Introduction

Managing patients with severe irritable bowel syndrome (IBS) has significant challenges for practicing physicians due to the condition's refractoriness to standard therapy and the lack of clinical remission. The prevalence of IBS reaches 9–21% among the adult working population and is associated with a low quality of life. According to various sources, visceral hypersensitivity (VHS) plays a key role in the pathogenesis of IBS.

Aims & Methods

The aim is to show the relationship between clinical symptoms, the visceral sensitivity index, and the visceral sensitivity threshold in patients with severe IBS-D.
A total of 84 patients with severe IBS-D, according to the Rome IV criteria, were examined. The median (Me) patient age was 32 (25; 37.2) years, with a disease duration of 5 (4; 6) years. Pain syndrome was assessed using the VAS scale in points (pts.), the level of visceral sensitivity index (VSI) using the J. Labus questionnaire reflecting gastrointestinal anxiety (pts.), and the visceral sensitivity threshold (VST) was studied via balloon dilatation test (BDT) (ml). Statistical analysis was conducted using non-parametric methods (Statistica 12). Quantitative data were described using Me and interquartile ranges (Q1 – Q3). Differences were considered statistically significant at p < 0.05.

Results

Before treatment, all patients showed a high level of pain syndrome - 9 (8; 9) pts. on VAS, and level of gastrointestinal anxiety at 71.00 (63; 75) according to the J. Labus questionnaire. BDT data revealed a low VST (first threshold—urge to defecate): 34.00 (27; 43.5) mm Hg. After examination, patients were randomly divided into two equal groups. The first group received the SNRI antidepressant (duloxetine) 60 mg/day, while the second group received trimebutine maleate 600 mg/day for 8 weeks, followed by assessment of therapy effectiveness. In the first group, SNRI therapy showed positive dynamics: a decrease of pain levels (from 9 (9 - 10) to 2 (1.75 - 3), p < 0.01*), an increase in VST (from 34.0 (29.75, 45.0) to 92.0 (86.0, 123.0), p < 0.01*), and a reduction in gastrointestinal anxiety (from 56.50 (47.50 – 68.00) to 12.00 (10.00 – 19.25), p < 0.01*). No significant positive changes were achieved in the second group. After the treatment, the overall group showed an inverse correlation between abdominal pain (VAS) and VST (BDT data) (ρ = -0.772; p < 0.01), and between gastrointestinal anxiety (VSI by J. Labus) and VST (BDT data) (ρ = -0.782; p < 0.001).

Conclusion

The effectiveness of therapy in the first group of patients was associated with the severe course of IBS, characterized by high gastrointestinal anxiety, abdominal pain, and low VST. In the overall group, post-treatment correlation analysis revealed a connection between the severity of clinical presentation and VST levels (BDT). Balloon dilatation test allows an objective assessment of IBS severity and therapeutic effectiveness. The treatment of choice for severe IBS-D is the SNRI duloxetine, which acts on the pain center and patients' emotional status.

Introduction

Acute pancreatitis (AP) during pregnancy is a rare but potentially life-threatening condition for both mother and fetus. The most common cause is gallstone disease, followed by hypertriglyceridemia and, less frequently, alcohol use. The physiological changes of pregnancy can mask the clinical presentation, delaying diagnosis and intervention. This review aims to synthesize current evidence on the diagnosis, management, and maternal-fetal outcomes of AP in pregnancy, with special attention to the role and timing of cholecystectomy during an acute episode.

Aims & Methods

A comprehensive literature search was conducted using PubMed, Scopus, and the Cochrane Library for studies published between 2000 and 2024. Inclusion criteria involved clinical trials, cohort studies, systematic reviews, and relevant guidelines discussing AP in pregnancy and cholecystectomy

Results

​The majority of AP cases in pregnancy occur in the third trimester or early postpartum period. Gallstones account for 65–100% of cases. Conservative management remains the first-line approach, particularly in the first trimester. However, recurrence rates up to 70% with conservative therapy alone have prompted a reevaluation of surgical timing. Recent studies support the safety of cholecystectomy during the second trimester and even during stabilized mild to moderate AP. In the third trimester, ERCP with endoscopic biliary sphincterotomy is preferred, with cholecystectomy deferred postpartum. Multidisciplinary management has significantly improved maternal and neonatal outcomes in recent years.

Conclusion

Acute pancreatitis in pregnancy remains a rare but serious condition requiring timely diagnosis and multidisciplinary care. Recent innovations support the safety and efficacy of cholecystectomy laparascopyce during the second trimester and even in selected stabilized cases of mild acute pancreatitis. Personalized management strategies based on gestational age and disease severity, along with minimally invasive techniques like ERCP, offer improved maternal and fetal outcomes.
Laparascopi Colecystectomy prevens the recurrent acute pancreatitis and other complications billiaris.
No differenc in the intra and postoperative complications during and after pregnancy.

References

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1. Forsmark CE, Vege SS, Wilcox CM. Acute pancreatitis. N Engl J Med. 2016;375(20):1972–81.
2. Tenner S, Baillie J, DeWitt J, Vege SS. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013;108(9):1400–15.
3. Yokoe M, Takada T, Mayumi T, et al. Japanese guidelines for the management of acute pancreatitis: JPN Guidelines 2015. J Hepatobiliary Pancreat Sci. 2
4. Rosing DK, de Virgilio C. Early cholecystectomy for mild gallstone pancreatitis: time for a paradigm shift
   

Disclosure

Taibe Haziri
*University Clinical Center University of Kosovo*

Introduction

​Pancreatic fibrosis (PF), a pathological hallmark of chronic pancreatitis, serves as a critical mediator in the progression of numerous pancreatic disorders. Early identification of fibrotic changes presents a strategic opportunity to intervene in disease pathways, potentially curbing the advancement of pancreatic pathologies. It makes research of non-invasive radiological PF assessment perspective.

Aims & Methods

Aim of our study was to evaluate the possibility of multidetector computed tomography (MDCT) post-processing parameters in PF grade assessment.
Methods. Results of contrast-enhanced 128-row MDCT from 165 patients (mean age 57.9±13.5) who underwent surgery from April 2022 to February 2024 due to pancreatic tumors and advanced chronic pancreatitis were analyzed. We calculated contrast enhancement ratio (CR) between venous phase (VP) and non-contrast MDCT, and normalized CR (NCR) during the pancreatic phase (PP) and VP, also we measured pancreas attenuation during MDCT examination. PF morphological grade was assessed according to Klöppel & Maillet’s scoring system [1] and scaled into three grades: mild, moderate and severe PF.
This study was conducted within the healthcare research project “Assessment of pancreatic fibrosis as a prognostic factor for its diseases course” funded by Autonomous non-profit organization "Moscow Center for Innovative Technologies in Healthcare" administered by the Moscow Healthcare Department.

Results

The values of post-processing CT results were compared in groups with different degrees of PF. Mean CR were significantly higher (p=0.001) in patients with severe PF (CR 1.16±0.65 HU) than in patients with mild PF (CR 0.78±0.31 HU). CR significant increase (p=0.03) was found in patients with signs of inflammatory changes in the pancreas tissue (CR 1.14±0.6 HU) than in those without them (CR 0.81±0.3 HU). There were no significant differences between the NCRPP and NCRVP, and the degree of PF, which we had shown in publications of our preliminary results. We suppose the main reason of this fact is study groups enlargement as well as measurement technique improvement, led to results clarification.

Conclusion

The CR value increased in patients with severe degree of PF and decreased in patients with mild PF. Also, there was a significant relation between CR increase and presence of early signs of pancreatic inflammatory changes. Thus, there was a relationship between MDCT postprocessing results and morphological signs of PF, which can be used for pancreatic fibrosis non-invasive diagnosis and identification of additional signs of early chronic pancreatitis.

References

1. Esposito I, Hruban RH, Verbeke C, et al. Guidelines on the histopathology of chronic pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with the International Association of Pancreatology, the American Pancreatic Association, the Japan Pancreas Society, and the European Pancreatic Club. Pancreatology. 2020;20(4):586-593. doi:10.1016/j.pan.2020.04.009

Clinical Case Summary

Splenic granulomas are a rare extraintestinal manifestation of Crohn’s disease (CD). In previously reported cases, the diagnosis was confirmed by biopsy. However, due to the increased risk of complications associated with biopsy, confirmation by imaging is desirable.
52-year-old male patient presented with a previously diagnosed, currently untreated CD.
Symptoms:

• Abdominal pain in the right lower quadrant for several weeks, postprandial
• Bowel movements: 4-6 times/day for a few weeks, liquid consistency
• No fever or weight loss
• Palpation: tenderness in the lower right abdomen

Findings:

• C-reactive protein and leukocytes: not elevated
• Calprotectin: 184ug/g. Stool culture and intestinal cytomegaly virus PCR biopsy negative
• Tuberculosis interferon-g release assay: negative
• Colonoscopy and magnetic resonance enterography (MRE): ileitis of terminal Ileum (Fig. 1)
• MRE: multiple T2w-hyperintense splenic lesions, increased in number since last imaging 2024 (Fig. 2)
• B-mode ultrasound: splenomegaly, round nodules of mixed echogenicity (Fig. 3)
• Contrast-enhanced ultrasound (CEUS): 1,5ml contrasting agent (sulphur hexafluoride microbubbles): arterial isoenhancement and late phase hypoenhancement of nodules (Fig. 3), atypical for haemangiomas
• 18-Fluorodeoxyglucose positron emission tomography with computed tomography: no uptake in the spleen (Fig. 4)

After excluding malignancy, abscesses, sarcoidosis, and infectious causes, the splenic granulomatous lesions represented an extraintestinal manifestation of CD. The patient was started on prednisolone, 60mg/day, resulting in marked clinical improvement in 4 days; with reduced abdominal pain and decreased stool frequency. Patient declined recommended maintenance therapy with ustekinumab.
This CEUS pattern is novel to CD and resembles previously reported enhancement patterns of inflammatory lesions. This is a rare reported case of splenic granulomas as an extraintestinal manifestation of CD diagnosed non-invasively by CEUS.

References

Figure 1: Colonoscopy shows 2-4mm aphthous ulcers in the terminal Ileum
Figure 2: (A)T2-Haste and (B)T2-STIR MRE depicting multiple hyperintense splenic lesions
Figure 3: B-mode (left) and CEUS (right) of the splenic lesions. (A) Nodules appear mixed in echogenicity, nodules show isoenhancement during the arterial phase. (B) Nodules exhibit hypoenhancement in the late phase
Figure 4: 18F-Fluorodeoxyglucose (FDG) positron emission tomography with computed tomography shows no uptake of FDG in the spleen
1. Castellani L, Sartini A, Marocchi M, Balbi T, Belluzzi A. Splenic granulomas in a patient with severe Crohn's disease associated with multiple extraintestinal manifestations. Inflamm Bowel Dis. 2011 Jun;17(6):E35-7. doi: 10.1002/ibd.21665. Epub 2011 Feb 11. PMID: 21319276.
2. Schulz C, von Arnim U, Kuester D, Fischbach F, Malfertheiner P. Milzbefall - seltene extraintestinale Manifestation bei Morbus Crohn [Splenic granulomas - rare extraintestinal manifestation of Crohn's disease]. Z Gastroenterol. 2010 Dec;48(12):1367-70. German. doi: 10.1055/s-0029-1245562. Epub 2010 Dec 1. PMID: 21125512
3. Safai Zadeh E, Prosch H, Ba-Ssalamah A, Findeisen H, Alhyari A, Raab N, Görg C. Contrast-enhanced ultrasound of the liver: basics and interpretation of common focal lesions. Rofo. 2024 Aug;196(8):807-818. English, German. doi: 10.1055/a-2219-4726. Epub 2024 Jan 4. PMID: 38176437

Disclosure

Travel grant from Johnson & Johnson