GE Portuguese Journal of Gastroenterology最新文献

Background: The gastrointestinal microbiota is vital for a well-functioning digestive tract, nutrient metabolism, immune support, and protection against pathogenic microorganisms. Disruption of this balance is known as dysbiosis. Rifaximin, an oral antibiotic with selective action, reduces harmful gut bacteria while preserving beneficial species, aiding in microbiota restoration.

Summary: Alterations in the intestinal microbiota are implicated in many gastrointestinal disorders. Rifaximin, by targeting and modulating the microbiota, may serve as a powerful tool in the approach of these conditions.

Key messages: This narrative review summarizes the main uses of rifaximin in gastrointestinal disorders like irritable bowel syndrome, diverticular disease, small intestinal bacterial overgrowth, traveler's diarrhea, hepatic encephalopathy, Clostridioides difficile infection, and inflammatory bowel disease.

Background: Lactose intolerance (LI) is a condition in which the consumption of lactose-containing products leads to gastrointestinal symptoms. Despite being a common digestive disorder worldwide, LI is often overlooked, and there are few established recommendations for its diagnosis and management. This review aims to provide a comprehensive overview of LI, focusing on its clinical features, diagnostic evaluation, and management strategies.

Summary: A review of literature published from 2013 to 2023 on PubMed was conducted. Systematic reviews, meta-analyses, randomized controlled trials, case-control studies, cohort studies, and expert reviews were prioritized for analysis. LI is a common condition that shares symptoms with several other diseases. Various diagnostic tests are available to identify LI, including hydrogen breath test (HBT), lactose tolerance test, urinary galactose test, gaxilose test, rapid lactase test, and genetic testing. Managing LI may involve adopting a lactose-free or low-lactose diet, taking oral enzyme supplements, using probiotics and prebiotics, or consuming plant-based alternative beverages.

Key messages: LI affects many people worldwide and can significantly impact their quality of life. The HBT is the most widely used and effective method for diagnosing LI, along with a thorough assessment of symptoms. Instead of following a completely dairy-free diet, adopting a low-lactose diet - allowing up to 12-15 g of lactose per day - has been shown to be well tolerated and beneficial for most individuals with LI. While probiotics, prebiotics, and plant-based beverages may be helpful, their effectiveness in managing LI has not yet been proven.

After a consensus meeting including experts from all over the country (more than 6 years of experience, at least 50 procedures and their center perform more than 30 procedures/year), several recommendations were issued. Main recommendations: (1) Single-operator digital cholangioscopy is indicated in cases of undetermined biliary strictures (UBSs) in which visual inspection, with or without histology, may change the patient's approach. (Strong recommendation, moderate quality of evidence). (2) In a cholangioscopy for a stricture of unclear etiology, the optical assessment aspects should be recorded in a standardized report and, according to the endoscopist's visual impression, suggest a malignant or benign etiology. (Strong recommendation, high quality of evidence). (3) When using cholangioscopy regardless of the visual impression, biopsies of the stenosis should be taken (ideally in a number equal to or greater than 6 fragments). (Strong recommendation, moderate quality of evidence). (4) Cholangioscopy with biopsies has a high diagnostic accuracy in the evaluation of UBSs, with a technical success >98% and visual diagnosis with sensitivity/specificity >95%. However, it must be considered that the sensitivity of histological diagnosis is lower (around 70%). (Strong recommendation, high quality of evidence). (5) The single-operator cholangioscopy (SOC)-assisted lithotripsy is a safe procedure associated with high rates of success. (Strong recommendation, high quality of evidence). (6) SOC-assisted lithotripsy should be reserved for selected cases in which conventional techniques for the treatment of difficult biliary stones have failed. However, SOC-assisted lithotripsy should be used early in the treatment algorithm to avoid repeated procedures. (Strong recommendation, moderate quality of evidence). (7) Pancreatoscopy can allow the diagnosis of lesions suggestive of malignancy in the pancreatic duct of patients with intraductal papillary mucinous neoplasm of the main duct with high sensitivity and specificity. The groups of patients who benefit most from its use are those with a diffusely dilated duct with a diameter greater than 10 mm, and in whom sectional imaging methods and endoscopic ultrasound do not reveal focal lesions. (Weak recommendation, low quality of evidence). (8) The use of intraductal lithotripsy guided by pancreatoscopy in patients with lithiasis in the main pancreatic duct should be reserved for patients with pain and lithiasis greater than 5 mm that cannot be removed using conventional techniques. Patients with an excessively distal location in the tail or head may cause increased technical difficulty. (Low recommendation, low quality of evidence).

[This corrects the article DOI: 10.1159/000537685.].

Introduction: The referral of patients with cirrhosis to liver transplant (LT) is a multi-stage, complex process. There is a lack of data on potential challenges to this process. We aimed to characterize challenges faced by Portuguese referring clinicians.

Methods: This was a cross-sectional survey from Curry Cabral Hospital, Lisbon, Portugal. The survey was open for 90 days, from August to November 2024. The survey included 13 questions: characterization of participants with 5 questions and characterization of the process of referral to LT with 8 questions.

Results: Overall, 56 clinicians responded to the survey (response rate of 46.7%). Their median (IQR) age was 38.1 (33.2-42.1) years. Their level of training was specialist grade for 47 (83.9%) and fellow or intern grade for 9 (16.1%) individuals. The responders were from 21 different hospitals in Portugal; 8 (38.1%) provided tertiary care and 2 (9.5%) were LT centers. Among responders, there was heterogeneity regarding the following topics: referring criteria to LT, liver-related prognostic scores, contact channels with the LT center, tests and visits part of the LT workup. Many of them suggested the following improvements to develop national or regional referral criteria, to expedite communication with the LT team, to accelerate access to the tests or visits part of the LT workup, and to shorten the time to the first appointment with the LT team.

Conclusion: Portuguese clinicians identified several challenges and improvements to the referral of patients with cirrhosis to LT. These findings may inform future strategies to streamline the referral to LT.

Background: Hepatic tuberculosis in itself is a rare condition, and that causing portal hypertension is even rarer. We present a unique clinical scenario of portal hypertension in a 64-year-old woman, with tuberculosis causing both sinusoidal and prehepatic portal hypertension.

Case presentation: A 64-year-old woman presented with esophageal variceal bleeding. Evaluation revealed a rare combination of sinusoidal portal hypertension from hepatic tuberculosis and a prehepatic component of portal hypertension due to tubercular periportal lymphadenopathy compressing the portal vein at the hilum. Hepatic venous pressure gradient was 7 mm Hg, indicative of sinusoidal portal hypertension. Liver biopsy demonstrated bridging fibrosis and hepatic granulomas accounting for the sinusoidal component of portal hypertension. Since clinically significant portal hypertension is more than 10 mm Hg, variceal bleeding resulted from the additional element of prehepatic portal hypertension contributed by compression of extrahepatic portal vein by periportal lymph nodes. Positive tuberculosis polymerase chain reaction from lymph nodes confirmed the diagnosis and initiation of antitubercular therapy (ATT) led to significant clinical and biochemical improvement. This case represents a novel occurrence; hepatic tuberculosis causing both intrahepatic and prehepatic components of portal hypertension has not been reported in the literature.

Conclusion: This case sheds light on the rarity of hepatic tuberculosis causing portal hypertension and also the importance of considering this diagnosis in patients with atypical presentations of tuberculosis. Recognizing and treating this unique complication promptly with ATT can lead to favorable clinical outcomes.

Introduction: Celiac crisis is a rare, severe manifestation of celiac disease, characterized by acute gastrointestinal symptoms, malnutrition, metabolic disturbances, and potential life-threatening complications. Postpartum celiac crisis is particularly rare but can be triggered by the physiological and hormonal changes of the puerperal period.

Case presentation: We report the case of a 42-year-old woman with a 3-month history of watery diarrhea, significant weight loss, extremity paresthesias, muscle spasms, and lower limb edema following childbirth. Initial evaluation revealed severe malnutrition, electrolyte imbalances, and hypoalbuminemia. Endoscopic studies showed significant villous atrophy and mucosal damage, suggestive of celiac disease, which was confirmed by serological and histological findings. The patient was diagnosed with celiac crisis and initiated on a strict gluten-free diet with supportive care, resulting in full clinical and biochemical recovery.

Discussion: This case highlights the importance of considering CD in the differential diagnosis of postpartum malnutrition and chronic diarrhea. Postpartum period may trigger the disease, underscoring the need for awareness in clinical settings. Celiac hepatitis is a prevalent occurrence within the spectrum of CD, with transient transaminase elevation with resolution following the initiation of a gluten-free diet. Celiac crisis, though rare, requires prompt diagnosis and intervention to avoid further complications.

Introduction: Malignant melanoma of the esophagus is an uncommon cause of dysphagia and accounts for only 0.1-0.2% of esophageal neoplasms. Diagnosis is based on esophagogastroduodenoscopy (EGD) with biopsies and immunohistochemical analysis, the latter being crucial in the amelanocytic variant. Gastrointestinal melanomas are more invasive and comprise poorer prognosis than cutaneous melanomas.

Case presentation: The authors present the case of a 70-year-old woman admitted to the emergency department for progressive dysphagia with 2 months of evolution. EGD revealed the presence of an extensive, eccentric lesion, occupying approximately half of the luminal circumference at the level of the distal esophagus with circumferential involvement of the esophagogastric junction and cardia. Thoracoabdominopelvic computed tomography and positron emission tomography showed signs of advanced disease. The initial endoscopic biopsies were inconclusive, and EGD was repeated with multiple biopsies directed at the most infiltrative areas, whose histopathological analysis with immunohistochemistry revealed neoplastic cells with marked nuclear positivity for SOX10 and cytoplasmic positivity for vimentin, Melan-A, and HMB45 with absence of melanin pigment, findings suggestive of esophagocardiac amelanocytic malignant melanoma. In a multidisciplinary team meeting, the neoplasm was deemed unresectable, and the proposal was for esophageal stent placement and palliative hormone therapy.

Discussion: Primary amelanocytic malignant melanoma is an exceptionally rare neoplasm and an extremely uncommon cause of dysphagia. In this context, we present a compelling case study that underscores the rarity of this histological type, the importance of directing biopsies to the most suspicious areas of the lesion to increase diagnostic yield, the need for a high clinical suspicion, and the atypical endoscopic presentation associated with the amelanocytic subtype.