Introduction

Non-alcoholic liver disease (NAFLD) is a leading cause of liver-related morbidity and mortality having an overall prevalence of about 30%. Inflammatory bowel diseases (IBD) are caused by a dysregulated immune response in the hosts, favored by genetic susceptibility. In addition to symptoms related to the digestive tract, about 40% of patients with IBD also experience extraintestinal manifestations. Although, NAFLD has been frequently associated with IBDs, the relationship between these two pathologies remains unclear.

Aims & Methods

The aim of this study was to investigate the prevalence of NAFLD among IBD patients, as well as the factors that connect these two conditions.From January 2022 to November 2022, consecutive IBD patients were enrolled from a tertiary care center hospital in Iasi. All patients' demographic information, clinical characteristics including blood pressure, biological parameters, and anthropometric measurements were collected. Following informed consent, participants underwent a fibroscan evaluation for liver stiffness measurement (LSM) and controlled attenuation parameter (CAP).

Results

A total of 93 patients with IBD were enrolled (65,3% men, 55,6% with ulcerative colitis). 45 (48,3%) of them were diagnosed with NAFLD, with a mean CAP score of 283 ± 33.4 vs. 215 ± 23.7 in patients with IBD only. Regarding liver fibrosis, mean LSM value in the NAFLD group was 6.8 ± 1.9 kPa vs. 5.7 ± 2.3 kPa in the non-NALFD group. Subjects with NAFLD exhibited higher body mass indexes than those with IBD only (26.2 vs. 33.1, p<0.05). In addition, the prevalence of diabetes was much greater among this group (27.5% vs. 0%; p=0.0001), as was the prevalence of elevated HbA1c levels in the absence of a diabetes diagnosis (14% vs. 7.35%; p=0.23). They also had a non-significantly higher mean systolic blood pressure and greater incidences of hypertension. Age (β=0.357, p=0.034), body mass index (BMI) (β=0.185, p=0.048), disease duration (β=0.297, p=0.037), C - reactive protein (β=0.321, p=0.013), fasting plasma glucose (β=0.269, p=0.018) and triglycerides (β=0.273, p=0.021) were strongly associated at the multivariate analysis with the diagnosis of NAFLD in our cohort of patients with IBD. Advanced fibrosis (LSM > 9.7 kPa) was associated with age, BMI and the level of triglycerides. After adjusting for classic metabolic risk factors, age and gender the multivariate logistic regression analysis showed that the presence of IBD (odds ratio, 2.45; 95% confidence interval,1.17–4.391; p < 0.001). Also, in regard to age and male gender they were independent risk factors for NAFLD. Of note, the 10-year risk of myocardial infarction or death estimated by the Framingham risk scores for hard coronary heart disease was higher in the NAFLD group (2.32% vs. 4.27%, p=0.0024).

Conclusion

NAFLD is an intricate condition that has become more common in IBD patients. The connection between these two pathologies is not fully understood, although metabolic disorders, age and male gender have a notable role. Current evidence in the literature suggests a minor risk for the progression of liver fibrosis, the cardiovascular risk appears to be of more concern. Given the information presented above, patients with IBD should be assessed using a multidisciplinary approach.

Introduction

Chronic pancreatitis is a progressive inflammatory disease characterized by irreversible damage to the pancreas. The etiology of the disease is heterogenous and includes alcohol abuse, smoking, genetic risk factors and autoimmune diseases. Several clinical classification and severity scoring systems have been proposed, but none have been globally accepted or reached broad clinical use. Identifying patients at a higher risk of death is crucial for improving patient care and management.

Aims & Methods

This study aimed to develop a prediction model based on promoter hypermethylation of specific genes and clinical factors to differentiate patients with chronic pancreatitis who are at a higher risk of mortality. Clinical variables such as age, sex, smoking status, alcohol consumption, exocrine insufficiency, and endocrine insufficiency, as well as the methylation status of 16 genes, were analyzed using a backward stepwise Cox regression model. The methylation status was determined by a specialized bisulfite based PCR technique. The final model's performance was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC), and used to determine a risk score for each patients. The “cutpt” package in Stata was used to determine an optimal cut-off, in order to stratify patients into low and high-risk groups. Kaplan-Meier survival curves, and cox regression, and AUC were used to determine the accuracy of the risk groups.

Results

Ninety-seven patients with chronic pancreatitis were included in the study. The final prediction model included age, sex, exocrine insufficiency, endocrine insufficiency, and the methylation status of 5 genes: SFRP2, HIC1, MLH1, RASSF1A, and CDKN2B. The AUC of the model was 0.84, indicating high reliability. The model was superior to a model including only clinical variables (AUC = 0.76), indicating added value of the methylation markers. The optimal cut-off value for the risk score was 7.76. According to this, 67 patients were in the low-risk group, and 30 in the high-risk group. The 5-year survival in the high-risk group was 53% compared to 94% in the low-risk group. Being in the high-risk group was significantly associated with an increased HR of death of 10.2 (95% CI; 4.9-21.1), demonstrating the model's strong prognostic value.

Conclusion

The developed prediction model, which combines clinical factors and gene promoter hypermethylation status, could be a valuable tool for identifying patients with chronic pancreatitis who are at a higher risk of death. This study serves as proof-of-concept of the unexplored potential of methylation analysis in cell-free DNA in chronic pancreatitis. This model can potentially enhance patient care by enabling targeted interventions and monitoring for high-risk individuals, ultimately improving their prognosis and quality of life.

Disclosure

S.D.H., P.H.M., O.T.-U., and H.B.K. declare that they have a patent on a diagnostic panel including the promoter hypermethylation status of 8 genes. Application No. 16161073.8 – 1403 Pancreatic Cancer methylation Markers (18.03.2016)

Introduction

Etiology of acute pancreatitis can be established in the majority of patients. However, in 25 % of cases it remains elusive. Biliary microlithiasis/sludge is detected in up to 75% of patients with idiopathic acute pancreatitis (IAP). As recurrent biliary pancreatitis can be prevented, the underlying etiology of IAP should be established. The aim of this multicentre retrospective study was to develop a machine learning-aided non-invasive prediction tool to guide clinicians in the selection of idiopathic acute pancreatitis patients to be referred to endosonography to establish etiology and allow treatment.

Aims & Methods

We retrospectively used routinely recorded clinical and laboratory parameters of 218 consecutive patients with confirmed acute pancreatitis admitted to our tertiary care hospital between 2015 and 2020. Patients who did not receive endosonography as part of the diagnostic work-up and whose pancreatitis episode could be adequately explained by other causes than biliary sludge and microlithiasis were excluded. We trained supervised machine learning classifiers using H2O.ai automatically selecting the best suitable predictor model to predict microlithiasis/sludge. The predictor model was validated in two independent retrospective cohorts from two tertiary care centers (TU Munich & University Medical Center Göttingen).

Results

28 categorized patients’ variables recorded at admission were identified to compute the predictor model with an accuracy of 0.84 [95% CI 0.791, 0.9185], positive predictive value of 0.84 and negative predictive value 0.80 in the identification cohort (218 patients). In the validation cohort, the robustness of the prediction model was confirmed with an accuracy of 0.76 [95% CI 0.673, 0.8347], positive predictive value of 0.76 and negative predictive value of 0.78 (117 patients).

Conclusion

We present a robust and validated machine learning-based predictor model consisting of routinely recorded lab work at admission that can predict biliary sludge and microlithiasis as cause of acute pancreatitis and select patients for EUS.

Introduction

Cardiorespiratory arrest is a recognized complication of endoscopic procedures, particularly when sedation is administered. Hospitalized patients, especially those with a prescribed Do Not Resuscitate (DNR) order, are more likely to have severe underlying illness, and consequently a higher risk of cardiorespiratory complications. Additionally, the request for endoscopic exams, especially urgent ones, in this group of patients is becoming increasingly common.

Aims & Methods

The aim of this study was to asses the current clinical practices, as well as the beliefs of gastroenterologists in Portugal regarding the management of the code status in hospitalized patients with prescribed DNR undergoing endoscopic procedures.
Self-reported data was obtained through a voluntary and anonymous survey of gastroenterologists and gastroenterology trainees in Portugal.

Results

One hundred and forty five gastroenterologists, of which 26 (17.9%) were trainees, responded to the survey, with an average age of 42 years (27-83 years), and 59.3% female. The majority are aware of the patient's code status prior to the endoscopic procedure (73.1%, n=106). However, DNR is rarely discussed (<25% of cases) with the patient/legal representative (66.9%, n=97) or attending physician (58.6%, n=85). In patients with prescribed DNR, the rate of reversal prior to the procedure is rarely performed (reversal in all or almost all in 8,3%, n=12). Most respondents are unaware of the procedures necessary for DNR prescription (81.3%, n=118), as well as existing national/international recommendations on DNR reversal (96.5%, n=140). Regarding personal beliefs, the majority consider that in these patients DNR should be reversed to an intermediate option that includes limited resuscitation maneuvers according to the patient's preference (62.1%, n=90). They also believe that the urgency of a procedure should not influence the decision to reverse DNR (n=89, 61.4%), and that if DNR is reversed, it should be done by the attending physician who initially prescribed it (91.7%, n=133). Finally, respondents are divided when asked if they would perform an endoscopic procedure on a patient with prescribed DNR that has not been previously reversed: 49.7% answered yes (n=72), 22.1% no (n=32), and 28.3% have no formed opinion (n=41). There is a consensus on the need for recommendations on this topic for gastroenterologists (97.9%, n=142).

Conclusion

The majority of Gastroenterologists rarely reverse DNR before endoscopic procedures, however, it is mostly advocated that limited resuscitation maneuvers should be offered according to patient preference. Most are unaware of the existence of institutional, national, or international policies regarding DNR. These findings suggest considerable variation in knowledge and approach to hospitalized patients with DNR, highlighting the need for specific recommendations for Gastroenterology in this area.

References

H. Carneiro A, Carneiro R. DNR A Decisão de Não Reanimar. Revista Portuguesa de Medicina Interna [Internet]. 5 de Dezembro de 2021
Braga I, Dutschmann L, Fiuza T, Almeida H, Gil V, Brandão T. Implementação da Ordem de Não Reanimar. Revista Ordem Médicos. 2012;133:20-23.
Wada K, Szego MJ. Revisiting code status in patients undergoing GI endoscopy with a "do not resuscitate" order. Gastrointest Endosc. 2019 Feb;89(2):380-382.
Feld LD, Mergener K, Rubin DT, Rao VL. Management of code status in the periendoscopic period: a national survey of current practices and beliefs of U.S. gastroenterologists. Gastrointest Endosc. 2021 Jul;94(1):172-177.e2.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential technique for pancreato-biliary diseases. Pancreatico-biliary infection occurs after 0.4–0.8% of endoscopic biliary procedures, with cholangitis and sepsis occurring in up to 3% of cases. These episodes must always be taken seriously because fatality has been reported in 8–20% of such cases.
During the pandemic from coronavirus disease 19, recommendations by the European Society of Gastrointestinal Endoscopy (ESGE) suggested postponing elective procedures, use of triage, use of personal protective equipment and creation of differentiated in-hospital pathways, in order to protect both patients and endoscopy unit personnel.
Currently, it is not know whether, as a result of the change in these procedures, the overall mortality and the infection's rate related to ERCP has been modified in the post-COVID era.

Aims & Methods

In this study, we retrospectively compared ERCP activity, post-ERCP infection rate and 30 days-mortality in our tertiary center before and after the adoption of new criteria for patient's selection and protective equipment implementation, specifically from October 2016 to December 2019 (before COVID) and from January 2020 to March 2023 (after COVID).

Results

During the 39 months before COVID, we performed 417 ERCP for 285 patients, while in the same amount of time after COVID, we executed 257 consecutive ERCP for 191 patients. The indications for performing ERCP were made for obstructive cholangitis caused by stones, by pancreatic or bile ducts neoplasms, by malignant lymph nodes or for post-surgical complications.
Positive blood cultures done within 1 week from ERCP were 13 among 417 exams before COVID and 9 among 257 ERCP after COVID, with septicemia related to ERCP only in 2 procedures (0.5%) before COVID and another 2 (0.8%) after COVID. Cultures resulted positive for Klebsiella pneumoniae and Candida albicans in the first group, while in the group after COVID, patient’s blood cultures were positive for Enterococcus faecium and Klebsiella oxytoca.
Overall mortality at 30-days after ERCP accounted for 16 patients (5.6%) during 39 months considered before COVID and 9 patients (4.7%) after COVID. In the first group, the fatal complications were related to ERCP in 2 cases (0.7% of patients), due to the perforation of the digestive tract, while in the second group, 1 patient (0.5%) had a septic shock from Klebsiella oxytoca after ERCP.

Conclusion

In conclusion, our retrospective analysis of a real life cohort of consecutive patients undergoing ERCP in a single tertiary center, demonstrated that the shortages of medical resources caused a significant drop in the ERCP activity, notably about 38%, Ultimately, the delay due to the COVID pandemic, the rational use of antibiotics and the intensification of personal protective equipment did not change significantly the rate of adverse events, like post-ERCP septicemia (0.5-0.8% before and after COVID respectively), or the 30-days mortality rate after ERCP (0.7%-0.5% before and after COVID respectively).

References

- Khashab MA, Tariq A, Tariq U, et al. Delayed and unsuccessful endoscopic retrograde cholangiopancreatography are associated with worse outcomes in patients with acute cholangitis. Clin Gastroenterol Hepatol 2012;10:1157-61
- Gralnek I M, Hassan C, Beilenhoff U et al. ESGE and ESGENA Position Statement on gastrointestinal endoscopy and the COVID-19 pandemic. Endoscopy. 2020;52:483–490.
- Dumonceau JM, Kapral C, Aabakken L, Papanikolaou IS, Tringali A, Vanbiervliet G, Beyna T, Dinis-Ribeiro M, Hritz I, Mariani A, Paspatis G, Radaelli F, Lakhtakia S, Veitch AM, van Hooft JE. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2020 Feb;52(2):127-149.
- Casini B, Pan A, Guarini A, Rivara C, Zullo A, Monica F, Cimbro M, Casarano S, Inglese A, Vaghi A, Schiffino L, Capezzuto E, Da Massa Carrara P, Pasquale L; Working Team on Infections in Endoscopy. Multisocieties position paper: Microbiological surveillance on flexible endoscopes. Dig Liver Dis. 2021; 53(9):1105-1111.

Clinical Case Summary

Case: W present a case of a 43-year-old man with hepatic cirrhosis complicated by hypertensive gastrointestinal bleeding, in a program to eradicate esophageal varices. One week after an elective endoscopic variceal ligation (EVL), he presented with fever, anorexia, pain in the dorsolumbar region, headaches, and psychomotor retardation. Subsequently, there was the appearance of focal motor seizures. The analyses showed C-reactive protein of 113 mg/L, without leukocytosis. Peripheral blood cultures were negative. A head computed tomography (CT) showed mild left parietal and occipital cortical hypodensities. Analysis of the cerebrospinal fluid was compatible with central nervous system (CNS) infection. Cerebral magnetic resonance revealed multiple supra and infratentorial rounded lesions, compatible with abscesses and ventriculitis. He started antibiotics with a meningeal dose. Hospitalization was complicated by SARS-COV 2 infection, so a chest CT was performed after 1 month of hospitalization, and was identified a mediastinal abscess with 5 cm with fistulization from the esophagus, compatible with iatrogenic esophageal perforation after EVL. Other possible causes of brain abscesses were excluded. He completed several weeks of antibiotic and parenteral nutrition, with normalization of the neurological status and resolution of brain lesions. About 1 month after targeted antibiotic treatment, he performed an endoscopy, revealing a deformed area in the distal esophagus but no evidence of an orifice or suppuration. Conclusion: Neurological manifestations in patients with liver cirrhosis are usually due to hepatic encephalopathy (HE). However, CNS infection, especially in patients who underwent recent procedures, such as EBL, should be considered in the differential diagnosis, given that early treatment influences the prognosis. Clinically, CNS infection can be very variable, however, it is important to be aware of atypical signs of HE, such as focal neurological deficits.

References

Krige JE, Bornman PC, Shaw JM, Apostolou C. Complications of endoscopic variceal therapy. S Afr J Surg. 2005 Nov;43(4):177-88, 190-4.

Disclosure

Nothing to disclosure

Introduction

Colonoscopy is the ‘gold standard’ investigation for assessment of the large bowel allowing diagnosis, biopsies, and therapy to be undertaken. Colonoscopy detects and prevents colorectal cancer through detection and removal of polyps, and is important in the diagnosis and treatment of non-neoplastic conditions. Poor quality colonoscopy is associated with increased rates of interval cancers. High quality colonoscopy cannot occur without good quality bowel preparation. Evidence in the UK show that 22% of failed colonoscopies were due to poor bowel preparation. Apart from the bowel cleansing agent, dietary restriction prior to colonoscopy has been shown to enhance quality of bowel preparation at colonoscopy.

Aims & Methods

We aimed to assess the information received and followed by patients in terms of dietary modification prior to colonoscopy.
A single centre prospective analysis of 60 consecutive patients attending colonoscopy at Chase Farm Hospital in London was undertaken in May 2022. Patients were asked to complete a questionnaire with information gathered about: type of bowel prep undertaken, whether written information about how to take bowel prep was received, whether a telephone consultation explaining dietary restriction prior to procedure happened, whether they followed a low fibre diet and the amount of fluid drunk.

Results

57 patients returned the questionnaire.
Of the 57 patients, 39% patients received written information on dietary restriction. A further 35% of patients received telephone information, 26% of patients receiving both written and verbal information. 56.9% of patients followed the 3 day dietary restriction. The quality of bowel preparation was inadequate (fair and poor by Aronchick scale) in 60% of those who did not follow the low fibre diet compared to 24% when followed. Patients who had seen a clinician in clinic and patients undergoing surveillance procedure were more likely to follow dietary restriction compare to direct access patients.

Conclusion

In this prospective study of clinical practice, we conclude that advice regarding dietary fibre restriction prior to colonoscopy is variable. In clinical practice, there is low compliance of dietary restriction prior to colonoscopy. We find that those who followed a low fibre diet are 40 % more likely to have a favourable bowel preparation compared to those following a high fibre diet. Those that had inadequate bowel prep required a repeat colonoscopy adding to the burden of the already stretched service. We recommend improvements in the implementation of the low residue diet in addition to the guidance of cleansing agents prior to colonoscopy.