GE Portuguese Journal of Gastroenterology最新文献

Introduction: Inflammatory bowel disease (IBD) care demands a multidisciplinary approach and adherence to quality indicators to optimize patient outcomes. This study aimed to evaluate the structure and quality of IBD care in Portugal, exploring the perceptions of gastroenterologists and identifying areas for improvement.

Methods: A cross-sectional online survey was conducted among Portuguese gastroenterologists between January and February 2024. The questionnaire assessed IBD care organization, processes and perceptions regarding quality indicators. Responses from 57 participants were analyzed using descriptive and inferential statistics.

Results: Most participants (74%) work in public hospitals, with 89.5% providing specialized IBD consultations. Multidisciplinary teams are present in 58% of the participants' centers. In addition to gastroenterologists, IBD multidisciplinary teams include mostly surgeons (88%) and radiologists (62%). Waiting times for nonurgent IBD-specific consultations varied, with 61% of the respondents reporting delays exceeding 1 month. More than two-thirds reported waiting times for nonurgent endoscopic and cross-sectional exams longer than 3 months. Psychological and nutritional assessments were underprioritized, with only 6% and 37% of centers routinely performing these evaluations, respectively. Only 42% of participants answered that their centers keep updated patient registries and 16% used quality indicators known to all team members. Most responders (76%) reported research activity in their units, mainly through national multicenter (88.1%) and observational studies (71%). Units with multidisciplinary teams were significantly more likely to follow structured protocols, provide timely care, and adopt advanced diagnostic tools. Most participants acknowledge the importance of quality indicators, classifying them as mandatory or relevant, with 96% supporting the auditing of IBD centers.

Conclusions: This study highlights strengths in the Portuguese IBD care, including multidisciplinary collaboration, research engagement, and widespread awareness of quality indicators. However, challenges remain, such as delays in specialized IBD consultations, endoscopic and cross-sectional exams, and inadequate scheduling for other consultations. Moreover, gaps persist in integrating psychological and nutritional care and maintaining updated patient registries. Expanding multidisciplinary teams and strengthening quality monitoring are critical for improving care outcomes for Portuguese IBD patients.

Introduction: Ascites, the abnormal accumulation of fluid within the peritoneal cavity, is commonly associated with decompensated liver cirrhosis, primary or secondary malignancy, right-sided heart failure, and peritoneal tuberculosis. The underlying pathophysiology is usually related to one of portal hypertension, hypoalbuminaemia, or peritoneal inflammation. When these common causes are excluded, autoimmune aetiologies such as systemic lupus erythematosus (SLE) should be considered, albeit being rare. SLE is a chronic, multisystem autoimmune disease with diverse manifestations, and serositis is a recognized but variably expressed feature. Lupus peritonitis, a form of serosal inflammation leading to ascites, occurs infrequently and is often overshadowed by more typical pulmonary or pericardial involvement. We report an unusual case of massive painless ascites as the presenting feature of SLE in a middle-aged man, underscoring the diagnostic challenges of this rare presentation.

Case presentation: A 43-year-old man presented to the Emergency Department with a 2-week history of painless, progressive abdominal distension. He denied any associated symptoms and a thorough physical examination was unremarkable except for ascites. An extensive diagnostic panel followed to identify the cause of ascites, as the hepatobiliary system appeared normal on imaging and serum ascites albumin gradient was less than 1.1, making cirrhosis and portal hypertension unlikely. Echocardiogram and thyroid function tests were normal. His autoimmune serological markers revealed the presence of anti-Smith and anti-RNP antibodies, and the patient fulfilled the 2019 EULAR/ACR classification for SLE.

Discussion: Ascites as the initial presentation of SLE is uncommon, especially massive ascites. Lupus peritonitis, the underlying mechanism, is thought to result from immune complex deposition and complement activation leading to peritoneal inflammation and exudative effusion. In this patient, the absence of typical features such as rash, arthritis, or haematological abnormalities initially obscured the diagnosis. This case illustrates how SLE can present insidiously and emphasizes the need for thorough autoimmune evaluation in unexplained exudative ascites once hepatic, cardiac, malignant, and infectious causes have been excluded. The rapid response to corticosteroid therapy underscores the importance of early recognition and immunosuppressive treatment to prevent complications.

Zollinger-Ellison Syndrome (ZES) is a rare condition caused by gastrin-secreting neuroendocrine tumours (gastrinoma) that induce excessive gastric acid production, leading to severe peptic ulcer disease (PUD) and gastrointestinal (GI) complications. Its nonspecific presentation often delays diagnosis, increasing the risk of life-threatening outcomes. We report the case of a 53-year-old man with chronic gastroesophageal reflux disease and long-standing unexplored diarrhoea who presented with worsening abdominal pain and severe diarrhoea. Laboratory tests showed acute kidney injury, and CT revealed gastric wall thickening and a hyperdense nodule at the gastroduodenal junction, raising suspicion for ZES. Despite proton pump inhibitor (PPI) therapy, he developed recurrent upper GI bleeding requiring intensive care unit admission. Hormonal and imaging studies confirmed ZES, and he underwent antrectomy with lymphadenectomy. Postoperatively, he experienced further GI bleeding managed with over-the-scope clip (OTSC®) haemostasis and gastroduodenal artery ligation. Pathology confirmed a well-differentiated neuroendocrine tumour (pT2N1, G1). One year later, he remained asymptomatic with no evidence of recurrence. This case illustrates the diagnostic and therapeutic challenges of ZES, underscoring the risks associated with PPI withdrawal during evaluation and the need for multidisciplinary management. Recurrent GI bleeding in ZES requires a coordinated approach integrating medical, endoscopic, and surgical therapies. Early recognition is essential to prevent severe complications, and a high index of suspicion is warranted in patients with refractory PUD, chronic diarrhoea, or unexplained GI bleeding.

Background: Cirrhosis is associated with significant morbidity and mortality. Recent studies have highlighted the potential role of allopurinol in reducing the incidence of hepatic decompensation among individuals with cirrhosis. This study aimed to evaluate the association of allopurinol use with the incidence of hepatic decompensation and overall mortality in patients with cirrhosis in a large, propensity-matched cohort.

Methods: A retrospective cohort study of adults with cirrhosis was conducted using the national TriNetX database, with 1:1 propensity score matching. Allopurinol exposure was assessed in three categories compared to individuals with no allopurinol use: 100 mg, 300 mg, and exposure at any dose. The primary outcome was the incidence of overall hepatic decompensation. Secondary outcomes included the incidence of ascites, esophageal variceal bleeding, hepatic encephalopathy (HE), hepatorenal syndrome, spontaneous bacterial peritonitis (SBP), hepatocellular carcinoma, and overall mortality. The outcomes were assessed at 6, 12, and 18 months. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated.

Results: After propensity score matching, 5,358 patients who received allopurinol were compared with 5,358 controls. Dose-specific analyses included two additional matched cohorts: 2,124 patients receiving 100 mg of allopurinol and their matched controls, and 1,020 patients receiving 300 mg of allopurinol and their matched controls. At 18 months, a statistically significantly lower incidence of hepatic decompensation was seen in the overall allopurinol exposure cohort (OR: 0.77; 95% CI: 0.70-0.84), the 100 mg cohort (OR: 0.66; 95% CI: 0.57 to 0.76), and 300 mg cohort (OR: 0.76; 95% CI: 0.62 to 0.94). Allopurinol exposure was associated with a decreased incidence of esophageal variceal bleeding (OR: 0.71; 95% CI: 0.55 to 0.92), ascites (OR: 0.77; 95% CI: 0.69 to 0.84), HE (OR: 0.76; 95% CI: 0.63 to 0.92), SBP (OR: 0.61; 95% CI: 0.46 to 0.80), and overall death (OR: 0.86; 95% CI: 0.77 to 0.96) compared to the control group.

Conclusion: In a propensity score-matched analysis of a large national database, individuals with cirrhosis and allopurinol use had significantly lower risk of hepatic decompensation and overall mortality. These findings suggest that allopurinol may play a potential role in managing cirrhosis, and randomized clinical trials are needed to confirm these findings.

Background: Intraductal papillary mucinous neoplasms (IPMNs) are the most common cystic tumors of the pancreas. They are usually incidental findings in asymptomatic individuals and have an uncertain natural history. In most cases, the diagnosis relies on imaging and may be supported by endoscopic ultrasound-guided cystic fluid sampling (and eventually other advanced EUS-based techniques).

Summary: Determining which IPMNs require further investigation and follow-up involves identifying features associated with a higher risk of high-grade dysplasia or invasive cancer, which may ultimately require surgery. The clinical management of IPMNs remains challenging, placing an increasing burden on healthcare systems.

Key messages: A thorough understanding of this condition is essential to guide clinical decisions, optimize resource allocation, and improve patient care. In this review, the Portuguese Pancreatic Club summarizes the most recent literature regarding epidemiology, classification and natural history of IPMNs.

Introduction: Iatrogenic colonic perforation following diagnostic colonoscopy is rare (0.016-0.8%) but carries significant morbidity. Reported mechanisms include direct mechanical injury, thermal damage or barotrauma. Management options range from immediate endoscopic treatment to surgical intervention or clinical observation.

Case presentation: A 49-year-old asymptomatic female patient underwent a screening colonoscopy. During the procedure, altered mucosal perfusion of the ascending colon was suspected, prompting referral to the Emergency Department. Imaging revealed a large pneumoperitoneum. Diagnostic laparoscopy identified serosal lacerations of the ascending colon with a punctiform perforation. An invaginating suture was performed to reinforce the fragile areas of the colon. The postoperative course was uneventful, and the patient remained asymptomatic at the 10-month follow-up.

Discussion/conclusion: Serosal laceration is a rare complication, usually related to increased intraluminal pressure during colonoscopy. In the presence of atypical endoscopic findings, hyper pressure-related injury should be considered. Early recognition is essential to reduce the morbidity associated with iatrogenic colonic perforation.

Introduction: The use of oral iron in iron deficiency (ID) and ID anemia (IDA) in inflammatory bowel disease (IBD) is controversial. Its lower cost and ease of administration must be weighed against side effects and efficacy. The aim of this study was to compare the efficacy and tolerability of two oral iron formulations (Sucrosomial® iron [SI] and ferric hydroxide-polymaltose complex [FHPC] for correcting ID and IDA in IBD. As a secondary objective, we aimed to assess the impact of oral iron on correcting ID, IDA, and disability in IBD.

Methods: This was a prospective, observational, bicentric cohort study. We included patients with IBD diagnosed with ID or IDA between November 2022 and November 2023. Physicians were preassigned by the investigators to prescribe SI or FHPC. The primary outcome was the efficacy of treatment with oral iron (Hb increase ≥2 g/dL and/or normalization of Hb levels in patients with IDA or correction of iron parameters in patients with ID alone) by week 12. The secondary outcomes were tolerability and the impact of oral iron on the quality of life and disability (IBD-Disk).

Results: A total of 56 patients were included in this study (FHPC group, 33; SI group, 23). A total of 47 patients had ID alone and 9 had IDA. There was no difference in the efficacy between the two formulations. After 12 weeks, 22% of the patients had an increase in Hb ≥2 g/dL and/or normalization of Hb levels or iron parameters. There was an improvement in serum iron (53.5 [45] vs. 64.5 [73]; p = 0.017), transferrin saturation index (17.0 [10] vs. 26.0 [13]; p < 0.001), and Hb levels (in patients with IDA) (11.9 ± 0.9 vs. 12.5 ± 1.2; p = 0.041). The IBD-Disk scores improved (p = 0.004) after treatment, and this improvement correlated with increased serum iron (rs = -0.43; p = 0.010) and Hb (rs = -0.50; p = 0.002) levels. Twelve (21.4%) patients had side effects (8.7% in the SI group vs. 30.3% in the FHPC group [p = 0.006]), leading to iron discontinuation in 5 (4/1: FHPC group/SI group).

Discussion: Both iron formulations had similar efficacy. There were fewer side effects in the SI group. Oral iron replacement improved Hb and iron levels after 12 weeks of treatment, and these changes correlated with improvement in disability.

Background: Full-thickness gastrointestinal tract defects (FGTDs) have been an unsettling occurrence in clinical practice, with an increasing incidence due to the growing use of third-space endoscopy and surgical procedures. With advancing technology, many of these events are now being managed endoscopically in a minimally invasive manner, and surgery is being increasingly reserved for refractory cases. Available devices for their treatment include through-the-scope clips, over-the-scope clips, endoscopic suturing devices, self-expandable metal stents, and endoscopic vacuum therapy.

Summary: In this review, we present available literature on different techniques for endoscopic defect closure and discuss their indications, efficacy, and limitations.

Key messages: There is a scarcity of guidelines regarding FGTD endoscopic treatment. Selection of devices is still largely dependent on endoscopist's preference, while considering defect size, chronicity, characteristics of adjacent mucosa, and device availability.

Background: Adverse events (AEs) are unintentional patient outcomes expected in medicine, but their impact on physicians remains underexplored.

Objectives: This study assessed the psychological state experienced by gastroenterologists following endoscopic AEs.

Methods: A nationwide online survey was sent to all registered gastroenterologists (n = 709). Psychological state was assessed using validated scales assessing psychological distress (DASS-21), professional quality of life (ProQOL-5), self-compassion (SCS-12), and shame feelings (OAS2). Results are presented as mean and 95% confidence interval.

Results: Seventy responded (9.87% response rate; median age 41; 41% female). Nearly all (99%) experienced AEs, most during polypectomy/mucosectomy (66%). None consulted psychological support. Stress (9.4 [7.3-11.5]), anxiety (5.1 [3.5-6.7]), and depression (5.2 [3.7-6.8]) were normal, while burnout (25.9 [24.5-27.2]) and traumatic stress (24.3 [23.0-25.5]) were moderate. Higher compassion satisfaction was associated with consultant status (41.5 vs. 37.7, p = 0.039), >10 years' experience (44.3 vs. 40.2, p = 0.032), age >50 years (41.9 vs. 39.3, p = 0.008) and those involved in legal actions (45.5 vs. 40.6; p = 0.023). Age >50 was also associated with higher stress (15.2 vs. 8.7, p = 0.023) and traumatic stress (26.3 vs. 23.8, p = 0.035). Stopping procedures after AEs was associated with higher anxiety (12.0 vs. 4.8, p = 0.026).

Conclusions: This is among the first studies to assess the psychological state of AEs on gastroenterologists. Participants showed moderate burnout and traumatic stress, but none consulted psychological support. Findings highlight the need for targeted healthcare support and further research on the emotional burden of AEs among endoscopists.