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Healthy Diet, Exercise Cut Liver Death Risk in Drinkers
Following a healthy diet and engaging in a high level of physical activity can significantly lower the risk for alcohol-related liver mortality, even among all drinking patterns, including heavy and binge drinking, according to a new study from Indiana University researchers.
Notably, any amount of daily alcohol intake or binge drinking increases the liver mortality risk, the researchers found. However, that risk can be reduced somewhat with healthy dietary patterns and increased physical activity.
Although previous studies suggested that one or two drinks per day could be associated with lower risks for cardiovascular disease, cancer, or liver-related outcomes, other confounders and unmeasured lifestyle behaviors could vary significantly between consumers and influence their health risks, the researchers said.
“A significant knowledge gap exists regarding the interplay of dietary patterns and physical activity with alcohol-attributable liver-specific mortality,” said senior author Naga Chalasani, MD, AGAF, professor of gastroenterology and hepatology at the Indiana University School of Medicine in Indianapolis.
“It is not well understood whether healthy diets or increased physical activity levels explain differences in liver-specific mortality risks between lifetime abstainers and light-to-moderate alcohol consumers,” he said. “More importantly, it remains unclear whether a healthy diet and physical activity can lower liver-specific mortality in individuals engaging in high-risk alcohol consumption, such as heavy or binge drinking.”
The study was published online in the Journal of Hepatology.
Analyzing Alcohol-Related Effects
Chalasani and colleagues analyzed data from more than 60,000 adults in the National Health and Nutrition Examination Surveys for 1984-2018 and linked data in the National Death Index through December 2019.
The research team looked at self-reported alcohol use, diet quality based on the Healthy Eating Index, and physical activity levels. Heavy drinking was defined as more than three drinks per day for women and more than four drinks per day for men, while binge drinking was defined as four or more drinks per day for women and five or more drinks per day for men.
Physically active participants had at least 150 minutes of moderate-intensity physical activity or 75 minutes of vigorous-intensity physical activity per week. Participants with healthier diets were in the top quartile of the Healthy Eating Index, which included diets high in vegetables, fruits, whole grains, seafood, plant-based proteins, and unsaturated fats, as well as diets low in solid fats, alcohol, and added sugars.
During a 12-year follow-up period, 12,881 deaths were reported, including 252 related to liver disease. An increased risk for liver-related death was associated with older age, smoking, diabetes, higher BMI, waist circumference, average daily alcohol intake, and binge drinking.
Compared to nondrinkers, those with daily alcohol intake had an increased liver-specific mortality risk, with an adjusted subdistribution hazard ratio (aSHR) of 1.04 for men and 1.08 for women.
Binge drinking had an even greater liver mortality risk, with an aSHR of 1.52 for men and 2.52 for women, than nonbinge drinking.
In contrast, a healthier diet — among those at the top quartile of the Healthy Eating Index — had a lower liver mortality risk in nonheavy drinkers (aSHR, 0.35), heavy drinkers (aSHR, 0.14), and binge drinkers (aSHR, 0.16).
In addition, physically active participants had a lower liver mortality risk for nonheavy drinkers (aSHR, 0.52), heavy drinkers (aSHR, 0.64), and binge drinkers (aSHR, 0.31).
Overall, the benefits of higher diet quality and physical activity were substantially greater in women than in men, the researchers found.
“The uniqueness of our study lies in its ability to simultaneously assess the moderating effects of two important lifestyle behaviors on liver mortality risk across different levels and patterns of alcohol consumption in a representative US population, offering a more nuanced and complete view of the risks of drinking,” Chalasani said.
Messaging From Clinicians to Patients
Despite some attenuation from a healthy diet and physical activity, alcohol consumption still carries an increased liver mortality risk, the researchers noted. Economically disadvantaged groups face higher exposure to high-risk alcohol use, unhealthy diets, and physical activity — and as a result, increased liver mortality.
“This study challenges the long-held belief that light-to-moderate drinking might be safe for the liver. It shows that any level of alcohol raises risk, but healthy diet and exercise can meaningfully reduce that harm,” said Joseph Ahn, MD, AGAF, assistant professor of medicine in the Division of Gastroenterology and Hepatology at the Mayo Clinic in Rochester, Minnesota.
“The results should change how we think about alcohol — not as something potentially protective, but as a risk factor that can be partly mitigated by lifestyle,” he said.
“The key takeaway is that there is no safe level of alcohol for liver health. Clinicians should move away from reassuring patients about ‘moderate’ drinking and instead stress both alcohol reduction and the protective role of diet and physical activity,” Ahn added. “The next step is bringing these insights into guidelines and patient counseling, especially for populations at higher risk.”
The study was funded by departmental internal funding. Chalasani declared having no conflicts of interest for this paper, but he disclosed paid consulting agreements with numerous pharmaceutical companies. Ahn reported having no disclosures.
A version of this article appeared on Medscape.com.
Following a healthy diet and engaging in a high level of physical activity can significantly lower the risk for alcohol-related liver mortality, even among all drinking patterns, including heavy and binge drinking, according to a new study from Indiana University researchers.
Notably, any amount of daily alcohol intake or binge drinking increases the liver mortality risk, the researchers found. However, that risk can be reduced somewhat with healthy dietary patterns and increased physical activity.
Although previous studies suggested that one or two drinks per day could be associated with lower risks for cardiovascular disease, cancer, or liver-related outcomes, other confounders and unmeasured lifestyle behaviors could vary significantly between consumers and influence their health risks, the researchers said.
“A significant knowledge gap exists regarding the interplay of dietary patterns and physical activity with alcohol-attributable liver-specific mortality,” said senior author Naga Chalasani, MD, AGAF, professor of gastroenterology and hepatology at the Indiana University School of Medicine in Indianapolis.
“It is not well understood whether healthy diets or increased physical activity levels explain differences in liver-specific mortality risks between lifetime abstainers and light-to-moderate alcohol consumers,” he said. “More importantly, it remains unclear whether a healthy diet and physical activity can lower liver-specific mortality in individuals engaging in high-risk alcohol consumption, such as heavy or binge drinking.”
The study was published online in the Journal of Hepatology.
Analyzing Alcohol-Related Effects
Chalasani and colleagues analyzed data from more than 60,000 adults in the National Health and Nutrition Examination Surveys for 1984-2018 and linked data in the National Death Index through December 2019.
The research team looked at self-reported alcohol use, diet quality based on the Healthy Eating Index, and physical activity levels. Heavy drinking was defined as more than three drinks per day for women and more than four drinks per day for men, while binge drinking was defined as four or more drinks per day for women and five or more drinks per day for men.
Physically active participants had at least 150 minutes of moderate-intensity physical activity or 75 minutes of vigorous-intensity physical activity per week. Participants with healthier diets were in the top quartile of the Healthy Eating Index, which included diets high in vegetables, fruits, whole grains, seafood, plant-based proteins, and unsaturated fats, as well as diets low in solid fats, alcohol, and added sugars.
During a 12-year follow-up period, 12,881 deaths were reported, including 252 related to liver disease. An increased risk for liver-related death was associated with older age, smoking, diabetes, higher BMI, waist circumference, average daily alcohol intake, and binge drinking.
Compared to nondrinkers, those with daily alcohol intake had an increased liver-specific mortality risk, with an adjusted subdistribution hazard ratio (aSHR) of 1.04 for men and 1.08 for women.
Binge drinking had an even greater liver mortality risk, with an aSHR of 1.52 for men and 2.52 for women, than nonbinge drinking.
In contrast, a healthier diet — among those at the top quartile of the Healthy Eating Index — had a lower liver mortality risk in nonheavy drinkers (aSHR, 0.35), heavy drinkers (aSHR, 0.14), and binge drinkers (aSHR, 0.16).
In addition, physically active participants had a lower liver mortality risk for nonheavy drinkers (aSHR, 0.52), heavy drinkers (aSHR, 0.64), and binge drinkers (aSHR, 0.31).
Overall, the benefits of higher diet quality and physical activity were substantially greater in women than in men, the researchers found.
“The uniqueness of our study lies in its ability to simultaneously assess the moderating effects of two important lifestyle behaviors on liver mortality risk across different levels and patterns of alcohol consumption in a representative US population, offering a more nuanced and complete view of the risks of drinking,” Chalasani said.
Messaging From Clinicians to Patients
Despite some attenuation from a healthy diet and physical activity, alcohol consumption still carries an increased liver mortality risk, the researchers noted. Economically disadvantaged groups face higher exposure to high-risk alcohol use, unhealthy diets, and physical activity — and as a result, increased liver mortality.
“This study challenges the long-held belief that light-to-moderate drinking might be safe for the liver. It shows that any level of alcohol raises risk, but healthy diet and exercise can meaningfully reduce that harm,” said Joseph Ahn, MD, AGAF, assistant professor of medicine in the Division of Gastroenterology and Hepatology at the Mayo Clinic in Rochester, Minnesota.
“The results should change how we think about alcohol — not as something potentially protective, but as a risk factor that can be partly mitigated by lifestyle,” he said.
“The key takeaway is that there is no safe level of alcohol for liver health. Clinicians should move away from reassuring patients about ‘moderate’ drinking and instead stress both alcohol reduction and the protective role of diet and physical activity,” Ahn added. “The next step is bringing these insights into guidelines and patient counseling, especially for populations at higher risk.”
The study was funded by departmental internal funding. Chalasani declared having no conflicts of interest for this paper, but he disclosed paid consulting agreements with numerous pharmaceutical companies. Ahn reported having no disclosures.
A version of this article appeared on Medscape.com.
Following a healthy diet and engaging in a high level of physical activity can significantly lower the risk for alcohol-related liver mortality, even among all drinking patterns, including heavy and binge drinking, according to a new study from Indiana University researchers.
Notably, any amount of daily alcohol intake or binge drinking increases the liver mortality risk, the researchers found. However, that risk can be reduced somewhat with healthy dietary patterns and increased physical activity.
Although previous studies suggested that one or two drinks per day could be associated with lower risks for cardiovascular disease, cancer, or liver-related outcomes, other confounders and unmeasured lifestyle behaviors could vary significantly between consumers and influence their health risks, the researchers said.
“A significant knowledge gap exists regarding the interplay of dietary patterns and physical activity with alcohol-attributable liver-specific mortality,” said senior author Naga Chalasani, MD, AGAF, professor of gastroenterology and hepatology at the Indiana University School of Medicine in Indianapolis.
“It is not well understood whether healthy diets or increased physical activity levels explain differences in liver-specific mortality risks between lifetime abstainers and light-to-moderate alcohol consumers,” he said. “More importantly, it remains unclear whether a healthy diet and physical activity can lower liver-specific mortality in individuals engaging in high-risk alcohol consumption, such as heavy or binge drinking.”
The study was published online in the Journal of Hepatology.
Analyzing Alcohol-Related Effects
Chalasani and colleagues analyzed data from more than 60,000 adults in the National Health and Nutrition Examination Surveys for 1984-2018 and linked data in the National Death Index through December 2019.
The research team looked at self-reported alcohol use, diet quality based on the Healthy Eating Index, and physical activity levels. Heavy drinking was defined as more than three drinks per day for women and more than four drinks per day for men, while binge drinking was defined as four or more drinks per day for women and five or more drinks per day for men.
Physically active participants had at least 150 minutes of moderate-intensity physical activity or 75 minutes of vigorous-intensity physical activity per week. Participants with healthier diets were in the top quartile of the Healthy Eating Index, which included diets high in vegetables, fruits, whole grains, seafood, plant-based proteins, and unsaturated fats, as well as diets low in solid fats, alcohol, and added sugars.
During a 12-year follow-up period, 12,881 deaths were reported, including 252 related to liver disease. An increased risk for liver-related death was associated with older age, smoking, diabetes, higher BMI, waist circumference, average daily alcohol intake, and binge drinking.
Compared to nondrinkers, those with daily alcohol intake had an increased liver-specific mortality risk, with an adjusted subdistribution hazard ratio (aSHR) of 1.04 for men and 1.08 for women.
Binge drinking had an even greater liver mortality risk, with an aSHR of 1.52 for men and 2.52 for women, than nonbinge drinking.
In contrast, a healthier diet — among those at the top quartile of the Healthy Eating Index — had a lower liver mortality risk in nonheavy drinkers (aSHR, 0.35), heavy drinkers (aSHR, 0.14), and binge drinkers (aSHR, 0.16).
In addition, physically active participants had a lower liver mortality risk for nonheavy drinkers (aSHR, 0.52), heavy drinkers (aSHR, 0.64), and binge drinkers (aSHR, 0.31).
Overall, the benefits of higher diet quality and physical activity were substantially greater in women than in men, the researchers found.
“The uniqueness of our study lies in its ability to simultaneously assess the moderating effects of two important lifestyle behaviors on liver mortality risk across different levels and patterns of alcohol consumption in a representative US population, offering a more nuanced and complete view of the risks of drinking,” Chalasani said.
Messaging From Clinicians to Patients
Despite some attenuation from a healthy diet and physical activity, alcohol consumption still carries an increased liver mortality risk, the researchers noted. Economically disadvantaged groups face higher exposure to high-risk alcohol use, unhealthy diets, and physical activity — and as a result, increased liver mortality.
“This study challenges the long-held belief that light-to-moderate drinking might be safe for the liver. It shows that any level of alcohol raises risk, but healthy diet and exercise can meaningfully reduce that harm,” said Joseph Ahn, MD, AGAF, assistant professor of medicine in the Division of Gastroenterology and Hepatology at the Mayo Clinic in Rochester, Minnesota.
“The results should change how we think about alcohol — not as something potentially protective, but as a risk factor that can be partly mitigated by lifestyle,” he said.
“The key takeaway is that there is no safe level of alcohol for liver health. Clinicians should move away from reassuring patients about ‘moderate’ drinking and instead stress both alcohol reduction and the protective role of diet and physical activity,” Ahn added. “The next step is bringing these insights into guidelines and patient counseling, especially for populations at higher risk.”
The study was funded by departmental internal funding. Chalasani declared having no conflicts of interest for this paper, but he disclosed paid consulting agreements with numerous pharmaceutical companies. Ahn reported having no disclosures.
A version of this article appeared on Medscape.com.
Repeat Intubation of the Sigmoid Colon Improves Adenoma Detection
, new research showed.
“After eliminating the impact of time, the adenoma-detection rate [with a second intubation vs standard withdrawal] was still significantly increased, indicating that the second intubation technique could enhance the visualization of the sigmoid colon mucosa and reduce the rate of missed lesions,” reported the authors of the study, published in The American Journal of Gastroenterology.
When precancerous polyps are removed during standard colonoscopies, as many as 70%-90% of colorectal cancers can be prevented; however, rates of missed polyps during colonoscopy are notoriously high.
Recent studies have shown improved adenoma-detection rates with the use of Endocuff, water-assisted colonoscopy, full-spectrum endoscopy, and repeat withdrawal examinations, which include retroflexion and forward-viewing methods.
The repeat colonoscopy examinations may represent “the easiest and most practical option for endoscopists as they do not require additional tools, staff, or funding,” the authors explained.
However, most studies on the issue have focused mainly on the right colon and forward-viewing examinations, whereas the sigmoid colon, which has the most turns and is the most easily compressed, can be easily missed during withdrawal observation.
To investigate if use of a second colon intubation of the sigmoid colon could improve detection rates, senior author Jianning Yao, MD, of the Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China, conducted a randomized trial, enrolling 650 patients between December 2023 and April 2024 who were aged 45 or older and had overweight or obesity (BMI ≥ 24).
At the time of the first withdrawal during the colonoscopy, the patients were randomized 1:1 to groups of 325 each to either receive standard withdrawal, with withdrawal to the anus, or to receive a second intubation, with reinsertion into the sigmoid colon.
In the second intubation, the colonoscope was pushed forward without straightening, “allowing for slight looping that could be used to flatten the colonic folds as the tip of the instrument was advanced,” they explained.
The patients had a mean age of 55; about 25% had a smoking habit, and the mean BMI was about 28. There were no significant differences in other baseline characteristics.
The results showed that patients in the second-intubation group vs standard-withdrawal group had a substantially higher adenoma-detection rate (24.3% vs 14.5%) and polyp-detection rate (29.2% vs 17.8%, P = .001 for both) in the sigmoid colon.
In the second-intubation group, 85% of the adenomas discovered throughout the second inspection in the sigmoid colon were 5 mm or smaller in size. In addition, 90% of the 40 adenomas were somewhat raised or pedunculated, and all were tubular adenomas.
No high-grade dysplasia adenomas were discovered.
Of note, the colonoscopy in the second-intubation group’s colonoscopic examinations took just 1.47 minute longer overall than the standard-withdrawal group’s examinations.
Factors that were determined in a multivariate analysis to be independent predictors of higher adenoma detection in the second-intubation group included older age, smoking habit, longer duration of the second inspection, and the identification of lesions during the initial withdrawal from the sigmoid colon.
Patients’ vital signs were monitored at intervals of 3 minutes throughout the colonoscopy procedure, and patients were followed up to monitor for any adverse events occurring within 2 weeks after the examination, with no notable disparities observed between the two groups.
Alternative to AKS Approach in Second Intubation
The authors explained that, in their approach in the second intubation, the common axis-keeping shortening (AKS) was not utilized, and instead they pushed the colonoscope forward without straightening it, which offers important advantages.
“In this way, slight looping of the colonoscope can be used to flatten the colonic folds as the tip of the instrument is advanced, thereby achieving an observation effect that cannot be reached by any number of withdrawal examinations.”
In general, the stimulation of peristalsis during a second examination allows for the observation of the colonic mucosa from different angles, thereby reducing the rate of missed lesions, the authors added.
“Although the detection of these lesions may not significantly affect clinical outcomes, it serves as a reminder for patients regarding regular follow-ups and lifestyle adjustments,” they explained. “Additionally, it may reduce the likelihood of missing some smaller lesions that progress rapidly, such as de novo cancer.”
Based on the results, the authors concluded that older patients, patients who smoke, or those with lesions found on the first sigmoid inspection have a higher chance of having missed adenomas discovered in the sigmoid colon during the second intubation examination.
“If one of these risk factors is present, a second examination of the sigmoid colon may be considered to detect missed lesions,” they said.
The added time commitment of just 1.47 minutes can be a worthwhile tradeoff, they added.
“Considering the improvements in the adenoma-detection rate provided by the second intubation, this modest time increase may be acceptable.”
The authors had no disclosures to report.
A version of this article appeared on Medscape.com.
, new research showed.
“After eliminating the impact of time, the adenoma-detection rate [with a second intubation vs standard withdrawal] was still significantly increased, indicating that the second intubation technique could enhance the visualization of the sigmoid colon mucosa and reduce the rate of missed lesions,” reported the authors of the study, published in The American Journal of Gastroenterology.
When precancerous polyps are removed during standard colonoscopies, as many as 70%-90% of colorectal cancers can be prevented; however, rates of missed polyps during colonoscopy are notoriously high.
Recent studies have shown improved adenoma-detection rates with the use of Endocuff, water-assisted colonoscopy, full-spectrum endoscopy, and repeat withdrawal examinations, which include retroflexion and forward-viewing methods.
The repeat colonoscopy examinations may represent “the easiest and most practical option for endoscopists as they do not require additional tools, staff, or funding,” the authors explained.
However, most studies on the issue have focused mainly on the right colon and forward-viewing examinations, whereas the sigmoid colon, which has the most turns and is the most easily compressed, can be easily missed during withdrawal observation.
To investigate if use of a second colon intubation of the sigmoid colon could improve detection rates, senior author Jianning Yao, MD, of the Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China, conducted a randomized trial, enrolling 650 patients between December 2023 and April 2024 who were aged 45 or older and had overweight or obesity (BMI ≥ 24).
At the time of the first withdrawal during the colonoscopy, the patients were randomized 1:1 to groups of 325 each to either receive standard withdrawal, with withdrawal to the anus, or to receive a second intubation, with reinsertion into the sigmoid colon.
In the second intubation, the colonoscope was pushed forward without straightening, “allowing for slight looping that could be used to flatten the colonic folds as the tip of the instrument was advanced,” they explained.
The patients had a mean age of 55; about 25% had a smoking habit, and the mean BMI was about 28. There were no significant differences in other baseline characteristics.
The results showed that patients in the second-intubation group vs standard-withdrawal group had a substantially higher adenoma-detection rate (24.3% vs 14.5%) and polyp-detection rate (29.2% vs 17.8%, P = .001 for both) in the sigmoid colon.
In the second-intubation group, 85% of the adenomas discovered throughout the second inspection in the sigmoid colon were 5 mm or smaller in size. In addition, 90% of the 40 adenomas were somewhat raised or pedunculated, and all were tubular adenomas.
No high-grade dysplasia adenomas were discovered.
Of note, the colonoscopy in the second-intubation group’s colonoscopic examinations took just 1.47 minute longer overall than the standard-withdrawal group’s examinations.
Factors that were determined in a multivariate analysis to be independent predictors of higher adenoma detection in the second-intubation group included older age, smoking habit, longer duration of the second inspection, and the identification of lesions during the initial withdrawal from the sigmoid colon.
Patients’ vital signs were monitored at intervals of 3 minutes throughout the colonoscopy procedure, and patients were followed up to monitor for any adverse events occurring within 2 weeks after the examination, with no notable disparities observed between the two groups.
Alternative to AKS Approach in Second Intubation
The authors explained that, in their approach in the second intubation, the common axis-keeping shortening (AKS) was not utilized, and instead they pushed the colonoscope forward without straightening it, which offers important advantages.
“In this way, slight looping of the colonoscope can be used to flatten the colonic folds as the tip of the instrument is advanced, thereby achieving an observation effect that cannot be reached by any number of withdrawal examinations.”
In general, the stimulation of peristalsis during a second examination allows for the observation of the colonic mucosa from different angles, thereby reducing the rate of missed lesions, the authors added.
“Although the detection of these lesions may not significantly affect clinical outcomes, it serves as a reminder for patients regarding regular follow-ups and lifestyle adjustments,” they explained. “Additionally, it may reduce the likelihood of missing some smaller lesions that progress rapidly, such as de novo cancer.”
Based on the results, the authors concluded that older patients, patients who smoke, or those with lesions found on the first sigmoid inspection have a higher chance of having missed adenomas discovered in the sigmoid colon during the second intubation examination.
“If one of these risk factors is present, a second examination of the sigmoid colon may be considered to detect missed lesions,” they said.
The added time commitment of just 1.47 minutes can be a worthwhile tradeoff, they added.
“Considering the improvements in the adenoma-detection rate provided by the second intubation, this modest time increase may be acceptable.”
The authors had no disclosures to report.
A version of this article appeared on Medscape.com.
, new research showed.
“After eliminating the impact of time, the adenoma-detection rate [with a second intubation vs standard withdrawal] was still significantly increased, indicating that the second intubation technique could enhance the visualization of the sigmoid colon mucosa and reduce the rate of missed lesions,” reported the authors of the study, published in The American Journal of Gastroenterology.
When precancerous polyps are removed during standard colonoscopies, as many as 70%-90% of colorectal cancers can be prevented; however, rates of missed polyps during colonoscopy are notoriously high.
Recent studies have shown improved adenoma-detection rates with the use of Endocuff, water-assisted colonoscopy, full-spectrum endoscopy, and repeat withdrawal examinations, which include retroflexion and forward-viewing methods.
The repeat colonoscopy examinations may represent “the easiest and most practical option for endoscopists as they do not require additional tools, staff, or funding,” the authors explained.
However, most studies on the issue have focused mainly on the right colon and forward-viewing examinations, whereas the sigmoid colon, which has the most turns and is the most easily compressed, can be easily missed during withdrawal observation.
To investigate if use of a second colon intubation of the sigmoid colon could improve detection rates, senior author Jianning Yao, MD, of the Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China, conducted a randomized trial, enrolling 650 patients between December 2023 and April 2024 who were aged 45 or older and had overweight or obesity (BMI ≥ 24).
At the time of the first withdrawal during the colonoscopy, the patients were randomized 1:1 to groups of 325 each to either receive standard withdrawal, with withdrawal to the anus, or to receive a second intubation, with reinsertion into the sigmoid colon.
In the second intubation, the colonoscope was pushed forward without straightening, “allowing for slight looping that could be used to flatten the colonic folds as the tip of the instrument was advanced,” they explained.
The patients had a mean age of 55; about 25% had a smoking habit, and the mean BMI was about 28. There were no significant differences in other baseline characteristics.
The results showed that patients in the second-intubation group vs standard-withdrawal group had a substantially higher adenoma-detection rate (24.3% vs 14.5%) and polyp-detection rate (29.2% vs 17.8%, P = .001 for both) in the sigmoid colon.
In the second-intubation group, 85% of the adenomas discovered throughout the second inspection in the sigmoid colon were 5 mm or smaller in size. In addition, 90% of the 40 adenomas were somewhat raised or pedunculated, and all were tubular adenomas.
No high-grade dysplasia adenomas were discovered.
Of note, the colonoscopy in the second-intubation group’s colonoscopic examinations took just 1.47 minute longer overall than the standard-withdrawal group’s examinations.
Factors that were determined in a multivariate analysis to be independent predictors of higher adenoma detection in the second-intubation group included older age, smoking habit, longer duration of the second inspection, and the identification of lesions during the initial withdrawal from the sigmoid colon.
Patients’ vital signs were monitored at intervals of 3 minutes throughout the colonoscopy procedure, and patients were followed up to monitor for any adverse events occurring within 2 weeks after the examination, with no notable disparities observed between the two groups.
Alternative to AKS Approach in Second Intubation
The authors explained that, in their approach in the second intubation, the common axis-keeping shortening (AKS) was not utilized, and instead they pushed the colonoscope forward without straightening it, which offers important advantages.
“In this way, slight looping of the colonoscope can be used to flatten the colonic folds as the tip of the instrument is advanced, thereby achieving an observation effect that cannot be reached by any number of withdrawal examinations.”
In general, the stimulation of peristalsis during a second examination allows for the observation of the colonic mucosa from different angles, thereby reducing the rate of missed lesions, the authors added.
“Although the detection of these lesions may not significantly affect clinical outcomes, it serves as a reminder for patients regarding regular follow-ups and lifestyle adjustments,” they explained. “Additionally, it may reduce the likelihood of missing some smaller lesions that progress rapidly, such as de novo cancer.”
Based on the results, the authors concluded that older patients, patients who smoke, or those with lesions found on the first sigmoid inspection have a higher chance of having missed adenomas discovered in the sigmoid colon during the second intubation examination.
“If one of these risk factors is present, a second examination of the sigmoid colon may be considered to detect missed lesions,” they said.
The added time commitment of just 1.47 minutes can be a worthwhile tradeoff, they added.
“Considering the improvements in the adenoma-detection rate provided by the second intubation, this modest time increase may be acceptable.”
The authors had no disclosures to report.
A version of this article appeared on Medscape.com.
Screening for H. pylori May Reduce Bleeding in Some Patients With MI
Screening for H. pylori May Reduce Bleeding in Some Patients With MI
, according to the HELP-MI SWEDEHEART trial published in JAMA and presented at the European Society of Cardiology (ESC) Congress 2025.
Bleeding in the upper gastrointestinal tract is a common complication after MI. It increases morbidity and mortality itself but can also reduce the effectiveness of antithrombotic treatments and lead to new cardiovascular events. It is often related to infection with H. pylori, the bacterium that can cause stomach inflammation, ulcers, and cancer, said Robin Hofmann, MD, PhD, a cardiologist at the Karolinska Institute in Stockholm, Sweden, who presented the trial results.Hofmann and his colleagues wondered whether screening for the bacterium using a simple urea breath test would help reduce the risk for bleeds. Using Sweden’s national SWEDEHEART registry, researchers performed a cluster-randomized crossover trial of more than 18,000 patients with MI at 35 Swedish hospitals. They found that screening for H. pylori reduced the risk for upper gastrointestinal bleeding by 10%, but the results were not statistically significant.
Several factors may have contributed to the neutral result, noted Hofmann. Just 70% of the people in the screening population were actually screened — though he said that is a fairly good number for a diagnostic test. A relatively small number, around 23%, were positive for H. pylori, a much lower rate than in many other parts of the world, and about 25% of participants in both arms of the trial were already taking proton pump inhibitors to reduce the risk for bleeding.
Signals of Benefit in High-Risk Patients
But in some high-risk subgroups, there was a clearer signal of benefit. Patients with anemia or kidney failure, for example, who are at higher risk for bleeding, saw a relative risk reduction of around 50% in the screening group — though the numbers were too small for formal statistical analysis.
“In unselected patients with myocardial infarction we could not show a significant reduction in bleeding,” said Hofmann. “But it’s very likely that there is a clinical effect, at least in those individuals at increased risk of bleeding.”
Discussant Paul Ridker, MD, a cardiologist at Harvard Medical School, Boston, said he agreed that the trial was technically neutral but clinically positive. He noted that in every subgroup, the trend was in the direction of benefit, with only the top end of the cardiac indices crossing over into no benefit. And the benefit appeared larger among high-risk patients with anemia or kidney failure.
“These are the very patients I’m most concerned about and don’t want to bleed,” he said.Because the urea breath test and eradication therapy are simple, safe, and inexpensive, Hofmann said he thinks there is “good evidence to recommend H. pylori screening in patients at higher risk of bleeding.”
“I’m very sure from a clinical perspective that we will be able to identify the groups that are low-hanging fruit,” he said. “But the guideline committees will have to decide if this evidence is enough.”
Hofmann and Ridker reported having no financial conflicts of interest.
A version of this article appeared on Medscape.com.
, according to the HELP-MI SWEDEHEART trial published in JAMA and presented at the European Society of Cardiology (ESC) Congress 2025.
Bleeding in the upper gastrointestinal tract is a common complication after MI. It increases morbidity and mortality itself but can also reduce the effectiveness of antithrombotic treatments and lead to new cardiovascular events. It is often related to infection with H. pylori, the bacterium that can cause stomach inflammation, ulcers, and cancer, said Robin Hofmann, MD, PhD, a cardiologist at the Karolinska Institute in Stockholm, Sweden, who presented the trial results.Hofmann and his colleagues wondered whether screening for the bacterium using a simple urea breath test would help reduce the risk for bleeds. Using Sweden’s national SWEDEHEART registry, researchers performed a cluster-randomized crossover trial of more than 18,000 patients with MI at 35 Swedish hospitals. They found that screening for H. pylori reduced the risk for upper gastrointestinal bleeding by 10%, but the results were not statistically significant.
Several factors may have contributed to the neutral result, noted Hofmann. Just 70% of the people in the screening population were actually screened — though he said that is a fairly good number for a diagnostic test. A relatively small number, around 23%, were positive for H. pylori, a much lower rate than in many other parts of the world, and about 25% of participants in both arms of the trial were already taking proton pump inhibitors to reduce the risk for bleeding.
Signals of Benefit in High-Risk Patients
But in some high-risk subgroups, there was a clearer signal of benefit. Patients with anemia or kidney failure, for example, who are at higher risk for bleeding, saw a relative risk reduction of around 50% in the screening group — though the numbers were too small for formal statistical analysis.
“In unselected patients with myocardial infarction we could not show a significant reduction in bleeding,” said Hofmann. “But it’s very likely that there is a clinical effect, at least in those individuals at increased risk of bleeding.”
Discussant Paul Ridker, MD, a cardiologist at Harvard Medical School, Boston, said he agreed that the trial was technically neutral but clinically positive. He noted that in every subgroup, the trend was in the direction of benefit, with only the top end of the cardiac indices crossing over into no benefit. And the benefit appeared larger among high-risk patients with anemia or kidney failure.
“These are the very patients I’m most concerned about and don’t want to bleed,” he said.Because the urea breath test and eradication therapy are simple, safe, and inexpensive, Hofmann said he thinks there is “good evidence to recommend H. pylori screening in patients at higher risk of bleeding.”
“I’m very sure from a clinical perspective that we will be able to identify the groups that are low-hanging fruit,” he said. “But the guideline committees will have to decide if this evidence is enough.”
Hofmann and Ridker reported having no financial conflicts of interest.
A version of this article appeared on Medscape.com.
, according to the HELP-MI SWEDEHEART trial published in JAMA and presented at the European Society of Cardiology (ESC) Congress 2025.
Bleeding in the upper gastrointestinal tract is a common complication after MI. It increases morbidity and mortality itself but can also reduce the effectiveness of antithrombotic treatments and lead to new cardiovascular events. It is often related to infection with H. pylori, the bacterium that can cause stomach inflammation, ulcers, and cancer, said Robin Hofmann, MD, PhD, a cardiologist at the Karolinska Institute in Stockholm, Sweden, who presented the trial results.Hofmann and his colleagues wondered whether screening for the bacterium using a simple urea breath test would help reduce the risk for bleeds. Using Sweden’s national SWEDEHEART registry, researchers performed a cluster-randomized crossover trial of more than 18,000 patients with MI at 35 Swedish hospitals. They found that screening for H. pylori reduced the risk for upper gastrointestinal bleeding by 10%, but the results were not statistically significant.
Several factors may have contributed to the neutral result, noted Hofmann. Just 70% of the people in the screening population were actually screened — though he said that is a fairly good number for a diagnostic test. A relatively small number, around 23%, were positive for H. pylori, a much lower rate than in many other parts of the world, and about 25% of participants in both arms of the trial were already taking proton pump inhibitors to reduce the risk for bleeding.
Signals of Benefit in High-Risk Patients
But in some high-risk subgroups, there was a clearer signal of benefit. Patients with anemia or kidney failure, for example, who are at higher risk for bleeding, saw a relative risk reduction of around 50% in the screening group — though the numbers were too small for formal statistical analysis.
“In unselected patients with myocardial infarction we could not show a significant reduction in bleeding,” said Hofmann. “But it’s very likely that there is a clinical effect, at least in those individuals at increased risk of bleeding.”
Discussant Paul Ridker, MD, a cardiologist at Harvard Medical School, Boston, said he agreed that the trial was technically neutral but clinically positive. He noted that in every subgroup, the trend was in the direction of benefit, with only the top end of the cardiac indices crossing over into no benefit. And the benefit appeared larger among high-risk patients with anemia or kidney failure.
“These are the very patients I’m most concerned about and don’t want to bleed,” he said.Because the urea breath test and eradication therapy are simple, safe, and inexpensive, Hofmann said he thinks there is “good evidence to recommend H. pylori screening in patients at higher risk of bleeding.”
“I’m very sure from a clinical perspective that we will be able to identify the groups that are low-hanging fruit,” he said. “But the guideline committees will have to decide if this evidence is enough.”
Hofmann and Ridker reported having no financial conflicts of interest.
A version of this article appeared on Medscape.com.
Screening for H. pylori May Reduce Bleeding in Some Patients With MI
Screening for H. pylori May Reduce Bleeding in Some Patients With MI
Large Language Models Cut Time, Cost of Guideline Development
, according to a pilot study from the American Gastroenterological Association (AGA).
Faster, cheaper study screening could allow societies to update clinical recommendations more frequently, improving alignment with the latest evidence, lead author Sunny Chung, MD, of Yale School of Medicine, New Haven, Connecticut, and colleagues, reported.
“Each guideline typically requires 5 to 15 systematic reviews, making the process time-consuming (averaging more than 60 weeks) and costly (more than $140,000),” the investigators wrote in Gastroenterology . “One of the most critical yet time-consuming steps in systematic reviews is title and abstract screening. LLMs have the potential to make this step more efficient.”
To test this approach, the investigators developed, validated, and applied a dual-model LLM screening pipeline with human-in-the-loop oversight, focusing on randomized controlled trials in AGA guidelines.
The system was built using the 2021 guideline on moderate-to-severe Crohn’s disease, targeting biologic therapies for induction and maintenance of remission.
Using chain-of-thought prompting and structured inclusion criteria based on the PICO framework, the investigators deployed GPT-4o (OpenAI) and Gemini-1.5-Pro (Google DeepMind) as independent screeners, each assessing titles and abstracts according to standardized logic encoded in JavaScript Object Notation. This approach mimicked a traditional double-reviewer system.
After initial testing, the pipeline was validated in a 2025 update of the same guideline, this time spanning 6 focused clinical questions on advanced therapies and immunomodulators. Results were compared against manual screening by 2 experienced human reviewers, with total screening time documented.
The system was then tested across 4 additional guideline topics: fecal microbiota transplantation (FMT) for irritable bowel syndrome and Clostridioides difficile, gastroparesis, and hepatocellular carcinoma. A final test applied the system to a forthcoming guideline on complications of acute pancreatitis.
Across all topics, the dual-LLM system achieved 100% sensitivity in identifying randomized controlled trials (RCTs). For the 2025 update of the AGA guideline on Crohn’s disease, the models flagged 418 of 4,377 abstracts for inclusion, captur-ing all 25 relevant RCTs in just 48 minutes. Manual screening of the same dataset previously took almost 13 hours.
Comparable accuracy and time savings were observed for the other topics.
The pipeline correctly flagged all 13 RCTs in 4,820 studies on FMT for irritable bowel syndrome, and all 16 RCTs in 5,587 studies on FMT for Clostridioides difficile, requiring 27 and 66 minutes, respectively. Similarly, the system captured all 11 RCTs in 3,919 hepatocellular carcinoma abstracts and all 18 RCTs in 1,578 studies on gastroparesis, completing each task in under 65 minutes. Early testing on the upcoming guideline for pancreatitis yielded similar results.
Cost analysis underscored the efficiency of this approach. At an estimated $175–200 per hour for expert screeners, traditional abstract screening would cost around $2,500 per review, versus approximately $100 for the LLM approach—a 96% reduction.
The investigators cautioned that human oversight remains necessary to verify the relevance of studies flagged by the models. While the system’s sensitivity was consistent, it also selected articles that were ultimately excluded by expert reviewers. Broader validation will be required to assess performance across non-RCT study designs, such as observational or case-control studies, they added.
“As medical literature continues to expand, the integration of artificial intelligence into evidence synthesis processes will become increasingly vital,” Dr. Chung and colleagues wrote. “With further refinement and broader validation, this LLM-based pipeline has the potential to revolutionize evidence synthesis and set a new standard for guideline development.”
This study was funded by National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. The investigators reported no conflicts of interest.
Ethan Goh, MD, executive director of the Stanford AI Research and Science Evaluation (ARISE) Network, described the AGA pilot as both timely and promising.
“I’m certainly bullish about the use case,” he said in an interview. “Their study design and application is also robust, so I would congratulate them.”
Goh, a general editor for BMJ Digital Health & AI, predicted “huge potential” in the strategy for both clinicians and the general population, who benefit from the most up-to-date guidelines possible.
“I believe that using AI can represent a much faster, more cost effective, efficient way of gathering all these information sources,” he said.
Still, humans will need to be involved in the process.
“[This AI-driven approach] will always need some degree of expert oversight and judgement,” Goh said.
Speaking more broadly about automating study aggregation, Goh said AI may still struggle to determine which studies are most clinically relevant.
“When we use [AI models] to pull out medical references, anecdotally, I don’t think they’re always getting the best ones all the time, or even necessarily the right ones,” he said.
And as AI models grow more impressive, these shortcomings become less apparent, potentially lulling humans into overconfidence.
“Humans are humans,” Goh said. “We get lazy over time. That will be one of the challenges. As the systems get increasingly good, humans start to defer more and more of their judgment to them and say, ‘All right, AI, you’re doing good. Just do 100% automation.’ And then [people] start fact checking or reviewing even less.”
AI could also undermine automated reviews in another way: AI-generated publications that appear genuine, but aren’t, may creep into the dataset.
Despite these concerns, Goh concluded on an optimistic note.
“I think that there are huge ways to use AI, tools, not to replace, but to augment and support human judgment,” he said.
Ethan Goh, MD, is senior research engineer and executive director of the Stanford AI Research and Science Evaluation (ARISE) Network, at Stanford (Calif.) University. He declared no conflicts of interest.
Ethan Goh, MD, executive director of the Stanford AI Research and Science Evaluation (ARISE) Network, described the AGA pilot as both timely and promising.
“I’m certainly bullish about the use case,” he said in an interview. “Their study design and application is also robust, so I would congratulate them.”
Goh, a general editor for BMJ Digital Health & AI, predicted “huge potential” in the strategy for both clinicians and the general population, who benefit from the most up-to-date guidelines possible.
“I believe that using AI can represent a much faster, more cost effective, efficient way of gathering all these information sources,” he said.
Still, humans will need to be involved in the process.
“[This AI-driven approach] will always need some degree of expert oversight and judgement,” Goh said.
Speaking more broadly about automating study aggregation, Goh said AI may still struggle to determine which studies are most clinically relevant.
“When we use [AI models] to pull out medical references, anecdotally, I don’t think they’re always getting the best ones all the time, or even necessarily the right ones,” he said.
And as AI models grow more impressive, these shortcomings become less apparent, potentially lulling humans into overconfidence.
“Humans are humans,” Goh said. “We get lazy over time. That will be one of the challenges. As the systems get increasingly good, humans start to defer more and more of their judgment to them and say, ‘All right, AI, you’re doing good. Just do 100% automation.’ And then [people] start fact checking or reviewing even less.”
AI could also undermine automated reviews in another way: AI-generated publications that appear genuine, but aren’t, may creep into the dataset.
Despite these concerns, Goh concluded on an optimistic note.
“I think that there are huge ways to use AI, tools, not to replace, but to augment and support human judgment,” he said.
Ethan Goh, MD, is senior research engineer and executive director of the Stanford AI Research and Science Evaluation (ARISE) Network, at Stanford (Calif.) University. He declared no conflicts of interest.
Ethan Goh, MD, executive director of the Stanford AI Research and Science Evaluation (ARISE) Network, described the AGA pilot as both timely and promising.
“I’m certainly bullish about the use case,” he said in an interview. “Their study design and application is also robust, so I would congratulate them.”
Goh, a general editor for BMJ Digital Health & AI, predicted “huge potential” in the strategy for both clinicians and the general population, who benefit from the most up-to-date guidelines possible.
“I believe that using AI can represent a much faster, more cost effective, efficient way of gathering all these information sources,” he said.
Still, humans will need to be involved in the process.
“[This AI-driven approach] will always need some degree of expert oversight and judgement,” Goh said.
Speaking more broadly about automating study aggregation, Goh said AI may still struggle to determine which studies are most clinically relevant.
“When we use [AI models] to pull out medical references, anecdotally, I don’t think they’re always getting the best ones all the time, or even necessarily the right ones,” he said.
And as AI models grow more impressive, these shortcomings become less apparent, potentially lulling humans into overconfidence.
“Humans are humans,” Goh said. “We get lazy over time. That will be one of the challenges. As the systems get increasingly good, humans start to defer more and more of their judgment to them and say, ‘All right, AI, you’re doing good. Just do 100% automation.’ And then [people] start fact checking or reviewing even less.”
AI could also undermine automated reviews in another way: AI-generated publications that appear genuine, but aren’t, may creep into the dataset.
Despite these concerns, Goh concluded on an optimistic note.
“I think that there are huge ways to use AI, tools, not to replace, but to augment and support human judgment,” he said.
Ethan Goh, MD, is senior research engineer and executive director of the Stanford AI Research and Science Evaluation (ARISE) Network, at Stanford (Calif.) University. He declared no conflicts of interest.
, according to a pilot study from the American Gastroenterological Association (AGA).
Faster, cheaper study screening could allow societies to update clinical recommendations more frequently, improving alignment with the latest evidence, lead author Sunny Chung, MD, of Yale School of Medicine, New Haven, Connecticut, and colleagues, reported.
“Each guideline typically requires 5 to 15 systematic reviews, making the process time-consuming (averaging more than 60 weeks) and costly (more than $140,000),” the investigators wrote in Gastroenterology . “One of the most critical yet time-consuming steps in systematic reviews is title and abstract screening. LLMs have the potential to make this step more efficient.”
To test this approach, the investigators developed, validated, and applied a dual-model LLM screening pipeline with human-in-the-loop oversight, focusing on randomized controlled trials in AGA guidelines.
The system was built using the 2021 guideline on moderate-to-severe Crohn’s disease, targeting biologic therapies for induction and maintenance of remission.
Using chain-of-thought prompting and structured inclusion criteria based on the PICO framework, the investigators deployed GPT-4o (OpenAI) and Gemini-1.5-Pro (Google DeepMind) as independent screeners, each assessing titles and abstracts according to standardized logic encoded in JavaScript Object Notation. This approach mimicked a traditional double-reviewer system.
After initial testing, the pipeline was validated in a 2025 update of the same guideline, this time spanning 6 focused clinical questions on advanced therapies and immunomodulators. Results were compared against manual screening by 2 experienced human reviewers, with total screening time documented.
The system was then tested across 4 additional guideline topics: fecal microbiota transplantation (FMT) for irritable bowel syndrome and Clostridioides difficile, gastroparesis, and hepatocellular carcinoma. A final test applied the system to a forthcoming guideline on complications of acute pancreatitis.
Across all topics, the dual-LLM system achieved 100% sensitivity in identifying randomized controlled trials (RCTs). For the 2025 update of the AGA guideline on Crohn’s disease, the models flagged 418 of 4,377 abstracts for inclusion, captur-ing all 25 relevant RCTs in just 48 minutes. Manual screening of the same dataset previously took almost 13 hours.
Comparable accuracy and time savings were observed for the other topics.
The pipeline correctly flagged all 13 RCTs in 4,820 studies on FMT for irritable bowel syndrome, and all 16 RCTs in 5,587 studies on FMT for Clostridioides difficile, requiring 27 and 66 minutes, respectively. Similarly, the system captured all 11 RCTs in 3,919 hepatocellular carcinoma abstracts and all 18 RCTs in 1,578 studies on gastroparesis, completing each task in under 65 minutes. Early testing on the upcoming guideline for pancreatitis yielded similar results.
Cost analysis underscored the efficiency of this approach. At an estimated $175–200 per hour for expert screeners, traditional abstract screening would cost around $2,500 per review, versus approximately $100 for the LLM approach—a 96% reduction.
The investigators cautioned that human oversight remains necessary to verify the relevance of studies flagged by the models. While the system’s sensitivity was consistent, it also selected articles that were ultimately excluded by expert reviewers. Broader validation will be required to assess performance across non-RCT study designs, such as observational or case-control studies, they added.
“As medical literature continues to expand, the integration of artificial intelligence into evidence synthesis processes will become increasingly vital,” Dr. Chung and colleagues wrote. “With further refinement and broader validation, this LLM-based pipeline has the potential to revolutionize evidence synthesis and set a new standard for guideline development.”
This study was funded by National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. The investigators reported no conflicts of interest.
, according to a pilot study from the American Gastroenterological Association (AGA).
Faster, cheaper study screening could allow societies to update clinical recommendations more frequently, improving alignment with the latest evidence, lead author Sunny Chung, MD, of Yale School of Medicine, New Haven, Connecticut, and colleagues, reported.
“Each guideline typically requires 5 to 15 systematic reviews, making the process time-consuming (averaging more than 60 weeks) and costly (more than $140,000),” the investigators wrote in Gastroenterology . “One of the most critical yet time-consuming steps in systematic reviews is title and abstract screening. LLMs have the potential to make this step more efficient.”
To test this approach, the investigators developed, validated, and applied a dual-model LLM screening pipeline with human-in-the-loop oversight, focusing on randomized controlled trials in AGA guidelines.
The system was built using the 2021 guideline on moderate-to-severe Crohn’s disease, targeting biologic therapies for induction and maintenance of remission.
Using chain-of-thought prompting and structured inclusion criteria based on the PICO framework, the investigators deployed GPT-4o (OpenAI) and Gemini-1.5-Pro (Google DeepMind) as independent screeners, each assessing titles and abstracts according to standardized logic encoded in JavaScript Object Notation. This approach mimicked a traditional double-reviewer system.
After initial testing, the pipeline was validated in a 2025 update of the same guideline, this time spanning 6 focused clinical questions on advanced therapies and immunomodulators. Results were compared against manual screening by 2 experienced human reviewers, with total screening time documented.
The system was then tested across 4 additional guideline topics: fecal microbiota transplantation (FMT) for irritable bowel syndrome and Clostridioides difficile, gastroparesis, and hepatocellular carcinoma. A final test applied the system to a forthcoming guideline on complications of acute pancreatitis.
Across all topics, the dual-LLM system achieved 100% sensitivity in identifying randomized controlled trials (RCTs). For the 2025 update of the AGA guideline on Crohn’s disease, the models flagged 418 of 4,377 abstracts for inclusion, captur-ing all 25 relevant RCTs in just 48 minutes. Manual screening of the same dataset previously took almost 13 hours.
Comparable accuracy and time savings were observed for the other topics.
The pipeline correctly flagged all 13 RCTs in 4,820 studies on FMT for irritable bowel syndrome, and all 16 RCTs in 5,587 studies on FMT for Clostridioides difficile, requiring 27 and 66 minutes, respectively. Similarly, the system captured all 11 RCTs in 3,919 hepatocellular carcinoma abstracts and all 18 RCTs in 1,578 studies on gastroparesis, completing each task in under 65 minutes. Early testing on the upcoming guideline for pancreatitis yielded similar results.
Cost analysis underscored the efficiency of this approach. At an estimated $175–200 per hour for expert screeners, traditional abstract screening would cost around $2,500 per review, versus approximately $100 for the LLM approach—a 96% reduction.
The investigators cautioned that human oversight remains necessary to verify the relevance of studies flagged by the models. While the system’s sensitivity was consistent, it also selected articles that were ultimately excluded by expert reviewers. Broader validation will be required to assess performance across non-RCT study designs, such as observational or case-control studies, they added.
“As medical literature continues to expand, the integration of artificial intelligence into evidence synthesis processes will become increasingly vital,” Dr. Chung and colleagues wrote. “With further refinement and broader validation, this LLM-based pipeline has the potential to revolutionize evidence synthesis and set a new standard for guideline development.”
This study was funded by National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. The investigators reported no conflicts of interest.
FROM GASTROENTEROLOGY
New Guidelines for Pregnancy and IBD Aim to Quell Fears
, suggesting this approach will not harm the fetus.
The guidelines also recommend that all women with IBD receive preconception counseling and be followed as high-risk pregnancies.
“Management of chronic illness in pregnant women has always been defined by fear of harming the fetus,” said Uma Mahadevan, MD, AGAF, director of the Colitis and Crohn’s Disease Center at the University of California San Francisco and chair of the Global Consensus Consortium that developed the guidelines.
As a result, pregnant women are excluded from clinical trials of experimental therapies for IBD. And when a new therapy achieves regulatory approval, there are no human pregnancy safety data, only animal data. To fill this gap, the PIANO study, of which Mahadevan is principal investigator, looked at the safety of IBD medications in pregnancy and short- and long-term outcomes of the children.
“With our ongoing work in pregnancy in the patient with IBD, we realized that inflammation in the mother is the leading cause of poor outcome for the infant,” she told GI & Hepatology News.
“We also have a better understanding of placental transfer of biologic agents” and the lack of exposure to the fetus during the first trimester, “a key period of organogenesis,” she added.
Final recommendations were published simultaneously in six international journals, namely, Clinical Gastroenterology and Hepatology, American Journal of Gastroenterology, GUT, Inflammatory Bowel Diseases, Journal of Crohn’s and Colitis, and Alimentary Pharmacology and Therapeutics.
Surprising, Novel Findings
Limited provider knowledge led to varied practices in caring for women with IBD who become pregnant, according to the consensus authors. Practices are affected by local dogma, available resources, individual interpretation of the literature, and fear of harming the fetus.
“The variations in guidelines by different societies and countries reflect this and lead to confusion for physicians and patients alike,” the authors of the guidelines wrote.
Therefore, the Global Consensus Consortium — a group of 39 IBD experts, including teratologists and maternal fetal medicine specialists and seven patient advocates from six continents — convened to review and assess current data and come to an agreement on best practices. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used when sufficient published data were available, and the Research and Development process when expert opinion was needed to guide consistent practice.
“Some of the findings were expected, but others were novel,” said Mahadevan.
Recommendations that might surprise clinicians include GRADE statement 9, which suggests that pregnant women with IBD take low-dose aspirin by 12 to 16 weeks’ gestation to prevent preterm preeclampsia. “This is based on the ASPRE study, showing that women at risk of preeclampsia can lower their risk by taking low-dose aspirin,” with no risk for flare, Mahadevan said.
In addition, GRADE statements 17-20 recommend/suggest that women continue their biologic throughout pregnancy without stopping. “North America has always recommended continuing during the third trimester, while Europe only recently has come to this,” Mahadevan said. “However, there was always some looseness about stopping at week X, Y, or Z. Now, we do recommend continuing the dose on schedule with no holding.”
Continuing medications considered low risk for use during pregnancy, such as 5-amino salicylic acids, sulfasalazine, thiopurines, and all monoclonal antibodies during preconception, pregnancy, and lactation, was also recommended.
However, small-molecule drugs such as S1P receptor molecules and JAK inhibitors should be avoided for at least 1 month, and in some cases for 3 months prior to attempting conception, unless there is no alternative for the health of the mother. They should also be avoided during lactation.
Grade statement 33, which suggests that live rotavirus vaccine may be provided in children with in utero exposure to biologics, is also new, Mahadevan noted. “All prior recommendations were that no live vaccine should be given in the first 6 months or longer if infants were exposed to biologics in utero, but based on a prospective Canadian study, there is no harm when given to these infants.”
Another novel recommendation is that women with IBD on any monoclonal antibodies, including newer interleukin-23s, may breastfeed even though there are not clinical trial data at this point. The recommendation to continue them through pregnancy and lactation is based on placental physiology, as well as on the physiology of monoclonal antibody transfer in breast milk, according to the consortium.
Furthermore, the authors noted, there was no increase in infant infections at 4 months or 12 months if they were exposed to a biologic or thiopurine (or both) during pregnancy.
Overall, the consortium recommended that all pregnancies for women with IBD be considered as “high risk” for complications. This is due to the fact that many parts of the world, including the US, are “resource-limited,” Mahadevan explained. Since maternal fetal medicine specialists are not widely available, the consortium suggested all these patients be followed with increased monitoring and surveillance based on available resources.
In addition to the guidelines, patient videos in seven languages, a professional slide deck in English and Spanish, and a video on the global consensus are all available at https://pianostudy.org/.
This study was funded by The Leona B. and Harry H. Helmsley Charitable Trust.
Mahadevan reported being a consultant for AbbVie, Bristol Myers Squibb, Boehringer Ingelheim, Celltrion, Enveda, Gilead, Janssen, Lilly, Merck, Pfizer, Protagonist, Roivant, and Takeda.
A version of this article appeared on Medscape.com.
, suggesting this approach will not harm the fetus.
The guidelines also recommend that all women with IBD receive preconception counseling and be followed as high-risk pregnancies.
“Management of chronic illness in pregnant women has always been defined by fear of harming the fetus,” said Uma Mahadevan, MD, AGAF, director of the Colitis and Crohn’s Disease Center at the University of California San Francisco and chair of the Global Consensus Consortium that developed the guidelines.
As a result, pregnant women are excluded from clinical trials of experimental therapies for IBD. And when a new therapy achieves regulatory approval, there are no human pregnancy safety data, only animal data. To fill this gap, the PIANO study, of which Mahadevan is principal investigator, looked at the safety of IBD medications in pregnancy and short- and long-term outcomes of the children.
“With our ongoing work in pregnancy in the patient with IBD, we realized that inflammation in the mother is the leading cause of poor outcome for the infant,” she told GI & Hepatology News.
“We also have a better understanding of placental transfer of biologic agents” and the lack of exposure to the fetus during the first trimester, “a key period of organogenesis,” she added.
Final recommendations were published simultaneously in six international journals, namely, Clinical Gastroenterology and Hepatology, American Journal of Gastroenterology, GUT, Inflammatory Bowel Diseases, Journal of Crohn’s and Colitis, and Alimentary Pharmacology and Therapeutics.
Surprising, Novel Findings
Limited provider knowledge led to varied practices in caring for women with IBD who become pregnant, according to the consensus authors. Practices are affected by local dogma, available resources, individual interpretation of the literature, and fear of harming the fetus.
“The variations in guidelines by different societies and countries reflect this and lead to confusion for physicians and patients alike,” the authors of the guidelines wrote.
Therefore, the Global Consensus Consortium — a group of 39 IBD experts, including teratologists and maternal fetal medicine specialists and seven patient advocates from six continents — convened to review and assess current data and come to an agreement on best practices. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used when sufficient published data were available, and the Research and Development process when expert opinion was needed to guide consistent practice.
“Some of the findings were expected, but others were novel,” said Mahadevan.
Recommendations that might surprise clinicians include GRADE statement 9, which suggests that pregnant women with IBD take low-dose aspirin by 12 to 16 weeks’ gestation to prevent preterm preeclampsia. “This is based on the ASPRE study, showing that women at risk of preeclampsia can lower their risk by taking low-dose aspirin,” with no risk for flare, Mahadevan said.
In addition, GRADE statements 17-20 recommend/suggest that women continue their biologic throughout pregnancy without stopping. “North America has always recommended continuing during the third trimester, while Europe only recently has come to this,” Mahadevan said. “However, there was always some looseness about stopping at week X, Y, or Z. Now, we do recommend continuing the dose on schedule with no holding.”
Continuing medications considered low risk for use during pregnancy, such as 5-amino salicylic acids, sulfasalazine, thiopurines, and all monoclonal antibodies during preconception, pregnancy, and lactation, was also recommended.
However, small-molecule drugs such as S1P receptor molecules and JAK inhibitors should be avoided for at least 1 month, and in some cases for 3 months prior to attempting conception, unless there is no alternative for the health of the mother. They should also be avoided during lactation.
Grade statement 33, which suggests that live rotavirus vaccine may be provided in children with in utero exposure to biologics, is also new, Mahadevan noted. “All prior recommendations were that no live vaccine should be given in the first 6 months or longer if infants were exposed to biologics in utero, but based on a prospective Canadian study, there is no harm when given to these infants.”
Another novel recommendation is that women with IBD on any monoclonal antibodies, including newer interleukin-23s, may breastfeed even though there are not clinical trial data at this point. The recommendation to continue them through pregnancy and lactation is based on placental physiology, as well as on the physiology of monoclonal antibody transfer in breast milk, according to the consortium.
Furthermore, the authors noted, there was no increase in infant infections at 4 months or 12 months if they were exposed to a biologic or thiopurine (or both) during pregnancy.
Overall, the consortium recommended that all pregnancies for women with IBD be considered as “high risk” for complications. This is due to the fact that many parts of the world, including the US, are “resource-limited,” Mahadevan explained. Since maternal fetal medicine specialists are not widely available, the consortium suggested all these patients be followed with increased monitoring and surveillance based on available resources.
In addition to the guidelines, patient videos in seven languages, a professional slide deck in English and Spanish, and a video on the global consensus are all available at https://pianostudy.org/.
This study was funded by The Leona B. and Harry H. Helmsley Charitable Trust.
Mahadevan reported being a consultant for AbbVie, Bristol Myers Squibb, Boehringer Ingelheim, Celltrion, Enveda, Gilead, Janssen, Lilly, Merck, Pfizer, Protagonist, Roivant, and Takeda.
A version of this article appeared on Medscape.com.
, suggesting this approach will not harm the fetus.
The guidelines also recommend that all women with IBD receive preconception counseling and be followed as high-risk pregnancies.
“Management of chronic illness in pregnant women has always been defined by fear of harming the fetus,” said Uma Mahadevan, MD, AGAF, director of the Colitis and Crohn’s Disease Center at the University of California San Francisco and chair of the Global Consensus Consortium that developed the guidelines.
As a result, pregnant women are excluded from clinical trials of experimental therapies for IBD. And when a new therapy achieves regulatory approval, there are no human pregnancy safety data, only animal data. To fill this gap, the PIANO study, of which Mahadevan is principal investigator, looked at the safety of IBD medications in pregnancy and short- and long-term outcomes of the children.
“With our ongoing work in pregnancy in the patient with IBD, we realized that inflammation in the mother is the leading cause of poor outcome for the infant,” she told GI & Hepatology News.
“We also have a better understanding of placental transfer of biologic agents” and the lack of exposure to the fetus during the first trimester, “a key period of organogenesis,” she added.
Final recommendations were published simultaneously in six international journals, namely, Clinical Gastroenterology and Hepatology, American Journal of Gastroenterology, GUT, Inflammatory Bowel Diseases, Journal of Crohn’s and Colitis, and Alimentary Pharmacology and Therapeutics.
Surprising, Novel Findings
Limited provider knowledge led to varied practices in caring for women with IBD who become pregnant, according to the consensus authors. Practices are affected by local dogma, available resources, individual interpretation of the literature, and fear of harming the fetus.
“The variations in guidelines by different societies and countries reflect this and lead to confusion for physicians and patients alike,” the authors of the guidelines wrote.
Therefore, the Global Consensus Consortium — a group of 39 IBD experts, including teratologists and maternal fetal medicine specialists and seven patient advocates from six continents — convened to review and assess current data and come to an agreement on best practices. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used when sufficient published data were available, and the Research and Development process when expert opinion was needed to guide consistent practice.
“Some of the findings were expected, but others were novel,” said Mahadevan.
Recommendations that might surprise clinicians include GRADE statement 9, which suggests that pregnant women with IBD take low-dose aspirin by 12 to 16 weeks’ gestation to prevent preterm preeclampsia. “This is based on the ASPRE study, showing that women at risk of preeclampsia can lower their risk by taking low-dose aspirin,” with no risk for flare, Mahadevan said.
In addition, GRADE statements 17-20 recommend/suggest that women continue their biologic throughout pregnancy without stopping. “North America has always recommended continuing during the third trimester, while Europe only recently has come to this,” Mahadevan said. “However, there was always some looseness about stopping at week X, Y, or Z. Now, we do recommend continuing the dose on schedule with no holding.”
Continuing medications considered low risk for use during pregnancy, such as 5-amino salicylic acids, sulfasalazine, thiopurines, and all monoclonal antibodies during preconception, pregnancy, and lactation, was also recommended.
However, small-molecule drugs such as S1P receptor molecules and JAK inhibitors should be avoided for at least 1 month, and in some cases for 3 months prior to attempting conception, unless there is no alternative for the health of the mother. They should also be avoided during lactation.
Grade statement 33, which suggests that live rotavirus vaccine may be provided in children with in utero exposure to biologics, is also new, Mahadevan noted. “All prior recommendations were that no live vaccine should be given in the first 6 months or longer if infants were exposed to biologics in utero, but based on a prospective Canadian study, there is no harm when given to these infants.”
Another novel recommendation is that women with IBD on any monoclonal antibodies, including newer interleukin-23s, may breastfeed even though there are not clinical trial data at this point. The recommendation to continue them through pregnancy and lactation is based on placental physiology, as well as on the physiology of monoclonal antibody transfer in breast milk, according to the consortium.
Furthermore, the authors noted, there was no increase in infant infections at 4 months or 12 months if they were exposed to a biologic or thiopurine (or both) during pregnancy.
Overall, the consortium recommended that all pregnancies for women with IBD be considered as “high risk” for complications. This is due to the fact that many parts of the world, including the US, are “resource-limited,” Mahadevan explained. Since maternal fetal medicine specialists are not widely available, the consortium suggested all these patients be followed with increased monitoring and surveillance based on available resources.
In addition to the guidelines, patient videos in seven languages, a professional slide deck in English and Spanish, and a video on the global consensus are all available at https://pianostudy.org/.
This study was funded by The Leona B. and Harry H. Helmsley Charitable Trust.
Mahadevan reported being a consultant for AbbVie, Bristol Myers Squibb, Boehringer Ingelheim, Celltrion, Enveda, Gilead, Janssen, Lilly, Merck, Pfizer, Protagonist, Roivant, and Takeda.
A version of this article appeared on Medscape.com.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
GLP-1 Use After Bariatric Surgery on the Rise
, a large retrospective cohort study showed.
GLP-1 initiation was also more common among women, those who underwent sleeve gastrectomy, and those with lower postoperative weight loss as measured by BMI.
“Some patients do not lose as much weight as expected, or they regain weight after a few years. In such cases, GLP-1 therapies are emerging as an important option for weight management,” said principal investigator Hemalkumar Mehta, PhD, associate professor at Johns Hopkins Bloomberg School of Public Health in Baltimore.
“We also noted many personal stories circulating on social media in which patients shared their experiences using GLP-1 after bariatric surgery,” he told GI & Hepatology News.
But when the researchers reviewed the scientific literature, they found no published evidence on GLP-1 use in this setting and little or no data on outcomes with the newer drugs such as semaglutide and tirzepatide. “This gap motivated us to conduct the current study,” said Mehta. The study was published in JAMA Surgery.
The researchers analyzed data from a national multicenter database of electronic health records of approximately 113 million US adults to characterize the use of and factors associated with GLP-1 initiation after bariatric surgery.
Among 112,858 individuals undergoing bariatric surgery during the study period, the mean age was 45.2 years, and 78.9% were women.
By self-report race, 1.1% were Asian, 22.1% were Black or African American, 64.2% were White individuals, and 12.6% reported belonging to other races (American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, or unknown).
A total of 15,749 individuals (14%) initiated GLP-1s post-surgery, with 3391 (21.5%) beginning within 2 years of surgery and the remainder initiating during postsurgical years 3-4 (32.3%), 5-6 (25.2%), or later (21%).
Notably, the proportion of GLP-1 use increased more in the more recent cohort, from 1.7% in the January 2015-December 2019 cohort to 12.6% from June 2020 to May 2025.
Differences Between Users and Nonusers
Those who initiated GLP-1s differed significantly from those who did not: GLP-1 users vs nonusers were younger (mean age, 44.9 years vs 45.2 years), and use was more common among women vs men (15.1% vs 9.7%), among Black or African American vs White patients (15.8% vs 13.5%), and among those who underwent sleeve gastrectomy vs Roux-en-Y gastric bypass (14.9% vs 12.1%).
Looked at another way, women (adjusted hazard ratio [aHR], 1.61), those undergoing sleeve gastrectomy (aHR, 1.42), and those with type 2 diabetes (aHR, 1.34) were more likely to initiate GLP-1s than their counterparts.
The overall median presurgical BMI was 42. On analyzing obesity classification based on BMI, the researchers found that the chances of GLP-1 use were 1.73 times higher among class 1 obesity patients (BMI, 30.0-34.9), 2.19 times higher among class 2 obesity patients (BMI, 35.0-39.9), and 2.69 times higher among patients with class 3 obesity (BMI ≥ 40) than among overweight patients (BMI, 25.0-29.9).
The median post-surgery BMI for GLP-1 users at drug initiation was 36.7. Each one-unit increase in postsurgical BMI was associated with an 8% increase in the likelihood of GLP-1 initiation (aHR, 1.08).
“Importantly, our study did not specifically evaluate the effectiveness of GLP-1 therapy on weight loss after surgery,” Mehta noted. That issue and others, such as optimal timing for initiating GLP-1s, are currently under investigation.
In a related editorial, Kate Lauer, MD, of the University of Wisconsin-Madison and colleagues noted that the study had several limitations. It relied on data prior to the USFDA approvals of semaglutide and tirzepatide, the two most prescribed GLP-1s currently, potentially limiting its applicability to current practice.
Furthermore, the prescribing data did not capture dose, titration schedules, or adherence, which are “critical for understanding treatment efficacy,” they wrote. “Nonetheless, the findings highlight two important trends: (1) GLP-1s are being increasingly used as an adjunct after bariatric surgery, and (2) there is substantial variability in the timing of their initiation.”
‘Logical’ to Use GLP-1s Post Surgery
Commenting on the study findings for GI & Hepatology News, Louis Aronne, MD, director of the Comprehensive Weight Control Center at Weill Cornell Medicine in New York City, who was not involved in the study, said, “I think it is perfectly logical to use GLP-1s in patients who have had bariatric surgery.”
In this study, weight loss in those who took GLP-1s was about 12% (from a median BMI of 42 pre-surgery to 36.7 when a GLP-1 was initiated), which is significantly less than average, Aronne noted. “The patients still had Class 2 obesity.”
“Obesity is the same as other metabolic diseases,” he added. “We have to use common sense and good medical judgment when treating patients. If surgery isn’t completely effective and weight loss is inadequate, I would recommend medications.”
Of note, his team has found that lower doses of GLP-1s are required in those who have had surgery than in those who have not. “My opinion is that patients who have undergone bariatric surgery seem to be more sensitive to the medications than the average patient, but this hasn’t been carefully studied.”
To prepare patients for the possible use of GLP1s post-surgery, he suggested telling those with very high BMI that “they may need medication in addition to the procedure in order to get the best result.”
Mehta added, “Ultimately, the decision to start GLP-1s after surgery is shared between patients and clinicians. Given the amount of media coverage on GLP-1 therapies, it is not surprising that more patients are initiating these discussions with their doctors.”
Mehta is supported by the US National Institute on Aging and reported receiving grants from the institute for this study; no other funding was reported. Lauer reported receiving grants from the US National Institutes of Health.
A version of this article first appeared on Medscape.com.
, a large retrospective cohort study showed.
GLP-1 initiation was also more common among women, those who underwent sleeve gastrectomy, and those with lower postoperative weight loss as measured by BMI.
“Some patients do not lose as much weight as expected, or they regain weight after a few years. In such cases, GLP-1 therapies are emerging as an important option for weight management,” said principal investigator Hemalkumar Mehta, PhD, associate professor at Johns Hopkins Bloomberg School of Public Health in Baltimore.
“We also noted many personal stories circulating on social media in which patients shared their experiences using GLP-1 after bariatric surgery,” he told GI & Hepatology News.
But when the researchers reviewed the scientific literature, they found no published evidence on GLP-1 use in this setting and little or no data on outcomes with the newer drugs such as semaglutide and tirzepatide. “This gap motivated us to conduct the current study,” said Mehta. The study was published in JAMA Surgery.
The researchers analyzed data from a national multicenter database of electronic health records of approximately 113 million US adults to characterize the use of and factors associated with GLP-1 initiation after bariatric surgery.
Among 112,858 individuals undergoing bariatric surgery during the study period, the mean age was 45.2 years, and 78.9% were women.
By self-report race, 1.1% were Asian, 22.1% were Black or African American, 64.2% were White individuals, and 12.6% reported belonging to other races (American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, or unknown).
A total of 15,749 individuals (14%) initiated GLP-1s post-surgery, with 3391 (21.5%) beginning within 2 years of surgery and the remainder initiating during postsurgical years 3-4 (32.3%), 5-6 (25.2%), or later (21%).
Notably, the proportion of GLP-1 use increased more in the more recent cohort, from 1.7% in the January 2015-December 2019 cohort to 12.6% from June 2020 to May 2025.
Differences Between Users and Nonusers
Those who initiated GLP-1s differed significantly from those who did not: GLP-1 users vs nonusers were younger (mean age, 44.9 years vs 45.2 years), and use was more common among women vs men (15.1% vs 9.7%), among Black or African American vs White patients (15.8% vs 13.5%), and among those who underwent sleeve gastrectomy vs Roux-en-Y gastric bypass (14.9% vs 12.1%).
Looked at another way, women (adjusted hazard ratio [aHR], 1.61), those undergoing sleeve gastrectomy (aHR, 1.42), and those with type 2 diabetes (aHR, 1.34) were more likely to initiate GLP-1s than their counterparts.
The overall median presurgical BMI was 42. On analyzing obesity classification based on BMI, the researchers found that the chances of GLP-1 use were 1.73 times higher among class 1 obesity patients (BMI, 30.0-34.9), 2.19 times higher among class 2 obesity patients (BMI, 35.0-39.9), and 2.69 times higher among patients with class 3 obesity (BMI ≥ 40) than among overweight patients (BMI, 25.0-29.9).
The median post-surgery BMI for GLP-1 users at drug initiation was 36.7. Each one-unit increase in postsurgical BMI was associated with an 8% increase in the likelihood of GLP-1 initiation (aHR, 1.08).
“Importantly, our study did not specifically evaluate the effectiveness of GLP-1 therapy on weight loss after surgery,” Mehta noted. That issue and others, such as optimal timing for initiating GLP-1s, are currently under investigation.
In a related editorial, Kate Lauer, MD, of the University of Wisconsin-Madison and colleagues noted that the study had several limitations. It relied on data prior to the USFDA approvals of semaglutide and tirzepatide, the two most prescribed GLP-1s currently, potentially limiting its applicability to current practice.
Furthermore, the prescribing data did not capture dose, titration schedules, or adherence, which are “critical for understanding treatment efficacy,” they wrote. “Nonetheless, the findings highlight two important trends: (1) GLP-1s are being increasingly used as an adjunct after bariatric surgery, and (2) there is substantial variability in the timing of their initiation.”
‘Logical’ to Use GLP-1s Post Surgery
Commenting on the study findings for GI & Hepatology News, Louis Aronne, MD, director of the Comprehensive Weight Control Center at Weill Cornell Medicine in New York City, who was not involved in the study, said, “I think it is perfectly logical to use GLP-1s in patients who have had bariatric surgery.”
In this study, weight loss in those who took GLP-1s was about 12% (from a median BMI of 42 pre-surgery to 36.7 when a GLP-1 was initiated), which is significantly less than average, Aronne noted. “The patients still had Class 2 obesity.”
“Obesity is the same as other metabolic diseases,” he added. “We have to use common sense and good medical judgment when treating patients. If surgery isn’t completely effective and weight loss is inadequate, I would recommend medications.”
Of note, his team has found that lower doses of GLP-1s are required in those who have had surgery than in those who have not. “My opinion is that patients who have undergone bariatric surgery seem to be more sensitive to the medications than the average patient, but this hasn’t been carefully studied.”
To prepare patients for the possible use of GLP1s post-surgery, he suggested telling those with very high BMI that “they may need medication in addition to the procedure in order to get the best result.”
Mehta added, “Ultimately, the decision to start GLP-1s after surgery is shared between patients and clinicians. Given the amount of media coverage on GLP-1 therapies, it is not surprising that more patients are initiating these discussions with their doctors.”
Mehta is supported by the US National Institute on Aging and reported receiving grants from the institute for this study; no other funding was reported. Lauer reported receiving grants from the US National Institutes of Health.
A version of this article first appeared on Medscape.com.
, a large retrospective cohort study showed.
GLP-1 initiation was also more common among women, those who underwent sleeve gastrectomy, and those with lower postoperative weight loss as measured by BMI.
“Some patients do not lose as much weight as expected, or they regain weight after a few years. In such cases, GLP-1 therapies are emerging as an important option for weight management,” said principal investigator Hemalkumar Mehta, PhD, associate professor at Johns Hopkins Bloomberg School of Public Health in Baltimore.
“We also noted many personal stories circulating on social media in which patients shared their experiences using GLP-1 after bariatric surgery,” he told GI & Hepatology News.
But when the researchers reviewed the scientific literature, they found no published evidence on GLP-1 use in this setting and little or no data on outcomes with the newer drugs such as semaglutide and tirzepatide. “This gap motivated us to conduct the current study,” said Mehta. The study was published in JAMA Surgery.
The researchers analyzed data from a national multicenter database of electronic health records of approximately 113 million US adults to characterize the use of and factors associated with GLP-1 initiation after bariatric surgery.
Among 112,858 individuals undergoing bariatric surgery during the study period, the mean age was 45.2 years, and 78.9% were women.
By self-report race, 1.1% were Asian, 22.1% were Black or African American, 64.2% were White individuals, and 12.6% reported belonging to other races (American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, or unknown).
A total of 15,749 individuals (14%) initiated GLP-1s post-surgery, with 3391 (21.5%) beginning within 2 years of surgery and the remainder initiating during postsurgical years 3-4 (32.3%), 5-6 (25.2%), or later (21%).
Notably, the proportion of GLP-1 use increased more in the more recent cohort, from 1.7% in the January 2015-December 2019 cohort to 12.6% from June 2020 to May 2025.
Differences Between Users and Nonusers
Those who initiated GLP-1s differed significantly from those who did not: GLP-1 users vs nonusers were younger (mean age, 44.9 years vs 45.2 years), and use was more common among women vs men (15.1% vs 9.7%), among Black or African American vs White patients (15.8% vs 13.5%), and among those who underwent sleeve gastrectomy vs Roux-en-Y gastric bypass (14.9% vs 12.1%).
Looked at another way, women (adjusted hazard ratio [aHR], 1.61), those undergoing sleeve gastrectomy (aHR, 1.42), and those with type 2 diabetes (aHR, 1.34) were more likely to initiate GLP-1s than their counterparts.
The overall median presurgical BMI was 42. On analyzing obesity classification based on BMI, the researchers found that the chances of GLP-1 use were 1.73 times higher among class 1 obesity patients (BMI, 30.0-34.9), 2.19 times higher among class 2 obesity patients (BMI, 35.0-39.9), and 2.69 times higher among patients with class 3 obesity (BMI ≥ 40) than among overweight patients (BMI, 25.0-29.9).
The median post-surgery BMI for GLP-1 users at drug initiation was 36.7. Each one-unit increase in postsurgical BMI was associated with an 8% increase in the likelihood of GLP-1 initiation (aHR, 1.08).
“Importantly, our study did not specifically evaluate the effectiveness of GLP-1 therapy on weight loss after surgery,” Mehta noted. That issue and others, such as optimal timing for initiating GLP-1s, are currently under investigation.
In a related editorial, Kate Lauer, MD, of the University of Wisconsin-Madison and colleagues noted that the study had several limitations. It relied on data prior to the USFDA approvals of semaglutide and tirzepatide, the two most prescribed GLP-1s currently, potentially limiting its applicability to current practice.
Furthermore, the prescribing data did not capture dose, titration schedules, or adherence, which are “critical for understanding treatment efficacy,” they wrote. “Nonetheless, the findings highlight two important trends: (1) GLP-1s are being increasingly used as an adjunct after bariatric surgery, and (2) there is substantial variability in the timing of their initiation.”
‘Logical’ to Use GLP-1s Post Surgery
Commenting on the study findings for GI & Hepatology News, Louis Aronne, MD, director of the Comprehensive Weight Control Center at Weill Cornell Medicine in New York City, who was not involved in the study, said, “I think it is perfectly logical to use GLP-1s in patients who have had bariatric surgery.”
In this study, weight loss in those who took GLP-1s was about 12% (from a median BMI of 42 pre-surgery to 36.7 when a GLP-1 was initiated), which is significantly less than average, Aronne noted. “The patients still had Class 2 obesity.”
“Obesity is the same as other metabolic diseases,” he added. “We have to use common sense and good medical judgment when treating patients. If surgery isn’t completely effective and weight loss is inadequate, I would recommend medications.”
Of note, his team has found that lower doses of GLP-1s are required in those who have had surgery than in those who have not. “My opinion is that patients who have undergone bariatric surgery seem to be more sensitive to the medications than the average patient, but this hasn’t been carefully studied.”
To prepare patients for the possible use of GLP1s post-surgery, he suggested telling those with very high BMI that “they may need medication in addition to the procedure in order to get the best result.”
Mehta added, “Ultimately, the decision to start GLP-1s after surgery is shared between patients and clinicians. Given the amount of media coverage on GLP-1 therapies, it is not surprising that more patients are initiating these discussions with their doctors.”
Mehta is supported by the US National Institute on Aging and reported receiving grants from the institute for this study; no other funding was reported. Lauer reported receiving grants from the US National Institutes of Health.
A version of this article first appeared on Medscape.com.
SGLT2 Inhibition Promising for Patients With Cirrhosis and on Diuretics
, a large cohort study of more than 10,000 patients found.
Reporting in JAMA Network Open, Dian J. Chiang, MD, MPH, a section head of Hepatology at the Cleveland Clinic in Cleveland looked at the impact of these antihyperglycemic agents, also known as gliflozins, used in diabetes and kidney disease to block the reabsorption of glucose in the kidneys and causing more glucose to be excreted in the urine.
“Patients with cirrhosis were previously not included in SGLT2 inhibition clinical trials, and there is no large real-world evidence on the safety and effectiveness of this class of medication in patients with cirrhosis. Therefore, we decided to conduct the study to assess its safety and effectiveness,” Chiang told GI & Hepatology News.
The study’s primary endpoint was a composite of serious hepatic events, defined as ascites, varices, hyponatremia, and all-cause mortality. Secondary outcomes included variceal bleeding, paracentesis, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome, liver carcinoma, hypoglycemia, and all-cause hospitalizations.
The cohort consisted of 10,660 propensity-matched adult patients with cirrhosis from more than 120 healthcare organizations in the TriNetX database who were receiving furosemide and spironolactone from January 2013 to July 2021. Those also receiving SGLT2 inhibitors (n = 5330) were compared with a matched control group receiving diuretics only (n = 5330). The mean age of participants was 63.8 years, 57.8% were men, 66.3% were White individuals, and all were followed for 3 years.
The SGLT2 inhibitor group had a 32% lower incidence of serious liver events than the control group, for a hazard ratio (HR) of 0.68 (95% CI, 0.66-0.71; P < .001).
Secondary risk reductions in the intervention group were as follows:
- Hepatorenal syndrome: HR, 0.47 (95% CI, 0.40-0.56)
- Spontaneous bacterial peritonitis: HR, 0.55 (95% CI, 0.46-0.65)
- Paracentesis: HR, 0.54 (95% CI, 0.50-0.60)
- Variceal bleeding: HR, 0.79 (95% CI, 0.73-0.84)
- Hypoglycemia: HR, 0.75 (95% CI, 0.62-0.91)
- All-cause hospitalizations: HR, 0.67 (95% CI, 0.63-0.71)
The authors conjectured that SGLT2 inhibition might also benefit patients with other stages of liver disease. They pointed to a 2020 study in patients with diabetes, metabolic dysfunction-associated steatotic liver disease (MASLD), and high baseline fibrosis that revealed a significant reduction in fibrosis after 12 months’ SGLT2 inhibition.
The study findings also align with those of another large propensity-matched cohort in which patients with type 2 diabetes and cirrhosis receiving metformin plus SGLT2 inhibition showed significantly lower 5-year mortality, decreased incidence of decompensated cirrhosis, and reduced hepatocellular carcinoma incidence compared with those taking metformin alone.
Prospective trials are needed to further evaluate safety and efficacy, however, the authors stressed. Future studies should specifically examine changes in sodium levels following SGLT2 inhibitor initiation, as well as the incidence of recurrent urinary tract infections and euglycemic diabetic ketoacidosis, given that these are known adverse effects of this drug class. Additionally, research comparing different types and dosing regimens would provide valuable insights into optimizing treatment.
Commenting on the analysis but not participating in it, Karn Wijarnpreecha, MD, MPH, a hepatologist at College of Medicine, The University of Arizona, Phoenix, said the study was interesting but did not show the adjusted HR for all-cause mortality separately from other serious liver events, “so we do not know if SGLT2 inhibitor group was associated with lower mortality.”
It would be premature to conclude that using SGLT2 inhibitors in patients with cirrhosis and ascites and on diuretics will decrease the need for liver transplant or significantly improve liver-related outcomes based on this study, Wijarnpreecha told GI & Hepatology News. “Moreover, we do not know the dose of diuretics or specific drugs and doses for SGLT2 inhibitors that were used in the study. Indications for using SGLT2 inhibitors are mainly from diabetes and heart failure, so this may not apply to those with cirrhosis without these two conditions as well.”
In addition, the etiology of cirrhosis in this database study is unknown. “Is it mainly from MASLD or alcohol or other conditions such as viral hepatitis or autoimmmunity? We need more thorough study to answer this question.” He also pointed out that the authors urged caution in using SGLT2 inhibitors in the context of hepatic encephalopathy (HE), which could be worsened with these agents. “This should be taken into consideration before starting medication in decompensated cirrhosis with HE,” Wijarnpreecha said.
In an accompanying commentary, Mohamed I. Elsaid, PhD, MPH, a biomedical informatics researcher and assistant professor at The Ohio State University in Columbus, Ohio, said that if confirmed, the findings could substantially improve cirrhosis care. “The signal is exciting but needs strong confirmation from large observational studies and prospective trials,” he wrote. “To turn promise into practice, the next wave of observational studies must embrace the target-trial emulation framework for bolstering firm causal conclusions and doubly robust learners that tease apart who benefits, who does not, and why.”
He added that head-to-head comparisons with the type 2 diabetes drugs known as incretin mimetics will clarify the best antihyperglycemic agents for different patient phenotypes. “With these advanced causal-inference approaches, repurposed type 2 diabetes therapies could shift cirrhosis management from reactive to proactive, improving quality of life and bending the mortality curve,” Elsaid wrote.
For Wijarnpreecha, important pending questions include the benefits of SGLT2 inhibition in cirrhosis without diabetes or heart failure “Can it be used to prevent cirrhosis in MASLD if we start at the early fibrosis stage in F0-F3?”
Chiang conceded that the study had limitations as it relied on 10th revision of the International Classification of Diseases codes to define outcomes, which may not have captured the complexity of cirrhotic complications. “And the retrospective design may have introduced confounding, selection, and information bias, which could have impacted the results,” he said. “Future prospective studies may help confirm our findings.”
No specific funding was reported for this study. The study authors and Wijarnpreecha had no relevant conflicts of interest to declare. Elsaid reported receiving research funding from Genentech and AstraZeneca outside of the submitted work.
A version of this article first appeared on Medscape.com.
, a large cohort study of more than 10,000 patients found.
Reporting in JAMA Network Open, Dian J. Chiang, MD, MPH, a section head of Hepatology at the Cleveland Clinic in Cleveland looked at the impact of these antihyperglycemic agents, also known as gliflozins, used in diabetes and kidney disease to block the reabsorption of glucose in the kidneys and causing more glucose to be excreted in the urine.
“Patients with cirrhosis were previously not included in SGLT2 inhibition clinical trials, and there is no large real-world evidence on the safety and effectiveness of this class of medication in patients with cirrhosis. Therefore, we decided to conduct the study to assess its safety and effectiveness,” Chiang told GI & Hepatology News.
The study’s primary endpoint was a composite of serious hepatic events, defined as ascites, varices, hyponatremia, and all-cause mortality. Secondary outcomes included variceal bleeding, paracentesis, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome, liver carcinoma, hypoglycemia, and all-cause hospitalizations.
The cohort consisted of 10,660 propensity-matched adult patients with cirrhosis from more than 120 healthcare organizations in the TriNetX database who were receiving furosemide and spironolactone from January 2013 to July 2021. Those also receiving SGLT2 inhibitors (n = 5330) were compared with a matched control group receiving diuretics only (n = 5330). The mean age of participants was 63.8 years, 57.8% were men, 66.3% were White individuals, and all were followed for 3 years.
The SGLT2 inhibitor group had a 32% lower incidence of serious liver events than the control group, for a hazard ratio (HR) of 0.68 (95% CI, 0.66-0.71; P < .001).
Secondary risk reductions in the intervention group were as follows:
- Hepatorenal syndrome: HR, 0.47 (95% CI, 0.40-0.56)
- Spontaneous bacterial peritonitis: HR, 0.55 (95% CI, 0.46-0.65)
- Paracentesis: HR, 0.54 (95% CI, 0.50-0.60)
- Variceal bleeding: HR, 0.79 (95% CI, 0.73-0.84)
- Hypoglycemia: HR, 0.75 (95% CI, 0.62-0.91)
- All-cause hospitalizations: HR, 0.67 (95% CI, 0.63-0.71)
The authors conjectured that SGLT2 inhibition might also benefit patients with other stages of liver disease. They pointed to a 2020 study in patients with diabetes, metabolic dysfunction-associated steatotic liver disease (MASLD), and high baseline fibrosis that revealed a significant reduction in fibrosis after 12 months’ SGLT2 inhibition.
The study findings also align with those of another large propensity-matched cohort in which patients with type 2 diabetes and cirrhosis receiving metformin plus SGLT2 inhibition showed significantly lower 5-year mortality, decreased incidence of decompensated cirrhosis, and reduced hepatocellular carcinoma incidence compared with those taking metformin alone.
Prospective trials are needed to further evaluate safety and efficacy, however, the authors stressed. Future studies should specifically examine changes in sodium levels following SGLT2 inhibitor initiation, as well as the incidence of recurrent urinary tract infections and euglycemic diabetic ketoacidosis, given that these are known adverse effects of this drug class. Additionally, research comparing different types and dosing regimens would provide valuable insights into optimizing treatment.
Commenting on the analysis but not participating in it, Karn Wijarnpreecha, MD, MPH, a hepatologist at College of Medicine, The University of Arizona, Phoenix, said the study was interesting but did not show the adjusted HR for all-cause mortality separately from other serious liver events, “so we do not know if SGLT2 inhibitor group was associated with lower mortality.”
It would be premature to conclude that using SGLT2 inhibitors in patients with cirrhosis and ascites and on diuretics will decrease the need for liver transplant or significantly improve liver-related outcomes based on this study, Wijarnpreecha told GI & Hepatology News. “Moreover, we do not know the dose of diuretics or specific drugs and doses for SGLT2 inhibitors that were used in the study. Indications for using SGLT2 inhibitors are mainly from diabetes and heart failure, so this may not apply to those with cirrhosis without these two conditions as well.”
In addition, the etiology of cirrhosis in this database study is unknown. “Is it mainly from MASLD or alcohol or other conditions such as viral hepatitis or autoimmmunity? We need more thorough study to answer this question.” He also pointed out that the authors urged caution in using SGLT2 inhibitors in the context of hepatic encephalopathy (HE), which could be worsened with these agents. “This should be taken into consideration before starting medication in decompensated cirrhosis with HE,” Wijarnpreecha said.
In an accompanying commentary, Mohamed I. Elsaid, PhD, MPH, a biomedical informatics researcher and assistant professor at The Ohio State University in Columbus, Ohio, said that if confirmed, the findings could substantially improve cirrhosis care. “The signal is exciting but needs strong confirmation from large observational studies and prospective trials,” he wrote. “To turn promise into practice, the next wave of observational studies must embrace the target-trial emulation framework for bolstering firm causal conclusions and doubly robust learners that tease apart who benefits, who does not, and why.”
He added that head-to-head comparisons with the type 2 diabetes drugs known as incretin mimetics will clarify the best antihyperglycemic agents for different patient phenotypes. “With these advanced causal-inference approaches, repurposed type 2 diabetes therapies could shift cirrhosis management from reactive to proactive, improving quality of life and bending the mortality curve,” Elsaid wrote.
For Wijarnpreecha, important pending questions include the benefits of SGLT2 inhibition in cirrhosis without diabetes or heart failure “Can it be used to prevent cirrhosis in MASLD if we start at the early fibrosis stage in F0-F3?”
Chiang conceded that the study had limitations as it relied on 10th revision of the International Classification of Diseases codes to define outcomes, which may not have captured the complexity of cirrhotic complications. “And the retrospective design may have introduced confounding, selection, and information bias, which could have impacted the results,” he said. “Future prospective studies may help confirm our findings.”
No specific funding was reported for this study. The study authors and Wijarnpreecha had no relevant conflicts of interest to declare. Elsaid reported receiving research funding from Genentech and AstraZeneca outside of the submitted work.
A version of this article first appeared on Medscape.com.
, a large cohort study of more than 10,000 patients found.
Reporting in JAMA Network Open, Dian J. Chiang, MD, MPH, a section head of Hepatology at the Cleveland Clinic in Cleveland looked at the impact of these antihyperglycemic agents, also known as gliflozins, used in diabetes and kidney disease to block the reabsorption of glucose in the kidneys and causing more glucose to be excreted in the urine.
“Patients with cirrhosis were previously not included in SGLT2 inhibition clinical trials, and there is no large real-world evidence on the safety and effectiveness of this class of medication in patients with cirrhosis. Therefore, we decided to conduct the study to assess its safety and effectiveness,” Chiang told GI & Hepatology News.
The study’s primary endpoint was a composite of serious hepatic events, defined as ascites, varices, hyponatremia, and all-cause mortality. Secondary outcomes included variceal bleeding, paracentesis, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome, liver carcinoma, hypoglycemia, and all-cause hospitalizations.
The cohort consisted of 10,660 propensity-matched adult patients with cirrhosis from more than 120 healthcare organizations in the TriNetX database who were receiving furosemide and spironolactone from January 2013 to July 2021. Those also receiving SGLT2 inhibitors (n = 5330) were compared with a matched control group receiving diuretics only (n = 5330). The mean age of participants was 63.8 years, 57.8% were men, 66.3% were White individuals, and all were followed for 3 years.
The SGLT2 inhibitor group had a 32% lower incidence of serious liver events than the control group, for a hazard ratio (HR) of 0.68 (95% CI, 0.66-0.71; P < .001).
Secondary risk reductions in the intervention group were as follows:
- Hepatorenal syndrome: HR, 0.47 (95% CI, 0.40-0.56)
- Spontaneous bacterial peritonitis: HR, 0.55 (95% CI, 0.46-0.65)
- Paracentesis: HR, 0.54 (95% CI, 0.50-0.60)
- Variceal bleeding: HR, 0.79 (95% CI, 0.73-0.84)
- Hypoglycemia: HR, 0.75 (95% CI, 0.62-0.91)
- All-cause hospitalizations: HR, 0.67 (95% CI, 0.63-0.71)
The authors conjectured that SGLT2 inhibition might also benefit patients with other stages of liver disease. They pointed to a 2020 study in patients with diabetes, metabolic dysfunction-associated steatotic liver disease (MASLD), and high baseline fibrosis that revealed a significant reduction in fibrosis after 12 months’ SGLT2 inhibition.
The study findings also align with those of another large propensity-matched cohort in which patients with type 2 diabetes and cirrhosis receiving metformin plus SGLT2 inhibition showed significantly lower 5-year mortality, decreased incidence of decompensated cirrhosis, and reduced hepatocellular carcinoma incidence compared with those taking metformin alone.
Prospective trials are needed to further evaluate safety and efficacy, however, the authors stressed. Future studies should specifically examine changes in sodium levels following SGLT2 inhibitor initiation, as well as the incidence of recurrent urinary tract infections and euglycemic diabetic ketoacidosis, given that these are known adverse effects of this drug class. Additionally, research comparing different types and dosing regimens would provide valuable insights into optimizing treatment.
Commenting on the analysis but not participating in it, Karn Wijarnpreecha, MD, MPH, a hepatologist at College of Medicine, The University of Arizona, Phoenix, said the study was interesting but did not show the adjusted HR for all-cause mortality separately from other serious liver events, “so we do not know if SGLT2 inhibitor group was associated with lower mortality.”
It would be premature to conclude that using SGLT2 inhibitors in patients with cirrhosis and ascites and on diuretics will decrease the need for liver transplant or significantly improve liver-related outcomes based on this study, Wijarnpreecha told GI & Hepatology News. “Moreover, we do not know the dose of diuretics or specific drugs and doses for SGLT2 inhibitors that were used in the study. Indications for using SGLT2 inhibitors are mainly from diabetes and heart failure, so this may not apply to those with cirrhosis without these two conditions as well.”
In addition, the etiology of cirrhosis in this database study is unknown. “Is it mainly from MASLD or alcohol or other conditions such as viral hepatitis or autoimmmunity? We need more thorough study to answer this question.” He also pointed out that the authors urged caution in using SGLT2 inhibitors in the context of hepatic encephalopathy (HE), which could be worsened with these agents. “This should be taken into consideration before starting medication in decompensated cirrhosis with HE,” Wijarnpreecha said.
In an accompanying commentary, Mohamed I. Elsaid, PhD, MPH, a biomedical informatics researcher and assistant professor at The Ohio State University in Columbus, Ohio, said that if confirmed, the findings could substantially improve cirrhosis care. “The signal is exciting but needs strong confirmation from large observational studies and prospective trials,” he wrote. “To turn promise into practice, the next wave of observational studies must embrace the target-trial emulation framework for bolstering firm causal conclusions and doubly robust learners that tease apart who benefits, who does not, and why.”
He added that head-to-head comparisons with the type 2 diabetes drugs known as incretin mimetics will clarify the best antihyperglycemic agents for different patient phenotypes. “With these advanced causal-inference approaches, repurposed type 2 diabetes therapies could shift cirrhosis management from reactive to proactive, improving quality of life and bending the mortality curve,” Elsaid wrote.
For Wijarnpreecha, important pending questions include the benefits of SGLT2 inhibition in cirrhosis without diabetes or heart failure “Can it be used to prevent cirrhosis in MASLD if we start at the early fibrosis stage in F0-F3?”
Chiang conceded that the study had limitations as it relied on 10th revision of the International Classification of Diseases codes to define outcomes, which may not have captured the complexity of cirrhotic complications. “And the retrospective design may have introduced confounding, selection, and information bias, which could have impacted the results,” he said. “Future prospective studies may help confirm our findings.”
No specific funding was reported for this study. The study authors and Wijarnpreecha had no relevant conflicts of interest to declare. Elsaid reported receiving research funding from Genentech and AstraZeneca outside of the submitted work.
A version of this article first appeared on Medscape.com.
Forceps Assistance Improves Outcomes in Difficult ERCP Cannulations
The results emerged from the small, single-center SOCCER trial of 152 patients recruited from March 2022 to October 2024 and are published in The American Journal of Gastroenterology.
Both groups had a slightly higher number of female participants, and the mean ages of the participants were 61.9 years in the forceps group and 68.3 years in the no forceps group.
First author Steven M. Hadley Jr, an MD candidate at Northwestern Feinberg School of Medicine in Chicago, and colleagues reported that forceps assistance in difficult cannulations yielded significantly higher success rates than no forceps assistance (100% vs 83.9%; P < .001).
The investigators noted that difficult cannulations during ERCP have a frequency of 42%. Cannulation failure is associated with increased morbidity — including longer hospitalization, increased ICU admissions, readmissions, and increased financial cost — as well as mortality rates of up to 10%.
SOCCER defined difficult cannulation as a papilla in or on the rim of a diverticulum, five or more attempts, attempts lasting 5 or more minutes, or two or more unintended pancreatic duct wire passages. Other features were redundant tissue overlaying the papilla or a type 2, 3, or 4 papilla.
The study found forceps assistance also had a nonstatistically significant lower rate of difficult cannulations than no forceps (57.1% vs 69.1%; P = .132). The rate of post-ERCP pancreatitis (PEP) was similarly low in both groups: 5.7% with forceps vs 3.7% without forceps (P = .705). The no forceps group had significantly more cannulation attempts after randomization than the forceps group (14 vs 8.3; P = .026).
Patients who crossed over to forceps assistance all had successful cannulations.
The technique has long been used to overcome cannulation difficulties, said Timothy B. Gardner, MD, MS, a gastroenterologist at the Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, and a coauthor of the study. “It was particularly effective for cannulations with redundant tissue limiting access to the papilla,” Gardner told GI & Hepatology News. “We decided to design a randomized trial to determine the extent to which this technique worked. We believed our study would answer an important question that would hopefully lead to an improvement in endoscopy practice.”
While a few case reports and video demos had described the technique, no trials had assessed its effectiveness, Hadley added. “We found the technique to be effective based on our experience, but it was exciting to see that a rigorously designed randomized trial proved that it is indeed a very effective technique to facilitate cannulation.”
Hadley noted the technique does not increase PEP incidence, unlike the commonly used precut sphincterotomy and the double-wire method for difficult cannulations. “As a result, the forceps-assisted technique may be an effective first-line option and may reduce the need for additional, more invasive procedures including surgery and repeat ERCP to obtain the therapeutic intent of the original ERCP.”
The paper outlines the technique’s methodology, he added, “so we believe endoscopists who read the manuscript will be able to start implementing the technique into their practice.”
Commenting on the paper but not involved in it, Christopher J. DiMaio, MD, regional director of Endoscopy for Northwell Health Physician Partners Gastroenterology and a gastroenterologist in Greenlawn, New York, called it potentially helpful but aimed at a niche group of expert practitioners. “The technique appears safe and very effective, which is the number one concern, and I would definitely keep it in my back pocket,” he said. “I expect it will be used more commonly now because of this study.”
He added that although expert endoscopists are familiar with the approach, they use more time-tested and sometimes more aggressive maneuvers to cope with difficult cannulations. “But this is a simple technique using a device that should be available to most high-volume endoscopists.”
DiMaio also noted that he would have liked to see an actual decrease in PEP incidence in the intervention group.
Looking ahead, Hadley said it would be interesting to compare the effectiveness of the double-wire technique against forceps-assisted cannulation in a randomized context. “A study we’re already looking into is seeing whether physician experience with the technique impacts outcomes.”
This study was supported by the American College of Gastroenterology. The authors and DiMaio reported having no relevant competing interests.
A version of this article first appeared on Medscape.com.
The results emerged from the small, single-center SOCCER trial of 152 patients recruited from March 2022 to October 2024 and are published in The American Journal of Gastroenterology.
Both groups had a slightly higher number of female participants, and the mean ages of the participants were 61.9 years in the forceps group and 68.3 years in the no forceps group.
First author Steven M. Hadley Jr, an MD candidate at Northwestern Feinberg School of Medicine in Chicago, and colleagues reported that forceps assistance in difficult cannulations yielded significantly higher success rates than no forceps assistance (100% vs 83.9%; P < .001).
The investigators noted that difficult cannulations during ERCP have a frequency of 42%. Cannulation failure is associated with increased morbidity — including longer hospitalization, increased ICU admissions, readmissions, and increased financial cost — as well as mortality rates of up to 10%.
SOCCER defined difficult cannulation as a papilla in or on the rim of a diverticulum, five or more attempts, attempts lasting 5 or more minutes, or two or more unintended pancreatic duct wire passages. Other features were redundant tissue overlaying the papilla or a type 2, 3, or 4 papilla.
The study found forceps assistance also had a nonstatistically significant lower rate of difficult cannulations than no forceps (57.1% vs 69.1%; P = .132). The rate of post-ERCP pancreatitis (PEP) was similarly low in both groups: 5.7% with forceps vs 3.7% without forceps (P = .705). The no forceps group had significantly more cannulation attempts after randomization than the forceps group (14 vs 8.3; P = .026).
Patients who crossed over to forceps assistance all had successful cannulations.
The technique has long been used to overcome cannulation difficulties, said Timothy B. Gardner, MD, MS, a gastroenterologist at the Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, and a coauthor of the study. “It was particularly effective for cannulations with redundant tissue limiting access to the papilla,” Gardner told GI & Hepatology News. “We decided to design a randomized trial to determine the extent to which this technique worked. We believed our study would answer an important question that would hopefully lead to an improvement in endoscopy practice.”
While a few case reports and video demos had described the technique, no trials had assessed its effectiveness, Hadley added. “We found the technique to be effective based on our experience, but it was exciting to see that a rigorously designed randomized trial proved that it is indeed a very effective technique to facilitate cannulation.”
Hadley noted the technique does not increase PEP incidence, unlike the commonly used precut sphincterotomy and the double-wire method for difficult cannulations. “As a result, the forceps-assisted technique may be an effective first-line option and may reduce the need for additional, more invasive procedures including surgery and repeat ERCP to obtain the therapeutic intent of the original ERCP.”
The paper outlines the technique’s methodology, he added, “so we believe endoscopists who read the manuscript will be able to start implementing the technique into their practice.”
Commenting on the paper but not involved in it, Christopher J. DiMaio, MD, regional director of Endoscopy for Northwell Health Physician Partners Gastroenterology and a gastroenterologist in Greenlawn, New York, called it potentially helpful but aimed at a niche group of expert practitioners. “The technique appears safe and very effective, which is the number one concern, and I would definitely keep it in my back pocket,” he said. “I expect it will be used more commonly now because of this study.”
He added that although expert endoscopists are familiar with the approach, they use more time-tested and sometimes more aggressive maneuvers to cope with difficult cannulations. “But this is a simple technique using a device that should be available to most high-volume endoscopists.”
DiMaio also noted that he would have liked to see an actual decrease in PEP incidence in the intervention group.
Looking ahead, Hadley said it would be interesting to compare the effectiveness of the double-wire technique against forceps-assisted cannulation in a randomized context. “A study we’re already looking into is seeing whether physician experience with the technique impacts outcomes.”
This study was supported by the American College of Gastroenterology. The authors and DiMaio reported having no relevant competing interests.
A version of this article first appeared on Medscape.com.
The results emerged from the small, single-center SOCCER trial of 152 patients recruited from March 2022 to October 2024 and are published in The American Journal of Gastroenterology.
Both groups had a slightly higher number of female participants, and the mean ages of the participants were 61.9 years in the forceps group and 68.3 years in the no forceps group.
First author Steven M. Hadley Jr, an MD candidate at Northwestern Feinberg School of Medicine in Chicago, and colleagues reported that forceps assistance in difficult cannulations yielded significantly higher success rates than no forceps assistance (100% vs 83.9%; P < .001).
The investigators noted that difficult cannulations during ERCP have a frequency of 42%. Cannulation failure is associated with increased morbidity — including longer hospitalization, increased ICU admissions, readmissions, and increased financial cost — as well as mortality rates of up to 10%.
SOCCER defined difficult cannulation as a papilla in or on the rim of a diverticulum, five or more attempts, attempts lasting 5 or more minutes, or two or more unintended pancreatic duct wire passages. Other features were redundant tissue overlaying the papilla or a type 2, 3, or 4 papilla.
The study found forceps assistance also had a nonstatistically significant lower rate of difficult cannulations than no forceps (57.1% vs 69.1%; P = .132). The rate of post-ERCP pancreatitis (PEP) was similarly low in both groups: 5.7% with forceps vs 3.7% without forceps (P = .705). The no forceps group had significantly more cannulation attempts after randomization than the forceps group (14 vs 8.3; P = .026).
Patients who crossed over to forceps assistance all had successful cannulations.
The technique has long been used to overcome cannulation difficulties, said Timothy B. Gardner, MD, MS, a gastroenterologist at the Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, and a coauthor of the study. “It was particularly effective for cannulations with redundant tissue limiting access to the papilla,” Gardner told GI & Hepatology News. “We decided to design a randomized trial to determine the extent to which this technique worked. We believed our study would answer an important question that would hopefully lead to an improvement in endoscopy practice.”
While a few case reports and video demos had described the technique, no trials had assessed its effectiveness, Hadley added. “We found the technique to be effective based on our experience, but it was exciting to see that a rigorously designed randomized trial proved that it is indeed a very effective technique to facilitate cannulation.”
Hadley noted the technique does not increase PEP incidence, unlike the commonly used precut sphincterotomy and the double-wire method for difficult cannulations. “As a result, the forceps-assisted technique may be an effective first-line option and may reduce the need for additional, more invasive procedures including surgery and repeat ERCP to obtain the therapeutic intent of the original ERCP.”
The paper outlines the technique’s methodology, he added, “so we believe endoscopists who read the manuscript will be able to start implementing the technique into their practice.”
Commenting on the paper but not involved in it, Christopher J. DiMaio, MD, regional director of Endoscopy for Northwell Health Physician Partners Gastroenterology and a gastroenterologist in Greenlawn, New York, called it potentially helpful but aimed at a niche group of expert practitioners. “The technique appears safe and very effective, which is the number one concern, and I would definitely keep it in my back pocket,” he said. “I expect it will be used more commonly now because of this study.”
He added that although expert endoscopists are familiar with the approach, they use more time-tested and sometimes more aggressive maneuvers to cope with difficult cannulations. “But this is a simple technique using a device that should be available to most high-volume endoscopists.”
DiMaio also noted that he would have liked to see an actual decrease in PEP incidence in the intervention group.
Looking ahead, Hadley said it would be interesting to compare the effectiveness of the double-wire technique against forceps-assisted cannulation in a randomized context. “A study we’re already looking into is seeing whether physician experience with the technique impacts outcomes.”
This study was supported by the American College of Gastroenterology. The authors and DiMaio reported having no relevant competing interests.
A version of this article first appeared on Medscape.com.
GI Disorders Linked With Sleep Problems
“Emerging evidence suggests a bidirectional relationship between GI diseases and sleep disorders, whereby dysfunction in one domain may exacerbate the other,” wrote Shicheng Ye, PhD, of The Third Clinical Medical College of Guangzhou University of Chinese Medicine, and colleagues. However, previous studies on the association between GI and sleep problems have been small, and the role of depression as a mediator has not been well explored.
In the study, which was published online in BMC Gastroenterology, the researchers reviewed data from the US National Health and Nutrition Examination Survey between 2005 and 2014. The study population included 10,626 adults aged 20 years or older, with a mean age of 45.6 years, 50.8% of whom were women. Of these, 6444 were identified as having GI disease on the basis of a “yes” response to the question of whether they had a stomach or intestinal illness with vomiting or diarrhea within the past 30 days.
Researchers also examined responses to survey questions related to sleep duration, trouble sleeping, and diagnosis of a sleep disorder. Individuals with vs without GI diseases had a significantly higher prevalence of sleep trouble (37.99% vs 24.21%; P < .001) and a greater frequency of diagnosed sleep disorders (14.99% vs 8.08%; P < .001).
An analysis adjusted for demographic, lifestyle, and clinical factors found that individuals with vs without GI diseases were 70% more likely to have sleep trouble. Individuals with vs without GI diseases were also significantly more likely to have a diagnosed sleep disorder and a reduction in sleep duration (adjusted odds ratio, 1.8; adjusted beta, -0.15).
The association between GI diseases and sleep problems remained consistent across individuals of multiple subgroups, including those without hypertension, diabetes, or a history of smoking. It also remained significant among individuals with coronary heart disease and higher scores on the dietary index for gut microbiota. No significant interaction effects related to age, sex, or chronic disease appeared in any subgroup (P > .05).
An additional mediation analysis found that depression partly mediated the associations between GI diseases and sleep issues. Depression accounted for 21.29% of the total effect on sleep problems, 19.23% of the effect on sleep disorders, and 26.68% of the effect on sleep duration.
The mediating role of depression on the association between GI disease and sleep problems may not be exclusive, the researchers wrote. Other potential mechanisms may include systemic inflammation, visceral hypersensitivity, and metabolic dysfunction.
The findings were limited by several factors, including the possibly underpowered sample size for machine-learning models and the reliance on self-reports of GI diseases, sleep outcomes, and coronary heart disease, the researchers noted. Other limitations included the inability to adjust for confounding factors, including obstructive sleep apnea, chronic pain, and hypertension.
However, the results illustrate the need to address both psychological and GI factors in clinical practice to improve sleep health, the researchers wrote. More research is needed to identify causal pathways and develop targeted, multidimensional interventions for this interconnected trio of health problems.
Increasing Evidence for Gut-Brain Interaction
Both sleep disorders and disorders of GBI (DGBI) are highly prevalent worldwide, Jatin Roper, MD, gastroenterologist and associate professor of medicine at Duke University, Durham, North Carolina, told GI & Hepatology News.
“A growing body of evidence suggests that DGBI, including irritable bowel syndrome, are caused by imbalances in signaling between the brain and the intestine, which include the vagus nerve, hormonal signals, the gut microbiota, and immune system,” said Roper, who was not involved in the current study.
“Since many sleep disturbances are centrally mediated, it is plausible that sleep and gastrointestinal disorders could be mechanistically linked,” he said. Rigorous analysis of patient databases for a possible association between sleep and GI disorders, as was done in the current study, is an important step.
The current study findings were not unexpected, “particularly the finding that depression may mediate a link between sleep and GI disorders, because depression is well known to be associated to sleep disturbances and DGBI,” Roper said.
However, GI doctors often do not ask patients about problems with sleep, and pulmonary doctors or sleep specialists may not ask patients about GI symptoms, Roper noted. Similarly, patients may not bring up all their symptoms when seeing these specialists.
“The current study underscores the need for comprehensive, multisystem evaluations in specialty clinics for sleep and GI conditions and appropriate referrals to specialists, when necessary,” he said.
The research raised an important question of whether sleep and GI disorders are associated with each other because of other underlying medical conditions, which may be difficult to control for in cross-sectional studies, or whether sleep problems cause GI problems or vice versa, Roper said. Other uncertainties include whether the conditions are biologically linked, possibly through shared changes in the brain-gut axis.
Long-term observational studies would be useful to identify whether sleep disturbances precede DGBI or vice versa, Roper added.
The study received no outside funding. The researchers and Roper had no financial conflicts to disclose.
A version of this article first appeared on Medscape.com.
“Emerging evidence suggests a bidirectional relationship between GI diseases and sleep disorders, whereby dysfunction in one domain may exacerbate the other,” wrote Shicheng Ye, PhD, of The Third Clinical Medical College of Guangzhou University of Chinese Medicine, and colleagues. However, previous studies on the association between GI and sleep problems have been small, and the role of depression as a mediator has not been well explored.
In the study, which was published online in BMC Gastroenterology, the researchers reviewed data from the US National Health and Nutrition Examination Survey between 2005 and 2014. The study population included 10,626 adults aged 20 years or older, with a mean age of 45.6 years, 50.8% of whom were women. Of these, 6444 were identified as having GI disease on the basis of a “yes” response to the question of whether they had a stomach or intestinal illness with vomiting or diarrhea within the past 30 days.
Researchers also examined responses to survey questions related to sleep duration, trouble sleeping, and diagnosis of a sleep disorder. Individuals with vs without GI diseases had a significantly higher prevalence of sleep trouble (37.99% vs 24.21%; P < .001) and a greater frequency of diagnosed sleep disorders (14.99% vs 8.08%; P < .001).
An analysis adjusted for demographic, lifestyle, and clinical factors found that individuals with vs without GI diseases were 70% more likely to have sleep trouble. Individuals with vs without GI diseases were also significantly more likely to have a diagnosed sleep disorder and a reduction in sleep duration (adjusted odds ratio, 1.8; adjusted beta, -0.15).
The association between GI diseases and sleep problems remained consistent across individuals of multiple subgroups, including those without hypertension, diabetes, or a history of smoking. It also remained significant among individuals with coronary heart disease and higher scores on the dietary index for gut microbiota. No significant interaction effects related to age, sex, or chronic disease appeared in any subgroup (P > .05).
An additional mediation analysis found that depression partly mediated the associations between GI diseases and sleep issues. Depression accounted for 21.29% of the total effect on sleep problems, 19.23% of the effect on sleep disorders, and 26.68% of the effect on sleep duration.
The mediating role of depression on the association between GI disease and sleep problems may not be exclusive, the researchers wrote. Other potential mechanisms may include systemic inflammation, visceral hypersensitivity, and metabolic dysfunction.
The findings were limited by several factors, including the possibly underpowered sample size for machine-learning models and the reliance on self-reports of GI diseases, sleep outcomes, and coronary heart disease, the researchers noted. Other limitations included the inability to adjust for confounding factors, including obstructive sleep apnea, chronic pain, and hypertension.
However, the results illustrate the need to address both psychological and GI factors in clinical practice to improve sleep health, the researchers wrote. More research is needed to identify causal pathways and develop targeted, multidimensional interventions for this interconnected trio of health problems.
Increasing Evidence for Gut-Brain Interaction
Both sleep disorders and disorders of GBI (DGBI) are highly prevalent worldwide, Jatin Roper, MD, gastroenterologist and associate professor of medicine at Duke University, Durham, North Carolina, told GI & Hepatology News.
“A growing body of evidence suggests that DGBI, including irritable bowel syndrome, are caused by imbalances in signaling between the brain and the intestine, which include the vagus nerve, hormonal signals, the gut microbiota, and immune system,” said Roper, who was not involved in the current study.
“Since many sleep disturbances are centrally mediated, it is plausible that sleep and gastrointestinal disorders could be mechanistically linked,” he said. Rigorous analysis of patient databases for a possible association between sleep and GI disorders, as was done in the current study, is an important step.
The current study findings were not unexpected, “particularly the finding that depression may mediate a link between sleep and GI disorders, because depression is well known to be associated to sleep disturbances and DGBI,” Roper said.
However, GI doctors often do not ask patients about problems with sleep, and pulmonary doctors or sleep specialists may not ask patients about GI symptoms, Roper noted. Similarly, patients may not bring up all their symptoms when seeing these specialists.
“The current study underscores the need for comprehensive, multisystem evaluations in specialty clinics for sleep and GI conditions and appropriate referrals to specialists, when necessary,” he said.
The research raised an important question of whether sleep and GI disorders are associated with each other because of other underlying medical conditions, which may be difficult to control for in cross-sectional studies, or whether sleep problems cause GI problems or vice versa, Roper said. Other uncertainties include whether the conditions are biologically linked, possibly through shared changes in the brain-gut axis.
Long-term observational studies would be useful to identify whether sleep disturbances precede DGBI or vice versa, Roper added.
The study received no outside funding. The researchers and Roper had no financial conflicts to disclose.
A version of this article first appeared on Medscape.com.
“Emerging evidence suggests a bidirectional relationship between GI diseases and sleep disorders, whereby dysfunction in one domain may exacerbate the other,” wrote Shicheng Ye, PhD, of The Third Clinical Medical College of Guangzhou University of Chinese Medicine, and colleagues. However, previous studies on the association between GI and sleep problems have been small, and the role of depression as a mediator has not been well explored.
In the study, which was published online in BMC Gastroenterology, the researchers reviewed data from the US National Health and Nutrition Examination Survey between 2005 and 2014. The study population included 10,626 adults aged 20 years or older, with a mean age of 45.6 years, 50.8% of whom were women. Of these, 6444 were identified as having GI disease on the basis of a “yes” response to the question of whether they had a stomach or intestinal illness with vomiting or diarrhea within the past 30 days.
Researchers also examined responses to survey questions related to sleep duration, trouble sleeping, and diagnosis of a sleep disorder. Individuals with vs without GI diseases had a significantly higher prevalence of sleep trouble (37.99% vs 24.21%; P < .001) and a greater frequency of diagnosed sleep disorders (14.99% vs 8.08%; P < .001).
An analysis adjusted for demographic, lifestyle, and clinical factors found that individuals with vs without GI diseases were 70% more likely to have sleep trouble. Individuals with vs without GI diseases were also significantly more likely to have a diagnosed sleep disorder and a reduction in sleep duration (adjusted odds ratio, 1.8; adjusted beta, -0.15).
The association between GI diseases and sleep problems remained consistent across individuals of multiple subgroups, including those without hypertension, diabetes, or a history of smoking. It also remained significant among individuals with coronary heart disease and higher scores on the dietary index for gut microbiota. No significant interaction effects related to age, sex, or chronic disease appeared in any subgroup (P > .05).
An additional mediation analysis found that depression partly mediated the associations between GI diseases and sleep issues. Depression accounted for 21.29% of the total effect on sleep problems, 19.23% of the effect on sleep disorders, and 26.68% of the effect on sleep duration.
The mediating role of depression on the association between GI disease and sleep problems may not be exclusive, the researchers wrote. Other potential mechanisms may include systemic inflammation, visceral hypersensitivity, and metabolic dysfunction.
The findings were limited by several factors, including the possibly underpowered sample size for machine-learning models and the reliance on self-reports of GI diseases, sleep outcomes, and coronary heart disease, the researchers noted. Other limitations included the inability to adjust for confounding factors, including obstructive sleep apnea, chronic pain, and hypertension.
However, the results illustrate the need to address both psychological and GI factors in clinical practice to improve sleep health, the researchers wrote. More research is needed to identify causal pathways and develop targeted, multidimensional interventions for this interconnected trio of health problems.
Increasing Evidence for Gut-Brain Interaction
Both sleep disorders and disorders of GBI (DGBI) are highly prevalent worldwide, Jatin Roper, MD, gastroenterologist and associate professor of medicine at Duke University, Durham, North Carolina, told GI & Hepatology News.
“A growing body of evidence suggests that DGBI, including irritable bowel syndrome, are caused by imbalances in signaling between the brain and the intestine, which include the vagus nerve, hormonal signals, the gut microbiota, and immune system,” said Roper, who was not involved in the current study.
“Since many sleep disturbances are centrally mediated, it is plausible that sleep and gastrointestinal disorders could be mechanistically linked,” he said. Rigorous analysis of patient databases for a possible association between sleep and GI disorders, as was done in the current study, is an important step.
The current study findings were not unexpected, “particularly the finding that depression may mediate a link between sleep and GI disorders, because depression is well known to be associated to sleep disturbances and DGBI,” Roper said.
However, GI doctors often do not ask patients about problems with sleep, and pulmonary doctors or sleep specialists may not ask patients about GI symptoms, Roper noted. Similarly, patients may not bring up all their symptoms when seeing these specialists.
“The current study underscores the need for comprehensive, multisystem evaluations in specialty clinics for sleep and GI conditions and appropriate referrals to specialists, when necessary,” he said.
The research raised an important question of whether sleep and GI disorders are associated with each other because of other underlying medical conditions, which may be difficult to control for in cross-sectional studies, or whether sleep problems cause GI problems or vice versa, Roper said. Other uncertainties include whether the conditions are biologically linked, possibly through shared changes in the brain-gut axis.
Long-term observational studies would be useful to identify whether sleep disturbances precede DGBI or vice versa, Roper added.
The study received no outside funding. The researchers and Roper had no financial conflicts to disclose.
A version of this article first appeared on Medscape.com.
Intestinal Methanogen Overgrowth Fosters More Constipation, Less Diarrhea
, according to a systematic review and meta-analysis published in Clinical Gastroenterology and Hepatology.
“The distinct phenotype of patients with IMO should be incorporated in patient-reported outcome measures and further correlated with mechanistic microbiome studies,” wrote investigators led by gastroenterologist Ali Rezaie, MD, MSc, medical director of the GI Motility Program at Cedars-Sinai Medical Center and director of biotechnology in the center’s Medically Associated Science and Technology (MAST) Program. Recognizing specific GI symptom profiles can improve diagnosis and treatment strategies, facilitating further clinical trials and targeted microbiome studies to optimize patient care.
Excessive luminal loads of methanogenic archaea – archaea being bacteria-like prokaryotes and one of the main three domains of the tree of life – have been implicated in the pathophysiology of various diseases, including constipation.
The Study
To elucidate the phenotypical presentation of IMO in patients, Rezaie’s group compared the prevalence and severity of gastrointestinal (GI) symptoms in individuals who had IMO with those who did not have IMO. IMO was based on excess levels of this gaseous GI byproduct in exhaled breath tests.
Searching electronic databases from inception to September 2023, the researchers identified 19 eligible studies from diverse geographical regions with 1293 IMO patients and 3208 controls. Eleven studies were performed in the United States; the other studies were conducted in France (n = 2), India (n = 2), New Zealand (n = 1), South Korea (n = 1), Italy (n = 1), and the United Kingdom (n = 1). Thirteen studies were of high quality, as defined by a Newcastle-Ottawa Assessment Scale score of 6.
Patients with IMO were found to exhibit a range of GI symptoms, including bloating (78%), constipation (51%), diarrhea (33%), abdominal pain (65%), nausea (30%), and flatulence (56%).
In other findings:
- Patients with IMO had a significantly higher prevalence of constipation vs controls: 47% vs 38% (odds ratio [OR], 2.04, 95% confidence interval [CI], 1.48-2.83, P < .0001).
- They had a lower prevalence of diarrhea: 37% vs 52% (OR .58, 95% CI, .37-.90, P = .01); and nausea: 32% vs 45%; (OR, .75; 95% CI, .60-.94, P = .01).
- Patients with IMO had more severe constipation: standard mean deviation [SMD], .77 (95% CI, .11-1.43, P = .02) and a lower severity of diarrhea: SMD, –.71 (95% CI, –1.39 to –.03, P = .04). Significant heterogeneity of effect, however, was detected.
- Constipation was more prevalent in IMO diagnosed with the lactulose breath test and the glucose breath test and constipation was particularly prevalent in Europe and the United States.
Mechanism of Action
The findings on constipation and diarrhea corroborate methane’s slowing physiologic effects on motility, the authors noted. It has been consistently found to delay gut transit, both small bowel and colonic transit.
Mechanistically, methane reduces small intestinal peristaltic velocity while augmenting non-propagating contraction amplitude, suggesting that reduction of intestinal transit time is mediated through promotion of non-propulsive contractions.
“This study further consolidates methane’s causal role in constipation and paves the way to establish validated disease-specific patient-reported outcomes,” Rezaie and associates wrote, calling for longitudinal and mechanistic studies assessing the archaeome in order to advance understanding of IMO.
This study was funded in part by Nancy Stark and Stanley Lezman in support of the MAST Program’s Innovation Project at Cedars-Sinai.
Rezaie serves as a consultant/speaker for Bausch Health. Cedars-Sinai Medical Center has a licensing agreement with Gemelli Biotech, in which Rezaie and coauthor Pimentel have equity. They also hold equity in Good LIFE. Pimentel consults for and has received grant support from Bausch Health.
, according to a systematic review and meta-analysis published in Clinical Gastroenterology and Hepatology.
“The distinct phenotype of patients with IMO should be incorporated in patient-reported outcome measures and further correlated with mechanistic microbiome studies,” wrote investigators led by gastroenterologist Ali Rezaie, MD, MSc, medical director of the GI Motility Program at Cedars-Sinai Medical Center and director of biotechnology in the center’s Medically Associated Science and Technology (MAST) Program. Recognizing specific GI symptom profiles can improve diagnosis and treatment strategies, facilitating further clinical trials and targeted microbiome studies to optimize patient care.
Excessive luminal loads of methanogenic archaea – archaea being bacteria-like prokaryotes and one of the main three domains of the tree of life – have been implicated in the pathophysiology of various diseases, including constipation.
The Study
To elucidate the phenotypical presentation of IMO in patients, Rezaie’s group compared the prevalence and severity of gastrointestinal (GI) symptoms in individuals who had IMO with those who did not have IMO. IMO was based on excess levels of this gaseous GI byproduct in exhaled breath tests.
Searching electronic databases from inception to September 2023, the researchers identified 19 eligible studies from diverse geographical regions with 1293 IMO patients and 3208 controls. Eleven studies were performed in the United States; the other studies were conducted in France (n = 2), India (n = 2), New Zealand (n = 1), South Korea (n = 1), Italy (n = 1), and the United Kingdom (n = 1). Thirteen studies were of high quality, as defined by a Newcastle-Ottawa Assessment Scale score of 6.
Patients with IMO were found to exhibit a range of GI symptoms, including bloating (78%), constipation (51%), diarrhea (33%), abdominal pain (65%), nausea (30%), and flatulence (56%).
In other findings:
- Patients with IMO had a significantly higher prevalence of constipation vs controls: 47% vs 38% (odds ratio [OR], 2.04, 95% confidence interval [CI], 1.48-2.83, P < .0001).
- They had a lower prevalence of diarrhea: 37% vs 52% (OR .58, 95% CI, .37-.90, P = .01); and nausea: 32% vs 45%; (OR, .75; 95% CI, .60-.94, P = .01).
- Patients with IMO had more severe constipation: standard mean deviation [SMD], .77 (95% CI, .11-1.43, P = .02) and a lower severity of diarrhea: SMD, –.71 (95% CI, –1.39 to –.03, P = .04). Significant heterogeneity of effect, however, was detected.
- Constipation was more prevalent in IMO diagnosed with the lactulose breath test and the glucose breath test and constipation was particularly prevalent in Europe and the United States.
Mechanism of Action
The findings on constipation and diarrhea corroborate methane’s slowing physiologic effects on motility, the authors noted. It has been consistently found to delay gut transit, both small bowel and colonic transit.
Mechanistically, methane reduces small intestinal peristaltic velocity while augmenting non-propagating contraction amplitude, suggesting that reduction of intestinal transit time is mediated through promotion of non-propulsive contractions.
“This study further consolidates methane’s causal role in constipation and paves the way to establish validated disease-specific patient-reported outcomes,” Rezaie and associates wrote, calling for longitudinal and mechanistic studies assessing the archaeome in order to advance understanding of IMO.
This study was funded in part by Nancy Stark and Stanley Lezman in support of the MAST Program’s Innovation Project at Cedars-Sinai.
Rezaie serves as a consultant/speaker for Bausch Health. Cedars-Sinai Medical Center has a licensing agreement with Gemelli Biotech, in which Rezaie and coauthor Pimentel have equity. They also hold equity in Good LIFE. Pimentel consults for and has received grant support from Bausch Health.
, according to a systematic review and meta-analysis published in Clinical Gastroenterology and Hepatology.
“The distinct phenotype of patients with IMO should be incorporated in patient-reported outcome measures and further correlated with mechanistic microbiome studies,” wrote investigators led by gastroenterologist Ali Rezaie, MD, MSc, medical director of the GI Motility Program at Cedars-Sinai Medical Center and director of biotechnology in the center’s Medically Associated Science and Technology (MAST) Program. Recognizing specific GI symptom profiles can improve diagnosis and treatment strategies, facilitating further clinical trials and targeted microbiome studies to optimize patient care.
Excessive luminal loads of methanogenic archaea – archaea being bacteria-like prokaryotes and one of the main three domains of the tree of life – have been implicated in the pathophysiology of various diseases, including constipation.
The Study
To elucidate the phenotypical presentation of IMO in patients, Rezaie’s group compared the prevalence and severity of gastrointestinal (GI) symptoms in individuals who had IMO with those who did not have IMO. IMO was based on excess levels of this gaseous GI byproduct in exhaled breath tests.
Searching electronic databases from inception to September 2023, the researchers identified 19 eligible studies from diverse geographical regions with 1293 IMO patients and 3208 controls. Eleven studies were performed in the United States; the other studies were conducted in France (n = 2), India (n = 2), New Zealand (n = 1), South Korea (n = 1), Italy (n = 1), and the United Kingdom (n = 1). Thirteen studies were of high quality, as defined by a Newcastle-Ottawa Assessment Scale score of 6.
Patients with IMO were found to exhibit a range of GI symptoms, including bloating (78%), constipation (51%), diarrhea (33%), abdominal pain (65%), nausea (30%), and flatulence (56%).
In other findings:
- Patients with IMO had a significantly higher prevalence of constipation vs controls: 47% vs 38% (odds ratio [OR], 2.04, 95% confidence interval [CI], 1.48-2.83, P < .0001).
- They had a lower prevalence of diarrhea: 37% vs 52% (OR .58, 95% CI, .37-.90, P = .01); and nausea: 32% vs 45%; (OR, .75; 95% CI, .60-.94, P = .01).
- Patients with IMO had more severe constipation: standard mean deviation [SMD], .77 (95% CI, .11-1.43, P = .02) and a lower severity of diarrhea: SMD, –.71 (95% CI, –1.39 to –.03, P = .04). Significant heterogeneity of effect, however, was detected.
- Constipation was more prevalent in IMO diagnosed with the lactulose breath test and the glucose breath test and constipation was particularly prevalent in Europe and the United States.
Mechanism of Action
The findings on constipation and diarrhea corroborate methane’s slowing physiologic effects on motility, the authors noted. It has been consistently found to delay gut transit, both small bowel and colonic transit.
Mechanistically, methane reduces small intestinal peristaltic velocity while augmenting non-propagating contraction amplitude, suggesting that reduction of intestinal transit time is mediated through promotion of non-propulsive contractions.
“This study further consolidates methane’s causal role in constipation and paves the way to establish validated disease-specific patient-reported outcomes,” Rezaie and associates wrote, calling for longitudinal and mechanistic studies assessing the archaeome in order to advance understanding of IMO.
This study was funded in part by Nancy Stark and Stanley Lezman in support of the MAST Program’s Innovation Project at Cedars-Sinai.
Rezaie serves as a consultant/speaker for Bausch Health. Cedars-Sinai Medical Center has a licensing agreement with Gemelli Biotech, in which Rezaie and coauthor Pimentel have equity. They also hold equity in Good LIFE. Pimentel consults for and has received grant support from Bausch Health.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY