Clinical Case Summary

A 77-year-old patient with diabetes insipidus underwent an abdominal computed tomography scan due to upper quadrant abdominal pain. The exam showed concentric thickening of the main and intrahepatic bile ducts. A subsequent magnetic resonance cholangiopancreatography, with diffuse thickening of the main and intrahepatic bile ducts, with diffusion restriction and reduced biliary duct caliber, without lithiasis. Due to the suspiecion of a malignant biliary stricture, the patient was proposed for endoscopic retrograde cholangiopancreatography (ERCP) with cholangioscopy. The cholangiogram showed diffuse rarefaction of the intra and extrahepatic bile ducts, with focal dilatation of the intrahepatic bile ducts. After biliary sphincterotomy, cholangioscopy revealed a narrowed main bile duct extending to the hepatic hilum, with neovascularization, and papillary projections. Multiple biopsies were taken and a plastic stent was placed. Cholangioscopy-guided biopsy revealed granulation tissue and stroma with numerous histiocytes and eosinophils. Immunohistochemistry identified histocytes expressing CD68, S100, and CD1a, consistent with biliary involvement by Langerhans Cell Histiocytosis. The procedure was complicated by acute pancreatitis, requiring Intensive Care Unit admission. The patient’s hydroelectrolytic disorders were caused by pituitary involvement (lymphocytic hypophysitis associated with granulomatous disease). The patient started corticosteroid therapy with clinical and analytical improvement.
Langerhans Cell Histiocytosis is characterized by histiocytes proliferation, with progressive fibrosis due to tissue infiltration. In this case, diabetes insipidus was the first disease manifestation, due to lymphocytic hypophysitis. LCH is a rare cause of secondary sclerosing cholangitis, and early diagnosis through cholangioscopy was essential to initiate appropriate systemic therapy, preventing disease progression with multiorgan involvement.

Clinical Case Summary

A 72-year-old patient with a history of atrial fibrillation on treatment and cirrhosis, presented with subjective fevers and abdominal distention for 2 months. An initial laboratory work-up showed an inflammatory syndrome and a prothrombin level of 40 %. The rest of the work-up was unremarkable. A computed tomography (CT) scan of the abdomen showed dysmorphic liver with signs of portal hypertension and abundant ascites with micronodular infiltration of the greater omentum.
Paracentesis showed ascitic fluid (AF) with total nucleated cells 2400 with 5% neutrophils and 87% lymphocytes and protein levels at 40. Cytology was negative for malignancy.
Initially, the patient was considered for diagnostic laparoscopy to investigate the persistent abdominal symptoms. However, in light of the current epidemiological context, marked by a heightened incidence of tuberculosis in the region, a systematic workup for tuberculosis was prioritized. Direct examination and culture for acid-fast bacilli (AFB) were negative, however Xpert Mtb/Rif was positive. standard chest X-ray showed a normal parenchyma with a small right pleural effusions. Thoracentesis was done and pleural fluid AFB culture was negative.
He was started on isoniazid, rifampin, pyrazinamide and ethambutol and was discharged with a close follow up.

Clinical Case Summary

Cryptosporidiosis is a gastrointestinal infection caused by the protozoan Cryptosporidium spp. It is typically self-limited in immunocompetent patients. However, in immunocompromised individuals, it can lead to moderate to severe diarrhea and significant morbidity and mortality.¹
We present the case of a 31-year-old woman with a history of Crohn’s disease in remission, who presented with a one-week history of diarrhea (up to 10 bowel movements daily), abdominal pain, and fever (38°C). Laboratory tests revealed an elevated C-reactive protein (CRP), and intestinal ultrasound showed bowel wall thickening, hyperemia and wall disruption, suggestive of an active flare. However, routine stool culture isolated Cryptosporidium, and based on her clinical background, oral paromomycin and azithromycin were initiated, resulting in complete clinical remission.
Cryptosporidiosis is a common parasitic cause of diarrhea, particularly affecting immunocompromised patients, such as those with HIV, cancer or solid organ transplants.²
Although few cases have been described in inflammatory bowel disease (IBD), the immunosuppressive state of these patients may increase the risk of infection. Diagnosing cryptosporidiosis in this population can be challenging, as stool tests detect only about 30% of cases, and the clinical presentation often mimics an IBD flare.³
Treatment is generally supportive and reserved for severe or refractory cases. Nitazoxanide is the drug of choice, and in non-responders, it can be combined with fluoroquinolones or azithromycin. In IBD patients, the decision to initiate specific antiparasitic treatment depends on the degree of immunosuppression and the clinical scenario.⁴
A clear association between IBD and cryptosporidiosis has not been established, but it is crucial to rule out opportunistic gastrointestinal infections in suspected flare-ups before starting specific therapies.
image "Bowel wall thickening, hyperemia, and disruption of the normal layer pattern."

References

(1) Janssen B, Snowden J. Cryptosporidiosis. 2023 Jul 10. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 28846353.
(2) Liu B, Schnider A, DeArmond M, Banach DB, Haubrich BA. Cryptosporidiosis in individuals with inflammatory bowel disease: a scoping review protocol. BMJ Open. 2024 Oct 15;14(10):e086529. doi: 10.1136/bmjopen-2024-086529. PMID: 39414295; PMCID: PMC11481120.
(3) Ferreira J, Baden R, Magge S, Cheifetz A. Cryptosporidiosis masquerading as a Crohn's flare. Inflamm Bowel Dis. 2011 Oct;17(10):E133-4. doi: 10.1002/ibd.21811. Epub 2011 Jul 7. PMID: 21739536.
(4) Manthey MW, Ross AB, Soergel KH. Cryptosporidiosis and inflammatory bowel disease. Dig Dis Sci 1997;42:1580–6.

Clinical Case Summary

Hydatid cyst disease, caused by the Echinococcus parasite, is a zoonotic infection that typically targets the liver, lungs, and nervous system. It commonly occurs in regions such as the Maghreb countries, where it presents a significant health concern. While hydatid cysts in the liver are usually asymptomatic, complications such as cyst rupture, infection, or obstruction can arise, with portal vein involvement being particularly rare. This case report describes a 56-year-old male with a history of surgery for hydatid liver cyst, who presented with portal vein invasion mimicking portal vein thrombosis. Diagnostic imaging, including Color Doppler ultrasound and MRI, revealed a multiloculated cyst in the fourth liver segment with communication to the portal vein, leading to thrombosis and cavernous transformation of the portal vein. Despite the rupture of the hydatid cyst into the portal vein, no anaphylactic shock occurred. Portal vein thrombosis and cavernous transformation due to hydatid cysts represent an exceptional and complex complication of echinococcosis, highlighting the importance of early recognition and appropriate management. Treatment strategies should address both the hydatid liver cyst and associated portal hypertension, with surgical intervention being the cornerstone, including hepatectomies and laparoscopic approaches. This case highlights the necessity of heightened clinical awareness in endemic regions for managing this rare, potentially life-threatening complication.

Introduction

Exocrine pancreatic insufficiency (EPI) is defined as a reduction in the exocrine pancreatic secretion and/or intraluminal activity of pancreatic enzymes below the level that allows normal digestion of nutrients. Currently, diagnosing EPI presents challenges: the most accurate method requires collecting faecal samples for several days to measure faecal fat excretion following a specific diet, while faecal elastase test, although simpler, has a high incidence of false positives.
The study assesses whether measuring lipase in blood, following the ingestion of a standard high-fat meal could provide a more accessible diagnosis of EPI. The hypothesis is that blood lipase increases proportionally to pancreatic secretion in individuals without EPI, allowing differentiation between patients with and without insufficiency.

Aims & Methods

The study's main objective was to investigate whether blood levels of lipase increase after a fatty meal in normal subjects. If blood lipase and lipase secreted by the pancreas have a correlation, by calculating the area under the curve of several determinations of blood lipase in healthy subjects, we could set a normal pattern of lipase secretion. In the future, this pattern can be compared to patients with EPI to test if it can be a screening tool for EPI.
For the study, 10 healthy volunteers were tested. All participants fasted before receiving a test meal designed to stimulate lipase secretion. Blood samples were then taken every 30 minutes for six hours to measure lipase blood levels and calculate the area under the curve (AUC) using the trapezoid method.

Results

The mean (standard deviation) of the maximum and minimum lipase blood levels was 24 (9) and 19 (8) U/L, respectively. The mean percentage change in lipase was 31% (standard deviation 16%). The area under the curve of blood lipase levels between the baseline sample and the sample at 360 minutes had a mean of 7749 (standard deviation 3129) units per litre per hour. The median time to peak lipase was 0 minutes, meaning that the expected peak in blood lipase did not occur after the test meal: in 60% of cases, the highest peak of all measurements was the baseline measurement, with no clear peak in response to the meal in the remaining cases, in contrast with pancreatic secretion into the duodenum.

Conclusion

According to our patient sample, lipase does not increase in the blood after stimulation with a test meal, as occurs in pancreatic lipase secretion into the duodenum. Lipasemia is, therefore, independent of pancreatic secretion and does not seem to be a promising parameter for screening exocrine pancreatic insufficiency.

References

1. Sastre J, Sabater L, Aparisi L. [Physiology of pancreatic secretion]. Gastroenterol Hepatol. 2005;28 Suppl 1:3-9.
2. Gonzalez-Sanchez V, Amrani R, Gonzalez V, Trigo C, Pico A, de-Madaria E. Diagnosis of exocrine pancreatic insufficiency in chronic pancreatitis: (13)C-Mixed Triglyceride Breath Test versus Fecal Elastase. Pancreatology. 2017;17(4):580-5.
3. Sabater L, Ausania F, Bakker OJ, Boadas J, Dominguez-Munoz JE, Falconi M, et al. Evidence-based Guidelines for the Management of Exocrine Pancreatic Insufficiency After Pancreatic Surgery. Ann Surg. 2016.
4. Lohr JM, Dominguez-Munoz E, Rosendahl J, Besselink M, Mayerle J, Lerch MM, et al. United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis (HaPanEU). United European Gastroenterol J. 2017;5(2):153-99.
5. Lundh G. Pancreatic exocrine function in neoplastic and inflammatory disease; a simple and reliable new test. Gastroenterology. 1962;42:275-80.

Introduction

Gastric peroral endoscopic myotomy (G-POEM) is an emerging endoscopic technique for the treatment of refractory gastroparesis, particularly benefiting patients with pylorospasm. It is considered a safe procedure with a low risk of adverse events when performed by experienced endoscopists. Our aim was to perform a comprehensive analysis of all adverse events associated with G-POEM.

Aims & Methods

We performed a retrospective analysis of prospectively collected data from all patients who underwent G-POEM for gastroparesis at our centers (Prague, Brno) between November 2017 and April 2025. All procedures were performed by a single endoscopist (JM). The primary outcome was procedure-related adverse events rate and severity occurring during the perioperative and early postoperative period. Adverse events were categorized as follows: deviations from the expected peri and postoperative course were defined as "undesirable events." Undesirable events that met the criteria of the Clavien Dindo surgical classification (C-D) were considered "true adverse events".

Results

Out of 70 procedures, no true adverse or undesirable events occurred in 51 procedures (72.9%). Perioperatively, the following undesirable events occurred in 18 patients: : gastric (4; 5.7%) and duodenal mucosal injuries (2; 2.8%), major bleeding during the procedure treated endoscopically (1; 1.4%), serosal perforation (10; 14.3%), capnoperitoneum requiring puncture (3; 4.3%), and subcutaneous emphysema (1; 1.4%). In the early postoperative period, adverse events occurred in 3 patients: one patient complained of significant abdominal pain necessitating analgetics, subsequently, a small leak from the pyloric region to the subhepatic region was described on CT and gastroscopy confirmed ulceration at the tunnel site. The patient responded well to treatment with intravenous proton pump inhibitors. In two other cases, both involving patients with diabetic gastroparesis, decompensation of diabetes occurred during the hospital stay post-procedure. The following “undesirable” events were considered true adverse events according to the C-D classification: serosal perforation (10; C-D I), leak requiring prolonged hospitalization (1; C-D IIIa) and diabetes decompensation (2; C-D II). These complications occurred in 13 procedures (18.6%).
The mean duration of hospitalization after the procedure was 2 days (range 1-7). Three months after the procedure, 1 patient developed mild dumping syndrome, which was successfully treated conservatively.

Conclusion

G-POEM is a safe procedure. The rate of true adverse events according to Clavien-Dindo classification is low and severe AEs occurs rarely.