Introduction

2018 European Association for the Study of the Liver (EASL) guidelines suggest a six-month radiological surveillance interval for cirrhotic patients with either Child-Pugh stage A and B, or C awaiting liver transplantation, to reduce hepatocellular carcinoma (HCC) associated mortality.

Aims & Methods

We aimed to audit our compliance with HCC screening guidelines.
Our hepatology clinic, liver elastography and radiology databases were cross referenced to yield 91 patients attending with cirrhosis over the years 2013 to 2022.

Results

69% (n=63) were male. Median age at diagnosis was 58 years (IQR: 50-64.75). 84% (n=76) and 12% (n=11) had alcohol and non-alcoholic steatohepatitis (NASH) as a documented aetiology. Median MELD3 was 13 (IQR: 9-17). 14% (n=13) had died at the time of writing. Median age at death was 62 (IQR 52-66).
34% (n=31) and 46% (n=42) had radiological features of splenomegaly and hepatic steatosis respectively. 56% (n=51) had evidence of varices with 67% (n=34) of those taking non-selective beta blockers (NSBBs). 20% (n=18) had prior hepatic encephalopathies and 67% (n=12) of those were taking rifaximin. 33% (n=30) had prior GI bleeding. 71% (n=65) had prior ascites with 75% (n=49) prescribed diuresis. 4% (n=4) had prior documented hepatorenal syndrome. 10% (n=9) had prior spontaneous bacterial peritonitis (SBP) with 44% (n=4) taking secondary prophylaxis. 2% (n=2) had prior trans-jugular intrahepatic portosystemic shunts (TIPSS). 3% (n=3) had prior portal vein thrombosis.
5% (n=5) were diagnosed with HCC. Median age at time of HCC diagnosis was 74 years (IQR: 66-74). Median alpha-fetoprotein (AFP) at time of diagnosis was 10.9 (IQR: 5.4-756).
Patients with Child Pugh C cirrhosis (N=24, 18%) were excluded from the analysis.
167 surveillance studies on those with no more than Child Pugh B cirrhosis were analysed over the ten-year period. The median number of months between surveillance imaging was 9.77 months (IQR: 5.9-17.8). 40% of surveillance studies were carried out at an interval of greater than 12 months. The average number of months between imaging pre- and post-COVID were 12.8 and 8.26 months respectively (95% CIs: 10.9-14.8, 6.4-10.1).
60% (n=3) of HCC diagnoses were made in the absence of a known history of cirrhosis. Two patients with Child-Pugh C cirrhosis had HCC diagnosed. One was a male in his 60s who had a diagnosis made on ultrasound 10.5 months after prior surveillance at another site. Another male in his late 70s had a HCC diagnosis made 35 months after a prior ultrasound identified cirrhosis, though his performance status made surveillance inappropriate.

Conclusion

Alcohol was the most prevalent cause of cirrhosis in our cohort. 5% of our cohort were diagnosed with HCC, with none as a result of failures to follow surveillance guidelines. Surveillance intervals post March 2020 fell significantly (p < 0.01). This may be attributable to an increase in radiology resources in the latter part of the decade.

References

European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu; European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J Hepatol. 2018 Jul;69(1):182-236. doi: 10.1016/j.jhep.2018.03.019. Epub 2018 Apr 5. Erratum in: J Hepatol. 2019 Apr;70(4):817. PMID: 29628281.

Clinical Case Summary

For decompensated advanced chronic liver disease (dACLD) individuals, the onset of refractory ascites (RA) represents a dramatic event (6-month survival rate < 50%). In this setting, a relevant proportion of RA patients develop Hepatorenal Syndrome-Acute Kidney Injury (HRS-AKI) with limited therapeutic and survival chances.
An 81-year-old female dACLD RA patient was admitted to our department to receive large-volume paracentesis (LVP). Eradicated HCV infection, type II diabetes, and chronic obstructive pulmonary disease were her comorbidities.
The AKI onset imposed the intravenous (i.v.) human albumin (HA) (1 g/kg/die) administration, followed by the proper dosage of terlipressin (for HRS-AKI) within the first 72 hours (h), subsequently discontinued due to the persistence of anuria and the worsening of respiratory failure.
To simultaneously address uremic symptoms and facilitate ascites drainage, a Tenckhoff catheter was placed, and peritoneal dialysis (PD) started with a single icodextrin dwell, resulting in the removal of 14 L of ascites and an improvement in AKI within the subsequent 72h. After one week, she was discharged, receiving a specific PD schedule. After the readmission due to the difficulties in administering i.v. HA, we proposed administering HA via the intraperitoneal route, creating an HA-enriched PD (PD+HA) home-performable schedule by adding two vials of 100 ml of HA 20% to 800 ml of icodextrin solution (40 g in 1000 ml/die; lasting: 12 hours; frequency: every other day) (Figure 1).
The patient has been performing this PD schedule for 12 months (~0.5 L of ascites is discharged every other day before performing PD+HA dwell). During the follow-up, no PD-related complications (e.g., peritonitis) and liver-related events requiring hospitalization have been observed.
We report the first successful use of PD+HA, highlighting the cruciality of a multidisciplinary (hepatologists-nephrologists) approach in the management of dACLD-RA HRS-AKI patients.

References

1. Moreau, R.; Delègue, P.; Pessione, F.; Hillaire, S.; Durand, F.; Lebrec, D.; Valla, D.-C. Clinical Characteristics and Outcome of Patients with Cirrhosis and Refractory Ascites. Liver Int 2004, 24, 457–464, doi:10.1111/j.1478-3231.2004.0991.x.
2. Moore, K.P.; Wong, F.; Gines, P.; Bernardi, M.; Ochs, A.; Salerno, F.; Angeli, P.; Porayko, M.; Moreau, R.; Garcia-Tsao, G.; et al. The Management of Ascites in Cirrhosis: Report on the Consensus Conference of the International Ascites Club. Hepatology 2003, 38, 258–266, doi:10.1053/jhep.2003.50315.
3. Nadim, M.K.; Kellum, J.A.; Forni, L.; Francoz, C.; Asrani, S.K.; Ostermann, M.; Allegretti, A.S.; Neyra, J.A.; Olson, J.C.; Piano, S.; et al. Acute Kidney Injury in Patients with Cirrhosis: Acute Disease Quality Initiative (ADQI) and International Club of Ascites (ICA) Joint Multidisciplinary Consensus Meeting. J Hepatol 2024, 81, 163–183, doi:10.1016/j.jhep.2024.03.031
4. Brown, E.A.; Blake, P.G.; Boudville, N.; Davies, S.; de Arteaga, J.; Dong, J.; Finkelstein, F.; Foo, M.; Hurst, H.; Johnson, D.W.; et al. International Society for Peritoneal Dialysis Practice Recommendations: Prescribing High-Quality Goal-Directed Peritoneal Dialysis. Perit Dial Int 2020, 40, 244–253, doi:10.1177/0896860819895364.

Clinical Case Summary

Introduction: Typical complications of pancreatitis include the development of pseudocysts, obstruction of the bile duct or duodenum, and thrombosis of the splenic veins. Furthermore, pancreatitis can often lead to ascites or pleural effusions. Despite these known complications, detection of hemodynamic relevant pancreatogenic pericardial effusion is rare.
Case report: We present the case of an 81-year-old patient admitted to the emergency department with symptoms including shortness of breath, arterial hypotension, abdominal pain, dizziness, and chills. Additionally, the patient has been experiencing chronic abdominal pain since being diagnosed with acute pancreatitis four years ago. Anamnesis confirmed chronic alcohol consumption. Laboratory parameters showed increased serologcal inflammatory markers and lipase levels. Further diagnostic evaluation by computed tomography (CT) revealed characteristic findings of chronic pancreatitis, including perihepatic and perigastric abscess formations. Moreover, a circular pericardial effusion and bilateral pleural effusions were also detected. Due to the patient's hemodynamic and respiratory instability, endotracheal intubation was performed in the intensive care unit. Due to escalating indications of pericardial tamponade with arterial hypotension, tachycardia, and desaturation, emergency pericardial drainage and bilateral pleural drainage were performed immediately. Two percutaneous drains were inserted to address the intra-abdominal abscesses. Following the intervention, hemodynamic and respiratory stabilization allowed for extubation. The patient could be discharged from the hospital one month later.
Conclusion: The emergence of pericardial tamponade as a complication of pancreatitis is exceptionally rare and poses a potentially life-threatening scenario. Therefore, our case underscores the importance of excluding pericardial effusion in patients with pancreatitis using echocardiography or other radiological methods.

Introduction

In Crohn’s disease (CD) a symptomatic luminal stricture occurs in up to 20% of patients at the diagnosis and in more than 50% during lifetime (1,2). Endoscopic balloon dilatation (EBD) or surgical procedures are the currently available treatments (3,4). However, a considerable percentage of patients often require further surgery for post-operative CD recurrence (5). A consequent increased burden of short bowel syndrome is warranted. The combination of biological therapy with EBD could potentially reduce this risk.

Aims & Methods

The aim of our study was to evaluate the efficacy of EBD combined with biologic therapy in symptomatic gastrointestinal strictures in CD’s patients. We conducted a retrospective study including consecutive CD patients who underwent EBD for low bowel strictures from December 2015 until November 2022 at our tertiary IBD Center. Clinical strictures recurrence, needs for steroids and for surgery due to CD stenosis relapse were the primary outcomes evaluated during a follow-up period of six and twelve months. Chi-square and univariate statistical analyses were used when appropriate.

Results

A total of 52 patients treated with EBD with an overall number of 55 strictures were included. In the study population, 14 patients (27%) were smoker, the mean age was of 46,8 (18-77) years; the median of disease duration was 9 (0-42) years. Thirty-nine patients (75%) were in active treatment with biologic therapy at the moment of EBD. Twenty-three patients (44%) underwent EBD for anastomotic stricture, 8 (15%) for ileal stricture, 11 (21%) for ileocecal valve stricture, 5 (6%) for anal stricture and 4 (8%) for colic stricture. Three patients (6%) underwent EBD for multifocal bowel stenosis. Twenty-two (42%) patients had increased CRP value, 40 patients (77%) had evidence of moderate or severe endoscopic disease activity and 42 (81%) patients showed ulcerative lesions at stricture site. EBD was performed by 8-10, 12-15 or 15-18 mm dilation balloon. Technical success was reported in 60% of procedures and no adverse events were registered.
After 6 months from EBD, at univariate analysis, active smoke resulted a risk factor for clinical stricture recurrence (OR 10,25; IC 1,350 to 135,4; p value = 0,022) and for subsequent surgery (OR 10,25; IC 1,350 to 135,4; p value = 0,022). Moreover, increased CRP at the time of dilatation resulted a risk factor for need of steroids (OR 14,63; IC 2,69 to 71,50; p value = 0,0006). Concomitant biologic therapy and presence of ulcerative lesions did not show significative correlation with considered outcomes.
After 12 months from EBD, concomitant biologic therapy resulted a protective factor for prevention of surgery (OR 0,061; IC 0,005 to 0,502; p value = 0,0047), while anastomotic strictures were associated with a lower risk of sub-occlusion events than ileal stenosis (OR 0,07; IC 0,005 to 0,651; p value = 0,015). Increased CRP at the time of EBD, ulcerative lesions at the stricture site and active smoke were not significantly correlated with the considered outcome.

Conclusion

Our results suggest that in patients with CD undergoing EBD for bowel CD stricture, concomitant biological therapy reduces the risk of surgery for CD stenosis recurrence. Further prospective and controlled studies are underway to confirm these observations.

References

1. Rieder F Managing Intestinal Fibrosis in Patients With Inflammatory Bowel Disease. Gastroenterology &amp; hepatology. 2018. February; 14(2):120–122
2. Yoo JH, Holubar S, Rieder F. Fibrostenotic strictures in Crohn’s disease. Intest Res. 2020;0.
3. Paine E, Shen B. Endoscopic therapy in inflammatory bowel diseases (with videos). Gastrointest Endosc 2013;78:819–35.
4. Hassan C, Zullo A, De Francesco V, Ierardi E, Giustini M, Pitidis A, Taggi F, Winn S, Morini S. Systematic review:
Endoscopic dilatation in Crohn's disease. Aliment Pharmacol Ther. 2007 Dec;26(11-12):1457-64
5. Olaison G, Smedh K, Sjödahl R. Natural course of Crohn’s disease after ileocolic resection: endoscopically visualised ileal ulcers preceding symptoms. Gut 1992;33:331–5.

Introduction

Lactose malabsorption (LM) is a common digestive disorder. The hydrogen breath test (HBT) is currently the non-invasive gold standard in diagnosing LM and lactose intolerance (LI), which is defined only in case of developing symptoms directly related to lactose ingestion in subjects with LM. (Misselwitz et al. 2019) The analysis of methane values in air samples may increase the accuracy of the test by including subjects “non hydrogen producers”. (De Geyter et al. 2021)

Aims & Methods

The aim of this study is to describe the relationship between pre-test clinical features, symptoms reported during lactose challenge and the result of the HBT in adults. In this prospective study we included a consecutive series of adult patients who underwent a HBT during a 5-month period. Air samples were taken every 30 minutes for 4 hours after the ingestion of a charge of 25 g of lactose. Symptoms reported in the previous 15 days (abdominal pain, bloating, diarrhoea, flatulence) and those experienced after lactose ingestion were assessed using a standard questionnaire establishing their presence or absence, and relative severity using 0-10 scale. The results were considered positive when a H₂ peak exceeded 20 parts per million (ppm) above the baseline or in case CH₄ excretion reached 10 ppm above the baseline, for experimental purpose. LI was defined by at least one symptom experienced during the test in subjects with LM.

Results

68 patients were included in the study and 40 of them (59%) were positive at the HBT. 52 (76%) developed at least one symptom while LI was diagnosed in 34 patients of them (65%). Only 40% of patients who referred pre-test symptoms had LM and none of the four symptoms was associated with LM or LI. A positive trend was found between abdominal bloating after lactose ingestion and a positive HBT (p 0.08). This association was statistically significant (73% vs 43%, p 0.02), with a positive trend also for flatulence (p 0.08) (Table), implementing diagnostic test with values of exhaled methane, finding 10 more intolerant patients. Considering the variation of symptoms (new or worsening of symptoms after lactose ingestion), the worsening of bloating was significantly more frequent in subjects with positive HBT compared to those with a negative test (40% vs 14%, p 0.03) and predictive of LI (PPV= 80%). Diarrhoea was the most predictive symptom of LI (PPV up to 88%). An association between the number of symptoms experienced during the test and LM was confirmed, while we didn’t find the same relationship with pre-test symptoms. (Beyerlein et al. 2008)

Conclusion

Symptoms reported before HBT seems to be non-related to LI. This may lead to arbitrary dietary exclusion of dairy products with consequences on bone health (Infante and Tormo 2000) and suggest that the causal role of lactose should be confirmed by HBT. In adult, the development ex-novo or the exacerbation of abdominal bloating and diarrhoea during the test, in subjects with LM, seems to be the most predictive of LI. Furthermore, the increase of the number of symptoms complained makes the diagnosis of LI more likely. On these basis, a domestic screening with 25 g of lactose (500 ml of milk) to establish whether the patient really needs the execution of breath test should be explored.

References

Beyerlein et al. 2008
De Geyter et al. 2021
Infante and Tormo 2000
Misselwitz et al. 2019

Clinical Case Summary

A 27-year-old patient diagnosed with necrotizing pancreatitis was scheduled for cholecystectomy with the diagnosis of acute biliary pancreatitis. During the operation, widespread necrotic debris was seen in the abdominal cavity, so the surgical plan was changed and a drainage catheter was placed in the gallbladder and peripancreatic region. After the operation, the patient applied to our center with a complaint of fever and malaise. An appropriate examination and treatment plan was prepared and he was admitted to the hospital. In the intravenous contrast computed tomography images, a necrotic collection of 16 cm in size was observed in the peripancreatic region and extending to the small pelvis. The patient underwent a linear endoscopic ultrasonography examination after 5 weeks of hospitalization. During the examination, a thin-walled cystic-necrotic lesion (walled-of necrosis) was observed in the peripancreatic region with solid debris and fluid. According to the technique, a 14 mm wide NAGI stent was placed inside the cyst. In the following days, the transluminal endoscopic necrosectomy procedure was repeated with various endoscopic instruments (snares, nets, forceps, stone removal baskets) at intervals of 2-3 days. The procedure was continued until the peripancreatic region was completely cleared of necrotic debris. Since the necrotic debris seen in the right iliac fossa could not be treated endoscopically, surgical necrosectomy and cholecystectomy were performed in this area after consultation with a general surgeon. Control computed tomography images showed that intra-abdominal necrotic debris was completely cleared and granulation tissue was formed. The patient, who was clinically and laboratory stable during the examinations, was discharged home for outpatient follow-up.

Introduction

EUS guided cysto- gastrostomy/duodenostomy is well established now as a standard treatment option for symptomatic pancreatic pseudocyst in adult. Pancreatic pseudocyst in children is rare and tend to resolve spontaneously. Pancreatic pseudocyst that persists more than 6 weeks and cause symptoms considered a troublesome and need drainage either surgical, radiological or endoscopic. There are limited data regarding EUS guided cysto-gastrostomy in the childhood age group (2- 12 years). This is due to limited number of cases in this age group, the lack of experienced pediatric gastroenterologist with this technique and relatively large diameter of therapeutic EUS with a rigid tip that may restricts its use in young children.
We assessed the feasibility of EUS guided drainage of symptomatic pancreatic pseudocyst in children as an effective and safe procedure.

Aims & Methods

This is a multi-center retrospective study. We reviewed our data base for all children between the ages of 3 and 12 years underwent EUS guided pancreatic pseudocyst drainage between Oct 2018 and Dec 2022. We assessed preprocedural patient indication (including cause of previous pancreatitis, present complaint, and imaging), procedure technical success, early and delayed procedure related complication and clinical success.

Results

EUS guided cysto-gastrostomy was performed in nine children (six were males and 3 were females). The median age of the included children was 8 years (ranging from 3: 12 years) and the median Weight was 26.4 kg (ranging from 14.5: 37 kg). The cause of previous pancreatitis was blunt trauma in 4 cases, post chemotherapy for ALL in 3 cases and two were biliary cause. We had 100% clinical success with deployment of short double pigtail plastic stent (10Fr x 5 or 7 cm) through created fistula between the gastric lumen and cyst (the fistula was done by using 6 fr cystotome over guidewire and was dilated using mechanical dilator in 5 cases and 6:8 mm balloon in 4 cases). All patients resolved completely from pre- procedure symptoms and eight patients had complete cyst resolution after one month. One case has marked regression from 9.5 cm to less than 2 cm, this case also did trans-papillary drainage for pancreatic duct disruption. No post procedure complications were observed, only mild pancreatitis managed conservatively for 3 days in the child underwent concomitant trans-papillary drainage.

Conclusion

EUS guided cysto- gastrostomy for childhood population with symptomatic pseudocyst appeared to be feasible, effective, and safe procedure using therapeutic endoscopic ultrasound. Larger number of cases needed to support this procedure as a standard treatment option for these cases.