Endoscopic Skills Training: The Impact of Virtual Exercises on Simulated Colonoscopy.

Background: A previous study suggested that psychomotor training improves the performance on colonoscopy. Since then, newer exercises have been included in the latest generation of GI Mentor®. In order to optimize a colonoscopy training program, we aimed to determine the impact of 3 virtual exercises in simulated colonoscopy skills. Methods: This was a prospective and randomized study. Nineteen residents completed a pre-training questionnaire and a colonoscopy trial before randomization in a study group (n = 10) that performed three exercises (Endobubble I, Navigation I, and Mucosal Evaluation I) until they achieved expert level, and a control group (n = 9). Both groups performed 10 repetitions of a simulated colonoscopy and were assessed on a final case. Learning curves and skills transfer were assessed by four parameters: mucosal surface examined (%), time to reach the cecum (s), screening efficiency (%), and time the patient was in pain (%). We also evaluated the construct validity for the exercises. Results: Construct validity was confirmed for Endobubble I and verified in Navigation I (experts were faster than novices; 5 vs. 7 s, p = 0.040), but not for Mucosal Evaluation I. Analyzing the learning curves and performance in the 10 repetitions, the study group reached the cecum faster (278 vs. 356 s, p = 0.035) and achieved a higher screening efficiency (83% vs. 75%, p = 0.019). Concerning skills transfer, the control group took longer to reach the cecum (241 vs. 292 s, p = 0.021) and the percentage of time the patient was in pain was higher (6% vs. 9%, p = 0.021). General performances of the study group had smaller interquartile variations. Conclusion: Psychomotor training has a significant impact on the homogeneous acquisition and assimilation of colonoscopy skills. Endobubble I and Navigation I should be considered in the training programs for novices.

Introdução: Um estudo anterior sugeriu que o treino psicomotor melhora o desempenho em colonoscopia. Desde então, outros exercícios virtuais foram incluídos na nova geração do simulador GI Mentor®. De forma a otimizar o programa de treino em colonoscopia procurou-se determinar o impacto de três exercícios virtuais nas competências de colonoscopia simulada. Métodos: Estudo prospetivo e randomizado. Dezanove internos completaram um questionário pré-treino e uma colonoscopia, tendo sido depois randomizados: Grupo de Estudo (n = 10) que realizou três exercícios (Endobubble I, Navigation I, Mucosal Evaluation I) até atingir o nível expert e Grupo Controlo (n = 9). Posteriormente, ambos os grupos realizaram dez repetições de um caso de colonoscopia simulada e um caso de avaliação final. As curvas de aprendizagem e a transferência de competências foram avaliadas com quatro métricas: superfície da mucosa examinada (%), tempo para atingir o cego (s), taxa de eficiência (%) e tempo que o doente teve dor (%). Adicionalmente, avaliou-se a validade do constructo para os novos exercícios. Resultados: Foi confirmada a validade do constructo no Endobubble I e verificada no Navigation I (os experts foram mais rápidos do que os formandos; 5 vs. 7 s, p = 0.040), mas não no Mucosal Evaluation I. Analisando as curvas de aprendizagem e o desempenho nas 10 repetições, o Grupo de Estudo atingiu mais rapidamente o cego (278 vs. 356 s, p = 0.035) e apresentou uma taxa de eficiência mais elevada (83% vs. 75%, p = 0.019). Na transferência, o Grupo Controlo demonstrou uma degradação significativa no tempo para atingir o cego (241 vs. 292 s, p = 0.021) e na % de tempo que o doente teve dor (6% vs. 9%, p = 0.021). O desempenho do Grupo de Estudo apresentou uma menor variabilidade interquartil. Conclusão: O treino psicomotor teve um impacto significativo na aquisição e assimilação homogénea de competências em colonoscopia. Os exercícios Endobubble I e Navigation I devem ser considerados nos programas de treino em simulador para iniciados.

Comprehensive geriatric assessment of older patients and associated factors of admission to Emergency Departments in pre-covid 19 Era - A Portuguese study.

OBJECTIVES: Identifying frequent users' (≥3admissions/year) associated factors in an emergency department (ED), using a comprehensive geriatric assessment (CGA), describing the characteristics of patients over 65 years of age. METHODS: A cross-sectional study was performed between August 2017 and June 2018 in an ED in Lisbon, Portugal. CGA was applied and completed with clinical records. Clinical, functional, mental and social scores were created based in Portuguese Society of Internal Medicine, and a statistical model was developed. RESULTS: CGA was applied to 426 patients over 64 years old in an ED. The mean age was 79.3, 84.7% had multimorbidity. 51.2%, 75.6%, and 40% had dependence on basic, instrumental, and walking activities, respectively. 52% had depressive symptoms, 65.7% had cognitive impairment, 63% were undernourished/at risk for malnutrition. 33.1% were socially at risk. Polypharmacy was present with a use on average of 6.5 drugs daily. Social, clinical, functional, and mental scores were unfavourable in 48.6%, 79.6%, 54.9% and 83.1% of the population, respectively. There were 2.7 hospital admissions/year and 39.9% were frequent ED users (≥3/year). The logistic regression model was weak, but showed that patients with polypharmacy, elevated Charlson Comorbidity index and an impairment nutritional status presented higher risk of being frequent users. CONCLUSIONS: This study showed that 97.1% of patients had needs that would justify an interventional care plan. This intervention should be extended to primary care and nursing homes. While not providing a robust model, our study has indicated nutritional problems, polypharmacy, and an elevated Charlson index as the features with more weight in frequent users' admissions.

Comprehensive geriatric assessment of older patients and associated factors of admission to Emergency Departments in pre-covid 19 Era – A Portuguese study / Valoración geriátrica integral de pacientes mayores y factores asociados de frecuentación en servicios de urgencias en la era pre-COVID-19 – Un estudio portugués

Objectives: Identifying frequent users’ (≥3admissions/year) associated factors in an emergency department (ED), using a comprehensive geriatric assessment (CGA), describing the characteristics of patients over 65 years of age. Methods: A cross-sectional study was performed between August 2017 and June 2018 in an ED in Lisbon, Portugal. CGA was applied and completed with clinical records. Clinical, functional, mental and social scores were created based in Portuguese Society of Internal Medicine, and a statistical model was developed. Results: CGA was applied to 426 patients over 64 years old in an ED. The mean age was 79.3, 84.7% had multimorbidity. 51.2%, 75.6%, and 40% had dependence on basic, instrumental, and walking activities, respectively. 52% had depressive symptoms, 65.7% had cognitive impairment, 63% were undernourished/at risk for malnutrition. 33.1% were socially at risk. Polypharmacy was present with a use on average of 6.5 drugs daily. Social, clinical, functional, and mental scores were unfavourable in 48.6%, 79.6%, 54.9% and 83.1% of the population, respectively. There were 2.7 hospital admissions/year and 39.9% were frequent ED users (≥3/year). The logistic regression model was weak, but showed that patients with polypharmacy, elevated Charlson Comorbidity index and an impairment nutritional status presented higher risk of being frequent users. (AU)

Objetivos: Identificar factores asociados con usuarios frecuentadores (≥ 3 ingresos/año) en un departamento de urgencias (DU), mediante valoración geriátrica integral (VGI) y describir las características de los pacientes mayores de 65 años que acuden a urgencias.Métodos: El estudio transversal se realizó entre agosto del 2017 y junio del 2018 en un DU de Lisboa, Portugal. Se realizó una VGI además de la historia clínica. Se crearon scores clínicos, funcionales, mentales, sociales, basándose en el protocolo de cuestionario del grupo de geriatría de la Sociedad Portuguesa de Medicina Interna y se desarrolló un modelo estadístico para identificar los factores asociados con la alta frecuentación.Resultados: Se realizó una VGI a 426 usuarios mayores de un DU. La edad media fue de 79,3 años, siendo 53,8% mujeres con un 84,7% de multimorbilidad, 51,2% de dependencia de las actividades básicas (Katz), 75,6% instrumentales (Lawton < 5 en mujeres, < 3 hombres y 40% de dependencia de la marcha (Holden). El 52% tenían síntomas depresivos (Yesavage), 65,7% tenían deterioro cognitivo (MMSE < 24), 63% estaban desnutridos/en riesgo de desnutrición (MNA < 23,5). El 33,1% estaba en riesgo social (Gijón, APGAR familiar). La polifarmacia con el uso de un promedio de 6,5 medicamentos al día. Los scores sociales, clínicos, funcionales y mentales fueron adversos en el 48,6, 79,6, 54,9 y 83,1%, respectivamente. Hubo 2,7 admisiones/año y el 39,9% eran usuarios frecuentes de DU (≥ 3/año). Un modelo de regresión logística fue débil, pero mostró que los pacientes con polifarmacia, índice de comorbilidad de Charlson elevado y un estado nutricional adverso presentaban mayor riesgo de ser usuarios frecuentes. (AU)

Dieulafoy Lesion: Predictive Factors of Early Relapse and Long-Term Follow-Up.

INTRODUCTION: The Dieulafoy lesion (DL) is a rare cause of gastrointestinal bleeding. Advances in the endoscopy field have allowed an increased rate of detection and therapeutic efficacy. However, doubts remain about the most effective hemostatic approach, the affecting variables of therapeutic failure, and early relapse, as well as in the long-term follow-up. AIMS: To assess the efficacy of endoscopic treatment of DL and to identify possible risk factors for early relapse and long-term results. METHODS: All patients with DL admitted to a tertiary hospital between 01/01/2007 and 12/31/2018 were evaluated. The form of presentation, associated pathologies, chronic medication, therapeutic approach, and eventual relapse were determined. A telephone interview was conducted for all patients to find out the long-term results. RESULTS: We identified 73 patients with DL, 45 (61.6%) males, with a mean age of 74 ± 15 years. Thirty-nine patients presented the DL in the stomach, 15 in the duodenum, 2 in the small bowel, 3 in the colon, and 11 in the rectum. The median number of endoscopic examinations required for diagnosis was 2. Median Rockall was 4 (range 2-7). After endoscopic treatment, in 95% of the cases, no active bleeding was evident. Only 2 patients required interventional radiology procedures and 1 needed surgery. Fourteen patients (19%) had a rebleeding, 12 during hospitalization and 2 after a median time of 51 months (range 1-117). There was no difference between the groups with and without early relapse in relation to age, gender, hemoglobin values at presentation, presence of shock, associated pathologies, and anticoagulation. Antiplatelet agents intake had a statistically significant relationship with early relapse (p = 0.003). CONCLUSION: Endoscopic therapy is safe and effective in DL. Patients under antiplatelet therapy are more likely to have an early relapse. The long-term prognosis is excellent, even in patients only treated with endoscopic methods.

INTRODUÇÃO: A lesão de Dieulafoy (LD) é uma causa pouco frequente de hemorragia digestiva. Os avanços na endoscopia permitiram um aumento na taxa de deteção e na eficácia terapêutica, contudo, permanecem dúvidas na abordagem hemostática mais eficaz, nas causas de falência terapêutica e de recidiva precoce, assim como no follow up a longo prazo. OBJECTIVOS: Avaliar a eficácia do tratamento endoscópico para a LD, identificar eventuais factores de risco para a recidiva precoce e os resultados a longo prazo. Métodos: Avaliaram-se todos os pacientes com LD, admitidos num hospital terciário, entre 01/01/2007 e 31/12/2018. Determinou-se a forma de apresentação, patologias associadas, medicação habitual, abordagem terapêutica e eventual recidiva. Uma entrevista telefónica foi realizada a todos os doentes para averiguar os resultados a longo prazo. RESULTADOS: Identificaramse 73 doentes com LD, 45 (61.6%) do sexo masculino, idade média no diagnóstico 74 ± 15 anos. Trinta e nove apresentavam a LD no estômago, 15 no duodeno, dois no delgado, três no cólon e 11 no recto. Foram necessarios um número mediano de 2 exames endoscópicos para diagnóstico. O Rockall médio, na hemorragia digestiva alta, foi de 4 (range 2­7). Em 95% dos casos não se verificou hemorragia activa após tratamento endoscópico. Apenas dois doentes necessitaram de radiologia de intervenção e um de cirurgia. 14 doentes (19%) apresentaram recidiva, 12 durante o internamento e dois num periodo de follow up mediano de 51 meses (range 1­117). Não houve diferença entre os grupos com e sem recidiva precoce em relação á idade, género, valores de hemoglobina á apresentação, presença de choque, patologias associadas e anticoagulação. A toma de antiagregantes teve uma relação estatisticamente significativa com a recidiva precoce (p = 0.003). CONCLUSÃO: A terapêutica endoscópica é segura e eficaz na LD. Pacientes antiagregados têm maior propabilidade de recidiva precoce. O prognóstico a longo prazo é excelente, mesmo nos pacientes apenas tratados por métodos endoscópicos.

Risk Factors for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis in the Indomethacin Era - A Prospective Study.

BACKGROUND AND AIMS: Although endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure used to treat conditions affecting the biliopancreatic system, it can lead to several complications. Post-ERCP pancreatitis (PEP) is the most frequent one, with an incidence ranging from 3 to 14%. Our aim was to assess the potential risk factors associated with PEP occurrence in patients undergoing ERCP with indomethacin prophylaxis. METHODS: Prospective, single-center, real-world observational study (January to December 2015) with inclusion of patients submitted to ERCP, where relevant patient-related and procedure-related data had been collected. Patients had to have been admitted for a minimum of 24 h in order to establish the presence of early complications. All patients were submitted to PEP prophylaxis with 1 or 2 methods: rectal indomethacin and pancreatic duct (PD) stenting. RESULTS: A total of 188 patients who had undergone ERCP were included (52.7% women; mean age 69.2 ± 16.0 years) and PEP was diagnosed in 13 (6.9%). PEP prophylaxis consisted of indomethacin in all cases (100%) and PD stenting in 7.4%. The pancreatitis was mild in 11 patients (84.6%) and severe in the other 2. One of them died (0.5%). None of the patient-related risk factors were associated with changes in PEP probability. Of all patients, 33.0% had 2 or more procedure-related risk factors. A higher number of synchronous procedure-related risk factors showed a statistically significant correlation with PEP occurrence, p = 0.040. CONCLUSIONS: The 6.9% PEP rate is considered acceptable since 33.0% patients had a medium-high risk for PEP due to challenging biliary cannulation. The total number of procedure-related risk factors seems to play a critical role in the development of PEP despite indomethacin prophylaxis.

INTRODUÇÃO E OBJETIVO: A colangiopancreatografia retrógrada endoscópica (CPRE) é um método terapáutico crucial em doenças biliopancreáticas, mas pode levar a várias complicações. A pancreatite pós-CPRE (PPC) é a complicação mais frequente, podendo atingir uma incidáncia de 3 a 14%. O objetivo foi estudar os fatores de risco associados à PPC em doentes submetidos a CPRE com profilaxia por indometacina. MÉTODOS: Estudo prospetivo e observacional com inclusão (janeiro-dezembro 2015) de doentes submetidos a CPRE num centro terciário, em condições de prática real. Foram registados os dados relevantes do doente e procedimento. Os doentes foram observados em internamento por, pelo menos, 24 horas para deteção de complicações. Todos os doentes incluídos foram submetidos a profilaxia de PPC, com recurso a um ou dois métodos indometacina retal e prótese pancreática. RESULTADOS: Estudados 188 doentes, 52.7% mulheres, com idade média de 69.2 ± 16.0 anos. Profilaxia de PPC envolveu indometacina em todos os casos (100%) e colocação de prótese pancreática em 7.4%. Registou-se PPC em 13 doentes (6.9%), sendo que 11 (84.6% de PPC) tiveram pancreatite ligeira. Os restantes dois apresentaram pancreatite grave e um deles faleceu (0.5%). Nenhum dos fatores de risco do doente se relacionou com maior probabilidade de PPC. Do total de doentes, em 33.0% estiveram presentes 2 ou mais fatores de risco associados ao procedimento. A presença simultânea de um número superior de fatores de risco associados ao procedimento relacionou-se significativamente com a ocorráncia de PPC, p = 0.040. CONCLUSÕES: Considera-se aceitável a taxa de PPC de 6.9%, tendo em conta que 33.0% dos doentes apresentavam risco médio-alto para PPC devido a canulação biliar difícil. O número total de fatores de risco associados ao procedimento parece desempenhar um papel crucial no desenvolvimento de PPC, apesar da profilaxia com indometacina.

The Role of the CLIF-C OF and the 2016 MELD in Prognosis of Cirrhosis with and without Acute-on-Chronic Liver Failure.

INTRODUCTION AND AIM: Acute-on-chronic liver failure (ACLF) is defined by the development of acute deterioration of liver function associated with failure of other organs and high short-term mortality in patients with chronic liver disease (CLD). There is no consensus on the diagnostic criteria, and its independence from ordinary decompensation of CLD has frequently been questioned. This study aimed to identify and characterize this condition and to test the CLIF-C OF score comparing it to the 2016-MELD (with sodium) and the Child-Pugh. MATERIAL AND METHODS: 18-month prospective observational study with systematic inclusion of admitted patients with CLD decompensation. RESULTS: 39 patients had ACLF (33.1%). These patients experienced higher 28-day and 90-day mortality, when compared to patients without ACLF (43.6% and 64.1% vs. 2.5% and 7.6% respectively, p < 0.0001). ACLF was linked with a higher acute infection rate (74.4%). For all patients (N = 118), the scores 2016-MELD, CLIF-C OF and Child-Pugh showed an area under the curve (AUC) for 28-day mortality of 0.908, 0.844, 0.753 and for 90-day of 0.902, 0.814, 0.724 respectively, p < 0.0001 for all scores. The 90-day mortality 2016-MELD AUC was greater than the CLIF-C OF AUC, p = 0.021. Within ACLF patients, the 2016-MELD, CLIF-C ACLF and Child-Pugh scores showed an AUC of 0.774, 0.734, 0.584 (28-day) and 0.880, 0.771, 0.603 (90-day); for 2016-MELD p = 0.004 (28-day) and p < 0.0001 (90-day). CONCLUSION: ACLF is a frequent and relevant condition, associated with high mortality. The CLIF-C OF score revealed good accuracy and diagnoses ACLF when it is present. However, the 2016-MELD performed better for 90-day mortality prediction.

Lysosomal Acid Lipase: Can it be a New Non-Invasive Serum Biomarker of Cryptogenic Liver Fibrosis and Cirrhosis?

INTRODUCTION AND AIM: The association between lysosomal acid lipase (LAL) activity and liver steatosis or fibrosis is poorly studied. The aim of our study was to determine the predictive power of LAL for cryptogenic liver steatosis and cryptogenic significant fibrosis/cirrhosis. MATERIAL AND METHODS: Cross-sectional observational study of 101 adult patients with unexplained elevated liver enzymes/hepatomegaly with or without dyslipidemia submitted to the determination of LAL activity and LIPA gene (E8SJM-C.894G^A) mutation. Seventy-one patients underwent liver biopsy or FibroScan®. Patients with an identifiable liver dysfunction cause and well-stablished NAFLD/NASH risk factors were excluded. Predictors for liver steatosis, significant fibrosis (> F2) or cirrhosis (F4) were evaluated. RESULTS: Liver steatosis and fibrosis were mainly assessed by liver biopsy (74.6%; n = 53). Steatosis was present in 62.0% (n = 44), significant fibrosis in 47.9% (n = 34) and cirrhosis in 39.4% (n = 28). The median LAL was 0.36 (0.21-0.46)nmol/spot/h (vs. 0.29 (0.20-0.47); p = 0.558) for liver steatosis, 0.22 (0.11-0.29) nmol/spot/h (vs. 0.40 (0.34-0.51); p <0.001) for significant fibrosis and 0.21 (0.11-0.27) nmol/spot/h (vs. 0.40 (0.32-0.52); p < 0.001) for cirrhosis. No LIPA gene mutations were found. LAL activity was the strongest predictor of significant fibrosis (AUROC: 0.833; p < 0.001) with a cut-off of 0.265 (sensitivity: 85.9%; specificity: 75.0%) and cirrhosis (AUROC: 0.859; p < 0.001) with a cut-off of 0.235 (sensitivity: 86.2%; specificity: 75.0%), being higher than FIB4, GUCI or APRI. However, LAL activity was not associated with liver steatosis (AUROC: 0.536; p =0.558). CONCLUSION: LAL activity can be considered a non-invasive new marker of cryptogenic liver fibrosis with higher accuracy than other known biomarkers. LAL activity < 0.265 nmol/spot/h was strongly associated with cryptogenic significant fibrosis and <0.235 nmol/spot/h with cryptogenic cirrhosis. LAL activity was not associated with cryptogenic liver steatosis.

An uncommon cause of acute abdominal pain and diarrhoea in systemic lupus erythematosus / Una causa poco común de dolor abdominal agudo y diarrea en el Lupus Eritematoso Sistémico

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Clinical Practice Impact of the Boston Bowel Preparation Scale in a European Country.

INTRODUCTION: The diagnostic acuity of colonoscopy requires a careful evaluation of the colonic mucosa, so an adequate bowel cleansing is a key element of the procedure. It is internationally recommended that an evaluation of the quality of the intestinal preparation should be included in the colonoscopy report. The Boston Bowel Preparation Scale (BBPS) is a bowel cleanliness rating scale that has gained some preponderance in this context. However, its application implies some degree of subjective appreciation, and it is important to conduct interobserver reproducibility studies in different contexts. The objective of the present study was to evaluate the reliability of the BBPS in the Portuguese gastroenterological community. METHODS: A prospective study involving Portuguese gastroenterologists with clinical practice in several contexts, and using different methods of evaluation of the intestinal preparation. Participants were invited to answer a questionnaire encompassing 93 static images and 12 video segments of colonoscopy examinations, with different levels of intestinal preparation. For each item, the participant gastroenterologist assigned a score of 0-3, according to the BBPS criteria. A statistical analysis was performed with SPSS 20.0 software, using the intraclass correlation coefficient (ICC). RESULTS: From 45 invited gastroenterologists, 36 replied (mean age 39 ± 9 years). Fifteen (41%) had more than 10 years of colonoscopy experience and 20 (56%) performed more than 40 examinations per month. Twenty-seven (77%) usually used the BBPS in their daily practice. Statistical analysis revealed a strong interobserver correlation (ICC = 0.783) in the application of the BBPS, even in those gastroenterologists who did not use the scale in their daily routine (ICC = 0.775) and those with less years of experience (ICC = 0.820). The correlation in the videos was slightly lower than that observed in the static images (ICC = 0.74 vs. ICC = 0.78). CONCLUSION: The application of the BBPS in the Portuguese gastroenterology community is reproducible and can represent a way to harmonize the colonoscopy reports, contributing to its correct interpretation and subsequent patient orientation.

INTRODUÇÃO: A acuidade diagnóstica da colonoscopia exige uma visualização cuidadosa da mucosa, pelo que uma adequada preparação intestinal é um dos elementos chave para otimização do exame. É internacionalmente recomendado que a avaliação da qualidade da preparação intestinal seja incluída no relatório da colonoscopia. A escala de preparação intestinal de Boston (BBPS) tem ganho alguma preponderância neste contexto, mas a sua determinação inclui uma apreciação algo subjetiva, sendo importante realizar estudos de reprodutibilidade interobservador em diferentes contextos. O objetivo do presente estudo foi avaliar esta mesma reprodutibilidade na comunidade gastrenterológica portuguesa. MÉTODOS: Estudo prospetivo envolvendo Gastrenterologistas portugueses de diferentes faixas etárias e com prática clínica em diferentes contextos Os Gastrenterologistas foram convidados, de forma aleatória, para avaliar, online, 93 imagens estáticas e 12 vídeos de segmentos intestinais, com diferentes níveis de preparação. Para cada uma destas imagens/vídeos o participante atribuía uma pontuação de 0 a 3, segundo os critérios da BBPS. A análise estatística foi realizada com o software SPSS 20.0, utilizando o coeficiente de correlação intraclasses (ICC). RESULTADOS: Dos 45 Gastrenterologistas convidados, 36 (Média etária − 39 ± 9 anos) aceitaram participar (taxa de resposta de 80%). Quinze (41%) tinham mais de 10 anos de experiência em colonoscopia e 20 (56%) realizavam mais de 40 exames por mês. Recorriam a diferentes métodos de avaliação da preparação intestinal (27 (77%) utilizavam habitualmente a BBPS). A análise estatística revelou uma correlação interobservador forte (ICC = 0.783) na aplicação da BBPS, mesmo nos Gastrenterologistas que não utilizavam a escala no seu dia-a-dia (ICC = 0.775) e nos com menos anos de experiência (ICC = 0.820). A correlação nos vídeos foi ligeiramente inferior à observada nas imagens estáticas (ICC = 0.74 vs. ICC = 0.78). Conclusão: A aplicação da BBPS na comunidade gastrenterológica portuguesa revela-se reprodutível, podendo representar uma forma de harmonizar os relatórios, contribuindo assim para a sua correta interpretação e posterior orientação dos doentes.

Red cell distribution width and red cell distribution width to total serum calcium ratio as major predictors of severity and mortality in acute pancreatitis.

BACKGROUND: Acute pancreatitis (AP) is associated with considerable morbidity and mortality. Current severity scores include multiple variables and some of them are only complete within 48 h of admission. Red cell distribution width (RDW) is a simple and routine parameter that seems to be related to inflammatory status. Our aims were to evaluate the diagnostic value of RDW in severity and mortality of AP comparing with other prognostic scoring systems. METHODS: Retrospective case-control study of a total of 312 patients with AP admitted between 2014 and 2016. Patients with severe AP (cases) were compared with patients with mild AP (controls) in the 1:1 proportion. Additionally, a comparison between survivor and nonsurvivor AP patients was performed. Diagnosis and severity of AP were defined according to the revised Atlanta classification 2012. Variables evaluated included demographics, comorbidities, hospital stay, laboratorial parameters, arterial blood gas analysis, prognostic scores within 24 h of admission (Ranson, BISAP and Modified Marshall) and mortality. RESULTS: Included 91 cases of severe AP, most males (58.2% vs 51.6%; p = 0.228) with mean age of 64.8 ± 16.3 years (vs 67.9 ± 13.7; p = 0.239). RDW0h was higher in patients with severe AP (14.6 ± 1.3 vs 12.7 ± 0.5; p < 0.001), as well as RDW0h-to-serum calcium ratio (1.8 ± 0.3 vs 1.3 ± 0.1; p < 0.001). After multivariate and ROC curve analysis, RDW0h (AUROC: 0.960; p < 0.001) and RDW0h-to-serum calcium ratio (AUROC: 0.973; p < 0.001) were the major predictors of severe AP for a cut-off value of 13.0 (S: 92.7%; Sp: 84.3%) and 1.4 (S: 96.3%; Sp: 84.3%), respectively. These factors were superior to prognostic scores, such as Ranson (AUROC: 0.777; p < 0.001; cut-off: 3.0), BISAP (AUROC: 0.732; p < 0.001; cut-off: 2.0) and Modified Marshall (AUROC: 0.756; p < 0.001; cut-off: 1.0). The mortality rate was 8.8% (16/182), all cases associated with severe AP (17.6%; 16/91). RDW0h and RDW0h-to-serum calcium ratio were higher in nonsurvivor AP patients (15.3 ± 1.4 vs 13.5 ± 1.3; p < 0.001 and 2.0 ± 0.3 vs 1.6 ± 0.3; p < 0.001, respectively). In multivariate and ROC curve analysis, RDW0h (AUROC: 0.842; p < 0.001; cut-off: 14.0), RDW24h (AUROC: 0.848; p < 0.001; cut-off: 13.8) and RDW0h-to-serum calcium ratio (AUROC: 0.820; p < 0.001; cut-off: 1.7) were independent predictors for AP mortality, superior to conventional prognostic scoring systems Ranson (AUROC: 0.640; p = 0.003; cut-off:3.0), BISAP (AUROC: 0.693; p = 0.017; cut-off: 2.0) and Modified Marshall (AUROC: 0.806; p < 0.001; cut-off:1.0). CONCLUSIONS: RDW is a simple routine parameter, available at admission. This AP cohort showed that RDW0h > 13.0 and RDW0h-to-total serum calcium ratio > 1.4 were excellent predictors for severity and RDW0h > 14.0 and RDW0h-to-total serum calcium ratio > 1.7 were very-good predictors for mortality, being superior to conventional prognostic scoring systems.

Ulcerative Colitis: Are We Neglecting Its Progressive Character.

INTRODUCTION: Ulcerative colitis (UC) is a chronic disease but its progressive character, with structural damage, is insufficiently studied. OBJECTIVES: To analyze a group of patients without referral bias, regarding its clinical course, the morphological damage, and functional status. METHODS: We evaluated UC patients diagnosed between January 1, 2000 and December 31, 2004, living in the direct referral area of the hospital and determined the medication use, colectomy rate, structural damage ("lead pipe," stenosis, pseudopolyps, fibrous bridges), and anorectal function (prospective evaluation with the Cleveland Clinic Incontinence Score [CCIS] and the Fecal Incontinence Quality of Life Scale). RESULTS: We identified 104 patients, 47% female, with a mean age at diagnosis of 38 ± 17 years, 24% with proctitis, 57% with left colitis, and 19% with pancolitis. In 3 patients, it was not possible to obtain follow-up data. Of the studied patients, 56% needed corticosteroid therapy, 38% immunosuppressants, and 16% anti-tumor necrosis factors (anti-TNFs). After a mean follow-up of 13 ± 2 years, we found structural damage in 25 patients (24%): 5% with proctocolectomy, 15% with "lead pipe," 16% with pseudopolyps, and 3% with stenosis and fibrous bridges. Reference to functional anorectal disorders was identified in 49%, mostly previous and self-limited episodes of incontinence, but including persistent incontinence in 10% (CCIS 8 ± 4.8). There was an increased incidence of structural damage and anorectal dysfunction in patients who needed corticosteroid therapy (p = 0.001), immunosuppressants (p < 0.001), and anti-TNFs (p = 0.002) and an association of structural damage with anorectal dysfunction (p < 0.001). There was no association between age and anorectal dysfunction, including incontinence episodes. CONCLUSIONS: UC is a disease with structural and functional consequences in a significant subset of patients. This should be incorporated when defining the therapeutic strategy.

INTRODUÇÃO: A colite ulcerosa (CU) é uma doença crónica mas o seu carácter progressivo, com danos estruturais, encontra-se insuficientemente estudado. OBJETIVOS: Analisar um grupo de doentes, sem viés de referenciação, quanto ao percurso clínico, aos danos morfológicos e ao estado funcional. MÉTODOS: Avaliaram-se os doentes com diagnóstico de CU estabelecido entre 01-01-2000 e 31-12-2004, com residência na área de referenciação directa do hospital, tendo-se determinado a medicação usada, a taxa de colectomia, os danos estruturais ("cano de chumbo", estenoses, pseudopolipos, pontes fibrosas) ou funcionais ano-rectais (avaliação prospectiva com Cleaveland Clinic Incontinence Score, CCIS e Fecal Incontinence Quality of Life, FIQL). RESULTADOS: Identificaram-se 104 doentes, 47% do sexo feminino, idade média no diagnóstico de 38 ± 17 anos, proctite 24%, colite esquerda 57%, pancolite 19%. Em 3 doentes não foi possível obter dados de seguimento. Dos doentes estudados 56% tiveram necessidade de corticoterapia, 38% de imunossupressores e 16% de anti-TNFs. Após um seguimento médio de 13 ± 2 anos, encontraram-se danos estruturais em 25 doentes (24%), protocolectomia em 5%, "cano de chumbo" 15%, pseudopolipos 16% e estenoses e pontes fibrosas 3%. Verificamos referência a disfunção ano-rectal em 49% (maioritariamente episódios prévios e autolimitados de incontinência) mas incluindo incontinência persistente em 10% (CCIS 8 ± 4.8). Verificou-se uma incidência aumentada de danos estruturais e disfunção ano-rectal nos doentes com necessidade de corticoides (p = 0.001), imunossupressores (p < 0.001) e anti-TNF (p = 0.002) e uma relação entre os danos estruturais e a disfunção ano-rectal (p < 0.001). Não existiu associação entre a idade e a disfunção ano-rectal, incluindo episódios de incontinência. CONCLUSÕES: A CU é uma doença com consequências estruturais e funcionais num subgrupo significativo de doentes. Este facto deve ser integrado na definição da estratégia terapêutica.© 2017 Sociedade Portuguesa de Gastrenterologia Publicado por S. Karger AG, Basel.

Flupirtine drug-induced liver injury in a patient developing acute liver failure.

A patient is admitted with complaints of recent onset nausea, discomfort, jaundice and blood tests that reveal severe hepatitis. At the time, she had been taking medication with Hypericum perforatum (St John's wort) for 6 months, and 6 weeks before this event, she took flupirtine maleate. A few days after being admitted, she developed encephalopathy progressing to acute liver failure (ALF) requiring unsuccessful liver transplantation. The patient was ultimately diagnosed with drug-induced liver injury (DILI). In this context, while H. perforatum could interfere with other medication or trigger DILI itself, flupirtine appears to have triggered the DILI, given its liver toxicity capacity. DILI is one of the major ALF causes and can jeopardise patient's life. Accordingly, all efforts to reduce medication potentially hazardous to the liver are recommended.

Cytomegalovirus ulcerative oesophagitis in a young healthy immunocompetent patient.

Cytomegalovirus (CMV) gastrointestinal disease usually arises in patients with immunodeficiency or immunosuppression, being rare in immunocompetent hosts. Although increasing in incidence, few cases of CMV gastrointestinal disease have been described among young healthy patients. Currently, there is uncertainty in approaching these patients, including the need for antiviral therapy that remains to be established. This case report describes a CMV ulcerative oesophagitis in a young healthy immunocompetent patient with good evolution with no need for antiviral therapy, the youngest case being reported in the literature until now.