Diagnostic Value of the 13C Methacetin Breath Test in Various Stages of Chronic Liver Disease

The accuracy of the 13C-methacetin breath test (13C-MBT) in differentiating between various stages of liver disease is not clear. A cross-sectional study of Asian patients was conducted to examine the predictive value of the 13C-MBT in various stages of chronic liver diseases. Diagnostic accuracy of the breath test was determined by sensitivity, specificity, positive predictive value, negative predictive value, and area under the curve analysis. Seventy-seven patients (47 men/30 women, mean age 50 ± 16 years) were recruited. Forty-seven patients had liver cirrhosis (Child Pugh A = 11, Child Pugh B = 15, and Child Pugh C = 21), 21 had fibrosis, and 9 had chronic inflammation. The sensitivity and positive predictive value for liver fibrosis, cirrhosis (all stages), Child-Pugh A, Child-Pugh B, and Child-Pugh C were 65% and 56%, 89% and 89%, 67% and 42%, 40% and 40%, and 50% and 77%, respectively. Area under curve values for fibrosis was 0.62 (0.39–0.86), whilst that for cirrhosis (all stages) was 0.95 (0.91–0.99). The 13C-methacetin breath test has a poor predictive value for liver fibrosis but accurately determines advanced cirrhosis

Efficacy and safety of per-oral endoscopic myotomy for the treatment of achalasia cardia in Malaysia: a single centre study

INTRODUCTION: Peroral Endoscopic Myotomy (POEM), introduced in 2010, has become a widely accepted treatment for achalasia cardia. However, POEM procedure is technically challenging and recommended to be performed by experienced endoscopists. Our objective was to assess the efficacy and safety of POEM procedures performed in a tertiary referral centre. METHODOLOGY: This is a retrospective single-centre study. All consecutive achalasia patients that underwent POEM procedure (posterior approach) from November 2015 to June 2022 were recruited. Demographic data, achalasia type, technical success, procedure duration, myotomy length, duration of hospital stay, clinical success and adverse events were recorded. Technical success was defined as completion of POEM procedure from mucosa incision, to tunnel creation followed by myotomy and finally, mucosal closure. Clinical success was defined as a post-procedure Eckardt score ≤3, or a reduction of 4 or more points at 2 months or more after a successful procedure. All POEM procedures were performed by 3 endoscopists (2 gastroenterologists and 1 surgeon) who have had experience in ESD or Heller’s myotomy. RESULT: A total of 86 patients were recruited. The detailed results are summarised in Table 1. CONCLUSION: The high efficacy (with good intermediate to long-term outcome follow up) and good safety profile of the POEM procedure for achalasia cardia in our centre are comparable with the published literature. Adverse events were generally mild, and all were managed conservatively. The improvement seen in the technical success rate after the first 20 cases is in line with mastering the POEM skill after the initial learning experience

Quality of life in South East Asian patients who consult for dyspepsia: Validation of the short form Nepean Dyspepsia Index

This is an Open Access article distributed under the terms of the Creative Commons Attribution Licens

The EQ-5D (Euroqol) is a valid generic instrument for measuring quality of life in patients with dyspepsia

<p>Abstract</p> <p>Background</p> <p>There is little information of the validity of generic instruments in measuring health-related quality of life (HRQOL) in patients with dyspepsia. We aimed to assess the reliability and validity of the EQ-5D, a brief and simple instrument, in measuring HRQOL in adult patients with dyspepsia.</p> <p>Methods</p> <p>Consecutive adults with dyspepsia attending the Gastroenterology clinic in a tertiary referral center were interviewed with the EQ-5D (both English and Malay versions), the short-form Nepean Dyspepsia Index (SF-NDI), the SF-36 and Leeds Dyspepsia Questionnaire (LDQ). Known-groups and convergent construct validity were investigated by testing hypotheses at attribute and overall levels. A repeat telephone interview was conducted 2 weeks later to assess test-retest reliability.</p> <p>Results</p> <p>A total of 113 patients (mean (SD) age: 53.7 (14) years; 49.5% male; 24.8% Malays, 37.2% Chinese; 70.8% functional dyspepsia) were recruited. Response rate was 100% with nil missing data. Known-groups validation revealed 20/26 hypotheses fulfillment. Patients with more severe dyspepsia reported more problems with their usual activity (p = 0.07) and pain (p = 0.06) and demonstrated lower median VAS scores (60 vs 70, p = 0.002) and EQ-5D utility scores (0.72 vs 0.78, p = 0.002). Those reporting problems in various EQ-5D dimensions had significantly lower scores in relevant SF-36 and SF-NDI dimensions. The overall EQ-5D utility score also demonstrated good correlation with the SF-36 summary physical and mental scores and the SF-NDI total score. Intraclass correlation coefficient for test-retest reliability was 0.66 (95% CI = 0.55 – 0.76).</p> <p>Conclusion</p> <p>The EQ-5D is an acceptable, valid and reliable generic instrument for measuring HRQOL in adult patients with dyspepsia.</p

When is poem truly equivalent to LHM? A comparison of complication rates during the learning curve

INTRODUCTION: Per-Oral Endoscopic Myotomy (POEM) has been shown to be an effective treatment for Achalasia, but the endoscopic technique required is complex and not routinely performed. We believe that, for any new procedure, competency can be demonstrated when the complication rate of a new procedure (POEM) equals that of an established one, ie Laparoscopic Heller’s Myotomy + Fundoplication (LHM+F). METHODS: A multicentre, retrospective cohort, comparing complication rates during the learning curve of POEM to a historical cohort of LHM+F, was conducted. A direct head-to-head comparison was performed, followed by a population pyramid of complication frequency. Case sequence was then divided into blocks of 5, and the complication rates during each block was compared to the historical cohort. RESULTS: A total of 123 cases ( LHM+F n=60, POEM n=63) were analysed. Mean age was lower for the POEM group (41.7 years vs 48.1 years, p = 0.03), but there was no difference in gender nor type of Achalasia. The POEM group recorded a shorter overall procedural time (125.9 minutes vs 144.1 minutes, p = 0.023) and longer myotomies (10.1cm vs 6.2cm, p = 0.023). Complication rates were higher in the POEM group (20.6% vs 10.0%, p=0.10), but was not statistical significant. Complication frequency tapered off dramatically after the 25th case in the sequence, and subsequently equalled that of LHM+F. Length of stay was shorter for the POEM group (3.4 days vs 4.8 days, p = 0.014). The post-procedural findings favoured LHM+F, with the post-procedural Eckardt scores significantly lower (0.4 vs 1.6, p < 0.001) and the usage of PPIs lower in this group (20.7% vs 39.4%, p = 0.03). CONCLUSION: POEM is challenging even for experienced endoscopists. From our data, complication rates between POEM and LHM+F equalize after approximately 25 POEMs

Appointment waiting times and education level influence the quality of bowel preparation in adult patients undergoing colonoscopy

<p>Abstract</p> <p>Background</p> <p>Risk factors for poor bowel preparation are recognized to be independent of the type of bowel preparation method used. Patient and administrative factors influencing bowel preparation are known to vary in different healthcare systems.</p> <p>Methods</p> <p>A prospective, cross-sectional study of patients undergoing colonoscopy in an Asian tertiary centre was conducted to identify risk factors associated with poor bowel preparation, and to evaluate the impact of poor bowel preparation on technical performance and patient comfort.</p> <p>Results</p> <p>Data on 501 patients (mean age 60.1 ± 14.0 years old, 51.2% males, 60.9% with secondary education or higher) was available for analysis. Poor bowel preparation was present in 151 patients (30.1%). Lower education level (OR = 2.35, 95% CI = 1.54 - 3.60), colonoscopy appointment waiting time beyond 16 weeks (OR = 1.86, 95% CI = 1.04 - 3.37) and non-adherence to bowel preparation instructions (OR = 4.76, 95% CI = 3.00 - 7.55) were identified as independent risk factors for poor bowel preparation. Poor bowel preparation was associated with a lower cecal intubation rate (78.1% versus 98.3%, p < 0.001), prolonged total colonoscopy time (25.4 ± 12.6 minutes versus 16.7 ± 10.2 minutes, p < 0.001), and increased patient discomfort during colonoscopy (patient with moderate to severe abdominal discomfort 31.8% versus 3.2%, p < 0.001).</p> <p>Conclusions</p> <p>Education levels and appointment waiting times, in addition to non-adherence to bowel preparation instructions, increase the risk of poor bowel preparation in adult patients undergoing colonoscopy. The latter has a significant impact on colonoscopy performance and patient comfort.</p

Anthropometric, biochemical and clinical assessment of malnutrition in Malaysian patients with advanced cirrhosis

<p>Abstract</p> <p>Background</p> <p>There is limited data on the nutritional status of Asian patients with various aetiologies of cirrhosis. This study aimed to determine the prevalence of malnutrition and to compare nutritional differences between various aetiologies.</p> <p>Methodology</p> <p>A cross-sectional study of adult patients with decompensated cirrhosis was conducted. Nutritional status was assessed using standard anthropometry, serum visceral proteins and subjective global assessment (SGA).</p> <p>Results</p> <p>Thirty six patients (mean age 59.8 ± 12.8 years; 66.7% males; 41.6% viral hepatitis; Child-Pugh C 55.6%) with decompensated cirrhosis were recruited. Malnutrition was prevalent in 18 (50%) patients and the mean caloric intake was low at 15.2 kcal/kg/day. SGA grade C, as compared to SGA grade B, demonstrated significantly lower anthropometric values in males (BMI 18.1 ± 1.6 vs 26.3 ± 3.5 kg/m2, p < 0.0001; MAMC 19.4 ± 1.5 vs 24.5 ± 3.6 cm, p = 0.002) and females (BMI 19.4 ± 2.7 vs 28.9 ± 4.3, p = 0.001; MAMC 18.0 ± 0.9 vs 28.1 ± 3.6, p < 0.0001), but not with visceral proteins. The SGA demonstrated a trend towards more malnutrition in Child-Pugh C compared to Child-Pugh B liver cirrhosis (40% grade C vs 25% grade C, p = 0.48). Alcoholic cirrhosis had a higher proportion of SGA grade C (41.7%) compared to viral (26.7%) and cryptogenic (28.6%) cirrhosis, but this was not statistically significant.</p> <p>Conclusion</p> <p>Significant malnutrition in Malaysian patients with advanced cirrhosis is common. Alcoholic cirrhosis may have more malnutrition compared to other aetiologies of cirrhosis.</p

A multi-ethnic study of a PNPLA3 gene variant and its association with disease severity in non-alcoholic fatty liver disease

The adiponutrin (PNPLA3) rs738409 polymorphism has been found to be associated with susceptibility to non-alcoholic fatty liver disease (NAFLD) in various cohorts. We further investigated the association of this polymorphism with non-alcoholic steatohepatitis (NASH) severity and with histological features of NAFLD. A total of 144 biopsy-proven NAFLD patients and 198 controls were genotyped for PNPLA3 gene polymorphism (rs738409 C>G). The biopsy specimens were histologically graded by a qualified pathologist. We observed an association of G allele with susceptibility to NAFLD in the pooled subjects (OR 2.34, 95% CI 1.69–3.24, p < 0.0001), and following stratification, in each of the three ethnic subgroups, namely Chinese, Indian and Malay (OR 1.94, 95% CI 1.12–3.37, p = 0.018; OR 3.51, 95% CI 1.69–7.26, p = 0.001 and OR 2.05, 95% CI 1.25–3.35, p = 0.005, respectively). The G allele is associated with susceptibility to NASH (OR 2.64, 95% CI 1.85–3.75, p < 0.0001), with NASH severity (OR 1.85, 95% CI 1.05–3.26, p = 0.035) and with presence of fibrosis (OR 1.95, 95% CI 1.17–3.26, p = 0.013) but not with simple steatosis nor with other histological parameters. Although the serum triglyceride level is significantly higher in NAFLD patients compared to controls, the G allele is associated with decreased level of triglycerides (p = 0.029) in the NAFLD patients. Overall, the rs738409 G allele is associated with severity of NASH and occurence of fibrosis in patients with NAFLD

Frequency of significant fibrosis in various chronic liver diseases: an evaluation with Transient Elastography (TE)

INTRODUCTION: Liver biopsy has long been the gold standard to evaluate liver fibrosis. TE was developed as a non- invasive method to assess liver fibrosis by measuring liver stiffness using shear wave velocity. Many studies have proven its’ effectiveness as a method for evaluating liver fibrosis.1-2 The use of TE in UMMC began in 2013. OBJECTIVE: To determine the frequency and aetiology of liver fibrosis and cirrhosis in our local population METHOD: This was a retrospective study conducted at UMMC. Inclusion criteria was all patients who had TE performed from 1 January 2013 to 31 December 2021. Their demographics, clinical characteristics and TE findings were charted. RESULTS: A total of 3066 patients were included, in which 51.7% were males and 48.3% were females. The median CAP value was 271 dB/m. The median E value was 6.5kPa. 11.2% and 11.3% of patients had significant fibrosis (10.1-14.9kPa) and cirrhosis(≥15kPa) respectively. Non-alcoholic fatty liver disease (NAFLD) was noted to be the most common aetiology for fibrosis (32.8%), followed by chronic hepatitis B (CHB) at 25.2%, chronic hepatitis C (CHC) at 6.7% and alcoholic liver disease (ALD) with 1.3%. This finding was also found to be similar in the cirrhosis group (NAFLD 32.5%, CHB 17.2%, CHC 11.9% and ALD 1.4%). 219 DISCUSSION: Our study shows that the most common cause for significant fibrosis and cirrhosis is NAFLD. This is in contrast with previous studies, that reported the most common aetiology being CHB.3-4 This is likely due to the availability of effective treatment for hepatitis B and C. This may also be attributed to the initiation of the national Hepatitis B vaccination program for newborns and the improvement in blood transfusion safety. CONCLUSION: NAFLD has the greatest frequency of fibrosis compared with other aetiologies of liver disease - mainly as there is no effective treatment, unlike viral hepatitis