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Clinical Case Summary

A 48-year-old woman was admitted due to abdominal pain, bloody diarrhea, and fever. She was diagnosed with extensive ulcerative colitis (UC) and has been under mesalamine for the past ten years. The patient refused advanced therapy after two courses of corticosteroids. She was also diagnosed with unclassified neutropenia in 2017. Blood work-up at admission revealed anemia (hemoglobin 7.7g/dL), leucopenia (1600x10^9/L) with absolute neutropenia, and elevation of C-reactive protein (12.03mg/dL). These findings led to the diagnosis of acute severe ulcerative colitis (ASUC) and febrile neutropenia. Broad-spectrum antibiotics, antifungal, and prednisolone therapy were started, however, the patient's condition continued to deteriorate. The stool and blood cultures were negative. Over the following days, an elevation in ferritin and triglycerides was noticed. A rectosigmoidoscopy showed deep ulcers, and the histology revealed surprisingly the presence of Aspergillus spp. The patient was diagnosed with Disseminated Aspergillosis. Due to the presence of bicytopenia, hyperferritinemia, and hypertriglyceridemia, Hemophagocytic Lymphohistiocytosis (HL) was considered and then confirmed by bone biopsy (presence of hemophagocytic cells). The patient was started on amphotericin B and directed therapy to HL with dexamethasone and etoposide. She underwent an emergency colectomy due to clinical worsening, hyperlactatemia, and megacolon detected on the abdominal CT scan. The patient was discharged and is currently in clinical remission.
In an immunosuppressed patient with uncontrolled inflammatory bowel disease, colonic aspergillosis is a rare cause of ASUC and is suspected to trigger the onset of HL.(1) HL is a hyperinflammatory syndrome induced by the activation of macrophages and cytotoxic T cells, with multiple etiologies, such as infections and autoimmune diseases.(2) Timely diagnosis and treatment resulted in a positive outcome. This case is being presented due to its rarity.

References

(1) Ali RS, Sen M, Tan IJ. Pulmonary Aspergillosis Complicated by Hemophagocytic Lymphohistiocytosis: A Case Report and Literature Review. Cureus. 2022;14(10):e30908. Published 2022 Oct 31. doi:10.7759/cureus.30908
(2) Soy M, Atagündüz P, Atagündüz I, Sucak GT. Hemophagocytic lymphohistiocytosis: a review inspired by the COVID-19 pandemic. Rheumatol Int. 2021;41(1):7-18. doi:10.1007/s00296-020-04636-y

ULCERATIVE COLITIS AND HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS

Sérgio Bronze 1, Inês Rodrigues 1, Juliana Serrazina 1, Sonia Bernardo 1, Samuel Raimundo Fernandes 1, Pedro Marques Da Costa 1, Luis Correia 1

1 Hospital Santa Maria, Lisboa, Portugal

Conference

UEG Week Vienna 2024

Topics

IBD

Submission format

Clinical Case

Session

Clinical Cases (Posters)

Published

2024

UEG Podcast Episode

UEG Podcast

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Innovation - A journey from idea to product

Pradeep Mundre 1, Alexander Meining 2

1 Bradford Teaching Hospitals NHS trust, Leeds, United Kingdom

2 University of Würzburg, Germany

Published

2023

UEG Podcast Episode

Journal Podcast

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The impact of COVID-19 pandemic in Gastroenterology: focus on IBD

Katarzyna Pawlak 1, Fernando Magro 2, Candida Abreu 2

1 Department Gastroenterology, Endoscopy Unit, Hospital of the Ministry of Interior and Administration, Szczecin, Poland

2 Hospital de São João, Porto, Portugal

Topics

IBD

Published

2021

UEG Standards and Guidelines

Clinical Practice Guideline

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Main recommendations

1 ESGE suggests that high definition endoscopy, and dye or virtual chromoendoscopy, as well as add-on devices, can be used in average risk patients to increase the endoscopist’s adenoma detection rate. However, their routine use must be balanced against costs and practical considerations.

Weak recommendation, high quality evidence.

2 ESGE recommends the routine use of high definition systems in individuals with Lynch syndrome.

Strong recommendation, high quality evidence.

3 ESGE recommends the routine use, with targeted biopsies, of dye-based pancolonic chromoendoscopy or virtual chromoendoscopy for neoplasia surveillance in patients with long-standing colitis.

Strong recommendation, moderate quality evidence.

4 ESGE suggests that virtual chromoendoscopy and dyebased chromoendoscopy can be used, under strictly controlled conditions, for real-time optical diagnosis of diminutive (<= 5mm) colorectal polyps and can replace histopathological diagnosis. The optical diagnosis has to be reported using validated scales, must be adequately photodocumented, and can be performed only by experienced endoscopists who are adequately trained, as defined in the ESGE curriculum, and audited.

Weak recommendation, high quality evidence.

5 ESGE recommends the use of high definition white-light endoscopy in combination with (virtual) chromoendoscopy to predict the presence and depth of any submucosal invasion in nonpedunculated colorectal polyps prior to any treatment.

Strong recommendation, moderate quality evidence.

6 ESGE recommends the use of virtual or dye-based chromoendoscopy in addition to white-light endoscopy for the detection of residual neoplasia at a piecemeal polypectomy scar site.

Strong recommendation, moderate quality evidence.

7 ESGE suggests the possible incorporation of computeraided diagnosis (detection and characterization of lesions) to colonoscopy, if acceptable and reproducible accuracy for colorectal neoplasia is demonstrated in high quality multicenter in vivo clinical studies. Possible significant risks with implementation, specifically endoscopist deskilling and over-reliance on artificial intelligence, unrepresentative training datasets, and hacking, need to be considered.

Weak recommendation, low quality evidence.

Advanced imaging for detection and differentiation of colorectal neoplasia: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2019

Raf Bisschops

Publisher

European Society of Gastrointestinal Endoscopy

Guideline

Clinical Practice Guideline

Topics

Endoscopy Radiology & Imaging

Citation

Endoscopy. 2019 Dec;51(12):1155-1179

Published

2019

UEG Presentation

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Gastro-oesophageal reflux disease diagnosis and how to avoid them

Sabine Roman 1

1 Hôpital Edouard Herriot, Lyon, France

Event

UEG Week Berlin 2025

Topics

Endoscopy Nurses Small Intestine & Nutrition Oesophagus Surgery

Session

Mistakes in…: Upper GI

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

UEG Presentation

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UTILIZATION OF PROTON PUMP INHIBITORS IN PATIENTS WITH OVERT GASTROINTESTINAL BLEEDING: EFFECTS ON SHORT- AND LONG-TERM MORTALITY AND REBLEEDING

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Introduction

Proton pump inhibitors (PPI) may be over or underutilized in patients with acute gastrointestinal bleeding (AGIB). Further, the effects of their use on short- and long-term outcomes are not clear.

Aims & Methods

We examined utilization of PPI in patients with AGIB and its effect on short- and long-term rebleeding and mortality in a prospective study of patients admitted with AGIB to a tertiary referral center between Jan. 2013 and Aug. 2023. We determined intake of PPI on admission and on discharge, and intake of antithrombotics [antiplatelets (AP) only, anticoagulants (AC) only or both AP and AC] on admission and on discharge. Univariate analysis was done to compare patients using PPI on admission or on discharge to patients not using PPI. Multivariate analysis was done to determine independent predictors of mortality and rebleeding.

Results

846 patients with AGIB (462 had upper GIB) were admitted and followed-up for a median of 59 (29-88) months. 385 were admitted already taking PPI. 623 patients were discharged on PPI and 150 were discharged off PPI (73 patients died in hospital). 49% of patients admitted on PPI and 27% of patients discharged on PPI did not have a clear indication for their use. The overall PPI overutilization rate was 36%. 25% of patients discharged off PPI had at least one clear indication for their use.
Compared to patients admitted off PPI, those admitted on PPI were older (66 vs 70 years, p<0.001), had higher Charlson Comorbidity Index (CCI) (2.4 vs 3.2, p<0.001), were more likely to be on antithrombotics (56% vs 70%, p<0.001) and to require blood transfusion (54% vs 64%, p=0.003). They also had higher 1-month mortality (8% vs 16%, p<0.001). However, they had less stigmata of recent hemorrhage (SRH) (39% vs 30%, p=0.022) and were less likely to require endoscopic therapy (25% vs 15%, p=0.002). Compared to patients discharged off PPI, patients discharged on PPI were more likely to have had in-hospital re-bleeding (1.3% vs 5.3%, p=0.036) but had similar short- and long-term mortality (4.7% vs 2.9%, p= 0.301 and 37% vs 44%, p=0.122, respectively).
On multivariate analysis, PPI on admission was not an independent predictor of 1-month mortality or re-bleeding [OR 1.46 (0.83, 2.57), p= 0.187 and 0.91 (0.51, 1.59), p=0.730], respectively. Predictors of 1-month mortality were CCI [OR 1.13 (1.04,1.22), p=0.002], severe bleeding [OR 2.48 (1.21, 5.10), p=0.013], blood transfusion [OR 2.72 (1.20, 6.15), p=0.017], and SRH [OR 2.53 (1.40, 4.59), p=0.002]. Predictors of 1-month re-bleeding were AC only on admission [OR 2.30 (1.20, 4.42), p= 0.012], severe bleeding [OR 1.96 (1.03, 3.73), p=0.041], and SRH [OR 2.03 (1.16, 3.54), p=0.013]. PPI on discharge was not a predictor of long-term mortality or re-bleeding (table 1). Being on AC only on discharge was a predictor of long-term mortality, while being on AP only on discharge was protective against long-term re-bleeding (table 1).

	Variables	OR (95% CI)	p-value		Variables	OR (95% CI)	p-value
Long-term Mortality**	PPI on discharge	1.38 (0.85, 2.26)	0.194	Long-term Re-bleeding**	PPI on discharge	1.26 (0.76, 2.07)	0.375
	Age-related CCI	1.53 (1.41, 1.67)	<0.001		AP only on discharge	0.45 (0.28, 0.72)	0.001
	Blood transfusion	1.72 (1.18, 2.51)	0.005		AC only on discharge	0.91 (0.54, 1.56)	0.741
	AP only on discharge	0.85 (0.55, 1.32)	0.479		AP and AC on discharge	0.56 (0.29, 1.10)	0.095
	AC only on discharge	2.51 (1.45, 4.36)	0.001		Severe bleeding*	1.53 (1.03, 2.25)	0.034
	AP and AC on discharge	0.91 (0.50, 1.7)	0.749		SRH	1.78 (1.21, 2.64)	0.004
Table 1: Multivariate analysis showing predictors of long-term mortality and re-bleeding in patients with acute GIB. AP: antiplatelets; AC: anticoagulants; Hb: Hemoglobin level; CCI: Charlson Comorbidity Index; Severe bleeding is defined as: Hb drop ≥ 2 units, blood transfusions ≥ 2 units, or systolic blood pressure on admission ≤ 100 mmHg. * long term mortality and re-bleeding are defined as mortality or re-bleeding by the end of follow-up.

Conclusion

There is marked overutilization and underutilization of PPI in patients with GIB, without a significant effect on short- or long-term mortality or rebleeding. A PPI utilization stewardship program is needed to decrease health care costs and potential PPI related side effects.

UTILIZATION OF PROTON PUMP INHIBITORS IN PATIENTS WITH OVERT GASTROINTESTINAL BLEEDING: EFFECTS ON SHORT- AND LONG-TERM MORTALITY AND REBLEEDING

Kassem Barada 1, Ali ElHadi Zreik 1, Jamil Mrad 1, Chantal Rizk 1, Hani Tamim 2, Walaa ElSheikh 3, Ala Sharara 1, Fadi Mourad 1, Fady Daniel 1, Assaad Soweid 1, Yasser Shaib 1, Noëlle El Asmar 1, Don Rockey 4

1 American University of Beirut Medical Center, Beirut, Lebanon

2 American University of Beirut, Clinical Research Institute, Beirut, Lebanon|||Alfaisal University, College of Medicine, Riyadh, Saudi Arabia

3 American University of Beirut, Clinical Research Institute, Beirut, Lebanon

4 Medical University of South Carolina, Digestive Disease Research Center, Charleston, SC, United States

Event

UEG Week Vienna 2024

Topics

Endoscopy Small Intestine & Nutrition Stomach & H. Pylori Oesophagus

Submission format

Abstract

Session

Upper GI bleeding: Treatment and outcome

Citation

United European Gastroenterology Journal 2024; 12 (Supplement 8)

Published

2024

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Introduction

Barrett’s oeosphagus (BO) is the precursor to oesophageal adenocarcinoma (OAC), a malignancy with a poor overall prognosis. Endoscopic surveillance of patients with BO aims to detect dysplasia and OAC to improve long-term outcomes. However, the majority of patients with BO do not progress to cancer.^1,2 It is therefore important to establish the relevant clinical risk factors for malignant progression in this cohort to enable risk stratification and facilitate a personalised approach to management. While obesity is an independent risk factor for both BO and OAC,^3-5 the role of obesity in the malignant progression of BO is unclear. We undertook a systematic review and dose-response meta-analysis to estimate the association between obesity and malignant progression in patients with BO.

Aims & Methods

We searched MEDLINE and EMBASE databases via the OVID interface to December 2023. Studies which reported the effect of body mass index (BMI) on the progression of BO (no dysplasia or low-grade dysplasia[LGD] at baseline) to HGD or OAC were included. Two-stage dose-response meta-analysis was performed to estimate the association between BMI and malignant progression. Study quality was appraised using a modified Newcastle-Ottawa scale. The review was registered on PROSPERO (CRD42017051046).

Results

Twenty studies reported data on 38565 patients in total, of whom 1684 patients were diagnosed with HGD/OAC/OC. Each 5kg/m²increase in BMI was associated with a 4% increase in malignant progression to HGD or OAC (unadjusted OR 1.04; 95% CI 1.00 to 1.07; p<0.001; I² 57.2%). The association remained consistent after adjusting for potential confounders (adjusted OR 1.06; 95% CI 1.02 to 1.10;p<0.001; I² 0%). Nineteen studies were considered moderate to high quality.

Conclusion

Our meta-analysis suggests that obesity as measured by BMI is associated with malignant progression of BO with a dose-response relationship. The findings from our study are consistent with mechanistic evidence for the role of obesity in the pathogenesis of OAC. Future risk prediction models could incorporate measures of obesity to potentially improve risk stratification in patients with BO. Weight loss might reduce the risk of malignant progression in patients with BO.

References

1. Bhat S, Coleman HG, Yousef F, et al. Risk of malignant progression in Barrett's esophagus patients: results from a large population-based study. J Natl Cancer Inst 2011;103:1049-57.
2. Hvid-Jensen F, Pedersen L, Drewes AM, et al. Incidence of adenocarcinoma among patients with Barrett's esophagus. N Engl J Med 2011;365:1375-83.
3. Kubo A, Cook MB, Shaheen NJ, et al. Sex-specific associations between body mass index, waist circumference and the risk of Barrett's oesophagus: a pooled analysis from the international BEACON consortium. Gut 2013;62:1684-91.
4. Renehan AG, Tyson M, Egger M, et al. Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies. Lancet 2008;371:569-78.
5. Corley DA, Kubo A, Zhao W. Abdominal obesity and the risk of esophageal and gastric cardia carcinomas. Cancer Epidemiol Biomarkers Prev 2008;17:352-8

THE ASSOCIATION BETWEEN OBESITY AND MALIGNANT PROGRESSION OF BARRETT’S OESOPHAGUS: A SYSTEMATIC REVIEW AND DOSE-RESPONSE META-ANALYSIS

Mie Thu Ko 1, Tom Thomas 2, Emily Holden 1, Ian Beales 3, Leo Alexandre 4

1 University Of East Anglia, Norwich, United Kingdom

2 Kennedy Institute of Rheumatology, University of Oxford, Oxford, United Kingdom

3 Norfolk & Norwich University Hospital, Norwich, United Kingdom

4 Norfolk and Norwich University Hospital, Norwich, United Kingdom

Conference

UEG Week Vienna 2024

Topics

Oesophagus

Submission format

Abstract

Session

Barrett's oesophagus (Posters)

Citation

United European Gastroenterology Journal 2024; 12 (Supplement 8)

Published

2024

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