Introduction

Endoscopic resection of the appendiceal orifice polyps extending into the appendiceal lumen is challenging given the inability to determine polyp’s lateral margins. Endoscopic full thickness resection (EFTR) is an alternative technique for managing these polyps, but it is limited in polyps larger than 2 cm, or polyps extending to the base of the cecum or inside the appendiceal lumen. In addition, EFTR may lead to appendicitis. In this case series, we describe a novel technique for the removal of complex appendiceal orifice polyps via transcecal endoscopic appendectomy (TEA).

Aims & Methods

This case series includes patients who underwent TEA performed by a single endoscopist in the US for polyps larger than 2 cm that extended deeply into the appendiceal lumen or obstructed the appendiceal lumen. All cases were done under general anesthesia in endoscopy unit. The technique entailed performing a circumferential incision around the lateral margin of the polyp in the base of the cecum. Once the polyp was dissected by endoscopic submucosal dissection (ESD) technique from the base of the cecum, the incision was extended into the serosa of the cecal wall with continuous dissection of the appendix from the mesoappendix. Traction was then applied to pull the tip of the appendix intra-luminally within the cecum. The appendix was then dissected from the remining mesoappendix and cecal base. The defect was then closed using hemostatic clips. A 14-gauge catheter was routinely inserted above the umbilicus to prevent tension pneumo-peritoneum. Technical success was defined as achieving complete removal of the appendix and the polyp in an en bloc fashion.

Results

In total, five patients were included (60% female). The mean age of patients was 65.6 ± 7.5 years old. The average polyp size was 3.08 ± 0.6 cm. Technical success was achieved in 100% of the patients. The average procedure length was 98.6 ± 36.22 minutes. Completed closure of the defect was made via clips in all cases (average 5.8 ± 1.7 clips). The en bloc resection rate, R0 resection rate and curative resection rates were 100%. Patients were observed post procedurally for an average of 3 ± 1.3 days (range 1-5 days). Post-procedural mild abdominal discomfort (n=4) and leukocytosis (n=3) were managed conservatively with empiric antibiotics. One patient developed loculated fluid collection nine days post-procedure without development of any clinical symptoms. After treatment with empiric antibiotics, complete resolution of all collection was noted on follow-up outpatient imaging on day 17.

Table 1- Patient, polyp and procedure characteristics, outcome and follow up information

Conclusion

This is the first reported experience of transcecal endoscopic appendectomy for management of complex appendiceal orifice polyps in the West. This novel technique is safe and is associated with minimal risk profile in expert hands. Further prospective studies are needed to standardize the technique.

Disclosure

Mohamed O. Othman: Mohamed O Othman is a consultant for Olympus, Boston Scientific Corporation, Abbvie, ConMed, Creo Medical, Lumendi and Apollo. Mohamed O Othman received research grants from Lucid Diagnostics, AbbVie and ConMed.
Tara Keihanian: Tara Keihanian is a consultant for Lumendi, Neptune Medical and ConMed.

Introduction

Natural history of anal stricture observed in Crohn’s disease (CD) remains poorly known, especially in pediatric onset CD.

Aims & Methods

All patients with a diagnosis of CD before the age of 17 years between 1988 and 2011 within the population-based registry EPIMAD were followed retrospectively until 2013. At diagnosis and during follow-up, the clinical and therapeutic features of perianal disease were recorded.

Results

Among the 1,007 included patients (females, 451 (44.8%); median age at diagnosis 14.4 years (IQR, 12.0-16.1)), one (0,1%) had an anal stricture at diagnosis and 26 (2.6%) during follow-up. Cumulative incidence of anal stricture at 5 and 10 years from diagnosis was 0.6% (95%CI, 0.1-1.1) and 1.4% (95%CI, 0.5-2.3), respectively. Twenty-five (n=25/27, 92.6%) patients had at least one episode of anal ulceration or fistulizing perianal Crohn’s disease (pCD). In multivariable analysis, the presence of extra-intestinal manifestations (HR 2.3 (95%CI, 1.1-4.9), p=0.0378), colonic location (L1 vs L3 HR 0.0 (95%CI, 0.0-na), L2 vs L3 HR 1.2 (95%CI, 0.5-2.7), p=0.0246) and history of fistulizing pCD (HR 7.6 (95%CI, 3.2-17.9), p<0.0001) were significantly associated with the onset of anal stricture. Eleven (40.7%) patients needed at least one dilatation. After a median follow-up of 6.2 years (IQR, 2.4-10.6), after anal stricture diagnosis, healing was observed only once. One patient (3.7%) had an anal cancer seven years after stricture diagnosis and nine (33.3%) patients needed a stoma. Anal stricture was significantly associated with the need of stoma (HR 5.8, 95%CI 2.3-14.3), p=0.0002).

Conclusion

The occurrence of anal stricture is an infrequent event in pediatric onset CD, since only 1.5% of patients will present an event after 10 years. Anal stricture increased the risk of stoma by a factor of 5.

Introduction

Infection with SARS-CoV-2 leads to pronounced changes in the intestinal microbiome and also decay of tryptophan that are both related to disease severity. Supplementation of tryptophan metabolism using ileocolonic-release nicotinamide may stabilize the microbiome and alleviate COVID-19 symptoms.

Aims & Methods

This prospective, double-blind, randomized, placebo-controlled trial evaluated safety and efficacy of a 4-week intervention with a novel oral formulation of nicotinamide (1,000 mg/d) in symptomatic, unvaccinated, non-hospitalized outpatients with PCR-proven early COVID-19. The primary outcome was full recovery from reduced physical performance after 2 weeks in the prespecified symptomatic primary analysis population with at least one risk factor for severe COVID-19. Stools from a part of the patients (4 timepoints) were submitted to 16S rRNA (n=70) and shotgun metagenomics (n=18) sequencing.

Results

Screening of 7,013 patients resulted in randomization of 900 participants (nicotinamide or placebo (1:1), from which 867 received the investigational product and 500 qualified for the acute disease analysis population. 110 of 191 patients (57.6%) receiving nicotinamide and 80 of 188 patients receiving placebo (42.6%) recovered from their performance drop at week 2 (absolute difference, 15.0 percentage points; odds ratio, 1.33; 95% confidence interval, 1.03 to 1.70; P=0.004). Nicotinamide was also superior in the secondary endpoints ability to perform normal activities (P=0.009) and shortness of breath (P=0.012). Substantial effects on gut microbiome constitution were seen counteracting COVID-19 related changes. Reduction of tryptophan biosynthesis in the microbiome in placebo patients was restored and NAD salvage pathways were activated in nicotinamide-treated individuals. No relevant safety signals were observed.

Conclusion

Oral treatment with nicotinamide stabilized the gut microbiome against COVID-19 related changes and led to faster recovery of physical performance in symptomatic patients at risk for severe Covid-19. (Funded by the German Research Foundation [DFG], the State of Schleswig-Holstein and the UEG Research Prize; ClinicalTrials.gov number: NCT04751604)

Disclosure

SS reports indirect stock ownership in Gerion Biotech GmbH as well as consulting and personal fees from AbbVie, Allergosan, Amgen, Arena, BMS, Biogen, Celltrion, Celgene, Falk, Ferring, Fresenius, Galapagos/Gilead, HIKMA, I-Mab, Janssen, Lilly, Morphic, MSD, Mylan, Pfizer, Prometheus, Protagonist, Provention Bio, Sandoz/Hexal, Takeda, and Theravance.
GHW is employed part-time by CONARIS Research Institute AG (Kiel, Germany).
TB reports consulting fees, honoraria or other support from AstraZeneca, Boehringer-Ingelheim, Chiesi, GlaxoSmithKline, Merck, MSD, Novartis, Pfizer, and Roche.
KA reports consulting fees, honoraria or other support from AbbVie, Falk, Galapagos, Janssen, Pfizer, and Takeda.
ML reports a lecture honorarium and travel support by AstraZeneca.
PR reports stock ownership in Gerion Biotech GmbH and consulting fees from Takeda.

Introduction

Cholangiocarcinoma (CCA) prevalence is high in East and Southeast Asia, especially in northeast Thailand. The first line of treatment for unresectable CCA is systemic chemotherapy which a median OS of less than 1 year under palliative systemic therapy. Albumin-Bilirubin (ALBI) prognosis score is the new method for the evaluation of liver performance status and prediction of treatment outcome but there is a lack of data in CCA patients.

Aims & Methods

Aim: To study the association of overall survival and ALBI prognostic score in unresectable CCA patients who received systemic chemotherapy.
Methods: This retrospective cohort study was conducted in Maha Chakri Sirindhorn Medical Center, Thailand. Demographic data, Clinical information, Laboratory profile, and survival analysis were extensively reviewed in the patient who received systemic chemotherapy from 2012 - 2022. All patients were monitored for at least 1 year after initial treatment with chemotherapy or until death.

Results

​69 patients of Unresectable CCA received systemic chemotherapy enrolled in this study. Most of the patients were men (45/69, 65.22%) and Intrahepatic type CCA (55/69, 79.71%). 17 patients (24.6%) need Biliary drainage before systemic chemotherapy which median pre-drainage TB was 11.35 mg/dL (10.7 – 20.6). Most ALBI prognostic score were group 2 (37/69, 53.6%) and anemia was significantly in ALBI 2 group (81.08%, P <0.001). The median overall survival was 10.23 months and the median progression-free survival was 5.77 months. Significantly better overall survival of the ALBI 1 group compared with the ALBI 2 group (ALBI 1, 13.76 months; ALBI 2, 6.33 months; log-rank test, P <0.001). The estimated 6, 12, 18, and 24-month survival rates were 72.46%, 40.58%, 18.84%, and 8.70%, respectively, whereas the estimated progression-free survival rate at 6, 12, 18, and 24 months were 47.83% and 10.14%, respectively.

Conclusion

ALBI prognosis score may serve as a surrogate marker in predicting the overall survival and progression-free survival of CCA patients who received Systemic chemotherapy.

References

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Disclosure

There is no any conflict of interest in this study

Clinical Case Summary

A 70-year-old patient with diabetes mellitus and cholecystectomy performed six months earlier was admitted to the emergency department for generalized abdominal pain, hyporexia and weight loss.
An abdominal CT scan showed a solid-cystic pancreatic lesion suggestive of mucinous neoplasia, together with peritoneal nodules in the right paracolic gout. In view of the suspicion of malignancy, an echoendoscopy with fine needle aspiration puncture (EUS-FNA) was performed, identifying an irregular lesion with heterogeneous and hypovascular ultrastructure in the pancreatic neck-body and a discrete dilatation of the main pancreatic duct. Finally, the histological study didn´t show neoplastic cells.
Suddenly the patient experienced a clinical worsening with severe pain and high fever. Laboratory tests showed a progressive increase in C-reactive protein and leukocytosis with left shift. In a control CT scan, a reduction in the size of the pancreatic lesion is observed, together with an increase in the peritoneal lesions which present a polyglobulated contour, hypercapillary margins and rarefaction of the surrounding fat. These finding suggesting the presence of peritoneal abscesses secondary to dropped gallstones. After broad-spectrum antibiotic therapy, the intra-abdominal abscesses improved radiologically, but the collection persisted in the right posterior pararenal space which was drained under ultrasound control with subsequent disappearance of fever and normalization of analytical parameters.
Dropped gallstones occur in approximately 7% of cholecystectomies. The secondary granulomatous reaction in paucisymptomatic patients can simulate peritoneal tumor processes in imaging tests, being one of the adverse effects described in relation to this pathology. In our case, the concomitant presence of peritoneal lesions together the pancreatic lesion oriented the initial case as a malignant process; however, the patient's evolution were key to the final diagnosis.

Introduction

Periodontitis (gum disease) and inflammatory bowel disease (IBD) are both chronic progressive inflammatory diseases with many similarities in their aetiopathogenesis. In addition, patients with IBD are reported to be at increased risk of developing periodontitis, which in turn seems to impact IBD activity and disability as shown in recent studies. However, these findings need to be validated. Thus, we aimed to assess whether the presence of periodontitis is associated with increased IBD activity, disability, and severity, and/or reduced IBD specific quality of life, in a Swedish patient cohort.

Aims & Methods

An on-line questionnaire was distributed to the members of the Swedish patient organisation for gastrointestinal diseases. The survey included questions on social demographics, oral health, as well as IBD-related characteristics. Oral health was assessed by the number of missing teeth, self-reported state of teeth and gums, and the Periodontal Screening Score (PESS), which is a validated instrument to screen for severe periodontitis. Disease activity in patients with Ulcerative Colitis (UC) and Crohn’s disease (CD) was assessed by the Simple Clinical Colitis Index (SCCAI) and the Harvey & Bradshaw’s Activity Index (HBI), respectively. Disease related disability was assessed by the Inflammatory bowel disease disability index (IBD-DI). IBD-specific health-related quality of life measured by the short inflammatory bowel disease questionnaire (sIBDQ).

Results

A total of 786 IBD patients responded to the invitation, including 371 patients with CD and 415 patients with UC. For both CD and UC, self-reported severe periodontitis was significantly associated with a higher level of current disease activity [OR 1.72 (1.86;2.49); p=0.004] based on the HBI (for CD) and the SCCAI (for UC), an increased IBD disability score [Coef. 5.07 (1.86;8.27); p=0.002], and an increased self-reported disease activity in the last 12 months [OR 1.44 (1.05;1.98); p=0.025]. Likewise, number of missing teeth (tooth loss is the ultimate outcome of untreated periodontitis and as such an indirect indicator of its severity), was associated with an increased IBD disability score [Coef. 4.47 (0.71;8.22); p=0.020]. IBD severity (analysed as composite parameter of history of IBD-related surgery and/or treatment with biological therapy) was neither associated with tooth loss [OR 1.57 (0.97;2.52); p=0.065], nor with self-reported severe periodontitis [OR 1.20 (0.80;1.80); p=0.367]. IBD-specific health-related quality of life measured by sIBDQ score showed a tendency to be decreased in the presence of self-reported severe periodontitis [OR -1.45 (-3.01;0.10); p=0.067] but was not associated with tooth loss [Coef. -1.20 (-3.01;0.62); p=0.194].

Conclusion

The present study provides further evidence that the presence of periodontitis is associated with an increased disease activity and disability in IBD patients. These results underline that increased attention should be given to the oral health of IBD patients.

Introduction

The overall burden of B / D and C viral hepatitis remains substantial, despite the major advances in the prevention and treatment of patients in recent years, due to comorbidities and complications associated with liver disease. In this context, the national screening program LIVE (RO) 2 aims to further assess all patients identified as positive for one of the hepatitis B / D / C viruses.

Aims & Methods

The study aimed to identify fortuitous pathologies discovered in patients with chronic viral B / D / C infection diagnosed in the LIVE (RO) screening program 2. We conducted a prospective study that included people from vulnerable groups (poor, uninsured, rural people, people in foster care, homeless, Roma population, people with disabilities, and suffering from alcohol or drug addiction) in different areas of North-Eastern Romania, between July 2021 - April 2023, during the national screening program LIVE (RO) 2-EAST. We also investigated the presence of newly discovered conditions in patients who tested positive and directed to the Institute of Gastroenterology and Hepatology in Iasi for the staging of liver disease and the establishment of antiviral treatment.

Results

The study group included 1176 patients, of which 422 men (35.8%) and 754 women (64.1%), aged between 35 and 83 years, with a mean age of 56.32 years. The predominant source of origin was rural (73.1%). Of the patients with positive RDTs, 635 (53.9%) patients were detected with HBsAg, 521 (44.3%) patients with anti-HCV antibodies, and 20 (1.7%) patients with anti-HVD antibodies. Of these, 215 patients (18.2%) were diagnosed with a new pathology associated with B / D / C viral infection. The most common pathologies discovered incidentally were liver cirrhosis (94, 43.7%), liver cysts (35, 16.2%), liver hemangiomas (29, 13.4%), gallstones (24, 11.1%), type II diabetes mellitus (T2DM) (15, 6.9%), uterine fibroids (9, 4.1%), hepatocellular carcinoma (7, 3.2%), choledochal lithiasis (2, 0.9%). In addition, the presence of fortuitous pathologies was higher among patients with HBV infection than in those with HCV infection (65.3% vs. 42.1%, p = 0.012). Among the risk factors associated with hepatocellular carcinoma (HCC) are chronic alcohol consumption (43%, compared to 19% in the group of patients without HCC), and the association of T2DM in 3 patients (31%, compared to 10% in the group of patients with HCC).

Conclusion

Patients with chronic B / D / C viral infection had a high prevalence of incidentally detected comorbidities, which necessitates the need for public health policies in vulnerable groups to promote access to existing health services to reduce the future burden of chronic diseases but also secondary complications of chronic liver disease.