Clinical Case Summary

Endoscopic submucosal dissection (ESD) is a minimally invasive endoscopic procedure used for the removal of early gastric cancers. Although ESD has a good safety profile overall, some complications have been reported as bleeding, perforation, infection, and late stenosis. Here we report a clinical case in which two of these complications occurred in the first 24 hours after ESD and where prompt endoscopic management was essential.
A 77-year-old man with a medical history of chronic gastritis with extensive intestinal metaplasia was submitted to endoscopic submucosal dissection (ESD) of a 12 mm lesion in the greater curvature of the proximal corpus (0-IIa [Paris Classification]). The lesion was removed using an IT Knife 2, and intraprocedural bleeding was negligible. After the ESD, the patient was asymptomatic. Sixteen hours later, the patient presented with hematemesis and new-onset anemia (9.5 g/dL), without hemodynamic instability, and denied abdominal pain. An urgent esophagogastroduodenoscopy (EGD) was performed, and a deep eschar was identified, with no signs of free perforation. Eschar closure with 4 through-the-scope (TTS) clips was attempted, without success. Due to the emergence of new-onset abdominal pain after the EGD, a CT scan was done, and free intraperitoneal air was identified. With the aim of endeavoring eschar closure, a second EGD was emergently performed. The previously placed TTS clips were removed, and three partially overlapping over-the-scope clips were placed to completely close the eschar. Complete eschar closure was confirmed in a CT scan with oral contrast, and the patient's evolution was uneventful.
This clinical case illustrates the importance of prompt action to ensure ESD safety and reinforces the feasibility of endoscopic techniques to treat challenging iatrogenic perforations, reducing the need for urgent surgery and related morbidity and mortality.

Introduction

Since the advent of the BAVENO VII consensus, Transient elastography (Fibroscan) has taken on a key role in the assessment of clinically significant portal hypertension (CSPH) and the prediction of decompensation and death. A liver stiffness measurement (LSM) ≤ 15 kPa associated with platelets ≥ 150 G/L excludes CSPH (NPV > 90%), while a LSM > 25 kPa is very much in favor of CSPH (PPV > 90%). CSPH remains possible in non-obese patients with LSM between 20 and 25 kPa with platelets < 150 G/L or LSM between 15 and 20 kPa with platelets < 110 G/L) but with a 40% risk of error.

Aims & Methods

We conducted this study to evaluate the reliability of transient elastography (TE) and platelet count in the diagnosis of CSPH, and to determine the extent of adherence to the consensus recommendations in our center.
This is a monocentric and retrospective study made in the gastroenterology and hepatology department of Mohamed Taher Maamouri Hospital in Nabeul, Tunisia, in which we collated reports of Fibroscans performed from March 2023 to March 2024.
We excluded patients with etiologies other than viral, alcoholic, or non-obese non-alcoholic steatohepatitis (NASH).
Platelet count and upper gastrointestinal endoscopy (EGD) data (if performed) were collected.
Data were entered and analyzed using SPSS version 27 software, with a significance level of 0.05.

Results

One hundred and fifty-nine Fibroscans were performed, of which 127 were included.
Women accounted for 64.6%, with a M/F sex ratio of 0.55. Mean age was 55.13 years [20-83].
The indications for Fibroscan were distributed as follows: 53.5% (68 patients) for non-obese NASH, 33.1% (42 patients) for HBV, 11.8% (15 patients) for HCV and only 2 cases for chronic ethylism.
The mean LSM value was 6.45 kPa [2-41.5], with thresholds distributed as follows; LSM <5 kPa in 70 patients (55.1%), LSM between 5 and 10 kPa in 44 patients (34.6%), LSM between 10 and 15 kPa in seven patients (5.5%), LSM between 15 and 20 kPa in two patients (1.6%), LSM between 20 and 25 kPa in a single patient, and LSM >25 kPa in three patients (2.4%).
The mean platelet count was 220 G/L [20-440], with a count > 150 G/L in 111 patients (87.4%), a count between 110 and 150 G/L in 13 patients (10.2%) and a count < 110 G/L in 3 patients.
Of all patients, 24 FOGDs were performed. Signs of Portal hypertension (PH) were noted in only 5 cases, represented by grade I esophageal varices.
In analytical study, hepatic elastography and platelet count were significantly correlated with the presence of endoscopic PH (p=0.009). Indeed, among patients with signs of endoscopic PH, 60% had a LSM > 25 kPa, 20% had a LSM between 15 and 20 kPa with a platelet count < 110 G/L and only 20% had a LSM < 10 kPa.
Furthermore, the consensus recommendations for the indication or not of EGD were not respected in our center (p=0.004); of all endoscopies performed 87.5% (21 EGD) were not indicated, and we noted one case where EGD was indicated but not performed.

Conclusion

Our study highlighted the recommendations of the latest BAVENO VII consensus regarding the reliability of transient elastography and platelet count in the evaluation of CSPH (p=0.009). This must be taken into consideration by practitioners in order to implement adequate preventive measures and to rationalize the indication of EGD which remains an inconvenient procedure for our patients.

Introduction

In order to meet the requirements of the WHO, namely - the eradication of viral hepatitis by 2030, UMF “Grigore T. Popa” from Iasi together with ARAS and the Hospital “St. Spiridon" from Iasi, carries out since 2020 the project "LIVE(RO) 2 - Integrated regional program for prevention, early detection (screening), diagnosis and targeting treatment of patients with chronic liver disease secondary to viral infections with liver viruses B/D and C in the North-East and South-East regions”.

Aims & Methods

This study aimed to assess the epidemiological characteristics of the vulnerable population in the eastern part of the country diagnosed with chronic B/D and C viral infection. Between July 2021 and April 2023, we performed a prospective screening of chronic viral hepatitis B/D and C in vulnerable people in the counties of North-East and South-East of Romania, within the national program LIVE(RO) 2 - EST. Rapid diagnostic tests were used to detect HBs antigen (HBsAg) and anti-HCV antibodies (HCVA): HBV (Wama Immuno-Rapid HBV®) and HCV (Wama Immuno-Rapid HCV®). Rapid test-positive patients were tested for HBV DNA and HCV RNA and those eligible under the national protocol were treated with antivirals.

Results

The study included 55593 individuals tested rapidly, of which 2160 (3.8%) patients were tested positive (1120 women, 1040 men, mean age 55.86 ± 6.023 years, predominantly rural background - 76.19%). Of these, 1077 (49.8%) were HBsAg positive, 918 (42.5%) with HCV positive needle, 37 (1.7%) HBV/HCV coinfection and 128 (5.9%) HBV/VHD coinfection. HBV-DNA was performed in 724 (67.3%) individuals, of which 452 (62.5%) subjects > 2,000 children/ml. Also, 518 (54.3%) patients with HCV-positive Ac had detectable HCV RNA, of which 375 (72.3%) received antiviral treatment. Depending on the ethnicity, the prevalence of viral infection was 4.29% in Roma people and 3.23% in Romanian people. Among the vulnerable groups determined by work, inactive people (27.7%), uninsured people (11.2%), unskilled people (1.87%), unemployed people (0.6%) and people working in agriculture (0.59%) were predominantly tested. Among the special vulnerable groups, people with disabilities (3.99%), people addicted to alcohol (2.43%) and people with a minimum income (1.21%) were predominantly tested.

Conclusion

The high prevalence of B/D and C viral infection in the vulnerable population tested in the North-East and South-East Region of Romania compared to the rest of the population, indicates the significant viral spread of the infection in these people, a condition that requires further testing and the need for policies public health in vulnerable groups to promote access to existing health services and early initiation of optimal antiviral treatment.