Clinical Case Summary

References

Introduction

The quality of gastrointestinal endoscopy in inflammatory bowel disease (IBD) patients has been recently identified as a major priority being associated with better outcomes.

Aims & Methods

We aim to assess the adherence of Italian gastroenterologists to current international recommendations on quality performance measures for IBD endoscopy.
From March to July 2023 a total of 178 Italian consultants were invited to participate to an online questionnaire-based survey, which included questions on their demographics, professional characteristics and clinical behaviour as well as structural features of their affiliations. Four clinical domains were analysed: A) the first endoscopy for suspected IBD; B) assessment of endoscopic activity; C) post-operative Crohn’s disease; and D) surveillance endoscopy for patients at high risk of colorectal neoplasia. Recommendations from three consensus on quality performance measures for IBD endoscopy (BRIDGE, ECCO, ESGE) were used as reference standards. A p value ≤0.05 was considered statistically significant.

Results

Overall, responders paid low attention to perform ileal biopsies in case of the first colonoscopy for suspected IBD (67% vs standard of care 80%) as well as to the use of the Paris (70%) and mucosal pattern classifications (60%) for lesion characterization of endoscopic visible lesions. Ileal intubation (97%) and colonic biopsies (80%) during the first colonscopy for suspected IBD, adequate tissue samples management (96%), post-operative schedule within 1 year (94%), implementation of surveillance plans (96%) and use of endoscopic index of activity (95%) were highly reported. No significant regional differences were observed, while significantly lower performances were reported for many outcomes by small centers (<100 IBD patients in follow-up and/or no more than 2 physicians for each IBD unit) or physicians spending <50% of their clinical activity for IBD. Young doctors <35 years old had a significantly higher use of modern classifications for lesion characterization (Paris: 89% vs 68%; Kudo:82% vs 56%).

Conclusion

In Italy, the adherence to current standards of care for IBD endoscopy is generally good, with some practices to be improved. There is a need to support the endoscopic activity of small centers and doctors less engaged in IBD.

Clinical Case Summary

Introduction: Kaposi sarcoma is the most common digestive malignancy in Human Immunodeficiency Virus (HIV)-positive patients, but it can also occur in HIV-negative individuals. It is a low-grade vascular tumor associated with Human Herpes Virus-8 (HHV-8) and can appear in immunosuppressed patients. Lesions can develop on the skin, but they could also be found in internal organs and lymph nodes.
Case-report: A 61-year-old Caucasian female with alcoholic liver cirrhosis and diabetes mellitus presented in the Dermatology Department with multiple painless red-to-purple papular nodules across the thorax, cervical area, limbs, and face. Skin biopsies from the posterior cervical area and internal part of the right foot revealed a well-defined nodular dermal tumor with submucosal vascular spindle cells forming slits containing red blood cells and low mitotic activity. Immunohistochemistry confirmed CD34, CD31, HHV-8, and Ki67>30% expression, indicative of cutaneous Kaposi sarcoma. HIV serological tests were negative. Further assessments performed in the Gastroenterology Department established decompensated liver cirrhosis. Moreover, upper digestive endoscopy revealed esophageal varices, portal hypertension gastropathy, along with multiple umbilicated nodules with central ulcerations in the gastric fundus and body. Biopsy samples from these lesions described histopathological findings suggestive of Kaposi sarcoma, while immunostaining for HHV-8 and CD31 was positive. Proposed systemic chemotherapy was declined by the patient. Tumors of the gut with spindle-shaped cells such as leiomyomas, rhabdomyosarcomas, or gastrointestinal stromal tumors must be considered in the differential diagnosis of Kaposi sarcoma.
Conclusion: Kaposi sarcoma can develop in HIV-negative immunosuppressed patients, with conditions such as liver cirrhosis and HHV-8 infections, potentially affecting the digestive tract.

References

1. Xu H, Edwards JR, Espinosa O, Banerji S, Jackson DG, Athanasou NA. Expression of a lymphatic endothelial cell marker in benign and malignant vascular tumors. Hum Pathol 2004;35:857–861.
2. Rossi S, Orvieto E, Furlanetto A, Laurino L, Ninfo V, Dei Tos AP. Utility of the immunohistochemical detection of FLI-1 expression in round cell and vascular neoplasm using a monoclonal antibody. Mod Pathol 2004;17:547–552.
3. Antman K, Chang Y. Kaposi's sarcoma. N Engl J Med. 2000;342:1027–1038.
4. Huang WY, Pantanowitz L, Dezube BJ. Unusual sites of malignancies: CASE 3. AIDS-related Kaposi's sarcoma of the gastrointestinal tract. J Clin Oncol. 2005;23:2098–2099.
5. Arora M, Goldberg EM. Kaposi sarcoma involving the gastrointestinal tract. Gastroenterol Hepatol (N Y). 2010 Jul;6(7):459-62. PMID: 20827371; PMCID: PMC2933764.

Disclosure

No conflict of interest.

Introduction

The severity of bleeding and the time-to-endoscopy are generally recognised as risk factors for mortality in patients with GI bleeding. However, how to grade the bleeding severity (BS) is not clearly defined and it is not clear its relationship with the time-to-endoscopy. We found that the bleeding severity correlates with 5 clinical items: altered mental status, systolic blood pressure ≤100 mmHg, blood ureic nitrogen ≥130 mg/dl, haemoglobin ≤8 gr/dl and clinical presentation with hematemesis.

Aims & Methods

The aim of the study is to evaluate if the interaction between bleeding severity and timing-to-endoscopy could impact on the death risk. A prospective multicentre cohort study, including all consecutive patients with upper gastrointestinal bleeding admitted to 50 Italian hospitals was conducted. Charlson's comorbidity index and ASA scores were used to define the patients’ performance status. According to the previously cited clinical items, we defined bleeding severity (BS) and graded it in low, intermediate, and high-risk classes depending on the presence and the number of items at the time of admission. Timing to endoscopy was defined according to ESGE* guidelines and was divided into 4 time-frames (<6h; 6/12h; 12/24h; >24h).

Results

2,525 patients were included (mean age 68 [±15.8], male 67.3%); the bleeding was non-variceal in 82.3%. Overall, 176 patients died (6.9%); 28 (1.9%) in the low BS group (1,463 patients), 28 (8.6%) in the intermediate BS group (606 pts) and 96 (21%) in the high BS group (p<0.000). In our population, the 4-time frames do not impact on the mortality in the low and intermediate classes of risk. In the high BS class, there is an interaction between the time to endoscopy and the mortality, with the lower mortality observed in the 6/12 hrs frame.

Conclusion

In our population, the death risk gradually rises as the bleeding severity increases. Bleeding severity identifies 3 different classes of death risk and the time to endoscopy seems unrelated to mortality in low and intermediate BS classes. In the high BS patients, the lower mortality was observed in the timing to endoscopy 6-12 hrs.

References

* Ian M. Gralnek et al. Endoscopy 2021; 53: 300–332

Disclosure

nothing to disclose