Endoscopic retrograde cholangiopancreatography (ERCP) has significant diagnostic and therapeutic roles in pancreaticobiliary disorders. Post-ERCP pancreatitis (PEP) is the most common adverse event that can be encountered and affects 1% to 9% of the average-risk group and 11% to 40% of the high-risk group. Several methods have been used to prevent PEP, including pancreatic duct (PD) stenting and pharmacological use, including indomethacin. We conducted a systematic review of PubMed (MEDLINE), Scopus and Web of Science (WOS) databases until November 1, 2024, using relevant keywords. Only randomized clinical trials (RCTs) were included. The network meta-analysis is reported using odds ratios (ORs) with 95% confidence intervals (CIs) with a significance level < 0.05. Rank probabilities were calculated using p-scores to rank treatments based on their effectiveness. All analyses were performed using R version 4.3.1 (2023-06-16 ucrt) with the netmeta package. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) assessment of the certainty of the evidence was performed. Of 1828 references, total 31 RCTs with 9050 participants were included in this meta-analysis. Compared to placebo, indomethacin (OR = 0.50, 95% CI = 0.39-0.64, p < 0.001), PD stenting (OR = 0.33, 95% CI = 0.23-0.47, p < 0.001) and indomethacin combined with PD stenting (OR = 0.36, 95% CI = 0.18-0.73, p = 0.005) were effective in reducing PEP. Sub-group analysis of high-risk patients revealed similar results, indomethacin (OR = 0.43, 95% CI = 0.31-0.61, p < 0.001), PD stenting (OR = 0.32, 95% CI = 0.22-0.47, p < 0.001) and indomethacin combined with PD stenting (OR = 0.32, 95% CI = 0.14-0.72, p = 0.006). Notably, indomethacin did not show significant effects in mild, moderate or severe PEP. Notably, indomethacin showed significant benefit in the prevention of moderate-severe PEP only. The present network meta-analysis indicated that PD stenting seems to be the most effective in reducing PEP incidence among the examined treatments, particularly in high-risk patients, with inconsistent benefits of indomethacin in different PEP severities.
The Mediterranean diet is a nutritional approach reported to be beneficial in various diseases. We performed a systematic review about its role in the treatment of inflammatory bowel disease (IBD). Electronic databases (PubMed, Embase and Scopus) were searched on 10th February 2025 to identify reports on the use of the Mediterranean diet in the treatment of IBD. We extracted data with respect to clinical response, remission and endoscopic and histological responses with the use of the Mediterranean diet in the treatment of IBD. Pooled clinical response rates and remission rates were calculated. Eight studies were eventually included. Seven studies involving 223 participants provided information about the induction of remission. The pooled clinical remission rate with Mediterranean diet was 0.62 (95% CI = 0.39-0.80, I2 = 78.6%). A sub-group analysis showed similar remission rates for Crohn's disease (CD) (RR = 0.67, 95% CI = 0.38; 0.87) and ulcerative colitis (0.56, 95% CI = 0.24-0.84), (p = 0.7531). Compared to control diets, Mediterranean diet showed no significant advantage in inducing remission (pooled OR = 0.98, 95% CI = 0.74-1.30, I2 = 42.9%). No studies reported outcomes for endoscopic or histological responses. The Mediterranean diet in conjunction with standard medical therapy is associated with a clinical remission rate of approximately 62% in IBD, with comparable efficacy in CD and ulcerative colitis. The studies on Mediterranean diet are compromized by heterogenous study, definitions of disease activity and outcomes and concurrent use of medical therapies. Further high-quality randomized trials are needed to evaluate the impact of the Mediterranean diet on objective disease markers and long-term outcomes in IBD.
The most common causes for ulcero-stricturing diseases of the ileo-cecal region and colon in Southeast Asia are Crohn's disease (CD) and gastrointestinal tuberculosis (GI TB). Diagnosing these conditions is challenging because they share several clinical, endoscopic, radiological and histological features on mucosal biopsies. Therefore, there is a need to standardize the sampling, processing and interpretation of mucosal biopsies to aid clinical decision-making. Recognizing this challenge, core subject experts nominated by the Indian Association of Pathologists and Microbiologists (IAPM), the Indian Society of Gastroenterology (ISG) and the Colitis and Crohn's Foundation, India (CCFI), collaborated to formulate comprehensive recommendations for pathologists regarding optimal biopsy protocols, histological interpretation and reporting for differentiating CD from GI TB. A structured Delphi process was followed. The recommendations from the core domain expert groups were based on discussions, brainstorming sessions and extensive literature reviews conducted over three virtual group meetings, multiple online voting sessions and one physical meeting involving all experts. This document is expected to standardize the practice of luminal gastroenterology by providing a ready reference for budding specialists and pathologists, thereby promoting uniformity in practice. These multi-society, evidence-based and practically applicable recommendations developed by core subject experts aim to promote uniformity and confidence in pathology reports, facilitate timely patient management and prevent complications arising from erroneous treatment.
Cyclical vomiting syndrome (CVS) is a functional gastrointestinal disorder marked by recurrent vomiting. Lack of awareness and symptom overlap often leads to incorrect diagnosis. There is limited data from the developing world, especially on the natural history of the disease in children. Thus, the aim of our study was to evaluate the clinical presentation, natural history, treatment and outcomes of CVS in children. Retrospective audit of children (≤ 18 years) diagnosed with CVS between January 2008 to December 2024. Clinical data was retrieved from hospital records and telephonic interviews. Seventy-one patients (age of onset 7[IQR 4-9] years, boys [39, 54.9%]) were enrolled. Median diagnostic delay was 1.2 (IQR 1-3) years and 31(43.6%) were misdiagnosed elsewhere initially. Patients had five (IQR 4-8) episodes of vomiting per year. Most (n = 55, 77.5%) required hospitalization. Precipitants were identified in 48 (67.6%) cases, most common being psychological stress (n = 23, 32.4%). Family history of migraine was present in 37 (52.1%) cases. Rome IV, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and International Classification of Headache Disorders, 3rd edition (ICHD-3) criteria fulfilled in 71(100%), 47 (66.2%) and 44 (62%) cases, respectively. Younger children (≤ 5 years) had longer delay in diagnosis, more often required hospitalization and had fewer early morning episodes as compared to older children. All patients presented with severe disease phenotype and received prophylaxis. At follow-up of eight (interquartile range [IQR] 5-12) years, 36 (50.7%) had complete, 25 (35.3%) significant, five (7.6%) partial and five (7.5%) no response. Prophylaxis was successfully stopped in 13 (36.1%) complete responders of which three relapsed post-withdrawal. CVS is often underdiagnosed in children. Awareness of CVS is necessary for early diagnosis and reduced morbidity. Younger children had longer diagnostic delay and more often required hospitalization. Timely recognition and optimal management were associated with favorable outcomes.
Traditionally, lower gastrointestinal bleeding (LGIB) was defined as a bleed that originates from the gastrointestinal (GI) tract distal to the ligament of Treitz. In recent literature, LGIB is defined as bleeding from the colon or anorectum. The global incidence of LGIB ranges from 20.5 to 87.0 per 100,000 person-years with an estimated mortality rate of 2.5% to 3.9% and rebleeding rates after one year ranges from 13% to 19%. Diverticular bleeding is the most common cause for LGIB in west, while colitis and hemorrhoids were the leading causes for LGIB in studies conducted across India. Colonoscopy has both diagnostic and therapeutic roles in patients with acute LGIB. It should be considered the initial diagnostic modality in all hemodynamically stable patients presenting with acute LGIB. The initial assessment should include a focused history, physical examination, laboratory evaluation that hints towards the site of bleeding and possible etiology. Patients with hemodynamic instability should be resuscitated with intra-venous crystalloids with the goal of normalization of heart rate and blood pressure before conducting any diagnostic or therapeutic procedure. It should be considered the initial diagnostic modality in all hemodynamically stable patients presenting with acute LGIB. Various endoscopic hemostatic measures such as adrenaline injection, clip application, thermal coagulation and/or band ligation can be used to control bleeding during colonoscopy. Computed tomography angiography (CTA) plays an important role in the diagnosis and management of acute LGIB especially in hemodynamically unstable patients and when colonoscopy fails to achieve hemostasis. Management of GI bleeding in patients who are on anticoagulants and antiplatelets and also those who have undergone cardiac stenting within one year should involve a multi-disciplinary approach.
The natural history of ulcerative colitis is characterized by the occurrence of recurrent flares. Flares in ulcerative colitis may be attributed to the natural history of the disease or other extraneous factors. Two important causes for iatrogenic flares are Clostridioides difficile infection and cytomegalovirus (CMV) colitis. We evaluated the prevalence of Clostridioides difficile infection in patients with moderate to severe ulcerative colitis admitted to a tertiary care hospital. This prospective study carried out at a tertiary care center in India evaluated patients of ulcerative colitis who presented with an acute flare of the disease over a 13-month period from May 2023 to May 2024. An enquiry of antibiotic exposure in the preceding eight weeks prior to the current admission was obtained. Simultaneous testing of glutamate dehydrogenase (GDH) and Clostridioides difficile toxin assay was done in all patients within 24 hours of admission by the enzyme-linked immunosorbent assay (ELISA) technique. Of the 140 patients with an acute flare associated with ulcerative colitis who were evaluated for Clostridioides difficile infection, four tested positive for both GDH and toxin A and/or B giving an overall prevalence of 2.9%. Two of these four (50%) patients had prior exposure to antibiotics at the time of admission. Each of the four patients with Clostridioides difficile infection had an uneventful recovery post treatment with oral vancomycin and metronidazole. Our data suggests that C. difficile is not a major causative factor for flares in patients with moderate to severe ulcerative colitis at a tertiary care hospital in northern India.
Although upper gastrointestinal endoscopy (UGIE) is the diagnostic gold standard for esophageal varices (EV), its invasive nature and limited accessibility present considerable challenges. This study aimed at evaluating liver stiffness measurement (LSM) and spleen stiffness measurement (SSM) via transient elastography (TE) as the non-invasive indicators for the presence and severity of EVs in cirrhotic patients. This prospective, cross-sectional, observational study enrolled patients with compensated cirrhosis undergoing UGIE for the presence and grading of EVs. LSM and SSM were performed using FibroScan®. Non-invasive markers, including APRI, FIB-4, liver stiffness-spleen size-to platelet ratio score (LSPS) and spleen stiffness-spleen size-to platelet ratio score (SSPS), were also computed. Diagnostic efficacy was assessed through area under receiver-operating characteristic curve (AUROC) analysis, sensitivity and specificity. EVs were identified in 52.3% of the 132 enrolled patients (55% small, 45% large). Significant differences in laboratory parameters and non-invasive markers were observed between patients with and without EVs and between those with small vs. large EVs. SSM demonstrated superior diagnostic performance for predicting any EVs compared to LSM (AUROC = 0.955 vs. 0.847). The combined assessment of LS and SS, LSPS and particularly SSPS exhibited excellent predictive accuracy, with SSPS (AUROC = 0.997) proving the most robust predictor for any EVs. All elastography parameters had excellent diagnostic performance for the prediction of large EVs with SSM and combined assessment of LS and SS having the highest accuracy (AUROC = 1.000 for both). Both LSM and SSM are significantly associated with the presence and severity of EVs, with SSM exhibiting superior performance. The integration of these parameters, especially SSPS, further augments predictive accuracy.
The occurrence of hepatitis E virus (HEV) infection in pregnant women is a significant concern for maternal and neonatal health. Detection of HEV can be done through anti-HEV antibodies (immunoglobulin G [IgG] and immunoglobulin M [IgM]) or RNA-based tests. Robust estimates of exposure of hepatitis E among pregnant women in northern India are limited. So, this study was done to evaluate the seroprevalence of hepatitis E in pregnant females. The prospective cohort study was conducted at the department of obstetrics and gynecology for one year. The study was approved by the Institutional Ethical Committee (ECR/262/Inst/UP/2013RR-19 Ref code XV-PGTSC-IIA/P24). A 5-mL blood sample was collected from each participant's median cubital vein, centrifuged and serum/plasma separated early to prevent hemolysis of red blood cells and stored at - 20 °C for further analysis. The study used the Wantai HEV IgG ELISA diagnostic kit manufactured in Beijing, a commercially available enzyme-linked immunosorbent assay for qualitative detection of IgG antibodies to hepatitis E virus in human serum or plasma. Results were calculated by relating each specimen absorbance value to the cut-off value (C.O). All specimens fulfilled quality control criteria and the index was defined as A/C.O. Of 602 pregnant patients tested, 287 patients (47.7%) were IgG HEV positive and 326 patients (52.3%) were IgG HEV negative. Seropositivity increases with an increase in age. Total 51.3% of rural area females were seropositive than 45.3% in urban population. Low body mass index (BMI) was associated with high seropositivity. Seroprevalence of hepatitis E in the north Indian population in the present study was quite high. The result of the present study can be used in formulating the guidelines for hepatitis E vaccination in pregnant females.
We aimed at assessing the level of knowledge and awareness about hepatitis B virus (HBV) infection among high school children. This prospective, observational, cross-sectional study was conducted at a tertiary care teaching hospital from November 2023 to December 2024. We included children aged 12 to 19 years who were studying in the 8th, 9th or 10th grade at a nearby school. Participants were excluded if they had a hepatitis B positive family member. The students were asked to complete a set of 19 questions and responses were recorded as 'Yes', 'No' or 'Not sure'. The following domains of their knowledge and awarness were assessed: causative agent, epidemiology, routes of transmission, consequences of infection, methods for infection prevention and treatment. Data was collected from 365 of the 510 (71.6%) students. Thirty-six participants were excluded and the remaining 329 participants were included in the analysis. Only two-thirds (66.6%) of the students correctly stated that hepatitis B is a virus. Only 4.9% of students believed that HBV could infect young people. A large percentage of children failed to correctly indicate that HBV is not transmitted through food and water (93.9%), casual physical contact (91.5%) or mosquito bites (79.6%). Only 41.4% were aware that HBV is a vaccine-preventable disease and 19.8% knew that three doses of the vaccine are required for adequate protection. Overall performance was particularly low in epidemiology (25.6%), routes of HBV transmission (28.1%) and treatment (16.7%) domains. School-going children of grades 8-10 demonstrated inadequate knowledge about the burden, transmission routes and prevention of hepatitis B infection.
Bile acid malabsorption (BAM) is often missed in patients with chronic diarrhea as diagnostic tests are technically challenging and not available widely. Quantitative estimation of fecal bile acids (FBA) in a single stool sample has been reported recently for the diagnosis of BAM and may be easily applied. We performed a pilot observational cross-sectional study to estimate the optimal FBA cut-point for the diagnosis of BAM, using the IDK® Bile Acid test, an enzymatic spectrophotometry-based assay for measuring total stool bile acids. We estimated FBA concentrations in healthy adults (n = 100; negative controls) and patients with known ileal Crohn's disease (n = 67; positive controls), generating a receiver-operator characteristics (ROC) curve for assessing its diagnostic accuracy. FBA levels were then assessed in three groups of patients, namely diarrhea-predominant irritable bowel syndrome (IBS-D) and functional diarrhea (FD) (n = 100), post-cholecystectomy (n = 100) and ileal tuberculosis (n = 33). Optimal cut-off point for FBA was identified at 2.8 µg/g (sensitivity = 89.5%; specificity = 92.0%; area under ROC = 0.959 [95%CI = 0.929-0.989]), with median FBA in healthy controls (1.5 [IQR = 0.7-2.2]) being significantly lower than that in patients with ileal Crohn's disease (6.0 [IQR = 4.7-8.0]; p < 0.001). Median FBA in patients with IBS-D/FD, post-cholecystectomy and those with ileal tuberculosis were 2.0 (IQR = 1-2.8), 3.4 (IQR = 1.7-5.3) and 3.0 (IQR = 2.2-4.6), respectively. Overall, 21%, 57% and 54.5% of patients with IBS-D/FD, post-cholecystectomy and ileal tuberculosis had BAM. We demonstrate the feasibility of quantitative estimation of fecal bile acids in a single stool sample to diagnose BAM.
Irritable bowel syndrome (IBS) is a common disorder with multi-factorial pathophysiology. Emerging evidence suggests a role of low-grade mucosal inflammation in IBS. Small intestinal bacterial overgrowth (SIBO), which has symptoms similar to IBS, may be misdiagnosed as IBS. Data on the prevalence of SIBO and elevated fecal calprotectin (FCP) levels in IBS patients remains sparse and conflicting. We aimed at determining the prevalence and clinical significance of SIBO and elevated FCP in patients with refractory IBS. This prospective cross-sectional study enrolled refractory IBS patients (Rome-IV criteria). SIBO was diagnosed using the glucose hydrogen breath test and FCP levels ≥ 50 μg/g were considered elevated. Clinical evaluation was performed using standardized questionnaires: IBS Symptom Severity Scale (IBS-SSS) and IBS Quality of Life (IBS-QoL).  Of 209 patients screened, 148 with refractory IBS were enrolled (mean age 35.8 ± 11.9 years; 66.1% male). SIBO was detected in 46 (31.1%) and elevated FCP in 41 (27.7%) patients, with the highest prevalence in the IBS-D group (37.1% and 33.3%, respectively). Patients who were SIBO and/or FCP-positive had a longer duration of symptoms, higher IBS symptom burden and poorer QoL. Multi-variate analysis identified bloating (aOR = 4.59) and the IBS-SSS (aOR = 1.20) as independent predictors of SIBO. Approximately one-third of patients with refractory IBS, particularly those with IBS-D, have SIBO and/or elevated FCP. This subset of patients demonstrates a higher symptom burden and poorer QoL, emphasizing the crucial need for accurate diagnosis and personalized treatment. Incorporating non-invasive biomarkers (SIBO testing and FCP) into the management of refractory IBS may optimize patient care.
Endoscopic ultrasound (EUS)-guided drainage with metal stents is a standard therapy for walled-off necrosis (WON). However, some patients require re-interventions such as stent unclogging, necrosectomy or percutaneous drainage. This study aimed at identifying predictors of re-intervention to facilitate risk stratification and optimize management. This study included consecutive patients who underwent EUS-guided WON drainage with metal stents between January 2023 and December 2024 at a tertiary referral center. Demographic, clinical and radiological data was collected prospectively. Multi-variate logistic regression identified independent predictors of re-intervention. Model performance was evaluated using receiver operating characteristic (ROC) curve, calibration plot and decision curve analysis. Model's diagnostic performance was evaluated in the validation cohort. Of 500 patients (83.2% male), 28.6% had alcohol-related and 10% had biliary pancreatitis. Re-intervention was required in 24% (n = 120), primarily for stent unclogging (85.8%), nasocystic tube placement (70%) and necrosectomy (50%). Independent predictors of re-intervention included WON size (odds ratio [OR] 1.38; 95% confidence interval [CI], 1.25-1.52), paracolic extension (OR 9.96; 95% CI, 1.77-55.98) and solid debris content (OR 1.10; 95% CI, 1.08-1.13). The model demonstrated good discrimination (area under the curve [AUC] = 0.85) and calibration (Hosmer-Lemeshow p = 0.19). The overall accuracy of the model in the validation cohort was 86.67% (95% CI, 73.21-94.95%). Adverse events occurred in 6% of patients, including bleeding (n = 11), stent migration (n = 13) and sepsis-related death (n = 6). Larger WON size, paracolic extension and higher solid debris content are independent predictors of re-intervention after EUS-guided drainage. Early identification of these factors may allow for individualized step-up therapy and improved clinical outcomes.
Esophageal/gastric varices (EV), especially clinically significant varices (CSV), represent life-threatening complications of pediatric portal hypertension (PH), necessitating timely detection. While esophagogastroduodenoscopy (EGD) remains the gold standard, its invasive nature and requirement for sedation in children highlight the need for reliable non-invasive alternatives for screening and risk stratification. Splenic stiffness measurement (SSM) has emerged as a potential tool. This systematic review and meta-analysis aimed to evaluate diagnostic accuracy of SSM for detecting EV and CSV in pediatric PH. A comprehensive search of PubMed, Scopus and Embase was performed up to January 2025. Studies assessing SSM via elastography in pediatric (< 18 years) PH, with EGD as reference standard for EV/CSV detection, were included. Data was synthesized using hierarchical summary receiver operating characteristic (HSROC) model to estimate pooled sensitivity, specificity, diagnostic odds ratio (DOR) and area under the receiver operating characteristic curve (AUROC). Risk of bias was evaluated using Quality Assessment of Studies of Diagnostic Accuracy (QUADAS-2) tool. Ten studies encompassing 618 patients were analyzed. For EV prediction (3 studies, n = 158), pooled sensitivity, specificity and DOR were 0.80 (95% CI: 0.70-0.88), 0.89 (95% CI: 0.80-0.95) and 26.22 (95% CI: 5.39-98.83), respectively, with AUROC 0.838 (95% CI: 0.806-0.864). For CSV (7 studies, n = 460), values were 0.86 (95% CI: 0.81-0.90), 0.82 (95% CI: 0.76-0.87) and 31.00 (95% CI:12.33-80.21) with AUROC 0.905 (95% CI: 0.882-0.924), indicating very good diagnostic performance. Substantial heterogeneity noted for pooled sensitivity (I2 = 69.2%, p = 0.0006) for CSV prediction. Sub-group analysis revealed that etiology of PH, elastography techniques and ethnicity of study population were sources of heterogeneity. SSM showed superior accuracy in non-cirrhotic PH (DOR: 48.61 [95% CI: 13.62-188.37]) than cirrhotic PH (DOR: 18.89 [95% CI: 8.65-40.53]). SSM demonstrates good diagnostic accuracy for non-invasive variceal predictionin pediatric PH. However, further multicentre studies with standardized protocols and disease-specific cut-offs for pediatric population are necessary for its integration in routine clinical practice as a screening tool.
Gallbladder cancer (GBC) is the most common biliary tract malignancy and a leading cause for mortality in the Asian sub-continent. The low survival rate is attributed to current invasive diagnostic methods and late-stage disease detection. The aim of this study was to estimate the potential value of miR 183_5p and 3651 as diagnostic blood-based biomarkers in GBC patients. This single center observational study evaluates differential expression of miRNAs in GBC and normal gallbladder tissues via micro-array analysis. The level of selected oncogenic miRNAS were detected in 130 individuals comprising GBC patients, Gallbladder stone (GBS) and healthy controls by using qRT-PCR. The diagnostic value of miR-183-5p and 3651 in GBC was evaluated and compared with the tumor markers carcinoembryonic antigen (CEA) and carbohydrate antigen 19.9 (CA 19.9). As many as 45 differentially expressed microRNAs (p < 0.05) were determined, of which 23 were upregulated and 22 were down regulated. miR 183_5p (2.5-fold) and 3651 (5.6-fold) were significantly over expressed in GBC patients compared to controls (p < 0.05). The area under the curve (AUC) value of miR 183_5p and 3651 for GBC diagnosis was 0.684 and 0.752, respectively, which was more valuable than those including CEA (0.617) and CA19.9 (0.718). Study underscores ability of serum miRNAs 183_5p and 3651 as diagnostic biomarkers for early GBC detection.
Viral gastroenteritis is a significant public health concern in developing countries, primarily affecting children under five years. Human astrovirus (HAstV) is one of the key viral agents causing gastroenteritis. Despite the global recognition of HAstV as a causative agent of acute gastroenteritis, its impact on Asian populations, particularly among hospitalized children, is lacking. This systematic review and meta-analysis aimed at determining the prevalence of HAstV-associated acute gastroenteritis among hospitalized pediatric patients in Asia. This systematic review and meta-analysis was conducted following PRISMA Guidelines and registered with PROSPERO (ID CRD42024519527). A comprehensive literature search was performed on PubMed, Web of Science and Scopus databases for studies published between January 2000 and December 2023. Keywords related to astrovirus, prevalence, pediatric populations and hospitalization in Asia were used. A pre-designed Excel sheet was used for data extraction and the Joanna Briggs Institute critical appraisal tool was used for quality assessment. Generalized Linear Mixed Models with logit transformation were used to calculate the effect sizes. The analysis included 49 studies, encompassing data from various Asian countries. The pooled prevalence of HAstV in hospitalized pediatric patients due to acute gastroenteritis was 2.39%, highlighting the significant burden in Asia. Sub-group analysis revealed considerable difference in HAstV prevalence among Asian countries. This systematic review and meta-analysis summarizes the prevalence of HAstV among hospitalized pediatric patients in Asia, highlighting the need for country-specific strategies to improve surveillance and diagnostics.
Diastasis recti (DR) is a common condition, particularly in post-partum women, which may impair core function and alter intra-abdominal pressure (IAP). Gastro-esophageal reflux disease (GERD) is frequently associated with IAP imbalance, to which DR may be a contributing factor. This study aims to evaluate whether surgical correction of DR using pre-aponeurotic endoscopic repair (REPA) improves symptoms of GERD. Symptom changes were assessed in 115 REPA patients using a validated questionnaire (modified Italian GERD Health-Related Quality of Life, MI-GERD-HRQL) administered pre-operatively and post-operatively. All respondents had a body mass index (BMI) ≤ 25 and no other relevant gastrointestinal or systemic comorbidities. This study showed a significant reduction in both prevalence and severity of GERD symptoms after surgery. The presence of reflux symptoms decreased from 75% pre-operatively to 50% post-operatively, p < 0.001. In particular, a significant reduction in prevalence was observed for heartburn after meals (28% vs. 57%), sensation of reflux (19% vs. 57%), reflux after meals (25% vs. 57%), heartburn (30% vs. 54%) and reflux when lying down (24% vs. 53%). Mean MI-GERD-HRQL score went from 16 (± 17) pre-operatively to 5 (± 10) post-operatively, p < 0.001. Mean scores for all symptoms examined showed a significant reduction in the post-operative period. Male sex, age ≥ 50 years and patients' geographical location (Italian sub-group) did not influence post-operative MI-GERD-HRQL score. Our findings suggest a possible mechanistic link between abdominal wall integrity and GERD. Epidemiological and prospective comparative studies are necessary to validate our results and provide a more precise understanding of the physiological impact of DR repair on GERD.
Helicobacter pylori infection is highly prevalent globally. Standard bismuth quadruple therapy is commonly used in India, but there are growing concerns regarding the emergence of anti-microbial resistance and treatment failure, necessitating the search for newer modalities. This study evaluated the efficacy and safety of adding mastic gum to standard bismuth quadruple therapy (BQTs) for H. pylori eradication. In this single-blind, randomized pilot trial, adults with Helicobacter pylori infection were assigned to receive two weeks' course of either standard bismuth quadruple therapy combined with mastic gum (Group A, n = 32) or bismuth quadruple therapy alone (Group B, n = 32). The primary endpoint was the eradication rate of Helicobacter pylori assessed by urea breath test at six weeks after therapy. Secondary endpoints included symptom improvement, measured by Dyspepsia Symptom Severity Index (DSSI), adverse events and compliance. Urea breath test demonstrated higher eradication rates in Group A vs. Group B (85% vs. 67%, absolute risk reduction = 0.18, number needed to treat ≈ six). However, it failed to reach statistical significance (p = 0.19). Both groups showed significant reductions in DSSI scores, with greater mean improvement in Group A (0.941 vs. 0.766, p = 0.001). Both treatment regimens were well-tolerated and treatment compliance was notably high in both groups, with 84.4% in each group reporting 100% compliance. In this pilot study, the addition of mastic gum to standard bismuth quadruple therapy resulted in an observed increase in the proportion of eradicated cases; however, it did not meet the primary endpoint due to a lack of statistical significance. Nevertheless, the adjunct therapy was associated with significantly greater dyspepsia symptom relief and was well-tolerated without increasing adverse effects.
Endoscopic ultrasound (EUS) can detect significant pathologies in patients with unexplained common bile duct (CBD) dilatation. The aim was to develop and validate a scoring system to identify patients likely to have 'actionable findings (AF)' and will be benefited by EUS examination. Endoscopic ultrasound database was analyzed from January 2018 to January 2022 to identify patients who underwent EUS for unexplained CBD dilatation (derivation cohort; n = 142). From February 2022 to January 2024, patients were prospectively recruited (validation cohort; n = 230). Demographics, clinical presentation, liver function test (LFT) and imaging findings were noted. Unexplained CBD dilatation was defined as dilated CBD without demonstrable cause on abdominal ultrasound, computed tomography and/or magnetic resonance cholangiopancreatography. Actionable findings, defined as those conditions requiring endoscopic or surgical intervention, were noted. Logistic regression was used to determine predictors of AF. Prediction model was developed using nomogram and validated in the validation cohort. AF were detected in 57.54% and 50.86% in derivation and validation cohorts, respectively. On multi-variate regression, abnormal gallbladder, p = 0.026, OR = 3.21, CBD diameter = 9-12 mm, p = 0.023, OR = 3.47; CBD diameter = > 12 mm, p = 0.004, OR = 18.0; age > 55 years, p = 0.001, odds ratio (OR) = 7.1 and abnormal LFT, p < 0.0005, OR = 15.82 (GCAL score) predicted AF on EUS. Risk scores were assigned to predictors using nomogram. Nomogram performed well in terms of discrimination with area under curve 0.904, 95% confidence interval (CI) = 0.854-0.954, p < 0.001. At cut-off value of 10.90, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of 94.18%, 58.92%, 77.88% 86.84% and 80.28% were obtained in derivation cohort. In validation cohort, sensitivity, specificity, PPV, NPV and accuracy of 95.97%, 83.96%, 90.43%, 87.5% and 94.68% were observed. EUS can detect 'actionable findings' in patients with unexplained CBD dilatation. 'GCAL score' provides a simple validated risk stratification tool, which can help in selecting patients for EUS examination.
Gastrointestinal (GI) cancers remain a leading cause for global cancer-related morbidity and mortality, affecting both-men and women. Recent research highlights significant differences between the sexes in terms of incidence, development and treatment outcomes. The interplay between genetic, environmental, diet and lifestyle, and hormonal factors such as estrogen, progesterone and androgens forms a pivotal axis influencing various GI cancer development and therapeutic responses. Women's unique vulnerability and resilience to GI cancers are influenced by differences in immune response, genetic profiles and exposure to risk factors. Site-specific evaluations show that hormonal factors can either protect or predispose women to certain cancers, often depending on life stage and hormonal status. Gender-directed approaches to prevention, screening and treatment, along with tackling psycho-social burdens and detection challenges, will significantly impact the outcomes of GI cancer in women. Further research in this area is vital to enhance outcomes and address gaps in GI cancer care for women.