Assessment of Ileal Crohn's Disease Activity by Gastrointestinal Ultrasound and MR Enterography: A Pilot Study.

INTRODUCTION: In some cases, there may be a discrepancy between the symptomatology alleged by Crohn's disease (CD) patients and the results of laboratory tests or imaging investigations. Ileocolonoscopy with biopsy is the primary investigation for diagnosing and monitoring CD patients. Cross-sectional imaging techniques such as CT or MR enterography (MRE) and intestinal ultrasonography (IUS) have been proposed as complementary methods to colonoscopy for a complete evaluation of this category of patients. This study aims to identify the role of IUS, contrast-enhanced ultrasound (CEUS) and MRE in evaluating ileal CD activity, using clinical severity scores (Crohn's disease activity index-CDAI, Harvey-Bradshaw index-HBI) and faecal calprotectin or C-reactive protein (CRP) levels as reference methods. MATERIALS AND METHODS: A total of 44 adult patients with ileal CD confirmed using an ileocolonoscopy with biopsy and histopathological examination were assessed by IUS, CEUS and MRE. The evaluation of the disease activity based on the results obtained from the cross-sectional imaging tests was carried out by using some severity scores available in the literature. The sensitivity and specificity of IUS + CEUS and MRE for differentiating active from inactive forms of CD were determined using CDAI, HBI, faecal calprotectin and CRP as reference methods. The accuracy of the results was assessed by the receiver operating characteristics method. The Pearson correlation coefficient was used to determine the types of correlation. A p-value less than 0.05 suggested a statistically significant relationship. RESULTS: Compared to CDAI, the best correlation was identified for Limberg score (r = 0.667, 95% confidence interval (CI) [0.46, 0.8], p < 0.001), followed by MaRIAs score (r = 0.614, 95% CI [0.39, 0.77], p < 0.001). A sensitivity of 93.33% and a specificity of 71.43% (AUC = 0.98) were demonstrated in the case of Limberg score for differentiating patients with active disease from those in remission and for MaRIAs score a sensitivity of 100.00% and a specificity of 57.14% (AUC = 0.97). Regarding HBI, the best correlation was observed for MaRIAs score (r = 0.594, 95% CI [0.36, 0.76], p < 0.001). Also, faecal calprotectin showed the best correlation with MaRIAs score (r = 0.697, 95% CI [0.46, 0.84], p < 0.001), but in the case of CRP, there was only a weak correlation for all evaluated scores. CONCLUSIONS: Although magnetic resonance imaging does not appear to be superior to ultrasonography in terms of accuracy for differentiating active forms of CD from those in remission, the results of our study suggest that MRE associates a better correlation with clinical severity scores and faecal calprotectin levels compared to ultrasonography. More studies are needed to validate these results.

Outcomes in Patients Admitted for Upper Gastrointestinal Bleeding and COVID-19 Infection: A Study of Two Years of the Pandemic.

Upper gastrointestinal bleeding (UGIB) represents a major emergency, and patient management requires endoscopic assessment to ensure appropriate treatment. The impact of COVID-19 on patient mortality in UGIB may be related to the combination of respiratory failure and severe bleeding and indirectly to delayed admissions or a reduction in endoscopic procedures. METHODS: We conducted a retrospective study involving patients admitted between March 2020 and December 2021 with UGIB and confirmed. Our objective was to compare these types of patients with those negative for SARS-CoV-2 infection, as well as with a pre-pandemic group of patients admitted between May 2018 and December 2019. RESULTS: Thirty-nine patients (4.7%) with UGIB had an active COVID-19 infection. A higher mortality rate (58.97%) and a high risk of death (OR 9.04, p < 0.0001) were noted in the COVID-19 pandemic, mostly because of respiratory failure; endoscopy was not performed in half of the cases. Admissions for UGIB have decreased by 23.7% during the pandemic. CONCLUSIONS: COVID-19 infection in patients admitted for UGIB was associated with a higher mortality rate because of respiratory failure and possible delays in or contraindications of treatment.

The Accuracy of Pre-Endoscopic Scores for Mortality Prediction in Patients with Upper GI Bleeding and No Endoscopy Performed.

(1) Background: The assessment of mortality and rebleeding rate in upper gastrointestinal bleeding (UGIB) is essential, and several prognostic scores have been proposed. Some patients with UGIB did not undergo endoscopy, either because they refused the procedure, suffered from alcohol withdrawal symptoms or altered general status, or because the bleeding was severe enough to cause death before the endoscopy. The mortality risk in the subgroup of patients without endoscopy is poorly evaluated in the literature. (2) Methods: The purpose of the study was to identify the most useful scores for the assessment of in-hospital mortality in patients with UGIB with no endoscopy performed and no known etiology. A total of 198 patients with UGIB and no endoscopy performed were admitted between January 2017 and December 2021 and the accuracy of 12 prognostic scores and the Charlson comorbidity index for in-hospital mortality prediction were analyzed, as well as Child-Pugh Turcotte (CPT) and Meld scores in patients with cirrhosis. (3) Results: The mortality rate was 37.9%, higher than in variceal (21.9%, p < 0.0001) and non-variceal bleeding (7.4%, p < 0.0001). The most accurate scores by AUC were the International Bleeding score (INBS, 0.844), Glasgow Blatchford (0.783), MAP score (0.78), Iino (0.766), AIM65 and modified N-score (0.745 each), modified Glasgow-Blatchford (0.73), H3B2 and N-score (0.701); Rockall, Baylor, and T-score had an AUC below 0.7. MELD score was superior to CPT in patients with cirrhosis (AUC 0.811 versus 0.670). (4) Conclusions: The mortality rate in UGIB with no endoscopy was higher than in both variceal and non-variceal bleeding and was higher in the pandemic period but with no statistical significance (45.3% versus 32.14%, p = 0.0586), mainly because of positive cases. Only one case of rebleeding was noted; the hospitalization period was significantly shorter. The most accurate score was International Bleeding Score; the MELD score had a higher but moderate accuracy compared with CPT in patients with cirrhosis.

The Use of Endoscopic Ultrasonography in Inflammatory Bowel Disease: A Review of the Literature.

The diagnosis of inflammatory bowel disease (IBD) can sometimes be challenging. By corroborating clinical, imaging and histological data, the two main entities of IBD, ulcerative colitis and Crohn's disease (CD), can be differentiated in most cases. However, there remains 10-20% of patients where the diagnosis cannot be accurately established, in which case the term "IBD unclassified" is used. The imaging techniques most used to evaluate patients with IBD include colonoscopy, ultrasonography and magnetic resonance imaging. Endoscopic ultrasonography is mainly recommended for the evaluation of perianal CD. Through this work, we aim to identify other uses of this method in the case of patients with IBD.

Endoscopic ultrasound-guided fine needle aspiration: from the past to the future.

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a technique which allows the study of cells obtained through aspiration in different locations near the gastrointestinal tract. EUS-FNA is used to acquire tissue from mucosal/submucosal tumors, as well as peri-intestinal structures including lymph nodes, pancreas, adrenal gland, gallbladder, bile duct, liver, kidney, lung, etc. The pancreas and lymph nodes are still the most common organs targeted in EUS-FNA. The overall accuracy of EUS is superior to computed tomography scan and magnetic resonance imaging for detecting pancreatic lesions. In most cases it is possible to avoid unnecessary surgical interventions in advanced pancreatic cancer, and EUS is considered the preferred method for loco-regional staging of pancreatic cancer. FNA improved the sensitivity and specificity compared to EUS imaging alone in detection of malignant lymph nodes. The negative predictive value of EUS-FNA is relatively low. The presence of a cytopathologist during EUS-FNA improves the diagnostic yield, decreasing unsatisfactory samples or need for additional passes, and consequently the procedural time. The size of the needle is another factor that could modify the diagnostic accuracy of EUS-FNA. Even though the EUS-FNA technique started in early nineteen's, there are many remarkable progresses culminating nowadays with the discovery and performance of needle-based confocal laser endomicroscopy. Last, but not least, identification and quantification of potential molecular markers for pancreatic cancer on cellular samples obtained by EUS-FNA could be a promising approach for the diagnosis of solid pancreatic masses.

Expression of vascular endothelial growth factor and epidermal growth factor receptor in pancreatic ductal adenocarcinomas, neuroendocrine tumours and chronic pancreatitis.

OBJECTIVE: Angiogenesis is a crucial event for pancreatic carcinogenesis, and it also plays an important role in chronic pancreatitis. The aim of our study was to evaluate the mRNA expression of vascular endothelial growth factor (VEGF) and epidermal growth factor receptor (EGFR) in chronic inflammatory or malignant pancreatic pathology in order to elucidate the differences in expression patterns and potential clinical implications. METHODS: Thirty-five patients who had undergone endoscopic ultrasonography followed by endoscipic ultrasound-guided fine needle aspiration (EUS-FNA) of focal pancreatic masses were included in the study. VEGF and EGFR mRNA expression levels in the samples collected by EUS-FNA were analyzed using quantitative real-time polymerase chain reaction (PCR). RESULTS: VEGF expression was detected in all chronic pancreatitis and adenocarcinoma samples and in only 62.5% of pancreatic neuroendocrine tumors. EGFR expression was detected in only 40% of the chronic pancreatitis cases, 76.9% of adenocarcinomas and in 50% of pancreatic neuroendocrine tumors. Both VEGF and EGFR mRNA levels were significantly higher in pancreatic ductal adenocarcinoma than those in normal tissue. VEGF expression inversely correlated with pancreatic ductal adenocarcinoma size, while EGFR expression was related to local invasiveness of adenocarcinoma. CONCLUSION: Both VEGF and EGFR mRNA expression in EUS-FNA samples may be used as a diagnostic marker associated with invasiveness in patients with pancreatic adenocarcinoma.