Introduction

Differences between males and females were reported in digestive diseases and upper endoscopy.

Aims & Methods

The objective of the study was to investigate the similarities and differences in colonoscopy indications and findings between men and women. Multi-center, large cohort, retrospective study included all colonoscopies performed between 2016 and 2021. Multi-center study, data collected from seven Assuta endoscopy departments. All performed colonoscopies were included, and the indications and findings of the procedures were compared between men and women.

Results

287,930 were included, 151,411(52.5%) women and 136,519 men, aged 56.54±12.9 years and 56.59±12.7, with no difference in cecal intubation (95.6% vs 95.5%, p=0.251). 71.4% of the females had excellent or good bowel preparation, while 65.6% of the males had the same grade of quality. 22,650 (15%) of the females had Abdominal pain as the indication compared to 13,568 (9.9%) of males, while 11,846 (7.8%) had positive fecal occult testing compared to 12,955 (9.5), p<0.001.
Higher rates of change in Bowel habits, constipation, diarrhea, family history of colon cancer and Anemia were found among females compared to males (4.3% vs 3.7%, 3.9% vs 2.2%, 12.6% vs 11.4% and 7.6% vs 4.9%, p<0.001, respectively), while rectal bleeding, weight loss, polyp follow up and screening colonoscopy were more among males (10.7% vs 7.8%, 1.5% vs 1.3%, 10.8% vs 7.1% and 23.4% vs 20.6%, p<0.001, respectively. The colonoscopy findings showed that males had significantly higher rates of colon cancer, polyp detection rates, Crohn’s disease, ulcerative colitis and diverticulosis (0.5% vs 0.4%, 35.1% vs 24.6%, 1.5% vs 1.3%, 1.6% vs 1.5%, and 14.9% vs 12.8%.

Conclusion

We found significant differences between men and women regarding the indications and pathological findings of colonoscopy; these findings highlighted the need of the identification of factors contributing to these differences and the development of sex-specific approaches for the diagnosis and management of gastrointestinal diseases.

Introduction

Post-ERCP pancreatitis (PEP) is the most frequent adverse event (AE) following ERCP with a 3.5-9.7% overall incidence across studies. ERCP is performed also to treat post-liver transplantation (LT) biliary complications. The occurrence of PEP in LT patients is not well studied, however in some series a slight increase in PEP incidence has been described.
The aim of this study is to perform a case-control study to evaluate the risk for PEP in post-LT patients.

Aims & Methods

This is a case-control retrospective study performed at a single high-volume endoscopy center. All consecutive patients undergoing ERCP for the first time (native papilla) for post-LT biliary complications from January 2015 to September 2022, were reviewed from a prospectively maintained ERCP database. The control group consisted of patients with native papilla undergoing ERCP for indications different than post-LT biliary complications at the same unit from January 2019 to December 2019. Demographic data, technical data, and post-ERCP AEs were recorded. Rectal indomethacin was administrated in all cases as PEP prophylaxis. General anesthesia or deep sedation was used in all cases. Statistical analysis was performed with SPSS 20 software. Descriptive data are reported as mean/median ± standard deviation/range, or percentage. Categorical data were compared using the χ₂ test. P values <0.05 were considered statistically significant.

Results

One hundred and six post-LT patients were included in the “case” group and 452 in the “control” group. Patients’ characteristics are summarized in Table 1. PEP prevalence was significantly higher in the case group (8/106, 7.5%) compared with the control group (15/452, 3.5%) (OR: 2.37, 95% CI: 0.98-5.75, P= 0.048). Double guide-wire cannulation prevalence (considered a criterion of difficult cannulation) was significantly higher in the case group (21/106, 19.8%) compared with the control group (54/442, 12.2%) (OR: 1.78, 95% CI: 1.02-3.10, P= 0.041). PEP prevalence resulted still higher in LT patients (OR: 4.19, 95% CI: 1.01-6.06, P= 0.04) after exclusion from the control group of pancreatic cancer patients (n=104), considered at lower risk for PEP assuming pancreatic duct obstruction as a protective factor.

Table 1: Patients characteristics (n: number, LT: liver transplantation, AEs: adverse events, PEP: post-ERCP pancreatitis).

Conclusion

LT patients are at higher risk of PEP when compared with patients undergoing ERCP for other indication. Biliary cannulation seems to be more difficult in LT patients and this could explain the higher risk of PEP. The main limitations of this study are the retrospective design and the presence of a historic cohort group as controls. Prospective studies are needed to confirm these data.

References

[1] Kochar B, Akshintala VS, Afghani E, et al. Incidence, severity, and mortality of post-ERCP pancreatitis: a systematic review by using randomized, controlled trials. Gastrointest Endosc 2015; 81: 143-149.e9.
[2] Moy BT, Birk JW. A review on the management of biliary complications after orthotopic liver transplantation. Journal of clinical and translational hepatology. 2019 Mar 28;7(1):61.
[3] Kochhar G, Parungao JM, Hanouneh IA, Parsi MA. Biliary complications following liver transplantation. World J Gastroenterol. Published online 2013. doi:10.3748/wjg.v19.i19.284.

Introduction

Individuals with Lynch syndrome (LS) have an increased risk of developing gastric cancer (GC) and duodenal cancer (DC), particularly individuals with MLH1 and MSH2 pathogenic variants (PVs). Lack of consensus exists whether individuals with LS benefit from esophagogastroduodenoscopy (EGD) surveillance. In order to gain further insight in GC and DC risk in LS individuals, we studied tumor characteristics and cumulative incidence of GC and DC in a large Dutch cohort of LS individuals.

Aims & Methods

Clinical data of LS individuals registered between 1985-2021 at the Dutch Hereditary Cancer Registry (StOET) was retrospectively matched with pathology reports filed between 1989-2021 by the Dutch Pathology Registry. All pathology reports describing results of gastric or duodenal tissue specimens were reviewed for presence of GC and DC. Cumulative incidences of GC and DC were estimated for individuals with high-risk (MLH1, MSH2 and EpCAM) and low-risk (MSH6 and PMS2) PVs using a competing risk model with death as competing risk. Standardized incidence ratios (SIR) were determined by dividing the observed number of carcinomas in the study cohort by the expected number of carcinomas per age group based on the GC and DC incidence in the general Dutch population.

Results

Among the 1002 individuals with high-risk and 765 individuals with low-risk PVs registered at the StOET, 29 cases of GC (1.6%) and 39 cases of DC (2.2%) were diagnosed. The median age at diagnosis was 68 (IQR 58–74) years for GC and 59 (IQR 53–66) years for DC. Cumulative incidence of GC and DC were higher in individuals with high-risk compared to individuals with low-risk PVs (Table 1; HR 3.60 [95% CI 1.45–8.92], p=0.006 and HR 2.56 [95% CI 1.25–5.26], p=0.01, respectively). Cumulative risk of GC and DC under the age of 50 years was very low (≤1%) for individuals with both high and low-risk PVs. At age 70 years and lifetime, cumulative risk for individuals with high-risk PVs was 3% and 8% for GC and 5% and 6% for DC, respectively. Individuals with low-risk PVs had 1% and 3% cumulative incidence of GC and 1% and 5% cumulative incidence of DC at the age of 70 and lifetime, respectively. The cumulative risk of GC and DC combined at age 70 and lifetime was 8% and 14% for high-risk and 2% and 8% for low-risk PVs, respectively. Primary tumor resection could be performed in the majority of GC (62%) and DC (77%) patients. UICC 8^th TNM stage 1 was found in 56% of resected GCs. Stage 2 was found in 56% of resected DCs. Individuals with LS had a 4.9 (SIR, 95% CI 3.3–7.0) and 250 (SIR, 95% CI 178-290) times higher risk of GC and DC, respectively, compared to the general Dutch population.

Conclusion

This retrospective nationwide cohort study shows that individuals with MLH1, MSH2 and EpCAM mutations have a substantial risk of developing GC and DC at the age of 70 years, but that this risk is negligible before the age of 50 years. The majority of GC and DC were detected at a relatively early stage. Yield of GC, DC and their precursor lesions during surveillance and cost-effectiveness should be determined in future studies.

Clinical Case Summary

We collected clinical, laboratory, radiological, cholangiographic, endoscopic and pathological findings from a 58 years old male, obese, with type 2 diabetes and with cardiovascular comorbidity. During 2020-2021, he was admitted several times at the Emergency Department for abdominal and thoracic pain, nausea and cold sweating, with night onset. Radiological, including abdominal Computed Tomography (CT) and laboratoristic findings were persistently negative. In 2022 he was hospitalized for acute mild biliopancreatitis. Abdominal Ultrasound (US) resulted negative for bile duct dilatation. During hospitalization, symptomatology improved, but he developed jaundice. Abdominal CT with contrast medium was performed, confirming mild pancreatitis (CT Severity Index 2), thickening and hyperemia of the common bile duct wall. Magnetic Resonance Cholangiopancreatography (MRCP) showed cholelithiasis, choledocolithiasis with multiple chained filling defects, without bile ducts dilatation. Endoscopic Retrograde CholangioPancreatography (ERCP) was then performed, demonstrating a 2 cm filling defect, with extraction of mucus and sludge, mixed with intraluminal tissue. Histopathology described a Bile Duct Intraductal Papillary Mucinous Neoplasm (IPMN-B) with low grade (and focally high grade) dysplasia. Clinical onset and imaging were misleading and ERCP findings were unexpected. IPMN-B is a rare premalignant disease, presenting as an intraluminal papillary mass, sometimes secreting mucus, and leading to abdominal pain, obstructive jaundice and cholangitis. Associated lithiasis is not rare and can be confusing. Pathological and radiological classification have been proposed. Here we focus on clinical presentation and radiological appearance aiming to raise the awareness about this rare entity.

References

1. Endoscopic image showing mucus and sludge, mixed with friable tissue, draining from papilla maior
2. Magnetic Resonance Cholangiopancreatography demonstrating focal lack of signal in common bile duct
3. Retrograde Cholangiogram showing a “peculiar” filling defect in a fusiform dilated choledocus

Introduction

According to the latest clinical practice guidelines, the empirical antimicrobial therapy used for managmente of patients with acute cholangitis should be established according to its level of severity. However, this recommendation have been highly questioned in those settings where the prevalence of broad spectrum beta-lactamase (ESBL) producing E.coli or Klebsiella exceeds 10-20%, and some experts recommend starting with a broader coverage in a systematic way.

Aims & Methods

To evaluate the prevalence of multidrug-resistant cholangitis in our hospital setting, identify possible predictors and antibiotic adequacy.
We made a retrospective analysis of 331 patients diagnosed with acute cholangitis (gathering demographic, clinical, analytical and microbiological data) admitted to the Hospital del Mar during the period from 2018 to 2021.

Results

After assessing the baseline characteristics of theses sample, we obtained a mean age of 78 years, and 53% male. Blood cultures were extracted in 92% of the patients, of which 49% were positive (149 patients) and of these, 12% had multiresistant germs (19 patients, with 17 cases positive for BLEE). The most frequent empirical regimens were amoxicillin-clavulanic acid (112 cases) and cephalosporins with metronidazole (120 cases) with 94.8% and 96.1% of therapeutic adequacy, respectively. The bacteria identified were mainly: E.coli (88%), Enterobacter spp (16%) and Klebsiella spp (21%). Previous colonization by multidrug-resistant germs (3.9%) and institutionalized patients (5.14%) were the only variables related to the presence of cholangitis due to multidrug-resistant germs, but in the multivariate analysis only colonization was a predictor factor (OR 6.69, CI 1.16-38.35). No analytical or hemodynamic variables were found to be associated to bacteremia due to multidrug-resistant germs. Otherwise, bacteremia due to multidrug-resistant germs didn't correlate with a higher mortality.

Conclusion

The prevalence of multidrug-resistant cholangitis in our setting is considerable. However, high antibiotic adequacy is achieved with amoxicillin-clavulanic acid or third generation cephalosporins in most cases. In patients with history of infection or previous colonization by conflicting germs, a broad-spectrum antibiotic coverage including multidrug-resistant germs should be considered empirically.

Introduction

The role of ustekinumab and vedolizumab in articular extra-intestinal manifestations of IBD remains unclear and most existing studies are retrospective.

Aims & Methods

The aim of this study is to analyze the incidence of new onset or worsening of a preexisting IBD-associated arthropathy in patients treated with ustekinumab or vedolizumab.
An observational prospective study in a tertiary care University hospital was conducted. IBD patients undergoing treatment with vedolizumab or ustekinumab with previous or new onset arthropathy were included. Articular manifestations were evaluated by a rheumathologist. IBD and rheumatological related variables were assessed at baseline and after 6 months, including demographics, clinical, biochemical, endoscopic and ultrasound data.

Results

201 patients are treated with ustekinumab/vedolizumab for IBD in our center.
36 patients (17.1%) with previous arthropaties and 5 (3.3%) patients who developed new onset arthropathy after the starting of the treatment were included.
Most patients were anti-TNF experienced (26, 72.2%) or other biological therapy (9, 24.9%) with a median of 2 previous biological treatments per patient (IQR: 1-3).
Of the patients with new onset arthropaty 1 was treated with ustekinumab (20%) and 4 with vedolizumab (80%). Type of arthritis was: peripheral arthritis 3 (60%), axial 1 (20%) and mixed 1 (20%).
Among patients with previous arthropaties, 14 were under treatment with vedolizumab (38.9%) and 22 (61.1%) with ustekinumab for a mean time of 27.8 ± 19.7 months. 12 (38.7%) had worsening joint activity or flare-ups during ustekinumab/vedolizumab treatment. Of these, 5 (41.7%) had parallel intestinal activity (4 with ustekinumab and 1 with vedolizumab). There were no significant differences between the two biological therapy groups and worsening joint activity.
In our study, in most of the patients, joint symptoms were independent of clinical intestinal activity, although the differences were not significant. However, we did find that fecal calprotectin levels was significantly higher in patients with joint worsening (588.4 µg/g) vs. no joint activity (188.8 µg/g); p=0.05.

Conclusion

A significant proportion of patients treated with ustekinumab/vedolizumab have poor control of both axial and peripheral joint activity. In our experience, joint activity is not related to the clinical but biochemical activity of IBD.