GiT Updates and More

✴️STUDY Effect of glycerin on colonic motility in children * Glycerin is more effective than bisacodyl in triggering fully propagated high-amplitude propagating contractions (HAPCs) in children during colonic manometry (CM). * Glycerin led to a greater extent of HAPC propagation compared to bisacodyl. * In 36% of studies, glycerin improved colonic motility response compared to bisacodyl. * Glycerin's effectiveness was not dose-dependent, as median doses were similar across different response groups. * Older children and those with a longer duration of symptoms showed a better response to glycerin. * The study suggests incorporating glycerin into standard CM protocols, especially when bisacodyl is ineffective. * Glycerin's mechanism of action differs from bisacodyl, making it a valuable alternative for patients who do not respond to bisacodyl. * The study highlights the need for further research to understand why older children or those with longer symptom durations respond better to glycerin. * The effectiveness of glycerin was not influenced by underlying medical history, history of colorectal surgery, or daily use of bisacodyl or glycerin. * The study recommends considering glycerin as a first-line or additional option in manometry algorithms for patients with refractory constipation.

⚠️Summary of the AGA Clinical Practice Update on Management of Portal Vein Thrombosis in Patients with Cirrhosis 1. Prevalence and Impact: - Portal vein thrombosis (PVT) is common in cirrhosis, with a 5-year incidence of 11%. It is associated with advanced portal hypertension and increased mortality. 2. Diagnosis and Evaluation: - Screening: Routine screening is not recommended for asymptomatic patients with compensated cirrhosis. - Imaging: Doppler ultrasound is the initial diagnostic tool, but cross-sectional imaging (CT or MRI) is necessary to confirm PVT, assess clot extent, and rule out malignancy. - Hypercoagulable Workup: Not required unless additional thromboemboli, family history, or lab abnormalities suggest thrombophilia. 3. Management Strategies: - Urgent Anticoagulation: Required for patients with intestinal ischemia to minimize ischemic injury. Multidisciplinary care is recommended. - Nonurgent Anticoagulation: - Observation: For recent (<6 months), minimally obstructive (<50% occlusion) PVT without ischemia. Repeat imaging every 3 months. - Anticoagulation: For recent PVT with >50% occlusion or involvement of main portal/mesenteric veins, especially in transplant candidates or those with thrombus progression. - Chronic PVT: Anticoagulation is not advised for chronic (>6 months) PVT with complete occlusion and collateralization (cavernous transformation). 4. Anticoagulant Options: - Vitamin K antagonists (VKAs), low-molecular-weight heparin (LMWH), and direct oral anticoagulants (DOACs) are all viable. - DOACs (e.g., rivaroxaban, apixaban) are convenient and may be used in Child-Turcotte-Pugh (CTP) class A/B cirrhosis but are not recommended for CTP class C. 5. Variceal Screening: - Endoscopic screening for varices is recommended before anticoagulation, but delays in anticoagulation should be avoided to improve recanalization odds. 6. Monitoring and Duration: - Patients on anticoagulation should undergo cross-sectional imaging every 3 months. Anticoagulation should continue until clot resolution or transplantation. 7. Interventional Approaches: - Transjugular intrahepatic portosystemic shunt (TIPS): Considered for patients with refractory ascites, variceal bleeding, or as a bridge to transplant to improve vascular anatomy. 8. Gaps and Future Directions: - More randomized controlled trials are needed to standardize PVT classification and compare treatment efficacy across anticoagulants and interventions.

portal vein thrombosis ( April 2025 )

Abdominal pain

SUMMARY Rectal diclofenac versus indomethacin for prevention of post-ERCP pancreatitis (DIPPP): a multicentre, double-blind, randomised, controlled trial: - The study compared the efficacy of 100 mg rectal diclofenac and indomethacin in preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in a multicentre, double-blind, randomised controlled trial involving 1204 patients. - The primary outcome showed that PEP occurred in 8.8% of patients receiving diclofenac and 6.1% receiving indomethacin, indicating no significant superiority of diclofenac over indomethacin (p=0.074). - Among high-risk patients, PEP incidence was 14.2% in the diclofenac group compared to 9.8% in the indomethacin group, again showing no significant difference (p=0.124). - The study was stopped early due to a lack of evidence supporting the superiority of diclofenac, as interim analyses indicated low probability of achieving significant results. - Both drugs were deemed safe, with no significant differences in overall complications, post-ERCP bleeding, or mortality rates between the two treatment groups. - The findings support current clinical guidelines recommending either 100 mg rectal indomethacin or diclofenac for PEP prophylaxis in patients without contraindications. - Previous meta-analyses suggested diclofenac might be more effective than indomethacin; however, this study did not confirm that hypothesis. - The trial included diverse patient populations from nine tertiary centres across China, enhancing the generalizability of the findings. - It emphasized the need for further research to explore the differential effects of NSAIDs and their mechanisms in preventing PEP. - The study highlighted the importance of rigorous trial designs and interim analyses in determining the efficacy of clinical interventions.

Rectal diclofenac versus indomethacin for prevention of post-ERCP pancreatitis (DIPPP): a multicentre, double-blind, randomised, controlled trial: - The study compared the efficacy of 100 mg rectal diclofenac and indomethacin in preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in a multicentre, double-blind, randomised controlled trial involving 1204 patients. - The primary outcome showed that PEP occurred in 8.8% of patients receiving diclofenac and 6.1% receiving indomethacin, indicating no significant superiority of diclofenac over indomethacin (p=0.074). - Among high-risk patients, PEP incidence was 14.2% in the diclofenac group compared to 9.8% in the indomethacin group, again showing no significant difference (p=0.124). - The study was stopped early due to a lack of evidence supporting the superiority of diclofenac, as interim analyses indicated low probability of achieving significant results. - Both drugs were deemed safe, with no significant differences in overall complications, post-ERCP bleeding, or mortality rates between the two treatment groups. - The findings support current clinical guidelines recommending either 100 mg rectal indomethacin or diclofenac for PEP prophylaxis in patients without contraindications. - Previous meta-analyses suggested diclofenac might be more effective than indomethacin; however, this study did not confirm that hypothesis. - The trial included diverse patient populations from nine tertiary centres across China, enhancing the generalizability of the findings. - It emphasized the need for further research to explore the differential effects of NSAIDs and their mechanisms in preventing PEP. - The study highlighted the importance of rigorous trial designs and interim analyses in determining the efficacy of clinical interventions.

Cardiac bio markers

Insulin Resistance

Diagnosis and treatment approach for type 2 DM ( NICE guidelines) Taken from Passmedicine • Metformin is still first-line and should be offered if the HbA1c rises to 48 mmol/mol (6.5%) on lifestyle interventions. • If the HbA1c has risen to 58 mmol/mol (7.5%) then a second drug should be added from the following list: o sulfonylurea o gliptin o pioglitazone o SGLT-2 inhibitor • If despite this the HbA1c rises to, or remains above 58 mmol/mol (7.5%) then triple therapy with one of the following combinations should be offered: o metformin + gliptin + sulfonylurea o metformin + pioglitazone + sulfonylurea o metformin + sulfonylurea + SGLT-2 inhibitor o metformin + pioglitazone + SGLT-2 inhibitor o OR insulin therapy should be considered Key points: If HBA1C : 48 mmol/mol (6.5%)>>> start Metformin. If HBA1C rises to 58 mmol/mol (7.5%)>>> Add second drug. If HBA1C still 58 mmol/mol (7.5%)>>> Add third drug or INSULIN. HBA1C should be checked every 3-6 months until stable, then 6 monthly. Target HBA1C 48 mmol/mol (6.5%) if on monotherapy. Target HBA1C 53 mmol/mol (7%) if on dual or triple therapy.