American College Of Gastroenterology Research Articles

NSAID PRESCRIPTION SURVEY IN INTEGRATED TRADITIONAL AND WESTERN MEDICINE TREATMENT: ASSESSING GASTROINTESTINAL AND CARDIOVASCULAR RISKS

Introduction: Non-steroidal anti-inflammatory drug (NSAID) usage should be carefully considered based on gastrointestinal (GI) and cardiovascular (CV) risks. In light of restricted evidence, this study aims to assess the prescription of NSAIDs concerning the GI and CV risks in the integrated treatment of Traditional medicine (TM) and Western medicine (WM). Materials and method: A retrospective cross-sectional study was conducted on 393 medical records of inpatients using NSAIDs in 2022 at the Traditional Medicine Hospital of Ho Chi Minh City. GI and CV risks, as well as information regarding NSAID prescriptions, were recorded. A multivariable regression model was employed to identify factors associated with the prescription of NSAID groups. Results: NSAIDs were primarily prescribed for musculoskeletal and connective tissue disorders (87.28%). Approximately half of the cases exhibited moderate to high GI risk (47.59%), while for CV risk, there were 68.95% with moderate to very high risk. COX-2 inhibitors were the most commonly prescribed (94.66%), even when considering GI and CV risks separately. In the majority, NSAID prescriptions aligned with both risks according to American College of Gastroenterology (ACG) guidelines (73.79%). The prescription of NSAID groups was significantly influenced by patient gender, ailment type, and physician education (p<0.05), but not by GI and CV risks (p>0.05). Conclusion: Patients receiving NSAIDs in integrated TM and WM treatment often faced an increased GI and CV risk, with the majority adhering to ACG guidelines. However, GI and CV risks were not significantly considered for NSAID group selections. Multi-center studies should be conducted.

Management of irritable bowel syndrome: a narrative review.

As our understanding of the pathophysiology of irritable bowel syndrome (IBS) has advanced, so too has the therapeutic landscape, offering a myriad of approaches to alleviate symptoms and enhance the well-being of patients. This review paper is dedicated to a comprehensive exploration of the diverse therapeutic modalities available for managing IBS. By delving into the complexities of IBS therapeutics, our aim is to contribute to the enhancement of patient care and the overall quality of life for patients grappling with this complex condition. This review utilized information from PubMed/MEDLINE using the key search term "irritable bowel syndrome" as well as the 2020 American College of Gastroenterology (ACG) and 2022 American Gastroenterological Association (AGA) society guidelines on IBS. The search was restricted to articles in the English language only and included peer-reviewed observational studies and randomized controlled trials (RCTs) in adult patients from April 22, 2020 to October 16, 2023. This review will start with an overview of the current guidelines for pharmacologic therapies for IBS as recommended by the ACG and the AGA, with an emphasis on clinical trials published after the most recent guidelines. It will then delve into the literature on dietary modifications, probiotics, fecal microbiota transplant, behavioral therapy, and complementary and alternative medicine approaches to IBS. It is evident that the management of IBS has transcended a one-size-fits-all approach. As the field of IBS management continues to evolve, it is imperative for physicians to stay informed and receptive to the array of therapeutic options available, ultimately providing patients with the most effective and personalized care.

Laboratory diagnosis of Clostridioides dif f icile infection: guidelines and status of practice in Korea

Clostridioides difficile infection (CDI) is a common healthcare-associated infection that is expected to increase with the increases in the elderly population, immunocompromised patients treated with chemotherapy and immunosuppressive drugs, antimicrobial-resistant bacteria, and invasive medical technologies. Accurate diagnosis is critical for proper treatment and management of CDI. Clinical laboratories typically use four methods to diagnose CDI: C. difficile culture, toxin detection using immunoassays, detection of glutamate dehydrogenase using immunoassays, and detection of toxin A/B gene. Each CDI diagnostic test has strengths and limitations, and varies in performance. Guidelines for CDI diagnosis have been developed by organizations that include the European Society of Clinical Microbiology and Infectious Diseases, Infectious Diseases Society of America/Society for Healthcare Epidemiology of America, and American College of Gastroenterology. Certain other countries have guidelines. In Korea, surveys on CDI diagnosis performed in 2015 and 2018 revealed a shift in CDI testing in clinical laboratories in Korea. It is necessary to develop standardized diagnostic guidelines for CDI appropriate for the Korean context.

The Role of Imaging for GI Bleeding: ACG and SAR Consensus Recommendations.

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high health care utilization and costs. Radiologic techniques including CT angiography, catheter angiography, CT enterography, MR enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist, which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided. © Radiological Society of North America and the American College of Gastroenterology, 2024. Supplemental material is available for this article. This article is being published concurrently in American Journal of Gastroenterology and Radiology. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Citations from either journal can be used when citing this article. See also the editorial by Lockhart in this issue.

Continuing Medical Education Questions: March 2024

Article Title: The Role of Imaging for GI Bleeding: Consensus Recommendations From the American College of Gastroenterology and Society of Abdominal Radiology

Gastroscopy for dyspeptic symptoms in patients <65 years has a low yield of clinically important findings: a retrospective study

Abstract Background Dyspepsia is a common, generally low-risk gastrointestinal condition. The American College of Gastroenterology and Canadian Association of Gastroenterology recommend avoiding gastroscopy in healthy patients <60 years old. Many dyspeptic patients can be effectively managed in primary care. This study aimed to determine: (1) the proportion of gastroscopies performed for dyspepsia among patients <65 years old with no alarm symptoms or clinically appropriate indications and (2) to determine the frequency of clinically actionable findings and dyspepsia-related healthcare utilization in the year following gastroscopy. Methods Outpatient endoscopy reports were sampled and reviewed retrospectively from 2019 to –2021 in Edmonton, Alberta to identify gastroscopies performed for the indication of dyspepsia. Gastroscopies were considered low-risk for significant endoscopic findings if age <65, no alarm symptoms or other concerning indications, and insufficient evidence that first-line treatments and diagnostic approaches had been tried prior to gastroscopy. Clinically important findings were defined as those impacting management, not otherwise identifiable non-invasively. Results Of the 358 reviewed gastroscopies for dyspepsia, 293 (81.8%) had no alarm symptoms, and 130 (36.3%) had no alarm symptoms or other appropriate indications. Clinically important findings were identified in 9 (6.9%) of the 130 low-risk cases. In the year following, one patient (1/130) visited the emergency department 3 times for their symptoms and no patients required hospital admission. No malignancies were detected. Conclusions Many gastroscopies are performed on patients <65 years old with dyspepsia, even when they lack alarm symptoms or other clinical indications, despite recommendations against this practice and low procedure yield. Strategies to improve the uptake of current guidelines may optimize endoscopy resource utilization.

Gastroesophageal reflux disease management and chronic use of proton pump inhibitors.

Proton pump inhibitors (PPIs) are one of the most commonly prescribed drugs worldwide and have changed the treatment of gastroesophageal reflux disease (GERD). However, these drugs have been associated with several potentially serious adverse reactions if used chronically. Guidelines from the American College of Gastroenterology in 2021 and the American Gastroenterological Association's 2022 clinical practice updates reflect the latest recommendations. This article reviews the management and treatment of GERD and the adverse reactions to long-term PPI use.

Colonoscopy withdrawal times and adenoma detection rates in a large, multi-site colorectal surgery practice.

433 Background: Colonoscopy withdrawal times (CWT) and adenoma detection rates (ADR) have been extensively correlated in medical literature. The American College of Gastroenterology (ACG) 2021 guidelines recommend measuring quality indicators for screening colonoscopy that achieve minimum benchmarks for ADR (>=25%) and CWT (>=6 minutes). In October 2022, M Desai et al reported in a sample of 1142 patients (46% screening and 54% surveillance), ADR increased as withdrawal time increased from 6 to 13 minutes. Results demonstrated a 6% increase per minute in the likelihood of detecting an additional patient with at least 1 adenoma. Texas Colon and Rectal Specialists routinely reviews ADR’s and CWT’s. This retrospective descriptive study presents a concise review of the correlation between CWT’s and ADR’s in a homogenous set of screening and surveillance patients. Methods: We examined 7164 abstracted colonoscopy records from 31 colorectal surgeons. Diagnostic colonoscopies were excluded. We studied patients between 45 and 84 years of age at the time of the colonoscopy. Each patient was noted for the colonoscopy CWT as well as whether at least one adenomatous polyp was detected. These data were reported in a scatter plot of ADR over CWT as well as a bubble chart of ADR over CWT by each surgeon. A two-sample t-test confirmed a statistical difference between the mean CWT of the adenoma-positive patients and those that were not positive. Results: Consistent with the literature, ADR increased with CWT. The mean CWT was 14.2 minutes in the group where an adenoma was detected (n=3289) and 10.6 minutes in the group where an adenoma was not detected (n=3875), (p<0.05 and CI of 95%). Mean CWT was 12.3 minutes, mode was 7 minutes, median was 10.25 minutes, and the mean ADR was 45.9%. The best ADR performance was 62.5% at a mean of 26.8 minutes CWT and the worst performance was 27.7% at 10 minutes CWT. A bubble chart demonstrates the relationship between CWT and ADR by surgeon with the bubbles representing individual colonoscopy volumes. Consistent with the literature, ADR increased with CWT. The mean CWT was 14.2 minutes in the group where an adenoma was detected (n=3289) and 10.6 minutes in the group where an adenoma was not detected (n=3875), (p<0.05 and CI of 95%). Mean CWT was 12.3 minutes, mode was 7 minutes, median was 10.25 minutes, and the mean ADR was 45.9%. The best ADR performance was 62.5% at a mean of 26.8 minutes CWT and the worst performance was 27.7% at 10 minutes CWT. Conclusions: Our data indicate a significant relationship between CWT and ADR, and may suggest that CWT well beyond six minutes may yield better ADR’s. Furthermore, scope volume appears to play a role in the achievement of higher ADR’s, though this would require further investigation for optimal CWT, minimum expected ADR, optimal techniques and bowel prep, and emerging assistive technology.

Burnout Among US Gastroenterologists and Fellows in Training: Identifying Contributing Factors and Offering Solutions.

Consequences of physician burnout include medical errors, higher rate of staff turnover, and decreased patient satisfaction. We examined the prevalence of burnout and identified the contributing factors in gastroenterologists and fellows in training. We performed 3 separate surveys through the American College of Gastroenterology. (1) A national survey of practicing gastroenterologists in the United States that measured burnout and contributing factors, (2) a survey of gastroenterology fellows in training to determine self-identified burnout, as well as mitigating and exacerbating factors, and (3) a follow-up survey of fellows during the COVID-19 pandemic. One thousand and twenty-one persons responded (9.2% response rate) to the first survey, including 756 individuals who completed the Maslach Burnout Inventory survey. Overall, the prevalence of high burnout was 49.3%. Factors associated with high burnout included female sex, younger age, shorter duration in practice, considering the electronic health record non-user-friendly, 2 or more hours of patient-related work at home per day, 8 or more hours of outpatient time per day, 6 or more inpatient consults per day, taking call with procedures 10 or more times per year, and having children at home. With regard to lifestyle factors, taking 20 days or more of vacation time was associated with a lower rate of burnout. The level of burnout for fellows was observed to be high (42.7% in survey 2 and 35.3% in survey 3). Burnout is high in gastroenterologists and fellows in training. Specific contributing factors were both systems based and personal and provide insight into changes that can be made to address burnout.

The Role of Imaging for Gastrointestinal Bleeding: Consensus Recommendations From the American College of Gastroenterology and Society of Abdominal Radiology

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high healthcare utilization and costs. Radiologic techniques including computed tomography angiography, catheter angiography, computed tomography enterography, magnetic resonance enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided.

Evaluating the derangement of LFTs concerning statin use and probable liver injury among non-cardiac patients, in the light of R ratio.

Background: To evaluate the derangement of Liver Function Tests (LFTs) concerning statin use and probable liver injury among non-cardiac patients in light of the R ratio.  Methodology: This retrospective observational cohort study was conducted at Sindh Government Hospital Liaquatabad (SGHL) in Karachi, including 142 non-cardiac patients. Both male and female patients, aged ≥ 18 years, continuously using statin irrespective of dose or duration, were included in the study. While non-alcoholic fatty liver disease (NAFLD) patients, those with alcoholic liver diseases, chronic or acute hepatitis, chronic renal failure, disorders of the thyroid or parathyroid glands, cardiovascular, endocrine and any other disease that might alter or elevate liver enzymes, recreational drug users, smokers, users of tobacco products and those patients using herbal medications were excluded from the study sample. The data regarding patients' characteristics, including demographics and clinical characteristics (LFTs result and treatment), were obtained from the hospital records and noted using a structured questionnaire. The R ratio for suspected drug-induced liver injury was calculated following the American College of Gastroenterology (ACG) guidelines. The statistical analysis was performed on SPSS version 22.0 Results: The enrolled patients predominantly used rosuvastatin 20 mg/day 124(87.3%), and the mean duration of statin use after the first prescription was 18.28 ± 14.33 months. The LFT levels were mildly elevated concerning statin use, and this borderline elevation did not require further investigation, nor was there any evidence of clinical liver injury. The mean R ratio was 1.81 ± 0.56; most cases presented a cholestatic picture 86(60.6%) complementing the liver safety profile of statins in patients without cardiac diseases. Conclusion: In conclusion, statins use caused only borderline clinically and statistically insignificant elevations in the LFTs over time among non-cardiac patients.

Chinese clinical practice guidelines for the prevention and treatment of radiation‐induced esophagitis

AbstractAcute radiation‐induced esophagitis is a common complication of radiotherapy for esophageal, lung, and other malignancies. Therefore, understanding the diagnosis, grading, risk factors, prevention, and treatment of radiation‐induced esophagitis is essential. Currently, there are few consensuses and guidelines on radiation‐induced esophagitis worldwide, mainly the American College of Gastroenterology (ACG) clinical guideline: evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE) and the Digestive Endoscopy Society of Chinese Medical Association's “Guidelines for the Diagnosis and Treatment of Reflux Esophagitis.” However, no consensus or guidelines specifically addressing radiation‐induced esophagitis have been established. Efforts have been made to organize experts to draft Chinese consensus or guidelines, but the recommendations in these guidelines also vary owing to differences in expert backgrounds. The clinical practice guidelines presented herein were developed for the first time with the joint participation of Chinese radiotherapy experts. Drugs and methods with clinical significance were selected by reviewing and summarizing the prevention and treatment of radiation‐induced esophagitis and combining them with China's national conditions. After multiple rounds of discussion and revision, clinical practice guidelines were established in line with the needs of Chinese clinicians, providing useful clinical guidance for the prevention and treatment of radiation‐induced esophagitis.

Capsule Endoscopy for the Diagnosis of Suspected Small Bowel Bleeding

   This review discusses the role of capsule endoscopy in diagnosing suspected small bowel bleeding and compares guidelines of the European Society of Gastrointestinal Endoscopy (ESGE), the American College of Gastroenterology (ACG), the American Society for Gastrointestinal Endoscopy (ASGE), the Canadian Association of Gastroenterology (CAG), and the consensus document of 4 Japanese medical societies. European and North American experts recommend capsule endoscopy as a first-line diagnostic modality for suspected small bowel bleeding without life-threatening signs in adult patients when ileocolonoscopy and esophagogastroduodenoscopy failed to be informative. Japanese experts, on the contrary, prefer cross-sectional imaging “from the chest to the pelvis” and consider capsule endoscopy as an alternative.

Assessing Family Leave Policies and Pregnancy Outcomes Among Gastroenterologists: A Survey of Physicians in the American College of Gastroenterology.

Given variability in parental leave policies in gastroenterology (GI) with little data on outcomes, the American College of Gastroenterology conducted a survey to assess policies and outcomes. A survey was distributed to American College of Gastroenterology members with questions on demographics, fertility, pregnancy outcomes, and parental leave policies. There were 796 responses, with 52.5% female individuals. Many (57%) delayed parenting. High rates of infertility (21%) and pregnancy complications (68%) were observed. Satisfaction with parental leave policies in GI was low (35%). Our survey highlights the need for policies that support the well-being of our GI colleagues and families.

An Overview of Emerging Trends and Technologies in Ulcerative Colitis


 This report provides an overview of the evolving therapeutic landscape for moderate to severe ulcerative colitis (UC), including recent changes to clinical practice guidelines, key trends in therapeutic strategies, and new or emerging treatment options, with a focus on biologics and small-molecule therapies.
 Recent guidelines on the medical management of patients with UC include those of the American Gastroenterological Association (AGA), American College of Gastroenterology (ACG), and European Crohn’s and Colitis Organisation (ECCO), which were published in 2019, 2020, and 2022, respectively. These guidelines provide an accurate reflection of how clinical practice has changed to incorporate newer therapies that have entered the market and newer evidence that has been published since the release of the Canadian guidelines in 2015. The ACG, AGA, and ECCO guidelines all recommend use of a tumour necrosis factor (TNF) antagonist, vedolizumab, or tofacitinib for induction of remission in patients with moderate to severe UC; the AGA and ECCO guidelines also recommend ustekinumab as an option and recommend vedolizumab over adalimumab, whereas the AGA guidelines recommend early use of biologic drugs over a step-up approach after failure of 5-aminosalicylates.
 Two important trends in therapeutic strategies for UC include changes in the use and definition of treatment targets and recommendations regarding therapeutic drug monitoring (TDM).
 
 The 2021 Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE-II) guidelines provide contemporary consensus recommendations for using new and updated targets throughout an individualized treatment timeline in patients with inflammatory bowel disease (IBD). Although histologic remission is not considered a formal UC treatment target in STRIDE-II, it is acknowledged as an adjunctive measure to endoscopic remission to represent a deeper level of healing and is the focus of many current studies.
 The use of TDM emerged from challenges associated with the use of older biologics (primarily TNF antagonists), which posed difficulties related to immunogenicity and dosing. The relevance of TDM for newer biologics with different mechanisms of action, reduced immunogenicity, and fixed dosing (e.g., vedolizumab and ustekinumab) is a topic of ongoing debate. Although AGA guidelines on TDM in IBD and expert consensus statements support the use of reactive TDM for patients with UC who lose response to a TNF antagonist, evidence gaps remain regarding appropriate use of proactive TDM, utility of TDM for small molecules and biologics outside of the TNF antagonist class, and consistent target concentration thresholds to guide dose changes.
 
 
 There is a substantial pipeline of new and emerging drugs for the treatment of adults with moderate to severe UC, with many in phase IIb or III of clinical development; several notable trends of emerging pharmacotherapies exist, including an increasing number of Janus kinase inhibitors, several therapies with biologic targets that are new in UC (e.g., interleukin-23 antibodies, TNF-like ligand 1A inhibitors), an increasing number of oral therapies, and the first combination of 2 biologic therapies in UC.
 The Canadian health care system should be prepared to adapt to the rapidly evolving treatment landscape and potential clinical practice changes in moderate to severe UC. Drugs with new mechanisms of action in the treatment area and the new paradigm of combination therapy with multiple biologics of different classes may lead to improved patient outcomes but can also further complicate the treatment decision-making process. Therefore, it is important for health care providers to stay up to date on new and upcoming treatment options, which may require educational initiatives for both providers and patients as well as updates to the Canadian treatment guidelines. Overall, potential changes on the horizon may have substantial implications for the health care system given the prevalence of UC in Canada, the costs of advanced therapies, and the increasing number of available treatment options.

The management of Clostridioides difficile infection: from empirism to evidence.

Clostridioides difficile infection (CDI) in clinical practice represents a challenge for its management and also prevention of recurrence. Even though there are updated guidelines for infection prevention, control and treatment, CDI remains a leading cause of healthcare acquired diarrhea with increasing incidence in the community. We present here a synthesis of the most recent international guidelines on the management of CDI. In 2021 updated guidelines on the treatment of CDI in adults were published by the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA), American College of Gastroenterology (ACG) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). These guidelines focused on CDI management in adults, including new data on the clinical efficacy of Fidaxomicin (FDX) and Bezlotoxumab. The 2017 publication of IDSA and SHEA - Clinical Practice Guidelines for Clostridium difficile infection also included pediatric treatment recommendations that are not a part of the 2021 update. Vancomycin (VAN) treatment for an initial CDI episode remains an acceptable alternative to FDX, considering the monetary and logistical challenge of acquiring FDX. There is growing literature on fecal microbiota transplantation (FMT) and the 2021 guidelines describe its role in severe complicated refractory CDI cases and for which surgical management is not feasible. Moreover, there are new data on the secondary prophylaxis with VAN in refractory CDI in patients with risk factors who receive broad spectrum antibiotics.

Treatment of small intestinal bacterial overgrowth: Conventional antibiotic therapy and alternative therapy - probiotics and low FODMAP diet

Introduction and purpose of the study: Small intestinal bacterial overgrowth syndrome (SIBO) is a syndrome characterized by an increased number of bacteria in the small intestine. The condition causes many non-specific symptoms such as diarrhea, abdominal pain and bloating. The purpose of this study is to review the current knowledge regarding treatment options for SIBO.                                            
 Methodology: A literature review was conducted based on PubMed, GoogleScholar databases and American College of Gastroenterology (ACG) guidelines.
 Current knowledge: SIBO is a heterogeneous syndrome. Symptoms of bacterial overgrowth include bloating, abdominal pain and abnormal bowel motility. In more severe cases, patients may experience malabsorption leading to weight loss and malnutrition. SIBO can occur in healthy individuals, but very often accompanies other conditions. The primary test for diagnosis is non-invasive lactulose or glucose breath tests. For treatment, the antibiotic rifaximin is preferred. It exhibits a broad spectrum of activity and a low toxicity profile. Treatment may also include diet therapy and the use of probiotics.
 Summary: SIBO continues to be both a diagnostic and therapeutic problem. Effective treatment includes not only elimination of the bacteria but also treatment of predisposing conditions. Conclusions of the study show a positive effect of rifaximin on the reduction of SIBO symptoms and improvement of patients' quality of life. The use of certain probiotics has a proven effect. According to the currently available literature, the effectiveness of the low-FODMAP diet in SIBO is hypothetical and further studies are needed to unequivocally confirm its efficacy.

Prevalence and metabolic determinants of abnormal alanine aminotransferase: A cross-sectional study of Iranian adults, 2018-2022.

Alanine aminotransferase (ALT) is an enzyme whose activity became the principal biomarker for liver disease. In the current study, we aimed to determine the prevalence of abnormal ALT, as a surrogate of nonalcoholic fatty liver disease (NAFLD) and its associated determinants using different criteria among Tehranian subjects between 2018 and 2022. This is a cross-sectional study on 5676 Tehranian individuals aged 20-70 years. The weighted prevalence of abnormal ALT was calculated using both the National Health and Nutrition Examination Survey in the United States (US-NHANCE; ALT ≥30 U/L for females and ≥40 U/L for males) and the American College of Gastroenterology (ACG) guideline (ALT >25 U/L for females, and >33 U/L for males) thresholds. Moreover, uni/multivariable logistic regression analysis was performed to find the determinants of abnormal ALT. The weighted prevalence of abnormal ALT was 12.8% (7.6% females and 18% males) and 22.5% (17.7% females and 27.3% males) based on US-NHANCE and ACG criteria, respectively. Our results showed every decade increase in age decreased the risk of abnormal ALT by 32%. We also found that generally male gender, being overweight/obese, central adiposity, TG ≥6.9 mmol/L, non-HDL-C ≥3.37 mmol/L, lipid-lowering medications, pre-diabetes/T2DM were associated with abnormal ALT using different cutoff points. Moreover, among men resting tachycardia (≥90 beats per min), hypertension, and females past-smoker were also found as other determinants of abnormal ALT. High prevalence of abnormal ALT among non-elderly Iranian adults, especially among men, necessitates immediate multifaceted strategies by policymakers to prevent potential complications caused by NAFLD.

Perfluorooctanoic Acid (PFOA) Exposure and Abnormal Alanine Aminotransferase: Using Clinical Consensus Cutoffs Compared to Statistical Cutoffs for Abnormal Values.

Per- and polyfluoroalkyl substances (PFASs) including perfluorooctanoic acid (PFOA) are ubiquitous environmental contaminants. Prior analysis in the large "C8 Health Project" population defined abnormal alanine aminotransferase (ALT) with statistically derived cutoffs (>45 IU/L in men, >34 IU/L in women). To explore the degree to which PFOA was associated with modern, clinically predictive ALT biomarker cutoffs in obese and nonobese participants, excluding those with diagnosed liver disease. We reevaluated the relationship of serum PFOA to abnormal ALT using predictive cutoff recommendations including those of the American College of Gastroenterology (ACG). Evaluations modeled lifetime cumulative exposure and measured internal PFOA exposure. ACG cutoff values (≥34 IU/L for males, ≥25 IU/L for females) classified 30% of males (3815/12,672) and 21% of females (3359/15,788) above ALT cutoff values. Odds ratios (OR) for above cutoff values were consistently associated with modeled cumulative and measured serum PFOA. Linear trends were highly significant. ORs by quintile showed near monotonic increases. Trends were stronger for the overweight and obese. However, all weight classes were affected. Predictive cutoffs increase the OR for abnormal ALT results. Obesity increases ORs, yet association with abnormal ALT pertains to all weight classes. The results are discussed in context of current knowledge about the health implications of PFOA hepatotoxicity.

NSAID-esophagitis: how to break the vicious circles of pathogenesis? Clinical case

The article presents a complex clinical case of drug‑induced erosive esophagitis grade C with the formation of Schatzki ring in patient S., 85 years old. A feature of the case under consideration is the long‑term persistence of both esophageal (dysphagia, odynophagia) and extraesophageal (thoracalgia) complaints, which required an extensive differential diagnosis to rule out the cardiac genesis of the pain syndrome. The diagnostic search was complicated by the patient’s advanced age, the presence of serious accompanying somatic pathology, moderate cognitive decline, contradictory data from X‑ray examination and computer tomography, and the patient’s categorical refusal to perform a biopsy, which made histological confirmation of the presumptive diagnosis impossible. Empirical appointment of pantoprazole (Nolpaza) made it possible to level the phenomenon of odynophagia and improve the condition of the esophageal mucosa, but long‑term use of Nolpaza in high doses was required for restoration of erosive‑destructive changes in the damaged esophagus and stomach.
 Moreover, the literature review is presented, which reveals modern ideas about the mechanisms of Schatzki ring, the features of management and treatment of patients with dysphagia and Schatzki ring according to the guidelines of authoritative international organizations — the World Gastroenterology Organization, the American College of Gastroenterology. The key provisions of the specified organizations, which regulate the doctor’s actions in the management of patients with Schatzki ring, are given. The advantages of prescribing pantoprazole (Nolpaza) are described, taking into account the peculiarities of its mechanism of action, bioequivalence to the original pantoprazole, CYP450‑unassociated hepatic metabolism, the absence of significant drug interactions, serious adverse events, the possibility of its administration to elderly and senile patients without dose correction, the expediency and safety of the long‑term intake.