Volume 86 - 2023 - Fasc.3 - Reviews
Dumping syndrome after bariatric surgery: prevalence, pathophysiology and role in weight reduction – a systematic review
Background: Dumping syndrome is a frequent and wellknown
adverse event after bariatric surgery and covers a dynamic
spectrum of early and late dumping. Accelerated gastric emptying
is generally considered to be the cause of gastrointestinal and
vasomotor complaints. However, there is much uncertainty
regarding the exact pathophysiology of dumping. It has been
speculated that the syndrome is a desired consequence of bariatric
surgery and contributes to more efficient weight loss, but supporting
data are scarce.
Methods: A systematic search was conducted in PubMed in
July-August 2021. The prevalence of dumping after the most
frequently performed bariatric procedures was analyzed, as well as
underlying pathophysiology and its role in weight reduction.
Results: Roux-en-Y gastric bypass (RYGB) is associated with
the highest postoperative prevalence of dumping. The fast transit
induces neurohumoral changes which contribute to an imbalance
between postprandial glucose and insulin levels, resulting in
hypoglycemia which is the hallmark of late dumping. Early
dumping can, when received in a positive way, become a tool to
maintain a strict dietary pattern, but no significant relationship to
the degree of weight loss has been shown. However, late dumping is
detrimental and promotes overall higher caloric intake.
Conclusion: Dumping syndrome is common after bariatric
surgery, especially after RYGB. The pathophysiology is complex
and ambiguous. Currently available data do not support dumping
as a necessary condition to induce weight loss after bariatric
surgery.
Local and systemic autoimmune manifestations linked to hepatitis A infection
Hepatitis A virus (HAV) represents a global burdening infectious
agent causing in the majority of cases a self-limiting acute icteric
syndrome, the outcome is related to the hepatic substrate and the
potential pre-existing damage, whereas a plethora of extra-hepatic
manifestations has also been reported. Despite the absence of post-
HAV chronicity it has been associated with an additional burden
on existing chronic liver diseases. Moreover, the induced immune
response and the antigenic molecular mimicry are considered as
triggering factors of autoimmunity with regional and distal impact.
Diseases such as autoimmune hepatitis, Guillain-Barré syndrome,
rheumatoid arthritis, Still’s syndrome, Henoch-Schönlein purpura,
autoimmune hemolytic anemia, antiphospholipid syndrome,
systematic lupus erythematosus or cryoglobulinemic vasculitis
have been described in patients with HAV infection. Although the
exact mechanisms remain unclear, this review aims to accumulate
and clarify the pathways related to this linkage.
Novel corticosteroid formulations in the treatment of eosinophilic esophagitis: what is the evidence?
Background and study aims: Eosinophilic esophagitis (EoE)
is a food allergen-induced disease of the esophagus. Chronic,
eosinophil-predominant inflammation eventually leads to fibrosis,
esophageal dysfunction and severe morbidity. Swallowed topical
corticosteroids (STCs) are a mainstay of anti-inflammatory
therapy in the treatment of active EoE. Data on the efficacy of novel
corticosteroid formulations, developed specifically for esophageal
delivery, have recently become available.
Methods: A comprehensive review was performed aiming to
summarize evidence on the role of STCs in the treatment of EoE.
Two biomedical bibliographic databases (PubMED, EMBASE)
were searched for articles providing original information on the
efficacy and safety of STCs in adult EoE patients.
Results: Budesonide orodispersible tablet (BOT) and
budesonide oral suspension (BOS) both surpassed placebo
formulations regarding the efficacy of inducing and maintaining
histologic, symptomatic and endoscopic remission. Overall, BOT
displayed the highest grade of efficacy with clinico-histologic
remission rates up to 75% after 1 year. Fluticasone propionate
(APT-1011) achieved and maintained histologic and endoscopic
responses in the majority of patients, whereas only a positive trend
was demonstrated for symptomatic improvement. Mometasone
and ciclesonide were studied in a limited number of smaller-scale
trials and placebo-controlled data are required to substantiate the
promising findings. All STCs displayed a similar side effects profile
and were generally considered safe and well-tolerated.
Conclusions: Current evidence supports long-term treatment
with novel corticosteroid formulations, challenging the established
treatment paradigm of EoE. BOT appears to be the most effective
steroid therapy, although head-to-head comparative trials between
STCs are needed.
Non-esophageal eosinophilic gastrointestinal diseases: a narrative review
Eosinophilic gastrointestinal disorders are a group of rare
diseases characterized by the infiltration of eosinophils in the
gastrointestinal wall in a greater amount than in homeostatic
conditions. ‘Non-esophageal eosinophilic gastrointestinal disorders’
is the umbrella term for all eosinophilic gastrointestinal disorders
outside of the well known eosinophilic esophagitis. This includes
eosinophilic gastritis, eosinophilic enteritis and eosinophilic
colitis. The clinical presentation is atypical and not very different
for the three disorders. The depth of infiltration has a bigger
influence on the presenting symptoms than the disease location.
Although the frequency of diagnosis and research in this subject
is increasing over time, non-esophageal eosinophilic disorders
are rare and high quality evidence is limited to date. In this
narrative review, we provide an overview of the latest insights in
the pathophysiology, diagnostic approach and available treatment
options. Transcriptome studies have found the pathogenesis to be
T helper type 2 driven. Various laboratory findings can be used
to trigger raised suspicion and investigation with endoscopy.
As the endoscopic appearance of the mucosa is normal in most
cases, multiple biopsies in each segment are needed to quantify
the amount of eosinophils in the tissue. Eosinophilic cut-offs for
diagnosis are a controversial topic and a consensus is still lacking.
A recently developed tissue based diagnostic platform which
measures differentially expressed genes might be available in the
future to classify patients with intermediate eosinophilic tissue
levels under the cut-off. For the treatment, corticosteroids are still
the cornerstone of treatment but promising research suggests a role
of biologicals, such as Lirentelimab (anti-siglec 8) in particular.
Intestinal helminthic infections: a narrative review to guide the hepatogastroenterologist
Intestinal helminthic infections are not uncommon in Western Europe, mainly due to modern travel, emigration and globalization. Moreover, some helminthic infections are endemic in Western Europe and are part of the everyday clinical practice. The hepatogastroenterologist should therefore recognize and manage these patients or at least refer them to appropriate reference centers. Signs and symptoms are often unspecific or even absent. Discerning the disease at an early stage avoids expensive diagnostic testing, life-threatening complications and in some cases even further spread of the disease. This review article aims to guide the hepatogastroenterologist when suspecting a helminthic infection by addressing the most prevalent symptoms, summarizing the most probable associated helminthic entities, highlighting practical steps in diagnosis and available treatments.
What do we know today about drug-induced microscopic colitis? A case of lymphocytic colitis on olmesartan
Microscopic colitis is part of the differential diagnosis of chronic watery diarrhea. Colonoscopy discloses a normal looking mucosa, therefore its diagnosis is based on histology of colonic biopsies. Two main phenotypes are distinguished: collagenous colitis and lymphocytic colitis. A third entity, incomplete microscopic colitis or unspecified microscopic colitis has been reported in the literature. It affects preferentially women over 60 years of age and its association with certain drugs is increasingly established. In case of suspected drug-induced microscopic colitis, identification of the responsible drug is a key to management. After discontinuation of the suspected drug, the gold standard of treatment is budesonide both for induction and for maintenance in case of clinical relapse, as is often the case after discontinuation. Therapy with immunomodulators, biologics, or surgery is reserved for refractory forms of microscopic colitis after multidisciplinary consultation. Through the clinical case of colitis on olmesartan, we will review the latest recommendations on drug-induced microscopic colitis.
