Matea Majerović

Endoscopic ultrasound elastography strain histograms in the evaluation of patients with pancreatic masses

AIM To investigate the accuracy of the strain histogram endoscopic ultrasound (EUS)-based method for the diagnostic differentiation of patients with pancreatic masses. METHODS In a prospective single center study, 149 patients were analyzed, 105 with pancreatic masses and 44 controls. Elastography images were recorded using commercially available ultrasound equipment in combination with EUS linear probes. Strain histograms (SHs) were calculated by machine integrated software in regions of interest and mean values of the strain histograms were expressed as Mode 1 (over the mass) and Mode 2 (over an adjacent part of pancreatic tissue, representing the reference area). The ratio between Mode 2 and Mode 1 was calculated later, representing a new variable, the strain histogram ratio. After the final diagnosis was established, two groups of patients were formed: a pancreatic cancer group with positive cytology achieved by fine needle aspiration puncture or histology after surgery (58 patients), and a mass-forming pancreatitis group with negative cytology and follow-up after 3 and 6 mo (47 patients). All statistical analyses were conducted in SPSS 14.0 (SPSS Inc., Chicago, IL, United States). RESULTS Results were obtained with software for strain histograms with reversed hue scale (0 represents the hardest tissue structure and 255 the softest). Based on the receiver operating characteristics (ROC) curve coordinates, the cut-off point for Mode 1 was set at the value of 86. Values under the cut-off point indicated the presence of pancreatic malignancy. Mode 1 reached 100% sensitivity and 45% specificity with overall accuracy of 66% (95%CI: 61%-66%) in detection of pancreatic malignant tumors among the patients with pancreatic masses. The positive and negative predictive values were 54% and 100%, respectively. The cut-off for the new calculated variable, the SH ratio, was set at the value 1.153 based on the ROC curve coordinates. Values equal or above the cut-off value were indicative of pancreatic malignancy. The SH ratio reached 98% sensitivity, 50% specificity and an overall accuracy of 69% (95%CI: 63%-70%). The positive and negative predictive values were 92% and 100%, respectively. CONCLUSION SH showed high sensitivity in pancreatic malignant tumor detection but disappointingly low specificity. Slight improvements in specificity and accuracy were achieved using the SH ratio.

Rectal cancer and Fournier’s gangrene - current knowledge and therapeutic options

Fourniers gangrene (FG) is a rapid progressive bacterial infection that involves the subcutaneous fascia and part of the deep fascia but spares the muscle in the scrotal, perianal and perineal region. The incidence has increased dramatically, while the reported incidence of rectal cancer-induced FG is unknown but is extremely low. Pathophysiology and clinical presentation of rectal cancer-induced FG per se does not differ from the other causes. Only rectal cancer-specific symptoms before presentation can lead to the diagnosis. The diagnosis of rectal cancer-induced FG should be excluded in every patient with blood on digital rectal examination, when urogenital and dermatological causes are excluded and when fever or sepsis of unknown origin is present with perianal symptomatology. Therapeutic options are more complex than for other forms of FG. First, the causative rectal tumor should be removed. The survival of patients with rectal cancer resection is reported as 100%, while with colostomy it is 80%. The preferred method of rectal resection has not been defined. Second, oncological treatment should be administered but the timing should be adjusted to the resolution of the FG and sometimes for the healing of plastic reconstructive procedures that are commonly needed for the reconstruction of large perineal, scrotal and lower abdominal wall defects.

Differentiation of Pancreatic Masses via Endoscopic Ultrasound Strain Ratio Elastography Using Adjacent Pancreatic Tissue as the Reference.

Objectives The aims of this study were to evaluate diagnostic value of endoscopic ultrasound strain ratio elastography in patients with focal pancreatic masses and to determine the cutoff value between the pancreatic malignancies and inflammatory pancreatic masses using reference areas different than those used by other investigators. Methods In a prospective single-center study, strain ratio was measured in patients with pancreatic masses. After the diagnosis was established, statistical analysis was used to compare the group with pancreatic malignancies to the one with inflammatory masses. Results Strain ratio cutoff of 7.59 provided 100% sensitivity, 95% specificity, and 97% overall accuracy for differentiation of patients with pancreatic malignancies from those with inflammatory masses. Conclusions Our data show high sensitivity and specificity for the calculated strain ratio. Adjacent normal pancreatic tissue is adequate as a reference area based on the inclusion criteria. Diverse cutoff values and standardization of methods in the studies published so far require further investigations, before the implementation of the method in a routine clinical practice becomes possible.

Terminal ileum resection as a trigger for Strongyloides stercoralis hyperinfection and ensuing serial sepsis in a 37-year-old patient with complicated Crohnʼs disease: a case report

The nematode Strongyloides stercoralis, outside the tropics and subtropics present in small endemic foci, can cause an infection after direct skin contact with contaminated soil containing infective filariform larvae and, rarely, after intimate interhuman contact or after transplantation of an infected solid organ. Following skin penetration, migration, and maturation through several stages, a small number of invasive filariform larvae can develop anew in the gut lumen, perpetuating new cycles of penetration, tissue migration, and reproduction, without leaving the host.In a state of immunosuppression, autoinfection can progress to life-threatening hyperinfection and/or infection disseminated through virtually any organ. In developed countries, the most frequently recognized risk for severe hyperinfection is corticosteroid therapy, but this has been also described in malnourished, alcoholic, cancer, and transplant patients. Due to the frequent need for immunosuppressive therapy, patients suffering from inflammatory bowel disease (IBD) are susceptible to develop overwhelming strongyloidiasis. Strongyloidiasis can be easily overlooked in clinical settings, and in many European regions there is poor insight into the epidemiological burden of this disease.We present a case of S. stercoralis hyperinfection that triggered 3 successive episodes of sepsis caused by pathogens of the gut flora in a young patient suffering from stenotic form of Crohns disease. S. stercoralis hyperinfection occurred in the corticosteroid-free period, shortly after resection of the terminal ileum, which was probably the trigger for the overwhelming course. The patient was successfully treated with 10-day albendazole therapy.

P655 Diffuse jejunoileitis – a unique subtype of Crohn's disease?

with a nation-wide survey in 19 community hospitals and 12 academic referral centers. Methods: The survey was conducted between June and December 2011, using a standardized questionnaire administered during the hospital visits over a one month period. The patients’ attitudes and perceptions, adherence to therapy, QoL (assessed by IBDQ), and access to health service was evaluated. Eligible patients (pts) consisted of men and women at least of 15 years of age with UC confirmed by standard clinical, endoscopic and histopathological criteria. Pts with previous colectomy or proctitis were excluded. Results: A total of 858 pts completed the survey. The majority self-reported to be in remission (51%), with a mean of 4.1 flares during the past 5 years with no differences for age and gender. A mean of 1.1 and 0.5 hospitalizations related or not to UC during the past 5 years were reported, respectively. Overall, the IBDQ scores were similar in pts with disease duration over 10 years than in pts diagnosed less than 3 years (4.97 and 5.01, respectively). The IBDQ scores were also lower in pts with active and chronically active disease than in pts with remission (4.18, 4.22 and 5.55, respectively). Only 35% of pts on combined (oral and topical) therapy reported to adhere to treatment, whereas 47% of pts reported to forget at least one pill during last 2 weeks. Twenty-eight per cent of pts reported a poor adherence to therapy, irrespective of gender, education, and employment status. Conclusions: Patients generally revealed a great impact of UC on day-by-day life, including disease burden and control, quality of life, coping skills, and treatment adherence. On behalf of: Ardizzone S. Milano, Atzei A. Cagliari, Bernasconi G. Busto Arsizio, Biancone L. Roma, Castiglione F. Napoli, Coccia G. Genova, D’Inca’ R. Padova, Costa F. Pisa, Danese S. Milano, Daperno M. Torino, De Petris G. Trento, Di Mario F. Treviso, Di Todaro E. Taranto, Di Sabatino A. Pavia, Fries W. Messina, Gallo V. Salerno, Gionchetti P. Bologna, Hadad Y. Lecce, Kohn A. Roma, Manca A. Cuneo, Milla M. Firenze, Merli M. Roma, Neri M. Chieti, Orlando A. Palermo, Pomarico G. Andria, Salvagnini M. Vicenza, Sarpi L. Perugia, Terpin M. Legnano, Tomarelli L. Ancona, Vecchi M. Milano, Zilli M. Udine.

P303 Anticardiolipin antibodies as potential serologic markers of thrombosis risk in IBD patients; a pilot study in referral IBD center

Results: 98 patients were recruited. One patient was lost to follow up and the care of 4 patients was transferred to another centre before 12 months of follow up data was available. Of the 93 remaining patients 11 (12%) relapsed within 12 months. The median FC was lower for non-relapsers, 79mg/g (IQR 39 226) than for relapsers, 322mg/g (IQR 136 557) (p = 0.002). The area under the ROC curve to predict relapse using FC was 74.8%. (Figure 1). Utilising a cut-off FC value of 240mg/g to predict relapse of quiescent Crohn’s disease over the course of one year was associated with a sensitivity of 72.7% and specificity of 74.3%, negative predictive value was high at 95.3% and a positive predictive value of 27.6%. On Kaplan Meier plots, there is a significant difference in time to relapse for those with the first FC value below or above 240 mg/g (p = 0.01) (Figure 2).