The gender-related differences of nutrient intakes in a group of Italian obese patients display the ongoing transition from Mediterranean to western dietary patterns.

BACKGROUND: The purpose of this study was to compare nutrients and energy intakes between obese women and men and the variation rates over or below the recommended dietary allowances. METHODS: A retrospective survey was conducted on the records of obese patients, categorized into gender-related groups (36 women, 36 men). Total energy and nutrient intakes were determined. RESULTS: The highest variation rates were found for animal protein, averaging 225 % over the recommended dietary allowance, without significant differences between women and men. The simple carbohydrate intake was quite elevated in women with variations almost 80% over the RDA, significantly higher than in men (22%). CONCLUSION: The consumption of high-protein foods in both sexes, and even more the association with high-simple carbohydrate foods in women, display the Westernization of traditional eating habits.

Upper GI endoscopy in elderly patients: predictive factors of relevant endoscopic findings.

Elderly patients are at increased risk for peptic ulcer and cancer. Predictive factors of relevant endoscopic findings at upper endoscopy in the elderly are unknown. This was a post hoc analysis of a nationwide, endoscopic study. A total of 3,147 elderly patients were selected. Demographic, clinical, and endoscopic data were systematically collected. Relevant findings and new diagnoses of peptic ulcer and malignancy were computed. Both univariate and multivariate analyses were performed. A total of 1,559 (49.5%), 213 (6.8%), 93 (3%) relevant findings, peptic ulcers, and malignancies were detected. Peptic ulcers and malignancies were more frequent in >85-year-old patients (OR 3.1, 95% CI = 2.0-4.7, p = 0.001). The presence of dysphagia (OR = 5.15), weight loss (OR = 4.77), persistent vomiting (OR = 3.68), anaemia (OR = 1.83), and male gender (OR = 1.9) were significantly associated with a malignancy, whilst overt bleeding (OR = 6.66), NSAIDs use (OR = 2.23), and epigastric pain (OR = 1.90) were associated with the presence of peptic ulcer. Peptic ulcer or malignancies were detected in 10% of elderly patients, supporting the use of endoscopy in this age group. Very elderly patients appear to be at higher risk of such lesions.

24-h pH-metry and multichannel intraluminal impedance monitoring in obese patients with and without gastroesophageal reflux disease symptoms.

BACKGROUND: The 24-h ambulatory pH-metry with multichannel intraluminal impedance monitoring (24-h pH-metry+MII) allows the simultaneous assessment of chemical and physical properties of esophageal refluxes and the detection of its proximal migration. METHODS: Gastroesophageal reflux (GER) was investigated in obese symptomatic (obese gastroesophageal reflux disease, GERD) and asymptomatic (obese non-GERD) patients. The data were compared with those obtained from non-obese GERD patients and a control group. Thirty-five (20 non-GERD, 15 GERD) obese patients and 15 non-obese GERD were investigated with 24-h pH-metry+MII. Ten normal weight subjects with normal 24-h pH-metry+MII were used as control group. RESULTS: The percent time acid exposure was significantly higher in obese non-GERD than controls (p = 0.007). Acid reflux episodes were increased vs. controls in obese non-GERD (p = 0.005) and obese GERD (p = 0.034). Upright position showed a significant increase of reflux episodes in non-obese GERD (p = 0.034) and in obese non-GERD (p = 0.027) vs. controls. Recumbent position showed reflux episodes significantly increased vs. controls in obese non-GERD (p = 0.002), obese GERD (p = 0.021), and non-obese GERD (p = 0.033). In obese non-GERD, waist circumference (WC) correlated negatively with upright position episodes (r = -0.53; p = 0.043) and with proximal migration episodes, i.e., total (r = -0.60; p = 0.018), acid (r = -0.55; p = 0.033), and weakly acidic refluxes (r = -0.56; p = 0.031). CONCLUSIONS: Obese patients showed an increased number of refluxes with acid content. Refluxes with proximal extent were significantly higher in obese non-GERD than in controls and non-obese GERD patients. No difference was observed between the two obese patient groups. In asymptomatic obese patients, the WC correlated with proximal extent episodes.

Nutrient intake in Italian obese patients: relationships with insulin resistance and markers of non-alcoholic fatty liver disease.

OBJECTIVE: We investigated the prevalence of insulin resistance, elevated liver enzymes, and Non-Alcoholic Fatty Liver Disease Fibrosis Score (NFS) in obese and severely obese patients. Relations between inadequate nutrient intakes and the markers of metabolic and hepatic disorders were evaluated. METHODS: From January to September 2009, 63 consecutive obese patients (21 men and 42 women, 19-68 y old) were admitted to the study. According to the World Health Organization obesity classification, patients were categorized into three subgroups (classes I, II, and III). NFS scores lower than -1.455 were defined as NFS(-); higher scores were positive (NFS(+)). Insulin resistance (IR) was assessed by the homeostasis model assessment. Nutrient intakes and their potential role as risk factors for IR and liver damage were determined. RESULTS: Body mass index ranged from 30.9 to 73.7 kg/m(2) and most patients (54%) were in class III (body mass index ≥40 kg/m(2)). Homeostasis model assessment of IR (>2.5) was recorded in 63.5%. The prevalence of NFS(+) was significantly higher in class III than in classes II and I. Excessive nutrient and energy intake prevalence showed significant differences for protein, fat, and carbohydrate among the obesity classes. Animal protein (odds ratio 3.43, 95% confidence interval 1.15-10.20) and carbohydrate (odds ratio 3.83, 95% confidence interval 1.33-10.94) intakes were the risk factors for IR and NFS(+). CONCLUSION: Non-normal alanine aminotransferase and γ-glutamyltranspeptidase values were observed in less than one-third of patients, whereas NFS(+) and IR were significantly prevalent, suggesting a close relation between the progression of liver fibrosis and metabolic derangement. An excessive intake of animal protein is associated with an increased risk of IR. Carbohydrate intake, albeit at the highest limit of the recommended dietary allowance range, is associated with an increased risk of liver fibrosis.

Appropriateness guidelines and predictive rules to select patients for upper endoscopy: a nationwide multicenter study.

OBJECTIVES: Selecting patients appropriately for upper endoscopy (EGD) is crucial for efficient use of endoscopy. The objective of this study was to compare different clinical strategies and statistical methods to select patients for EGD, namely appropriateness guidelines, age and/or alarm features, and multivariate and artificial neural network (ANN) models. METHODS: A nationwide, multicenter, prospective study was undertaken in which consecutive patients referred for EGD during a 1-month period were enrolled. Before EGD, the endoscopist assessed referral appropriateness according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines, also collecting clinical and demographic variables. Outcomes of the study were detection of relevant findings and new diagnosis of malignancy at EGD. The accuracy of the following clinical strategies and predictive rules was compared: (i) ASGE appropriateness guidelines (indicated vs. not indicated), (ii) simplified rule (>or=45 years or alarm features vs. <45 years without alarm features), (iii) logistic regression model, and (iv) ANN models. RESULTS: A total of 8,252 patients were enrolled in 57 centers. Overall, 3,803 (46%) relevant findings and 132 (1.6%) new malignancies were detected. Sensitivity, specificity, and area under the receiver-operating characteristic curve (AUC) of the simplified rule were similar to that of the ASGE guidelines for both relevant findings (82%/26%/0.55 vs. 88%/27%/0.52) and cancer (97%/22%/0.58 vs. 98%/20%/0.58). Both logistic regression and ANN models seemed to be substantially more accurate in predicting new cases of malignancy, with an AUC of 0.82 and 0.87, respectively. CONCLUSIONS: A simple predictive rule based on age and alarm features is similarly effective to the more complex ASGE guidelines in selecting patients for EGD. Regression and ANN models may be useful in identifying a relatively small subgroup of patients at higher risk of cancer.

Bariatric therapy with intragastric balloon improves liver dysfunction and insulin resistance in obese patients.

BACKGROUND: Obesity is often associated with fatty liver (FL). In most cases, bright liver at ultrasound (US) and increased alanine aminotransferase (ALT) and gamma-glutamyltranspeptidase (GGT) levels are considered the hallmarks of nonalcoholic fatty liver disease (NAFLD). Insulin resistance (IR) is the main link between obesity and NAFLD. The use of the Bioenterics intragastric balloon (BIB) is a safe procedure either for inducing a sustained weight loss with diet support or for preparing those patients who are candidates for bariatric surgery. The aim of the study was to investigate whether the weight loss induced by intragastric balloon might improve IR and liver enzymes. The presence or absence of FL at US and the influence of a body mass index (BMI) decrease > or = 10% after BIB (DeltaBMI > or = 10%) were also considered. METHODS: One hundred and three consecutive obese (BMI > 30 kg/m(2)) patients (38 males/65 females; mean age 41.3, range 20-63 years) underwent BIB insertion under endoscopic control. The BIB was removed 6 months later. US, clinical, and routine laboratory investigations were performed before and after BIB. IR was calculated by the homeostasis model assessment (HOMA-IR > 2.5). Exclusion criteria were hepatitis B virus positive, hepatitis C virus positive, alcohol consumption >30 g/day, history of hepato-steatogenic drugs, and type 1 diabetes. RESULTS: Ninety-three patients were eligible for the study. The BMI significantly decreased in all investigated patients, and it was > or = 10% in 59% of the patients. FL was seen at US in 70%, impaired fasting blood glucose was present in 13%, ALT exceeded the normal limit in 30.1%, GGT exceeded the normal limit in 15%, and HOMA-IR was >2.5 in 85%. Median HOMA-IR decreased significantly in FL (4.71 vs 3.10; p < 0.05) and non-FL (3.72 vs 2.81; p < 0.01) groups. Median ALT decreased significantly in the FL group (31.5 vs 24; p < 0.001) and GGT significantly decreased in the FL group (31 vs 23.5; p < 0.05). In the FL group with DeltaBMI > or = 10%, the median values of HOMA-IR (4.95 vs 2.69; p < 0.05), ALT (30 vs 23; p < 0.01), and GGT (28 vs 20; p < 0.001) significantly decreased after BIB. In the non-FL group, HOMA-IR values significantly decreased (4.07 vs 2.36; p < 0.01) in patients with a DeltaBMI > or = 10%; ALT and GGT did not significantly decrease. CONCLUSIONS: Weight loss induced by intragrastric balloon reduces IR. The ALT and GGT decrease suggests an improvement in hepatic damage. The benefit depends on the decrease of BMI higher than 10%.

Intragastric balloon insertion increases the frequency of erosive esophagitis in obese patients.

BACKGROUND: The BioEnterics intragrastric balloon (BIB) has been successfully used for treatment with BMI >35 or BMI >40. Gastroesophageal reflux (GER) symptoms are sometimes reported to occur and/or to worsen in patients with BIB, with a variable onset of erosive esophagitis (EE). The aim of this study was to investigate the prevalence and the severity of esophagitis after BIB placement. METHODS: 121 patients (93 F, 28 M, mean age 45 (19-65), mean BMI 41.5 (30-63.5) were studied. Patients with severe esophagitis (grade C-D Los Angeles (LA) classification), gastric or duodenal ulcers were excluded from the BIB treatment. After BIB placement, proton-pump inhibitors (PPI) were administered in the first month to each patient. The BIB was removed after 6 months. The presence of EE and related severity by LA classification were recorded RESULTS: Before BIB insertion, 18 patients (15%) showed mild EE (16 grade A and 2 grade B). After BIB removal, EE was observed in 22 patients (18.2%): 11 grade A, 7 grade B, 4 grade C-D. The difference in the prevalence of EE after BIB was statistically significant (Wilcoxon's test P =0.030). CONCLUSION: EE prevalence was significantly increased after BIB placement. We suggest that EE due to enhanced GER could be considered as an adverse effect of such treatment. We therefore recommend maintaining intragastric acid suppression with PPIs during the 6 months of BIB placement.

Appropriateness of upper-GI endoscopy: an Italian survey on behalf of the Italian Society of Digestive Endoscopy.

BACKGROUND AND OBJECTIVE: Open-access endoscopy allows physicians to directly schedule endoscopic procedures for their patients without prior consultation. An evaluation of both appropriateness and diagnostic yield of endoscopic procedures is critical when assessing the costs and benefits of endoscopy in an open-access setting. The aim of this Italian multicenter study was to assess the appropriate use of upper endoscopy (EGD) in an open-access system and to establish the yield of diagnostic information relevant to patient care. DESIGN AND SETTING: Cross-sectional, prospective, multicenter study. PATIENTS: A total of 6270 patients referred to 44 Italian centers for open-access EGD during 1 month were prospectively enrolled. INTERVENTIONS: The American Society for Gastrointestinal Endoscopy (ASGE) guidelines were used to assess the relation between the appropriate use of EGD and the presence of relevant endoscopic findings. MAIN OUTCOME MEASUREMENTS AND RESULTS: The rate for "generally not indicated" EGDs was 22.9%: 29.4% for primary care physicians and 12.9% for specialists (P < .01). A relevant endoscopic finding was detected in 2929 examinations (46.7%). The diagnostic yield was significantly higher for "generally indicated" EGDs compared with "generally not indicated" procedures (52% vs 29%; odds ratio [OR] 2.65, 99% confidence interval [CI] 2.23-3.20; P < .01). Of the 133 malignant lesions diagnosed, all but 1 were diagnosed in patients with an appropriate indication (OR >20, 99% CI 3 to >100; P < .01). CONCLUSIONS: Open-access EGD is an useful procedure for clinical practice. Because most of the relevant findings were detected during examinations performed for appropriate indications, the use of ASGE guidelines emerges as crucial to the cost-effectiveness of an open-access system.

Comparison between the two systems to evaluate the appropriateness of endoscopy of the upper digestive tract.

OBJECTIVES: The aim of this study was to compare the diagnostic performance of the two systems for the evaluation of the appropriateness of upper digestive endoscopy suggested by the American Society of Gastrointestinal Endoscopy (ASGE) and by the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE). METHODS: Patients referred for the upper digestive endoscopy (EGD) to a University Outpatients Clinic of Northeastern Italy were consecutively included in this prospective observational study. Before the EGD, the endoscopist assigned the patients to one of the ASGE appropriateness classes; another endoscopist then identified the detailed clinical scenario for the patients, which corresponds to scenarios examined by EPAGE by using a nine-point scale: 1-3 inappropriate; 4-6 uncertain; and 7-9 appropriate. The relationship between the appropriateness of use and the presence of relevant endoscopic lesions (neoplasms, ulcers, esophagitis, erosive gastritis/duodenitis, stenosis, and varices) was assessed, calculating the sensitivity and the specificity for each of the ASGE criteria, and each of the EPAGE scores, and plotting them to form a receiver operating characteristic (ROC) curve. The area under the ROC curve (AUC) provides a summary measure of test performance, and can vary from a minimum of 0.5 to a maximum of 1.0. We compared the AUC of the ROC curve derived from the ASGE criteria against that derived from the EPAGE criteria. RESULTS: A total of 2,300 consecutive patients were included in the study (42% men; mean age: 57.3; range: 12-99); comparison of appropriateness criteria according to the ASGE and EPAGE could be made for 2,000 patients. The AUC of the ROC curve derived from the ASGE criteria was 0.553 (95% CI: 0.527-0.579), significantly higher than the AUC of the ROC curve derived from the EPAGE score: 0.523 (95% CI: 0.497-0.549; p < 0.05). CONCLUSIONS: We suggest that the diagnostic yield for relevant endoscopic findings obtained by both the systems (ASGE and EPAGE) is low; slightly better results could be accomplished by the ASGE criteria.

ASGE guidelines for the appropriate use of upper endoscopy: association with endoscopic findings.

BACKGROUND: This prospective study examined the appropriate use of EGD in an open-access system with the American Society for Gastrointestinal Endoscopy (ASGE) guidelines and determined whether the ASGE guidelines were associated with relevant endoscopic findings. METHODS: In a cohort of 1777 consecutive patients referred for open-access EGD, the proportion of patients who underwent EGD for appropriate indications was prospectively assessed. The relationship between appropriateness and the presence of clinically relevant endoscopic diagnoses was assessed by calculating (1) the likelihood ratio, positive and negative, of the indications; and (2) the change in the probability of relevant endoscopic diagnoses in the presence of the ASGE criteria. RESULTS: The rate for EGDs "generally not indicated" was 15.6%. Relevant endoscopic diagnoses were present in 47.4% of cases with ASGE indications versus 28.8% of patients without appropriate indications as defined by the ASGE criteria (OR: 2.23; 99% CI [1.55, 3.22]; p < 0.01). A similar difference was observed for erosive gastritis (OR: 1.86; 99% CI [1.17, 2.95]; p < 0.01), erosive esophagitis (OR: 1.48; 99% CI [0.87, 2.52]; p < 0.05), and Barrett's esophagus (OR: 9.76; 99% CI [0.72, 132]; p < 0.05). The pretest probability of finding a relevant endoscopic diagnosis was modified slightly when an ASGE indication(s) was present and decreased markedly when ASGE criteria were absent. CONCLUSIONS: The use of the ASGE guideline for appropriate indications for EGD can improve patient selection for the procedure. However, to avoid missed diagnoses of serious disease, use of the guidelines must be tailored to the specific clinical setting.