Introduction

Toxic hepatitis is a significant hepatic condition that can occur due to drugs, fungi, herbal agents and supplements, sometimes progressing fulminantly and resulting in transplantation or mortality. As it is a diagnosis of exclusion, it can be challenging to establish and the etiological factors vary societally. In our study, we investigated the etiology, epidemiology, factors related to prognosis, and clinical outcomes of patients diagnosed and treated for toxic hepatitis.

Aims & Methods

The demographic characteristics, etiological factors, laboratory and imaging results, biopsy findings, and information about the drugs used in the treatment of 254 patients hospitalized and treated for toxic hepatitis between February 2019 and June 2022 at Ankara Bilkent City Hospital were retrospectively examined. After evaluating the results according to the RUCAM scale, patients interpreted as possible and highly probable were included in the study, and they were classified based on severity as mild, moderate, severe or fatal.

Results

Of the patients included in the study, 60.6% were female, and 30.3% of these patients presented to the hospital with jaundice symptoms. The mean age of the patients was 43.9 years. Hepatocellular damage was observed in 68.5% of the developed liver toxicities. The most common etiological factors were antibiotics and NSAIDs in sequence. When antibiotic drugs were evaluated separately, amoxicillin-clavulanate (9.8%) was considered the most common antibiotic causing toxic hepatitis, and dexketoprofen (9.1%) was identified as the most common NSAID. A total of 45 patients (18.1%) were associated with herbal and dietary supplements, while 18 patients (7.1%) were related to mushroom consumption in the etiology. Of the patients included in the study, 56% had a moderate or severe hepatitis course, 3 (1.18%) patients progressed to liver transplantation, and 6 (2.5%) patients died, including one post-transplant. The severity of toxic hepatitis was mild in 109 participants (42.9%), moderate in 89 patients (35.0%), severe in 48 patients (18.9%), and fatal in 8 patients (3.1%). In 5.9%, there was worsening of the disease (transition from mild
or moderate severity to severe or fatal groups) after admission. In our study, 14.3% of patients in the severe-fatal group died due to acute liver failure or underwent liver transplantation. Both groups exhibited a dominant pattern of hepatocellular-type damage, and there was no difference in the evaluation of etiological factors between the groups. When biochemical parameters were evaluated, elevation in ALT, AST, LDH, initial and peak total bilirubin, direct bilirubin, initial and peak INR, prolonged prothrombin time, and low albumin were significant in both the severe patient group and the group admitted to intensive care. Liver biopsy was performed on 60 of the 254 patients included in the study.

Conclusion

In our study, the median age, gender distribution, dominant injury type, and the most commonly detected agents in etiology (NSAIDs and antibiotics) and dominant were consistent with the literature. Factors such as the consumption of Toxic hepatitis is a disease that can be challenging to diagnose and treat. Given that our center receives a high number of patient admissions, accepts patients from surrounding areas, and serves as a transplant center, we believe that the data we have obtained can closely approximate current and real data. We also believe that our study on these 254 patients will contribute to the literature in terms of etiological, epidemiological, and prognostic insights.

Introduction

The prevalence of musculoskeletal disorders (MSD) among gastroenterologists is estimated between 39 to 89%. Factors associated with MSDs among endoscopists include a high number of procedures (over 20/week), prolonged procedure times (over 16 hours/week), the age of the endoscopist (> 40 years vs ≤ 40 years), and female sex.
This study aimed to evaluate the prevalence of MSD among French gastroenterologists and identify risk factors of MSD

Aims & Methods

A computerized, anonymized questionnaire was e-mailed to all members of French society of endoscopy (SFED) over a one-month period. Demographic data were collected, as well as the level of endoscopic activity performed, the quantity and volume of endoscopies performed per week, the presence of pain associated with the practice of endoscopy, and an assessment of stress.

Results

485 gastroenterologists responded to the questionnaires, the majority were male (55%), with a median age of 48 years (IQR 37–60), and 45.6% practiced endoscopy for more than 20 years. 74.3% of respondents worked full-time, mostly in private practice (47% in private practice, 13% in mixed public-private practice). Endoscopy was performed for a median of 15 hours per week (IQR 10–18.8), with 24 procedures per week (IQR 15–30).
76.3% of participants had already experienced joint and/or musculoskeletal pain related to work. Pain complaints mainly concerned the lower back (55%), shoulders (36% left, 37% right%), neck (50%), and wrists (30% both side). More than half of the participants (55.9%) reported that the pain persisted after procedures, with 17.8% experiencing nocturnal pain and about a quarter reporting pain lasting more than 3 months.
The impact of MSD on workload was evaluated. 5.1% of the gastroenterologists reported loss of efficiency, 3,8% adapted their job, 2.4% decreased their activity, and 2.1% had work stoppage. 35% declared to have management of their MSD (28.1% painkiller, 23.2% reeducation, 3.5% surgery). To reduce discomfort, 74.7% of respondents reported using an adjustable-height examination table, and half adjusted the height and distance of the screen.
In multivariate analysis, factors associated with MSD were, femal sexe (OR 1.85 (1.15-3.01) p = 0.012, number of endoscopy (OR 1.05 (1.01-1.11) p=0.03, activity > 20 years (OR 2.42 (0.89, 6.47) p=0.079.) The risk of MSD was higher after 16.5 hours of endoscopy/ week (Se 35%, Sp 83%).

Conclusion

Musculoskeletal pain among French gastroenterologists is common and concerning. Therefore, it is essential to develop preventive programs to support their health and ensure the quality and safety of care.

Introduction

Esophageal varices (EV) are a critical complication of portal hypertension in patients with cirrhosis, and early detection is essential to prevent potentially life-threatening hemorrhage. The Baveno VII consensus recommends performing endoscopy in patients with transient elastography (TE) values exceeding 20 kPa and platelet counts below 150,000/mm³. While endoscopy remains the gold standard for diagnosis, non-invasive tests are gaining importance as a promising alternative for predicting EV(1) .The objective of our study is to predict the grade of varices in cirrhotic patients using a score derived from both their biological blood test results and clinical parameters.

Aims & Methods

The objective of our study was to predict the grade of varices in cirrhotic patients using a score derived from their biological blood test results and clinical parameters. This retrospective study involved patients recruited from Hôtel-Dieu de France, with data collected a few months prior to their gastroscopy for esophageal varices detection.
We calculated the ALBI-PLT score based on the method described by Inoue-Yuri et al.(2). The modified ALBI-PLT (mALBI-PLT) score was derived from the mALBI grade, assigning 1 point for grades 1 or 2a, and 2 points for grades 2b or 3. It also incorporated platelet counts, awarding 1 point for counts greater than 150,000/μL and 2 points for counts of 150,000/μL or lower. In addition to the mALBI-PLT score, we considered various variables, including blood test results and established predictive scores such as Child-Pugh, MELD-Na, FIB-4, and APRI.

Results

This study analyzed 108 cirrhotic patients (mean age: 63.94 years, 64.8% men, 33.03% had hepatocellular carcinoma (HCC)) out of 115 recruited, excluding cases with missing data. Key predictors of varice grades included lymphocyte count (L, β = −0.43, p = 0.011) and sodium (Na^10, β = −3.22 × 10^−22, p = 0.005) as significant negative associations. Positive associations were observed for the modified ALBI-platelet score (β = 0.43, p < 0.001), HCC (β = 0.51, p = 0.005), and gastrointestinal (GI) bleeding (β = 0.48, p = 0.013).
A derived formula for predicting varice grades is: VariceGrade = 3.49 − 0.43×ln(L) + 0.43×mALBI-PLT score − 3.22×10^−22×Na^10 + 0.51×HCC + 0.48×GI Bleeding.
The model showed strong specificity (94.5%) for identifying varices when the score was ≥ 1 and high sensitivity (97.8%) for excluding grade 3 varices when the score was ≤ 2.

Conclusion

This study introduces a non-invasive scoring system to accurately stratify esophageal varices severity, optimizing clinical decision-making and endoscopic screening in cirrhotic patients.

References

(1) de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C, Baveno VII Faculty. Baveno VII—Renewing consensus in portal hypertension. J Hepatol. 2022;76:959–974. doi: 10.1016/j.jhep.2021.12.022.
(2) Inoue-Yuri M, Enomoto H, Wakabayashi I, Yuri Y, Aizawa N, Ikeda N, Takashima T, Fujiwara A, Yoshioka R, Kawata S, Yoshihara K, Ota S, Nakano R, Shiomi H, Nishimura T, Nishiguchi S, Iijima H. Modification of the ALBI-PLT Score for the Prediction of High-risk Varices. In Vivo. 2022 May-Jun;36(3):1360-1366. doi: 10.21873/invivo.12839. PMID: 35478164; PMCID: PMC9087093.

Introduction

During the COVID-19 pandemic the British Society of Gastroenterology (BSG) introduced interim guidelines supporting a non-biopsy pathway for the diagnosis of coeliac disease. These guidelines reflect the current recommendations of the American Gastroenterological Association (AGA). According to these guidelines, symptomatic or high risk adults with anti-Tissue transglutaminase (TTG) IgA titres ≥10× the upper limit of normal (ULN) and a positive endomysial antibody (EMA) on a repeat sample can be diagnosed without endoscopy and referred directly to a specialist coeliac clinic. Patients who do not meet these criteria should be referred for a gastroscopy (OGD) with biopsy for the confirmation of coeliac, prior to starting a gluten free diet.

Aims & Methods

To assess whether general practitioners (GPs) in the community appropriately referred patients with suspected coeliac disease in line with the AGA and BSG interim non-biopsy diagnostic criteria.
A retrospective review was conducted of all new patients referred to the Coeliac clinic in Galway university hospital between January 2023 and December 2024. Data regarding TTG level at diagnosis, EMA result, and compliance with the diagnostic pathway outlined above was collected for each new referral. This data was collected via Evolve - the hospital's electronic based patient record system.

Results

• There were 119 “new” referrals to our Coeliac Service between January 2023 and December 2024. Of these, 44 cases were known coeliac who were referred by primary care for re-engagement with the clinic, 18 were referred from secondary or tertiary care including GI surgery, Dermatology, Paediatrics, etc. 4 coincidental diagnoses (i.e. OGD performed for indications other than coeliac disease), and 5 outliers (i.e. with incomplete data or incorrectly referred to coeliac clinic) leaving 48 new coeliac cases referred from primary care.
• 18 of these referrals met the non-biopsy criteria for diagnosis (TTG ≥100 + positive EMA)
  • Within this cohort 66% (n=12) were incorrectly referred directly for an OGD which may have delayed the diagnosis of coeliac disease while the remaining 33% (n=6) were correctly referred for direct review at the coeliac clinic.
• The remaining 29 patients all had TTG values less that 10x ULN. 48% (n=14) of these patients were incorrectly referred to clinic prior to endoscopy and of greater concern, 45% (n=13) were recommended by their primary care physician to start a gluten free diet prior to any review or endoscopic procedure.
• Overall, only 44% (n=21) of referrals were compliant with the AGA/BSG guidance.

Conclusion

There is a notable gap in adherence to AGA and BSG non-biopsy coeliac diagnostic guidance in community settings. Half of patients eligible for a non-biopsy diagnosis underwent unnecessary endoscopy, and the majority of ineligible patients were commenced on a gluten free diet prior to, or without, referral for endoscopy. Further GP education is warranted to align referral practices with evidence-based pathways. Dedicated streamlined referral pathways for coeliac disease should ensure a timely diagnosis without mandatory endoscopy in those fulfilling the criteria for a non-biopsy diagnosis and facilitate a timely endoscopy prior to gluten elimination in those who require histological diagnosis.

References

Husby, S., Murray, J.A. and Katzka, D.A. (2019) ‘AGA clinical practice update on diagnosis and monitoring of celiac disease—changing utility of serology and histologic measures: Expert review’, Gastroenterology, 156(4), pp. 885–889. doi:10.1053/j.gastro.2018.12.010.
Tashtoush, L.B. et al. (2021) ‘Letter: The BSG covid‐19 interim coeliac disease guidance no‐biopsy approach is safe in adults’, Alimentary Pharmacology &amp; Therapeutics, 54(8), pp. 1090–1092. doi:10.1111/apt.16553.

Disclosure

No conflict of interest

Clinical Case Summary

A 64-year-old woman with a prior diagnosis of type I achalasia underwent Heller myotomy with Dor fundoplication in 2015, which resulted in the resolution of dysphagia and regurgitation. However, she kept experiencing chest pain, which partially improved with nitro-glycerine. In 2018, due to worsening pain, she underwent high-resolution oesophageal manometry (HROM), which demonstrated absent peristalsis without oesophageal pressurization. Also, upper endoscopy was unremarkable, and timed barium swallow (TBS) revealed some tertiary contractions. By 2019, the patient received botulinum toxin injections with partial improvement. Another TBS performed in 2023 showed tertiary contractions in the distal third of the oesophagus, contributing to mild oesophageal emptying delay but without stasis. In 2024, repeat HROM revealed pan-oesophageal pressurization, except in the distal-most centimetres of the oesophagus. During rapid drink challenge, the patient reported pain. Given these findings, she was proposed for peroral endoscopic myotomy (POEM) to extend the myotomy proximally. In August 2024, she underwent a complete distal oesophageal myotomy, including the lower oesophageal sphincter and cardia. Endoscopic assessment in November showed no evidence of stasis, esophagitis, or resistance at the cardia. Latest clinical evaluation in March 2025 confirmed complete resolution of chest pain.
Conclusion: Non-cardiac chest pain is a less common yet challenging symptom to manage in achalasia. Its persistence after disease-directed treatment has been described in the literature, with its primary risk factor being its presence preoperatively¹. However, comparative data on different therapeutic approaches for achalasia-related chest pain remain limited. To our knowledge, only two similar cases have been reported in which pain persisted after Heller myotomy but improved following POEM, probably linked to the inadequate or incomplete myotomy of the oesophageal muscle layer^2,3.

References

1. Olvera-Prado H, et al. Predictive factors associated with the persistence of chest pain in post-laparoscopic myotomy and fundoplication in patients with achalasia. Front Med (Lausanne). 2022 Oct 14;9:941581.
2. Miftahussurur M, Tandan M, Makmun D, Nabi Z. Peroral Endoscopic Myotomy in a Patient with Achalasia Cardia with Prior Heller's Myotomy. Case Rep Gastroenterol. 2020 Jan 22;14(1):48-55.
3. Sato C, et al. Salvage therapy for postoperative residual chest pain due to esophageal achalasia. SAGES 2017 Annual Meeting in Houston [Abstract], https://www.sages.org/meetings/annual-meeting/abstracts-archive/salvage-therapy-for-postoperative-residual-chest-pain-due-to-esophageal-achalasia/