Niti-S Esophageal Covered stent (double anti-reflux type). An observational patient registry/post-market clinical follow-up study.

Background: Relieving dysphagia is the main goal of palliative care in advanced esophageal cancer. We aimed to evaluate the safety and clinical performance of the Niti-S esophageal double covered, anti-reflux stent (Taewoong Medical, Seoul, Korea) in inoperable carcinoma of the esophagus or gastric cardia. Methods: This was a retrospective patient registry/post-market clinical follow-up study of all patients with esophageal malignant strictures undergoing self-expandable metal stent (SEMS) placement with the Niti-S Esophageal covered stent, double antireflux in a community hospital (AZ St Maarten Mechelen, Belgium) between March 2013 and July 2021. Results: In twenty-nine patients, thirty self-expandable metal stents (SEMS) were placed. The median dysphagia score before stent placement was 3 and 0 after stent placement (p < 0.001). Stent migration did not occur. Two patients (7%) had new onset reflux symptoms. The most common adverse event was retrosternal pain (5 patients, 17%). One patient (3%) had recurrent dysphagia due to proximal tumoral overgrowth and two patients (7%) because of proximal benign tissue overgrowth. There were no perforations, fistula formations or episodes of food impaction. Conclusion: The Niti-S esophageal double covered, antireflux stent (Taewoong Medical, Seoul, Korea) is an effective and safe treatment option for malignant esophageal stenosis.

An unusual cause of massive rectal bleeding.

A 76-year old female was referred to the gastro-enterology department because of massive rectal bleeding with hemoglobin decrease to 9 g/dL. She was in follow-up at the oncology department for a multiple myeloma and treated with Lenalidomide-Dexamethason since 2018. She had a past medical history of rectal bleedings due to angiodysplastic lesions of the right colon, treated with argon plasma coagulation (APC). The last left colonoscopy in 2019, performed for chronic diarrhea, was macroscopically normal and histopathologic examination ruled out a microscopic colitis. During colonoscopy significant edema of the caecal-colon ascendens and recto-sigmoidal mucosa was seen, with important submucosal hematomas and some bleeding mucosal tears. The remaining colon mucosa was slightly reddish (Figure 1: A and B). What is your diagnosis?

Cold snare endoscopic resection of nonpedunculated colorectal polyps larger than 10 mm. A retrospective series.

BACKGROUND AND AIMS: Cold snare polypectomy (CSP) is an accepted technique to remove diminutive or small (6-9 mm) polyps. Here we present a series of CSP for advanced non-pedunculated polyps (> 10 mm). PATIENTS AND METHODS: This is a retrospective, single operator study. A total of 111 patients with non-pedunculated polyps (Paris classification 0-IIa, 0-IIb, 0-Is) estimated > 10 mm, underwent CSP. RESULTS: A total of 129 polyps were removed (87 0-IIa, 18 0-IIb, 24 0-Is). The number of these polyps ranked according to size were as follows : 11-19 mm : 63 (49%), 20-29 mm : 44 (34%), > 30 mm : 22 (17%). Thirty-eight (29.5%) were sessile serrated adenomas, 47 (36%) were tubular adenomas, 25 (19.3%) were villous adenoma's and 18 (14%) were hyperplastic polyps. Forty-nine (38%) polyps were resected in a piecemeal fashion, submucosal injection with diluted Indigo Carmine was used in 24 (19%). Immediate oozing bleeding was frequent but in almost all patients rapid spontaneous haemostasis occurred. In only one patient haemostatic clipping was required (in order to achieve hemostasis). Preventive clipping was used in 3 patients. There were no complications. Seventy-two patients (with 87 lesions) had a follow-up colonoscopy. Of these 87 lesions, 9 had residual adenomatous tissue (10.3 %). According to the size of the original polyp, the distribution was as follows: 11-19 mm : 2/36 (5.5 %), 20-29 mm : 4/32 (12.5 %), > 30 mm : 3/19 (15.7%). CONCLUSION: CSP for advanced, non-pedunculated lesions is feasible, effective and extremely safe.

The risk of early occurrence and recurrence of hepatocellular carcinoma in hepatitis C-infected patients treated with direct-acting antivirals with and without pegylated interferon: A Belgian experience.

Recently, concerns were raised of high rates of HCC recurrence in patients treated with direct-acting antivirals (DAA) for hepatitis C infection. We investigated the HCC occurrence and recurrence rates within 6 months after treatment with DAA with or without pegylated interferon (PEG-IFN) in real life. This is a retrospective, multicenter cohort trial, executed in 15 hospitals distributed across Belgium. Populations were matched based on fibrosis score (Metavir F3-F4). Patients with a Child-Pugh score ≥ B were excluded. In total, 567 patients were included, of whom 77 were treated with PEG-IFN+DAA between 2008 and 2013 and 490 with DAA without PEG-IFN between 2013 and 2015. Patients treated with PEG-IFN+DAA (53±9y) were younger than patients treated with DAA without PEG-IFN (59±12y) (P=.001). 47% of patients treated with PEG-IFN+DAA were in the F4 stage vs 67% of patients treated with DAA without PEG-IFN (P=.001). Screening was inadequate in 20% of both patient groups (P=.664). The early occurrence rate of HCC was 1.7% and 1.1% in patients treated with DAA with and without PEG-IFN, respectively (P=.540). The early recurrence rate was 0% in patients treated with PEG-IFN+DAA and 15.0% in patients treated with DAA without PEG-IFN (P=.857). There is no difference in early occurrence of new HCC between patients treated with DAA with and without PEG-IFN. We did observe a high early recurrence rate of HCC in patients treated with DAA without PEG-IFN. However, these patients were at baseline more at risk for HCC. Finally, in 20%, screening for HCC was inadequate.

Belgian experience with triple therapy with boceprevir and telaprevir in genotype 1 infected patients who inject drugs.

No data have been reported yet on treatment outcome in persons who inject drugs (PWID) infected with hepatitis C virus treated with boceprevir or telaprevir in combination with peginterferon (Peg IFN) and ribavirin (RBV). Additionally, there are concerns about the safety of boceprevir and telaprevir in some subgroups of patients with hepatitis C (HCV). In a cohort of HCV patients infected with genotype 1 in Belgium, treatment outcome of patients infected due to IV drug use was analyzed and compared with patients who have no history of substance use. The study population consisted of 179 patients: 78 PWID and 101 controls treated with boceprevir (n = 79) or telaprevir (n = 100) additional to Peg IFN and RBV; 53 (30%) had advanced disease (F3, F4) and 79 (44%) had an antiviral therapy previously. There were no significant differences in the baseline characteristics between both groups, except that PWID patients were more frequently infected with genotype 1a (67% vs 21%), were younger and were predominantly male. Psychiatric complaints during follow-up occurred more frequently in the PWID patients: 24% versus 11% (P = .02). Treatment failure for other reasons than absence of viral response was 70% and 64% in PWID and non-PWID respectively. The sustained viral response (SVR) rates were similar in both groups (71% in PWID vs 72% in non-PWID); with a non-inferiority test with -5% margin there is a difference of -1% (95% CI [-15%, 13%]) and P = 0.30. There are no reasons to exclude PWID from treatment with boceprevir, telaprevir and novel antiviral therapies.

Idiopathic acute eosinophilic hepatitis: does it exists?

Until now, "eosinophilic hepatitis" has not been recognized as a separate disease entity. We report a case of a middle-aged women with an acute febrile, severe cholestatic hepatitis accompanied with rash and quincke oedema, and an elevated serum IgE level. Liver biopsy showed lymphocytic inflammation with a remarkably high number of eosinophils. She responded rapidly to methylprednisolone treatment, which could be quickly tapered off and stopped without relapse. The term 'idiopathic acute eosinophilic hepatitis' seems to be the best fitting diagnostic term.

Hepatosplenic Sarcoidosis Complicated by Liver Cirrhosis.

Sarcoidosis is a multisystemic disease usually affecting the lungs and mediastinal lymph nodes. Other organs, such as the liver and the spleen, are less commonly involved. Patients usually present with mild nonspecific symptoms. On imaging, hepatosplenomegaly with or without multiple focal lesions within the spleen may be seen in the active disease stage. Rarely, the disease may evolve to cirrhosis and liver failure. We report such a rare case of hepatosplenic sarcoidosis complicated by acute esophageal bleeding due to portal hypertension.

Ileocolic intussusception due to lipomatosis of the ileum: a common complication of a rare clinical entity.

We report a case of intestinal ileal lipomatosis in a 56-year-old Caucasian male complicated with small bowel obstruction due to ileocolic intussusception with a lipoma serving as lead point. This rare disease is often only discovered incidentally as a consequence of mechanical complications and not well reported in the international literature, compared to intussusception due to an isolated lipoma. Computed tomography is the imaging modality of choice to depict complications of this distinct clinicopathological entity. Density measurements can confirm the fatty content and homogeneity analysis of the lesions can guide the radiologist in the differential diagnosis.

Acute abdomen due to intestinal angioedema induced by ACE inhibitors: not so rare?

During the last 5 years we identified 7 patients with a history of episodic acute abdominal pain and subobstruction due to intestinal angioedema secondary to the use of Angiotensin Converting Enzyme (ACE) inhibitors. These cases were all diagnosed in one gastroenterology department. This is thereby the largest single centre case series of ACE inhibitor-induced angioedema that has been published until now. Our findings suggest that this syndrome is far more frequent than international literature would let us believe. We also describe one of the first male cases diagnosed with this entity for which there is a significant female predominance. In the presence of an appropriate history and suggestive findings on CT scan, this diagnosis can relatively easily be made if one is sufficiently intent on it. An appropriate diagnosis can save these patients a lot of unnecessary diagnostic procedures and discomfort.

What is the role of celiac disease in enteropathy-type intestinal lymphoma? A retrospective study of nine cases.

BACKGROUND AND AIMS: It is generally accepted that enteropathy-type intestinal lymphoma (EATL) arises against a background of gluten enteropathy. We investigate whether patients with this diagnosis had celiac disease or pre-existing celiac disease, based on gliadin and endomysium antibodies, as well as duodenal biopsies, HLA typing and response to gluten-free diet. METHODS AND RESULTS: Retrospective study of patients with the diagnosis of peripheral T cell lymphoma of the intestine between January 1990 and January 2002 at the university hospital Gasthuisberg Leuven (n = 14). Patients in whom serologic testing was performed or patients known with pre-existing celiac disease (CD) were included (n = 9). Six of these nine patients were tested for endomysium antibodies (AEM), none of them were positive. Of the six patients with biopsies of mucosa uninvolved by lymphoma, all of them had villous atrophy; five had increased intraepithelial lymphocytes (IEL). In the four patients were HLA typing was performed, the results were compatible with CD. The three patients with initially diagnosed celiac disease all improved on gluten free diet (control biopsies improved as well, but failed to normalise). Of the six other patients, one patient never started GFD, two didn't get better, one initially went better after GFD, and one went better with the concomitantly started chemotherapy. CONCLUSION: There are two possible explanations: Either these patients with EATL have indeed gluten intolerance but the sensitivity of AEM is overestimated in this patient population; or these patients don't have gluten intolerance and EATL itself can mimic CD or other factors mimicking CD are at risk for developing EATL.