Expert Recommendations on the Diagnosis of Eosinophilic Esophagitis in the United Arab Emirates.

Eosinophilic esophagitis (EoE) is a chronic, progressive, type 2 inflammatory esophageal disease presenting as dysphagia to solid food and non-obstructive food impaction. Knowledge gaps exist in its diagnosis and management. These expert recommendations focused on the diagnosis of EoE in the United Arab Emirates. An electronic search of PubMed and Embase databases was used to gather evidence from systematic reviews, randomized controlled trials, consensus papers, and expert opinions from the last five years on the diagnosis of EoE. The evidence was graded using the Oxford system. Literature search findings were shared with the expert panel. A 5-point scale (strongly agree, agree, neither agree nor disagree, disagree, and strongly disagree) was used, and a concordance rate of >75% among experts indicated agreement. Using a modified Delphi technique, 18 qualified experts provided 17 recommendations. Eleven statements achieved high agreement, four got moderate agreement, and two got low agreement. Challenges exist in diagnosing EoE, particularly in children. Esophageal biopsies were crucial in diagnosis, irrespective of visible mucosal changes. Further research on diagnostic tools like endoscopic mucosal impedance and biomarkers is needed. Diagnosis relies on esophageal biopsies and symptom-histology correlation; however, tools like EoE assessment questionnaires and endoscopic mucosal impedance could enhance the accuracy and efficiency of EoE diagnosis. The diagnosis of EoE is challenging since the symptoms seldom correlate with the histological findings. Currently, diagnosis is based on patient symptoms and endoscopic and histological findings. Further research into mucosal impedance tests and the role of biomarkers is needed to facilitate diagnosis.

Essential phospholipids for nonalcoholic fatty liver disease associated with metabolic syndrome: A systematic review and network meta-analysis.

BACKGROUND: Essential phospholipids (EPL) are used for the supportive treatment of non-alcoholic fatty liver disease (NAFLD), but data are mostly from small-scale studies. AIM: To evaluate the efficacy of EPL treatment in adult patients with NAFLD and type 2 diabetes and/or obesity. METHODS: The MEDLINE, PubMed, Embase, and Cochrane databases were searched up to March 2019 for clinical trials and comparative observational studies. Eligible studies were those published in English or Chinese that enrolled adult patients (≥ 18 years) with NAFLD and type 2 diabetes mellitus and/or obesity receiving EPL as monotherapy or as add-on therapy to existing therapy, and that included at least one of the efficacy outcomes of interest. A variety of studies were identified; thus, direct, indirect and cohort meta-analyses were performed. Mean difference (MD) and 95% confidence interval (CI) were calculated for continuous variables, and relative risk with 95%CI for disease response and recovery. A random-effects model was used to address between-study heterogeneity. RESULTS: Ten studies met the inclusion criteria (n = 22-324). EPL treatment duration ranged from 4 to 72 wk. In the direct meta-analysis (four randomized controlled trials), compared with antidiabetic therapy alone, EPL plus antidiabetic therapy was associated with a significantly greater reduction in [alanine aminotransferase (ALT); MD: 11.28 U/L (95%CI: -17.33, -5.23), P = 0.0003], triglyceride [MD: -49.33 mg/dL (95%CI: -66.43, -32.23), P < 0.0001] and total cholesterol levels [MD: -29.74 mg/dL (95%CI: -38.02, -21.45), P < 0.0001]. There was also a significant increase in the rate of overall improvement [relative risk 1.50 (95%CI: 1.26-1.79), P < 0.0001], and risk of no disease (P = 0.0091), and a reduction in moderate disease (P = 0.0187); there were no significant differences in severe disease, mild disease, or significant improvement. In the cohort meta-analysis of three non-randomized clinical trials, the MD in ALT levels was -16.71 U/L (95%CI: -24.94, -8.49) and 23% of patients had improved disease. In the cohort meta-analysis of five randomized trials, MD in ALT levels was -28.53 U/L (95%CI: -35.42, -21.65), and 87% (95%CI: 81%, 93%) and 58% (95%CI: 46%, 70%) of patients showed clinical improvement and significant clinical improvement. CONCLUSION: This analysis provides evidence for a benefit of EPL in patients with NAFLD and diabetes and/or obesity. Further large-scale trials are warranted.

Standard triple therapy versus sequential therapy for eradication of Helicobacter pylori in treatment naïve and retreat patients.

BACKGROUND AND STUDY AIMS: Untreated Helicobacter pylori infection causes increased risk of gastric cancer, GI morbidity and mortality. Standard treatment for eradication of Helicobacter pylori infection, is the triple therapy which consists of a proton pump inhibitor; together with two antibiotics (amoxicillin 1000mg with clarithromycin 500mg or metronidazole 400mg) given twice daily for 7-14days. Recent evidence revealed, that cure rates of Helicobacter pylori infection with triple therapy had fallen below satisfactory targets. Sequential therapy consisting of a twice daily dose of a PPI for ten days with Amoxicillin given at 1000mg twice daily in the first 5days followed by clarithromycin 500mg and Metronidazole 400mg given twice daily in the subsequent 5days, was recommended to improve eradication rates. We performed a randomised open label study to compare the efficacy of sequential against triple therapy in Helicobacter pylori naive and retreat patients. PATIENTS AND METHODS: In a randomised open label observational study 485 patients fulfilling inclusion and exclusion criteria were randomly assigned to be treated with triple therapy (n=231) or sequential therapy (n=254). Eradication of Helicobacter pylori was documented with 14C Urea breath test (UBT) performed 6weeks after the treatment. RESULTS: The intention-to-treat eradication rate was better in sequential therapy group 84.6% than triple therapy 68% (p<0.001). Eradication rates were significantly higher for treatment naive than retreat patients in triple therapy group (70.5% and 58.3%, respectively, p<0.01). A trend of a better response was observed in eradication rate for treatment naive 88.55% versus retreat 74.6% in sequential therapy group but was not statistically significant (p=0.76). Compliance was similar in the two groups, however side effects were less and the clinical response was better in the sequential therapy group.

New combined parameter of liver and splenic stiffness as determined by elastography in healthy volunteers.

BACKGROUND: The diagnosis of chronic liver disease (CLD) leading to fibrosis, cirrhosis, and portal hypertension had witnessed dramatic changes after the introduction of noninvasive figure accessible tools over the past few years. Imaging techniques that are based on evaluation of the liver stiffness was particularly useful in this respect. Acoustic radiation force impulse (ARFI) emerged as an interesting figure tool with reliable repute and high precision. AIMS: To evaluate liver stiffness measurement (LSM) and splenic stiffness measurement (SSM) in healthy volunteers as concluded by the ARFI technique and to out a numeric calculated ratio that may reflect their correlation in the otherwise healthy liver. PATIENTS AND METHODS: A ratio (splenic stiffness/liver stiffness in kPa) was determined in 207 consenting healthy subjects and was investigated with respect to age, gender, ethnic origin, body mass index (BMI), liver and spleen sizes healthy volunteers, alanine aminotransferase (ALT), aspartate aminotransferase (AST), platelet count (PLT), APRI, and FIB-4 scores. RESULTS: Data from this work led to computing an index of 4.72 (3.42-7.33) in healthy persons on an average. Females had a higher index than males 6.37 vs 4.92, P=0.002. There was not any significant difference of the ratio in different age groups; ethnic origins; any correlation between SSM/LSM ratio and BMI; liver and spleen sizes; or ALT, AST, PLT, APRI, and FIB-4 scores. CONCLUSIONS: A quantifiable numeric relationship between splenic and liver stiffness in the healthy subjects could be computed to a parameter expressed as SSM/LSM ratio. We believe that this ratio can be a useful reference tool for further researches in CLD.

Treatment of nonalcoholic fatty liver disease: Where do we stand? an overview.

Nonalcoholic fatty liver disease (NAFLD) is currently the most common liver disease worldwide, the prevalence of which had progressively increased over the past 10 years where other liver diseases remained at the same prevalence rates or are expected to decrease as in the case of hepatitis C virus (HCV). The treatment of NAFLD is of prime concern to health care professionals and patients due to the significant mortality and morbidity it implies; the problem is further escalated by the fact that standard of care medications targeting NAFLD remain experimental and without evidence base. Treatment nowadays is focused on lifestyle modification and managing the comorbid associated diseases, with a possible role for some hepatic protective agents. This review presents all the medications that had been proposed and used for the treatment of NAFLD with or without scientific rationale and includes agents for weight loss, insulin sensitizers, drugs that reduce blood lipids, glucagon-mimetics, drugs that may reduce fibrosis, angiotensin receptor blockers, and medicines believed to reduce endoplasmic reticular stress such as vitamin E, ursodeoxycholic acid, and S-adenosyl methionine. A quick review of the newer agents that proved to be promising such as obeticholic acid and GFT505 and the medicines that are still in the pipeline is also presented.

Essential phospholipids as a supportive adjunct in the management of patients with NAFLD.

BACKGROUND AND STUDY AIMS: Treatment of nonalcoholic fatty liver (NAFLD) is important because NAFLD patients have a 1.7-fold increase in standardised age and gender matched mortality. Currently treatment is based on life style modification and managing comorbid associating disease. Other medications remain experimental. Essential phospholipid (EPL) is a nutrient for the liver, helping to maintain vitality of cell membranes where the vast majority of liver activities are regulated. We performed a randomised open label study to evaluate EPL as an adjuvant nutrient to the treatment of primary NAFLD or NAFLD with comorbid disease. PATIENTS AND METHOD: Three groups of NAFLD patients were recruited: lone (n=113), diabetes mellitus type 2 (n=107) and mixed hyperlipidaemia (n=104). Diagnosis was established by excluding other chronic liver diseases. A standard diet and physical activity plan were advised to all patients. 1800mg of EPL a day was given for 24weeks, followed by 900mg for 48weeks. RESULTS: Essential phospholipid EPL led to a significant improvement of symptoms and a mean reduction of ALT of 50.8IU and AST of 46.1IU per patient (p<0.01). Abdominal ultrasonography indicated normalisation in 4.6% and a shift from grade II to grade I in 24% of patients. Liver stiffness measurement indicated an improvement in 21.1%, with a mean reduction in the LSM of 3.1K Pascal/patient. Reducing the dosage after six months led to a limited relapse in 43.8-63.2% of patients, for lone and NAFLD with co-morbid conditions. CONCLUSION: Essential phospholipid (EPL) as a nutritional supplement resulted in a significant improvement in clinical parameters and transaminases for all NAFLD patients. Ultrasound and LSM revealed modest improvement. There is a need for uninterrupted maintenance to avoid relapse.

Do probiotics improve eradication response to Helicobacter pylori on standard triple or sequential therapy?

BACKGROUND: The standard triple therapy for the eradication of Helicobacter pylori consists of a combination of a proton pump inhibitor at a standard dose together with two antibiotics (amoxicillin 1000 mg plus either clarithromycin 500 mg or metronidazole 400 mg) all given twice daily for a period of 7-14 days. Recent reports have shown a dramatic decline in the rate of H. pylori eradication utilizing standard triple therapy from 95% down to 70-80%. AIMS: Our study was designed to evaluate the effect of adding a probiotic as an adjuvant to common regimens used for H. pylori eradication. MATERIALS AND METHODS: An open label randomized observational clinical study was designed to test three different regimens of H. pylori eradication treatment: Standard triple therapy with a concomitant probiotic added at the same time (n = 100), starting the probiotic for 2 weeks before initiating standard triple therapy along with the probiotic (n = 95), and the third regimen consists of the probiotic given concomitantly to sequential treatment (n = 76). The three arms were compared to a control group of patients treated with the traditional standard triple therapy (n = 106). RESULTS: The eradication rate for the traditional standard therapy was 68.9%, and adding the probiotic "Bifidus infantis" to triple therapy, led to a successful rate of eradication of 83% (P < 0.001). Pre-treatment with 2 weeks of B. infantis before adding it to standard triple therapy increased the success rate of eradication to 90.5%. Similar improvement in eradication rate was noted when B. infantis was added as an adjuvant to the sequential therapy leading to an eradication rate of 90.8%. CONCLUSION: Adding B. infantis as an adjuvant to several therapeutic regimens commonly used for the eradication of H. pylori infection significantly improves the cure rates.