Saudi Journal of Gastroenterology
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   Table of Contents - Current issue
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January-February 2023
Volume 29 | Issue 1
Page Nos. 1-65

Online since Wednesday, January 25, 2023

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EDITORIAL  

Periampullary diverticulum in endoscopic retrograde cholangiopancreatography: A paper tiger? p. 1
Tarek Z Arabi, Aymen Almuhaidb
DOI:10.4103/sjg.sjg_9_23  PMID:36647939
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REVIEW ARTICLE Top

Application and development of fecal microbiota transplantation in the treatment of gastrointestinal and metabolic diseases: A review p. 3
Hassan Mahmoudi, Hadi Hossainpour
DOI:10.4103/sjg.sjg_131_22  
Fecal microbiota transplantation (FMT) restores a balanced intestinal flora, which helps to cure recurrent Clostridium difficile infections (RCDI). FMT has also been used to treat other gastrointestinal diseases, including inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), and chronic constipation, as well as a variety of non-GI disorders. The purpose of this review is to discuss gut microbiota and FMT treatment of GI and non-GI diseases. An imbalanced gut microbiota is known to predispose one to Clostridium difficile infections (CDI), IBD, and IBS. However, the complex role of the gut microbiota in maintaining health is a newer concept that is being increasingly studied. The microbiome plays a major role in cellular immunity and metabolism and has been implicated in the pathogenesis of non-GI autoimmune diseases, chronic fatigue syndrome, obesity, and even some neuropsychiatric disorders. Many recent studies have reported that viral gastroenteritis can affect intestinal epithelial cells, and SARS-CoV-2 virus has been identified in the stool of infected patients. FMT is a highly effective cure for RCDI, but a better understanding of the gut microbiota in maintaining health and controlled studies of FMT in a variety of conditions are needed before FMT can be accepted and used clinically.
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ORIGINAL ARTICLES Top

Factors and techniques associated with endoscopic retrograde cholangiopancreatography outcomes in patients with periampullary diverticulum: Results from a large tertiary center p. 12
Chuanchao Xia, Liqi Sun, Lisi Peng, Fang Cui, Zhendong Jin, Haojie Huang
DOI:10.4103/sjg.sjg_311_22  PMID:36124489
Background: Endoscopic retrograde cholangiopancreatography (ERCP) for patients with periampullary diverticulum (PAD) remains a challenge. This study aims to investigate the factors and techniques related to successful and safe ERCP in patients with PAD. Methods: We enrolled patients who underwent ERCP in a large tertiary center. The difficult cannulation rate, technical success rate, clinical success rate, and adverse events (AEs) rate were compared between patients with or without PAD. Three independent logistic regression models were established to identify factors and techniques associated with difficult cannulation, clinical success, and AEs. Results: Five thousand five hundred and ninety patients were included, of which 705 (12.6%) were diagnosed with PAD. Patients with PAD had a significantly higher difficult cannulation rate compared with patients without PAD (10.6% vs 8.0%, P < 0.0001), but the rates of technical success (clinical success (95.2% vs 95.2%, P = 0.951), and AEs (16.5% vs 14.4%, P = 0.156) were similar. Type I PAD (odds ratio [OR] = 2.114, 95% confidence interval [CI]:1.05-5.25) and ERCP indication for pancreatic diseases (OR = 1.196, 95%CI: 1.053-1.261) were independently associated with difficult cannulation. Small endoscopic sphincterotomy (EST) with balloon dilatation (OR = 1.581, 95%CI: 1.044-2.393) was independently associated with clinical success. Somatostatin injection showed no preventive effect on post-ERCP pancreatitis (OR = 1.144, 95%CI: 1.044-1.254). Moreover, the auxiliary cannulation techniques were safe for PAD patients. Conclusions: PAD did not affect ERCP outcomes. However, the choice of techniques and AE prophylactic measures should be more specific, especially for patients with type I PAD.
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Radiomics signature for prediction of long-term survival and recurrence patterns in patients with gastric cancer after radical gastrectomy: A multicenter study p. 21
Jing-Min Huang, Lv-Ping Zhuang, Hua-Gen Wang, Li-Ying Zhong, Sheng-Jin Xue, Fang-Xi Tian, Hua-Yang Lin
DOI:10.4103/sjg.sjg_253_22  PMID:36588364
Background: This study aimed to develop and validate a radiomics score to predict the long-term survival and patterns of recurrence of gastric cancer (GC). Methods: A total of 513 patients who underwent radical gastrectomy for GC after curative resection between 2008 and 2016 at two institutions were analyzed. A radiomics score was generated using the least absolute shrinkage and selection operator Cox regression model on 327 patients and was validated in 186 patients. A nomogram consisting of the radiomics score and clinicopathological factors was created and compared with the tumor-lymph node-metastasis (TNM) staging system. Model performance was assessed using calibration, discrimination, and clinical usefulness. Results: The radiomics score was established based on five selected features. A higher score was significantly associated with poorer recurrence-free survival (RFS) and overall survival (OS) rates, both in the training and validation cohorts (P < 0.05). Multivariate analysis demonstrated that the radiomics score was an independent prognostic factor for both RFS and OS (P < 0.05). A nomogram incorporating the radiomics score had a significantly better prognostic value than the TNM system alone. Moreover, a high score was significantly associated with an increased risk of distant recurrence, a medium score was significantly associated with an increased risk of peritoneal recurrence, and a low score was significantly associated with an increased risk of locoregional recurrence, in the entire cohort (P < 0.05). Conclusions: The newly proposed radiomics score may be a powerful predictor of long-term outcomes and recurrence patterns of GC. Further studies are warranted to confirm these findings.
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Diagnostic performances of celiac disease serological tests among Saudi patients p. 31
Rim Sghiri, Hana Ben Hassine, Adel Almogren, Zahid Shakoor, Mohammed Alswayyed
DOI:10.4103/sjg.sjg_280_22  PMID:36571384
Background: The prevalence of celiac disease (CD) is relatively high in Saudi Arabia, and little is known about the accuracy of serological markers in the local population. This study aimed to assess the diagnostic performance of various serological markers for detecting CD in Saudi children and adults. Methods: We conducted a retrospective study of 148 CD patients and 512 controls to assess the diagnostic performances of IgA anti-tissue transglutaminase antibodies (TTG), IgG anti-TTG, IgA anti-deamidated gliadin peptide antibodies (anti-DGP), IgG anti-DGP, and endomysium antibodies (EMA). Results: Immunoglobulin A (IgA) anti-TTG was the most sensitive test [98.9% (95% confidence interval (CI) 94.1–99.8%)], while EMA was the most specific [100%, 95%CI 98.6–100%]. By applying the criteria of IgA anti-TTG titers ≥10 × upper limit of normal (ULN) and positive EMA, 57.3% of patients could have avoided intestinal biopsy. IgG anti-DGP test had a sensitivity of 85.9% (95% CI = 77.3–91.5%) and a specificity of 93.5% (95% CI = (90.0–95.9%). Titers of IgA anti-TTG, IgA anti-DGP, and IgG anti-DGP were higher in CD patients with the Marsh 3c class than in those with the Marsh 3b and Marsh 3a classes. IgG anti-TTG and IgA anti-DGP had no additional diagnostic value. Conclusions: IgA anti-TTG and EMA are excellent CD markers in children and adults. The use of IgA anti-TTG titers ≥10 × ULN and positive EMA as criteria for CD diagnosis in children and adults might be a good alternative to intestinal biopsy.
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Serum 25-hydroxyvitamin D levels and the risk of non-alcoholic fatty liver: A two-sample Mendelian randomization study p. 39
Qi Sheng, Huanchen Shi, Shousheng Liu, Likun Zhuang, Zhenzhen Zhao, Yongning Xin
DOI:10.4103/sjg.sjg_297_22  
Background: Accumulated studies have shown that low expression of 25-hydroxyvitamin D [25(OH)D] was significantly associated with the risk of non-alcoholic fatty liver disease (NAFLD). However, the exact causality is still unknown. The aim of this study was to investigate whether levels of 25(OH)D are associated with risk of NAFLD, using a two-sample Mendelian randomization (MR). Methods: Data from a recent large vitamin D genome-wide association study (GWAS) on 417,580 Europeans were utilized, and the largest published histology-based NAFLD GWAS study (1,483 cases and 17,781 healthy controls) for genetic variants predicted to cause NAFLD were searched. All genetic datasets for the MR analyses were obtained using publicly available summary statistics based on individuals of European ancestry from the MR-Base and NHGRI-EBI GWAS Catalog database. Inverse-variance weighted (IVW) MR approach was used to estimate causal effects in the main analysis, complemented by 4 additional methods to control for pleiotropy. Sensitivity analyses were conducted to verify whether heterogeneity and pleiotropy can bias the MR results. Results: The MR analysis did not provide strong evidence for the causal association of circulating 25(OH)D with NAFLD by IVW method (OR = 0.746, 95%CI 0.517–1.078; P = 0.119). The results were consistent using four other MR methods. Sensitivity analysis using all different analytical approaches yielded similar results. There was no evidence for pleiotropy (MR-Egger intercept: −0.0003758, P = 0.970). The replication process also showed consistent results using IVW method (P = 0.710). Conclusion: This study indicates that serum 25(OH)D levels did not possess an obvious effect on the risk of NAFLD. The associations in previous studies may be due to residual confounding or reverse causation.
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Acute myocardial infarction post-gastrointestinal bleeding: A clinical dilemma with poor prognosis p. 47
Xin Su, Junlei Li, Lijuan Du, Yuzhen Wei, Haiyu Li, Haiqiang Sang
DOI:10.4103/sjg.sjg_301_22  PMID:36153929
Background: Gastrointestinal bleeding (GIB) complicating acute myocardial infarction (AMI) is a severe clinical condition with treatment contradiction and poor prognosis. This study aimed to evaluate the rate of in-hospital mortality in patients with GIB who subsequently suffered from AMI and to explore the potential risk factors for this condition. Methods: In this retrospective study, a total of 77 patients diagnosed with GIB, who subsequently suffered from AMI, were enrolled from January 2013 to March 2022. Demographic, laboratory, and clinical data were collected. The in-hospital mortality was the outcome of interest. Logistic regression analysis was used to investigate the potential risk factors of in-hospital mortality. Results: Among the 77 patients included in this study, 62 (80.52%) were males. The mean age of patients was 65.88 ± 12.15 years, and 48 patients (62.34%) were non-ST-segment elevation myocardial infarction (NSTEMI). There were 16 (20.78%) cases of in-hospital deaths. The subjects who died showed higher levels of white blood cell count (13.05 ± 5.76 vs. 9.31 ± 4.07 × 109/L, P = 0.003) and troponin I (TnI) (9.23 ± 9.17 vs. 4.12 ± 5.03 μg/L, P = 0.003). Besides, there were higher proportions of cardiogenic shock (81.25% vs. 26.23%, P < 0.001) and mechanical ventilator usage (75.0% vs. 11.48%, P < 0.001) among the patients who died. The multivariate logistic regression analysis showed that white blood cell count (odds ratio [OR] 1.19, 95% confidence interval [CI] 1.02–1.39, P = 0.030), cardiogenic shock (OR 12.18, 95% CI 3.06–48.39, P = 0.017), and mechanical ventilator usage (OR 7.21, 95% CI 1.28–40.51, P = 0.025) were independently associated with in-hospital mortality. Conclusions: The in-hospital mortality of patients with GIB who subsequently develop AMI is high. White blood cell count, cardiogenic shock, and mechanical ventilator usage are independent predictors of in-hospital mortality.
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In vitro and in vivo phototoxicity on gastric mucosa induced by methylene blue p. 53
Hui Yeong Oh, Hyun Ho Choi, Eui Jin Kim, Ji Hye Choi, Sung Sook Choi, Hae Kyung Lee, Hyung-Keun Kim, Sang Woo Kim, Won Sang H. Park, Hiun Suk Chae
DOI:10.4103/sjg.sjg_315_22  PMID:36571385
Background: Methylene blue (MB) is used endoscopically to demarcate tumors and as a photosensitizer in photodynamic therapy (PDT). However, there are few in vivo studies about its toxicity in healthy stomach tissue. We performed sequential in vitro and in vivo analyses of MB-induced phototoxicity. Methods: We performed in vitro experiments using the AGS human gastric cancer cell line treated with light-emitting diode (LED) irradiation (3.6 J/cm2) and MB. Cytotoxicity was evaluated using terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) assay. In vivo toxicity was evaluated in the stomach of beagles using the same dose of fiber-optic LED via gastroscopy, after spraying 0.1% and 0.5% MB solutions. Stomach tissue was also evaluated using the TUNEL assay. Results: In vitro, increased concentrations of MB led to higher TUNEL scores. However, cell viability was significantly lower after MB plus LED irradiation than after treatment with MB alone (P < 0.001). In vivo, the TUNEL score was highest immediately after treatment with 0.1% or 0.5% MB plus light irradiation, and the score was significantly higher in the LED illumination plus MB group than in the control group (P < 0.05). The elevated TUNEL score was maintained for 3 days in the MB plus light irradiation group but returned to normal levels on day 10. Conclusions: Endoscopic light application with MB 0.5% concentration to the stomach may be regarded as a safe procedure despite some DNA injuries in the early period.
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Identification of celiac disease associated IgA nephropathy by IgA anti-tissue transglutaminase2 antibody deposits in archived formalin-fixed tissues p. 59
Rimlee Dutta, Ramakant Rawat, Prasenjit Das, Geetika Singh, Alka Kumari, Muzafer Ahmad, Ashish Chauhan, Vineet Ahuja, Sanjay K Agrawal, Govind K Makharia
DOI:10.4103/sjg.sjg_326_22  PMID:36348611
Background: The causal association between IgA nephropathy (IgAN) and celiac disease (CeD) is based on their clinical coexistence. In this prospective study, we screened patients with IgAN for CeD and explored the utility of analysis of IgA anti-TG2 antibody deposits, for establishing a causal association. Methods: Biopsy-proven patients of IgAN were screened for serum IgA anti-tissue transglutaminase antibody (IgA anti-tTG Ab) titer and thereafter were invited to undergo endoscopic duodenal biopsy. Corresponding duodenal and kidney biopsies were subjected to IgA anti-TG2 antibody colocalization study using dual-color immunohistochemistry and immunofluorescence techniques. Additionally, kidney biopsies from 105 patients with IgAN who did not give consent for serology analysis, 30 non-IgA nephropathies, and 10 normal controls were also included. Dual-color-stained slides were interpreted based on stain distribution and intensity scores, and Pearson's index >0.3–1 on confocal imaging was considered significant. Results: Of a cohort of 151 patients with IgAN, 32 consented to undergo sero-screening and 5 of them had high serum anti-tTG Ab titer. Two out of the latter consented to endoscopic duodenal biopsies, in whom modified Marsh grade 3b changes were identified. Strong IgA anti-TG2 antibody deposits were noted in the kidney and duodenal biopsies of these patients. One patient out of non-consenting 105 patients with IgAN and 3 out of 30 patients with other non-IgA nephropathies also showed IgA anti-TG2 deposits. None of the healthy kidney tissues showed IgA anti-TG2 Ab deposits. Conclusions: Co-localized IgA anti-TG2 deposits in the kidney biopsies in patients with IgAN help to establish a pathogenic link with CeD. A small proportion of patients with IgAN have associated CeD.
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