Primary colon mantle lymphoma: a misleading macroscopic appearance!

Mantle cell lymphoma (MCL) of the colon is a rare entity, usually presenting as lymphomatous polyposis. We report the case of a 43-year-old male with an unusual colonic MCL in the form of a single exophytic and ulcerous lesion with necrotic areas associated with an ileo-cecal intussusception. The endoscopic appearance suggested adenocarcinoma. However, the diagnosis was made by histology and immunohistochemistry studies of the endoscopic biopsies

Esophagogastroduodenoscopy findings in patients on the waiting list for bariatric surgery

Background: Bariatric surgery (BS) is one of the most effective approaches to weight loss. Performing esophagogastroduodenoscopy (EGD) prior to BS is controversial but allows the detection and treatment of mucosal lesions that may affect surgical decision and type of surgery. Aim: The aim of this study was to identify the frequency of gastric lesions and Helicobacter pylori (Hp) infection in a group of asymptomatic patients on the waiting list for BS. Methods: This is a retrospective descriptive study including patients undergoing EGD before BS. Results: A total of 360 patients were included with a mean age of 42.1 ± 10.8 years, 319 (88.6%) were females, with a mean body mass index of 42.8 ± 5.44 kg/m2. Regarding endoscopic findings, 25.6% presented no endoscopic lesions, 61.6% presented hyperemic gastropathy, 11.4% erosive gastropathy, 1.1% gastric polyp, and 0.3% gastric ulcer. Histologically, no changes were observed in 20.8% of the patients, 239 (66.4%) presented with superficial gastritis, 11.7% (n = 42) had chronic atrophic gastritis and intestinal metaplasia (n = 34 in the antrum, n = 1 in the body, and n = 7 in both the antrum and the body), and 1.7% (n = 6) had low-grade dysplasia. Hp was positive in 251 (69.7%) patients. We found that patients with metaplasia or dysplasia were more frequently submitted to surgical techniques that did not exclude the stomach (55.8 vs. 16.4%, p < 0.001). Conclusion: EGD with histological analysis plays an important role in the pre-surgical evaluation in BS, with a high rate of pathological findings in asymptomatic patients. These findings may have an impact on the long-term management and outcomes of these patients.(undefined

Common variable immunodeficiency-associated inflammatory enteropathy: the new era of biological therapy

Common variable immunodeficiency (CVID) is the most frequent form of immunodeficiency in adults. Clinical manifestations are heterogeneous with an increased susceptibility to infections and inflammatory conditions, namely autoimmune diseases, such as inflammatory bowel disease. We present the clinical case of a Caucasian female patient, 21 years old, with a past medical history of CVID, with multiple visits to the emergency department due to abdominal pain in the lower quadrants and diarrhea. Her biochemical analysis showed elevated inflammatory parameters. Stool cultures and parasitological examination of feces were negative. Ileocolonoscopy revealed lymphoid nodular hyperplasia of the terminal ileum, and the small bowel capsule endoscopy demonstrated edema and multiple pleomorphic ulcers (Lewis score = 1,104). CVID-associated inflammatory enteropathy was suspected. Budesonide 9 mg/day was started, but no positive clinical response was observed. It was decided to initiate biological therapy with infliximab. The patient's condition is currently clinically improved with no complications due to biological therapy.(undefined

Finding the solution for incomplete small bowel capsule endoscopy

To evaluate whether the use of real time viewer (RTV) and administration of domperidone to patients with delayed gastric passage of the capsule could reduce the rate of incomplete examinations (IE) and improve the diagnostic yield of small bowel capsule endoscopy (SBCE). METHODS: Prospective single center interventional study, from June 2012 to February 2013. Capsule location was systematically checked one hour after ingestion using RTV. If it remained in the stomach, the patient received 10 mg domperidone per os and the location of the capsule was rechecked after 30 min. If the capsule remained in the stomach a second dose of 10 mg of domperidone was administered orally. After another 30 min the position was rechecked and if the capsule remained in the stomach, it was passed into the duodenum by upper gastrointestinal (GI) endoscopy. The rate of IE and diagnostic yield of SBCE were compared with those of examinations performed before the use of RTV or domperidone in our Department (control group, January 2009 - May 2012). RESULTS: Both groups were similar regarding age, sex, indication, inpatient status and surgical history. The control group included 307 patients, with 48 (15.6%) IE. The RTV group included 82 patients, with 3 (3.7%) IE, P = 0.003. In the control group, average gastric time was significantly longer in patients with IE than in patients with complete examination of the small bowel (77 min vs 26 min, P = 0.003). In the RTV group, the capsule remained in the stomach one hour after ingestion in 14/82 patients (17.0%) vs 48/307 (15.6%) in the control group, P = 0.736. Domperidone did not significantly affect small bowel transit time (260 min vs 297 min, P = 0.229). The capsule detected positive findings in 39% of patients in the control group and 49% in the RTV group (P = 0.081). CONCLUSION: The use of RTV and selective administration of domperidone to patients with delayed gastric passage of the capsule significantly reduces incomplete examinations, with no effect on small bowel transit time or diagnostic yield

Validation of the Lewis score for the evaluation of small-bowel Crohn’s disease activity

"Published online: 2014"Background and study aims: The Lewis score was developed to measure mucosal inflammatory activity as detected by small-bowel capsule endoscopy (SBCE). The aim of the current study was to validate the Lewis score by assessing interobserver correlation and level of agreement in a clinical setting. Patients and methods: This was a retrospective, single-center, double-blind study including patients with isolated small-bowel Crohn's disease who underwent SBCE. The Lewis score was calculated using a software application, based on the characteristics of villous edema, ulcers, and stenoses. The Lewis score was independently calculated by one of three investigators and by a central reader (gold standard). Interobserver agreement was assessed using intraclass correlation (ICC) coefficient and Bland - Altman plots. Results: A total of 70 patients were consecutively included (mean age 33.9 ± 11.7 years). The mean Lewis score was 1265 and 1320 for investigators and the central reader, respectively. There was a high correlation, both for scores obtained for each tertile (first tertile r = 0.659 - 0.950, second tertile r = 0.756 - 0.906, third tertile r = 0.750 - 0.939), and for the global score (r = 0.745 - 0.928) (P < 0.0001). Interobserver agreement was almost perfect between the investigators and the central reader (first tertile ICC = 0.788 - 0.971, second tertile ICC = 0.824 - 0.943, third tertile ICC = 0.857 - 0.968, global score ICC = 0.852 - 0.960; P < 0.0001). The inflammatory activity was classified as normal (score < 135) in 2.9 % vs. 2.9 %, mild (score ≥ 135 - < 790) in 51.4 % vs. 55.7 %, and moderate to severe (score ≥ 790) in 45.8 % vs. 41.4 % of patients, respectively (P < 0.001). Conclusion: A strong interobserver agreement was demonstrated for the determination of the Lewis score in a practical clinical setting, validating this score for the reporting of small-bowel inflammatory activity. The Lewis score might be used for diagnosing, staging, follow-up, and therapeutic assessment of patients with isolated small-bowel Crohn's disease

Ensaio Clínico Randomizado para o Tratamento do Helicobacter pylori em Doentes Portugueses Naive : É o Tratamento Sequencial Superior ao Tratamento Triplo na Prática Clínica?

Introduction: Helicobacter pylori eradication has become increasingly difficult as resistances to several antibiotics develop. We aimed to compare Helicobacter pylori eradication rates between triple therapy and sequential therapy in a naive Portuguese population. Material and Methods: Prospective randomized trial including consecutive patients referred for first-line Helicobacter pylori eradication treatment. Exclusion criteria: previous gastric surgery/neoplasia, pregnancy/lactancy, allergy to any of the drugs. The compared eradication regimens were triple therapy (pantoprazol, amoxicillin and clarithromycin 12/12 hours, 14 days) and sequential therapy (pantoprazol 12/12 hours for 10 days, amoxicillin 12/12 hours for days 1-5 and clarithromycin plus metronidazol 12/12 hours during days 6 -10). Eradication success was confirmed with urea breath test. Statistical analysis was performed with SPSS v21.0 and a p-value < 0.05 was considered statistically significant. Results: Included 60 patients, 39 (65%) female with mean age 52 years (SD +/- 14.3). Treatment groups were homogeneous for gender, age, indication for treatment and smoking status. No statistical differences were encountered between sequential and triple therapy eradication rates (86.2% vs 77.4%, p = 0.379), global eradication rate was 82%. Tobacco consumption was associated with a significantly lower eradication success (54.5 vs 87.8%, p = 0.022). Discussion: In this randomized controlled trial in a naive Portuguese population, we found a satisfactory global Helicobacter pylori eradication rate of 82%, with no statistical differences observed in the efficacy of the treatment between triple and sequential regimens. Conclusion: These results support the use of either therapy for the first-line eradication of Helicobacter pylori.info:eu-repo/semantics/publishedVersio

Small bowel capsule endoscopy in obscure gastrointestinal bleeding : normalcy is not reassuring

BACKGROUND/AIM: Small bowel capsule endoscopy (SBCE) is currently a fundamental tool in the etiological study of obscure gastrointestinal bleeding (OGIB). However, the impact of a negative exam and the risk of rebleeding are not entirely known. The aim of this study was to evaluate the outcomes of patients with OGIB and a negative SBCE examination in terms of follow-up duration, additional diagnostic studies, and achievement of a diagnosis as well as to assess the incidence of rebleeding and possible associated factors. MATERIALS AND METHODS: We retrospectively analyzed 256 patients who consecutively underwent an SBCE examination for the study of OGIB between April 2006 and December 2011, and then selected the 79 whose results excluded potentially bleeding lesions. Eleven patients were lost to follow-up and the remaining 68 were eligible for a nested case-control analysis. Pre-SBCE and post-SBCE information was collected, including follow-up interval and incidence of rebleeding, defined as admission to the hospital for symptomatic anemia, need for blood transfusion, decrease in hemoglobin value of greater than 2?g/dl, or evidence of melena or hematochezia. Univariate analysis included age, sex, OGIB presentation (occult or visible), hemoglobin levels at presentation, and comorbidities. RESULTS: In the 68 patients analyzed, the mean age was 52±18 years and 61.8% were women. The OGIB was occult in 54 patients (79.4%) and overt in 14 patients (20.6%). Patients were followed up for an average of 32 months. Thirty-nine patients (57.4%) underwent further diagnostic investigations during the period of follow-up and a cause for the gastrointestinal bleeding was found in five of them. Rebleeding was documented in 16 (23.5%) patients, occurring on average 15±13.8 months after the SBCE. Male sex was associated significantly with higher incidence of rebleeding (P=0.004). CONCLUSION: Approximately one quarter of patients with OGIB and negative SBCE examination will experience rebleeding, with higher incidence among men; thus, a negative SBCE in this setting is not reassuring. As the vast majority of rebleeding episodes seem to occur within the following 2 years after SBCE, the maintenance of regular medical surveillance during the above-mentioned period of time after a negative SBCE seems advisable

Endoscopic ultrasonography - emerging applications in hepatology

The inspection of the liver is a valuable part of the upper endoscopic ultrasonography (EUS) studies, regardless of the primary indication for the examination. The detailed images of the liver segments provided by EUS allows the use of this technique in the study of parenchymal liver disease and even in the diagnosis and classification of focal liver lesions. EUS has also emerged as an important tool in understanding the complex collateral circulation in patients with portal hypertension and their clinical and prognostic value. Recently, EUS-guided portal vein catheterization has been performed for direct portal pressure measurement as an alternative method to evaluate portal hemodynamics. In this review, the authors summarize the available evidence regarding the application of EUS to patients with liver diseases and how we can apply it in our current clinical practice.info:eu-repo/semantics/publishedVersio

Mucosal healing in ulcerative colitis – when zero is better

Background and aims: Extensive evidence has underlined the importance of mucosal healing as a treatment aim for ulcerative colitis (UC). We aimed to assess differences in the incidence of clinical relapse at 12 months between UC patients with Mayo endoscopic scores (MES) 0 and 1. Methods: This retrospective study included consecutive patients in corticosteroid-free remission between 2008 and 2013 and with follow-up of at least 1 year, with MES 0 or 1 in complete colonoscopy. Clinical relapse was defined as need for induction treatment, treatment escalation, hospitalization or surgery. A p value < 0.05 was considered statistically significant. Results: The study included 138 patients, 72 (52.2%) female, with mean age of 49 (+/- 14) years. Inflammatory activity was classified as MES 0 in 61 (44.2%) patients and MES 1 in 77 (55.8%) patients. Clinical relapse during follow-up was significantly more frequent in patients with MES 1 than MES 0 (27.3 vs 11.5%, p = 0.022), and in the multivariate analysis MES 1 was the only factor significantly associated with an increased risk of relapse (odds ratio 2.89, 95% confidence interval 1.14-7.36, p = 0.026). This association was encountered in the subgroup of patients with left-sided/ extensive colitis (29.7 vs 11.1%, p = 0.049), but not proctitis (25.0 vs 12.0%, p = 0.202). Conclusions: In patients with UC in corticosteroid-free remission, particularly those with left-sided colitis or extensive colitis, MES 1 was significantly associated with a 3-fold increased risk of relapse compared with endoscopic MES 0. Our results support the use of endoscopic MES 0 as the most suitable treatment endpoint to define mucosal healing in patients with UC.info:eu-repo/semantics/publishedVersio

PillCam® SB3 capsule: does the increased frame rate eliminate the risk of missing lesions?

Since its emergence in 2000, small bowel capsule endoscopy (SBCE) has assumed a pivotal role as an investigation method for small bowel diseases. The PillCam (R) SB2-ex offers 12 h of battery time, 4 more than the previous version (SB2). Rahman et al recently found that the PillCam (R) SB2-ex has a significantly increased completion rate, although without higher diagnostic yield, compared with the SB2. We would like to discuss these somewhat surprising results and the new potentialities of the PillCam (R) SB3 regarding the diagnostic yield of small bowel studies. PillCam (R) SB3 offers improved image resolution and faster adaptable frame rate over previous versions of SBCE. We recently compared the major duodenal papilla detection rate obtained with PillCam (R) SB3 and SB2 as a surrogate indicator of diagnostic yield in the proximal small bowel. The PillCam (R) SB3 had a significantly higher major duodenal papilla detection rate than the PillCam (R) SB2 (42.7% vs 24%, P = 0.015). Thus, the most recent version of the PillCam (R) capsule, SB3, may increase diagnostic yield, particularly in the proximal segments of the small bowel