Introduction

In spite of its high prevalence and impact on health, non-alcoholic fatty liver disease (NAFLD) is not sufficiently addressed in European primary care (PC), with a large proportion of cases going undiagnosed or receiving late diagnosis. An international project was developed to design and evaluate an integrated, multidisciplinary, patient-centered model for NAFLD screening, diagnosis and linkage to specialty care and translate learnings into PC practice guidance.

Aims & Methods

Based on learning from this project, latest research evidence and existing guidelines for the management of NAFLD, we sought to develop a set of practice recommendations for screening, referral and management of NAFLD in PC.
The Rand/UCLA modified Delphi panel methods with 2 rounds was used to reach consensus on pre-defined statements. The international panel consisted of 15 experts from 6 countries, representing family medicine, gastroenterology, hepatology, cardiology and public health. Initially, 15 statements were drafted based on a synthesis of evidence from the literature and findings of this project. Prior to the consensus meeting, statements were rated by the experts in a first round. Subsequently, during a hybrid meeting of eight hours, experts discussed findings of round one, modified statements and rescored the updated recommendations in a second round.

Results

In round one, 10 of the 15 statements received high level of agreement (75% or greater). During the consensus process, 14 of 15 statements were considered appropriate and consensus was reached for all, with high agreement (>90%). The approved list included recommendations from several domains, including NAFLD risk assessment. diagnosis, referral to specialists, management, treatment, surgical management and integrated care.

Conclusion

The final set of 14 recommendations seeks to increase the comprehensive care for NAFLD in PC. We anticipate these recommendations to contribute to the ongoing discussion on systematic approaches to tackle NAFLD and support European PC providers through the integration of latest evidence into practice.

References

A relevant to the project publication:
Development and implementation of a continuing medical education program on non-alcoholic fatty liver disease for primary care practitioners in Europe. Papadakis S, Anastasaki M, Gergianaki I, Koek G, Mendive J, Anastasiou F, Heyens L, Garcia-Retortillo M, Muris J, Lionis C. Front Med (Lausanne). 2023 Mar 23;10:1034626. doi: 10.3389/fmed.2023.1034626. eCollection 2023. PMID: 37035308

Disclosure

It was based on a unrestricted research grant provided to the University of Crete by GILEAD Siences, Inc. after an open call.

Introduction

Inflammatory Bowel Diseases (IBD) can lead to various complications, with Acute Severe Colitis (ASC) being among the most critical. ASC is a medical and surgical emergency that poses a significant risk to life, necessitating prompt and effective diagnosis and management. The first-line treatment typically involves intravenous corticosteroids. However, some cases are resistant to corticosteroids and require second-line medical therapy or immediate surgical intervention.

Aims & Methods

The objective was to identify factors associated with the failure of first-line medical treatment in patients with ASC. A retrospective descriptive and analytical study was conducted over ten years (January 2014 to March 2024) in the gastroenterology department of Charles Nicolle Hospital. The study included patients with IBD complicated by ASC, defined by the Truelove and Witts criteria and a Lichtiger score greater than 10.Patients with bacterial superinfection were not included.

Results

Forty-five patients over 18 years old were included, with a mean age of 37.87 years (range: 18–74 years). There was a slight female predominance (53%), with a male-to-female ratio of 0.87. In 31% of cases, ASC was the initial presentation of the disease. Endoscopic signs of severity at admission were observed in 49% of patients. All patients received intravenous corticosteroid therapy with hydrocortisone hemisuccinate as the first-line treatment. The response rate to first-line treatment was 64.5%. Second-line medical therapy was administered to 24.4% of patients, consisting of cyclosporine in 11.1% and infliximab in 13.3%. Five patients (11.1%) underwent subtotal colectomy due to corticosteroid failure.
In univariate analysis, factors associated with corticosteroid failure included male gender (p=0.011), absence of extraintestinal manifestations (p=0.017), higher average number of stools on the first day (p=0.013), Lichtiger score >10 on the third (p=0.011) and fifth day (p<0.001), hemoglobin levels >11 g/dL on the first day (p<0.001), >10 g/dL on the third day (p=0.009), >9 g/dL on the seventh day (p=0.013), white blood cell count >10,000/mm³ on the first day (p=0.008), >12,000/mm³ on the third (p=0.001) and seventh day (p=0.004), C-reactive protein (CRP) level >30 mg/L on the seventh day (p=0.005), and persistent endoscopic signs of severity after three to five days of corticosteroid therapy (p=0.001).
Multivariate Analysis showed that only the presence of severe endoscopic signs on follow-up endoscopy after three to five days of corticosteroid therapy was predictive of corticosteroid failure (Odds Ratio = 42.2; p=0.028).

Conclusion

Acute Severe Colitis is a potentially life-threatening complication. The presence of severe endoscopic signs after five days of corticosteroid therapy should prompt the initiation of second-line therapy. Understanding the predictive factors for corticosteroid failure is essential for individualized management to improve both immediate and long-term outcomes.

Disclosure

The authors declare no conflicts of interest.

Introduction

Pancreatobiliary disease during pregnancy, though uncommon, poses significant risks. Gallstone-related disorders affect 3–12% of pregnancies and may progress to life-threatening complications such as cholangitis or biliary pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) is a highly effective therapeutic approach; however, concerns about foetal radiation exposure and procedure-related maternal complications limit its broader acceptance. There remains a need for rigorous real-world data on the safety and neonatal outcomes of ERCP during pregnancy.

Aims & Methods

This retrospective observational study aimed to evaluate the safety of ERCP in pregnant patients, focusing on two key outcomes:
(1) Maternal and foetal safety during and after the procedure, and
(2) Effectiveness of radiation-minimisation strategies, including fluoroscopy reduction and abdominal shielding.
We reviewed 25 pregnant patients undergoing ERCP at a tertiary referral centre. Indications included choledocholithiasis (84%), cholangitis (4%), biliary pancreatitis (4%), and stent management (8%). Mean maternal age was 19.2 years; mean gestational age at ERCP was 28.3 weeks. Fluoroscopy usage, post-ERCP complications, Apgar scores, and neonatal follow-up at day 30 were recorded. Fluoroscopy-minimising techniques included suction-verification of bile and stent release without imaging.

Results

No maternal or foetal adverse events occurred peri- or post-procedure. ERCP was performed successfully in all 25 patients, with 23 (92%) undergoing sphincterotomy. Fluoroscopy was utilised in 20 cases (80%), with lead shielding employed in all. In five cases (20%), ERCP was conducted without fluoroscopy by using alternative bile verification techniques. Apgar scores ranged from 7 to 10, and all neonates exhibited normal development at 30-day follow-up.

Conclusion

This study confirms that ERCP can be safely performed during pregnancy when executed by skilled endoscopists adhering to radiation-limiting protocols. Fluoroscopy-free ERCP appears feasible in selected cases, significantly reducing foetal radiation exposure without compromising efficacy. Our findings support ERCP as a viable and safe therapeutic option in pregnant patients with biliary obstruction, providing novel evidence for the growing implementation of protective strategies and alternative imaging techniques in high-risk obstetric settings.

References

• Cappell MS, Friedel D. The role of endoscopy in pregnant and lactating women. Gastrointest Endosc Clin N Am. 2020;30(1):69–95.

• Lee SH, et al. Safety of ERCP during pregnancy: systematic review. World J Gastroenterol. 2009;15(4):357–64.

• Ko CW, et al. Complications of ERCP: a prospective study. Gastrointest Endosc. 2007;66(5):1114–9