Introduction

Few population-based studies have investigated rates and management of perianal disease and long-term perianal surgery rates in Crohn’s disease (CD). The present study is a continuation of the Veszprem IBD population based cohort with a follow-up osince 1977.

Aims & Methods

Our aim was to analyze the long-term rates of perianal surgical procedures over different therapeutic eras in a prospective population-based database from Veszprem Province, including incident CD patients. Patient inclusion was between January 1, 1977 and December 31, 2018; follow-up ended December 31, 2020. Both in-hospital and outpatient records were collected. Perianal surgical procedure was defined as any perianal surgical procedure including fistulotomy, abscess drainage or seton placement. Surgery rates were examined in three different eras based on time of diagnosis: cohort-A, 1977-1995; cohort-B, 1996-2008; and cohort-C, 2009-2018.

Results

Data of 946 incident CD patients were analyzed (male/female: 496/450; median age at diagnosis: 28 years(y) [IQR: 22-40]). Median follow-up time for the entire cohort was 15 years (IQR: 9-21). Perianal disease at diagnosis was present in 17.4% (n=165) of the total cohort, and in 24.7%/ 18.5%/ 13.2% in cohorts A/B/C, respectively. By the end of follow-up, an additional 9.3% (n=88) of the total cohort developed perianal disease. Cumulative immunosuppressive and biologic therapy exposure increased by time. Cumulative probability of biological therapy after diagnosis in patients with perianal disease was 0.0±0% / 15.1±3.2% / 42.5±6.2% at 5 years after diagnosis between cohorts A/B/C. Biologic use was higher in patients with perianal disease compared to the overall population. [pLogRank<0.001]. The overall rate of perianal surgical procedures was 44.7% (113/253) in patients with perianal disease during the total follow-up. The cumulative probability of perianal surgical procedure in patients with perianal disease was 28.3±2.9% after 10 years, 41.0±3.5% after 20 years, and 64.1±5.1% after 30 years. No statistically significant differences have been observed in the cumulative probability of perianal intervention between cohorts A/B/C: 24.2±5.4%/ 19.9±3.5%/ 29.4±5.8% after 5 years; 33.9±6.0%/ 23.6±3.8%/ 31.7±6.1% after 10 years; [pLogRank=0.594]. Cox-regression multivariate analysis showed that stenosing or penetrating disease (B2/B3) behavior (HR 1.81; 95%CI 1.19-2.75; p=0.005) was independent predictor of perianal surgical procedure. Table 1.

Table 1. Predictive factors for first perianal surgical procedure in incident CD patients diagnosed between 1977 and 2018 – Cox-regression analysis

Conclusion

The burden of perianal disease and perianal surgical interventions was high in this cohort. Patients with perianal CD had higher exposure to biologicals. No difference was observed in perianal surgical intervention rates despite the increasing use of immunosuppressives and biologicals over time, however these procedures may partly represent a medical decision and the complex management of perianal disease.

Introduction

A male patient in his twenties presented with clinical aspects of primary sclerosing cholangitis (PSC), chronic cholestatic liver disease, and hypothyroidism. PSC is a rare, chronic cholestatic liver disease characterized by biliary strictures and peribiliary fibrosis (1). Susceptible loci were identified in GWAS but the correlation between genetic background and disease pathogenesis needs further investigation (2). In the index patient we identified a heterozygote candidate variant in the ABCC6 gene (c.2279G>A, p.(Arg760Gln)). Dysfunctional ABCC6 was described to cause ABCB11 and ABCG5/G8 genes overexpression, leading to imbalanced bile composition resulting in gallstone formation and cholestasis (3). ABCC6 variants were previously described in cases with low phospholipid-associated cholelithiasis (LPAC) and intrahepatic cholestasis of pregnancy (ICP)(4-6) . Subsequently, we aimed to investigate rare variants in ABCC6 gene in whole exome sequencing (WES) results from patients with suspected cholestatic liver disease.

Aims & Methods

Variant evaluation and annotation analysis was carried out on WES data, with focus on loss of function and missense variants, presenting allele frequency (AF) of ≤1% based on gnomAD database (https://gnomad.broadinstitute.org). Variants were filtered to include only those in genes relevant to the patients’ clinical phenotype. For each rare variant, a comprehensive in silico assessment was performed using tools such as REVEL, AlphaMissense, EVE, SIFT, and MetaLR to evaluate potential pathogenicity. Filtered were prioritized and interpreted using ACMG-AMP guidelines. This systematic approach ensured a clinically meaningful and evidence-based evaluation of the identified variants.

Results

Nine different rare heterozygote variants were identified in fifteen samples of 247 WES results. Among these, the missense variants c.179G>A, p.(Arg60Gln) and c.3139C>T, p.(Arg1047Cys) were found in two LPAC patients. Additionally, the c.1171A>G, p.(Arg391Gly) variant was observed in two related cases: a mother with ICP and her child with elevated gamma-glutamyl transferase (GGT) levels and jaundice. Moreover, this variant was also detected in another patient with elevated transaminases. c.3871G>A, p.(Ala1291Thr) and c.955A>G, p.(Ile319Val) were seen in patients with ICP and cholestasis, respectively. Three other variants were also identified in patients with liver disease of unknown etiology (c.1540G>A, p.(Val514Ile) and c.2707G>C, p.(Glu903Gln) and c.4397G>A, p.CYS1466Tyr). Additionally one splicing variant (c.37-1G>A, p,?) was also detected in a patient with cholangiocarcinoma (CCA). All variants were observed in heterozygote state and classified as variants of uncertain significance (VUS).

Conclusion

An in-depth analysis of WES data led to the identification of several potentially disease-relevant variants in the ABCC6 gene. These variants may play a contributory role in the observed hepatic phenotypes, suggesting a broader functional involvement of ABCC6 beyond its well-established association with pseudoxanthoma elasticum (PXE). Our findings highlight the importance of integrating genetic data with detailed clinical phenotyping to enhance understanding of genotype–phenotype correlations and reveal novel roles for known genes in atypical or organ-specific presentations.

References

1. Reich M, Spomer L, Klindt C, Fuchs K, Stindt J, et al. Downregulation of TGR5 (GPBAR1) in biliary epithelial cells contributes to the pathogenesis of sclerosing cholangitis. J Hepatol. 2021;75(3):634-46.
2. Goode EC, Fachal L, Panousis N, Moutsianas L, McIntyre RE, Bai BYH, et al. Fine-mapping and molecular characterisation of primary sclerosing cholangitis genetic risk loci. Nat Commun. 2024;15(1):9594.
3. Ibold B, Faust I, Tiemann J, Gorgels T, Bergen AAB, Knabbe C, et al. Abcc6 deficiency in mice leads to altered ABC transporter gene expression in metabolic active tissues. Lipids Health Dis. 2019;18(1):2.
4. Liu X, Lai H, Xin S, Li Z, Zeng X, Nie L, et al. Whole-exome sequencing identifies novel mutations in ABC transporter genes associated with intrahepatic cholestasis of pregnancy disease: a case-control study. BMC Pregnancy Childbirth. 2021;21(1):110.
5. Liu X, Zheng J, Xin S, Zeng Y, Wu X, Zeng X, et al. Whole-exome sequencing expands the roles of novel mutations of organic anion transporting polypeptide, ATP-binding cassette transporter, and receptor genes in intrahepatic cholestasis of pregnancy. Front Genet. 2022;13:941027.
6. Romeo M, Dallio M, Federico A. Is it time to reconsider the MRP6 role in bile secretion and LPAC genetic signature? J Hepatol. 2023;79(4):e152-e4.

Disclosure

The authors declare that they have no conflict of interest.

Clinical Case Summary

We present the case of a 43-year-old black male with a relevant medical history of arterial hypertension, alcoholism, and epilepsy. He was admitted to the emergency department for cough with purulent sputum, shortness of breath and chest pain for the past week. On observation, he presented several perianal fistula openings with bloody and purulent discharge. A computed tomography (CT) revealed perirectal densification, fistulous tracts to the ischioanal fossae, ascites, mesenteric fat densification and necrotic inguinal adenopathies. Due to the presence of hematochezia, a rectosigmoidoscopy was performed which showed deep ulceration causing destruction of the posterior wall of the distal rectum, involving one third of its luminal circumference, with bloody and purulent discharge. The patient developed septic and hemorrhagic shock and was admitted to the intensive care unit. He underwent urgent surgery for hemostasis of the rectal ulcer, partial fistulectomy, seton placement in the other three fistulous tracts, and loop colostomy. Analysis of the perianal discharge detected Mycobacterium tuberculosis by polymerase chain reaction. Sputum acid-fast bacilli smear was also positive, and a thoracic CT scan showed cavitating consolidations in the upper pulmonary lobes and a tree-in-bud pattern reflecting active tuberculosis (TB) with endobronchial spread. Remarkably, the patient was HIV-negative and did not have other causes for immunosuppression besides the chronic alcoholism. He was started on antitubercular medication and evolved favorably.
Gastrointestinal TB represents less than 1% of all tuberculosis cases. Anorectal involvement is even rarer, being present in 1% of all cases of gastrointestinal TB. Its most common presentation is complex perianal fistulizing disease. In most cases, pulmonary TB is also present. Although it is more prevalent in immunosuppressed patients, it should be included in the differential diagnosis of complex perianal fistulizing disease.

References

1- Photographs of perianal fistulizing disease with purulent discharge;
2- CT scan suggesting disseminated TB;
3- Rectosigmoidoscopy showing destruction of the distal rectal wall.

Introduction

The role of prophylactic biliary stenting after clearance of common bile duct stones (CBDS) in patients awaiting cholecystectomy for concomitant gallstones is controversial.

Aims & Methods

Aim: To study the effect of prophylactic biliary stenting after achieving biliary clearance in reducing CBDS recurrence and biliary complications in patients awaiting cholecystectomy.
Methods: Patients with concomitant gallstones and CBDS were included and those who had evidence of clearance of CBDS that was documented on occlusion cholangiogram during endoscopic retrograde cholangiography (ERC) were randomized to prophylactic biliary stenting (group A) or no stenting (group B). After clearance, the patients were advised to undergo cholecystectomy as early as possible. The patients were followed up at 1 week, 1, 2, and 3 months after clearance, and at 3 months or after cholecystectomy (whichever was early) they were assessed for recurrence of CBDS by either endoscopic ultrasound or MRCP or ultrasound abdomen and liver function test whichever was convenient for the patient. During each follow-up visit patients were assessed for symptoms and were requested to do a hemogram and liver function test. The primary outcome was to compare the CBDS recurrence rate, while the secondary outcomes were to compare the biliary complications and the need for repeat/ emergency ERC. Statistical analysis was performed using IBM SPSS version 22. Quantitative variables were analysed by mean and standard deviation (SD) while categorical variables were analysed by frequency and proportion. Median and interquartile range (IQR) were used for non-normally distributed quantitative variables. Comparison of categorical outcomes was done between study groups using Chi-square test/Fisher's Exact test. At different time periods, categorical variables were compared using the McNemar test. For quantitative parameters with normal distribution, the mean values were compared between study groups using an independent sample t-test (2 groups). Change in the quantitative parameters before and after the intervention was assessed by paired t-test. P value < 0.05 was considered statistically significant.

Results

Between September 2021 to July 2022, 70 patients were randomized into Group A-stenting (n-35) and Group B- no stenting (n-35). Sixty-six patients were included in the final analysis. The baseline characteristics were comparable between the 2 groups. Ten (15.15%) patients had a recurrence of CBDS and it was comparable between the 2 groups [7/34 (20.59%) and 3/32 (9.38%), p=0.306]. Two patients in the stent group developed biliary complication (cholecystitis) while none of the patients in the no stent group developed any biliary complication. Three patients in the stent group while none in the no-stent group developed post-ERC pancreatitis (p=0.085). None of the patients in both the groups needed emergency ERC during the follow-up.

Conclusion

This randomized trial shows no advantage of prophylactic stenting in preventing CBDS recurrence or biliary complications in patients waiting for cholecystectomy after biliary clearance. (CTRI registration number: CTRI/2021/09/036538)

Introduction

The endoscopic retrograde cholnagio-pancreatography (ERCP) with endoscopic sphincterotomy results in a complete bile duct stones (CBDSs) clearance in about 80-90%. However, in case of incomplete CBDSs clearance, an endoprosthesis could be placed. A plastic stent is commonly used, with a success rate after a previous ERCP, ranging from 44% to 96%. However, there are no comparative studies between plastic and metal stent. Moreover, data concerning the safety and efficacy of antimigration Fully covered Metal stents – flare type (aFCMS) are lacking.

Aims & Methods

In this single-center retrospective study we collected data concerning all patients who underwent ERCP with antimigration metal stent placement for incomplete removal of CBDSs between January 2021 to January 2023. All patients were contacted in order to program stent remotion within 3-6 months (considering their general clinical condition) or to evaluate their clinical status. We aim to estimate the incidence of migration rate, and adverse events, and complete biliary clearance after 3-6 months from the index ERCP.

Results

Out of 34 patients included patients, 20 underwent a second ERCP after a median of 164 (±78) days. The reasons for the lack of a second ERCP evaluation are reported in the table. In 11/20 (55%) a distal migration occurred. Only one proximal migration was reported. Among the 34 included patients only one presented a clinical recurrence linked to the proximal migration of aFCMS. 19/20 patients achieved a complete clearance after the second ERCP. No serious adverse events were reported.

Conclusion

The aFCMS represents an effective and safe therapeutic chance in case of incomplete CBDSc clearance in particular in case of difficult CBDSs. Moreover, the very low incidence of stent proximal migration makes this device particularly useful in the case of this clinical condition.

Disclosure

None

Introduction

Pain is the hallmark and most disabling symptom of chronic calcific pancreatitis (CCP), often severe and significantly impairing patients' quality of life. Its pathophysiology involves increased intraductal pressure, chronic inflammation, and neuropathic changes.

Aims & Methods

This study aimed to assess the prevalence of pain in CCP and to identify factors associated with its occurrence and severity.
This was a retrospective analytical study including patients followed for CCP. We collected data on disease duration, etiology, clinical manifestations, complications, analgesic treatments (AT), and symptom evolution under treatment. Pain intensity and impact on quality of life were assessed using the Izbicki Score (IS), which categorizes pain as mild (0–20), moderate (21–40), severe (41–60), or very severe (>60). Incomplete records that prevented IS calculation were excluded. Data were entered and analyzed using SPSS software, with statistical significance set at p < 0.05.

Results

We included 22 patients (14 men and 8 women), with a mean age of 55.6 years [27–80 years]. The most common symptoms were epigastric pain (n=18), weight loss (n=13), and chronic diarrhea (n=6). The mean delay between symptom onset and diagnosis was 25 months [1–120 months]. Etiologies included hyperparathyroidism (n=6), alcohol use (n=2), pancreas divisum (n=2), autoimmune causes (n=2), and were undetermined in 10 cases. The IS ranged from 0 to 93.75, with a mean of 40.22. Eight patients had an IS >40. Morphine was required in four cases; paracetamol was prescribed for 12 patients, and tramadol for two. Endoscopic treatment was indicated in three cases, while one patient underwent a Wirsungojejunostomy.
In univariate analysis, alcohol consumption was significantly associated with the occurrence of epigastric pain (p=0.01). Smoking and alcohol use were both linked to a higher IS (>50) (p=0.04). Smoking cessation was associated with a better analgesic response (p=0.04). Morphine use was significantly more frequent among alcoholic patients (p=0.01), and their treatment response was often unfavorable (p=0.02).

Conclusion

In our cohort, 80% of patients with CCP experienced pain, which was severe to very severe in nearly half the cases. Pain intensity was significantly associated with tobacco and alcohol consumption, while cessation improved treatment response. These findings underscore the importance of therapeutic education focused on smoking and alcohol cessation, in addition to analgesic management, to slow disease progression and improve pain control.