Introduction

Cirrhosis is a condition of hypercoagulability that increases the risk of portal vein thrombosis (PVT) contrasting with thrombocytopenia related to hypersplenism. In this context, we propose to determine the profile of platelet parameters at the diagnosis of cirrhosis and to study their relevance in predicting PVT in this population.

Aims & Methods

This is a retrospective case-control study involving cirrhotic patients diagnosed between 2000 and 2015, at the Gastroenterology department of La Rabta Hospital. Epidemiological, clinical, and biological data were collected from medical records. Platelet parameters, including platelet count (PC), mean platelet volume (MPV), and platelet distribution width (PDW) were recorded at diagnosis. The MPV/PC, PC/lymphocytes, and PC/splenic index ratios were calculated. The occurrence of portal vein thrombosis, documented by abdominal Doppler ultrasound, was recorded. Statistical analysis was performed using SPSS 23.0 software.

Results

A total of 103 patients were included in our study. The gender ratio was 0.5, and the median age at diagnosis of cirrhosis was 59 years [14-80]. The etiological distribution of cirrhosis was as follows: post-hepatitis C cirrhosis (n=47), post-hepatitis B cirrhosis (n=35), cirrhosis due to other etiologies (n=10), and undetermined for 11 patients.
The median platelet count (PC) for the entire population was 85 G/L [16-480], with thrombocytopenia in 82% of cases. Portal vein thrombosis (PVT) was diagnosed in more than 1/5 of cases (n=23). The splenic index was significantly higher in the "cirrhosis with PVT" group (15.865 cm vs. 14.646 cm in the "cirrhosis without PVT" group; p=0.04).
However, no statistically significant differences were found between the two groups regarding platelet parameters such as PC, mean platelet volume (MPV), platelet distribution width (PDW), and MPV/PC ratio (respectively: 92 G/L vs. 83 G/L, p=0.9; 10.9 fl vs. 11.35 fl, p=0.2; 15.5% vs. 15.1%, p=0.2, and 0.12 fl/G/L vs. 0.11 fl/G/L, p=0.9). Nevertheless, the PC/lymphocytes ratio showed a modest discriminating power between the two groups, with an area under the curve (AUC) of 0.6; 95% CI: [0.475-0.748].
In addition, 19% of patients developed hepatocellular carcinoma (HCC) during the course of their disease. Analysis showed that the presence of HCC increases the risk of PVT occurrence (odds ratio 3, 95% CI: [1.052-8.679], p=0.03).

Conclusion

Platelets are key players in the inflammatory response found in several pathologies. In our study, the predictive power of platelet parameters for portal vein thrombosis could not be demonstrated due to the presence of other likely confounding factors (infection at diagnosis, used automated methods...). A larger prospective study would be desirable.

Introduction

Management of poscholecystectomy complications has been variably discussed. Various options exist but the recent trend has been towards the endoscopic retrograde approach favoring a simultaneous diagnostic and therapeutic potential.

Aims & Methods

Objetive: A single institution retrospective analysis of 203 with bile duct injuries (BDI) after laparoscopic cholecystectomy (LC). We studied the various endoscopic modalities to evaluate the efficacy of the approach.
Patients and Methods: From January 2005 to January 2025, a retrospective analysis was conducted of 5528 patients referred to the endoscopy department. During this period, 434 were referred after related BDI. These 434 (7,8%) are BDI. 231(53,2%) after open cholecystectomy and 203 (46,8%) after LC, formed the basis for this study. 154 (75,8%) were female and 49 (24,2%) were male, with an average age of 49,1years (range,13-88 years). The clinical presentation of the BDI: jaundice 134 (66,0%); pain 47 (23,1%); fever 79 (38,9%); persistent drainage 75 (36,9%); pruritus 74 (36,4%) and acute biliary pancreatitis 18 (8,8%). ERCP was used in all cases.

Results

There were 103 patients with stricture (26 total transaction and 77 partial) and 64 (31,6%) patients with leaks and 36 (17,7%) had a combination of leaks and stricture. Endoscopic diagnosis was feasible in all cases. Subsequently, 170 (83, 7% ) patients were considered for endotherapy and endoscopic treatment was interrupted in 17 patients, required surgical intervention, success healing was shown in 90% There 64 biliary fistulae: 40 of the cystic stump, 20 of the common hepatic and 2 of the right hepatic and 2 of the left hepatic; 36 (17,7%) biliary fistulae with stenosis (9 complete transaction and 27 partial transaction) and 103 stenosis (26 total transaction and 77 partial). The 35 total transaction required surgical treatment; however two were treated by endoscopies. There was success in the endoscopic treatment of biliary fistulae, which 64 esphincterotomy transpapilar (ETP) and four stents. 27 patients with biliary fistulae with stenosis were 6 ETP; 11 ETP with stents; 8 ETP, dilatation, stents and two ETP with dilatation and two patients need the surgical treatment. 71/77 (92,2%) patients with stenosis could be treated: 34 ETP, stents; 36 ETP, dilatation, stents; and 3 ETP, dilatation. Complications occurred in 6 (3, 5%), perforation (n = 1), mild pancreatites (n=3), and cholangitis (n=2) and 17 patients failed endoscopic treatment.

Conclusion

The ERCP in biliary complications of LC is feasible and with good results. It firms as coadjuvant treatment of the definitive surgery and in some situations being the method close for the definitive treatment.

Disclosure

No Conflict of Interest

Introduction

Diarrhea after cholecystectomy is a well-known complication that worsens the quality of life of the patient and may become a real challenge for the doctor.
Both changes in the bile acids spectrum (BAsS) and possible changes in microbiota and Small Intestinal Bacterial Overgrowth (SIBO) may have a major impact. What is primary in this circle is not fully understood.

Aims & Methods

The aim was to assess BAsS and SIBO in patients prior to cholecystectomy, three and twelve months after cholecystectomy.
Methods: Initially, the bile of the patients was obtained directly from the gallbladder after it was removed during the surgery. For the second and third time, the bile of the same patients after cholecystectomy was obtained in 3 and 12 months postoperatively, after the intubation of the duodenum under ultrasound control. The spectrum of BA was assessed using photocalorimetry. To assess the possible influence of SIBO, all the patients underwent a hydrogen breath test before cholecystectomy, and if SIBO was confirmed, they were not included in the study. Successive hydrogen breath tests were performed 3 and 12 months after cholecystectomy to all the patients who were included. The data were analyzed using parametric and non-parametric methods of evaluating the results through the Statistica program (StatSoft Inc, USA).

Results

14 patients, predominantly women (71.4%) were enrolled in the study. The spectrum of BA three months after cholecystectomy showed a tendency for secondary BA (deoxycholic acid) to predominate over primary BA (cholic acid) (P>0.05). After 12 months, the BAs pool returned to the baseline in most of the patients (P>0.05). SIBO was not registered in patients 3 months after cholecystectomy, but it was detected in 50% of cases (P>0.05) after 12 months.

Conclusion

The predominance of secondary BA in the early postoperative period probably indicates an increase in the number of bacteria, for the transformation of primary BA in the ileum, but the breath test is not sensitive enough to determine this.
Over time, if the equilibrium in a complex mechanism of BA homeostasis is not achieved (the amount of bile in the ileum, bacteria, FXR, etc.), this may lead to the SIBO development.

Introduction

Peripheral musculoskeletal (MSK) symptoms are the most common extra intestinal manifestations (EIMs) in IBD patients, with substantial impact on quality of life. IBD related spondyloarthritis (IBD-SpA) often requires a multidisciplinary evaluation to enable optimal choice of treatment and patient care, but systematic rheumatological characterisation of this population is scarce [1].
Characterisation of IBD-SpA is challenged by the variety of MSK involvement (from arthralgia to ankylosing spondylitis), the co-existence of osteoarthritis, overuse enthesopathies or fibromyalgia, and by the heterogeneity in methodologies used to describe the SpA features. Recently developed recommendations for endpoints for EIMs in IBD trials [2] were applied in the present study.

Aims & Methods

To determine the prevalence and distribution of inflammatory lesions in peripheral joints and entheses in newly diagnosed IBD patients, assessed for presence of MSK symptoms, and by rheumatological and ultrasound (US) evaluation.
Patients from the IBD prognosis inception cohort (IBD-Pro) were consecutively included [2]. They reported MSK symptoms using a validated questionnaire (IBD-TASQ). A clinical examination was performed by rheumatologist, as was US examination (grey scale (GS) and colour Doppler (CD)) of 38 peripheral joints and 14 entheses, applying OMERACT-EULAR definitions and scoring systems for synovitis and enthesitis [3]. Synovitis was defined as GS score ≥2 and/or CD≥1 and entheseal inflammation was defined as presence of hypoechogenicity/thickening and/or CD score ≥1. Further, OMERACT-EULAR sum score (GLOESS) was calculated (0-114).

Results

110 newly diagnosed IBD patients (mean age 42, 39% male) were included (34% Crohn’s disease, 59% ulcerative colitis (UC), 5% unclassified IBD). The IBD disease activity scores indicated mild activity in UC patients (Simple Clinical Colitis Activity Index mean (SD) 6.7 (3.6), and low in Crohn's (Harvey-Bradshaw Index 4.5 (2.9)). Four patients received systemic glucocorticoids (2%) or biologics (2%) at the time of rheumatological evaluation. History of other SpA-associated features such as psoriasis was reported in 2% and uveitis in 5% of the patients.
40% of the patients reported positive history for ≥1 MSK symptom. Joint pain and swelling were the most common complaints (30%), followed by heel enthesitis (17%) and dactylitis in 20%. Patient pain VAS was low, mean (SD) 12(21).
Clinical examination revealed 52% of all patients had arthritis and/or enthesitis and 46% fulfilled ASAS classification criteria for peripheral SpA (25% ≥1 tender joint, 12% ≥1 swollen joint, 46% ≥1 tender enthesis (most affected sites were Achilles and lateral epicondyle).
US found inflammation in ≥1 joint or enthesis in 49% of the IBD patients - synovitis in 29%, mean GLOESS sum score 5.2 SD (4.6) and entheseal inflammation in 34% (US enthesitis sum, mean (SD) 2.6(2).
Among those patients reporting MSK symptoms, 69% had ≥1 tender/swollen joint and/or enthesis at clinical evaluation and 64% had joint/entheseal inflammation by US. Suggesting good overlap between patient-reported symptoms, clinical and US findings. 36% of the asymptomatic patients also had clinical and US signs of arthritis and/or enthesitis.

Conclusion

At the time of IBD diagnosis, more than half of the patients had musculoskeletal manifestations by clinical examination and half had objectively verified synovitis and/or enthesitis by ultrasound, indicating that SpA may be underdiagnosed among IBD patients.

References

1 Schwartzman M et al., RMD Open 2022
2 Guillo L et al., Lancet Gastroenterol Hepatol 2022
3 Bruyn GA et al., The Journal of Rheumatology 2019
4 Attauabi M, et al., BMJ Open 2022

Disclosure

no conflict of interest

Introduction

Patients with gastric intestinal metaplasia (GIM) can be stratified into non-extensive and extensive GIM. In patients with extensive GIM surveillance is recommended based on a higher risk of neoplastic progression. The updated Sydney protocol is the most widely accepted biopsy system to identify extended GIM, and includes, besides biopsies of the corpus and antrum also biopsies of the incisura angularis (IA). However, data on the added value of additional biopsies of the IA in patients with premalignant gastric lesions is scarce. Our aim is to evaluate the yield and added value of the updated Sydney protocol in a low incidence gastric cancer region.

Aims & Methods

This prospective cohort study included patients with GIM who underwent follow-up endoscopies. Biopsies were taken according to the updated Sydney protocol.

Results

In total 177 patients with GIM were included. Median age was 62 (IQR 20) and 55.9% was male. During follow-up seven (4.0%) patients developed gastric neoplasia after a median follow-up of 37 months (IQR 38). At baseline 50 patients were classified as extensive GIM (28.2%), of which only one patient showed neoplastic progression. The other six patients that showed progression were classified as non-extensive GIM. At baseline, angular GIM was found in 97 (54.8%) patients of which six showed neoplastic progression; two patients had GIM in antrum and IA, two patients had GIM in IA and corpus, one patient had GIM in antrum, IA and corpus and in one patient there was GIM in the IA only.

Conclusion

In patients with gastric intestinal metaplasia angular GIM might be a better risk factor for neoplastic progression than the extension of GIM.

Clinical Case Summary

A 56-year-old woman was referred to tertial hospital for decompensated liver cirrhosis of unknown origin. She was slightly overweight (BMI 25.3) and denied alcohol consumption or any history of liver disease. Since childhood, she had been diagnosed with congenital ichthyosis, strabismus, and myopia, had a history of bilateral neurosensory hearing loss, arterial hypertension, and cataracts. Since 2016, she had been experiencing progressive muscle weakness, and intermittent speech impairment. The patient complained of eyes dryness, episodic joint and muscle pain, muscle weakness, general malaise, dizziness, dry and scaling skin. Physical examination revealed diffuse skin dryness, scaling and an enlarged abdomen. Radiological examination revealed a cirrhotic liver, splenomegaly and moderate ascites. The MELD score was 18 and the Child-Pugh - 9. Laboratory tests excluded Wilson's disease, autoimmune liver diseases, hemochromatosis, α-1 antitrypsin deficiency. Liver biopsy showed macro and microvesicular steatosis (>50% of hepatocytes with lipid vacuoles), hepatocytes ballooning and inflammation compatible with MAFLD related liver cirrhosis. In peripheral blood smear was detected multiple lipid vacuoles in the leukocytes cytoplasm, known as Jordan‘s anomaly, confirming Chanarin–Dorfman syndrome (CDS) - a rare autosomal recessive neutral lipid storage disease. Genetic testing confirm diagnosis and revealed a potentially pathogenic homozygous c.133+3A>C mutation in the ABHD5 gene. Due to progression of liver failure patient was referred for liver transplantation (LT) and liver was successfully transplanted in 2024.
The case showed that LT is a realistic option if liver function deteriorates in CDS. LT does not affect neurological, dermatological and other extrahepatic symptoms of the syndrome. In early post-transplant period attention should be paid to possible temporary worsening of heart failure due to cardiomyopathy associated with CDS.