Introduction

International Association of Pancreatology Guidelines suggest endoscopic ultrasonography (EUS) as surveillance and diagnosis tool for pancreatic cysts despite reliable data on its ability to influence presumptive diagnosis and treatment indications has been either scarce or conflicting.

Aims & Methods

To assess the rate of patients in which EUS changed presumptive diagnosis and treatment indication, compared to radiological investigations alone. All patients who underwent EUS for a presumed pancreatic cyst at the Verona Pancreas Institute from January 2019 to December 2021 were included.

Results

	Changing diagnosis, n (%)	Changing treatment, n (%)
cNET (n= 15)	7 (46.7)	3 (20.0)
IPMN with HRS (n= 72)	34 (47.2)	19 (26.4)
IPMN with WF (n= 149)	55 (36.9)	53 (35.6)
MCN (n= 45)	15 (33.3)	12 (26.7)
SCN (n= 45)	10 (22.2)	10(22.2)
SPT (n= 9)	0 (0)	0 (0)
Other rare benign/non-neoplastic (n= 19)	10 (52.6)	4 (21.1)

EUS changed the presumptive diagnosis in 131 (36.9%) patients. A change of diagnosis was more frequent when the presumptive diagnosis was a rare benign/non-neoplastic cyst an IPMN with HRS (n=34, 47.2%) or a cNET (n=7, 46.7%). On the contrary, all radiologically presumed SPT were confirmed by EUS. In the entire cohort, EUS identified a PDAC in 20 (5.6%) patients. Of note, all presumed SCN in which EUS changed diagnosis had an atypical macrocystic multilocular presentation. EUS changed the treatment indication in 101 (28.5%) patients. Table 1 outlines how EUS changed presumptive diagnosis and treatment indication according to cyst's type.

Conclusion

The impact of EUS on diagnosis and treatment indications of pancreatic cysts is so remarkable that performing this exam should be considered always at least once during the clinical-radiological pathway of pancreatic cysts. Hopefully, in the next future cyst fluid analysis with next-generation sequencing will fill the accuracy gap left by the current radiological criteria of the guidelines and allow to distinguish IPMN-derived and concomitant PDAC extending the indication to perform EUS even in IPMN with HRS. EUS performance in presumed SPT is not supported by this data, but appears common sense given that they mainly occur in young women, frequently teenagers.

Introduction

Non-alcoholic fatty liver disease (NAFLD) can progress to fibrosis and cirrhosis. The evaluation of fibrosis in chronic liver disease using non-invasive methods is a current topic. Standard methods are liver stiffness measurement and serum biomarkers. Splenic elasticity measurement is a recent and interesting non-invasive approach that arouses the interest of the latest studies to evaluate fibrosis severity in NAFLD.
The aim of this study is to identify patients with NAFLD and advanced liver fibrosis, by establishing correlations between splenic and liver elasticity and fibrosis serum biomarkers.

Aims & Methods

This is a prospective study conducted in the hepato-gastroenterology department including all patients followed for hepatic steatosis during the period from July 2022 to January 2023. Patients with a family or personal history of chronic liver disease, and women with acute steatohepatitis in pregnancy or cholestasis in pregnancy were excluded. Measurement of hepatic and splenic stiffness and the degree of hepatic steatosis was done using liver elastrography (Fibroscan®) and Transient elastography with controlled attenuation parameter (CAP), respectively. NAFLD fibrosis (NFS) and Fibrosis-4 scores were calculated. Data were entered and processed using SPSS software version 22.0.

Results

We included 44 patients, divided into 28 women and 16 men (Sex-ratio F/M = 1.75), with a mean age of 61.4 years [32 to 84 years]. Three patients were smokers and four were alcoholics. Hypertension was found in 56.8%, 54.5% were diabetics and 52.3% were dyslipidemics. The mean BMI was 29.6 kg/m²±4.15 kg/m². Obesity was found in 45.5%, 36.4% were overweight and 18.2% of patients were normal weight. Hepatic steatosis was discovered following pain in the right hypochondrium in 79.5% of the cases and in front of a cytolysis in the remaining cases. All patients had diffuse steatosis without portal hypertension or degeneration signs on ultrasound.
Biological results showed cytolysis in seven patients. No patient had cholestasis. All patients had preserved liver function: normal prothrombin level and albumin. Hyperglycemia and lipid disturbance were observed in 43.2% and 36.4% of cases respectively.
Fibrosis was assessed by FIB4 score with a mean value of 1.11± 0.78; NFS score with a mean value of -1.16±1.18 and liver stiffness ranging from 2.4Kpa to 28.4Kpa (mean value 6.67Kpa). The degree of fibrosis judged by Fibroscan results was F0-F1 in 31 cases, F2 in 5 cases, F3 in 5 cases and F4 in 3 cases. Advanced fibrosis was correlated with NFS score (p=0.016), FIB-4 (p=0.001); but not associated with CAP value (p=0.51).
The mean splenic elasticity was 27.57 Kpa (ranging from 8.3 to 75 Kpa). It was significantly associated with liver elasticity (p=0.012) with an AUROC of 0.784. A threshold of 17.4 Kpa was predictive of advanced fibrosis with a specificity of 85.7% and a sensitivity of 73.5% (CI [0.029-0.404]). Similarly, splenic elasticity was correlated with CAP value (p=0.013). No association was identified with NFS and FIB4 scores.

Conclusion

Measurement of splenic elasticity is a simple and reliable non-invasive tool, comparable to liver elasticity, for the prediction of liver fibrosis during NAFLD.

Disclosure

no conflict of interest

Introduction

Device-assisted enteroscopy (DAE) is the only exam capable of a panendoscopic diagnostic and therapeutic intervention in gastrointestinal tract. Despite the limited data, DAE appears to be a safe procedure in pediatric population. In fact, a few studies demonstrate ​the feasibility and safetiness of DAE in several clinical contexts, namely small ​bowel ​bleeding, polyposis syndromes or inflammatory bowel disease.

Aims & Methods

With this study, the authors aim to describe DAE experience, specifically balloon assisted enteroscopy, in a pediatric population of a tertiary center.
A unicentric retrospective study was performed in patients up to 18 years old undergoing DAE (either by anterograde or retrograde pathway), between January 2011 and February 2024.

Results

A total of 23 DAE exams from 16 patients were included in the study, 56% from the male gender. The study population had a medium age of 13 years (ranging from 4 to 18 years old). DAE was performed due to polyposis syndromes in 8 cases (6 cases of Peutz-Jeghers syndrome and 2 cases of juvenile polyposis) and in suspicious cases of middle gastrointestinal bleeding in 8 patients (5 with melena and 3 with ferropenic anemia). There was a total of 17 anterograde DAE, 5 retrograde DAE and 1 intraoperatory enteroscopy. 35% of the procedures were performed in an inpatient setting.
DAE had a diagnostic yield of 95%, identifying polyps in the small bowel or other locations, ulcers, small bowel stenosis and foreign body. A therapeutic procedure was performed in 56% of the cases, namely polypectomy, argon plasma coagulation and foreign body removal. A self-limited bleeding was observed in the first 24 hours after an anterograde DAE, solved without the need of an additional endoscopic or surgical procedure. DAE led to a modification in the clinical outcome in over 90% of the patients.

Conclusion

The present study confirms the safety profile of DAE in the pediatric population. In a cohort from a tertiary referral center, DAE led to therapeutic procedure in the majority of patients, without significant procedure related complications.

References

1. Pennazio, Marco et al. “Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022.” Endoscopy vol. 55,1 (2023): 58-95.
2. Di Nardo, Giovanni et al. “Enteroscopy in children.” United European gastroenterology journal vol. 6,7 (2018): 961-969.

Disclosure

1. Pennazio, Marco et al. “Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022.” Endoscopy vol. 55,1 (2023): 58-95.
2. Di Nardo, Giovanni et al. “Enteroscopy in children.” United European gastroenterology journal vol. 6,7 (2018): 961-969.