Introduction

High-Resolution Manometry (HRM) is the most sensitive and specific test available for clinical assessment of hiatal hernia (HH), a common condition defined as the separation between the Lower Esophageal Sphincter (LES) and crural diaphragm (CD). While the link between HH and Gastroesophageal Reflux Disease (GERD) is established, the potential role of Hiatal Hernia in inducing oesophageal dismotility, independently form GERD, is uncertain.

Aims & Methods

We aimed to analyze whether the presence of HH, with or without GERD, is able to alter the oesophageal motility, in terms of Ineffective Peristalsis (IP), Jackhammer Esophagus (JE) or Outflow Obstruction (OO). Consecutive patients without previous esophageal surgery who underwent HRM between 2018 and 2022 were enrolled (56.8% females; mean age 57 years, CI 47 – 69; BMI 24.2, CI 21.5 – 26.8). All patients with symptoms suspicious for GERD underwent impedance-pH testing off-therapy. HH was defined as a separation > 1 cm between LES and CD and esophagogastric junction (EGJ) morphology was classified as: Type I, no separation between LES and CD; Type II, minimal separation (>1 and <2 cm); Type III, ≥ 2 cm separation. Demographic characteristics collected included: age, gender, alcohol and coffee intake, smoke habits, GERD diagnosis and symptoms duration. Two cohorts of patients, with and without HH, were individuated and the potential association with ineffective peristalsis, jackhammer esophagus and outflow obstruction was analyzed with univariate and multivariate logistic regressions.

Results

Eight-hundred-forty-eight patients were enrolled and 295 cases of HH (38.8%), subdivided in 199 (23.5%) Type II- and 96 (11.3%) Type III-EGJ patients were identified. Ineffective peristalsis was diagnosed in 162 (19.1 %) patients, jackhammer oesophagus in 32 (3.8 %), and outflow obstruction in 91 (10.7 %), while GERD was present in 473 (55.8%) patients. HH was significantly associated with ineffective peristalsis (P<0.001) and GERD (P<0.001). Furthermore, HH resulted a risk factor for ineffective peristalsis (OR = 1.60, 95%CI 1.12-2.27, P<0.001) when the analysis was conducted in both all the 848 subjects and in patients without GERD (OR = 1.84, 95%CI 1.05-3.21, P=0.03). The risk for ineffective peristalsis was 1.3 time greater for every centimeter of HH. No statistically significant association was found between HH and outflow obstruction or jackhammer esophagus.

Conclusion

Increasing separation between LES and CD can cause a gradual and significant increasing risk of ineffective peristalsis. Interestingly, this association with HH is true not only in patients with but also in those without GERD. These results suggest that EGJ morphology seems to be able to alter esophageal motility as measured with High-Resolution Manometry.

Introduction

EUS guided cysto- gastrostomy/duodenostomy is well established now as a standard treatment option for symptomatic pancreatic pseudocyst in adult. Pancreatic pseudocyst in children is rare and tend to resolve spontaneously. Pancreatic pseudocyst that persists more than 6 weeks and cause symptoms considered a troublesome and need drainage either surgical, radiological or endoscopic. There are limited data regarding EUS guided cysto-gastrostomy in the childhood age group (2- 12 years). This is due to limited number of cases in this age group, the lack of experienced pediatric gastroenterologist with this technique and relatively large diameter of therapeutic EUS with a rigid tip that may restricts its use in young children.
We assessed the feasibility of EUS guided drainage of symptomatic pancreatic pseudocyst in children as an effective and safe procedure.

Aims & Methods

This is a multi-center retrospective study. We reviewed our data base for all children between the ages of 3 and 12 years underwent EUS guided pancreatic pseudocyst drainage between Oct 2018 and Dec 2022. We assessed preprocedural patient indication (including cause of previous pancreatitis, present complaint, and imaging), procedure technical success, early and delayed procedure related complication and clinical success.

Results

EUS guided cysto-gastrostomy was performed in nine children (six were males and 3 were females). The median age of the included children was 8 years (ranging from 3: 12 years) and the median Weight was 26.4 kg (ranging from 14.5: 37 kg). The cause of previous pancreatitis was blunt trauma in 4 cases, post chemotherapy for ALL in 3 cases and two were biliary cause. We had 100% clinical success with deployment of short double pigtail plastic stent (10Fr x 5 or 7 cm) through created fistula between the gastric lumen and cyst (the fistula was done by using 6 fr cystotome over guidewire and was dilated using mechanical dilator in 5 cases and 6:8 mm balloon in 4 cases). All patients resolved completely from pre- procedure symptoms and eight patients had complete cyst resolution after one month. One case has marked regression from 9.5 cm to less than 2 cm, this case also did trans-papillary drainage for pancreatic duct disruption. No post procedure complications were observed, only mild pancreatitis managed conservatively for 3 days in the child underwent concomitant trans-papillary drainage.

Conclusion

EUS guided cysto- gastrostomy for childhood population with symptomatic pseudocyst appeared to be feasible, effective, and safe procedure using therapeutic endoscopic ultrasound. Larger number of cases needed to support this procedure as a standard treatment option for these cases.

Introduction

Lactose malabsorption (LM) is a common digestive disorder. The hydrogen breath test (HBT) is currently the non-invasive gold standard in diagnosing LM and lactose intolerance (LI), which is defined only in case of developing symptoms directly related to lactose ingestion in subjects with LM. (Misselwitz et al. 2019) The analysis of methane values in air samples may increase the accuracy of the test by including subjects “non hydrogen producers”. (De Geyter et al. 2021)

Aims & Methods

The aim of this study is to describe the relationship between pre-test clinical features, symptoms reported during lactose challenge and the result of the HBT in adults. In this prospective study we included a consecutive series of adult patients who underwent a HBT during a 5-month period. Air samples were taken every 30 minutes for 4 hours after the ingestion of a charge of 25 g of lactose. Symptoms reported in the previous 15 days (abdominal pain, bloating, diarrhoea, flatulence) and those experienced after lactose ingestion were assessed using a standard questionnaire establishing their presence or absence, and relative severity using 0-10 scale. The results were considered positive when a H₂ peak exceeded 20 parts per million (ppm) above the baseline or in case CH₄ excretion reached 10 ppm above the baseline, for experimental purpose. LI was defined by at least one symptom experienced during the test in subjects with LM.

Results

68 patients were included in the study and 40 of them (59%) were positive at the HBT. 52 (76%) developed at least one symptom while LI was diagnosed in 34 patients of them (65%). Only 40% of patients who referred pre-test symptoms had LM and none of the four symptoms was associated with LM or LI. A positive trend was found between abdominal bloating after lactose ingestion and a positive HBT (p 0.08). This association was statistically significant (73% vs 43%, p 0.02), with a positive trend also for flatulence (p 0.08) (Table), implementing diagnostic test with values of exhaled methane, finding 10 more intolerant patients. Considering the variation of symptoms (new or worsening of symptoms after lactose ingestion), the worsening of bloating was significantly more frequent in subjects with positive HBT compared to those with a negative test (40% vs 14%, p 0.03) and predictive of LI (PPV= 80%). Diarrhoea was the most predictive symptom of LI (PPV up to 88%). An association between the number of symptoms experienced during the test and LM was confirmed, while we didn’t find the same relationship with pre-test symptoms. (Beyerlein et al. 2008)

Conclusion

Symptoms reported before HBT seems to be non-related to LI. This may lead to arbitrary dietary exclusion of dairy products with consequences on bone health (Infante and Tormo 2000) and suggest that the causal role of lactose should be confirmed by HBT. In adult, the development ex-novo or the exacerbation of abdominal bloating and diarrhoea during the test, in subjects with LM, seems to be the most predictive of LI. Furthermore, the increase of the number of symptoms complained makes the diagnosis of LI more likely. On these basis, a domestic screening with 25 g of lactose (500 ml of milk) to establish whether the patient really needs the execution of breath test should be explored.

References

Beyerlein et al. 2008
De Geyter et al. 2021
Infante and Tormo 2000
Misselwitz et al. 2019

Introduction

Hepatitis C virus (HCV) infection is one of the leading causes of liver cirrhosis and hepatocellular carcinoma. Myeloid-derived suppressor cells (MDSC) are a heterogeneous population of activated immature myeloid cells that are characterized by different specific surface molecules, they express each of CD11b+CD33+ and lack expression of HLA-DR. MDSC are immunosuppressive cells that decrease immune cell activation and induce immunological tolerance in inflammation and cancer. Under normal conditions, MDSC remain in the bone marrow until differentiation; however, under pathological conditions these cells arrest at various stages of development, migrate out of the bone marrow in an immature state and, accumulate in circulation and peripheral lymphoid organs, causing negative regulation of immune responses via various mechanisms, primarily T cell suppression. MDSC are known to increase in patients with chronic hepatitis C virus infection. But it is not clear till now if eradication of HCV using directly acting antivirals can restore normal levels of MDSC on long term or not.

Aims & Methods

This study aimed to assess the levels of MDSC in patients with previous chronic hepatitis C after achieving sustained virologic response (SVR) for at least 2 years using sofosbuvir containing regimens.
This study was a case-control one. Fifty five subjects were involved in the study. All patients had completed DAAs therapy 2-3 years before involvement. Estimation of (CD33+ HLA-DR– CD11b+) expressing cells by flow cytometry was done and levels were compared between HCV patients achieved SVR for 2-3 years and healthy control without any current or previous chronic disease.

Results

MDSC were significantly higher among patients with eradicated HCV for 2-3 years than in healthy controls (4.98% (IQR=3.3 – 7.7) vs 3.09% (1.4 – 3.9), p = 0.001)

Conclusion

Normal MDSC levels are not restored after eradication of HCV using directly acting antivirals even after passage of 2 years on viral eradication. Clinical implications and consequences of these findings should be further investigated.

Clinical Case Summary

An hemoperitoneum may be the initial presentation of a liver tumour. A good differential diagnosis is critical, including trauma, vascular rupture and tumours.
A 79-year-old male, retired welder and painter, consulted for weight loss, abdominal pain and distension of 3 months of evolution. Ascitic semiology led to do a paracentesis with hematic debit. An urgent computerized tomography (CT) reported hemoperitoneum secondary to multicentric liver tumor with active bleeding (Figure 1) and intratumoral pseudoaneurysms compatible with angiosarcoma, performing an urgent transarterial embolization (Figure 2). Extension CT ruled out distant disease, magnetic resonance imaging (MRI) was realized (Figure 3) and fine needle aspiration (FNA) showed atypical cellular with CD31 expression (Figure 4), consistent with primary hepatic angiosarcoma (PHA). Given the bilobar involvement, surgery was dismissed and he was treated with chemotherapy (CTX), dying at 10 months of diagnosis.
PHA is a rare entity (2% of primary liver tumor) with an annual prevalence of 200 worldwide cases and a male predominance (3:1) at 60 years. It has been associated to exposure to vinyl chloride, arsenic or thoracotrast, but currently 75% of diagnoses have unknown aetiology.
Diagnosis is based on anatomopathology and inmunohistochemistry, including atypical cellularity in FNA and expression of vascular markers as ERG (100%), CD34 (87%) and CD31 (79%). Imaging tests are non-specific, with hypodense lesions in CT and T2-weighted hyperintense sequence in MRI.
Due to its aggressiveness, around 60% of PHA presents lymph nodes or lung, bones or spleen metastases at diagnosis. Liver resection is the only potentially curative treatment because it is a radioresistent tumour. Transplantation is not recommended due to its high recurrence rate. PHA has less than 6 months of overall survival (OS) without treatment. Otherwise, patients with CTX treatment has a OS of 3% at 2 years of diagnosis.

Introduction

Aging is associated with physiological changes in esophageal function, influencing motility and increasing susceptibility to dysphagia.

Aims & Methods

This study investigates esophageal peristaltic reserve across different age groups by employing multiple rapid swallow (MRS) during high-resolution manometry (HRM). A retrospective analysis was conducted on 331 patients presenting with dysphagia who underwent HRM between 2021 and 2023. Participants were stratified into four age groups: early adulthood (≤34 years, 12.1%), early middle-age (35–49 years, 12.7%), late middle-age (50–64 years, 45.3%), and late adulthood (≥65 years, 29.9%). Peristaltic reserve was assessed using MRS to evaluate esophageal contractile function.

Results

Among the 311 patients included, 195 (58.9%) were male, with a median age of 57 years (IQR 45–66). The prevalence of normal esophageal motility was highest in early adulthood (67.5%) and early middle-age (78.6%) but declined significantly in late middle-age (48.7%; p=0.014) and late adulthood (44.4%; p<0.001). Late adulthood was also characterized by lower median upper esophageal sphincter (UES) pressure (101 mmHg) and reduced UES length (3 cm; p<0.05). Additionally, esophagogastric junction (EGJ) type II and III morphology was more frequently observed in late adulthood (52.5%; p<0.05). In patients with normal motility (n=177), MRS motor wave transmission was lower in late adulthood (75%, p<0.05) compared to early adulthood (96.3%), early middle age (88.1%) and late middle age (93.2%), and the prevalence of incomplete MRS inhibition was higher in late adulthood (79.5%, p<0.05) compared to early adulthood (11.1%), early middle age (21.2%) and late middle age (46.6%). The DCI-MRS and DCI wet ratio were significantly lower in late adulthood (0.51, IQR 0.13 – 0.88; p<0.01).

Conclusion

Peristaltic reserve declines with advancing age, which may contribute to dysphagia. MRS proves to be a useful diagnostic tool for detecting subtle motility impairments related to aging.

Introduction

Anastomotic leakage after foregut surgeries are often difficult to manage. The conventional way of endoscopic treatment is endoscopic stenting (ES). However, it carries a risk of stent migration and erosion. Endoscopic vacuum therapy (EVT) has recently been proposed as an alternative way of treating these leaks. EVT has the benefit of providing negative suction and promotion of granulation tissue¹. However, an exchange every 3-7 days has been suggested.

Aims & Methods

The aim of this study was to compare the treatment outcomes between ES, EVT and the combination of both. This was a retrospective multi-centre cohort study from 3 major centres in Hong Kong that performs esophagectomy and gastrectomy. All patients with anastomotic leak after total gastrectomy and esophagectomy and who were treated with ES or EVT between Jul 2008 and Apr 2023 from the Prince of Wales Hospital, Queen Mary Hospital and United Chistian Hospital were included. Patients’ demographics, type of surgery, size of anastomotic defect, treatment success rate, complications, number of procedures, duration to healing were recorded and compared. Continuous data are compared with Mann-Whitney test and categorical data are compared with Chi-square/ Fisher's exact test.

Results

A total of 63 patients were recruited (ES: 49; EVT 14. The outcomes of the study are listed in Table 1. The mean (S.D.) of defect was 15.4 (16.0)mm in the ES group and 17.8 (14.1)mm in the EVT group (p=0.39). in the EVT group, there are 3/14 patients who had failed EVT therapy and converted to ES. The success rate of each arm as a single arm therapy were similar (29/49(59.2%) in the ES group vs 6/14(42.9%) in the EVT group; p=0.28). However, there were less complications in the EVT group (2/14 (14.3%) in ES group vs. 23/49(46.9%) in EVT group; p=0.03). On the other hand, the EVT group required more endoscopic procedures (median (range) 3 1-137) procedures in the ES group vs 6(2-16) in the EVT group ; p 0.002). The days required for the anastomosis to heal were also similar (ES (61.7 (38.4) vs EVT 45.3 (25.8); p=0.37). When comparing patients treated as a single-arm therapy (ES or ET) to combination therapy (ES + EVT), the success rates has a trend towards favouring combination treatment (p=0.07).

Conclusion

Both EVT and ES are feasible and safe in treating anastomotic leaks after foregut surgeries. Although more procedures are required, EVT achieved similar success rate while having less complications when compared to ES a single arm. The use of combination therapy as compared to single-arm endoscopic therapy may achieve a higher treatment success rate.

References

1. Chan SM, Auyeung KKY, Lam SF, Chiu PWY, Teoh AYB. Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas. Dig Endosc. 2022 Jan;34(1):43-62. doi: 10.1111/den.14061. Epub 2021 Jul 19. PMID: 34115407.

Disclosure

There is no COI.