Introduction

Nonalcoholic Fatty Liver Disease (NAFLD) is currently the most common chronic liver disease in the developed world where it has become a leading cause of cirrhosis, Hepatocellular carcinoma, and recourse to liver transplantation. It is highly associated with overweight and obesity. However, in Tunisia where obesity is recognized as a real public health problem, the prevalence of NAFLD, in this population, remains undetermined.

Aims & Methods

The aim of our study was to estimate the prevalence of NAFLD and the risk of advanced liver fibrosis in an obese population using Transient Elastography (Fibroscan), as well as to identify its main risk factors.
We conducted a prospective study, enrolling all patients followed for obesity in the department of Nutrition and Diabetology and referred to the department of Hepato-gastroenterology between January 2022 and July 2022, for non-invasive screening of hepatic steatosis. Controlled attenuated parameter (CAP) and liver stiffness measurement (LSM) were assessed by Fibroscan. The presence of hepatic steatosis was defined by CAP ≥ 248 dB/min. A high risk of advanced fibrosis was defined, based on EASL guidelines 2021, by LSM ≥ 12 kPa. The conditions for performing the examination, its reliability criteria, and its contraindications, as set by its manufacturer, were respected. Patients known to have pre-existing chronic liver disease, whatever its etiology, as well as chronic alcohol consumers or those with chronic medication other than that of a metabolic syndrome, were not included in this study.
For all patients diagnosed with hepatic steatosis, a specific check-up was systematically performed, in particular metabolic and virological, a measurement of ferritinemia and serum TSH levels. Statistical analysis of all data was performed using SPSS software (version 22) and P values < 0.05 were considered statistically significant.

Results

We enrolled 219 patients, 88.1% were women, with a mean age of 49 years [18-77 years], a mean body mass index (BMI) of 40.64 ± 10.08 kg/m2, and a mean waist circumference (WC) of 115.29 ± 17.51 cm.
The mean values of CAP and LSM were 291.41 ± 53.48 dB/m and 5.39 ±3.22 kPa, respectively. NAFLD was present in 76.9% of patients. Among them, 4.7% had a high risk of advanced fibrosis.
In univariate analysis, the presence of NAFLD was significantly associated with type 2 diabetes (T2D) (p=0.023), WC (p=0.033), total cholesterol level (p=0.016), triglyceride level (p=0.014), fasting blood glucose (p=0.004), while advanced fibrosis was significantly associated with T2D (p=0.031) and platelet count (p=0.014).
In multivariate analysis, only WC was independently associated with the presence of NAFLD (p=0.007). ROC curve analysis showed that WC had good specificity and sensitivity in predicting NAFLD (AUC=0.776 [0.634-0.918]) with a cut-off of 107.5. In contrast, no factor was independently associated with a high risk of advanced fibrosis.

Conclusion

More than 2/3 of obese people turned out to be affected by NAFLD in our Tunisian population, with more than 4% already having a completely unrecognized high risk of advanced fibrosis. This is an alarming result that should encourage us to implement a systematic screening for NAFLD in this population and in which case an evaluation of hepatic fibrosis in order to activate the management of obesity in its various aspects, which may go as far as to indicate metabolic surgery before it becomes contraindicated, particularly by advanced liver disease.

Introduction

Acute pancreatitis (AP) can pose challenges in diagnosing its underlying cause, with 10-30% of cases remaining elusive despite thorough clinical, biological, and morphological assessments. Echo-endoscopy (EUS) is particularly effective in exploring the bilio-pancreatic region. Our study aims to assess the role of EUS in elucidating the etiology of unexplained AP.

Aims & Methods

We performed a retrospective descriptive study at a university hospital's gastroenterology department between January 2018 and December 2023. It involved 118 patients diagnosed with AP, whose etiology was either suspected or remained undetermined after an initial radiobiological assessment (US, CT scan and MRI). These patients underwent EUS as part of their diagnostic evaluation.

Results

The average age of our patients was 55 ± 16 years, with a predominance of females (73.7%) and a male-to-female sex ratio of 0.35. 32.2% of patients had undergone cholecystectomy. 94.1% were admitted for their first episode of AP, while 5.9% had experienced at least one previous episode. Jaundice was observed in 29.7% of cases, and liver tests abnormalities were noted in 38.5%. Following initial radiological evaluation (ultrasonography, CT scan, MRCP), 53.4% of patients had biliary duct dilatation without visible obstruction, 33.9% had no dilatation, and 12.7% had diagnostic uncertainty. The diagnostic yield of EUS was 83%: micro lithiasis of the main bile duct accounted for 75.4% of cases, tumor-related causes for 4.2%, IPMN in 2 cases, biliopancreatic junction anomaly in 1 case, and Pancreas Divisum in 1 case. EUS findings were normal in 17% of cases.

Conclusion

EUS shows promise in elucidating the etiology of unexplained AP, boasting a high diagnostic yield in exploring the bilio-pancreatic region. Integrating EUS into diagnostic protocols could enhance the management of patients with AP, particularly in cases where initial investigations are inconclusive.

Introduction

Digestive hemorrhage is a frequent complication in advanced chronic kidney disease. Patients with end-stage renal disease (ESRD) are more likely to have gastrointestinal (GI) problems, including digestive bleeding of high or low origin.

Aims & Methods

The aim of our work is to study the particularities of HD in CKD patients.
This is a monocentric prospective analytical study over a period of 28 months: April 2020 to August 2022, including patients with HD with CKD at the dialysis stage or not, including renal transplant patients.
In order to be able to compare patients with ESRD with patients without ESRD, a control group of patients admitted for HD who had a GI endoscopy during the study period and with normal renal function were identified and grouped. In this group of patients, we took into account age, sex, indications, GI endoscopy results and ICU stay.
We also assessed all-cause mortality between the groups of CKD patients with HD versus the control group.

Results

A total of 378 patients underwent digestive exploration for HD. In this population, 46 (12.16%) patients with CKD were compared with 332 patients without RI.
70% (n=32) of the patients with RI were on chronic hemodialysis, 26% (n=12) had a GFR<60ml/min/1.73m2 but were managed without the aid of dialysis or transplantation, and 4% (n=2) patients were renal transplant recipients.
The most common etiologies in CKD patients were ulcer disease 65.2% (n=30); vascular ectasia 28.2% (n=13), gastritis 26% (n=12), esophagitis 10.8% (n=5); and tumors in 8.6% (n=4).
After statistical analysis patients with CKD had:
A higher risk of hemodynamic instability 69.5% (n=32) compared to the control group 11.14% (n=37) with p=0.002,
A higher rate of recurrence 26% (n=12) CKD patients compared to 9.6% (n=32) of the control group with a p=0.00.
A higher mortality rate 4.34% (n=2) in CKD patients compared to the control group 1.2% (n=4) with p=0.00.

Conclusion

GI bleeding in advanced chronic kidney disease is more severe it is accompanied by a higher risk of recurrence of ICU stay and mortality, hence the interest of prompt management and close monitoring. The main causes are peptic ulcer and vascular ectasia.

Clinical Case Summary

Small bowel bleeding can pose a diagnostic and therapeutic challenge.
We present an interesting case involving the use of different endoscopic modalities in jejunal diverticular bleeding. A 66-year-old male with gout and intermittent Naproxen use presented to the Emergency Department with melena. Oesophagogastroduodenoscopy (OGD) and colonoscopy did not reveal any source of bleeding. A Computed Tomography Mesenteric Angiography scan showed evidence of recent hemorrhage within the small bowel loops without active blush seen. Subsequent video capsule endoscopy (VCE) revealed blood pooling in the distal small bowel. He underwent a retrograde double balloon enteroscopy showing only coffee-ground stains in the distal jejunum. Further review of VCE images showed another small ‘dark spot’ in the proximal jejunum. Thus, he underwent an antegrade motorised spiral enteroscopy (MSE) which showed fresh blood clots in the proximal jejunum with multiple large diverticula. Active bleeding was identified from one of the diverticula but difficulty was encountered in manoeuvring the MSE into the jejunal diverticulum. The MSE was switched to a cap-fitted paediatric colonoscope which made it easier to advance into the proximal jejunal diverticulum to address the pulsating vessel. Hemostasis was achieved with adrenaline injection and application of hemostatic clips.
MSE can locate pathology that lies coaxial to the axis of the scope but it can be difficult to reach the culprit lesion due to its off axis location and acute angulation within the diverticulum. Push enteroscopy or balloon-assisted enteroscopy (BAE) maintains its benefit of having a more flexible shaft/tip and can safely enter a jejunal diverticulum for hemostasis even if located off axis compared to MSE. Although MSE represents an innovation, conventional push enteroscopy or BAE still remains an important tool in the endoscopic armamentarium.

References

Illustrative material

1. VCE image with ‘dark spot’
2. Endoscopic image of large diverticulum
3. Hemostasis was achieved with adrenaline injection and application of hemostatic clips
   

Introduction

Disorders of Gut-Brain Interaction (DGBI) are common, affecting 40% of the global population¹. They are associated with psychological distress and somatisation, and detrimentally impact quality of life. The prevalence of DGBI is highest amongst young adults, with medical students reportedly having higher rates than the general population. However, data assessing the prevalence and burden of DGBI amongst medical students is mainly confined to studies from Asia and Africa.

Aims & Methods

We aimed to assess the prevalence and burden of DGBI amongst medical students within a UK based university. An internet-based, cross-sectional, anonymous health survey on physical and mental health was disseminated to medical students enrolled at the University of Sheffield (UK). Information on demographics, past medical history, and gastrointestinal symptoms were collected, the latter using the Rome IV diagnostic questionnaire to determine the presence of DGBI. Additional validated questionnaires screened for somatisation, psychological distress, eating disorders, quality of life, and burnout.

Results

The questionnaire was completed by 378 of 1621 medical students (mean age 21 years, 73% female, and 70% white). The prevalence of having at least one DGBI was 76% (n=289), of which two-of-three had multiple affected sites. The most frequently met diagnostic criteria for DGBI were gastroduodenal (57%), followed by bowel (49%), oesophageal (29%), and anorectal (26%) disorders. Approximately 50% of students with DGBI experienced painful gastrointestinal symptoms at least one day per week.
Compared to students without DGBI, those with DGBI had significantly higher anxiety and depression scores, increased somatic symptom reporting, reduced mental and physical quality of life, poorer eating habits, and more frequent medication use (p-values, all <0.05). They were also at significantly higher risk of burnout, including study exhaustion and disengagement. The greatest health impairment across these domains was seen in those with multiple, painful, DGBI. Only 23% and 5% of students with DGBI had consulted a primary care provider and gastroenterologist, respectively, for their gastrointestinal symptoms.

Conclusion

DGBI are common amongst UK medical students and are associated with psychological distress, somatisation, reduced quality of life, and burnout. However, students with DGBI infrequently seek help for gastrointestinal symptoms. Greater awareness of the high prevalence and burden of DGBI amongst medical students may lead to increased support, improvement in health status, and better study engagement.

References

1. Sperber AD et al. Worldwide Prevalence and Burden of Functional Gastrointestinal Disorders, Results of Rome Foundation Global Study. Gastroenterology. 2021 Jan;160(1):99-114