Introduction

Colorectal cancer is one of the most common types of cancer worldwide. The majority of patients are operable at the time of diagnosis. One of the most severe surgical complications is anastomotic leakage (AL). The incidence of AL depends on where the anastomosis is located (1-2% for ileocolic anastomoses, increasing to 10-15% of anastomoses to the rectum). AL leads to prolonged hospital stay, decreased quality of life, increased risk of cancer recurrence, and increased mortality.
Experimental studies have shown that certain bacteria can contribute to the development of AL.
In Denmark, people aged 50-74 years are offered free of charge screening for colorectal cancer. They collect a stool sample at home to be analyzed for the presence for blood (a fecal immunochemistry sample). It is possible to extract bacterial DNA from the fecal sample, to characterize the gut microbiome at the time of sampling.

Aims & Methods

The objective of the study was to use third-generation sequencing methods to analyze screening fecal samples in a cohort of colorectal cancer patients, and to characterize and compare the gut microbiome between patients with or without postoperative AL.
Fecal samples sent to the Colorectal Cancer Screening Program that tested positive for blood, from 2016-2018, were place in a biobank and stored at -80 ⁰C. By combining the biobank with data from the Danish Colorectal Cancer Group, we identified 18 patients who had surgery for colonic or rectal cancer in the period and suffered a postoperative AL (AL group). We matched these patients in a 1:2-ratio, with 36 patients without AL (Control group). We analyzed the 16S ribosomal RNA genes in the screening fecal samples with third-generation sequencing (Oxford Nanopore Technologies).

Results

The data are preliminary, as the data analysis has not yet been completed.
The AL-group and Control group were similar on basic demographic parameters (age, gender, type of resection, smoker status and ASA classification). The gut microbiome composition was significant different in the two groups, based on the two main components of a principal coordinate analysis (PCoA) chart (PERMANOVA, p-value = 0.01).
The Bacteroidota phylum was more abundant in the Control group (p < 0.05). On the order level, Campylobacterales and Bacteroidales were more abundant in the Control group (p < 0.001). On family level, Campylobacteraceae were more abundant in the Control group (p < 0.001), whereas Burkholderiaceae were abundant in the AL-group (p < 0.001). The AL-group also had more Ralstonia and Burkholderia at genus level (p < 0.001), whereas the Control group had more Campylobacter and Oridobacter genera (p < 0.001).

Conclusion

The preoperative gut microbiome composition in colorectal patients with subsequent anastomotic leakage were significantly different from the control group without anastomotic leakage. Campylobacter and Oridobacter seem protective against AL, whereas Ralstonia and Burkholderia seem harmful. We are awaiting further analysis for the species level.
Further studies should focus on validating our results, including changes in the gut microbiome prior to surgery - for instance the impact of bowel preparation – and on estimating the predictive value of our findings.

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

Clinical Case Summary

Introduction: PSC is closely associated with IBD and affects up to 3.6% of Crohn's disease patients, while AIH is also more prevalent in IBD patients, in up to 16% of patients.
Case report: We report a female patient who, at the age of 14, presented with right hypochondrial pain and abnormal liver biochemistry (SGOT: 44 U/l, SGPT: 145 U/l, γ-GT: 300 U/l, ALP: 421 U/l, TBL: 1 mg/dL). The patient underwent MRCP (Figure A) which revealed local strictures with prostenotic dilatation in both intrahepatic and extrahepatic bile ducts, suggestive of PSC. One year later the patient presented with severe abdominal pain and bloody diarrhea. Ileocolonoscopy showed terminal ileitis (Figure B) and segmental colitis. Histological evaluation (Figure C) showed disruption of the architecture, focal erosions of the epithelium, mild mucopenia, inflammatory infiltrate in the dermis, sites of cryptitis and focal formation of crypt abscesses with extension of inflammation to the muscularis mucosae, suggestive of Crohn’s Disease. Two years later, in a regular laboratory test, the patient had abnormal liver function tests (SGOT: 211 U/l, SGPT: 603 U/l, γ-GT: 54 U/l, ALP: 105 U/l, TBL: 0.9 mg/dl). Further evaluation with immunoassay revealed ANA (+) 1/80, AMA (-), SMA (+) 1/160, + F-actin, anti-LKM (-), anti-LC (-), anti-LM (-), p ANCA (+) 1/80, so the patient underwent percutaneous liver biopsy with findings of portal spaces with presence of waxy-containing macrophages, thin fibrous septa, parenchyma with centrolobular necrosis with aggregates of inflammatory cells and waxy macrophages, suggestive of Autoimmune Hepatitis. Today, the patient is in clinical remission under treatment with Ursodeoxycholic acid, Ustekinumab and Mycophenolate Mofetil.
Conclusion: The association of IBD with PSC, AIH and variant forms is now known, however the complexity of the diseases presents a challenge for the clinician and the provision of individualized care.

References

1. Ballotin VR, Bigarella LG, Riva F, Onzi G, Balbinot RA, Balbinot SS, Soldera J. Primary sclerosing cholangitis and autoimmune hepatitis overlap syndrome associated with inflammatory bowel disease: A case report and systematic review. World J Clin Cases. 2020 Sep 26;8(18):4075-4093.
2. Saich R, Chapman R. Primary sclerosing cholangitis, autoimmune hepatitis and overlap syndromes in inflammatory bowel disease. World J Gastroenterol. 2008 Jan 21;14(3):331-7.
3. Rocha HC, Vilela EG. Clinical aspects and prognosis of patients with inflammatory bowel disease associated with autoimmune liver diseases. Gastroenterol Hepatol. 2022 Feb;45(2):83-90. English, Spanish.
4. Malik T, A, Gutierrez A, M, McGuire B, Zarzour J, G, Mukhtar F, Bloomer J: Autoimmune Hepatitis-Primary Sclerosing Cholangitis Overlap Syndrome Complicated by Crohn’s Disease. Digestion 2010;82:24-26.

Clinical Case Summary

Introduction: Eosinophilic enteritis (EoEo) is a rare condition characterized by eosinophilic infiltration of the intestinal wall without an identifiable secondary cause. Clinical presentation varies depending on the affected intestinal segment and layer. While mucosal involvement causes digestive symptoms, muscular involvement may lead to obstruction, and serosal involvement—least common—can present with eosinophilic ascites.
Case Report: A 15-year-old male presented with epigastric pain, vomiting, and oral intolerance. Laboratory tests revealed marked eosinophilia (>5,000/μL). Abdominal CT showed free fluid and ileocecal wall thickening. Diagnostic paracentesis revealed ascitic fluid with a high leukocyte count and eosinophil predominance. Endoscopic studies revealed ileitis, typhlitis, and duodenitis. Biopsies confirmed eosinophilic infiltration of the intestinal wall. Other causes of eosinophilia, including infections and malignancy, were ruled out. The patient was treated with intravenous corticosteroids, with good clinical response, and discharged on oral budesonide. A relapse occurred after tapering steroids, prompting initiation of azathioprine for maintenance. The patient remains clinically stable without further hospitalizations.
Discussion: EoEo with eosinophilic ascites is rare and should be considered in the differential diagnosis of unexplained ascites, particularly in patients with peripheral eosinophilia. Key diagnostic findings include eosinophil-predominant ascitic fluid and GI tract biopsies with eosinophilic infiltration. Early recognition and treatment are essential to prevent complications. It is crucial to rule out parasitic and infectious causes before initiating corticosteroid therapy to avoid worsening an undiagnosed infection.

Introduction

Barrett’s mucosal neoplasia can be endoscopically cured with minimal risk of lymph node metastasis while submucosally invasive neoplasia poses higher risk and usually requires surgery. Endoscopic optical diagnosis is often challenging to differentiate between the two. We aim to develop an artificial intelligence (AI) system using a deep neural network to stage Barrett’s neoplasia into mucosal (LGD, HGD, pT1a) and submucosally invasive (pT1b) lesions.

Aims & Methods

A VGG16-based deep neural network was used for the staging AI system. The model was trained with 69 images which were carefully selected from 79,159 frame images with histological ground truth. As a pre-trained model for training, the model from initial Barrett’s detection and delineation system was used, which was trained for 1,090,171 images from 161 Barrett's patients¹. We tested staging AI on pre-recorded images and its performance was compared to two experts who regularly perform Barrett's endoscopic resections.

Results

68 neoplastic images (white light, enhanced imaging, near focused/magnification) were used. 43 were mucosal (2 LGD, 31 HGD, 10 pT1a) and 25 were submucosal (6 pT1bSM1 and 19 pT1bSM2/3). The sensitivity, specificity and accuracy of AI were 80%, 84% and 82% while that of experts were 74%, 78% and 76% with no statistical difference (p=0.507).

Conclusion

This suggests that the staging AI system is good at differentiating submucosal neoplasia and it can perform as well as experts. It has the potential to help guide expert clinicians to decide if endoscopic resection of Barrett's neoplasia can be curative while helping non-expert to achieve more yield in targeted biopsy. However, more work is still needed to further refine and validate this staging AI model.

References

1. Mohamed Abdelrahim, Masahiro Saiko, Naoto Maeda, Ejaz Hossain, Asma Alkandari, Sharmila Subramaniam, Adolfo Parra-Blanco, Andres Sanchez-Yague, Emmanuel Coron, Alessandro Repici, Pradeep Bhandari, Development and Validation of Artificial Neural Networks Model for Detection of Barrett’s Neoplasia, a Multicenter Pragmatic Non-Randomized Trial, Gastrointestinal Endoscopy (2022)

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*