Clinical Case Summary

Biliary injury secondary to trauma is frequently associated with long-term complications. Liver transplantation is rarely indicated but might be the best therapeutic option in severe or intractable cases. There is limited data regarding the use of liver transplantation for biliary trauma and criteria for liver transplantation in the setting of secondary biliary cirrhosis are not well established.
A 14-year-old male was evacuated to Portugal due to biliary injury after abdominal trauma, after failure of cholecystectomy. A Roux-en-Y hepaticojejunostomy was initially performed without immediate complications. Four years later he presented with obstructive jaundice (total bilirubin of 22 mg/dL), pruritus and physical signs of chronic liver disease. A magnetic resonance cholangiopancreatography showed an anastomotic stricture with marked dilation of the intrahepatic biliary tree. Endoscopic resolution of the stricture was not feasible. A percutaneous transhepatic biliary drainage was performed with immediate efficacy, but the procedure failed to resolve cholestasis, with subsequent referral to a liver transplantation center. Abdominal imaging revealed a cirrhotic liver and dilation of the biliary tract. At the age of 19 years old, an orthotopic liver transplant was performed. Piggy-back technique was used along with a continuous hepaticojejunostomy. Two years post-transplant the patient is asymptomatic and with a markedly improved quality of life.
Management of extrahepatic biliary tree injury can be extremely demanding. Even after clinically successful treatment, the quality of life may be impaired. Some complicated cases culminate in refractory and intractable stenosis of the hepaticojejunostomy with secondary biliary cirrhosis. Timely referral to a tertiary center is essential. Liver transplantation is the last line of treatment, but an earlier referral for this treatment may be needed in order to improve outcomes in severe, complicated or intractable cases.

References

- Thomas MN, Stippel DL. Management of bile duct injuries [Management von Gallengangsverletzungen]. Chirurg 2020;91(1):18-22;
- Krawczyk M, Grat M, Adam R, et al. Liver Transplantation for Hepatic Trauma: A Study From the European Liver Transplant Registry. Transplantation 2016;100(11):2372-2381;
- Coccolini F, Kobayashi L, Kluger Y, et al. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg 2019;14:56;
- Schreuder AM, Busch OR, Besselink MG, et al. Long-Term Impact of Iatrogenic Bile Duct Injury. Dig Surg 2020;37(1):10–21;
- LeBedis CA, Bates DDB, Soto JA. Iatrogenic, blunt, and penetrating trauma to the biliary tract. Abdom Radiology 2017;42(1):28-45;
- Romine MM, White J. Role of Transplant in Biliary Disease. Surg Clin North Am. 2019;99(2):387-401;
- Pereira R, Vo T, Slater K. Extrahepatic bile duct injury in blunt trauma: A systematic review. J Trauma Acute Care Surg 2019;86(5):896-901.Coccolini F, Coimbra R, Ordonez C, et al. Liver trauma: WSES 2020 guidelines. World J Emerg Surg 2020;15(1):24.

Clinical Case Summary

Renal transplant recipients are at an increased risk of opportunistic infections, and a subset of this population may develop de novo inflammatory bowel disease (IBD). Differentiating the various forms of post-transplant colitis is challenging. Chronic active EBV enteritis is rarely reported and easily misdiagnosed as IBD, which results in death in severe cases.
A 61-year-old man with a history of kidney transplant presented with bloody diarrhea, fever and weight loss. Ileocolonoscopy showed ulcers in the ileum and the right colon. He was empirically started on ganciclovir and mycophenolate mofetil (MMF) was suspended. Colonic biopsies showed unspecific findings. Cytomegalovirus infection, Clostridioides difficile infection, intestinal tuberculosis and lymphoproliferative disease were excluded. The hypothesis of de novo IBD was postulated. Two months later the patient presented with non-bloody diarrhea and fever. Steroid therapy was increased and everolimus was added. A repeat ileocolonoscopy showed pancolitis and ileitis with oval transversal ulcers. Biopsies were positive for EBV by in-situ hybridization, suggesting an EBV-induced enteritis. Serum viral load was 1397 IU/mL. Immunosuppression was reduced and intravenous immunoglobulin therapy was administered. The patient did not respond and developed hemorrhagic shock with indication for salvage surgery (subtotal colectomy). Less than one month later the patient died due to hemorrhagic shock.
Chronic active EBV infective enteritis should be considered for patients who exhibit IBD-like symptoms and showing irregular ulcers in both colon and small intestine. Clinicians should recognize the presence of EBV infection to avoid misdiagnosis. However, chronic immunosuppression and opportunistic infections, such as EBV, are potential triggers of de novo IBD. Management is challenging and still controversial. Janus kinase inhibitors represent a promising treatment strategy as they target the EBV-driven pathway.

References

- Choi C, Yu Q, Deb PQ, Wang W. Rare case of EBV-induced colitis in an immunocompetent individual. BMJ Open Gastroenterol. 2020;7(1):e000360;
- Liu R, Wang M, Zhang L, et al. The clinicopathologic features of chronic active Epstein-Barr virus infective enteritis. Mod Pathol. 2019;32(3):387-395;
- Gioco R, Puzzo L, Patanè M, et al. Post-transplant colitis after kidney transplantation: clinical, endoscopic and histological features. Aging (Albany NY). 2020;12(24):24709-24720;
- Zhang H, Zhao S, Cao Z. Impact of Epstein-Barr virus infection in patients with inflammatory bowel disease. Front Immunol. 2022;13:1001055;
- Lv K, Yin T, Yu M, Chen Z, Zhou Y, Li F. Treatment Advances in EBV Related Lymphoproliferative Diseases. Front Oncol. 2022;12:838817.

Introduction

Cardiorespiratory arrest is a recognized complication of endoscopic procedures, particularly when sedation is administered. Hospitalized patients, especially those with a prescribed Do Not Resuscitate (DNR) order, are more likely to have severe underlying illness, and consequently a higher risk of cardiorespiratory complications. Additionally, the request for endoscopic exams, especially urgent ones, in this group of patients is becoming increasingly common.

Aims & Methods

The aim of this study was to asses the current clinical practices, as well as the beliefs of gastroenterologists in Portugal regarding the management of the code status in hospitalized patients with prescribed DNR undergoing endoscopic procedures.
Self-reported data was obtained through a voluntary and anonymous survey of gastroenterologists and gastroenterology trainees in Portugal.

Results

One hundred and forty five gastroenterologists, of which 26 (17.9%) were trainees, responded to the survey, with an average age of 42 years (27-83 years), and 59.3% female. The majority are aware of the patient's code status prior to the endoscopic procedure (73.1%, n=106). However, DNR is rarely discussed (<25% of cases) with the patient/legal representative (66.9%, n=97) or attending physician (58.6%, n=85). In patients with prescribed DNR, the rate of reversal prior to the procedure is rarely performed (reversal in all or almost all in 8,3%, n=12). Most respondents are unaware of the procedures necessary for DNR prescription (81.3%, n=118), as well as existing national/international recommendations on DNR reversal (96.5%, n=140). Regarding personal beliefs, the majority consider that in these patients DNR should be reversed to an intermediate option that includes limited resuscitation maneuvers according to the patient's preference (62.1%, n=90). They also believe that the urgency of a procedure should not influence the decision to reverse DNR (n=89, 61.4%), and that if DNR is reversed, it should be done by the attending physician who initially prescribed it (91.7%, n=133). Finally, respondents are divided when asked if they would perform an endoscopic procedure on a patient with prescribed DNR that has not been previously reversed: 49.7% answered yes (n=72), 22.1% no (n=32), and 28.3% have no formed opinion (n=41). There is a consensus on the need for recommendations on this topic for gastroenterologists (97.9%, n=142).

Conclusion

The majority of Gastroenterologists rarely reverse DNR before endoscopic procedures, however, it is mostly advocated that limited resuscitation maneuvers should be offered according to patient preference. Most are unaware of the existence of institutional, national, or international policies regarding DNR. These findings suggest considerable variation in knowledge and approach to hospitalized patients with DNR, highlighting the need for specific recommendations for Gastroenterology in this area.

References

H. Carneiro A, Carneiro R. DNR A Decisão de Não Reanimar. Revista Portuguesa de Medicina Interna [Internet]. 5 de Dezembro de 2021
Braga I, Dutschmann L, Fiuza T, Almeida H, Gil V, Brandão T. Implementação da Ordem de Não Reanimar. Revista Ordem Médicos. 2012;133:20-23.
Wada K, Szego MJ. Revisiting code status in patients undergoing GI endoscopy with a "do not resuscitate" order. Gastrointest Endosc. 2019 Feb;89(2):380-382.
Feld LD, Mergener K, Rubin DT, Rao VL. Management of code status in the periendoscopic period: a national survey of current practices and beliefs of U.S. gastroenterologists. Gastrointest Endosc. 2021 Jul;94(1):172-177.e2.

Clinical Case Summary

A 40-year-old male came to our emergency department referring worsening jaundice, mental status deterioration, epigastric pain and anorexia over the past week. Four weeks earlier he presented odynophagia, myalgias, and hand pruritus but didn’t seek medical attention.
Patient’s clinical background included cognitive impairment due to peripartum anoxia and type 2 Diabetes Mellitus. At admission, he had elevated liver enzymes (R value=2,7), coagulopathy (INR 1.3), pancreatic enzymes >3 times the upper normal level and hyperbilirubinemia (mostly conjugated).
The CT-scan revealed pancreatic tail globosity, diffuse abdominal and retroperitoneal peri-centimetric lymph nodes and excluded biliary lithiasis.
After common causes of acute hepatitis and pancreatitis were ruled out, and since patient was at risk of acute liver failure despite supportive treatment, a liver biopsy was performed. Autoimmune hepatitis, drug-induced liver injury or lymphoproliferative disease were held as potential differentials. Hepatitis E Virus (HEV) RNA was then found and genotyped in the serum (genotype 3). HEV infection was assumed as the cause for both hepatitis and pancreatitis. Histological pattern was inconclusive and epidemiological source wasn’t found.

HEV infection paradigm has changed and is now considered an endemic zoonotic infection in most high-income countries (Portuguese seroprevalence is 16.3%)¹. Infection occurs due to ingestion of undercooked pig or boar meat and should be suspected in every acute hepatitis, mostly with a cholestatic pattern.
The setting of acute HEV hepatitis complicated with acute pancreatitis (AP) is uncommon². AP usually starts after a median of 10 days of jaundice onset³. Literature only reports association between AP and HEV caused by genotype 1 from Southeast Asia^{3 4}, and genotype 3 was only related to gallstone-related pancreatitis, according to current knowledge⁵. This might be the first form of HEV genotype 3 infection with hepatitis and pancreatitis.

References

1. Nascimento MSJ, Pereira SS, Teixeira J, et al. A nationwide serosurvey of hepatitis E virus antibodies in the general population of Portugal. Eur J Public Health 2018;28(4):720-24. doi: 10.1093/eurpub/ckx213 [published Online First: 2017/12/14]
2. Debnath P, Datta AK, Chakraborty U, et al. Acute viral hepatitis E complicated with acute pancreatitis in an immunocompetent adult. BMJ Case Rep 2021;14(2) doi: 10.1136/bcr-2020-239684 [published Online First: 2021/02/06]
3. Haffar S, Bazerbachi F, Garg S, et al. Frequency and prognosis of acute pancreatitis associated with acute hepatitis E: A systematic review. Pancreatology 2015;15(4):321-6. doi: 10.1016/j.pan.2015.05.460 [published Online First: 2015/06/08]
4. European Association for the Study of the Liver. Electronic address eee, European Association for the Study of the L. EASL Clinical Practice Guidelines on hepatitis E virus infection. J Hepatol 2018;68(6):1256-71. doi: 10.1016/j.jhep.2018.03.005 [published Online First: 2018/04/04]
5. Karlsson M, Norder H, Bergstrom M, et al. Hepatitis E virus genotype 3 is associated with gallstone-related disease. Scand J Gastroenterol 2019;54(10):1269-73. doi: 10.1080/00365521.2019.1666163 [published Online First: 20190925]

Clinical Case Summary

Case: W present a case of a 43-year-old man with hepatic cirrhosis complicated by hypertensive gastrointestinal bleeding, in a program to eradicate esophageal varices. One week after an elective endoscopic variceal ligation (EVL), he presented with fever, anorexia, pain in the dorsolumbar region, headaches, and psychomotor retardation. Subsequently, there was the appearance of focal motor seizures. The analyses showed C-reactive protein of 113 mg/L, without leukocytosis. Peripheral blood cultures were negative. A head computed tomography (CT) showed mild left parietal and occipital cortical hypodensities. Analysis of the cerebrospinal fluid was compatible with central nervous system (CNS) infection. Cerebral magnetic resonance revealed multiple supra and infratentorial rounded lesions, compatible with abscesses and ventriculitis. He started antibiotics with a meningeal dose. Hospitalization was complicated by SARS-COV 2 infection, so a chest CT was performed after 1 month of hospitalization, and was identified a mediastinal abscess with 5 cm with fistulization from the esophagus, compatible with iatrogenic esophageal perforation after EVL. Other possible causes of brain abscesses were excluded. He completed several weeks of antibiotic and parenteral nutrition, with normalization of the neurological status and resolution of brain lesions. About 1 month after targeted antibiotic treatment, he performed an endoscopy, revealing a deformed area in the distal esophagus but no evidence of an orifice or suppuration. Conclusion: Neurological manifestations in patients with liver cirrhosis are usually due to hepatic encephalopathy (HE). However, CNS infection, especially in patients who underwent recent procedures, such as EBL, should be considered in the differential diagnosis, given that early treatment influences the prognosis. Clinically, CNS infection can be very variable, however, it is important to be aware of atypical signs of HE, such as focal neurological deficits.

References

Krige JE, Bornman PC, Shaw JM, Apostolou C. Complications of endoscopic variceal therapy. S Afr J Surg. 2005 Nov;43(4):177-88, 190-4.

Disclosure

Nothing to disclosure

Introduction

Inflammatory bowel disease (IBD) is a chronic gastrointestinal disease with unknown causes. Patients experience periods with active disease and symptoms such as diarrhoea, pain and weight loss. Little is known about environmental factors that trigger flare-ups, including the effects of commonly used medications. Recent studies suggest a link between microbial factors and IBD, making it important to investigate the impact of antibiotics on flare-ups.

Aims & Methods

We aimed to investigate whether certain antibiotics increase the risk of flares in patients with IBD. We utilized a previously described¹ cohort of all patients with IBD in Denmark between 1974 and 2018. The cohort is based on the Danish Nationwide Patient Registry, which registers all healthcare related visits, treatments and procedure on an individual level. We utilized data between 1994 and 2018 and two distinct cohorts was created for the purpose of identifying flares. The first cohort was characterized by having an IBD-related hospital stay. The second cohort was characterized by experiencing a flare of IBD in need of systemic steroids. Patient were matched 1:5 using K-nearest neighbour. Antibiotics were grouped into the 3rd level of the Anatomical Therapeutic Chemical (ATC) classification system, with anthelmintics grouped into the 2nd level due to low numbers and all given within 60 days before the outcome. Logistic regression analysis was used to calculate odds ratios (ORs) with a 95% confidence interval (95% CI), with adjusting variables including year of remission/flare, sex, age at diagnosis, year of diagnosis, type of IBD, socioeconomic status², use of 5-ASA, use of budesonide, use of immunosuppressants, and use of subtypes of biologics.

Results

There were in total 69,908 IBD patients in the original cohort. After applying the abovementioned algorithm, a total of 15,636 and 5,178 patients were included in the cohort for hospitalisation and steroid use, respectively.
Using a multivariate logistic regression model, both cohorts observed a significant increase in odds ratios for certain antibiotics in relation to hospitalization and steroid course. Specifically, for the need of a course of steroids, quinolones (OR 3.83 (95% CI: 2.73-5.35)), antimycotics (OR 2.30 (95% CI: 1.53-3.40)), agents against amoebiasis and protozoal (OR 2.06 (95% CI: 1.39-3.01)), betalactam antibiotics (OR 1.35 (95% CI: 1.10-1.66)), and intestinal anti-infectives (OR 2.12 (95% CI: 1.08-3.98)) were associated with an increased risk for a flare requiring steroids.
Regarding the need for an IBD-related hospitalization, agents against amoebiasis and protozoal (OR 3.48 (95% CI: 2.72-4.44)), quinolones (OR 3.10 (95% CI: 2.48-3.86)), intestinal anti-infectives (OR 2.42 (95% CI: 1.54-3.76)) and antimycotics (OR 1.58 (95% CI: 1.17-2.12)) were all found to be significantly associated.

Conclusion

This study provides evidence that certain types of antibiotics increase the risk of flare-ups in patients with IBD. Quinolones, antimycotics, agents against amoebiasis and protozoal, betalactam, and intestinal anti-infectives were all associated with increased odds ratios for hospitalization and a need for a course of steroids. These findings highlight the importance of carefully considering the use of antibiotics in IBD patients and the need for further research on the effects of different antibiotics on disease progression.

References

¹ Lo B, Zhao M, Burisch J. Identifying patients with inflammatory bowel disease in the Danish National Patient Register. Dan Med J. 2023 Mar 27;70(4):A07220458. PMID: 36999818.
² https://www.dst.dk/en/Statistik/dokumentation/nomenklaturer/socio

Disclosure

An unrestricted grant was received from the Aage og Johanne Louis-Hansens Fond to support this study.