Clinical Case Summary

Introduction: Cronkhite-Canada syndrome (CCS) is a rare non-hereditary gastrointestinal polyposis syndrome. We illustrate a case with clinical presentation of dysgeusia, chronic diarrhoea and weight loss, and endoscopic features mimicking inflammatory bowel disease (IBD).
Case: Our patient is a 58-year-old Chinese lady who presented with dysgeusia, vomiting, loose stools, hair loss, peripheral numbness and weight loss. Examination revealed xerosis, onycholysis, periorbital hyperpigmentation and alopecia. (Fig. 1) Gastroscopy showed diffuse gastric mucosal hyperaemia, oedema and nodular changes (Fig. 2A). Helicobacter pylori was negative. Colonoscopy revealed a confluent pan-colonic circumferential nodular colitis (Fig. 3A) Histology showed features reminiscent of IBD with mild ileitis and continuous diffuse crypt architectural changes, cryptitis and crypt abscess formation (Fig. 4A-C). The final diagnosis was CCS based on the constellation of clinical and endoscopic features. She received high dose steroid therapy and mesalamine with significant improvement. However, upon tapering of her prednisolone to 15mg once daily, recrudescence occurred. Prednisolone was escalated with a more gradual taper with resultant improvement. At 4 months of treatment, the patient achieved clinical response with improvement of appetite, weight gain, diarrhoea and normalization of serum albumin. Repeat OGD showed gastric hyperplastic polyps (Fig. 4C) and colonoscopy showed improvement of confluent nodular and circumferential colitis (Fig. 2B and 3B). The severity of activity improved but features of chronicity remained on her colonic biopsies histologically (Fig. 5A-C).
Conclusion: The optimum treatment of CCS is currently unknown with no consensus guidelines. The mainstay of treatment remains as steroid therapy and nutritional support with clinical and endoscopic remission as therapeutic goals. Recurrences are not uncommon but often respond to corticosteroid retreatment as in our patient.

References

1. Kopáčová M, Urban O, Cyrany J, et al. Cronkhite-Canada Syndrome: Review of the Literature. Gastroenterology Research and Practice. 2013;2013:e856873. doi:10.1155/2013/856873
2. Watanabe C, Komoto S, Tomita K, et al. Endoscopic and clinical evaluation of treatment and prognosis of Cronkhite–Canada syndrome: a Japanese nationwide survey. J Gastroenterol. 2016;51:327-336. doi:10.1007/s00535-015-1107-7
3. Goto. Cronkhite-Canada syndrome: epidemiological study of 110 cases reported in Japan. Nihon Geka Hokan, vol. 64, no. 1, pp. 3–14, 1995
4. Mao E, Hyder S, Laskiewicz L, Taliano R, DeNucci T. A Rare Case of Cronkhite-Canada Syndrome: 1558. Official journal of the American College of Gastroenterology | ACG. 2017;112:S851.
5. Mao EJ, Hyder SM, DeNucci TD, Fine S. A Successful Steroid-Sparing Approach in Cronkhite-Canada Syndrome. ACG Case Rep J. 2019;6(3):e00055. doi:10.14309/crj.0000000000000055
6. Hewett DG, Kaltenbach T, Sano Y et al. Validation of a simple classification system for endoscopic diagnosis of small colorectal polyps using narrow-band imaging. Gastroenterology. 2012 Sep;143(3):599-607.e1. doi: 10.1053/j.gastro.2012.05.006. Epub 2012 May 15.
7. Schulte S, Kütting F, Mertens J, et al. Case report of patient with a Cronkhite-Canada syndrome: sustained remission after treatment with corticosteroids and mesalazine. BMC Gastroenterology. 2019;19(1):36. doi:10.1186/s12876-019-0944-x

Introduction

The undetermined pancreatic cystic neoplasms represent 20-30% of the total number of pancreatic cystic lesions(PCL). The diagnostic accuracy of endoscopic ultrasound (EUS) morphology is 51%. Endoscopic ultrasound-guided fine-needle aspiration(EUS-FNA) should be performed for differentiating between mucinous and non-mucinous pancreatic cysts when the characterization of the cyst cannot be made on the basis of non invasive imaging techniques.

Aims & Methods

Our aim was to assess the utility of the Neutrophil gelatinase-associated lipocalin(Ngal) concentration alone or combined with glucose level in cyst fluid obtained by EUS with EUS-FNA for discriminating between mucinous and non-mucinous PCL's.
This prospective study was performed between april 2018 and may 2020 at one tertiary referral hospital and included 63 patients , 30 with undetermined pancreatic cysts (group A) and the controlled group was represented by 33 patients with pancreatic pseudocysts after acute pancreatitis drained by EUS (group B). The patients from group A underwent EUS-FNA for liquid analysis and the patients from group B had liquid collection during the drainage of pseudocysts. The final diagnosis was based on surgery or EUS results (morphology, cytology, glucose and carcinoembryonic antigen(CEA) intracystic level) or on imaging during follow-up (24 month). We performed sandwich enzyme-linked immunosorbent assays (ELISA) for cystic and serum Ngal determination and measured glucose levels by a hand glucometer.

Results

The final diagnosis was pseudocyst in 33 patients, serous cystadenoma in 6, mucinous cystadenoma in 3, intraductal papillary mucinous neoplasms in 19 patients, and ductal adenocarcinoma in 2 patients. The cystic fluid analysis of these patients showed that the mean Ngal value for the serous cystic adenomas was 336ng/dl, 728ng/dl for the mucinous lesions and 1116ng/dl for the pseudocysts. The intracystic Ngal concentration (cut-off ≥ 500 and ≤ 800ng/dl) had diagnsotic sensitivity 70.8%, and specificity 92.3% for mucinous cysts. Serum Ngal concentration had no diagnostic contribution. The cystic glucose levels (cut-off ≤ 22mg/dl) had sensitivity 83.3% and specificity 82.1% for mucinous lesions. Combined glucose(cut-off ≤ 22mg/dl) and Ngal(cut-off ≥ 500 and ≤ 800ng/dl ) testing showed sensitivity of 58,3 and specificity 100% for mucinous cysts. Wheras either positive Ngal (cut-off ≥ 500 and ≤ 800ng/dl) or glucose (cut-off ≤ 22mg/dl) testing showed sensitivity 95.8% and specificity 74.4%.

Conclusion

Pancreatic cyst fluid NGAL concentration alone and combined with glucose level appeared to be useful in discriminating mucinous cysts.

References

State‑of‑the‑Art Update of Pancreatic Cysts -Andrew Canakis · Linda S. Lee2 Digestive Diseases and Sciences (2022) 67:1573–1587

Disclosure

Nothing to disclouse

Introduction

The quality of colonoscopy is influenced by patient and operator factors. Studies investigating operator attentional fatigue on adenoma detection rate (ADR) have yielded conflicting results.

Aims & Methods

This study aims to compare ADR, polyp detection rate (PDR) and sessile serrated lesion detection rate (SSLDR) and complication rates between elective colonoscopies performed early and late in the list, across multiple operators (n>15), over 10 years, in a tertiary Brisbane (Australia) hospital.
A retrospective study was conducted on elective colonoscopies performed between 2012 and 2022 at The Prince Charles Hospital. ‘Early procedures’ are defined as procedures starting in the first hour of the first procedure starting and ‘late procedures’ are defined as procedures starting within the last hour of the last procedure starting. This pre-defined early and late procedures were used as surrogate markers for operator fatigue, accounting for a possible non-linear relationship between time and onset of fatigue, as well as the variation in number of colonoscopies performed every hour. Timing and the order of colonoscopy were used as alternative surrogates, in a secondary analysis.
Logistic regression was performed on all categorical outcome variables, and Poisson regression was modelled on continuous outcome variables, due to their non-linear distribution. Multivariate analysis included all potential confounding variables related to outcomes of interest. Statistical significance was defined as a P-value less than 0.05. Statistical analyses were performed using the SAS® statistical software (SAS Institute Inc, USA).
Exclusion included; surveillance for IBD and elective ESD.

Results

In total, 15 proceduralist (11 gastroenterologists, 4 surgeons) performed 39, 206 elective colonoscopies from 2012 to 2022. The baseline characteristics of patients, year and procedure sessions are similarly distributed between the early and late groups.
Multivariant analysis found significant associations between late procedures and lower adenoma detection rates, polyp detection rates and SSL detection rates. After adjusting for age, gender, proceduralist, year, morning or afternoon procedure, and bowel preparation quality, PDR, ADR and SDR remain 20-28% lower in late colonoscopies compared with early ones. We also found that age, gender, proceduralist, year and bowel preparation independently affected ADR in multivariant analysis. However, morning or afternoon ADRs did not significantly differ after adjusting for other variables. Proceduralist were found to be the only additional significant variable for SDR in multivariant analysis. There was no significant association between timing of procedures and major adverse events.

Conclusion

This is the largest single-centre study on operator fatigue and its effect on colonoscopy quality. Although the minimum standards for ADR was achieved, ‘late procedures’ have statistically significant lower ADR, PDR and SSLDR compared to ‘early procedures’. There was no difference in the complication rates between ‘early procedures’ and ‘late procedures’.
This study highlights the detrimental effect of fatigue in later procedures affecting the quality of colonoscopies and may be applicable in principal to other procedural based clinical work. Importantly, this may or perhaps will or is having an impact on patient safety, satisfaction, outcomes and clinical KPI’s for the operators and hospital administrators.

Disclosure

None

Introduction

This study aimed to analyze the correlation between different attributes of doctors who prescribe colonoscopies and the cleanliness of the intestine to guide the development of colonoscopy application protocols.

Aims & Methods

Data on colonoscopy cases conducted in the gastroenterology department of Hangzhou First People's Hospital between April 2018 and March 2021 were collected. The gender, age, professional attributes of the prescribing doctors, and Boston Bowel Preparation Scale (BBPS) score were recorded. In addition, the correlation between the prescribing doctors' characteristics and the intestine's cleanliness was analyzed.

Results

The study included 22,522 patients with a mean BBPS score of 6.83±1.94. There were 16,459 male and 6,063 female doctors with similar BBPS scores (P = 0.212). The study found no significant difference in BBPS scores between 19,338 physicians and 3,184 non-physicians (P = 0.154). However, BBPS scores differed significantly between 18,168 gastroenterologists and 4,354 non-gastroenterologists (P = 0.016) and between 19,990 intestinal-related specialties and 2,532 non-intestinal-related specialties (P = 0.000). In addition, BBPS scores were significantly different between 18,126 prescribing doctors with colonoscopy ability and 4,352 without (P = 0.014). However, there was no significant difference in BBPS scores among doctors of different ages (P = 0.190). The study found significant differences in BBPS scores between male and female patients and those under or over 40 years (P = 0.000).

Conclusion

To improve colonoscopy preparation quality, priority should be given to doctors in gastroenterology, intestinal-related specialties, and with colonoscopy operation ability. Their expertise may result in better education and improved bowel cleanliness.

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.