Introduction

Patients with metabolic-dysfunction associated steatohepatitis (NAFLD activity score ≥4) and significant fibrosis (≥F2) (fibrotic MASH) are at increased risk for disease progression and development of cirrhosis. Following the recent approval of the first agent for the management of noncirrhotic MASH, timely identification of these patients is of major importance. Fibroscan-aspartate aminotransferase (FAST^TM) score enables the noninvasive diagnosis of fibrotic MASH, and has been assessed in several studies.

Aims & Methods

To assess the overall performance of FAST^TM score for diagnosing fibrotic MASH. We searched Medline, Cochrane library, Web of science and Scopus up to January 2024. We included diagnostic accuracy studies assessing the performance of FAST^TM score for ruling out (FAST^TM score ≤0.35) and ruling in (FAST^TMscore ≥0.67) fibrotic MASH using liver biopsy as the reference standard. We calculated pooled diagnostic accuracy estimates using bivariate random-effects models, and assessed risk of bias using the Quality Assessment of Diagnostic Accuracy Studies 2 tool.

Results

We included 16 studies with 8838 participants. Most studies (87.5%) were at high or unclear risk of bias due to concerns regarding patient selection, interpretation of FAST score without knowledge of biopsy results, and length of biopsy specimens for fibrotic MASH diagnosis. Across all participants, 54.8% were females and 31% had type 2 diabetes. Mean age and body mass index (BMI) were 52.4 years and 32.4 kg/m². Mean aspartate aminotransferase and alanine aminotransferase were 45.0 IU and 57.6 IU, respectively. The prevalence of fibrotic MASH across studies was 32.9% ranging from 14% to 55%. Using the rule out cut off (≤0.35), FAST^TM yielded a pooled sensitivity of 0.88 (95 % CI; 0.83, 0.91), specificity 0.52 (0.45, 0.60), positive likelihood ratio (LRp) 1.8 (1.6, 2.1) and negative likelihood ratio (LRn) 0.23 (0.18, 0.30). By applying the rule in cut off (≥0.67), pooled sensitivity, specificity, LRp, and LRn were 0.45 (0.39, 0.52), 0.87 (0.82, 0.90), 3.4 (2.8, 4.1) and 0.63 (0.58, 0.69) respectively. Assuming a pre-test probability (prevalence) of 30% for fibrotic MASH, a FAST^TM score ≥0.67 resulted in a positive predictive value of 60%, while with a FAST^TM score ≤0.35 the negative predictive value was 91%.

Conclusion

FAST^MT score has acceptable accuracy for the diagnosis of fibrotic MASH. Proposed thresholds of ≤0.35 and ≥0.67 might be useful for ruling out/in fibrotic MASH respectively.

Introduction

The Maastricht V/ Florence Consensus has updated guidelines for the management of Helicobacter Pylori (HP) infection with special emphasis in high clarithromycin resistance settings as it is the case in our country. In line with the recommendations of the European Guidelines on surgery of severe obesity [1] and the recommendations of the American Society of Gastrointestinal Endoscopy on endoscopy of the bariatric patient [2) a policy of systematic HP screening and overtime updated eradication was implemented in obese patients undergoing Roux-en Y gastric bypass (RYGB) surgery.

Aims & Methods

Five year period (2020-2024) single center study. The aim was, in obese patients undergoing RYGB surgery, to assess the cumulative HP eradication rate by adopting, at first line, a 10 days bismuth quadruple therapy (BQT) - proton pump inhibitor (PPI) bid and three-in-one single capsule containing bismuth, metronidazole, and tetracycline qid - and, at second line, a 14 days levofloxacin based therapy ( LBT) – PPI bid, amoxicillin 1000 mg bid and levofloxacin 500mg bid. HP infection status was assessed, at baseline, by histology or urea breath test and post treatment, by urea breath test 4-6 weeks after the end of the therapy.

Results

One thousand four hundred and forty-nine consecutive HP‑positive patients completed BQT treatment: 1160 (80.1%) female, age 43.5 (±10.5) years, median age of 44 years), age range of 18-69 years. HP was eradicated in 1220 patients – 84.2% (95%CI: 82.2%-86.0%). In the remaining 229 patients, 87 patients withdrew and HP was eradicated in 118 patients out of 145 with LBT. The intention to treat (ITT) and per protocol (PP) cumulative eradication rates were, respectively, 92.3% (95%CI: 90.9%-93.6%). and 98.0% (95%CI: 97.1%-98.6%). Eradication rates were not significantly different by gender and age.

Conclusion

By adopting the Maastricht V/ Florence Consensus BQT first line therapy and second line LBT therapy, high ITT and PP cumulative HP eradication rates are achieved leaving only a residual number of obese patients undergoing RYGB in need of the culture and susceptibility testing prior to third line treatment.

References

1. Fried M, Hainer V, Basdevant A, et al. European Guidelines on surgery of severe obesity. . International Journal Of Obesity 2007;31:569-577.
2. ASGE Guidelines. Role of endoscopy in the bariatric patient. Gastrointest Endosc 2008; 68:1-10.

Disclosure

NO CONFLICT OF INTEREST

Clinical Case Summary

Colorectal lymphomas are a rare cause of colonic neoplasia (0.2-0.6% malignant neoplasms of large bowel). Approximately 10% are primary colorectal lymphomas, while the rest correspond to colonic extension of systemic lymphoproliferative diseases.
We present the case of a 66-year-old woman with a history of rectum and pancreas adenocarcinoma (both in remission). During a follow-up CT, a thickening of the cecal pole was identified, with no adenopathy or other relevant findings (Photo1). The patient had no abdominal pain or B symptoms (night sweats, weight loss or fever).
The diagnosis was completed with a PET-CT that showed pathological uptake in the cecum (Photo2), so a colonoscopy was performed, which revealed a large polypoid lesion (30 mm) at the ileocecal level, with nodular areas with small ulcerations and no clear loss of the glandular pattern (Photo 3), from which multiple biopsies were taken.
Biopsies showed lymphoid proliferation with a ‘starry sky’ pattern, mitosis and apoptosis, and positive immunohistochemistry for CD45, CD20, CD10, BCL6, BCL2 and C-MYC, together with a high proliferation index (Ki-67 > 95%), all compatible with high-grade B-lymphoproliferative syndrome with Burkitt morphology (Photo 4).
Burkitt's lymphoma is a rare B-cell lymphoma (15% of GI lymphomas), associated with chromosomal translocation (8:14, 8:22 and 2:8) and overexpression of c-myc oncogene.
There are three clinical variants: endemic (common in Africa and associated with EBV and malaria), HIV-associated and sporadic (20%).
It is common in children and its most frequent symptoms are abdominal pain and weight loss, so diagnosis is often delayed. Although the yield of endoscopic biopsies is low (<20%), it is a key tool in its diagnosis, along with targeted biopsy of abdominal adenopathies.
Despite its aggressiveness, treatment with targeted chemotherapy achieves rates of more than 90%, and early diagnosis is essential to avoid complications and ensure adequate medical treatment.

References

- Photo 1: Thickening of the cecal pole seen in CT-Scan.
- Photo 2: Pathological uptake in the caecal area as seen on PET-CT Scan.
- Photo 3: Polypoid lesion in ileocecal area at colonoscopy
- Photo 4: Pathological anatomy of endoscopic biopsies: starry sky imaging and immunohistochemistry of Bcl-2 and C-myc

Introduction

Pruritus is common in primary biliary cholangitis (PBC) and can significantly impact patients' quality of life (QoL). Cholestyramine is recommended as the first-line treatment option for pruritus in PBC, but tolerability, inconvenient administration, and limited efficacy data restrict its use. Patient-focused drug development can help address this unmet need, but an understanding of patients' perspectives on pruritus and treatments is required. This study conducted semi-structured qualitative patient interviews to explore patients’ experiences, expectations, and concerns with regards to pruritus and treatments.

Aims & Methods

Semi-structured virtual interviews were designed following a literature review and conducted with patients from the USA, Germany, UK, and Italy. Eligible patients self-reported a PBC diagnosis and had a worst itch score of ≥4 on a 0–10 numerical rating scale (NRS) in the past 2 months. Interviews had four parts:
1) pruritus experience,
2) treatment desires and concerns,
3) treatment experience,
4) hypothetical choice questions that required patients to make trade-offs between two options.
Responses were used in an inductive thematic analysis and visually summarized.

Results

Ten patients per country were interviewed (N=40); most were female (78%) and mean (standard deviation) age was 52.5 (15.2) years. For 53% (n=21), pruritus had started within the last 3 years. On the NRS, patients rated their pruritus over the last 2 months on average as mean 5.4 (range 2–10), and worst itch as mean 7.1 (range 4–10). Key themes that emerged from patient discussions were visualized with a concept map. Pruritus was widespread over patients’ bodies, persistent despite scratching, and described as ‘crawling’, ‘burning’ and ‘nettles’. Pruritus impacted social interactions, sleep quality, appearance, emotional stability, and work productivity. Many patients wished for complete resolution, but primarily wanted treatment to reduce pruritus severity (60%; n=23). Of those who had ever received cholestyramine (n=12), 62% reported a repulsive taste and texture; 50% mentioned concerns about interactions between cholestyramine and PBC medication. From five potential pruritus medication side effects, diarrhea and nausea were of greatest concern.

Conclusion

Pruritus impacts QoL in PBC in several ways and the limitations of existing treatments mean patients would welcome alternative options. Future research will establish the relative importance to patients of treatment aspects such as administration, benefits, and tolerability.
Funding: GSK (218705).
Encore statement: This abstract was originally presented as poster 4550-C at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting on November 13, 2023, this encore is presented on behalf of the original authors with their permission.

Disclosure

HTS, AW and PJFT are employees of, and hold stocks/shares in, GSK. AH is an employee of, and holds stocks/shares in, GSK and is a former employee of, and holds stocks/shares in, Novartis. DS and KM are employees of Evidera who were funded by GSK to carry out this study. JS and SH are employees of Evidera who were funded by GSK to carry out this study and are minority stockholders in Thermofisher Scientific as part of their employment with Evidera.