Clinical Case Summary

This case describes a middle aged female patient who had a background of liver transplant due to primary sclerosing cholangitis two years previously. She presented with a 3 week history of worsening right upper quadrant pain, lethargy and discharge from her surgical wound. As part of her work up she underwent a computer tomography (CT) scan that showed a retrohepatic soft tissue mass with enlarged surrounding lymph nodes.
The differential for this lesion was wide but most radiologically in keeping with post transplant lymphoproliferative disease (PTLD) or a haematoma. However, biopsy and tissue analysis revealed a surprising result as the histology showed Actinomycosis.
Unfortunately follow up CT scan at 5 months showed progression of the lesion that was now abutting the inferior vena cava. Given the technically challenging site of the lesion, it was not felt amenable to surgical resection. A lymph nodes was arranged to rule out dual pathology, which again demonstrated Actinomycosis.
In view of the above, the patient has been treated with a prolonged course of broad spectrum antibiotics and remains closely followed up by the Hepatology and Infectious Diseases departments.
Hepatic Actinomycosis presents with vague non specific symptoms including RUQ pain, lethargy and raised LFTs.
There are multiple causes of soft tissue hepatic masses with lymphadenopathy in a liver transplant recipient, including Hepatic Actinomycosis, and so early tissue diagnosis should be considered.
When treated via antimicrobial therapy alone, Hepatic Actinomycosis shows a delayed response and requires surveillance imaging and a prolonged course.

References

1. NHS Blood and Transplant. Annual Activity Report - ODT Clinical - NHS Blood and Transplant 2020-2021 [Available from: https://www.odt.nhs.uk/statistics-and-reports/annual-activity-report/.
2. Chegini Z, Didehdar M, Tabaeian SP, Khoshbayan A, Shariati A. A systematic review of case reports of hepatic actinomycosis. Orphanet J Rare Dis. 2021;16(1):192.
3. Yang XX, Lin JM, Xu KJ, Wang SQ, Luo TT, Geng XX, et al. Hepatic actinomycosis: report of one case and analysis of 32 previously reported cases. World J Gastroenterol. 2014;20(43):16372-6.
4. Laish I, Benjaminov O, Morgenstern S, Greif F, Ben-Ari Z. Abdominal actinomycosis masquerading as colon cancer in a liver transplant recipient. Transpl Infect Dis. 2012;14(1):86-90.

Clinical Case Summary

Introduction: Cap polyposis is a rare benign inflammatory condition characterized by inflammatory polyps covered with a fibrinopurulent exudate. It is more commonly observed in women and the elderly, although it can present at any age. The disease typically affects the rectum and sigmoid colon. The most frequent symptoms include mucous diarrhea and rectal bleeding. It has been associated with mucosal prolapse due to altered intestinal motility, Helicobacter pylori infection, and even intestinal dysbiosis.
Endoscopy: A 46-year-old male with no relevant personal or family medical history presented with altered bowel habits, characterized by increased stool frequency, decreased consistency, and the presence of mucus and blood, along with tenesmus and urgency. H. pylori testing was negative. Colonoscopy revealed numerous sessile and pedunculated polyps with an inflammatory appearance distributed throughout the colon, predominantly in the sigmoid and rectum. Most polyps were covered at their apex by a fibrinopurulent exudate (Figures 1–4). The colonic mucosa adjacent to the polyps appeared normal. Multiple biopsies were taken, confirming inflammatory polyps. A first therapeutic colonoscopy was performed, during which multiple polyps consistent with cap polyps were resected (Figure 5). Additional sessions were scheduled to complete polyp resection. Furthermore, a molecular study was performed using next-generation sequencing (NGS) with a multigene panel including genes associated with polyposis, with negative results.
Conclusions: The clinical course of cap polyposis remains unclear. The need for and timing of colonoscopy should be individualized based on the number of polyps and symptom severity. Initial treatment should be conservative, focusing on resolving constipation and eradicating H. pylori. In cases with persistent symptoms, endoscopic resection of the lesions should be considered.

Introduction

Metabolic-dysfunction-associated-steatotic liver disease (MASLD) affects more than half of obese subjects. To date, weight reduction by diet and physical activity is recommended to improve liver injury. Recent studies have shown that bariatric surgery induces stable weight loss and ameliorates metabolic parameters.

Aims & Methods

The aim of this study is to evaluate the effect of bariatric surgery on liver steatosis and fibrosis.
This is a monocentric prospective study including all patients with severe obesity and MASLD candidates for bariatric surgery in a single Italian-center. Other causes of chronic liver disease were an exclusion criteria. Clinical and biochemical data were collected. Liver fibrosis and steatosis were non-invasively assessed with Liver Stiffness Measurements (LSM) and Controlled Attenuation Parameter (CAP) by Fibroscan at three time-points: before surgery, 6- and 12-months after surgery.

Results

A total of 112 patients (63.4% female, mean age 41.5 years) were enrolled. Before bariatric surgery, the BMI was 43.6±6.2kg/m², the LSM was 8±5.8kPa and the CAP was 319.7±57.8dB/m. Ninety-six patients continued follow-up up after surgery. These patients demonstrated a significant reduction in BMI and CAP as early as 6-months post-surgery, while a significant decrease in LSM was observed only after 12-months. Specifically, the mean BMI was 31.9±5.1kg/m² after 6 months and 28.0±3.5kg/m² after 12-months, representing an overall decrease of 35.9% from baseline (p<0.0001). The mean CAP was 264.5±57dB/m after 6-months and 214.8±47.8dB/m after 12-months, reflecting an overall decrease of 32.8% from baseline (p<0.0001). Finally, the mean LSM was 6.3±2.5kPa after 6-months and 5.8±1.9kPa after 12-months, showing an overall decrease of 21.6% from baseline (p=0.02).

Conclusion

This study demonstrated a significant weight loss and liver steatosis decrease already at 6-months after surgery, while liver fibrosis reduction takes longer at 12-months after surgery. Therefore, in adults with MASLD and severe obesity, bariatric surgery should be considered as a valid therapeutic option for improving the liver damage.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is a widely utilized procedure for managing biliary and pancreatic disorders (1). ERCP is associated with complications, and potential factors influencing the ERCP outcomes is a critical area of research (2). Among these factors, obesity has emerged as a variable of interest due to its increasing prevalence globally and its known associations with a range of health conditions (3). Previous studies have yielded conflicting results on the influence of obesity on ERCP outcomes, with some reporting higher complication rates, while others found no significant associations (4, 5). The interplay between weight and procedural outcomes across a spectrum of BMI categories remains underexplored. This study aimed to assess the impact of body mass index (BMI) on clinical aspects and procedural outcomes of ERCP.

Aims & Methods

A total of 2143 patients who underwent ERCP at Hitit University Hospital between January 2020 and February 2024 were initially included. Of these, 1315 patients were excluded due to incomplete clinical information, previous ERCP history, altered anatomy and pregnancy, resulting in a final cohort of 828 patients for analysis.
The included patients were stratified into BMI categories: ≤30 kg/m² and >30 kg/m². Additionally, subgroup analyses were performed across finer BMI classifications: ≤20, 20 to ≤25, 25 to ≤30, 30 to ≤35, and >35 kg/m². Clinical and procedural parameters evaluated included admission diagnoses of acute pancreatitis and acute cholangitis (according to Tokyo cholangitis grade), American Society of Anesthesiologists (ASA) scores, gender, history of cholecystectomy, cannulation success, cannulation time, post-ERCP complications including post-ERCP pancreatitis and other complications according to modified Cotton criteria and 30-day readmission rates. The relationships between BMI and the clinical aspects as well as procedural outcomes of ERCP were investigated.

Results

The study cohort consisted of 828 patients, with 75.8% (n=628) having a BMI ≤30 kg/m² and 24.2% (n=200) having a BMI >30 kg/m². Within the finer BMI categories, 3.7% (n=31) of patients had a BMI ≤20 kg/m², 24.2% (n=200) were in the 20 to ≤25 kg/m² range, 47.9% (n=397) were in the 25 to ≤30 kg/m² range, 19.7% (n=163) were in the 30 to ≤35 kg/m² range, and 4.5% (n=37) had a BMI >35 kg/m². The majority of patients (47.9%) were within the BMI range of 25–30 kg/m², reflecting a significant proportion of overweight individuals in the cohort. Patients with a BMI >35 kg/m² constituted the smallest group, accounting for only 4.5% of the total population.
The study found no statistically significant differences between the groups concerning admission rates for acute pancreatitis and acute cholangitis, ASA scores, cannulation success, post-ERCP complications, and readmission within 30 days after the procedure (p>0.05). Notably, women were found to be significantly more obese (p<0.001), and a higher weight was associated with an increased history of cholecystectomy (p=0.013).
Additionally, there were no significant differences in average age, Charlson comorbidity index, cannulation time, length of hospital stay, or white blood cell count at admission between the BMI groups (p>0.05). However, CRP and total bilirubin levels were significantly higher in the non-obese group compared to the obese group (p=0.01 and p=0.011, respectively).

Conclusion

BMI did not influence the incidence of acute pancreatitis or acute cholangitis on admission, ASA scores, cannulation success or time, post-ERCP complications, length of hospital stays, or 30-day readmission rates. Interestingly, higher CRP and total bilirubin levels were observed in patients without obesity at admission, warranting further investigation into their clinical implications.

References

1. Tokmak S TS. History of ERCP. The Turkish Journal of Academic Gastroenterology 2021;20: 1-2.
2. Duzenli T, Koseoglu H. Endoscopic Retrograde Cholangiopancreatography During the COVID-19 Pandemic: Effects of Enhanced Personal Protective Equipment. Dig Dis Sci 2021;66: 1845-1851.
3. Alfaris N, Alqahtani AM, Alamuddin N, Rigas G. Global Impact of Obesity. Gastroenterol Clin North Am2023;52: 277-293.
4. Deenadayalu VP, Blaut U, Watkins JL, Barnett J, Freeman M, Geenen J, et al. Does obesity confer an increased risk and/or more severe course of post-ERCP pancreatitis?: a retrospective, multicenter study. J Clin Gastroenterol2008;42: 1103-1109.
5. Fujisawa T, Kagawa K, Hisatomi K, Kubota K, Sato H, Nakajima A, et al. Obesity with abundant subcutaneous adipose tissue increases the risk of post-ERCP pancreatitis. J Gastroenterol 2016;51: 931-938.