Circadian Rhythm Disruption Aggravates DSS-Induced Colitis in Mice with Fecal Calprotectin as a Marker of Colitis Severity.

BACKGROUND: Inflammatory bowel disease (IBD) is a chronic immunologically mediated pathology that remains a major health burden. Circadian rhythm disruption leads to a deregulation in the immune system which is a major risk factor for IBD. AIMS: Since fecal calprotectin (FC) has been a useful tool for monitoring IBD, we aimed to evaluate the effect of circadian rhythm alteration on gut inflammation status and whether FC is associated with the severity of colitis. METHODS: C57BL/6J mice were exposed to circadian shifts for 3 months, and then colitis was induced by 2% dextran sulfate sodium (DSS). Colitis was evaluated according to clinical symptoms and histological scoring. Plasma and intestinal inflammatory and permeability markers as well as fecal and intestinal calprotectin were assessed. RESULTS: Circadian shifts aggravated DSS-induced colitis with increased diarrhea, flatulence, and fecal blood associated with decreased colon length. In addition, intestinal cryptic architecture was lost with the presence of increased inflammation, mucosal muscle thickening, and cryptic abscesses. Plasma tumor necrosis factor alpha, interleukin 1 beta, interleukin 6, and C-reactive protein upregulations were paralleled by the deterioration of intestinal permeability. Calprotectin expression and distribution increased in the intestines and feces of shifted animals, and levels highly correlated with the increases in intestinal inflammation and permeability. CONCLUSIONS: Circadian rhythm disruption aggravates DSS-induced colitis, whereas fecal and intestinal calprotectin associates with the severity of disease. Calprotectin might be a useful marker and tool for assessing patients at risk of IBD due to lifestyles with disruptive sleep patterns.

Spirulina (Arthrospira platensis) Improved Nonalcoholic Fatty Liver Disease Characteristics and Microbiota and Did Not Affect Organ Fibrosis Induced by a Fructose-Enriched Diet in Wistar Male Rats.

Spirulina (Arthrospira platensis) is reported to play a role in improving nonalcoholic fatty liver disease (NAFLD) and intestinal microbiota (IM). To study spirulina's effects in the improvement of NAFLD characteristics, IM, and pancreatic-renal lesions induced by a fructose-enriched diet, 40 Wistar healthy male rats, weighing 200-250 g, were randomly divided into four groups of 10, and each rat per group was assigned a diet of equal quantities (20 g/day) for 18 weeks. The first control group (CT) was fed a standardized diet, the second group received a 40% fructose-enriched diet (HFr), and the third (HFr-S5) and fourth groups (HFr-S10) were assigned the same diet composition as the second group but enriched with 5% and 10% spirulina, respectively. At week 18, the HFr-S10 group maintained its level of serum triglycerides and had the lowest liver fat between the groups. At the phylae and family level, and for the same period, the HFr-S10 group had the lowest increase in the Firmicutes/Bacteroidetes ratio and the Ruminococcaceae and the highest fecal alpha diversity compared to all other groups (p < 0.05). These findings suggest that at a 10% concentration, spirulina could be used in nutritional intervention to improve IM, fatty liver, metabolic, and inflammatory parameters associated with NAFLD.

Perception and Attitude of Lebanese IBD Patients During the COVID-19 Pandemic.

Objective: The emergence of the COVID pandemic affected daily living and healthcare access of IBD patients, due to delays of elective procedures and in-hospital treatments. Our aim is to determine the repercussions of the pandemic on the daily habits of IBD patients and on their compliance to follow-up and treatment. Methods: This was a cross-sectional observational study. A questionnaire was administered in between 2020 and 2022 to IBD patients in a tertiary center in Lebanon. The outcomes measured were patient perceptions regarding COVID and how it affected their treatment. Results: A total of 201 answers were included in the analysis with male predominance. Two-thirds had Crohn's disease. Near 80% were afraid of being infected by COVID-19 and 87.6% were afraid of physical contact. 91.5% reduced their daily habits and 96.0% have used personal protective equipment. 47.3% of the patients report that there are factors that reduced their worries, the most common factor being contacting their physician (61.0%). The main source of information was the treating physician (37.8%). A quarter of patients think that their condition predisposed to COVID-19 infection and about two-thirds believe that immunosuppressive therapy did so. The same amount reported concern regarding visiting the hospital. 27.4% preferred telemedicine and 44.8% preferred over-The-phone consultation to an in-person visit. Three-quarters were in favor of vaccination. 59.6% delayed their in-center treatment, which was associated with a reduction in daily life activities. 13.9% wanted to discontinue their treatment, which was associated with smoking, cardiovascular, and rheumatological comorbidities, but only 4% did so. Conclusion: The pandemic had significant repercussions on the everyday life of IBD patients, with some preferring to consult via telemedicine and others considering stopping their treatment.

Relation of Dietary Patterns and Nutritional Profile to Hepatic Fibrosis in a Sample of Lebanese Non-Alcoholic Fatty Liver Disease Patients.

Non-alcoholic fatty liver disease (NAFLD) is considered the most common liver injury worldwide. NAFLD can evolve into non-alcoholic steatohepatitis (NASH) with or without fibrosis. The objectives of this study were to determine the nutritional profile and dietary patterns of NAFLD Lebanese patients and to report the type of diet-related to the presence of hepatic fibrosis. We hypothesized that the traditional pattern was related to a low risk of fibrosis. This cross-sectional study included 320 eligible Lebanese NAFLD patients. Three dietary patterns were identified: the Traditional diet, the High Fruit diet, and the Westernized diet. Multivariate analysis showed a significant relationship between high adherence to the traditional diet and absence of hepatic fibrosis with a decreased risk of 82%, p = 0.031 after adjusting for its covariables. Fruits were absent from this dietary pattern. Although our results pointed to a possible relationship between fibrosis in NAFLD patients and fruit intake, experimental studies are needed to show whether this is a causal relationship. However, the results obtained in this study may contribute to the planning of dietary interventions and recommendations and enable a better follow-up for NAFLD patients with fibrosis.

Unusual etiology of epigastric pain.

BACKGROUND: Epigastric pain is a common presenting complaint encountered in urgent care settings. Although peptic, biliary, and pancreatic pathologies are the most frequent findings, other rare diagnoses also can be found. OBJECTIVES: We report an unusual case of acute epigastric pain in which abdominal ultrasound was of great support in revealing the diagnosis. CASE REPORT: A 64-year-old man presented to the Emergency Department after rapid onset of acute epigastric pain. Abdominal ultrasound showed a multi-cystic heterogeneous mass between the stomach and the liver. Abdominal computed tomography scan confirmed the gastric origin of the mass and showed torsion signs. Urgent laparotomy was performed with tumor excision. The diagnosis of pedunculated exophytic gastric stromal tumor was made and long-term follow-up was arranged. CONCLUSIONS: Acute presentation revealed the presence of the tumor, which was excised surgically.

Migration in two directions.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG), the modality of choice for long-term enteral access, is generally a safe procedure but can be associated with many potential complications. OBJECTIVES: Report two different and late complications of PEG in two patients fed at home, leading them to the emergency department. CASE REPORT: A 75-year-old man and a 14-year-old young man with PEG presented to the emergency department with two different complications related to the gastrostomy tube. The first patient developed fever and deterioration in mental status due to parietal abscess which developed secondary to the migration of the internal button of the gastrostomy tube in the abdominal wall. He was treated with antibiotics and the gastrostomy tube was extracted. The second one presented upper gastrointestinal bleeding due to intestinal perforation at the level of the internal button of the gastrostomy tube. Bleeding and perforation were treated conservatively and he had a good evolution. CONCLUSION: Persons taking care of patients with PEG tube must be aware of potential complications. The position and the permeability of the tube must be systematically checked before feeding and medical advice should immediately be asked for in case of doubt or in the presence of any alarming sign.

A Case Report Presenting an Undifferentiated Pancreatic Carcinoma with Osteoclastic-Like Giant Cells with an Unusual Indolent Course.

BACKGROUND Undifferentiated pancreatic carcinoma with osteoclast-like giant cells represents less than 1% of pancreatic cancers. Histogenesis and prognosis are still debated. Three subtypes are defined by the World Health Organization: osteoclastic, pleomorphic, and mixed. The differential diagnosis of a pancreatic tumor with giant cells varies from a benign osteoclastoma to an undifferentiated pancreatic carcinoma with osteoclastic-like cells. The specimen should be carefully examined to rule out conventional pancreatic adenocarcinoma even in the presence of the giant cells. CASE REPORT A 77-year-old male was diagnosed with a pancreatic tail tumor with osteoclastic like cells revealed by a biopsy done by echo-endoscopy; the patient was lost to follow up for 24 months before he was admitted to our institute for severe abdominal pain. A computed tomography showed the same lesion without progression. He was operated on using laparoscopic distal pancreatectomy with splenectomy. Pathology analysis revealed the presence of osteoclast-like giant cells without pleomorphic cells. Mutated KRAS on molecular study confirmed the diagnosis of undifferentiated pancreatic carcinoma with osteoclast-like giant cells. The patient was in good performance status and disease-free 19 months after surgery without any sign of progression. CONCLUSIONS Undifferentiated pancreatic carcinoma with osteoclast-like cells has a challenging pathology diagnosis. Molecular and immunostaining are essential to diagnosis. The absence of pleomorphic cells in the present case has classified it into the osteoclastic subtype. Further cases and studies are needed to confirm the heterogeneity of the malignant course between subtypes.

Fructose threshold for inducing organ damage in a rat model of nonalcoholic fatty liver disease.

A fructose-enriched diet has been shown to be associated with an increase in fatty infiltration of liver, kidney, and pancreas. Our objective was to determine the concentration threshold at which a fructose-enriched diet induces damage in these organs. We hypothesized that a 20% fructose-enriched diet will induce steatosis or histopathological changes in the kidneys or pancreas. In this study, 40 Wistar male rats were randomly divided into 4 groups of 10, and each group was assigned a diet of equal quantity (15 g/rat) but of varying fructose amount. The first group (control group) was fed a standardized diet. The second and third groups were fed 10% and 20% fructose-enriched diets, respectively, whereas the fourth group was fed a high-fructose diet (30% fructose). At week 16, the 30% fructose group had the highest percentage of fat-enriched cells (10%) and a significant decrease in adiponectin as compared with week 1 (P < .05). Twenty percent of this group developed interstitial fibrosis, but none presented changes in the pancreatic islet structure or fibrosis. The 10% fructose group showed the absence of perisinusoidal and interstitial fibrosis, whereas these were present in the 20% fructose group, but neither group showed significant steatosis (5%) or pancreatic damage. The results suggest that a 20% fructose-enriched diet could be considered as the threshold for inducing kidney and liver damage in the rat. Nutritional interventions to reduce fructose to less than 20% of the total energy intake should be considered to prevent metabolic risks and organ damage.

Diagnosis by endoscopic ultrasound guided fine needle aspiration of tuberculous lymphadenitis involving the peripancreatic lymph nodes: a case report.

Pancreatic tuberculosis is an extremely rare form of extrapulmonary disease. The diagnosis preoperatively is difficult because clinical, laboratory and radiologic findings are nonspecific. Published data indicate that these lesions mimic cystic neoplasms of the pancreas and the confirmation of clinical suspicion could only be obtained by an open surgical biopsy. Recently, fine needle aspiration cytology has been shown to be a safe, reliable and cost-effective alternative. We report a new case of a peripancreatic tuberculosis in a 52 year old woman and review the relevant literature, paying special attention to the usefulness of endoscopic ultrasound guided-fine needle aspiration in the diagnosis of abdominal tuberculosis.

A benign cause of obstructive jaundice with von Hippel-Lindau disease. A case report and review of the literature.

CONTEXT: Von Hippel-Lindau disease is a genetic disorder characterized by neoplasms with multiple organ involvement, the pancreas being involved in about half of the cases. Conservative treatment is indicated because the disease is usually asymptomatic with long-term follow-up. CASE REPORT: We herein present the case of a 64-year-old man with von Hippel-Lindau disease who presented with obstructive jaundice which resulted as being caused by a fibro-cystic pancreatic nodule. In addition, we reviewed the literature concerning pancreatic involvement in von Hippel-Lindau disease with emphasis on their presentation, type of lesions and appropriate management, especially in cases with obstructive jaundice. CONCLUSION: Conservative management is advocated in the majority of VHL disease patients with pancreatic involvement, but surgery is sometimes required, especially when patients are symptomatic (obstructive jaundice, upper gastrointestinal bleed).

[Pneumatic dilatation of achalasia: local experience in treating 41 patients]. / Traitement de l'achalasie par dilatation pneumatique: expérience locale sur une série de 41 cas.

L'achalasia is the best known primary motor disorder of the esophagus in which the lower esophageal sphincter (LES) has abnormally high resting pressure and incomplete relaxation with swallowing. Pneumatic dilatation (PD) remains the first choice of treatment. Our aim was to report, in a retrospective way, our experience in treating with pneumatic dilatation 41 achalasia patients admitted to the gastroenterology unit at Hôtel-Dieu de France (HDF) hospital between 1994 and 2004. A total of 46 dilatations were performed in 41 patients with achalasia [20 males and 21 females, the mean age was 46.8 years (range, 15-90)]. All patients underwent an initial dilatation by inflating a 35 mm balloon to 7 psi three times successively under fluoroscopic control. The need for subsequent dilatation with the same technique or for surgical treatment was based on symptom assessment. The mean follow-up period was 36.7 months (3 mo-7 years). Among the patients whose follow-up information was available, a satisfactory result was achieved in 29 patients (80.5%) after only one or two sessions of pneumatic dilatation. Esophageal perforation as a short-term complication was observed in one patient (2.17%). Seven patients were referred for surgery (one for esophageal perforation and six for persistent or recurrent symptoms). In conclusion, performing balloon dilatation under fluoroscopic observation is simple, safe and efficacious for treating patients with achalasia. Referral to repeated PD or to surgical myotomy should be discussed in case of no response to a first session of PD.

Nutritional Profile and Dietary Patterns of Lebanese Non-Alcoholic Fatty Liver Disease Patients: A Case-Control Study.

Nonalcoholic fatty liver disease (NAFLD) is considered the most common liver disease in the world. Dietary habits have a significant impact on the biological and physical profile of patients and increase the risk of NAFLD. The overall pattern of diet intake is more associated with health outcomes than nutrients. The aim of this study was to evaluate the nutritional profile and the dietary patterns of Lebanese NAFLD patients and compare it with controls. During this study; 112 NAFLD Lebanese adult patients (55 men and 57 women); and 110 controls (44 men and 66 women) were recruited. Dietary intake was evaluated by two 24-h recalls and a semi-quantitative 90-item food frequency questionnaire. Dietary patterns were determined by factor analysis. Results from the study demonstrated that 40% of cases belonged to the high fruit group as compared to 30% following a high meat; fast food dietary pattern. Both groups increased the odds of NAFLD by four-fold (p < 0.05). The traditional diet decreases the odds by 33% after adjustment with the covariables. The high fruit diet group was, as with the high meat, fast food dietary pattern, the main potential risk factor for NAFLD in Lebanese patients.

Adherence to systemic therapies for immune-mediated inflammatory diseases in Lebanon: a physicians' survey from three medical specialties.

BACKGROUND: Immune-mediated inflammatory diseases (IMIDs) are chronic conditions that may cause tissue damage and disability, reduced quality of life and increased mortality. Various treatments have been developed for IMIDs, including immune modulators and targeted biologic agents. However, adherence remains suboptimal. METHODS: An adherence survey was used to evaluate physicians' beliefs about adherence to medication in IMID and to evaluate if and how they manage adherence. The survey was distributed to 100 randomly selected physicians from three different specialties. Results were analyzed by four academic experts commissioned to develop an action plan to address practical and perceptual barriers to adherence, integrating it into treatment goals to maximize outcomes in IMID, thereby elevating local standards of care. RESULTS: Eighty-two physicians participated in this study and completed the questionnaire. Most defined adherence as compliance with prescribed treatment. Although the majority of surveyed physicians (74%) did not systematically measure adherence in their practice, 54% identified adherence as a treatment goal of equal or greater importance to therapeutic endpoints. Lack of time and specialized nursing support was reported as an important barrier to measuring adherence. The expert panel identified four key areas for action: 360° education (patient-nurse-physician), patient-physician communication, patient perception and concerns, and market access/cost. An action plan was developed centered on education and awareness, enhanced benefit-risk communication, development of adherence assessment tools and promotion of patient support programs. CONCLUSION: Nonadherence to medication is a commonly underestimated problem with important consequences. A customized target-based strategy to address the root causes of non-adherence is essential in the management of chronic immune-mediated diseases.

Hepatocellular carcinoma in Lebanon: Etiology and prognostic factors associated with short-term survival.

AIM: To study the epidemiology of HCC in Lebanon and prognostic factors predictive of early mortality. METHODS: An observational follow-up cohort study of HCC cases diagnosed over a five-year period was carried out. Multivariate analysis was conducted to identify prognostic factors in comparison to Cancer of the Liver Italian Program (CLIP) score. Multiple variables including the etiology of underlying liver disease, the demographic characteristics of patients, and the severity of liver disease evaluated by the Child-Pugh score were studied. Tumor parameters included the time of diagnosis of HCC, alpha-fetoprotein level, number and size of nodules, presence of portal vein thrombosis, and treatment modalities. Death or loss of follow-up was considered as an end-point event. RESULTS: Ninety-two patients (mean 60.5 +/- 22.3 years) were included. Etiology of underlying disease was hepatitis B, C, and alcohol in 67%, 20%, and 23.5% respectively. Child-Pugh class at diagnosis was A, B, and C in 34.8%, 39.3% and 25.8% respectively. Overall survival was 44.8%, 32.8% and 17.6% at 1, 2 and 3 years respectively (mean F/U 40.2 +/- 23.5 mo). Multivariate analysis identified three predictors of early mortality (< 6 mo): bilirubin > 3.2 mg/dL (P < 0.01), HCC as first presentation of liver disease (P = 0.035), and creatinine > 1 mg/dL (P = 0.017). A score based on these variables outperformed the CLIP score by Cox proportional hazard. ROC curve showed both models to be equivalent and moderately accurate. CONCLUSION: HBV is the leading cause of HCC in Lebanon. Independent predictors of early mortality are elevated bilirubin, creatinine and HCC as first manifestation of disease. Prospective validation of a score based on these clinical parameters in predicting short-term survival is needed.

Biliary ischemia following embolization of a pseudoaneurysm after pancreaticoduodenectomy.

AIM: To report an uncommon consequence of hepatic artery occlusion in the management of a bleeding pseudoaneurysm following pancreaticoduodenectomy. IMAGING: Analysis of a case involving a single patient in which a bleeding pseudoaneurysm of the gastroduodenal arterial stump following pancreaticoduodenectomy was treated by transcatheter arterial embolization. CASE REPORT: Effective hemostasis necessitated interruption of the hepatic arterial flow and was complicated by biliary ischemia and intrahepatic biloma.

Influence of acetaminophen at therapeutic doses on surrogate markers of severity of acute viral hepatitis.

OBJECTIVES: Data on the influence of acetaminophen intake on acute viral hepatitis is scarce, but it could play a role in the worsening of this disease. The aim of this study was to determine whether the intake of acetaminophen at therapeutic doses affects the severity of acute viral hepatitis. METHODS: This was a prospective study concerning 37 consecutive patients hospitalized for acute viral hepatitis. Acetaminophen consumption and time since last intake were assessed by a questionnaire. Parameters of severity were studied in comparison to time related serum concentrations of acetaminophen. RESULTS: Patients hospitalized for acute viral hepatitis (18 male, 19 female patients) had a mean age of 29.2 +/- 11.5 years. The causal virus was HAV (n=23), HBV (n=7) and other viruses (n=8). The mean cumulated dose of acetaminophen was 7.7 +/- 5.65 g. The daily dose did not exceed the therapeutic dosage and the mean was 1.95 +/- 0.81 g (1-3 g). Patients who received 7.5 g of acetaminophen or more had a lower prothrombin index 52.4 +/- 30.3% vs 74.2 +/- 17.2% (P=0.039), and a lower factor V 54.7 +/- 33.2% vs 83.3 +/- 19.6% (P=0.033). Prothrombin index and bilirubinemia were negatively correlated with time related plasma acetaminophen concentrations. CONCLUSIONS: The use of acetaminophen at therapeutic doses was associated with greater alterations of surrogate markers of the severity of acute viral hepatitis especially hepatitis A. This was related to cumulated dosages and correlated to the time related acetaminophen plasma concentrations. Acetaminophen use should be interrupted when acute hepatitis is suspected.

[Endoscopic resection of large pedunculated colonic polyps using Endoloop. Three case reports and review of the literature]. / Résection endoscopique des polypes coliques à large pédicule en utilisant l'Endoloop. Rapport de trois cas et revue de la littérature.

Endoscopic polypectomy is now an established procedure for the resection of colorectal polyps. One of the serious complications associated with colonoscopic polypectomy is hemorrhage. Several factors appear to be associated with increased risk of hemorrhage including patient age and colorectal polyp size, location, and morphology (thick stalk or sessile). In particular, resection of large polyps is associated with a higher risk of serious complications. Bleeding most often occurs within the first 24 hours. More than 95% of cases of bleeding can be treated endoscopically by epinephrine injection, heater probe, or band ligation, alone or in combination. Several methods have been proposed for the prevention of hemorrhage after polypectomy. The most interesting approach is the use of a detachable snare (Endoloop) which allows endoscopic ligation of the stalk of a large, pedunculated polyp. In order to avoid the more severe consequences of bleeding, we use a detachable snare in two patients with a pedunculated polyp with a large head and stalk (> 2 cm). In a third patient receiving anticoagulant, a detachable snare was chosen to safely and completely remove a large pedunculated polyp > 1.5 cm. In conclusion, colonoscopic polypectomy with Endoloop is safer than conventional polypectomy alone for resection of large, pedunculated polyps, especially in patients with liver disease, coagulopathy and receiving anticoagulant.

Rectal Dieulafoy's lesion. Report of two cases treated successfully by endoscopic means.

Rectal Dieulafoy's lesion is an unusual cause of abrupt and massive lower gastrointestinal hemorrhage. It is characterized histologically by a caliber-persistent submucosal artery that protrudes through a minute mucosal defect. Various theories and risk factors have been proposed to explain the occurrence of bleeding but none is completely satisfying. We present two cases of rectal Dieulafoy's lesion which were treated efficaciously by a simple injection of a sclerosing agent in the first case and by a combination of epinephrine injection and thermal probe coagulation in the second leading to a complete and rapid disappearance of the abnormal vessel.

Percutaneous endoscopic gastro-duodenostomy: modified technique.

OBJECTIVES: Percutaneous endoscopic gastro-jejunostomy is appropriate for patients with severe neurologic deficit to avoid repeated tube feeding-related aspiration. We describe a modified technique of endoscopic gastro-duodenostomy. PATIENTS AND METHODS: This technique was performed in 9 patients with severe neurologic deficit. No fluoroscopy was necessary. The gastrostomy button was pushed across the pylorus into the bulb; a nasogastric tube was then placed in the duodenum under endoscopic control and the button was drawn to the gastric wall. When the gastroduodenal tube migrated or was occluded, the button was placed in the bulb through the pylorus and maintained in this position for alimentation. RESULTS: Placement of the gastro-duodenostomy tube was successful without any complication in 100% of patients. The mean duration of the procedure was 15 min. The tube had to be removed for migration (N = 4) and occlusion (N = 5) after a mean period of 5.8 weeks (range: 2-10). During the follow-up period, no tube feeding-related aspiration was observed. CONCLUSION: This modified low-cost technique of endoscopic gastro-duodenostomy is simple and efficient.

[Endoscopic treatment of Dieulafoy's lesion. A case report and review of the literature]. / Traitement endoscopique des lésions de Dieulafoy. A partir d'un cas clinique et revue de la littérature.

Dieulafoy's lesion is a rare and important cause of gastrointestinal hemorrhage. It is a relatively large artery which lies in close proximity to the mucosal surface. Hemorrhage is often torrential and life threatening. Endoscopy is the most sensitive diagnostic test. Many reports described successful hemostasis utilizing a variety of endoscopic modalities in > 95% of cases. We report an upper gastrointestinal hemorrhage in a patient with Dieulafoy lesion treated successfully by injection, and a literature review.