Introduction

Despite the introduction into clinical practice of serological neoplastic biomarkers and typical radiological characteristics, useful for the differential diagnosis of focal liver lesions, liver biopsy (LB) is still often necessary, especially in unclear cases, to achieve histological diagnosis. Nowadays, LB via percutaneous approach (PC-LB), under computed tomography (CT) scan or ultrasonograpy (US) guidance, is the route of choice. However, there are focal liver lesions that are poorly reachable via percutaneous approach. In these cases endoscopic ultrasound (EUS) guided fine needle biopsy (FNB) may be represents an attractive minimally invasive alternative.

Aims & Methods

Aim of this retrospective observational study was to evaluate the efficacy, diagnostic performances and safety of EUS-FNB of focal liver lesions. The indication to perform EUS-LB was the presence of a focal liver lesion poorly accessible via a percutaneous approach or incidentally found during an EUS examination

Results

58 patients were included, 43 patients had a final diagnosis of malignancy. The localization of lesions was 72.4 % (42 cases) in the left lobe and 27.6 % (16 cases) in the right lobe. The focal liver lesions localizations were summarized in Table 2. The median number of needle passes was 2 (IQR: 3–4). Only in 3 cases (5 %) the specimen was suboptimal for histological evaluation and in all of these, the focal liver lesions were located in right lobe. The overall sensitivity and specificity were 95% and 100% respectively while overall adequacy and accuracy were 95 % and 96% respectively. Subgroup analysis, conducted for different gauge FNB needles used, showed different diagnostic yeld. In particular, adequacy and accuracy for 19-gauge FNB needle were 100% and 95%, adequacy and accuracy were both 100 % for 20-gauge FNB needle and were 90% and 96% for 22-gauge FNB needle. Of note, all three inadequate biopsies were performed with a 22-gauge needle. On the other hand, subgroup analysis for different FNB needle type used, showed adequacy and accuracy of 94 % and 95% respectively for Acquire needle (Boston Scientific, Natick, MA, United States) and, adequacy and accuracy of both 100% for ProCore needle (Cook Medical Inc., Winston-Salem, North Carolina, United States). Technical success was 100% both for right and left liver lobe. Adequacy for focal liver lesion located in left and right lobe was 100 % and 81.2 % respectively and the difference was statistically significant [p= 0.001]. We also compared the diagnostic yield of EUS‑LB between the right lobe and left lobe mass. Median size of lesions on EUS and median number of needle passes did not differ significantly between the left and right lobes. Sensitivity for lesions located in left liver lobe and right liver lobe were 96 % and 91% respectively [p=0.001]. Specificity was 100% for lesions located in left and right liver lobe. Predictive positive value (PPV) was 100% for lesions located in both liver lobe. Predictive negative value (PPV) for lesions located in left liver lobe and right liver lobe were 90% and 50% respectively [p= 0.001]. No intra/postprocedural adverse events were recorded according to AGREE classification.

Conclusion

EUS-guided focal liver lesions biopsy using FNB is effective in achieving accurate diagnosis with an excellent safety profile. The main indication for EUS-FNB of focal liver lesions could be to obtain a specimen from the lesions located in the left liver lobe, close to big vessels or in obese patients which are more difficult to obtain by other techniques.

Introduction

Chronic liver disease remains one of the most common causes for hospital admission and is associated with high morbidity and mortality rates. Timely and adequate management within the first 24 hours is crucial for improving clinical outcomes in cases of decompensated cirrhosis. This study aimed to evaluate the impact of implementing a care bundle checklist during the first 24 hours of hospital admission on management and outcomes of decompensated cirrhosis.

Aims & Methods

We developed an adapted care bundle (based on the BSG/BASL care bundle, AASLD quality measures proposal, Baveno VII consensus, and EASL guidelines) and compared two patient groups from two Portuguese hospital centers: Group-A (retrospective, pre-care bundle implementation) and Group-B (prospective, post-care bundle implementation).

Results

A total of 224 patients (Group-A: 148; Group-B: 76) were included. More than one decompensation was observed in 118 patients (52.7%), and 69 patients (30.8%) were experiencing their index hospitalization for liver decompensation. Regarding etiology, alcoholic liver disease was the most common (n=200; 89.3%). The groups were similar in terms of gender, age, length of hospital stay, and Child-Pugh and MELD-Na scores at admission. The most common decompensations were gastrointestinal bleeding (n=91; 40.6%), ascites (n=75; 33.5%), and hepatic encephalopathy (n=72; 32.1%). Group B was more likely to present with multiple decompensations at admission and exhibited significantly higher rates of acute kidney injury, hepatocellular carcinoma, acute-on-chronic liver failure, and portal vein thrombosis (p<0.05). Following care bundle implementation, we found significant improvements in patient care. At admission, patients were significantly more likely to undergo urine and blood cultures, chest X-ray, and abdominal ultrasound (p<0.05), receive diagnostic paracentesis (p<0.05), and have an accurate alcohol history documented (p=0.04). During admission, Group-B was significantly more likely to be prescribed lactulose for encephalopathy prophylaxis, vasopressor therapy for gastrointestinal bleeding, and venous thromboembolism prophylaxis, as well as undergo nutritional assessment (p<0.05). While in-hospital mortality rates were similar (4.7% vs. 5.3%; p=1), 6-week mortality rates (8.8% vs. 3.9%; p=0.01) and 3-month readmission rates (31.1% vs. 15.8%; p=0.02) were significantly lower in the post-intervention cohort.

Conclusion

The implementation of a standardized care bundle was associated with higher rates of appropriate investigation and treatment within the first 24 hours of hospital admission and improved patient outcomes, reducing 6-week mortality and 3-month readmission rates.

Clinical Case Summary

Introduction: A rare but serious side effect of SGLT-2 inhibitors is the euglycemic diabetic ketoacidosis (DKA), which is usually triggered by acute disease (e.g. infection), reduced food and fluid intake, reduced insulin doses, or alcohol consumption.^1-4
Case report: A 53-year-old patient, with a history of type 2 diabetes mellitus treated with metformin and empagliflozin, presented with abdominal pain, jaundice and abnormal liver function tests (AST: 338 U/l, ALT: 508 U/l, γ-GT: 2020 U/l, ALP: 483 U/l, TBL: 2.65 mg/dl, DBL: 2 .22 mg/dl). Abdominal U/S revealed intrahepatic and extrahepatic bile duct dilatations. The patient underwent ERCP (Figure A) where a stenosis in the intrapancreatic segment of the bile duct was revealed and a fully covered metal stent of 6 cm length was placed, while a cytological smear was positive for adenocarcinoma. Abdominal CT scan (Figure B) revealed a hypodense lesion (d. 3cm) in the head of the pancreas. Postoperatively, the patient manifested abdominal pain, fever, vomiting, lethargy, tachypnea and tachycardia with increased inflammatory markers and cholestatic enzymes and normal serum glucose. Arterial blood gases revealed metabolic acidosis (PH: 7.21, HCO3: 13 mmol/l, Lac: 0.8 mmol/l) with an increased anion gap (25 mmol/l) and ketonuria (ketone > 43 mg/dl). Euglycemic diabetic ketoacidosis was treated with an insulin pump with co-administration of glucose solution and intravenous administration of crystalline fluids and potassium replenishment. SGLT-2 inhibitor was discontinued. Microbemia due to Pseudomonas aeruginosa was detected and due to lack of apyrexia, an imaging re-evaluation with CT scan was performed where a liver abscess was detected (Figure C). Eventually, liver abscess was treated with drainage under CT guidance (Figure D).
Conclusion: Euglycemic diabetic ketoacidosis is a rare but serious complication of SGLT-2 inhibitors, which requires a high level of awareness from physicians for early recognition.

References

1. Sethi SM, Vohra M, Ali SA. EUGLYCEMIC DIABETIC KETOACIDOSIS (EDKA) IN A PATIENT RECEIVING DAPAGLIFLOZIN. Acta Endocrinol (Buchar). 2021 Apr-Jun;17(2):266-269.
2. Acevedo-Mendez BA, Ye Y, Hajizadeh N, Myers A. Hypertriglyceridemia-Induced Acute Pancreatitis, Euglycemic Diabetic Ketoacidosis and COVID-19 Infection in a Patient With Type 2 Diabetes Taking a Sodium-Glucose Cotransporter 2 Inhibitor. Cureus. 2021 Nov 23;13(11):e19828.
3. Sampani, E., Sarafidis, P., Dimitriadis, C. et al. Severe euglycemic diabetic ketoacidosis of multifactorial etiology in a type 2 diabetic patient treated with empagliflozin: case report and literature review. BMC Nephrol 21, 276 (2020).
4. Yii ESS, Azli AW, Sitaram PN. Sodium-glucose cotransporter 2 inhibitor-induced euglycemic diabetic ketoacidosis in a patient with coronavirus disease 2019: a case report. J Med Case Rep. 2022 Jan 4;16(1):17.

Clinical Case Summary

Introduction: Rituximab, a monoclonal anti-CD20 antibody, is widely used for treating hematologic malignancies and autoimmune disorders due to its B-cell depleting action. While gastrointestinal side effects like diarrhea are seen in up to 15% of patients, these are typically mild and self-limiting. Severe colitis is a rare but increasingly recognized complication.
Case Description: A 76-year-old diabetic male with a history of ACS (post-PTCA in 2021) presented with 2 months history of generalized abdominal pain, watery diarrhea (6–7 episodes/day), and weight loss. He had a history of follicular lymphoma diagnosed 4 years prior, treated with 6 cycles of CHOP-R followed by rituximab maintenance (375 mg/m² every 3 months). Symptoms began after the 6th maintenance dose.Physical exam revealed mild pallor;abdomen was soft, nontender. Labs showed normocytic anemia and mild neutrophilic leukocytosis. Stool tests were negative for common pathogens, including C. difficile. The patient was planned for a Colonoscopy, which revealed ulcers over the ileocecal valve and rectal erosions. Biopsies showed mixed inflammatory infiltrates, cryptitis, crypt abscesses, and crypt rupture, consistent with severe active ileocolitis. AFB culture and GeneXpert were negative for tuberculosis.The patient was started on oral mesalamine (500 mg TID) along with Rifaximin(400mg) BD for 2 weeks, showing marked clinical improvement.
Discussion: Rituximab-induced colitis is rare and poorly understood. It may result from disruption of mucosal immunoregulation due to B-cell depletion, leading to T-cell-mediated inflammation. Histology may resemble patterns seen in GVHD or autoimmune enteropathy. Most cases resolve with supportive care and discontinuation of the drug; however, some, like this case, may require treatment in the form of 5ASA, or steroids.There is no previous data on the use of rifaximin in such cases. Differentiating drug-induced IBD from primary IBD remains a diagnostic challenge.

References

There is limited evidence in the literature establishing a definitive association between rituximab therapy and the onset of colitis. However, emerging hypotheses suggest that rituximab-induced depletion of peripheral CD19+ B cells and colonic CD20+ lymphoid aggregates may disrupt mucosal immune homeostasis, thereby contributing to structural alterations in the intestinal architecture and promoting inflammation.
The role of the gut microbiota in the pathogenesis and persistence of mucosal inflammation in inflammatory bowel disease (IBD) provides a rationale for the therapeutic use of antibiotics in selected cases. While systemic antibiotics such as ciprofloxacin and metronidazole have demonstrated clinical efficacy in IBD management, their utility may be limited in drug-induced colitis due to the potential for systemic adverse effects.
In contrast, rifaximin, a non-systemic, presents a favorable safety profile and has shown promise as a therapeutic option in both idiopathic and drug-induced enterocolitis. Its targeted antimicrobial activity within the gastrointestinal tract, combined with minimal systemic exposure, renders it an attractive alternative. However, further prospective, randomized studies are warranted to substantiate its efficacy and long-term safety in this context.