) were hemodialysis-dependent. Most of the participants were females 49 (51.6%). The mean age of all the participants was 39.02 ± 13.5 years (range: 18–70 years). Overall, 75.8% of the participants responded to the ID vaccination with a mean HBsAb titer of 263.5 ± 350.1 IU/L. Almost similar vaccination response was observed in both the hemodialysis and general population i.e., 75.5% and 76.1%, respectively (P = 1.00). In the hemodialysis group, the absence of hypertension (P = 0.04) and age ≥36 years (P = 0.016) were associated with an ID vaccination response. Conclusion: For those not responding to the conventional IM route of the hepatitis B vaccine, the ID route is an effective way of immunization in this group and this approach would lead to a decrease in infection rates in the vulnerable population such as those on hemodialysis.
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Clinical features of Epstein–Barr virus in the intestinal mucosa and blood of patients with inflammatory bowel disease p. 312
Jin-Qiu Zhou, Li Zeng, Qiao Zhang, Xin-Yao Wu, Meng-Lan Zhang, Xing-Tao Jing, Yu-Fang Wang, Hua-Tian Gan
DOI:10.4103/sjg.SJG_30_20  PMID:33078719
Background: The role of Epstein–Barr virus (EBV) in inflammatory bowel disease (IBD) remains to be elucidated. The aim of this study was to investigate the presence of EBV in the blood and intestinal mucosa of patients with IBD and evaluate the association between EBV positivity and IBD. Methods: Patients with IBD, hospitalized between January 2015 and April 2018, were enrolled. The EBV-DNA load in blood samples from each subject was analyzed by quantitative real-time polymerase chain reaction. EBV-encoded small-RNA 1 (EBER-1) was detected by in-situ hybridization in intestinal mucosa tissue sections of patients with IBD. Result: EBV-DNA was detected in 48 out of 568 patients with IBD (8.4%), and EBER-1 positivity was detected in 27 of these patients (56.3%). Refractory IBD and severe mucosal inflammation were more common in patients with detectable levels of EBER-1 than in those without; the number of EBER-1-positive cells positively correlated with mucosal inflammation (P value < 0.05). Age (≥60 years old) and use of azathioprine were risk factors for EBV infection. There was no significant difference in clinical remission rate and surgical rate between the EBER-1 positive group and EBER-1 negative group, antiviral group and the non-antiviral group, among IBD patients who tested positive for EBV-DNA. Conclusion: Elderly patients with IBD, treated with azathioprine, are more susceptible to EBV positivity. Further, EBV mucosal detection correlated with the severity of mucosal damage and refractoriness, but not prognosis.
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Efficacy of single- versus split-dose polyethylene glycol electrolyte solution for morning colonoscopy: A randomized controlled study p. 321
Jing Shan, Mei Yang, Wenbin Ran, Weidong Xi, Lin Jiang, Xiaobin Sun
DOI:10.4103/sjg.SJG_58_20  PMID:32801257
Background: Split-dose (SPD) regimen has been proved more effective than a single-dose (SID) regimen for various drug preparations; however, limited data have focused on morning colonoscopy. We implemented this study to compare the bowel cleanliness and tolerability of a same-day SID versus SPD 2 L polyethylene glycol electrolyte solution (PEG) for morning colonoscopy. Methods: Patients undergoing morning colonoscopy were randomized into two groups, SID or SPD. In the SID group, patients had to complete 2 L PEG between 4 and 6 am on the day of colonoscopy. In the SPD group, patients had to complete 1 L PEG between 8 and 9 pm on the day before followed by another 1 L PEG between 5 and 6 am on the day of colonoscopy. Colonoscopy was performed between 8 and 12 am under anesthesia. Investigators and endoscopists were blinded to the allocation. The primary end point was the effectiveness of bowel cleansing according to the Boston Bowel Preparation Scale (BBPS). The secondary outcomes were polyp detection rate, compliance, tolerability, and patient satisfaction. Results: Overall, there were 147 and 148 patients in the SID and SPD group, respectively. The SPD group had a better quality of bowel preparation than the SID group with a total BBPS score of 7.25 ± 1.53 versus 6.71 ± 1.65 (P = 0.005). No difference in the polyp detection rate was noted, although more polyps were detected in the SPD group. More patients felt acceptable with the bowel preparation regimen in the SPD group compared to the SID group (76% vs. 65%, P = 0.03). The adverse events were more commonly observed in the SID group, presented as nausea and vomiting. Conclusion: For morning colonoscopy, split-dose 2 L PEG is superior to single-dose 2 L PEG by improved bowel preparation, better tolerability, and patient satisfaction.
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Developing a risk prediction model for multidrug-resistant bacterial infection in patients with biliary tract infection p. 326
Yingying Hu, Kongying Lin, Kecan Lin, Haitao Lin, Ruijia Chen, Shengcong Li, Jinye Wang, Yongyi Zeng, Jingfeng Liu
DOI:10.4103/sjg.SJG_128_20  PMID:32769261
Background/Aims: The aim of this study was to develop a tool to predict multidrug-resistant bacteria infections among patients with biliary tract infection for targeted therapy. Patients and Methods: We conducted a single-center retrospective descriptive study from January 2016 to December 2018. Univariate and multivariable logistic regression analysis were used to identify independent risk factors of multidrug-resistant bacterial infections. A nomogram was constructed according to multivariable regression model. Moreover, the clinical usefulness of the nomogram was estimated by decision curve analysis. Results: 121 inpatients were randomly divided into a training cohort (n = 79) and validation cohort (n = 42). In multivariate analysis, 5 factors were associated with biliary tract infections caused by multidrug-resistant bacterial infections: aspartate aminotransferase (Odds ratio (OR), 13.771; 95% confidence interval (CI), 3.747-64.958; P < 0.001), previous antibiotic use within 90 days (OR, 4.130; 95% CI, 1.192-16.471; P = 0.032), absolute neutrophil count (OR, 3.491; 95% CI, 1.066-12.851; P = 0.046), previous biliary surgery (OR, 3.303; 95% CI, 0.910-13.614; P = 0.079), and hemoglobin (OR, 0.146; 95% CI, 0.030-0.576; P = 0.009). The nomogram model was constructed based on these variables, and showed good calibration and discrimination in the training set [area under the curve (AUC), 0.86] and in the validation set (AUC, 0.799). The decision curve analysis demonstrated the clinical usefulness of our nomogram. Using the nomogram score, high risk and low risk patients with multidrug-resistant bacterial infection could be differentiated. Conclusions: This simple bedside prediction tool to predict multidrug-resistant bacterial infection can help clinicians identify low versus high risk patients as well as choose appropriate, timely initial empirical antibiotics therapy. This model should be validated before it is widely applied in clinical settings. we can differentiate between
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Post pancreaticoduodenectomy hemorrhage: A retrospective analysis of incidence, risk factors and outcome p. 337
Subhashish Das, Samrat Ray, Vivek Mangla, Siddharth Mehrotra, Shailendra Lalwani, Naimish N Mehta, Amitabh Yadav, Samiran Nundy
DOI:10.4103/sjg.SJG_145_20  PMID:32811797
Background: The operative mortality after pancreaticoduodenectomy (PD) has declined but morbidity still remains considerable. Post pancreaticoduodenectomy hemorrhage (PPH) occurs in 3-13% of patients following PD. We studied the incidence and outcomes of patients with PPH after PD to determine the associated risk factors and effect on hospital stay. Methods: We retrospectively analyzed from a prospectively collected data of patients developing PPH following PD between January 2007 and May 2018. ISGPS definition and grading system were used. By using univariate and multivariate analyses, independent predictors of PPH were identified. Results: Of the 340 patients undergoing PD, PPH occurred in 39 patients (11.5%), of whom 5 (12.8%) had Grade A, 22 (56.4%) had Grade B and 12 (30.8%) had Grade C PPH. Six (15.4%) of the 39 patients with PPH died against an overall mortality in the study population of 16 out of 340 patients (4.7%), reflecting higher mortality (P = 0.019) in patients with PPH . The independent risk factors for PPH were a high pre-operative bilirubin (mean 4.7 vs. 7.4 mg/dl, P = 0.01) and INR (mean 1.2 vs. 1.72, P = 0.024), whereas it was closely followed by but, but not significantly associated with pre-operative biliary stent placement (P = 0.09). Pancreatico-jejunostomy (PJ) leak was seen in 20.7% in non-hemorrhage group vs. 41% in hemorrhage group (P = 0.008) and was an independent risk factor for PPH. Conclusion: PPH occurred in 11.5% of patients and resulted in a mortality four times greater than those without a PPH. It occurred more frequently in patents with a high pre-operative serum bilirubin, INR, biliary stenting or those with a PJ leak.
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Evaluation of the safety and efficacy of minimal endoscopic sphincterotomy followed by papillary balloon dilation for the removal of common bile duct stones p. 344
Shigeto Ishii, Toshio Fujisawa, Mako Ushio, Sho Takahashi, Wataru Yamagata, Yusuke Takasaki, Akinori Suzuki, Yoshihiro Okawa, Kazushige Ochiai, Ko Tomishima, Ryo Kanazawa, Hiroaki Saito, Shuichiro Shiina, Hiroyuki Isayama
DOI:10.4103/sjg.SJG_162_20  PMID:32719239
Background/Aim: A sufficiently open papilla is needed to remove common bile duct stones (CBDS) but endoscopic sphincterotomy (EST) requires a high level of skill and is difficult with endoscopic papillary balloon dilation (EPBD). The main adverse event of EST is bleeding and perforation and that of EPBD is post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. To reduce these adverse events we employed minimal EST followed by papillary dilation (ESBD), and retrospectively evaluated its efficacy and safety compared with EST. Patients and Methods: CBDS patients who underwent EST (n = 114) or ESBD (n = 321) at Juntendo University Hospital from January 2009 to December 2018 were consecutively enrolled, retrospectively. The exclusion criteria were large-balloon dilation (≥ 12 mm), large CBDS (>12 mm), and previous EST/EPBD. We compared the overall stone removal rate, incidence of adverse event, procedure time, number of ERCP procedures, and rate of mechanical lithotripsy (ML) between the two groups. Results: Complete stone removal was successful in both ESBD and EST group. However, the rate of multiple ERCP sessions was significantly lower (35.1% vs. 12.8%, P < 0.001), procedure time was shorter (31.6 vs. 25.8 min, P = 0.01), and rate of ML was lower (16.7% vs. 7.8%, P = 0.01) in ESBD group. Bleeding was significantly more frequent in the EST group (9.6% vs. 1.2%, P < 0.001), particularly acute bleeding (7.9% vs. 0.9%, P < 0.001). Conclusions: ESBD is more efficient and safer in the management of CBD stones than EST. A prospective randomized study comparing ESBD with EST is needed to establish this combination technique.
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