Camelia Cojocariu

Natural course of nonmalignant partial portal vein thrombosis in cirrhotic patients

Background/Aim: Portal vein thrombosis (PVT) has a high incidence in patients with liver cirrhosis and determines a poor prognosis of hepatic disease. The aim of our study was to define the natural course of partial PVT in cirrhotic patients, including survival and decompensation rates. Patients and Methods: We performed a prospective, cohort study, in a tertiary referral center. There were 22 cirrhotic patients with partial nonmalignant PVT, without anticoagulant treatment, who were followed-up between January 2011 and October 2013. All patients were evaluated by Doppler abdominal ultrasound and computed tomography. Kaplan–Meier method was used to determine the difference in clinical events between the study subgroups. Results: After a mean follow-up period of 20.22 months, partial PVT improved in 5 (22.73%), was stable in 11 (50%), and worsened in 6 (27.27%) patients. Hepatic decompensation rate at 6 and 18 months was higher in patients with worsened PVT than in those with stable/improved PVT (50% vs. 25%, P < 0.0001 and 100% vs. 56.25%, P < 0.0001, respectively). The survival rate at 6 months was 66.66% in worsened PVT group vs. 81.25% (P = 0.005) in stable/improved group, and 16.66% vs. 81.25% (P < 0.0001) at 18 months, respectively. Multivariate analysis showed that Model of End-Life Disease was the independent predictor of hepatic decompensation [hazard ratio (HR) 1.42; 95% confidence interval (CI): 1.08−1.87, P = 0.012] and survival (HR 1.76; 95% CI: 1.06−2.92, P = 0.028). Conclusions: Nonmalignant partial PVT remained stable/improved in over half of cirrhotic patients and aggravated in more than one fourth in whom it negatively influenced the survival and decompensation rates.

Outcomes after symptomatic capsule retention in suspected small bowel obstruction.

Background and aim Capsule endoscopy (CE) has been proven to be a sensitive and a safe tool for the examination of the small bowel. However, careful patient selection is required to avoid complications, primarily capsule retention. The aims of this study were to evaluate the rate of capsule retention in patients with suspected chronic small bowel obstruction and to analyze the role and the impact of subsequent surgical intervention. Methodology Fifteen patients referred for CE with a clinical picture suggestive of chronic small bowel obstruction and with negative imaging studies were retrospectively analyzed. Results Capsule retention occurred in three (20%) patients who developed symptoms of subacute obstruction and subsequently underwent surgery. Radiation enteritis, Crohn’s disease, and an ileal tumor were demonstrated as the causes of the capsule retention in these patients. Surgical removal of the retained capsule was performed and the underlying small bowel disease was treated. Conclusion Capsule retention is a frequent complication of CE in patients with symptoms of chronic small bowel obstruction. Surgery, with the removal of the retained capsule, is proven to be beneficial in identifying the location of, and treating, the underlying disease in these patients.

Clostridium difficile infection and inflammatory bowel disease.

Over the past 15 years, Clostridium difficile infection (CDI) in patients with inflammatory bowel disease (IBD) has increased both in incidence and severity. Traditional risk factors for CDI are similar in IBD and non-IBD populations, but there is a significant proportion of IBD patients which have distinctive characteristics. Patients with ulcerative colitis (UC) are more susceptible to CDI and have more severe outcomes than those with Crohns disease (CD). CDI may be difficult to distinguish from an IBD flare due to similar clinical presentation, and therefore screening for CDI is recommended at every flare in such patients. Several studies showed worse clinical outcomes in IBD patients with CDI, including longer hospital stay, higher colectomy and mortality rates than in those without CDI. Vancomycin and metronidazole appear to have similar efficacy in patients with moderate disease, but vancomycin is preferred in severe disease. Measures must be taken to prevent the spread of infection. Clinicians should have a high index of suspicion for CDI when evaluating a patient with IBD flare, as rapid detection and prompt treatment of infection improve outcomes. This review summarizes the available literature on epidemiology, risk factors, clinical aspects, diagnostic methods, treatment, outcome, and prevention of CDI in IBD patients.

Pseudomembranous colitis associated with a triple therapy for Helicobacter pylori eradication

Helicobacter pylori (H. pylori) is one of the most common chronic bacterial infections in humans, affecting half of worlds population. Therapy for H. pylori infection has proven to be both effective and safe. The one-week triple therapy including proton pump inhibitor, clarithromycin, and amoxicillin or metronidazole is still recommended as a first-line treatment to eradicate H. pylori infection in countries with low clarithromycin resistance. Generally, this therapy is well-tolerated, with only a few and usually minor side effects. However, rare but severe adverse effects such as pseudomembranous colitis have been reported, Clostridium difficile (C. difficile) infection being the main causative factor in all cases. We report the cases of two women who developed pseudomembranous colitis after a 1-wk triple therapy consisting of pantoprazole 20 mg bid, clarithromycin 500 mg bid, and amoxicillin 1 g bid to eradicate H. pylori infection. A limited colonoscopy showed typical appearance of pseudomembranous colitis, and the stool test for C. difficile toxins was positive. Rapid resolution of symptoms and negative C. difficile toxins were obtained in both patients with oral vancomycin. No relapse occurred during a four and eleven-month, respectively, follow up. These cases suggest that physicians should have a high index of suspicion for pseudomembranous colitis when evaluate patients with diarrhea following H. pylori eradication therapy.

Clostridium difficile infection in hospitalized octogenarian patients

To evaluate the risk factors and outcome of Clostridium difficile infection in hospitalized octogenarian patients.

Severe hepatic toxicity after administration of infliximab in psoriasis treatment

The true incidence of drug-induced liver injury (DILI) is difficult to discern because of an unknown denominator of individuals receiving a drug, lack of a simple objective test for the diagnosis of DILI, lack of consensus on what liver test abnormalities constitute DILI, difficulty in attribution of causation to a single drug in those on many medicines, and lack of systematic reporting. Over 1000 medications and herbal products have been involved in causing liver injury, and the list continues to grow. Regarding the biologic therapy with infliximab, according to specialized studies, usually there were mild to moderate elevations of liver enzymes. Hereby, we present a clinical case of drug-induced hepatitis, after the administration of monoclonal antibodies over six months, with a remarkable contrast between the major biochemical changes and the absence of any symptoms.

Capsule endoscopy in acute upper gastrointestinal bleeding: goodbye to nasogastric tube aspiration?

We read with interest the article by Gralnek et al. [1] evaluating the role of video capsule endoscopy (VCE) in patients who present at the emergency department with acute upper gastrointestinal bleeding (UGIB), and we would like to make a few comments. Firstly, Gralnek et al. [1] found that fresh or coffee-ground blood in the upper gastrointestinal tract was identified significantly more often by VCE than by nasogastric tube (NGT) aspiration (83% vs. 33%) and that patient satisfaction was significantly higher with VCE. The initial evaluation of a patient with acute UGIB in the emergency department is now well summarized in international consensus statements and guidelines [2]. There are several scoring systems [3] that allow the identification of patients who are at low risk and therefore suitable for elective esophagogastroduodenoscopy (EGD), early hospital discharge, or outpatient treatment. However, none of the published risk scores are routinely used by emergency physicians, who usually rely on clinical and laboratory data and, in many cases, on the assessment of NGT aspirate. The use of NGT aspiration remains controversial [4]. It should be emphasized that although a bloody gastric aspirate may be useful in identifying patients at high risk, the absence of blood does not exclude the presence of an active lesion. Subsequently, a serious lesion may be overlooked and thus, its effective treatment undermined. In addition, NGT aspiration is one of the most distressful procedures for bleeding patients in the emergency department. Despite these limitations, NGT aspiration is still recommended by consensus guidelines [2]. Obviously, both patients and emergency physicians would prefer a non-invasive method such as VCE rather than the conventional but unpleasant NGT aspiration. However, before saying goodbye to NGT aspiration, important questions remain unanswered: Does the use of VCE instead of NGT aspiration improve the outcomes in patients with acute UGIB or does it just add to medical costs? Are we ready to use an expensive method such as VCE (€ 500) just for detecting blood in the upper gastrointestinal tract rather than NGT, which costs only a few cents? Acute UGIB is a costly condition, mainly due to the hospital admission. The use of VCE may generate additional costs if its use in the emergency department does not result in a significant reduction in the number of patients admitted or the requirement for further EGD. Secondly, Gralnek et al. found that VCE had an ability to identify inflammatory lesions, excluding gastric and duodenal ulcers, similar to EGD (68% vs. 84%, respectively). However, if we take a closer look at the details of the diagnosis obtained by VCE and EGD, we see that findings were concordant in only 15 patients (32.6%). Moreover, 4 patients (8.7%) with normal EGD had positive VCE results, and 13 patients (28.2%) with positive EGD findings had normal VCE results. Therefore, we fully agree with the authors’ conclusion that VCE should not be considered as a substitute for standard EGD. Thirdly, although the study has a solid basis (prospective, multicenter, well designed), it also suffers from limitations such as the small number of patients included and manufacturer support. There is a need for further high quality prospective, non-manufacturer-supported, randomized controlled studies to evaluate the role of VCE in patients with UGIB who present at the emergency department. Until then, complete risk stratification can only be accomplished after EGD examination which, according to current guideline recommendations, should be performed within 24 hours from patient arrival at the department [2]. Our emergency department physicians are reluctant to discharge a patient with acute UGIB without first carrying out an EGD, mainly because of patient safety andmedico-legal concerns. Finally, Gralnek’s study might be followed by enthusiastic support for VCE among emergency physicians who are eager to use it in triage of patients with acute UGIB. Nevertheless, until it is clearly demonstrated that the use of VCE in the emergency department improves the outcomes and cost-effectiveness of healthcare, its applicability will be only sporadic and certainly not adopted as a routine method for evaluation of a patient with suspected acute UGIB. Perhaps in the future, advanced VCE technologies will lead to the “promised land” of safety and low cost!