The great pretender : Autoimmune Pancreatitis

Autoimmune pancreatitis is a benign disorder which frequently presents with symptoms and imaging suggestive of pancreatic malignancy. Up to 21% of pancreatoduodenectomies performed for suspected pancreatic cancer are found to have benign disease. Autoimmune pancreatitis responds rapidly to corticosteroids and may be associated with extra- pancreatic manifestations. Type 1 forms part of the IgG4-related disease while type 2 autoimmune pancreatitis is less likely to have elevated levels of IgG4. This review discusses the characteristics of the two types of autoimmune pancreatitis and highlights the management and prognosis of this condition.peer-reviewe

Endoscopic ultrasound in the staging of gastrointestinal luminal malignancies

Endoscopic ultrasound (EUS) is an important tool in the staging of gastrointestinal cancers. This review highlights the use of EUS in the staging of gastrointestinal luminal malignancies and compares the performance of EUS with other imaging modalities (CT, MRI and PET-CT) in the staging of these malignancies. Management algorithms in the staging of these malignancies are also presented.peer-reviewe

Cystic Lesions of the Pancreas

With the increasing use of abdominal imaging, cystic lesions of the pancreas are being more frequently detected. These lesions may carry a significant premalignant potential. Current guidelines recommend that mucinous cystic neoplasms, solid pseudopapillary neoplasms, main duct-intraductal papillary mucinous neoplasms and branch duct-intraductal papillary mucinous neoplasms (DB-IPMN) with "high-risk stigmata" for malignancy should be resected while asymptomatic BD-IPMN without mural nodules, no main duct involvement, and a size less than 30 mm can be followed up. Serous cystadenomas carry a very small malignant risk and are usually resected only if they cause symptoms. This review article highlights the common characteristics and recommended management of these cystic lesions of the pancreas.peer-reviewe

Non-Invasive monitoring of Inflammatory Bowel Disease : time to use newer tools?

Introduction: In inflammatory bowel disease (IBD), commonly used biomarkers employed for non-invasive monitoring of disease activity are the C-reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR). Ulcerative colitis (UC) has a modest to absent CRP response despite active inflammation. Iron deficiency anaemia (IDA) is often a marker of active disease in IBD. Methods: CRP, ESR, and Haemoglobin level taken within 7 days of a colonoscopy were analysed and compared with histopathological findings from colonic and ileal biopsies. Results: Colonic biopsies from 95 colonoscopies in UC patients; and colonic and ileal biopsies from 98 colonoscopies in CD patients were analyzed. The Positive Predictive Values and Negative Predictive Values relating to ESR, CRP and iron deficiency anaemia in the two groups of patients were calculated. Conclusion: UC has a similar CRP response to CD in active inflammation. Commonly used biomarkers have poor sensitivities in demonstrating active mucosal disease. IDA has little value when used as a marker of disease activity on its own but may be used as an adjunct to ESR and CRP. Faecal biomarkers and novel antibodies may help to increase the sensitivity and specificity in non-invasive monitoring of IBD.peer-reviewe

Endoscopic retrograde cholangiopancreatography stents : indications, risks and novel uses

Stents cannulating the common bile duct and/or the pancreatic duct are frequently used during endoscopic retrograde cholangiopancreatography in both temporary and definitive management of several conditions. While plastic stents have a high risk of occlusion within a few months, metal stents have larger diameters and may, therefore, last longer. However, they tend to have a higher initial cost and once placed, tend to be more difficult to manipulate or remove. Emerging data are now showing that the removal of covered self-expandable metal stents can be achieved relatively easily without the risks of major complications. This review article investigates the indications and complications for stent insertion, as well as the recommended type of stent for each indication.peer-reviewe

Risks associated with long-term use of proton pump inhibitors

Proton pump inhibitors (PPIs) are widely used in the management of upper gastrointestinal disorders. In recent years, concerns have been raised on the potential adverse effects of long-term PPI use. This article reviews the published evidence of the effect of long-term PPI use on the absorption of minerals and vitamins, risk of infections, chronic kidney disease and dementia.peer-reviewe

The influence of innate and adaptive immunity on Crohn’s disease severity

This article was originally published in a special issue, entitled: "Inflammatory Bowel Disease", Edited by Nancy Louis, Emory University, USA and Ostanin Dmitry Vladimirovich, Louisiana State University Health Sciences Center, USAStricturing and penetrating disease are classified as severe Crohn’s disease types and are frequently associated with an increased risk for bowel surgery. Research has shown that early treatment with aggressive immunosuppression (including biological and thiopurine therapies – the so-called “top-down approach”) results in a diminished risk of developing these complicated disease types. However, these therapies carry significant risks and cost. Being able to predict which patients are at an increased risk of developing severe Crohn’s disease may enable us to treat patients individually, with the aggressive “top-down approach” started at diagnosis in patients with a significantly increased risk of developing complicated disease types. Defects of innate and adaptive immunity both play a role in Crohn’s disease pathophysiology. Identifying whether defects of innate immunity (through gene mutations) or adaptive immunity (through antibodies to microbial antigens) are associated with stricturing/penetrating disease types may enable us to predict the course of the disease and therefore decide on who would benefit most from the “top-down approach”. This review discusses the role of NOD2 and other gene polymorphisms in predicting Crohn’s disease severity. It also highlights the evidence linking the role of the various antibodies involved in adaptive immunity (ASCA, OmpC, GM-CSF) and complicated Crohn’s disease types.peer-reviewe

The management of patients positive to hepatitis C virus antibody in Malta

Hepatitis C virus (HCV) infection is one of the main causes of chronic liver disease and hepatocellular carcinoma worldwide and is an important public health concern. A retrospective analysis of the demographics and management of patients who had a positive anti-HCV detected by enzyme immunoassay test done at Mater Dei Hospital was carried out to analyse the epidemiology of HCV infection in Malta and assess our management when compared to the European Association for the Study of the Liver (EASL) guidelines. 72% of patients were male. The majority of patients were aged 21-50 years. The main mode of infection was via intravenous drugs use, accounting for 68% of cases. Only 56% of patients found to be HCV Ab positive had a scheduled appointment with an infectious diseases specialist or gastroenterologist documented on the MDH online appointment system. 58% of patients had HCV RNA testing done and 45% had genotype testing. 7.3% with HCV infection were given treatment, of which 43% had a Sustained Virological Response (SVR).peer-reviewe

Thr300Ala ATG16L1 polymorphisms and bone strength in Crohn’s disease patients

Introduction: Studies on the effect of deletion of ATG5 and ATG7 proteins on bone cell function and bone strength in laboratory mice have revealed an association between autophagy and osteoporosis. The effect on bone strength of the Thr300Ala variant (rs2241880 polymorphism) of the ATG16l1 gene, a Crohn’s disease susceptibility gene essential in macroautophagy, has not yet been explored. Methods: 101 Crohn’s disease patients underwent DEXA bone density scanning. Real time PCR, high resolution melt (HRM) and restriction fragment length polymorphism (RFLP) were made use of as to assess for the rs2241880 polymorphism of the ATG16L1 gene in these patients. Results: HRM and RFLP demonstrated that 39.6% had the wild type rs2241880 (Thr300Ala) polymorphism while 7.9% were homozygous and 52.5% were heterozygous for the polymorphism. Mean DEXA bone mineral density scores in these patients showed lower T scores at the hip (1.74) among patients with the homozygous polymorphism than among patients with the heterozygous polymorphism (mean T score hip: -1.29). The highest mean T scores were found in patients with the wild type polymorphism (-1.04). Discussion: This study demonstrates the first evidence that polymorphisms in the ATG16L1 gene may play a role in bone metabolism.peer-reviewe