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Update on the endoscopic treatments for achalasia

World Journal of gastroenterology 2016年第39期22卷 8670-8683页

作者： Dushant S Uppal Andrew Y Wang division of gastro-enterology and hepatology University of Virginia Health System

Achalasia is the most common primary motility disorder of the esophagus and presents as dysphagia to solids and liquids. It is characterized by impaired deglutitive relaxation of the lower esophageal sphincter. Highresolution manometry allows for definitive diagnosis and classification of achalasia, with type Ⅱ being the most responsive to therapy. Since no cure for achalasia exists, early diagnosis and treatment of the disease is critical to prevent end-stage disease. The central tenant of diagnosis is to first rule out mechanical obstruction due to stricture or malignancy, which is often accomplished by endoscopic and fluoroscopic examination. Therapeutic options include pneumatic dilation(PD), surgical myotomy, and endoscopic injection of botulinum toxin injection. Heller myotomy and PD are more efficacious than pharmacologic therapies and should be considered first-line treatment options. Per oral endoscopic myotomy(POEM) is a minimally-invasive endoscopic therapy that might be as effective as surgical myotomy when performed by a trained and experienced endoscopist, although long-term data are lacking. Overall, therapy should be individualized to each patient's clinical situation and based upon his or her risk tolerance, operative candidacy, and life expectancy. In instances of therapeutic failure or symptom recurrence re-treatment is possible and can include PD or POEM of the wall opposite the site of prior myotomy. Patients undergoing therapy for achalasia require counseling, as the goal of therapy is to improve swallowing and prevent late manifestations of the disease rather than to restore normal swallowing, which is unfortunately impossible.

关键词： Per oral endoscopic myotomy Dilation Achalasia Treatment Endoscopy Myotomy Per oral

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Direct-acting antiviral agents against hepatitis C virus and lipid metabolism

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World Journal of gastroenterology 2017年第31期23卷 5645-5649页

作者： tatsuo kanda mitsuhiko moriyama division of gastro-enterology and hepatology department of medicine nihon university school of medicine

Hepatitis C virus (HCV) infection induces steatosis and is accompanied by multiple metabolic alterations including hyperuricemia, reversible hypocholesterolemia and insulin resistance. Total cholesterol, low-density lipoprotein-cholesterol and triglyceride levels are increased by peginterferon and ribavirin combination therapy when a sustained virologic response (SVR) is achieved in patients with HCV. Steatosis is significantly more common in patients with HCV genotype 3 but interferon-free regimens are not always effective for treating HCV genotype 3 infections. HCV infection increases fatty acid synthase levels, resulting in the accumulation of fatty acids in hepatocytes. Of note, low-density lipoprotein receptor, scavenger receptor class B type I and Niemann-Pick C1-like 1 proteins are candidate receptors that may be involved in HCV. They are also required for the uptake of cholesterol from the external environment of hepatocytes. Among HCV-infected patients with or without human immunodeficiency virus infection, changes in serum lipid profiles are observed during interferon-free treatment and after the achievement of an SVR. It is evident that HCV affects cholesterol metabolism during interferon-free regimens. Although higher SVR rates were achieved with interferon-free treatment of HCV, special attention must also be paid to unexpected adverse events based on host metabolic changes including hyperlipidemia.

关键词： Cholesterol Hepatitis C virus Interferon-free Lipid metabolism

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Systematic review: Safety of balloon assisted enteroscopy in Crohn's disease

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World Journal of gastroenterology 2016年第40期22卷 8999-9011页

作者： Ahilan Arulanandan Parambir S Dulai Siddharth Singh William J Sandborn Denise Kalmaz division of gastro-enterology University of California San Diego

AIM To determine the overall and comparative risk of procedure related perforation of balloon assisted enteroscopy(BAE) in Crohn's disease(CD). METHODS Systematic review(PROSPERO #CRD42015016381) of studies reporting on CD patients undergoing BAE. Seventy-three studies reporting on 1812 patients undergoing 2340 BAEs were included. Primary outcome of interest was the overall and comparative risk of procedure related perforation of diagnostic BAE in CD. Secondary outcomes of interest were risk of procedure related perforation of diagnostic double balloon enteroscopy(DBE), risk of procedure related perforation of therapeutic BAE, efficacy of stricture dilation, and clinical utility of endoscopically assessing small bowel disease *** Per procedure perforation rate of diagnostic BAE in CD was 0.15%(95%CI: 0.05-0.45), which was similar to diagnostic BAE for all indications(0.11%; IRR = 1.41, 95%CI: 0.28-4.50). Per procedure perforation rate of diagnostic DBE in CD was 0.12%(95%CI: 0.03-0.44), which was similar to diagnostic DBE for all indications(0.22%; IRR = 0.54, 95%CI: 0.06-0.24). Per procedure perforation rate of therapeutic BAE in CD was 1.74%(95%CI: 0.85-3.55). Eighty-six percentof therapeutic perforations were secondary to stricture dilation. Dilation was attempted in 207 patients and 30% required surgery during median follow-up of 18 months. When diagnostic BAE assessed small bowel disease activity, changes in medical therapy resulted in endoscopic improvement in 77% of patients. CONCLUSION Diagnostic BAE in CD has a similar rate of perforation as diagnostic BAE for all indications and can be safely performed in assessment of mucosal healing.

关键词： Crohn’s disease Balloon Enteroscopy Safety Perforation Stricture

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Feasibility of initial endoscopic common bile duct stone removal in patients with acute cholangitis

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World Journal of Clinical Cases 2017年第7期5卷 280-285页

作者： Akira Yamamiya Katsuya Kitamura Yu Ishii Yuta Mitsui Tomohiro Nomoto Hitoshi Yoshida division of gastro- enterology Department of MedicineShowa University School of Medicine

AIM To investigate the feasibility of initial endoscopic common bile duct(CBD) stone removal in patients with acute cholangitis(AC).METHODS A single-center,retrospective study was conducted between April 2013 and December 2014 and was approved by the Medical Ethics Committee at our *** informed consent was obtained from each patient prior to the *** cohort comprised 31 AC patients with CBD stones who underwent endoscopic biliary drainage(EBD) for na?ve papilla within 48 h after AC *** retrospectively divided the participants into two groups: 19 patients with initial endoscopic CBD stone removal(initial group) and 12 patients with delayed endoscopic CBD stone removal(delayed group).We evaluated the feasibility of initial endoscopic CBD stone removal in patients with *** We observed no significant differences between the groups regarding patient *** to the assessments based on the Tokyo Guidelines,the AC severity of patients with initial endoscopic CBD stone removal was mild to *** use of antithrombotic agents before EBD was less frequent in the initial group than in the delayed group(11% vs 58%,respectively; P = 0.004).All the patients underwent successful endoscopic CBD stone removaland adverse events did not differ significantly between the *** number of endoscopic retrograde cholangiopancreatography procedures was significantly lower in the initial group than in the delayed group [median(interquartile range) 1(1-1) vs 2(2-2),respectively; P < 0.001].The length of hospital stay was significantly shorter for the initial group than for the delayed group [10(9-15) vs 17(14-20),respectively; P = 0.010].CONCLUSION Initial endoscopic CBD stone removal in patients with AC may be feasible when AC severity and the use of antithrombotic agents are carefully considered.

关键词： Acute cholangitis Common bile duct stone Feasibility Initial endoscopic common bile stone removal Endoscopic retrograde cholangiopancreatography

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Esophagogastric junction distensibility assessed using the functional lumen imaging probe

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World Journal of gastroenterology 2017年第7期23卷 1289-1297页

作者： Joan W Chen Joel H Rubenstein Department of gastro-enterology and hepatology University of Michigan Health SystemsAnn ArborMI 48109United States

To assess reference values in the literature for esophageal distensibility and cross-sectional area in healthy and diseased subjects measured by the functional lumen imaging probe (FLIP).METHODSSystematic search and review of articles in Medline and Embase pertaining to the use of FLIP in the esophagus was conducted in accordance with the PRISMA guidelines. Cross-sectional area and distensibility at the esophagogastric junction (EGJ) were abstracted for normal subjects, achalasia, and gastroesophageal reflux disease (GERD) patients, stratified by balloon length and volume of *** achalasia studies (n = 154), 3 GERD (n = 52), and 5 studies including healthy controls (n = 98) were included in the systematic review. Normative data varied widely amongst studies of healthy volunteers. In contrast, studies in achalasia patients uniformly demonstrated low point estimates in distensibility ≤ 1.6 mm2/mmHg prior to treatment that increased to ≥ 3.4 mm2/mmHg following treatment at 40mL bag volume. In GERD patients, distensibility fell to the range of untreated achalasia (≤ 2.85 mm2/mmHg) following *** may be a useful tool in assessment of treatment efficacy in achalasia. The drastic drop in EGJ distensibility after fundoplication suggests that FLIP measurements need to be interpreted in the context of esophageal body motility and highlights the importance of pre-operative screening for dysmotility. Future studies using standardized FLIP protocol and balloon size are needed.

关键词： Impedance planimetry gastroesophageal reflux disease Esophageal distensibility Achalasia

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Obstructive jaundice due to a rare periampullary tumor

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World Journal of gastrointestinal Oncology 2013年第10期5卷 195-197页

作者： Anjana Sathyamurthy Abhishek Choudhary Dennis Ng Shuaib Okponobi Alberto Diaz-Arias Ajitinder Grewal Ghassan M Hammoud division of gastro-enterology and hepatology University of Missouri-Columbia Department of Pathology and Anatomical Sciences University of Missouri Health Sciences Center

Gangliocytic paraganglioma is a rare neuroendocrine tumor predominantly arising in the second part of the duodenum with rare local recurrence or metastasis to regional lymph nodes.A 92-year-old female presented with obstructive *** exam she had pale conjunctiva and icteric *** examination revealed tenderness in the upper *** data was consistent with obstructive *** tomography of the abdomen revealed a dilated gall bladder and a common bile duct(CBD)with no evidence of liver lesions or pancreatic head *** ultrasonography revealed a 1 cm isoechoic submucosal nodule at the periampullary area,dilated CBD(9 mm),a prominent pancreatic duct(4.1 mm)and a hydropic gall bladder with no *** retrograde cholangiopancreaticography was performed to relieve obstruction and showed a 1 cm periampullary mass which underwent an en-bloc snare *** analyses with immunohistochemical stains were positive for cytokeratin,synaptophysin,S-100 protein,neuron specific enolase and negative for actin and desmin consistent with periampullary gangliocytic *** gangliocytic paraganglioma is a rare benign tumor of the small *** presentation includes abdominal pain and obstructive jaundice which should be included in differential diagnosis of obstructive *** resection is a curative therapy in the absence of local invasion or distant metastasis.

关键词： Gangliocytic paraganglioma Periampullary tumor Spindle-shaped Epitheloid Ganglion cells Jaundice Duodenum Endoscopic mucosal resection

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Novel CD9-targeted therapies in gastric cancer

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World Journal of gastroenterology 2015年第11期21卷 3206-3213页

作者： Yoko Murayama Kenji Oritani Shusaku Tsutsui Department of gastro-enterology and hepatology Itami City Hospital Department of Hematology/Oncology Graduate School of MedicineOsaka University

There are 33 human tetraspanin proteins,emerging as key players in malignancy,the immune system,fertilization,cellular signaling,adhesion,morphology,motility,proliferation,and tumor ***9,a member of the tetraspanin family,associates with and influences a variety of cell-surface *** these interactions,CD9 modifies multiple cellular events,including adhesion,migration,proliferation,and ***9 is therefore considered to play a role in several stages during cancer *** CD9 expression is generally related to venous vessel invasion and metastasis as well as poor *** found that treatment of mice bearing human gastric cancer cells with anti-CD9 antibody successfully inhibited tumor progression via antiproliferative,proapoptotic,and antiangiogenic effects,strongly indicating that CD9 is a possible therapeutic target in patients with gastric ***,we describe the possibility of CD9 manipulation as a novel therapeutic strategy in gastric cancer,which still shows poor prognosis.

关键词： CD9 Tetraspanin Gastric cancer Tumo-rigenicity The

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Mini-loop ligation of a bleeding duodenal Dieulafoy's lesion

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World Journal of gastroenterology 2013年第22期19卷 3505-3507页

作者： Marija Gomeri Pali Neven Ljubii division of gastro-enterology and hepatology Department of Internal Medicine Medical and Dental Faculty "Sestre Milosrdnice" University Hospital Center University of Zagreb 10000 Zagreb Croatia

Two percent of gastrointestinal hemorrhages are caused by Dieulafoy's lesions, which are located in duodenum in only 15% of cases. There are no recommendations regarding the prime endoscopic treatment technique for this condition. A 61-year-old woman presented with melena without signs of hemodynamic instability. During an urgent upper endoscopy, blood oozing from the normal mucosa of the duodenum was seen and this was classified as a Dieulafoy's lesion. A mini-loop was opened at the rim of a transparent ligation chamber, at the end of the endoscope, and after aspiration of the lesion, closed and detached. Complete hemostasis was achieved without early or postponed complications. In every day clinical practice, mini-loop ligation is rarely used because of possible complications, such as site ulceration, organ perforation, re-bleeding and possible inexperience of the operator. To the best of our knowledge this is the first case of successful treatment of bleeding duodenal Dieulafoy's lesion by mini-loop ligation.

关键词： Dieulafoy’s lesion Duodenum Endoscopy Mini-loop Hemostasis

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Low serum albumin predicts early mortality in patients with severe hypoxic hepatitis

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World Journal of hepatology 2017年第22期9卷 959-966页

作者： Pik-Eu Chang Boon-Bee George Goh Victoria Ekstrom Ming-Liang Ong Chee-Kiat Tan Department of gastro enterology and hepatology Singapore General Hospital Duke-NUS Medical School

To evaluate the incidence, etiology, and predictors of mortality of severe hypoxic hepatitis. METHODSWe used computerized patient records to identify consecutive cases of severe hypoxic hepatitis admitted to a tertiary hospital in Singapore over a one-year period. We defined severe hypoxic hepatitis as elevation of serum transaminases more than 100 times upper limit of normal in the clinical setting of cardiac, circulatory or respiratory failure after exclusion of other causes of hepatitis. We used multivariable regression analysis to determine predictors for mortality. RESULTSWe identified 75 cases of severe hypoxic hepatitis out of 71380 hospital admissions over one year, providing an incidence of 1.05 cases per 1000 admissions. Median age was 65 years (range 19-88); 57.3% males. The most common etiologies of severe hypoxic hepatitis were acute myocardial infarction and sepsis. Fifty-three patients (71%) died during the hospitalization. The sole independent predictive factor for mortality was serum albumin measured at the onset of severe hypoxic hepatitis. Patients with low serum albumin of less than 28 g/L have more than five-fold increase risk of death (OR = 5.39, 95%CI: 1.85-15.71). CONCLUSIONSevere hypoxic hepatitis is uncommon but has a high mortality rate. Patients with low serum albumin are at highest risk of death.

关键词： Severe Mortality Albumin Incidence Hypoxic hepatitis Predictors Etiology Prognosis

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Eight-week ledipasvir/sofosbuvir in non-cirrhotic, treatment-na?ve hepatitis C genotype-1 patients with hepatitis C virus-RNA < 6 million: Single center, real world effectiveness and safety

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World Journal of gastroenterology 2017年第26期23卷 4759-4766页

作者： Nyan L Latt Beshoy T Yanny Derenik Gharibian Rita Gevorkyan Amandeep K Sahota division of gastroenterology and hepatology Mayo Clinic College of Medicine division of gastro-enterology and hepatology Kaiser Permanente Los Angeles Medical Center Pharmacy Operations Office Kaiser Permanente Los Angeles Medical Center Department of Clinical Operations Kaiser Permanente Southern California

AIM To evaluate sustained viral response(SVR) of 8-wk ledipasvir/sofosbuvir therapy among non-cirrhotic, genotype-1 hepatitis C virus(HCV) patients with RNA < 6 million IU/m *** We performed a retrospective cohort study to examine SVR rates, predictors of treatment failure and safety analysis of 8-wk ledipasvir/sofosbuvir(LDV/SOF) therapy among non-cirrhotic, genotype 1 HCV patients with viral load < 6 million IU/m L. Primary outcome was an achievement of SVR at 12 wk after treatment. Secondary outcomes were identifying predictors of treatment failure and adverse events during *** Total 736 patients: 55% males, 51% Caucasians and 65% were genotype 1a. Non-cirrhotic state of 53% was determined by clinical judgment(imaging, AST, platelet count) and 47% had documented liver fibrosis testing(biopsy, vibration-controlled transient elastography, serum biomarkers). Overall SVR12 was 96%. No difference in SVR12 was seen between patients whose non-cirrhotic state was determined by clinical judgment and patients who had fibrosis testing. Age groups, gender, ethnicity and genotype 1 subtype did not predict SVR. Non-cirrhotic state determined by clinical judgment based on simple, non-invasive tests were not associated with lower SVR [OR = 1.02, 95%CI: 0.48-2.17, P = 0.962]. The AUROC for hepatitis C RNA viral load was 0.734(P < 0.001, 95%CI: 0.66-0.82). HCV RNA 2.2 million IU/m L was identified as the cutoff value with sensitivity 73% and specificity 64%. HCV RNA < 2.2 million IU/m L was associated with significantly higher SVR 98% with OR = 0.22(95%CI: 0.1-0.49, P < 0.001) compared to SVR 92% in HCV RNA ≥ 2.2 million IU/m L. No death or morbidities were *** Our outcomes validate safety and effectiveness of 8-wk LDV/SOF therapy in non-cirrhotic, untreated HCV genotype 1 patients with HCV RNA < 6 million IU/m L.

关键词： Hepatitis C Sustained viral response Ledipasvir Cirrhosis Sofosbuvir

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