The Doctor's Channel - Gastroenterology

Endoscopic resection for Barrett's esophagus usually avoids surgery

2010-03-11T22:47:25+00:00

NEW YORK (Reuters Health) - In patients with Barrett's high-grade dysplasia or early esophageal adenocarcinoma, endoscopic resection improves staging and "dramatically" reduces esophagectomy rates, Australian physicians report.

Esophagectomy, the standard of care, produces high morbidity, and mortality from the procedure ranges from 4% to 20%, according to the researchers. Moreover, the surgery is often done on the basis of biopsy results alone, but biopsy staging is not very accurate.

For these reasons, endoscopic resection is becoming more popular for staging and management, Dr. Michael J. Bourke, from Westmead Hospital in Sydney, and his colleagues say in their article, published online on February 23rd by the American Journal of Gastroenterology.

The researchers studied 75 consecutive patients (ages 45 to 87) who underwent endoscopic resection for biopsy-proven Barrett's high-grade dysplasia or esophageal adenocarcinoma. The mean follow-up was 31 months.

Barrett's mucosa ranged in length from 1 to 16 cm, with a mean of 3.6 cm. In 35 otherwise healthy patients younger than 75, with Barrett's segments no longer than 3 cm, the authors attempted complete excision by 2- to 3-stage radical mucosectomy - which was successful in 33 cases (94%). One patient required esophagectomy; in another, comorbidities interfered.

Among the remaining 40 patients, 8 developed metachronous lesions. Another 5 had esophagectomy because resection revealed submucosal invasion, but there was no recurrence at endoscopic resection sites. Four patients (ages 81 to 92 years) died, but none of the deaths was due to adenocarcinoma.

The authors staged the resections over at least two sessions six weeks apart to minimize the risk of strictures. The number of sessions ranged from one to five per patient, with a median of two resections at the index procedure.

Overall, histologic findings led to changes in grade or stage in nearly half of patients, with lesions downgraded/staged in 21 patients and upgraded/staged in 15. Diagnoses "included the full spectrum of pathology," the authors report, ranging from no dysplasia to submucosal invasive adenocarcinoma. Seventeen patients had only low-grade dysplasia or none at all.

"Nearly one in four patients would have undergone unnecessary esophagectomy if surgery based on biopsy alone was the first-line therapy" in their series, the authors point out.

Unlike biopsy, endoscopic resection also adds data on breadth, depth, and areas of more advanced pathology. Furthermore, because mucosal lesions have a very low rate of nodal involvement, endoscopic resection is likely to be curative, the investigators note.

The absence of serious procedure-related complications in this series "further enhances" the potential utility of endoscopic resection "as a low-risk definitive dysplasia grading and local T-staging tool," Dr. Bourke and associates write.

In conclusion, they say, "We believe it is no longer acceptable to refer patients with early disease for esophagectomy without including endoscopic resection in the preoperative staging strategy."

Reference:
Am J Gastroenterol 2010.

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Chromocolonoscopy not helpful for routine colon cancer screening

2010-03-02T16:00:45+00:00

NEW YORK (Reuters Health) - Although high-definition chromocolonoscopy may detect some adenomas missed with standard high-definition colonoscopy, it should not be used for routine colon cancer screening in average-risk patients, new research suggests.

The newer technology slightly improved detection of flat and small adenomas, but it was similar to standard high-definition white light colonoscopy for detecting advanced neoplasms, according to the February 23rd online report in The American Journal of Gastroenterology.

The improved detection rates reported with high-definition chromocolonoscopy have come from studies in patients at increased risk for colorectal neoplasms, lead author Dr. Charles J. Kahi, from Indiana University School of Medicine, Indianapolis, and associates note. Whether this modality offers any benefit in average-risk patients, however, is unclear.

To investigate, the researchers randomized 660 average-risk patients to undergo either high-definition chromocolonoscopy or white-light colonoscopy at four centers in the US.

Nearly 55% of patients evaluated with chromocolonoscopy had at least one adenoma compared with 48.4% assessed with white light colonoscopy. The number of adenomas per patient was also slightly higher in the chromocolonoscopy group: 1.3 vs. 1.1. Neither of these differences was statistically significant.

Both methods were comparable in detection of advanced neoplasms. One invasive malignancy was detected in each group, neither of which was a flat adenoma.

Chromocolonoscopy detected significantly more small (<5 mm) adenomas per patient (0.8 vs. 0.7) and more flat adenomas (0.6 vs. 0.4) than did white light colonoscopy, but the absolute difference was small.

"Given the small magnitude and uncertain clinical significance of the differences, our findings do not support the routine performance of high-definition chromocolonoscopy for colorectal cancer screening in average-risk patients," the authors conclude.

Reference:
Am J Gastroenterol 2010.

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Avoid diphenhydramine, ranitidine after perforated appendicitis: study

2010-02-19T18:52:45+00:00

NEW YORK (Reuters Health) – Giving the antihistamines ranitidine or diphenhydramine to patients with perforated appendicitis dramatically increases their risk of an intra-abdominal abscess, according to a new study.

Giving one or the other agent doubled the risk, while giving both drugs increased the risk four-fold.

“Anybody not having an indication for these meds probably shouldn’t get them,” lead researcher Dr. Shawn D. St. Peter told Reuters Health by phone.

He and his coauthors note that clinicians often treat the pain of perforated appendicitis with ketorolac tromethamine, which can lead to gastritis, or narcotics, which can cause itching. Ranitidine, a histamine-2 (HR) receptor blocker that suppresses gastric acid, and diphenhydramine, an H1 receptor blocker than stops itching and induces sleep, are prescribed, often prophylactically, to counter these side effects.

In the February Archives of Surgery, Dr. St. Peter and his colleagues at Children’s Mercy Hospital in Kansas City, Missouri explain that during a prospective trial of two antibiotic regimens for perforated appendicitis, they saw that patients on ranitidine seemed to have a higher rate of intra-abdominal abscess.

The trial included 98 children (mean age, 8.6 years). The 41 children who didn’t receive either ranitidine or diphenhydramine had an abscess rate of 10%. In contrast, the researchers found abscess rates of 17% in the 24 children who received ranitidine only, 18% in the 17 who received diphenhydramine only, and 44% in the 16 children who took both medications.

On multivariate analysis, the abscess rate was significantly higher with ranitidine (p = 0.05) and diphenhydramine (p = 0.03). Ranitidine also had a significant dose-related effect on abscess rate (p = 0.003).

By contrast, there was no link between abscess rates and use of ketorolac, naloxone, ondansetron or narcotics.

“The effect of blocking (histamine) receptors is diffusely integral to the inflammatory response,” the authors write. They explain that both H1 and H2 receptors are expressed in neutrophils, eosinophils, monocytes, dendritic cells, and T and B cells.

Concluding, Dr. St. Peter said, “I don’t want to say that these drugs are detrimental, but I can absolutely unequivocally say they don’t help… and shouldn’t be given unless there is a clear indication.”

Reference:
Arch Surg 2010;145:143-146.

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Probiotic formula prevents diarrhea

2010-02-19T18:49:59+00:00

NEW YORK (Reuters Health) - A commercially available formula of Lactobacillus acidophilus and L. casei prevents Clostridium difficile infection and diarrhea during antibiotic treatment, according to a single-center study from China.

Although meta-analyses indicate that probiotics decrease antibiotic-associated diarrhea, most trials are flawed, senior author Dr. Larry E. Miller and colleagues state. They say that their randomized, double-blind trial is the largest to address these issues and the first to examine dose effects.

The trial included 255 hospital patients, ages 50 to 70, receiving penicillin, cephalosporin or clindamycin. Within 36 hours of starting antibiotic therapy, patients began to take (each day, 2 hours after breakfast) either 2 probiotic capsules (n = 86), 1 probiotic capsule and 1 placebo capsule (n = 85), or 2 placebo capsules (n = 84). All patients were hospitalized for at least 5 days and received antibiotics for at least 3 days (but not more than 14 days). They continued with their assigned treatment for 5 days after finishing the course of antibiotics.

Each probiotic capsule contained 50 billion colony-forming units of L acidophilus CL1285 and L. casei.

As reported online February 9 in the American Journal of Gastroenterology, at 21 days after the end of their assigned treatments, the incidence of antibiotic-associated diarrhea was 44.1% in the placebo group, 28.2% in the 1-capsule group and 15.5% in the 2-capsule group.

Rates of diarrhea due to C. difficile were 23.8%, 9.4%, and 1.2% with placebo, 1 capsule, and 2 capsules, respectively.

The authors estimate that treating five patients at the higher probiotic dose would prevent one case of C. difficile-associated diarrhea.

Overall, the 2-capsule group had the lowest rate of gastrointestinal symptoms, followed by the 1-capsule group. The investigators observed a similar pattern for symptom duration.

They attribute their high response rates to the high probiotic dosage: “The probiotic load of this quantity likely overwhelms the intestinal tract and repopulates the gut with nonpathogenic flora, as well as enhances immune response to inhibit or destroy pathogenic bacteria.”

The researchers note that their findings cannot be generalized to other probiotic products or to younger patients or those of non-Asian descent, and that the effects of probiotic therapy with prolonged antibiotic treatment are unknown.

On the other hand, “this trial used very stringent data collection and data analysis methods…and an intent-to-treat analysis.”

The probiotic capsules used in this study are manufactured by Bio-K+ International (Laval, Quebec, Canada) and marketed as Bio-K+ CL1285. Bio-K+ provided financial support for the trial.

Reference:
Am J Gastroenterol 2010.

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Is laparoscopy feasible for early gallbladder cancer?

2010-02-18T20:17:50+00:00

NEW YORK (Reuters Health) – In selected patients with suspected early-stage gallbladder carcinoma, laparoscopy is a safe approach, Korean physicians report in the February Archives of Surgery.

“Although laparoscopic surgery is widely applied in a variety of malignant diseases, such as colon cancer, gastric cancer, and hepatoma, its application to gallbladder malignancy was not tried before, so it is considered ‘taboo,’” lead author Dr. Ho-Seong Han from Seoul National University Bundang Hospital told Reuters Health by email.

As long as oncologic principles are observed, however, “including radical resection of tumor and adequate lymph node dissection, there is no reason” that laparoscopy can’t be used for gallbladder cancer, Dr. Han added.

If the gallbladder disease turns out to be benign, patients will have been spared unnecessary open surgery, according to Dr. Han and colleagues. Even with malignant disease, they note, lymphadenectomy can be done laparoscopically, for a less invasive procedure.

In the same issue of the journal, however, Dr. Jeffrey B. Matthews from the University of Chicago argues in an invited critique that this approach is too risky. Dr. Matthews would rather see all patients with malignant disease undergo conversion to open operation. He worries that laparoscopic surgery increases the risk of “rendering a potentially curative situation incurable through operative error or inadequate tumor clearance.”

For their prospective study, Dr. Han and colleagues considered 36 patients with suspected gallbladder carcinoma at stage T2 or less, without evidence of liver invasion on computed tomography. Three patients had liver involvement revealed by endoscopic ultrasound, which ruled out laparoscopy. Another 3 had hepatic involvement on ultrasonography at the start of laparoscopy, so their surgeries were converted to open procedures.

In the remaining 30 patients, the course of surgery was based on results of intraoperative frozen biopsy. Twelve patients whose frozen sections suggested benign disease had laparoscopic cholecystectomy only. Pathology reports later showed that 2 patients had T1a carcinoma, for which cholecystectomy is considered definitive treatment.

For the 18 patients with malignant disease, the authors write, “The gallbladder, including about 2 mm of the thin liver tissue adhered to the gallbladder, was carefully resected so as not to spill the potentially malignant bile and not to expose the subserosal layer of the gallbladder…. Once the specimen had been completely detached, it was inserted into a protective bag and extracted through the umbilical port site.” This procedure was followed by locoregional laparoscopic lymphadenectomy.

There were no bile spills due to gallbladder perforation, the authors report. Median operative time for carcinoma cases was 190 minutes, and median blood loss was 50 mL. Tumors ranged from 1.4 to 7.5 cm. None of the patients required repeat resection, although 10 had stage pT2 carcinoma. Median postoperative stay was 4 days.

At a median follow-up of 27 months, all 18 cancer patients were alive without recurrence or port site metastasis.

“We are still accumulating cases at about 5 or 10 a year, therefore, totaling more than 50 cases,” Dr. Han told Reuters Health. “Among the patients who underwent this operation, all the patients survived until now, with only one recurrent case. When compared with open surgery, our survival result is good, considering the prognosis of T2 gallbladder cancer is poor.”

Two patients had complications during lymphadenectomy: a hemorrhage from a torn branch of the main portal vein, which required conversion to laparotomy, and a bile duct injury that was repaired laparoscopically.

Three postoperative complications – symptomatic fluid collection at the gallbladder fossa, transient blood drainage from an indwelling drain, and voiding difficulty – were successfully handled without radiologic intervention or reoperation.

In his comments to Reuters Health, Dr. Han pointed out that the ideal candidate for laparoscopic surgery is someone suspected of having early gallbladder cancer (stage T2 or lower). However, “if tumor has invaded the liver or the gallbladder serosa, open radical cholecystectomy should be considered, although laparoscopic liver wedge resection or S4b & S5 resection can be performed in the future.”

In response to Dr. Matthews’ critique, Dr. Han said, “He is right that we should be prudent when we start the new procedure. However, many new scientific developments have to get through due and sincere critics. Laparoscopic radical cholecystectomy using our technique is exactly the same as open surgery except that it is a minimal approach. The oncologic principle should be the same whether it is open or laparoscopic surgery.”

The article recommends that in the event of a positive margin of the gallbladder or cystic duct, or for surgeons lacking expertise in advanced laparoscopic dissection, laparoscopy should be converted to an open procedure for further resection and lymphadenectomy.

Also, the authors emphasize, if carcinoma is suspected prior to surgery, “one should pay as close attention as possible to not perforate the gallbladder and must use a protective bag during the extraction.”

Dr. Han and colleagues conclude that laparoscopic resection with lymphadenectomy is technically feasible and “the interim outcome is acceptable for highly selected patients who have early-stage gallbladder carcinoma without liver invasion.” They acknowledge, however, that long-term follow-up and randomized trials are needed to confirm their results.

Reference:
Arch Surg 2010;145:128-133.

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H. pylori eradication in peptic ulcer disease may up risk of GERD

2010-02-09T18:45:06+00:00

NEW YORK (Reuters Health) - In patients with peptic ulcers, eradication of Helicobacter pylori seemed to double the risk of new-onset reflux - but only in cohort study subgroups, and not in randomized trials, according to a new meta-analysis.

In the January 19 advance online issue of the American Journal of Gastroenterology, the Canadian authors of the report observe that over the past few decades, hospitalization rates for duodenal and gastric ulcer and gastric carcinoma have fallen, whereas rates have risen for gastroesophageal reflux disease (GERD), Barrett's esophagus, and esophageal adenocarcinoma. This pattern has led some to conjecture that H. pylori eradication may be responsible for both trends.

The research team, led by Dr. Richard H. Hunt from McMaster University in Hamilton, Ontario, conducted a comprehensive search of literature published from 1983 through 2007. Their meta-analyses included 7 randomized controlled trials (RCTs) and 5 cohort studies involving more than 4000 patients.

All had H. pylori infection and no evidence of GERD at the time of treatment. At 1 to 3 months after treatment, patients were tested for H. pylori resolution, and all were followed for 6 to 24 months for development of GERD. GERD was defined as heartburn more than once a week or endoscopic erosion in the distal esophagus.

Overall, there was no association of H. pylori eradication with GERD. In the 11 studies that confirmed erosive GERD with endoscopy (6 RCTs, 5 cohort studies, n = 4058), the OR was 1.17 (p = 0.17).

With pooled data from just the 6 RCTs, rates of erosive GERD were 6.9% after eradication and 4.9% with ongoing infection (OR, 1.11, p = 0.52).

Furthermore, in 5 RCTs (n = 760) that reported on development of symptomatic GERD, the rates were 39.6% in patients with H. pylori eradication and 36.9% in those with persistent infection (OR, 1.22, p = 0.22).

The 5 cohort studies included 1895 subjects. Rates of post-eradication GERD were 7.3% and 6.1% in the cured group and persistent-infection group, respectively (OR 1.37, p = 0.15).

The only signal that H. pylori eradication might increase the risk of new-onset GERD was in the subset of patients with peptic ulcer disease in four of the cohort studies. In this population, H. pylori eradication was associated with double the risk of erosive GERD (OR 2.04, p = 0.03).

Otherwise, there was no significant link between cure rates and GERD. Also, the researchers said, results did not differ when they compared "high quality" with "low quality" trials, or those with longer versus shorter follow-up periods.

They note that treatment regimens varied across trials. However, in RCTs, the control groups only received proton pump inhibitors.

"This could rule out the possibility of medication used for H. pylori eradication as a possible confounding factor for the development of GERD," Dr. Hunt's group suggests.

The investigators do not advise waiving anti-H. pylori therapy in patients with peptic ulcer disease for the sake of preventing GERD. Instead, patient instruction regarding GERD symptoms and long-term risk may be warranted.

Reference:
Am J Gastroenterol 2010.

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Long-term antibiotic treatment effective for Crohn's disease

2010-02-08T20:01:56+00:00

NEW YORK (Reuters Health) - Long-term treatment with clofazimine or nitroimidazoles may help control Crohn's disease, according to the authors of a systematic review and meta-analysis.

Several bacteria have been implicated in Crohn's disease, but antibiotics are currently recommended only for certain complications, such as sepsis or perianal disease, the researchers note in the February 15th issue of Clinical Infectious Diseases.

The meta-analysis, by Dr. Martin Feller from the University of Bern, Switzerland, and colleagues, pooled data from 16 randomized, placebo-controlled trials involving a total of 865 patients, in order to assess the effectiveness of long-term antibiotic treatment for Crohn's disease. The outcomes were remission (in patients with active disease) or relapse (in patients with inactive disease).

The studies examined 13 different treatment regimens, ranging from single drugs to combinations of up to 4 drugs. The median treatment duration was 6 months. Four studies specifically excluded the use of steroids; the others either included them or allowed them to be added when indicated.

The quality of reporting of study methods was generally low, the authors report.

Three trials of nitroimidazoles (206 patients) showed a significant benefit (odds ratio, 3.54), the researchers note, as did 4 trials of clofazimine (322 patients; OR, 2.86).

The number of patients with active disease needed to treat to keep 1 additional patient in remission was 3.4 for nitroimidazoles and 4.2 for clofazimine. For inactive disease, the number needed to treat was 6.1 for nitroimidazoles and 6.9 for clofazimine.

One trial of ciprofloxacin, involving 47 patients, showed a benefit (OR, 11.3), but with a wide confidence interval.

Three trials involving 107 patients showed no benefit from treatment with classic anti-tuberculosis drugs.

The 4 studies of clarithromycin alone or in combination with other antibiotics (287 patients) were highly heterogeneous and could not be combined in the meta-analysis, according to the report.

"We believe that further research is justified to better define the role of antibacterial agents and combination regimens in Crohn's disease," the investigators say. "Future studies should focus on clofazimine, alone or in combination with a macrolide and a rifamycin, as well as in combination with a nitroimidazole, and perhaps ciprofloxacin."

Reference:
Clin Infect Dis 2010;50:473-480.

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Radiofrequency ablation safely combined with surgery for Barrett's esophagus

2010-02-03T18:59:39+00:00

NEW YORK (Reuters Health) - In patients with Barrett's esophagus, radiofrequency ablation (RFA) before or after anti-reflux surgery can reduce metaplasia and dysplasia, but whether the multi-treatment approach improves long-term outcomes remains unclear, researchers say.

"In theory, combining an antireflux procedure with mucosal ablation of Barrett's changes should provide superior control of Barrett's changes by eliminating or decreasing the high-risk metaplastic or dysplastic mucosa and decreasing further acid injury to the esophagus," notes senior author Dr. Hiran C. Fernando, from Boston Medical Center, and his coauthors.

In an online paper January 14 in the Journal of Thoracic and Cardiovascular Surgery, Dr. Fernando's team reports its initial experience in combining RFA and surgery in 14 patients with Barrett's metaplasia (n = 11) or low-grade dysplasia (n = 3). The median patient age was 60 years.

RFA sessions were performed, as needed, 6 weeks before surgery. At 3 months postoperatively, RFA was repeated if necessary. On average, 2.6 ablation procedures were performed per patient, the authors note.

No patients died, but two complications -- pneumonia and atrial fibrillation -- occurred after the anti-reflux procedure. One patient had mild dysphagia that necessitated a single dilation 2 months after ablation.

The average length of Barrett's esophagus fell from 6.2 cm to 1.2 cm after treatment (p = 0.001) and Barrett's grade also dropped significantly. Also, the number of patients with circumferential disease fell from 13 to 1 after treatment.

As the number of RFA sessions increased, so did the likelihood of treatment success. Moreover, all patients who received three or more treatments had full resolution of Barrett's metaplasia.

However, the median follow-up interval was only 17 months.

"Although we have demonstrated that this combined approach can be undertaken safely, the small number of patients and short follow-up cannot address the question of long-term success," the researchers conclude.

"Further evaluation with larger controlled trials will be necessary to better define the success and durability of this approach for preventing progression to esophageal cancer," they add.

Reference:
J Thorac Cardiovasc Surg 2010.

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Best ablative therapy for small liver tumors still unclear

2010-02-03T18:33:03+00:00

NEW YORK (Reuters Health) - For hepatocellular carcinomas (HCC) larger than 2 cm, radiofrequency ablation (RFA) is the best ablative therapy, a meta-analysis shows - but for smaller tumors, it's not clear whether RFA is best or whether cheaper, less invasive treatments work just as well.

"The data confirm better results for RFA compared to the other techniques, but what is new is that the data are not conclusive for hepatocellular carcinomas up to 2 cm," senior author Dr. Andrew Kenneth Burroughs, from Royal Free Hospital, London, told Reuters Health by email.

"Given that both alcohol and acetic acid are far, far cheaper, this is an area that needs a prospective randomized trial as we have suggested. Developing countries do not have wide availability of RFA so if a cheaper alternative is as effective for a subgroup this is helpful."

For the analysis, reported online January 18th in the Journal of Hepatology, Dr. Burroughs and his colleagues searched MEDLINE and other sources for randomized trials comparing survival, recurrence, tumor necrosis, and complications with RFA, percutaneous ethanol injection, and percutaneous acetic acid injection.

All told, they found 8 studies that involved 1035 patients in nine comparisons. Five studies compared RFA vs. ethanol injection, 2 compared ethanol vs. acetic acid injection, and 1 compared all three.

Compared with ethanol injection, RFA provided better survival (OR, 0.52, p = 0.001), complete tumor necrosis, and local recurrence. On further analysis, however, RFA provided no significant advantage with tumors of 2 cm or less.

Acetic acid injection was comparable to ethanol injection regarding survival and local recurrence, but required fewer treatment sessions.

In the direct and indirect comparisons, acetic acid injection provided similar outcomes to RFA with the exception of a higher local recurrence rate.

Along with trials in patients with smaller lesions, more studies are needed directly comparing all three treatment modalities, the authors note. In addition, RFA should be compared with transarterial embolization, which is currently considered standard therapy, they add.

Reference:
J Hepatol 2010.

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L-carnitine improves liver function in fatty liver disease

2010-02-02T21:42:00+00:00

NEW YORK (Reuters Health) - L-carnitine supplements can improve liver function, liver histology and other manifestations of nonalcoholic steatohepatitis (NASH), Italian researchers say.

"L-carnitine supplementation induces regression of NASH even if both plasma and hepatic carnitine levels have been shown to be normal," the investigators report in the January 21 online issue of the American Journal of Gastroenterology.

Overall, 35 of the 36 patients (97%) in the intervention group had a histological response, and the NASH activity score - a 12-point scale assessing steatosis, parenchymal inflammation, and hepatocellular injury - fell by at least 2 points in every patient, according to lead author Dr. Mariano Malaguarnera and associates at the University of Catania.

In their double-blind study, Dr. Malaguarnera and colleagues randomized 74 patients with NASH to either L-carnitine (a 1 g tablet after breakfast and another after dinner) or placebo for 24 weeks. All patients were put on a 1600-calorie/day diet that met requirements of the National Cholesterol Education Program, as well as a whole-body stretching routine performed 3 times a week.

At the end of the study, the NASH activity score improved significantly more in the L- carnitine group (mean decrease 6.23 vs 3.63, p < 0.001). On a scale of 1 to 4, fibrosis also improved significantly more in the L-carnitine group (mean change 1.31 vs 0.85, p < 0.05).

In addition, the L-carnitine group had significantly greater decreases in liver enzymes (aspartate aminotransferase, alanine aminotransferase, and gamma-glutamyl-transpeptidase, P < 0.01 for each). Similarly, L-carnitine was associated with greater reductions in total cholesterol and LDL cholesterol (p = 0.000 for both).

Only the L-carnitine group had a significant reduction in mean plasma glucose, and the change in insulin resistance also favored L-carnitine treatment (p = 0.000).

Finally, levels of C-reactive protein and tumor necrosis factor-alpha declined significantly more in the carnitine group (p < 0.005).

L-carnitine was well tolerated, according to the report.

The authors note that before their study, they had theorized that L-carnitine would benefit NASH patients through its interference with oxidation, inflammation and accumulation of the lipotoxic metabolites that cause mitochondrial dysfunction and insulin resistance.

Now, they conclude, "L-carnitine treatment and lifestyle changes, including weight loss and exercise, can represent therapeutic options in NASH."

Reference:
Am J Gastroenterol 2010.

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