Home » AGEB Journal » Issues » Volume 85 » Fasc.3 - Original articles

Volume 85 - 2022 - Fasc.3 - Original articles

The impact of rifaximin on the hospital burden and infections in patients with hepatic encephalopathy: a retrospective observational study

Background and study aims: Advanced liver disease frequently culminates in hepatic encephalopathy (HE), which can be classified as covert or overt HE, with subtle or clinically obvious changes respectively. 30-40% of patients with cirrhosis develop overt HE, which negatively affects the patients’ quality of life. Next to lactulose, rifaximin-a has been prescribed as a second line therapy to treat and reduce the risk of recurrence of overt HE. In this study, we aimed to evaluate the effect of rifaximin-a therapy, both on the number of occurring infections and on the evolution in hospital admissions of patients with overt HE. Patients and methods: A total of 66 cirrhotic patients, treated for at least 6 months with rifaximin-a at AZ Maria Middelares, between October 1st 2014 and January 1st 2020, were included in the study analysis. Medical records of all patients were evaluated over a period of 6 months prior and after initiation of rifaximin-a therapy. Results: Data analysis revealed that the included cirrhotic patients were severely ill, with a mean model for end-stage liver disease (MELD) score of 21, and a median Child Pugh score of 11. Among these patients, rifaximin-a treatment significantly downgraded the total number of infections, with a main effect on respiratory infections. Furthermore, rifaximin-a therapy led to a significant decrease in HE-related, as well as in other liver-related hospital admissions. Conclusions: This study confirms the potential value of rifaximin-a in reducing the number of developing infections and hospital admissions in a severely ill cirrhotic patient population.

Read more ->

Liver abscesses in the Western pediatric population

Background and study aims: Liver abscesses are rare in the Western pediatric population and data on predisposing factors and etiology are scarce. We aimed to describe predisposing factors, microbiological characteristics, and treatment. Patients and methods: Retrospective analysis of children admitted to two tertiary care hospitals in Belgium from 1 January 1996 to 31 December 2019. We analyzed clinical features, predisposing factors, imaging characteristics, microbiological data, treatment, and outcome in children with a liver abscess and compared these data with the literature. Results: We collected 24 cases with a male to female ratio of 1.4 and a median age of 3.2 years at time of diagnosis. Survival was 95.8%. Invasive culture specimens were obtained in 83.3% and showed growth of bacteria in 55%. Parenteral antibiotics were administered before invasive culture sampling in 80%. Liver abscesses were cryptogenic in four (16.7%) patients. Hepatobiliary disease was the most prevalent predisposing factor (n = 6; 25%), followed by recent antineoplastic therapy for malignancies (n = 5; 20.8%), intra-abdominal surgical pathology (n = 4; 16.7%) and umbilical venous catheters (n = 2; 8.3%). In two patients there was a parasitic origin (n = 2; 8.3%) and in one it was caused by Bartonellosis. There was no diagnosis of chronic granulomatous disease (CGD) in our cohort. Conclusions: Pediatric liver abscesses have a favorable outcome in the developed world. Whenever feasible, invasive abscess culture specimens should be obtained. In patients presenting with a cryptogenic liver abscess or atypical disease course, immunological workup should be ensured.

Read more ->

5-year mortality of alcohol-related cirrhosis: patients die just as much but not in the same manner

Background and study aim: Patients with alcohol-related cirrhosis have a poor short-term prognosis. We aimed to determine whether the 5-year mortality of alcohol-related cirrhosis has changed over the past two decades in our institution. Patients and methods: From January 1995 to December 2014, 932 cirrhotic patients who attended the hepatology outpatient’s clinics of our institution were consecutively listed in a registry. From this registry, 565 patients had alcohol-related cirrhosis and were the subject of this study. 16 patients were excluded because they were loss to follow-up and 114 patients were excluded because the diagnosis of cirrhosis was made more than 2 years before the inclusion in the registry. We separated the 435 remaining patients into two cohorts collected during two similar period of 10-year duration, but 10 years apart: the cohort 1, patients included in the registry from 1995 to 2004 (n = 206) and the cohort 2, patients included from 2005 to 2014 (n = 229). The 5-year mortality was assessed in both cohorts and the precipitating events leading to death were compared. Results: From the 206 patients in the cohort 1, 80 died within 5 years after the diagnosis of cirrhosis (Group A) compared to 83 patients from the 229 patients in the cohort 2 (Group B) (Cohort 1: 39 % vs Cohort 2: 36 %, p = 0.6). Patients in Group A died more often from gastrointestinal bleeding than patients in Group B (Group A: 30 % vs Group B: 9 %, p = 0.003). Patients in Group A died less by sepsis than patients in Group B (Group A: 1.5 % vs Group B: 14 %, p = 0.009). Conclusions: The 5-year mortality rate in patients with alcoholrelated cirrhosis has not changed however, the circumstances of death have changed.

Read more ->

The psoas muscle depletion index is related to the degree of cirrhosis and skeletal muscle loss in patients with end-stage liver disease

Objective: To establish a new psoas muscle depletion index (PDI) from healthy young donors and to explore the correlation between the PDI and the severity of cirrhosis in patients with endstage liver disease (ESLD). Methods: Clinical data of 461 healthy donors were collected during the period 2014-2019, and clinical data of 331 patients with ESLD were collected during the period 2014-2018. The patients were divided into four groups by PDI severity: PDI ≥ 0.90, PDI = 0.75-0.90, PDI = 0.50-0.75 and PDI ≤ 0.50 (Gsev). Differences in international normalised ratio (INR), total bilirubin and serum creatinine levels, and Child-Pugh (CP) and model for end-stage liver disease (MELD) scores were compared. The sarcopenia incidence according to the PDI and the psoas muscle index (PMI) in different weight groups were also compared. Results: Gsev had the highest CP (10.2 ± 2.1) and MELD (20.1 ± 7.4) scores and total bilirubin (166.3 ± 192.0 umol/L) and blood creatinine (92.9 ± 90.2 umol/L) levels and the lowest haemoglobin (93.8 ± 21.7 g/L) and blood albumin (30.9 ± 5.8 g/L) levels. Gsev showed significant changes in INR (1.74 ± 0.65) and blood sodium (135.3 ± 5.65 mmol/L). If PDI <0.75 was used as the diagnostic criterion for sarcopenia, the incidence was 53.3% in patients weighing >90 kg and 53.6% in those weighing <60 kg. This differed from the PMI, with an incidence of 3.3% in patients weighing >90 kg. Conclusions: The PDI had no significant correlation with body height, body weight or body mass index (BMI) in healthy individuals and patients with ESLD. The PDI was significantly correlated with the severity of cirrhosis and loss of skeletal muscle.

Read more ->

Wall maturation in necrotic collections in acute pancreatitis: a computed tomography based evaluation

Aim: To systematically investigate the timing of encapsulation of necrotic collections in acute necrotizing pancreatitis (ANP) using contrast-enhanced computed tomography (CECT). Methods: This retrospective study comprised consecutive patients of ANP who underwent CECT of the abdomen between the second and fourth weeks of illness. Number and site of collections and presence and completeness of the wall (defined as a thin smooth enhancing rim more than 1 mm in thickness) were documented. Results: A total of 195 patients of ANP were included. Seven hundred seventy-three collections were evaluated in 284 CECT scans. The most common site of the collection was anterior pararenal space (n=290, 37.5%). The mean maximum dimension of the collection was 8.1 cm (range, 3.1-16 cm). Two hundred twentytwo (28.7%) collections had a complete wall. The mean interval to complete wall maturation was 18 days (range, 8-28). Overall, 13.3%, 37.1%, and 56.2% of the collections showed complete encapsulation in the second, third, and fourth weeks, respectively. Conclusions: Our study suggests that a significant proportion of necrotic collections show complete encapsulation within 4 weeks of the onset of ANP.

Read more ->

Active breathing control guided stereotactic body ablative radiotherapy for management of liver metastases from colorectal cancer

Background: Liver metastases may occur during the course of several cancer types and may be associated with significant morbidity and mortality. There is paucity of data regarding the utility of Active Breathing Control (ABC) guided Stereotactic Ablative Body Radiotherapy (SABR) for management of Liver Metastases from Colorectal Cancer (LMCC). Our aim is to investigate the role of ABC guided SABR for management of liver metastases Patients and methods: 42 liver metastases of 29 patients treated with ABC guided SABR between February 2015 and October 2018 were retrospectively assessed for local control (LC), overall survival (OS), and toxicity outcomes. Primary endpoint was LC. Secondary endpoints were OS and treatment toxicity. Results: At a median follow up duration of 16 months (range: 9-74 months), median OS was 20 months and 3 patients were still alive at last follow up. 1-year OS was 83% and 2-year OS was 28%. LC rates were 92% and 61% at 1 and 2 years, respectively. Comparative analysis of Biological Effective Dose (BED) values revealed that higher BED10 values were associated with higher LC rates (p=0.007). While LC rates for BED10 = 100 Gray (Gy) were 94% and 86% at 1 and 2 years, corresponding LC rates for BED10 < 100 Gy were 89% and 36%, respectively with statistical significance (p=0.007). Assessment of acute and late toxicity outcomes revealed that most common toxicity was fatigue, however, no patients had = grade 3 toxicity. Conclusion: ABC guided SABR is an effective and safe treatment modality for LMCC management.

Read more ->

Characteristic endoscopic findings of gastrointestinal malignant lymphomas other than mucosa-associated lymphoid tissue lymphoma

Background and study aims: The gastrointestinal (GI) tract is the most common site of extra-nodal involvement for non-Hodgkin’s lymphoma (NHL). The features of GI NHLs remain unclear. The aim of this study was to clarify endoscopic characteristics of GI NHLs. Patients and methods: We retrospectively analyzed the morphological characteristics of 63 GI malignant lymphomas other than mucosa-associated lymphoid tissue lymphoma. Lesions were diagnosed between 2005 and 2020. Macroscopic findings were classified into five subtypes: superficial (S); protruding without ulcer (P); protruding with ulcer (PU); fungating (F); and multiple nodules (MN). Results: Thirty-one lesions in the stomach were classified as S type in 3 cases (9.6%), P type in 6 (19%), PU type in 13 (42%), and F type in 9 (29%). In the stomach, the ulcerated phenotype was more frequent for diffuse large B-cell lymphoma (DLBCL) (89.5%) than for other histological types (41.7%; P = 0.01). In the intestine, 23 tumors were classified as S type in 4 cases (17%), P type in 1 (4%), PU type in 6 (26%), F type in 1 (4%), and MN in 11 (48%). Eleven of the 14 cases (78.6%) of intestinal follicular lymphoma lesions showed MN type. In the colon, eight tumors were classified as S type in 2 cases (25%), P type in 2 (25%), PU type in 1 (13%), and F type in 3 (38%). Conclusion: We have clarified the endoscopic features of GI NHL using macroscopic classifications. The ulcerated phenotype was the most frequent endoscopic finding for DLBCL.

Read more ->

Monitoring endoscopic postoperative recurrence in Crohn’s disease after an ileocecal resection. Does capsule endoscopy have a role in the short and long term?

Background: Small bowel capsule endoscopy (SBCE) is a noninvasive method to detect endoscopic postoperative recurrence (POR) after an ileocolonic resection in Crohn’s Disease (CD). Few studies have evaluated the role of SBCE in the early POR (= 12 months). Data for detection of late POR (>12 months) and evaluation of treatment response in previous POR is scarce. We aimed to assess the SBCE performance in the three scenarios (early-POR, late-POR, and previous-POR) Methods: Retrospective 11-year cohort study of SBCE procedures performed on CD patients with ileocolonic resection. Disease activity by Rutgeerts score (RS), correlation with biomarkers, and therapeutic changes were recorded. Results: We included 113 SBCE procedures (34 early-POR, 44 late-POR, and 35 previous-POR). 105 procedures (92.9%) were complete and 97 SBCE (85.5%) were conclusive with no differences between groups. Relevant POR (RS ≥i2) was more frequent in the early-POR group compared to late-POR (58.8% vs 27.3%, p=0.02). In the previous-POR, RS improved in 43.5% of procedures, worsened in 26%, and remained unchanged in 30.5%. Fecal calprotectin (FCP) value of 100µg/g displayed the best accuracy: sensitivity 53.8%, specificity 78.8%, positive predictive value 66.7% and negative predictive value 68.4%. SBCE guided therapeutic changes in 43 patients (38%). No adverse events occurred in our cohort. Conclusion: SBCE is a safe and effective method to assess POR in the early and late setting in clinical practice, and for the evaluation of treatment response to previous POR. FCP is an accurate surrogate marker of POR and 100µg/g value had the best overall accuracy.

Read more ->

Niti-S Esophageal Covered stent (double anti-reflux type). An observational patient registry/post-market clinical follow-up study

Background: Relieving dysphagia is the main goal of palliative care in advanced esophageal cancer. We aimed to evaluate the safety and clinical performance of the Niti-S esophageal double covered, anti-reflux stent (Taewoong Medical, Seoul, Korea) in inoperable carcinoma of the esophagus or gastric cardia. Methods: This was a retrospective patient registry/post-market clinical follow-up study of all patients with esophageal malignant strictures undergoing self-expandable metal stent (SEMS) placement with the Niti-S Esophageal covered stent, double antireflux in a community hospital (AZ St Maarten Mechelen, Belgium) between March 2013 and July 2021. Results: In twenty-nine patients, thirty self-expandable metal stents (SEMS) were placed. The median dysphagia score before stent placement was 3 and 0 after stent placement (p < 0.001). Stent migration did not occur. Two patients (7%) had new onset reflux symptoms. The most common adverse event was retrosternal pain (5 patients, 17%). One patient (3%) had recurrent dysphagia due to proximal tumoral overgrowth and two patients (7%) because of proximal benign tissue overgrowth. There were no perforations, fistula formations or episodes of food impaction. Conclusion: The Niti-S esophageal double covered, antireflux stent (Taewoong Medical, Seoul, Korea) is an effective and safe treatment option for malignant esophageal stenosis.

Read more ->

How to track and register adverse events and incidents related to gastrointestinal endoscopy

Background and study aims: Gastrointestinal endoscopic procedures have evolved significantly in the last sixty years revolutionising the approach to the diagnostic and therapeutic spheres of medicine. Despite the advantages of using natural orifices to the bowel, adverse events (AE) may occur following endoscopy. Systematic AE registration is an objective in every realm of quality medicine. Despite the obvious advantage as a quality indicator, tracking endoscopy-related AE is not evident. The current study aimed at tracking all AE of all endoscopic procedures during a 3-month period. The three methods used were voluntary reporting by the endoscopist and by the patient in parallel with retrospective data analysis of patients’ electronic medical records to allow capture of all AE and comparison of the three methods. Patients and methods: During a 3-month period endoscopists and patients were requested to report any possible AE. At the end of the period, a systematic review of all patient files was performed to track all AE related to the endoscopic procedure or the endoscopyrelated anaesthesia. In total 2668 endoscopic procedures were reviewed. Results: The total AE rate was 1.95%. Only half (51.9%) of all AE were voluntarily reported by endoscopists, the other half were extracted from the electronic medical record. There were no patient-reported AE. Although the majority (66.7%) of unreported AE were mild, these findings illustrate that voluntary AE reporting is unreliable. However, the retrospective tracking process proved to be difficult and time-consuming. Conclusions: The current study highlighted that systematic registration of all endoscopy-related AE is feasible, but challenging because of multiple hurdles. More practical methods are warranted to obtain reliable and long-term data as part of endoscopy quality measures.

Read more ->