Introduction

Gastric cancer is associated with a poor prognosis due to the late stage of the disease at the time of diagnosis. Consequently, the detection and surveillance of the established premalignant gastric lesions becomes imperative. Despite Eastern Europe being a region of high – intermediate gastric cancer incidence, the guidelines (MAPS-II) (1) are mainly based on the data from Western countries due to a lack of research in this area in Eastern countries.

Aims & Methods

This study aimed to assess a) the incidence of gastric cancer in patients with proven histologically proven premalignant gastric lesions b) the efficacy of endoscopic diagnosis of premalignant gastric lesions and c) trends of subsequent management of patients at an intermediate risk for the development of gastric cancer in an academic center in Lithuania.
We conducted a retrospective cohort study of patients who underwent esophagogastroduodenoscopy with histological sampling between 2012 and 2020 in a single academic centre. The pathology database was filtered for keywords “atrophy” and/or “intestinal metaplasia” in pathological conclusions or descriptions to identify patients with possible premalignant gastric lesions. Demographic (age and gender), pathology report (histological findings, presence of H.pylori), endoscopic evaluation (diagnosis, location of biopsies, endoscopic recognition of premalignant or cancerous lesions), patient history (family history of gastric cancer) and subsequent management (recommended H.pylorieradication and follow-up) data were collected.

Results

This retrospective cohort study conducted in a single academic centre identified 1842 patients who underwent diagnostic esophagogastroduodenoscopy with histological sampling between 2012 and 2020. Out of 1842 patients screened in the pathology database, 1762 had histologically proven premalignant gastric lesions (extensive gastric mucosal atrophy, intestinal metaplasia or both).
The study cohort consisted of 51% males with an average age of 64.42 (SD ±1.573). A positive family history of gastric cancer was reported in 0.7% of the patients.
Histological evaluation identified gastric atrophy in 9.9% (n = 183) of samples, distal atrophy in 6.1% (n = 113) of cases, and panatrophy in 3.8% (n = 70) of samples. Distal intestinal metaplasia was observed in 47.9% (n = 883) of cases, while extensive intestinal metaplasia was found in 47% (n = 866) of samples. Dysplasia was detected in 1.03% (n = 19) of the samples.
Endoscopically precancerous lesions were identified in only 14.4% (n = 254) of cases, with follow-up recommendations provided for 3.4% (n = 60) of the patients.
Helicobacter pylori presence on biopsy samples was detected in 37.6% (n = 662) of cases, with eradication recommended only for 36.7% (n = 243) of these cases.
Subsequently, during follow-up 0.8% (n = 14) of patients with premalignant gastric lesions were diagnosed with gastric cancer.

Conclusion

This study reveals poor efficacy of endoscopic evaluation for precancerous gastric lesions and suboptimal adherence to current guidelines for their management. These findings underpin the importance of high-quality endoscopy, dissemination and adherence to the guidelines in the hopes of reducing the morbidity and mortality of gastric cancer.

References

(1) Pimentel-Nunes P, Libânio D, Marcos-Pinto R, Areia M, Leja M, Esposito G, et al. Management of epithelial precancerous conditions and lesions in the stomach (MAPS II): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG), European Society of Pathology (ESP), and Sociedade Portuguesa de Endoscopia Digestiva (SPED) guideline update 2019. Endoscopy. 2019;51(4):365–88.

Introduction

It has been reported that diverticulum hemorrhage has a high spontaneous hemostasis rate of 70 to 90% and rarely leads to hemorrhagic shock, so emergency colonoscopy is not widely performed. However, there is a report that the identification rate of stigmata of recent hemorrhage increases with early colonoscopy administration, so we have performed many emergency colonoscopy within 24 hours after the ER visit.

Aims & Methods

We retrospectively examined 68 cases of diverticulum bleeding who visited our hospital from April 2011 to October 2016; 38 cases in the emergency group who underwent colonoscopy within 24 hours and 30 cases in the elective group who underwent colonoscopy after 24 hours.

Results

The age was 73 ± 11 in the emergency group and 72 ± 12 in the elective group. The blood Hb concentration at the first ER visit was 10.0 ± 3.0 g / dL in the emergency group and 10.5 ± 2.4 in the elective group, showing no significant difference. There were no significant differences in blood pressure or pulse rate at the first ER visit. The oral antiplatelet drug use was 39% in the emergency group, which was higher than that in the elective group 23%, but there was no significant difference in the oral anticoagulant and NSAIDS use. The length of hospital stay was 8.0 ± 6.1 days in the emergency group, 8.0 ± 4.6 days in the elective group, and the blood transfusion rate was 53% in the emergency group and 46% in the elective group, showing no significant differences. A significant difference was observed in the rate of identifying bleeding sources. In 26% of the emergency group and 10% of the elective group, stigmata of recent hemorrhage was identified and hemostatic treatment was performed (p<0.05). No major complications such as intestine perforation was observed in the two group.

Conclusion

Emergency colonoscopy for diverticulum bleeding does not reduce blood transfusion during hospital stay, but it identifies bleeding sources and may lead to effective treatment.

Clinical Case Summary

Aims: Williams syndrome is characterized by facial dysmorphic features, mental retardation, a unique cognitive profile, hypercalcemia and connective tissue abnormalities. Gastrointestinal manifestations include feeding problems, gastroesophageal reflux, constipation, diverticulosis, chronic abdominal pain, hernias and celiac disease (Figure), while liver cirrhosis has never been reported.
Case report: We report a male patient who was diagnosed with Williams syndrome (FISH method) at the age of 2.5 years old. He developed the characteristic face with broad forehead, underdeveloped chin, short nose and full cheeks in combination with hypercalcemia, supravalvular aortic stenosis and hypothyroidism. During development, the patient showed slow physical growth, mild mental retardation, hypersociality and hearing disorders and at the age of 7 years old the patient demonstrated transaminasemia and hepatosplenomegaly. Abdominal computed tomography showed hepatomegaly with a lobular margin due to cirrhosis, splenomegaly and the presence of ectopic varices with a palpable splenoportal axis, while gastroscopy revealed Grade 1 esophageal varices. Further serology, genetic mutation and metabolic disorders tests were performed without revealing findings suggestive of the etiology of cirrhosis. Eventually, a percutaneous liver biopsy revealed extensive bridging fibrosis and the formation of incomplete regenerative nodules with macrovesicular steatosis, without specific chronic liver disease as the cause of cirrhosis. No other case of Williams syndrome with development of liver cirrhosis has been described in the literature before. Having ruled out the classic causes of cirrhosis the suspected mechanism may be genetic or metabolic in the context of the syndrome.
Conclusion: Williams syndrome is a complex disorder with variable involvement of different organs, so further research is needed to identify the factors responsible for these variations.

References

1. Morris CA, Mervis CB. Williams syndrome and related disorders. Annu Rev Genomics Hum Genet. 2000;1:461-84.
2. Pober BR. Williams-Beuren syndrome. N Engl J Med. 2010 Jan 21;362(3):239-52.
3. Kozel BA, Barak B, Kim CA, Mervis CB, Osborne LR, Porter M, Pober BR. Williams syndrome. Nat Rev Dis Primers. 2021 Jun 17;7(1):42.
4. Twite MD, Stenquist S, Ing RJ. Williams syndrome. Paediatr Anaesth. 2019 May;29(5):483-490.

Disclosure

Conflict of Interest disclosure
The authors declare that there are not conflicts of interest.

Clinical Case Summary

Biliary injury secondary to trauma is frequently associated with long-term complications. Liver transplantation is rarely indicated but might be the best therapeutic option in severe or intractable cases. There is limited data regarding the use of liver transplantation for biliary trauma and criteria for liver transplantation in the setting of secondary biliary cirrhosis are not well established.
A 14-year-old male was evacuated to Portugal due to biliary injury after abdominal trauma, after failure of cholecystectomy. A Roux-en-Y hepaticojejunostomy was initially performed without immediate complications. Four years later he presented with obstructive jaundice (total bilirubin of 22 mg/dL), pruritus and physical signs of chronic liver disease. A magnetic resonance cholangiopancreatography showed an anastomotic stricture with marked dilation of the intrahepatic biliary tree. Endoscopic resolution of the stricture was not feasible. A percutaneous transhepatic biliary drainage was performed with immediate efficacy, but the procedure failed to resolve cholestasis, with subsequent referral to a liver transplantation center. Abdominal imaging revealed a cirrhotic liver and dilation of the biliary tract. At the age of 19 years old, an orthotopic liver transplant was performed. Piggy-back technique was used along with a continuous hepaticojejunostomy. Two years post-transplant the patient is asymptomatic and with a markedly improved quality of life.
Management of extrahepatic biliary tree injury can be extremely demanding. Even after clinically successful treatment, the quality of life may be impaired. Some complicated cases culminate in refractory and intractable stenosis of the hepaticojejunostomy with secondary biliary cirrhosis. Timely referral to a tertiary center is essential. Liver transplantation is the last line of treatment, but an earlier referral for this treatment may be needed in order to improve outcomes in severe, complicated or intractable cases.

References

- Thomas MN, Stippel DL. Management of bile duct injuries [Management von Gallengangsverletzungen]. Chirurg 2020;91(1):18-22;
- Krawczyk M, Grat M, Adam R, et al. Liver Transplantation for Hepatic Trauma: A Study From the European Liver Transplant Registry. Transplantation 2016;100(11):2372-2381;
- Coccolini F, Kobayashi L, Kluger Y, et al. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg 2019;14:56;
- Schreuder AM, Busch OR, Besselink MG, et al. Long-Term Impact of Iatrogenic Bile Duct Injury. Dig Surg 2020;37(1):10–21;
- LeBedis CA, Bates DDB, Soto JA. Iatrogenic, blunt, and penetrating trauma to the biliary tract. Abdom Radiology 2017;42(1):28-45;
- Romine MM, White J. Role of Transplant in Biliary Disease. Surg Clin North Am. 2019;99(2):387-401;
- Pereira R, Vo T, Slater K. Extrahepatic bile duct injury in blunt trauma: A systematic review. J Trauma Acute Care Surg 2019;86(5):896-901.Coccolini F, Coimbra R, Ordonez C, et al. Liver trauma: WSES 2020 guidelines. World J Emerg Surg 2020;15(1):24.

Introduction

Cardiorespiratory arrest is a recognized complication of endoscopic procedures, particularly when sedation is administered. Hospitalized patients, especially those with a prescribed Do Not Resuscitate (DNR) order, are more likely to have severe underlying illness, and consequently a higher risk of cardiorespiratory complications. Additionally, the request for endoscopic exams, especially urgent ones, in this group of patients is becoming increasingly common.

Aims & Methods

The aim of this study was to asses the current clinical practices, as well as the beliefs of gastroenterologists in Portugal regarding the management of the code status in hospitalized patients with prescribed DNR undergoing endoscopic procedures.
Self-reported data was obtained through a voluntary and anonymous survey of gastroenterologists and gastroenterology trainees in Portugal.

Results

One hundred and forty five gastroenterologists, of which 26 (17.9%) were trainees, responded to the survey, with an average age of 42 years (27-83 years), and 59.3% female. The majority are aware of the patient's code status prior to the endoscopic procedure (73.1%, n=106). However, DNR is rarely discussed (<25% of cases) with the patient/legal representative (66.9%, n=97) or attending physician (58.6%, n=85). In patients with prescribed DNR, the rate of reversal prior to the procedure is rarely performed (reversal in all or almost all in 8,3%, n=12). Most respondents are unaware of the procedures necessary for DNR prescription (81.3%, n=118), as well as existing national/international recommendations on DNR reversal (96.5%, n=140). Regarding personal beliefs, the majority consider that in these patients DNR should be reversed to an intermediate option that includes limited resuscitation maneuvers according to the patient's preference (62.1%, n=90). They also believe that the urgency of a procedure should not influence the decision to reverse DNR (n=89, 61.4%), and that if DNR is reversed, it should be done by the attending physician who initially prescribed it (91.7%, n=133). Finally, respondents are divided when asked if they would perform an endoscopic procedure on a patient with prescribed DNR that has not been previously reversed: 49.7% answered yes (n=72), 22.1% no (n=32), and 28.3% have no formed opinion (n=41). There is a consensus on the need for recommendations on this topic for gastroenterologists (97.9%, n=142).

Conclusion

The majority of Gastroenterologists rarely reverse DNR before endoscopic procedures, however, it is mostly advocated that limited resuscitation maneuvers should be offered according to patient preference. Most are unaware of the existence of institutional, national, or international policies regarding DNR. These findings suggest considerable variation in knowledge and approach to hospitalized patients with DNR, highlighting the need for specific recommendations for Gastroenterology in this area.

References

H. Carneiro A, Carneiro R. DNR A Decisão de Não Reanimar. Revista Portuguesa de Medicina Interna [Internet]. 5 de Dezembro de 2021
Braga I, Dutschmann L, Fiuza T, Almeida H, Gil V, Brandão T. Implementação da Ordem de Não Reanimar. Revista Ordem Médicos. 2012;133:20-23.
Wada K, Szego MJ. Revisiting code status in patients undergoing GI endoscopy with a "do not resuscitate" order. Gastrointest Endosc. 2019 Feb;89(2):380-382.
Feld LD, Mergener K, Rubin DT, Rao VL. Management of code status in the periendoscopic period: a national survey of current practices and beliefs of U.S. gastroenterologists. Gastrointest Endosc. 2021 Jul;94(1):172-177.e2.

Clinical Case Summary

Case: W present a case of a 43-year-old man with hepatic cirrhosis complicated by hypertensive gastrointestinal bleeding, in a program to eradicate esophageal varices. One week after an elective endoscopic variceal ligation (EVL), he presented with fever, anorexia, pain in the dorsolumbar region, headaches, and psychomotor retardation. Subsequently, there was the appearance of focal motor seizures. The analyses showed C-reactive protein of 113 mg/L, without leukocytosis. Peripheral blood cultures were negative. A head computed tomography (CT) showed mild left parietal and occipital cortical hypodensities. Analysis of the cerebrospinal fluid was compatible with central nervous system (CNS) infection. Cerebral magnetic resonance revealed multiple supra and infratentorial rounded lesions, compatible with abscesses and ventriculitis. He started antibiotics with a meningeal dose. Hospitalization was complicated by SARS-COV 2 infection, so a chest CT was performed after 1 month of hospitalization, and was identified a mediastinal abscess with 5 cm with fistulization from the esophagus, compatible with iatrogenic esophageal perforation after EVL. Other possible causes of brain abscesses were excluded. He completed several weeks of antibiotic and parenteral nutrition, with normalization of the neurological status and resolution of brain lesions. About 1 month after targeted antibiotic treatment, he performed an endoscopy, revealing a deformed area in the distal esophagus but no evidence of an orifice or suppuration. Conclusion: Neurological manifestations in patients with liver cirrhosis are usually due to hepatic encephalopathy (HE). However, CNS infection, especially in patients who underwent recent procedures, such as EBL, should be considered in the differential diagnosis, given that early treatment influences the prognosis. Clinically, CNS infection can be very variable, however, it is important to be aware of atypical signs of HE, such as focal neurological deficits.

References

Krige JE, Bornman PC, Shaw JM, Apostolou C. Complications of endoscopic variceal therapy. S Afr J Surg. 2005 Nov;43(4):177-88, 190-4.

Disclosure

Nothing to disclosure