Marc Nguyen-Tat

Computed Virtual Chromoendoscopy for Classification of Small Colorectal Lesions: A Prospective Comparative Study

OBJECTIVES:Standard colonoscopy offers no reliable discrimination between neoplastic and nonneoplastic colorectal lesions. Computed virtual chromoendoscopy with the Fujinon intelligent color enhancement (FICE) system is a new dyeless imaging technique that enhances mucosal and vascular patterns. This prospective trial compared the feasibility of FICE, standard colonoscopy, and conventional chromoendoscopy with indigo carmine in low- and high-magnification modes for determination of colonic lesion histology.METHODS:Sixty-three patients with 150 flat or sessile lesions less than 20 mm in diameter were enrolled. At colonoscopy, each lesion was observed with six different endoscopic modalities: standard colonoscopy, FICE, and conventional chromoendoscopy with indigo carmine (0.2%) dye spraying in both low- and high-magnification modes. Histopathology of all lesions was confirmed by evaluation of endoscopic resection or biopsy specimens. Endoscopic images were stored electronically and randomly allocated to a blinded reader.RESULTS:Of the 150 polyps, 89 were adenomas and 61 were hyperplastic polyps with an average size of 7 mm. For identifying adenomas, the FICE system with low and high magnifications revealed a sensitivity of 89.9% and 96.6%, specificity of 73.8% and 80.3%, and diagnostic accuracy of 83% and 90%, respectively. Compared with standard colonoscopy, the sensitivity and diagnostic accuracy achieved by FICE were significantly better under both low (P < 0.02) and high (P < 0.03) magnification and were comparable to that of conventional chromoendoscopy.CONCLUSIONS:The FICE system identified morphological details that efficiently predict adenomatous histology. For distinguishing neoplastic from nonneoplastic lesions, FICE was superior to standard colonoscopy and equivalent to conventional chromoendoscopy.

The impact of patient and tumour baseline characteristics on the overall survival of patients with advanced hepatocellular carcinoma treated with sorafenib

BACKGROUNDnImpact of patient and tumour baseline characteristics on the overall survival is not well characterized in patients with advanced hepatocellular carcinoma (HCC) treated with sorafenib.nnnAIMS/METHODSnUnivariate/multivariate analyses were conducted to identify retrospectively the impact of baseline characteristics on the survival of 110 patients with advanced HCC treated with sorafenib.nnnRESULTSnMedian survival of the whole cohort was 6.7 months, median survival in Child-Pugh A, B, C patients was 10.5, 6.1 and 3.0 months and median survival of patients with Barcelona Clinic Liver Cancer (BCLC) stage C/D was 6.8/2.6 months. Presence of ascites, presence of macrovascular invasion and BCLC stage D (mainly determined by Child-Pugh C status and Eastern Cooperative Oncology Group Performance Status>2) remained independent prognostic factors for the survival on multivariate analysis. Particularly, the presence of macrovascular invasion significantly influenced survival both in patients with liver cirrhosis Child-Pugh A and Child-Pugh B.nnnCONCLUSIONnWell maintained liver function and performance status are prerequisites for sorafenib treatment in patients with advanced HCC. Our findings do not support routine clinical use of sorafenib in Child-Pugh B patients. Evaluation of ascites and particularly macrovascular invasion might help to identify patients more likely to benefit from sorafenib treatment.

Severe paraneoplastic gastroparesis associated with anti-Hu antibodies preceding the manifestation of small-cell lung cancer.

Gastroparesis is a common but challenging disorder which can be idiopathic or induced by a variety of underlying diseases, most frequently by diabetes, or post-surgical conditions of the upper abdomen. Clinicians must also consider rare causes of gastric motor dysfunction, such as collagen vascular disorders and paraneoplastic syndromes. Here we present the case of a patient with severe gastroparesis, who was admitted to our hospital for vomiting and weight loss of 25 kg within four months. Endoscopy showed a dilated fluid-filled stomach without peristalsis but no obstruction. High titres of anti-Hu antibodies were detected in patients serum, supporting the diagnosis of severe paraneoplastic gastroparesis with chronic intestinal pseudo-obstruction. Fine-needle aspiration of suspicious mediastinal lymph nodes guided by endoscopic ultrasound revealed lymphatic metastases of a small-cell lung carcinoma. Jejunal tube feeding and chemotherapy with carboplatin and etoposide were initiated. Paraneoplastic gastrointestinal dysmotility is rare, however, clinicians should consider this differential diagnosis in otherwise unexplained gastrointestinal motor dysfunction. The pathophysiology of paraneoplastic gastroparesis, the diagnostic relevance of anti-Hu antibodies as well as therapeutic options are discussed.

Surveillance of Hepatocellular Carcinoma and Diagnostic Algorithms in Patients with Liver Cirrhosis.

Background: Hepatocellular carcinoma (HCC) is the most deadly complication of all major chronic liver diseases. Since early detection is the most significant determinant of overall survival, intense screening is of major importance. Methods: This overview is based on a systematic review of the available literature on HCC screening and surveillance in the PubMed database. Results: Over the last decades, major etiological risk factors were identified and the population at highest risk for the development of HCC was clearly defined. Screening in these patients has been repeatedly demonstrated to detect early tumor stages and to be cost-effective. Therefore, screening is recommended by all current guidelines and usually comprises a bi-annual ultrasound examination in Western countries. In some Asian countries biomarkers are also used; however, their efficiency for Western HCCs remains to be determined. The detection of lesions >1 cm during routine screening requires subsequent confirmation of HCC. The diagnosis can be accurately established by modern imaging techniques, i.e. computed tomography or magnetic resonance imaging, in the majority of patients. In ambiguous cases and if radiological criteria are not met by two imaging techniques, biopsies remain the gold standard for diagnosis. Furthermore, histology is of key importance for the development of new diagnostic and predictive biomarkers. Conclusion: Screening and detection algorithms for patients at risk for HCC are effective and should be rigorously implemented in clinical routine.

Ätiologie und Komplikationen der Leberzirrhose: Daten eines deutschen Zentrums

BACKGROUNDnLiver cirrhosis develops as a terminal complication of chronic liver disease. The clinical course is determined by the underlying etiology and the accompanying risk factors, which are influenced by the geographic and cultural background.nnnMETHODSnA total of 236 patients (159 men, 77 women, median age 57 [22-81] years) were included for retrospective analysis between July 2012 and February 2014 using standardized questionnaires during an outpatient visit at a hepatology clinic.nnnRESULTSnThe most common etiologies of liver cirrhosis were related to alcohol consumption (52u200a%), chronic hepatitis C (28u200a%) or hepatitis B (14u200a%) infection and NASH (nonalcoholic steatohepatitis, 6u200a%). At the time of presentation 55u200a% patients had compensated cirrhosis corresponding to Child-Turcotte-Pugh (CTP) stage A, while 45u200a% were in a decompensated stage (30u200a% CTP B and 15u200a% CTP C). Subgroups were analyzed for the incidence of complications and the emergence of infections. Most frequently esophageal varices (60u200a%) and ascites (49u200a%) were observed, followed by pleural effusion (14u200a%), hepatic encephalopathy (25u200a%) or hepatorenal syndrome (18u200a%). 16u200a% of patients exhibited infection based on clinical criteria. An infective agent was isolated in 38u200a% of all cases with infection and of those 50u200a% were gram positive bacteria. In multivariate analysis only the presence of ascites was an independent risk factor for infection.nnnCONCLUSIONnDespite improved medical therapies for viral hepatitis, these were the most frequent causes of liver cirrhosis, closely followed by alcoholic cirrhosis. The observed complications included bacterial infection and complication related to portal hypertension.

Clinicopathologic features and prognosis of young patients with hepatocellular carcinoma in a large German cohort.

Goals and Background: Hepatocellular carcinoma in non-hepatitis B virus endemic areas is rare in patients younger than 40 years of age. The aim of this study was to characterize young patients in a large German cohort in comparison with older patients with regard to underlying liver disease, clinical management, and survival. Study: We analyzed the clinical data and medical records of 1108 consecutive patients with confirmed hepatocellular carcinoma. Twenty-five patients (2%) were younger than 40 years of age. We compared this subgroup with patients older than 40 years of age. Results: Underlying chronic liver disease was less common in young patients and detectable in only 56% of patients. Fibrolamellar carcinoma was more frequent in young versus old patients (20% vs. 0.7%; P<0.001). There was a trend toward more potentially curative treatment options in young patients, and overall survival was longer in the young group compared with older patients (56.0 vs. 15.2 mo; P=0.048). Conclusions: This western cohort of young patients is distinctly different from described Asian cohorts, especially with regard to a lower rate of underlying liver disease and particularly hepatitis B virus. Young patients had a better overall survival than older patients.

Leberzirrhose und hepatorenales Syndrom: Das Ansprechen auf Terlipressin und Albumin ist mit besserem Überleben assoziiert

BACKGROUND AND AIMnHepatorenal syndrome (HRS) is a severe but potentially reversible complication in patients with cirrhosis. Untreated it is associated with a poor prognosis. Several randomized controlled trials (RCT) demonstrated that treatment with terlipressin and albumin improves renal function. However the effect on overall survival is unclear. Aim of the study was to gain further insight into the effect of terlipressin treatment in patients with HRS on renal function, overall survival and survival without liver transplantation or renal replacement.nnnMETHODSnAll patients presenting with HRS and treated with terlipressin in our tertiary referral liver and transplantation center between April 2013 and April 2014 were included. Clinically relevant parameters such as response to therapy, overall survival and transplant- and renal-replacement-free-survival were prospectively investigated.nnnRESULTSnOverall 57 patients were prospectively followed over a median of 65 days. In the majority of patients cirrhosis was in an advanced stage (Child-Pugh C: 46; 81%). Median cumulative terlipressin dosage and treatment duration were 20 mg and 5 days, respectively. Complete or partial response to terlipressin with recovery from HRS was observed in 20 and 3 out of 57 patients (51%; 5%). Median overall survival was significantly better in patients with response to terlipressin than in patients with non-response (167 vs. 27 days; p > 0.0001), as well as median survival free of liver transplantation and renal-replacement-therapy (81 vs. 4 days; p > 0.0001). In uni- and multivariate analysis, non-response was associated with a high baseline serum-bilirubin-concentration.nnnCONCLUSIONnTerlipressin in combination with albumin is effective in the majority of patients with HRS. Response to therapy is associated with improved survival.

Prospective evaluation of the impact of covert hepatic encephalopathy on quality of life and sleep in cirrhotic patients

Minimal hepatic encephalopathy (HE) and HE grade 1 (HE1) according to the West Haven criteria have recently been grouped as one entity named—covert HE‐ (CHE). Data regarding the impact of CHE on health‐related quality of life (HRQoL) and sleep quality are controversial.

Obere gastrointestinale Blutung mit hämorrhagischem Schock am Ende einer Urlaubsreise: Präklinische und innerklinische Versorgung eines gastrointestinalen Notfalls

Upon returning from holidays, a 55-year-old patient presenting with melena and haemorrhagic shock was admitted to a University hospital after receiving first emergency medical care in a German InterCity train. In an interdisciplinary effort, haemodynamics were stabilised and the airway and respiratory function were secured. Under emergency care conditions the patient then underwent an emergency upper GI endoscopy where a spurting arterial upper gastrointestinal bleeding (Forrest 1a) was found. While the bleeding could not be controlled with endoscopic techniques, definitive haemostasis was achieved with a surgical laparotomy. While not commonly established for patients with severe GI bleeding, by spontaneous implementation of an interdisciplinary trauma room approach following established trauma algorithms the team was able to achieve stabilisation of vital functions and final control of bleeding in this highly unstable patient. Although the majority of upper gastrointestinal bleedings spontaneously cease, emergency care algorithms should be developed and implemented for patients with severe gastrointestinal bleedings in shock. Following the case vignette, we discuss a potential approach and develop an exemplary protocol for shock room management in this patient subgroup.Upon returning from holidays, a 55-year-old pa- tient presenting with melena and haemorrhagic shock was admitted to a University hospital after receiving first emergency medical care in a Ger- man InterCity train. In an interdisciplinary effort, haemodynamics were stabilised and the airway and respiratory function were secured. Under emergency care conditions the patient then un- derwent an emergency upper GI endoscopy where a spurting arterial upper gastrointestinal bleeding (Forrest 1a) was found. While the bleed- ing could not be controlled with endoscopic tech- niques, definitive haemostasis was achieved with a surgical laparotomy. While not commonly es- tablished for patients with severe GI bleeding, by spontaneous implementation of an interdisciplin- ary trauma room approach following established trauma algorithms the team was able to achieve stabilisation of vital functions and final control of bleeding in this highly unstable patient. Although the majority of upper gastrointestinal bleedings spontaneously cease, emergency care algorithms should be developed and implemented for pa- tients with severe gastrointestinal bleedings in shock. Following the case vignette, we discuss a potential approach and develop an exemplary protocol for shock room management in this pa- tient subgroup.

The Manchester Triage System (MTS): a score for emergency management of patients with acute gastrointestinal bleeding

BACKGROUNDnu2002Suspected gastrointestinal (GI) bleeding is a common initial diagnosis in emergency departments. Despite existing endoscopic scores to estimate the risk of GI bleeding, the primary clinical assessment of urgency can remain challenging. The 5-step Manchester Triage System (MTS) is a validated score that is often applied for the initial assessment of patients presenting in emergency departments.nnnMETHODSnu2002All computer-based records of patients who were admitted between January 2014 and December 2014 to our emergency department in a tertiary referral hospital were analyzed retrospectively. The aim of our retrospective analysis was to determine if patient triage using the MTS is associated with rates of endoscopy and with presence of active GI bleeding.nnnRESULTSnu2002In summary, 5689 patients with a GI condition were treated at our emergency department. Two hundred eighty-four patients (4.9u200a%) presented with suspected GI bleeding, and 165 patients (58u200a%) received endoscopic diagnostic. Endoscopic intervention for hemostasis was needed in 34 patients (21u200a%). In patients who underwent emergency endoscopy, triage into MTS categories with higher urgency was associated with higher rates of endoscopic confirmation ofxa0suspected GI bleeding (79u200a% of patients with MTS priority levels 1 or 2, 53u200a% in level 3 patients, and 40u200a% in levels 4 or 5 patients; pu200a=u200a0.024).nnnCONCLUSIONSnu2002The MTS is an established tool for triage in emergency departments and could have a potential to guide early clinical decision-making with regards to urgency of endoscopic evaluation in patients with suspected GI bleeding.