Volume 79 - 2016 - Fasc.3 - Original articles
Conscious sedation : clues for diagnosing obstructive sleep apnea syndrome
Background and aims: The use of anesthetic agents for endoscopic sedation has recently increased. However, sedation introduces additional risks in patients with obstructive sleep apnea syndrome (OSAS). The presence of sleep apnea is not often enough questioned in clinical practice. The purpose of this study was to determine whether patients with sedation-induced snoring and decreased arterial oxygen saturation during gastroscopy are more likely to have OSAS.
Methods: This study considered 600 consecutive patients undergoing elective outpatient upper gastrointestinal endoscopy under conscious sedation for evaluation of dyspepsia. Ten patients with observed snoring and decreased arterial saturation during the gastroscopy procedure were enrolled in the study. The control group was comprised of 13 patients matched by sex, age, and body mass index (BMI) who did not snore and had a more stable oxygen saturation under conscious sedation during an elective outpatient gastroscopy for the evaluation of dyspepsia and were selected using a computer-generated randomized sequence. Patients were monitored and an overnight polysomnography was performed in the study group. Statistically significant differences between groups were assessed using the nonparametric Wilcoxon and independent-samples t-tests.
Results: There was no significant difference in age or BMI between the two groups (p>0,05)
Predictive value of neutrophiltolymphocyte ratio in the severity of non-alcoholic fatty liver disease among type 2 diabetes patients
Background: Non-alcoholic fatty liver disease is a progressive inflammatory disease that ultimately results in cirrhosis and liver failure. It is assosiciated with two step hit scenario; the first step is fat accumulationin liver and in the second step inflammation and fibrosis are the major compenents. The incidence of this disease is increasing worldwide, following rising incidences of obesity and diabetes mellitus.
Aims: The aim of this study is to analyze the relationship between non-alcoholic fatty liver disease andseverity and neutrophil- to-lymphocyte ratio among the patients having type 2 diabetes mellitus.
Methods: This study involved 143 patients with type 2 diabetes who were placed into four groups (grade 0, 1, 2, 3) based on steatosis level due to blinded ultrasonographic evaluation. Biochemical parameters and counts of total white blood cells, neutrophils, and lymphocytes were determined. Neutrophil-to- lymphocyte ratio was compared across the four patient groups.
Results: Levels of hemoglobin A1c, creatinine, alanine aminotransferase, high-density lipoprotein cholesterol and triglycerides were significantly different between the four patient groups (ANOVA p-values: p <0.001, p=0.011, p=0.002, p=0.034, p=0.002, respectively). Counts of white blood cells, neutrophils, lymphocytes, and neutrophil-to-lymphocyte ratio significantly differed between the groups (p <0.001). Neutrophil-to-lymphocyte ratio was positively correlated with steatosis grade (p < 0.001).
Conclusions: Neutrophil-to-lymphocyte ratio increases with increasing grade of non-alcoholic fatty liver disease in patients with type 2 diabetes, and may be a convenient marker to follow progression of non-alcoholic fatty liver disease. (Acta gastroenterol. belg., 2016, 79, 295-300).
Adult intussusception: 10-year experience in two Belgian centres
Background: adult intussusception is a rare entity with a different clinical presentation and aetiology than in children. Objective: To provide a comprehensive overview of the clinical presentation, aetiology, diagnosis and management of adult intussusception
Methods: We review 43 cases with a preoperative diagnosis of symptomatic gastrointestinal adult intussusception.
Results: In 67% of the cases an underlying lead point was discovered. Most intussusceptions were of the enteric type (65%) with a predominant benign or idiopathic origin. Malignancy was present in half of the cases with a colonic lead point. CT was the preferred imaging technique (81%) with a sensitivity of 94%. Colonoscopy provided the correct diagnosis in 89% of the cases involving a colonic lead point. Surgical intervention occurred in 72% of the cases.
Conclusion: The combination of low incidence and non-specific symptoms makes intussusception in the adult difficult to diagnose. Modern imaging techniques often provide the correct preoperative diagnosis. A culprit lesion is usually identified after a careful search. Suspicion for a malignant lead point should be high in case of colonic involvement and colonoscopy can be of added value in these cases. The therapeutic strategy depends on several variables and requires for a patient-tailored approach mostly involving surgery. (Acta gastroenterol. belg., 2016, 79, 301-308).
DKK1 in relation to HCV induced liver cirrhosis and HCV induced HCC curative resection
Background: hepatitis C virus (HCV) is an RNA virus that induces hepatocarcinogenesis by mechanisms other than integration in the host cell genome. Dickkopf-1 (DKK1) expression has been studied mostly in hepatitis B virus induced HCC but not properly investigated in HCV induced HCC.
Aim: we aimed to assess serum DKK1 in HCV induced HCC, HCV induced liver cirrhosis and viral infection-free controls. Moreover, we assessed serum DKK1 level after curative resection of HCC.
Methods: Serum DKK1 was measured by ELISA in 20 HCV induced HCC patients; both pre-resection and post-resection, 20 HCV induced liver cirrhosis patients and 20 viral infection-free controls.
Results: DKK1 levels were significantly higher in HCC than cirrhosis patients (P = 0.000). DKK1 did not differ significantly between cirrhotic patients and controls (P = 0.11). DKK1 levels significantly reduced 5 days post-resection compared to their pre- resection levels (P = 0.000).
Conclusion: We documented serum DKK1 as a marker for detection of early HCC in HCV infected patients. Significant reduction of DKK1 5 days after curative resection might indicated it as a follow up marker for recurrence in surgically resected HCV induced HCC patients. Larger scale studies to follow up its level at various intervals postoperatively and evaluate its pre-resection level as a prognostic marker in HCV induced HCC patients will be needed. (Acta gastroenterol. belg., 2016, 79, 309-313).
Optimization of steroid injection intervals for prevention of stricture after esoph- ageal endoscopic submucosal dissection: A randomized controlled trial
Background and study aims: Esophageal endoscopic submucosal dissection enables en bloc resection of large superficial esophageal cancer; however, this procedure may induce severe stricture. Intralesional steroid injection is an effective treatment for prevention of stricture after endoscopic resection; however, there have been no studies assessing the duration of such treatment. The aim of this study was to reduce treatment duration and to evaluate the effectiveness of weekly and biweekly steroid injections in preventing esophageal stricture after endoscopic resection.
Patients and methods: We performed a randomized controlled trial comparing patients receiving weekly or biweekly intralesional triamcinolone injections. Patients with a mucosal defect greater than 75% (3/4) of the luminal circumference after esophageal endoscopic submucosal dissection for superficial esophageal cancers were enrolled. The primary endpoint was the duration of steroid injection treatment.
Results: The median duration of treatment was 37.0 days in the weekly group and 34.2 days in the biweekly group (P = 0.059). Among patients with a mucosal defect larger than 50 mm, there was a significant difference in the median duration of treatment between the weekly and biweekly groups (42.5 days vs 29.0 days, P = 0.013).
Conclusions: Biweekly steroid injection of triamcinolone reduces treatment duration, particularly in those with mucosal defects larger than 50 mm. (Acta gastroenterol. belg., 2016, 79, 315-320).
Clinical characteristics and management of insulin-producing neuroendocrine carcinomas
Background and study aims: Due to rarity of insulin-producing pancreatic neuroendocrine carcinomas, no large, nor randomized studies of the clinical course, treatment options and outcome are available. Therefore, we want to share our personal experience and we retrospectively reviewed a cohort of five patients.
Patients and methods: This study reports on the clinical characteristics, disease course, management and outcome of five patients with an advanced pancreatic neuroendocrine carcinoma with insulin production, which we followed recently in our center (between 2006 and 2015). Extraordinary for our cohort is that, except for one patient, which was diagnosed with a de novo malignant insulinoma, all other patients were diagnosed with a non-functional pancreatic neuroendocrine tumor which evolved during the disease course to a malignant insulinoma.
Results: Although various treatment strategies, both surgical and medical, are used to prolong survival and prevent hypoglycemic events, long-term prognosis of these patients remains poor, especially after transformation of a non-functional pancreatic neuroendocrine tumor to an insulin-producing neuroendocrine carcinoma. Of all five patients, only one is still alive, the other four died 25, 17, 3 and 1 month(s) after diagnosis of the malignant insulinoma. In general, prognosis is determined by early diagnosis and treatment, and by resectability of the tumor and its biological behavior.
Conclusions: Management of a malignant insulinoma is very challenging and a better understanding of the underlying mechanisms of this disease entity and its biological behavior is absolutely necessary to improve diagnostic tools, treatment and outcome in the future. (Acta gastroenterol. belg., 2016, 79, 321-327).
Long term efficacy of pegylated ınterferone in the treatment of delta hepatitis: a single center experience
Background and aims: Currently there is no satisfactory treatment of chronic HDV. We aimed to evaluate the long term efficacy of PEG-interferones.
Patients and Methods: Patients who received PEG-interferone for chronic delta hepatitis during a 7-year period were retrospectively analysed. End of treatment response, virologic response at 6 months after treatment, and long term efficacy were evaluated. Predictors of treatment response were determined.
Results: The study group consisted of 31 patients. Twenty-three patients received either PEG-interferone alfa-2a (n=8) or PEG- interferone alfa-2b (n=15) for at least 48 weeks. Thirteen patients had an end of treatment virologic response (ITT:56.5%, PP:68.4%). HDV RNA negativity after 6 months off PEG-interferone treatment was achieved in 12 patients (ITT:52.1%, PP:63.1%). The patients were followed for a median duration of 36 months after PEG-interferone treatment (min-max:12-120 months). Four patients (33.3%) relapsed during the follow-up. Sustained virologic response (ITT) was 34.8% in the long term. Undetectable HDV RNA level at week 24 of treatment and biochemical response were independent predictors of end of treatment response and sustained virologic response in the long term, respectively.
Conclusion: PEG-interferones have an unsatisfactory efficacy on the treatment of HDV because of a considerable relapse in the long term. (Acta gastroenterol. belg., 2016, 79, 329-335).