Clinical Case Summary

Gastrointestinal stromal tumors are rare neoplasms arising from the interstitial cells of Cajal [1]. The jejunum is a rare location for these neoplasms and is considered to have a less favorable prognosis [2]. Generally, small bowel bleeding (SBB) is the cause of 5-10% of gastrointestinal bleeds and is often a diagnostic challenge for GI practitioners. Guidelines on SBB published by the American Gastroenterology Association, the European Society of Gastrointestinal Endoscopy and the Japanese Gastroenterological Endoscopic Society vary on recommended management strategies [3-5]. One of the key differences between the guidelines is that CT is placed higher in the algorithm proposed by the Japanese society. We present a case of a jejunal GIST manifested as recurrent and severe GI gastrointestinal bleeding. A 65-year-old male was admitted for further investigation of recurrent, massive melena which he experienced twice before in the previous six months. The patient underwent esophagogastroduodenoscopy (EGD) and colonoscopy twice which failed to identify the source of bleeding. After assuming the bleeding originated from the small bowel, we performed multi-slice CT angiography (CTA) which identified a 3x3 cm small bowel tumor mass with a vascular supply from the superior mesenteric artery (Image a,b). Multi slice CT enterography demonstrated a well defined tumor mass arising from the jejunum suggestive of GIST. The patient underwent laparoscopic surgical resection of the ulcerated mass lesion (Image c). The histology was consistent with a low-grade GIST with a TNM staging of T2, N0, M0. Immunohistochemistry was positive for CD117, CD34 and actin SMA-alpha, and negative for desmin and S-100 protein. After 2 years of follow-up, the patient remains symptom-free with no evidence of recurrence. This case highlights the importance of considering small bowel GIST as the cause of obscure overt GI bleeding and favors CTA as the method of choice in achieving the correct diagnosis.

References

1. Hirota S, Isozaki K, Moriyama Y, et al. Gain-of-function mutations of c-kit in human gastrointestinal stromal tumors. Science. 1998 Jan 23;279(5350):577-80.
2. Yang Z, Wang F, Liu S, et al. Comparative clinical features and short-term outcomes of gastric and small intestinal gastrointestinal stromal tumours: a retrospective study. Sci Rep. 2019 Jul 11;9(1):10033.
3. Gerson LB, Fidler JL, Cave DR, et al. ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding. Am J Gastroenterol. 2015 Sep;110(9):1265-87;
4. Pennazio M, Rondonotti E, Despott EJ, et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022. Endoscopy. 2023 Jan;55(1):58-95.
5. Yamamoto H, Ogata H, Matsumoto T, et al. Clinical Practice Guideline for Enteroscopy. Dig Endosc. 2017 Jul;29(5):519-546.

Introduction

MASLD patients is increasing worldwide and the clinical outcomes of different phenotypes had shown varied especially the occurrence of of liver related events (LRE) or major cardiovascular events (MACE)(Eslam M, et al. Hepato Inter 2020, 14:889–919) In addition, the prognostic factors for LRE. or MACE. are not well studied.

Aims & Methods

Aims: We aimed to study the rate of LRE. or MACE and the predictors for LRE. Or MACE. in MASLD patients with liver biopsy proven.
Methods: In a single-tertiary-center prospective cohort, we collected data of MASLD patients with biopsy-proven who were followed up of at least 1 years at King Chulalongkorn Memorial Hospital during 2005-2022. The primary outcome was the presence of LRE. or MACE. which included cirrhotic complications: acute decompensations; EV/GV bleeding, ascites, hepatic encephalopathy or HCC or acute complications requiring liver transplantation or death. MACE was defined by the occurrence of stroke or acute coronary disease or myocardial infarction. Related baseline characteristics, LSM, FIB-4, and liver biopsy were collected.

Results

Among 286 MASLD patients, the MASLD patients with mean age of 50.1 +/- 14.5 years old (range 19-80 yr.) Male and female were 44% and 56 % respectively. MASLD patients were categorized into 3 groups which were type 2 diabetes mellitus (T2DM) in 119 (41.6%), overweight or obese group in 149 (52.1%), and lean MASLD (BMI<23) in 18 (6.3%). Their baseline characteristics were shown in Table 1.
The average BMI was 41.3 kg/m² (range 19.1-88.7). Other metabolic abnormalities were hypertension in 165 (57.7%), and dyslipidemia in 157 (54.9%). There were 6 cirrhotic cases (2.1%) at diagnosis. Presence of advanced liver fibrosis (TE>12KPA) was found in 15 cases (5.2%). After a mean follow-up of 9.5 years (range 1-19); there were 11 cases (3.8%) developed coronary artery disease and 3 cases (1%) developed stroke. LRE. were present in 7 cases (2.4%) which included acute decompensation (3 cases; 1%), HCC (3 cases; 1%), and death (1 cases; 0.3%). The overall complications of LRE. or MACE. were present in 16 cases (5.6%). By using multivariate analysis, the predictors of LRE. or MACE. were in presence of hypertriglyceridemia (aOR 1.01 (1.00-1.01); p =0.002) and older age (aOR 1.06 (1.01-1.11); p =0.023).

Conclusion

The overall complication of LRE. or MACE. was not uncommon (5.6% of this cohort with a mean follow-up of 9.5 years). Older age and hypertriglyceridemia were predictors of LRE. or MACE. occurrence.

References

Eslam M, et al. Hepato Inter 2020, 14:889–919.

Introduction

Intestinal ultrasound (IUS) is a non-invasive, reproducible, low-cost technique for the assessment of intestinal diseases.¹
Crohn's disease (CD) and irritable bowel syndrome (IBS) are two of the major causes of chronic diarrhoea and abdominal pain in high-income countries.² IBS, especially in the diarrheal (IBS-D) or mixed (IBS-M) variants, has clinical features similar to those of CD.
The role of IUS in the diagnosis and monitoring of CD is well established,^{3, 4} whereas only scanty data are available on IBS. Current IBS guidelines do not recommend the use of IUS even to distinguish between IBS-D or IBS-M and CD.^{5, 6}

Aims & Methods

The aim of this two-gate diagnostic study was to assess the accuracy of IUS in discriminating between IBS-D or IBS-M and CD in patients presenting with similar symptoms.
In a high-volume tertiary Centre, consecutive patients symptomatic for chronic diarrhoea and abdominal pain underwent IUS performed by three experienced gastroenterologists.
In the group with clinically active CD, patients had a previous diagnosis based on clinical, biochemical, endoscopic, radiologic and histologic criteria, while in the IBS group subjects had a previous diagnosis based on Rome IV Criteria.
Bowel wall thickness (BWT) of the terminal ileum, ascending colon, transverse colon and descending colon/sigma was evaluated using two cut-offs of 3 mm and 4 mm.⁷ Enlarged lymph nodes, mesenteric fat hypertrophy, bowel wall stratification and submucosal vascularity were also assessed.
The diagnostic accuracy of IUS in discriminating between the two groups was estimated in terms of sensitivity, specificity, positive and negative likelihood ratios (LR+ and LR-) and overall accuracy (OA) (Table 1).

Results

A total of 50 patients with IBS (62% female, mean age 41 years, SD ± 13 years, 54% IBS-D) and 50 subjects with CD (44% female, mean age 47 years, SD ± 17 years) were enrolled.
Forty-nine patients with IBS (98%) and 8 patients with CD (16%) and had a BWT < 3 mm. 49 patient with IBS (98%) and 12 patients with CD (24%) had a BWT < 4 mm.
Sensibility, specificity, LR+ and LR- of BWT < 3 mm were 98%, 84%, 6.13 and 0.02, respectively.
Sensibility, specificity, LR+ and LR- of BWT < 4 mm were 98%, 76%, 4.08 and 0.03, respectively.
BWT with 3 mm and 4 mm cut-offs showed an OA in discriminating between CD and IBS-D or IBS-M of 91% and 87%.
The absence of altered IUS parameters had 94% OA in discriminating between CD and IBS (Table 1).

Conclusion

IUS seems able to discriminate between IBS-D or IBS-M and CD in patients with chronic diarrhoea and abdominal pain. Particularly, a BWT < 3 mm may rule out the presence of clinically active CD and support the diagnosis of IBS. On the other hand, a BWT > 3 mm or a single altered ultrasound parameter might raise suspicion of CD and justify further testing. Cross-sectional studies are needed to confirm these preliminary results.

References

[1] Bryant RV, et al. Gastrointestinal ultrasound in inflammatory bowel disease: an underused resource with potential paradigm-changing application. Gut 2018;67(May (5)):973–85.
[2] Arasaradnam TP, et al. Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition. Gut vol. 67,8 (2018): 1380-1399.
[3] Castiglione F, et al. Noninvasive diagnosis of small bowel Crohn’s disease: direct comparison of bowel sonography and magnetic resonance enterography. Inflamm Bowel Dis 2013;19:991–8.
[4] Maaser C et al. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detection of complications. Journal of Crohn's & colitis vol. 13,2 (2019): 144-164.
[5] Vasant, Dipesh H et al. British Society of Gastroenterology guidelines on the management of irritable bowel syndrome. Gut vol. 70,7 (2021): 1214-1240.
[6] Savarino E et al. “Functional bowel disorders with diarrhoea: Clinical guidelines of the United European Gastroenterology and European Society for Neurogastroenterology and Motility.” United European gastroenterology journal vol. 10,6 (2022): 556-584.
[7] Fraquelli M, et al. Role of US in detection of Crohn disease: meta-analysis. Radiology. 2005;236(1):95-101.