Full text from ACG article: NASH: What Helps Beyond Weight Loss?
The article reinforces the value of weight loss and exercise for nonalcoholic steatohepatitis (NASH). It suggests that Vitamin E and/or pioglitazone may be helpful. Many more medications are being evaluated.
My take: As of now, losing weight and exercise remain the cornerstone for NASH treatment.
Another study (NZ Borren et al Inflamm Bowel Dis 2017; 23: 1234-9) has shown detrimental outcomes due to distance from the health care team.
In this study with 2136 patients with IBD (1197 Crohn’s disease, 9393 ulcerative colitis) with mean age of 41 years, the distance from the hospital (Massachusetts General) was compared with need for IBD-related surgery and secondary outcomes of needing biological and immunomodulator therapy.
Key findings:
According to the authors, with other indications besides IBD, “over three-quarters of the examined studies demonstrated a distance-decay association with worse outcomes in individuals living further away from health care facilities. Limitation: it is possible that patients who travel a greater distance have more disease severity and that those who have milder diseases are more likely to receive care closer to home.
My take: When highly qualified subspecialists are far away, the associated reduced access likely counters this potential benefit. Early effective therapy is important in reducing complications.
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Shem Creek, SC
It is said that “absence makes the heart grow fonder.” This expression certainly cannot be extrapolated to the liver. A recent study (DS Goldberg et al. Clin Gastroenterol Hepatol 2017; 15: 958-60) showed that increased distance to a liver transplant center was associated with higher mortality for patients with chronic liver failure (CLF).
This study examined 16,824 patients with CLF. In the cohort (879, 5.2%) who lived >150 miles from the closest LT center there was a 20% higher mortality rate (Hazard ratio of 1.20; P <.001). According to the authors, mortality with distance “modeled as a continuous variable per unit increase in 50 miles.”
From the discussion:
My take: This study, though with some limitations, bolsters the view that patients with chronic liver disease (and probably other chronic diseases) live longer if in proximity to specialized care.
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Exquisite windows in St. Vitus Cathedral, Prague
A large observation study provides some bad publicity for proton pump inhibitors (PPI):
BMJ Open Access: Risk of death among users of Proton Pump Inhibitors: a longitudinal
observational cohort study of United States veterans (Y Xie et al BMJ Open
2017;7:e015735. doi:10.1136/bmjopen-2016-01573) Thanks to Ben Enav for this reference.
This study selected ~350,000 patients from a database which identified more than 1.7 million PPI users. These patients were ‘new’ PPI users.
Key finding: Over a median follow-up of 5.71 years, PPI use was associated with increased risk of death compared with H2 blockers use (HR 1.25, CI 1.23 to 1.28).
The authors note the limitations of this observational study; however, they suggest that the findings cannot be fully explained by residual confounders. They recommend limiting PPI use to “instances and durations where it is medically indicated.”
My take: As noted in a recent post (see below), some risks attributed to PPIs in observational studies do not pan out. Yet, PPI therapies need to be better-targeted to those who will truly benefit from them.
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The Battery, Charleston, SC
From Axios: This is what Washington has been fighting about
An excerpt:
Every time you hear the Trump administration or Congress fight about rising Affordable Care Act premiums, or what will happen to people with pre-existing conditions, just remember — we’re talking about issues that affect 7 percent of the population. That’s how many people are in the individual health insurance market, or the “non-group” market…
But when you hear about those sky-high rate hikes because of “Obamacare,” chances are, they’re not your sky-high rate hikes — unless you happen to be in that market…
The spending limits that have been proposed for Medicaid really do matter, and they affect a larger group — 20 percent of the population.
A recent study (C AM Zar-Kessler et al. JPGN 2017; 65: 16-21) retrospectively reviewed a single center’s 8 year experience (2005-2013) using antidepressant medications to treat nonorganic abdominal pain. Of 531 cases, 192 initiated treatment with either a selective serotonin reuptake inhibitor (SSRI) or a tricyclic antidepressant (TCA).
Key findings:
In the discussion, the authors note that “all patients who experienced GI adverse effect were prescribed medications that would worsen their underlying bowel complaint…these issues may have been mitigated if more attention was paid” to this. “Specifically, TCAs should be used cautiously in those with constipation, whereas SSRIs should be avoided in those with diarrhea.”
My take: This study shows that both classes of antidepressants were associated with improvement. The conclusions about effectiveness are limited as this is a retrospective study and could not control/evaluate many variables. That being said, particularly if there is coexisting anxiety, as was frequent in this study population, a SSRI may be more effective.
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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.
Tynn Church, Prague
A recent case report (JJ Thomas et al. NEJM 2017; 376: 2377-86) provides insight into something I’ve seen a lot but did not have a good label for previously: Avoidant Restrictive Food Intake Disorder (ARFID).
This report highlights an 11 year old who after a having a piece of meat briefly lodged into an orthodontic palate expander, stopped eating solid foods because she was “afraid I can’t chew it up enough to swallow it so I don’t choke.” Even before this event, she had been a highly selective eater since infancy. “Similar to many patients with ARFID, this patient had a long-term failure to gain weight appropriately and now had more acute weight loss.” She did desired to gain weight and did not have any body distortion typical for anorexia nervosa.
This report provides a good list of etiologies which could trigger acute food refusal as well as conditions that could cause chronic poor weight gain.
Definition of ARFID:
Treatment of ARFID:
There is little data to guide treatment. Treatment of coexisting psychiatric conditions is recommended and behavioral interventions to improve eating. In this patient with a choking phobia, the treatment included a gradual stepwise progression in food textures:
My take: I think being able to use this relatively new term of Avoidant Restrictive Food Intake Disorder will improve disease classification and ultimately help promote better treatments.
I thought this candy store icon was funny due to the missing tooth
In a study examining 68.5 million people in 195 countries, the authors demonstrated increasing disease burden and death rates due to increasing prevalence of obesity over the last 25 years.
A two minute summary from NEJM: The Health Effects of Overweight and Obesity
A terrific 12 page review of irritable bowel syndrome (IBS): AC Ford, BE Lacy, NJ Talley. NEJM 2017; 376: 2566-78. While yesterday’s post reviewed some of the updated diagnostic and pathophysiology information, today’s will focus on treatment.
The article’s Table 2 outlines the most frequent treatments, their efficacy, side effects, costs, and quality of evidence. I’ve tried to highlight the key points from table and discussion:
The authors recommend judicious testing “Any reassurance derived from colonoscopy to rule out organic disease in patients with IBS is short-lived.”
The authors outline their typical approach. “Reassurance, explanation, and a positive diagnosis are essential steps in management. We recommend starting with dietary modification (slowly increasing soluble fiber if the patient has IBS with constipation or instituting a low-FODMAP diet temporarily if the patient has IBS with diarrhea or the mixed subtype of IBS). We also recommend increased exercise and stress reduction. A probiotic may be added, especially if bloating is prominent. Pain may be ameliorated with an antispasmodic agent or a tricyclic antidepressant, diarrhea with loperamide or a bile acid sequestrant (eg. colestipol) and constipation with polyethylene glycol.” The other therapies may be used in those with persistent IBS symptoms.
My take: When a disease has this many treatments, usually this means that none of the treatments are all that great.
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Chattahoochee River
Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.
A terrific 12 page review of irritable bowel syndrome (IBS): AC Ford, BE Lacy, NJ Talley. NEJM 2017; 376: 2566-78.
Diagnosis of Irritable Bowel:
Testing: National guidelines recommend that for a patient who meets Rome IV criteria, “the physician should make a positive diagnosis of IBS without resorting to a battery of tests.” Nevertheless, many physicians obtain some workup. If a workup is undertaken, the authors state “consider limited testing (CBC, CRP level, celiac serological test, fecal calprotectin level)”
Rome IV criteria of IBS are reviewed in Table 1 and includes warning signs. Summary of Rome IV critieria from emedicine website on Irritable Bowel Syndrome: The Rome IV criteria for the diagnosis of irritable bowel syndrome require that patients have had recurrent abdominal pain on average at least 1 day per week during the previous 3 months that is associated with 2 or more of the following [2]:
The Rome IV criteria (May 2016) only require abdominal pain in defining this condition; “discomfort” is no longer a requirement owing to its nonspecificity, and the recurrent abdominal pain.
Supporting symptoms include the following:
Four bowel patterns may be seen with irritable bowel syndrome, and these remain in the Rome IV classification. These patterns include the following:
Symptoms not consistent with irritable bowel syndrome should alert the clinician to the possibility of an organic pathology. Inconsistent symptoms include the following:
The authors provide a diagnostic algorithm which is straight-forward. The caption includes “tenderness is not increased by tensing abdominal wall muscles.” The inclusion of Carnett’s sign is a useful reminder to consider/exclude muscle wall etiologies.
Another important point is that bile-acid diarrhea occurs in a significant fraction of adults with the diarrhea subtype of IBS, more than 25% of cases in a meta-analysis; thus, a therapeutic trial of a bile acid sequestrant may be useful.
Pathophysiology:
There are likely multiple pathways leading to IBS. In fact, Figure 2 lays out a Brain-Gut pathway as well as a Gut-Brain pathway. In the former, genetic predisposition and environmental factors/CNS alterations, could make one more susceptible to IBS after localized GI inflammation. In the later, changes in the GI tract induced by infection, inflammation, food antigens, and medications which could alter intestinal permeability and/or microbiome could result in changes in CNS function (eg. new-onset anxiety, depression or somatization). It is well-recognized that after gastrointestinal infections (bacterial, protozoal, viral), “IBS-type symptoms persist in 10 to 20% of infected patients.”
Image from NEJM twitter feed. It is noted that not all pathophysiological processes shown occur in all patients with IBS or in all IBS subtypes.
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