Paul Meunier

Development of the Lémann Index to Assess Digestive Tract Damage in Patients With Crohn's Disease

BACKGROUND & AIMS There is a need for a scoring system that provides a comprehensive assessment of structural bowel damage, including stricturing lesions, penetrating lesions, and surgical resection, for measuring disease progression. We developed the Lémann Index and assessed its ability to measure cumulative structural bowel damage in patients with Crohns disease (CD). METHODS We performed a prospective, multicenter, international, cross-sectional study of patients with CD evaluated at 24 centers in 15 countries. Inclusions were stratified based on CD location and duration. All patients underwent clinical examination and abdominal magnetic resonance imaging analyses. Upper endoscopy, colonoscopy, and pelvic magnetic resonance imaging analyses were performed according to suspected disease locations. The digestive tract was divided into 4 organs and subsequently into segments. For each segment, investigators collected information on previous operations, predefined strictures, and/or penetrating lesions of maximal severity (grades 1-3), and then provided damage evaluations ranging from 0.0 (no lesion) to 10.0 (complete resection). Overall level of organ damage was calculated from the average of segmental damage. Investigators provided a global damage evaluation (from 0.0 to 10.0) using calculated organ damage evaluations. Predicted organ indexes and Lémann Index were constructed using a multiple linear mixed model, showing the best fit with investigator organ and global damage evaluations, respectively. An internal cross-validation was performed using bootstrap methods. RESULTS Data from 138 patients (24, 115, 92, and 59 with upper tract, small bowel, colon/rectum, and anus CD location, respectively) were analyzed. According to validation, the unbiased correlation coefficients between predicted indexes and investigator damage evaluations were 0.85, 0.98, 0.90, 0.82 for upper tract, small bowel, colon/rectum, anus, respectively, and 0.84 overall. CONCLUSIONS In a cross-sectional study, we assessed the ability of the Lémann Index to measure cumulative structural bowel damage in patients with CD. Provided further successful validation and good sensitivity to change, the index should be used to evaluate progression of CD and efficacy of treatment.

Effects of infliximab therapy on transmural lesions as assessed by magnetic resonance enteroclysis in patients with ileal Crohn's disease☆ , ☆☆ , ★

BACKGROUND AND AIMS Anti TNF therapy induces mucosal healing in patients with Crohns disease, but the effects on transmural inflammation in the ileum are not well understood. Magnetic resonance-enteroclysis (MRE) offers excellent imaging of transmural and peri-enteric lesions in Crohns ileitis and we aimed to study its responsiveness to anti TNF therapy. METHODS In this multi-center prospective trial, anti TNF naïve patients with ileal Crohns disease and with increased CRP and contrast enhanced wall thickening received infliximab 5 mg/kg at weeks 0, 2 and 6, and q8 weeks maintenance MRE was performed at baseline, 2 weeks and 6 months and assessed based on a predefined MRE score of severity in ileal Crohns Disease. RESULTS Twenty patients were included; of those, 18 patients underwent MRE at week 2 and 15 patients at weeks 2 and 26 as scheduled. Inflammatory components of the MRE index decreased by ≥2 points and by ≥50% at week 26 (primary endpoint) in 40% and 32% of patients (per protocol and intention to treat analysis, respectively). The MRE index improved in 44% at week 2 and in 80% at week 26. Complete absence of inflammatory lesions was observed in 0/18 at week 2 and 13% (2/15) at week 26. The obstructive elements did not change. Clinical and CRP improvement occurred as early as wk 2, but only CDAI correlated with the MRE index. CONCLUSION Improvement of MRE occurs from 2 weeks after infliximab therapy onwards and correlates with clinical response but normalization of MRE is rare.

Role of endoscopy, cross-sectional imaging and biomarkers in Crohn's disease monitoring

Crohns disease is characterised by recurrent and/or chronic inflammation of the gastrointestinal tract leading to cumulative intestinal tissue damage. Treatment tailoring to try to prevent this tissue damage as well as achieve optimal benefit/risk ratio over the whole disease course is becoming an important aspect of Crohns disease management. For decades, clinical symptoms have been the main trigger for diagnostic procedures and treatment strategy adaptations. However, the correlation between symptoms and intestinal lesions is only weak. Furthermore, preliminary evidence suggests that a state of remission beyond the simple control of clinical symptoms, and including mucosal healing, may be associated with better disease outcome. Therefore monitoring the disease through the use of endoscopy and cross-sectional imaging is proposed. However, the degree of mucosal or bowel wall healing that needs to be reached to improve disease outcome has not been appropriately studied. Furthermore, owing to their invasive nature and cost, endoscopy and cross-sectional imaging are not optimal tools for the patients or the payers. The use of biomarkers as surrogate markers of intestinal and systemic inflammation might help. Two biomarkers have been most broadly assessed in Crohns disease: C-reactive protein and faecal calprotectin. These markers correlate significantly with endoscopic lesions, with the risk of relapse and with response to therapy. They could be used to help make decisions about diagnostic procedures and treatment. In particular, with the use of appropriate threshold values, they could determine the need for endoscopic or medical imaging procedures to confirm the disease activity state.

Non-invasive approaches in the diagnosis of acute rejection in kidney transplant recipients, part II: omics analyses of urine and blood samples

Kidney transplantation (KTx) represents the best available treatment for patients with end-stage renal disease. Still, the full benefits of KTx are undermined by acute rejection (AR). The diagnosis of AR ultimately relies on transplant needle biopsy. However, such an invasive procedure is associated with a significant risk of complications and is limited by sampling error and interobserver variability. In the present review, we summarize the current literature about non-invasive approaches for the diagnosis of AR in kidney transplant recipients (KTRs), including in vivo imaging, gene-expression profiling and omics analyses of blood and urine samples. Most imaging techniques, such as contrast-enhanced ultrasound and magnetic resonance, exploit the fact that blood flow is significantly lowered in case of AR-induced inflammation. In addition, AR-associated recruitment of activated leucocytes may be detectable by 18F-fluorodeoxyglucose positron emission tomography. In parallel, urine biomarkers, including CXCL9/CXCL10 or a three-gene signature of CD3ε, CXCL10 and 18S RNA levels, have been identified. None of these approaches has yet been adopted in the clinical follow-up of KTRs, but standardization of analysis procedures may help assess reproducibility and comparative diagnostic yield in large, prospective, multicentre trials.

Non-invasive approaches in the diagnosis of acute rejection in kidney transplant recipients. Part I. In vivo imaging methods

Kidney transplantation (KTx) represents the best available treatment for patients with end-stage renal disease. Still, full benefits of KTx are undermined by acute rejection (AR). The diagnosis of AR ultimately relies on transplant needle biopsy. However, such an invasive procedure is associated with a significant risk of complications and is limited by sampling error and interobserver variability. In the present review, we summarize the current literature about non-invasive approaches for the diagnosis of AR in kidney transplant recipients (KTRs), including in vivo imaging, gene expression profiling and omics analyses of blood and urine samples. Most imaging techniques, like contrast-enhanced ultrasound and magnetic resonance, exploit the fact that blood flow is significantly lowered in case of AR-induced inflammation. In addition, AR-associated recruitment of activated leukocytes may be detectable by 18F-fluoro-deoxy-glucose positron emission tomography. In parallel, urine biomarkers, including CXCL9/CXCL10 or a three-gene signature of CD3ε, IP-10 and 18S RNA levels, have been identified. None of these approaches has been adopted yet in the clinical follow-up of KTRs, but standardization of procedures may help assess reproducibility and compare diagnostic yields in large prospective multicentric trials.

GIST anale@@@Anal GIST

RésuméLes tumeurs stromales gastrointestinales (GIST) sont les tumeurs mésenchymateuses les plus fréquentes du tractus gastro-intestinal. Elles sont positives pour le c-kit (CD117). Elles sont plus fréquentes chez l’homme adulte et se localisent la plupart du temps dans l’estomac et moins fréquemment dans le côlon, le rectum et l’œsophage. La GIST rectale survient peu fréquemment et la GIST anale est encore plus rare. La résection chirurgicale est le traitement de choix pour les GIST résécables ainsi que pour les autres tumeurs mésenchymateuses bénignes ou malignes. Elles seront le plus souvent traitées par une amputation abdomino-périnéale.Un diagnostic de nature et un staging précis préopératoire sont indispensables pour une prise en charge optimale. Nous rapportons ici le cas d’une patiente porteuse d’une GIST du canal anal et discuterons des caractéristiques de cette entité peu fréquente.SummaryGastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. They are positive to c-kit (CD117), more frequent in adult male, and are mostly found in the stomach, more rarely in the colon, rectum and oesophagus. Rectal GIST is uncommon, and anal GIST is even rarer. Surgery is the treatment of choice for resectable GISTs, and for other benign or malignant mesenchymal tumours. Surgery treatment consist of abdomino-perineal resection. Preoperative pathological diagnosis and staging are required. We hereafter report the case of one patient with anal GIST and discuss the characteristics of this rare entity.

Alveolar echinococcosis in southern Belgium: retrospective experience of a tertiary center.

Dear Editor, Alveolar Echinococcosis (EA) is a zoonosis due to the larval stage of the fox tapeworm Echinococcus multilocuris. Humans are dead-end hosts and are exposed through sylvatic (fox) or domestic (cat and dog) cycles. Infection is acquired through the fecal-oral route. The metacestodes of E. multilocularis proliferate in the liver, inducing a Btumorlike^ lesion that can invade the neighboring organs or spread away from the primary lesion [1]. Until recently, Belgium was considered as a low-risk country for AE. However, in 2008, Hanosset et al. demonstrated by necropsies of red foxes (Vulpes vulpes), a prevalence of AE at up to 60% in some parts of Wallonia, the Southern part of Belgium [2]. The first indigenous Belgian human AE case was diagnosed in 1999 at the Centre Hospitalier Universitaire (CHU) of Liege, a tertiary university hospital in Wallonia [3]. Since this first case, other patients have been diagnosed with EA and managed by the different departments of the CHU Liege [4]. The aim of this study was to evaluate the overall experience and results of the different teams of the CHU Liege with AE and to better determine the number of indigenous AE cases to provide this information to authorities in charge of public health. After University Hospital Ethical committee approval, the authors retrospectively collecteddata from the laboratoryof clinical microbiology (for Echinococcus serologies and PCR), the hospital pharmacy in charge of supplying albendazole, and by searching through patient files from themedico-economic informationservice. Informationwascollectedfrom1999toFebruary 2018. Belgian regulations do not require patient informed consent for a purely retrospective review of medical files. Between 1999 and February 2018, a total of 22 human indigenous AE cases were recorded and their medical files were studied. In all cases, the diagnosis was established based on Echinococcus sp. serology (inhibition of hemagglutination (Fumouze, France), ELISA specific for E. granulosus (Rbiopharm, Germany) and E. multilocularis (Bordier, Suisse) respectively and Western Blot), clinical imaging, histopathology and in some cases an E. multilocularis specific PCR assay on tissue [5]. According to the criteria of Brunetti et al. [1], 11 possible and 11 confirmed cases were diagnosed. The mean age of the patients at the time of diagnosis was 69 years (ranges: 34–85 years). Sixty-four percent of the patients were male. Some degree of immunosuppression could be identified in 36% of cases (solid or hematologic cancers, chronic inflammatory disease, diabetes, and chronic alcoholism). At least one of the risk factors described by Conraths et al. [6] (owning a dog and/or a cat, living in a rural zone, working as farmer, or forestry worker) was identified in all patients but one (data are missing). Patients lived in rural * Audrey Cambier au.cambier@gmail.com

Hepatic alveolar echinococcosis.

Olivier Detry, Nicolas Meurisse, Jean Delwaide, Jean-Baptiste Giot, Philippe Leonard, Bertrand Losson, Marie-Pierre Hayette, Noella Bletard, Paul Meunier and Pierre Honor e Department of Abdominal Surgery and Transplantation, CHU Liege, University of Liege (CHU-ULg), Liege, Belgium; Multidisciplinary Unit for Echinococcosis Management and Research of the University of Liege (Echino-Liege), University of Liege, Liege, Belgium; Department of Hepatogastroenterology, CHU Liege, University of Liege (CHU-ULg), Liege, Belgium; Department of Infectious diseases, CHU Liege, University of Liege (CHU-ULg), Liege, Belgium; Laboratory of Parasitology and Pathology of Parasitic Diseases, Faculty of Veterinary Medicine, University of Liege (ULg), Liege, Belgium; Department of Microbiology, CHU Liege, University of Liege (CHU-ULg), Liege, Belgium; Department of Pathology, CHU Liege, University of Liege (CHU-ULg), Liege, Belgium; Department of Radiology, CHU Liege, University of Liege (CHU-ULg), Liege, Belgium

Acute pelvic inflammatory disease as a rare cause of acute small bowel obstruction

Abstract Introduction: Small bowel obstruction (SBO) is a common presentation to emergency abdominal surgery. The most frequent causes of SBO are congenital, postoperative adhesions, abdominal wall hernia, internal hernia and malignancy. Patients: A 27-year-old woman was hospitalized because of acute abdominal pain, blockage of gases and stools associated with vomiting. Abdominal computed tomography showed an acute small bowel obstruction without any obvious etiology. In view of important abdominal pain and the lack of clear diagnosis, an explorative laparoscopy was performed. Diagnostic of pelvic inflammatory disease was established and was comforted by positive PCR for Chlamydia Trachomatis. Results: Acute small bowel obstruction resulting from acute pelvic inflammatory disease, emerging early after infection, without any clinical or X-ray obvious signs was not described in the literature yet. This infrequent acute SBO etiology but must be searched especially when there is no other evident cause of obstruction in female patients. Early laparoscopy is mostly advised when there are some worrying clinical or CT scan signs.

18-Fluoro-deoxyglucose uptake in inflammatory hepatic adenoma: A case report

Positron emission tomography computed tomography (PET-CT) using 18-Fluoro-deoxyglucose (18FDG) is an imaging modality that reflects cellular glucose metabolism. Most cancers show an uptake of 18FDG and benign tumors do not usually behave in such a way. The authors report herein the case of a 38-year-old female patient with a past medical history of cervical intraepithelial neoplasia and pheochromocytoma, in whom a liver lesion had been detected with PET-CT. The tumor was laparoscopically resected and the diagnosis of inflammatory hepatic adenoma was confirmed. This is the first description of an inflammatory hepatic adenoma with an 18FDG up-take.