Introduction

Chemoradiotherapy (CRT) is a standard non-surgical treatment for esophageal squamous cell carcinoma (ESCC). One of the major disadvantages of CRT is poor local control, and salvage esophagectomy is generally indicated for local failure; however, it is invasive with a high rate of postoperative complications and mortality so that patients often refused or are intolerant to salvage esophagectomy. Alternatively, photodynamic therapy (PDT) with talaporfin sodium (TS) is less invasive salvage treatment for local failure after CRT/ radiotherapy (RT) and was reported to have relatively high local complete response (L-CR) rate and few adverse events (AEs) in the short term. However, long-term outcomes of PDT with TS are unknown.

Aims & Methods

This retrospective study aimed to clarify the long-term outcomes of PDT with TS for local failure after CRT/RT for ESCC. Patients who underwent PDT with TS for histologically proven local failure of ESCC between December 2012 and December 2021 at the National Cancer Center Hospital East were enrolled. Patients with other active cancers or a prior history of PDT were excluded. Basic indication criteria of PDT were as follows: invasion depth limited to the shallow muscle layer, <1/2 of the esophageal circumference, absence of metastasis, and patient’s refusal or unsuitable physical condition for salvage surgery. We assessed L-CR rate, incidence of AEs, clinical courses after PDT, 3-year overall survival (OS), progression free survival (PFS) and major PFS (mPFS) in which major disease progression after PDT which defined as disease progression requiring more invasive treatment than repeated endoscopic treatment and death from all causes were considered as events. We also assessed pre-PDT factors associated with L-CR. L-CR was defined as no apparent residual tumor, disappearance of post-PDT ulcer and confirmation of the scar formation, and absence of cancer cells in biopsy.

Results

108 patients (92 men; median age 74 years [range, 52-88 years]) were enrolled. Patients with pre-CRT/RT cT1/ T2/ T3/ T4/ unknown were 50/ 22/ 24/ 9/ 3. Those with residual lesion/ local recurrence/ unknown were 63/ 39/ 6. Patients with pre-PDT ycT1a/ T1b/ T2 were 6/ 85/ 17. Pre-PDT median lesion size was 20 mm (range, 4-50 mm). 60 patients achieved L-CR after PDT, 41 had L-nonCR, and 7 were not evaluable. L-CR rate of PDT was 58.8% (60/101). During median follow-up of 23 months (range, 1-90 months), 39 patients (36.1%) finally had no recurrence after PDT. 18 patients, including 8 with L-nonCR after PDT and 10 with local recurrence after achieving L-CR, underwent re-endoscopic treatments alone and remained disease-free afterward. The other 44 patients had major disease progression, and 15 received salvage surgery among them. As for the lesion characteristics associated with L-CR, the lesions with <1/2 circumference and with <20 mm in size were more likely to achieve L-CR than those with ≥1/2 circumference (64.4% vs. 16.7%, P=0.003) and with ≥20 mm (80.0% vs. 45.2%, P=0.001), respectively. The 3-year OS/ PFS/ mPFS of all patients were 78.1%/ 29.8%/ 48.1%. The 3-year OS of L-CR cases was better than that of L-nonCR cases (89.3% vs. 67.7%, P=0.003). There was no grade 3 < AEs. Non-cardiac chest pain (60.2%), skin phototoxicity (4.6%), and esophageal stricture requiring balloon dilatation (4.7%) occurred.

Conclusion

PDT with TS for local failure after CRT/RT for ESCC showed the preferable long-term outcomes. Moreover, achieving local control with PDT could improve prognosis of patients even with local failure after CRT/RT.

Clinical Case Summary

Introduction: PSC is closely associated with IBD and affects up to 3.6% of Crohn's disease patients, while AIH is also more prevalent in IBD patients, in up to 16% of patients.
Case report: We report a female patient who, at the age of 14, presented with right hypochondrial pain and abnormal liver biochemistry (SGOT: 44 U/l, SGPT: 145 U/l, γ-GT: 300 U/l, ALP: 421 U/l, TBL: 1 mg/dL). The patient underwent MRCP (Figure A) which revealed local strictures with prostenotic dilatation in both intrahepatic and extrahepatic bile ducts, suggestive of PSC. One year later the patient presented with severe abdominal pain and bloody diarrhea. Ileocolonoscopy showed terminal ileitis (Figure B) and segmental colitis. Histological evaluation (Figure C) showed disruption of the architecture, focal erosions of the epithelium, mild mucopenia, inflammatory infiltrate in the dermis, sites of cryptitis and focal formation of crypt abscesses with extension of inflammation to the muscularis mucosae, suggestive of Crohn’s Disease. Two years later, in a regular laboratory test, the patient had abnormal liver function tests (SGOT: 211 U/l, SGPT: 603 U/l, γ-GT: 54 U/l, ALP: 105 U/l, TBL: 0.9 mg/dl). Further evaluation with immunoassay revealed ANA (+) 1/80, AMA (-), SMA (+) 1/160, + F-actin, anti-LKM (-), anti-LC (-), anti-LM (-), p ANCA (+) 1/80, so the patient underwent percutaneous liver biopsy with findings of portal spaces with presence of waxy-containing macrophages, thin fibrous septa, parenchyma with centrolobular necrosis with aggregates of inflammatory cells and waxy macrophages, suggestive of Autoimmune Hepatitis. Today, the patient is in clinical remission under treatment with Ursodeoxycholic acid, Ustekinumab and Mycophenolate Mofetil.
Conclusion: The association of IBD with PSC, AIH and variant forms is now known, however the complexity of the diseases presents a challenge for the clinician and the provision of individualized care.

References

1. Ballotin VR, Bigarella LG, Riva F, Onzi G, Balbinot RA, Balbinot SS, Soldera J. Primary sclerosing cholangitis and autoimmune hepatitis overlap syndrome associated with inflammatory bowel disease: A case report and systematic review. World J Clin Cases. 2020 Sep 26;8(18):4075-4093.
2. Saich R, Chapman R. Primary sclerosing cholangitis, autoimmune hepatitis and overlap syndromes in inflammatory bowel disease. World J Gastroenterol. 2008 Jan 21;14(3):331-7.
3. Rocha HC, Vilela EG. Clinical aspects and prognosis of patients with inflammatory bowel disease associated with autoimmune liver diseases. Gastroenterol Hepatol. 2022 Feb;45(2):83-90. English, Spanish.
4. Malik T, A, Gutierrez A, M, McGuire B, Zarzour J, G, Mukhtar F, Bloomer J: Autoimmune Hepatitis-Primary Sclerosing Cholangitis Overlap Syndrome Complicated by Crohn’s Disease. Digestion 2010;82:24-26.

Introduction

​Pancreatic fibrosis (PF), a pathological hallmark of chronic pancreatitis, serves as a critical mediator in the progression of numerous pancreatic disorders. Early identification of fibrotic changes presents a strategic opportunity to intervene in disease pathways, potentially curbing the advancement of pancreatic pathologies. It makes research of non-invasive radiological PF assessment perspective.

Aims & Methods

Aim of our study was to evaluate the possibility of multidetector computed tomography (MDCT) post-processing parameters in PF grade assessment.
Methods. Results of contrast-enhanced 128-row MDCT from 165 patients (mean age 57.9±13.5) who underwent surgery from April 2022 to February 2024 due to pancreatic tumors and advanced chronic pancreatitis were analyzed. We calculated contrast enhancement ratio (CR) between venous phase (VP) and non-contrast MDCT, and normalized CR (NCR) during the pancreatic phase (PP) and VP, also we measured pancreas attenuation during MDCT examination. PF morphological grade was assessed according to Klöppel & Maillet’s scoring system [1] and scaled into three grades: mild, moderate and severe PF.
This study was conducted within the healthcare research project “Assessment of pancreatic fibrosis as a prognostic factor for its diseases course” funded by Autonomous non-profit organization "Moscow Center for Innovative Technologies in Healthcare" administered by the Moscow Healthcare Department.

Results

The values of post-processing CT results were compared in groups with different degrees of PF. Mean CR were significantly higher (p=0.001) in patients with severe PF (CR 1.16±0.65 HU) than in patients with mild PF (CR 0.78±0.31 HU). CR significant increase (p=0.03) was found in patients with signs of inflammatory changes in the pancreas tissue (CR 1.14±0.6 HU) than in those without them (CR 0.81±0.3 HU). There were no significant differences between the NCRPP and NCRVP, and the degree of PF, which we had shown in publications of our preliminary results. We suppose the main reason of this fact is study groups enlargement as well as measurement technique improvement, led to results clarification.

Conclusion

The CR value increased in patients with severe degree of PF and decreased in patients with mild PF. Also, there was a significant relation between CR increase and presence of early signs of pancreatic inflammatory changes. Thus, there was a relationship between MDCT postprocessing results and morphological signs of PF, which can be used for pancreatic fibrosis non-invasive diagnosis and identification of additional signs of early chronic pancreatitis.

References

1. Esposito I, Hruban RH, Verbeke C, et al. Guidelines on the histopathology of chronic pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with the International Association of Pancreatology, the American Pancreatic Association, the Japan Pancreas Society, and the European Pancreatic Club. Pancreatology. 2020;20(4):586-593. doi:10.1016/j.pan.2020.04.009

Clinical Case Summary

Splenic granulomas are a rare extraintestinal manifestation of Crohn’s disease (CD). In previously reported cases, the diagnosis was confirmed by biopsy. However, due to the increased risk of complications associated with biopsy, confirmation by imaging is desirable.
52-year-old male patient presented with a previously diagnosed, currently untreated CD.
Symptoms:

• Abdominal pain in the right lower quadrant for several weeks, postprandial
• Bowel movements: 4-6 times/day for a few weeks, liquid consistency
• No fever or weight loss
• Palpation: tenderness in the lower right abdomen

Findings:

• C-reactive protein and leukocytes: not elevated
• Calprotectin: 184ug/g. Stool culture and intestinal cytomegaly virus PCR biopsy negative
• Tuberculosis interferon-g release assay: negative
• Colonoscopy and magnetic resonance enterography (MRE): ileitis of terminal Ileum (Fig. 1)
• MRE: multiple T2w-hyperintense splenic lesions, increased in number since last imaging 2024 (Fig. 2)
• B-mode ultrasound: splenomegaly, round nodules of mixed echogenicity (Fig. 3)
• Contrast-enhanced ultrasound (CEUS): 1,5ml contrasting agent (sulphur hexafluoride microbubbles): arterial isoenhancement and late phase hypoenhancement of nodules (Fig. 3), atypical for haemangiomas
• 18-Fluorodeoxyglucose positron emission tomography with computed tomography: no uptake in the spleen (Fig. 4)

After excluding malignancy, abscesses, sarcoidosis, and infectious causes, the splenic granulomatous lesions represented an extraintestinal manifestation of CD. The patient was started on prednisolone, 60mg/day, resulting in marked clinical improvement in 4 days; with reduced abdominal pain and decreased stool frequency. Patient declined recommended maintenance therapy with ustekinumab.
This CEUS pattern is novel to CD and resembles previously reported enhancement patterns of inflammatory lesions. This is a rare reported case of splenic granulomas as an extraintestinal manifestation of CD diagnosed non-invasively by CEUS.

References

Figure 1: Colonoscopy shows 2-4mm aphthous ulcers in the terminal Ileum
Figure 2: (A)T2-Haste and (B)T2-STIR MRE depicting multiple hyperintense splenic lesions
Figure 3: B-mode (left) and CEUS (right) of the splenic lesions. (A) Nodules appear mixed in echogenicity, nodules show isoenhancement during the arterial phase. (B) Nodules exhibit hypoenhancement in the late phase
Figure 4: 18F-Fluorodeoxyglucose (FDG) positron emission tomography with computed tomography shows no uptake of FDG in the spleen
1. Castellani L, Sartini A, Marocchi M, Balbi T, Belluzzi A. Splenic granulomas in a patient with severe Crohn's disease associated with multiple extraintestinal manifestations. Inflamm Bowel Dis. 2011 Jun;17(6):E35-7. doi: 10.1002/ibd.21665. Epub 2011 Feb 11. PMID: 21319276.
2. Schulz C, von Arnim U, Kuester D, Fischbach F, Malfertheiner P. Milzbefall - seltene extraintestinale Manifestation bei Morbus Crohn [Splenic granulomas - rare extraintestinal manifestation of Crohn's disease]. Z Gastroenterol. 2010 Dec;48(12):1367-70. German. doi: 10.1055/s-0029-1245562. Epub 2010 Dec 1. PMID: 21125512
3. Safai Zadeh E, Prosch H, Ba-Ssalamah A, Findeisen H, Alhyari A, Raab N, Görg C. Contrast-enhanced ultrasound of the liver: basics and interpretation of common focal lesions. Rofo. 2024 Aug;196(8):807-818. English, German. doi: 10.1055/a-2219-4726. Epub 2024 Jan 4. PMID: 38176437

Disclosure

Travel grant from Johnson & Johnson

Clinical Case Summary

Introduction: Eosinophilic enteritis (EoEo) is a rare condition characterized by eosinophilic infiltration of the intestinal wall without an identifiable secondary cause. Clinical presentation varies depending on the affected intestinal segment and layer. While mucosal involvement causes digestive symptoms, muscular involvement may lead to obstruction, and serosal involvement—least common—can present with eosinophilic ascites.
Case Report: A 15-year-old male presented with epigastric pain, vomiting, and oral intolerance. Laboratory tests revealed marked eosinophilia (>5,000/μL). Abdominal CT showed free fluid and ileocecal wall thickening. Diagnostic paracentesis revealed ascitic fluid with a high leukocyte count and eosinophil predominance. Endoscopic studies revealed ileitis, typhlitis, and duodenitis. Biopsies confirmed eosinophilic infiltration of the intestinal wall. Other causes of eosinophilia, including infections and malignancy, were ruled out. The patient was treated with intravenous corticosteroids, with good clinical response, and discharged on oral budesonide. A relapse occurred after tapering steroids, prompting initiation of azathioprine for maintenance. The patient remains clinically stable without further hospitalizations.
Discussion: EoEo with eosinophilic ascites is rare and should be considered in the differential diagnosis of unexplained ascites, particularly in patients with peripheral eosinophilia. Key diagnostic findings include eosinophil-predominant ascitic fluid and GI tract biopsies with eosinophilic infiltration. Early recognition and treatment are essential to prevent complications. It is crucial to rule out parasitic and infectious causes before initiating corticosteroid therapy to avoid worsening an undiagnosed infection.

Introduction

Acute pancreatitis (AP) during pregnancy is a rare but potentially life-threatening condition for both mother and fetus. The most common cause is gallstone disease, followed by hypertriglyceridemia and, less frequently, alcohol use. The physiological changes of pregnancy can mask the clinical presentation, delaying diagnosis and intervention. This review aims to synthesize current evidence on the diagnosis, management, and maternal-fetal outcomes of AP in pregnancy, with special attention to the role and timing of cholecystectomy during an acute episode.

Aims & Methods

A comprehensive literature search was conducted using PubMed, Scopus, and the Cochrane Library for studies published between 2000 and 2024. Inclusion criteria involved clinical trials, cohort studies, systematic reviews, and relevant guidelines discussing AP in pregnancy and cholecystectomy

Results

​The majority of AP cases in pregnancy occur in the third trimester or early postpartum period. Gallstones account for 65–100% of cases. Conservative management remains the first-line approach, particularly in the first trimester. However, recurrence rates up to 70% with conservative therapy alone have prompted a reevaluation of surgical timing. Recent studies support the safety of cholecystectomy during the second trimester and even during stabilized mild to moderate AP. In the third trimester, ERCP with endoscopic biliary sphincterotomy is preferred, with cholecystectomy deferred postpartum. Multidisciplinary management has significantly improved maternal and neonatal outcomes in recent years.

Conclusion

Acute pancreatitis in pregnancy remains a rare but serious condition requiring timely diagnosis and multidisciplinary care. Recent innovations support the safety and efficacy of cholecystectomy laparascopyce during the second trimester and even in selected stabilized cases of mild acute pancreatitis. Personalized management strategies based on gestational age and disease severity, along with minimally invasive techniques like ERCP, offer improved maternal and fetal outcomes.
Laparascopi Colecystectomy prevens the recurrent acute pancreatitis and other complications billiaris.
No differenc in the intra and postoperative complications during and after pregnancy.

References

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1. Forsmark CE, Vege SS, Wilcox CM. Acute pancreatitis. N Engl J Med. 2016;375(20):1972–81.
2. Tenner S, Baillie J, DeWitt J, Vege SS. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013;108(9):1400–15.
3. Yokoe M, Takada T, Mayumi T, et al. Japanese guidelines for the management of acute pancreatitis: JPN Guidelines 2015. J Hepatobiliary Pancreat Sci. 2
4. Rosing DK, de Virgilio C. Early cholecystectomy for mild gallstone pancreatitis: time for a paradigm shift
   

Disclosure

Taibe Haziri
*University Clinical Center University of Kosovo*

Introduction

Crohn’s disease (CD) complicated with intra-abdominal abscess often requires surgical intervention. Image guided percutaneous drainage (PD) can help to avoid surgical interventions, however there is limited evidence on the optimal management after PD.

Aims & Methods

Our study aimed to analyze the long-term outcomes of CD complicated with intra-abdominal abscess after intervention. In this multicenter, interational retrospective trial penetrating CD patients with simplex intra-abdominal abscess were enrolled and followed until 12-24 months. Baseline was the day of the first detection of abdominal abscess. Patients with urgent resection were excluded. Patients were grouped based on elective surgical need during follow-up after a successful PD, while the control group consisted of patients who underwent resection without PD. Primary outcome was the abscess recurrence, while stoma rate, post procedural complications rate (<30 days), need for re-drainage and postoperative luminal recurrence were analyzed as secondary outcomes.

Results

A total of 151 CD patients from 9 countries were recruited and 86/151 patients had PD due to simplex abdominal abscess (Table 1.). Abscess recurrence rates were similar (12.8% vs. 7.7%, p=0.231). Need for re-drainage was more common amongst PD patients (OR=0.088, 95% CI=0.011-0.682), while hospital admission need was more frequent in control patients (OR=2.56, 95% CI=1.22-5.37). Postoperative luminal recurrence, new stoma, and biological treatment escalation needs were similar between groups based on PD. Surgical complications were coupled with increased odds in patients without prior PD (OR=3.3, 95% CI=1.09-10.0), septic complications, perforation and new fistula formation were reported the most, while PD associated complication did not occur. Higher baseline diameter of the abscess increased the odds for postoperative recurrence (OR=1.05, 95% CI=1.02-1.08) and new biological treatment initiation (OR=0.98, 95% CI=0.96-0.98). Elective resection was delayed after PD compared to control (24 vs 10 week, p=0.003). Time until resection increased the odds for redrainage (OR=1.03, 95% CI 1.01-1.05), and outcome was worse exceeding 17 weeks.

Variables	Total (n = 151)	PD group (n = 86)	Control group (n = 65)	Sig.
FU duration, weeks, median (IQR)	103 (71-109)	104 (64-112)	101 (77-105)	0.895
Sex, male (%)	88 (58.3)	49 (57.0)	39 (60.0)	0.419
Age at inclusion, years, median (IQR)	33.0 (26-44)	36.3 (27-46)	30.2 (25-38)	0.006
CD disease duration at inclusion, years, median (IQR)	11 (6-17)	11 (5-18)	11 (7-17)	0.916
Disease activity at baseline
CDAI, mean (± SD)	302 (109)	290 (126)	307 (115)	0.389
CRP, mg/l, mean (±SD)	92 (57)	112 (88)	107 (80)	0.753
SES-CD, mean (±SD)	10.0 (8.1)	7.1 (5.8)	12.0 (9.0)	0.071
Elective resection during FU, n (%)	126 (83.4)	61 (70.9)	65 (100)	-

Conclusion

The size of the abscess determines the outcomes, while surgical treatment alone may be associated with post-procedural complications. PD may delay resection; however, this delay can necessitate re-drainage.