Eosinophilic Colitis, an Uncommon Cause of Diarrhea: Case Report and Literature Review

Eosinophilic colitis and hypereosinophilic syndrome with colic involvement are rare diagnosis that are characterized by wide-ranging gastrointestinal symptoms and idiopathic infiltration of eosinophils in the colon. The diagnostic workup is challenging since there are no standardized criteria. We report a case of a man admitted to the hospital with a history of nonbloody chronic diarrhea. The detailed workup demonstrated blood eosinophilia, and the colonic biopsies revealed extensive eosinophilic infiltration. He was treated with steroids with clinical and analytical improvement. Due to relapsing colitis after therapy withdrawal, he was chronically medicated with 10 mg of prednisolone with ultimate symptom control. This case report describes the diagnostic workup and highlights the most important features of this often underdiagnosed entity.

Endoscopic treatment of upper gastrointestinal postsurgical leaks: a narrative review

Upper gastrointestinal postsurgical leaks are life-threatening conditions with high mortality rates and are one of the most feared complications of surgery. Leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Steady advancements in interventional endoscopy in recent decades have allowed the development of new endoscopic devices and techniques that provide a more effective and minimally invasive therapeutic option compared to surgery. Since there is no consensus regarding the most appropriate therapeutic approach for managing postsurgical leaks, this review aimed to summarize the best available current data. Our discussion specifically focuses on leak diagnosis, treatment aims, comparative endoscopic technique outcomes, and combined multimodality approach efficacy.

Best Practices in Esophageal, Gastroduodenal, and Colonic Stenting

Endoscopic stenting is an area of endoscopy that has witnessed noteworthy advancements over the last decade, resulting in evolving clinical practices among gastroenterologists around the world. Indications for endoscopic stenting have progressively expanded, becoming a frequent part of the management algorithm for various benign and malignant conditions of the gastrointestinal tract, from esophagus to rectum. In addition to expanded indications, continuous technological enhancements and development of novel endoscopic stents have resulted in an increased success of these approaches and, in some cases, allowed new applications. This review aimed to summarize best practices in esophageal, gastroduodenal, and colonic stenting.

Best Practices in Pancreatico-biliary Stenting and EUS-guided Drainage

Indications for endoscopic placement of endoluminal and transluminal stents have greatly expanded over time. Endoscopic stent placement is now a well-established approach for the treatment of benign and malignant biliary and pancreatic diseases (ie, obstructive jaundice, intra-abdominal fluid collections, chronic pancreatitis etc.). Ongoing refinement of technical approaches and development of novel stents is increasing the applicability and success of pancreatico-biliary stenting. In this review, we discuss the important developments in the field of pancreatico-biliary stenting, with a specific focus on endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-associated developments.

An Unexpected Cause of Acute Abdomen Late After Heart Transplantation-A Case Report

Cytomegalovirus (CMV) infection is a frequent complication after a solid organ transplant, and in 86% of the cases, CMV disease occurred during the first 6 months after transplantation. Invasive CMV infections may be present as ulcerative infections of the upper gastrointestinal tract with esophagitis, gastritis, and ulcerations of the duodenum and the small bowel; however, CMV infections of the pancreatobiliary system, especially papillitis, are rarely observed. We present a case report of a man who underwent a heart transplant 6 years before, with a clinical picture of duodenitis and a simultaneous pseudotumor of major duodenal papilla who developed signs of acute abdomen caused by gastrointestinal CMV infection, successfully treated with medical therapy with valganciclovir. There is an urgent need for developments in CMV and solid organ transplantation to stratify the risk of late-onset CMV disease.

Pneumatosis intestinalis: a rare endoscopic feature of colonic ischemia

A 71-year-old male was admitted on intensive care unit after endovascular aneurysm repair of ruptured infrarenal abdominal aortic aneurysm. 2 weeks later, he had multiple episodes of bloody diarrhea. Colonoscopy revealed diffuse dusky mucosal coloration with loss of vasculature pattern, diseased haustrations, and diffuse areas of pneumatosis, suggestive of severe colonic ischemia.

Technical Review on Endoscopic Treatment Devices for Management of Upper Gastrointestinal Postsurgical Leaks

Upper gastrointestinal postsurgical leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Nowadays, endoscopy is considered the first-line approach for their management, however, there is no definite consensus on the most appropriate therapeutic approach. There is a wide diversity of endoscopic options, from close-cover-divert approaches to active or passive internal drainage approaches. Theoretically, all these options can be used alone or with a multimodality approach, as each of them has different mechanisms of action. The approach to postsurgical leaks should always be tailored to each patient, taking into account the several variables that may influence the final outcome. In this review, we discuss the important developments in endoscopic devices for the treatment of postsurgical leaks. Our discussion specifically focuses on principles and mechanism of action, advantages and disadvantages of each technique, indications, clinical success, and adverse events. An algorithm for endoscopic approach is proposed.

Triple-sized intragastric balloon due to spontaneous hyperinflation

A 38-year-old female with medical history of breast cancer, hypertension, diabetes mellitus and obesity (body max index 55kg/m2), was admitted to the emergency room with complains of nausea and vomits. Three weeks prior to the presentation, she placed an intragastric balloon (IGB) (Orbera365™, Apollo endosurgery Inc., Austin, TX), for weight loss, filled with 600ml solution of saline and methylene blue dye. Upon physical examination, she was dehydrated and presented with a bulging of the upper abdominal wall associated with mild abdominal pain. Laboratory tests showed severe metabolic alkalosis, hypocalcemia and hypokalemia. Abdominal x-ray revealed gastric distension with an increased size IGB, measuring 164.3*145.6*144.1 mm (estimated volume of 1800mL), with an air-fluid level. Upper endoscopy revealed the balloon stuck in the antrum. A catheter needle was used to puncture and deflate the balloon. Once deflated it was removed with endoscopic forceps. The fluid was not sent for microbiologic culture. After IGB removal, hydroelectrolytic disturbances were resolved and oral feeding was promptly resumed without further complications.

Clinicopathological characteristics and prognostic factors of small bowel lymphomas: a retrospective single-center study

Background

There is little information on diagnosis and management of small bowel lymphomas, and optimal management strategies are still undefined. This study aims to describe their main clinical and pathological characteristics and identify poor prognostic factors.

Methods

A retrospective observational study of all patients with histological diagnosis of small bowel lymphoma between January 2010 and December 2020 was performed.

Results

We included 40 patients, with male predominance (60%) and mean age of 60.7 years. The ileum was the most common location, and the most common histological subtypes were follicular lymphoma and diffuse large B-cell lymphoma. Clinical presentation was variable from asymptomatic patients (30%) to acute surgical complications (35%) including perforation, intestinal obstruction, ileal intussusception, or severe bleeding. Diagnosis was established by endoscopy in 22 patients (55%), and the most common findings included polyps, single mass, diffuse infiltration, or ulceration, whereas 18 (45%) required surgery because of acute presentations or tumor resection, and lymphoma was diagnosed postoperatively. Surgery was curative in one-third of those patients. Median survival was 52 months. Acute presentation (P = 0.001), symptomatic disease (P = 0.003), advanced stage (P = 0.008), diffuse large B-cell lymphoma (P = 0.007), anemia (P = 0.006), hypoalbuminemia (P < 0.001), elevated lactate dehydrogenase (P = 0.02), elevated C-reactive protein (P < 0.001), and absence of treatment response (P < 0.001) were significant predictors of mortality.

Conclusion

Small bowel lymphoma is a rare malignancy with diverse clinical and endoscopic presentations that require a high index of suspicion. Primary factors associated with worse outcome included acute presentation, advanced stage, histological subtype, biochemical abnormalities, and absence of treatment response.

Exosomal glypican-1 is elevated in pancreatic cancer precursors and can signal genetic predisposition in the absence of endoscopic ultrasound abnormalities

BACKGROUND

Individuals within specific risk groups for pancreatic ductal adenocarcinoma (PDAC) [mucinous cystic lesions (MCLs), hereditary risk (HR), and new-late onset diabetes mellitus (NLOD)] represent an opportunity for early cancer detection. Endoscopic ultrasound (EUS) is a premium image modality for PDAC screening and precursor lesion characterization. While no specific biomarker is currently clinically available for this purpose, glypican-1 (GPC1) is overexpressed in the circulating exosomes (crExos) of patients with PDAC compared with healthy subjects or those harboring benign pancreatic diseases.

AIM

To evaluate the capacity of GPC1⁺ crExos to identify individuals at higher risk within these specific groups, all characterized by EUS.

METHODS

This cross-sectional study with a prospective unicentric cohort included 88 subjects: 40 patients with MCL, 20 individuals with HR, and 20 patients with NLOD. A control group (CG) was submitted to EUS for other reasons than pancreatic pathology, with normal pancreas and absence of hereditary risk factors (n = 8). The inclusion period was between October 2016 and January 2019, and the study was approved by the Ethics Committee of Centro Hospitalar Universitário de São João, Porto, Portugal. All patients provided written informed consent. EUS and blood tests for quantification of GPC1⁺ crExos by flow cytometry and carbohydrate antigen 19-9 (CA 19-9) levels by ELISA were performed in all subjects. EUS-guided tissue acquisition was done whenever necessary. For statistical analysis, SPSS^® 27.0 (IBM Corp., Armonk, NY, United States) version was used. All graphs were created using GraphPad Prism 7.00 (GraphPad Software, San Diego, CA, United States).

RESULTS

Half of MCLs harbored worrisome features (WF) or high-risk stigmata (HRS). Pancreatic abnormalities were detected by EUS in 10.0% and 35.0% in HR and NLOD individuals, respectively, all considered non-malignant and “harmless.” Median levels of GPC1⁺ crExos were statistically different: MCL [99.4%, interquartile range (IQR): 94.9%-99.8%], HR (82.0%, IQR: 28.9%-98.2%), NLOD (12.6%, IQR: 5.2%-63.4%), and CG (16.2%, IQR: 6.6%-20.1%) (P < 0.0001). Median levels of CA 19-9 were within the normal range in all groups (standard clinical cut-off of 37 U/mL). Within HR, individuals with a positive history of cancer had higher median levels of GPC1⁺ crExos (97.9%; IQR: 61.7%-99.5%), compared to those without (59.7%; IQR: 26.3%-96.4%), despite no statistical significance (P = 0.21). Pancreatic cysts with WF/HRS were statistically associated with higher median levels of GPC1⁺ crExos (99.6%; IQR: 97.6%-99.8%) compared to those without (96.5%; IQR: 81.3%-99.5%) (P = 0.011), presenting an area under the receiver operating characteristic curve value of 0.723 (sensitivity 75.0% and specificity 67.7%, using a cut-off of 98.5%; P = 0.012).

CONCLUSION

GPC1⁺ crExos may act as biomarker to support the diagnosis and stratification of PDAC precursor lesions, and in signaling individuals with genetic predisposition in the absence of EUS abnormalities.

Hepatic Glycogenosis: An Underdiagnosed Entity?

Hepatic glycogenosis (HG) is a rare complication of long-standing poorly controlled type 1 diabetes mellitus (T1DM), which is often misdiagnosed as non-alcoholic fatty liver disease (NAFLD). Despite the existence of several reports in the literature, it still is underrecognized, even among gastroenterologists. Differential diagnosis between these entities is essential since they have different prognoses.

We report a case of an 18-year-old female, with a medical history of poorly controlled T1DM, admitted to an intensive care unit with severe diabetic ketoacidosis (DKA). Upon admission, aminotransferases were significantly elevated; bilirubin and coagulation tests were normal. Despite adequate DKA treatment, she had persistently elevated aminotransferases and hyperlactacidemia. Imaging studies showed hepatomegaly and bright liver parenchyma. Extensive laboratory workup was negative for other causes of liver disease. So, a liver biopsy was performed, which was consistent with the diagnosis of HG. Under strict metabolic control, she had progressive improvement, achieving biochemical normalization within 6 months.

This case highlights the need for clinicians to be aware of this condition due to non-negligible differences between HG and NAFLD, with the latter progressing to fibrosis, and ultimately cirrhosis and hepatocarcinoma. On the opposite, HG is considered a benign condition, associated with an excellent prognosis that can be reversible after adequate metabolic control. Liver biopsy remains the gold standard method for HG diagnosis since it can distinguish it from NAFLD.

Discontinuation of antiviral therapy in chronic hepatitis B patients

Nucleos(t)ide analogs (NUC) are the first-line therapy for patients with chronic hepatitis B (CHB) recommended by most current guidelines. NUC therapy decreases progression of liver disease, reduces the risk of liver-related complications, and improves the quality of life of patients with CHB. Although indefinite or long-term NUC therapy is usually recommended, this strategy raises several concerns, such as side-effects, adherence, costs, and patient willingness to stop therapy. Recent data showed the feasibility, efficacy, and safety of stopping antiviral therapy in carefully selected CHB patients, leading to its incorporation in international guidelines. Patients who discontinue NUC have a higher likelihood of hepatitis B surface antigen (HBsAg) loss compared to patients who continue on therapy. Recommendations pertaining endpoints allowing safety discontinuation of NUC therapy differ among international guidelines. For hepatitis B e antigen (HBeAg)-positive patients, durable HBeAg seroconversion is considered an acceptable treatment endpoint. For HBeAg-negative patients, some guidelines propose undetectability hepatitis B virus DNA for at least 2 or 3 years, while others consider HBsAg loss as the only acceptable endpoint. CHB patients who stop therapy should remain under strict clinical and laboratorial follow-up protocols to detect and manage relapses in a timely manner. No reliable predictor of relapse has been consistently identified to date, although quantitative HBsAg has been increasingly studied as a reliable biomarker to predict safe NUC discontinuation.