Introduction

Experimental data have shown increased expression of angiogenic factors in portal hypertension and disruption of endothelial integrity in small intestinal mucosal vessels that is possibly correlated with antigen translocation to the portal circulation. ZO-1 is a tight junction structural protein of the intestinal epithelium. Recent data revealed that ΖΟ-1 is also expressed by endothelial and mesenchymal cells and plays a dominant role in mucosal healing. Decreased ZO-1 expression may unsettle epithelial restorative capacity following mucosal damage and contribute to the impaired endothelial integrity and bacterial translocation.

Aims & Methods

We therefore aimed to assess changes in mucosal vascular density and evaluate intestinal vessel endothelial integrity in cirrhotic patients by assessing the immunohistochemical expression of ZO-1 in small intestinal biopsy samples. Sixty-three cirrhotic patients were enrolled (M/F:35/28, mean age ±SD: 62±13) during an 18-month period. Nine non-cirrhotic patients served as controls. Patients with current or recent alcohol consumption, porto-splenic vein thrombosis, non-cirrhotic portal hypertension, hepatocellular carcinoma, transjugular intrahepatic portosystemic shunt, chronic kidney disease, celiac disease, acute infection, or any other chronic intestinal disease were excluded. Small intestine biopsy samples were taken during endoscopy and endothelial ZO-1 expression was assessed by immunohistochemistry using the indirect streptavidin biotin peroxidase method. Mucosal vascular density was evaluated by counting the number of mucosal vessels per x20 optical field. Serum lipopolysaccharide-binding protein (LBP) levels were measured by ELISA.

Results

Thirty-four patients (54%) had compensated and 29(46%) had decompensated cirrhosis. Child-Turcotte-Pugh (CTP) classification was: A 46 (73%)/B 14 (22%)/ C 3 (5%). The mean MELD score was 10.5±3.7. Mean LBP levels were 7511.97±2868.90 μg/ml. The mean number of mucosal vessels per x20 optical field did not differ between cirrhotic patients and controls (3.7±1.1 vs 3.2±0.9, p=0.238) but patients with CTP-A class had increased number of mucosal vessels compared to controls (3.8±1.1 vs 3.2±0.9, p=0.048) and CTP-B class patients (3.8±1.1 vs 3.2±0.7, p=0.045). A negative correlation was observed between the number of mucosal vessels and CTP score (r: -0.428, p=0.016). In cirrhotic patients, ZO-1 immunostaining was detected in the whole perimeter of all counted vessels per optical field in only 10/63 (16.4%) samples. Loss of endothelial ZO-1 immunostaining in more than 50% of the vessel perimeter or total loss of ZO-1 in more than 50% of counted vessels was observed more frequently in cirrhotic patient samples (42/63, 66.6%) compared to controls (1/9, 11.1%, p=0.001). Mean (±SD) LBP levels were numerically, albeit not significantly, higher in patients with than without significant loss of ZO-1 endothelial expression (7801±3698 vs 6761±1032 μg/ml, p=0.342).

Conclusion

Cirrhotic patients show increased loss of small intestinal endothelial ZO-1 expression compared to control patients. Intestinal mucosal vessel number is increased in CTP-A patients compared to control and CTP-B patients. These findings are in agreement with novel theories proposing that mechanisms leading to bacterial translocation in cirrhosis are not confined to the small intestinal lumen and merit further investigation.

Introduction

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is an important diagnostic tool for suspected parenchymal lesions within the gastrointestinal tract and adjacent organs. However, the amount of literature on EUS-FNA for sampling focal liver lesions (FLLs) is limited.

Aims & Methods

This study aims at evaluating the safety and effectiveness of EUS-FNA in FLLs. Data from 88 patients who were diagnosed with FLLs by imaging and underwent EUS-FNA was reviewed in this retrospective study at the Second Affiliated Hospital of Soochow University and Ruijin Hospital of School of Medicine of Shanghai Jiao Tong University from 1 January 2017 to 31 August 2022.The EUS-FNA biopsy results were compared with the final diagnosis to evaluate the diagnostic value. Meanwhile, the relevant factors were analyzed to determine their influences on the EUS-FNA biopsy results.

Results

A final diagnosis was obtained (86 malignant and 2 benign) from the 88 cases. The overall diagnostic accuracy of EUS-FNA in FLLs was 93.18% (82／88; 95% confidence interval [CI ],87.9–98.5), with a sensitivity, specificity, positive predictive value, and negative predictive value of 93.02% (80／86; 95%CI, 87.6–98.4), 100% (2／2; 95%CI, 100–100), 100% (80／80; 95%CI, 100–100), and 25% (2／8; 95%CI, -5–55.0), respectively . The parameters related to lesion and procedure were not statistically significant between these two groups (p> 0.05) (Table 1). The number of puncture needles in the groups showed a statistically significant difference between multiple and single punctures (p = 0.001).

Conclusion

It is revealed in this study that EUS-FNA is a safe and excellent diagnostic method for FLLs with high accuracy.

Introduction

Simple renal cyst is one of the most common diseases in the urinary system. Intervention is only considered under circumstances of large cysts (＞5cm), bleeding, recurrent infection or pain^[1]. Ethanol percutaneous sclerotherapy and laparoscopy are two main treatment modalities for simple renal cysts^[2]. However, in cases of cysts in superior renal pole, percutaneous sclerotherapy is often excluded due to the unsafety of percutaneous puncture. In recent years, endoscopic ultrasound (EUS) guided fine-needle aspiration has been proven as a safe and efficient treatment for biopsy of renal and renicapsule lesions^[3], inspired by which, we successfully performed an EUS-guided sclerotherapy on cyst in the superior renal pole^[4]. Since then, we performed nine more cases of EUS-guided sclerotherapy on cyst in the superior renal pole. This research is an retrospective analysis of the nine cases and is aimed to compare the efficacy, safety and cost-benefit analysis of endoscopic ultrasound guided sclerotherapy and laparoscopic surgery treating cyst in the superior renal pole.

Aims & Methods

To compare the efficacy, safety and cost-benefit analysis of endoscopic ultrasound guided sclerotherapy and laparoscopic surgery treating cyst in the superior renal pole.
Methods: A retrospective analysis was performed in 25 patients with cyst in the superior renal pole hospitalized in the Second Affiliated Hospital of Soochow University from January 2021 to August 2022.The efficacy, operation time, intraoperative blood loss volume, hospital stay, complications and treatment cost of EUS-guided sclerotherapy (9 cases) and laparoscopic surgery (16 cases) were compared.

Results

The EUS and laparoscopic groups had comparable efficacy (100% vs 87.5%, P=0.520). The EUS group exhibited shorter operation time (29.8±4.8 vs 70.1±11.1 min, P=0.000), less intraoperative blood loss (0 vs 26.1±5.9 ml, P=0.000), shorter length of postoperative hospital stay (3.5±0.7 vs 5.4±2.0 days, P=0.014) and lower total cost (10547.85±2388.19 vs15316.09±5352.45 yuan, P=0.019). There were no difference on total length of hospital stay(8.1±2.0 vs 9.3±3.1 days) and operation cost (3946.79±490.82 vs 3860.18.17±857.42 yuan) (both P＞0.05).

Conclusion

Compared with laparoscopic surgery, EUS-guided sclerotherapy was an effective but safer technique in treating cyst in the superior renal pole.

References

1. Richard PO, Violette PD, Jewett MA, et al. CUA guideline on the management of cystic renal lesions[J].Can Urol Assoc J. 2017, 11(3-4):E66-E73.DOI: 10.4253/wjge.v7.i3.253.
2. Eissa A, El Sherbiny A, Martorana E, et al. Non-conservative management of simple renal cysts inadults: a comprehensive review of literature[J]. Minerva Urol Nefrol. 2018, 70(2):179-192. DOI: 10.23736/S0393-2249.17.02985-X.
3. Lopes RI, Moura RN, Artifon E. Endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of kidney lesions: A review[J]. World J Gastrointest Endosc. 2015, 7(3):253-7. DOI: 10.4253/wjge.v7.i3.253.
4. Wu W, Zhang Y, Hu D, Song K. EUS-guided sclerotherapy as a new therapy for renal cyst (with video)[J]. Gastrointest Endosc. 2022, 95(3):587-588. DOI:10.1016/j.gie.2021.10.029.

Clinical Case Summary

Introduction: Mastocytosis is an uncommon hematopoietic neoplasm characterized by clonal proliferation of atypical mast cells. The clinical manifestations of mastocytosis are heterogeneous,ranging from limited cutanous involvement to aggressive disease with various levels of extra cutanous multi-organ involvement. Most cases of mastocytosis are indolent, usually cutanous or indolent systemic mastocytosis (SM). Aggressive SM is a rare and often fatal disease. Gastrointestinal involvement in aggressive SM presents with non specific symptoms and the final diagnosis depends on the pathology. Herein, we present a special case of colonic mastocytosis
Clinical case: We report a case of 66 years old female patient who presented with chronic abdominal pain not responding to treatment. On physical examination showed abnormal abdominal pigmentation and reported that skin biopsy previously revealed urticaria pigmentosa. Laboratory investigations were unremarkable. Colonscopy was planned and showed diffuse reddish mottling of cecum and ascending colon. Multiple biopsies were taken and histopathological examination revealed focal crypt architectural distortion. The lamina showed moderate inflammatory cellular infiltrate. These are formed of lymphocytes and plasma cells with excess eosinophils > 100/HPF. Esinophilic cryptitis is seen. Subtle population of scattered ovoid cells with rounded ovoid nuclei are seen. Slide stained for CD117 revealed positive reaction highlighting frequent mast cells. Moderate diffuse colitis with frequent mast cells and excess eosinophils > 100/HPF. Picture is suggestive of mastocytosis involving colon. The patient started imatinib and prednisone and long term follow up showed complete relieve of abdominal pain.

Introduction

Endoscopic colonic stenting is a treatment method in which a colonoscope is used to insert a self-expandable metal stent (SEMS) into a stenotic site and allow its expansion to alleviate colonic obstruction and permit urgent colonic decompression. It is an effective and extensively practiced minimally invasive procedure compared with emergency surgery. However, perforation, stent migration, and reocclusion may occur. Perforation is particularly a serious adverse event with a mortality rate of 50%. There are three possible causes of perforation:
(1) Local perforation due to stimulation of the stent itself directly into the intestinal tract;
(2) Perforation due to guidewire or catheter manipulation during stent insertion; and
(3) Perforation due to increased pressure in the intestinal tract at the oral side of the obstruction (especially in the cecum) caused by air supply during colonoscopy insertion.
For the first possible cause, an improved colonic stent was developed to reduce irritation to the intestinal tract, and for the second possible cause, a strategy for safe stent insertion was established.
However, perforation due to the third possible cause remains a concern, and appropriate countermeasures should be urgently developed.
In endoscopic colonic stenting, we hypothesized that colonoscope insertion using the gel immersion method, which uses a recently developed endoscopic view-securing gel, would allow safe and rapid access to the lesion without increasing intestinal pressure, thereby decreasing the incidence of perforation.

Aims & Methods

This study aimed to clarify the usefulness of the gel immersion method during colonoscope insertion with endoscopic view-securing gel for colonic stenting. Eight patients in whom colorectal stenting was performed using the gel immersion method between May 2022 and January 2023 were included.
The primary endpoint was the endoscopic lesion reach rate, and the secondary endpoints were the technical and clinical success rates of SEMS deployment, colonoscope insertion time, total procedure time, and adverse event rate.

Results

Of the included patients, four were males (50%), and the mean age of patients was 67.6 ± 15.6 years. Seven patients (87.5%) had colorectal cancer and one patient (12.5%) had gastric cancer. The cancer was localized at the following sites: sigmoid colon in three patients, descending colon in three patients, transverse colon in one patient, and ascending colon in one patient. The purpose of SEMS deployment was bridge to surgery in four (50%) and palliation in four (50%) patients. In all cases, the endoscope was inserted without the preparation and insertion of the endoscope into the lesion at the origin of the obstruction without insufflation, and the endoscopic lesion reach rate was 100% (8/8). No worsening of intestinal dilatation was observed. The technical and clinical success rates each were 100% (8/8). The scope insertion time was 9.8 ± 5.2 min, total procedure time was 27.3 ± 6.5 min, and the adverse event rate was 0% (0/8).

Conclusion

For endoscopic colonic stenting, endoscope insertion using the gel immersion method could be performed safely and effectively and has the potential to become the standard method.

Clinical Case Summary

A 68-year-old woman presented after 24 hours of painless jaundice, preceded by 48 hours of dark urine and pale stools without pruritis. No history of weight loss, recent foreign travel, or high risk behaviours. She denied any illicit drug or alcohol abuse. Her co-morbidities included pre-diabetes, and obesity and only took over-the-counter vitamin supplementation with no new or regular prescribed therapies. On clinical examination, she was fully alert with jaundice with no stigmata of chronic liver disease and haemodynamic stable.

Liver tests at presentation (normal in 2020) were ALT 766 U/L, AST 984 U/L, bilirubin 463, ALP 314 U/L. PT 35.3s, APTT 45.5s, TT 26.2s and albumin was 33 g/L. Haemoglobin (139 g/L), platelet count (158 x109/L), and normal eosinophil count (0.89 x109/L). Renal function was unremarkable. Arterial blood gas demonstrated a pH 7.4, Lactate 1.8, glucose 6. CT scan demonstrated moderate volume ascites and a grossly dilated gallbladder. No intra- or extra-hepatic duct dilatation and patent vasculature. Homogenous ANA 1:400, strongly positive SMA, polyclonal gammopathy (IgG 18.8, IgM 5.5, IgA 4.2) and negative AMA/ LKM. Viral hepatitis screen was negative. Given the severity of hepatic failure, she was referred for consideration of transplantation.

This lady presented with an acute hepatocellular pattern of liver injury with hepatic failure. It came to light that her injury was a consequence of exposure to ashwagandha. Although her exposure was in 2021, a latency period prior to drug-related injury is not unusual. Previous case series have shown similar patterns of injury with ashwagandha but no hepatic failure.

1. How do we overcome the challenges distinguishing drug-induced liver injury as a cause of acute hepatic failure, particularly when markers of alternative aetiology are present?
2. What is the role of steroids in patients ?
2. What is the relationship between DILI from herbal/ dietary supplementation and acute liver failure?

References

1. Katarey D, Verma S. Drug-induced liver injury. Clin Med. 2016;16(Suppl 6):s104-s109. doi:10.7861/clinmedicine.16-6-s104
2. Chalasani N, Bonkovsky HL, Fontana R, et al. Features and Outcomes of 899 Patients With Drug-Induced Liver Injury: The DILIN Prospective Study. Gastroenterology. 2015;148(7):1340-52.e7. doi:10.1053/j.gastro.2015.03.006
3. Paul S, Chakraborty S, Anand U, et al. Withania somnifera (L.) Dunal (Ashwagandha): A comprehensive review on ethnopharmacology, pharmacotherapeutics, biomedicinal and toxicological aspects. Biomed Pharmacother. 2021;143:112175. doi:10.1016/j.biopha.2021.112175
4. Mandlik Ingawale DS, Namdeo AG. Pharmacological evaluation of Ashwagandha highlighting its healthcare claims, safety, and toxicity aspects. J Diet Suppl. 2021;18(2):183-226. doi:10.1080/19390211.2020.1741484
5. Björnsson HK, Björnsson ES, Avula B, et al. Ashwagandha-induced liver injury: A case series from Iceland and the US Drug-Induced Liver Injury Network. Liver Int. 2020;40(4):825-829. doi:10.1111/liv.14393

Introduction

The sensitivity and accuracy of diagnosis for extrahepatic cholangiocarcinoma (EHCC) can be greatly improved by Spyglass DS choledochoscope, which can realize direct observation and biopsy . Studies have shown that endoscopic radiofrequency ablation (RFA) could prolong stent patency and survival in patients with unresectable extrahepatic cholangiocarcinoma (EHCC) . However, there are few reports about Spyglass DS choledochoscopy and endoscopic RFA therapy in the same stage of diagnosis and treatmen for unresectable EHCC.

Aims & Methods

Aim: To investigate the feasibility and safety of Spyglass DS combined with endoscopic RFA)for unresectable EHCC on the same stage.
Methods A total of 90 patients with extrahepatic bile duct obstruction treated in Hangzhou First People's Hospital from January 2013 to January 2022 were divided into two groups according to the diagnosis and treatment process: conventional group: ERCP + cytobrush/ Spyglass DS cholangioscopy first, and ERCP + RFA again when the pathological results were positive; simultaneous group: ERCP was performed via Spyglass DS cholangioscopy to examine the bile duct and biopsy the lesion under direct vision, and RFA was performed on the same stage for patients identified as malignant tumor. The success rate of procedure, recovery of liver function, the number of ERCPs and the incidence of postoperative adverse events were compared between the two groups.

Results

The sensitivity of Spyglass DS choledochoscope biopsy for EHCC was 87.5% (35/40) significantly higher than that of the cell brush group (38.9% (14/36), and the difference was statistically significant (P<0.05); All patients in both groups successfully completed endoscopic RFA with a 100% of procedure success rate; there was no statistically significant difference in the improvement of bilirubin between the two groups (P>0.05); the mean number of ERCPs in simultaneous group was significantly less than that in conventional group (1.00 vs. 2.59, P<0.001), which was statistically different; the incidence of postoperative adverse events between the two groups was 14.7% (5/34) vs. 14.3% (5/35), with no statistical significance (P=0.889).

Conclusion

Spyglass direct vision diagnosis + biopsy combined with RFA for unresectable extrahepatic cholangiocarcinoma can significantly improve the diagnostic sensitivity, reduce the number of ERCPs, and not increase the incidence of postoperative adverse events, which is a safe and effective diagnosis and treatment method with a high cost-benefit ratio.

Disclosure

NO