Saudi Journal of Gastroenterology
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   Table of Contents - Current issue
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November-December 2021
Volume 27 | Issue 6
Page Nos. 317-391

Online since Thursday, November 25, 2021

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EDITORIAL  

Despise the free lunch p. 317
Majid A Almadi, Abdulaziz Altowaijri
DOI:10.4103/sjg.sjg_541_21  PMID:34755713
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REVIEW ARTICLE Top

Nonalcoholic fatty liver disease: The role of quercetin and its therapeutic implications p. 319
Maria Sotiropoulou, Ioannis Katsaros, Michail Vailas, Irene Lidoriki, George V Papatheodoridis, Nikolaos G Kostomitsopoulos, Georgia Valsami, Alexandra Tsaroucha, Dimitrios Schizas
DOI:10.4103/sjg.sjg_249_21  PMID:34810376
Nonalcoholic fatty liver disease (NAFLD) is the most common form of chronic liver disease, affecting almost one-third of the general population and 75% of obese patients with type 2 diabetes. The aim of this article is to review the current evidence concerning the role of quercetin, a natural compound and flavonoid, and its possible therapeutic effects on this modern-day disease. Despite the fact that the exact pathophysiological mechanisms through which quercetin has a hepatoprotective effect on NAFLD are still not fully elucidated, this review clearly demonstrates that this flavonoid has potent antioxidative stress action and inhibitory effects on hepatocyte apoptosis, inflammation, and generation of reactive oxygen species, factors which are linked to the development of the disease. NAFLD is closely associated with increased dietary fat consumption, especially in Western countries. The hepatoprotective effect of quercetin against NAFLD merits serious consideration and further validation by future studies.
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SYSTEMATIC REVIEW/META-ANALYSIS Top

Effectiveness and safety of the different endoscopic resection methods for 10- to 20-mm nonpedunculated colorectal polyps: A systematic review and pooled analysis p. 331
Xin Yuan, Hui Gao, Cenqin Liu, Hongyao Cui, Zhixin Zhang, Jiarong Xie, Hongpeng Lu, Lei Xu
DOI:10.4103/sjg.sjg_180_21  PMID:34643573
Background: We performed a systematic review and pooled analysis to assess the effectiveness and safety of different endoscopic resection methods for 10- to 20-mm nonpedunculated colorectal polyps. Methods: Articles in PubMed, EMBASE, and the Cochrane Library related to the common endoscopic treatment of 10- to 20-mm nonpedunculated polyps published as of April 2020 were searched. Primary outcomes were the R0 resection rate and en bloc resection rate. Secondary outcomes were safety and the recurrence rate. Meta-regression and subgroup analysis were also performed. Results: A total of 36 studies involving 3212 polyps were included in the final analysis. Overall, the effectiveness of resection methods with a submucosal uplifting effect, including endoscopic mucosal resection (EMR), cold EMR and underwater EMR (UEMR), was better than that of methods without a nonsubmucosal uplifting effect [R0 resection rate, 90% (95% confidence interval (CI) 0.81–0.94, I2 = 84%) vs 82% (95% CI 0.78–0.85, I2 = 0%); en bloc resection rate 85% (95% CI 0.79–0.91, I2 = 83%) vs 74% (95% CI 0.47–0.94, I2 = 94%)]. Regarding safety, the pooled data showed that hot resection [hot snare polypectomy, UEMR and EMR] had a higher risk of intraprocedural bleeding than cold resection [3% (95% CI 0.01–0.05, I2 = 68%) vs 0% (95% CI 0–0.01, I2 = 0%)], while the incidences of delayed bleeding, perforation and post-polypectomy syndrome were all low. Conclusions: Methods with submucosal uplifting effects are more effective than those without for resecting 10- to 20-mm nonpedunculated colorectal polyps, and cold EMR is associated with a lower risk of intraprocedural bleeding than other methods. Additional research is needed to verify the advantages of these methods, especially cold EMR.
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ORIGINAL ARTICLES Top

Undisclosed payments by pharmaceutical manufacturers to authors of inflammatory bowel disease guidelines in the United States Highly accessed article p. 342
Eman Al Sulais, Majid Alsahafi, Turki AlAmeel
DOI:10.4103/sjg.sjg_426_21  PMID:34755712
Background: Payments from pharmaceutical drug manufacturers to authors of clinical practice guidelines (CPGs) may have an impact on their recommendations. In this study, we aimed to evaluate the accuracy of financial conflict of interest (FCOI) declarations among authors of Inflammatory Bowel Disease (IBD) guidelines. Methods: We collected data on industry payments to authors of IBD guidelines published by the American Gastroenterology Association (AGA), American College of Gastroenterology (ACG) and American Society of Gastrointestinal Endoscopy (ASGE). We reported the accuracy of the authors' declarations by comparing their statements in the FCOI section of the guidelines with the data reported on the Centers for Medicare and Medicaid Services website (CMS-OP). We also investigated the adherence of IBD guidelines to the National Academy of Medicine (NAM) criteria for trustworthy guidelines. Results: A total of eight clinical practice guidelines and 35 individual authors were included. Four authors had no profile identified at CMS-OP. The total payment to all included authors was $10,575,843.06, with a mean payment of $314,242.38 per author. A total of 28/35 authors (80%) received payment from pharmaceutical companies, 23/35 (65.7%) received $10,000 or more, 15/35 (42.8%) received $100,000 or more and 3/35 (8.57%) received $1,000,000 or more. Total discrepancies identified while comparing the authors' declaration of their FCOI and CMS-OP were 28: ACG had 12/14 (85.7%), AGA had 7/12 (53.8%) and ASGE had 9/10 (90%) discrepancies. None of the guidelines met all NAM criteria and 4/8 (50%) guidelines met none. Conclusions: Discrepancies exist between authors' declarations in the FOCI section and data on CMS-OP. Poor compliance with the NAM criteria was prevalent among authors of IBD guidelines. More transparency in reporting and monitoring is needed.
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Prevalence, severity and associated factors of restless leg syndrome in inflammatory bowel disease patients p. 348
Othman R AlHarbi, Ahmad Bahammam, Awad H Olaish, Nahla A Azzam, Abdulrahman A Aljebreen, Majid A Almadi, Suhail A Alsaleh
DOI:10.4103/sjg.sjg_642_20  PMID:34596594
Background: The association between restless leg syndrome (RLS) and inflammatory bowel disease (IBD) has often been an under-investigated and clinically misdiagnosed entity. An emphasis should be made on the severity and associated factors, as the prevalence of both entities is on the rise globally. In this study we aimed to investigate the prevalence, severity and associated risk factors of RLS in patients with IBD. Methods: A multi-center, prospective cross-sectional study was conducted with age and gender matched controls in the ratio of 1:3. Cases of IBD were confirmed according to European Crohns and Colitis Organization guidelines. The study recruited 377 cases and 1131 age and gender-matched controls. RLS severity and prevalence was determined using a validated International Restless Legs Syndrome Study Group questionnaire. The anthropometric and blood biochemical measurements were retrieved from the patient's medical records. Associated factors were analyzed by regression analysis. Results: The prevalence of RLS in patients with IBD and non-IBD control groups was 21.5% and 9.7%, respectively (P = 0.001). The severity index of RLS symptoms in all the three categories of mild, moderate and severe RLS was higher in the IBD group (P = 0.001). Obesity (BMI >30 Kg/m2) was more prevalent in patients with IBD with RLS than without RLS (21.9%: 10.3%, P = 0.009). Ages between 46 and 59 years (OR = 18.7 [2.6–29.4], P = 0.008), obesity (OR = 22 [2.6–29.4], P = 0.005), higher TSH levels (OR = 1.7 [1.0–3.0], P = 0.033), and lower hemoglobin levels (P = 0.028) showed a greater risk associated with RLS. Conclusion: Prevalence and severity of RLS was higher in patients with IBD. The risk factors for RLS in IBD include increasing age, obesity, higher TSH, and lower hemoglobin.
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Does restricting fluid volume impact post-ERCP pancreatitis in patient with heart disease? p. 355
Ko Tomishima, Shigeto Ishii, Toshio Fujisawa, Noboru Yatagai, Daishi Kabemura, Sho Sato, Nozomi Amano, Ayato Murata, Hironori Tsuzura, Shunsuke Sato, Kouhei Matsumoto, Yuji Shimada, Takuya Genda, Akihito Nagahara, Hiroyuki Isayama
DOI:10.4103/sjg.sjg_693_20  PMID:34213425
Methods: Two hundred and forty seven of 480 patients with naïve papilla undergoing therapeutic ERCP between April 2013 and March 2018 were enrolled for the study. The following patient characteristics were investigated: age, sex, body mass index, previous diseases (heart disease, renal failure, cerebrovascular disorders, coexisting malignancy and pulmonary disease), history of PEP, common bile duct diameter, diverticula and volume of fluid infused 24 hours after the procedure. All ERCP cases had naïve papilla and had undergone treatment. Results: The incidence of PEP was 8.5%. Significant differences were observed in the volume of fluid infused between patients without and with a history of heart disease (1,380 vs. 1,755 mL). The mean volume of the infused fluid was significantly lower in the PEP than non-PEP group (1,483 vs. 1,688 mL, P = 0.02). Moreover, PEP incidence differed according to a fluid infusion cutoff of 1,000 mL (7 vs. 11 cases of PEP in those with ≦1,000 mL and >1,000 mL fluid volume, respectively, P < 0.001). Conclusion: Restricted fluid volume was a newly identified risk factor for PEP, particularly in patients with heart and renal diseases as comorbidities.
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TMAO promotes apoptosis and oxidative stress of pancreatic acinar cells by mediating IRE1α-XBP-1 pathway p. 361
Guodong Yang, Xiaoying Zhang
DOI:10.4103/sjg.sjg_12_21  PMID:34755714
Background: Acute pancreatitis caused by hyperlipidemia is a severe life-threatening condition. Therefore, it is urgent to develop new therapeutic methods to treat this disease. Methods: Cell viability was determined by the Cell Counting Kit-8 (CCK-8) assay. Western blotting (WB) was used to detect the expression levels of apoptotic and endoribonuclease inositol-requiring enzyme 1α (IRE1α)/X-box binding protein 1 (XBP-1) pathway-associated proteins. The induction of cell apoptosis was determined using flow cytometry. The expression levels of the oxidative stress indicators were measured by an enzyme-linked immunosorbent assay. Results: WB analysis and the CCK-8 assay demonstrated that trimethylamine-N-oxide (TMAO) decreased cell viability and facilitated apoptosis of MPC-83 cells in a dose-dependent manner. Furthermore, the induction of oxidative stress was assessed by evaluating the levels of specific markers, including hydrogen peroxide, reactive oxygen species, nitric oxide, and superoxide dismutase. The levels of the aforementioned markers were increased in the TMAO-treated group. Subsequently, the IRE1α/XBP-1 pathway-associated proteins were analyzed by WB analysis and the data demonstrated that the regulatory effects of TMAO on MPC-83 cells were meditated by the IRE1α/XBP-1 signaling pathway. Subsequently, rescue experiments were performed to further assess the effects of TMAO. Conclusion: The present study provides evidence on the application of TMAO as a potential diagnostic and therapeutic strategy for the therapeutic intervention of hyperlipidemic acute pancreatitis.
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Clinical comparison of febrile and afebrile patients with pyogenic liver abscess: A two-centre retrospective study p. 370
Jie Yu, Jun Ma, Hairong Wang, Yujun Shi, Shuangjun He, Yi Chen, Chao Tang
DOI:10.4103/sjg.sjg_17_21  PMID:34657029
Background: Limited research has been conducted on afebrile pyogenic liver abscess (PLA). This poses a challenge in rapid diagnosis and early tailored care to physicians. In his study, we aimed to compare the clinical characteristics of afebrile and febrile patients with PLA. Methods: We retrospectively analyzed the data of patients with PLA who were admitted to the emergency departments of two university hospitals between January 2014 and March 2020. Patients were classified into afebrile and febrile groups by using body temperature higher than 38°C as the reference standard. The demographic, clinical, and laboratory characteristics of both groups were compared. The primary outcome was all-cause in-hospital mortality and length of hospital stay. Multivariate analysis was performed to define factors associated with afebrile PLA. Results: Of the 239 patients included in this study, 51 patients (21.3%) were afebrile and 188 patients (78.7%) were febrile. There were no differences between the abscess characteristics, laboratory manifestations, and disease severity of both groups; however, age and Charlson score differed between the groups (P = 0.009 and P = 0.011). The all-cause in-hospital mortality rate was much higher in the afebrile PLA group than in the febrile PLA group (9.8% vs. 2.1%, P = 0.011). Regarding the length of stay, no significant differences were noted in the febrile PLA group compared with the afebrile PLA group (18.5% vs 17.3%, P = 0.514). In multivariate analyses, only age greater than 65 years was significantly associated with afebrile PLA. Conclusions: Afebrile patients with PLA tend to be older, have higher Charlson scores, and in-hospital mortality rate than those with febrile patients. PLA patients older than 65 years are more likely to present without fever (<38°C) at the time of the emergency visit.
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Development and validation of a nomogram for predicting varices needing treatment in compensated advanced chronic liver disease: A multicenter study p. 376
Jitao Wang, Wenxin Wei, Zhihui Duan, Jinlong Li, Yanna Liu, Chuan Liu, Liting Zhang, Qingge Zhang, Shengyun Zhou, Kunpeng Zhang, Fengxiao Gao, Xiaojuan Wang, Yong Liao, Dan Xu, Yifei Huang, Shuai Wang, Weiling Hu, Hua Mao, Ming Xu, Tong Dang, Bin Wu, Li Yang, Dengxiang Liu, Xiaolong Qi
DOI:10.4103/sjg.sjg_22_21  PMID:34341248
Background: Only a small proportion of patients with compensated advanced chronic liver disease (cACLD) had varices needing treatment (VNT) after recommended esophagogastroduodenoscopy (EGD) screening. We aimed to create a non-invasive nomogram based on routine tests to detect VNT in cACLD patients. Methods: The training cohort included 162 cACLD patients undergoing EGD in a university hospital, between January 2014 and September 2019. A nomogram was developed based on the independent predictors of VNT, selected using a multivariate logistic regression analysis. Thirty-three patients from eight university hospitals were prospectively enrolled as validation cohort between December 2018 and December 2019. Results: The prevalence of VNT was 32.7% (53/162) and 39.4% (13/33) in training and validation cohorts, respectively. The univariate analysis identified six risk factors for VNT. On the multivariate analysis, four of them, i.e., gallbladder wall thickness (odds ratio [OR]: 1.23; 95% confidence interval [CI]: 0.98-1.56), spleen diameter (OR: 1.02; 95% CI: 1.00-1.04), platelet count (OR: 0.98; 95% CI: 0.97-0.99), and international normalized ratio (OR: 0.58; 95% CI: 0.06-5.84) were independently associated with VNT. Thus, a nomogram based on the four above - mentioned variables was developed, and showed a favorable performance for detecting VNT, with an area under receiver operating characteristic curve of 0.848 (95% CI: 0.769-0.927) in training cohort. By applying a cut-off value of 105 in validation cohort, 31.0% of EGD were safely spared with 3.4% of missed VNT. Conclusion: A nomogram based on routine clinical parameters was developed for detecting VNT and avoiding unnecessary EGD in cACLD patients.
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The prevalence of irritable bowel syndrome among Saudi population in Riyadh by use of Rome IV criteria and self-reported dietary restriction p. 383
Hussein S Amin, Farhana Irfan, Syed I Karim, Saif M Almeshari, Khaled A Aldosari, Abdullah M Alzahrani, Adnan T Almogbel, Saad M Alfouzan, Anas A Alsaif
DOI:10.4103/sjg.sjg_43_21  PMID:34747875
Background: Irritable bowel syndrome (IBS) is the most prevalent functional gastrointestinal disorder. Diet may play a role in triggering the symptoms. We aimed to measure the prevalence of IBS and its types, and its association with food restrictions among the Saudi population, using the Rome IV criteria. Methods: A cross-sectional study was conducted in the outpatient clinics of three major hospitals in Riyadh in conjunction with an electronic survey which was shared on social media. A total of 1,319 subjects (706 males and 613 females) completed a questionnaire of four domains (sociodemography, Rome IV, food restriction, and herbs) between Nov 2019 and February 2020. Convenience sampling was used. Results: IBS was diagnosed in 104 subjects (7.9%) and, of these, 52% were IBS-M (mixed) type. The prevalence was higher in women than in men (4.9% vs. 3.0%; P = 0.006). A significant association was found between the presence of IBS symptoms and low income (P = 0.010), and not working (P < 0.0001). Most of the IBS patients showed food restriction related to milk (P < 0.0001) and legumes (P = 0.0029), besides other types of food and drinks. Conclusions: IBS is less common among the Saudi population. A female gender, low family income, and working status, have the highest association with IBS. The foods most often restricted were legumes and milk. Future community studies may present an opportunity to relate with cultural differences and food preferences.
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LETTER TO EDITOR Top

Optimal drugs for sedation in pediatric colonoscopy p. 391
Soon Chul Kim
DOI:10.4103/sjg.sjg_480_21  PMID:34806660
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