GE Portuguese Journal of Gastroenterology最新文献

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.

Yersinia enterocolitica infection, the third most prevalent gastrointestinal infection in Europe, poses a diagnostic challenge due to its resemblance to other common conditions such as acute appendicitis, Crohn's disease, and malignancy. We report the case of a 48-year-old female patient who sought medical attention for abdominal pain and diarrhoea. Her endoscopic examination revealed a cobblestone pattern affecting the entire colon, more pronounced in the right colon, but with normal mucosa in the terminal ileum. This unique presentation created a challenge in distinguishing Yersiniosis from Crohn's disease. This case report aimed to highlight this atypical endoscopic manifestation of Y. enterocolitica infection. We underline the subacute nature of the symptoms, which can last up to 4-6 weeks. This reinforces the importance of considering Y. enterocolitica infection as a diagnostic possibility, even when the endoscopic appearance closely resembles other chronic intestinal diseases.

Background: To search for H. pylori infection and gastric precancerous lesions in cirrhotic patients is worthwhile when considering the high incidence of peptic ulcers and gastric cancer in these patients. We tested if gastric juice analysis allows to avoid unrewarding gastric biopsies.

Methods: This prospective study enrolled consecutive patients with liver cirrhosis who underwent upper endoscopy with standard gastric biopsies. Real-time gastric juice analysis was performed with a specific device (EndoFaster^®) that test ammonium concentration for H. pylori diagnosis, and pH values to suspect extensive atrophy/metaplasia involving gastric body mucosa. Sensitivity, specificity, positive predictive value, negative predictive value (NPV), the overall accuracy, and the likelihood ratio were calculated for both H. pylori infection and extensive precancerous lesions on gastric mucosa.

Results: A total of 78 cirrhotic patients (males: 55; mean age: 66 ± 12 years) were enrolled. When considering as positive EndoFaster^® results when at least one of two (ammonium and pH levels) tests were positive, the NPVs were as high as 89% and 86%, respectively, to rule out H. pylori and extensive precancerous lesions on gastric mucosa, with an overall accuracy of 83% and 74%.

Conclusions: This study supports the evidence that real-time gastric juice analysis allows to avoid clinically unrewarding and potentially unsafe gastric biopsies in a definite portion of cirrhotic patients, but more data are needed.

Introduction: Chronic infection with hepatitis C virus (HCV) causes 25% of hepatocellular carcinoma (HCC) cases worldwide, a major cause of morbimortality even after sustained virologic response (SVR). Universal screening to all patients with advanced liver fibrosis is currently recommended. A risk-based strategy could improve the detection rate of early HCC and diminish the surveillance burden. Although several risk prediction models exist, exclusion of a subgroup of patients from surveillance has not yet been recommended. The objective of this study was the comparison of the predictive accuracy of transient elastography, FIB-4, and aMAP for HCC in HCV patients after SVR in Portugal.

Methods: This was a multicentric retrospective study including patients with HCV after SVR. Comparative, univariate, multivariate, area under the ROC (receiver-operating characteristic) curve (AUC), and Youden's J-statistic analysis were performed.

Results: HCC incidence was 4.2% (1.3/100 patient-years) after a median follow-up of 31 months with inclusion of 337 patients. All patients had a liver stiffness measurement (LSM) before SVR (considered the baseline), but only 148 (43.9%) had a transient elastography after SVR. FIB-4 and aMAP post-SVR were calculated in all patients. Multiple parameters positively correlated with HCC, but only age and baseline transient elastography remained as independent predictors in the multivariate analysis. The optimal cutoffs for prediction of HCC were baseline transient elastography 13.7 kPa, post-SVR transient elastography 16.5 and 15.8 kPa (first and last measurements, respectively), FIB-4 1.6, and aMAP 58. Baseline transient elastography revealed a fair accuracy in predicting HCC (AUC 0.776, p < 0.001), with the cutoff of 13.7 kPa presenting a sensitivity of 85% and a specificity of 69%. Regarding patients who were F3-4 at baseline (n = 162), almost one-third had a baseline LSM ≤13.7 kPa (n = 51, 31.5%), an FIB-4 ≤1.6 (n = 50, 30.9%), and an aMAP score ≤58 (n = 48, 29.6%), and these cutoffs presented an NPV of 98%, 94%, and 96%, respectively, when considering HCC development.

Conclusion: Transient elastography (FibroScan) before SVR was a fair predictor of HCC, being more accurate than FIB-4 and aMAP. Transient elastography values ≤13.7 kPa at baseline, FIB-4 ≤1.6 and aMAP ≤58 were the cutoffs considered of low risk for HCC in a Portuguese cohort of HCV patients after SVR with advanced fibrosis. aMAP score is a risk-based surveillance tool that could improve the current HCC screening strategy, but further validation is needed.

Introduction: Capsule endoscopy (CE) is a minimally invasive exam suitable of panendoscopic evaluation of the gastrointestinal (GI) tract. Nevertheless, CE is time-consuming with suboptimal diagnostic yield in the upper GI tract. Convolutional neural networks (CNN) are human brain architecture-based models suitable for image analysis. However, there is no study about their role in capsule panendoscopy.

Methods: Our group developed an artificial intelligence (AI) model for panendoscopic automatic detection of pleomorphic lesions (namely vascular lesions, protuberant lesions, hematic residues, ulcers, and erosions). 355,110 images (6,977 esophageal, 12,918 gastric, 258,443 small bowel, 76,772 colonic) from eight different CE and colon CE (CCE) devices were divided into a training and validation dataset in a patient split design. The model classification was compared to three CE experts' classification. The model's performance was evaluated by its sensitivity, specificity, accuracy, positive predictive value, negative predictive value, and area under the precision-recall curve.

Results: The binary esophagus CNN had a diagnostic accuracy for pleomorphic lesions of 83.6%. The binary gastric CNN identified pleomorphic lesions with a 96.6% accuracy. The undenary small bowel CNN distinguished pleomorphic lesions with different hemorrhagic potentials with 97.6% accuracy. The trinary colonic CNN (detection and differentiation of normal mucosa, pleomorphic lesions, and hematic residues) had 94.9% global accuracy.

Discussion/conclusion: We developed the first AI model for panendoscopic automatic detection of pleomorphic lesions in both CE and CCE from multiple brands, solving a critical interoperability technological challenge. Deep learning-based tools may change the landscape of minimally invasive capsule panendoscopy.

Introduction: Colorectal cancer is the third most prevalent cancer among both men and women with 80% of patients having localized disease enabling curative treatments. Given the low recurrence rate in early-stage disease, there is a growing interest in reviewing follow-up protocols. The aim of this study was to assess the frequency and timing of recurrence in early-stage colon cancer, as well as recurrence patterns.

Methods: The data from all patients with colon adenocarcinoma consecutively treated with surgery at the Instituto Português de Oncologia do Porto, EPE, between January 2013 and December 2016, were retrospectively reviewed.

Results: A total of 1,372 patients with colon cancer were submitted to surgery during the study period. From this group, 51.4% (n = 705) were early-stage colon cancers. Regarding the pathological stage, 3.5% were stage 0, 37.4% were stage I and 59.1% were stage II. The overall recurrence rate was 6.7%. When considering the group of patients without risk factors, the recurrence rate was 5.6%. The majority of recurrences occurred in the first 3 years of follow-up. The recurrence was diagnosed in the majority of patients through carcinoembryonic antigen elevation, followed by imaging exams. The presence of one or more risk factors (high nuclear grade, vascular invasion, extramural venous invasion, and perineural invasion) showed a statistically significant association with recurrence rate.

Conclusion: The recurrence rate was low in early-stage colon cancer, with the majority of recurrences occurring in the first 3 years. Our study results show that surveillance should be tailored according to individual risk factors.

Background: Autoimmune gastritis (AIG) is an infrequent disease predisposing to both neuroendocrine tumours and cancer. This study aimed to evaluate whether pH measurement of gastric juice allows accurate exclusion of the presence of AIG in real time so that gastric mucosa sampling on normal-appearing mucosa may be avoided.

Methods: This study enrolled patients diagnosed with AIG and matched controls (ratio 1:5) who underwent upper endoscopy with standard gastric mucosa sampling and real-time, gastric juice pH assessment. A threshold of pH less than 4.5 was adopted as cut-off to rule out the presence of a feature of AIG. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), overall accuracy, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were calculated.

Results: Data of 40 patients (M/F: 19/21; mean age: 58 years, range: 18-89) with AIG and 212 matched controls were evaluated. Among AIG patients, the feature of atrophy/metaplasia of the oxyntic mucosa was staged as mild in 9 cases, moderate in 9, and severe in the remaining 22 patients. Gastric juice analysis showed a pH value >4.5 in 29 (72.5%) patients and 12 (5.7%) controls. Sensitivity, specificity, accuracy, PPV, NPV, LR+, and LR- were 73% (95% CI = 0.57-0.84), 94% (95% CI = 0.90-0.97), 71% (95% CI = 0.64-0.74), 95% (95% CI = 0.93-0.97), 91% (95% CI = 0.87-0.95), 12.9 (95% CI = 7.19-23.03), and 0.29 (95% CI = 0.18-0.48), respectively. The histological assessment of false-negative cases showed the presence of only mild-moderate atrophy of oxyntic mucosa in 6 (54.5%) cases, and severe in the others.

Conclusions: Our data found that real-time pH evaluation of gastric juice allows ruling out AIG with a very high NPV, but further studies are needed.