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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
