HCV & Diabetes Mellitus lecture about link.pptx

theoretical review

1. NAFLD , Chronic HCV and DM Multisystem systemic diseases with hepatic flavor

2. Non-alcoholic fatty liver disease, hepatitis C virus infection and type 2 diabetes: the “ vicious circle”. The liver plays a pathogenic role in the development of type 2 diabetes both in the context of non-alcoholic fatty liver disease and hepatitis C virus infection through the development of systemic and hepatic insulin resistance, partly mediated by the release of multiple pro-inflammatory cytokines, diabetogenic hepatokines and reactive oxygen species. If left uncorrected, insulin resistance will eventually lead to progressive pancreatic beta cell failure in predisposed individuals. Moreover, the strong interconnection between type 2 diabetes and liver disease may result into a “vicious circle” [25] eventually leading to liver disease progression with an excess risk of liver-related, i.e., cirrhosis and hepatocellular carcinoma (HCC), and cardiovascular complications, i.e., atheroscler

3. Review Type 2 Diabetes in Non-Alcoholic Fatty Liver Disease and Hepatitis C Virus Infection—Liver: The “Musketeer” in the Spotlight Stefano Ballestri 1, Fabio Nascimbeni 2,3, Dante Romagnoli 2, Enrica Baldelli 3, Giovanni Targher 4 and Amedeo Lonardo 2,* Received : 16 February 2016; Accepted: 2 March 2016; Published: 9 March 2016

4. Nutritional Management for GORD Dr Abdel Rahman A Mokhtar Professor Internist & Gastroenterolgist Mansoura University EGYPT 2016

5. Our understanding of the pathogenesis, clinical spectrum and epidemiology of GORD has continuously evolved. Historicaly

6. At first, reflux was synonymous with oesophagitis and hiatus hernia. Then , it was a motility disorder, defined by sphincter or peristaltic dysfunction. Next, it was an acid-peptic disorder. Now, we see GORD emerging as a heterogeneous entity encompassing elements of all these concepts

7. These developments prompted the formation of an international consensus conference , resulting in the ‘Montreal definition’ of GORD.

8. Cowen, S. G. Therapeutic Categories Outlook (SG Cowen,2005)

9. While typical GERD symptoms are balanced between comparator groups, the distribution of complications becomes progressively skewed in gender, geographic and racial distribution. *GORD symptoms are similar between Western and Middle Eastern countries, but are lower in Eastern countries. Epidemiological trends in GORD-related disorders.

10. PATHOPHYSIOLOGY The earlier belief that increased gastro esophageal reflux mainly results from one dominant mechanism has been replaced by acceptance that GORD is multifactorial

11. | Possible gastroesophageal reflux disease pathophysiologies

12. AT Cellular level : Exposure of the oesophageal wall to the refluxate results in :

13. a | An inflammatory response occurs in the squamous epithelium, induced by the release of inflammatory mediators, which

14. b | Leads to the subsequent chemoattraction and infiltration of immune cells and is

15. c | Followed by the proliferative response of the epithelium..

16. Kandulski , A. & Malfertheiner , P. Nat. Rev. Gastroenterol . Hepatol . 9, 15–22 (2012);

17. So , it is not that simple

18. THREE ROLES

19. OBESITY

20. Gastroesophageal Pressure Gradients & GERD: The Importance of Obesity From de Vries DR et al. Am J Gastroenterol 2008;103:1349-54.

21. Optimizing body weight is a must

22. GUT MICROBIOTA

23. The intestinal microbiota lies strategically at the interface of the internal and external environment of the gut. It plays several important biological roles including: aiding in digestion and absorption of nutrients from partially digested food, production of SCFA – a primary energy source for intestinal epithelial cells (IECs), stimulating immune responses by releasing ligands , and protection against enteropathogens by production of antimicrobial peptides (AMPs)

24. Factors affecting gut microbiota

25. Is dysbiosis of the upper-GI tract to blame for esophageal gastroesophageal reflux disease (GERD) and it’s related conditions, Barrett’s esophagus and adenocarcinoma?

26. Undoubtedly, we need to eradicate virulent  H. pylori  in people with adverse clinical manifestations, but this conclusion cannot be generalized to all  H. pylori  positive subjects.

27. For the past four years we’ve known that  individuals with GERD have imbalances in the microbial ecology of the distal esophagus . One consequence of this microbial shift is  increased levels of Gram-negative bacteria, which harbor on their cell surface an inflammatory membrane component known as lipopolysaccharides (LPS) or endotoxin

28. Clinical and Translational Gastroenterology (2015) 6, e91; doi:10.1038/ctg.2015.16; published online 18 June 2015 Type1-microbiota (Gram-positive predominant) with H. pylori provides a neutral esophageal environment. Type-II microbiota (Gram-negative predominant) with loss of H. pylori invokes a pro-inflammatory state in two ways. First, loss of H. pylori allow for increased acid secretion resulting in gastroesophageal reflux disease and its sequelae . Second, predominance of Gram-negative bacteria upregulate the pro-inflammatory cascade due to the interaction between lipopolysaccharide and Toll-like receptor 4. Gut microbiota & esophageal adenocarcinoma .

29. Microbiota and its influence on obesity.

30. Probiotics , Prebiotics and Symbiotics Probiotics are defined as live microorganisms which confer health benefits to the host when taken in adequate quantities. Prebiotics are nondigestible food ingredients that beneficially affect the host by selectively stimulating the growth and/or activity of beneficial colonic bacteria. Acombination of probiotics and prebiotics is termed symbiotics . Various kinds of probiotics have been tested clinically as potential therapeutic agents for both localized and systemic diseases.

31. Should dietary guidelines consider microbiota needs ???

32. Potential therapeutic window

33. STOP Firing foods

34. It is a common belief that some foods may induce or worsen GERD symptoms; in fact, in daily clinical practice, this belief leads to advising patients to avoid the suspect foods . Further more, since GERD symptoms are most commonly reported postprandially , the role of diet components in inducing symptoms has been suggested. However, different and conflicting results exist in the literature for identifying the most “ refluxogenic ” foods Festi etal.,World J Gastroenterol April 14, 2009

35. Dietary elements may ppt reflux episode via : Increasing acid secretion e.g Coffee. Decrease LOS pressure e.g peppermint & ess oils. Slow gastric emptying e.g fatty food . Impairing oesophageal motility e.g alcohol. Triggering pain by irritating an already inflammed oesophageal mucosa e.g Tomato , citrus , soft drinks and spicy food.

36. Foods Not Recommended It is recommended that a trial of limiting or eliminating the following foods may reduce the symptoms of GERD: • Peppermint and spearmint • Chocolate • Alcohol • Caffeinated beverages (regular tea, coffee, colas, energy drinks, other caffeinated soft drinks) • Decaffeinated coffee and decaffeinated regular tea (herbal teas, except those with peppermint or spearmint, are allowed) • Pepper • High-fat foods, including: o 2% milk, whole milk, cream, high-fat cheeses, high-fat yogurt, chocolate milk, cocoa o Fried meats, bacon, sausage, pepperoni, salami, bologna, frankfurters/hot dogs o Other fried foods (doughnuts, french toast, french fries, deep-fried vegetables) o Nuts and nut butters o Pastries and other high-fat desserts o More than 8 teaspoons of oil, butter, shortening per day • Any fruits or vegetables that cause symptoms. (These will vary from person to person.) American Dietetic Association.

37. Other Lifestyle Tips • Exercise at least three or four times each week. • Wear loose-fitting clothes. • Do not smoke. • Raise the head of your bed 6 to 9 inches. You can put a foam wedge under the top part of the mattress, or prop up the legs on the head of the bed with wooden blocks. (Stacking pillows is not effective.) • Wait 3 hours after eating before lying down. • Eat several small meals throughout the day. • Eat in a calm, relaxed place. Sit down while you eat.

38. To Conclude

39. Weight control Healthy microbiota Avoid diets ppt reflux episodes

40. Thank You