Introduction

Digestive hemorrhage is a frequent complication in advanced chronic kidney disease. Patients with end-stage renal disease (ESRD) are more likely to have gastrointestinal (GI) problems, including digestive bleeding of high or low origin.

Aims & Methods

The aim of our work is to study the particularities of HD in CKD patients.
This is a monocentric prospective analytical study over a period of 28 months: April 2020 to August 2022, including patients with HD with CKD at the dialysis stage or not, including renal transplant patients.
In order to be able to compare patients with ESRD with patients without ESRD, a control group of patients admitted for HD who had a GI endoscopy during the study period and with normal renal function were identified and grouped. In this group of patients, we took into account age, sex, indications, GI endoscopy results and ICU stay.
We also assessed all-cause mortality between the groups of CKD patients with HD versus the control group.

Results

A total of 378 patients underwent digestive exploration for HD. In this population, 46 (12.16%) patients with CKD were compared with 332 patients without RI.
70% (n=32) of the patients with RI were on chronic hemodialysis, 26% (n=12) had a GFR<60ml/min/1.73m2 but were managed without the aid of dialysis or transplantation, and 4% (n=2) patients were renal transplant recipients.
The most common etiologies in CKD patients were ulcer disease 65.2% (n=30); vascular ectasia 28.2% (n=13), gastritis 26% (n=12), esophagitis 10.8% (n=5); and tumors in 8.6% (n=4).
After statistical analysis patients with CKD had:
A higher risk of hemodynamic instability 69.5% (n=32) compared to the control group 11.14% (n=37) with p=0.002,
A higher rate of recurrence 26% (n=12) CKD patients compared to 9.6% (n=32) of the control group with a p=0.00.
A higher mortality rate 4.34% (n=2) in CKD patients compared to the control group 1.2% (n=4) with p=0.00.

Conclusion

GI bleeding in advanced chronic kidney disease is more severe it is accompanied by a higher risk of recurrence of ICU stay and mortality, hence the interest of prompt management and close monitoring. The main causes are peptic ulcer and vascular ectasia.

Introduction

Fatigue, defined as “an overwhelming sense of tiredness, lack of energy and feeling of exhaustion” [1] is a frequent complaint in celiac disease. A strict, lifelong gluten free diet is the only established treatment for celiac disease, however its long-term effect on fatigue is unknown.

Aims & Methods

Our aims were to investigate the course of fatigue severity and prevalence in celiac patients from diagnosis to five to seven years on a gluten free diet, and to investigate whether diet adherence, disease activity and selected biochemical markers are associated with fatigue.
We conducted a single-center prospective study in 45 patients with newly diagnosed celiac disease. The primary endpoints were fatigue severity, as measured by the Fatigue Severity Scale (FSS) [2], the fatigue Visual Analog Scale (fVAS) [3], and the Vitality subscale of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36vs) [4]. SF-36vs scores were inverted (100 – SF-36vs = inverted SF-36vs) to ease comparison between the other scales, so that higher scores indicate more fatigue. Clinically relevant fatigue was defined by an FSS score of ≥4, a fVAS score of ≥50, and an inverted SF-36vs score of ≥65. Study visits were performed at the time of diagnosis (Visit 1), after adhering to a gluten free diet for one year (Visit 2) and for five to seven years (Visit 3). Diet adherence was evaluated through urinary gluten immunogenic peptides (GIP) and the Celiac Diet Adherence test (CDAT) [5]. Disease activity was assessed through Celiac Symptom Index (CSI) [6], celiac autoantibodies (anti tissue transglutaminase IgA and deamidated gliadin peptide IgG) and histologic evaluation (Marsh score). Nutritional status was assessed through BMI, hemoglobin, 25-hydroxy vitamin D, cobalamin, ferritin and folic acid levels.

Results

Fatigue severity was significantly reduced from time of diagnosis, for all three instruments (Table 1). Fatigue prevalence rates were significantly decreased from Visit 1 (40-53%) to Visit 3 (27-31%). Fatigue was significantly lower in patients with good adherence compared to patients with poor adherence according to CDAT scores (For FSS p=0.022, fVAS p=0.017, and for inverted SF-36vs p=0.033). There was however no difference in fatigue severity between adherent and nonadherent patients when evaluating adherence through urinary GIP. Fatigue was lower in patients in clinical remission according to CSI scores (for FSS p=0.002, fVAS p=0.004, and for inverted SF-36vs p=0.002), but not associated with autoantibodies or nutritional status. In multiple linear regression analysis, depression was the only independent variable significantly associated with all three fatigue measures at Visit 3, whereas pain was positively associated with inverted SF-36vs scores.

Table 1.

Conclusion

Fatigue remains a frequent complaint in celiac disease even after five to seven years on a gluten free diet. However, fatigue severity is reduced from time of diagnosis. Fatigue was associated with dietary adherence as assessed by CDAT. Disease activity according to CSI was associated with fatigue, whereas nutritional status, autoantibodies and histologic changes were not.

References

1. Krupp, L.B. and D.A. Pollina, Mechanisms and management of fatigue in progressive neurological disorders. Curr Opin Neurol, 1996. 9(6): p. 456-60.
2. Krupp, L.B., et al., The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol, 1989. 46(10): p. 1121-3.
3. Wolfe, F., Michaud K, Pincus T, Preliminary evaluation of a visual analog function scale for use in rheumatoid arthritis. J Rheumatol, 2005. 32(7): p. 1261-6.
4. Ware, J.E., Jr. and C.D. Sherbourne, The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care, 1992. 30(6): p. 473-83.
5. Leffler, D.A., et al., A simple validated gluten-free diet adherence survey for adults with celiac disease. Clin Gastroenterol Hepatol, 2009. 7(5): p. 530-6, 536.e1-2.
6. Leffler, D.A., et al., A validated disease-specific symptom index for adults with celiac disease. Clin Gastroenterol Hepatol, 2009. 7(12): p. 1328-34, 1334.e1-3.

Disclosure

Berit Mære Skjellerudsveen: Received lecture honoraria from Takeda for lectures on IBD and pregnancy. This study is partly funded by a grant from the patient organization “The Norwegian Coeliac Society”.

Introduction

Colorectal cancer (CRC) is a global health problem with high incidence and mortality rates. Although the incidence has decreased with the use of screening tests, the mortality rate is approximately 1,6 – 2,0 % per year. Recent studies have shown a steady increase in the incidence of early onset (<50 years) CRC compared to that of patients >50 years of age. Early-onset CRC cancer is reported to have a more progressive course and may have a genetic and epigenetic background. In this study, we aimed to investigate the disease characteristics and risk factors for colorectal cancer in patients <50 years old and compare with patients over 50 years of age.

Aims & Methods

Patients younger than 50 years, diagnosed with colorectal adenocarcinoma and followed in our hospitals' gastroenterology, oncology, or general surgery departments between January/2009 and June/2022 were included in this retrospective study. A total of 6102 patients’ files were examined. Among these, 1166 were under the age of 50, whilst 4936 were 50 years and older. Patients younger than 18 years, who had a previous history of CRC, a known familial CRC syndrome, who had synchronous tumors at the time of diagnosis or had in situ CRC were not included in the study. After applying the exclusion criteria, 989 patients were included in the under-50 age group. The comparison group consisted of 1009 patients randomly selected from a group of 4000 patients aged 50 years or older. Patients were divided into Group A (<50 years) and Group B (≥ 50 years) according to the age at diagnosis. Patients’ demographic characteristics, body mass index, history of cigarette smoking and alcohol use, presenting symptoms, history of H. pylori infection, co-morbidities and medications were recorded from the files. Tumour characteristics, localization, size, TNM stage, and treatment methods were also analyzed and the relationship with each other was examined comparatively.

Results

The results of 1998 patients included in the study are shown in Table 1. TNM stages and the duration of symptoms before the diagnosis were similar between the groups but the rate of stage 1 disease was higher in group B. The rates of metastatic disease and rectal cancer were higher in Group A, but statistically non-significant. Abdominal pain was significantly more frequent in Group A, while anemia was significantly more common in Group B. Patients in Group A had higher rates of IBD, family history of CRC, mucinous adenocarcinoma, poorly differentiated tumor, higher histological grade and higher microsatellite instability (MSI-H). Although perineural and lymphatic invasion rates were similar, vascular invasion was higher in group B.

Table1. Comparison of Patients in Group A and Group B

Conclusion

Our study revealed that Early-onset CRC is more frequently diagnosed at the metastatic stage, is characterized by a more common presence of mucinous cells, poorly differentiated histology, and microsatellite instability.

Introduction

The only effective treatment for celiac disease (CD) is lifelong compliance with a gluten-free diet. Lactobacilli and Bifidobacterium spp. may play a role in the breakdown of gluten. Ithas been demonstrated that Lactobacilli can detoxify gliadin peptides after partial digestion by human proteases. These findings could suggest the use of probiotics as complementary therapy for CD.

Aims & Methods

We designed a study to determine the potential effect of a combination of Lactobacillus (acidophilus HA-122, casei HA-108) and Bifidobacterium bifidum HA-132 on perception of symptoms and on the inflammatory-immunological markers in patients with active CD.
25 adult patients were randomized to receive bid of a probiotic combination of Lactobacilus and Biffidobacter for six weeks (13 pts) va a placebo group (12 pts) while being on gluten-free diet. Laboratory studies included routine blood tests, CD specific antibodies, determination of IL-1b, IL-6 and TNF-alpha. CD serology and duodenal histology were performed at baseline, at the end of treatment and at 30 days after therapy. Histological damage in intestinal biopsy samples was graded according to the Marsh modified classification. At baseline and follow-up visit, patients completed the Gastrointestinal Symptom Rating Scale (GSRS) questionnaire. Histological damage in intestinal biopsy samples was graded according to the Marsh modified classification.

Results

25 pacients, 13 in the probiotic associated arm, 12 in the placebo arm, with median age of 40, BMI 21.2, 18 with symptomatic CD (equal distribuited) and 7 with sublinical CD (4 in the probiotic arm, 9 in the placebo arm). Baseline serology: IGA tTG 1986.6 (group A) vs 1507.1 (placebo group). Baseline hystology (Marsh classification)- Marsh 3a 1 pacient in probiotic group, 2 in the placebo arm. 5 pts Mars 3b3 in group A and 2 in the placebo arm and 17 pts Marsh 3c (9 pts probiotic, 8 pts placebo). IELs density (mean range) was 44.5 in the first group vs 42.5
After treatment: clinical aleviation of indigestion and diareea (p=0.002), constipation (p=0. 0396), gastro-esophageal reflux (p=0.0493) and abdominal pain (p=0.0378)-superior in the probiotic associated treatment.
Serologic parameters: IgA tTG 0,96 in the probiotic arm vs 1,16 in the placebo (p=0.048), IgA EMA 1,05 vs 0,97 (p=0.028), IgG DGP 0,91 vs 1,12 (p=0.21).
Improvement of the inflamatory status: decrease of IL-1b, IL 6 and TNF-a was superior in the probiotic associated group (p=0.071, p=0.083, p=0.078).
Regarding the histologic response: IELs 0,83 vs 1.07 in the placebo arm (p=0.049).

Conclusion

Tests and the lymphocyte infiltrates in the mucosal biopsy specimen in uur study suggests that prebiotic/probiotic treatment may improve symptoms and serology in celiac disease.

Disclosure

I don t have any conflict of interest to declare

Introduction

With the improvement of endoscopic resection techniques, there has been recent interest in real-time in vivo characterization of polyp histology. Of all the new imaging technologies for characterizing polyp histology, narrow-band imaging (NBI) has been the most extensively studied and is easy to feasible. Correct histological prediction allows determining the optimal endoscopic technique for resection of lesions with the achievement of R0 resection. The NBI International Colorectal Endoscopic Classification (NICE) and the Japanese NBI Expert Team (JNET) classification are mostly used to predict the depth of invasion. However, the effectiveness of diagnostics using NBI in clinical practice is variable and is associated with low sensitivity for superficial invasive carcinoma.

Aims & Methods

Primary aim was to determine and compare the diagnostic accuracy of NICE and JNET classifications in predicting histology in community practice. Secondary aim was to determine the positive predictive value (PPV) for the NICE and JNET classification.
In this single-center prospective study we have included 211 patients aged 18–75 years (130 men, 62%; 81 women, 38%; mean age 60 years) who underwent colonoscopies with endoscopic resection of advanced colorectal neoplasia (defined by size lesions ≥ 10 mm). The NICE and JNET classifications were used for each lesion. The results were compared with the final histopathological finding to determine and compare NICE and JNET classification accuracy.

Results

257 lesions were analyzed including 8 (3.1 %) hyperplastic polyps, 47 (18.3 %) sessile serrated polyps, 152 (59.1 %) adenomas with low grade dysplasia, 36 (14.0 %) high-grade adenomas, 12 (4,7 %) intramucosal carcinomas, 1 (0.4 %) T1sm1 carcinoma and 1 (0.4 %) T2 carcinoma. A total of 199 lesions (77.4 %) were correctly classified according to the JNET classification and 241 lesions (93.8 %) were correctly classified according to the NICE classification. The PPV for NICE 1 lesion was 95.9 %, NICE 2 97.0 % and NICE 3 22.0 %. The PPV for JNET 1 lesions was 95.9 %, JNET 2A 83.0 %, JNET 2B 52.2 % and JNET 3 22.5 %.

Conclusion

The NICE classification was associated with a higher proportion of correctly classified lesions (93.8 %) compared to the JNET classification (77.4 %). However, NBI virtual chromoendoscopy shows a low PPV for HGD adenomas, intramucosal carcinomas and T1sm1 carcinomas (NICE 2 22.1 %, JNET 2B 52.2 %). Therefore, additional investigations in these lesions are still required with magnifying chromoendoscopy prior a final decision of endoscopic therapy. Improvement of predictive accuracy of these lesions and determining the limiting factors will be the subject of further investigation.
Supported by program projects of the Ministry of Health of the Czech Republic with reg. no. NV18-08-00246, NU22-08-00424, MO1012 and Cooperatio.

References

Kobayashi S et al. Diagnostic yield of the Japan NBI Expert Team (JNET) classification for endoscopic diagnosis of superficial colorectal neoplasms in a large-scale clinical practice database. United European Gastroenterology Journal 2019;7(7):914- 923.
Hayashi N et al. Endoscopic prediction of deep submucosal invasive carcinoma: validation of the narrow-band imaging international colorectal endoscopic (NICE) classification. Gastrointest Endosc 2013;78:625–632.
Sano Y et al. Narrow-band imaging (NBI) magnifying endoscopic classification of colorectal tumors proposed by the Japan NBI Expert Team. Dig Endosc 2016;28:526–533.
Wang Y et al. Diagnostic performance of narrow-band imaging international colorectal endoscopic and Japanese narrow-band imaging expert team classification systems for colorectal cancer and precancerous lesions. World J Gastrointest Oncol 2021;13(1):58-68.

Introduction

Celiac disease (CeD) is an immune-mediated disease with excess morbidity and mortality. CeD is associated with inflamed intestinal mucosa, which may be mediated IL-15. There are currently no established non-invasive biomarkers to monitor disease activity following treatment of CeD.

Aims & Methods

Thus, we aimed to characterize disease biomarkers of CeD, primarily IL-15 levels, in the gut and in the serum of non-responsive CeD (NRCD), Treated responsive CeD (TrCD), and non-CeD controls to evaluate the relationship between cytokine levels and CeD disease status.
Based on the existing archives of our Olmsted County Celiac Registry, we identified 29 NRCD, 30 TrCD, and 24 non CeD controls. NRCD was defined as patients with a diagnosis of CeD presenting with continued celiac symptoms and partial or total villous atrophy after 1 or more years of following a strict gluten-free diet (GFD). In contrast, TrCD was defined as patients with a diagnosis of CeD who were presenting with no celiac symptoms and normal duodenal histology after 1 year or more of a strict GFD. Control samples were matched by age, gender, and confirmed as negative celiac serology. We assessed duodenal biopsy and serum IL-15 protein expression levels in patients with NRCD, TrCD, and controls using a quantitative ligand binding assay with electrochemiluminescent detection. Furthermore, we conducted the proteomic profiling by utilizing targeted proteomics panels to assess the changes in serum and duodenal biopsy tissues samples of patients with NRCD, TrCD, or non-CeD controls.

Results

The measured levels of IL-15 in serum and duodenal biopsy samples are summarized according to disease status in Table 1. No apparent separation in median IL-15 levels (serum and gut tissue) was observed across the three groups (non-CeD controls, TrCD and NRCD). It was also difficult to draw a correlation between serum and gut tissue IL-15 levels. In contrast to the TrCD and control groups, high variability in IL-15 levels was seen with the NRCD group, potentially due to differences in histology and/or other clinical manifestations by the subjects within the group. Interestingly, the highest IL-15 level (serum or tissue) was noted in NRCD patients with total villous atrophy. However, small n (2 out of 29) precludes definitive association.

Table 1. Demographics and IL-15 protein levels in samples from patients with NRCD, RCD, and non-CeD controls.

Conclusion

Data generated from this retrospective study did not show clear difference in the mean IL-15 (serum or tissue) levels between the responsive and non-responsive CeD groups. However, for the limited number of NRCD samples with total villous atrophy, the IL-15 levels were substantially higher (either in serum or tissue) compared to partial or near normal. Testing of more samples representing the different villous atrophy status is warranted to confirm these results.

Disclosure

Study was conducted as part of a Teva funded research collaboration between the Mayo Clinic, which provided the gut biopsies and serum samples, and Teva, Pharmaceuticals Industries, Ltd., which developed and performed the assays and analyses.