Clinical Case Summary

Introduction: Primary epiploic appendagitis (PEA) is a rare cause of acute abdominal pain. The clinical is non-specific, making the diagnosis difficult; hence the interest of CT scan. The preferred treatment is essentially medical.
Objectives: Focus on the particularities of this entity, which can mimic the picture of an acute surgical abdomen, in order to minimize the risk of an unnecessary surgery.
Materials and methods: We present a retrospective and descriptive study of 4 cases diagnosed with PEA, managed in the hepatogastroenterology department in collaboration with the visceral surgery department 2, during the year 2021.
Results:
- The average age of the patients was 50.75 years, with a male predominance.
- Obesity was a predisposing factor for PEA; three patients were overweight.
- The clinical picture was dominated by abdominal pain, found in all patients.
- Associated signs (nausea, vomiting, transit disorders) were rare or absent, found respectively in 2 patients and one patient.
- The clinical examination revealed abdominal tenderness in 3 patients, defensiveness in only one patient, and a temperature higher than 37.3 °Cin 3 patients.
- Laboratory examinations showed hyperleukocytosis in 2 patients and a moderate increase in C-reactive protein in 3 patients.
- CT scan was the key examination for the diagnosis of PEA, performed in all patients.
- Three patients benefited from conservative management, only one patient was operated on.
- The evolution was favorable; no case of recurrence or complication was noted.
Conclusion: PEA is a condition that should be kept in mind as it is managed medically and to spare patients unnecessary surgery or hospitalization.

Clinical Case Summary

Ballon-occluded retrograde transvenous occlusion (BRTO) is a minimal invasive procedure to treat mainly the gastric varices but it may be used in ectopic varices as well. We report a case of 70years old male known to have Alcoholic liver disease (cirrhosis) with portal hypertension, presented with malena. He underwent an urgent Gastroscopy which showed GAVE (Gastric antral vascular ectasia) and Grade 1 varix not needing any therapy. Due to persistent malena and haemoglobin drop, CT mesenteric angiogram was performed which reported multiple enlarged varices in the abdomen with no active site of haemorrhage. Video capsule endoscopy was performed which showed small bowel varices with evidence of fresh blood. Unfortunately, the ultrasound liver showed thrombosis of portal vein. Due to portal vein thrombosis TIPSS (Transjugular intrahepatic porto systemic shunt) was not performed and MDT decision for BRTO (Balloon-occluded retrograde transvenous occlusion) was made which the patient underwent successfully.
BRTO is advantageous over TIPSS because this can be performed with poor hepatic reserve and with hepatic encephalopathy however it increases the risk of bleeding from oesiphageal varices and ascites. Gastro-renal shunts are the most sites for use of BRTO however, this procedure was successfully done in this case.
Based on literature review BRTO procedure has been successfully used in gastric varices.
I’ve found few cases reported with small bowel varices treated with BRTO.
Learning points:

1. Whether BRTO is superior to TIPPS for ectopic varices
2. Whether BRTO can be considered in ectopic varices in patients without portal vein thrombosis

References

https://www.sciencedirect.com/science/article/pii/S1930043317305022


https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3444869/#!po=0.806452

Disclosure

No conflict of interest

Introduction

Amyotrophic Lateral Sclerosis (ALS) is a progressive neurodegenerative disease in which muscle weakness develops insidiously. In advanced stages of the disease dysphagia, weight loss and malnutrition occur in the majority of patients. Thus, the consideration of Percutaneous Endoscopic Gastrostomy (PEG) tube placement is common. However, the optimal timing and setting for the procedure as well desired spirometry results are either are not stated in most guidelines or debated. Previous studies have suggested greater procedural risk for patients whose forced vital capacity (FVC) was less than 50% than predicted

Aims & Methods

The aim of this study was to assess the safety of our tertiary center simplified approach to PEG tube placement in patients with ALS.
The electronical records of patients who underwent percutaneous endoscopic gastrostomy (PEG) placement between 1.1.2020 to 1.1.2023 were retrospectively reviewed. All adult patients diagnosed with ALS who underwent ambulatory PEG tube placement were included. Patients who underwent PEG tube placement during hospitalization due to acute illness were excluded. The common practice of our center regarding PEG placement in patients with ALS is as follows: initial evaluation at the Gastroenterology clinic of patients referred by the neurology clinic, followed by ambulatory PEG placement under sedation by an anesthesiologist. We collected baseline information from the neurology and gastroenterology clinic visits regarding comorbidities and baseline FVC and the functional rating score [ALS-FRS, 0-48 points, lower score indicating a more severe disease). The data concerning the procedure and possible complications were collected from endoscopy reports, emergency department visits and clinic visits after the procedure.

Results

Six hundred and sixty patients had underwent PEG tube placement in our center during study period. Of them, 67 patients had an established diagnosis of ALS (10.2%). One patient was excluded due to PEG placement in the setting of an acute illness during admission, thus 66 patients were included (mean age at PEG placement 63.5±12.7 years and 37.8% were females). Mean ALS-FRS score was 23.6±8.81 and mean FVC was 49.8±19.45% of predicted. More than half (54.7%) of the patients were using non-invasive ventilation support device at home prior to the procedure and 12.1% of patients had underwent endotracheal tube placement prior to PEG tube placement.
The averaged duration of PEG tube placement was 11.96±5.3 minutes. All PEG procedures were completed successfully. Complications were documented during two PEG placements (3%): one patient suffered from aspiration and was hospitalized and later diagnosed with aspiration pneumonia and the second patient suffered from gastric perforation and peritonitis which was diagnosed a few hours after the procedure. During the 30 days following PEG placement, 3 (4.5%) complications were documented: Two patients (3%) suffered from PEG site infections and were treated with antibiotics and one (1.5%) was diagnosed with aspiration pneumonia. No deaths occurred during the procedure or during the 30 days that followed.

Conclusion

The simple straight forward approach to PEG placement in our institution was successful and safe in the vast majority of cases. The complications rate in our cohort is comparable to other studies, even though the patients in our cohort had significantly reduced lung function and functional scores then accepted in the common practice.

References

1. Miller R G, Jackson C E, Practice parameter update: the care of the patient with amyotrophic lateral sclerosis: drug, nutritional, and respiratory therapies (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology, Neurology, 2009 Oct 13;73(15):1218-26
2. EFNS Task Force on Diagnosis and Management of Amyotrophic Lateral Sclerosis: Andersen P M, Abrahams S, EFNS guidelines on the clinical management of amyotrophic lateral sclerosis (MALS)--revised report of an EFNS task force, Eur J Neurol 2012 Mar;19(3):360-75.
3. Korner S, Hendricks M, Weight loss, dysphagia and supplement intake in patients with amyotrophic lateral sclerosis (ALS): impact on quality of life and therapeutic options, BMC Neurol 13, 84 (2013).
4. Russ K B, Phillips MC, Percutaneous Endoscopic Gastrostomy in Amyotrophic Lateral Sclerosis, Am J Med Sci . 2015 Aug;350(2):95-7.
5. Gregory S, Siderowf A, Gastrostomy insertion in ALS patients with low vital capacity: respiratory support and survival, Neurology . 2002 Feb 12;58(3):485-7.
6. Thomas K, Schrager J, Percutaneous endoscopic gastrostomy tube placement in amyotrophic lateral sclerosis: a case series with a multidisciplinary, team-based approach, Ann Gastroenterol 2020 Sep-Oct;33(5):480-484

Introduction

Colonic diverticular bleeding (CDB) is the most common cause of acute lower gastrointestinal bleeding (ALGIB) and often requires blood transfusion. There are several studies regarding the use of restrictive blood transfusion for acute upper gastrointestinal bleeding, but there is only one previous study regarding the use of restrictive blood transfusion for ALGIB [1]. Therefore, the efficacy of restrictive blood transfusion for CDB remains unclear.

Aims & Methods

This study sought to elucidate the association between the restrictive blood transfusion strategy and the clinical outcomes in patients with CDB. We retrospectively analyzed 475 patients who were urgently hospitalized for CBD and received blood transfusions at two facilities between November 2013 and December 2021. Transfusion strategy was defined as the restrictive group when patients received transfusion for hemoglobin (Hb) ≤ 7 g/dl, and the liberal group when patients received for Hb > 7 g/dl. The hemoglobin cut-off value for restrictive blood transfusion was determined based on a prior randomized clinical trial regarding UGIB [2]. Rebleeding within 30-days, mortality within 30-days, and composite outcome within 30-days were evaluated. The composite outcome comprised the following endpoints: rebleeding, need for surgery or IVR for hemostasis, and mortality within 30 days. We also investigated medical costs during hospitalization. Logistic regression analysis was performed to calculate the odds ratios (OR) with 95% confidence interval (CI) to analyze associations between restrictive transfusion strategy and outcomes.

Results

Of 475 patients, 184 (38.7%) (124 males, 60 females, mean age 76.5±11.5 years) patients received blood transfusion. The mean hemoglobin levels at the time of transfusion in the restrictive and liberal groups were 6.3±0.6 g/dl and 8.2±1.2 g/dl, In the restrictive and liberal group, rebleeding within 30-days was 53.9% and 45.3% (P = 0.24), the mortality within 30-days was 1.1% and 0% (P = 0.30), the composite outcome within 30-days was 56.1% and 52.6% (P = 0.63), respectively. After adjusting for potential confounders, multivariate analysis revealed that restrictive transfusion strategy not associated with decreased rebleeding risk within 30-days, (P = 0.42 ; odds ratio [OR], 1.3), whereas endoscopic hemostasis significantly associated with decreased rebleeding risk (P < 0.01 ; OR 0.2). There was no statistically significant difference in total medical costs between the two groups (P = 0.68).

Conclusion

There were no statistically significant differences in rebleeding within 30-days, mortality within 30-days, and compositeoutcome within 30-days between the restrictive and liberal blood transfusion strategies. Restrictive blood transfusion may be a reasonable therapeutic strategy for patients with CDB, except for patients in which shock status cannot be withdrawn. However, further evidence is needed to advocated the efficacy of restrictive transfusion strategies for lower gastrointestinal bleeding.

References

[1] Kherad O, Restellini S, Martel M, Sey M, Murphy MF, Oakland K, et al. Outcomes following restrictive or free red blood cell transfusion in patients with lower gastrointestinal bleeding. Aliment Pharmacol Ther. 2019 Apr;49(7):919–25.
[2] Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan;368(1):11–21.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive endoscopic procedure that is crucial for pancreato-biliary diseases and selective cannulation is the most important step. However, even an experienced endoscopist can face cannulation failure in up to 15-30% of cases in the first ERCP when standard methods alone are used.¹ Many studies suggested the various needle knife fistulotomy or papillotomy as an alternative technique in difficult cannulation cases.^2,3 However, needle knife papillotomy (NKP), which is modified technique with needle knife has not been evaluated well.

Aims & Methods

To evaluate the clinical outcomes and adverse events of bile duct cannulation by NKP, we performed a retrospective review on medical records of all ERCP cases in Sheikh Khalfia Specialty Hospital, UAE. For six years, Sphincterotomy (SPT) naïve patients except altered-anatomy cases were enrolled and their procedure times, cannulation success rates, radiation exposures, and adverse events were measured between the procedure time matched two cohort group of SPT only and rescue NKP.

Results

In total 416 ERCP cases, 43 procedure time matched cases were selected among 352 (84.7%) SPT only cohort and 43 cases from 64 rescue NKP cohort. Biliary cannulation was succeeded in all cases (100%) by using SPT cannulation with rescue NKP technique without failure. There was no differences in cumulative radiation doses, cannulation time, and adverse event rates in rescue NKP group compared to SPT only group: Post-ERCP hyperamylasemia/hyperlipasemia (16.5% vs. 34.8%, p=0.080), pancreatitis (3.9% vs. 4.3%, p=0.883), cholangitis (4.7% vs. 4.3%, p=0.695), and no perforation case was noticed in both groups.

Conclusion

The SPT with rescue NKP technique can be used in the difficult biliary cannulation cases during ERCP safely and effectively.

References

(1) Testoni PA , Testoni S , Giussani A .
Difficult biliary cannulation during ERCP: how to facilitate biliary access and minimize the risk of post-ERCP pancreatitis.
Dig Liver Dis 2011;43:596–603
[2] Testoni PA , Mariani A , Aabakken L , Arvanitakis M , Bories E , Costamagna G,et al.
Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline.
Endoscopy 2016;4 8:657–6 83 .
[3] Lopes L , Dinis-Ribeiro M , Rolanda C .
Early precut fistulotomy for biliary access: time to change the paradigm of "the later, the better"?
Gastrointest Endosc 2014;80:634–641 .

Introduction

There is an increasing incidence of young-onset colorectal cancer (YOCRC), which is defined as patients with colorectal cancer at age 50 years and younger. They present with a distinct clinical phenotype compared to classical-onset CRC (COCRC), with a more aggressive disease at presentation, as well as different tumour location and mutational signatures. There is an unmet clinical need to elucidate the unexplained epidemiologic rise in incidence as well as disease pathogenesis of YOCRC.

Aims & Methods

Aim: To compare the clinical presentation, tumour characteristics and survival of young-onset versus classical-onset CRC.

A retrospective evaluation of patients diagnosed with colorectal cancer from 2019 to 2022 at a district general hospital was performed. We extracted data from electronic patient records for clinical, biochemical, radiological as well as histopathological reports. Comparisons were made between patients diagnosed at </=50 years (YOCRC) and >50 years of age (COCRC) respectively, and statistical analyses were performed. A p-value of <0.05 was considered statistically significant.

Results

34 (11.1%) and 273 (88.9%) patients were diagnosed as YOCRC and COCRC respectively. There was a difference in clinical presentation between the two groups, with haematochezia (n=12, 35.3%) (p=0.03) and change in bowel habit (n=7, 20.6%) predominating in the YOCRC group, versus positive faecal immunochemical test (FIT) (n=102, 37.4%) and anaemia (n=78, 28.6%) in the COCRC group respectively. There were no differences in the tumour location between groups, with >50% of cases arising from the left colon (22 YOCRC versus 149 COCRC). Thrombocytosis (platelet count>450x10⁹/L) (24% vs 11%, p=0.038) and tumour budding (12% vs 3%, p=0.006) were significantly increased in the YOCRC group. There were no significant differences in the histological subtype, TNM staging, mutational profiling and survival between groups. 6 (17.6%) YOCRC patients had died compared to 116 (37.8%) in the COCRC cohort over a median follow-up of 16 months.

Conclusion

Young-onset colorectal cancer represents a challenging subset of CRC, which has a different clinical and tumour phenotype to classical-onset CRC. Our study reflects the reported incidence rates of YOCRC of 11%, although the true epidemiology and frequency of YOCRC remains to be clarified. Haematochezia was the commonest presentation, while thrombocytosis and tumour budding were higher in the YOCRC group, suggesting a more advanced disease at diagnosis. Although the overall survival rates were similar between groups, further research would benefit from larger prospective studies with subdivision of YOCRC cases by age as poorer survival have been suggested in patients aged <30 years. There is a need to elucidate the respective aetiologies, environmental risk factors and pathogenesis of YOCRC, to allow early targeted treatment of such cases.

Table 1: Clinical presentation of YOCRC and COCRC

References

Mauri G, Sartore-Bianchi A, Russo AG, Marsoni S, Bardelli A, Siena S. Early-onset colorectal cancer in young individuals. Mol Oncol. 2019;13(2):109-131.