Clinical Case Summary

We report the case of a 64-year-old man with preexisting hepatic sarcoidosis complicated by liver cirrhosis, who presented with confusion as an initial manifestation of COVID-19 confirmed by rapid Antigenic test. His Child Pugh score was 8 (Class B) and MELD was 16. Chest radiographs showed bilateral patchy interstitial opacities. Computed tomography (CT) of the brain was normal. Lumbar puncture was not performed because of a marked thrombocytopenia. Urine cytobacteriological examination did not show a urinary tract infection. An abdominal ultrasound showed normal hepatoportal flow and a mild ascites. Ascitic fluid analysis did not show spontaneous bacterial peritonitis. Since the patient was cirrhotic, we have considered the diagnosis of hepatic encephalopathy as a possible explanation for the neurological symptoms, so he started Lactulose and Rifaximin. However, his clinical condition showed no improvement, the neurological disorders remained the same. A brain MRI showed in FLAIR MR sequences a few hyperintensities punctiform in the white matter of the supratentorial region and the subcortical of the left insula region. There were no signs of a cerebral granuloma nor toxoplasmosis. It did not show venous thrombosis. There were no microheamorragies neither ischemic lesions. After careful evaluation by neurologic experts, encephalitis associated with SARS-CoV-2 infection was concluded. The patient was treated by intravenous Dexamethasone and he fully recovered without sequelae. This case illustrates the fact that neurological manifestations associated with COVID-19 infection are not necessarily a reflection of critical illness, and should incite clinicians to actively look for any evidence of COVID-19 infection as a differential diagnosis in patients with preexisting cirrhosis, presenting with neurological symptoms, during the epidemic period of COVID-19.

Clinical Case Summary

Closure of mucosal defects after endoscopic submucosal dissection (ESD) may reduce the risk of postprocedural perforation and bleeding. However, defect closure with traditional through-the-scope (TTS) or over-the-scope (OTS) clips and OTS suturing devices may be technically limited by defect size and location. The development of a new through-the-scope helix tack suture system (TTSS) has emerged as a promising tool for overcoming these limitations, particularly when combined with TTS clips.

We present two cases of gastric ESD defect closure with TTSS and adjunctive TTS clip application, highlighting the outcomes and main challenges to achieve complete defect closure.

CASE 1: 73-year-old woman with a 15mm Paris 0-IIb dysplastic lesion of the posterior wall of the antrum. En-bloc ESD was performed and the 25mm mucosal defect was closed with TTSS in a ‘Z’ pattern. However, suboptimal tack placement resulted in incomplete closure of the central portion of the scar, leaving two areas of exposed submucosa at the edges. Complete defect closure was accomplished with the additional placement of four TTS clips at the edges, only possible due to the previously achieved proximity.

CASE 2: 55-year-old man referred for ESD of a 13mm Paris 0-IIa dysplastic lesion in the lesser curvature of the antrum. En-bloc ESD was accomplished, and the resulting 25mm mucosal defect was closed using TTSS in a 'Z' pattern. Complete defect closure was achieved with the additional placement of one TTS clip.

Both patients were discharged the following day and presented with no complications at 1-month follow-up.

These cases highlight the potential of TTSS becoming a practical solution for the closure of complex post-ESD defects, allowing earlier patient discharge. While this novel TTSS with adjunctive TTS clip application appears to be effective in the management of sizable defects, proper suture pattern and tack placement are paramount for achieving complete defect closure.

References

1. Kobara H, Tada N, Fujihara S, Nishiyama N, Masaki T. Clinical and technical outcomes of endoscopic closure of postendoscopic submucosal dissection defects: Literature review over one decade. Dig Endosc. 2023 Jan;35(2):216-231.
2. Hernandez-Lara A, Garcia Garcia de Paredes A, Rajan E, Storm AC. Step-by-step instruction: using an endoscopic tack and suture device for gastrointestinal defect closure. VideoGIE. 2021;6(6):243-245.
3. Hernandez A, Marya NB, Sawas T, Rajan E, Gades NM, Wong Kee Song LM, et al. Gastrointestinal defect closure using a novel through-the-scope helix tack and suture device compared to endoscopic clips in a survival porcine model (with video). Endosc Int Open. 2021 Apr;9(4):E572-E577.
4. Canakis A, Dawod SM, Dawod E, Simons M, Di Cocco B, Westerveld DR, et al. Efficacy, Feasibility, and Safety of the X-Tack Endoscopic HeliX Tacking System: A Multicenter Experience. J Clin Gastroenterol. 2024 Jan 29.
5. Canakis A, Deliwala SS, Frohlinger M, Twery B, Canakis JP, Shaik MR, et al. Endoscopic outcomes using a novel through-the-scope tack and suture system for gastrointestinal defect closure: a systematic review and meta-analysis. Endoscopy. Published online March 22, 2024.

Clinical Case Summary

A 67-year-old man initially presented in 2020 with intermittent dysphagia for solid food. An endoscopy of the upper gastrointestinal tract revealed an inflammatory, presumed peptic stenosis at the level of the Z-line. No hiatus hernia was present. A balloon dilatation was performed and therapy with proton pump inhibitors was started. This maintained remission until 2023, when he represented with frequent bolus retention, retrosternal chest pain and regurgitation. A repeat endoscopy appeared normal; however, biopsies revealed lymphocytic esophagitis. A high-resolution oesophageal manometry was performed to clarify the cause of dysphagia. Water swallows showed no abnormal findings; however, the patient had repeated, symptomatic outlet-obstruction during the solid test meal. This finding is often seen in eosinophilic esophagitis.¹ The diagnosis of primary lymphocytic esophagitis, considered to be a variant of this condition,² was proposed. Treatment with oro-dispersible budesonide (1mg bid) was started.
At the same time, an abnormal AV conduction pattern was noted on ECG. Echocardiography and a cardiac stress test were normal; however, CT imaging showed bihilar lymphadenopathy with peri-lymphatic pulmonary nodules. Broncho-alveolar lavage showed lymphocytic alveolitis (29% lymphocytes) and an elevated CD4/CD8 ratio (ratio = 4). ACE (51 U/l) was normal and granulomas were not seen on fine needle aspiration of the lymph nodes; however, the diagnosis of stage 2 pulmonary sarcoidosis was confirmed on PET-CT. Oral prednisolone (30mg od) replaced locally active steroids. The patient was symptom free after one month treatment.
Sarcoidosis is a granulomatous disease that often affects the lungs, skin and lymph nodes; however, involvement of the digestive tract is rare, and secondary lymphocytic esophagitis has hardly ever been described.³ The investigation, primary or secondary aetiology, and management of dysphagia in this case of lymphocytic esophagitis will be discussed.

References

1. Sykes C, Fairlamb G, Fox M, et al. Assessment of Esophageal Motility in Patients With Eosinophilic Esophagitis: A Scoping Review. J Clin Gastroenterol 2023;57:10-30.
2. Greuter T, Straumann A, Fernandez-Marrero Y, et al. Characterization of eosinophilic esophagitis variants by clinical, histological, and molecular analyses: A cross-sectional multi-center study. Allergy 2022;77:2520-2533.
3. Brito-Zeron P, Bari K, Baughman RP, et al. Sarcoidosis Involving the Gastrointestinal Tract: Diagnostic and Therapeutic Management. Am J Gastroenterol 2019;114:1238-1247.

Disclosure

None of the authors have any conflict of interest to disclose

Introduction

Functional gastrointestinal disorders (FGIDs) are more prevalent in female than in male patients [1,2]. This triggers the question whether this is also reflected in medical care, especially also in self-medication, where often botanicals are used. A potential source of data to address this question is the PhytoVIS study, a pharmacoepidemiological study conducted in Germany in more than 20,000 patients taking herbal medicinal products.

Aims & Methods

To have a large and homogenous data base for a gender-related evaluation, records for a clinically proven herbal medicinal product (HMP) often used in FGIDs, STW 5 [3,4], were evaluated to uncover potential gender-related differences in the pharmacotherapy of FGIDs.

Results

1513 records were evaluated, 71 % of them from females and 29 % from males, i.e. a 4 % higher proportion of females compared to the overall population of the PhytoVIS study. Main criterium for the evaluation was the Clinical Global Impression Scale – Efficacy (CGI-E). No major differences between females and males were found, apart that women perceived a minimally better effect of the therapy. The reported symptoms were differentiated into symptoms associated with functional dyspepsia (FD), irritable bowel syndrome (IBS), or symptoms that can be associated with both. As far as the records allow a differentiation, no gender differences could be observed. This applies also to the perceived efficacy, the tolerability and the onset of action.

Conclusion

So, while there are differences in the prevalence of FGIDs in women and men, there are no therapeutically relevant pharmacoepidemiological differences in patients with functional gastrointestinal diseases treated with a medicinal product indicated in these diseases, so suggesting that there is no gender gap in this highly relevant therapeutic field.

References

1. Kim YS, Kim N. Sex-Gender Differences in Irritable Bowel Syndrome. J Neurogastroenterol Motil. 2018;24:544-558
2. Houghton LA, Heitkemper M, Crowell M, Emmanuel A, Halpert A, McRoberts JA, Toner B. Age, Gender and Women's Health and the Patient. Gastroenterology. 2016; S0016-5085(16)00183-9;
3. Malfertheiner P. STW 5 (Iberogast) Therapy in Gastrointestinal Functional Disorders. Dig Dis. 2017;35 Suppl 1:25-29
4. Madisch A, Vinson BR, Abdel-Aziz H, Kelber O, Nieber K, Kraft K, Storr M. Modulation of gastrointestinal motility beyond metoclopramide and domperidone : Pharmacological and clinical evidence for phytotherapy in functional gastrointestinal disorders. Wien Med Wochenschr. 2017;167:160-168

Disclosure

JW and EC were interns, OK, is employee of Steigerwald Arzneimittelwerk GmbH, Darmstadt, Germany, KN und KK have received fees from the same company.

Introduction

Different pathophysiological mechanisms are thought to play a role in functional dyspepsia (FD) subgroups defined by Rome IV criteria. Studies are needed to determine whether Rome IV subgroups are linked to distinct pathophysiologies and treatment responses. This study aims to investigate the impact of Helicobacter pylori (H. pylori) infection in the pathogenesis of each FD subgroups, subdivided according to the Rome IV consensus, within a high H. pylori prevalence country, Turkey. The investigation centered on assessing the frequency of H. pylori and examining the impact of eradication therapy on alleviating symptoms, in each Rome IV subgroup.

Aims & Methods

Eradication treatment was applied to cases who were initially diagnosed with FD using the Rome IV criteria and subsequently found to have H. pylori gastritis through endoscopic biopsy. 8-12 weeks after treatment, H. pylori state was evaluated with fecal antigen test. Symptom responses were evaluated in each subgroup at 2, 6, and 12 months post-therapy using a Likert scale and statistically with SPSS version 23.0.

Results

The H. Pylori frequency was statistically more common in individuals with symptoms consistent with epigastric pain syndrome (EPS) (73.1% in EPS, 41% in postprandial distress syndrome (PDS), and 43.9% in overlapping subgroups (p< .001)). With eradication treatment of H. pylori-positive cases, all subgroups demonstrated a significant response and the response rates didn’t exhibit significant difference between subgroups (73.7% in total cases; 70.5% in EPS; 71.4% in PDS; 82.6% in overlapping, in the 12th month (p>0.05)). Eradicated patients showed significant symptomatic improvement with 70.2% in the 12th month. None of the non-eradicated patients experienced symptomatic improvement.

Conclusion

Using Rome IV consensus confirmed the data that H. pylori plays a notable role as a pathogenic factor in FD, particularly in EPS, and it is recommended to screen all FD subgroups, particularly EPS, for H. pylori and eradicate, if detected. Additionally, this study suggests that regions with a high H. pylori prevalence tend to have a higher H. pylori-associated dyspepsia prevalence.

References

1. Wauters L, Dickman R, Drug V, et al. United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on functional dyspepsia. United European Gastroenterol J. 2021 Apr;9(3):307-331.
2. Houte KVD, Carbone F, Goelen N, et al. Effects of Rome IV Definitions of Functional Dyspepsia Subgroups in Secondary Care. Clinical Gastroenterology and Hepatology 2021;19:1620–1626.
3. Carbone F, Vanuytsel T, and Tack J. Analysis of Postprandial Symptom Patterns in Subgroups of Patients With Rome III or Rome IV Functional Dyspepsia. Clinical Gastroenterology and Hepatology 2020;18:838–846.
4. Vanheel H, Vanuytsel T, Van Oudenhove L, Farre R, Verbeke K, Tack J. Postprandial symptoms originating from the stomach in functional dyspepsia. Neurogastroenterol Motil 2013;25:911-e703
5. Ford AC, Tsipotis E, Yuan Y, Leontiadis GI, Moayyedi P. Efficacy of Helicobacter pylori eradication therapy for functional dyspepsia: updated systematic review and meta-analysis. Gut. 2022 Jan 12:gutjnl-2021-326583. doi: 10.1136/gutjnl-2021-326583.
6. Kang SJ, Park B, Shin CM. Helicobacter pylori Eradication Therapy for Functional Dyspepsia: A Meta-Analysis by Region and H. pylori Prevalence. J Clin Med. 2019 Aug 28;8(9):1324. doi: 10.3390/jcm8091324.
7. Malfertheiner P, Megraud F, Rokkas T, et al. European Helicobacter and Microbiota Study group. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022 Aug 8:gutjnl-2022-327745. doi: 10.1136/gutjnl-2022-327745.

Disclosure

The authors declare that they have no conflict of interest.

Introduction

Dietary and lifestyle recommendations are the cornerstones of the treatment of GERD. However, the evidence of the efficacy of those recommendations is lacking. We performed a retrospective analysis of the GISTAR study¹ participants evaluating the symptoms of GERD and dietary and lifestyle parameters developing a tool for predicting GERD symptoms based on the aforementioned criteria.

Aims & Methods

The aim of the study was to analyse the factors pointing to GERD symptoms through the use of data mining and decision tree classifier.
Methods: GERD diagnosis was evaluated using a self-assessment questionnaire ². Dietary, demographic and lifestyle data were collected within the GISTAR study protocol¹. 3340 40-64 year old participants from the GISTAR study were included in the analysis. 1670 of them did not have GERD symptoms. 41 attributes describing demographic, lifestyle, and dietary habits were used for these respondents to induce a decision tree classification model using Orange Data Mining software³.

Results

Fried potatoes including French fries were the most predictive factor of GERD symptoms (65.3% with symptoms; 1516 from 2321), especially for females (82.6%; 1048/1228). This was more pronounced in the group who consumed sweets once per week (87.2%, 950/1090). In males, who consumed fried potatoes, the next most important factor was the consumption of sweets (46.3%, 431/930).
For participants who didn’t consume fried potatoes (14.6%; 147/1008), 1-3 cups of green tea (37.9%; 66/174) and male gender (71.4 % 20/28) were predictors of GERD symptoms.
The accuracy of the decision tree model was: sensitivity (74.8%), precision (75.6%), specificity (75.9%) and AUC (0.841%).

Conclusion

Fried potatoes, female gender and consumption of sweets are the risk factors predicting the diagnosis of GERD. None of the lifestyle factors were displayed as significant.

References

1. Leja M, Park JY, Murillo R, et al. Multicentric randomised study of Helicobacter pylori eradication and pepsinogen testing for prevention of gastric cancer mortality: the GISTAR study. BMJ Open 2017;7:e016999. doi: 10.1136/bmjopen-2017-016999
2. Jones R, Junghard O, Dent J, Vakil N, Halling K, Wernersson B, Lind T. Development of the GerdQ, a tool for the diagnosis and management of gastro-oesophageal reflux disease in primary care. Aliment Pharmacol Ther. 2009 Nov 15;30(10):1030-8. doi: 10.1111/j.1365-2036.2009.04142.x. Epub 2009 Sep 8. PMID: 19737151.
3. Demsar J, Curk T, Erjavec A, Gorup C, Hocevar T, Milutinovic M, Mozina M, Polajnar M, Toplak M, Staric A, Stajdohar M, Umek L, Zagar L, Zbontar J, Zitnik M, Zupan B (2013) Orange: Data Mining Toolbox in Python, Journal of Machine Learning Research 14(Aug): 2349−2353.