Volume 83 - 2020 - Fasc.4 - Original articles
Celiac disease and COVID-19 pandemic : should we worry?
Background and study aims : The Coronavirus Disease 2019 (COVID-19) epidemic especially worries people with chronic diseases the entire world. In this study, the frequency, and clinical course of COVID-19 infection in patients with Celiac disease (CD) were investigated. CD patients’ adherence to purchasing gluten free products (GFPs), the strict diet, and how patients’ anxiety affects CD symptoms during the COVID-19 outbreak were also examined.
Patients and methods : A detailed-questionnaire was admi- nistered by telephone, and e-mail to the CD patients to determine the status of these patients in obtaining GFPs, and dietary compliance during the COVID-19 pandemic. State and trait anxiety levels of patients were evaluated using the State-trait Anxiety Inventory (STAI) scale. Additionally, whether patients with CD were diagnosed with COVID-19, and if diagnosed, their clinical course of the disease were investigated.
Results: One hundred and one patients were included in the study. The total number of patients who could obtain GFPs decreased significantly in the pandemic than before the pandemic. The patients’ state anxiety index was 40.7±7.9, and the trait anxiety index was 44.5±8.5, and all patients were evaluated as mildly anxious. During the pandemic, two female patients were diagnosed with COVID-19.
Conclusion : CD patients did not have any additional risk compared to other individuals in terms of becoming infected with COVID-19 for patients under gluten free diet, and these patients will have a similar clinical course as individuals without CD. (Acta gastroenterol. belg., 2020, 83, 517-525).
Effect of appetite-conditioned reflex stimulation on early enteral nutrition tolerance after surgery
Objective : This study aimed to discuss the effects of appetite- conditioned reflex stimulation on the early enteral nutrition (EEN) tolerance, complications, and postoperative hospital stay in patients who underwent surgery.
Methods: Seventy patients who underwent laparoscopic radical resection of colorectal cancer surgery in our hospital between February and December 2017 were randomly divided into a stimulated appetite group (experimental group, including visual stimulation, nasal stimulation, taste stimulation and hearing stimulation) and a control group (n = 35). Both groups received EEN. EEN tolerance, complications, and postoperative hospital stay were then compared between the groups.
Results : Sixty-six patients, including 34 in the experimental group and 32 in the control group, completed the relevant experiment. The experimental group had significantly lower incidence rates of nausea, vomiting, bloating, use of prokinetic drugs, and gastric tube replacement (P < 0.05), and shorter tolerable regular eating time (5.0 ± 1.0 d vs 6.4 ± 1.9 d, P < 0.05) and postoperative hospital stay (7.0 ± 2.0 d vs 8.0 ± 1.8 d, P < 0.05) than the control group. No significant difference in complication rate was detected (P > 0.05).
Conclusion : Appetite-conditioned reflex stimulation can improve EEN tolerance, decrease the risk of complications, and shorten ordinary diet recovery time and hospital stay. (Acta gastroenterol. belg., 2020, 83, 527-531).
The efficacy of a simple single-paged visual illustration on anxiety during pediatric gastroscopy : a randomized clinical trial
Background and study aims: Pediatric gastroscopy is a widely used invasive procedure and causes significant anxiety. In this prospective trial, the efficacy of a new original single-page illustration in reducing anxiety was evaluated.
Patients and methods : One hundred fifty-two consecutive children aged between 7 and 18 years who were scheduled to undergo gastroscopy were randomized to receive a standard consent form plus the new single-page visual illustration (group I) and the usual text consent brochure (group II). The Hospital Anxiety and Depression Scale (HADS) was administered to mothers just before, at the first hour, and at the second week after gastroscopy. Also, Visual Analogue Scale (VAS) scores were obtained from children to measure anxiety at the same time intervals.
Results : The demographic characteristics of the groups were similar. A higher number of cases refused gastroscopy in group II (p=0.040). The proportion of mothers with significant HADS- Anxiety scores at the baseline evaluation (≥8) was 33.8% in group I, whereas it was 58.1% in group II (p=0.003). This remarkable difference in anxiety was also observed at the first hour and second week. Moreover, significant baseline HADS-Depression scores (≥8) of the mothers were more common in group II (2.7% vs. 12.7%, p=0.028). In addition, overall HADS scores revealed considerably higher values in group II at all time intervals. VAS scores in children revealed significantly less anxiety in group I at both the baseline and the first hour assessment.
Conclusions : Lower anxiety scores were observed in both mothers and children with the incorporation of the single-page illustration. This new modality may provide less anxiety and prevent insufficient comprehension with higher acceptance of gastroscopy. (Acta gastroenterol. belg., 2020, 83, 533-539).
Impact of prior different abdominal or pelvic surgery on cecal intubation time: a prospective observational study
Background: Studies investigating the effect of different abdominopelvic surgeries on cecal intubation time (CIT) are limited and their results are heterogeneous. The aim of this study was to investigate the effect of different abdominopelvic surgeries on CIT.
Methods : The study was designed as a single-center, prospective, investigator-blinded and compared patients with previous pelvic surgery, appendectomy, hepatobiliary surgery, upper abdominal region surgery, and umbilical hernioraphy with patients that had no history of surgery. Factors associated with prolonged CIT (>600 sec) were determined using both univariate and multivariate analyses.
Results: This study included a total of 1,420 consecutive colonoscopy procedures that were undertaken between October 2018 and December 2019. The patients comprised 55.1% women and the mean age was 53.05±13.9 years. Mean CIT was 361.87±192.2 sec and prolonged CIT was detected in 176 (12.4%) patients. Of all patients, 523 (36.8%) of them had a history of abdominopelvic surgery. On multivariate analysis, diabetes mellitus (p=0.032, OR 1.766, 95% CI 1.051-2.968) and previous umbilical hernioraphy (p=0.002, OR 3.614, 95% CI 1.623-8.049) were found to be significant factors for CIT and prolonged CIT.
Conclusion: Previous umbilical hernioraphy and diabetes mellitus were identified as independent factors associated with prolonged CIT and difficult colonoscopy. (Acta gastroenterol. belg., 2020, 83, 541-548).
Differential diagnosis of traditional serrated adenomas and tubulovillous adenomas : a compartmental morphologic and immunohistochemical analysis
Aim : Traditional serrated adenomas are the rarest member of the serrated polyps, that have endoscopic and morphologic similarities with conventional adenomas, tubulovillous adenomas, in particular. We aimed to compare the histopathologic and immunohistochemical features of TSAs showing overt dysplasia with conventional TVAs in a compartmental manner using digitalized images.
Patients and methods : For 25 TSAs and 25 TVAs, extent of the morphologic features including cytoplasmic eosinophilia, mid-zonal nuclei, ECFs, slit-like serration, brush border, gastric foveolar-like epithelium and goblet cells were evaluated. Immunohistochemistry was perfomed using primary antibodies including CK7, CK20, MUC2, MUC5AC, MUC6, B-catenin, Ki67, p53, p16, MLH1, MSH2, MSH6 and PMS2.
Results : Eosinophilic cells, mid-zonal nuclei, slit-like serration and ECF were significantly more extensive in TSAs compared to TVAs (p<0,001) while gastric epithelium was also more extensive in TSA cohort with a lower significance (p<0,01). Cut-offs for these features yielding the highest sensitivity and specificity in discriminating TSAs from TVAs were determined ; mid-zonal nucleus resulted as the best discriminating histopathologic feature (100%, 92%) followed by eosinophilia (88%, 92%),and slit-like serration (84%, 92%) with highest sensitivity and specificities, respectively. Compartmental immunohistochemical evaluation revealed that CK20 and CK7 were mainly expressed in ECF while MUC5AC together with CK7 were found in epithelial compartment more frequently in TSAs compared to TVAs. P16 was more common in TSAs in all compartments whereas Ki67 and p53 were restricted to dysplastic compartments in both polyp groups.
Conclusions : The present study demonstrated that mid-zonal nuclei, eosinophilic cells and slit-like serration followed by ECF proved to be the most discriminatory features for TSAs.The correct diagnosis of TSAs will allow to develop appropriate treatment and follow up modalities which seem to be crucial as their progression rate may be different from TVAs. (Acta gastroenterol. belg., 2020, 83, 549-556).
The changing pattern of cirrhosis in Belgium: a study based on two cohorts prospectively collected 15 years apart
Background and study aim : The epidemiology of cirrhosis is evolving over the past decades in Western countries. The aim of this study was to assess the changes in the epidemiology of cirrhosis in our region by comparing two cohorts of patients diagnosed 15 years apart.
Patients and methods : From the outpatient’s liver clinics of our hospital and from January 1995 to December 2017, we consecutively recorded all patients with cirrhosis. From this registry, the current study compared two cohorts of patients diagnosed 15 years apart. Epidemiologic data and liver-related mortality were compared between both cohorts with a 3 to 8-year follow-up.
Results : During a 23-year period, 1151 patients consented to be included in the cirrhosis registry. The current study compared 197 patients with cirrhosis diagnosed from 1995 to 1999 (cohort C1) with 237 patients with cirrhosis diagnosed from 2010 to 2014 (cohort C2). Our results showed that in the cohort C2, compared with the cohort C1, the prevalence of NAFLD-related cirrhosis increased (C1 : 3% vs C2 : 16%, p< 0.0001) while the prevalence of HCV-related cirrhosis decreased (C1 : 22% vs C2 : 10%, p< 0.0001). In the more recent cohort, liver biopsy was less frequently performed (C1 : 65% vs C2 : 20%, p<0.0001). An intriguing finding was the increasing age at cirrhosis diagnosis for patients with alcohol-related cirrhosis (C1 : 52±11 years vs C2 : 57±10 years, p<0.0001).
Conclusions : The epidemiology of cirrhosis has changed over time. Effective prevention strategies are needed to reduce the burden of liver disease. (Acta gastroenterol. belg., 2020, 83, 559-563).
Microvesicular steatosis : a missed item in the management of nonalcoholic fatty liver disease?
Background : Nonalcoholic fatty liver disease (NAFLD) is among the most common causes of chronic liver disease and cirrhosis. In NAFLD, histological course of steatosis is usually macrovesicular (MacroS), but it may be accompanied by varying degrees of microvesicular steatosis (MicroS). Thus, in this study, we aimed to evaluate the prevalence and significance of MicroS in subjects with NAFLD.
Methods : A retrospective analysis of clinical and laboratory data of patients with histologically proven NAFLD was performed. The liver biopsy specimens which stained with hematoxylin eosin, reticulin, and Masson’s Trichrome stains were evaluated by single expert liver pathologist. Scoring and semiquantitative assessment of steatosis and NAFLD severity was done according to Kleiner scale known as NAFLD activity score (NAS). Grading for steatosis, steatosis type, zonal distribution of steatosis and other histological findings were also determined.
Results : The prevalence of MicroS among the study population (n= 191) was 30.4%. There was no difference regarding the demographic and biochemical parameters between patients with or without MicroS. On the other hand, the prevalence of ballooning injury and megamitochondria were higher in patients with MicroS (p= 0.019 and p= 0.036, respectively). There was a significant association of MicroS with ballooning injury (OR 2.65, 95% CI= 1.26-5.55 ; p= 0.005) and the presence of megamitochondria (OR 3.72, 95% CI= 1.00-13.72 ; p= 0.037).
Conclusion : MicroS is common in patients with NAFLD and is associated with early histological findings in this clinically relevant condition. Further longitudinal studies are needed to characterize the role of MicroS in the natural history of NAFLD. (Acta gastroenterol. belg., 2020, 83, 565-570).
Diagnostic value of the choledochal sphericity index in the diagnosis of obstructive cholestasis using magnetic resonance cholangiopancreatography
Background and study aims : Dilatation of common bile duct (CBD) is the first sign in the diagnosis of obstructive jaundice. On magnetic resonance cholangiopancreatography (MRCP), the measurement of the CBD diameter is commonly performed on the widest part of the duct, and the long axis diameter is used in clinical practice. It is aimed to investigate the role of long axis, short axis and sphericity index (SI) of CBD in the diagnosis of obstructive cholestasis.
Patients and methods : MRCP images of 68 patients who had a bile duct diameter of ≥6 mm were retrospectively evaluated. The cases with a direct bilirubin value ?0.4 mg/dl were determined to be cholestasis. Using the curved planar images, the long and short axis measurements were obtained from the widest portion of the bile duct in the transverse section and SI were obtained by calculating the ratio of the long axis over short axis. Short axis, long axis and SI was compared between cholestatic and non-cholestatic group.
Results : The mean age of the patients was 58.97 ± 17.84. Long axis, short axis, and SI showed statistically significant difference between groups (p=0.034, p=0.001, and p=0.014, respectively). Sensitivity and specificity were 60.7% and 80% for long axis, %53.6 and 82.5% for short axis, 65% and 71.4% for SI, respectively.
Conclusions: In addition to the long axis measurement, evaluation of the short axis measurement and calculation of the SI on MRCP examination will help exclude physiological dilatation in the suspicion of cholestasis. (Acta gastroenterol. belg., 2020, 83, 571-575).
Basket versus balloon extraction for choledocholithiasis : a single center prospective single-blind randomized study
Background and study aims : endoscopic retrograde cholangio- pancreatography (ERCP) is essential when dealing in patients with choledocholithiasis. However, the proper extraction device selection is, often, a matter of the endoscopists’ preference. We conducted a single center prospective randomized controlled study to access success rates for basket versus balloon catheters for small stones.
Patient and methods : in our non-inferiority study, 180 patients with bile duct stones were randomized in a basket and a balloon catheter group. Inclusion criteria were fluoroscopically bile duct stones ≤10mm in diameter and a common bile duct diameter ≤15mm. The primary endpoint was the rate of complete bile duct clearance for each method. Secondary endpoints included time completed and amount of radiation dose recorded in each ERCP session, as well as any reported adverse events.
Results : balloon was non-inferior to basket stone extraction (OR 3.35, 95% CI 1.12-10.05, p=0.031). Complete clearance was achieved in 69 out of 82 patients (84.1%) in the basket catheter group versus 79 out of 84 patients (94%) in the balloon catheter group (p=0.047) ; this seems to be especially true for patients with few stones and of small size (≤2 stones, p=0.043 and stone diameter ≤5mm, p=0.032). Complete stone clearance in the basket group patients took longer than that in the balloon group (4.52 and 4.06 min, respectively, p=0.015). Higher median radiation doses for stone clearance were recorded in the basket versus the balloon catheter group (1534.43 Gy versus 1245.45 Gy, p=0.023).
Conclusions : our study showed that balloon was non-inferior to basket stone extraction. (Acta gastroenterol. belg., 2020, 83, 577- 584).
Development of pancreatic injuries in the course of COVID-19
Background and study aims : To investigate the clinical and laboratory characteristics of the cases with high lipase levels in the course of COVID-19.
Patients and methods : Hospital records of all cases, where lipase levels were measured, and the reverse transcriptase-polymerase chain reaction test due to SARS-CoV-2 was found positive, were retrospectively investigated. Of 127 COVID-19 patients tested for lipase, 20 (15.7%) had serum lipase levels above the upper laboratory limit. The patient group with the “high lipase level” was created from these subjects, and the rest constituted the “control” group.
Results : While body mass index (BMI) levels were higher in the high lipase group, (p=0.014), the number of those with pre-existing diabetes mellitus (DM) was also found higher in the high lipase group than the controls (p=0.002). The history of DM was detected to increase the risk of developing high lipase level 4.63 times higher. Only two patients were diagnosed with acute pancreatitis (AP). While oxygen saturations on admission (p=0.019) and discharge (p=0.011) were lower in the high lipase group than the controls, amylase (p<0.001), C-reactive protein (CRP) (p=0.002) and D-dimer (p=0.004) levels were found higher. In addition, more patients required the treatment in intensive care unit in the high lipase group, compared to the controls (p=0.027). Accordingly, time of hospital stay became also prolonged (p=0.003).
Conclusions : Pancreatic injuries or even AP may develop during SARS-CoV-2 infection, especially in those with pre-existing DM. Monitoring of pancreatic enzymes is important in COVID-19 patients, especially with pre-existing DM. (Acta gastroenterol. belg., 2020, 83, 585-592).
Variability of contrast enhancement of pancreas on computed tomography in patients with acute pancreatitis and isolated extrapancreatic necrosis
Background and study aim : To evaluate the variability in the enhancement of pancreas on computed tomography (CT) in patients with acute pancreatitis (AP) and isolated extrapancreatic necrosis (EPN) and to investigate whether it affects the extrapancreatic findings and patient outcomes.
Patients and methods : This retrospective study comprised of consecutive patients with isolated EPN evaluated between April 2017 and April 2019. A radiologist measured the pancreatic attenuation values (PAV) of head, body, and tail on a contrast enhanced CT. Using a cut-off PAV of 100HU, patients were divided into two groups. The extrapancreatic CT findings and outcome parameters were compared between the two groups.
Results : Thirty patients (mean age, 42.13 years, 17 males) with isolated EPN were evaluated. The mean PAV in the head, body, and tail was 83.13 HU (range, 59-161), 84.17 HU (range, 60-160), and 82.23 HU (range, 53-137). The overall mean PAV was 83.12 HU (range, 58-152). There were six patients with overall mean PAV≥100 HU. The group with PAV≥100 HU had a higher number of patients with infected necrosis (66.6% vs. 14.2%, P=0.018). PAV had a significant association with length of hospitalization (P=0.045).
Conclusion : There is significant variability in the pancreatic enhancement on CT among patients with AP and isolated EPN. Patients with PAV≥100 HU had a significantly longer hospital stay. This, however, may be related to a greater number of patients with infected necrosis in this group. (Acta gastroenterol. belg., 2020, 83, 593-597).
Keywords : acute pancreatitis, computed to
Risk factors for post-ERCP pancreatitis : it depends on the ERCP indication
Background and aims : Endoscopic retrograde cholangiopan- creatography (ERCP) is an invasive modality, and has a high risk of causing post-ERCP pancreatitis (PEP). Risk factors of PEP have been investigated and conflicting results are present for most risk factors. The aim of this study was to evaluate the risk factors for PEP and to determine whether the risk factors differ due to the ERCP indication.
Patients and methods : A retrospective study was conducted which included 666 patients with 968 ERCP procedures. Some risk factors were evaluated for PEP, and they were also evaluated separately for patients with bile duct stones and patients who underwent ERCP for other reasons than bile duct stones.
Results : In patients with bile duct stones detected on ERCP ; female gender, lower diameter of the common bile duct, placing a biliary plastic stent and not having a cholecystectomy history were risk factors for PEP, whereas in patients without bile duct stones the only risk factor for PEP was not having a prior endoscopic sphincterotomy.
Conclusions : Our study revealed that PEP risk factors depend on the indication of ERCP. To the best of our knowledge our study is the first study defining cholecystectomy as a protective factor for PEP in patients with bile duct stones and endoscopic sphincterotomy history as a protective factor for PEP in patients without bile duct stones. Our study also showed that female gender, lower diameter of the common bile duct and placing a plastic biliary stent were risk factors for PEP in patients with bile duct stones. (Acta gastroenterol. belg., 2020, 83, 598-602).