Clinical Case Summary

A 34 year old female attended electively for liver biopsy for investigation of deranged liver function tests (LFTs).
Ultrasound guided percutaneous liver biospy was complicated by immediate abdominal pain with computed tomography (CT) abdomen revealing right subphrenic intracapsular fluid contained within the liver capsule in keeping with post biopsy haemorrhage. This was managed conservatively with overnight admission for observation.
The patient represented within 48h hours with worsening jaundice and severe abdominal pain. LFTs had significantly worsened with a hyperbilirubinaemia of 153 umol/L with a cholestatic pattern. Repeat CT abdomen showed new intrahepatic and extrahepatic bile duct dilation with common bile duct (CBD) measuring up to 16 mm in diameter. In the lower CBD, there was an obstructing opacity measuring approximately 7 mm in diameters by 24 mm longitudinal and given the clinical history, a blood clot was to be the most felt likely be the underlying aetiology.
Urgent endoscopic retrograde cholangiopancreatography (ERCP) was performed. An initial cholangiogram revealed a dilated biliary system with ill-defined opacity distally. Following sphincterotomy a large clot was extracted with a 12 millimetre balloon. Final cholangiogram showed clearance of bile ducts with no post procedural complications. The next day updated imaging with CT abdomen showed complete resolution of the biliary duct dilatation and LFTs had improved to pre-liver biopsy baseline. The patient was discharged with no further complications.
Discussion: Haemobilia is recognised as a rare complication from percutaneous liver biopsy with incidence rate of less than 1% (1). The management of haemobilia may be conservative in minor cases with transcatheter arterial embolization usually recommended as first line intervention and ERCP used for biliary drainage (2). In this case we demonstrated a successful outcome in biliary decompression following clot extraction with ERCP.

References

(1) Thomaides-Brears, H.B., Alkhouri, N., Allende, D. et al. Incidence of Complications from Percutaneous Biopsy in Chronic Liver Disease: A Systematic Review and Meta-Analysis. Dig Dis Sci 67, 3366–3394 (2022).
(2) Yilmaz N: Hemobilia Causing Acute Cholecystitis and Pancreatitis after Percutaneous Liver Biopsy: A Case Report and Review of the Literature. Visc Med 2020;36:246-250.

Introduction

Non-invasive biomarkers are needed to improve the management of eosinophilic esophagitis (EoE). We investigated whether eosinophil and lymphocyte counts could be used to diagnose EoE among patients with dysphagia and assess histological, endoscopic, and clinical disease activity in patients with known EoE.

Aims & Methods

This was a prospective study conducted at four EoE referral centers (Pisa, Padova, Humanitas Research Hospital, Milano Policlinico San Donato). We enrolled consecutive patients undergoing esophagogastroduodenoscopy (EGD) for suspected or known EoE who had performed blood counts within one month before EGD. Histological remission and non-EoE-related dysphagia (NED) were defined according to current guidelines on EoE. Endoscopic characteristics were classified according to the EoE reference score (EREFS). Demographic, clinical and full blood count data were collected. After the EGD, all patients completed the Dysphagia Symptom Questionnaire over 14 days (DSQ). Kruskal-Wallis Rank Sum Test and Pearson’s Chi-squared were used for comparisons. ROC curve analysis was used to assess the diagnostic accuracy. Spearman’s test was used for correlations. Significance threshold was p<0.05.

Results

We included 210 consecutive patients. Of these, 123 had EoE (58.5% active; 41.5% in histological remission) while 87 had non-EoE dysphagia (NED). Characteristics in Table 1. Absolute eosinophil count (AEC) of active EoE was significantly higher than NED (335 vs 90/mm3; p<0.001), and so was eosinophil percentage (4.6% vs 1.1%; p<0.001), and median lymphocyte percentage (30 vs 27%; p<0.001). ROC curve analysis showed that a cut-off of 155 eosinophils/mm3 had an AUC of 0.85, with 71% specificity and 87% sensitivity for the identification of EoE among patients with dysphagia (Figure 1a). Other ROC analyses on the diagnosis of EoE reported in Table 2. With regards to disease monitoring, only eosinophil counts differed significantly between EoE and NED. Median AEC of active EoE was higher than EoE in remission (335 vs 200/mm3; p<0.01), and so was eosinophil percentage (4.6 vs 1.4%; p<0.001) (Table 3). Based on ROC analysis, a cut-off of 325 eosinophils/mm3 had and AUC of 0.70 for the identification of histological remission in EoE, with a specificity of 52.7%% and sensitivity of 82.3% (Figure 1b) (Table 3). There was modest positive correlation between AEC and the EREFS with Spearman’s Rho of 0.4 (p<0.0001), but there was no correlation between AEC and DSQ scores (Rho= -0.01; p=0.9).

Conclusion

Our results show that the AEC in peripheral blood has good accuracy for the diagnosis of EoE in patients with dysphagia and moderate accuracy for monitoring histological disease activity. In addition, AEC was modestly correlated with endoscopic disease activity (EREFS score) but not with symptoms.

Disclosure

Speaker or Consultancy for Apogee Therapeutics, Dr Falk Pharma, Malesci, JB Pharmaceuticals, Sanofi, Alfasigma

Introduction

Non-alcoholic fatty liver disease (NAFLD) is a common liver condition, and liver biopsy is considered the gold standard to diagnose and stage the disease [1]. However, the risks associated with the invasive procedure limit its widespread use, making noninvasive methods for assessing the severity and progression of fibrosis essential in pediatric NAFLD cohorts [2].

Aims & Methods

To investigate the levels of transforming growth factor-beta 1 (TGF-β1) and glycosaminoglycans (GAGs) in obese children with NAFLD and assess their diagnostic accuracy.
94 children aged 9 to 17 years (average age 12.15 ± 2.51 years) were examined. According to the transient elastography data (FibroScan®502touch, Echosence, France) and body mass index, children were divided into four groups:1 group - 27 obese NAFLD children with fibrosis ≥F1, group 2 - 35 obese NAFLD children without fibrosis, group 3 - 18 obese children without NAFLD and fibrosis. Group 4 (control) comprised 14 children with normal weight without NAFLD and liver fibrosis. Serum transforming growth factor-beta 1 (TGF-β1) levels were evaluated by enzyme-linked immunosorbent assay (ELISA) using the IBL International (Germany) test system, and glycosaminoglycans (GAG) levels were determined spectrophotometrically. ROC analysis was performed for cut-off values calculation.

Results

The highest level of TGF-β1 was found in 1 group children –up to 153.4 (99.7; 189.1) pg/ml, which was significantly higher than in 2 group- 72.4 (53.1; 111.3) pg/ml (p˂0,05), 3 group - 74.0 (50.6; 99.4) pg/ml (p˂0,05) and 4 group - 56.1 (46.0; 77.4) pg/ml (p˂0,05). Moreover, 1 group of children demonstrated increased GAG content up to 4.50 (3.21; 4.60) mmol/L (p˂0,05). ROC analysis revealed that cut-off serum TGF-β1 96.8 pg/ml predicted liver fibrosis in NAFLD children. The area under the curve (AUROC) was 0.787 (p<0.001), the sensitivity of the test was 80.0%, and the specificity was 65.7%. The threshold GAG value for fibrosis was 4.24 mmol/L (sensitivity 70.6%, specificity 69.6%, AUROC 0.743 (p<0.01)).

Conclusion

TGF-β1 and GAG are reliable noninvasive fibrosis markers in children with NAFLD, allowing for their use in liver fibrosis screening.

References

1. Gawrieh S, Harlow KE, Pike F, et al. Relationship of Enhanced Liver Fibrosis Score with Pediatric Nonalcoholic Fatty Liver Disease Histology and Response to Vitamin E or Metformin. J Pediatr. 2021;239:161-167.e5. doi:10.1016/j.jpeds.2021.08.012.
2. Draijer L, Benninga M, Koot B. Pediatric NAFLD: an overview and recent developments in diagnostics and treatment. Expert Rev Gastroenterol Hepatol. 2019;13(5):447-461. doi:10.1080/17474124.2019.1595589

Introduction

Pancreatic cysts are a common finding in imaging studies, and, considering the different malignant potentials of mucinous and non-mucinous cysts, it is necessary to develop accurate methods and algorithms to differentiate between them. We conducted this study to compare the diagnostic performance of glucose levels and CEA levels in the diagnosis of mucinous pancreatic cysts.

Aims & Methods

We conducted a retrospective study of patients who underwent EUS-FNA of pancreatic cystic lesions between September 2020 and March 2023 at a tertiary referral center. We included patients whose glucose and CEA levels had been measured. Indicators of mucinous cysts include glucose levels less than 2.7 mmol/l and CEA levels greater than 192 ng/ml. It was compared to the final pathology (obtained after surgery or by EUS-FNB) result to determine their accuracy.

Results

	Non-mucinous	Mucinous
Gender (%male)	47.3%	33.3%
Age ( Median)	50.2	58.3
Cyst location
head	9	3
body	2	5
tail	8	4

A total of 31 patients were included in the study, 13 males and 18 females. The mean age was 55.7 years. Of the 31 patients, 12 (38.7%) were diagnosed with mucinous cysts (6 mucinous cystic neoplasms, 6 intraductal papillary mucinous neoplasms), and 19 (61.2%) were diagnosed with non-mucinous cysts (9 serous cystic neoplasm, 8 pseudocysts, 1 solid pseudopapillary neoplasm, and 1 lymphoepithelial cyst). There was a female prevalence in patients with mucinous cysts (8 females and 4 males) with a mean age of 59,6 years. From the cyst fluid analysis, the sensitivity, specificity, and accuracy of glucose in diagnosing mucinous cysts were 91.7%, 89.5%, and 90.3%, respectively. CEA’s sensitivity, specificity, and accuracy were 81.8%, 85.0%, and 83.9%, respectively.

Conclusion

In the diagnosis of pancreatic cystic lesions, glucose levels have high diagnostic performance with high sensitivity and accuracy. In contrast, CEA levels have a lower diagnostic performance. The findings of our study support the use of EUS-FNA and glucose levels in the diagnosis of pancreatic cystic lesions, as well as EUS-FNB to obtain histological specimens for a more accurate diagnosis of pancreatic cysts. Further studies are needed to validate these findings and explore the potential of other biomarkers in diagnosing and managing pancreatic cystic lesions.