Current challenges and future needs of clinical and endoscopic training in gastroenterology: a European survey.

Background and study aims A universal European training program in gastroenterology and hepatology is currently not available. The European Board of Gastroenterology and Hepatology (EBGH) has produced guidance regarding expected competencies for European gastroenterology trainees but it is unclear whether these have been incorporated in national curricula. The aim of this study was to provide an in-depth assessment of training and research opportunities, professional activities and of socioeconomic aspects of gastroenterology training across Europe through a web-based 90-point questionnaire. Materials and methods Physicians in their last year or who had recently finished their training, from 16 European countries, were invited to answer the questionnaire. Results A total of 144 physicians answered the survey. A minimum number of procedures is required before completing training in nine of 16 countries (56 %). Overall, European trainees dedicate a median of 12 months (IQR 6-25) of their training period to endoscopy and a median of 3 months (IQR 0-6) to ultrasound. Training in interventional endoscopy was not always exhaustive, as about 50 % of participants performed fewer of several interventional procedures than was recommended by EBGH, most participants did not perform endoscopic hemostasis or endoscopic mucosal resection, and nearly a half of participants had no access to pancreatobiliary endoscopy training. Finally, up to 13 % of residents complete their training without the supervision of a mentor. Conclusion In this large European survey, deep gaps and considerable differences in several gastroenterology training activities were found both among and within 16 European countries. Homogenization of educational programs and training opportunities across Europe is therefore necessary.

Colorectal Cancer Screening: What Is the Population's Opinion.

BACKGROUND: Colorectal cancer (CRC) is the first cause of death by cancer in Portugal and mortality has been increasing in the last 30 years. MATERIALS AND METHODS: During a raising awareness campaign performed by our Gastroenterology Department, in Setúbal, Portugal, an anonymous written questionnaire was developed and presented in order to evaluate the population's knowledge and attitude regarding CRC screening. RESULTS: The following results were reported: 140 persons; mean age 54.6 years; 61.4% women; 22.1% had a family history of colorectal cancer. The main risk factors mentioned by the respondents were family history of CRC, previous history of intestinal polyps, and intestinal infection. Screening was considered useful by all respondents. About 60% of the respondents had been counselled, at least, on one screening technique, mainly by their general practitioner: colonoscopy in 31, fecal occult blood test in 44, and flexible sigmoidoscopy in 9. Most of the respondents had had the appropriate screening test, according to their age and family history. Fourteen of the respondents had not undergone the recommended screening. Their answers showed that this was due to fear of pain/discovering a disease as well as embarrassment. CONCLUSION: Although the majority of the respondents were aware of the importance of CRC screening, results show that there are still several misconceptions about risk factors, fear, and reluctance concerning the screening techniques. Awareness actions are useful to clarify possible questions and inform the population in order to increase compliance with screening.

INTRODUÇÃO: O cancro colorretal (CCR) é a primeira causa de morte por cancro em Portugal, com uma mortalidade que tem aumentado nos últimos 30 anos. MATERIAIS E MÉTODOS: Durante uma acção de sensibilização levada a cabo por profissionais de saúde do Serviço de Gastrenterologia, em Setúbal, Portugal, foi realizado um inquérito escrito, anónimo, no sentido de avaliar os conhecimentos e atitudes da população face ao CCR. RESULTADOS: 140 indivíduos; idade média 54.6 anos; 61.4% mulheres; 22.1% tinham pelo menos 1 familiar com CCR. Os factores de risco para CCR mais referidos foram a presença de pólipos e a história familiar. A infecção intestinal foi considerada como um factor de risco para CCR por 74% dos inquiridos, sendo que o rastreio foi considerado útil por todos. Tinha sido recomendado pelo menos um exame de rastreio a cerca de 60% dos participantes, a maioria por indicação do médico assistente de medicina geral e familiar: colonoscopia total em 31, pesquisa de sangue oculto nas fezes em 44 e rectossigmoidoscopia em 9. Atendendo à idade e história familiar, a maioria efectuou um rastreio apropriado. Catorze pessoas não efectuaram o rastreio aconselhado; os motivos mais apontados foram o medo da dor/descobrir uma doença e vergonha. CONCLUSÃO: Embora a maioria dos inquiridos estivesse alerta para a importância do rastreio do CCR, persistem muitas ideias erradas em relação a factores de risco, receios e reticências quanto à realização dos exames de rastreio. Acções de sensibilização são úteis para clarificar dúvidas e informar a população no sentido de aumentar a adesão ao rastreio.

Colonic diverticulosis and the metabolic syndrome: an association?

Background and objectives: Colonic diverticulosis (CD) is related to advanced age and a lack of dietary fiber. Recently, several studies have shown that metabolic syndrome (MS) is also implicated in the etiopathogenesis of CD. This study aimed to assess the association between MS, obesity and CD. Methods: This was a prospective study of a one-year duration. The MS was defined according to the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III). Demographic data, risk factors for MS and endoscopic findings of patients who underwent a total colonoscopy in the department were collected. Obesity was defined as a body mass index ≥ 30 kg/m2. Informed consent was obtained. The local Ethics Committee and National Data Protection Committee approved the study. Statistical analysis was performed with SPSS 21 and statistical significance was defined as p < 0.05. Results: The study included 203 patients, 95 males with a mean age of 65.5 years. CD was diagnosed in 30.5% of patients. Univariate analysis showed that age, hypertension, increased waist circumference and hyperlipidemia were associated with colonic diverticulosis. There was no association with gender, obesity or type 2 diabetes mellitus. Multivariate analysis showed that age and a greater waist circumference increased the risk of diverticulosis. Ageadjusted analysis showed that MS was associated with diverticulosis. The prevalence of adenoma in patients with CD was similar to that in patients without CD. Conclusion: In this series, MS was significantly associated with CD. The identification of risk groups is important since diverticulosis can have serious and potentially fatal complications. To our knowledge, this is the first Southern European prospective study evaluating the association between MS and CD (AU)

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Colonic diverticulosis and the metabolic syndrome: an association?

BACKGROUND AND OBJECTIVES: Colonic diverticulosis (CD) is related to advanced age and a lack of dietary fiber. Recently, several studies have shown that metabolic syndrome (MS) is also implicated in the etiopathogenesis of CD. This study aimed to assess the association between MS, obesity and CD. METHODS: This was a prospective study of a one-year duration. The MS was defined according to the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III). Demographic data, risk factors for MS and endoscopic findings of patients who underwent a total colonoscopy in the department were collected. Obesity was defined as a body mass index ≥ 30 kg/m2. Informed consent was obtained. The local Ethics Committee and National Data Protection Committee approved the study. Statistical analysis was performed with SPSS 21 and statistical significance was defined as p < 0.05. RESULTS: The study included 203 patients, 95 males with a mean age of 65.5 years. CD was diagnosed in 30.5% of patients. Univariate analysis showed that age, hypertension, increased waist circumference and hyperlipidemia were associated with colonic diverticulosis. There was no association with gender, obesity or type 2 diabetes mellitus. Multivariate analysis showed that age and a greater waist circumference increased the risk of diverticulosis. Age-adjusted analysis showed that MS was associated with diverticulosis. The prevalence of adenoma in patients with CD was similar to that in patients without CD. CONCLUSION: In this series, MS was significantly associated with CD. The identification of risk groups is important since diverticulosis can have serious and potentially fatal complications. To our knowledge, this is the first Southern European prospective study evaluating the association between MS and CD.

Impact of Early Surgery and Immunosuppression on Crohn's Disease Disabling Outcomes.

BACKGROUND AND AIMS: The definition of early therapeutic strategies to control Crohn's disease aggressiveness and prevent recurrence is key to improve clinical practice. This study explores the impact of early surgery and immunosuppression onset in the occurrence of disabling outcomes. METHODS: This was a multicentric and retrospective study with 754 patients with Crohn's disease, who were stratified according to the need for an early surgery (group S) or not (group I) and further divided according to the time elapsed from the beginning of the follow-up to the start of immunosuppression therapy. RESULTS: The rate of disabling events was similar in both groups (S: 77% versus I: 76%, P = 0.700). The percentage of patients who needed surgery after or during immunosuppression therapy was higher among group S, both for first surgeries after the index event (38% of groups S versus 21% of group I, P < 0.001) and for reoperations (38% of groups S versus 12% of group I, P < 0.001). The time elapsed to reoperation was shorter in group I (HR = 2.340 [1.367-4.005]), stratified for the onset of immunosuppression. Moreover, reoperation was far more common among patients who had a late start of immunosuppression (S36: 50% versus S0-6: 27% and S6-36: 25%, P < 0.001) and (I36: 16% versus I0-6: 5% and I6-36: 7%, P < 0.001). CONCLUSIONS: Although neither early surgery nor immunosuppression seem to be able to prevent global disabling disease, an early start of immunosuppression by itself is associated with fewer surgeries and should be considered in daily practice as a preventive strategy.

Development and Validation of Risk Matrices for Crohn's Disease Outcomes in Patients Who Underwent Early Therapeutic Interventions.

INTRODUCTION: The establishment of prognostic models for Crohn's disease [CD] is highly desirable, as they have the potential to guide physicians in the decision-making process concerning therapeutic choices, thus improving patients' health and quality of life. Our aim was to derive models for disabling CD and reoperation based solely on clinical/demographic data. METHODS: A multicentric and retrospectively enrolled cohort of CD patients, subject to early surgery or immunosuppression, was analysed in order to build Bayesian network models and risk matrices. The final results were validated internally and with a multicentric and prospectively enrolled cohort. RESULTS: The derivation cohort included a total of 489 CD patients [64% with disabling disease and 18% who needed reoperation], while the validation cohort included 129 CD patients with similar outcome proportions. The Bayesian models achieved an area under the curve of 78% for disabling disease and 86% for reoperation. Age at diagnosis, perianal disease, disease aggressiveness and early therapeutic decisions were found to be significant factors, and were used to construct user-friendly matrices depicting the probability of each outcome in patients with various combinations of these factors. The matrices exhibit good performance for the most important criteria: disabling disease positive post-test odds = 8.00 [2.72-23.44] and reoperation negative post-test odds = 0.02 [0.00-0.11]. CONCLUSIONS: Clinical and demographical risk factors for disabling CD and reoperation were determined and their impact was quantified by means of risk matrices, which are applicable as bedside clinical tools that can help physicians during therapeutic decisions in early disease management.

Seronegative Intestinal Villous Atrophy: A Diagnostic Challenge.

Celiac disease is the most important cause of intestinal villous atrophy. Seronegative intestinal villous atrophy, including those that are nonresponsive to a gluten-free diet, is a diagnostic challenge. In these cases, before establishing the diagnosis of seronegative celiac disease, alternative etiologies of atrophic enteropathy should be considered. Recently, a new clinical entity responsible for seronegative villous atrophy was described-olmesartan-induced sprue-like enteropathy. Herein, we report two uncommon cases of atrophic enteropathy in patients with arterial hypertension under olmesartan, who presented with severe chronic diarrhea and significant involuntary weight loss. Further investigation revealed intestinal villous atrophy and intraepithelial lymphocytosis. Celiac disease and other causes of villous atrophy were ruled out. Drug-induced enteropathy was suspected and clinical improvement and histologic recovery were verified after olmesartan withdrawal. These cases highlight the importance for clinicians to maintain a high index of suspicion for olmesartan as a precipitant of sprue-like enteropathy.

Systemic mastocytosis: A rare cause of non-cirrhotic portal hypertension.

Mastocytosis is a clonal neoplastic disorder of the mast cells (MC) that can be limited to the skin (cutaneous mastocytosis) or involve one or more extracutaneous organs (systemic mastocytosis). The clinical manifestations of mastocytosis are heterogeneous ranging from indolent disease with a long-term survival to a highly aggressive neoplasm with survival of about 6 mo. Although liver involvement in aggressive systemic mastocytosis (ASM) is relatively common, the development of portal hypertension with or without cirrhosis is rare. We report a case of ASM without skin involvement in a 72-year-old caucasian male who presented with non-cirrhotic portal hypertension based on clinical, analytical, imagiological and endoscopic findings. Given the hematological picture, the correct diagnosis was established based on ancillary tests for MC using bone marrow aspirates and biopsy. Extensive involvement of the liver and gastrointestinal tract was histologically documented. The disease progressed rapidly and severe pancytopenia and recurrent upper gastrointestinal bleeding became the dominant problem. This case illustrates the challenge in establishing a diagnosis of ASM especially when the clinical picture is atypical and without skin involvement. Gastroenterologists should consider infiltrative disease, particularly systemic mastocytosis, as a differential diagnosis in a clinical case of portal hypertension of unknown etiology.

Disseminated Tuberculosis in an Immunocompetent Patient: The Answer is in the Liver.

Tuberculosis, a chronic infectious disease caused by Mycobacterium tuberculosis, may invade all organs but mainly affect the lungs. We report a case of disseminated tuberculosis with hepatic, pericardial and pleural involvement and a review of the relevant literature. A 64-year-old Portuguese male was admitted with epigastric and right upper quadrant pain associated with low grade fever, fatigue, nausea, anorexia, weight loss (6 kg) and mild jaundice. A chest X-ray showed cardiomegaly and a computed tomographic scan of the thorax and abdomen revealed a mild left pleural effusion, a thickened pericardium with signs of incipient calcification and hepatomegaly. The echocardiogram suggested the diagnosis of constrictive pericarditis. Liver biopsy revealed granulomatous lesions with central caseating necrosis. Tuberculosis is usually associated with atypical clinical manifestations. Imaging examination combined with histopathological features, a high index of clinical suspicion and improvement with antibacilar therapeutic are necessary to confirm a diagnosis, especially in the cases of extrapulmonary tuberculosis.

A tuberculose, uma doença infecciosa causada pelo Mycobacterium tuberculosis, pode invadir todos os órgãos, afectando sobretudo os pulmões. Relatamos um caso de tuberculose hepática com envolvimento pericárdico e pleural e uma revisão da literatura relevante. Um homem de 64 anos, de nacionalidade portuguesa, foi admitido por dor no quadrante superior direito do abdómen e no epigastro associada a febre baixa, astenia, náuseas, anorexia, perda de peso (6 kg) e icterícia. A radiografia de tórax revelou cardiomegalia e a tomografia computadorizada de tórax e abdómen revelou um derrame pleural esquerdo ligeiro, um pericárdio espessado com sinais incipientes de calcificação e hepatomegalia. O ecocardiograma era sugestivo de pericardite constritiva. A biopsia hepática revelou granuloma com necrose caseosa central. A tuberculose geralmente está associada a manifestações clínicas atípicas. A presença de aspectos imagiológicos em conjunto com características histológicas típicas, um elevado índice de suspeita clínica e resposta à terapêutica antibacilar são necessários para confirmar o diagnóstico, especialmente nos casos de tuberculose extrapulmonar.

Esophageal stenosis with sloughing esophagitis: A curious manifestation of graft-vs-host disease.

We report a case of a 56-year-old woman with a history of allogenic bone marrow transplantation for two years, complaining with dysphagia and weight loss. Upper endoscopy revealed esophageal stenosis and extensive mucosa sloughing. Biopsies confirmed the diagnosis of graft-vs-host disease (GVHD). Balloon dilation, corticosteroids and cyclosporin resulted in marked clinical improvement. Gastrointestinal tract is involved in the majority of patients with chronic GVHD. Esophageal manifestations are rare and include vesiculobullous disease, ulceration, esophageal webs, casts or strictures. Sloughing esophagitis along with severe stenosis requiring endoscopic dilation has never been reported in this context.

Metabolic syndrome and colorectal neoplasms: An ominous association.

AIM: To evaluate the association of metabolic syndrome (MS) and colorectal cancer and adenomas in a Western country, where the incidence of MS is over 27%. METHODS: This was a prospective study between March 2013 and March 2014. MS was diagnosed according to the National Cholesterol Education Program-ATP III. Demographic characteristics, anthropometric measurements, metabolic risk factors, and colonoscopic pathologic findings were assessed in patients with MS (group 1) who underwent routine colonoscopy at our department. This data was compared with consecutive patients without metabolic syndrome (group 2), with no differences regarding sex and age. Patients with incomplete colonoscopy, family history, or past history of colorectal neoplasm were excluded. Informed consent was obtained and the ethics committee approved this study. Statistical analysis was performed using Student's t-test and χ(2) test, with a P value ≤ 0.05 being considered statistically significant. RESULTS: Of 258 patients, 129 had MS; 51% males; mean-age 67.1 years (50-87). Among the MS group, 94% had high blood pressure, 91% had increased waist circumference, 60% had diabetes, 55% had low high-density lipoprotein cholesterol level, 50% had increased triglyceride level, and 54% were obese [body mass index (BMI) 30 kg/m(2)]. 51% presented 4 criteria of MS. MS was associated with increased prevalence of adenomas (43% vs 25%, P = 0.004) and colorectal cancer (13% vs 5%, P = 0.027), compared with patients without MS. MS was also positively associated with multiple (≥ 3) adenomas (35% vs 9%, P = 0.024) and sessile adenomas (69% vs 53%, P = 0.05). No difference existed between location (P = 0.086), grade of dysplasia (P = 0.196), or size (P = 0.841) of adenomas. In addition, no difference was found between BMI (P = 0.078), smoking (P = 0.146), alcohol consumption (P = 0.231), and the presence of adenomas. CONCLUSION: MS is positively associated with adenomas and colorectal cancer. However, there is not enough information in western European countries to justify screening in patients with MS. To our knowledge, no previous study has evaluated this association in Portuguese patients.

Caffeinated energy drink intoxication.

In recent years an increasing number of different energy drinks have been introduced to provide an energy boost. They contain high levels of caffeine and other additives that act as stimulants. Several recent studies present that energy drinks could increase the risk of seizures, acid-base disorders and cardiovascular events. The authors report a 28-year-old man who was brought to the emergency room after sudden onset of tonic-clonic seizures and metabolic acidosis after drinking several cans of a caffeinated energy drink. The authors believe that this clinical picture was caused by caffeine intoxication from an energetic drink causing a syndrome of catecholamine excess. The patient was discharged within a week with no complaints and no neurological signs. Finally, recognising the features of caffeine intoxication and its potential health consequences may be especially relevant when treating younger persons who may be more likely to consume energy drinks.