Gastroenterology and Functional Medicine

Hepatocellular carcinoma surveillance in cirrhotic patients: Beyond guidelines

Mohammed Omar Khalifa Elsayed — Tue, 24 Oct 2023 00:00:00 +0800

Hepatocellular carcinoma (HCC) surveillance of individuals with cirrhosis or other conditions that confer a high risk of HCC development is essential for early detection and improved overall survival. HCC surveillance is a complex process, with failure at any step in the process contributing to a gap between its efficacy and effectiveness. Biannual ultrasonography with or without alpha-fetoprotein is widely recommended as the standard method for HCC surveillance, but it has limited sensitivity in early disease and may be inadequate in certain individuals. HCC surveillance implementation can be affected by either provider or patient-related factors. Proper screening for HCC is a continuum of services, extending from initial patient screening, diagnosis, treatment and ultimately surveillance. As one may expect, there are numerous chances for failure in the delivery of cancer screening care. When considering the risk versus benefits of HCC surveillance, we must consider the possible harm to the patient. Such concerns include false-positive testing resulting in unnecessary and risk-associated procedures such as liver biopsy, overdiagnosis of HCC among patients with cirrhosis, as well as false-negative investigations resulting in delayed diagnosis of HCC. The development of tools to enhance our ability in optimizing available surveillance is likely to improve the prognosis of patients with HCC. This review article will provide a comprehensive overview of the rationale behind current HCC surveillance guidelines, their utilisation, effectiveness, limitations, benefits, and harms as well as methods to improve the outcome of HCC surveillance.

Unraveling CagA’s potential: A promising frontier for gastric cancer

Asma Boudouaia Ouali — Thu, 21 Sep 2023 00:00:00 +0800

In the relentless pursuit of conquering gastric cancer, researchers have uncovered a promising avenue: CagA, the captivating oncoprotein encoded by Helicobacter pylori (H. pylori). This review delves deep into the multifaceted role of CagA in the pathogenesis of gastric cancer, shedding light on its remarkable ability to manipulate signaling pathways and trigger the epithelial-mesenchymal transition (EMT) phenomenon, which underlies cancer invasion. By unraveling the mysteries of H. pylori’s influence on signaling pathways within gastric cells, this review presents cutting-edge insights into the pathogenesis of this devastating malignancy. Moreover, it unveils the fascinating relationship between H. pylori infection and extra-gastric diseases, offering a panoramic view of the broader impact of this microbe on human health Beyond the realm of basic science, this exploration of H. pylori’s dark secrets holds the promise of revolutionizing the realm of gastric cancer prevention, diagnosis, and treatment. With CagA as the spotlight, the stage is set for a transformative journey towards conquering this devastating malignancy and embracing a brighter future in cancer therapeutics.

The role of 3D printing, virtual and augmented reality in liver surgery: The technological imperative!

Thu, 20 Jul 2023 00:00:00 +0800

Technological innovation has been proven a valuable tool in the modern era of liver surgery. 3-dimensional (3D) printing along with virtual and augmented reality (VR and AR), as part of this technological development, can contribute to avoid high-risk complications during liver surgery. More specific, in terms of liver transplantation, small-for-size and large-for-size syndromes can be avoidable with timely utilization of these modalities, by measuring the volume of both the donor’s liver and recipient’s abdomen. Additionally, artificial bio-printed livers have the potential to minimize the shortage of grafts, yet this novelty needs further development. The same artificial livers can participate in clinical trials of drugs’ hepatotoxicity, removing the risk from living human beings. In hepatic resection, the employment of VR can help hepatobiliary surgeons identify and comprehend the complexity of the anatomic structures of liver parenchyma, especially the related vessels and biliary branches. VR and AR represent new alternatives for the traditional 3D printed models, especially after the increasing availability of relevant medical applications outweighing the disadvantages of 2D models. Apart from their surgical applications, VR and AR can play a valuable role with regards to medical education, not only for medical students, but also for surgical trainees as several studies have shown. Certain limitations, such as those associated with the cost and the time required to generate a 3D prototype, tent to be eliminated due to VR and AR. Unambiguously, further evolution of this
technology will lead to wider application for the best of patients’ care and perfection of surgical outcomes.

Contemporary diagnosis and management of gallbladder polyps

Efstathios T. Pavlidis, Ioannis N. Galanis , Theodoros E. Pavlidis — Tue, 26 Dec 2023 00:00:00 +0800

Gallbladder (GB) polyps are present in 5%–10% of the general population and consist of true neoplastic polyps (adenomas) and pseudopolyps (predominantly cholesterol, inflammatory, hyperplastic, focal adenomyomatosis). True polyps, although relatively rare neoplastic lesions (0.5%) are considered an important factor in malignant transformation and cancer development (5%) when their size is ≥ 1 cm. Given that it is essential to diagnose GB adenocarcinoma at an early stage to optimize therapeutic management, controversy exists about whether cholecystectomy is always necessary. Their imaging characteristics, size ≥ 1 cm, age > 50 years and genetic predisposition determine the indications for immediate cholecystectomy. In younger patients with polyps < 1 cm in size and without a familial history of GB carcinoma, imaging follow-up by ultrasound (US) seems to be a reasonable recommended policy. A scoring system by multivariate analysis (cross-sectional area > 123 mm², positive blood flow signal, age > 55.5 years, alanine aminotransferase (ALT) levels > 50 U/L and an ALT/AST (aspartate aminotransferase) ratio > 0.77) can accurately predict true polyps. The widely accepted size threshold for US follow-up is 7 mm, and for intervention, it is 10 mm. Computed tomography or better magnetic resonance imaging can overcome any misdiagnosis of conventional US incidental findings alone that may lead to potentially unnecessary operations. In challenging cases, high-resolution US, novel three-dimensional US, endoscopic US or contrast-enhanced endoscopic US could be helpful. Novel microflow imaging can safely predict polyps. Risk factors for malignancy include age > 60 years, large gallstones, primary sclerosing cholangitis, Asian ethnicity and sessile polyps accompanied by focal gallbladder wall thickening > 4 mm. For polyps sized 6–9 mm, the absence of growth at recommended follow-up (6 months, one year, and two years) indicates treatment discontinuation; however, it is not required for size < 5 mm without risk factors. In addition to laparoscopic cholecystectomy, the standard management, novel interventional modalities preserving the GB in selected cases include per-oral transmural endoscopic resection of GB polyps after a bridge of endoscopic US-guided cholecystostomy or laparoscopic gallbladder-preserving polypectomy. Generally, there are still no precise and strong evidence-based guidelines; thus, the management policy of GB polyps should be individualized in ambiguous cases.

Renal response of solute carrier transporters and related proteins in obstructive jaundice

Adriana M. Torres — Thu, 20 Jul 2023 00:00:00 +0800

Obstructive jaundice mainly takes place after cholelithiasis and neoplasms that affect the pancreas and the common bile duct. The liver and kidney eliminate toxins, pharmacotherapeutic drugs, and endogenous metabolites. It has been reported that the alteration of one route of excretion can be compensated by the other route. Modifications in the expression of several carrier proteins have been observed after the impairment of the hepatic function. The present work updates the modifications reported in the renal expression and in the urinary levels of some proteins belonging to the solute carrier family (such as Oatp1, Oat1, Oat3, Oat5, Asbt, and NKCC2) and some proteins related in some way to these ones (such as AQP2,
Cav-1, and Cav-2). An increased renal expression of Oatp1, Oat1, Oat3, Oat5, and a decreased abundance of Abst was observed after 21 h of bile duct ligation, explaining the increase in the renal clearance of different compounds that could not be excreted by the liver because the biliary excretion is impaired. Moreover, the decreased expression of NKCC2 and AQP2 together with the increase in medullary renal blood flow could account for the increase in the urinary flow previously reported in this pathological state. In addition, a decreased expression of Cav-1 and an increased expression of Cav-2 in kidneys were reported in the early phase of acute cholestasis. It is well-known that renal function is altered during cholestasis and that the impairment of this organ increases with the time course of cholestasis. Increase urinary levels of NaDC1, Cav-1, and
Cav-2 together with a decrease of Oat5, plus the absence of modifications of NKCC2 and AQP2 were detected after 21 h of bile duct ligation in the absence of alterations in traditional parameters of renal function. Thus, the urinary levels of these proteins were proposed as a novel panel of biomarkers of the early phase of acute obstructive jaundice.

Non-alcoholic fatty liver disease: An emerging epidemic of global importance

Muhammed Mubarak — Thu, 21 Sep 2023 00:00:00 +0800

Nonalcoholic fatty liver disease (NAFLD), a condition that affects 30% of the world’s population, is one of the leading causes of chronic liver disease (CLD) and liver transplantation. Although exact data are not available in many developing countries, its prevalence is increasing at alarming rates in many studies from these countries. The rising prevalence of NAFLD has paralleled the increasing rates of obesity and metabolic syndrome. Hence, more recently, it has been renamed metabolic dysfunction-associated fatty liver disease (MAFLD). Since several studies have demonstrated an association between NAFLD and an increased risk of cardiovascular events, it has been proposed that NAFLD may be an independent risk factor for atherosclerosis. However, the data is conflicting in this regard and more studies are needed. In this review, we discussed the epidemiology, risk factors, clinical presentation, diagnosis, classification, and complications of NAFLD to help increase awareness among the medical community of this looming epidemic of metabolic liver injury.

Gardner syndrome: a mini review

Harleen Chela, Mustafa Gandhi, Mohammad Hazique , Hamza Ertugrul, Karthik Gangu — Mon, 21 Aug 2023 00:00:00 +0800

Gardner syndrome is one of the hereditary gastrointestinal cancer syndromes and is not commonly encountered. It is a variant of familial adenomatous polyposis associated with cutaneous and soft tissue tumors. It is important to be aware of these syndromes as they are often associated with systemic manifestations and have implications for family members.

Serum alpha-fetoprotein level (> 10,000 U/mL) is a marker of hepatocellular carcinoma: A case study

Prasan Kumar Panda — Tue, 24 Oct 2023 00:00:00 +0800

Hepatocellular Carcinoma (HCC) development in young adults is strongly multifactorial. Important risk factors for the same are smoking, alcohol abuse and hepatitis C virus (HCV) infection at an early age. However, suspecting HCC is enigmatic at early age in which biochemical marker may aid in identifying such patients. In this article, we describe an unusual case of a 27-years-old male who presented with complaints of vague right upper abdominal fullness, non-bilious, non-projectile vomiting, loss of appetite, and significant weight loss for the past 2 months. On examination, there was firm, non-tender hepatomegaly. Patient had normal liver enzymes with very high alpha-fetoprotein (AFP) level (> 10,000 U/mL). Ultrasound
abdomen suggested hetero-echoic lesion in liver along with chronic kidney disease (CKD) changes. The triple phase CT of the abdomen showed a liver mass with arterial enhancement and delayed washout suggestive of HCC. Chronic HCV infection was confirmed with high RNA titres (> 50,000 IU/mL). Patient was diagnosed as HCC at an early stage, which allowed for timely initiation of treatment. This early age onset of HCC in a young adult may be due to multiple factors such as HCV infection, alcoholism, cirrhosis, and CKD. This single case study confirms that alcohol-induced liver injury increases the risk of developing early age HCC in persons infected with HCV and complicated with CKD. And AFP measurement helps in
early identification of HCC, especially at such high level > 10,000 U/mL.

Retrospective analysis of endoscopic dilatation for pediatric patients with esophageal stricture: Bangladesh perspective

Rafia Rashid — Mon, 21 Aug 2023 00:00:00 +0800

Background and objectives: Esophageal stricture in children is an intrinsic narrowing of the esophagus due to different etiologies, including congenital anomalies, corrosive substance or foreign body ingestion, and post-esophageal surgeries. The purpose of this study is to retrospectively evaluate the results and procedures of endoscopic dilatation (ED) performed on children with esophageal strictures in a specialized center in Bangladesh. Methods: Between September 2018 and October 2022, 21 children aged 0.2 to 15 years at the time of the first procedure who underwent 48 ED sessions were included at Bangladesh Specialized Hospital (Dhaka, Bangladesh). We documented the basic characteristics of patients, indications for ED, therapeutic procedures, and outcomes. Outcome parameters were the frequency of dilatations, complications (if any), and clinical success rates. Clinical success was defined as no necessity of ED for a minimum of one year or increasing intervals among repeated dilatations. Results: Among the studied patients, the most common causes of stricture were congenital esophageal atresia and ingestion of corrosive substances. More than half of the studied patients required multiple ED sessions, with one patient requiring eight sessions who had congenital esophageal atresia with a postsurgical stricture. Dilatation was achieved mostly using Savary-Gilliard or controlled radial expansion balloons varying in sizes between 8.0 mm to 30 mm. More than 76% of the studied patients had clinical success, while the rest had clinical failures or unfinished treatment. Conclusion: ED attained good clinical success if performed by skilled gastroenterologists. However, repeated dilatation is frequent, especially in patients with a corrosive-caused stricture.

Radiologic imaging utilization in the diagnosis of acute pancreatitis

Tue, 26 Dec 2023 00:00:00 +0800

Background and objectives: Acute pancreatitis is a major cause of hospitalizations in the United States. Imaging is often unwarranted in early, uncomplicated pancreatitis however can prove to be useful in specific clinical scenarios. This study aimed to investigate whether our institution overutilizes abdominal imaging in diagnosis of pancreatitis. Methods: Patients with acute pancreatitis admitted to our institution between 2015 and 2020 were identified using the International Classification of Diseases diagnosis codes. A total of 669 patients met the criteria for acute pancreatitis according to the revised Atlanta Classification. The data was presented using frequencies and percentages and patients with abdominal imaging were compared to those without. Mann Whitney U test and chi-square test were used to compare continuous and categorical variables respectively. Univariable and multivariable regression analysis was used to analyze factors associated with the performance of abdominal imaging. Results: Our results found that 495 patients (74%) had an abdominal computerized tomography (CT) scan, while 363 patients (52%) had an abdominal ultrasound. More than half of the patients who already met 2 out of 3 clinical and laboratory criteria of the revised Atlanta classification still underwent abdominal imaging, even though it was not necessary. However, we found no significant difference in outcomes between patients who underwent imaging and those who did not, including the need for mechanical ventilation, intensive care unit admission, and inpatient death. Conclusion: A significant number of patients admitted for acute pancreatitis undergo abdominal imaging even after fulfilling clinical and laboratory diagnostic criteria.