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Timing of endoscopy in dyspepsia: not so simple ▸

Overuse of endoscopy in countries where gastric cancer (GC) is uncommon is not cost effective, with guidelines recommending “test and treat” strategies and age thresholds for endoscopy of 45 or 55 years in the absence of alarm symptoms. Whether this is appropriate for countries with a higher prevalence of GC is unclear. The authors prospectively studied all dyspeptic patients undergoing open access endoscopy over five years to study the age distributions of GC cases and compared the prevalence of early and advanced cases in those with “simple” dyspepsia versus those with alarm symptoms. Of 461 cancers, 45 (10%) were in <45 and 5% were in <40 year olds. GC occurred in 12.6/1000 patients presenting with uninvestigated dyspepsia, 51% of whom had no alarm symptoms. Patients without alarm symptoms were more likely to have early cancer than those with alarm symptoms (p = 0.002) and 12/225 (5.3%) of cases would have been missed had an age cut off of 45 years for simple dyspepsia been implemented. Lessons? Early GC is found in a significant minority with simple dyspepsia in high GC prevalence countries and policies regarding age thresholds for endoscopy should be determined locally.

Fat thickens ▸

Association of non-alcoholic fatty liver disease (NAFLD) with metabolic syndrome is well established. Whether NAFLD itself perpetuates metabolic syndrome and its cardiovascular consequences is unclear. Villanova et al measured the vasodilatory response of the brachial artery to ischaemia, a methodology validated to detect early atherosclerosis in 52 subjects with NAFLD and 28 age and sex matched controls. Flow mediated vasodilatation, a measure of endothelial function, was significantly lower in patients with NAFLD compared with controls and was lower in those with pure steatosis compared with those with non-alcoholic steatohepatitis (NASH). In logistic regression analysis, NAFLD was associated with a lower tertile flow mediated vasodilatation (odds ratio (OR) 6.7 (95% confidence interval (CI) 1.3–36.2)), after adjustment for age, sex, body mass index, and insulin resistance. Among NAFLD patients, lower flow mediated vasodilatation was associated with NASH (adjusted OR 6.8 (95% CI 1.2–40.2)). The 10 year probability of cardiovascular events (calculated according to the Framingham equation) was moderately increased in NAFLD especially in those with NASH.

These findings are consistent with the observation that cardiovascular events rather than liver failure determine the clinical outcome in the majority of patients with NAFLD. More importantly, endothelial dysfunction related to NAFLD increases the risk of cardiac events independent of its association with metabolic syndrome. The risk appears to increase with the severity of liver disease.

Gastro-oesophageal reflux disease and oesophageal adenocarcinoma: a big problem ▸

The prevalence of gastro-oesophageal reflux disease (GORD) and oesophageal adenocarcinoma (OA) have increased dramatically in recent years. The reasons for this are unclear but it is possible that part of the explanation is the rise in obesity in Western populations. Hampel et al have conducted a systematic review of observational studies to evaluate the association between obesity, GORD, and OA. They identified eight studies with extractable data on reflux symptoms and obesity and reported an adjusted odds ratio (OR) of 1.43 (95% confidence interval (CI) 1.16–1.77) for symptoms with a body mass index (BMI) ⩾25 kg/m2. The OR increased to 1.94 (95% CI 1.47–2.57) for those with a BMI ⩾30 kg/m2. There were no eligible studies evaluating the association with Barrett’s oesophagus and obesity. Six studies reported extractable data on the association between obesity and OA with an adjusted OR of 1.52 (95% CI 1.15–2.01) for those with a BMI ⩾25 kg/m2 increasing to an adjusted OR of 2.78 (95% CI 1.85–4.16) for those with a BMI ⩾30 kg/m2.

As with all epidemiological data, it is uncertain whether this association is causal but obesity is associated with a number of causes of morbidity and mortality. This meta-analysis gives us one more reason why we should advise our obese patients to lose weight.

Does a lesser cut mean lesser treatment? ▸

Radiofrequency coagulation (or ablation) for the treatment of liver tumours has grown in popularity, particularly due to the ability to treat patients percutaneously under either ultrasound or computed tomography guidance. This paper has reviewed 95 independent series, analysing factors influencing the local recurrence rate of 5224 treated liver tumours following radiofrequency treatment. Tumour dependent factors related to a reduced incidence of local recurrence were smaller tumour size, neuroendocrine metastases, non-subcapsular location, and tumour location away from large vessels. Operator dependent favourable factors were surgical (laparoscopic or laparotomy) approach, vascular occlusion, general anaesthesia, a 1 cm intentional treatment margin, and greater experience. In a multivariate analysis, fewer local recurrences were seen with small size (4% versus 16% for tumours less than 3 cm in diameter) and a surgical (versus percutaneous) approach.

One of the main advantages of this technique over surgical resection and other ablation techniques is the use of the percutaneous approach which extends the procedure to patients unfit for major laparotomy. These data do however suggest caution in the use of the percutaneous approach and emphasise the fact that innovative less invasive techniques should obtain at least the same quality of results as traditional more invasive techniques.

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