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.

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.

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.

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.

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.

Methylation patterns in dysplasia in inflammatory bowel disease patients.

Background and aims: Inflammatory Bowel Disease (IBD) with colonic involvement increases colorectal cancer risk. However, the distinction between IBD related and sporadic dysplasia in IBD patients is difficult. Some data favors the importance of abnormal DNA methylation in IBD-related carcinogenesis. We aimed to define methylation patterns in patients with colonic cancer or dysplasia diagnosis following an IBD diagnosis.Methods: Multicentric cross-sectional study-91 samples from colonic mucosa with/without dysplasia from 9 patients with IBD-related dysplasia/cancer and 26 patients with IBD and sporadic dysplasia/cancer were included. Methylation patterns of CpG islands in the promoter regions of 67 genes were studied by Methylation-specific Multiplex Ligation-dependent Probe Amplification.Results: Mean age at IBD diagnosis: 42 ± 16 years;at dysplasia diagnosis: 56 ± 14 years. Twenty-ninepatients had ulcerative colitis. Twenty-five patients had at least 1 lesion endoscopically described as adenoma-like, 4 at least 1 non-adenoma like, 3 had cancer and 3 had dysplasia in flat mucosa. No patient had both adenoma-like and non-adenoma-like lesions. Patients with an IBD-related lesion were significantly younger at IBD diagnosis (p = .003) and at dysplasia/cancer diagnosis (p = .039). Promoter methylation of IGF2, RARB, ESR1, CHFR, CDH13, WT1, GATA5, WIF1genes was significantly associated to dysplasia/cancer; methylation of MSH6, TIMP3 was significantly associated to IBD-related dysplasia/cancer. Promoter methylation of MSH6, MSH3, RUNX3, CRABP1, TP73, RARB, CDH13, PAX5, WT1, THBS1, TP53, SFRP1, WIF1, APAF1, BCL2 genes was significantly associated to active IBD.Conclusions: Methylation analysis, namely of MSH6, may contribute to the classification of dysplastic lesions in IBD- to be further tested in prospective studies.

Lewis score: a useful tool for diagnosis and prognosis in Crohn's disease.

BACKGROUND: videocapsule endoscopy (VCE) is currently the most sensitive diagnostic tool to detect early small bowel inflammation. A Lewis score (LS) of ≥ 135 as the cutoff value for the presence of significant inflammatory activity in patients undergoing VCE for suspected Crohn's disease (CD) has been suggested as a useful tool for the diagnosis of CD. The aim of this study was to evaluate the diagnostic and prognostic accuracy of the LS in patients with suspected CD undergoing VCE. METHODS: a retrospective single-center study was performed that included patients who underwent VCE for suspected CD between January 2010 and December 2015. Inflammatory activity was assessed with the LS. Patients were grouped according to the criteria of the International Conference on Capsule Endoscopy (ICCE) for the definition of suspected CD; group 1: patients not fulfilling ICCE and group 2: patients with ≥ 2 ICCE criteria. RESULTS: one hundred and ninety-one patients were included, 61% were female and the mean age was 39 ± 14 years. VCE detected significant inflammatory activity (LS ≥ 135) in 81 patients (42%); 24 patients from group 1 (32%) and 57 patients from group 2 (50%) (p = 0.014). During a mean follow-up period of 41 ± 21 months (12-79), a CD diagnosis was determined in 60 patients (31%); 55 patients with LS ≥ 135 (92%) and five patients with LS < 135 (5%) (p < 0.001). The LS showed a good diagnostic accuracy with an AUROC of 0.93 (p < 0.001). During the first year after diagnosis, there was a significant association between a higher LS and the need for immunomodulatory therapy, biological therapy, bowel resection surgery or hospital admission due to a CD flare-up. CONCLUSIONS: the LS (cutoff ≥ 135) is very useful in the diagnosis of CD in patients undergoing VCE. Moreover, higher values of this score was associated with prognostic variables.

A rare cause of rectal bleeding.

A 54-year-old male patient, with recent medical history of acute myocardial infarction, performed a colonoscopy in context of rectal bleeding that revealed, in the sigmoid and rectum colon, erythematous and hemorrhagic lesions, with high friability to the touch, surrounded by normal mucosa. Histologically, the lesions was compatible with a chronic inflammatory process, with eosinophilic structures and hyaline material evident, characterized as amyloid substance after staining with Congo Red. The authors describe the present clinical case because of its rarity, highlighting the importance of a careful differential diagnosis in the approach of these clinical signs present in the daily practice of Gastroenterology.

Hepatic granulomas: a 17-year single tertiary centre experience.

AIMS: Hepatic granulomas have an estimated prevalence of 5% in liver biopsies, with a wide range of aetiologies globally. Our aim was to assess the clinical relevance, presenting features and underlying aetiology in a non-transplant, tertiary referral centre from a western country. METHODS AND RESULTS: This was a retrospective, single-centre review of clinical, laboratory and histological data including all adult patients for whom a liver biopsy was performed from January 1998 to December 2014. A total of 297 cases with hepatic granulomas were found in 9374 biopsies, but 57 were excluded from analysis either because they were lipogranulomas or the biopsy/aetiological work-up had not been performed at our institution. Overall, the most common aetiology was tuberculosis (35.8%), followed by primary biliary cholangitis (PBC) - 15.0%. In 30 patients (12.5%) granulomas were classified as idiopathic. From 1998 to June 2006 there were 147 granulomas in 5304 biopsies (2.8%), a frequency that did not change significantly compared to the period from July 2006 to December 2014 (93 granulomas in 4070 biopsies, 2.3%, P > 0.05). However, for the majority of cases (61.9%) there was a shift in granuloma aetiology during the former time-period that infectious diseases were responsible, whereas in the latter, autoimmune liver diseases (43%) were the main aetiology. In addition, while three cases of drug-induced granulomas were found from 1998 to June 2006, we report two cases in the second time-period. CONCLUSIONS: Hepatic granulomas can result from various infectious and non-infectious diseases. During recent years, an epidemiological shift regarding granuloma aetiology was observed, from systemic infectious diseases to non-infectious, mainly immune-mediated primary liver disorders. With an appropriate work-up the aetiology can be identified in the vast majority of cases (~90%), rendering its histological identification and characterisation essential, as disease-specific therapies are becoming available.

Anal cytology, histopathology and anoscopy in an anal dysplasia screening program: is anal cytology enough?

BACKGROUND AND AIM: The human papilloma virus is the leading cause of anal squamous cell carcinoma. Cytological screening may reduce the associated morbidity and mortality. The aim of the study was to estimate the agreement between anal cytological examination, histopathology and anoscopic visual impression. METHODS: A prospective study of patients who underwent anal dysplasia screening between 2011 and 2015, in a proctology clinic of a tertiary referral center. RESULTS: During the study period, 141 patients (91% men, 87% with HIV infection) underwent 175 anal cytology tests. Of these, 33% were negative for intraepithelial lesions or malignancy (NILM), 22% were atypical squamous cells of uncertain significance (ASCUS), 33% were low-grade squamous intraepithelial lesion (LSIL) and 12% were high-grade squamous intraepithelial lesion (HSIL). With regard to anoscopic visual impression, 46% of patients had no lesions and excision/biopsy of the identified lesions was performed in the remaining patients. The weighted kappa-agreement between abnormal cytological results and anoscopic visual impression was moderate (k = 0.48). The weighted kappa-agreement between simultaneous anal cytological examinations and anal histopathologic findings was low (kappa = 0.20). With regard to the histological examination of cases with HSIL or superficially invasive squamous cell carcinoma, 64% of patients had dysplasia of a lower grade according to the cytological analysis (6 ASCUS, 18 LSIL and 4 NILM). CONCLUSION: There was a poor correlation between anal cytology, histopathology and anoscopic visual impression and a high number of histological studies of HGD that were of a lower dysplastic degree according to the cytological examination. Therefore, anal cytology screening should not be used as the sole method of anal dysplasia screening.

Cancer Survivor Study (CASUS) on colorectal patients: longitudinal study on physical activity, fitness, nutrition, and its influences on quality of life, disease recurrence, and survival. Rationale and design.

PURPOSE: Evidence suggests that being physically active in combination with a healthy diet contributes to diminish colorectal cancer risk. However, if this is true for colorectal cancer primary prevention, the same is not clear for its recurrence after colorectal cancer treatments. Data on cancer survival are scarce, and there is a need for greater attention on these survivors' lifestyle behavior. This manuscript describes rationale and design of the Cancer Survival Study (CASUS) on colorectal patients, a longitudinal observational study with the aim of investigating how physical activity, physical fitness, and dietary intake are related with their quality of life, disease recurrence, and survival. METHODS: The CASUS on colorectal patients is a longitudinal cohort study on colorectal survivors, aged 18 years or older, recruited 6, 12, and 24 months after surgery. Upon recruitment, patients fill in a battery of questionnaires about physical activity, dietary intake, and quality of life, donate blood samples, do physical fitness tests, and use an accelerometer during 7 days. Repeated analyses will be performed to assess changes over time in physical activity, physical fitness, dietary intake, and other factors in relation to recurrence and survival. CONCLUSIONS: Results will contribute to highlight the role of physical activity, physical fitness, and nutrition in the quality of life of colorectal cancer survivors, recurrence, and survival. This study will provide important information for policymakers on the potential benefits of future physical activity and nutritional interventions, which are inexpensive, as a way to improve general health of colorectal cancer survivors.

Cholangitis after endoscopic retrograde cholangiopancreatography: a rare complication?

In our experience, post-ERCP acute cholangitis developed in approximately 5% of cases with a not negligible mortality of nearly 30% in spite of antibiotic therapy. Analytical factors can help to identify the most serious cases that could benefit from a more aggressive approach.

The clinical challenge of chronic Q fever with isolated liver involvement.

Chronic Q fever is defined as an infection by Coxiella burnetii (C. burnetii) that lasts for six months or more. It occurs in 1-5% of individuals infected with this agent and develops over a period of months to years after the acute infection. Cases of hepatic involvement are rare.

All that glitters is not gold. A different cause for an "ulcerative colitis".

The authors present the case of a 32-year-old Caucasian male, engineer, who was submitted to a colonoscopy after a presumptive diagnosis of ulcerative colitis. The patient referred an acute bloody and mucous diarrhea, lasting for three weeks, with no fever or rectal tenesmus. Stool studies were negative. During the procedure, colonic segments with continuous hyperemic and exudative mucosa, with small papules with apical ulcers and erosions, were observed.

Fishbone impaction in the colon.

Postoperative benign biliary stricture in the anastomotic site is one of the most common complications of biliary-enteric anastomosis, with a rate of 6.87% after 2-13 years of follow-up. If untreated, biliary strictures can induce other complications such as recurrent cholangitis, intrahepatic stones, pancreatitis and secondary biliary cirrhosis. We report our experience with extracorporeal shock wave lithotripsy (ESWL) in a patient with a massive symptomatic stone proximal to an anastomotic biliary stricture.

Misleading Gastrointestinal Symptoms: The Ongoing Story of Chronic Lead Intoxication.

Inorganic lead intoxication has emerged as an important and challenging clinical problem owing to increased awareness of lead and enhanced surveillance of exposed individuals. However, recognition may not be very difficult when there is an obvious history of exposure. Our interest began a few years ago when we could trace an outbreak, following a patient who was admitted with colickly abdominal pain, convulsions, and coma. After that, 16 more cases were identified and characterized. All patients recovered completely after adequate chelation therapy. Although the clinical picture of lead intoxication is pleomorphic, the increased awareness of gastroenterologists in this subject may possibly bring chronically complaining difficult patients to an earlier, unexpected, and fairly treatable disease.