Introduction

Acute kidney injury is a complication in patients with decompensated cirrhosis (26%). Hepatorenal syndrome has high morbidity and mortality (90%), characterized by renal functional circulatory changes. Abdominal ultrasound, as a medical tool, in the VexUS protocol assessing intravascular congestion (Inferior vena cava, suprahepatic vein, portal vein, and renal vein), could be routinely used in cirrhotic patients with acute kidney injury to objectify the degree of venous congestion and improve decision-making, changing the treatment paradigm with albumin.

Aims & Methods

Prospective, observational, and analytical cohort study in hospitalized hepatic cirrhosis patients with acute kidney injury due to acute decompensation, receiving intravenous albumin at a dose of 1 g/kg/day for 48 hours with subsequent assessment of response. Before albumin administration, abdominal ultrasound (VExUS) was performed to determine the venous congestion status (Period: July 2022 to December 2023). No sample calculation was performed, as all patients meeting selection criteria were included. Sociodemographic, clinical, and biochemical variables were recorded.

Results

Out of 36 patients, 16 (44.4%) responded to albumin therapy, while 20 (55.6%) did not respond. Analyzing according to the VExUS score, 12 patients with VExUS 0 had a response rate of 54.5%, and 10 did not respond (45.5%). When classifying patients based on the presence or absence of venous congestion (VExUS = 0 vs. VExUS 1 or 2), it was observed that in patients with venous congestion, 4 responded (28.6%) and 10 did not respond (71.4%), with a decrease in the p-value without reaching statistical significance.

A logistic regression analysis revealed that both the VExUS score and serum creatinine at admission are predictors of non-response to albumin. The presence of congestion (VExUS I or II) and a 1 mg/dL increase in creatinine were associated with a 5 and 10 times higher risk of non-response, respectively. Regarding the MELD Na score, the 14 deceased patients had a median of 32.5, while the 22 survivors had a median of 23.77.

Conclusion

Non-invasive diagnostic tools like ultrasound (VexUs), widely used due to availability, prove useful in determining the volume status of cirrhotic patients with acute kidney injury and hepatorenal syndrome. This helps establish the prognosis of response to a volume expander like albumin or the utility of other targeted therapeutic measures in patients with evidence of volume overload and/or abdominal hypertension data.

References

1. Bhardwaj V, Vikneswaran G, Rola P, Raju S, Bhat RS, Jayakumar A, et al. Combination of Inferior Vena Cava Diameter, Hepatic Venous Flow, and Portal Vein Pulsatility Index: Venous Excess Ultrasound Score (VEXUS Score) in Predicting Acute Kidney Injury in Patients with Cardiorenal Syndrome: A Prospective Cohort Study. Indian J Crit Care Med 2020;24(9): 783–789.
2.David Jury and Andrew D. Shaw. Utility of bedside ultrasound derived hepatic and renal parenchymal flow patterns to guide management of acute kidney injury. Curr Opin Crit Care 2021, 27:587 – 592
3. Scott W. Biggins, Paulo Angeli, Guadalupe Garcia-Tsao,et al.Diagnosis,Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver. Diseases Hepatology, VOL 74, NO. 2, 2021.
4. Douglas A Simonetto, Pere Gines, Patrick S Kamath. Hepatorenal syndrome: pathophysiology, diagnosis, and management. BMJ 2020;370:m2687.

Clinical Case Summary

Meckel's diverticulum, affecting around 2% of the population, is more common in men and typically presents before age two. The lifetime risk of complications, including gastrointestinal bleeding, is about 4%. Symptomatic cases during pregnancy are rare, with only 38 documented since 1949. A unique case of gastrointestinal bleeding in the second trimester is reported.
Case report: An 18-year-old female in her 19th week of pregnancy presented at the hospital with multiple black stools, dizziness, and severe pallor. Initial tests showed a hemoglobin level of 4.5 g/dL, prompting a transfusion that raised it to 9.5 g/dL. An endoscopy revealed no bleeding lesions, and a colonoscopy was incomplete due to abundant clots. An abdominal angiotomography indicated a reduction in the middle ileum caliber. Surgery revealed a Meckel's diverticulum,an intestinal resection with end-to-end ileal anastomosis was performed.Histopathology confirmed ectopic gastric mucosa within the diverticulum
Meckel's diverticulum, commonly called “the great simulator,” exhibits a range of non-specific symptoms that make diagnosis challenging, particularly during pregnancy when imaging choices are restricted.If required, CT scans and radiography can be utilized as long as radiation exposure remains under 100 mGy, given that standard CT scans are typically below 50 mGy. From a histological standpoint, Meckel's diverticulum is similar to the ileum; however, ectopic gastric tissue can be present in 12-26% of cases, leading to issues such as ulceration and bleeding,this is thought to result from alterations in the local intestinal environment due to the secretion of hydrochloric acid, pepsin, and other endogenous factors by the ectopic tissue.The importance of this case is that symptomatic Meckel's diverticulum during pregnancy is rare, with only a few case reports documented.

References

Figure 1. Angiotomography showing hyperenhancement, venous engorgement and reduction in the caliber of a segment of the middle ileum.
Figure 2. Intra-operative finding Meckel’s diverticulum.
Figure 3. Photomicrograph showing diverticular wall composed of oxyntic gastric mucosa. H&E stain (x5).

1. Tremblay, E., Thérasse, E., Thomassin-Naggara, I., & Trop, I. (2012). Quality Initiatives: Guidelines for Use of Medical Imaging during Pregnancy and Lactation. RadioGraphics, 32(3), 897–911. doi:10.1148/rg.323115120.
2. Féria, B., Trindade, M., Palma, M. J., Figueiredo, J., & Passos, F. (2022). Meckel's Diverticulum: The "Great Mimic" but Often a Forgotten Cause of Acute Abdomen during Pregnancy. Case reports in obstetrics and gynecology, 2022, 2383075. https://doi.org/10.1155/2022/2383075
3. Sima, R. R., Rajan, C. S., & Aithal, S. K. (2016). Bleeding Meckel’s in pregnancy: A rare cause of a rare phenomenon. Surgical science, 07(02), 96–99. https://doi.org/10.4236/ss.2016.72013
4. Lequet, J., Menahem, B., Alves, A., Fohlen, A., & Mulliri, A. (2017). Meckel’s diverticulum in the adult. Journal of Visceral Surgery, 154(4), 253–259. https://doi.org/10.1016/j.jviscsurg.2017.06.006

Introduction

Jejunal feeding and medication such as levodopa-carbidopa intestinal gel for Parkinson’s disease can be administered via percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) and direct percutaneous endoscopic jejunostomy (D-PEJ). PEG-J is currently common practice because technically less difficult to insert, but comparative studies are scarce. Also, data on patient related outcomes are lacking.

Aims & Methods

Our aim was to examine patient experiences and adverse events (AE) in a retrospective study, conducted in a referral hospital. Clinical experience and patient related outcomes were analysed. Ninety-six patients had received either PEG-J or D-PEJ between January 1. 2010 to July 1. 2022. Forty-five patients answered a questionnaire including the EQ-5D-5L and questions regarding their experiences.

Results

No statistical differences were found in Quality of Life. Patients with PEG-J underwent significantly more re-endoscopies per tube-year compared to D-PEJ patients (0.63 (SD 0.72) versus 0.27 (SD; 0.50)). PEG-J patients received at least one re-endoscopy in 76.8% (range 0-3.85 per year), of which 77.4% because of dislocation of the jejunal extension. Tube related adverse events (including dislocation, occlusion, perforation and ulceration) occurred significantly more after PEG-J insertion (76.7% versus 25.9%). However, D-PEJ patients reported significantly more tube related pain (44.4% versus 15.9%).

Conclusion

In conclusion, D-PEJ is an interesting alternative for PEG-J. D-PEJ should at least be considered in patients with frequent problems with the jejunal extension of their PEG-J.

Introduction

Hypermobile Ehlers-Danlos syndrome (hEDS) is a hereditary non-inflammatory disorder of connective tissue laxity characterized by joint hyperextensibility in association with musculoskeletal symptoms. The prevalence of gastrointestinal (GI) symptoms, such as abdominal pain, nausea, and constipation is high in hEDS. Research on the relationship between EDS and GI symptoms has mostly been restricted to disorders of the gut-brain axis, whereas the relationship between hEDS and GI dysmotility remains to be clarified.

Aims & Methods

This study aimed to explore antro-duodenal manometry (ADM) patterns in patients with hEDS presenting with GI symptoms.

In a prospective open-label study, patients with hEDS and GI symptoms presumed to be the results of GI dysmotility underwent a 6-hour high resolution ADM. The manometry tracings were analyzed by two investigators (KS and JC) independently. Antral contraction frequency (contractions per minute) < 1.0 was considered as antral hypomotility. Pylorospasm was defined as isolated pyloric pressure waves within 60 minutes postprandial. The following neuropathic enteric patterns were scored: presence of retrograde peristalsis, bursts, clustered contractions, and absence of phase III contractions. Abnormal ADM was defined as having antral hypomotility and/ or pylorospasm and/ or neuropathic enteric patterns.

Results

Fifty patients (48 women, mean age 30.4 ± 11.1 yrs.) were included. At baseline, 74% of patients were dependent on enteral feeding and the mean BMI was 20.4 ± 4.4 kg/m².
Overall, ADM tracings with one or more abnormal patterns were identified in 53% of patients. Antral hypomotility and pylorospasm were detected in 29% and 15% of patients, respectively. Neuropathic enteric patterns were only seen in 17% of patients. In all cases, no more than one neuropathic pattern was identified. Among the observed neuropathic enteric patterns, 15% of patients showed retrograde peristalsis, 13% absence of phase III contractions, and 2% bursts. Clustered contractions were not identified in this cohort.

Conclusion

Hypermobile Ehlers-Danlos patients presenting with gastrointestinal symptoms showed low numbers of abnormal ADM patterns. In particular, enteric dysmotility was observed in only a small minority of cases. Antroduodenal dysmotility therefore does not appear to be a principle pathomechanism in the majority of hEDS cases studied. Further research is needed to understand the mechanisms that underlie GI symptom generation in this population.

Clinical Case Summary

Introduction: Henoch Schoenlein Purpura (HSP) is an IgA immune mediated vasculitis. It is usually preceded by upper respiratory tract infection. It is more common in males. It is more predominant in paediatric population. However, its incidence in adults is extremely rare with 3.4-14.3 cases / million. Only 10-20% of patients present with gastrointestinal symptoms.
Case presentation: A 39-year-old male presented with rash, abdominal pain, vomiting and watery diarrhoea. His rash was non-itchy non-painful purpuric petechial which covered both upper and lower limbs consistent with HSP. He had diffuse angiokeratoma type lesions on the dorsum of his feet, hands, lateral side of thighs and buttocks. He upper respiratory tract infection for 1 week. Vitals signs were unremarkable. Bloods showed high CRP, ESR, IgA and WBCs. Procalcitonin was negative. ASO showed high titers. The rest of his bloodwork was negative including autoimmune screen and ANCA. Urine analysis showed persistent haematuria with negative urine culture.
CT abdomen showed jejunal wall thickening and oedema with fat stranding and mesenteric nodes. MRI small bowel found abnormal oedematous loops of small bowel proximally within the left flank. keeping with acute small bowel inflammation. However, distribution was not classical for inflammatory bowel disease. Rheumatology team started him on steroids for suspected Henoch-Schoenlein Purpura. He improved subsequently.
Discussion: This patient presented with HSP related enteritis after he had a recent upper respiratory tract infection and HSP characteristic rash. He was treated successfully with steroids.
Conclusion: Clinicians should be aware that Henoch Schoenlein Purpura could be present in adults despite being more prevalent in children. Clinicians should suspect HSP in adults when a patient presents with classic rash, abdominal symptoms and raised inflammatory makers after a recent upper respiratory infection.

References

Nevrekar RP, Bhandare P, Khandeparkar A. Clinical Spectrum of Henoch Schonlein Purpura in Adults: A Hospital Based Study. J Assoc Physicians India. 2022;70(2):11-12.