Predicting the risk of rebleeding after capsule endoscopy in obscure gastrointestinal bleeding - External validation of the RHEMITT Score.

BACKGROUND AND AIMS: Prediction of rebleeding after small bowel capsule endoscopy (SBCE) in obscure gastrointestinal bleeding (OGIB) is challenging. The recently described RHEMITT score includes 7 variables: chronic kidney disease (CKD); heart failure (HF); P1/P2 lesions (Saurin's classification); major bleeding; incomplete examination; smoking and endoscopic treatment. This tool has been shown to accurately predict the risk of recurrence after a SBCE study. The primary aim of this study was to perform an external validation of the RHEMITT score. METHODS: Retrospective cohort-study, which consecutively included all patients submitted to SBCE (Mirocam®) for OGIB between January 2017 and December 2018. Rebleeding was defined as: (1) a drop in hemoglobin>2g/dL or (2) Melena or hematochezia. The RHEMITT score was calculated and subsequently the accuracy of the score for the prediction of rebleeding was assessed. RESULTS: One-hundred and sixty patients were enrolled. Mean age was 65.8±13.6years and 58.1% (n=93) were female. The mean follow-up time was 20 (SD 9) months. Rebleeding occurred in 14.4% (n=23). Rebleeding at 6, 12, 18 and 24 months was 6.3%, 12.0%, 14.2% and 15.5% respectively. There was a significant association between the RHEMITT score and rebleeding (p <0.001). The area under the (AUC) ROC curve was 0.756 (p<0.001). Rebleeding occurred earlier in intermediate and high-risk patients (RHEMITT score >3) being at 6-months 13.6% and 24 months 28.4% (p<0.01). CONCLUSION: The present study carried out in an external validation cohort confirms the usefulness and accuracy of the RHEMITT score in predicting rebleeding after SBCE.

Impact of the COVID-19 Pandemic on Gastroenterology Department Activity: The Gastroenterologist's Perspective Nationwide and the Real Impact in a Portuguese Center.

BACKGROUND: Several gastroenterology societies have created recommendations in order to reduce nonessential exposure to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. Our aim is to evaluate the national gastroenterologists' perspective on the impact of COVID-19 and the impact of reorganization of a gastroenterology department during the COVID-19 pandemic. METHODS: For the first purpose, an online survey was distributed to gastroenterologists nationwide. For the second purpose, the authors conducted an analysis of some endoscopic procedures performed at the Gastroenterology Department of the Centro Hospitalar Vila Nova de Gaia/Espinho (CHVNG/E) between March 16 and May 8 during the years 2019 and 2020. RESULTS: Sixty-seven gastroenterologists answered our survey. Only 14.9% were residents and 86.6% worked in a hospital with COVID-19 patients, with 16.4% assigned to assist those patients. All of the departments suffered modifications. Ninety percent of the residents affirmed that their activity had changed. Ninety-four percent declared having nonessential endoscopic procedures postponed, and 85.1% maintained in-person medical visits, 88.1% were already having remote consultations, and 11.9% did not have any clinical visit. In our gastroenterology unit, the number of endoscopic procedures decreased by 73.1% from 2019 to 2020. In 2020, the proportion of urgent procedures was higher compared to 2019. CONCLUSION: The advent of COVID-19 has led to important changes in gastroenterology activities in Portugal, and national gastroenterology units are complying with the recommendations. Furthermore, Portuguese gastroenterologists believed that the decrease in endoscopic activity can compromise residents' education and training. The gastroenterology department at CHVNG/E has shown a significant reduction in the number of endoscopic procedures.

INTRODUÇÃO: As sociedades de Gastroenterologia criaram recomendações de modo a reduzir a exposição não necessária ao vírus da síndrome respiratória aguda grave (SARS-CoV-2). O nosso objetivo é avaliar a perspectiva nacional dos gastroenterologistas sobre o impacto da COVID-19 e avaliar o impacto da reorganização do nosso serviço de Gastroenterologia durante a pandemia. MÉTODOS: Para o 1° objetivo, um inquérito online foi disponibilizado aos gastroenterologistas de todo o país. Para o 2° objetivo, os autores realizaram uma análise dos procedimentos endoscópicos do serviço de Gastroenterologia do Centro Hospitalar Vila Nova de Gaia/Espinho (CHVNG/E) entre 16 de Março e 8 de Maio durante os anos de 2019 e 2020. RESULTADOS: 67 gastroenterologistas responderam o inquérito. Destes, 14.9% eram internos. 86.6% trabalharam num hospital com doentes com COVID-19, e 16.4% dos médicos prestavam cuidados a esses doentes. Todos os departamentos sofreram alterações. 90% dos internos referiram que a atividade tinha sido alterada. 94% dos médicos afirmaram que os procedimentos endoscópicos não-essenciais foram adiados. 85.1% mantinham algumas consultas médicas presenciais, 88.1% estavam a realizar consultas não presenciais, e 11.9% não tinham nenhum tipo de consulta. No nosso serviço, o número de procedimentos endoscópicos diminui em 73.1% de 2019 para 2020. Em 2020, a proporção de procedimentos endoscópicos de urgência foi superior em relação a 2019. CONCLUSÃO: A pandemia da COVID-19 conduziu a alterações importantes dentro das atividades da Gastroenterologia em Portugal, e os serviços de Gastroenterologia mostraram cumprir as recomendações. Além disso, os gastroenterologistas portugueses acreditam que a diminuição da atividade endoscópica dos internos pode comprometer a sua futura formação. O serviço de gastroenterologia do CHVNG/E mostrou uma redução significativa do número de procedimentos endoscópicos.

Enteroscopy in the Elderly: Review of Procedural Aspects, Indications, Yield, and Safety.

BACKGROUND: As human longevity continues to increase, age-related diseases are more common, which leads to a higher use of gastroenterology services. Endoscopic procedures are generally considered to be of higher risk in the elderly with multiple comorbidities. However, some endoscopic techniques have already been proved to be well tolerated in the elderly. SUMMARY: Enteroscopy enables the nonsurgical diagnosis and therapeutic management of a wide variety of small bowel diseases. Although it has been shown to be safe and effective, with high diagnostic yield and therapeutic success rate in the general population, its safety and efficacy in the elderly is largely unknown, and there are still some concerns about its use in these patients. KEY MESSAGES: This review will focus on enteroscopy in elderly people, taking into account patient and procedure characteristics, indications, findings, yield, and complication rate.

INTRODUÇÃO: Á medida que a longevidade humana continua a aumentar, as patologias relacionadas com a idade tornam-se mais prevalentes, o que conduz a um maior uso dos serviços da gastrenterologia. Os procedimentos endoscópicos geralmente acarretam maior risco nos idosos com múltiplas comorbilidades, porém algumas técnicas endoscópicas já foram consideradas bem toleradas nestes pacientes. SUMÁRIO: A enteroscopia permite o diagnóstico e terapéutica de uma ampla variedade de doenças do intestino delgado. Apesar de ter sido demonstrada a sua eficácia e segurança na população geral, com elevada rentabilidade diagnóstica e terapèutica, a sua eficácia e segurança nos idosos é desconhecida, e ainda permanecem dúvidas em relação ao uso deste exame nestes indivíduos. MENSAGENS-CHAVE: O objetivo desta revisão é avaliar o uso da enteroscopia nos idosos, tendo em conta as características dos doentes e do to, as indicações, os resultados, a rentabilidade e as compì icações.

Duodenal Crohn's Disease Complicated by Pancreatitis and Common Bile Duct Obstruction.

INTRODUCTION: Crohn's disease (CD) is characterized by segmental and transmural involvement of any portion of the gastrointestinal tract from the mouth to the anus. Duodenal CD is a rare clinical entity, with the majority of the patients being symptomless - its diagnosis requires a high level of clinical suspicion. CASE PRESENTATION: We present the case of a 29-year-old male patient with a 2-month history of weight loss, epigastric pain and postprandial vomiting. He underwent upper endoscopy, which revealed a circumferential duodenal ulcer causing non-transposable luminal stenosis and was medicated with proton pump inhibitors. While awaiting gastroenterology consultation, he presented at the emergency department for sudden onset of abdominal pain with dorsal irradiation, nausea and vomiting. Laboratory tests showed anaemia and increased liver enzymes, amylase and lipase. Abdominal computed tomography showed ectasia of the common bile duct (CBD) and intrahepatic biliary tract and a small amount of gas in the main pancreatic duct associated with duodenal thickening. The case was interpreted as probable CD complicated by pancreatitis and obstruction of the CBD, and he was hospitalized under antibiotic therapy and hydrocortisone with improvement of the condition. After discharge, he underwent colonoscopy that revealed several ulcers in the ileum and magnetic resonance imaging that showed distension of the stomach with reduction of the calibre of the transition from the duodenal bulb to the second portion of the duodenum in a 10- to 15-mm extension, as well as associated dilatation of the intrahepatic bile ducts and CBD and diffuse and regular ectasia of the main pancreatic duct. Combination therapy with azathioprine and infliximab was initiated; the patient presented clinical response at 12 weeks and endoscopic/imaging remission at 9 months. DISCUSSION/CONCLUSION: Hepatobiliary and pancreatic manifestations are common in CD patients involving multiple mechanisms. In this case report, we pre-sent a patient with duodenal CD complicated with pancreatitis and CBD obstruction due to distortion phenomena by duodenal stenosis, a condition that is rarely described.

INTRODUÇÃO: A Doença de Crohn (DC) é caracterizada pelo envolvimento segmentar e transmural de qualquer porção do trato gastrointestinal desde a boca até ao ânus. A DC duodenal é uma entidade clínica rara, sendo que a maioria dos doentes são assintomáticos − o seu diagnóstico requer um alto grau de suspeição clínica. APRESENTAÇÃO DO CASO: Doente do sexo masculino com 29 anos, apresentou quadro com 2 meses de evolução de perda de peso, dor epigástrica e vómitos pós-prandiais. Realizou endoscopia digestiva alta, que revelou úlcera duodenal circunferencial causando estenose luminal não transponível, tendo sido medicado com inibidor da bomba de protões. Enquanto aguardava pela consulta de Gastroenterologia, recorreu ao serviço de urgência por dor abdominal com irradiação dorsal com início súbito, náuseas e vómitos. Os exames laboratoriais revelaram anemia, aumento dos testes hepáticos e aumento da lípase e amílase. A tomografia computadorizada abdominal mostrou ectasia da via biliar principal (VBP) e dos ductos biliares intra-hepáticos e pequena quantidade de gás no ducto pancreático principal associado a marcado espessamento duodenal. Interpretado como provável DC complicada por pancreatite e obstrução da VBP, foi internado sob antibioterapia e hidrocortisona com melhoria clínica. Após a alta, realizou colonoscopia que revelou várias úlceras no íleo terminal e ressonância magnética que mostrou marcada distensão do estômago com redução do calibre da transição do bulbo duodenal para a segunda porção do duodeno em 10­15 mm extensão; associadamente, dilatação dos ductos biliares intra-hepáticos e da VBP e ectasia difusa e regular do ducto pancreático principal. O doente iniciou terapêutica combinada com azatioprina e infliximab apresentando resposta clínica às 12 semanas e remissão endoscópica/imagiológica aos 9 meses. DISCUSSÃO/CON-CLUSÃO: Manifestações hepatobiliares e pancreáticas são comuns em doentes com DC tendo por base múltiplos mecanismos. Neste caso, mostramos um doente com DC duodenal complicada com pancreatite e obstrução da VBP por distorção causada por estenose duodenal, condição raramente descrita.