Clinical Case Summary

Introduction: Since the covid-19 pandemic, there has been a significant resurgence of tuberculosis in endemic countries. As a result, extremely rare localizations of tuberculosis have appeared. Stomach involvement is rarely seen in gastrointestinal tuberculosis. The clinical presentation can be either alarming symptoms (anorexia, weight loss...), or a complication (digestive hemorrhage, perforation). In front of the weight loss and the alteration of the general state, the diagnosis is often directed towards a neoplastic pathology, which represents a diagnostic challenge.

Clinical case: We received in our institution a 77-year-old woman, referred from the emergency room for hematemesis with epigastric pain. She had experienced important weight loss during the last month. The clinical examination was unremarkable, and blood tests was normal, despite an hemoglobin of 8,7 g/dl. An upper endoscopy was performed, which showed the existence of 3 ulcerations localized on the greater curvature of the stomach, the largest measuring 4 centimeters. Biopsies of the ulceration borders were performed. Histology revealed the presence of an epithelio-giganto-cellular granuloma with caseous necrosis.
The final diagnosis was gastric tuberculosis. We started an antituberculosis therapy, with a proton pump inhibitor, with significant improvement within one month.

Conclusion: In conclusion, gastric tuberculosis, even if it is a rare entity, should be considered when gastric signs are associated with signs of tuberculosis impregnation, especially in endemic countries. The endoscopic signs are not specific, only histology can establish a reassuring diagnosis. Our patient was successfully treated by Antitubercular drug despite the severity of his bleeding.

References

Endoscopic images showing tow small gastric ulcers and a large gastric ulcer of the greater curve of the stomach
Histological image showing epithelio-giganto-cellular granuloma with caseous necrosis

Clinical Case Summary

We present a case of a 37-year-old woman with ulcerative pancolitis (diagnosis in 2004), under therapy with salicylates until 2016. At that time, the patient had a flare up with need of corticosteroid therapy and started infliximab and azhatioprine. In 2018, she was in deep remission, so azathioprine was stopped. In may 2022, the patient developed intermittent fever and palpable purpura on lower limbs. It was evaluated by Dermatology who, after extensive negative ethiological study and partial response to corticosteroids, decided to perform a skin biopsy - leukocytoclastic vasculitis. Subsequently, she started intermittent episodes of hematuria, fatigue and arthralgias. Laboratory tests showed an increase in creatinine twice above the patient's baseline value, large amounts of red blood cells in the urinary sediment and moderate (subnephrotic) proteinuria. From the additional study, only an immunoglobulin A (IgA) elevation of 538 (LSN < 400) is reported. At this time, due to suspicion of IgA nephropathy, a renal biopsy was performed, which confirmed the presence of IgA deposits in the glomerular mesangium. After ruling out infectious, autoimmune and neoplastic causes, Henoch-Schönlein purpura (non-thrombocytopenic purpura and IgA nephropathy) secondary to anti-TNFα was assumed. In an IBD meeting, it was decided to stop anti-TNF and start azathioprine. Due to gastrointestinal intolerance and herpetic infection, vedolizumab was proposed, with a favorable response so far.
The approach of the adverse effects of IBD therapy can be challenging and not very consensual, requiring a multidisciplinary discussion. Henoch-Schönlein purpura is a rare adverse effect of anti-TNFα, particularly in adulthood, which in the present case appeared several years after the start of therapy. We intend to emphasize the need for a high degree of suspicion in this condition, as an early diagnosis has an impact on discontinuation of therapy and can radically change the prognosis.

Introduction

The recommended treatment for severe complications of portal hypertension (PH) is transjugular intrahepatic portosystemic shunt (TIPS) implantation. Despite alcohol-related liver disease (ALD) representing the most frequent cause of advanced chronic liver disease (ACLD) and PH, literature on the effects of ongoing alcohol use (AU) after TIPS placement currently remains scarce.

Aims & Methods

The study population consisted of patients with ALD-related ACLD who had undergone TIPS implantation at two Viennese tertiary care centers (pooled cohort from the prospective AUTIPS study, NCT03409263: 01/2017-11/2022; and a retrospective cohort: 09/2000-09/2019). Through the electronic patient management system, individual demographic, laboratory, and clinical data were retrieved. AU after TIPS placement was investigated according to clinical documentation, serum ethanol quantification if available, and patients' reporting.

Results

Overall, the study population consisted of 276 patients (median follow-up 29 [IQR 54] months), 196 (71.0%) of which had received TIPS for refractory ascites while in 80 (29.0%) the indication for TIPS implantation had been variceal hemorrhage. The median age was 56 (IQR 13) years and 215 (77.9%) of the patients were men. At the time of the TIPS insertion, the median MELD was 11 (IQR 9) and 38 (13.8%) individuals were classified as Child-Pugh C. AU after TIPS placement was documented in 85 (30.8%) study participants. Baseline characteristics at TIPS implantation were similar in patients with and without post-TIPS AU, specifically regarding the prevalence of ascites (p=0.51), variceal hemorrhage (p=0.87), and hepatic encephalopathy (p=0.87).
Bacterial infections were more frequently detected among patients with ongoing AU (log-rank p=0.002). Importantly, patients with ongoing AU showed a higher incidence of acute-on-chronic liver failure (ACLF; log-rank p<0.001) and higher overall mortality (log-rank p=0.005; including liver-related death [log-rank p<0.001]).
Furthermore, cumulative incidence of ACLF (p=0.014) and liver-related death (p=0.004) were significantly higher in patients with ongoing AU. Of note, ongoing AU was independently associated with ACLF (asHR: 1.66; 95%CI: 1.13-2.44; p=0.010) and liver-related death (asHR: 2.09; 95%CI: 1.32-3.33; p=0.002) in multivariable competing risks regression analysis adjusted for age, MELD, and portal pressure gradient after TIPS implantation.

Conclusion

AU represents an independent risk factor for outcome deterioration after TIPS placement. These findings emphasize the paramount role of psychiatric care and harm reduction measures in addition to hepatological optimization after TIPS implantation.

Disclosure

C.S. received travel support from Gilead, Abbvie, Galapagos and Gebro; speaking honoraria from Abbvie and Gilead; and payments for consulting from Gilead.
M.S. received travel support from MSD, Sandoz, BMS, Abbvie and Gilead; and speaking honoraria from BMS.
M.J. received speaking honoraria from Abbvie and Gilead.
T.R. received grant support from Abbvie, Boehringer- Ingelheim, Gilead, MSD, Philips Healthcare, Gore; speaking honoraria from Abbvie, Gilead, Gore, Intercept, Roche, MSD; consulting/advisory board fee from Abbvie, Bayer, Boehringer-Ingelheim, Gilead, Intercept, MSD, Siemens; and travel support from Boehringer-Ingelheim, Gilead, and Roche.
M.M. served as a speaker and/or consultant and/or advisory board member for AbbVie, Bristol-Myers Squibb, Collective Acumen, Gilead, and W. L. Gore & Associates and received travel support from AbbVie, Bristol-Myers Squibb, and Gilead.
B.S. received travel support from AbbVie and Gilead.

Clinical Case Summary

75 years old female reporting vomiting, chronic diarrhea, epigastric pain and weight loss since 2021. She was initially investigated with Esophagogastroduodenoscopy and biochemical exams (both negative). Computed Tomography (CT) showed enlarged mesenteric lymph nodes in right iliac fossa, mesenterial fibrous distortion, venous vessels stenosis, wall thickening in distal ileal tract and mucosal hyperemia. Several differential diagnoses were proposed: ileal Neuroendocrine Tumor (NET) with mesenteric metastases, small bowel neoplasia/ileal lymphoma, inflammatory bowel disease, vascular disruption/ischemia, infections (i.e. tuberculosis). NET markers were negative, as well as Positron Emission Tomogaphy (PET) with Gallium. Total body FDG PET showed hypermetabolism in terminal ileum. Ileocolonoscopy showed sub stenosis, with a serpiginous ulcer of 8 mm located 15 cm from the ileocecal valve and mucosal edema. Histology was nonspecific. The patient underwent ileal resection and right hemicolectomy. Surgical specimen histopatology with immunohistochemical staining (for S100, CD117, Bcl-2 and Calretinin) diagnosed sporadic diffuse ganglioneuromatosis. Post-operative follow up was regular. The differential diagnosis was indeed challenging. The symptoms were confusing, i.e. the presence of diarrhea and the absence of anemia, and the endoscopic appearence was nonspecific. The lesion was hard to sample endoscopically, so surgical specimen evaluation was needed. Video capsule or device-assisted enteroscopy could have been attempted, but with caveats related to luminal stenosis. Multiple neuroendocrine neoplasia (MEN) IIB had to be ruled out since the patient had multiple thyroid nodules, to exclude medullary carcinoma. Subsequent follow up has yet to be established.

References

1. Endoscopic image showing ileal ulcer and stenosis
2. CT scan with mesenterial distortion and lymph nodes enlargment
3. CT scan showing ileal wall thickening and corresponding FDG PET uptake