Clinical Case Summary

Introduction: Demodicosis is a disease of the pilosebaceous unit, involving mainly face and head areas, caused by Demodex mites.
It can be seen in primary or secondary forms (Chen and Plewig). Secondary demodicosis is defined as skin lesions associated with an abnormal increase of Demodex mites due to skin or systemic diseases. It occurs significantly in immunosuppressed patients with leukaemia, human immunodeficiency virus infection or those being treated with topical or systemic immunosuppressants.
We report the case of a patient treated for Crohn's disease with Infliximab who developed Demodicosis.
Case report: A 26-year-old man, with 4 years history of stricturing ileo-caecal Crohn’s for which he had an ileo-caecal resection with an ileo-colic anastomosis, and perianal fistula treated by seton placement and antibiotics.
Subsequently, Infliximab treatment was initiated at a dose of 5mg/kg every 8 weeks.1 year into the treatment, the patient experienced pruritus, redness and dryness of the cheeks leading to a referral for a dermatology consultation.
Physical examination revealed skin xerosis, scaly erythematous plaques around the periphery, circinate on the forearm and facial erythema.
At polarized-light dermoscopy of the facial lesions, Demodex tails with Demodex follicular openings and telangiectasias were observed.
The diagnosis of demodicosis was made and the patient was treated with oral doxycycline (100mg/day), and a topical cream based on sertaconazole with noticeable improvement .
Conclusion: Demodicosis should be taken into account in patients treated with biological medications and presenting atypical inflammatory skin lesions.

References

1. Chen W, Plewig G. Human demodicosis: revisit and a proposed classification. Br J Dermatol 2014; 170: 1219-25.
2. CORDAN YAZICI A, Güliz İKİZOĞLU G. Demodicosis. Turkiye Klinikleri J Med Sci. 2019;39(2):231-6

Introduction

There has been a shift from percutaneous drainage towards endoscopic ultrasound (EUS)-guided drainage for management of post-operative pancreatic fluid collections (POPFC). However, available series have been limited by sample size and little is known about the factors that may influence clinical success.

Aims & Methods

Our aim was to evaluate the outcomes of EUS-guided drainage of POPFC following pancreatic surgery and identify predictors of clinical success.
We performed a retrospective review of patients who underwent EUS-guided drainage of POPFC between 2014 and August 2024 at three academic centers. Primary outcome was clinical success, defined as the complete radiological regression of the collection and resolution of symptoms without the need for additional drainage procedures.

Results

In total, 265 cases were included (mean age 64 [SD±13.9] years, 37% pylorus-resecting pancreatoduodenectomy). Early drainage (≤14 days) was performed in 52% of cases (n=138) and DPPS were used in 209 cases (79%).
Clinical success with a single EUS drainage procedure was achieved in 160 cases (60.4%). Step-up interventions were required in 67 patients (25.3%), 37 of which required endoscopic revision only. Technical success was achieved in 90% (n=238) and adverse events occurred in 43 cases (16%).
Stent type, drainage timing, splenectomy and drainage route did not seem to significantly influence clinical success. Multivariate analysis including stent type and surgical history, showed that distal pancreatectomy was an independent risk factor for clinical failure.

Conclusion

EUS-guided drainage of POPFC was effective in the majority of cases with a single procedure, although distal pancreatectomy was suggested as an independent risk factor for clinical failure. These results further support the use of EUS-guided drainage for the management of postoperative collections.

Disclosure

HH declares no competing interests. MB received trial support from Boston Scientific and holds consultancy agreements with Dekra, Ovesco and Prion Medical. GV received lecture fees from Boston Scientific and travel grants from Pentax Medical and Euromedical. RVW holds a consultancy agreement with Boston Scientific. Schalk van der Merwe holds the Cook chair in Interventional endoscopy, has consultancy agreements with Cook, Pentax and Olympus and co-chairs the Boston-Scientific Chair in Therapeutic Biliopancreatic Endoscopy.

Clinical Case Summary

Introduction: Locally advanced pancreatic tumors can lead to both biliary and duodenal obstruction by invasion or compression. Quality of life is severely affected if obstruction occurs: jaundice, emesis and pain can become invalidating and patients become too frail for palliative chemotherapy and are sometimes declared unfit even for derivative surgery. Recently, endoscopic techniques under EUS or ERCP guidance are being used to create biliodigestive and enteral anastomoses.
Clinical case: A 75-year-old female was diagnosed with locally advanced pancreatic head adenocarcinoma in January 2024. The tumor was declared unresectable and chemotherapy was initiated. A plastic stent was inserted into the main biliary duct (MBD) to ensure biliary drainage. In May 2024, she presented with cholangitis and emesis. EGD revealed duodenal stenosis and ERCP failed due to tumor infiltration. A combined endoscopic approach was performed: EUS-guided hepatico-gastrostomy (EHG) for biliary drainage and EUS-guided gastro-enterostomy using a lumen-apposing metal stent (LAMS). In July 2024, the plastic stent was removed, and in August 2024, two fully covered 60 x 10 mm SEMS were inserted antegrade through the EHG into the MBD to improve patency. At 11 months post-intervention, the patient returned for routine reassessment, declaring good clinical performance: she remained asymptomatic, with routine blood tests, including bilirubin levels within normal range and with all stents patent and correctly positioned (confirmed radiologically and endoscopically). The patient was able to maintain oral intake and continue chemotherapy. No late adverse events were noted.
Conclusion: This case demonstrates the long-term clinical and technical success of a staged endoscopic triple bypass for the management of complex biliary and duodenal obstruction due to unresectable pancreatic cancer. The approach was minimally invasive, well tolerated and remarkably improved the patient's quality of life.

References

1. Adler, Douglas G MD; Baron, Todd H MD, FACP. Endoscopic Palliation of Malignant Gastric Outlet Obstruction Using Self-Expanding Metal Stents: Experience in 36 Patients. American Journal of Gastroenterology 97(1):p 72-78, January 2002. | DOI: 10.1111/j.1572-0241.2002.05423.x
2. Giovannini, Marc. (2019). EUS-guided hepaticogastrostomy. Endoscopic Ultrasound. 8. 35. 10.4103/eus.eus_47_19.
3. Dumonceau, Jean-Marc & Tringali, Andrea & Blero, Daniel & Devière, J & Laugiers, R & Heresbach, D & Costamagna, Guido. (2012). Biliary stenting: Indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy. 44. 277-98. 10.1055/s-0031-1291633.
4. Van Der Merwe, S. W., Van Wanrooij, R. L., Bronswijk, M., Everett, S., Lakhtakia, S., Rimbas, M., ... & Van Hooft, J. E. (2022). Therapeutic endoscopic ultrasound: European society of gastrointestinal endoscopy (ESGE) guideline. Endoscopy, 54(02), 185-205. 10.1055/a-1717-1391

Introduction

In Australian patients receiving intravenous (IV) infliximab (IFX) treatment, 44% of patients do not respond to standard regimen and require dose escalation within a year. The REMSWITCH (6-month evaluation) and REMSWITCH-LT (18-months evaluation) investigated the effectiveness of switching from IV to subcutaneous (SC) IFX in patients with inflammatory bowel disease (IBD) who received standard and dose-escalated IV regimen. The two studies concluded that a fixed dose of 120 mg Q2W is feasible, safe and well-accepted leading to a low risk of long-term relapse in patients with escalated IV doses except for those on 10mg/kg/4weeks regimen. In this study, we developed a model to estimate the financial implications of switching.

Aims & Methods

Clinical efficacy parameters were derived from the REMSWITCH and REMSWITCH-LT studies and applied to the Australian context. Number of Australian patients who are on IFX, the proportion of patients on dose escalated regimen, and cost parameters were identified from the published literature or publicly available resources. A financial model was developed based on the assumption that a cohort of patients will receive either IV or SC IFX, and the analysis concluded with the cost difference.

Results

The model assumes that a total of 5.6K patients are receiving IV IFX, with 44.2% of them receiving dose escalation and/or shortened interval of IV IFX. The model produced 6 months and 12 months results, suggesting savings between 582 and 882 AUD per patient, respectively, and equates to a yearly societal savings of 5 million AUD.

Conclusion

IFX SC deserves premium over IFX IV, given that the novel formulation offers tangible and intangible benefits that originator Remicade and biosimilars cannot provide. There is a concern regarding the affordability of SC IFX because it is generally priced higher than IV IFX, which has many biosimilars on the market. However, this study asserts that fixed dosing of 120mg of IFX is cost-saving for society, considering highly prevalent practice of dose escalation and/or shortened intervals of IFX regimen.

Introduction

The Maastricht V/ Florence Consensus has updated guidelines for the management of Helicobacter Pylori (HP) infection with special emphasis in high clarithromycin resistance settings as it is the case in our country. In line with the recommendations of the European Guidelines on surgery of severe obesity [1] and the recommendations of the American Society of Gastrointestinal Endoscopy on endoscopy of the bariatric patient [2) a policy of systematic HP screening and overtime updated eradication was implemented in obese patients undergoing Roux-en Y gastric bypass (RYGB) surgery.

Aims & Methods

Five year period (2020-2024) single center study. The aim was, in obese patients undergoing RYGB surgery, to assess the cumulative HP eradication rate by adopting, at first line, a 10 days bismuth quadruple therapy (BQT) - proton pump inhibitor (PPI) bid and three-in-one single capsule containing bismuth, metronidazole, and tetracycline qid - and, at second line, a 14 days levofloxacin based therapy ( LBT) – PPI bid, amoxicillin 1000 mg bid and levofloxacin 500mg bid. HP infection status was assessed, at baseline, by histology or urea breath test and post treatment, by urea breath test 4-6 weeks after the end of the therapy.

Results

One thousand four hundred and forty-nine consecutive HP‑positive patients completed BQT treatment: 1160 (80.1%) female, age 43.5 (±10.5) years, median age of 44 years), age range of 18-69 years. HP was eradicated in 1220 patients – 84.2% (95%CI: 82.2%-86.0%). In the remaining 229 patients, 87 patients withdrew and HP was eradicated in 118 patients out of 145 with LBT. The intention to treat (ITT) and per protocol (PP) cumulative eradication rates were, respectively, 92.3% (95%CI: 90.9%-93.6%). and 98.0% (95%CI: 97.1%-98.6%). Eradication rates were not significantly different by gender and age.

Conclusion

By adopting the Maastricht V/ Florence Consensus BQT first line therapy and second line LBT therapy, high ITT and PP cumulative HP eradication rates are achieved leaving only a residual number of obese patients undergoing RYGB in need of the culture and susceptibility testing prior to third line treatment.

References

1. Fried M, Hainer V, Basdevant A, et al. European Guidelines on surgery of severe obesity. . International Journal Of Obesity 2007;31:569-577.
2. ASGE Guidelines. Role of endoscopy in the bariatric patient. Gastrointest Endosc 2008; 68:1-10.

Disclosure

NO CONFLICT OF INTEREST

Introduction

Apelin (APL), originally isolated from alimentary tract, has been defined as the endogenous ligand for APJ, which is a known G protein-coupled receptor. It has been reported that APL is upregulated in the colonic tissues of an animal model of acute colitis induced by dextran sodium sulfate (DSS), and it is suggested to be associated with the pathogenesis of inflammatory bowel diseases (IBD), such as Crohn’s disease and ulcerative colitis, in humans. However, the mechanism and function of APL in the context of IBD remain unclear.

Aims & Methods

The aim of this study was to define the function of APL in the pathogenesis of IBD. To this end, each cell type in the colonic tissue, including epithelial cells and lamina propria lymphocytes, were first isolated from wild-type C57BL6 mice (WT) to assess APL expression. Next, naïve T cells isolated from WT were adoptively transferred into Rag deficient mice (Rag^-/-) to induce chronic colitis, followed by isolation of splenic and colonic CD4⁺ T cells from these T cell-reconstituted Rag^-/- to compare with those of WT. In addition, WT naïve T cells were differentiated into either Th1, Th2 or Th17 in vitro to analyze APL expression. Finally, the Rag^-/- receiving naïve T cells were administered synthetic APL peptide, APL-13, to assess the severity of colitis.

Results

Semi-quantitative PCR (qPCR) revealed that CD4⁺ T cells express relatively higher level of APL when compared to other cell types including the epithelial cells in colonic tissue from WT. However, APL expression in the colonic tissues from the Rag^-/- induced chronic colitis was unexpectedly downregulated compared to those without colitis, which is not consistent with the previous report using acute DSS colitis model. Subsequently, qPCR revealed significantly decreased APL expression in the splenic and colonic T cells from Rag^-/- induced colitis compared to that of WT. APL expressions in all of the differentiated T cells in vitro, such as Th1, Th2 and Th17, were also significantly downregulated compared to that of non-differentiated control T cells. Given these results, APL-13 was injected into the Rag^-/- that underwent T cell reconstitution to antagonize the APL downregulation. This resulted in reduced severity of colitis compared to that of vehicle control-injected mice.

Conclusion

Our results indicate that T cells can be one of the major sources of APL in colonic tissues, and the downregulated APL expression in effecter T cells may lead to the development of chronic colitis. In addition, our current study also suggests that APL may be a novel therapeutic target for IBD.