Introduction

Biliary adverse events manifest in approximately 25% of liver transplant recipients. Among these, anastomotic biliary strictures (ABS) are the most prevalent, occurring in approximately 6%‐12% of cases and can be successfully managed endoscopically.

Aims & Methods

Our study aims to present the evolution of method and long-term results of placing multiple plastic stents to treat ABS after orthotopic liver transplantation (OLT). All consecutive patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for liver transplantation-related biliary complications at our Endoscopy Unit between July 1994 and September 2022 were retrospectively identified. The analysis focused only on the patients diagnosed with ABS undergoing dilatation by a progressively increasing number of plastic stents. Follow-up after stent removal was obtained by office visit, telephone contact with the patient or referring physician and extended to this year or until patient succumbed.

Results

Two hundred and ninety-five patients referred by 4 Liver Transplant Units underwent ERCP in need of endoscopic treatment for biliary complications after liver transplantation. However only 151 represented our intention-to-treat group with ABS. Out of these, 21 patients were excluded because of split liver transplantation, the use of metallic stents or incomplete endoscopic treatment. The mean age of the remaining 130 patients was 56 ± 9 years old and included 107 males and 23 females. We divided these patients in 2 groups according to similar timeframes, 28 ABS patients being treated before 2008 and 102 patients after 2008. In the first group the median number of stents was 4 (range 2-7), with a median of 3 ERCPs (range 2-5) per patient. Patients treated after 2008 received a median number of 6 stents (range 3-9) (p = .000, Mann-Whitney U), with a median of 4 ERCPs (range 3-7) (p = .002, Mann-Whitney U). The mean treatment duration was 15.3 ± 16.7 months in the first group and 14 ± 10 months in the second. Stricture recurrence was noted in 14.2% of patients treated before 2008 versus 4.9% after 2008. Nevertheless, the follow-up period was 10.6 ± 7.5 years for the first group and 4.7 ± 4 years in the second group.

Conclusion

The endoscopic treatment with multiple plastic stents proved to be effective for the majority of patients with ABS after OLT. In the last decade, the endoscopists shifted towards a more aggressive treatment strategy, with an increased number of stents and a reduced period between stent replacement procedures. This intensive approach seems also to underline a lower stricture recurrence rate however a longer follow-up period needs to be considered for the patients treated after 2008.

Introduction

Eosinophilic Oesophagitis (EOE) has a mean estimate of 63 new cases per 100,000 in the Western World and is in increasing prevalence¹. It must be considered as a differential diagnosis amongst patients presented with dysphagia and food bolus obstruction. British Society of Gastroenterology (BSG) guideline recommends that patients undergoing endoscopy should have oesophageal biopsies taken if they have endoscopic signs associated with EOE or symptoms of dysphagia or food bolus obstruction with normal looking oesophagus. At least six biopsies should be taken from at least 2 different anatomical sites within the oesophagus for diagnosis of EOE². (GDG recommendation).

Aims & Methods

A single-centre, retrospective analysis of patients presenting for an oesophagogastroduodenoscopy (OGD) with an indication of dysphagia or food bolus obstruction and coded as oesophagitis over the past 5 years was performed. The study was undertaken at a tertiary NHS Hospital Trust in West Midlands which provides hospital services for approximately 900,000 people³. Data was then collected for demographics, sedation, macroscopic findings, quality and location of biopsies as well as histology. This is measured against BSG recommendations.

Results

In total, 31 patients were included. 68% of patients were male and the mean age was 53 (range 14-90) 35% (n=11) had pharyngeal anaesthesia only, 16% (n=5) had midazolam and pharyngeal anaesthesia, 35% (n=11) had midazolam and fentanyl and 6% (n=2) had general anaesthesia (GA). Both patients who had GA were 14 and 15 years old. In terms of macroscopic findings, 61 % (n=19) had normal findings, 19% (n=6) had oesophagitis, 10 % (n=3) had EOE changes and 3% (n=1) had benign stricture with the same number for achalasia and tertiary contraction. 81% (n=25) had biopsies taken from at least 2 different anatomical sites and 32% (n=10) had more than 6 biopsies taken in total. There were 29 % (n=9) patients with a histological diagnosis of EOE, 29% was normal, 29% (n=9) had inflammation, 6% (n=2) had gastric metaplasia, 3% (n=1) had basal hyperplasia with 7-8 eosinophils per high-power field (HPF) and 3% (n=1) had basal hyperplasia with lymphocytic infiltration. In all patients with EOE, the histopathological report explicitly documented the presence of >15 eosinophils per HPF.

Conclusion

Our data suggest that our practice for diagnosis of EOE falls short of national recommendation, both in the number of anatomical sites and the number of biopsies taken. In terms of histopathology, we have adhered to the recommended diagnostic criteria of >15 eosinophils per HPF. Further work must be done to improve awareness and adherence to the guidelines for the diagnosis of this treatable condition.

References

1. Navarro P, Arias Ángel, Arias-González L, et al. Systematic review with meta-analysis: the growing incidence and prevalence of eosinophilic oesophagitis in children and adults in population-based studies. Aliment Pharmacol Ther 2019;49:1116–25.
2. Dhar A, Haboubi HN, Attwood SE, et al. British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults. Gut 2022;71:1459-1487.
3. University Hospitals of North Midlands. About us. https://uhnm-appointments.co.uk/about-us/ [Accessed 23^rd November 2023]

Introduction

Transmural response (TR) and healing (TH) assessed by intestinal ultrasound (IUS) are gaining increasing relevance as treatment targets in Crohn’s disease (CD) [1]. Even though less established in ulcerative colitis [UC], in which the inflammation mainly affects mucosa and submucosa, there is clear evidence that applying IUS in UC is beneficial to monitor short-term response to therapy [2]. However, the long-term IUS outcome, its association to clinical and lab parameters as well as the predictive value of early TR remain elusive.

Aims & Methods

The TRUST BEYOND study is an ongoing, prospective, non-interventional, multi-centre study in patients with active CD or UC who receive a biologic- or Januskinase-inhibitor (JAKi)-therapy at baseline. The study aims to assess the predictive value of TR or TH, evaluated at week 12 for the disease outcome after 52 weeks (TR: reduction of bowel wall thickness (BWT) of at least 25% and/or normalization; TH: normalization of BWT and Colour Doppler signal). For this interim analysis, we report IUS and clinical results as well as fecal calprotectin levels of 77 UC patients on the same therapy after 12 (W12) and 52 weeks (W52) and assessed the predictive value of TR at W12 for clinical remission at W52.

Results

Seventy-seven UC patients (63.6% were male, median age was 38.6 years (30.6 – 55.7) median disease duration of 5.85 years (2.49–12.77)) with clinically active disease (SCCAI 8.5 ± 2.2) with increased BWT at baseline had a documented visit after 52 weeks until February 2023. For the vast majority, the most affected bowel wall segment was the sigmoid colon with a mean BWT of 5.22 ± 1.28 mm at baseline.
At W12 after induction of therapy, the proportion of UC patients with TR and TH was 67.5% (n = 52) and 31.2% (n = 24). At W52, the rates of UC patients increased to 77.9% (n = 60) for TR and 41.6% (n = 32) for TH. Over the study course, patients with TR at W12 and W52 had a numerically lower SCCAI score and reduced fecal calprotectin levels than patients without TR.
Of note, 72.2% (n = 39) of patients with TR at W12 were in clinical remission at W52 compared to 27.8% (n = 15) of patients without early transmural response (p = 0.178).

Conclusion

In this interim analysis of the TRUST BEYOND study, UC patients demonstrated substantial rates of transmural improvements on IUS after 12 and 52 weeks. Patients with early transmural response were more likely to be in remission after one year. This suggests that in UC, IUS has to some degree a predictive value as observed for CD.

References

1. Kucharzik T, Wittig BM, Helwig U, et al. Use of Intestinal Ultrasound to Monitor Crohn's Disease Activity. Clin Gastroenterol Hepatol. 2017; 15:4, 535-42 e2.
2. Maaser C, Petersen F, Helwig U On behalf of the German IBD Study Group and the TRUST&UC study group, et alIntestinal ultrasound for monitoring therapeutic response in patients with ulcerative colitis: results from the TRUST&UC studyGut 2020;69:1629-1636.

Disclosure

T. Kucharzik, U. Helwig, F. Seibold, L. Biedermann, C. Högenauer and C. Maaser have received lecture and consulting fees from AbbVie.
I. Fischer has received consulting fees from AbbVie. L. Hammer and S. Rath are AbbVie employees and may own AbbVie stock or options.
AbbVie sponsored the study; contributed to the design; participated in the collection, analysis, and interpretation of data; in writing, reviewing, and approval of the final version. No honoraria or payments were made for authorship.

Clinical Case Summary

Introduction: Tuberculosis (TB) is a transmissible disease associated to a high morbidity and mortality. Within the extrapulmonary forms, peritoneal TB corresponds to 11% of reported cases in the literature (1). Despite its high prevalence, its diagnosis remains a challenge due to its pauci-bacillary nature, and its nonspecific clinical findings.
Clinical case: 29 years old male patient, who consulted for abdominal pain and ascites. Abdominal and pelvis Contrast enhanced tomography revealed infiltrative material in the omental fat, ascites, irregular peritoneal thickening, and retroperitoneal mesenteric adenopathies (Fig.1). Paracentesis fluid: seroascitic albumin gradient (SAAG) estimated 1.8. The adenosine deaminase (ADA) of the ascitic fluid 181.1U/L. In diagnostic laparoscopy, it was observed miliary infiltration in the peritoneum. The pathology report described a caseating necrotizing granulomatous inflammatory process (Fig.2); confirming the diagnosis of PTB. Isoniazid, rifampicin, pyrazinamide, and ethambutol was initiated for 2 months, followed by isoniazid and rifampicin for 4 months with total improvement of the patient.
Discussion: The diagnostic approach of the patient with ascites is based on the study of ascitic fluid and the determination of SAAG; a value of >1.1 points towards ascites due to portal hypertension (PHT) and <1.1 towards ascites due to non-PHT. (2) In our patient, the biochemical analysis of the ascitic fluid determined (SAAG>1.1) with a high probability of PHT, leading the physician to initially suspect this cause and dismiss other neoplastic, infectious, and granulomatous diseases. However, the medical history did not correlate with PHT. In contrast, ADA study was positive. The sensitivity and specificity of this measure in PTB is 98 and 95% respectively, with a positive predictive value of 100% and a negative predictive value of 98%. (3)
Conclusión: The measurement of ADA in ascitic fluid , constitutes an essential, rapid diagnostic tool, with high sensitivity and negative predictive value for diagnostic PTB.

References

1. Gómez-Piña JJ. Tuberculosis peritoneal. Med Int Méx. 2018 mayo-junio;34(3):490-496
2. Rodríguez Brainy, Monge Eduardo, Montes Pedro, Salazar Sonia, Guzmán Edson. Eficacia de gradiente de albúmina sangre-ascitis y los análisis de proteínas en líquido ascítico en el diagnóstico de ascitis hipertensiva portal. Rev. gastroenterol. Perú 2014
3. Vasen Walter, Mauriño Eduardo, Ferro Diego, Brotto Claudia, Fernández Marty, Cabanne Ana. Acta Gastroenterol Latinoam 2016;46: 205-212.

Disclosure

No conflict of interest.