Volume 84 - 2021 - Fasc.1 - Original articles
High- versus low-dose proton pump inhibitors post endoscopic hemostasis in hemodialysis cases with peptic ulcer bleeding
Post-endoscopic hemostasis treatment is not adequately addressed in high-risk patients on regular hemodialysis (HD) with emergency peptic ulcer bleeding. This study aimed to compare post-endoscopic high- versus low-dose proton pump inhibitors (PPIs) for peptic ulcer bleeding in patients undergoing regular HD.
This prospective study comprised 200 patients on regular hemodialysis having emergency peptic ulcer bleeding confirmed at endoscopy and managed with endoscopic hemostasis. Half of the
patients received high-dose intensive regimen and the other half received the standard regimen. Patients who were suspected to have recurrent bleeding underwent a second endoscopy for bleeding
control. The primary outcome measure was rate of recurrent bleeding during period of hospitalization that was detected through second endoscopy.
Rebleeding occurred in 32 patients ; 15 in the High-Dose Cohort and 17 in the Low-Dose Control (p = 0.700). No significant differences between the two dose cohorts regarding the time of rebleeding (p = 0.243), endoscopic hemostasis mode (p = 1.000), and need for surgery (p = 0.306). The highdose regimen Inhospital mortality in high-dose group was 9.0% compared to 8.0% in the low-dose group (p = 0.800). Apart from the pre-hemostatic Forrest classification of ulcers, there were no significant differences between patients with re-bleeding ulcers (n=32) and those with non-rebleeding (n=168). Rebleeding was more common in class Ia, i.e. spurting bleeders (p < 0.001).
Endoscopic hemostasis followed by the standard low-dose PPI regimen of 40 mg daily IV boluses is safe and effective option for bleeding peptic ulcers in the high-risk patients under regular hemodialysis.
Role of endoscopy in suspicion of atrophic gastritis with and without intestinal metaplasia in comparison to histopathology
Background and study aims: Atrophic gastritis (AG) and intestinal metaplasia (IM) are established premalignant gastric lesions. Many studies documented a poor correlation between esophagogastroduodenoscopy (EGD) and histopathological (HP) findings of precancerous gastric lesions. The aim was to bridge the gap between endoscopy and HP in detection of chronic gastritis,
AG and IM.
Patients and methods: a prospective single-center study involved 150 patients with endoscopic criteria of gastric lesions with upper gastrointestinal symptoms referred for upper GI endoscopy met the endoscopic criteria and classified according to HP of biopsies from targeted gastric lesions into chronic gastritis (GI), AG(GII) or IM(GI II). We correlated the endoscopic criteria of the 3 groups
with the HP results.
Results: (73males & 75 females) with ages ranged17-75 years and mean± SD was 41.96 ± 15.95. GI, GII &GIII were [42 patients (28%),82 patients (54.7%) and 26 patients (17.3%)], respectively. Diffuse gastric mottling was more common in GI (74.3%, P<0.001), visible submucosal vessels, gastric atrophy predominated in GII (75.6, 82.3 & 73.1% (P 0.005,0.4 & <0.01)), respectively. Whitish raised lesions were more specific in GIII (85.7%) (P<0.001). The sensitivity and specificity of endoscopic suspicion of chronic gastritis were (86&88% in GI), (87&85% in GII) and (54% &100% in GIII) (p-0.001). The logistic regression model for risk factors was χ2= 25.74 and 49.32, p < 0.001.
Conclusion: Conventional endoscopy has high sensitivity and specificity for suspicion of chronic gastritis and AG, but low sensitivity and very high specificity for IM. Targeted biopsies may be valuable with image enhanced techniques.
Impact of antithrombotics on the fecal immunochemical test for colorectal cancer screening : a multi-center Belgian experience
Background: Impact of antithrombotics on the fecal immunochemical test (FIT) for colorectal cancer (CRC) screening remains unclear.
Methods: Patients undergoing colonoscopy for positive FIT in 2015 were assessed at 3 Belgian centers. Significant findings were advanced polyps (AP) (sessile serrated, tubular or villous adenomas
>1cm or high-grade dysplasia) and CRC. False positive FIT and detection of AP/CRC with antithrombotics were calculated.
Results: 510 patients (64% male, median (IQR) age 63.2 (60.2 - 66.4) years) were included. Colorectal pathology in 371/510 (73%) was associated with male gender (70% vs. 48% ; p= .0001) and family history (16% vs. 8% ; p= .02). Antithrombotics in 125/510 (25%) were associated with male gender (78% vs. 59% ; p= .0001), older age (65.2 (62.2-70.3) vs. 62.3 (58.7-66.3) years ; p= .0001) and GI-symptoms (18% vs. 11% ; p= .04). False positive FIT (25% vs. 28% ; p= .52) and detection of AP (42% vs. 36% ; p=.27) or CRC (6% vs. 5% ; p= .69) were similar in patients with vs. no antithrombotics. Use of antithrombotics did not predict a higher chance of colorectal pathology after adjusting for confounders.
Conclusion: Although antithrombotics were prescribed more frequently in male and older patients, detection of AP/CRC was similar. Despite increased GI symptoms, false positive FIT was similar with antithrombotics.
Risk of hepatocellular carcinoma and fibrosis evolution in hepatitis C patients with severe fibrosis or cirrhosis treated with direct acting antiviral agents
Background and study aims: Cirrhosis associated to chronic
hepatitis C virus (HCV) is one of the leading cause of hepatocellular
carcinoma (HCC). The goal of our study was to evaluate first the
risk and determinants of HCC and second the evolution of fibrosis
in patients treated for HCV with advanced fibrosis stages who
achieved sustained virological response (SVR) after direct-acting
antivirals (DAA) treatment.
Patients and methods: We conducted a prospective study on HCV patients with F3 or F4 Metavir fibrosis scores treated with DAA between October 2014 and February 2017. The annual incidence rate for HCC was calculated. We used Cox regression model in order to identify factors associated with HCC. Transient elastography (TE) was performed 12 and 24 months after the end of DAA treatment and non-invasive liver fibrosis biomarkers were performed twice a year during follow-up.
Results: 143 patients with severe fibrosis or cirrhosis were enrolled in the study. 6 patients developed HCC. The annual incidence rate of HCC in our cohort was 2.7 per 100 patients. Risk factors associated with HCC after DAA were genotype 2 and steatosis. Overall TE values significantly decreased after DAA treatment with a median value prior to treatment of 16.9 kPa to a median of 10.8 kPa 24 months after the end of the treatment. Biological fibrosis scores also significantly decreased following viral eradication.
Conclusions: DAA treatment does not seem to be associated with HCC promotion after HCV eradication in patients with severe fibrosis stages. DAA-induced SVR is associated with a reduced estimation of fibrosis.
Comorbidities and concomitant medications in patients with chronic hepatitis C virus infection receiving second-generation direct-acting antiviral regimens in Belgium : an observational study
Objective: To describe comorbidities and concomitant
medications in patients initiating treatment for hepatitis C virus
(HCV) infection with direct-acting antiviral (DAA) regimens in
Methods: This was a noninterventional, observational, multicenter
study of data from patient charts. Adult patients with HCV
infection receiving second-generation DAA therapy were included.
Comorbidities were assessed at the time of HCV treatment
initiation. Concomitant medications were recorded at the time of
diagnosis and at treatment initiation. Potential clinically relevant
drug-drug interactions (DDIs) were assessed based on information
available at www.hep-druginteractions.org. The primary objective
was to describe concomitant medication use ; secondary objectives
were to describe modifications in concomitant therapies and
Results: 405 patients were included. A total of 956 comorbidities
were reported by 362 patients (median, 2 ; range, 0-15). The
most common comorbidities were hypertension (27.2%) ; HIV
coinfection (22.5%), and type 2 diabetes mellitus (14.3%). Overall,
1455 concomitant medications were being taken by 365 patients
(90.1% ; median, 3 ; range 0-16). The most common concomitant
medications were psycholeptics (28.6%), antiviral agents (24.2%),
and medications for acid-related disorders (21.0%) Overall, 74/365
(20.3%) patients receiving a concomitant medication required
an adaptation to their concomitant medication. The medications
that most frequently required change were drugs for acid-related
disorders (n = 14) and antiviral drugs (n = 5) ; those that were most
frequently stopped were lipid-modifying drugs (n = 25) and drugs
for acid-related disorders (n = 13).
Conclusion: Physicians are aware of the potential for DDIs
with DAAs, but improved alignment between clinical practice and
theoretical recommendations is required.
Serum biomarkers as an alternative to vibration controlled transient elastography in liver fibrosis staging in chronic hepatitis C
Background: Assessment of liver disease severity in chronic Hepatitis C (CHC) is essential both in pretreatment and posttreatment period. We assessed the impact of direct-acting antiviral therapy on liver stiffness regression measured by Vibration Controlled Transient Elastography (VCTE) in patients with CHC and evaluated the diagnostic performance of the APRI and FIB-4 scores compared to VCTE in detecting advanced fibrosis and cirrhosis (F3/F4).
Methodology: Retrospective analysis of consecutive patients with CHC who underwent VCTE before and after DAA therapy was done. APRI and FIB-4 scores were compared to VCTE.
Results: 88 (56.78%) patients-12 (F3) and 76 (F4) according to VCTE, had advanced fibrosis pretreatment, which reduced to 69 (44.52%) - 10 (F3) and 59 (F4) after 12 weeks DAA therapy. Significant reduction in VCTE value from 14.08 ± 9.05 KPa to 11.84 ± 8.31 KPa (p=0.002) was noted. There is significant reduction in APRI, FIB-4 and GUCI score posttreatment which was not the case with Lok score and Bonacini score. Before therapy, FIB-4 outperformed others to predict advanced fibrosis with score >2.13 (AUC 0.93), having sensitivity 76%, specificity 96% and accuracy 86%. However posttreatment, APRI and GUCI score performed best to predict F3/F4 fibrosis with score >0.63 (AUC 0.97) and >0.64 (AUC 0.96), having sensitivity, specificity and accuracy of 85%, 96.6% and 92% ; 85%, 6.6% and 92% respectively.
Conclusion: Before therapy, FIB-4 had the best accuracy in predicting advanced fibrosis whereas APRI and GUCI score were the best indices post-treatment.
Platelet safety range before splenectomy for hypersplenism : based on 244 cases of splenectomy in hepatolenticular degeneration patients
Background and study aims: To investigate the safety and efficacy of splenectomy for hepatolenticular degeneration (HLD) patients with PLT less than 20 × 109/L.
Patients and methods: A total of 244 HLD patients with hypersplenism underwent splenectomy. According to the preoperative PLT values, the patients were divided into three groups : group A of 53 patients with PLT < 20 × 109/L ; group B of 92 patients with 20 × 109/L ≤ PLT ≤ 30 × 109/L ; group C of 99 patients with PLT > 30 × 109/L. General information including : blood cell counts, liver function , coagulation function 1 day before sugery and 1, 7, 14 days after surgery ; intraoperative blood loss ; operation time ; vital signs at the beginning, at 60 minutes and the end of the operation. Pressure and blood oxygen ; postoperative drainage ; postoperative complications and mortality.
Results: Blood cell counts, liver function, and coagulation function were improved after splenectomy in three groups (P<0.05) ; there was no significant difference in blood loss, operation time, vital signs during the operation, postoperative drainage, postoperative complications and mortality between three groups (P>0.05).
Conclusion: For HLD patients with hypersplenism, it is safe and effective to conduct splenectomy under PLT < 20 × 109/L.
Tolvaptan reduces the required amount of albumin infusion in patients with decompensated cirrhosis with uncontrolled ascites : a multicenter retrospective propensity score-matched cohort study
Background: The aim of this retrospective study was to determine whether tolvaptan treatment reduces the amount of albumin administered, volume of ascites removed, and frequency of paracentesis procedures in patients with decompensated cirrhosis with uncontrolled ascites with conventional diuretics.
Patients and methods: The control (C) group included patients treated with conventional diuretics. The tolvaptan (T) group included patients treated with both tolvaptan and conventional diuretics. Both groups were matched according to baseline parameters. The amount of albumin administered, volume of ascites removed, and frequency of paracentesis within 30 days of onset of uncontrolled ascites were compared between the two groups.
Results: After matching, 74 patients (C=37, T=37) were included. Baseline parameters (C vs. T group) were as follows: age, 69.5 ± 9.3 vs. 70.4 ± 11.0 years (p = 0.702) ; males, 24 (64.9%) vs. 25 (67.6%) (p = 0.999) ; patients with hepatocellular carcinoma, 17 (45.9%) vs. 18 (48.6%) (p = 0.999) ; serum albumin levels at treatment initiation, 2.76 ± 0.48 vs. 2.73 ± 0.49 g/dL (p = 0.773), and serum creatinine levels at treatment initiation, 1.18 ± 1.23 vs. 1.09 ± 0.48 g/dL (p = 0.679). In the C vs. T groups, respectively, mean amount of albumin administered was 51.0 ± 31.4 vs. 33.4 ± 29.8 g/month (p = 0.016) ; mean volume of ascites removed was 2,905 ± 4,921 vs. 1,824 ± 3,185 mL/month (p = 0.266) ; and mean frequency of paracentesis was 0.92 ± 1.46 vs. 0.89 ± 1.45 procedures (p = 0.937).
Conclusions: Tolvaptan reduced the use of albumin infusion in patients with decompensated cirrhosis and was effective and acceptable for uncontrolled ascites.
A change in the timing for starting systemic therapies for hepatocellular carcinoma : the comparison of sorafenib and lenvatinib as the first-line treatment
Aim: The aim of this retrospective multicenter study was to evaluate the differences in the timing for starting systemic therapies as the first-line treatment for hepatocellular carcinoma (HCC).
Methods: A total of 375 patients with HCC treated with sorafenib from May 2009 to March 2018 and 56 patients treated with lenvatinib from March 2018 to November 2018 at our affiliated hospitals were included in this study.
Results: The median ages of the sorafenib and lenvatinib groups were 71.0 (interquartile range [IQR]: 64.0-77.0) and 73.5 (IQR: 68.0 -80.0) years old, and 300 (80.0%) and 42 (75.0%) patients were men, respectively. The Barcelona Clinic Liver Cancer stage was early, intermediate and advanced in 39 patients (10.4%), 133 patients (35.5%) and 203 patients (54.1%) in the sorafenib group and 1 patient (1.8%), 17 patients (30.4%) and 38 patients (67.9%) in the lenvatinib group, respectively. In the analysis of intermediate HCC, patients who satisfied the criteria of TACE failure/refractoriness (P=0.017), those with ALBI grade 1 (P=0.040), and those with a serum AFP level < 200 ng/ml (P=0.027) were found more frequently in the lenvatinib group than in the sorafenib group, with statistical significance. The objective response rate (ORR) of lenvatinib was 34.8% in the overall patients and 46.7% in the intermediate-stage HCC patients, which was significantly higher than sorafenib (P=0.001, P=0.017).
Conclusions: The emergence of lenvatinib has encouraged physicians to start systemic chemotherapy earlier in intermediatestage HCC patients.
Current ERCP practice in Belgium: the BSGIE survey
Background and study aims: Data on procedural outcome and quality of endoscopic retrograde cholangiopancreatography (ERCP) in Belgian practice are scarce. The aim of this study is to assess current status of ERCP-performance in Belgium.
Methods: National multi-institutional survey (online questionnaire) among members of the Belgian Society of Gastrointestinal Endoscopy (BSGIE), conducted in the period June-August 2018. The RIZIV/INAMI provided real-life data on the total number of ERCPs performed in Belgium.
Results: Forty-five responders completed the survey (for 43 centers performing ERCP), providing information for 8368 ERCPs performed in 45% (43/95) of institutions performing ERCP in Belgium. Fifty-eight percent of centers performed > 100 ERCPs/year and 7% of centers (n=3) performed < 50 ERCPs/year. According to the RIZIV/INAMI data, low case-volume centers are underrepresented in this survey. The most common ERCPindication was stone extraction (52%). 74% of endoscopists had more than 10 years of experience in performing ERCP. The majority of centers had their own written protocol (84%) for microbiological duodenoscope surveillance. Monitoring of cannulation rate and post-ERCP pancreatitis (PEP) was only performed in a minority of centers (30%). The majority of centers (76%) provided verbal informed consent relating to the ERCP-procedure ; a minority also requested a written informed consent (23%). 65% of centers systematically use NSAIDs for PEP prophylaxis.
Conclusion: This is the first survey of ERCP performance in Belgium. There were wide variations in practice. Adherence to key performance measures and measurement and evaluation of ERCP performance in daily practice at center and endoscopist level are not uniformly widespread.