Introduction

Diagnosis of non-calcific chronic pancreatitis (CP) is a clinical challenge. EUS shows a high diagnostic sensitivity in this context, but specificity of mild EUS changes is limited. New advanced imaging techniques associated to EUS, such as strain elastography (SE), have proven to be useful in this context. Recently, the development of shear wave elastography (SWE) opens a new alternative for the evaluation of pancreatic fibrosis.

Aims & Methods

Aim of our study was to evaluate the accuracy of SWE for the evaluation of patients with clinical suspicion of CP.
Methods: Prospective study of patients undergoing EUS. Procedures were performed with a linear echoendoscope (Fujifilm 740UT) attached to the ultrasound system Arietta 850. EUS criteria for CP from Rosemont classification were evaluated. A significant area corresponding to the pancreatic body was selected for SWE. Five SWE measurements were done and the mean wave velocity (Vs) and pressure (Kpas) were calculated. SE was performed at the same location, and the strain histogram (SH) and the strain ratio (SR) were quantified. Data are shown as mean (95%CI) and percentage, and were analyzed by ANOVA and linear regression.

Results

81 patients were included (mean age 54 years, range 21-85, 40 males). Eighteen patients (22.2%) presented a normal pancreas, 14 (17.3%) indeterminate findings for CP, 45 (55.6%) suggestive of CP and 4 (3.6%) consistent with CP. The Vs was 1.66 (1.41-21.91), 2.14 (1.84-2.43), 2.72 (2.58-2.86) and 3.31 (2.64-3.99) in patients with normal pancreas, indeterminate for CP, suggestive for CP, and consistent with CP respectively (p<0.0001). Pressure (KPas) was 9.07 (6.01-12.12), 14.97 (10.66-19.26), 23.28 (21.03-25.52) and 31.25 (23.77-38.73) in patients with normal pancreas, indeterminate for CP, suggestive for CP, and consistent with CP respectively (p<0.0001). Number of EUS criteria of CP (r=0.708 and r=0.682), SR (r=0.684 and r=0.668) and SH (r=0.697 and 0.660) correlated significantly with Vs and Kpas (p<0.001 in all cases).

Conclusion

EUS-SWE (Vs and Kpas) allows evaluating the degree of pancreatic fibrosis in CP. EUS-SWE results correlate significantly with EUS-SE.

Disclosure

Julio Iglesias Garcia. Advisor Pentax, FujiFilm, Mediglobe

Clinical Case Summary

Celiac disease (CD) has been associated with gastrointestinal malignancies, most commonly gastrointestinal lymphoma. Nevertheless, rarer malignancies have also been reported, such as small bowel adenocarcinoma (SBA), mainly located in the duodenum or jejunum.
We report a case of a 59-year-old female with the diagnosis of CD in pediatric age, with poor adherence to a gluten-free diet (GFD), who presented with a 10-day history of nausea, vomiting, abdominal pain, and a 6-month history of anorexia and significant involuntary weight loss. Carbohydrate antigen 19-9 and carcinoembryonic antigen were negative. After a plain abdominal radiograph (figure1), an abdominopelvic computed tomography with oral and intravenous contrast was performed, identifying a thickened segment of ileum with stenotic characteristics, with proximal bowel dilation (figure2). The patient underwent antegrade and retrograde single-balloon-assisted enteroscopy, without abnormalities identified (figure3). An exploratory laparotomy was conducted, in which an enterectomy of the stenotic ileal segment with en bloc removal of regional lymph nodes was performed (figure4). Immunohistopathological analysis described a low-grade, infiltrative adenocarcinoma involving the serosa with venous and perineural invasion and presence of DNA mismatch repair proteins. The surgical margins and the five resected lymph nodes were tumor-free (figure5). A final TNM stage was defined (T4, N0, M0 – IIB), and adjuvant chemotherapy was administered (capecitabine plus oxaliplatin). Six months after finishing chemotherapy, there was no clinical, biochemical, or imaging evidence of cancer recurrence.
This is one of the very limited number of cases in which a diagnosis of a primary adenocarcinoma associated with CD is described in a female patient and located in the ileum. Moreover, it emphasizes the importance of the GFD and the early diagnosis and appropriate management of rare small bowel malignant complications of CD.

Introduction

The part of NAFLD children has a progressive sub-phenotype known as nonalcoholic steatohepatitis (NASH), characterized by the ability to develop advanced fibrosis, cirrhosis, and end-stage liver disease [1]. Given the high prevalence of NAFLD and invasiveness of the liver biopsy, there is an essential need to find safe non-invasive modalities to determine liver fibrosis in children [2].

Aims & Methods

To investigate serum fibrosis markers in obese children with non-alcoholic fatty liver disease (NAFLD) depending on the presence of liver fibrosis.
94 children aged 9 to 17 years (average age 12.15 ± 2.51 years) were included in the study. According to the transient elastography data (FibroScan®502touch, Echosence, France) and body mass index, children were divided into four groups: group 1 - 27 obese NAFLD children with fibrosis ≥F1, group 2 - 35 obese NAFLD children without fibrosis, group 3 - 18 obese children without NAFLD and fibrosis. Group 4 (control) consisted of 14 children with normal weight without NAFLD and liver fibrosis. The serum levels of vascular endothelial growth factor (VEGF) (Wuhan Fine Biotech Co Ltd, China), transforming growth factor-beta 1 (TGF-β1) (IBL International, Germany), cytokeratin-18 (CK-18) (IDL Biotech AB, Sweden) were determined by enzyme-linked immunosorbent assay (ELISA). Serum content of hydroxyproline free (HPf) and hydroxyproline protein-bound (HPp/b) according to Osadchuk and glycosaminoglycans (GAG) according to Rimington were evaluated.

Results

In 1 group children, a significant increase in the median level of CK-18 (in 2.2 times, p<0.05), VEGF (in 2.4 times, p<0.05), and TGF-β1 (in 2.7 times, p<0.05) was found compared to 4 group children. Moreover, CK-18 level was significantly higher in 1 group of patients compared to 2 group (in 1.4 times, p<0.05) and 3 group (in 1.8 times, p<0.05). In all group children, an increase in the serum HPp/b content was found: in 1 group - in 1.2 times (p<0.01), in 2 group - in 1.2 times (p<0.05), in 3 group - in 1.3 times (p<0.05) compared to 4 group. The changes in the content of hydroxyproline led to an increase in the HPp/b/HPf ratio in all groups: 1.4 times (p<0.01) in 1 and 2 groups, in 1.3 times (p<0.01) in 3 group. Also, in 1 group of children median GAG level was increased by 1.3 times (p<0.001).
In children with NAFLD HPf content negatively correlated with CAP (r= - 0.408; p<0.01), CK-18 (r=-0.469; p<0.01), the ratio HPp/b/HPf positively correlated with CAP (r=0.307; p<0.05). CK-18 positively correlated with fibrosis degree (according to METAVIR) (r=0.468; p=0.008) and liver steatosis degree (r=0.357; p=0.048). A positive correlation was also found between VEGF levels and the degree of liver fibrosis (r=0.372, p=0.036).

Conclusion

Serum levels of VEGF, TGF-β1, HPp/b, and GAG were significantly elevated in children with non-alcoholic fatty liver fibrosis. Assessment of these parameters may be useful for early diagnosis of liver fibrosis in children with NAFLD.

References

1. Schwimmer JB, Johnson JS, Angeles JE, et al. Microbiome Signatures Associated With Steatohepatitis and Moderate to Severe Fibrosis in Children With Nonalcoholic Fatty Liver Disease. Gastroenterology. 2019;157(4):1109-1122. doi:10.1053/j.gastro.2019.06.028.
2. Alkhouri N. Putting it all together: Noninvasive diagnosis of fibrosis in nonalcoholic fatty liver disease in adults and children. Clin Liver Dis (Hoboken). 2017;9(6):134-137. Published 2017 Jun 29. doi:10.1002/cld.636