GE Portuguese Journal of Gastroenterology最新文献

Introduction: Propafenone is a widely used class Ic antiarrhythmic drug that is mainly metabolised by the liver. Hepatotoxicity associated with propafenone is rare, with only a few clinical cases reported in the literature.

Case presentation: We presented a case of propafenone-related hepatotoxicity, with cholestatic liver injury and development of jaundice and pruritus within 3 to 4 weeks of treatment initiation. Three months after discontinuation, the patient was asymptomatic, and all liver tests normalised.

Conclusion: With this clinical case, we aimed to emphasise the importance of the medication history and the exclusion of other possible causes of altered liver enzymes.

Introduction: Laparoscopic sleeve gastrectomy (LSG) is a bariatric surgical procedure associated with a non-negligible risk of postoperative adverse events, especially fistulas, the majority of which occur at the angle of His. This adverse event requires a multidisciplinary approach involving intensive care, surgery, interventional endoscopy, and radiology. Despite the absence of an algorithmic endoscopic approach, a primarily endoscopic management of fistulas after LSG is now standard of care in most institutions.

Case report: A 66-year-old female with grade III obesity, obstructive sleep apnea, type 2 diabetes, and hypertension underwent LSG. She developed abdominal pain, hypovolemic shock, and severe anemia (Hb 6.5 g/dL). A computed tomography (CT) scan revealed hemoperitoneum without active bleeding, managed with transfusion of packed blood cells. A week later, a new CT scan performed for leukocytosis and abdominal pain revealed pneumoperitoneum. An esophagogastroduodenoscopy revealed a 20-mm fistula orifice at the angle of His. A novel esophageal covered metallic stent was placed for a period of 5 weeks. The fistula orifice decreased to 4 mm and communicated through a fistulous tract with a residual subphrenic abscess measuring 62 × 20 mm. Pus was collected from the abscess and drained internally with a 10-Fr double pigtail plastic stent through the fistula orifice. Following an initial period of improvement, clinical deterioration required percutaneous subphrenic abscess drainage. Two weeks later, the double pigtail plastic stent was removed, the fistula orifice was ablated with argon plasma 40W/1L and closed with an over-the-scope clip of 10 mm. Patient improved and was discharged 4 months after the LSG.

Conclusion: The Luso-Cor esophageal stent is a specifically designed covered metallic stent with a 5-mm uncovered ring near the proximal edge, which reduces the risk of migration. Two articulating zones in the middle portion allow better adaptation to altered anatomy after LSG and a distal flare reduces retrograde reflux of fluid. This stent overcomes strictures in the gastric tube, concomitantly present in nearly 50% of patients with fistulas after LSG. The novel Luso-Cor esophageal stent provided a bridge to clinical stability with a significant reduction in the size of the fistula orifice which was closed with complementary therapeutic endoscopic procedures.

Introduction: Several studies have highlighted the potential benefits of early prophylactic transjugular intrahepatic portosystemic shunt (preemptive TIPS) placement in reducing morbidity and mortality following variceal bleeding (VB). Baveno VII recommends its placement less than 72 h after VB (Child-Pugh class C <14 or class B >7 plus active bleeding). This study aimed to evaluate the effectiveness of preemptive TIPS compared to a control group in a referral center.

Methods: The control group included cirrhotic patients with VB and Child-Pugh class C or B with active bleeding, retrospectively selected between 2016 and 2022 and divided into 2 subgroups: those that never underwent TIPS placement during the course of their illness (subgroup A) and those submitted to TIPS placement due to rebleeding (subgroup B). Additionally, patients who received preemptive TIPS placement between August 2022 and January 2024 were prospectively included into the preemptive transjugular intrahepatic portosystemic shunt (pTIPS) group.

Results: A total of 47 patients were included, 19 (40.4%) in the pTIPS group and 28 (59.6%) in control group (17 in subgroup A). There were no differences in baseline characteristics between the groups, except hepatic encephalopathy that was significantly higher in the control group when compared to the pTIPS group: 19 (67.9%) versus 6 (31.6%), p = 0.014. Early rebleeding rates were significantly lower in the pTIPS group: 1 (5.3%) versus 13 (46.4%) (p = 0.002). There were no significant differences in 6-week survival between the groups: 25 (89.3%) versus 17 (89.5%), p = 0.683. Regarding hepatic encephalopathy, no significant differences were observed between the control and the pTIPS group: 6 (21.4%) versus 4 (21.1%), p = 0.632, even when comparing subgroup A (4, 23.5%) with the pTIPS group (p = 0.432).

Conclusion: This real-world study highlights the potential benefits of preemptive TIPS placement in reducing early relapse of VB, thereby lowering morbidity and complications. The findings advocate for the proactive incorporation of preemptive TIPS into clinical practice to optimize patient outcomes following VB.

Introduction: Celiac disease has been associated with gastrointestinal malignancies, most commonly gastrointestinal lymphoma. Nevertheless, rarer malignancies have also been reported, such as small bowel adenocarcinoma, mainly located in the duodenum or jejunum.

Case presentation: We report a case of a female patient with celiac disease with poor adherence to a gluten-free diet who presented with small bowel obstruction due to a primary ileal adenocarcinoma. The patient remains asymptomatic, adherent to the gluten-free diet, and without clinical, biochemical, or imaging evidence of cancer recurrence.

Discussion/conclusion: This case should raise awareness about the importance of the gluten-free diet and the early diagnosis and appropriate management of rare small bowel malignant complications of celiac disease, namely, adenocarcinoma.

Background and study aims: Positron emission tomography/computed tomography (PET/CT) with 2-[18F]FDG (FDG) has been increasingly used to detect or monitor neoplasms. Gastrointestinal tract (GIT) is one of the most common sites of FDG uptake, leading to increasing requests for endoscopic examinations. We aimed to evaluate the nature and significance of unexpected PET/CT-FDG findings in the GIT.

Patients and methods: We retrospectively analyzed 371 consecutive patients with incidental GIT findings on PET/CT-FDG between June 2016 and October 2021 who were subsequently referred to endoscopic examinations. Demographic data, PET/CT-FDG results, endoscopic findings, and histological analysis were analyzed.

Results: Of 194 colonic incidental uptakes, 102 (52.6%) corresponded to at least premalignant lesions, being 57 (29.4%) advanced adenomas and 23 (11.9%) adenocarcinomas. Of 193 upper GIT incidental uptakes, there were 11 (13.8%) esophageal and 14 (14.4%) gastric malignant/premalignant lesions. The maximum standardized uptake value (SUVmax) significantly varied according to the nature of the lesion, being higher in malignant lesions (in the esophagus, stomach, and colon). However, an optimal SUVmax cutoff was only found for stomach (SUVmax 8.2; sensitivity of 79% and specificity of 76%). There was a significant association between the site of uptake and the nature of the lesion - left colon and gastric body uptake were associated with neoplastic origin whereas rectum and lower esophagus were associated with inflammatory or no endoscopic changes.

Conclusions: Any incidental uptake in the lower GIT should be investigated provided that patients are suitable for further treatment. However, in the upper GIT the characteristics of uptake on ¹⁸F-FDG-PET/CT may allow to select those who need endoscopic examination.

Introduction: A pelvic abscess is a potential life-threatening condition that should be managed conservatively whenever possible. Currently, computed tomography or ultrasound-guided percutaneous drainage is still the gold standard approach for pelvic fluid collections (PFCs) requiring intervention. More recently, endoscopic ultrasound (EUS) drainage using lumen-apposing metal stents (LAMSs) has been used off-label in PFCs with similar efficacy, a favorable safety profile, better quality of life, and generally a shorter duration of treatment when compared to the gold standard treatment.

Methods: An observational retrospective analysis of 6 patients who underwent EUS-guided PFC drainage with LAMS at our institution was conducted. Records were reviewed to identify etiology, size of the collection, number of endoscopic procedures required until complete resolution, stent indwelling time, concomitant surgical or percutaneous associated procedures, successful removal and resolution.

Results: The 6 patients included had an average age of 69 years old and 5 (83.3%) were male. The average size of the PFCs was 72.5 mm. All patients (100%) had successful drainage following LAMS placement, though 1 patient had an early recurrence. The mean stent indwelling time in our study was 6.7 days. An additional percutaneous or surgical drainage intervention was not required in any of the participants. Also, no adverse events related to the procedure were reported during the follow-up period.

Conclusion: EUS-guided drainage of PFCs with LAMS is a safe and minimally invasive technique, which allows rapid PFC resolution, with no need for percutaneous or surgical drainage interventions.

Introduction: The IBD-Control questionnaire and IBD-Disk are two patient-reported outcome measures designed to evaluate the impact of inflammatory bowel disease (IBD) on different health domains. Unlike IBD-Disk, there is no fully published validated Portuguese version of IBD-Control. Furthermore, the two instruments have not yet been compared. We aimed to translate and validate IBD-Control in Portugal and compare it with IBD-Disk.

Methods: After translation into Portuguese, the IBD-Control was administered to IBD patients, at baseline (T0), after 1-4 weeks (T1), and >3 months (T2). Patients also completed the Portuguese versions of the PRO2, EQ-5D, SIBDQ, and IBD-Disk. We assessed the reliability, validity, responsiveness, and interpretability of IBD-Control. We compared the usability (3 questions) and the ability to identify good disease control (area under the curve [AUC]) of IBD-Control and IBD-Disk.

Results: At T0, the IBD-Control was completed by 142 patients (108 Crohn's disease, 34 ulcerative colitis). At T1 and T2, 68 and 101 patients completed the questionnaire, respectively. Factor analysis confirmed the one-dimensionality of the scale with 8 items (IBD-Control-8). Internal consistency (Cronbach's alpha) was 0.80. Test-retest reproducibility for stable patients (n = 54) was high (intraclass correlation coefficient-0.86). IBD-Control-8 significantly correlated (r between 0.55 and 0.82; p ≤ 0.001) with PRO2, EQ-5D, SIBDQ and IBD-Disk. The variation in IBD-Control-8 between T0 and T2 correlated significantly (r between 0.48 and 0.53; p ≤ 0.01) with the variation in PRO2 (only for Crohn's disease), SIBDQ and IBD-Disk. The IBD-Control-8 significantly discriminated between well and poorly controlled disease (15 ± 2 vs. 11 ± 4; p < 0.001). No significant differences were observed between IBD-Control-8 and IBD-Disk regarding usability and the ability to identify good disease control (AUC: -0.79 vs. 0.76, respectively).

Conclusions: The IBD-Control is reliable and valid for measuring disease control from the perspective of patients with IBD in Portugal, presenting no significant differences regarding usability and assessment of disease control when compared to IBD-Disk.

Introduction: Hepatogenous diabetes (HD) is a disorder of glucose metabolism (DGM) that develops as a complication of advanced chronic liver disease (ACLD) with an estimated prevalence of 20-70%. It appears to be associated with a larger number of decompensations, but its impact on the natural history of the disease is unclear. The treatment of DGM is hampered by the fact that some therapeutic agents are associated with a risk of complications in ACLD. The aim of this work was to study DGM in a population of patients with ACLD: prevalence, liver disease decompensation episodes, mortality analysis and study of the impact of antidiabetic therapies in patients with ACLD who developed DGM.

Materials and methods: A cohort of consecutive patients with ACLD without previous DGM, who attended a Hepatology clinic in the period of January to June 2015 was selected. Follow-up was carried out for 5 years. Data on age, gender, date of diagnosis and etiology of ACLD, Child-Pugh and MELD-Na classifications at enrollment, development of DGM, and antidiabetic therapy were collected. Logistic regression models for hospitalizations due to decompensated ACLD, ascites, hepatic encephalopathy (HE), upper gastrointestinal bleeding (UGB), hepatocellular carcinoma (HCC), portal vein thrombosis (PVT), infectious complications, acute-on-chronic liver failure (ACLF), and death were built. A survival analysis for patients with and without DGM was also performed. Treatment effectiveness for patients with DGM was assessed.

Results: Initially, 221 patients were included, 154 (69.7%) of whom developed DGM after the diagnosis of ACLD. DGM patients presented a significantly higher number of hospitalizations. Odds ratio (OR) for death was not significantly related with DGM. At 5 years of follow-up, 68.9% of patients with DGM were alive, against 81.8% without DGM (p = 0.087). From the 154 patients who were diagnosed with DGM, 42.9% were not receiving pharmacological treatment for DGM. Treated patients were prescribed with either biguanides (34.8%), a SGLT2 inhibitor (8.6%), or insulin (7.7%). Only 1 patient was treated with a GLP-1 analogue. A tendency of OR favoring treatment was observed for biguanides and SGLT2 inhibitors in all outcomes except ascites. In the univariable analysis, the use of biguanides was associated with lower risk of death (OR: 0.84 [95% CI: 0.73-0.96]) and HE (OR: 0.85 [95% CI: 0.73-0.98]).

Conclusion: DGM occurs with high prevalence in patients with ACLD and it seems to be related to more hospitalizations, which highlights the importance of its early identification and appropriate therapeutic approach. In the absence of contraindications, biguanides should be considered for treatment of patients with ACLD and DGM as they appear to be associated with a tendency to better outcomes and may present some advantage in terms of survival.