Clinical Case Summary

Wilkie syndrome or aortomesenteric clamp syndrome is a rare vascular pathology caused by a decrease in the angle between aorta and superior mesenteric artery. This syndrome is more frequent in women and produces nonspecific intestinal obstruction.
We present the case of a 47-year-old male who came to the ER with abdominal pain, nausea ,vomiting and a loss of 10 kgs in 3 months. A X-ray was performed showing a large gastric distension. A nasogastric tube was placed with an output of 4L of retained food content. A CT showed a decrease in the aortomesenteric angle with a compression at the third duodenal portion, producing dilatation of the first and second duodenal portions and gastric chamber. Progressive oral tolerance failed and conservative treatment with enteral nutrition (EN) was decided. A nasojejunal tube was placed with good tolerance to EN, and the patient was discharged with close follow-up.
The reduction of the aortomesenteric angle compresses the structures located between both arteries: third duodenal portion and left renal vein. As a consequence, patients may present intestinal obstruction and left varicocele. Although this syndrome can be congenital (appearing in childhood), the most frequent cause is acquired due to an important weight loss in a short time (anorexia, malabsorption); cachexia (cancer, AIDS); or states of hypermetabolism with reduction of abdominal fat and appearance of obstructive symptoms. This cycle leads to malnutrition causing an aggravation of the syndrome.
Diagnosis is based on radiological criteria with compatible clinical manifestations. Initial treatment is conservative, with hypercaloric diet by oral, enteral or parenteral nutrition to increase abdominal fat. However, most eventually require surgical intervention (duodenojejunostomy). These patients have an uncertain long-term prognosis, with poor quality of life and high mortality, so given the nonspecific symptoms, we must raise the index of suspicion in these patients.

Introduction

Constipation is a common anorectal symptom that causes significant changes in the patients' quality of life. Anorectal manometry (ARM) and magnetic resonance (MR) defecography are important tools in diagnosing disorders associated with constipation, which are mainly structural and/or functional. Pelvic floor dyssynergia is diagnosed in the presence of alterations in 2 of the following: defecation kinetics in ARM, balloon expulsion test (BET) and/or MR defecography.

Aims & Methods

Compare the findings in ARM and MR defecography, in patients with constipation.
Retrospective cohort study including patients who fulfilled the Roma IV criteria for functional constipation, who were submitted to ARM and MR defecography. The London classification was used to describe the findings in ARM, establishing 3 groups of patients: Group 1 with those who had normal anorectal coordination and normal BET, Group 2 had altered anorectal coordination and altered BET, and Group 3 with those who had inconclusive findings: altered anorectal coordination and normal BET or normal anorectal coordination with abnormal BET. The structural alterations considered significant in MR defecography were those described as moderate to severe, which lead to defecation obstruction.

Results

A total of 51 patients were included, most were female (98.0%), with a mean age of 55 ± 12 years. Regarding the ARM findings, 16 patients were in Group 1 (31.4%), 11 in Group 2 (21.6%) and 24 in Group 3 (47.1%). Forty-three patients had alterations in MR defecography (84.3%), with 42 patients having at least one structural alteration and the most common being rectocele (72.5%) and descending perineum syndrome (66.7%). Pelvic floor dyssynergia was diagnosed by MR defecography in 9 patients (17.6%).
In the group of patients with normal anorectal coordination in ARM and normal BET (Group 1: n=16), 14 had significant structural alterations in MR defecography (87.5%) and 2 patients had no alterations (12.5%). In the group of patients with altered anorectal coordination in ARM and altered BET (Group 2: n=11), 8 also had structural alterations in MR defecography (72.7%). In the group of patients with inconclusive findings in ARM (Group 3: n= 24), 20 had structural alterations (83.3%) and 3 patients had pelvic floor dyssynergia diagnosed by MR defecography (12.5%), 2 of whom had both alterations (8.3%). In this group, 3 patients had no alterations in MR defecography (12.5%).
Patients with pelvic floor dyssynergia, with or without structural alterations, had a significantly lower rectoanal pressure differential than those with solely structural alterations (-25.0 ± 27.1 vs 5.7 ± 30.0 mmHg, p=0.004). There were no statistically significant differences in the values of anal pressure at rest and voluntary contraction pressure between patients with pelvic floor dyssynergia and those with solely structural alterations (p=0.350 and p=0.833), as well as in the values of residual anal pressure, intrarectal pressure and percentage of relaxation during defecation (p=0.267, p=0.257 and p=0.348).

Conclusion

Most patients had alterations in MR defecography, regardless of the ARM findings. Therefore, it is important to interpret the results of the ARM in conjunction with an imaging test capable of identifying structural alterations that may condition defecation in patients with functional constipation. In addition, those with pelvic floor dyssynergia, with or without associated structural alterations, had a lower rectoanal pressure differential than those with solely structural alterations.

Introduction

The link between the misuse in global antibiotic consumption and increased antimicrobial resistance is well documented. Clarithromycin-based anti-H. pylori eradication therapy as a triple regimen (encompassing a PPI plus two antibiotics) has been used empirically worldwide without antimicrobial susceptibility testing. In the last decade, a marked decreased in the effectiveness of clarithromycin-based regimens has been observed globally.

Aims & Methods

This study aimed at exploring the potential relationship between the consumption of macrolides in the overall population as a factor influencing the effectiveness of H. pylori clarithromycin-containing regimens.
Data from the European Registry on Helicobacter pylori management (Hp-EuReg) were used for this analysis. A multivariate logistic regression was built using the modified intention-to-treat (mITT) effectiveness analysis as the outcome and the following main effects: first-line treatment scheme (using the 10 most frequent antibiotic combinations), duration of treatment (as 7, 10 or 14-day lengths), proton-pump inhibitor (PPI) dose (categorised as low, standard, or high; that is, 20 mg, 40 mg or 80 mg omeprazole equivalent twice a day), compliance (that is, >90% of drug intake), and clarithromycin consumption expressed as daily doses per 1,000 inhabitants per day. Data of macrolide community consumption was taken from the European Surveillance of Antimicrobial Consumption Network (ESAC-Net). Hierarchical nested models were constructed by adding macrolide consumption, matching by year and country with the corresponding patients’ therapy, and the interaction between consumption and treatment scheme (taken from the Hp-EuReg).

Results

In total, 28,590 first-line treated patients from 24 European countries participating in the Hp-EuReg, on which data of macrolides consumption in the period 2013-2022 was available, were evaluated. Three nested models were analysed: the first one with the main effects without including macrolides consumption (A), the second with the full set of main effects (including macrolides consumption) (B) (likelihood ratio test A-B p-value=2.11.10^-2), and the third one included both macrolides consumption and interactions between this main effect and treatments (C) (likelihood ratio test B-C p-value=4.08 10^-10). Model B (without interactions) showed a global decrease in treatment mITT effectiveness (OR: 0.95 [0.91-0.99]). Model C (with interactions) showed a significant decrease in the mITT effectiveness in three different treatments (Table): triple-clarithromycin-metronidazole (OR: 0.37 [0.25-0.53]), triple-clarithromycin-amoxicillin (OR: 0.60 [0.43-0.82]), and sequential-clarithromycin-amoxicillin-metronidazole/tinidazole (OR: 0.60 [0.43-0.84]); whereas, bismuth quadruple therapy (single capsule) remained unaffected.

Conclusion

The models showed an inverse association between the clarithromycin consumption and empirical first-line therapy overall effectiveness in Europe; particularly, in those clarithromycin-containing regimens. Further research will consider a broader time lag to assess this association.

Disclosure

Javier P. Gisbert has served as speaker, consultant, and advisory member for or has received research funding from: Mayoly, Allergan/Abbvie, Diasorin, Richen, Juvisé and Biocodex.
Olga P. Nyssen received research funding from: Mayoly, Allergan/Abbvie, Richen, Juvisé and Biocodex.