BACKGROUND AND STUDY AIMS:Non-invasive liver indices are valuable tools for identifying patients with Metabolic dysfunction-associated steatotic liver disease, given their simplicity and relatively low cost. This study examined the accuracy of several published indices, the hepatic steatosis index (HSI), Framingham steatosis index (FSI), and Dallas steatosis index (DSI), in predicting steatosis compared to the Transient elastography controlled attenuation parameter (CAP). PATIENTS AND METHODS:This is a retrospective cross-sectional study on 720 patients who underwent a FibroScan at the American University of Beirut Medical Center, between 2015 and 2020. The following indices, HSI, FSI, and DSI were calculated. The sensitivity, specificity, and C-statistics of each index were determined and compared to CAP. RESULTS:Out of 557patients who met inclusion criteria, 67 % were found to have hepatic steatosis with an average CAP 289.5 (±70.9). The mean age was 50 (±15.6), and 70 % were male. Those patients were found to have higher BMI and higher prevalence of diabetes and HTN as well as dyslipidemia than the control group with no steatosis. The FSI outperformed the other two indices with fair accuracy in detecting hepatic steatosis based on the C-statistics. HSI and DSI, on the other hand, showed poor discriminatory ability. At the cut-off, where specificity was 90 %, the FSI had the highest sensitivity, 49.6 %, compared to the DSI, 28.6 %, and HSI, 21.8 %. CONCLUSION:Our study demonstrated the non-invasive index FSI's accuracy in diagnosing steatosis compared to the transient elastography-CAP and highlighted its superiority to other indices, the HSI and DSI.

Background: We aimed to identify predictors of rebleeding in patients with overt gastrointestinal bleeding (GIB) and to develop a rebleeding index. Methods: This was a prospective study of patients admitted with GIB from 2013 to 2023 at a tertiary care center. Rebleeding was defined as the recurrence of visible bleeding after initial stabilization, endoscopic evaluation, and/or hemostatic therapy, accompanied by a change in vital signs or a hemoglobin (Hgb) decrease of ≥2 g/dL. Independent predictors were determined after adjusting for confounders. Results: Seven hundred ninety-seven patients with GIB were recruited between 2013 and 2023 and were followed up until death or January 2023. In-hospital, 1-month, 1-year, and end of follow-up rebleeding rates were: 5.3%, 8.9%, 16.2%, and 21.8%, respectively. Sources of rebleeding were different from the original sources in 36% of patients. Predictors of 1-month rebleeding included need for ≥3 packed red blood cell (PRBC) units (HR=1.86; p=0.041), endoscopic stigmata of recent hemorrhage (SRH) (HR=1.99; p=0.007), and Hgb level (HR=0.82; p=0.018; lower Hgb predicts higher rebleeding risk). A rebleeding index based on SRH, Hgb level, and ≥3 PRBC units showed modest performance (AUC=0.68), with higher scores indicating increased rebleeding risk. At the end of follow-up, SRH remained a predictor (HR=1.61; p=0.003), whereas antiplatelets on admission or discharge appeared protective against rebleeding (HR=0.66; p=0.021; HR=0.63; p=0.026). Conclusion: Predictors of rebleeding after GIB were SRH, PRBC transfusion, and lowest Hgb. The novel index based on these predictors performed favorably compared with the GBS, Rockall systems for UGUB and ABC scores. These data will help guide management and risk stratification of patients with GIB.

Immune checkpoint inhibitors (ICIs) have significantly improved outcomes across multiple malignancies but are associated with immune-related adverse events, including colitis. Although generally uncommon, ICI-induced colitis can lead to significant morbidity and treatment interruption, and data on its incidence and risk factors in the Middle East remain limited. We conducted a retrospective study of adult cancer patients treated with ICIs at a tertiary care center between December 2018 and March 2023. Clinical and treatment-related variables were collected, and univariable and multivariable logistic regression analyses were performed to identify predictors of colitis. Among 784 patients, 19 (2.4%) developed ICI-related colitis. Most cases were moderate to severe, and 57.9% required hospitalization, with a median length of stay of 7 days. All patients had advanced disease. Endoscopic evaluation, performed in 42.1% of patients, demonstrated heterogeneous disease distribution. ICI therapy was discontinued in 78.9% of patients and resumed in 36.8%. Corticosteroids were administered in 68.4% of patients, with a response rate of 92.3%; 1 patient required infliximab. One colitis-related death occurred. In univariable analysis, autoimmune disease, CTLA-4 inhibitor exposure, combination immunotherapy, and concurrent targeted therapy were significantly associated with colitis. In multivariable analysis, autoimmune disease (OR=6.10, 95% CI: 1.55-24.08; P=0.010), combination immunotherapy (OR=3.56, 95% CI: 1.09-11.63; P=0.035), and concurrent targeted therapy (OR=3.88, 95% CI: 1.31-11.54; P=0.015) remained independent predictors. ICI-induced colitis is an uncommon but clinically meaningful toxicity, and recognizing patients at higher risk may help guide closer monitoring and improve clinical management.

Clostridioides difficile infection (CDI) is a major healthcare-associated infection, but its impact after pancreatoduodenectomy (PD) for pancreatic cancer is unclear. This study assessed the incidence of CDI after PD for pancreatic cancer and evaluated preoperative factors associated with CDI, as well as the relationship between CDI and postoperative morbidity and mortality. A retrospective cohort study using the ACS-NSQIP database included patients who underwent PD for pancreatic head cancer. Patients were stratified by postoperative CDI, and univariate and multivariate logistic regression analyses identified risk factors and outcomes. Among 16,757 patients, 249 (1.5

BACKGROUND:The fecal immunochemical test (FIT) is a diagnostic modality for colorectal cancer (CRC) screening, with the US Multisociety Task Force setting an 80% adherence benchmark for follow-up colonoscopy (FUC). Guidelines recommend that FITs be performed only in the context of CRC screening. METHODS:Our study is a retrospective review of all patients with positive FIT records from 2018 to 2023. Patient characteristics, FIT ordering practices, and clinical settings were collected. The compliance rates with FUC, colonoscopy diagnostic yield, and adenoma detection were analyzed, and adherent and nonadherent patients were compared via univariate and logistic regression analyses. RESULTS:A total of 1424 patients had positive FIT results, with ages ranging between 18 and 92 years. Among the 1424 patients, 245 (17.2%) were < 45 years (group 1), 829 (52.9%) were 45-75 years (group 2), and 350 (24.6%) were > 75 years (group 3). In group 2, 241 (16.9%) tests were conducted for CRC screening. Seven hundred and three (49.3%) positive FIT tests, including tests for abdominal pain and anemia, were carried out for diagnostic purposes. Only 618 (43.3%) patients with positive FIT results underwent FUC, of whom 277 (44.8%) had adenomas and 28 (4.5%) were diagnosed with CRC. Bivariate analysis revealed that age, fewer comorbidities, prior colonoscopy, family history of CRC, diagnostic FIT, and outpatient setting increased FUC adherence. Multivariate analysis revealed that age and outpatient setting were predictive factors. CONCLUSION:Although FITs are used for CRC screening, our study found a discrepancy between guidelines and real-world practice. Compliance with FUC after a positive FIT is below the optimal range, with adherence decreasing with age.

Gastric polyps are commonly detected during upper gastrointestinal endoscopy. They are most often benign and rarely become malignant. Nevertheless, adequate knowledge, diagnostic modalities, and management strategies should be the endoscopist's readily available "weapons" to defeat the potentially malignant "enemies". This article sheds light on the valuable effort by Costa et al to generate a new classification system of gastric polyps as "good", "bad", and "ugly". This comprehensive overview provides clinicians with a simplified decision-making process.

Preoperative use of biologics has been inconsistently reported to be associated with increased frequency of infectious and surgical anastomotic complications in inflammatory bowel disease patients. We aimed to evaluate the rates of 30-day postoperative morbidity and mortality in Crohn’s disease patients exposed preoperatively to biologics. Data were collected from the NSQIP (National Surgical Quality Improvement Program). Crohn’s disease patients undergoing open or laparoscopic ileocolectomy were identified using corresponding ICD 10 and CPT Codes from the NSQIP Participant Use Data File (PUF) for 2021. Patients were divided based on the preoperative use of biologics (group 1) and (group 2) for whom no biologics were used. A total of 910 patients (female n = 473; 52

OBJECTIVE:Casting more information on the link between GERD and LPR by investigating the prevalence of laryngopharyngeal symptoms in patients with severe GERD refractory to medical treatment. DESIGN:Prospective Study METHODS: Fifty patients with typical GERD symptoms presenting for EGD were recruited. All patients filled the GERD-Health-Related Quality of Life (HRQL) questionnaire and were screened for LPR using the Reflux Symptom Score questionnaire. All patients were also evaluated for the presence of hiatal hernia, esophagitis, inlet patch, gastritis (erosive vs. non erosive), polyps, intestinal metaplasia and or Helicobacter pylori infection. Laryngeal images were taken during EGD and evaluated using the Reflux Sign Assessment (RSA). RESULTS:A total of 50 patients were recruited for this study. The prevalence of heartburn was the highest (90%). The mean score of GERD-HRQL was 30.76±15.09. The mean RSS score was 70.96±46.08. Laryngeal examination was documented in 49 patients. the most common finding was edema (34.7%) followed by redness (28.6%). The mean RSA score for the total group was 21.15±8.04. There was a strong correlation between RSS score and GERD-HQRL score. There was no significant correlation between the RSS and any of the EGD findings (P > 0.05). There was no significant correlation between RSA and GERD-HRQL scores or any of the EGD findings (P > 0.05). However, there was a significant correlation between total RSA and RSS scores (rho=0.287, P = 0.04). CONCLUSION:The suggested high prevalence of LPRD should alarm the treating physician to the need for a thorough otolaryngologic examination in patients presenting with severe GERD, particularly those in whom the LPR symptoms may be masked by the typical symptoms of GERD.

The model for end-stage liver disease (MELD) score has been shown to be a valid predictive tool for postoperative risks across various types of surgeries, after initially being restricted to liver transplantation eligibility assessment in cirrhotic patients. Since appendectomy is one of the most common surgical procedures, our objective is to compare the impact of the three versions of the MELD score (1.0, 2.0, and 3.0) on the risk assessment of 30-day postoperative morbidity and mortality in patients undergoing appendectomy for acute appendicitis. Data on patients undergoing appendectomy for acute appendicitis were collected from the ACS-NSQIP database from 2018 to 2022 using the Current Procedural Terminology (CPT) codes 44,950, 44,960, and 44,970. The different MELD scores and outcomes were compared using the Chi-square test. The outcomes measured included 30-day mortality, wound infection, cardiac, respiratory, urinary, and central nervous system complications, thromboembolism, sepsis, bleeding, return to the operating room, and composite morbidity. A total of 121,207 patients were included, with a mean age of 45.31 ± 17.89 years, of which 58,495 (48.3

Utilization of proton pump inhibitors (PPIs) in patients with overt gastrointestinal bleeding (GIB) is poorly characterized and its impact on clinical outcomes remains unclear. This study determined PPIs utilization in patients with GIB and its impact on short- and long-term mortality and rebleeding. A prospective cohort of patients admitted with GIB from January 2013 to August 2023 at a tertiary referral center was examined. Appropriate use of PPIs was based on AGA guidelines. 846 patients admitted with GIB were followed up until death or August 2023; 462 had upper GIB including 243 from acid-related lesions. Overutilization rate of PPIs was 51% upon admission and 27% upon discharge. The underutilization rate was 25% upon discharge. Compared to PPI non-users, PPI users had less endoscopic stigmata of recent hemorrhage (SRH) and decreased need for endoscopic therapy. However, they had similar 1-month and end of follow-up mortality and rebleeding. Independent predictors of 1-month and end of follow up rebleeding were SRH [OR 2.03 (1.16-3.54), and 1.78 (1.21-2.64)], and severe bleeding. Being admitted on anticoagulants was predictive of 1-month rebleeding [OR 2.3 (1.2, 4.4)], while being discharged on antiplatelets was protective against long term rebleeding [OR 0.45 (0.28-0.72)]. Blood transfusion and Charlson Comorbidity Index were predictors of 1-month and long-term mortality. Being discharged on anticoagulants predicted long-term mortality [OR 2.51(1.45-4.36)]. There is significant over- and underutilization of PPIs in patients with GIB without a significant effect on outcomes. PPI stewardship would likely reduce healthcare costs and minimize side effects.

Abstract Background Preoperative use of biologics has been inconsistently reported to be associated with increased frequency of infectious and surgical anastomotic complications in inflammatory bowel disease patients. We aimed to evaluate the rates of 30-day post operative morbidity and mortality in Crohn’s disease patients exposed preoperatively to biologics. Methods Data was collected from the NSQIP (National Surgical Quality Improvement Program) which is a nationally validated, risk adjusted program designed to measure and improve the quality of surgical care. Crohn’s disease patients undergoing open or laparoscopic ileocolectomy were identified using corresponding ICD 10 and CPT Codes from NSQIP PUF (Participant Use Data File) for the year 2021.Patients were divided based on the preoperative use of biologics (group 1) and (group 2) for whom no biologics were used. Univariate analysis was done on SPSS via Chi-squared and Fisher exact test for categorical variables, while independent sample T-test was used for continuous variables. Composite morbidity was defined as the association of any two morbidity events in the database. A multivariate regression analysis was done to predict post operative morbidity while controlling for the following variables: age, BMI, smoking, steroid use, diabetes, hypertension, sepsis, ASA classification, and preoperative transfusion. Results A total of 910 patients (female n=473; 52%, mean age of 42.3 ± 16.1) were included. The group1 patients were significantly younger (40.30 years ±15.33) than group 2 (43.58 years ±16.8 p=0.002) and had significantly slightly higher ASA III and IV scores (97.4% vs 97.2%, p=0.004). On the other hand, group 2 had a significantly higher prevalence of hypertension (20.2% vs 12.8%, p=0.003) and chronic obstructive pulmonary disease (2.6% vs 0, p=0.001). No significant difference in remaining preoperative variables, surgical approach (laparoscopic vs open) and comorbidities were found between the two groups. On univariate analysis of morbidity, only a significant prevalence of deep vein thrombosis and thromboembolism was found in patients exposed to biologics (1.1% vs 0 p=0.027). No significant difference was found in surgical site infections, sepsis, infectious complications, anastomotic failure, composite morbidity, or mortality. On multivariate analysis, no significant morbidity was noted between the two groups. Conclusion Crohn’s disease patients undergoing ileocolectomy and exposed preoperatively to biologics did not show a significant increase in 30-day postoperative morbidity and mortality.

BACKGROUND:Our aim was to describe the clinical outcomes of surgical interventions performed for the management of colonoscopy-related perforations and to compare these outcomes with those of matched colorectal surgeries performed in elective and emergency settings.METHODS:We included patients with endoscopic colonic perforation who underwent surgical intervention from the 2014-2017 National Surgery Quality Improvement Program participant use data colorectal targeted procedure file. The primary outcome in this study was short term surgical morbidity and mortality. Patients (group 1) were matched with 1:2 ratio to control patients undergoing same surgical interventions for other indications on an elective (group 2) or emergency basis (group 3). Bivariate analysis was conducted to compare categorical variables between the three groups, and multivariate logistic regression was used to evaluate the association between the surgical indication and 30-day postoperative outcomes.RESULTS:A total of 590 patients were included. The average age of the patients was 66.5±13.6 with female gender predominance (381, 64.6%) The majority of patients underwent open colectomy (365, 61.9%) while the rest had suturing (140, 23.7%) and laparoscopic colectomy (85, 14.4%). Overall mortality occurred in 4.1% and no statistically significant difference in mortality was found between the three techniques (P=0.468). Composite morbidity occurred in 163 patients (27.6%). It was significantly lower in laparoscopic colectomy (14.1%) compared to 30.2% and 29.4% in open colectomy and suturing approaches (P=0.014). Patients undergoing colectomy for iatrogenic colonic perforation had less mortality, infection rates and sepsis, as well as bleeding episodes compared to those who had colectomy on an emergent basis. Outcomes were comparable between the former group and patients undergoing elective colectomy for other indications.CONCLUSIONS:Surgical management of colonoscopy related perforations is safe and effective with outcomes that are similar to that of patients undergoing elective colectomy.