Tomislav Bokun

Real-time two-dimensional shear wave ultrasound elastography of the liver is a reliable predictor of clinical outcomes and the presence of esophageal varices in patients with compensated liver cirrhosis

Aim Primary: to evaluate predictivity of liver stiffness (LS), spleen stiffness (SS), and their ratio assessed by real-time 2D shear wave elastography (RT-2D-SWE) for adverse outcomes (hepatic decompensation, hepatocellular carcinoma or death; “event”) in compensated liver cirrhosis (LC) patients. Secondary: to evaluate ability of these measures to discriminate between cirrhotic patients with/without esophageal varices (EV). Methods Predictivity of LS, SS, and LS/SS was assessed in a retrospectively analyzed cohort of compensated LC patients (follow-up cohort) and through comparison with incident patients with decompensated cirrhosis (DC) (cross-sectional cohort). Both cohorts were used to evaluate diagnostic properties regarding EV. Results In the follow-up cohort (n = 44) 18 patients (40.9%) experienced an “event” over a median period of 28 months. LS≥21.5 kPa at baseline was independently associated with 3.4-fold (95% confidence interval [CI] 1.16-10.4, P = 0.026) higher risk of event. Association between SS and outcomes was weaker (P = 0.056), while there was no association between LS/SS ratio and outcomes. Patients with DC (n = 43) had higher LS (35.3 vs 18.3 kPa, adjusted difference 65%, 95% CI 43%-90%; P < 0.001) than compensated patients at baseline. Adjusted odds of EV increased by 13% (95% CI 7.0%-20.0%; P < 0.001) with 1 kPa increase in LS. At cut-offs of 19.7 and 30.3 kPa, LS and SS had 90% and 86.6% negative predictive value, respectively, to exclude EV in compensated patients. Conclusion This is the first evaluation of RT-2D-SWE as a prognostic tool in LC. Although preliminary and gathered in a limited sample, our data emphasize the potential of LS to be a reliable predictor of clinical outcomes and the presence of EV in LC patients.

Liver Elastography Malignancy Prediction (LEMP) score for noninvasive characterization of Focal Liver Lesions

To analyse elastographic characteristics of focal liver lesions (FLL)s and diagnostic performance of real‐time two‐dimensional shear‐wave elastography (RT‐2D‐SWE) in order to differentiate benign and malignant FLLs.

EUS-Guided Vascular Procedures: A Literature Review

Endoscopic ultrasound (EUS) is continuously stepping into the therapeutic arena, simultaneously evolving in different directions, such as the management of pancreatic and biliary diseases, celiac neurolysis, delivering local intratumoral therapy, and EUS-guided endosurgery. EUS-guided vascular procedures are also challenging, considering the variety of vascular pathology, proximity of the vascular structures to the GI tract wall, high resolution, and real-time guidance offering an attractive access route and precise delivery of the intervention. The literature on vascular therapeutic EUS demonstrates techniques for the management of upper GI variceal and nonvariceal bleeding, pseudoaneurysms, and coiling and embolization procedures, as well as the creation of intrahepatic portosystemic shunts. The paucity of studies, diversity of study designs, and the number of animal model studies hamper a systematic approach to the conclusion and decision making important to clinicians and healthcare policy makers. Nevertheless, theoretical benefits and findings up to date concerning technical feasibility, efficacy, and safety of the procedures drive further research and development in this rather young therapeutic arena.

Leptomeninges as the first and only dissemination site of colorectal cancer

Dear Editor, Colorectal cancer (CRC) is one of the most common cancer types in the world, ranked second in developed countries for both genders, with the incidence of around 70–80 per population of 100,000. CRC disseminates most frequently to liver, lung, and bones, whereas it is rather rare in other organs. The incidence of colorectal adenocarcinoma dissemination to the leptomeninges is not estimated and seems to be quite rare. We report a case of a woman with CRC and the disease dissemination to the leptomeninges as the first and only dissemination site. A 61-year-old woman presented to the infectious diseases emergency room with a one-month history of fatigue, fever, photophobia, and mild headache that progressed to severe headache and vertigo. All of these symptoms appeared shortly after a mild conjunctivitis on both eyes that was treated with tobramycin eye-drops. The patient also emphasized a 1-year history of strabismus of the right eye and substantial weight loss of about 12 kg in a period of several months. She had no history of malignancies or any other serious diseases. Fifteen years ago, she had cataract surgery with a plastic lens implemented in her left eye. Physical examination, except for nonparalytic convergent strabismus of the right eye, was unremarkable with no clinical signs of meningitis. Body temperature was 38.0°C. Upon admission to the infectious diseases ward, a lumbar puncture was performed. The cerebrospinal fluid (CSF) analysis showed hypercellular sterile CSF with predominantly adenocarcinoma cells of unknown origin with elevated total protein level (64.5 g/dL) and low glucose level (1.9 mmol/L—33% of the blood level). The contrast-enhanced computed tomography (CECT) of the brain, made in order to enlighten this finding, did not find any pathological substrate except mild maxillary sinusitis on the left. Computed tomography (CT) of the abdomen was performed thereafter, and a large tumor mass in the ascending colon was found, though the patient had no symptoms or clinical signs of gastrointestinal obstruction. No lesions elsewhere in the abdomen were detected. Chest X-ray examination was normal. Thereafter, the patient was referred to the gastroenterology ward. Physical examination on admission to the gastroenterology ward showed moderate pain on deep palpation in the right iliac region and nonparalytic convergent strabismus of the right eye with hypermature cataract of the same eye. Neurological examination revealed no evidence of motor dysfunction or sensory changes including pathologic reflexes, except the aforementioned convergent strabismus, photophobia, and vertigo. The complete blood count revealed mild anemia with hemoglobin concentration of 114 g/L. Laboratory serum examination results showed high cholesterol (7.56 mmol/L) and triglyceride (2.84 mmol/L) level, increased gamma glutamyl-transpeptidase (90 U/L) and low concentration of iron (2.5 μmol/L). Blood coagulation was also slightly impaired with prothrombin time of 0.93 INR, fibrinogen of 5.8 g/L, and prolonged fibrinolysis. Additionally, C-reactive protein of 31.1 mg/L was detected. Tumor marker carbohydrate antigen 19-9 was highly increased (>1,000 kIU/L) with carcinoembryonic Int J Colorectal Dis (2009) 24:355–356 DOI 10.1007/s00384-008-0560-7

Treatment of Pancreatic Diseases

Treatment of acute pancreatitis should be started as early as possible because fluid resuscitation in the first 24 h is of the utmost importance. Pain should be alleviated and early changes to nutrition considered. Antibiotics should not be introduced unless signs of systemic inflammatory response syndrome with suspicion of infection, concomitant biliary infection, or another organ infection are present. Various local complications can occur, which may be treated conservatively, minimally invasively, or surgically. Early endoscopic biliary decompression should be considered in patients with biliary pancreatitis. For chronic pancreatitis, lifestyle modifications should be encouraged, and pain relief medications should be gradually introduced. Patients with obstructive forms of chronic pancreatitis might benefit from endoscopic treatment, whereas surgical treatment should be considered for patients with disabling pain that cannot be controlled by medical treatment and is refractory to endoscopic treatment. Pancreatic exocrine insufficiency is often difficult to define and should be treated with pancreatic enzyme replacement therapy. Pancreatic cancer has a poor prognosis, and its management depends on the disease stage. Generally, in cases of resectable illness, surgery should be considered, with postoperative chemotherapy. Locally advanced disease (unresectable) can be treated with chemo(radio)therapy or stereotactic body radiotherapy; the best supportive care should be offered to patients with poor performance status. Systemic chemotherapy should be considered for patients with metastatic disease, and supportive care and palliative treatment should be provided.

Editorial Comment to Non-invasive assessment of kidney allograft fibrosis with shear wave elastography: A radiological-pathological correlation analysis

Kidney transplantation is the best treatment option for patients with end-stage renal disease. Despite major improvements in surgical techniques and immunosuppression therapy, today, long-term allograft survival after kidney transplantation remains a major clinical issue. The most common cause of late allograft failure is chronic allograft nephropathy (CAN), which is a consequence of various immune-dependent and immune-independent factors. Aside from other histological findings (glomerulopathy, tubular atrophy, vasculopathy), the most prominent histological characteristic of CAN is interstitial fibrosis, which is a strong predictor of kidney allograft failure, and the early appearance of CAN is an independent predictor for poor long-term kidney transplant survival. Biopsy remains the “gold standard” for the evaluation of kidney allograft dysfunction, thus some transplant units carry out protocol biopsies for CAN detection. However, kidney biopsy has some limitations, such as its invasive nature (with risk of complications) and sampling error, as well as total costs and patient discomfort. In contrast, some transplant centers monitor changes in serum creatinine values in order to detect CAN, but this occurs late in the course of the disease when significant and irreversible histological changes have already developed, precluding timely interventions in order to prevent further damage to the kidney transplant. Therefore, non-invasive methods for early CAN detection are required. Ultrasound elastography (UE) methods determine tissue stiffness, and have been extensively evaluated in the context of liver fibrosis in the past two decades. In recent years, some investigators reported on the efficacy of UE methods in evaluating kidney allograft fibrosis. A few years ago, we published our results on the usefulness of transient elastography in the assessment of CAN in our renal transplant recipients. However, transient elastography allows only unidimensional measurements without the possibility to precisely position and to adjust the size and depth of the region of interest for stiffness evaluation. Thus, we rejoice in reading the great experience of Ma et al. from Hong Kong that evaluated the use of shear wave elastography (SWE) in the assessment of kidney allograft tubulointerstitial fibrosis, which is a real-time two-dimensional method that allows clinicians to precisely choose the region of interest for stiffness evaluation. The authors investigated the relationship between tissue stiffness and histological severity of tubulointerstitial fibrosis in 32 patients. Interestingly, they showed that the tissue stiffness determined by SWE correlated with the histological severity of interstitial fibrosis and tubular atrophy, with good interobserver agreement. More importantly, SWE performed better than serum creatinine in detecting early tubulointerstitial fibrosis. To conclude, we agree with the authors that SWE and other two-dimensional UE methods have the potential to become non-invasive bedside tests for screening patients at risk for early changes related to CAN. These methods are promising because they are reliable, noninvasive, safe, fast, low cost, increasingly available and can be carried out on an ambulatory basis. However, these methods cannot verify the cause of CAN and the degree of fibrosis, thus, the current value of UE methods in the assessment of kidney allograft function still remains experimental and more in the field of screening or follow-up methods. More investigations with larger sample sizes are required to define the exact role of these methods in kidney transplantation patients. As other authors also suggested, the main role of UE methods could be in the long-term observation and evaluation of allograft fibrosis during follow up, possibly selecting patients for timely (re)evaluation with kidney biopsy.

Gastroesophageal reflux disease, Barrett esophagus, and esophageal adenocarcinoma – where do we stand?

Almost 25% of all human cancers are located in the gastrointestinal tract (GIT), making it the dominant cancer-affected site. The reason for this could be constant GIT exposure to organ damage and chronic inflammation (1). Despite all medical breakthroughs, less than half of patients survive one year after the esophageal adenocarcinoma (EAC) diagnosis (2). Most malignancies, including most GIT malignancies, are preceded by precursor/premalignant lesions. Premalignant condition for EAC development is Barrett esophagus (BE), a disorder characterized by abnormal transformation of the squamous epithelium. BE is strongly associated with prolonged gastro-esophageal reflux of gastric and bile acids (1,3,4). Since patients with BE carry 30-40 times higher risk for EAC than general population, it is not surprising that in the last 10-20 years the research interest in BE has been growing (3).