Gastroenterol. Insights, Volume 12, Issue 3 (September 2021) – 11 articles

Introduction. Ultrasound-guided (US-guided) percutaneous drainage (PD) of abdominal collections represents the first-choice alternative to surgical intervention. The aim of our study was to assess the efficacy and safety of PD of visceral and non-visceral abdominal collections by reviewing our personal experience over a period of 5 years. Material and methods. The present study included 66 patients who underwent PD under ultrasound guidance. We analyzed clinical variables (collection size, catheter diameter, collection type, microbiological analysis, antibiotic regimens) along with the outcomes of the procedure. Results. Visceral collections were predominant, encompassing 38 hepatic abscesses and 1 splenic hematoma. Microbiological analysis showed that the majority (54%) were monomicrobial. The most encountered pathogens were Klebsiella pneumoniae and Escherichia coli. Technical success was achieved in all cases and clinical success was observed in 84.6% of the cases. No immediate procedural complications were detected. There were 6 patients who needed reinterventions, either by catheter replacement or by surgical treatment. The mortality rate was 4.5%, due to patients’ poor overall status and oncological comorbidities. Conclusions. Percutaneous drainage under ultrasound guidance is a safe and effective procedure in the management of abdominal collections. Full article

(Background) Endoscopic procedures are interventions that have been defined as carrying a high-risk of infection with COVID-19. Most endoscopy units restrict their activity based on pre-endoscopic diagnosis. (Objective) To determine the consequences of endoscopic restrictions as a result of the COVID-19 pandemic and their impact on digestive cancer diagnosis. (Design) A comparison of upper digestive endoscopies and colonoscopies with gastrointestinal cancers diagnosed between three endoscopic centers, two of which restricted their procedures and one that did not but performed the procedures under a strict protocol. (Setting) A retrospective analysis was performed collecting data between 15 March 2019 and 15 August 2020. Two-factor ANOVA and a Tukey’s a posteriori test were used as statistical tests. (Main outcome measures) There was variation in gastrointestinal cancer diagnosis between 2019 and 2020, considering the endoscopic procedures performed each year. (Result) There was a significant decrease in the total endoscopic procedures performed between 2019 and 2020 (p < 0.001), the result of reduced testing at the two centers (p < 0.001) with pre-endoscopic restrictions, which was not compensated for by a slight increase in procedures at the center without restrictions (p = 0.139). Regarding the total cancers diagnosed, while a significant decrease was observed for the two centers with pre-endoscopic restrictions (p = 0.007), a significant increase was registered in the center that maintained its endoscopic productivity (p < 0.001). After 851 procedures (537 upper digestive endoscopies and 314 colonoscopies) there was no evidence of COVID-19 infection in the endoscopic staff. (Conclusion) Endoscopic restrictions based on pre-endoscopic diagnosis should be reassessed in consideration of local pandemic situations, and a balance should be sought between COVID-19 infection risk and the detrimental delay of potential cancer diagnosis. Full article

Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory condition of unknown etiology, with presumed autoimmune mechanisms. It is characterized by high levels of IgG4 and variable clinical manifestations. It can involve one or multiple organs. Herein, we reported the case of a 62-year-old man with three organs involvement. He initially presented with recurrent jaundice. Laboratory analysis revealed cholestasis, high gamma-globulin levels, renal failure, and proteinuria. Abdominal Magnetic Resonance Imaging (MRI) showed segmental strictures of the left intrahepatic bile ducts and the wirsung duct with an increased volume of the pancreas and diffuse bilateral enlargement of the kidneys. Laboratory tests revealed high IgG4 levels (770 mg/dL). Based on the biological and radiological findings, we have suggested the diagnosis of systemic IgG4-related disease involving bile ducts, the pancreas, and probably the kidneys. Renal biopsy revealed lymphoplasmacytic infiltrate and fibrosis, but no IgG4-positive cell. The patient received corticosteroid therapy with a complete resolution of all symptoms and a rapid normalization of all blood tests. The present case underlines the complexity of IgG4-RD because of its variable clinical presentation. The diagnosis is challenging and should be carefully assessed for possible multi-organ involvement. Full article

Background: Hepatitis C virus treatment has dramatically improved by direct-acting antiviral (DAA) therapy. The aim of this study was to assess the efficacy and safety of DAA in elderly Egyptian chronic hepatitis C (CHC) patients. Methods: The study was carried out on 327 CHC elderly patients >60 years; patients were divided into 3 age subgroups (<65, 65–75 and >75 years) on DAA therapy for 12 weeks. Ninety-one patients (27.8%) were treated with dual therapy, 234 patients (71.6%) with triple therapy and 2 patients (0.6%) with quadrable therapy. Results: All patients achieved end-of-treatment virological response (100%). ALT levels normalized during therapy. The follow-up rate of sustained virological response at 12 weeks after the end of treatment (SVR12) was 100%. One hundred and two patients had missed SVR12 data due to being lost tofollow-up. Two hundred twenty-two adverse events were reported (67.8%), including anemia in 30 patients (9.1%), leucopenia in 129 patients (39.4%) and thrombocytopenia in 63 patients (19.2%). No serious side effects led to discontinuation of therapy. No hepatic decompensation was observed, and no patients died. Conclusion: Age does not influence the success of DAA treatment and all DAA regimens are well tolerated, safe and highly efficacious, even in those aged 75 years or older. Full article

Children with complex medical issues often present different comorbidities that cause feeding difficulties. Gastrostomy is often helpful, and should be performed when nutritional supplementation is necessary for longer than 6 weeks. Recently, different techniques have been used for gastrostomy in children. The authors report on their experiences regarding the diagnostic and therapeutic management of children requiring gastrostomy. All patients managed in the last 10 years were reviewed, retrospectively. Everyone underwent investigation to exclude gastroesophageal reflux disease (GERD). A total of 148 patients: 111 cases (75%) were neurologically impaired patients, 18 (12%) had complex heart disease, 10 (6%) had metabolic diseases, 4 (3%) had fibrosis cystic, 4 (3%) had muscle disease, and one had chromosomopathy. After investigation, 49 patients had GERD. PEG was performed in 101 cases (68%), laparo-assisted gastrostomy was performed in 44 cases (29.7%), open gastrostomy was performed in three cases. At follow-up, all patients reported weight gain, but 13 cases had major complications. Currently, the surgeon has the possibility of choosing between several safe techniques for gastrostomy. In our experience, PEG is the most useful technique for patients without GERD, while a laparo-assisted technique is better for patients who require laparoscopic fundoplication. Full article

We describe an uncommon clinical presentation of caudal duplication syndrome and features of caudal regression syndrome in a female infant with complex urogenital and colorectal duplication associated with lipomyleomeningocele and left lower limb hypoplasia. A staged surgical treatment plan was carried out to maintain fecal and urine continence, potential fertility, and cosmetic appearance. Full article

Complete rectal prolapse or rectal procidentia is a debilitating disease that presents with fecal incontinence, constipation, and rectal discharge. Definitive surgical techniques described for this disease include perineal procedures such as mucosectomy and rectosigmoidectomy, and abdominal procedures such as rectopexy with or without mesh and concomitant resection. The debate over these techniques regarding the lowest recurrence and morbidity rates, and the best functional outcomes for constipation or incontinence, has been going on for decades. The heterogeneity of available studies does not allow us to draw firm conclusions. This article aims to review the surgical techniques for complete rectal prolapse based on the current evidence base regarding surgical and functional outcomes. Full article

Pain is the main symptom of pancreatic cancer (pancreatic ductal adenocarcinoma, PDAC). Pain in pancreatic cancer may be visceral, somatic or neuropathic in origin. Pain is produced by tissue damage, inflammation, ductal obstruction and infiltration. Visceral nociceptive signals caused by damage to the upper abdominal viscera are carried along sympathetic fibers, which travel to the celiac plexus nerves and ganglia, which are found at the T12-L2 vertebral levels, anterolateral to the aorta near the celiac trunk. From here, the signals are transmitted through the splanchnic nerves to the T5-T12 dorsal root ganglia and then on to the higher centers of the central nervous system. Somatic and neuropathic pain may arise from tumor extension into the surrounding peritoneum, retroperitoneum and bones and, in the latter case, into the nerves, such as the lumbosacral plexus. It should also be noted that other types of pain might arise because of therapeutic interventions, such as post-chemoradiation syndromes, which cause mucositis and enteritis. Management with non-steroidal anti-inflammatory agents and narcotics was the mainstay of therapy. In recent years, celiac plexus blocks and neurolysis, as well as intrathecal therapies have been used to control severe pain, at times resulting in a decreased need for drugs, avoiding their unwanted side effects. Pain may impair the patient’s quality of life, negatively affecting patient outcome and resulting in increased psychological stress. Even after recognizing the negative effect of cancer pain on patient overall health, studies have shown that cancer pain is still undertreated. This review focuses on neuropathic pain, which is difficult to handle; thus, the most recent literature was reviewed in order to diagnose neuropathic pain and its management. Full article

This commentary summarizes a collection of key references published within the last ten years, and identifies pharmacologic research directions to improve treatment access and success through greater biosimilar or “follow-on” biologic utilization combined with other targeted small molecule agents that possess unique pathophysiologic mechanisms for inflammatory bowel diseases (IBD) in adult and pediatric patients. Since they are not identical to the originator or reference biologic agent, all biosimilars are not generically equivalent. However, in the US and other countries, they are considered therapeutically interchangeable if the manufacturer has demonstrated no clinically meaningful differences from the reference product. Comparisons of different clinical initiation and switching scenarios are discussed with reference to interchangeability, immunogenicity, nocebo effect, cost effectiveness, and time courses for discontinuation rates. Full article

In liver transplant patients, solid tumors and post-transplant lymphoproliferative disorders (PTLD) have emerged as significant long-term mortality causes. Additionally, it is assumed that de novo malignancy (DNM) after liver transplantation (LT) is the second-leading cause of death after cardiovascular complications. Well-established risk factors for PTLD and solid tumors are calcineurin inhibitors (CNIs), tacrolimus (TAC), and cyclosporine, the cornerstones of all immunosuppressive (IS) therapies used after LT. The loss of immunocompetence facilitated by the host immune system due to prolonged IS therapy leads to cancer development, including in LT patients. Hindering DNA repair mechanisms, promoting tumor cell invasiveness, and hampering apoptosis are critical events in tumorigenesis and tumor growth in LT patients resulting from IS administration. This paper aims to overview the refined mechanisms of IS-induced tumorigenesis after LT and the loss of immunocompetence facilitated by the host immune system due to prolonged IS therapy. In addition, we also discuss in detail the mechanisms of action in different types of IS regimen used after LT, and their putative effect on DNM. Full article