Mafalda Sousa

Cheese-related listeriosis outbreak, Portugal, March 2009 to February 2012

In Portugal, listeriosis has been notifiable since April 2014, but there is no active surveillance programme for the disease. A retrospective study involving 25 national hospitals led to the detection of an outbreak that occurred between March 2009 and February 2012. The amount of time between the start of the outbreak and its detection was 16 months. Of the 30 cases of listeriosis reported, 27 were in the Lisbon and Vale do Tejo region. Two cases were maternal/neonatal infections and one resulted in fetal loss. The mean age of the non-maternal/neonatal cases was 59 years (standard deviation: 17); 13 cases were more than 65 years old. The case fatality rate was 36.7%. All cases were caused by molecular serogroup IVb isolates indistinguishable by pulsed-field gel electrophoresis and ribotype profiles. Collaborative investigations with the national health and food safety authorities identified cheese as the probable source of infection, traced to a processing plant. The magnitude of this outbreak, the first reported food-borne listeriosis outbreak in Portugal, highlights the importance of having an effective listeriosis surveillance system in place for early detection and resolution of outbreaks, as well as the need for a process for the prompt submission of Listeria monocytogenes isolates for routine laboratory typing.

Impact of Histological and Endoscopic Remissions on Clinical Recurrence and Recurrence-free Time in Ulcerative Colitis

Background: Clinical and endoscopic remissions constitute the therapeutic goals in ulcerative colitis (UC). Histological healing is currently not a target in UC. This study aims to determine the impact of the definition of endoscopic remission (Mayo endoscopic subscore [MSe] 0–1) and histological activity in the recurrence of UC and recurrence-free survival time. Methods: Patients with UC in clinical remission (partial Mayo score ⩽ 1) and endoscopic remission (MSe ⩽ 1) who underwent colonoscopy with biopsies between March 2010 and December 2013 were included. The validated Nancy score was used to evaluate histological activity, which considers inactivity if 0 to 1 and activity if 2 to 4. The recurrence-free time was evaluated and recurrence was defined as partial Mayo score ≥ 2, therapy to induce remission, hospitalization, or colectomy. Predictive factors associated with recurrence and time to recurrence were determined. Results: Sixty patients were included; 58.3% (n = 35) were women, with a mean age of 52.7 years. MSe = 1 was observed in 46.7% (n = 28) and histological activity in 38.3% (n = 23). Clinical recurrence occurred in 31.7% (n = 19) of patients, with a cumulative risk of 17.1%/24.5%/26.7%/40.1% at 12/24/36/48 months, respectively. MSe = 1 (P = 0.02) and histological activity (P = 0.007) were significantly associated with recurrence. Of these, only histological activity (P = 0.03) was an independent predictive factor of recurrence. Patients with MSe = 1 (P = 0.02) and with histological activity (P = 0.01) had a significantly shorter recurrence-free time in univariate analysis. In multivariate analysis, only histological activity (P = 0.02) was an independent predictive factor of lower recurrence-free time. Conclusion: The presence of histological activity represents an independent predictive factor of recurrence and time to recurrence, which was not verified with MSe 0 to 1.

Appropriateness of the study of iron deficiency anemia prior to referral for small bowel evaluation at a tertiary center

AIM To evaluate the adequacy of the study of iron deficiency anemia (IDA) in real life practice prior to referral to a gastroenterology department for small bowel evaluation. METHODS All consecutive patients referred to a gastroenterology department for small bowel investigation due to iron deficiency anemia, between January 2013 and December 2015 were included. Both patients referred from general practitioners or directly from different hospital departments were selected. Relevant clinical information regarding prior anemia workup was retrospectively collected from medical records. An appropriate pre-referral study was considered the execution of esophagogastroduodenoscopy (EGD) with Helicobacter pylori (H. pylori) investigation, colonoscopy with quality standards (recent, total and with adequate preparation) and celiac disease (CD) screening (through serologic testing and/or histopathological investigation). RESULTS A total of 77 patients (58.4% female, mean age 67.1 ± 16.7 years) were included. Most (53.2%) patients were referred from general practitioners, 41.6% from other hospital specialties and 5.2% directly from the emergency department. The mean pre-referral hemoglobin concentration was 8.8 ± 2.0 g/dL and the majority of anemias had microcytic (71.4%) and hypochromic (72.7%) characteristics. 77.9% of patients presented with an incomplete pre-referral study: EGD in 97.4%, with H. pylori investigation in 58.3%, colonoscopy with quality criteria in 63.6%, and CD screening in 24.7%. Patients with an appropriate study at the time of referral were younger (48.7 ± 17.7 vs 72.3 ± 12.3 years, P < 0.001). Small bowel evaluation was ultimately undertaken in 72.7% of patients, with a more frequent evaluation in patients with a quality colonoscopy at referral (78.6% vs 23.8%); P < 0.001 (OR = 11.7, 95%CI: 3.6-38.6). The most common diagnosis regarded as the likely cause of IDA was small bowel angioectasia (18.2%) but additional causes were also found in the upper and lower gastrointestinal tracts of near 20% of patients. Small bowel studies detected previously unknown non-small bowel findings in 7.7% of patients. CONCLUSION The study of anemia prior to referral to gastroenterology department is unsatisfactory. Only approximately a quarter of patients presented with an appropriate study.

Impact of the timing of capsule endoscopy in overt obscure gastrointestinal bleeding on yield and rebleeding rate - is sooner than 14 d advisable?

AIM To evaluate the impact of the timing of capsule endoscopy (CE) in overt-obscure gastrointestinal bleeding (OGIB). METHODS Retrospective, single-center study, including patients submitted to CE in the setting of overt-OGIB between January 2005 and August 2017. Patients were divided into 3 groups according to the timing of CE (≤ 48 h; 48 h-14 d; ≥ 14 d). The diagnostic and therapeutic yield (DY and TY), the rebleeding rate and the time to rebleed were calculated and compared between groups. The outcomes of patients in whom CE was performed before (≤ 48 h) and after 48 h (> 48 h), and before (< 14 d) and after 14 d (≥ 14 d), were also compared. RESULTS One hundred and fifteen patients underwent CE for overt-OGIB. The DY was 80%, TY-46.1% and rebleeding rate - 32.2%. At 1 year 17.8% of the patients had rebled. 33.9% of the patients performed CE in the first 48 h, 30.4% between 48h-14d and 35.7% after 14 d. The DY was similar between the 3 groups (P = 0.37). In the ≤ 48 h group, the TY was the highest (66.7% vs 40% vs 31.7%, P = 0.005) and the rebleeding rate was the lowest (15.4% vs 34.3% vs 46.3% P = 0.007). The time to rebleed was longer in the ≤ 48 h group when compared to the > 48 h groups (P = 0.03). CONCLUSION Performing CE within 48 h from overt-OGIB is associated to a higher TY and a lower rebleeding rate and longer time to rebleed.

Evaluation of the Usefulness of Virtual Chromoendoscopy with Different Color Modes in the MiroCam® System for Characterization of Small Bowel Lesions

Background: Virtual chromoendoscopy (VC) in small bowel capsule endoscopy can improve the visualization and characterization of different small bowel lesions (SBLs). There are few studies of its usefulness in the Given® system, and there is no evidence yet of its utility in the MiroCam® system. Aim: The aim of this study was to evaluate whether VC can improve the characterization of SBLs with the MiroCam® system. Methods: Twenty-two patients were selected, in which 100 elementary lesions were identified, including erosions (n = 45), ulcers (n = 17), and angioectasias (n = 38). For each lesion identified, images were captured without chromoendoscopy (normal image [NI]) and with chromoendoscopy modes 1 (color mode [CM] 1), 2 (CM2), and 3 (CM3). A score from 1 to 4 was assigned to each image, in which a better evaluation of the characteristics and limits of the lesion was classified in ascending order, where 1 is the worst and 4 the best evaluation. The scores of the various modes were compared with Kendalls tau-c coefficient. Results: The average scores attributed to the photographs in NI, CM1, CM2, and CM3 were 3.83, 2.89, 1.85, and 1.43, respectively (tau-c = -0.75, p < 0.001). Evaluating the elementary lesions independently, the average scores for modes NI, CM1, CM2, and CM3 were 3.83, 2.92, 1.86, and 1.38 (tau-c = -0.77, p < 0.001) for erosions, respectively; 3.87, 2.96, 1.76, and 1.40 (tau-c = -0.80, p < 0.001) for ulcers, respectively; and 3.81, 2.82, 1.87, and 1.50 (tau-c = -0.71, p < 0.001) for angioectasias, respectively. Conclusions: VC using the CMs available in the MiroCam® system has not proven useful for a better assessment of any of the SBLs.

Validation of SPICE, a method to differenciate small bowel submucosal lesions from innocent bulges on capsule endoscopy

BACKGROUND AND AIMS Small bowel submucosal lesions (SBSL) and innocent bulges may have an identical appearance and be difficult to distinguish on small bowel capsule endoscopy (SBCE). Recently, Girelli et al. proposed a score, smooth, protruding lesion index on capsule endoscopy (SPICE), in order to differentiate between the two. We aimed to evaluate and validate SPICE as a differentiation method between innocent bulges and SBSLs. METHODS We evaluated all SBCEs performed in our department between January 2005 and September 2015, and selected the ones with a smooth, round, protruding lesion in the small bowel. Lesions with suspicious characteristics were excluded. A video clip of the region of interest was created and SPICE was assigned blindly and independently by two endoscopists. We determined the discriminative ability of SPICE using the definitive diagnosis of each patient as the standard criteria. RESULTS We included 30 SBCEs corresponding to 12 SBSLs (four gastrointestinal stromal tumors, two neuroendocrine tumors, four lipomas and two polypoid lymphangiectasias) and 18 innocent bulges. SPICE scores ranged from 0 to 4, allowing the distinction between SBSLs and innocent bulges (p < 0.001). SPICE > 2 had a 66.7% sensitivity, 100.0% specificity, 100.0% positive predictive value and 78.3% negative predictive value, and the area under the curve was 0.88 (95% CI, 0.73-1.00; p < 0.001) for the diagnosis of SBSL. CONCLUSIONS Our data support SPICE, namely a score > 2, as a predictive method of SBSLs. Taking into account its simplicity, it may be very useful in the distinction between SBSLs and innocent bulges on SBCE.

The Baveno VI criteria for predicting esophageal varices: validation in real life practice

BACKGROUND AND AIMS According to the Baveno VI consensus, patients with liver stiffness < 20 kPa and a platelet count > 150,000 ul have very low risk of clinically significant varices and do not need a screening endoscopy. The aim of this study was to evaluate non-invasive methods as predictors of esophageal varices according to the Baveno VI recommendations, in real life clinical practice. METHODS Retrospective evaluation of patients with chronic liver disease who underwent transient elastography between January 2013 and December 2015. RESULTS One hundred and four patients were included in the study, the median age was 56.8 years and 69.2% were male. The etiology of liver disease was hepatitis C in 80% of patients (including 20% with HIV co-infection), alcohol in 12%, hepatitis B in 4% and other causes in 5%. Varices were present in 25% of patients. A liver stiffness < 20 kPa had a sensitivity of 92.3% and a specificity of 84.6%. When considering high risk varices (small with red wales or large varices), a liver stiffness < 20 kPa had 100% sensitivity. A platelet count > 150,000/l had a sensitivity of 84.6% and a specificity of 64.1%. Four patients with a platelet count (PLT) > 150,000/l had esophageal varices. When both criteria were applied to the patient cohort, according to the Baveno VI consensus, the sensitivity was 100% and the specificity, 61.5%. CONCLUSION In this study, the Baveno VI criteria had 100% sensitivity but a relatively low specificity for the non-invasive diagnosis of esophageal varices. In clinical practice, all patients with varices are identified but many patients have a subsequent negative endoscopy.

Endoscopic resection of large gastrointestinal lipomas: Loop-and-let-go technique with some twists

Lipomas are benign subepithelial tumors occurring throughout the gastrointestinal tract, most commonly in the colon and rarely in the duodenum. The majority are asymptomatic and found incidentally. Nevertheless, lipomas may cause symptoms as abdominal pain, change in bowel habits or bleeding. This case series, of which 2 cases were previously published as single case reports, aims to describe endoscopic resection of large gastrointestinal lipomas (Table 1). In all cases, endoloop (MAJ-254, Olympus) ligation was performed and, in all but one, complemented with unroofing of the lesion to allow a sample for histological analysis. Slightly different technical aspects detailed in each case were adopted to adjust to the characteristics of the lesion. A 46-year-old man was referred for endoscopic resection of a large lipoma diagnosed incidentally in a computed tomography (CT). Although asymptomatic, the patient asked for resection regarding the dimension of the lesion. Upper endoscopy revealed a pseudopedunculated lesion measuring 20 mm, in the duodenum. With a double-channel endoscope, an endoloop was previously placed externally to a foreign body forceps which grasp and retract the lesion, while the endoloop was subsequently tightened around the base of the lesion. A second endoloop was positioned using the ‘‘loop-over-loop’’ technique, in which the first endoloop was mobilized with a foreign body forceps guiding the placement of the second endoloop in the base of the lesion, immediately beneath the first endoloop. After endoscopic ligation, a snare was used to unroof the top of the lesion. A follow-up endoscopy performed one month later revealed a regular scar with no residual lesion. A 72-year-old man was referred to our department with a chronic history of episodic abdominal pain and vomiting. A CT enterography was performed and revealed a large pedunculated lesion resembling a lipoma in the distal ileum. The patient underwent retrograde single-balloon enteroscopy that revealed a yellowish pedunculated subepithelial lesion covered with normal mucosa in the distal ileum, which was ligated with an endoloop around the false pedicle of the lesion. The patient underwent a followup enteroscopy one month later, which revealed complete resection of the lesion. After a year of follow-up the patient remained asymptomatic. A 51-year-old woman presented with a 6-month history of episodic abdominal pain and chronic diarrhea, which was presumed to be caused by the ball-valve effect of a large lipoma in the terminal ileum. As the manipulation of the lipoma resulted in consecutive retractions to the terminal ileum, a grasp-to-retract technique was employed using a 2-channel therapeutic colonoscope. While a forceps pulled and stabilized the lipoma at the ascending colon, a detachable snare, previously positioned over the forceps, was placed around the base of the pseudopedunculated lesion. The endoloop ligation was complemented with unroofing of the lesion. Two months after resection, the patient was asymptomatic and a regular scar was confirmed. A 67-year-old woman underwent an endoscopic resection of a large asymptomatic lipoma of 30 mm at the ileocecal valve (Video 1), due to the dimensions of the lesion and patient’s informed request. With a 2-channel therapeutic colonoscope, the lesion was stabilized with a foreign body forceps while an endoloop was applied and tightened around its base. Subsequently, a second endoloop was positioned using the ‘‘loop-over-loop’’ technique. Finally, unroofing through resection of the top of the lesion with a snare was performed. A follow-up endoscopy performed one month later revealed a regular scar with no residual lesion. A 57-year-old man underwent endoscopic resection of a pseudopedunculated subepithelial lesion of 25 mm at the sigmoid colon, regarding the dimensions of the lesion and preference of the patient to remove the lesion. With a double-channel colonoscope, a detachable snare was a tightly applied around the base of the lesion (Fig. 1) and another endoloop was further placed around the base of lesion using the ‘‘loop-over-loop’’ technique. Finally, unroofing was performed. Endoscopic follow-up assessment performed a month after the resection, revealed a regular scar with no residual lesion. The main reasons described in previous case series for resection of gastrointestinal lipomas include symptomatic lesions or asymptomatic lesions larger than 20 mm which may develop symptoms or complications, namely intestinal obstruction, invagination, perforation or bleeding. Nevertheless, larger asymptomatic lesions may be removed after discussion of the risks and benefits with the patient.

Underwater Endoscopic Mucosal Resection of a Large Flat Adenoma with Pseudoinvasion in the Rectum

optimal in pseudodepressed lesions. Air insufflation was switched off, luminal air was aspirated, water was instilled using the water jet until complete immersion of the lumen was achieved ( Fig. 2 a), and the lesion was resected in piecemeal fashion using a conventional 25-mm oval snare (CJ-ADR-23–230–025; Nova LightSystems, Life Partners Europe, Bagnolet, France) and usual electrosurgical settings (Endocut effect 2, ICC 200; ERBE Elektromedizin, Tübingen, Germany) ( Fig. 2 b, c). A bleeding vessel was identified during the procedure ( Fig. 3 a) and managed with a hemostatic clip ( Fig. 3 b). Histological analysis revealed a tubulovillous adenoma with high-grade dysplasia and rare adenomatous glands within the submucosa extending from the overlying epithelium, with no associated desmoplastic reaction, corresponding to an adenoma with misplaced epithelium ( Fig. 1 c). A follow-up procedure performed 3 months later revealed no residual lesion. Water immersion preserves the circular configuration of the muscularis propria of the colon while folds of mucosa and submucosa project into the lumen away from the muscle layer, avoiding the need for submucosal injection used in conventional EMR [1, 2] . Bleeding during UEMR is uncommon, and the point of origin is clearly identified underwater [1] . Adenoma with misplaced epithelium is a rare entity formerly known as pseudoinvasive adenoma, which corresponds to an extension of the adenomatous glands of an adenoma into the submucosa through minor defects of the muscularis mucosae [3, 4] . The distinction of this entity from an invasive cancer in which neoplastic epithelium, such as desmoplasia, frank atypia, or pleomorphism, is present in the submucosa may be difficult but is crucial as the management and prognosis of an adenoma with misplaced epithelium is identical to an adenomatous polyp [3, 4] . Keywords

Predictors of Complications and Mortality in Patients with Self-Expanding Metallic Stents for the Palliation of Malignant Colonic Obstruction

Introduction: Self-expanding metallic stents (SEMS) for palliative purposes in malignant colonic obstruction are an alternative to surgery that has gained popularity over time. Methods: We performed a retrospective study of patients submitted to SEMS for palliation of obstructing malignant colorectal cancer from 2005 to 2015 to evaluate predictive clinical factors for complications and mortality. Results: Forty-five patients with high rates of technical and clinical success were included (97.8 and 95.6%, respectively), with complications occurring in 17.8% (8.9% perforations, 4.4% obstructions, and 4.4% migrations). The length of the stenosis was superior in patients with complications (p = 0.01); 11.1% of patients had a re-intervention (2.2% surgery and 8.9% placement of another SEMS). Relief of obstruction without intervention was maintained until death in 77.8% of patients and in 81.4% of patients who had immediate clinical success. The mortality rate was 37.2% at 30 days, 56.5% at 60 days, and 87.5% at 1 year. There were no predictors of survival identified, including age, sex, tumor stage, metastasis, or complications of the procedure. Discussion and Conclusions: In this study, SEMS placement was associated with a high rate of technical and clinical success and a low rate of complications, being an option to palliate patients with obstructive neoplasia. The length of the stenosis was associated with a greater risk of complications. The majority of stent-related complications can be managed successfully without surgery.