Volume 79 - 2016 - Fasc.4 - Original articles
The predictive value of negative capsule endoscopy for the indication of Obscure Gastrointestinal Bleeding: no reassurance in the long term.
Background and aims : Capsule Endoscopy (CE) has become the first-line tool to identify an underlying etiology for Obscure Gastrointestinal Bleeding (OGIB) in the small bowel (SB). This study aims to investigate the long-term outcome of patients with a negative CE.
Patients and methods : Retrospective review of standardized application forms of all patients who underwent CE for OGIB at the Ghent University Hospital between 2002 and 2013. Follow-up data on patients with a negative CE result (n=263) were collected by contacting the referring physician.
Results : Follow-up was available for 211 patients (Male, n=107 ; Female, n=104 ; Overt bleeding, n=76 ; Occult bleeding, n=135). Median follow-up time was 51.7 months (range 1.4-139.6 months). Ninety-six patients underwent further diagnostics, showing a cause for OGIB in 57 (59.4%). Final outcome for the complete cohort of negative CEs was : 139 (65.9%) true negative (i.e. non-SB cause of bleeding/ resolved OGIB), 19 (9%) false negative (i.e. SB cause of OGIB) and 53 (25.1%) ongoing bleeding without cause. Missed SB lesions were : angiodysplasia (n=11), Meckel's diverticulum (n=3), SB malignancy (n=3), jejunal erosions (n=1) and NSAID-induced SB ulcerations (n=1). Bleeding resolved in 138/209 patients (66%) of which 79 underwent non-specific therapy.
Conclusions : Negative CEs in patients with OGIB do not reas- sure the treating physician, but warrant close monitoring. In sus- picious cases, alternative diagnostic modalities are recommended, showing a high diagnostic yield. (Acta gastroenterol. belg., 2016, 79, 405-413).
Does calcium score in great pelvic vessels predict colorectal anastomotic leakage? A prospective study of one hundred anastomoses
Background and study aims : Anastomotic leakage is one of the most severe surgical complications following surgery. This prospective study was designed to investigate an association between the calcification in the descending aorta and its major branches using a calcium-scoring software and colorectal anastomotic leakage.
Patients and methods : From January 2012 to March 2013, one hundred patients underwent surgeries involving colorectal anastomosis procedures. Calcium score in descending aorta and great pelvic vessels was measured using the Syngo-CT 2006G-W software. A questionnaire was completed containing demographic and underlying risk factors suspicious to be associated with anastomotic leakage, in addition to surgical characteristics data.
Results : 55 males and 45 females entered the study with the mean age of 63.70±7.17 years. The average duration time of surgery was 149.30±20.24 minutes. The type of surgery was elective for 90 patients and emergency for 10 others. The mean calcium score was higher in greater arteries as in abdominal aorta and common iliac arteries in comparison to the other pelvic vessels. Comparing two groups of patients with and without anastomotic leakage, the calcium score was higher in descending aorta and all great pelvic vessels of patients with colorectal anastomotic leakage (P<0.001). One patient (1%) died due to postoperative anastomotic leakage two weeks after the surgery.
Conclusions : Atherosclerotic calcification in the descending aorta and its major branches can be considered as a risk factor in the development of colorectal anastomotic leakage. (Acta gastroenterol. belg., 2016, 79, 415-420).
First results of the Flemish colorectal cancer screening program : start-up- period late 2013
Background & study aims : Investigation of the first participa- tion rate and follow-up results of the Flemish colorectal cancer screening program.
Patients & methods : In 2013 five age cohorts with an even age between 66 and 74 year old (n=243 335) were invited by mail to return a completed iFOBT. Participants who tested positive (=75ng/ml) were referred to a follow-up colonoscopy.
Results : Participation rate was 48.4% (n=117 774). Overall positivity rate was 10.1%, and 78.1% of those tested positive underwent a colonoscopy. The positive predictive value of colo- noscopy for CRC was 8.2%, for advanced adenoma 16.9% and for non-advanced adenoma 36.5%.
Conclusion : Based on the EU-guidelines 35% was expected as participation for a first screening round, thus a participation rate of 48.4% is more than acceptable for a first screening year. The high positivity rate can partly be explained by including only the older ages in the start-up-period and by the first year of mass screening in Flanders. (Acta gastroenterol. belg., 2016, 79, 421-428).
Role of Heart Rate Variability in Predicting Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis
Introduction : Early recognition of post-ERCP pancreatitis (PEP) would help deliver an appropriate discharge plan following ERCP. Functioning of the autonomic nervous system can be measured using non-invasive heart rate variability techniques (HRV) and provides quantitative information about the modulation of cardiac vagal and sympathetic activity. Pain evoked sympathetic activation is a well-known phenomenon, as exhibited in those suffering PEP. The aim of this study is to determine if a single post-procedural measurement of HRV identifies those at risk of developing PEP.
Methods : A prospective, observational, single-centre cohort study was performed including all patients undergoing either diagnostic or therapeutic ERCP. In addition to standard monitoring electrocardiographic (ECG) signals 4 hours post- ERCP were recorded using a digital ECG.
Results : A Total of 115 patients were enrolled over 11 months. PEP occurred in 12 (10.4%) patients. The low frequency (LF)/ high frequency (HF) ratio on HRV was significantly higher in those suffering PEP (median LF/HF 2.58 vs 2.10, p<0.001). It is possible to identify patients at high risk of PEP through HRV analysis where the LF/HF ratio is found to exceed 2.43, with an AUC of 0.827 and combined sensitivity of 83.3 % and specificity of 81.6 % (PPV 42%, NPV 97%).
Conclusions : In this first study of HRV analysis in those undergoing ERCP the index of sympathovagal balance (LF/HF) predicted PEP independently of other risk factors. This could lead to the use of post procedural HRV to identify patients suitable for early discharge following ERCP. (Acta gastroenterol. belg., 2016, 79, 429-434).
Diverticulitis in the Young Population: Reconsidering Conventional Recommendations
Background : In the past diverticulitis was believed to be uncommon in the young population. However, there is growing concern suggesting that these patients develop more severe clinical symptoms and may require more frequent intervention.
Methods : We performed a retrospective chart review of patients with diverticulitis in individuals with age less than 40 years over an 8 year period (2007-2015). Diagnosis was confirmed with a CT scan. In addition to age we took into consideration race, gender, anemia (hematocrit< 41), leukocytosis (WBC > 12), BMI and whether it was an initial episode or recurrence. Our outcome variables were complications (abscess, fistula, and perforation, results of colonoscopy (polyps or colon cancer)) and whether the patient required surgery.
Results : We identified 123 patients who were less than 40 years old with the diagnosis of diverticulitis. There was greater than a 3:1 ratio of males to females (77% males and 23% females) with an average age of 32.6 year. The race of the patients was nearly entirely Hispanic (88.6%). With regards to the outcome variables, 18.7% had abscesses as a complication. Perforations were observed in 26% of the patients, of which one was complicated by a fistula. A total of 25 (20%) patients went to surgery. Of these, 21 had an abscess, perforation, or tubular adenomatous polyps (TAP). Follow-up colonoscopy post-diverticulitis results were available for 42 patients. Of those patients, 9 had hyperplastic polyps and 3 had TAP. The remaining 30 patients had no polyps. No colon cancer or villous polyps were found in the entire cohort.
Conclusion : Our study highlights that young patients who have an index case of uncomplicated diverticulitis with no other risk factors or complications may not gain further benefit from routine colonoscopy as once traditionally thought. (Acta gastroenterol. belg., 2016, 79, 435-439).
Analysis of 15 patients with abnormal liver function as the first systemic lupus erythematosus symptom
Objective : To understand the clinical characteristics of patients with abnormal liver function as the first symptom of systemic lupus erythematosus (SLE).
Methods : Here, 15 patients admitted to a hospital from January 2010 to December 2013 with initial presentation of lupus- related hepatitis or cirrhosis were included. Their SLE-DAI scores and clinical and laboratory data were collected. All cases received liver protection therapy and active SLE controlling treatment with methylprednisolone combined with rapamycin.
Results : When hepatic abnormalities were the most prominent feature during the first visit, the patient was more likely to receive an incorrect diagnosis or be diagnosed with SLE late. Of the 15 cases, only 7 (46.7%) were identified as SLE within a week of presentation of abnormal liver function ; meanwhile, the 7 remaining patients (46.7%) were not correctly diagnosed until more than 2 weeks later and as late as 4 months ; in addition, 1 patient was not diagnosed with SLE until 8 years after the initial presentation of abnormal liver function. In the 3-month follow-up after active treatment, liver function was completely restored in 10 cases with no cirrhosis and significantly improved in 3 patients who still had cirrhosis. Another case showed no improvement in liver function and was self-discharged, and another died from chronic liver failure.
Conclusion : Liver injury caused by SLE is not uncommon, and it is easy to tentatively diagnose it as hepatitis, delaying the correct diagnosis of SLE. In such patients, physicians should perform a thorough differential diagnosis as soon as possible and administer proper treatment. Corticosteroid conjugated with immunosuppressants with no or little liver toxicity would be suitable for patients with SLE-induced liver injury. (Acta gastroenterol. belg., 2016, 79, 441-446).
Impact of gluten-free diet on quality of life in celiac patients.
Background and study aims : Celiac disease (CD) is a common gluten-related disorder, whose only treatment is a gluten-free diet (GFD). Since a unique view on psychological consequences of a GFD still lacks, our aim was to assess the quality of life (QoL) and the depression state in symptomatic CD patients after GFD. Socio- demographic features were considered.
Patients and methods : 210 adult CD patients were recruited and divided into 3 groups : 70 newly diagnosed patients (Group A),70 patients who have been on GFD for 6-12 months (Group B), and 70 patients who have been on GFD for more than 12 months (Group C). We recruited 210 healthy controls (Group D). Psychological General Well-Being Index (PGWBI) and Beck Depression Inventory (BDI) questionnaires were administered. Each group was evaluated according to age, gender and school ranking.
Results : Groups A and B showed lower PGWBI scores compared with both Group C and D (p <0.001 for each comparison). Moreover, Groups A and B showed higher BDI scores compared with both Group C and D (p <0.001 for each comparison). Women, the elderly and the poorly educated seemed to suffer more psychological stress.
Conclusions : GFD induces an improvement of well-being and a decrease of depression state after 12 months of strict GFD. Negative psychological implications were observed only in specific risk categories. (Acta gastroenterol. belg., 2016, 79, 447-453).
Diagnosis accuracy of ALT and waist circumference as a screening test for insu- lin resistance
ALT and waist circumference are both correlated to insulin resistance (IR).
Objective : To determine whether ALT provides information in addition to waist circumference for identifying IR.
Methods : IR was defined by HOMA-IR index =3. In this Europid population, a waist circumference =80 cm in women and =94 cm in men was considered excessive. Elevated ALT was defined using either the usual cut-off or updated cut-offs of 19 U/l in women and 30 U/l in men.
Results : 288 participants without medication affecting insulin concentration were included. 81 (28%) were insulin resistant, 30 (10%) and 98 (34%) had increased ALT using usual and updated cut-offs, respectively, and 218 (76%) had excessive waist circumference. Among subjects with normal waist circumference, IR was as frequent in participants with normal ALT as in those with increased ALT. Among subjects with excessive waist circumference, IR was less frequent in participants with normal ALT according to the usual cut-off (31% vs. 56%, p=0.01), and tended to be less frequent in participants with normal ALT according to updated cut-offs (29% vs. 41%, p=0.07) than in those with increased ALT.
Conclusion : ALT is useful for identifying IR only if waist circumference is excessive. In subjects with excessive waist circumference, IR is present in more than 40% in women with ALT >19 U/l and in men with ALT >30 U/l, and in more than 50% in individuals with ALT >45 U/l. (Acta gastroenterol. belg., 2016, 79, 455-462).