A recent prospective study (J Abdallah et al. Clin Gastroenterol Hepatol 2019; 17: 1073-80) examined adults patients with documented reflux at baseline. Patients who reported heartburn and/or regurgitation at least twice a week for 3 months (n=16) despite proton pump inhibitor (PPI) therapy were considered PPI failures. Those (n=13) who responded to standard dose PPI for at least 4 weeks were in the “PPI success” group.
Standard PPI dosing in this study:
- Omeprazole 20 mg per day
- Esomeprazole 40 mg per day
- Pantoprazole 40 mg per day
Methods: Both groups (PPI Failure group, PPI Success group) underwent EGD and pH-MII studies. Abnormal acid exposure was considered if pH <4 was present for >4.2%.
- 12 patients (75%) in the PPI failure group had either functional heartburn or reflux hypersensitivity
- 4 patients in both groups had abnormal pH test result.
- There was no statistically significant differences in the number of reflux events, acid exposure or nonacid reflux parameters between patients who failed or those who were successfully treated with PPIs.
- In the PPI failure group: 25% had persistent GERD, 12.% had overlap with reflux hypersensitivity, and 62.5% had overlap with functional heartburn
My take: The difference between PPI failure and PPI success largely is due to the overlapping presence of functional esophageal disorders.
Related blog posts:
- How Many Kids with Reflux Actually Have Reflux?
- Why didn’t patient with documented reflux get better with PPI …
- Failure of PPI test | gutsandgrowth
- Guidelines on Functional Heartburn
- Better to do a coin toss than an ENT exam to determine reflux
- How Likely is Reflux in Infants with “Reflux-like … – gutsandgrowth
- PPI Webinar
- The Connection Between Anxiety and Gastroesophageal Reflux Disease
A recent systematic review and meta-analysis (Y Lee, et al. Clin Gastroenterol Hepatol 2019; 17: 1040-60) included 32 cohort studies with 3093 liver biopsy specimens from patients with nonalcoholic fatty liver disease (NAFLD).
- Bariatric surgery resulted in a biopsy-confirmed resolution of steatosis in 66%, inflammation in 50%, ballooning degeneration in 76%, and fibrosis in 40%.
- Bariatric surgery resulted in worsening features of NAFLD in 12%.
- The authors note that Roux-en-Y Gastric Bypass (RYGB) “showed greater reduction of liver side effects and higher: resolution of NAFLD.”
- Jejejnoileal bypass (JIB) and biliopancreatic diversion (BPD) “both have been associated with higher liver function morbidity.”
- The overall GRADE quality of evidence was considered very low.
My take: Though better studies are needed, the majority of patients’ livers appear to benefit from bariatric surgery.
Related blog posts:
- Should Teenagers with Severe NAFLD Undergo Bariatric Surgery?
- Concise Review: Fatty Liver in Pediatrics
- Reaching Consensus on Bariatric Intervention in Children …
- Is a Three Year-Old Too Young for Bariatric Surgery …
- Should We Be Excited About a New Medication (Liraglutide …
- Overlooking Obesity in Hospitalized Children | gutsandgrowth
- Treating diabetes with surgery | gutsandgrowth
A recent prospective study (A Carrocio et al. Gastroenterol 2019; 17: 682-90) with 78 patients who were diagnosed with “nonceliac gluten or wheat sensitivity” (NCGWS) by double-blind challenge had duodenal and rectal biopsies collected and analyzed. More commonly NCGWS is referred to as NCGS.
- Duodenal tissues from patients with NCGWS had hihger numbers of eosinophils than non-NCGWS controls as did rectal mucosa. Other elevated markers included epithelial CD3+ T cells, and lamina proppria CD45+ cells.
- Rectal mean eosinophil infiltrations was more than 2.5-fold the upper limit of normal and it was almost 2-fold increased in the duodenum.
- Sensitivity and specificity of rectal eosionphilia, defined by >9 eos in the lamina propria) was 94% and 70% respectively.
My take: This study is intriguing but needs more confirmation. Overall, it appears that the frequency of NCGS is very low.
Related blog posts:
- The latest on Pediatric Nonceliac Gluten Sensitivity
- What Happens When Patients with Nonceliac gluten sensitivity are Challenged with Gluten?
- Is a Gluten-Free Diet a Healthy Diet for those without Celiac Disease?
- An Unexpected Twist for “Gluten Sensitivity” | gutsandgrowth
- The Science Behind IBS Dietary Interventions | gutsandgrowth
- Gluten sensitivity without celiac disease | gutsandgrowth
A recent review provides some helpful advice: “A Practical Guide to the Safety and Monitoring of New IBD Therapies” (B Click, M Regueiro. Inflamm Bowel Dis 209; 25: 831-42).
This review discusses infection risk, malignancy risk, immunologic issues and other complications.
In terms of infection risk assessment, the authors describe a pyramid in which they stratify the risks of medications. The safest to least safe in their assessment: vedolizumab –>ustekinumab–>anti-TNF monotherapy–>thiopurine or tofacintinib–>thiopurine/anti-TNF combination–>steroids.
- Table 1 lists potential infections and vaccination recommendations
- Table 2 suggests management of active infections by IBD Medication Class
- For anti-TNF agents and for IL12/23 agents: the authors recommend continuation of agent if viral (eg EBV, VZV, HSV) or bacterial (eg. Strep/Staph)/C difficile infections (unless severe) but holding for opportunistic infections.
- For integrin agents, the authors recommend continuation of medications in the face of infections except “consider holding dose” during active C difficile infection
- For JAK agents, the authors recommend stopping during viral infections and with opportunistic infections. They recommend continuing with bacterial infections (hold if severe) and continuing with C difficile infection
- Table 3 suggests management in the setting of active malignancy
- Table 4 lists recommendations in the setting of immunologic complications. Theses categories include antidrug antibodies,lupus-like reactions, demyelinating conditions, and psoriasis.
- One of the points alluding to in this chart is that addition of methotrexate may help in patients receiving anti-TNF therapy with psoriasis.
- No psoriatic reactions have been reported with vedolizumab, ustekinumab or tofacitinib; ustekinumab is FDA-approved for use in psoriasis and tofacitinib is FDA-approved for psoriatic arthritis.
- Table 5 suggests recommendations in the setting of altered liver enzymes and altered lipids/creatine kinase
- Anti-TNF Agents in Pediatrics Have NOT Been Shown to Cause Lymphoma | gutsandgrowth
- Safer Than You Think: Biologic Therapies for IBD and Risk of Infection and Malignancy | gutsandgrowth
- TNF-α antagonists and infections
- Disease modifying treatment in IBD
- Only one chance to make first impression
- More on IBD Medicine Risks