Small bowel capsule endoscopy and portal hypertensive enteropathy in cirrhotic patients: results from a tertiary referral centre.

BACKGROUND AND RATIONALE: Portal hypertensive enteropathy (PHE) remains difficult to diagnose in patients with cirrhosis and portal hypertension. Limited test choices exist for the inspection of the small bowel in these patients. Small bowel capsule endoscopy (SBCE) is ideal in this situation but rarely performed. We aimed to determine the prevalence of PHE using SBCE in a cirrhotic patient population and correlate its presence with clinical and CT imaging findings. MATERIAL AND METHODS: We retrospectively analysed data from cirrhotic patients who underwent SBCE at our unit. Studies were evaluated for the presence of cirrhosis-related findings in the oesophagus, stomach and small-bowel. The relationships between PHE and patients' clinical characteristics were evaluated. RESULTS: 53 patients with cirrhosis underwent SCBE. We used PillCam®SB on 36 patients and MiroCam® capsule on 17. Thirty patients were referred for iron deficiency anaemia, 15 for obscure gastrointestinal bleeding, and 4 for other indications. Four data sets were not available for review, leaving 49 patients. Mean age was 61.19 ± 14.54 years (M/F = 27/22). Six SBCE examinations were incomplete. Thirty three patients had evidence of portal hypertensive gastropathy (PHG) and 17 had evidence of oesophageal varices. In total, 29 patients had SCBE evidence of PHE (57%). 28/29 (96.5%) patients with PHE had also evidence of PHG. 13/17 (76.4%) patients with oesophageal varices had also evidence of PHE. CONCLUSIONS: The prevalence of PHE in our study was 57%. SBCE is a useful tool in evaluating PHE in cirrhotic patients irrespective of aetiology.

Actinomycotic liver abscess: a rare complication of colonic diverticular disease.

We present the first case of hepatic actinomycosis requiring both medical and surgical intervention due to liver dissemination from a primary colonic abscess. A 52-year-old white male had a computerised (CT) abdominal scan following an episode of collapse and was found to have peri-colonic and hepatic abscesses. Prior to this episode, he suffered with a two month history of fever, unexplained weight loss, and anaemia suggesting possible malignancy. He was treated with both radiological and surgical drainage of the abscesses, alongside the antibiotic cover and underwent an anterior colonic resection with primary anastomosis. There have been no previous reports of an actinomycotic liver abscess complicating colonic diverticular abscess. A multi- team approach is recommended when disseminated actinomycotic infection is encountered.

Hepatitis B virus and hepatocarcinogenesis.

Hepatitis B viral (HBV) infection is the commonest cause of hepatocellular carcinoma. HBV DNA is the most important predictor of hepatocarcinogenesis in HB surface antigen positive patients. We reviewed the mechanism of hepatocarcinogenesis on molecular level with a special emphasis on the role of X-protein. Hepatitis B X-protein communicates with host targets and disturbs cellular functions including cell cycle regulation, apoptosis, signalling, transcriptional regulation, encoding of cytoskeleton, cell adhesion molecules, oncogenes and tumour suppressor genes.

Pulmonary embolism after sclerotherapy treatment of bleeding varices.

We describe a case of pulmonary embolism after sclerosant injection for bleeding oesophageal varices. The patient was managed successfully with enoxaparin. Systemic embolization after sclerotherapy is rare and depends upon a number of factors including the amount of sclerosant agent used. The incidence of this complication could be as high as 6% which warrants careful post procedure monitoring of patients.

Bouveret's syndrome. Narrative review.

Obstruction at the level of the gastric outlet by a gallstone is defined as Bouveret's syndrome. It is an uncommon form of gallstone ileus. A single gallstone of at least 2.5 cm in diameter is the most common underlying cause of Bouveret's syndrome. Diagnosis is based on the clinical manifestations, existence of pneumobilia, visualization of lithiasis and demonstration of duodenal obstruction. Enterotomy or gastrotomy with or without cholecystectomy and fistula repair is the most common surgical therapy. It has high success rate, with acceptable surgical morbidity and mortality. Heightened awareness of this syndrome may lead to decreased morbidity and mortality.

Nitrofurantoin-induced lung- and hepatotoxicity.

We present the case of a patient referred to the gastroenterology service for investigation of abnormal liver function tests. She had been taking nitrofurantoin for 16 months as prophylaxis against urinary tract infections. CT scan showed evidence of lung pneumonitis and low attenuation in the liver parenchyma. Nitrofurantoin-induced pneumonitis and hepatotoxicity was diagnosed. The patient responded both clinically and biochemically to withdrawal of nitrofurantoin. This combination of adverse reaction to nitrofurantoin is rare.

Hepatic sarcoidosis.

Sarcoidosis is a multisystem disease of unknown aetiology. Histological evidence of non-caseating granulomas represents the main finding. It affects mostly young people, targeting primary the lung and hilar lymph nodes although liver involvement is often encountered. Hepatic sarcoidosis covers a broad spectrum from asymptomatic hepatic granulomas formation and slightly deranged liver function tests to clinically evident disease with cholestasis or, in advanced cases, cirrhosis and portal hypertension. Other granulomatous diseases (mainly systemic infections like tuberculosis) should be excluded prior to treatment, as longstanding corticosteroid administration is the main stem of therapy. In advanced cases, liver transplantation represents the ultimate therapeutic option.