|Year : 2021 | Volume
| Issue : 4 | Page : 175-176
Department of Medical Gastroenterology and Hepatology, SIMS Institute of Gastroenterology Hepatobiliary Sciences and Liver Transplantation, SRM Institute for Medical Science Hospital, Chennai, Tamil Nadu, India
|Date of Submission||30-Aug-2021|
|Date of Acceptance||31-Aug-2021|
|Date of Web Publication||24-Sep-2021|
No. 1, Jawaharlal Nehru Salai, 100 Feet Road, Vadapalani, Chennai - 600 026, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Jayaraman K. Gastroenterology elsewhere. Gastroenterol Hepatol Endosc Pract 2021;1:175-6
| Aerobic and Resistance Training, Equally Effective in Reducing Liver Steatosis|| |
Charatcharoenwitthaya P, Kuljiratitikal K, Aksornchanya O, Chaiyasoot K, Bandidniyamanon W, Charatcharoenwitthaya N. Moderate-intensity aerobic vs resistance exercise and dietary modification in patients with nonalcoholic fatty liver disease: A randomized clinical trial. Clin Transl Gastroenterol 2021;12:e00316.
With no approved medical therapy for nonalcoholic fatty liver disease (NAFLD), life style changes remain the mainstay of treatment. Among exercise, there is no standardized prescription for the type of exercise that helps most. Some studies have shown that aerobic and resistance forms of exercise are equally effective, while some suggest that they are not.
A total of 35 subjects with NAFLD exercised in aerobics (n = 18) and resistance (n = 17) groups, on an average of 3 sessions per week. Controlled attenuation parameter (CAP) compared at baseline and at week 12 showed significant reduction in both arms (P < 0.001). In both groups, the mean relative CAP reduction was similar: −10.3% (confidence interval [CI] −18.2 to −2.40) in aerobics and −12.6% (CI −20.5 to −4.69) in resistance groups. The more the exercise sessions, the more reduction in hepatic fat was observed. Changes in anthropometry, insulin sensitivity indices, and cardiorespiratory fitness were also similar in both groups. Liver stiffness, plasma lipid, and glucose did not change much in either group. A very practical paper and useful on many layers, because there is no one size fitness plan that fits all. For the economically challenged, brisk walking is as good as hitting the gym to reduce liver fat. For the differently abled or with cardiac disease, resistance training could be effective.
| Transglutaminase 2 Inhibitor in Celiac Disease, a Phase II Study|| |
Schuppan D, Mäki M, Lundin KE, Isola J, Friesing-Sosnik T, Taavela J, et al. A randomized trial of a transglutaminase 2 inhibitor for celiac disease. N Engl J Med 2021;385:35-45.
Transglutaminase 2 (TG2), located in small bowel mucosa, deaminates gluten peptide into negatively charged gluten fragments, which facilitates presentation by HLA-DQ2 and HLA-DQ8 molecules on antigen-presenting cells. This results in a cascade of immune-mediated response, which leads to villous atrophy and manifests clinically with a myriad of symptoms, called celiac disease (CD). Researchers in this multicenter, pharma-funded, phase II, double-blinded study have tested in patients with CD, a molecule ZED1227, an oral TG2 inhibitor in doses: 10 mg (n = 41), 50 mg (n = 41), and 100 mg (n = 41) against placebo (n = 40) with gluten re-challenge (3 g/day) for 6 weeks. Primary end point was attenuation of gluten-induced mucosal damage as measured by ratio of villus height to crypt depth, which at baseline was around two in all groups. With gluten challenge, all doses of ZED1227 attenuated mucosal damage when compared with placebo (P < 0.001). Among secondary outcomes, intraepithelial lymphocyte density was also significantly reduced in the drug group, whereas symptom indices showed varied results. The only existing treatment for CD is elimination diet, for which adherence is estimated to be 40%–80%. Besides the cost of gluten-free diet (GFD), accidental exposure, ability to follow GFD when dining out especially at social events, can be challenging. On that note, this study has opened up possibilities of therapy with a drug and to be exposed to gluten without suffering.
| Follow-Up Paracentesis and Mortality in Spontaneous Bacterial Peritonitis|| |
Saffo S, To UK, Santoiemma PP, Laurito M, Haque L, Rabiee A, et al. Changes in ascitic fluid polymorphonuclear cell count after antibiotics are associated with mortality in spontaneous bacterial peritonitis. Clin Gastroenterol Hepatol 2021:S1542-3565(21)00750-3.
In this retrospective analysis, 426 nonintensive care unit patients with a diagnosis of spontaneous bacterial peritonitis (SBP) (polymorphonuclear neutrophils [PMNs] >250 cells/μl) were analyzed to assess the impact of follow-up paracentesis at 48 h of antimicrobial treatment on mortality. Those who had >80% decrease in PMN had improved survival (adjusted OR 0.32 [0.17–0.58], P < 0.001). When combined with model for end-stage liver disease-sodium (MELD-Na), authors could risk stratify for mortality, with the highest risk for those with MELD-Na >30, without a reduction in PMN >80%, and the lowest for those with MELD-Na <30, with a reduction of PMN >80%.
While most guidelines suggest follow-up paracentesis, it is not a routine in many centers, due to various logistic reasons. At times, when clinicians choose to assess response to therapy based on clinical improvement, there is a potential blind spot as patients can be asymptomatic in partially treated infection. This paper re-emphasizes the importance of interval PMN in SBP.
| Which Regimen Works Best for Helicobacter pylori? A Network Meta-Analysis|| |
Rokkas T, Gisbert JP, Malfertheiner P, Niv Y, Gasbarrini A, Leja M, et al. Comparative effectiveness of multiple different first-line treatment regimens for Helicobacter pylori infection: A network meta-analysis. Gastroenterology 2021 Aug; 161:495-507.e4.
Multiple regimens exist for the treatment of Helicobacter pylori and also differ according to antibiotic resistance in that geographical area. 22,975 patients from 68 select randomized trials who had undergone one of the 8 first-line therapy regimens which spans over the standard triple therapy to the newer vonoprazan-based triple therapy were included in this study. Overall, cure rates were better with vonoprazan and reverse hybrid therapy (approximately 90%), when compared to standard triple therapy (75%) and bismuth-based quadruple therapy (81.3%). When these therapies were compared against standard triple therapy, vonoprazan triple therapy (odds ratio [OR] 3.80 [1.62, 8.94]) was the most effective followed by reverse hybrid therapy (OR 2.23 [0.58, 8.67]). From the above study, it appears vonoprazan-based therapy outperforms other regimens. More controlled trials with head-to-head comparison, including safety profile and resistance, are required.
| Do Rotating Antibiotics Work Better than Singleton in Small Intestinal Bacterial Overgrowth?|| |
Richard N, Desprez C, Wuestenberghs F, Leroi AM, Gourcerol G, Melchior C. The effectiveness of rotating versus single course antibiotics for small intestinal bacterial overgrowth. United European Gastroenterol J 2021;9:645-54.
Rifaximin is the commonly prescribed drug for small intestinal bacterial overgrowth (SIBO) with efficacy up to 78%. French researchers in this retrospective study have analyzed single antibiotic (azole or quinolone) versus rotational antibiotics (alternating azole and quinolone) for 3 months where rifaximin was not available for SIBO. Of 223 patients (based on 75 g glucose breath test and symptoms), 193 were on single antibiotics and 30 were on rotating antibiotic regimen. Negative glucose breath test, at the end of therapy, was considered remission, which was higher in rotational group than single group (70% vs. 50.8%, P = 0.05). Gastrointestinal quality of life indicator score and bloating also improved better in the rotational group. Though an interesting study, few controversies exist. For example, delta >10 parts per million (p.p.m) increase in hydrogen was considered diagnostic in the study, whereas major societies suggest >20 p.p.m from baseline as diagnostic of SIBO. In resource-limited situations, one may consider rotational over single antibiotics for SIBO.
| How “Early” Can Early Enteral Feeding Be in Acute Pancreatitis?|| |
Ramírez-Maldonado E, Gordo SL, Pueyo EM, Sánchez-García A, Mayol S, González S, et al. Immediate oral refeeding in patients with mild and moderate acute pancreatitis: A multicenter, randomized controlled trial (PADI trial). Ann Surg 2021;274:255-63.
Many clinicians believe in “pancreatic rest” and start oral feeding when patients exhibit clinical improvement though early feeding is widely suggested. Researchers in this study sought to find out the “early,” which most societies have endorsed but not defined. 131 patients with mild and moderate acute pancreatitis were randomized into two arms, the first group (n = 71) to receive low fat, solid diet immediately upon admission and the second group (n = 60) conventionally fed after clinical and laboratory improvement. Most patients presented within a day of their symptoms. Primary endpoint was length of hospital stay. Those who were fed early got discharged 5 days earlier than those who were conventionally fed (P < 0.001). Surprisingly, none of the patients in the early group had relapse of abdominal pain, whereas 16% in the conventional group relapsed (P < 0.001). In addition, complications, interventions, food intolerance, need for opioid analgesia, and costs were also significantly lower in the early group. Patients with severe pancreatitis were excluded from this trial. Furthermore, 48 h timeline to check for persistent organ failure makes it practically difficult to categorize a patient as “moderately severe” with confidence, at the time of presentation. Short follow-up and lack of details of complications are drawbacks. Despite the limitations, the study reinforces the societal guidelines of an early oral diet in terms of safety and benefits.
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