Introduction

Patients with typical Gastroesophageal reflux disease (GERD) symptoms frequently report Dysphagia. During HRM study patients with GERD show in an increased rate ineffective or absent esophageal motility and Low Esophageal Sphincter (LES) pressure though no data exist about disturbances of Distal latency (DL).

Aims & Methods

As typically patients with spastic disorders of the esophagus present with dysphagia and show decreased DL we aimed to investigate if there is a correlation between GERD, dysphagia and DL disturbances. We included 2629 patients with typical long-lasting symptoms, submitted to High Resolution Manometry and 24 hrs pH-Impedance study (pH-IM), off-PPI. Patients with a positive endoscopic GERD diagnosis undergoing pre-operativel HRM/pH-impedance, with a previous definite GERD diagnosis studied “on” PPI, using of opioids, history of esophageal surgery or diagnosed with major motility disorders except absent peristalsis (Chicago IV classification) were excluded. GERD diagnosis was made by using Lyon consensus criteria for pH-IM; Acid Exposure time (AET)> 6%.

Results

GERD was diagnosed in 845 (32.1%) pts while indefinite AET for GERD (4-6%) was found in 300 (11.4%). Any grade of dysphagia was reported by 934 (35.5%) pts. Patients with dysphagia had decrease DL (6.2±1.7 vs 6.5±2.7 in patients not reporting dysphagia, p=0.008) Patients with GERD showed decreased DL in comparison to patients without (6.1±1.8 vs 6.6±2.7, p<0.001). GERD diagnosis was not correlated to report of dysphagia (300/845 35.5% vs 536/1484, 36.1% in pts without GERD, p=0.788) and no difference in mean DL was observed in patients with GERD and or without dysphagia (6.2±1.8 vs 6.1±1.9, p=0.772). GERD was also correlated to Esophagogastric Junction (EGJ) type 2 or 3 anatomy (358/845, 42.4% vs 361/1484, 24.3%, p<0.001), diagnosis of ineffective esophageal motility/absent peristalsis (375/845, 44.7% vs 530/1484, 35.7%, p<0.001) and LES hypotension (449/845, 53.1% vs 665/1484, 44.8%, p<0.001). The correlation of DL to GERD was maintained in the multivariate logistic regression analysis (p=0.002, OR: 0.907, 95% C.I 0.853-0.964) fact also observed for type 2/3 EGJ (p<0.001, OR:2.255) and diagnosis of ineffective motility/absent peristalsis (p=0.001, OR: 1.468).

Conclusion

Patients reporting typical reflux symptoms and dysphagia show decreased DL even when a diagnosis of diffuse Esophageal Spasm is not met. Patients with GERD diagnosis by pH-impedance and typical reflux symptoms show decreased DL in comparison to patients without GERD. Though lower DL observed among patients with GERD was not correlated to dysphagia.

Clinical Case Summary

A 50 year old paraplegic gentleman (secondary to a road traffic accident) with a diversion colostomy and preserved small bowel length, and a history of idiopathic cirrhosis, was admitted with a one week history of high output stoma. Initially felt to be infectious, he was resuscitated with volume and electrolyte replacement. Despite a negative infection, autoimmune and extended inflammatory screen, the high stoma output persisted between 4-6L per 24 hours. He subsequently developed circulatory failure due to volume losses and required intensive care support for fluid management, parenteral nutrition (PN) and inotropes. Serial cross sectional imaging showed oedematous jejunal and ileal bowel without evidence of vascular insufficiency.

His stoma output failed to respond to maximum doses of loperamide, octreotide, proton pump inhibitors or opiates. He was commenced on a trial of high dose steroids without any benefit. A colonoscopy showed grossly oedematous bowel, with biopsies demonstrating preserved crypt architecture on a background of significant oedema. He was PN dependant with challenging management of his fluid balance. Due to a new acute renal injury with nephrotic range proteinuria, further stains on his colonic biopsies were requested. These stained positive with congo red, showing apple green birefringence which was suggestive of a diagnosis of Amyloidosis.
Following consultation with the National Amyloidosis Referral Centre, further investigations were requested which showed an amyloid load in the spleen (SAP scan) and chronic pelvic sepsis (PET CT) likely to be driving a chronic inflammatory state. Due to the advance nature of his disease, no active treatment could be offered and the patient unfortunately passed away 8 months into their hospital admission due to multi-organ failure.
Through reporting of this case, we want to raise awareness of Amyloidosis as a rare cause of Type 2 intestinal failure.

Clinical Case Summary

Introduction: Superior Mesenteric Vein (SMV) Thrombosis accounts for only 5% of all cases of intestinal ischemia. As opposed to acute mesenteric ischemia secondary to an arterial thrombus which has a more drastic presentation, SMV thrombus typically presents with non-specific signs and symptoms. Rarely, when venous congestion leads to bowel wall edema which can consequently head to intestinal obstruction.
Case presentation: We present the case of a 47-year-old male presenting with severe generalized abdominal pain and vomiting. Abdominal CT findings were suggestive of small bowel obstruction and venous thrombosis. CT angiogram confirmed SMV thrombus which was visualized as severe narrowing of the SMV at the midabdomen a few centimeters above the umbilicus, with consequent congestion and decreased contrast enhancement proximal to the area of narrowing. The patient was initially managed conservatively with anticoagulation, however the patient did not improve clinically. Since there were no signs of infarction or peritonitis that would warrant immediate surgical intervention, an alternative approach using endovascular technique was attempted. The patient underwent SMV stenting which subsequently relieved the obstruction.

References

1. Treatment of superior mesenteric and portal vein thrombosis with direct thrombolytic infusion via an operatively placed mesenteric catheter; https://pubmed.ncbi.nlm.nih.gov/1527918
2. A systematic review of the management of acute superior mesenteric vein thrombosis in adults https://mednexus.org/doi/full/10.1097/JP9.0000000000000051
3. Naffouj S, Al-Shammari M, Salgia R. Treatment of colonic varices with a superior mesenteric venous stent: a case report describing a unique approach. Gastroenterol Rep (Oxf). 2021 Feb 4;9(6):597-600. doi: 10.1093/gastro/goab003. PMID: 34925858; PMCID: PMC8677559
4. Vekariya P, Daneti D, Senthamizhselvan K, et al. (June 14, 2021) Acute Intestinal Obstruction as an Initial Presentation of Mesenteric Venous Thrombosis. Cureus 13(6): e15652. doi:10.7759/cureus.15652

Disclosure

None

Introduction

Upper gastrointestinal bleeding (UGIB) is associated with an unfavorable prognosis in cancer patients. In biliary tract cancers (BTCs), little is known about the occurrence of UGIB and its prognostic relevance for the course of the disease.

Aims & Methods

The aim of this study was to analyze the prevalence of UGIB in BTC patients, compare therapeutic approaches for efficacy, and identify parameters associated with survival and recurrence rates. This retrospective observational study included all patients with BTCs and UGIB, that were treated in our tertiary care hospital between 2010 and 2023.

Results

A total of 1033 patients with BTC were analyzed. 41 (4.0%) of these patients had a total of 60 bleeding events. At the time of the bleeding event, 30.8% of patients displayed symptoms of shock, and 67.5% received red blood cell transfusions. The most common causes of bleeding were tumor infiltration (24.4%), variceal bleeding (19.5%), or ulcer bleeding (14.6%). At the time of presentation, 56.4% of patients had stage IV cancer. Most patients had perihilar (39.0%) or intrahepatic (34.1%) cholangiocarcinoma. At index bleeding, endoscopic treatment was performed in 41,5% of cases, while conservative measures (53,7%) or interventional radiological procedures (4.9%) were used in the remaining cases. In cases of bleeding caused by tumor infiltration, endoscopic hemostasis was usually performed using hemostatic powder (18.8%) or clip application (12.5%). Admission to an intermediate or intensive care unit (odds ratio 6.7; 95% CI 1.5 – 33.9) as well as symptoms of shock at the time of the bleeding event (odds ratio 2.6; 95% CI 0.5 – 15.6) were risk factors of rebleeding within 14 days. In patients with UGIB due to tumor infiltration, bleeding recurred after endoscopic therapy in 33.3% of cases. With conservative therapy, the recurrence rate was 28.6%. Survival of Patients with UGIB due to tumor infiltration was significantly shorter compared with patients having non-tumor-associated UGIB (median survival 0.93 vs. 6.5 months, log-rank test p = 0.018).

Conclusion

UGIB is a rare but serious complication in patients with BTC. Patients with major bleeding episodes should be closely monitored for short-term rebleeding. The occurrence of UGIB due to tumor infiltration is associated with adverse outcomes and significantly shortened survival time.