Pub Date : 2023-07-12eCollection Date: 2024-02-01DOI: 10.1159/000530835
Tiago Cúrdia Gonçalves, Tiago Lima Capela, José Cotter
While common pancreatic diseases, such as acute pancreatitis (AP), chronic pancreatitis (CP), and pancreatic cancer (PC), may greatly impact the normal pancreatic physiology and contribute to malnutrition, the adequate nutritional approach when those conditions are present significantly influences patients' prognosis. In patients with AP, the goals of nutritional care are to prevent malnutrition, correct a negative nitrogen balance, reduce inflammation, and improve outcomes such as local and systemic complications and mortality. Malnutrition in patients with CP is common but often a late manifestation of the disease, leading to decreased functional capacity and quality of life and increased risk of developing significant osteopathy, postoperative complications, hospitalization, and mortality. Cancer-related malnutrition is common in patients with PC, and it is now well recognized that early nutritional support can favorably impact survival, not only by increasing tolerance and response to disease treatments but also by improving quality of life and decreasing postoperative complications. The aim of this review was to emphasize the role of nutrition and to propose a systematic nutritional approach in patients with AP, CP, and PC.
急性胰腺炎 (AP)、慢性胰腺炎 (CP) 和胰腺癌 (PC) 等常见胰腺疾病可能会极大地影响胰腺的正常生理功能并导致营养不良,而在这些疾病发生时采取适当的营养方法则会极大地影响患者的预后。对于 AP 患者,营养护理的目标是预防营养不良、纠正负氮平衡、减轻炎症反应以及改善局部和全身并发症及死亡率等预后。营养不良在 CP 患者中很常见,但往往是疾病的晚期表现,会导致功能能力和生活质量下降,并增加发生严重骨病、术后并发症、住院和死亡的风险。癌症相关营养不良在 PC 患者中很常见,现在人们普遍认识到,早期营养支持不仅能提高患者对疾病治疗的耐受性和反应,还能改善患者的生活质量并减少术后并发症,从而对患者的生存产生有利影响。本综述旨在强调营养的作用,并提出针对 AP、CP 和 PC 患者的系统营养方法。
{"title":"Nutrition in Pancreatic Diseases: A Roadmap for the Gastroenterologist.","authors":"Tiago Cúrdia Gonçalves, Tiago Lima Capela, José Cotter","doi":"10.1159/000530835","DOIUrl":"10.1159/000530835","url":null,"abstract":"<p><p>While common pancreatic diseases, such as acute pancreatitis (AP), chronic pancreatitis (CP), and pancreatic cancer (PC), may greatly impact the normal pancreatic physiology and contribute to malnutrition, the adequate nutritional approach when those conditions are present significantly influences patients' prognosis. In patients with AP, the goals of nutritional care are to prevent malnutrition, correct a negative nitrogen balance, reduce inflammation, and improve outcomes such as local and systemic complications and mortality. Malnutrition in patients with CP is common but often a late manifestation of the disease, leading to decreased functional capacity and quality of life and increased risk of developing significant osteopathy, postoperative complications, hospitalization, and mortality. Cancer-related malnutrition is common in patients with PC, and it is now well recognized that early nutritional support can favorably impact survival, not only by increasing tolerance and response to disease treatments but also by improving quality of life and decreasing postoperative complications. The aim of this review was to emphasize the role of nutrition and to propose a systematic nutritional approach in patients with AP, CP, and PC.</p>","PeriodicalId":51838,"journal":{"name":"GE Portuguese Journal of Gastroenterology","volume":null,"pages":null},"PeriodicalIF":0.9,"publicationDate":"2023-07-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10836866/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88340958","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Introduction: Acute liver failure (ALF), although rare in children, is a complex progressive pathology, with multisystem involvement and high mortality. Isolated variables or those included in prognostic scores have been studied, to optimize organ allocation. However, its validation is challenging. This study aimed to assess the accuracy of several biomarkers and scores as predictors of prognosis in pediatric ALF (PALF).
Methods: An observational study with retrospective data collection, including all cases of ALF, was defined according to the criteria of the Pediatric Acute Liver Failure Study Group, admitted to a pediatric intensive care unit (PICU) for 28 years. Two groups were defined: spontaneous recovery (SR) and non-SR (NSR) - submitted to liver transplantation (LT) or death at PICU discharge.
Results: Fifty-nine patients were included, with a median age of 24 months, and 54% were female. The most frequent etiologies were metabolic (25.4%) and infectious (18.6%); 32.2% were undetermined. SR occurred in 21 patients (35.6%). In NSR group (N = 38, 64.4%), 25 required LT (42.4%) and 19 died (32.2%), 6 (15.7%) of whom after LT. The accuracy to predict NSR was acceptable for lactate at admission (AUC 0.72; 95% CI: 0.57-0.86; p = 0.006), ammonia peak (AUC 0.72; 95% CI: 0.58-0.86; p = 0.006), and INR peak (AUC 0.70; 95% CI: 0.56-0.85; p = 0.01). The cut-off value for lactate at admission was 1.95 mmol/L (sensitivity 78.4% and specificity 61.9%), ammonia peak was 64 μmol/L (sensitivity 100% and specificity 38.1%), and INR peak was 4.8 (sensitivity 61.1% and specificity 76.2%). Lactate on admission was shown to be an independent predictor of NSR on logistic regression model. Two prognostic scores had acceptable discrimination for NSR, LIU (AUC 0.73; 95% CI: 0.59-0.87; p = 0.004) and PRISM (AUC 0.71; 95% CI: 0.56-0.86; p = 0.03). In our study, the PALF delta score (PALF-ds) had lower discrimination capacity (AUC 0.63; 95% CI: 0.47-0.78; p = 0.11).
Conclusions: The lactate at admission, an easily obtained parameter, had a similar capacity than the more complex scores, LIU and PRISM, to predict NSR. The prognostic value in our population of the promising dynamic score, PALF-ds, was lower than expected.
{"title":"Prognostic Markers in Pediatric Acute Liver Failure.","authors":"Andreia Filipa Nogueira, Catarina Teixeira, Carla Fernandes, Rita Moinho, Isabel Gonçalves, Carla Regina Pinto, Leonor Carvalho","doi":"10.1159/000531269","DOIUrl":"10.1159/000531269","url":null,"abstract":"<p><strong>Introduction: </strong>Acute liver failure (ALF), although rare in children, is a complex progressive pathology, with multisystem involvement and high mortality. Isolated variables or those included in prognostic scores have been studied, to optimize organ allocation. However, its validation is challenging. This study aimed to assess the accuracy of several biomarkers and scores as predictors of prognosis in pediatric ALF (PALF).</p><p><strong>Methods: </strong>An observational study with retrospective data collection, including all cases of ALF, was defined according to the criteria of the Pediatric Acute Liver Failure Study Group, admitted to a pediatric intensive care unit (PICU) for 28 years. Two groups were defined: spontaneous recovery (SR) and non-SR (NSR) - submitted to liver transplantation (LT) or death at PICU discharge.</p><p><strong>Results: </strong>Fifty-nine patients were included, with a median age of 24 months, and 54% were female. The most frequent etiologies were metabolic (25.4%) and infectious (18.6%); 32.2% were undetermined. SR occurred in 21 patients (35.6%). In NSR group (<i>N</i> = 38, 64.4%), 25 required LT (42.4%) and 19 died (32.2%), 6 (15.7%) of whom after LT. The accuracy to predict NSR was acceptable for lactate at admission (AUC 0.72; 95% CI: 0.57-0.86; <i>p</i> = 0.006), ammonia peak (AUC 0.72; 95% CI: 0.58-0.86; <i>p</i> = 0.006), and INR peak (AUC 0.70; 95% CI: 0.56-0.85; <i>p</i> = 0.01). The cut-off value for lactate at admission was 1.95 mmol/L (sensitivity 78.4% and specificity 61.9%), ammonia peak was 64 μmol/L (sensitivity 100% and specificity 38.1%), and INR peak was 4.8 (sensitivity 61.1% and specificity 76.2%). Lactate on admission was shown to be an independent predictor of NSR on logistic regression model. Two prognostic scores had acceptable discrimination for NSR, LIU (AUC 0.73; 95% CI: 0.59-0.87; <i>p</i> = 0.004) and PRISM (AUC 0.71; 95% CI: 0.56-0.86; <i>p</i> = 0.03). In our study, the PALF delta score (PALF-ds) had lower discrimination capacity (AUC 0.63; 95% CI: 0.47-0.78; <i>p</i> = 0.11).</p><p><strong>Conclusions: </strong>The lactate at admission, an easily obtained parameter, had a similar capacity than the more complex scores, LIU and PRISM, to predict NSR. The prognostic value in our population of the promising dynamic score, PALF-ds, was lower than expected.</p>","PeriodicalId":51838,"journal":{"name":"GE Portuguese Journal of Gastroenterology","volume":null,"pages":null},"PeriodicalIF":0.9,"publicationDate":"2023-07-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11095588/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84080714","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-06-15eCollection Date: 2024-04-01DOI: 10.1159/000530866
Mafalda João, Miguel Areia, Susana Alves, Luís Elvas, Daniel Brito, Sandra Saraiva, Ana Teresa Cadime
Introduction: Current guidelines suggest adding oral simethicone to bowel preparation for colonoscopy. However, its effect on key quality indicators for screening colonoscopy remains unclear. The primary aim was to assess the rate of adequate bowel preparation in split-dose high-volume polyethylene glycol (PEG), with or without simethicone.
Methods: This is an endoscopist-blinded, randomized controlled trial, including patients scheduled for colonoscopy after a positive faecal immunochemical test. Patients were randomly assigned to 4 L of PEG split dose (PEG) or 4 L of PEG split dose plus 500 mg oral simethicone (PEG + simethicone). The Boston Bowel Preparation Scale (BBPS) score, the preparation quality regarding bubbles using the Colon Endoscopic Bubble Scale (CEBuS), ADR, CIR, and the intraprocedural use of simethicone were recorded.
Results: We included 191 and 197 patients in the PEG + simethicone group and the PEG group, respectively. When comparing the PEG + simethicone group versus the PEG group, no significant differences in adequate bowel preparation rates (97% vs. 93%; p = 0.11) were found. However, the bubble scale score was significantly lower in the PEG + simethicone group (0 [0] versus 2 [5], p < 0.01), as well as intraprocedural use of simethicone (7% vs. 37%; p < 0.01). ADR (62% vs. 61%; p = 0.86) and CIR (98% vs. 96%, p = 0.14) did not differ between both groups.
Conclusion: Adding oral simethicone to a split-bowel preparation resulted in a lower incidence of bubbles and a lower intraprocedural use of simethicone but no further improvement on the preparation quality or ADR.
{"title":"The Effect of Oral Simethicone in a Bowel Preparation in a Colorectal Cancer Screening Colonoscopy Setting: A Randomized Controlled Trial.","authors":"Mafalda João, Miguel Areia, Susana Alves, Luís Elvas, Daniel Brito, Sandra Saraiva, Ana Teresa Cadime","doi":"10.1159/000530866","DOIUrl":"10.1159/000530866","url":null,"abstract":"<p><strong>Introduction: </strong>Current guidelines suggest adding oral simethicone to bowel preparation for colonoscopy. However, its effect on key quality indicators for screening colonoscopy remains unclear. The primary aim was to assess the rate of adequate bowel preparation in split-dose high-volume polyethylene glycol (PEG), with or without simethicone.</p><p><strong>Methods: </strong>This is an endoscopist-blinded, randomized controlled trial, including patients scheduled for colonoscopy after a positive faecal immunochemical test. Patients were randomly assigned to 4 L of PEG split dose (PEG) or 4 L of PEG split dose plus 500 mg oral simethicone (PEG + simethicone). The Boston Bowel Preparation Scale (BBPS) score, the preparation quality regarding bubbles using the Colon Endoscopic Bubble Scale (CEBuS), ADR, CIR, and the intraprocedural use of simethicone were recorded.</p><p><strong>Results: </strong>We included 191 and 197 patients in the PEG + simethicone group and the PEG group, respectively. When comparing the PEG + simethicone group versus the PEG group, no significant differences in adequate bowel preparation rates (97% vs. 93%; <i>p</i> = 0.11) were found. However, the bubble scale score was significantly lower in the PEG + simethicone group (0 [0] versus 2 [5], <i>p</i> < 0.01), as well as intraprocedural use of simethicone (7% vs. 37%; <i>p</i> < 0.01). ADR (62% vs. 61%; <i>p</i> = 0.86) and CIR (98% vs. 96%, <i>p</i> = 0.14) did not differ between both groups.</p><p><strong>Conclusion: </strong>Adding oral simethicone to a split-bowel preparation resulted in a lower incidence of bubbles and a lower intraprocedural use of simethicone but no further improvement on the preparation quality or ADR.</p>","PeriodicalId":51838,"journal":{"name":"GE Portuguese Journal of Gastroenterology","volume":null,"pages":null},"PeriodicalIF":0.9,"publicationDate":"2023-06-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10987070/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89966755","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-06-15eCollection Date: 2024-04-01DOI: 10.1159/000530834
Cláudio Melo Rodrigues, Ana Catarina Carvalho, Sofia Ventura, Ângela Pinto Domingues, Américo Silva, Paula Ministro
The development of vaccinations has been game-changing in the ongoing effort to combat the COVID-19 pandemic. Until now, adverse effects are being reported at low frequency, including thrombocytopenia and myocarditis. Careful monitoring for any suspicious symptoms and signs following vaccination is necessary. We report a case of hemophagocytic lymphohistiocytosis (HLH) after mRNA COVID-19 vaccine in a 23-year-old female with ulcerative colitis. Diagnosis was made according to HLH-2004 criteria and the patient was treated with dexamethasone with response. Our report aimed to draw attention to the potential relation between COVID-19 vaccines and HLH and the necessity of continued surveillance, especially in at-risk populations such as those with underlying immune dysregulation.
{"title":"Persistent Fever after COVID-19 Vaccination in a Patient with Ulcerative Colitis: A Call for Attention.","authors":"Cláudio Melo Rodrigues, Ana Catarina Carvalho, Sofia Ventura, Ângela Pinto Domingues, Américo Silva, Paula Ministro","doi":"10.1159/000530834","DOIUrl":"10.1159/000530834","url":null,"abstract":"<p><p>The development of vaccinations has been game-changing in the ongoing effort to combat the COVID-19 pandemic. Until now, adverse effects are being reported at low frequency, including thrombocytopenia and myocarditis. Careful monitoring for any suspicious symptoms and signs following vaccination is necessary. We report a case of hemophagocytic lymphohistiocytosis (HLH) after mRNA COVID-19 vaccine in a 23-year-old female with ulcerative colitis. Diagnosis was made according to HLH-2004 criteria and the patient was treated with dexamethasone with response. Our report aimed to draw attention to the potential relation between COVID-19 vaccines and HLH and the necessity of continued surveillance, especially in at-risk populations such as those with underlying immune dysregulation.</p>","PeriodicalId":51838,"journal":{"name":"GE Portuguese Journal of Gastroenterology","volume":null,"pages":null},"PeriodicalIF":0.9,"publicationDate":"2023-06-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10987068/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79766540","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-06-12eCollection Date: 2023-09-01DOI: 10.1159/000530704
Rui Silva
Endoscopic esophageal stent placement is an effective palliative treatment for malignant strictures and has also been successfully used for benign indications, including esophageal refractory strictures and iatrogenic leaks and perforations. Despite several decades of evolution and the wide variety of esophageal stents available to choose from, an ideal stent that is both effective and without adverse events such as stent migration, tissue ingrowth, or pressure necrosis has yet to be developed. This paper is an overview of how this evolution happened, and it also addresses the characteristics of some of the currently available stents, like their material and construction, delivery device, radial and axial force pattern, covering and size which may help to understand and avoid the occurrence of adverse events. The insertion delivery systems and techniques of placement of an esophageal self-expandable metal stent are reviewed, as well as some tips and tricks regarding placement and management of adverse events.
{"title":"Esophageal Stenting: How I Do It.","authors":"Rui Silva","doi":"10.1159/000530704","DOIUrl":"10.1159/000530704","url":null,"abstract":"<p><p>Endoscopic esophageal stent placement is an effective palliative treatment for malignant strictures and has also been successfully used for benign indications, including esophageal refractory strictures and iatrogenic leaks and perforations. Despite several decades of evolution and the wide variety of esophageal stents available to choose from, an ideal stent that is both effective and without adverse events such as stent migration, tissue ingrowth, or pressure necrosis has yet to be developed. This paper is an overview of how this evolution happened, and it also addresses the characteristics of some of the currently available stents, like their material and construction, delivery device, radial and axial force pattern, covering and size which may help to understand and avoid the occurrence of adverse events. The insertion delivery systems and techniques of placement of an esophageal self-expandable metal stent are reviewed, as well as some tips and tricks regarding placement and management of adverse events.</p>","PeriodicalId":51838,"journal":{"name":"GE Portuguese Journal of Gastroenterology","volume":null,"pages":null},"PeriodicalIF":0.9,"publicationDate":"2023-06-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10614487/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"71428996","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Carolina Chálim Rebelo, Nuno Nunes, Margarida Flor de Lima, Diogo Bernardo Moura, José Renato Pereira, Maria Antónia Duarte
Biliary decompression in cases of hilar obstruction is challenging, and the intrahepatic approach is often necessary [1]. We describe a case of endoscopic ultrasoundguided biliary drainage (EUS-BD) for unresectable hilar malignant obstruction, using lumen-apposing metal stent (LAMS). A 85-year-old woman was admitted due to abdominal pain, jaundice, and choluria. From the personal history, it is worth noting a rectovaginal septum gastrointestinal stromal tumor (GIST), treated surgically in 2002 and with imatinib for 2 years. She was also being followed for pulmonary nodules, suspected of malignancy. Abdominal computed tomography showed a 76 × 57 × 61 mm mass on the left hepatic lobe, with irregular borders, and central necrosis, suggestive of metastasis. This mass compressed the biliary tree at the hilar plaque and led to intrahepatic biliary dilatation (Fig. 1). She had portal vein invasion, pulmonary and peritoneal metastasis. Biochemical workup showed a cytocholestase pattern and total bilirubin of 26 mg/dL. The patient refused liver biopsy. After multidisciplinary discussion it was decided for an endoscopic palliative treatment. Transpapillary access through endoscopic retrograde cholangiopancreatography (ERCP) was attempted but failed due to impossibility of biliary cannulation. The procedure was performed under deep sedation. A linear echoendoscope (GF-UCT260; Olympus Medical Systems, Tokyo, Japan) was used. There was a significant intrahepatic biliary dilation (12.8 mm), and the right intrahepatic biliary duct was close enough to the duodenal bulb (5 mm), without intervening vessels (as confirmed by color doppler). As so, we performed an hepaticoduodenostomy using a 6 × 8 mm LAMS (HotAxiosTM, Boston Scientific®, Marlborough, MA, USA): under ultrasound control, the right intrahepatic biliary duct was punctured
{"title":"Hepaticoduodenostomy (Right Intrahepatic Biliary Duct) Using a Lumen-Apposing Metal Stent.","authors":"Carolina Chálim Rebelo, Nuno Nunes, Margarida Flor de Lima, Diogo Bernardo Moura, José Renato Pereira, Maria Antónia Duarte","doi":"10.1159/000522578","DOIUrl":"https://doi.org/10.1159/000522578","url":null,"abstract":"Biliary decompression in cases of hilar obstruction is challenging, and the intrahepatic approach is often necessary [1]. We describe a case of endoscopic ultrasoundguided biliary drainage (EUS-BD) for unresectable hilar malignant obstruction, using lumen-apposing metal stent (LAMS). A 85-year-old woman was admitted due to abdominal pain, jaundice, and choluria. From the personal history, it is worth noting a rectovaginal septum gastrointestinal stromal tumor (GIST), treated surgically in 2002 and with imatinib for 2 years. She was also being followed for pulmonary nodules, suspected of malignancy. Abdominal computed tomography showed a 76 × 57 × 61 mm mass on the left hepatic lobe, with irregular borders, and central necrosis, suggestive of metastasis. This mass compressed the biliary tree at the hilar plaque and led to intrahepatic biliary dilatation (Fig. 1). She had portal vein invasion, pulmonary and peritoneal metastasis. Biochemical workup showed a cytocholestase pattern and total bilirubin of 26 mg/dL. The patient refused liver biopsy. After multidisciplinary discussion it was decided for an endoscopic palliative treatment. Transpapillary access through endoscopic retrograde cholangiopancreatography (ERCP) was attempted but failed due to impossibility of biliary cannulation. The procedure was performed under deep sedation. A linear echoendoscope (GF-UCT260; Olympus Medical Systems, Tokyo, Japan) was used. There was a significant intrahepatic biliary dilation (12.8 mm), and the right intrahepatic biliary duct was close enough to the duodenal bulb (5 mm), without intervening vessels (as confirmed by color doppler). As so, we performed an hepaticoduodenostomy using a 6 × 8 mm LAMS (HotAxiosTM, Boston Scientific®, Marlborough, MA, USA): under ultrasound control, the right intrahepatic biliary duct was punctured","PeriodicalId":51838,"journal":{"name":"GE Portuguese Journal of Gastroenterology","volume":null,"pages":null},"PeriodicalIF":0.9,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/a3/54/pjg-0030-0243.PMC10305248.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10114472","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Ectopic adrenocorticotropic hormone secretion (EAS) from the pancreatic neuroendocrine tumour (PNET) is rare, aggressive, and challenging to treat. We hereby present a rare case of EAS from PNET presenting with Cushing syndrome diagnosed with endoscopic ultrasound-guided fine-needle aspiration cytology. This case highlights the advanced presentation of EAS from PNET with poor clinical correlation of hypercortisolism and the grade of PNET.
{"title":"A Rare Case of Ectopic Adrenocorticotropic Hormone Secretion from Pancreatic Neuroendocrine Tumour Presenting with Cushing Syndrome.","authors":"Soon Liang Lee, Chiun Yann Ng, Jasminder Sidhu, Asmawiza Awang","doi":"10.1159/000521518","DOIUrl":"https://doi.org/10.1159/000521518","url":null,"abstract":"<p><p>Ectopic adrenocorticotropic hormone secretion (EAS) from the pancreatic neuroendocrine tumour (PNET) is rare, aggressive, and challenging to treat. We hereby present a rare case of EAS from PNET presenting with Cushing syndrome diagnosed with endoscopic ultrasound-guided fine-needle aspiration cytology. This case highlights the advanced presentation of EAS from PNET with poor clinical correlation of hypercortisolism and the grade of PNET.</p>","PeriodicalId":51838,"journal":{"name":"GE Portuguese Journal of Gastroenterology","volume":null,"pages":null},"PeriodicalIF":0.9,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/8e/df/pjg-0030-0239.PMC10305245.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10114476","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Edgar Afecto, Catarina Gomes, Ana Ribeiro, Ana Ponte, João Paulo Correia, Manuela Estevinho
A 41-year-old male with a history of Crohn’s disease (CD) with penetrating phenotype (A2L2B3p, Montreal Classification), who was diagnosed aged 17 years and had started treatment with infliximab monotherapy at 30 years old, had been on clinical, imagiological, and endoscopic remission for the previous 2 years. On follow-up ileocolonoscopy with the purpose of considering stopping biological treatment (per the patient’s wishes), only 2 superficial ulcers in the sigmoid colon and 3 small erosions in the terminal ileum (shown in Fig. 1) were detected. Histological examination of the ileum erosions demonstrated an infiltrate of atypical lymphoepithelial cells, CD20 positive and CD5, CD23, CD10, and cyclinD1 negative, compatible with a marginal zone B-cell lymphoma of the mucosal-associated lymphoid tissue (MALT; shown in Fig. 2). Immunoglobulin deposition was not identified in this tissue. Cervico-thoraco-abdominopelvic computed tomography and magnetic resonance bowel enterography were unremarkable. The histological specimens were analyzed by two different pathologists with expertise in hematopathology. Serum lactate dehydrogenase, β2-microglobulin, and immunoglobulin levels were normal. Hepatitis C virus antibodies and DNA of Campylobacter jejuni on ileum tissue were negative. Staging was complete as a MALTlymphoma Galian stage A and Lugano stage I. A 6-month course of antibiotic therapy with combined metronidazole and ampicillin was proposed after consultation with Hematology. As the patient was in clinical remission and the endoscopic activity was residual, biologic therapy was suspended due to an unfavorable risk/benefit. Unfortunately, CD recurred clinically and endoscopically so vedolizumab was started after endoscopic and histologic documentation of MALT remission (1 year after diagnosis, 6 months after antibiotics). Due to a primary non-response, the patient was swapped to ustekinumab and is currently in clinical remission, with a further endoscopic evaluation at 6–9 months.
{"title":"Not Everything That Ulcerates Is Crohn's Disease.","authors":"Edgar Afecto, Catarina Gomes, Ana Ribeiro, Ana Ponte, João Paulo Correia, Manuela Estevinho","doi":"10.1159/000524062","DOIUrl":"https://doi.org/10.1159/000524062","url":null,"abstract":"A 41-year-old male with a history of Crohn’s disease (CD) with penetrating phenotype (A2L2B3p, Montreal Classification), who was diagnosed aged 17 years and had started treatment with infliximab monotherapy at 30 years old, had been on clinical, imagiological, and endoscopic remission for the previous 2 years. On follow-up ileocolonoscopy with the purpose of considering stopping biological treatment (per the patient’s wishes), only 2 superficial ulcers in the sigmoid colon and 3 small erosions in the terminal ileum (shown in Fig. 1) were detected. Histological examination of the ileum erosions demonstrated an infiltrate of atypical lymphoepithelial cells, CD20 positive and CD5, CD23, CD10, and cyclinD1 negative, compatible with a marginal zone B-cell lymphoma of the mucosal-associated lymphoid tissue (MALT; shown in Fig. 2). Immunoglobulin deposition was not identified in this tissue. Cervico-thoraco-abdominopelvic computed tomography and magnetic resonance bowel enterography were unremarkable. The histological specimens were analyzed by two different pathologists with expertise in hematopathology. Serum lactate dehydrogenase, β2-microglobulin, and immunoglobulin levels were normal. Hepatitis C virus antibodies and DNA of Campylobacter jejuni on ileum tissue were negative. Staging was complete as a MALTlymphoma Galian stage A and Lugano stage I. A 6-month course of antibiotic therapy with combined metronidazole and ampicillin was proposed after consultation with Hematology. As the patient was in clinical remission and the endoscopic activity was residual, biologic therapy was suspended due to an unfavorable risk/benefit. Unfortunately, CD recurred clinically and endoscopically so vedolizumab was started after endoscopic and histologic documentation of MALT remission (1 year after diagnosis, 6 months after antibiotics). Due to a primary non-response, the patient was swapped to ustekinumab and is currently in clinical remission, with a further endoscopic evaluation at 6–9 months.","PeriodicalId":51838,"journal":{"name":"GE Portuguese Journal of Gastroenterology","volume":null,"pages":null},"PeriodicalIF":0.9,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/05/47/pjg-0030-0246.PMC10305256.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9736982","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A 54-year-old male patient with long-standing Barrett’s esophagus underwent multiband ligation endoscopic mucosal resection (MBL-EMR) 1 year previously due to low-risk early cancer (pT1m2, L0, V0, G2, R0). Of note, a nodular-type small Barrett’s neoplasia was resected en bloc in one EMR specimen, while the remaining specimens contained areas of low-grade dysplasia without circumscribed lesions. Radiofrequency ablation of the remaining non-dysplastic Barrett’s mucosa with preserved acetic acid whitening was scheduled; however, the patient missed several follow-up appointments. At repeat EGD, a secondary Paris 0-IIa lesion estimated at 15 mm and representing a second Barrett’s neoplasia emerged adjacent to MBL-EMR scars at oral (towards the mouth) and anterior (towards the sternum) aspects (Fig. 1a, linked color imaging). Acetic acid staining was only abrogated within the lesion itself and endoscopic biopsies confirmed well-differentiated adenocarcinoma. The patient presented for endoscopic submucosal dissection (ESD) after adequate counselling, including alternative surgery. First, an uncomplicated C-shaped incision from the anal side around the posterior (towards the back, or towards 6 o’clock) parts was performed. Unlike the conventional ESD approach to high-grade fibrosis (distant mucosal incision, submucosal approach to fibrosis with or without tunnel technique), direct cutting into the scar area was tried using an articulating ESD knife (3.5-mm ClutchCutter, Fuji, Düsseldorf, Germany). An initial injection of indigo carmine-saline mixture likewise failed to reasonably lift the mucosa. Special attention was paid to first cut in an ultra-superficial fashion as indicated by a crepe paper-like appearance (electrosurgical settings as for mucosal incision: endo cut 1, effect 2, duration 4, interval 1; hemostasis: soft coagulation, effect 4, 100 W; Fig. 1b). Of note, a hard and longer Inoue-type cap was used to adequately grasp the tissue in a superficial fashion. With the incised mucosa continuously pushed aside by the opened scissors, deeper cuts through dense high-
{"title":"Direct Mucosal-Side Fibrosis Cutting for Salvage Endoscopic Submucosal Dissection of Secondary Barrett's Neoplasia Adjacent Multiband Resection Scars.","authors":"Vincent Zimmer, Bert Bier","doi":"10.1159/000524269","DOIUrl":"https://doi.org/10.1159/000524269","url":null,"abstract":"A 54-year-old male patient with long-standing Barrett’s esophagus underwent multiband ligation endoscopic mucosal resection (MBL-EMR) 1 year previously due to low-risk early cancer (pT1m2, L0, V0, G2, R0). Of note, a nodular-type small Barrett’s neoplasia was resected en bloc in one EMR specimen, while the remaining specimens contained areas of low-grade dysplasia without circumscribed lesions. Radiofrequency ablation of the remaining non-dysplastic Barrett’s mucosa with preserved acetic acid whitening was scheduled; however, the patient missed several follow-up appointments. At repeat EGD, a secondary Paris 0-IIa lesion estimated at 15 mm and representing a second Barrett’s neoplasia emerged adjacent to MBL-EMR scars at oral (towards the mouth) and anterior (towards the sternum) aspects (Fig. 1a, linked color imaging). Acetic acid staining was only abrogated within the lesion itself and endoscopic biopsies confirmed well-differentiated adenocarcinoma. The patient presented for endoscopic submucosal dissection (ESD) after adequate counselling, including alternative surgery. First, an uncomplicated C-shaped incision from the anal side around the posterior (towards the back, or towards 6 o’clock) parts was performed. Unlike the conventional ESD approach to high-grade fibrosis (distant mucosal incision, submucosal approach to fibrosis with or without tunnel technique), direct cutting into the scar area was tried using an articulating ESD knife (3.5-mm ClutchCutter, Fuji, Düsseldorf, Germany). An initial injection of indigo carmine-saline mixture likewise failed to reasonably lift the mucosa. Special attention was paid to first cut in an ultra-superficial fashion as indicated by a crepe paper-like appearance (electrosurgical settings as for mucosal incision: endo cut 1, effect 2, duration 4, interval 1; hemostasis: soft coagulation, effect 4, 100 W; Fig. 1b). Of note, a hard and longer Inoue-type cap was used to adequately grasp the tissue in a superficial fashion. With the incised mucosa continuously pushed aside by the opened scissors, deeper cuts through dense high-","PeriodicalId":51838,"journal":{"name":"GE Portuguese Journal of Gastroenterology","volume":null,"pages":null},"PeriodicalIF":0.9,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10305250/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9736981","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Catarina Félix, Pedro Barreiro, Rui Mendo, André Mascarenhas, Cristina Chagas
Introduction: Endoscopic submucosal dissection (ESD) of lesions with severe submucosal fibrosis has been associated with worse outcomes, such as lower curative resection rate and higher incidence of adverse events. This study aims to investigate its true impact on rectal ESD performed in the West and to assess predictive factors of severe fibrosis.
Methods: We conducted a retrospective study including all rectal ESDs performed at our tertiary center from January 2013 to January 2021. Lesions were grouped as nonsevere fibrosis or severe fibrosis. ESD outcomes, predictors of severe fibrosis, and the learning curve were evaluated.
Results: ESD was performed in 195 lesions, 45 with severe fibrosis. Three resections were interrupted (one due to severe fibrosis). The presence of severe fibrosis was related to a significantly lower resection speed (16.93 mm2/min vs. 24.66 mm2/min, p = 0.007), en bloc (86.4% vs. 96.6%, p = 0.019), R0 (61.4% vs. 79.7%, p = 0.013), and curative (54.5% vs. 78.4%, p = 0.003) resection rates and a higher rate of hybrid ESD required to complete resection (13.6% vs. 2.0%, p = 0.005). No significant difference was noted regarding adverse events rate (18.2% vs. 8.1%, p = 0.09). Male sex, ulcerative colitis, pelvic radiotherapy, a lesion on the anastomotic site, previous manipulation, and deep submucosal invasion were independent predictors for severe fibrosis. En bloc resection rate improved during time (60.0% vs. 94.1%, p = 0.018).
Conclusions: Severe submucosal fibrosis is an important factor related to noncurative resections and challenging rectal ESD. Factors predicting its severity are extremely important and could allow more experienced endoscopists to be assigned to more difficult cases, allowing safer procedures.
内镜下粘膜下剥离术(ESD)治疗严重粘膜下纤维化病变的预后较差,如治愈率较低,不良事件发生率较高。本研究旨在探讨其对西方国家直肠ESD的真正影响,并评估严重纤维化的预测因素。方法:我们进行了一项回顾性研究,包括2013年1月至2021年1月在我们三级中心进行的所有直肠esd。病变分为非严重纤维化和严重纤维化。评估ESD结果、严重纤维化的预测因素和学习曲线。结果:在195个病变中行ESD,其中45个有严重纤维化。3例手术中断(1例因严重纤维化)。严重纤维化的存在与较低的切除速度(16.93 mm2/min vs. 24.66 mm2/min, p = 0.007)、整体(86.4% vs. 96.6%, p = 0.019)、R0 (61.4% vs. 79.7%, p = 0.013)、治愈率(54.5% vs. 78.4%, p = 0.003)和完成切除所需的较高的混合型ESD率(13.6% vs. 2.0%, p = 0.005)相关。两组不良事件发生率无显著差异(18.2% vs 8.1%, p = 0.09)。男性、溃疡性结肠炎、盆腔放疗、吻合口病变、既往操作和深部粘膜下浸润是严重纤维化的独立预测因素。整体切除率随时间提高(60.0% vs 94.1%, p = 0.018)。结论:严重的粘膜下纤维化是导致直肠ESD无法治愈的重要因素。预测其严重程度的因素非常重要,可以让更有经验的内窥镜医生被分配到更困难的病例中,从而实现更安全的手术。
{"title":"Outcomes and Learning Curve in Endoscopic Submucosal Dissection of Rectal Neoplasms with Severe Fibrosis: Experience of a Western Center.","authors":"Catarina Félix, Pedro Barreiro, Rui Mendo, André Mascarenhas, Cristina Chagas","doi":"10.1159/000522579","DOIUrl":"https://doi.org/10.1159/000522579","url":null,"abstract":"<p><strong>Introduction: </strong>Endoscopic submucosal dissection (ESD) of lesions with severe submucosal fibrosis has been associated with worse outcomes, such as lower curative resection rate and higher incidence of adverse events. This study aims to investigate its true impact on rectal ESD performed in the West and to assess predictive factors of severe fibrosis.</p><p><strong>Methods: </strong>We conducted a retrospective study including all rectal ESDs performed at our tertiary center from January 2013 to January 2021. Lesions were grouped as nonsevere fibrosis or severe fibrosis. ESD outcomes, predictors of severe fibrosis, and the learning curve were evaluated.</p><p><strong>Results: </strong>ESD was performed in 195 lesions, 45 with severe fibrosis. Three resections were interrupted (one due to severe fibrosis). The presence of severe fibrosis was related to a significantly lower resection speed (16.93 mm<sup>2</sup>/min vs. 24.66 mm<sup>2</sup>/min, <i>p</i> = 0.007), en bloc (86.4% vs. 96.6%, <i>p</i> = 0.019), R0 (61.4% vs. 79.7%, <i>p</i> = 0.013), and curative (54.5% vs. 78.4%, <i>p</i> = 0.003) resection rates and a higher rate of hybrid ESD required to complete resection (13.6% vs. 2.0%, <i>p</i> = 0.005). No significant difference was noted regarding adverse events rate (18.2% vs. 8.1%, <i>p</i> = 0.09). Male sex, ulcerative colitis, pelvic radiotherapy, a lesion on the anastomotic site, previous manipulation, and deep submucosal invasion were independent predictors for severe fibrosis. En bloc resection rate improved during time (60.0% vs. 94.1%, <i>p</i> = 0.018).</p><p><strong>Conclusions: </strong>Severe submucosal fibrosis is an important factor related to noncurative resections and challenging rectal ESD. Factors predicting its severity are extremely important and could allow more experienced endoscopists to be assigned to more difficult cases, allowing safer procedures.</p>","PeriodicalId":51838,"journal":{"name":"GE Portuguese Journal of Gastroenterology","volume":null,"pages":null},"PeriodicalIF":0.9,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/a2/db/pjg-0030-0221.PMC10305249.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10114475","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}