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Innovative pathways allow safe discharge of mild acute pancreatitis from the emergency room

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World Journal of gastroenterology 2024年第11期30卷 1475-1479页

作者： Darshan J Kothari Sunil G Sheth Division of gastroenterology Duke University Medical CenterDurhamNC 27710United States Division of gastroenterology&hepatology Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMA 02215United States

Acute pancreatitis(AP)is a leading cause of gastrointestinal-related hospitalizations in the United States,resulting in 300000 admissions per year with an estimated cost of over$2.6 billion annually.The severity of AP is determined by the presence of pancreatic complications and end-organ damage.While moderate/severe pancreatitis can be associated with significant morbidity and mortality,the majority of patients have a mild presentation with an uncomplicated course and mortality rate of less than 2%.Despite favorable outcomes,the majority of mild AP patients are admitted,contributing to healthcare cost and burden.In this Editorial we review the performance of an emergency department(ED)pathway for patients with mild AP at a tertiary care center with the goal of reducing hospitalizations,resource utilization,and costs after several years of implementation of the pathway.We discuss the clinical course and outcomes of mild AP patients enrolled in the pathway who were successfully discharged from the ED compared to those who were admitted to the hospital,and identify predictors of successful ED discharge to select patients who can potentially be triaged to the pathway.We conclude that by implementing innovative clinical pathways which are established and reproducible,selected AP patients can be safely discharged from the ED,reducing hospitalizations and healthcare costs,without compromising clinical outcomes.We also identify a subset of patients most likely to succeed in this pathway.

关键词： Emergency department Mild pancreatitis Pathways Hospitalization Predictors

Microbiome and colorectal carcinogenesis:Linked mechanisms and racial differences

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World Journal of Gastrointestinal Oncology 2022年第2期14卷 375-395页

作者： Sofia C Tortora Vimal M Bodiwala Andrew Quinn Laura A Martello Shivakumar Vignesh department of Medicine and Division of gastroenterology&hepatology SUNY Downstate Health Sciences UniversityBrooklynNY 11203United States

Various studies have shown the interplay between the intestinal microbiome,environmental factors,and genetic changes in colorectal cancer(CRC)development.In this review,we highlight the various gut and oral microbiota associated with CRC and colorectal adenomas,and their proposed molecular mechanisms in relation to the processes of“the hallmarks of cancer”,and differences in microbial diversity and abundance between race/ethnicity.Patients with CRC showed increased levels of Bacteroides,Prevotella,Escherichia coli,enterotoxigenic Bacteroides fragilis,Streptococcus gallolyticus,Enterococcus faecalis,Fusobacterium nucleatum(F.nucleatum)and Clostridium difficile.Higher levels of Bacteroides have been found in African American(AA)compared to Caucasian American(CA)patients.Pro-inflammatory bacteria such as F.nucleatum and Enterobacter species were significantly higher in AAs.Also,AA patients have been shown to have decreased microbial diversity compared to CA patients.Some studies have shown that using microbiome profiles in conjunction with certain risk factors such as age,race and body mass index may help predict healthy colon vs one with adenomas or carcinomas.Periodontitis is one of the most common bacterial infections in humans and is more prevalent in Non-Hispanic-Blacks as compared to Non-Hispanic Whites.This condition causes increased systemic inflammation,immune dysregulation,gut microbiota dysbiosis and thereby possibly influencing colorectal carcinogenesis.Periodontal-associated bacteria such as Fusobacterium,Prevotella,Bacteroides and Porphyromonas have been found in CRC tissues and in feces of CRC patients.Therefore,a deeper understanding of the association between oral and gastrointestinal bacterial profile,in addition to identifying prevalent bacteria in patients with CRC and the differences observed in ethnicity/race,may play a pivotal role in predicting incidence,prognosis,and lead to the development of new treatments.

关键词： Colorectal cancer Oral microbiome Gut microbiome Hallmarks of cancer Racial/ethnic microbial diversity

Non-alcoholic Fatty Liver Disease:A Clinical Update

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Journal of Clinical and Translational hepatology 2017年第4期5卷 384-393页

作者： Joseph M Pappachan Shithu Babu Babu Krishnan Nishal C Ravindran department of Endocrinology Diabetes&MetabolismRoyal Lancaster InfirmaryUniversity Hospitals of Morecambe Bay NHS TrustLancasterUK department of Medicine Dorset County HospitalDorchesterUK Department of Gastroenterology&Hepatology Royal Bournemouth HospitalBournemouthUK Department of Gastroenterology&Hepatology Hinchingbrooke HospitalHinchingbrookeHuntingdonUK

Non-alcoholic fatty liver disease(NAFLD)is currently the most common chronic liver disease in developed countries because of the obesity epidemic.The disease increases liverrelated morbidity and mortality,and often increases the risk for other comorbidities,such as type 2 diabetes and cardiovascular disease.Insulin resistance related to metabolic syndrome is the main pathogenic trigger that,in association with adverse genetic,humoral,hormonal and lifestyle factors,precipitates development of NAFLD.Biochemical markers and radiological imaging,along with liver biopsy in selected cases,help in diagnosis and prognostication.Intense lifestyle changes aiming at weight loss are the main therapeutic intervention to manage cases.Insulin sensitizers,antioxidants,lipid lowering agents,incretin-based drugs,weight loss medications,bariatric surgery and liver transplantation may be necessary for management in some cases along with lifestyle measures.This review summarizes the latest evidence on the epidemiology,natural history,pathogenesis,diagnosis and management of NAFLD.

关键词： Nonalcoholic fatty liver disease(NAFLD) Nonalcoholic steatohepatitis NASH Insulin resistance Metabolic syndrome Lifestyle interventions Bariatric surgery

Clinical Considerations of Coagulopathy in Acute Liver Failure

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Journal of Clinical and Translational hepatology 2020年第4期8卷 407-413页

作者： hyoung Kim Bolin Niu Tinsay Woreta Po-Hung Chen Division of gastroenterology&hepatology Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA Division of gastroenterology&hepatology Department of MedicineCase Western Reserve University School of MedicineClevelandOHUSA

Acute liver failure (ALF) is the rapid onset of severe liver dysfunction, defined by the presence of hepatic encephalop-athy and impaired synthetic function (international normal-ized ratio of≥1.5) in the absence of underlying liver disease. The elevated international normalized ratio value in ALF is often misinterpreted as an increased hemorrhagic tendency, which can lead to inappropriate, prophylactic transfusions of blood products. However, global assessments of coagulop-athy via viscoelastic tests or thrombin generation assay suggest a reestablished hemostatic, or even hypercoagu-lable, status in patients with ALF. Although the current versions of global assays are not perfect, they can provide more nuanced insights into the hemostatic system in ALF than the conventional measures of coagulopathy.

关键词： Acute liver failure Coagulopathy Thrombin generation assay Viscoelastic test

“One-day,one-stay,and one-step”lessons from the Danish guidelines for the treatment of gallstone disease

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Hepatobiliary Surgery and Nutrition 2023年第4期12卷 607-610页

作者： Robert C.Verdonk Philip R.de Reuver Department of Gastroenterology&Hepatology St.Antonius HospitalNieuwegeinThe Netherlands department of Surgery Radboud University Medical CenterNijmegenThe Netherlands

Introduction.Gallstone disease is prevalent worldwide,and the incidence in Europe increased over the last decades.The median prevalence ranges from 5.9%to 21.9%,with the highest rates seen in Norway(21.9%)and the eastern part of Germany(19.7%)and the lowest rates in Italy(<7%)(1).In The Netherlands,over 100,000 patients are diagnosed with symptomatic gallstones annually,costing around 250 million euros,ranking gallstones disease in the top 10 of the most prevalent and costly gastrointestinal disorders(2).

关键词： Uncomplicated gallstone disease cholecystitis common bile duct stones

Validation of Non-invasive Fibrosis Scores for Predicting Advanced Fibrosis in Metabolic-associated Fatty Liver Disease

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Journal of Clinical and Translational hepatology 2022年第4期10卷 589-594页

作者： Xiaoning Chen George Boon-Bee Goh Jiaofeng Huang Yinlian Wu Mingfang Wang Rahul Kumar Su Lin Yueyong Zhu department of hepatology Hepatology Research InstituteThe First Affiliated Hospital of Fujian Medical UniversityFu-zhouFujianChina Department of Gastroenterology&Hepatology Singapore General HospitalSingapore Duke-NUS Medical School Singapore department of gastroenterology and hepatology Duke-NUS Academic Medical CentreChangi General HospitalSingapore

Background and Aims:Metabolic-associated fatty liver disease(MAFLD)is a newly proposed terminology from 2020;yet,the applicability of conventional noninvasive fi-brosis models is still unknown for it.We aimed to evaluate the performance of conventional noninvasive fibrosis scores in MAFLD.Methods:The NHANES 2017-2018 datasets were used to compare the performances of different non-invasive fibrosis scores in MAFLD,including the aspartate aminotransferase(AST)to platelet ratio index(APRI),body mass index(BMI)-AST/alanine aminotransferase(ALT)ratio and diabetes score(BARD),fibrosis-4 index(FIB-4),and NAFLD fibrosis score(NFS).Moreover,Asian patients with biopsy-proven MAFLD were enrolled to further validate the findings.Results:A total of 2,622 participants in the Na-tional Health and Nutrition Examination Survey(NHANES)cohort and 293 patients with MAFLD in the Asian cohort were included.Patients in the Asian cohort had a lower BMI and higher liver enzymes(p<0.001).The area under the receiver operating characteristic curve(AUROC)of NFS was the largest in the NHANES cohort and Asian cohorts(0.679 and 0.699,respectively).The AUROC of NFS was followed by APRI,FIB-4,and BARD in the NHANES cohort(0.616,0.601,and 0.589,respectively).In the Asian cohort,the AUROC of APRI,FIB-4,and BARD for predicting advanced fibrosis were 0.625,0.683,and 0.615,respectively.The performance of FIB-4 was better in the Asian cohort than that in the NHANES cohort.Conclusions:NFS is better for predicting advanced fibrosis in MAFLD.FIB-4 can be an al-ternative choice for MAFLD with high liver enzymes when NFS is unavailable.Novel efficient noninvasive fibrosis scor-ing systems are highly required for patients with MAFLD.

关键词： FIB-4 Metabolic-associated fatty liver disease Liver fibrosis NFS Noninvasive fibrosis scores

对于非酒精性脂肪肝病的认识——基于亚洲人群的研究

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gastroenterology Report 2016年第2期4卷 131-135,I0002页

作者： George B.B.Goh Clarence Kwan Sze Ying Lim Nanda KK Venkatanarasimha Rafidah Abu-Bakar Thinesh L Krishnamoorthy Hang Hock Shim Kiang Hiong Tay Wan Cheng Chow Department of Gastroenterology&Hepatology Singapore General HospitalSingapore Duke-NUS Graduate Medical School Singapore department of Diagnostic Radiology Singapore General HospitalSingapore

背景和目的:非酒性脂肪肝病(NAFLD)是最常见的慢性肝病,同时也是代谢综合征的一项危险因素。NAFLD在全球范围内的患病率基于地域差异在5%~30%不等。尽管流行病学资料显示代谢相关性疾病的患病率在新加坡呈快速增长,但对于该地区NAFLD的... 详细信息

背景和目的:非酒性脂肪肝病(NAFLD)是最常见的慢性肝病,同时也是代谢综合征的一项危险因素。NAFLD在全球范围内的患病率基于地域差异在5%~30%不等。尽管流行病学资料显示代谢相关性疾病的患病率在新加坡呈快速增长,但对于该地区NAFLD的数据却十分有限。本研究旨在了解新加坡NAFLD的患病率及公众对该病的认识。方法:本研究是一项横断面观察研究,旨在评估NAFLD患者的人口统计学、人体测量学及临床资料,研究对象来自于一项胃肠公众论坛的参会者。NAFLD的诊断基于超声学标准;代谢综合征的诊断则基于国际糖尿病联盟的指南。通过自行设计的调查问卷来了解大家对NAFLD这种疾病的看法。结果:共有227名研究对象纳入研究,其中40%被诊断为NAFLD。相对于那些非NAFLD人群,NAFLD者男性居多,年龄更大,体质指数更高,腰围更宽,患代谢性综合征的比例更高(均P0.05)。值得注意的是,75.6%的具有代谢危险因素者,并不认为自己存在NAFLD风险。结论:我们的研究显示NAFLD在新加坡具有较高的患病率,包括在那些非肥胖人群中。考虑到人们对NAFLD的发生风险认识不足,有必要加强公众教育,以提高人们对NAFLD的认识。

关键词：非酒精性脂肪肝病流行病学认识新加坡

Risk of pancreatic cancer in individuals with celiac disease in the United States:A population-based matched cohort study

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World Journal of Gastrointestinal Oncology 2023年第3期15卷 523-532页

作者： Arunkumar Krishnan Yousaf Bashir Hadi Sarah Shabih Diptasree Mukherjee Ruhee A Patel Rushik Patel Shailendra Singh Shyam Thakkar Section of gastroenterology&hepatology West Virginia University School of MedicineMorgantownWV 26505United States department of Medicine Apex Institute of Medical ScienceKolkata 700075West BengalIndia

BACKGROUND Celiac disease(CD)has been associated with gastrointestinal malignancies.However,the magnitude of the risk of pancreatic cancer(PC)associated with CD is much less clear,and risks have not been estimated from large populations.AIM To assess the risk of PC in CD patients.METHODS We conducted a population-based,multicenter,propensity score-matched cohort study with consecutive patients diagnosed with CD using the TriNeTx research network platform.We examined the incidence of PC in patients with CD compared with a matched cohort of patients without CD(non-CD,controls).Each patient in the main group(CD)was matched to a patient in the control group using 1:1 propensity score matching to reduce confounding effects.The incidence of PC was estimated using a Cox proportional hazards model with a hazard ratio(HR)and 95%confidence interval(CI).RESULTS A total of 389980 patients were included in this study.Among them,155877 patients had a diagnosis of CD,and the remaining 234103 individuals without CD were considered a control cohort.The mean duration of follow-up for patients in the CD and control cohorts was 5.8±1.8 and 5.9±1.1 years,respectively.During the follow-up,309 patients with CD developed PC,whereas 240 patients developed PC in the control group(HR=1.29;95%CI:1.09-1.53).In the secondary analyses in the first year after diagnosis of CD,patients with CD were at a significant increase in risk for PC;151 patients with CD had an incidence of PC compared with 96 incidences of PC among the patients in the non-CD control group(HR=1.56;95%CI:1.20-2.01)and sensitivity analysis showed similar magnitude to the one generated in the primary and secondary analysis.CONCLUSION Patients with CD are at increased risk of PC.Risk elevation persists beyond the first year after diagnosis to reference individuals without CD from the general population.

关键词： Celiac disease Cancer Epidemiology Pancreas Pancreatic cancer Malignancy Carcinoma

Microbe-based management for colorectal cancer

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Chinese Medical Journal 2021年第24期134卷 2922-2930页

作者： Zi-Yun Gao Zhe Cui Yu-Qing Yan Li-Jun Ning Zhen-Hua Wang Jie Hong State Key Laboratory for Oncogenes and Related Genes Key Laboratory of gastroenterology&hepatology Ministry of Health Division of Gastroenterology and Hepatology Shanghai Cancer Institute Shanghai Institute of Digestive Disease Ren Ji HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghai 200001China department of Gastrointestinal Surgery Ren Ji HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghai 200001China

Colorectal cancer(CRC)is one of the most prevalent,most lethal cancers in the world.Increasing evidence suggests that the intestinal microbiota is closely related to the pathogenesis and prognosis of CRC.The normal microbiota plays an essential role in maintaining gut barrier function and the immune microenvironment.Recent studies have identified carcinogenic bacteria such as enterotoxigenic Bacteroides fragilis(ETBF)and Streptococcus gallolyticus(S.gallolyticus),as well as protective bacterial such as Akkermansia muciniphila(A.muciniphila),as potential targets of CRC treatment.Gut microbiota modulation aims to restore gut dysbiosis,regulate the intestinal immune system and prevent from pathogen invasion,all of which are beneficial for CRC prevention and prognosis.The utility of probiotics,prebiotics,postbiotics,fecal microbiota transplantation and dietary inventions to treat CRC makes them novel microbe-based management tools.In this review,we describe the mechanisms involved in bacteria-derived colorectal carcinogenesis and summarized novel bacteria-related therapies for CRC.In summary,we hope to facilitate clinical applications of intestinal bacteria for preventing and treating CRC.

关键词： Colorectal cancer Intestinal bacteria Management Fecal microbiota transplantation