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Coffee breakthrough ▸

There is little evidence based nutritional advice to provide to patients with chronic liver disease. Ruhl and Everhart analysed data from the Third National Health and Nutrition Examination Survey (NHANES III) to investigate whether coffee intake is protective in subjects at risk for liver injury. Of 23 258 patients aged ⩾20 years, 16 573 attended an examination, including 5944 subjects considered high risk (any of the following: >2 alcohol drinks/day, positive hepatitis B or C serology, transferring saturation >50%, haemoglobin A1C >6.5%, diabetes, body mass index ⩾26.9 kg/m2, and waist to hip ratio ⩾0.94). Elevated serum alanine aminotransferase levels (ALT >43 U/l) were found in 4.1% of the whole group and 8.7% of the high risk group. The risk of elevated ALT declined with increasing coffee and caffeine intake in both the high risk group (adjusted for other risk factors) and in the whole NHANES III sample. Subjects who drank more than 2 cups/day were less likely to have raised ALT compared with non-coffee drinkers (odds ratio (OR) 0.56 (0.3–1.0)), indicating a protective effect of coffee and caffeine.

This is reinforced by a case control study from northern Italy. Gelatti et al, compared lifetime coffee consumption of 250 patients with hepatocellular carcinoma (HCC) with 500 controls hospitalised for reasons other than liver or alcohol related diseases and neoplasms. Coffee consumption in the decade before the interview was associated with a decreasing risk of HCC, with a clear dose-effect relationship (OR 0.8 (0.4–1.3) for 1–2 cups/day, OR 0.4 (0.2–0.8) for 3–4 cups/day, and OR 0.3 (0.1–0.7) for ⩾5 cups/day, all compared with non-coffee drinkers). Odds ratio for HCC in those who drank >2 cups/day was lower compared with non-coffee drinkers in each of the high risk groups (heavy drinkers (OR 3.3 v 5.7), those with hepatitis B virus infection (OR 7.3 v 16.4), and those with hepatitis C virus infection (OR 9.0 v 38.2)).

These results indicate that various coffee components (caffeine, aromatic extracts of coffee beans, and coffee oil) with their antioxidant properties could have clinically beneficial effects.

Preserving bones in Crohn’s ▸

With increasing awareness of the osteopenia and osteoporosis associated with Crohn’s disease, and the corticosteroid treatment often given for it, clinicians are in need of clearer guidance on how best to prevent bone loss. This Canadian study randomly assigned 154 patients with Crohn’s disease and bone density T scores <−1.0 to receive either cyclical etidronate plus calcium and vitamin D or calcium and vitamin D alone. The trial followed dual energy absorptiometry (DXA) scans over two years of treatment and 60% completed the full two year study.

These patients recruited with osteopenia or osteoporosis comprised 64% of consecutive patients seen in their clinic with either active or quiescent Crohn’s. Twenty per cent of the trial patients had osteoporosis (T <−2.5) and the rest osteopenia. In both treatment arms bone density increased significantly at the lumbar spine, radius, and trochanter, but not at the hip. There was no advantage of using etidronate in addition to calcium and vitamin D.

This study was non-blinded, and there was no record of calcium and vitamin D intake in the diet. Eighty per cent of patients had only osteopenia, and over half were on corticosteroids. The trial clearly demonstrates that in osteopenic patients with Crohn’s, calcium and vitamin D improve bone density over a two year period, and there is no virtue in adding etidronate, even in those who have used corticosteroids at some point. The trial does not answer the question as to whether newer better absorbed bisphosphonates have a role in osteoporotic Crohn’s disease patients, or in those using long term corticosteroids.

Will CT colonography replace colonoscopy? ▸

Colonoscopy is a safe procedure but is associated with a small risk of perforation and mortality. As colorectal cancer screening is introduced, the need for colonoscopy will rise and will be offered to asymptomatic subjects. The risk/benefit ratio is altered in these individuals and a test with less risk of perforation could be preferable. Computer tomographic (CT) colonography (also referred to as CT colography or virtual colonoscopy) is an emerging technique that has been proposed for screening, although the accuracy of this test varies widely between studies. Mulhall et al report a systematic review of studies evaluating the performance of CT colonography using colonoscopy or surgery as the reference standard. They identified 33 studies involving 6393 patients. The overall sensitivity of CT colonography was 70% (95% confidence interval (CI) 53–87%). Sensitivity increased with increasing polyp size (85% for polyps >9 mm) and with more modern technology being employed (95% for the seven studies using multidetector scanners, 91% for six studies that used concomitant three dimensional imaging, and 99% for the two studies that used fly-through technology). The overall specificity of CT colonography was better at 86% (95% CI 84–88%) and was homogeneous across polyp sizes and type of scanner evaluated. CT colonography is very specific but the sensitivity is not ideal. As the technology improves, this modality could be a useful screening tool but does not, as yet, replace colonoscopy.

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