Hepatic osteodystrophy in cirrhosis due to alcohol-related liver disease.

INTRODUCTION: hepatic osteodystrophy, including osteoporosis, is an abnormal bone metabolism related with chronic liver diseases. Osteoporosis is associated with an increased risk of bone fractures, with a significant impact on morbidity, mortality and healthcare costs. Nevertheless, bone disorders tend to be undervalued in cirrhosis due to alcohol-related liver disease (ALD cirrhosis). This study aimed to assess the prevalence of hepatic osteodystrophy and osteoporosis in ALD cirrhosis. METHODS: a prospective observational study was performed that included patients with ALD cirrhosis, between September 2017 and December 2018. Bone mineral density was determined by dual energy X-ray absorptiometry at the lumbar spine and the femoral neck. Hepatic osteodystrophy was defined as a T-score below -1 SD and osteoporosis as a T-score below -2.5 SD. RESULTS: ninety-four patients were included; 24.5 % (n = 23) had prior fragility fractures and ten patients suffered new osteoporotic fractures during the study period. Hepatic osteodystrophy was diagnosed in 79.8 % (n = 75) and osteoporosis in 21.3 % (n = 20) of cases. Patients with hepatic osteodystrophy presented significantly worse Child-Turcotte-Pugh (p < 0.05) and Model for End-Stage Liver Disease (MELD-sodium) scores (p = 0.01). According to the multivariate analysis, lower body mass index (BMI) (OR = 0.787, 95 % CI: 0.688-0.901, p = 0.001) and vitamin D deficiency (OR = 6.798, 95 % CI: 1.775-26.038, p = 0.005) were significantly and independently associated with hepatic osteodystrophy. Patients with osteoporosis also had a lower BMI (p = 0.01). Female patients and those with prior fragility fractures were more likely to suffer from osteoporosis (p < 0.05). CONCLUSION: our study revealed a high prevalence of hepatic osteodystrophy and osteoporosis in patients with ALD cirrhosis (particularly in those with a lower BMI) and a concerning high rate of fragility fractures. Bone mineral density should be assessed in order to allow for an early diagnosis and the implementation of preventive measures.

Prevalence, risk factors and global impact of musculoskeletal injuries among endoscopists: a nationwide European study.

Background and study aims Previous studies have suggested a high prevalence of musculoskeletal injuries (MI) in endoscopists. Little evidence has come from European countries. Our main aim was to evaluate the prevalence, type, and impact of MI among Portuguese endoscopists. We also sought to identify risk factors for the development, severity and number of endoscopy-related MI. Material and methods A 48-question electronic survey was developed by a multidisciplinary group. The electronic survey was sent to all members of Portuguese Society of Gastroenterology (n = 705) during May 2019. Study data were collected and managed using REDCap electronic data capture tools hosted at SPG - CEREGA. Results The survey was completed by 171 endoscopists (response rate of 24.3 %), 55.0 % female with a median age of 36 years (range 26-78). The prevalence of at least one MI related to endoscopy was 69.6 % (n = 119), the most frequent being neck pain (30.4 %) and thumb pain (29.2 %). The median time for MI development was 6 years (range 2 months-30 years). Severe pain was reported by 19.3 %. Change in endoscopic technique was undertaken by 61.3 % and reduction in endoscopic caseload was undertaken by 22.7 %. Missing work was reported by 10.1 %, with the median time off from work being 30 days (range 1-90). Female gender and ≥ 15 years in practice were independently associated with MI and severe pain. Years in practice, weekly-time performing endoscopy, and gender were significant predictors of the number of MI. Conclusions Prevalence of MI was significant among Portuguese endoscopists and had a relevant impact on regular and professional activities.

Misplacement of a nasogastric feeding tube: a case report

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Misplacement of a nasogastric feeding tube: a case report.

Nasogastric tube (NGT) insertion is widely used for enteral feeding. After blind insertion of a NGT, confirmation of correct placement prior to feeding using reliable methods is mandatory. NGT misplacement in the respiratory tract can lead to serious complications. We report a case of a patient with dysphagia and malnutrition that needed enteral feeding as nutritional support. A NGT was blindly inserted, and its gastric position was confirmed through air insufflation and epigastric auscultation. Enteral feeding was initiated. Few hours later, the patient presented with respiratory distress. An urgent thoracic computed tomography was requested due to suspiction of pulmonary embolism, which revealed the NGT in the respiratory tree and a pneumonia in the lower lobe of the right lung. The NGT was removed, a new insertion was attempted and its gastric position was confirmed by radiography. Enteral feeding was initiated uneventfully. This case highlights the need for use of reliable methods of confirming tube location in order to avoid complications of misplacement.

Late closure by secondary intention of a large gastrocutaneous fistula after complicated percutaneous endoscopic gastrostomy / Cicatrización tardía por segunda intención de una fístula enterocutánea de gran tamaño tras gastrostomía endoscópica percutánea complicada

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Clinical score predicting a successful endoscopic approach of esophageal anastomotic leaks: external validation.

BACKGROUND: Recently, a clinical prediction rule has been proposed to predict the chance of successful endoscopic stenting in benign esophageal anastomotic leakage, perforation and fistula. We aimed to validate this score in a cohort of patients with anastomotic leaks managed with self-expanding metal esophageal stents, by assessing technical and clinical success rates and comparing the agreement between the predicted and the actual clinical success. METHODS: A multicenter retrospective cohort study including patients submitted to endoscopic stenting due to anastomotic leak was conducted. Variables of the score (leak size, location and C-reactive protein) were collected and the chance of success (≤50, 50-70 and ≥70%) and its accuracy was assessed. RESULTS: Fifty-three patients, submitted to esophageal stenting after cancer (n = 47) and bariatric surgery were included. Clinical success was achieved in 62% of patients. The area under the ROC curve to differentiate between successful and failed therapies showed a good discriminative power of the score (AUC 0.705; P < 0.01). For a predicted chance of success >50%, the positive predictive value was 72.5%; for a chance of success ≤50%, the negative predictive value was 69.2%. CONCLUSIONS: The application of this predictive model in patients with anastomotic leaks proved to be valid in a different cohort from that in which it was derived. Its usefulness in clinical practice may be anticipated, favoring stenting in patients with a chance of success >50%. However, we must be cautious in patients with a lower probability of success and a case-by-case decision should be made.

Clube Português do Pâncreas Recommendations for Chronic Pancreatitis: Medical, Endoscopic, and Surgical Treatment (Part II).

Chronic pancreatitis (CP) is a complex disease that should be treated by experienced teams of gastroenterologists, radiologists, surgeons, and nutritionists in a multidisciplinary environment. Medical treatment includes lifestyle modification, nutrition, exocrine and endocrine pancreatic insufficiency correction, and pain management. Up to 60% of patients will ultimately require some type of endoscopic or surgical intervention for treatment. However, regardless of the modality, they are often ineffective unless smoking and alcohol cessation is achieved. Surgery retains a major role in the treatment of CP patients with intractable chronic pain or suspected pancreatic mass. For other complications like biliary or gastroduodenal obstruction, pseudocyst drainage can be performed endoscopically. The recommendations for CP were developed by Clube Português do Pâncreas (CPP), based on literature review to answer predefined topics, subsequently discussed and approved by all members of CPP. Recommendations are separated in two parts: "chronic pancreatitis etiology, natural history, and diagnosis," and "chronic pancreatitis medical, endoscopic, and surgical treatment." This abstract pertains to part II.

Clube Português do Pâncreas Recommendations for Chronic Pancreatitis: Etiology, Natural History, and Diagnosis (Part I).

Chronic pancreatitis (CP) is a heterogeneous disease, with different causes and often a long delay between onset and full classic presentation. Clinical presentation depends on the stage of the disease. In earlier stages, recurrent episodes of acute pancreatitis are the major signs dominating clinical presentation. As the inflammatory process goes on, less acute episodes occur, and pain adopts different aspects or may even disappear. After 10-15 years from onset, functional insufficiency occurs. Then, a classic presentation with pain and pancreatic exocrine and endocrine insufficiency appears. Diagnosis remains challenging in the early stages of the disease, as its initial presentation is usually ill-defined and overlaps with other digestive disorders. Computed tomography and magnetic resonance cholangiopancreatography should be the first choice in patients with suspected CP. If the results are normal or equivocal but still there is a high suspicion of CP, the next option should be endoscopic ultrasound. Endoscopic retrograde cholangiopancreatography is mainly a therapeutic technique, and for the diagnostic purpose should only be used when all other imaging modalities and pancreatic function tests have been exhausted. Indirect tests are used to quantify the degree of insufficiency in already-established late CP. Recommendations on CP were developed by Clube Português do Pâncreas (CPP), based on literature review to answer predefined topics, subsequently discussed and approved by all members of CPP. Recommendations are separated in two parts: "chronic pancreatitis etiology, natural history, and diagnosis," and "chronic pancreatitis medical, endoscopic, and surgical treatment." This abstract pertains to part I.

A pancreatite crónica (PC) é uma doença heterogénea, com diferentes etiologias, muitas vezes, com um longo período entre o início de sintomatologia e a apresentação clínica clássica. A clínica depende do estadio da doença, sendo que nos estadios iniciais, predominam episódios recorrentes de pancreatite aguda; com a progressão da doença, os episódios agudos tornam-se menos frequentes, e a dor adota padrões diferentes, podendo inclusive desaparecer; a insuficiência funcional desenvolve-se 10 a 15 anos após o início, assumindo-se então, a apresentação clássica com dor, insuficiência pancreática exócrina e endócrina. O diagnóstico pode ser desafiador nos estadios iniciais da doença, já que a apresentação inicial é geralmente mal definida e se sobrepõe a outros patologias gastrointestinais. A TAC e CPRM devem ser os primeiros métodos de imagem em doentes com suspeita de PC. Se os resultados forem normais ou ambíguos, a próxima opção deve ser a ecoendoscopia. A CPRE é uma técnica principalmente terapêutica, sendo que para fins de diagnóstico, deve ser reservada para quando todas os outros exames de imagem/testes de função pancreática forem inconclusivos. Testes indiretos de função pancreática devem ser usados para quantificação do grau de insuficiência pancreática em doentes com PC já estabelecida. As recomendações sobre PC foram desenvolvidas pelo Clube Português do Pâncreas (CPP), com base numa revisão da literatura para responder a questões predefinidas, posteriormente discutidos e aprovados por todos os membros do CPP. As recomendações encontram-se separadas em duas partes: "etiologia da pancreatite crónica, história natural e diagnóstico" e "tratamento médico, endoscópico e cirúrgico da pancreatite crónica." Este resumo corresponde à parte I.

Endoscopic removal of a giant lipoma of the caecum / Resección endoscópica de un lipoma gigante del ciego

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The unexpected finding: A fish bone mimicking a gastric tumour lesion / El hallazgo inesperado: una espina de pescado simulando una lesión tumoral gástrica

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Black stomach: acute gastric wall ischemia due to polycythemia of an unknown origin

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Acquired double pylorus: An unusual complication of duodenal ulcer / Doble piloro adquirido: una complicación poco usual de úlcera duodenal

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Black stomach: acute gastric wall ischemia due to polycythemia of an unknown origin.

Acute ischemia of the gastric mucosa, resulting in a black stomach, is a very rare event given the blood supply of the stomach, with a rich collateral blood flow system. We present the case of a 65-year-old man, with polycythemia of unknown origin under investigation, presented to the emergency department with a history of diffuse abdominal pain and hematemesis. Blood tests revealed a hemoglobin level of 22 g/dL.Upper endoscopy revealed a black ulcerated gastric mucosa compatible with acute necrosis of the corpus and antrum of the stomach . Despite few cases described in the literature, many etiologic factors have been suggested. In this particular case, given the severe polycythemia and associated hyperviscosity, vascular compromise of the gastric blood vessels might have played a major role in the pathogenesis of the ischemic process.