Clinical Case Summary

Introduction: Renal involvement has been reported in 4-23% in inflammatory bowel disease (IBD), most commonly with nephrolithiasis. Rarely, due to parenchymal renal disease, tubulointerstitial nephritis (TIN) may develop, remaining unclarified if it is caused by the disease itself or by side effects of therapy.
Case: We report a case of a 19-year-old man with ulcerative colitis (UC) diagnosed at the age of 7, with left colitis and no extraintestinal manifestations (EIM). The clinical course required multiple therapy changes due to refractory disease. 5-ASA were used only for 1 month due to intolerance. Corticotherapy was initiated, followed by anti-TNF therapy (infliximab then adalimumab) and immunomodulators (azathioprine then methotrexate) for 6 years. Due to loss of response, he was treated with vedolizumab for 3 years, only with partial response. Ustekinumab in monotherapy was started at the age of 18 achieving adequate levels. Regarding renal function, a creatinine increase was observed at the age of 15 (8 years of disease, when he was under vedolizumab). He did not take other medication or supplements than for UC. Currently, his blood pressure is normal, creatinine reached 2.2 mg/dL (glomerular filtration rate 43ml/min) with low proteinuria (<1g/g). Ultrasound revealed hyperechogenicity of renal parenchyma. Renal biopsy was compatible with TIN. He started lisinopril at the nephrology clinic. Since UC remission has not been achieved, tofacitinib was initiated.
Discussion: Almost all drugs used in IBD are potentially nephrotoxic, and some have been associated with TIN (5-ASA, anti-TNF therapy). However, TIN also occurs in patients with no exposure to nephrotoxic drugs, highlighting a possible EIM, mostly during active disease. In case of renal insufficiency, proteinuria or hematuria, a renal biopsy should be considered. A high suspicion is needed for early recognition and treatment, and nephrology collaboration is mandatory for optimal management.

References

1. Dincer MT, Dincer ZT, Bakkaloglu OK, Yalin SF, Trabulus S, Celik AF, Seyahi N, Altiparmak MR. Renal Manifestations in Inflammatory Bowel Disease: A Cohort Study During the Biologic Era. Med Sci Monit. 2022 Jul 6;28:e936497.
2. van Hoeve K, Hoffman I. Renal manifestations in inflammatory bowel disease: a systematic review. J Gastroenterol. 2022 Sep;57(9):619-629.
3. Ambruzs JM, Larsen CP. Renal Manifestations of Inflammatory Bowel Disease. Rheum Dis Clin North Am. 2018 Nov;44(4):699-714.

Introduction

The treatment outcomes and risk factors for the prognosis of acute variceal bleeding (AVB) in hepatocellular carcinoma (HCC) patients remain unclear. Hence, we assessed the clinical outcomes and prognostic factors of these patients.

Aims & Methods

To evaluate the treatment outcomes and risk factors of cirrhotic patients with hepatocellular carcinoma (HCC) and acute variceal bleeding (AVB).
This is a retrospective case-control study. Consecutive patients with HCC and AVB admitted between 2016 and 2022 were included. For each patient with HCC, a patient without HCC was matched by age, sex, and Child-Pugh class. Follow-up was continued until death and transplantation.

Results

A total of 620 patients were included. The five-day treatment failure and 6-week mortality rates of the whole cohort were 18.7% and 16.6%, respectively. Patients with HCC had higher 6-week mortality, respectively (24.2% vs. 9.0%, P<0.001). Among AVB patients with HCC, the Barcelona Clinic Liver Cancer (BCLC) stage (C-D vs. 0-B) (HR, 14.409; 95% CI, 5.758-36.055; P<0.001), and Child-Pugh score (HR, 1.239, 95% CI, 1.121-1.370; P<0.001) were independent risk factors of 6-week mortality in multivariate analysis. Furthermore, the risk of 6-week mortality was 60.2% among patients with a Child-Pugh score ≥ 9 and BCLC stage C–D, much higher than patients with low Child-Pugh score (<9) and earlier BCLC stage (0-B) (P<0.0001).

Conclusion

Among patients with cirrhosis and AVB, patients with HCC had a worse outcome than patients without. The severity of liver disease and the stage of HCC are the main determinants of mortality in HCC patients.

Introduction

The global health community has increasingly shifted its focus toward non-communicable diseases (NCDs), recognizing them as a critical public health emergency, particularly pronounced in low and lower middle-income countries (LMICs)[1]. Metabolic dysfunction associated steatotic liver disease (MASLD) is the most common liver disease with a worldwide prevalence of 30%[2], and represent the leading cause of liver-related morbidity and mortality. The prevalence, associated factors, and consequences of MASLD in the African continent, particularly in SSA, remain poorly understood. Indeed, no SSA studies were included in the latest major literature review and meta-analysis on the global epidemiology of MASLD[2].
Tanzania, like many other SSA countries, is undergoing a demographic and epidemiological transition, leading to a marked increase in the burden of NCDs [3].

Aims & Methods

The primary aim of this study was to estimate the prevalence of MASLD among an NCDs population in rural Tanzania. Additionally, secondary objective was to investigate whether the consumption of sugary drinks is associated with MASLD.
This study entailed a retrospective analysis of a prospectively collected cohort of consecutive patients attending the NCDs outpatient clinic of Tosamaganga Hospital, from August 2022 to March 2023. Detailed sociodemographic, clinical, laboratory, and abdominal ultrasound data were collected for all participants. Additionally, the Beverage Intake Questionnaire (BEVQ-15) was administered to evaluate their everyday drinking behaviors; and for each item, the average daily intake in fluid ounces (fl-oz), and calories (kcal) were calculated.

Results

Of 183 patients enrolled in the cohort, 128/183 (70%) were female. The mean age was 58±13.7 years and mean BMI was 28±6.67 Kg/m². Hypertension affected 141 individuals (77.0%), diabetes affected 77 (42.1%), and both conditions co-occurred in 35 patients (19.1%). Steatotic liver disease was found in 88/183 (48%) patients; with 39/88 (44.3%) of moderate or severe steatosis. MASLD was identified in all steatotic patients. Overall, on average the participants drank a mean of 12.6 fl-oz of SSB (throght sodas). MASLD patients drank an average of 22.4 fl-oz of SSB per day. Multivariable analysis revealed that BMI and daily SSB consumption (fl-oz) exhibited significant associations with MASLD, with respective OR of 1.16 (95% CI: 1.06 – 1.28, p = 0.002) and 1.19 (95% CI: 1.12 – 1.27, p < 0.001).

Conclusion

This study unveils a considerable prevalence of MASLD among the rural Tanzanian NCDs population, affecting nearly half (48%) of all patients studied. Timely identification of MASLD, facilitated by straightforward diagnostic means, holds pivotal importance for patient management and the dissemination of vital lifestyle modification guidance. Furthermore, our study, one of the pioneering efforts to demonstrate a significant association between SSB consumption and MASLD in an African context, underscores the imperative to heighten awareness regarding the risks posed by SSB consumption among NCDs patients and potentially the wider population.

References

[1] Boutayeb A. The Burden of Communicable and Non-Communicable Diseases in Developing Countries. Handbook of Disease Burdens and Quality of Life Measures 2010:531–46. https://doi.org/10.1007/978-0-387-78665-0_32.
[2] Younossi ZM, Golabi P, Paik JM, Henry A, Van Dongen C, Henry L. The global epidemiology of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH): a systematic review. Hepatology 2023;77:1335–47. https://doi.org/10.1097/HEP.0000000000000004.
[3] Gouda HN, Charlson F, Sorsdahl K, Ahmadzada S, Ferrari AJ, Erskine H, et al. Burden of non-communicable diseases in sub-Saharan Africa, 1990-2017: results from the Global Burden of Disease Study 2017. Lancet Glob Health 2019;7:e1375–87. https://doi.org/10.1016/S2214-109X(19)30374-2.

Introduction

Colorectal cancer incidence is increasing worldwide. Nowadays it is the third most diagnosed cancer¹. Screening colonoscopy is the gold standard for prevention and often treatment, both economically and efficiently. Hellenic Society of Gastroenterology recommends that screening colonoscopy should starts by 50 years old for average risk population¹. There are limited data about participation in screening colonoscopy in general population in Greece and the existing ones shows discouraging participation rates^2,3.

Aims & Methods

The aim of this study was to determinate general population’s knowledge about screening colonoscopy in Greece. We created a digital, anonymous questionnaire at Google Forms platform and transferred it via social media in general population that lives in Greece.

Results

In total 711 individuals answered the survey. 65.8% of them(468/711) were woman. 61.5% (437/711) were under 40 years old, 19.7% (140/711) were between 40 and 50 years old and 18.3% (130/711) were between 50 and 75 years old. 40.2% (286/711) did not know if there is an appropriate age for the first screening colonoscopy. 39% (277/711) answered that they thought an appropriate age is at 50 years old, 26.7% (190/711) at 45 years old and 8.2% (58/711) answered that they thought there is not an appropriate age for a screening colonoscopy. Regarding the performance of screening colonoscopy 363 out of 711 (51.1%) are willing to perform it in the future, 20.1% (143/711) answered that they do not know or do not answer the question,11% (78/711) are not willing to perform it and 2.1% (15/711) are not willing to perform it, because they think it is not necessary for preventing colorectal cancer.

Conclusion

Our study confirms that there is lack of information in general population and unwillingness to screen for colorectal cancer in Greece. General population tends to be uninformed and unwilling about screening colonoscopy¹. Despite the effectiveness of colonoscopy there is not an organized screening program in Greece. Individuals are usually self-referred for screening and usually later than the appropriate age and after symptoms occure¹. Primary health care providers should be well informed and correctly advise individuals about colorectal cancer screening and its privilege, options, and alarm symptoms⁴.

References

1. Viazis N, Tzouvala M, Theodoropoulou A, Giouleme O, Thomopoulos K, Christodoulou DK, Michopoulos S, Soufleris K, Koutroubakis I, Karamanolis G, Papatheodoridis G, Giotis I, Paspatis G, Mantzaris GJ. Comparison of the Uptake of Screening Colonoscopy between Physicians and the General Population in Greece. Dig Dis. 2020;38(1):23-30. doi: 10.1159/000501266. Epub 2019 Jul 9. PMID: 31288225.
2. Kamposioras K, Mauri D, Golfinopoulos V, Ferentinos G, Zacharias G, Xilomenos A, Polyzos NP, Bristianou M, Chasioti D, Milousis A, Vittoraki A, Koukourakis G, Chatziioannou I, Papadopoulos P. Colorectal cancer screening coverage in Greece. PACMeR 02.01 study collaboration. Int J Colorectal Dis. 2007 May;22(5):475-81. doi: 10.1007/s00384-006-0186-6. Epub 2006 Aug 29. PMID: 16941174.
3. Cardoso R, Guo F, Heisser T, Hoffmeister M, Brenner H. Utilisation of Colorectal Cancer Screening Tests in European Countries by Type of Screening Offer: Results from the European Health Interview Survey. Cancers (Basel). 2020 May 29;12(6):1409. doi: 10.3390/cancers12061409. PMID: 32486077; PMCID: PMC7352919.
4. Mastrokostas A, Gavana M, Gkrizioti M, Smyrnakis E, Cholongitas E, Benos A, Haidich AB. Discrepancies and misconceptions of perceived colorectal cancer screening barriers between primary health professionals and unscreened population. A comparative study in Greece. J BUON. 2018 Dec;23(7):67-76. PMID: 30722114.

Introduction

Numerous studies suggested a pivotal role of gut microbiota and its metabolites in the development and progression of metabolic-associated steatotic liver disease (MASLD) [1]. So, modification of the gut microbiota and/or the metabolites could be beneficial in children with MASLD [2].

Aims & Methods

The aim of our study was to determine the gut microbiome composition in obese children with metabolic-associated steatotic liver disease (MASLD) depending on the contractile function of the gallbladder.
A survey included 73 children aged 10 to 17 years (mean age – 12.15 ± 2.51 years). According to body mass index, transient elastography (Fibroscan®502 touch, Echosens, France), and ultrasound data patients were divided into 3 groups: 1 group – 35 obese MASLD children with gallbladder hypokinesia, 2 group – 30 obese MASLD children with gallbladder normokinesia, 3 group (control) – 8 healthy children with normal weight and gallbladder normokinesia. Contractile gallbladder function was assessed by ultrasound examination after physiological nutritional load. Qualitative and quantitative intestinal microbiome composition were investigated by bacterial culture method using ten-fold dilutions (10^-1 - 10^-9) on a standard set of selective and differential diagnostic culture media for the aerobic and anaerobic microbes isolation. Fecal short-chain fatty acid (SCFA) content was evaluated with gas chromatography (Chromatec-Crystal-5000).

Results

An increase in the fecal butyric acid concentration in 2.0 times (p<0.05) was observed in MASLD children with gallbladder hypokinesia compared to the control group. Also, an increase in the fecal acetic acid concentration in 6.9 times (p<0.05) in 1 group children and in 6.8 times (p<0.01) in 2 group children was found compared to the control group. However, a significant decrease in the fecal propionic acid content in 2.4 times (p<0.001) in MASLD children with gallbladder hypokinesia and in 3.6 times (p<0.001) in MASLD children with gallbladder normokinesia was revealed compared to the control group. Due to the increased content of fecal acetic and butyric acids, the total content of SCFA (Σ (C2-C4)) was increased in 2.3 times in 1 group children compared to the control group (p<0.05).
Patients with decompensated dysbiosis predominated in 1 group children (37.1% of patients). In 2 group children the subcompensated dysbiosis was more common (36.7% of patients). The concentration of Lactobacillus and Enterococcus in 1 group patients was significantly lower than in 2 group patients: in 1.9 times (p<0.05) and in 1.4 times (p<0.05), respectively.

Conclusion

Impaired contractile function of the gallbladder in MASLD children is associated with a sharp decrease in the number of major symbionts of the intestinal microbiota as well as increased production of fecal acetic and butyric SCFA.

References

1. Effenberger M, Grander C, Grabherr F, Tilg H. Nonalcoholic Fatty Liver Disease and the Intestinal Microbiome: An Inseparable Link. J Clin Transl Hepatol. 2023;11(7):1498-1507. doi:10.14218/JCTH.2023.00069.
2. Bonsembiante L, Targher G, Maffeis C. Non-alcoholic fatty liver disease in obese children and adolescents: a role for nutrition?. Eur J Clin Nutr. 2022;76(1):28-39. doi:10.1038/s41430-021-00928-z

Clinical Case Summary

The detection and management of overt gastrointestinal (GI) bleeding may be challenging, especially in case of limited resources, as during the COVID-19 pandemic. This case report shows how artificial intelligence (AI) technology applied to capsule endoscopy (CE) can contribute to this challenge.
In August 2020, a 80 year-old male patient was hospitalized for symptomatic iron-deficiency anemia three weeks after cardiovascular surgery and the start of dual antiplatelet therapy (DAPT). Since esophagogastroduodenoscopy (EGD) and ileocolonoscopy excluded any source of GI bleeding and the patient was stable, he was discharged. Two months later, the patient returned to the Emergency Department (ED) presenting with melena, and CE was recommended to rule out suspected small bowel bleeding.
Due to COVID-19, CE was not promptly scheduled. After two months, the patient was readmitted to the ED for persistent anemia (Hgb 7g/dL) and melena, without hemodynamic instability. Outpatient CE (Navicam SB system –AI tech embedded, Ankon, China) was performed two days later. The following morning the video was downloaded in 10 minutes and promptly reviewed in AI-assisted modality. After few seconds, active bleeding originating from the duodenum or proximal jejunum was detected. The patient was called back and an urgent EGD was performed after 4 hours from CE review. An actively bleeding Dieulafoy’s lesion was found in the third portion of the duodenum and treated with mechanical hemostasis. At 30-months follow-up, no episodes of re-bleeding occurred and Hgb was stable at 11 g/dL.
AI technology by Navicam SB system allows a rapid download of CE videos and offers a prompt detection of bleeding sources in patients with overt GI bleeding, leading to timely endoscopic management. This may potentially improve the long-term patients’ outcome and reduce the hospital stay, being particularly important in case of limited resources, as experienced during the COVID-19 pandemic.

Introduction

Capsule endoscopy (CE) is commonly used as the initial exam in situations of suspected mid-gastrointestinal bleeding, after normal upper and lower endoscopy. Although the assessment of the small bowel is the primary focus of CE, detection of upstream or downstream vascular lesions may also be clinically significant. This study aimed to develop and test a Convolutional Neural Network (CNN)-based model for panendoscopic automatic detection of vascular lesions during CE.

Aims & Methods

A multicentric retrospective study was conducted, based on 1022 CE exams. We used a total of 35655 frames, from seven types of CE devices (PillCam Colon 1, PillCam Crohn's, PillCam SB1, PillCam SB3, OMOM HD, Olympus, Mirocam), of which 11091 were considered to have vascular lesions (angiectasia or varices) after triple validation. We divided data into a training and a validation set, the latter being used to evaluate the model’s performance. At time of division, all frames from a given patient were assigned to the same dataset. Our primary outcome measures were sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV) and an area under the precision-recall curve (AUC-PR).

Results

A total of 35655 frames were used, with 11091 including vascular lesions. The validation data set contained 2433 frames with normal mucosa and 933 vascular lesions.
Sensitivity and specificity were 86.4% and 98.3%, respectively. PPV was 95.2%, while the NPV was 95.0%. Overall accuracy was 95.0%. The AUC-PR value was 0.96. The CNN processed 115 frames per second.

Conclusion

The study presents promising results for the application of AI deep learning models in panendoscopic automatic detection of vascular lesions in various gastrointestinal topographies. The methodological details, including the patient-split design and the use of frames from different types of CE devices, suggest that the model could be effectively used in routine clinical practice independently of the device brand. This study highlights the potential of panendoscopic evaluation of all gastrointestinal tract and the need for further research in this area. Overall, the high diagnostic performance of this CNN in multibrand devices addresses an important issue of technological interoperability, allowing it to be replicated in multiple technological settings. However, the study has some limitations, including a small number of frames and a retrospective design, which may introduce selection bias, therefore prospective and multicentric studies are needed before introducing this deep learning model into clinical practice. This is the first proof-of concept AI deep learning model developed for panendoscopic automatic detection of vascular lesions during CE.

References

Triester, S.L., et al., A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding. Am J Gastroenterol, 2005. 100(11): p. 2407-18.
Liao, Z., et al., Indications and detection, completion, and retention rates of small-bowel capsule endoscopy: a systematic review. Gastrointest Endosc, 2010. 71(2): p. 280-6.
Rondonotti, E., et al., Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy, 2018. 50(4): p. 423-446.
Ribeiro, T.F.-U.I.C.H., Colon capsule endoscopy and artificial intelligence: a perfect match por panendoscopy, in Artificial Intelligence in Capsule Endoscopy, C.H. Mascarenhas M, Macedo G, Editor. 2023, Academic Press.
Tsuboi, A., et al., Artificial intelligence using a convolutional neural network for automatic detection of small-bowel angioectasia in capsule endoscopy images. Dig Endosc, 2020. 32(3): p. 382-390.
Saurin, J.C., et al., Diagnostic value of endoscopic capsule in patients with obscure digestive bleeding: blinded comparison with video push-enteroscopy. Endoscopy, 2003. 35(7): p. 576-84.
Mascarenhas, M., et al., Deep learning and colon capsule endoscopy: automatic detection of blood and colonic mucosal lesions using a convolutional neural network. Endosc Int Open, 2022. 10(2): p. E171-e177