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ACG Partners with AGA, ASGE on “Value of Colonoscopy”

American College of Gastroenterology » News
ACG Partners with AGA, ASGE on “Value of Colonoscopy”

ACG has joined with AGA and ASGE on an important initiative, The Value of Colonoscopy: Saving Lives Through Expert Care, to further highlight the value of colonoscopy and the gastroenterologists who perform this life-saving procedure. Visit valueofcolonoscopy.org to learn more.

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New Technique Better Preserves Livers for Transplantation

AGA Journals Blog
New Technique Better Preserves Livers for Transplantation

A new supercooling technique keeps rat livers alive 3 times longer than previous techniques, raising hopes for reducing shortages of human transplant organs.

According to the AFP, the method involves cooling the livers while flushing them with oxygen and nutrients, and preserving them in a solution that allows them to be stored below 0°C without freezing or its associated cell damage. The organ is supercooled to –6°C and can be stored for 3–4 days. A machine (see picture) helps to rewarm the organ and prepare it for transplantation.

A supercooled rat liver in preservation solution in the machine perfusion system

All rats given livers supercooled for 72 hours were healthy after 3 months, a benchmark for survival. Of rats who received livers stored for 96 hours, 58% survived to the 3-month mark, Tim Berendsen et al. reported on June 29 in Nature Medicine. Rats that received transplant livers preserved with current methods survived only for hours or days.

“To our knowledge, this is the longest preservation time with subsequent successful transplantation achieved to date,” the study’s senior author, Korkut Uygun (Massachusetts General Hospital), told AFP. “If we can do this with human organs, we could share organs globally, helping to alleviate the worldwide organ shortage.”

“The next step will be to conduct similar studies in larger animals,” Rosemarie Hunziker, of the National Institute of Biomedical Imaging and Bioengineering (NBIB), said in a press release. The method will have to be thoroughly tested and refined before it can be considered for use in humans.

The Boston Globe explained that organs can only stay alive outside of the body from 5 to 24 hours, depending on the organ, before they begin to deteriorate. Since the 1980s, donor organs have been preserved at temperatures at or just above freezing in a solution that reduces their metabolism and deterioration. have previously attempted to cool organs to below 0°C without any success.

Some 120,000 people are waiting on donor organs in the United States alone, says the NBIB. They explained that extending the time a liver can survive outside the body would allow more time to prepare the patient and ease logistics at the donor hospital site, reduce the urgency of rushing the organ to its destination, and expand the donation area to allow for transcontinental and intercontinental transplantations. This would boost the chances of patients finding better donor organ matches, and reduce costs, the NBIB explains.

The BBC wrote that if the technique works on human organs, it could to transform the process of organ donation. Uygun told the BBC that the technique could lead to donated organs being shared around the world. He added that organs that are normally not considered for transplantation might be suitable if they were preserved by supercooling.

Video: New Tool Aids Determination of Colonoscopy Surveillance Intervals

With an increased emphasis on improving quality and decreasing costs, new tools are needed to improve adherence to evidence-based practices and guidelines in endoscopy.

In a video abstract, Timothy D. Imler describes an automated system that uses natural language processing (NLP) and clinical decision support to facilitate determination of colonoscopy surveillance intervals.

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In the video, Imler explains why NLP with clinical decision support is a promising new technology for tracking compliance with endoscopy surveillance intervals.

The full article by Imler et al. can be found in the July issue of Clinical Gastroenterology and Hepatology.

 

 

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Linking Herbal Supplements with Liver Injury

AGA Journals Blog
Linking Herbal Supplements with Liver Injury

Despite the perceived safety of herbal and dietary supplements, they can cause serious liver injury. In the July issue of Clinical Gastroenterology and Hepatology, Simona Rossi and Victor J. Navarro discuss the scope, use, and regulation of herbal and dietary supplements, as well as the diagnosis of herbal and dietary supplement-induced liver injury.

Patients take dietary supplements for many reasons, including anxiety, obesity, diabetes, rheumatoid arthritis, cancer, cardiovascular disease, and pain.

Pills3Almost a quarter of patients enrolled in a long-term hepatitis C treatment trial reported using herbal and dietary supplements.

Rossi and Navarro explain that the ease of access to these supplements allows consumers to assume that they are safe and can be used without consequences. Most patients do not divulge use of dietary supplements to health care providers.

However, in the US National Health and Nutrition Examination Survey, 52% of respondents reported using a dietary supplement, and other surveys have reported even higher use. In some Asian and African countries, up to 80% of the population use herbal supplements as their primary means of medical care.

Rossi and Navarro discuss the incidences of injury caused by different supplements in different countries. These range from 1%–2% of cases of liver injury in Spain (with antibiotics being among the most common class implicated) to Singapore, where 71% of cases of drug-related liver injury have been attributed to medicinal herbs—many adulterated with active drugs.

The authors discuss preliminary findings from the US Drug-Induced Liver Injury Network (DILIN) showing that herbal and dietary supplements are responsible for an increasing proportion of hepatotoxicity cases.

Rossi and Navarro discuss the US Dietary Supplement Health and Education Act of 1994, in which manufacturers are required to attest to a product’s safety, but give no authority to the Food and Drug Administration (FDA) to approve the supplements before marketing. Routine analysis of products’ contents by the FDA is performed on only a random basis.

They present strategies for diagnosis of herbal and dietary supplement–induced liver injury, and the process for linking a drug or dietary supplement to liver injury. Products and ingredients associated with hepatotoxicity include weight loss supplements (Hydroxycut, Herbalife/green tea, and usnic acid), joint health supplements (flavocoxid– and glucosamine-based supplements), and bodybuilding supplements.

Attributing liver injury to any specific ingredient in herbal and dietary supplements is the single greatest challenge to clinicians and researchers interested in liver injury. Rossi and Navarro explain that even detailed chemical analyses of products, which are expensive and complex, do not always identify the agents responsible for injury. The authors propose using chemical analyses to identify ingredients common to products implicated in injury; proposed culprits could then be tested in formal toxicologic analyses.

Nonetheless, Rossi and Navarro state that a better understanding of the epidemiology of supplement-induced liver injury is needed, to identify the scope of the problem and the groups most affected, as well as to develop management and prevention strategies. Without more accurate estimates of the overall use of herbal and dietary supplements and more complete reporting of adverse events, it is impossible to determine disease prevalence and incidence.

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New guideline warns physicians about risks of some supplements

American College of Gastroenterology » News
New guideline warns physicians about risks of some supplements

The American College of Gastroenterology released a new guideline this week warning physicians about the risks of supplements and how to counsel patients about their use. Most patients recover after going off the drugs or supplements with proper medical care that was outlined in the guidelines, but some may go into permanent liver failure that requires a liver transplant to treat. Boston Globe (6/19/14)

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What is the Cause of this Mechanic’s Abdominal Pain?

AGA Journals Blog
What is the Cause of this Mechanic’s Abdominal Pain?

A 56-year-old male auto mechanic experienced fever, chills, drenching night sweats, malaise, nausea, and abdominal pain and distention for 6 weeks, associated with 15 kg of lost weight. Twenty years ago he was diagnosed with ileocolonic Crohn’s disease, but he had been asymptomatic on mercaptopurine therapy for the past 10 years. He stopped smoking 20 years ago.

Upon physical examination, he had mild pallor and a distended, soft abdomen, which was mildly tender. He did not have jaundice, and there was no distinct palpable mass or evidence of ascites.

Laboratory tests revealed hemoglobin, 8.5 g/dL; mean corpuscular volume, 98; platelets, 790 × 109/L; erythrocyte sedimentation rate, 134; International Normalized Ratio, 1.8; total protein, 5.6 g/dL; and albumin, 1.8 g/dL. Levels of lectrolytes, creatinine, and liver enzymes were otherwise normal.

Computed tomography images of the abdomen and pelvis are shown in panels A and B.

CT images

CT images

CT-guided biopsy was performed and the pathology results are shown in panels C and D.

Histology

Histology

What is his diagnosis? Find out in the Clinical Challenges and Images in GI article by Leila Neshatian et al. in the June issue of Gastroenterology.

 

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Does EGD Identify Causes of Abdominal Pain in Children?

AGA Journals Blog
Does EGD Identify Causes of Abdominal Pain in Children?

Esophagogastroduodenoscopy (EGD) is a useful tool for the diagnosis of children with abdominal pain, researchers report in the June issue of Clinical Gastroenterology and Hepatology.

The procedure identified disorders for which medical therapy was effective in 67% of children. Chronic abdominal pain is the most common indication for EGD in children. However, little is known about the accuracy of EGD-based diagnosis or the outcomes of the patients who undergo this procedure. In a prospective study, Kalpesh Thakkar et al.  examined the diagnostic yield of EGD and short-term outcomes of 290 children who underwent this procedure for chronic abdominal pain.

They found that, overall, EGD provided an accurate diagnosis for 109 children (38%). Diagnoses included esophagitis (21.0%), eosinophilic gastroenteritis (4.1%), eosinophilic esophagitis (3.8%), Helicobacter pylori infection (2.0%), celiac disease (0.6%), and Crohn’s disease (0.4%). Short-term outcomes were available for 81% of patients with diagnostic findings, and medical therapy was effective in approximately 67% of these children.

The authors noted that esophagitis was the most common abnormal finding (26%) in children with chronic abdominal pain. Several studies in children confirm that abdominal pain is a frequent presenting symptom of gastroesophageal reflux disease (GERD). Most of the patients in the study of Thakkar et al. (68%) attempted treatment with proton pump inhibitors before EGD, but the presence or response to this therapy did not identify children with esophagitis or GERD.

Thakkar et al. therefore do not recommend proton pump inhibitor therapy before EGD, because the treatment was not associated with a higher diagnostic yield, and most of the children studied (79%) did not have reflux esophagitis.

Further, controlled studies are therefore required to investigate the long-term outcomes of children with chronic abdominal pain who undergo endoscopy.

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What is the Cause of this Dysphagia?

AGA Journals Blog
What is the Cause of this Dysphagia?

A 60-year-old woman visited the hospital with nonprogressive mild esophageal dysphagia (without oropharyngeal transfer difficulties for solids) for 10 years. Her clinical examination and screening blood tests were normal.

She had no previous medical problems except for carrying the hepatitis B virus. She underwent an upper gastrointestinal endoscopy, which revealed external compression and extrinsic arterial pulsations of the upper esophagus posteriorly (Figure A).

Redraw-template

A computed tomography scan showed a right-sided aortic arch and compression of the posterior wall of the upper part of the esophagus (Figures B and C).

The volume-rendered reconstruction image showed anomalous origin of left common carotid artery from the ascending aorta and left subclavian artery originating from the diverticulum (Figures D and E).

What is her diagnosis? Find out in the Electronic Image of the Month article by Myung Soo Kang in the June issue of Clinical Gastroenterology and Hepatology.

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Does Getting Rid of H pylori Stop Gastric Cancer’s Return?

AGA Journals Blog
Does Getting Rid of H pylori Stop Gastric Cancer’s Return?

Eradication of Helicobacter pylori after endoscopic resection of gastric lesions doesn’t prevent later development of new stomach tumors, researchers report in the May issue of Clinical Gastroenterology and Hepatology.

H pylori

H pylori

H pylori infection can lead to gastric atrophy, intestinal metaplasia, and dysplasia or cancer—specifically non-cardia gastric cancer. It does so by inducing inflammation and genetic and epigenetic alterations that promote genetic instability. The bacteria also cause mucosal damage that leads to hypochlorhydria and achlorhydria, allowing for overgrowth of other bacteria that produce carcinogens.

Eradication of H pylori stops the progression and can reverse some of the damage to the mucosa. Cancer risk is low when the bacteria are eradicated from patients with non-atrophic mucosa.

However, there have been conflicting results from studies to determine whether eradication of H pylori infection prevents development of new cancers in patients who have already been treated for gastric cancer or dysplasia.

Jeongmin Choi et al. performed a prospective study of 901 patients undergoing endoscopic resection for gastric dysplasia or cancer. After the lesions were removed, the patients were assigned to groups in which the H pylori infection was eradicated (with 20 mg omeprazole, 1 g amoxicillin, and 500 mg clarithromycin, twice daily for 1 week) or not treated. The patients then underwent endoscopic examination 3, 6, and 12 months later, and yearly thereafter, to identify any new carcinomas that developed the stomach (metachronous gastric carcinoma).

After a median follow-up period of 36.9 months, new cancers developed in 10 patients in the eradication group and in 17 patients in the control group—not a statistically significant difference. Furthermore, there was no significant difference in incidence of new cancers between patients ultimately positive or negative for H pylori infection.

Choi et al. conclude that these findings, along with those from previous studies, indicate that H pylori eradication does not benefit patients with precancerous lesions, dysplasia, or cancer.

A previous study reported that the incidence of metachronous cancer differed between the eradication and control groups only within 1 year of follow-up evaluation. Choi et al. propose that although H pylori eradication doesn’t prevent the development of later cancers, it might delay them.

In an accompanying editorial, David Y. Graham explains that by the time a gastric cancer becomes detectable, the stomach probably has other areas containing premalignant or even malignant microlesions. Eradicating H pylori could slow the progression of these lesions, reducing inflammation and further genetic damage and promoting healing of gastritis.

Graham proposes that eradication of H pylori does no harm and likely changes the gastric environment to improve patients’ outcomes. He says that markers are needed to identify patients at greatest risk for subsequent cancers and are most likely to benefit from H pylori eradication.

Choi et al. add that patients treated with endoscopic resection, compared with surgical resection, are at greater risk for development of gastric tumors, because the entire stomach is preserved. However, they observed that most of the new tumors that developed were intramucosal, and could be removed by endoscopy.

Choi et al. remind readers that careful surveillance endoscopy is important for detecting new lesions while they are still at a curable stage.

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See What’s New!

AGA Journals Blog
See What’s New!

Welcome to the new and improved AGA Journals Blog! We have redesigned our blog to make it easier to navigate, and will provide more frequent updates on GI and hepatology research findings.

As always, the AGA Journals Blog will be your place to learn about the latest research discoveries, advances in treatment, and technologies for the GI tract, liver, and pancreas.

We also will be including new sources of information including Q&A sessions with researchers, podcasts, and videos.

All articles are now categorized (see the box on the right) to make it easier to find what you are looking for—whether it’s the latest technology for detecting pancreatic cancer, the best way to cleanse a colon, or the newest treatments for hepatitis.

Popular posts and the latest comments are also highlighted on the right, so you can easily find our most topical content and join the conversation.

Please enjoy exploring our new site and post comments to let us know what you think!

 

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Special Issue: The Gut Microbiome

Special Issue: The Gut Microbiome

Gastroenterology is proud to present a special issue devoted to ‘The Gut Microbiome in Health and Disease’.

Cover-13th issue 14

The human body contains over 10 times more microbial cells than human cells. This microbiome (the commensal, symbiotic, and pathogenic microorganisms that share our body space) maintains the health and function of many tissues, and its disruption contributes to the pathogenesis of many diseases. Gastroenterology has therefore devoted an entire issue—14 review and perspective articles—to this rapidly developing area of research.

In an introduction to the special issue, editors Chung Owyang and Gary Wu explain the particular importance of the most densely populated and diverse of our microbial communities, the intestinal microbiome. Intestinal microorganisms interact with almost all body systems (immune, nervous, metabolic, etc). The effectiveness of fecal microbiota transplantation in the treatment of refractory Clostridium difficile infection has demonstrated how modification of the intestinal microbiome can be used to treat gastrointestinal disorders.

Articles published in this special issue cover the basic concepts of the mammalian gut microbiome and its potential roles in development of various disorders including inflammatory bowel diseases, cancer, and liver disease. Others discuss how the microbiome might be modified to maintain health or treat disease, such as through transplantation of fecal microbiota or with diet and pre or probiotics. Articles cover the latest technologies used to characterize the composition of the microbiome and its metabolic products, as well as the activities of nonbacterial organisms, such as the virome and mycobiome.

This issue is a must-read for anyone interested in learning more about how our microbiota contributes to our health and disease.

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