Scoping Review of Clinical Presentations and Outcomes in Patients with Concomitant COVID-19 Infection and Acute Mesenteric Ischaemia

OBJECTIVES

COVID-19 infection confers an increased risk of coagulation dysfunction (1) predisposing to thromboembolism in many anatomical sites including the gastrointestinal tract (GIT) (2). This study investigates the clinical presentation and outcome in patients presenting with concurrent COVID-19 infection and gastrointestinal tract ischaemia. Furthermore, differentiation and comparisons are drawn between those with arterial and venous aetiology for mesenteric ischaemia.

METHODS

A systematic search was undertaken on EMBASE, PubMed, and MEDLINE. Two independent reviewers screened titles, abstracts, and full-text articles according to the inclusion criteria and extracted relevant data. Data analyses were conducted using Excel®.

RESULTS

Forty-one studies were included in the data analyses, yielding 44 patients. Twenty-six patients had mesenteric arterial occlusion, sixteen patients had mesenteric venous occlusion, and two patients had both arterial and venous mesenteric occlusion. All patients had concurrent COVID-19 infection. The survival rate in patients with arterial aetiology was 38.5% in contrast to 68.8% in patients with venous aetiology. Twelve patients (29.3%) experienced respiratory symptoms in the community before the onset of gastrointestinal symptoms, and five (12.2%) developed gastrointestinal symptoms during their inpatient stay for COVID-19 pneumonitis.

CONCLUSIONS

Acute mesenteric ischaemia presents a clinical challenge to diagnose due to its non-specific symptoms. Concurrent COVID-19 infection with its predominant respiratory symptoms adds a further challenge in recognising the non-specific symptoms of mesenteric ischaemia. Our study draws attention to the increased thromboembolic risk posed by COVID-19 infection and the need for a high index of suspicion to aid prompt diagnosis and management of acute mesenteric ischaemia, even in the post-pandemic era.

Acute Gallstone Pancreatitis: If a Picture Is Worth a Thousand Words, How Many Images Do We Need?

Introduction Accurate diagnosis and prompt definitive management of choledocholithiasis are vital in acute gallstone pancreatitis. The sensitivity of detection of choledocholithiasis varies across imaging modalities. Magnetic resonance cholangiopancreatography (MRCP) is the most sensitive but may not be necessary, resulting in both delayed definitive management and increased costs. We aimed to evaluate the range of radiological investigations patients with acute gallstone pancreatitis underwent and the clinical appropriateness of MRCP when performed. Methods This was an observational study of patients diagnosed with acute gallstone pancreatitis between January 1, 2019 and November 30, 2021 in a district general hospital in London, UK. A detailed review of patient records, laboratory and radiological results, and endoscopic and/or operative intervention was undertaken. Results One hundred consecutive patients diagnosed with acute gallstone pancreatitis (median age 57 years) were included. Seventy-nine had a transabdominal ultrasound (USS), 46 had CT, and 40 patients had MRCP. The median waiting time for these investigations was 1, 0, and 4 days, respectively. Choledocholithiasis was identified in 21 patients (4 on USS, 5 on CT, and 12 on MRCP). As definitive management, 37% underwent endoscopic retrograde cholangiopancreatography, and 57% underwent laparoscopic cholecystectomy. A total of 19% of patients were readmitted with pancreatitis prior to definitive management. Conclusions First-line imaging investigations such as USS and CT can detect some cases of choledocholithiasis in patients with acute gallstone pancreatitis, but not all. Despite expenses in terms of cost and length of hospital stay, MRCP remains an essential resource to detect cases of choledocholithiasis not captured by USS or CT. We recommend establishing a guideline to streamline imaging in assessing acute gallstone pancreatitis.

Bowel ischaemia in COVID-19 infection: a scoping review protocol

INTRODUCTION

COVID-19 disease was declared as a pandemic by WHO since March 2020 and can have a myriad of clinical presentations affecting various organ systems. Patients with COVID-19 are known to have an increased risk of thromboembolism, including cardiovascular, pulmonary and cerebral ischaemic events. However, an increasing number of case studies have reported that COVID-19 infection is also associated with gastrointestinal ischaemia. This scoping review aims to collate the current evidence of COVID-19-related gastrointestinal ischaemia and raise awareness among healthcare professionals of this lesser known, but serious, non-pulmonary complication of COVID-19 infection.

METHODS

The proposed scoping review will be conducted as per the Arksey and O'Malley methodological framework (2005) the Joanna Briggs Institute methodology for scoping reviews. A systematic search will be undertaken on different databases including EMBASE, PubMed and MEDLINE. Two independent reviewers will screen titles, abstracts and full-text articles according to the inclusion criteria and extract relevant data from the included articles. Results will be presented in a tabular form with a narrative discussion.

ETHICS AND DISSEMINATION

Ethical approval will not be required for this scoping review. This scoping review will provide an extensive overview of the association between COVID-19 infection and bowel ischaemia. Further ethical and methodological challenges will also be discussed in our findings to define a new research agenda. Findings will be disseminated through peer-reviewed publications and presentations at both national and international conferences.

EP-289 Acute gallstone pancreatitis – if a picture is worth a thousand words, how many images do we need?

Aims

Accurate diagnosis and prompt definitive management of choledocholithiasis is vital in acute gallstone pancreatitis (GSP). Sensitivity of detection of choledocholithiasis varies across imaging modalities. Magnetic resonance cholangiopancreatography (MRCP) is most sensitive, but may not be necessary, and may result in delayed implementation of definitive management.

We aimed to evaluate the range of radiological investigations patients with acute GSP underwent at our Trust, and the clinical appropriateness of MRCP if performed.

Methods

An observational study of patients diagnosed with acute GSP between 01/05/2019 and 26/02/2021 was performed. Data were collected from electronic patient records.

Results

50 patients were diagnosed with acute GSP (median age 56years). 41 had transabdominal ultrasound (USS), 22 had computed tomography (CT) and 16 patients had MRCP. Median waiting time was 1, 0 and 4 days for respectively. All patients who had MRCP had prior USS and/or CT (Table 1).

As definitive management, 14% underwent endoscopic retrograde cholangiopancreatography (ERCP), 28% underwent laparoscopic cholecystectomy and 30% had initial ERCP followed by laparoscopic cholecystectomy. 14% patients were readmitted with pancreatitis prior to definitive management.

Conclusions

Detailed description of the CBD in initial radiology reports in acute GSP may mitigate the need for unnecessary subsequent imaging, reducing cost and facilitating early definitive management. We recommend establishment of a guideline to streamline imaging in the assessment of acute gallstone pancreatitis.

Pancreatic Incidentalomas on CT Colonography: Ignore, Follow up or Investigate?

Background: Increasing use of cross-sectional abdominal imaging such as CT colonography (CTC), has resulted in increased identification of incidental pancreatic cystic lesions. Such incidental findings are a cause for anxiety amongst patients and clinicians and can result in increased cost to healthcare delivery resultant from referral to subsequent investigations. Our study explored the prevalence of incidental cystic pancreatic lesions on CTC at a tertiary pancreatic centre, and their management. Methods: A detailed review of CTC reports and patient case notes between 2010-2016 was undertaken. Patients from both screening (National Bowel Cancer Screening) and non-screening cohorts were included in our study. Results: 136 of 4666 patients who underwent CTC had an incidental finding of a pancreatic lesion (2.9%) and 117 confirmed cystic pancreatic lesions (2.5%). Radiological diagnosis of intraductal papillary mucinous neoplasm (IPMN) was available in the CTC report for 71 patients. Twelve patients (0.2%) were found to have pancreatic ductal adenocarcinoma (PDAC) incidentally at CTC, 2 resectable and 10 unresectable with the diagnosis confirmed on biopsy. Follow-up surveillance imaging recommendations were made for 39.3% of patients within one year of the diagnosis of a cystic pancreatic lesion on CTC. One patient with pancreatic duct dilatation of 7mm was lost in follow-up and was found to develop PDAC at 21 months. Conclusions: Pancreatic lesions are increasingly found incidentally on CTC. All patients with pancreatic cystic tumour should be referred to pancreatic multidisciplinary team for discussion to determine management pathway.

Laparoscopic Cholecystectomy: Evaluation of Web-Based Information

Introduction

Laparoscopic cholecystectomy (LC), the gold standard treatment for symptomatic gallstone disease, is the most common procedure performed by general surgeons worldwide. The internet remains to be a popular source of medical information. Our aim was to evaluate the quality and readability of information available on the web for patients undergoing LC and to compare the information provided by the National Health Service (NHS) and non-NHS websites. 

Methods

We searched for the keywords ‘laparoscopic cholecystectomy’ using the three most popular search engines (Google, Yahoo and MSN) and looked at the first 50 websites only. The readability of each document was assessed using the Flesch Reading Ease (FRE) score. We checked Health on the Net Foundation Code of Conduct (HONcode) certification status, whether the sites had been checked by an expert and when the information was last updated.

Results

Fifty-five of the possible 150 sites were analysed thus excluding repetitions (n=65), irrelevant content (n=26) or inaccessible links (n=3). Only seven of those were HONcode-certified. The mean FRE score was 46 (range 0-68, SD=16.13). There were 13 NHS sites and 42 non-NHS sites. The mean FRE score for the NHS sites was significantly better compared to the non-NHS sites [58.31 (SD=5.01) vs 42.21 (SD=16.35); p=0.001]. Fifty-four per cent (54%) of the analysed websites had been checked by a medical expert and 22% were updated within the last year.

Conclusions

This study highlights the poor quality and readability of information on medical websites. The information provided by NHS sites have significantly better readability compared to non-NHS sites.

Aberrant epithelial GREM1 expression initiates colonic tumorigenesis from cells outside the stem cell niche

Hereditary mixed polyposis syndrome (HMPS) is characterized by the development of mixed-morphology colorectal tumors and is caused by a 40-kb genetic duplication that results in aberrant epithelial expression of the gene encoding mesenchymal bone morphogenetic protein antagonist, GREM1. Here we use HMPS tissue and a mouse model of the disease to show that epithelial GREM1 disrupts homeostatic intestinal morphogen gradients, altering cell fate that is normally determined by position along the vertical epithelial axis. This promotes the persistence and/or reacquisition of stem cell properties in Lgr5-negative progenitor cells that have exited the stem cell niche. These cells form ectopic crypts, proliferate, accumulate somatic mutations and can initiate intestinal neoplasia, indicating that the crypt base stem cell is not the sole cell of origin of colorectal cancer. Furthermore, we show that epithelial expression of GREM1 also occurs in traditional serrated adenomas, sporadic premalignant lesions with a hitherto unknown pathogenesis, and these lesions can be considered the sporadic equivalents of HMPS polyps.

Use of antibiotic prophylaxis in elective inguinal hernia repair in adults in London and south-east England: a cross-sectional survey

Purpose

Evidence regarding whether or not antibiotic prophylaxis is beneficial in preventing post-operative surgical site infection in adult inguinal hernia repair is conflicting. A recent Cochrane review based on 17 randomised trials did not reach a conclusion on this subject. This study aimed to describe the current practice and determine whether clinical equipoise is prevalent.

Methods

Surgeons in training were recruited to administer the Survey of Hernia Antibiotic Prophylaxis usE survey to consultant-level general surgeons in London and the south-east of England on their practices and beliefs regarding antibiotic prophylaxis in adult elective inguinal hernia repair. Local prophylaxis guidelines for the participating hospital sites were also determined.

Results

The study was conducted at 34 different sites and received completed surveys from 229 out of a possible 245 surgeons, a 93 % response rate. Overall, a large majority of hospital guidelines (22/28) and surgeons’ personal beliefs (192/229, 84 %) supported the use of single-dose pre-operative intravenous antibiotic prophylaxis in inguinal hernia repair, although there was considerable variation in the regimens in use. The most widely used regimen was intravenous co-amoxiclav (1.2 g). Less than half of surgeons were adherent to their own hospital antibiotic guidelines for this procedure, although many incorrectly believed that they were following these.

Conclusion

In the south-east of England, there is a strong majority of surgical opinion in favour of the use of antibiotic prophylaxis in this procedure. It is therefore likely to be extremely difficult to conduct further randomised studies in the UK to support or refute the effectiveness of prophylaxis in this commonly performed procedure.

Preoperative neutrophil to lymphocyte ratio >5 is a prognostic factor for recurrent colorectal cancer

AIM

Previous studies have demonstrated that raised preoperative neutrophil to lymphocyte ratio (NLR) is associated with poor prognosis in colorectal cancer (CRC). The aim of this study was to assess whether preoperative NLR could predict patients at risk of recurrence of CRC.

METHOD

All consecutive patients who underwent surgical resection for CRC over a 2-year period at our institution were analysed. Demographic data including CRC recurrence were prospectively collected from our institutional cancer database. CRC recurrence was diagnosed on radiological and endoscopic histopathological data. Preoperative NLR was calculated on baseline blood results, with a value >5 being a poor prognostic factor. Parametric survival analysis was used to identify risk factors for CRC recurrence. Hazard ratios (HRs) were calculated for gender, CRC stage using Jass score, preoperative NLR and CRC site. P < 0.05 was considered statistically significant.

RESULTS

In all, 297 patients (157 men) underwent CRC resection at a median age of 70 years (range 23-93); 164 patients had colon cancer, 111 rectal cancer and 22 recto-sigmoid cancer. The distribution by stage of CRC was 30.2% for stage 1, 23.8% for stage 2, 19.5% for stage 3 and 26.5% for stage 4. Over a median follow-up period of 3.35 (0.1-8) years, 59 (19.8%) patients had recurrent CRC. Multivariate analysis revealed CRC stage (HR 8.69, 95% CI 3.85-19.6, P < 0.0001) and NLR >5 (HR 1.81, 95% CI 1.07-3.07, P = 0.028) to be significant and independent risk factors predictive of recurrent CRC.

CONCLUSION

These data suggest that preoperative NLR >5 is predictive of CRC recurrence.

A basal gradient of Wnt and stem-cell number influences regional tumour distribution in human and mouse intestinal tracts

OBJECTIVE

Wnt signalling is critical for normal intestinal development and homeostasis. Wnt dysregulation occurs in almost all human and murine intestinal tumours and an optimal but not excessive level of Wnt activation is considered favourable for tumourigenesis. The authors assessed effects of pan-intestinal Wnt activation on tissue homeostasis, taking into account underlying physiological Wnt activity and stem-cell number in each region of the bowel.

DESIGN

The authors generated mice that expressed temporally controlled, stabilised β-catenin along the crypt-villus axis throughout the intestines. Physiological Wnt target gene activity was assessed in different regions of normal mouse and human tissue. Human intestinal tumour mutation spectra were analysed.

RESULTS

In the mouse, β-catenin stabilisation resulted in a graduated neoplastic response, ranging from dysplastic transformation of the entire epithelium in the proximal small bowel to slightly enlarged crypts of non-dysplastic morphology in the colorectum. In contrast, stem and proliferating cell numbers were increased in all intestinal regions. In the normal mouse and human intestines, stem-cell and Wnt gradients were non-identical, but higher in the small bowel than large bowel in both species. There was also variation in the expression of some Wnt modulators. Human tumour analysis confirmed that different APC mutation spectra are selected in different regions of the bowel.

CONCLUSIONS

There are variable gradients in stem-cell number, physiological Wnt activity and response to pathologically increased Wnt signalling along the crypt-villus axis and throughout the length of the intestinal tract. The authors propose that this variation influences regional mutation spectra, tumour susceptibility and lesion distribution in mice and humans.

Negative exploration for pyloric stenosis--is it preventable?

BACKGROUND

The diagnosis of infantile hypertrophic pyloric stenosis (IHPS), although traditionally clinical, is now increasingly dependent on radiological corroboration. The rate of negative exploration in IHPS has been reported as 4%. The purpose of our study was to look at elements of supportive clinical evidence leading to positive diagnosis, and to review these with respect to misdiagnosed cases undergoing negative exploration.

METHODS

All infants undergoing surgical exploration for IHPS between January 2000 and December 2004 were retrospectively analysed with regard to clinical symptoms, examination findings, investigations and operative findings.

RESULTS

During the study period, 343 explorations were performed with a presumptive diagnosis of IHPS. Of these, 205 infants (60%) had a positive test feed, 269 (78%) had a positive ultrasound scan and 175 (55%) were alkalotic (pH >or=7.45 and/or base excess >or=2.5). The positive predictive value for an ultrasound (US) diagnosis was 99.1% for canal length >or=14 mm, and 98.7% for muscle thickness >or=4 mm. Four infants (1.1%) underwent a negative surgical exploration; Ultrasound was positive in 3, and negative in 1(who underwent surgery on the basis of a positive upper GI contrast). One US reported as positive had a muscle thickness <4 mm. Two false positive US were performed at peripheral hospitals. One infant had a false positive test feed following a positive ultrasound diagnosis. Two infants had negative test feeds.

CONCLUSION

A 1% rate of negative exploration in IHPS compares favourably with other studies. However potential causes of error were identified in all 4 cases. Confident diagnosis comprises a combination of positive test feed and an 'in house US' in an alkalotic infant. UGI contrast study should not be used in isolation to diagnose IHPS. If the test feed is negative, strict diagnostic measurements should be observed on US and the pyloric 'tumour' palpated on table under anaesthetic before exploration.