Introduction

Adalimumabe (ADA) 160/80 mg is efficacious for induction of clinical remission in patients with intestinal Crohn’s disease (CD), but data on its long-term efficacy for perianal CD are more limited.

Aims & Methods

To determine whether treatment with Adalimumab is effectiveness in patients with perianal CD. A prospective randomized study , from January 2019 until January 2023 was enrolled with 100 patients (38f/62m, mean age 41, 15 smokers). The patients presented ( trans or suprasphinteric, horse-shoes, multiple with or without rectal involvement), perianal fistulising disease or resistant to immunosuppressive. All patients received 160/80 mg of Adalimumab as induction dose. Immunosupressive therapy was suspended at the start of treatment and steroid dose was reduced of 5 mg/week after the induction phase. The study was performed in a reference public/medical school hospital in Porto Velho, north region of Brazil
Definition of remission: complete closure of the fistula assessed with colonoscopy and magnetic resonance imaging ( MRI ).

Results

Medical charts of 100 patients with perianal CD receiving Adalimumab were investigated. Among them, 42 had infliximab failure, 67/100 colonic disease, 82/100 rectal involvement, 42/100 were also using steroid. At week 6, 18/100 patients (18%), were in remission; at week 30, 29/100 patients (29%) were in remission; at week 52, 66/100 (66%), were in remission and at 3 years, 77/96 patients (80%) were in remission. 4 patients loss response and moved to a temporary loop-ileostomy. No serious adverse events were registered.

Conclusion

Adalimumabe treatment was effective in the remission of perianal CD in 80% of the patients after a 4 years follow-up, showing the effectiveness of adalimumabe.

References

- Hanauer S.B. Sandborn W.J. Rutgeerts P. Fedorak R.N. Lukas M. MacIntosh D. et al. Human anti-tumor necrosis factor monoclonal antibody (adalimumab) in Crohn's disease: the CLASSIC-I trial Gastroenterology 130 2006 323 - 333
- Sandborn W.J. Hanauer S.B. Rutgeerts P. Fedorak R.N. Lukas M. MacIntosh D.G. et al. Adalimumab for maintenance treatment of Crohn's disease: results of the CLASSIC II trial Gut 56 2007 1232 123
- Colombel J.F. Sandborn W.J. Rutgeerts P. Enns R. Hanauer S.B. Panaccione R. et al. Adalimumab for maintenance of clinical response and remission in patients with Crohn's disease: the CHARM trial Gastroenterology 132 2007 52 - 65

Introduction

The global health community has increasingly shifted its focus toward non-communicable diseases (NCDs), recognizing them as a critical public health emergency, particularly pronounced in low and lower middle-income countries (LMICs)[1]. Metabolic dysfunction associated steatotic liver disease (MASLD) is the most common liver disease with a worldwide prevalence of 30%[2], and represent the leading cause of liver-related morbidity and mortality. The prevalence, associated factors, and consequences of MASLD in the African continent, particularly in SSA, remain poorly understood. Indeed, no SSA studies were included in the latest major literature review and meta-analysis on the global epidemiology of MASLD[2].
Tanzania, like many other SSA countries, is undergoing a demographic and epidemiological transition, leading to a marked increase in the burden of NCDs [3].

Aims & Methods

The primary aim of this study was to estimate the prevalence of MASLD among an NCDs population in rural Tanzania. Additionally, secondary objective was to investigate whether the consumption of sugary drinks is associated with MASLD.
This study entailed a retrospective analysis of a prospectively collected cohort of consecutive patients attending the NCDs outpatient clinic of Tosamaganga Hospital, from August 2022 to March 2023. Detailed sociodemographic, clinical, laboratory, and abdominal ultrasound data were collected for all participants. Additionally, the Beverage Intake Questionnaire (BEVQ-15) was administered to evaluate their everyday drinking behaviors; and for each item, the average daily intake in fluid ounces (fl-oz), and calories (kcal) were calculated.

Results

Of 183 patients enrolled in the cohort, 128/183 (70%) were female. The mean age was 58±13.7 years and mean BMI was 28±6.67 Kg/m². Hypertension affected 141 individuals (77.0%), diabetes affected 77 (42.1%), and both conditions co-occurred in 35 patients (19.1%). Steatotic liver disease was found in 88/183 (48%) patients; with 39/88 (44.3%) of moderate or severe steatosis. MASLD was identified in all steatotic patients. Overall, on average the participants drank a mean of 12.6 fl-oz of SSB (throght sodas). MASLD patients drank an average of 22.4 fl-oz of SSB per day. Multivariable analysis revealed that BMI and daily SSB consumption (fl-oz) exhibited significant associations with MASLD, with respective OR of 1.16 (95% CI: 1.06 – 1.28, p = 0.002) and 1.19 (95% CI: 1.12 – 1.27, p < 0.001).

Conclusion

This study unveils a considerable prevalence of MASLD among the rural Tanzanian NCDs population, affecting nearly half (48%) of all patients studied. Timely identification of MASLD, facilitated by straightforward diagnostic means, holds pivotal importance for patient management and the dissemination of vital lifestyle modification guidance. Furthermore, our study, one of the pioneering efforts to demonstrate a significant association between SSB consumption and MASLD in an African context, underscores the imperative to heighten awareness regarding the risks posed by SSB consumption among NCDs patients and potentially the wider population.

References

[1] Boutayeb A. The Burden of Communicable and Non-Communicable Diseases in Developing Countries. Handbook of Disease Burdens and Quality of Life Measures 2010:531–46. https://doi.org/10.1007/978-0-387-78665-0_32.
[2] Younossi ZM, Golabi P, Paik JM, Henry A, Van Dongen C, Henry L. The global epidemiology of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH): a systematic review. Hepatology 2023;77:1335–47. https://doi.org/10.1097/HEP.0000000000000004.
[3] Gouda HN, Charlson F, Sorsdahl K, Ahmadzada S, Ferrari AJ, Erskine H, et al. Burden of non-communicable diseases in sub-Saharan Africa, 1990-2017: results from the Global Burden of Disease Study 2017. Lancet Glob Health 2019;7:e1375–87. https://doi.org/10.1016/S2214-109X(19)30374-2.

Clinical Case Summary

The detection and management of overt gastrointestinal (GI) bleeding may be challenging, especially in case of limited resources, as during the COVID-19 pandemic. This case report shows how artificial intelligence (AI) technology applied to capsule endoscopy (CE) can contribute to this challenge.
In August 2020, a 80 year-old male patient was hospitalized for symptomatic iron-deficiency anemia three weeks after cardiovascular surgery and the start of dual antiplatelet therapy (DAPT). Since esophagogastroduodenoscopy (EGD) and ileocolonoscopy excluded any source of GI bleeding and the patient was stable, he was discharged. Two months later, the patient returned to the Emergency Department (ED) presenting with melena, and CE was recommended to rule out suspected small bowel bleeding.
Due to COVID-19, CE was not promptly scheduled. After two months, the patient was readmitted to the ED for persistent anemia (Hgb 7g/dL) and melena, without hemodynamic instability. Outpatient CE (Navicam SB system –AI tech embedded, Ankon, China) was performed two days later. The following morning the video was downloaded in 10 minutes and promptly reviewed in AI-assisted modality. After few seconds, active bleeding originating from the duodenum or proximal jejunum was detected. The patient was called back and an urgent EGD was performed after 4 hours from CE review. An actively bleeding Dieulafoy’s lesion was found in the third portion of the duodenum and treated with mechanical hemostasis. At 30-months follow-up, no episodes of re-bleeding occurred and Hgb was stable at 11 g/dL.
AI technology by Navicam SB system allows a rapid download of CE videos and offers a prompt detection of bleeding sources in patients with overt GI bleeding, leading to timely endoscopic management. This may potentially improve the long-term patients’ outcome and reduce the hospital stay, being particularly important in case of limited resources, as experienced during the COVID-19 pandemic.

Introduction

The treatment outcomes and risk factors for the prognosis of acute variceal bleeding (AVB) in hepatocellular carcinoma (HCC) patients remain unclear. Hence, we assessed the clinical outcomes and prognostic factors of these patients.

Aims & Methods

To evaluate the treatment outcomes and risk factors of cirrhotic patients with hepatocellular carcinoma (HCC) and acute variceal bleeding (AVB).
This is a retrospective case-control study. Consecutive patients with HCC and AVB admitted between 2016 and 2022 were included. For each patient with HCC, a patient without HCC was matched by age, sex, and Child-Pugh class. Follow-up was continued until death and transplantation.

Results

A total of 620 patients were included. The five-day treatment failure and 6-week mortality rates of the whole cohort were 18.7% and 16.6%, respectively. Patients with HCC had higher 6-week mortality, respectively (24.2% vs. 9.0%, P<0.001). Among AVB patients with HCC, the Barcelona Clinic Liver Cancer (BCLC) stage (C-D vs. 0-B) (HR, 14.409; 95% CI, 5.758-36.055; P<0.001), and Child-Pugh score (HR, 1.239, 95% CI, 1.121-1.370; P<0.001) were independent risk factors of 6-week mortality in multivariate analysis. Furthermore, the risk of 6-week mortality was 60.2% among patients with a Child-Pugh score ≥ 9 and BCLC stage C–D, much higher than patients with low Child-Pugh score (<9) and earlier BCLC stage (0-B) (P<0.0001).

Conclusion

Among patients with cirrhosis and AVB, patients with HCC had a worse outcome than patients without. The severity of liver disease and the stage of HCC are the main determinants of mortality in HCC patients.

Clinical Case Summary

The term mucosal prolapse polyps (MPP) is used to describe a group of rare colonic lesions that are part of the mucosal prolapse syndrome. They often pose a challenge for gastroenterologists due to their macroscopic similitude to adenomatous polyps and even neoplastic lesions, leading to unnecessary procedures for their removal.

We present the case of a 48-year old woman who underwent colonoscopy for rectal bleeding. Two nodular erythematous lesions of 8’5x4cm, stiff to touch, were identified in the recto-sigmoid. A biopsy was performed twice, showing no histological characterization. Thus, and due to the impossibility of carrying out an endoscopic resection because of their size and uncertain histological nature of the lesions, a trans-anal surgical resection was performed, this time being the histological characterization positive for inflammatory polyp with mucosal prolapse features.

MPP are extremely rare. The biggest case report series to date by Tendler et al. only features 15 cases. Due to the scarcity of published data, MPP’s prevalence and etiology are unclear, though there seems to be an association with constipation and diverticular disease. Their most common clinical presentation is rectal bleeding, although they can remain asymptomatic for years. The endoscopical image is an excrescent, hyperemic lesion, showing the annual tree ring sign, which is relatively new to gastroenterologists. There have been no reported cases where MPP have been a precursor lesion of malignancy.

A high fiber diet should be considered in asymptomatic pacients. In case of recurrent bleeding, an endoscopic or surgical removal seems reasonable depending on the center's experience.

In conclusion, the diagnosis of MPP could be challenging due to to the similarities with other lesions. Gastroenterologists and pathologists should take into account this entity into their differencial diagnosis when facing this kind of lesions to provide efficient healthcare assistance.

References

Tendler DA et al. Prolapsing mucosal polyps: an underrecognized form of colonic polyp--a clinicopathological study of 15 cases. Am J Gastroenterol. 2002 Feb;97(2):370-6. doi: 10.1111/j.1572-0241.2002.05472.x. PMID: 11866275 Libânio D, Meireles C, Afonso LP, Henrique R, Pimentel-Nunes P, Dinis-Ribeiro M. Mucosal Prolapse Polyp Mimicking Rectal Malignancy: A Case Report. GE Port J Gastroenterol. 2016 Feb 18;23(4):214-217. Wong YP, Kabincong C, Jabar MF, Tan GC. Rectal Polyposis in Mucosal Prolapse Syndrome. Diagnostics (Basel). 2022 Apr 12;12(4):966. nEinoder SH, Thomson ACM, Urquhart P, Smart PJ. Prolapsing mucosal fold: largest reported, presenting with major haemorrhage. J Surg Case Rep. 2018 Nov 22;2018(11):rjy312. Prolapsing mucosal polyp: A form of colonic polyp not to be forgotten. Revista de Gastroenterología de México (English Edition), Volume 84, Issue 3, July–September 2019, Pages 407-409. R. Monreal-Robles, J.A. González-González, D.E. Benavides-Salgado, H.J. Maldonado-Garza Huang CC, Frankel WL, Doukides T, Zhou XP, Zhao W, Yearsley MM. Prolapse-related changes are a confounding factor in misdiagnosis of sessile serrated adenomas in the rectum. Hum Pathol. 2013 Apr;44(4):480-6. R. Monreal-Robles, J.A. et al. Prolapsing mucosal polyp: A form of colonic polyp not to be forgotten. Servicio de Gastroenterología y Endoscopia Digestiva, Hospital Universitario «Dr. José E. González» México