Introduction

Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) is one of the best imaging modalities to visualize tumor blood flow, but conventional observation can sometimes be insufficient, particularly in lesions characterized by rapid changes in blood flow. Inflow-time mapping (ITM) is a colored parametric display of time-to-peak enhancement for each pixel in the display that allows a better differentiation of tissues by their speed of contrast agent uptake. ITM is a simple, easily reproducible computer-aided color parametric imaging (CPI) technique that can bring a more objective approach to CEH-EUS analysis and further improve the differential diagnosis of pancreatic masses.

Aims & Methods

To investigate the potential advantages and limitations of Inflow-time Mapping - a novel computer-aided color parametric imaging technique - in assessing focal pancreatic lesions using contrast-enhanced harmonic endoscopic ultrasound.
A total of 15 patients including 8 cases of pancreatic ductal adenocarcinomas (PDAC), 3 cases of chronic pancreatitis, 2 cases of pancreatic neuroendocrine tumors (NETs), one case of serous cystadenoma (SCA) and one case of intraductal papillary mucinous neoplasm (IPMN) were enrolled. CEH-EUS and ITM examinations were performed for the frames obtained during the arterial phase. All CEH-EUS and ITM images were retrospectively reviewed and two sets of criteria were assigned: (1) Routine CEH-EUS alone, focusing on the degree and pattern of enhancement, and (2) CEH-EUS and ITM, focusing on differentiating pancreatic lesions based on their speed of ultrasound contrast agent (UCA) uptake, compared to adjacent tissue. Final diagnosis was based on EUS-guided tissue fine needle aspiration biopsy (EUS-FNAB).

Results

Based on CEH-EUS, 11 pancreatic lesions were initially considered PDAC based on their hypoenhanced appearance. ITM analysis could not provide additional information in 8 patients due to insufficient vascularization. In 3 patients, by showing no difference in the speed of UCA uptake in the enhanced regions of the lesion compared to the surrounding parenchyma, ITM analysis was able to correctly identify chronic pancreatitis, as proven by histology. Among the 2 hyperenhanced pancreatic lesions described on CEH-EUS, ITM analysis was able not only to correctly diagnose but also to provide an extensive characterization of 2 pancreatic NETs by showing a greater speed of UCA uptake in the lesion and a typical pattern of the parametric map. ITM analysis also proved useful in objectively highlighting the speed and pattern of enhancement (septal/mural) of 2 included cystic lesions, IPMN and SCA.

Conclusion

ITM is a promising tool for an objective, simplistic approach, in the assessment of hypervascular pancreatic lesions, particularly pancreatic NETs. It can also become an important step in the evaluation of focal pancreatic masses in patients with chronic pancreatitis, where parenchymal inhomogeneity and altered local perfusion might influence the purely visual assessment of CEH-EUS.

References

Dietrich CF, Dong Y, Froehlich E, Hocke M. Dynamic contrast-enhanced endoscopic ultrasound: A quantification method. Endosc Ultrasound. 2017 Jan-Feb;6(1):12-20. doi: 10.4103/2303-9027.193595. PMID: 28218195; PMCID: PMC5331837

Introduction

Dysphagia is a common condition with consequences surpassing the physical dimension and extending to the patient’s psychological, personal, and professional life. However, when referring to non-obstructive esophageal dysphagia (NOD) and motility disorders, data is still scarce.

Aims & Methods

Our study consists in a prospective and multicentric evaluation of the severity of dysphagia and its impact on quality of life, that was measured with the Eckardt, EuroQol-5D (TTO and VAS) and PROMIS GI Disrupted Swallowing (PDS) scores, in patients with NOD and underlying motility disorders. We included 373 individuals (250 with NOD and 123 without dysphagia).

Results

Among patients with NOD, 97 had esophagogastric junction (EGJ) outflow disorders on manometry according to Chicago V4.0, 24 spastic motility disorders, 38 hypomotile disorders and 91 normal motility. Compared with non-dysphagic individuals, dysphagic patients had significantly worse scores of both EuroQol-5D and PDS (p-values <0.001).
Among esophageal motility disorders, Eckardt score was significantly different between groups (p-value <0.001) as determined by ANOVA. Specifically, it was significantly higher in EGJ outflow disorders (mean of 5.2), when compared to spastic motility disorders (mean of 3.3) or dysphagic patients with normal motility (mean of 3.2).
With respect to Patient-reported outcomes, PDS score was statistically different between groups (p-value 0.003), being higher in the EGJ outflow disorders (mean T-score of 64.1) when compared to hypomotiity disorders (mean of 60.2) and dysphagic patients with normal motility (mean of 60.3).
Regarding patient-reported quality of life, there were no differences between groups in terms of EuroQol-5D TTO or VAS score (p-value of 0.156 and 0.368, respectively).

Conclusion

Our findings highlights the impact of NOD on the quality-of-life of patients. Although physician and patient reported symptoms’ severity were worse on EGJ outflow disorders, overall quality of life seems equally affected among all esophageal motility profiles.

Introduction

Enteropathy Associated T Cell Lymphoma (EATL) is a rare and highly aggressive T-cell non-Hodgkin’s lymphoma (NHL)¹ that is strongly associated with refractory coeliac disease (RCD), particularly type 2 RCD ², and possibly inflammatory bowel disease (IBD). The incidence and prevalence of both coeliac disease³ and IBD⁴ have been rising around the world for several decades, including in both Englandand Denmark^​. Some of the potential drivers of EATL are the antigen-driven proliferation of intra-villous T-cells from coeliac disease and chronic inflammation in IBD, so it is important to understand if changes in these diseases are altering clinical presentations of EATL and its survival.

Aims & Methods

Our aim was to describe the contemporary incidence and survival of EATL from two European countries on a national scale, given the rising incidence and prevalence of coeliac disease and use of immunosuppression in inflammatory bowel disease, to give further insights into epidemiology of this rare and often fatal malignancy.
People with EATL were identified from national cancer registries from 2013-2019 in England and 2004-2020 in Denmark. Within each country we used direct standardisation to estimate incidence, Poisson regression to compare incidence between groups and Cox regression to assess overall survival.

Results

172 and 39 patients were identified in England (E) and Denmark (DK) respectively with a mean age at diagnosis of 66 and 68 years. Approximately half of all cases had coeliac disease (E 52%, DK 41%), and ~7% (E 6%, DK 8%) had inflammatory bowel disease (Table). The overall age-standardised incidence rate was (E) 0.48 (95% CI 0.41-0.56) and (DK) 0.44 (95% CI 0.30-0.58) per million population per year. In both countries incidence was higher in older age groups. The 5-year overall survival was 10% (95% CI: 6%-18%) in England and 20% (95% CI: 9%-33%) in Denmark. Those with coeliac disease fared better than those without: (adjusted Hazard Ratio E 0.65 (95% CI 0.45-0.93), DK 0.57 (95% CI 0.26-1.27)).

Table: Characteristics of people with EATL in England (2013-2019) and Denmark (2004-2020)

Conclusion

This analysis of two nationwide cancer registries is the largest population-based study to date to provide contemporary and comprehensive epidemiologic estimates of all ICD-O-3 coded EATL. It shows that a higher incidence is associated with older age, male sex (in England) and that half of cases also have coeliac disease. Our finding of the high proportion of people with inflammatory bowel disease compared to the background prevalence in both countries requires further investigation, as reasons for this are unclear, but it could be related to chronic inflammation or immunosuppression. Overall survival is poor and gets worse in older age groups but is better in those with coeliac disease, following surgical resection and those able to tolerate intensive therapies.

References

1. Ferreri AJ, Zinzani PL, Govi S, et al. Enteropathy-associated T-cell lymphoma. Crit Rev Oncol Hematol 2011;79:84-90.
2. Pelizzaro F, Marsilio I, Fassan M, et al. The Risk of Malignancies in Celiac Disease-A Literature Review. Cancers (Basel) 2021;13.
3. King JA, Jeong J, Underwood FE, et al. Incidence of Celiac Disease Is Increasing Over Time: A Systematic Review and Meta-analysis. Am J Gastroenterol 2020;115:507-525.
4. Ng SC, Shi HY, Hamidi N, et al. Worldwide incidence and prevalence of inflammatory bowel disease in the 21st century: a systematic review of population-based studies. Lancet 2017;390:2769-2778.

Introduction

Colonic diverticular bleeding (CDB) is the most common cause of acute lower gastrointestinal bleeding (ALGIB) and often requires blood transfusion. There are several studies regarding the use of restrictive blood transfusion for acute upper gastrointestinal bleeding, but there is only one previous study regarding the use of restrictive blood transfusion for ALGIB [1]. Therefore, the efficacy of restrictive blood transfusion for CDB remains unclear.

Aims & Methods

This study sought to elucidate the association between the restrictive blood transfusion strategy and the clinical outcomes in patients with CDB. We retrospectively analyzed 475 patients who were urgently hospitalized for CBD and received blood transfusions at two facilities between November 2013 and December 2021. Transfusion strategy was defined as the restrictive group when patients received transfusion for hemoglobin (Hb) ≤ 7 g/dl, and the liberal group when patients received for Hb > 7 g/dl. The hemoglobin cut-off value for restrictive blood transfusion was determined based on a prior randomized clinical trial regarding UGIB [2]. Rebleeding within 30-days, mortality within 30-days, and composite outcome within 30-days were evaluated. The composite outcome comprised the following endpoints: rebleeding, need for surgery or IVR for hemostasis, and mortality within 30 days. We also investigated medical costs during hospitalization. Logistic regression analysis was performed to calculate the odds ratios (OR) with 95% confidence interval (CI) to analyze associations between restrictive transfusion strategy and outcomes.

Results

Of 475 patients, 184 (38.7%) (124 males, 60 females, mean age 76.5±11.5 years) patients received blood transfusion. The mean hemoglobin levels at the time of transfusion in the restrictive and liberal groups were 6.3±0.6 g/dl and 8.2±1.2 g/dl, In the restrictive and liberal group, rebleeding within 30-days was 53.9% and 45.3% (P = 0.24), the mortality within 30-days was 1.1% and 0% (P = 0.30), the composite outcome within 30-days was 56.1% and 52.6% (P = 0.63), respectively. After adjusting for potential confounders, multivariate analysis revealed that restrictive transfusion strategy not associated with decreased rebleeding risk within 30-days, (P = 0.42 ; odds ratio [OR], 1.3), whereas endoscopic hemostasis significantly associated with decreased rebleeding risk (P < 0.01 ; OR 0.2). There was no statistically significant difference in total medical costs between the two groups (P = 0.68).

Conclusion

There were no statistically significant differences in rebleeding within 30-days, mortality within 30-days, and compositeoutcome within 30-days between the restrictive and liberal blood transfusion strategies. Restrictive blood transfusion may be a reasonable therapeutic strategy for patients with CDB, except for patients in which shock status cannot be withdrawn. However, further evidence is needed to advocated the efficacy of restrictive transfusion strategies for lower gastrointestinal bleeding.

References

[1] Kherad O, Restellini S, Martel M, Sey M, Murphy MF, Oakland K, et al. Outcomes following restrictive or free red blood cell transfusion in patients with lower gastrointestinal bleeding. Aliment Pharmacol Ther. 2019 Apr;49(7):919–25.
[2] Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan;368(1):11–21.

Clinical Case Summary

A 45-year-old woman was founded with a raised serum alpha-fetoprotein (AFP) level of 89 ng/ml ( normal range < 8ug/L ) when taking a routine physical examination. During the following year, the serum AFP concentration level was gradually rising, up to 6353 ng/ml. There was no significant loss of weight or loss of appetite, and she denied having any feeling of bloating or abdominal pain.
Although the serum AFP concentration level was abnormally high, the cancer antigen (CA)125, cancer antigen (CA)199, carcinoembryonic antigen (CEA), PIVKA-II, AFP-L3, β-HCG levels were all within normal limits at each check. There was no abnormal findings in the hepatobiliary systems except the modest increased bilirubin (within 2 times). Hepatitis A, hepatitis C, hepatitis E antibody screen was negative. The result of HBV markers were: HBsAg(-), HBsAb(+), HBeAb(-), HBeAb(-), HBcAb(+), While HBV DNA quantification was less than 5.00E+2 IU/ml. Moreover, there was no significant abnormality concerning autoimmune liver disease. During the one-year follow up, several imaging examinations were performed,including abdominal ultrasonography, enhanced computer tomography (CT) , magnetic resonance imaging (MRI) and PET-CT. However, there was no evidence of liver lesion or tumour on all of them, even the PET scan.To check for hepatoid adenocarcinoma, gastroscopy, colonscopy, enhanced chest CT enhanced abdomen CT, and thyroid ultrasound were performed. Nevertheless, no suspicious lesion was found.
One year later, a 2.8×2.6 cm mass was detected in the left lobe of liver in a surveillance ultrasound scan. She underwent laparoscopic hepatocarcinoma resection, and the mass was confirmed moderately differentiated hepatocellular carcinoma by pathology. After surgery, AFP levels took 3 months to normalize.
From this case, we found that a gradual rise elevation in AFP were positive predictors for tumor development, especially hepatocellular carcinoma.

Clinical Case Summary

Ballon-occluded retrograde transvenous occlusion (BRTO) is a minimal invasive procedure to treat mainly the gastric varices but it may be used in ectopic varices as well. We report a case of 70years old male known to have Alcoholic liver disease (cirrhosis) with portal hypertension, presented with malena. He underwent an urgent Gastroscopy which showed GAVE (Gastric antral vascular ectasia) and Grade 1 varix not needing any therapy. Due to persistent malena and haemoglobin drop, CT mesenteric angiogram was performed which reported multiple enlarged varices in the abdomen with no active site of haemorrhage. Video capsule endoscopy was performed which showed small bowel varices with evidence of fresh blood. Unfortunately, the ultrasound liver showed thrombosis of portal vein. Due to portal vein thrombosis TIPSS (Transjugular intrahepatic porto systemic shunt) was not performed and MDT decision for BRTO (Balloon-occluded retrograde transvenous occlusion) was made which the patient underwent successfully.
BRTO is advantageous over TIPSS because this can be performed with poor hepatic reserve and with hepatic encephalopathy however it increases the risk of bleeding from oesiphageal varices and ascites. Gastro-renal shunts are the most sites for use of BRTO however, this procedure was successfully done in this case.
Based on literature review BRTO procedure has been successfully used in gastric varices.
I’ve found few cases reported with small bowel varices treated with BRTO.
Learning points:

1. Whether BRTO is superior to TIPPS for ectopic varices
2. Whether BRTO can be considered in ectopic varices in patients without portal vein thrombosis

References

https://www.sciencedirect.com/science/article/pii/S1930043317305022


https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3444869/#!po=0.806452

Disclosure

No conflict of interest