Inês Pita

Advanced imaging techniques for small bowel Crohn’s disease: what does the future hold?

Treatment of Crohn’s disease (CD) is intrinsically reliant on imaging techniques, due to the preponderance of small bowel disease and its transmural pattern of inflammation. Ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) are the most widely employed imaging methods and have excellent diagnostic accuracy in most instances. Some limitations persist, perhaps the most clinically relevant being the distinction between inflammatory and fibrotic strictures. In this regard, several methodologies have recently been tested in animal models and human patients, namely US strain elastography, shear wave elastography, contrast-enhanced US, magnetization transfer MRI and contrast dynamics in standard MRI. Technical advances in each of the imaging methods may expand their indications. The addition of oral contrast to abdominal US appears to substantially improve its diagnostic capabilities compared to standard US. Ionizing dose-reduction methods in CT can decrease concern about cumulative radiation exposure in CD patients and diffusion-weighted MRI may reduce the need for gadolinium contrast. Clinical indexes of disease activity and severity are also increasingly relying on imaging scores, such as the recently developed Lémann Index. In this review we summarize some of the recent advances in small bowel CD imaging and how they might affect clinical practice in the near future.

Development and validation of risk matrices concerning ulcerative colitis outcomes – Bayesian network analysis

BACKGROUNDnUlcerative colitis [UC] is a chronic inflammatory disease often accompanied by severe and distressing symptoms that, in some patients, might require a surgical intervention [colectomy]. This study aimed at determining the risk of experiencing progressive disease or requiring colectomy.nnnMATERIAL AND METHODSnThis was a multicentre study: patients data [n = 1481] were retrieved from the Portuguese database of inflammatory bowel disease patients. Bayesian networks and logistic regression were used to build risk matrices concerning the outcomes of interest.nnnRESULTSnThe derivation cohort included a total of 1210 patients, of whom 6% required a colectomy and 37% had progressive disease [over a median follow-up period of 12 syears]. The risk matrices show that previously hospitalised patients with extensive disease, who are not on immunomodulators and who are refractory to corticosteroid treatment, are the ones at the highest risk of undergoing a colectomy [88%]; whereas male patients, with extensive disease and less than 40 years old at diagnosis, are the ones at the highest risk of experiencing progressive disease [72%]. These results were internally and externally validated, and the AUC [area under the curve] of the ROC [receiver operating characteristic] analysis for the derivation cohort yielded a high discriminative power [92% for colectomy and 72% for progressive disease].nnnCONCLUSIONSnThis study allowed the construction of risk matrices that can be used to accurately predict a UC patients likelihood of requiring a colectomy or of facing progressive disease, and can be used to individualise therapeutic strategies.

LAMS to the SEMS Rescue

We present the case of an 80-year-old woman with gastric outlet obstruction syndrome due to colorectal cancer metastasis in the distal duodenum. A 9-cm luminal uncovered self-expandable metal stent (SEMS) (Wallstent®, Boston Scientific, Marlborough, MA, USA) was inserted, with the proximal flange located in D2. The obstructive symptoms resolved but the patient was admitted a week later due to jaundice (total bilirubin 4.07 mg/dL, direct 2.84 mg/dL). Abdominal computerized tomography revealed marked dilation of the common bile duct (CBD) up to the level of the papilla (Fig. 1). An endoscopic retrograde cholangiopancreatography (ERCP) was scheduled. Anticipating difficulties in accessing the duodenal papilla, an endoscopic ultrasoundguided biliary drainage (EUS-BD) was also planned in advance. As suspected, the metal mesh in the duodenum hindered duodenoscope progression, precluding any attempt at biliary cannulation. Since the duodenal bulb was free, we decided to perform a choledochoduodenostomy using a 6 × 8 mm lumen-apposing metal stent (LAMS) (Hot AXIOS®, Boston Scientific, Marlborough, MA, USA). A therapeutic echoendoscope was advanced to the duodenal bulb and a 19-gauge needle was used to puncture the dilated CBD and aspirate bile. A 0.035-inch guidewire was then inserted into the CBD and the LAMS was deployed following the manufacturer’s instructions (Fig. 2). After the procedure, jaundice resolved and the patient was able to resume the palliative chemotherapy prescribed, with no recurrence of obstructive symptoms or jaundice in 4 months of follow-up. Figure 3 shows a predischarge gastroduodenography, revealing patency of the duodenal stents and oral contrast opacifying the biliary tree through the LAMS. This case highlights biliary obstruction as an uncommon adverse effect of endoscopic SEMS placement. We attributed jaundice to the procedure and not to malig-

How to Brush Your Way into the Bile Duct

The diagnosis of indeterminate biliary strictures remains a major challenge in the field of pancreatobiliary endoscopy. In an era of personalized medicine, the goal is to obtain a cytohistological diagnosis before proceeding to therapeutic actions. This objective is particularly difficult to achieve in the biliary tree due to several factors, which include the complex access route, the low cellularity and desmoplastic nature of some cholangiocarcinomas, and the systemic nature of some diseases that affect the biliary tree, such as autoimmune cholangitis and some infections. One should always keep in mind that approximately 30% of biliary strictures have a benign etiology and that in up to a quarter of resected cases, malignancy is not confirmed in the ex vivo examination. ERCP with brush cytology is considered a cornerstone exam in such cases and is probably the most frequently used endoscopic method. Despite its wide application, ERCP with brush cytology is hampered by a modest sensitivity and by the conspicuous adverse event rate associated to ERCP [1]. In order to improve the accuracy rate, several approaches have been proposed. These include doing additional procedures during ERCP such as fluoroscopic guided biopsies, fluorescent in situ hybridization (FISH), and cholangioscopy, whether using the single operator or direct peroral modality. A different approach based on endoscopic ultrasound is also possible, with the sensitivity of fine-needle biopsy of biliary lesions reaching 80% in a recent meta-analysis [2]. All these methods have pros and cons, but in general are not universally available and require extensive expertise. In this issue of GE – Portuguese Journal of Gastroenterology, Costa et al. [3] publish their experience with biliary brush cytology focusing on the method used to collect the cellular sample and on age as a factor to obtain a diagnosis of malignancy. One of the authors’ main findings is a trend for improved sensitivity when different methods were combined. In fact, increasing the number of strategies for tissue acquisition (doing standard smears; cutting

Prospective comparative study of endoscopic submucosal dissection and gastrectomy for early neoplastic lesions including patients’ perspectives

BACKGROUNDnThere are no prospective studies comparing endoscopic submucosal dissection (ESD) and gastrectomy, especially evaluating patient-reported outcomes. Our aim was to compare the safety and impact on quality of life (QoL) of ESD and gastrectomy in patients with early gastric neoplasia.nnnMETHODSnThis prospective study included consecutive patients presenting with early gastric neoplasia in a tertiary center from January 2015 to August 2016. Data collection included curative resection, adverse events (AEs), and patient-reported outcomes (questionnaires: EORTC QLQ-C30, EORTC STO-22, EQ-5D-5u200aL, and Assessment of Survivor Concerns) before and after interventions (after 1 month, 3u200a-u200a6 months, and 1 year).nnnRESULTSn254 patients with early lesions were included: 153 managed by ESD and 101 by gastrectomy, the former being significantly older and with less advanced lesions. Mean procedural time and length of stay were significantly higher in the surgery group (164 vs. 72 minutes and 16.3 vs. 3.5 days; Pu200a<u200a0.001). Complete resection was higher in the surgical group (99u200a% vs. 90u200a%; Pu200a=u200a0.02); ESD was curative in 79xa0% of patients. Severe AEs and surgical re-intervention were significantly more frequent in the gastrectomy group (21.8u200a% vs. 7.8u200a% and 11u200a% vs. 1u200a%, respectively). Endoscopic treatment was associated with a positive impact on global health-related QoL at 1 year (net differenceu200a+u200a9.9; Pu200a=u200a0.006), role function and symptom scales (fatigue, pain, appetite, eating restrictions, dysphagia, and body image). Concerns about recurrence did not differ between the groups.nnnCONCLUSIONSnIn patients with early gastric neoplasia, ESD is safer and is associated with a positive impact on health-related QoL when compared with gastrectomy, without increasing fear of recurrence and new lesions.

Deep Beneath the Skin: An Unusual Causa of Melena

68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 Question: A 76-year-old man presented to the emergency department complaining of exertional dyspnea in the previous 3 weeks and an episode of presyncope that day. He denied orthopnea, paroxysmal nocturnal dyspnea, and precordial pain. On further questioning, the patient revealed a 3-week history of melena. He denied hematemesis, hematochezia, hematuria, or any other macroscopic blood loss. Physical examination was unremarkable except for mucocutaneous pallor. Electrocardiography was normal. Bloodwork revealed a low hemoglobin of 6.7 g/dL, normal high-sensitivity troponin I, and low B-type natriuretic peptide. The patient had a history of a grade IIB malignant melanoma of the dorsum resected 5 years earlier and remained under annual surveillance consultations. He also had arterial hypertension, type 2 diabetes, and was medicated with acetylsalicylic acid, metformin, a statin, and 3 antihypertensive drugs. Upper gastrointestinal endoscopy revealed multiple gastric (Figure A) and duodenal nodular lesions (Figure B, C), 20 mm in diameter, with a pigmented and ulcerated center, which were biopsied. The histopathologic examination showed invasion of gastric and duodenal mucosa by neoplastic pigmented cells which stained positive for melana on immunohistochemistry (Figure D, E). What is the diagnosis? Look on page 000 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. 109 110 111 112 113 114 115 Conflicts of interest The authors disclose no conflicts.

Pelvic Catastrophe after Elastic Band Ligation in an Irradiated Rectum

Chronic radiation proctopathy is a frequent complication after both pelvic external radiation therapy and brachytherapy and most commonly presents as rectal bleeding. Deep rectal ulcers and fistulae are much rarer and more clinically challenging consequences. We present the case of a 72-year-old male with a history of prostate adenocarcinoma treated with brachytherapy, who was referred to our institution due to a deep painful rectal ulcer refractory to medical treatment. The ulcer presented shortly after a haemorrhoid elastic band ligation and progressed to rectourethral fistulisation despite both faecal and urinary diversion. Our case demonstrates the importance of favouring a conservative approach when dealing with an irradiated rectum.