Effect of prehabilitation for patients undergoing gastric cancer surgery: a protocol of a systematic review and meta-analysis.

INTRODUCTION: Gastric cancer is a high-risk cancer with surgical treatments often leading to significant postoperative complications and mortality. Prehabilitation, involving exercise, nutrition and psychological support before surgery, aims to boost patients' physical and mental health. While effective in other cancers, its benefits for gastric cancer need further study. This research will evaluate the impact of trimodal prehabilitation on patient outcomes in gastric cancer surgery, aiming to reduce complications and expedite recovery. METHODS AND ANALYSIS: This study will systematically review randomised controlled trials and cohort studies evaluating the role of prehabilitation in people undergoing gastric cancer resection. The primary outcomes of interest will include overall postoperative complications and length of hospital stay. The secondary outcomes of interest will include mortality, readmission rate or functional recovery. Databases including PubMed, EMBASE, CINAHL, CENTRAL, Chinese BioMedical Literature Database (CBM), Chinese National Knowledge Infrastructure (CNKI), Wanfang database and Chinese Science and Technology Periodicals (VIP) will be searched. All studies will be screened and selected using the criteria described in 'population, intervention/exposure, comparison, outcome and study design' format. Two independent reviewers will screen studies for relevance and methodological validity. Data from included studies will be extracted through a customised, preset data extraction sheet. The Cochrane Review Manager (V.5.3, Nordic Cochrane Centre, Copenhagen, Denmark) software will be used to perform the meta-analysis. ETHICS AND DISSEMINATION: Ethics approval is not required for this study as all results will be based on published papers. No primary data collection will be needed. Study findings will be presented at scientific conferences or published in a peer-reviewed scientific journal. PROSPERO REGISTRATION NUMBER: CRD42023488469.

Acute Colonic Pseudo-Obstruction: A Case of Ogilvie Syndrome.

Ogilvie syndrome is a pseudo-obstruction of the large colon that does not contain any mechanical obstruction. This is a case of a 32-year-old female who presented to the emergency department (ED) for acute onset vomiting and intermittent watery diarrhea. Based on her presentation, physical exam, and computed tomography (CT) findings, she was diagnosed with Ogilvie syndrome. The pathophysiology of Ogilvie syndrome involves a disruption of normal colonic motility, leading to excessive gas and fluid accumulation. Abdominal imaging typically reveals a massively dilated colon with no evident obstructive lesion. Initial management is conservative and includes supportive measures such as bowel rest and decompression, and may include medications to enhance colonic motility. In severe cases, endoscopic or surgical intervention to relieve symptoms and prevent complications such as bowel ischemia or perforation may be necessary. Identifying and addressing underlying precipitating factors is crucial for effective treatment and preventing recurrence.

Bile acid modulation by gut microbiota: a bridge to understanding cognitive health.

The gut microbiota plays an important role in regulating the body's physiological system, and more recently its impact on bile acid metabolism and cognitive function has been investigated by many studies. In addition to their conventional function in fat digestion and absorption, bile acids are now considered crucial signaling molecules that control several metabolic processes and immunological responses. For this purpose, the authors conducted comprehensive research using relevant terms in an attempt to understand more about the gut microbiota and its impact on bile acid metabolism and cognitive health. The gut-brain axis refers to the network of routes through which gut bacteria communicate with the brain. Through its capacity to bio-transform primary bile acids into secondary bile acids, the gut microbiota plays a significant role in bile acid metabolism. Bile acids function as signaling molecules and act on the brain through nuclear and membrane-bound receptors, influencing neurotransmitter production, neuroinflammation, and neuroplasticity to modify this communication. Any dysregulation in this axis can result in cognitive dysfunction. The link between gut microbiota, bile acids, and cognitive health cannot be ignored. It is imperative to explore this link further by conducting large-scale trials to improve the cognitive health of patients with multiple comorbidities, especially those involving the gastrointestinal tract and nervous system.

Generative AI in Pediatric Gastroenterology.

PURPOSE OF REVIEW: The integration of digital technology into medical practice is often thrust upon clinicians, with standards and routines developed long after initiation. Clinicians should endeavor towards a basic understanding even of emerging technologies so that they can direct its use. The intent of this review is to describe the current state of rapidly evolving generative artificial intelligence (GAI), and to explore both how pediatric gastroenterology practice may benefit as well as challenges that will be faced. RECENT FINDINGS: Although little research demonstrating the acceptance, practice, and outcomes associated with GAI in pediatric gastroenterology is published, there are relevant data adjacent to the specialty and overwhelming potential as professed in the media. Best practice guidelines are widely developed in academic publishing and resources to initiate and improve practical user skills are prevalent. Initial published evidence supports broad acceptance of the technology as part of medical practice by clinicians and patients, describes methods with which higher quality GAI can be developed, and identifies the potential for bias and disparities resulting from its use. GAI is broadly available as a digital tool for incorporation into medical practice and holds promise for improved quality and efficiency of care, but investigation into how GAI can best be used remains at an early stage despite rapid evolution of the technology.

Hepatic sarcoid resembling lymphoma.

Sarcoidosis is an inflammatory disease characterised by non-caseating granulomas that can affect any organ, although lung involvement is the most common. It is rare to find sarcoidosis isolated to extrapulmonary organs. We describe a case of extrapulmonary sarcoidosis with involvement of the liver in a man in his late 40s. His initial clinical history and investigations were more consistent with a diagnosis of lymphoma until a liver biopsy was performed revealing non-caseating granulomas more suggestive of a diagnosis of sarcoidosis. This patient had a history of young-onset ischaemic heart disease (IHD). We discuss the possible links between sarcoidosis, an inflammatory condition, and IHD, as well as the challenges to treating such patients with concurrent metabolic syndrome. This case also highlights the heterogeneous nature of sarcoidosis, with the diagnosis being important as prompt treatment can prevent complications of end-stage liver disease, including portal hypertension and cirrhosis.

Disorders of gut-brain interaction are common diagnoses among infants and toddlers in gastroenterology practices in Latin-America.

OBJECTIVES: To assess the relative frequency and associated factors of disorders of gut-brain interaction (DGBIs) in outpatient gastrointestinal (GI) clinics in young children of Latin America. METHODS: Cross-sectional study in 10 pediatric GI outpatient clinics (private and public) in five countries of Latin America (El Salvador, México, Colombia, Panamá, and Nicaragua). Parents of patients 1 month 4 years of age from outpatient clinics complete/d a diagnostic questionnaire for DGBIs per Rome IV criteria (QPGS-IV, Spanish version). We conducted descriptive analysis, two-sample t-tests and chi-square tests, univariate analyses, and logistic regression to evaluate risk factors. RESULTS: We collected data from 783 children. In total, 34.5% had a DGBI. Overall, functional constipation (FC) was the most common diagnosis (23.4%) in children of all ages (infants, 16.1%, 1-4-years-old, 32.7%). In infants, the second most common DGBI was regurgitation (6.6%) and in 1-4-years-old and cyclic vomiting syndrome (4.1%). The diagnosis of a DGBI was significantly associated with a family history of DGBIs (odds ratio [OR] 2.97, 95% confidence interval [CI] 1.61-5.57, p = 0.0001). Patients who identified as black (OR 2.25, 95% CI 1.28-3.92, p = 0.0021) or mixed race (OR 1.76, 95% CI 1.25-2.48, p = 0.0006) were also significantly associated with a higher likelihood of DGBIs. CONCLUSIONS: DGBIs are a common diagnosis in pediatric GI clinics of Latin America. Overall, FC was the most common DGBI.

Exploring the benefits and challenges of AI-driven large language models in gastroenterology: Think out of the box.

Artificial Intelligence (AI) has evolved significantly over the past decades, from its early concepts in the 1950s to the present era of deep learning and natural language processing. Advanced large language models (LLMs), such as Chatbot Generative Pre-Trained Transformer (ChatGPT) is trained to generate human-like text responses. This technology has the potential to revolutionize various aspects of gastroenterology, including diagnosis, treatment, education, and decision-making support. The benefits of using LLMs in gastroenterology could include accelerating diagnosis and treatment, providing personalized care, enhancing education and training, assisting in decision-making, and improving communication with patients. However, drawbacks and challenges such as limited AI capability, training on possibly biased data, data errors, security and privacy concerns, and implementation costs must be addressed to ensure the responsible and effective use of this technology. The future of LLMs in gastroenterology relies on the ability to process and analyse large amounts of data, identify patterns, and summarize information and thus assist physicians in creating personalized treatment plans. As AI advances, LLMs will become more accurate and efficient, allowing for faster diagnosis and treatment of gastroenterological conditions. Ensuring effective collaboration between AI developers, healthcare professionals, and regulatory bodies is essential for the responsible and effective use of this technology. By finding the right balance between AI and human expertise and addressing the limitations and risks associated with its use, LLMs can play an increasingly significant role in gastroenterology, contributing to better patient care and supporting doctors in their work.

A positive cytokine/chemokine feedback loop establishes plasmacytoid dendritic cell-driven autoimmune pancreatitis in IgG4-related disease.

The pathogenesis of the murine model of autoimmune pancreatitis associated with IgG4-related disease (AIP/IgG4-RD) induced by administration of polyinosinic-polycytidylic acid, is incompletely understood. While it is known that murine and human AIP/IgG4-RD is driven by plasmacytoid dendritic cells (pDCs) producing IFN-α, the origin of these cells and their relation to effector T cells is not known. Here we show that murine AIP was initiated by TLR3-bearing conventional DCs in the uninflamed pancreas whose activation by TLR3 ligand (polyinosinic-polycytidylic acid) caused IFN-α, CXCL9, and CXCL10 secretion. This, in turn, induced pancreatic recruitment of CXCR3+ T cells and these T cells, via their secretion of CCL25, facilitated migration of pDCs bearing CCR9 into the pancreas. This established a feedback loop anchored by the now dominant pDC production of IFN-α and the continued CXCR3+ T cell facilitation of pDC migration. Remarkably, the interaction between CXCR3+ T cells and pDCs also existed at the functional levels since this interaction enhanced the production of CCL25 and IFN-α by CXCR3+ T cells and pDCs, respectively. Evidence presented here that a similar disease mechanism was present in human AIP/IgG4-RD creates new avenues of disease treatment.

The Effect of the Coronavirus (COVID-19) Pandemic on Gender and Medical School Diversity in Gastroenterology Fellowship Matching.

Background and Aims: The COVID-19 pandemic brought unprecedented changes to the medical field, including the gastroenterology (GI) fellowship application process. This study aimed to assess the impact of the pandemic on GI fellowship applications, with a focus on applicants' gender and medical school training type. Methods: Data from the GI match results for 2018-2022 were collected, including the number and percentage of matched applicants per year, categorized by gender, US medical graduates, international medical graduates (IMGs), and Doctors of Osteopathic Medicine (DOs). Statistical analyses were performed to evaluate trends and changes in matching rates, both before and during the pandemic. Results: There was a significant increase in the number of females matching into GI fellowships over the 5-year period. DOs also witnessed a significant increase in matching rates during the COVID-19-impacted years (2021-2022). However, no significant changes were observed for US medical graduates and IMGs. Conclusion: The study highlights positive trends in gender and DO representation in GI fellowships. Despite these improvements, gender disparities persist, necessitating continued efforts to promote diversity and equity in the field. Additionally, challenges for IMGs remain, requiring attention to structural barriers. The long-term effects of the pandemic on fellowship matching and diversity warrant further investigation to inform future policies and practices in GI training programs.

Navigating global collaboration: challenges faced by the international network on esophageal atresia.

The International Network on Esophageal Atresia (INoEA) stands as a beacon of collaboration in addressing the complexities of this congenital condition on a global scale. The eleven board members, from various countries (USA, Canada, France, Australia, Italy, Sweden, Germany, and The Netherlands) and backgrounds (pediatric gastroenterology, pediatric surgery, pediatric pulmonology, nursing, and parents) met in a face-to-face symposium in Lille in November 2023, to identify challenges and solutions for improving global collaboration of the network.

Clinical characteristics and management of liver abscess in The Gambia, a resource-limited country.

Liver abscess is endemic in resource-limited countries such as The Gambia where access to advanced imaging techniques or modern treatment modalities is limited. Despite this, mortality in this cohort was low. Therefore antibiotic therapy combined with percutaneous abscess drainage remains a reasonable treatment strategy of liver abscess in resource-poor settings.

Late anastomotic perforation of the ileum 3 years after intestinal resection.

Late perforation of the ileum is a rare and potentially life-threatening complication following intestinal resection. We present a unique case of a woman in her 60s with a history of appendiceal carcinoid tumour, who underwent a right hemicolectomy. Positron emission tomography and surveillance CTs showed normal surgical changes and no recurrent malignancy. Three years postoperatively, she presented with severe abdominal pain. CT revealed a perforation along the ileal wall of the ileocolonic anastomosis. She underwent emergent resection and repeat ileocolonic anastomosis. We conclude that the patient had subclinical ischaemia of the anastomosis, which eventually progressed to perforation 3 years later. We discuss a literature review on late small intestinal anastomotic perforations and their associated risk factors. Our case and literature review emphasise the importance of considering delayed anastomotic leak in postoperative patients with a history of intestinal cancer, inflammatory bowel disease, Roux-en-Y enteroenterostomy or side-to-side anastomosis.

Effects of a live versus heat-inactivated probiotic Bifidobacterium spp in preterm infants: a randomised clinical trial.

BACKGROUND: Heat-inactivated probiotics (HPs) may provide an effective alternative to live probiotics (P) by avoiding their risks (eg, probiotic sepsis) while retaining the benefits. We assessed the safety and efficacy of a HP in very preterm (VP: gestation <32 weeks) infants. METHODS: VP infants were randomly allocated to receive a HP or P mixture (Bifidobacterium breve M-16V, Bifidobacterium longum subsp. infantis M-63, Bifidobacterium longum subsp. longum BB536, total 3×109 CFU/day) assuring blinding. Primary outcome was faecal calprotectin (FCP) levels were compared after 3 weeks of supplementation. Secondary outcomes included faecal microbiota and short chain fatty acid (SCFA) levels. RESULTS: 86 VP infants were randomised to HP or P group (n=43 each). Total FCP and SCFA were comparable between HP and P groups within 7 days (T1) and between day 21 and 28 (T2) after supplementation. At T2, median (range) FCP was 75 (8-563) in the HP group and 80 (21-277) in the P group (p=0.71). Propionate was significantly raised in both groups, while butyrate was significantly raised in the HP group (all p<0.01). Bacterial richness and diversity increased but was comparable between HP and P (p>0.05). Beta diversity showed similar community structures in both groups (all p>0.05). Changes in faecal Actinobacteria, Bacteroidetes and Bifidobacteriacae levels were comparable in both groups at T1 and T2. There was no probiotic sepsis. CONCLUSIONS: HP was safe and showed no significant difference in FCP as compared with a live probiotic. Adequately powered trials are needed to assess the effects of HP on clinically significant outcomes in preterm infants. TRIAL REGISTRATION NUMBER: ACTRN12618000489291.

Patched but Still Leaky: An Update on the Pipeline for Women in Gastroenterology.

BACKGROUND: Women remain underrepresented in gastroenterology (GI). Studies have identified that a lack of formal mentorship for women contributes to this underrepresentation. While many GI divisions have adopted models for supporting GI fellows and faculty, there is a gap in our knowledge regarding mentorship options for internal medicine (IM) residents interested in GI. AIMS: To evaluate representation of women at each level of their career (resident, fellow, and attending) and examine trends in representation of women in GI compared to other IM subspecialties. METHODS: We analyzed AAMC Physician Specialty Data Reports to compare gender representation and growth of women representation across all IM subspecialties and residencies from 2007 to 2021. RESULTS: In 2021, 44.3% of IM residents, 37.8% of GI fellows, and 19.7% of actively practicing attending gastroenterologists were women. Since 2007, GI comprised significantly lower proportions of women attendings except for cardiology, and lower representation in fellows, except for cardiology and nephrology, than other IM subspecialties (p < 0.001). There was a consistently higher proportion of women GI fellows than attendings over the past 14 years (p < 0.01). CONCLUSIONS: GI has among the lowest representation of women at each career level compared to other IM subspecialties. Given the previously reported preference of gender congruent mentoring, the underrepresentation of senior academic gastroenterologists who are women may be a contributing factor to lower proportions of women trainees choosing to pursue GI.

Co-occurrence of collagenous gastrointestinal disease in siblings in early childhood: New insight into a rare condition.

Collagenous gastrointestinal (GI) disease is a rare inflammatory condition characterized by subepithelial collagen deposition and inflammatory cell infiltrates of the GI mucosa, which typically occurs in the stomach in children. There are few published reports of more extensive involvement in children, and descriptions of familial involvement are rare, with no previous reported cases of affected siblings in early childhood. We describe two siblings with contrasting medical backgrounds, who were simultaneously diagnosed with collagenous GI disease in early childhood. Both children demonstrated gastric and colonic involvement on serial endoscopies, however, had distinct patterns of clinical presentation, disease course, and histological progression, providing new insights into the pediatric phenotype of collagenous GI disease and further, its relationship to microscopic colitis. Although rare, this condition should be considered as a differential in children presenting with severe or refractory iron deficiency anemia, chronic non-bloody watery diarrhea, or unexplained nonspecific chronic abdominal pain.

A case of Burkitt Lymphoma discovered by digital rectal exam.

Burkitt Lymphoma (BL) is an aggressive B-cell lymphoma predominantly encountered in pediatrics. Sporadic type typically involves the abdomen and/or pelvis. We present an 8-year-old Caucasian male with vomiting, weight loss, fatigue, and abdominal pain. An abdominal X-ray was unremarkable without any acute findings. Pediatric gastroenterology was consulted and recommended esophagogastroduodenoscopy and colonoscopy. A digital rectal exam (DRE) was performed, and a firm lesion was palpated. The colonoscopy was normal. Subsequent magnetic resonance imaging and computed tomography scans revealed a lesion in the left lower quadrant with mass-like processes involving the porta hepatis and encasing the left distal ureter. Tissue biopsy confirmed BL. The patient completed chemotherapy and achieved remission. This case highlights DRE as a basic physical exam skill in the evaluation of patients with nonspecific gastrointestinal symptoms.

A Complex Case of Obstructive Jaundice in a Septuagenarian: Diagnostic Challenges and Therapeutic Strategies.

Obstructive jaundice occurs when an obstruction in the bile duct system prevents bile from flowing from the liver into the intestine, accumulating bilirubin in the blood. This condition can result from various causes, including gallstones, tumors, or inflammation of the bile ducts. The management of obstructive jaundice depends on the underlying cause (malignant obstructions such as cholangiocarcinoma or pancreatic cancer), indicating the need for surgical intervention. The Whipple procedure (pancreaticoduodenectomy) is the standard curative approach for resectable distal common bile duct (CBD) adenocarcinoma. Doctors usually recommend adjuvant chemotherapy to reduce the risk of recurrence. We report the case of a 70-year-old male with a history of untreated hypertension, type 2 diabetes, and long-term smoking, who presented with classic signs of obstructive jaundice, including yellowing of the eyes, itching, right upper quadrant pain, and intermittent fevers. Laboratory findings revealed elevated inflammatory markers, bilirubin, liver enzymes, and leukocyte count, indicative of an inflammatory and obstructive biliary condition. Imaging studies confirmed a distal CBD stricture, including abdominal ultrasound, computed tomography scans, and endoscopic retrograde cholangiopancreatography (ERCP). Brush cytology obtained during ERCP revealed a well-differentiated adenocarcinoma of the distal CBD. The patient's treatment plan included preoperative optimization, surgical resection via the Whipple procedure, and postoperative adjuvant therapy. This case emphasizes the importance of a thorough diagnostic workup and a multidisciplinary treatment strategy in managing complex cases of obstructive jaundice in the elderly, highlighting the need for personalized care to achieve optimal outcomes.