Small-Bowel Angioectasias: Are They Responsible for a Real Impact on Survival?

Introduction: This study aimed to evaluate the effect of small-bowel angioectasia on survival, given the hypothesis that angioectasia might be an independent risk factor of frailty and poor outcomes. Methods: In this retrospective cohort study, all patients undergoing small-bowel capsule endoscopy between 2010 and 2013 for obscure gastrointestinal bleeding from a Portuguese tertiary centre were included. Follow-up started after capsule endoscopy and ended upon death or end of the study (November 2020). Survival analysis was performed using a Cox proportional-hazards model, in order to analyse the effect of small-bowel angioectasia on survival as well as potentially confounding factors (age, vascular diseases and chronic kidney disease). Results: A total of 176 patients were included in this study (50.6% male), with a median age of 68.5 years (IQR 24). The median follow-up was 7 years (IQR 4), during which 67 (38.1%) patients died. Seventy-three (41.5%) patients had at least one small-bowel angioectasia on capsule endoscopy. On multivariate Cox regression analysis, only age, peripheral arterial disease, history of previous mesenteric ischaemia and chronic kidney disease were independent risk factors of death. The presence of small-bowel angioectasia did not affect survival in this analysis (HR 1.30; 95% CI 0.75-2.23; p = 0.35). Conclusion: In this retrospective cohort study, some comorbidities and age were independent predictors of poor survival. The presence of small-bowel angioectasia per se did not affect survival.

Introdução: Este estudo pretendeu avaliar a influência das angiectasias do intestino delgado na sobrevida, dada a hipótese de que as angiectasias pudessem constituir um fator de risco independente para fragilidade e outcomes adversos. Métodos: Os autores incluíram neste estudo de coorte retrospetivo todos os doentes submetidos a cápsula endoscópica entre 2010 e 2013 por hemorragia digestiva obscura num centro português terciário. O followup iniciou-se após a realização da cápsula e terminou aquando da morte ou fim do estudo (Novembro de 2020). A análise da sobrevida foi realizada através de um modelo de regressão de Cox, no sentido de analisar o efeito na sobrevida das angiectasias do intestino delgado e de potenciais fatores confundidores (idade, doenças vasculares e doença renal crónica). Resultados: Neste estudo foram incluídos 176 doentes (50.6% do sexo masculino), com uma idade mediana de 68.5 anos (IQR 24). O tempo de follow-up mediano foi de 7 anos (IQR 4), durante o qual se verificaram 67 (38.1%) óbitos. 73 (41.5%) dos doentes apresentavam pelo menos uma angiectasia no intestino delgado. Na análise de sobrevida, apenas a idade, doença arterial periférica, história prévia de isquemia mesentérica e doença renal crónica foram fatores de risco independentes de mortalidade. A presença de angiectasias no intestino delgado não afetou a sobrevida nesta amostra (HR 1,30; 95% CI 0,75­2,23; p = 0.35). Conclusão: Neste estudo de coorte retrospetivo, algumas co-morbilidades e a idade foram fatores de risco independentes de mortalidade. A presença de angiectasias no intestino delgado, per se, não afetou a sobrevida.

Concordance of Dye-Spraying Chromoendoscopy and Virtual Chromoendoscopy for Colonic Dysplasia Detection in Longstanding Inflammatory Bowel Disease.

BACKGROUND/AIMS: In the past, dye-spraying chromoendoscopy was the technique of choice for colonic surveillance in patients with long-standing extensive inflammatory bowel disease. Recent evidence suggests that virtual chromoendoscopy is an equally acceptable technique. MATERIALS AND METHODS: Eleven gastroenterologists were given a survey with 20 pairs of pictures from inflammatory bowel disease surveillance colonoscopies (10 with nondysplastic lesions, 5 with dysplastic lesions, and 5 with no lesions). Each pair contained the same image captured during colonoscopy using indigo carmine and narrow-band imaging. For each picture, the gastroenterologist assessed the presence/absence of lesion and, when a lesion was identified, assessed the presence/absence of dysplasia and delineated its margins. To compare lesion and dysplasia detection between techniques, sensitivity, specificity, and interobserver agreement were calculated. The chi-square test was used to assess the accuracy of margins delineation. RESULTS: When assessing lesion and dysplasia detection, similar sensitivity and specificity values were obtained for both techniques. Interobserver agreement analysis revealed that dye-spraying chromoendoscopy and virtual chromoendoscopy had a moderate agreement in lesion detection but, for dysplasia detection, dye-spraying chromoendoscopy had a slight agreement [K = 0.11 (0.03-0.18), P < .01] and virtual chromoendoscopy a fair agreement [K = 0.30 (0.22-0.37), P < .01]. Margin delineation was similar between techniques. CONCLUSION: Sensitivity and specificity for lesion and dysplasia detection, as well as the accuracy of margins delineation, were similar between dye-spraying chromoendoscopy and virtual chromoendoscopy. Interobserver agreement for dysplasia detection was suboptimal in both techniques; however, it was superior when using virtual chromoendoscopy. These findings suggest that virtual chromoendoscopy constitutes a valid alternative for dysplasia screening in inflammatory bowel disease.

Capsule Enteroscopy Using the Mirocam® versus OMOM® Systems: A Matched Case-Control Study.

Although several devices are available for small bowel capsule endoscopy, few studies have compared their visualization quality and diagnostic yield, despite users reporting subjective differences between them. This study aims to compare two widely used systems (Mirocam® MC1600 and OMOM® HD). Patients who underwent OMOM® HD capsule enteroscopy between August 2022 and February 2023 were prospectively included consecutively (cases). Controls were retrospectively selected from a database of patients who underwent Mirocam® MC1600 enteroscopy between March 2018 and July 2022 in a 1:1 ratio. Controls were matched for potential confounders (age, sex, indication, hospitalization, comorbidities, and opioid prescription). The small bowel cleanliness (global and divided by tertiles), the diagnostic yield (positive findings) and the transit times (TT) were compared. Overall, 214 patients were included (107:107). Global bowel preparation was similar between the OMOM® and Mirocam® groups. However, the average scores for each tertile were significantly higher when the OMOM® HD capsule was used (p < 0.05). Small bowel TT was shorter for OMOM® HD (265 ± 118 versus 307 ± 87 min, p = 0.020), while the diagnostic yield (55.0%) and relative distribution of lesions were similar. This study suggests that capsule characteristics, namely resolution, and illumination, systematically interfere with the perception of preparation quality. However, this did not affect the diagnostic yield.

Critical Analysis of the Applicability of Small Bowel Capsule Endoscopy Performance Measures among 2 Portuguese Centers with Different Capsule Endoscopy Platforms.

Introduction: The European Society of Gastrointestinal Endoscopy (ESGE) identified the need to benchmark the quality of small bowel capsule endoscopy (SBCE) and produced a set of performance measures (PM). The aim of this study is to critically evaluate the accordance of the PM for SBCE in two Portuguese centers with different SBCE platforms. Methods: The authors conducted a cross-sectional analysis of consecutive SBCE performed in an 18-month period in 2 Portuguese centers that used two different SBCE platforms Mirocam® (IntroMedic, Seoul, South Korea) and PillCam® (Medtronic, Yokneam, Israel). A total of 10 PM (6 key, 4 minor) were evaluated and compared between the 2 centers. Results: A total of 493 SBCE were included. The minimum standard established by ESGE was reached in 3/6 key PM (complete visualization, lesion detection rate, and capsule retention rate), and none of the 4 minor PM. PM compliance significantly differed between the 2 centers: complete small bowel visualization 95.9 and 90% (p = 0.01), diagnostic yield 50.6 and 63% (p = 0.005), adequate small bowel cleansing level according to Brotz scale 69.54 and 84.6% (p ≤ 0.001), patients with high risk of capsule retention offered a patency capsule 4.2 and 73% (p ≤ 0.001), respectively. Conclusion: This study highlights and critically discusses technical and organizational issues that should be considered in defining more realistic PM thresholds, aiming to improve SBCE quality.

Introdução: A Sociedade Europeia de Endoscopia Digestiva (ESGE) identificou a necessidade de avaliar a qualidade da enteroscopia por videocápsula (EVC) e produziu um conjunto de medidas de desempenho (MD). O objetivo deste estudo é avaliar criticamente a concordância das medidas de desempenho de EVC em dois centros portugueses com diferentes plataformas de EVC. Métodos: Análise transversal de EVC consecutivas realizadas em 2 centros portugueses, com diferentes plataformas de EVC Mirocam® (IntroMedic, Seul, Coreia) e PillCam® (Medtronic, Yokneam, Israel), respetivamente. Um total de 10 medidas de desempenho (6 principais, 4 minor) foram avaliadas e comparadas entre os 2 centros. Resultados: Foram incluídas 493 EVC. O standard mínimo estabelecido pela ESGE foi alcançado em 3/6 MD principais (visualização completa, taxa de detecção de lesões e taxa de cápsula retida), e nenhum nas quatro MD minor. O cumprimento das MD diferiu significativamente entre os 2 centros: visualização completa do intestino delgado 95,9 e 90% (p = 0,01), taxa de deteção de lesões 50,6% e 63% (p = 0,005), adequada preparação do intestino delgado de acordo com a escala de Brotz 69,54 e 84,6% (p ≤ 0,001), doentes com alto risco de retenção da cápsula a quem foi oferecida cápsula de patência 4,2 e 73% (p ≤ 0,001), respectivamente. Introdução: Este estudo destaca e discute criticamente questões técnicas e organizacionais que devem ser consideradas na definição de limiares de MD mais realistas, com o objetivo de melhorar a qualidade da EVC.

Very High Yield of Urgent Small-Bowel Capsule Endoscopy for Ongoing Overt Suspected Small-Bowel Bleeding Irrespective of the Usual Predictive Factors.

Evidence for an urgent approach to ongoing overt suspected small-bowel bleeding (SSBB) is scarce. We aimed to analyze our series of urgent small-bowel capsule endoscopies (SBCEs) for ongoing overt SSBB and to identify factors associated with positive findings and outcomes. A retrospective study of all SBCEs performed in the first 48 h after admission for overt SSBB between January 2006 and February 2022 was performed. Descriptive and inferential analyses (univariate and multivariable) were performed. Eighty-three urgent SBCEs were performed for overt SSBB. Patients were mostly men (69.2%, median age 68) and were followed for a median of 58.2 months (range 5-176). The diagnostic yield was 80.7%; in 60.2%, blood was detected in the small bowel (SB), while in 50.6%, a bleeding lesion was identified, mostly angioectasia. Patients with diabetes mellitus or taking NSAIDs were more prone to present SB findings, yet the explanatory power was low. Endoscopic or surgical treatments were performed in 28.9% and 19.3%, respectively, with the "non-conservative" therapeutic yield being 56.6%. Rebleeding occurred in 20.5% and was associated in the multivariable analysis with the female gender and anticoagulants use. This cohort of urgent SBCE, the largest from a European center, reinforces the usefulness of SBCE for ongoing overt SSBB management. This prompt performance of this procedure is highly effective, regardless of patients' features.

Unexpected Small-Bowel Finding in Overt-Obscure Gastrointestinal Bleeding in a Patient with Neurofibromatosis Type 1 and Crohn's Disease.

Gastrointestinal stromal tumors (GIST) are the most frequent mesenchymal neoplasms affecting the gastrointestinal tract, and the small bowel is the second most frequent location. Approximately 5% of patients with GIST are not sporadic and have a familial autosomal dominant syndrome, such as neurofibromatosis type 1 (NF1). Gastrointestinal bleeding is a common presentation of GIST, and lesions such as submucosal tumors may be detected more readily by capsule endoscopy due to luminal impingement and overlying ulceration. Our report emphasizes the importance of small-bowel investigation in patients with Crohn's disease and NF1 presenting with recent overt bleeding.

Os tumores do estroma gastrointestinal (GIST) são as neoplasias mesenquimatosas que mais frequentemente afetam o trato gastrointestinal, e o intestino delgado é a segunda localização mais comum. Aproximadamente 5% dos GIST não são esporádicos e estão associados a uma síndrome autossómica dominante familiar, como a neurofibromatose tipo 1 (NF1). A hemorragia gastrointestinal é uma apresentação habitual dos GIST, e as lesões subepiteliais podem ser detectadas através da cápsula endoscópica devido à procidência luminal com ulceração subjacente em alguns casos. O nosso caso clínico enfatiza a importância da investigação do intestino delgado numa doente com doença de Crohn e NF1 que apresentou uma hemorragia gastrointestinal.

Readjustment of Capsule Endoscopy Protocols to the COVID-19 Pandemic in a Portuguese Tertiary Center.

BACKGROUND: The prevention of severe acute respiratory syndrome corona virus 2 transmission implies several social distancing mea- sures, imposing a change in the protocols of several hospital departments. Capsule endoscopy protocols changes were implemented and evaluated in a Portuguese tertiary center. METHODS: The authors compared pre-pandemic and peri-pandemic protocols, the latter favoring social distancing, used in MiroCam (IntroMedic, Seoul, Korea) and PillCam Crohn (Medtronic, Minneapolis, Minn, USA) capsule endoscopy, in a Gastroenterology Department of a tertiary center. All capsule endoscopy performed in outpatients between February 2018 and September 2020 was included. The authors compared significant lesions detection rate, completeness of procedure, adequate bowel preparation, complications rate, and patient satisfaction (through a brief phone call survey) among the protocols. RESULTS: This study included 70 MiroCam CE and 43 PillCam Crohn capsule endoscopy. No statistically significant differences concern- ing performance measures and patients satisfaction were found among the pre-pandemic protocol and the peri-pandemic protocol in MiroCam capsule endoscopy. Conversely, in PillCam Crohn capsule endoscopy, the rate of complete exams was significantly inferior in the peri-pandemic protocol (84.8% vs 50.0%, P = .036), with no other statistically significant differences in the remaining parameters. CONCLUSION: The performance measures and patient satisfaction were similar among the protocols analyzed for MiroCam capsule endoscopy. Thus, the readjustment of this capsule endoscopy system, which favors a reduction in hospital stay, appears to be a good alternative to the former protocols in this pandemic era. In contrast, the rate of complete exams was significantly inferior in the adapted protocol to the pandemic era for PillCam Crohn capsule endoscopy, disfavoring its maintenance in the clinical practice.

Evaluation of a new composite score combining SPICE and protrusion angle scores to distinguish submucosal lesions from innocent bulges

Introduction and aim: in capsule endoscopy (CE), small bowel subepithelial lesions (SBSL) are difficult to distinguish from innocent mucosal protrusions. The SPICE score (smooth, protruding lesions index on CE) and a score that assesses the SBSL protrusion angle were developed. The aim of the study was to determine if a composite score is superior to the proposed models.Methods: all CE between 01/2010 and 12/2020 were included in the study if a smooth, round protruding lesion was identified. Both scores and a composite score (SPICE > 2 and angle < 90°) were calculated after video review. Mucosal protrusions were defined as SBSL if they had a histological/imaging diagnosis and innocent protrusions if otherwise. All patients without at least one appointment and an additional diagnostic exam after CE were excluded.Results: a total of 34 CE were included; 64.7 % were males, aged 65.4 ± 14.7 years. The most common indication for CE was anemia (52.9 %). SBSL was identified in 17 cases, with lipomas (14.7 %) being the most frequent diagnosis. Both the SPICE (AUROC 0.90, p < 0.001) and protrusion angle scores (AUROC 0.74, p = 0.019) accurately distinguished SBSL from innocent protrusions. Applying a 90° cut-off, the protrusion angle had a sensitivity of 52.9 % and specificity of 88.2 %. Applying a cut-off of > 2 points, the SPICE score has a sensitivity of 64.7 % and specificity of 94.2 %. The composite score had a sensitivity, specificity, positive and negative predictive value of 47.0 %, 100 %, 100 % and 65.4 %.Conclusion: we propose that additional follow-up investigation should always be undertaken in cases where both a SPICE > 2 and angle of < 90° are obtained, as the likelihood of SBSL is high. (AU)

Diagnostic and therapeutic yields of early capsule endoscopy and device-assisted enteroscopy in the setting of overt GI bleeding: a systematic review with meta-analysis.

BACKGROUND AND AIMS: Small-bowel capsule endoscopy (SBCE) and device-assisted enteroscopy (DAE) are essential in obscure GI bleeding (OGIB) management. However, the best timing for such procedures remains unknown. This meta-analysis aimed to compare, for the first time, diagnostic and therapeutic yields, detection of active bleeding and vascular lesions, recurrent bleeding, and mortality of "early" versus "nonearly" SBCE and DAE. METHODS: MEDLINE, ScienceDirect, and Cochrane Central Register of Controlled Trials were searched to identify studies comparing early versus nonearly SBCE and DAE. Random-effects meta-analysis was performed; reporting quality was assessed. RESULTS: From 1974 records, 39 were included (4825 patients). Time intervals for the early approach varied, within 14 days in SBCE and 72 hours in DAE. The pooled diagnostic and therapeutic yields of early DAE were superior to those of SBCE (7.97% and 20.89%, respectively; P < .05). The odds for active bleeding (odds ratio [OR], 5.09; I2 = 53%), positive diagnosis (OR, 3.99; I2 = 45%), and therapeutic intervention (OR, 3.86; I2 = 67%) were higher in the early group for SBCE and DAE (P < .01). Subgroup effects in diagnostic yield were only identified for the early group sample size. Our study failed to identify differences when studies were classified according to time intervals for early DAE (I2 < 5%), but the analysis was limited because of a lack of data availability. Lower recurrent bleeding in early SBCE and DAE was observed (OR, .40; P < .01; I2 = 0%). CONCLUSIONS: The role of small-bowel studies in the early evaluation of OGIB is unquestionable, impacting diagnosis, therapeutic intervention, and prognosis. Comparative studies are still needed to identify optimal timing.

Evaluation of a new composite score combining SPICE and protrusion angle scores to distinguish submucosal lesions from innocent bulges.

INTRODUCTION AND AIM: in capsule endoscopy (CE), small bowel subepithelial lesions (SBSL) are difficult to distinguish from innocent mucosal protrusions. The SPICE score (smooth, protruding lesions index on CE) and a score that assesses the SBSL protrusion angle were developed. The aim of the study was to determine if a composite score is superior to the proposed models. METHODS: all CE between 01/2010 and 12/2020 were included in the study if a smooth, round protruding lesion was identified. Both scores and a composite score (SPICE > 2 and angle < 90°) were calculated after video review. Mucosal protrusions were defined as SBSL if they had a histological/imaging diagnosis and innocent protrusions if otherwise. All patients without at least one appointment and an additional diagnostic exam after CE were excluded. RESULTS: a total of 34 CE were included; 64.7 % were males, aged 65.4 ± 14.7 years. The most common indication for CE was anemia (52.9 %). SBSL was identified in 17 cases, with lipomas (14.7 %) being the most frequent diagnosis. Both the SPICE (AUROC 0.90, p < 0.001) and protrusion angle scores (AUROC 0.74, p = 0.019) accurately distinguished SBSL from innocent protrusions. Applying a 90° cut-off, the protrusion angle had a sensitivity of 52.9 % and specificity of 88.2 %. Applying a cut-off of > 2 points, the SPICE score has a sensitivity of 64.7 % and specificity of 94.2 %. The composite score had a sensitivity, specificity, positive and negative predictive value of 47.0 %, 100 %, 100 % and 65.4 %. CONCLUSION: we propose that additional follow-up investigation should always be undertaken in cases where both a SPICE > 2 and angle of < 90° are obtained, as the likelihood of SBSL is high.

Does urgent balloon-assisted enteroscopy impact rebleeding and short-term mortality in overt obscure gastrointestinal bleeding?

BACKGROUND AND AIMS: The diagnostic yield (DY) and therapeutic yield (TY) of balloon-assisted enteroscopy (BAE) in overt obscure gastrointestinal bleeding (OGIB) is higher in the first 72 h. This study aimed to evaluate if this higher DY and TY after urgent BAE impacted the rebleeding rate, time to rebleed and short-term mortality. METHODS: Retrospective cohort-study, which consecutively included all patients submitted to BAE for overt OGIB, between 2010 and 2019. Patients were distributed in 2 groups: (1) Urgent BAE; (2) Non-urgent BAE. Rebleeding was defined as an Hb drop >2 g/dL, need for transfusional support or presence of melena/hematochezia. RESULTS: Fifty-four patients were included, of which 17 (31.5%) were submitted to BAE in the first 72 h. DY and TY of urgent BAE (DY 88.2%; n = 15; TY 94.1%; n = 16) was higher compared to non-urgent BAE (DY 59.5%; n = 22; TY 45.9%; n = 17) (DY p = .03) (TY p = .001). The rebleeding rate at 1, 2, and 5 years was 32.0%, 34.0%and 37.0%, respectively. Rebleeding was lower after urgent BAE (17.6%; n = 3) compared to non-urgent BAE (45.9%; n = 17) (p = .04). Rebleeding tended to occurr earlier in non-urgent BAE, being at 6-months (32.5%) and 36 months (41.3%) (p = .05). OGIB related 30-day mortality was 5.4% (n = 2) for non-urgent BAE and 0% for urgent BAE (p = .5). CONCLUSION: Urgent BAE might be associated with higher DY and TY with lower rebleeding and trend toward higher rebleeding-free time.

Endoscopic and histologic activity assessment considering disease extent and prediction of treatment failure in ulcerative colitis.

BACKGROUND AND AIMS: DUBLIN score allows evaluation of disease activity and extent in ulcerative colitis (UC). This study aimed to evaluate DUBLIN score as a predictor of therapeutic failure as well as to associate endoscopic and histological activity scores to assess their joint performance. METHODS: Retrospective cohort study, with consecutive inclusion of patients undergoing total colonoscopy with serial biopsies between 2016 and 2019. DUBLIN score (0-9) was calculated as the product of Mayo endoscopic score (MSe 0-3) by disease extent (E1-E3). Histological activity was evaluated through Nancy score (0-4). Activity scores were correlated with biomarkers, treatment failure (therapeutic escalation, hospitalization and/or colectomy) and clinical remission at 6 months (Mayo partial score ≤ 1). RESULTS: One-hundred and seven patients were included. In 38.3% (n = 41) there was evidence of endoscopic activity (MSe ≥ 2) and in 50.5% (n = 54) histological activity (Nancy ≥ 2). MSe and DUBLIN scores showed good correlation (r = 0.943; p < .001) and both were significantly higher in patients with histological activity (p < .001). Therapeutic failure occurred in 25.2% (n = 27). MSe, DUBLIN, and Nancy scores were significantly associated with therapeutic failure (p < .001). The areas under the (AUC) ROC curve were 0.74 (MSe; p < .001), 0.78 (DUBLIN; p < .001) and 0.84 (Nancy; p < .001). Joint evaluation of endoscopic and histological activity by combining DUBLIN and Nancy scores was associated with therapeutic failure with a significantly higher AUC of 0.84 (p < .001) compared to the Dublin score alone (p = .003). CONCLUSION: Mayo and DUBLIN endoscopic scores correlated with each other and with histological activity. The joint evaluation of endoscopic and histological activity allowed to predict with greater accuracy treatment failure.

Predicting the risk of rebleeding after capsule endoscopy in obscure gastrointestinal bleeding - External validation of the RHEMITT Score.

BACKGROUND AND AIMS: Prediction of rebleeding after small bowel capsule endoscopy (SBCE) in obscure gastrointestinal bleeding (OGIB) is challenging. The recently described RHEMITT score includes 7 variables: chronic kidney disease (CKD); heart failure (HF); P1/P2 lesions (Saurin's classification); major bleeding; incomplete examination; smoking and endoscopic treatment. This tool has been shown to accurately predict the risk of recurrence after a SBCE study. The primary aim of this study was to perform an external validation of the RHEMITT score. METHODS: Retrospective cohort-study, which consecutively included all patients submitted to SBCE (Mirocam®) for OGIB between January 2017 and December 2018. Rebleeding was defined as: (1) a drop in hemoglobin>2g/dL or (2) Melena or hematochezia. The RHEMITT score was calculated and subsequently the accuracy of the score for the prediction of rebleeding was assessed. RESULTS: One-hundred and sixty patients were enrolled. Mean age was 65.8±13.6years and 58.1% (n=93) were female. The mean follow-up time was 20 (SD 9) months. Rebleeding occurred in 14.4% (n=23). Rebleeding at 6, 12, 18 and 24 months was 6.3%, 12.0%, 14.2% and 15.5% respectively. There was a significant association between the RHEMITT score and rebleeding (p <0.001). The area under the (AUC) ROC curve was 0.756 (p<0.001). Rebleeding occurred earlier in intermediate and high-risk patients (RHEMITT score >3) being at 6-months 13.6% and 24 months 28.4% (p<0.01). CONCLUSION: The present study carried out in an external validation cohort confirms the usefulness and accuracy of the RHEMITT score in predicting rebleeding after SBCE.

Extensive Refractory Perineal Pyoderma Gangrenosum Treated with Infliximab, Fecal Diversion, and Negative-Pressure Wound Therapy.

BACKGROUND: Pyoderma gangrenosum (PG) is a rare and difficult-to-diagnose disease that often associates with inflammatory bowel disease. CASE: We present a case of a 57-year-old female with ulcerative colitis receiving 5-ASA who presented with rapidly progressive ulcers in the right foot and on the inside of the thigh, extending from the left large vaginal lip to the perianal area, compatible with PG. She was initially treated with corticosteroids with no response. After multidisciplinary consultation, it was decided to initiate in-fliximab 5 mg/kg, and to perform ileostomy for fecal diversion and negative-pressure wound therapy. The patient presented with marked improvement of the lesions, being discharged after 2 months and demonstrating almost complete resolution of the lesions within 4 months. CONCLUSION: Due to the rarity of PG, there is no evidence of the optimal management. The role of surgery is controversial as PG lesions can demonstrate pathergy and theoretically could worsen with surgical intervention. In this case it was decided based on the extent of the lesions and the experience in other septic/ulcerative perianal conditions.

INTRODUÇÃO: O pioderma gangrenoso (PG) é uma doença rara e de difícil diagnóstico, que frequentemente se associa à doença inflamatória intestinal. CASO: Apresentamos um caso de uma mulher de 57 anos de idade com colite ulcerosa sob 5-ASA que recorreu ao serviço de urgência pelo aparecimento de úlceras rapidamente progressivas no pé direito e no interior da coxa, estendendo-se desde o grande lábio vaginal esquerdo até à área perianal, compatível com PG. A doente foi inicialmente tratada com corticosteroides, sem resposta. Após consulta multidisciplinar, optou-se por iniciar o infliximab 5 mg/kg, realizar ileostomia para desvio fecal e iniciar terapia de vácuo com pressão negativa. A doente apresentou melhoria marcada das lesões tendo tido alta após 2 meses e demonstrando resolução quase completa das lesões aos 4 meses. CONCLUSÃO: Devido à raridade do PG, não há evidências de qual a abordagem ideal. O papel da cirurgia é controverso, pois as lesões do PG podem demonstrar patergiae teoricamente poderiam piorar com a intervenção cirúrgica. Neste caso, a opção cirúrgica foi tomada com base na extensão das lesões e na experiência em outras condições perianais sépticas/ulcerativas.

Prediction of adenoma recurrence after piecemeal endoscopic mucosal resection: interobserver agreement and utilization of the Sydney EMR recurrence tool.

Background and aims: Piecemeal endoscopic mucosal resection (pEMR) allows resection of larger non-invasive colorectal lesions. Adenoma recurrence is an important limitation and occurs in ≤20%. The present study aimed to validate the Sydney EMR recurrence tool (SERT) score as a predictor of both endoscopic and histologic recurrence and evaluate interobserver agreement in adenoma recurrence based on endoscopic scar assessment, among nonexperts in EMR.Methods: Retrospective cohort and cross-sectional study, in which all patients submitted to pEMR in a tertiary care center in Portugal, between 2012 and 2018 were included. SERT-score was calculated for all lesions and compared with the SMSA (size, morphology, site, access) score already validated as a predictor of adenoma recurrence. Image based offline analysis was performed to evaluate adenoma recurrence prediction and assess the interobserver agreement within a heterogeneous group of participants, mostly composed by nonexperts in EMR.Results: There was a moderate positive correlation between the SERT and SMSA scores (p <.001; r = 0.61). SERT-score was significantly associated with endoscopic recurrence (p =.005) and histologic recurrence (p = .015). Endoscopic prediction of recurrence had high coefficient of agreement (k-0.806; p < .001).Conclusion: Histologic recurrence after pEMR can be predicted by SERT score and optical diagnosis of recurrent adenoma has high interobserver agreement between nonexperts in EMR.