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Year : 2023  |  Volume : 3  |  Issue : 1  |  Page : 29-30

Gastroenterology Elsewhere

Department of Medical Gastroenterology, SIMS Institute of Gastroenterology Hepatobiliary Sciences and Liver Transplantation, SRM Institute for Medical Science Hospital, Chennai, Tamil Nadu, India

Date of Submission15-Oct-2022
Date of Decision15-Nov-2022
Date of Acceptance17-Nov-2022
Date of Web Publication28-Dec-2022

Correspondence Address:
Kayalvizhi Jayaraman
Department of Medical Gastroenterology, SIMS Institute of Gastroenterology Hepatobiliary Sciences and Liver Transplantation, SRM Institute for Medical Science Hospital, Chennai - 600 026, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ghep.ghep_27_22

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How to cite this article:
Jayaraman K. Gastroenterology Elsewhere. Gastroenterol Hepatol Endosc Pract 2023;3:29-30

How to cite this URL:
Jayaraman K. Gastroenterology Elsewhere. Gastroenterol Hepatol Endosc Pract [serial online] 2023 [cited 2023 Jan 27];3:29-30. Available from: http://www.ghepjournal.com/text.asp?2023/3/1/29/365721

  Inflammatory Bowel Disease and Iron-Deficiency Anemia: Ferric Carboxymaltose or Ferric Isomaltoside? Top

Zoller H, Wolf M, Blumenstein I, Primas C, Lindgren S, Thomsen LL, et al. Hypophosphataemia following ferric derisomaltose and ferric carboxymaltose in patients with iron deficiency anemia due to inflammatory bowel disease (PHOSPHARE-IBD): A randomized clinical trial. Gut 2022. (Doi: 10.1136/gutjnl-2022-327897). Online ahead of print.

Hypophosphatemia has recently been noted as an adverse event of iron infusion. The infused iron increases the levels of the phosphatonin and fibroblast growth factor 23, which reduces renal phosphate reabsorption. The authors compare two forms of parenteral iron therapy in patients with inflammatory bowel disease (IBD) and iron-deficiency anemia (IDA). Baseline and 35-day phosphate levels were measured in 49 patients who received ferric derisomaltose (FDI) and 48 patients who received ferric carboxymaltose (FCM). More than half of the FCM group developed low levels of phosphate as compared to 8% in the FDI group (adjusted risk difference: 42.8% (95% confidence interval [CI] −57.1% to −24.6%) P < 0.0001). Fatigue, a symptom of IDA, hypophosphatemia, and IBD, was assessed using a scoring system. Fatigue improved in both groups but much less and slower in the FCM group, inversely relating to the degree of hypophosphatemia (P = 0.0063). Hemoglobin and other iron indices improved similarly in both groups. The differences in the incidence of hypophosphatemia are striking, but the study duration is small. Hypophosphatemia may likely be transient and resolve spontaneously. Whether FDI has a clear advantage over FCM besides the biochemical changes remains unanswered.

  Completion Rates: Cold Snare versus Hot Snare, a Randomized Controlled Trial Top

Pedersen IB, Rawa-Golebiewska A, Calderwood AH, Brix LD, Grode LB, Botteri E, et al. Complete polyp resection with cold snare versus hot snare polypectomy for polyps of 4-9 mm: A randomized controlled trial. Endoscopy 2022;54:961-9.

Cold snare polypectomy (CSP) has become widely popular for its efficacy and low rates of complications. Meta-analyses have shown that the completeness of resection by cold snare and hot snare is similar. In this randomized controlled trial (RCT), 425 patients with 601 sessile 4–9 mm and polyps were randomized to undergo hot snare polypectomy (HSP, n = 283) and CSP (n = 318). At the end of the polypectomy, biopsies from the margin were taken to assess the completeness of the procedure. Most of the polyps in both groups were elevated, located in the distal colon, had tubular histology, and resected en-bloc. The incomplete resection rates in CSP were 10.7% and 7.4% in the HSP group. The observed adjusted risk difference between the two groups was 3.2% (95% CI − 1.4%–7.8%). Although noninferiority of CSP was not demonstrated, complications such as bleeding and perforation were similar in both groups. The authors also found that serrated and hyperplastic polyps were more likely to be resected incompletely. With the cold snare revolution, this study reminds the gastroenterologist to be wary of the possibility of incompleteness, especially with serrated lesions. Nonetheless, CSP is here to stay and will remain the method of choice for diminutive polyps.

  Ethyl Glucuronide in Hair, A Marker of Long-Term Alcohol Use Top

Staufer K, Huber-Schönauer U, Strebinger G, Pimingstorfer P, Suesse S, Scherzer TM, et al. Ethyl glucuronide in hair detects a high rate of harmful alcohol consumption in presumed non-alcoholic fatty liver disease. J Hepatol 2022;77:918-30.

Clinicians rely on patients' statements for quantifying alcohol, especially when it comes to liver disease, and it is taken at face value. Patients may sometimes deny intake or have a recall bias when asked to quantify alcohol consumption. Patients with nonalcoholic fatty liver disease (NAFLD, n = 114) and alcoholic liver disease (ALD, n = 70) were enrolled, and their drinking pattern was quantified using the Systematic Inventory of Alcohol Consumption. Ethyl glucuronide (ETG), a metabolite of alcohol, can be detected in hair, with the proximal shaft (0 cm–3 cm) reflecting recent (past 3 months) and mid shaft (3–6 cm) reflecting longer (past 6 months) duration of alcohol consumption. Hair ETG reclassified at least 30% of those identified initially as NAFLD as ALD. In the ALD group, hair ETG identified a third of patients as active drinkers. Researchers compared its performance against the standard Alcohol Use Disorders Identification Test-Consumption and ALD/NAFLD index, which showed the greatest AUC for hair ETG (0.927). Other markers such as mean corpuscular volume, gamma-glutamyl transferase, and carbohydrate-deficient transferrin were unreliable. Although this test's feasibility and cost-effectiveness as a routine investigation still need to be explored, it seems like a valuable tool in diagnosing chronic liver disease.

  Is Endoscopic Ultrasound A Better Tool for Classifying pancreatic Fluid Collections? Top

Xu N, Li L, Zhao D, Wang Z, Wang X, Wang R, et al. A preferable modality for the differentiation of peripancreatic fluid collections: Endoscopic ultrasound. Endosc Ultrasound 2022;11:291-5.

Pancreatic pseudocyst and walled-off necrosis are well-known complications of acute pancreatitis. The presence of marked necrosis in the fluid collection is often associated with systemic symptoms and needs aggressive measures such as drainage and necrosectomy. Cross-sectional imaging such as computed tomography (CT) or magnetic resonance imaging (MRI) has been conventionally used in categorizing these collections. With the advent of endoscopic ultrasound (EUS), researchers sought to find whether EUS did better than CT/MRI. In a retrospective, multicenter study of 99 patients, 12 out of 99 patients were identified as WON by CT and MRI. After EUS, 42 out of 99 were reclassified as WON. The diagnostic accuracy of EUS for pancreatic fluid collections and walled-off necrosis was higher than CT (90.9% vs. 50.5%, P < 0.001 and 82.4% vs. 13.7%, P < 0.001). EUS cannot be a substitute for noninvasive, effective cross-sectional imaging, but rather a useful ancillary tool for the gastroenterologist. Nevertheless, this study reflects the existing wide practice of assessing the lesion by EUS before puncturing and planning accordingly for drainage and/or necrosectomy.

  Waterfall, A Landmark Trial in the Management of Acute Pancreatitis Top

De-Madaria E, Buxbaum JL, Maisonneuve P, García García de Paredes A, Zapater P, Guilabert L, et al. Aggressive or moderate fluid resuscitation in acute pancreatitis. N Engl J Med 2022;387:989-1000.

For much of our lives, we have practiced aggressive fluid hydration believing — the more fluid, the better the pancreatic microcirculation, and the lesser the pancreatic necrosis. However, evidence supporting this theory is limited. In this multicenter, open-labeled, RCT, 249 patients diagnosed with acute pancreatitis were randomized to receive aggressive (n = 122) and moderate (n = 127) hydration. In the aggressive group, the lactated Ringer's solution was given at a bolus of 20 ml per kg over 2 h, followed by 3 ml/kg/h. The loading and maintenance doses were halved in the moderate group. Patients were assessed at 12, 24, 48, and 72 h, and fluids were adjusted accordingly. The occurrence of moderately severe and severe pancreatitis (primary outcome) was similar in both groups (22% in aggressive vs. 17% in moderate, adjusted relative risk 1.30, 95% CI, 0.78–2.18; P = 0.32) and so were the frequency of organ failure and local complications. The vital data were evident in the safety outcome: Fluid overload was significantly higher in the aggressive group (20%) compared to the moderate group (6%), with adjusted relative risk 2.85, 95% CI, 1.36–5.94; P = 0.004. The researchers suspended the trial due to this observed risk of volume overload in the aggressive hydration group in the interim analysis (the original calculated sample size was 744). This ground-breaking trial has revealed a crucial aspect of patient care: Concepts should be constantly challenged and practices revisited.

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