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.

A colite eosinofílica e síndrome hipereosinofílico com atingimento gastrointestinal é um diagnóstico raro caracterizado por uma grande variedade de sintomas gastrointestinais e pela evidência de infiltração por eosinófilos na mucosa cólica. A marcha diagnóstica é desafiante dado não haver até à data critérios de diagnóstico. Os autores apresentam um caso de um homem hospitalizado com história de diarreia crónica não sanguinolenta. Durante a investigação etiológica foi identificada eosinofilia periférica e as biópsias cólicas realizadas evidenciaram predominante infiltração eosinofílica. Foi iniciado tratamento com corticoterapia tendo-se verificado normalização da contagem de eosinófilos e resolução do quadro clínico. Dado o carácter recidivante da colite que pode ocorrer com o desmame de corticoterapia, o doente ficou medicado cronicamente com 10 mg de prednisolona. Destaca-se este caso pela sua raridade na literatura de forma a realçar aspetos particulares desta entidade incomum.

A Rare Case of Autoimmune Enteropathy Associated with Autoimmune Hepatitis.

A 74-year-old woman was admitted for weight loss, abdominal pain and diarrhea for a year. Blood tests showed elevated transaminases, cholestasis and hyperbilirubinemia. Capsule endoscopy revealed extensively scattered lymphangiectasias, shortened villi and erosions in the jejunum and ileum. The histological examination of the small bowel mucosa biopsies evidenced severe mucosal atrophy and crypt hyperplasia, without significant intraepithelial lymphocytosis. The clinical picture, lack of response to a gluten-free diet and endoscopic and histopathologic findings were compatible with autoimmune enteropathy. Simultaneously, autoimmune hepatitis was also diagnosed. The patient showed significant improvement after starting treatment with prednisolone and azathioprine. To our knowledge, this is the first case of autoimmune enteropathy diagnosed simultaneously with autoimmune hepatitis.

Cumulative dose and length of methotrexate treatment were not shown to be predictors of hepatic fibrosis by elastography - a monocentric cohort study.

OBJECTIVE: Methotrexate is used in several inflammatory diseases, such as rheumatoid arthritis (RA), spondyloarthritis (SpA) or inflammatory bowel disease (IBD). There has been some controversy regarding methotrexate liver toxicity, especially since the use of newer techniques. We aim to evaluate the prevalence of liver injury in methotrexate-treated patients with inflammatory diseases. METHODS: We performed a cross-sectional study where consecutive patients diagnosed with RA, SpA or IBD, treated with methotrexate, were submitted to liver elastography. The cutoff for fibrosis was ≥7.1 kPa. Comparisons between groups were evaluated using chi-square, t test and Mann-Whitney U test. Correlations were made between continuous variables using Spearman correlation. Logistic regression was performed to determine predictors of fibrosis. RESULTS: A total of 101 patients were included, 60 (59.4%) females, aged 46.2±12.6 years. Eleven patients (10.9%) had fibrosis, with a median score of 4.8 (4.1-5.9) kPa. Patients with fibrosis had higher rates of daily alcohol consumption (63.6% vs 31.1%, p=0.045). Methotrexate exposure time (OR 1.001, 95% CI 0.999-1.003, p=0.549) and cumulative dose (OR 1.000, 95% CI 1000-1000, p=0.629) were shown not to be predictors of fibrosis, unlike alcohol (OR 3.875, 95% CI 1.049-14.319, p=0.042). In multivariate logistic regression analysis, methotrexate cumulative and exposure times were not predictors of significant fibrosis, even when adjusted for alcohol consumption. CONCLUSIONS: In this study, we found that fibrosis detected on hepatic elastography was not associated with methotrexate, unlike alcohol. Therefore, it is of paramount importance to redefine risk factors for liver toxicity in patients with inflammatory diseases under treatment with methotrexate.

"Long-term follow-up and prognosis of celiac hepatitis".

INTRODUCTION: Celiac disease has been associated with abnormal liver function tests at diagnosis that usually resolve with a gluten-free diet (GFD). The aim of this study was to assess the evolution of liver involvement and possible long-term complications in patients on a GFD. METHODS: Retrospective and single-center study, which included all individuals with Celiac disease followed in specialized consultation in a tertiary referral hospital. RESULTS: A total of 162 patients were included, most of them female (77.8%) with a median age of 24 years (IQR, 7-39). Seventy-four (45.7%) patients had abnormal liver function tests at diagnosis. These individuals had higher anti-tissue transglutaminase IgA (tTG-IgA) antibody titers (126 vs. 29 IU/L; P = 0.003). There were no significant differences in the Marsh classification ( P = 0.599). During follow-up, most celiac hepatitis patients had normalization of liver function tests and tTG-IgA antibodies. At the last follow-up, all the patients had fibrosis-4 index <2.4 and an aspartate aminotransferase-to-platelet ratio index score <0.6. Vibration-controlled transient elastography showed values <6.4 kPa in all cases. On the other hand, it was found that 42.9% of the individuals had a controlled attenuation parameter >206.5 db/m. CONCLUSIONS: In our cohort, liver function tests normalized in the vast majority of celiac hepatitis patients on a GFD, with no progression to chronic liver disease. It should be noted the high number of individuals who present hepatic steatosis during follow-up, which may be related to a diet that tends to be hyperlipidemic and hypercaloric.

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.

The long life of a hemoclip.

An 87-year-old male with frequent episodes of food impaction underwent esophageal high-resolution manometry, which revealed type-I achalasia. Due to his advanced age and the presence of comorbidities, botulinum toxin injection was proposed and accepted by the patient. In June 2021, esophagogastroduodenoscopy revealed an esophageal dilatation with liquid and food retention and narrowing of the esophagogastric junction. An injection of 25 units of botulinum toxin diluted in 10 mL of saline was administered in each of the 4 lower esophageal sphincter quadrants, with no complications.

Clinical and endoscopic findings in gastrointestinal amyloidosis: a single-center experience.

Gastrointestinal involvement occurs in approximately 4% of cases of systemic amyloidosis. The most common site of amyloid deposition is small bowel, followed by stomach, colorectum and esophagus. Although rare, gastrointestinal amyloidosis may be associated with severe complications including gastrointestinal bleeding or perforation and may be mistaken for malignancy.

Gastroduodenal ischemia in a patient with severe SARS-CoV-2 infection.

A 54-year-old male with a past medical history of hypertension, dyslipidemia, obesity, and diastolic heart failure, was admitted due to COVID-19 pneumonia. Respiratory failure gradually deteriorated and the patient was transferred to the intensive care unit (ICU), where mechanical ventilation and veno-venous extracorporeal membrane oxygenation (VV-ECMO) were started. On the second day in the ICU, he went into septic shock due to ventilator-associated pneumonia. Five days later, the patient had new-onset melena and laboratory data showed a hemoglobin level of 7.8 g/dL. He required blood transfusions and vasopressor requirements increased.

Physical Fitness and Health-related Quality of Life in Patients with Colorectal Cancer.

Colorectal cancer is now a frequently treatable illness for most and a chronic disease for many. The number of people living with a diagnosis of colorectal cancer is thus expected to rise. Yet even after successful treatment, colorectal cancer survivors, mostly the elderly, frequently experience health problems and impaired health-related quality of life. We investigated the cross-sectional association between physical fitness, measured with the 6-min walk test, 30-second chair-stand test, and isometric handgrip strength, as well as health-related quality of life, in a cohort of colorectal cancer patients (n=71, mean [SD] age 67±10 years, 63% men; 35, 39 and 25% in stages I, II and III, respectively). Greater performance in the 6-minute walk test and 30-second chair-stand test was associated with higher levels of global health status (p<0.001, p=0.001 respectively), higher functioning (p<0.001) and lower levels of symptomatology (p<0.001; pain and fatigue). Additionally, greater 6-min walk test performance was associated with a better cognitive function (p=0.005). Our results suggest that greater aerobic fitness and lower-extremity muscle strength are cross-sectionally associated with higher levels of global health status, higher functioning and lower levels of symptomatology such as pain and fatigue in colorectal cancer patients.

Development of an Online App to Predict Post-Endoscopic Retrograde Cholangiopancreatography Adverse Events Using a Single-Center Retrospective Cohort.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is a technically demanding procedure with a high risk for adverse events (AEs). AIM: evaluate patient- and procedure-related risk factors for ERCP-related AEs and develop an online app to estimate risk of AEs. METHODS: retrospective study of 1,491 consecutive patients who underwent 1,991 ERCPs between 2012 and 2017 was conducted. AEs definition and severity were classified according to most recent ESGE guidelines. Each variable was tested for association with occurrence of overall AEs, post-ERCP pancreatitis (PEP) and cholangitis. For each outcome, 2 regression models were built, from which an online Shiny-based app was created. RESULTS: Overall AE rate was 15.3%; in 19 procedures, >1 AE occurred. Main post-ERCP AE was PEP (7.5%), followed by cholangitis (4.9%), bleeding (1.3%), perforation (1%), cardiopulmonary events (0.9%), and cholecystitis (0.3%). Seventy-eight percent of AEs were mild/moderate; of severe (n = 55) and fatal (n = 20) AEs, more than half were related to infection, cardiac/pulmonary AEs, and perforation. AE-related mortality rate was 1%. When testing precannulation, procedural covariates, and ERCP findings, AE occurrence was associated with age (odds ratio [OR] 0.991), previous PEP (OR 2.198), ERCP complexity grade III/IV (OR 1.924), standard bile duct cannulation (OR 0.501), sphincterotomy (OR 1.441), metal biliary stent placement (OR 2.014), periprocedural bleeding (OR 3.024), and biliary duct lithiasis (OR 0.673). CONCLUSION: Our app may allow an optimization of the patients' care, by helping in the process of decision-making, not only regarding patient or endoscopist's selection but also definition of an adequate and tailored surveillance plan after the procedure.

Implications of COVID-19 for the busy gastroenterologist.

Coronavirus disease 2019 (COVID-19) is an infection caused by a novel coronavirus (SARS-CoV-2) originated in China in December 2020 and declared pandemic by WHO. This coronavirus mainly spreads through the respiratory tract and enters cells through angiotensin-converting enzyme 2 (ACE2). The clinical symptoms of COVID-19 patients include fever, cough, and fatigue. Gastrointestinal symptoms (diarrhea, anorexia, and vomiting) may be present in 50% of patients and may be associated with worst prognosis. Other risk factors are older age, male gender, and underlying chronic diseases. Mitigation measures are essential to reduce the number of people infected. Hospitals are a place of increased SARS-CoV-2 exposure. This has implications in the organization of healthcare services and specifically endoscopy departments. Patients and healthcare workers safety must be optimized in this new reality. Comprehension of COVID-19 gastrointestinal manifestations and implications of SARS-CoV-2 in the management of patients with gastrointestinal diseases, under or not immunosuppressant therapies, is essential. In this review, we summarized the latest research progress and major societies recommendations regarding the implications of COVID-19 in gastroenterology, namely the adaptations that gastroenterology/endoscopy departments and professionals must do in order to optimize the provided assistance, as well as the implications that this infection will have, in particularly vulnerable patients such as those with chronic liver disease and inflammatory bowel disease under or not immunosuppressant therapies.