Endoscopy for PEG and foreign bodies, opportunistic detection of liver disease and drugs for intestinal failure

In this May edition of the BMJOG blog we take a break from discussing COVID-19 and look at some of the recently published articles in hepatology, intestinal failure and endoscopy. The journal continues to accept articles on a wide range of topics and we would encourage readers to explore the full range of manuscripts available at the latest content section of the BMJOG website. Finally, we also take a look at recently published article in Frontline Gastroenterology describing an increasing problem in both adult and paediatric practice, recurrent foreign body ingestion.

In their article on discovery of undiagnosed liver disease in a population attending colonoscopy Koo et al, the authors describe the OSCAR Study, consisting of a cross-sectional assessment of patients attending hospital for colonoscopy. The authors measured metabolic and liver disease risk factors and assessed the prevalence of undiagnosed fatty liver disease using the Fatty Liver Index (FLI) and Fibrosis-4 score (FIB-4). Of the 1429 patients, nearly ¾ were overweight or obese and 30% had diabetes or metabolic syndrome. Recommenced alcohol levels were exceeded in 20% of patient. Patients with known liver disease were excluded leading to identification of 43% of the cohort had a high FLI, equating to a high likelihood of fatty liver. Of these patients 5% also had a high FIB-4 score indicating a high probability of advanced fibrosis. The authors conclude that high levels of cardiovascular risk and undiagnosed fatty liver disease were found in individuals attending for colonoscopy. There may be an opportunity to intervene at an earlier stage for these patients attending routine outpatient appointments.

The role of Sitagliptinin in patients with short bowel syndrome (SBS) and colon in continuity is explored as part of the open label trial by Naimi et al. Intestinal adaptation and improved enteral autonomy may be enhanced by glucagon-like peptide (GLP)-1 and GLP-2, these hormones are normally degraded by dipeptidyl peptidase (DPP)-4. This small study aimed to evaluate sitagliptin (a DPP-4 inhibitor) on reducing faecal excretions in this patient group with SBS and colon in continuity. The study involved administration of 100 mg oral sitagliptin twice daily to 8 patients, 7 of whom completed the 8-week study. Postprandial endogenous GLP-2 concentrations increased but sitagliptin did not significantly reduce faecal volume or increase intestinal absorption. However, there was significant heterogeneity in the treatment effect across the small study size. The authors conclude that a larger, placebo-controlled, study is required to establish the therapeutic potential of DPP-4 inhibition in this patient group.

The role of percutaneous endoscopic gastrostomy insertion is broad. In their narrative review article Boeykens et al discuss the prevention and management of major complications in PEG insertion. PEG is an endoscopic technique to insert a tube through the abdominal wall to enable administration of medication or enteral nutrition. Several placement techniques are described with the ‘pull’ technique (Ponsky-Gardener) as the most popular. All methods involve the ‘blind’ perforation of the stomach through a small acute surgical abdominal wound. Whilst the technique is generally safe there can be serious and life-threatening complications. This review discusses how to prevent, identify and treat these problems.

The endoscopic removal of intentional foreign bodies (FB) that have been intentionally ingested is increasing. Recurrent presentations to the emergency department are frequently seen and often require intervention. Whilst surgery is occasionally required for items such as magnets or batteries that have passed beyond the stomach, Yadollahi et al describe the endoscopic management of intentional foreign body ingestion through their experience in Southampton. This 5-year retrospective study looked at the 239 episodes of intentional FB ingestion seen in 51 individuals from 2015-2020. There was a significant increase in incidence throughout the study period. Oesophageal FB were more likely to lead to mucosal injury. Interestingly ingested item type and timing of endoscopy were not related to complications or length of stay. The authors conclude that in all patients except those with oesophageal FB on x-ray, endoscopic extraction can wait until availability during working hours. The authors raise important questions around holistic support and treatment for patients presenting with recurrent ingestion.

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