Volume 84 - 2021 - Fasc.3 - Case series
The role of neuromodulation in chronic functional constipation: a systematic review
Background: Chronic functional constipation is a highly
prevalent disorder in which, when conservative measures fail to
relieve symptoms, surgical interventions are sometimes indicated.
In recent years, neuromodulation for the treatment of functional
constipation has gained interest but its role and effectiveness are
still unclear. The purpose of this review is to provide a systematic
overview on the current literature on the different modalities of
neurostimulation and their effect on chronic functional constipation
in adults as reported in the literature.
Methods: A search in the literature for articles concerning
the effect of different types of neuromodulation on constipation
was performed in PubMed using extensive search terms for the
different modalities of neuromodulation. Studies and trials were
checked for eligibility. For all types of neuromodulation together,
27 articles were included.
Results: 17 studies were included on SNM (sacral nerve
modulation). Although multiple studies show positive results on
the effect of SNM in constipation, double-blind crossover RCT’s
(randomised controlled trials) showed no significant effect. 3 studies
were included for tSNS (transcutaneous sacral nerve stimulation),
2 for PTNS (percutaneous tibial nerve stimulation) and 2 for TTNS
(transcutaneous tibial nerve stimulation). Studies and trials on
these modalities of neuromodulation reported ambiguous results
on statistical significance of the effect. For transcutaneous IFC
(interferential current therapy) 2 studies were included, which
both reported a statistically significant effect on all outcomes.
Conclusion: The beneficial effect of neuromodulation in
chronic functional constipation remains questionable. However,
neuro-modulation might be worth considering in patients refractory
to treatment before turning to more invasive measures. Future
research should shed more light on the effects of neuromodulation
in constipation.
Triggers of benign recurrent intrahepatic cholestasis and its pathophysiology: a review of literature
Benign recurrent intrahepatic cholestasis (BRIC) is a rare
genetic disorder that is characterized by episodes of cholestasis
followed by complete resolution. The episodic nature of BRIC raises
concerns about its possible trigger factors. Indeed, case reports of
this orphan disease have associated BRIC to some triggers. In the
absence of any reviews, we reviewed BRIC trigger factors and its
pathophysiology. The study consisted of a systematic search for case
reports using PubMed. Articles describing a clear case of BRIC
associated with a trigger were included resulting in 22 articles
that describe 35 patients. Infection was responsible for 54.3% of
triggered episodes, followed by hormonal, drugs, and miscellaneous
causes reporting as 30%, 10%, and 5.7% respectively. Females
predominated with 62.9%. The longest episode ranged between 3
months to 2 years with a mean of 32.37 weeks. The mean age of
the first episode was 14.28 ranging between 3 months to 48 years.
Winter and autumn were the major seasons during which episodes
happened. Hence, BRIC is potentially triggered by infection,
which is most commonly a viral infection, hormonal disturbances
as seen in oral contraceptive pills and pregnancy state, and less
commonly by certain drugs and other causes. The appearance of
cholestasis during the first two trimesters of pregnancy compared
to intrahepatic cholestasis of pregnancy could help to differentiate
between the two conditions. The possible mechanism of BRIC
induction implicates a role of BSEP and ATP8B1. While estrogen,
drugs, and cytokines are known to affect BSEP, less is known about
their action on ATP8B1.
Diagnostic and prognostic scoring systems for autoimmune hepatitis: a review
Introduction: Auto-immune hepatitis (AIH) is a rare condition
which primarily affects young women. Several diagnostic scoring
systems exist based on clinical, biochemical, immunologic
and histologic characteristics of AIH. Additionally, prognostic
parameters can be identified. The purpose of this literature review
is to compare the clinical value, strengths and limitations of these
diagnostic and prognostic scoring systems.
Methods: A literature search was performed in two databases
and selected based on diagnostic and prognostic criteria. Only
studies concerning AIH in adults were included.
Results: The backbone of scoring systems remains the revised
AIH criteria published in 1999 and the simplified from 2008. The
revised system shows a higher sensitivity, lower specificity and
lower diagnostic accuracy compared to the simplified. Limitations
to these scoring systems include limited diagnostic accuracy in
acute or fulminant liver failure, insufficient inclusion of atypical
auto-antibodies and lacking diagnostic power in presence of
overlap syndromes. Concerning these overlap syndromes, the
Paris criteria show a higher diagnostic accuracy compared to the
scoring systems for AIH. Presently, no clinical prognostic scoring
systems are available. However, a first system based on response to
treatment accurately predicts long-term survival in AIH.
Conclusion: Diagnostic scoring systems are useful in diagnosing
AIH and have complementary value. However, they are no
substitute for the gold standard of appropriate clinical assessment
and are mostly useful in defining cohorts for research purposes. An
evolution towards a more dynamic scoring system, using prognostic
parameters and the progression of typical features, seems more
valuable than the current diagnostic systems.
