Volume 82 - 2019 - Fasc.2 - Original articles
Eosinophilic peak counts in eosinophilic esophagitis : a retrospective study
Background : The histologic diagnosis of eosinophilic esophagitis (Eoe) is based on finding >15 eosinophils/high power field (HPF) on any level within the squamous epithelium of the esophagus. However, this criterion is based on a consensus statement, and controversy remains about the exact number of eosinophils/HPF needed to diagnose Eoe. We aimed to determine eosinophilic peak counts in esophageal, gastric, and duodenal biopsies from suspected Eoe patients, investigate the correlation between eosinophilic peak counts at different biopsy locations, and determine inter-observer and intra-observer reliability in reporting eosinophilic peak counts.
Methods: We selected 103 suspected Eoe patients, who underwent an endoscopic procedure between June 1, 2010 and July 15, 2017. Eosinophilic peak counts in 1 HPF were obtained by a medical student and an experienced gastrointestinal pathologist.
Results : Eosinophilic peak counts in suspected Eoe patients are highly variable (esophagus : IQR 66-178, median 110 ; stomach : IQR 2-10, median 3 ; duodenum : IQR 16-44, median 25). No significant correlation was found between eosinophilic peak counts at different biopsy locations. The inter-observer and intra-observer correlation for reporting eosinophilic peak counts was in the near- perfect range (? ranged from 0.93 to 0.99, P < 0.0001).
Conclusions : Our data suggest that the accuracy of determining eosinophilic peak counts is not influenced by the pathologist's experience. Therefore, variability in reporting eosinophilic peak counts is unlikely to influence the diagnostic accuracy of Eoe. To further improve diagnostic accuracy, investigation of other histologic features observed in Eoe is needed. (Acta gastroenterol. belg., 2019, 82, 243-250).
Necessity of fundoplication and mesh in the repair of the different types of paraesophageal hernia
Background : The management of paraesophageal hernia (PEH) has changed significantly since the introduction of laparoscopic surgery in the 1990's. This study aims to explore the need of a Nissen fundoplication or a posterior gastropexy and the use of mesh reinforcement in the surgical repair of PEH.
Patients and methods : Seventy-three patients with a symptomatic and documented PEH type II, III or IV were included in this retrospective study. The following data were collected: type of PEH, surgical procedure, complications, length of hospital stay, recurrences, time to recurrence, type of PEH recurrence and treatment of recurrent PEH.
Results : All 73 patients underwent laparoscopic surgery without any conversion to open surgery. In 80% a posterior gastropexy was performed, while the remaining 20% suffered from GERD- symptoms and were treated with a Nissen fundoplication. In 18% of the patients a mesh was used as reinforcement of the repair. The surgical repair differed significantly according to the type of PEH. Fourteen percent of the patients suffered from a postoperative complication, pneumothorax and dysphagia being the most frequent. There were no perioperative deaths. The recurrence rate was 22% with a median time to recurrence of 12 months.
Conclusion : Laparoscopic PEH repair is a safe and efficacious procedure with no mortality and minimal early morbidity. The surgical repair of PEH should be adjusted to the type of PEH. However, up until now the literature fails to produce clear guidelines on when to perform a gastropexy or Nissen fundoplication and which patients might benefit from a mesh reinforcement. (Acta gastroenterol. belg., 2019, 82, 251-256).
Endoscopic features, pathological correlates and possible origin of foveolar gastric metaplasia presenting as a duodenal polyp
It has recently been shown that duodenal foveolar gastric metaplasia (FGM) sometimes presents as a polyp. The mechanism by which FGM develops into a polypoid lesion is unknown and it is unclear whether this form of FGM is indistinguishable from other polypoid lesions or whether endoscopists do not recognize it because they are unfamiliar with it.
We identified and retrieved archival cases of FGM endoscopically suspicious for adenomatous polyp and examined their pathological, clinical and endoscopic features.
Endoscopic features of the 13 identified FGMs presenting as polyps were heterogeneous and overlapping with those of adenomatous polyps. FGM was frequently associated with mucosal and submucosal Brunner's glands, but defining and recognizing hyperplasia of these glands remains difficult. Other pathological features could not explain the development of a polypoid lesion.
The endoscopic features of FGM polyps are non-specific, overlapping with those of adenomatous polyps. FGM polyps probably acquire their polypoid aspect due to association with Brunner's gland hyperplasia (BGH), which also arises due to chronic inflammation and damage. Because BGH is ill-defined and difficult to recognize, while FGM is diagnosed easily, this type of polypoid lesions has until now only been recognized based on the presence of FGM, although FGM is most likely a secondary phenomenon and not the primary cause of the polyp. (Acta gastroenterol. belg., 2019, 82, 257-260).
Changes in the patterns and microbiology of spontaneous bacterial peritonitis : analysis of 200 cirrhotic patients
Background & aims : The microbiological characteristics of spontaneous bacterial peritonitis (SBP) are changing worldwide with a shift in patterns of SBP and increasing prevalence of antibiotic-resistant bacteria. We, therefore, conducted this retrospective study aiming to characterise the current patterns and microbiology of SBP in our region.
Methods : We performed a retrospective chart review of patients presenting with their first episodes of SBP. The demographical, clinical and laboratory parameters of all patients at first paracentesis were recorded.
Results : The study included 200 cirrhotic patients with SBP. Mean age was 60.4±13.5 years and 116 (58%) patients were males. Liver cirrhosis was predominantly viral in 138 (69%) patients. Ascitic fluid cultures were positive in 103 (51.5%) patients and negative in 97 (48.5%). Ninety-eight (95.1%) patients had monomicrobial bacterial growth. The most common variants of spontaneous ascitic fluid infection were culture negative neutrocytic ascites (CNNA) in 97(48.5%) patients and SBP in 65 (32.5%) patients. E.Coli was most frequently isolated microorganism in 41 (39.8%) patients followed by staphylococcus species in 19 (18.4%) patients, Klebsiella pneumonae in 14(13.6%) patients and streptococcus species in 13 (10.7%) patients. The prevalence of extended spectrum beta-lactamases (ESBL) resistant E.Coli was 29.3%. Antibiotic resistance rate for meropenem, piperacillin\ tazobactam, ceftriaxone and ciprofloxacin was 0%, 22.0%, 29.0%, and 28.6% respectively.
Conclusions : Changes in the patterns and microbiology of SBP are evident in our region with increasing prevalence of culture negative SBP, extended spectrum beta-lactamases resistant E.Coli, and increased resistance rate to first line antibiotics. Our data argue for relying on periodic hospital based antibiotic susceptibility data whenever SBP is treated. (Acta gastroenterol. belg., 2019, 82, 261-266).
The comparison of the efficacy of diffusion weighted imaging (DWI) sequences with 3 different T2-weighted sequences in the detection of focal liver lesions
Purpose : In this study we aimed to compare and evaluate the efficacies of the low and high b value diffusion weighted imaging (DWI) sequences with three different T2-weighted (T2W) sequences.
Materials and Methods : 255 liver lesions of 147 patients who had undergone MR examinations of the upper abdomen were evaluated. A maximum number of 4 lesions was taken for consideration in patients with multiple lesions. Low and high b valued DWI and 3 different T2W sequences (ssFSE, FIESTA, and PROPELLER FSE) were utilized. The evaluations were done by 3 different radiologists, by utilizing the double blind principle.
Results : The lesion detection performances of the b 0 DWI, b 600 DWI, FIESTA T2W, ssFSE T2W, and PROPELLER FSE T2W sequences, were 95.7 %, 66.3 %, 94.4 %, 92.8 %, and 93.8 %, in sequence order. The high b value DWI sequence was able to detect malignant lesions with a higher accuracy rate than the T2W sequences. There was a moderate to high rate of agreement among the interpreters, and the lesion-detection rates of the interpreters were in line with their levels of expertise.
Conclusion : Even though the higher lesion detection rates of the DWI sequences were not found to be statistically significant, it was concluded that making the evaluations with the addition of DWI to the imaging protocol would certainly decrease the lesion-missing rate, and it would be wise to utilize the DWI technique in routine liver MR imaging. (Acta gastroenterol. belg., 2019, 82, 267-272).
Effects of entecavir, tenofovir and telbivudine treatment on renal functions in chronic hepatitis B patients
Background and study aims : The aim of this study was to enlighten the controversy about the renal safety of entecavir, tenofovir, and telbivudine treatments in chronic hepatitis B (CHB) patients by comparing these treatments in real-world conditions.
Patients and methods : We retrospectively enrolled 104 treatment- naive patients with CHB monoinfection into our study. Patients were treated with entecavir monotherapy (n=38), tenofovir monotherapy (n=35), or telbivudine monotherapy (n=31). We then compared and statistically analyzed the effects of these drugs on the estimated glomerular filtration rate (eGFR) over a 24-month follow-up period.
Results : In the entecavir group, time-dependent change in eGFR was not statistically significant (p = 0.357). There was a statistically significant increase in eGFR in the telbivudine group at 12 months (p < 0.001) and at 24 months (p < 0.001) and, in contrast, a statistically significant decrease in the tenofovir group at 12 months (p < 0.001) and at 24 months (p < 0.001). There was no significant relationship between entecavir and eGFR change (p = 0.763). We found that tenofovir and telbivudine were independent predictors of eGFR change (decrease in eGFR, p < 0.001 and increase in eGFR, p = 0.001, respectively)
Conclusions : We recommend close follow-up of renal functions, especially for patients treated with tenofovir. Telbivudine was superior to the other drugs in terms of renal function. We conclude that an individualized therapy program considering treatment efficacy and side effects is the best option for patients. (Acta gastroenterol. belg., 2019, 82, 273-277).
The efficacy of a computer alert programme for increasing HBV screening rates before starting immunosuppressive therapy
Background/Aim : Hepatitis B Virus (HBV) screening before starting immunosuppressive treatment is of vital importance in order to prevent HBV reactivation and its associated clinical consequences. Despite all recommendations by international organizations, screening rates are far below desired. The aim of this study was to assess the efficacy of a computer alert programme 'HBVision' for increasing HBV screening rates.
Material and Methods : 'HBVision' identifies patients at risk of HBV reactivation by specific ICD-10 codes and immunosuppressive medication reports and sends sequential alert messages to screen for HBsAg, anti-HBc IgG and consult a specialist if one of them is positive. The demographic variables, treatment protocols, HBV screening and consultation rates of oncology and hematology patients who started immunosuppressive treatments within one year before (control group) and after "HBVision" (study group) were retrospectively compared.
Results : HBsAg and anti-HBc IgG screening rates (68.6% and 13.1%, respectively) were significantly higher in the study group (n=602) compared to control group (n=815) (55% and 4.3%, respectively) (p<0.001, for both). Subgroup analysis revealed significant improvements in the screening rates of HBsAg (65.8%) and anti-HBc IgG (5.1%) in oncology patients (p<0.001), anti-HBc IgG (89.1%) in hematology patients (p<0.001).
Conclusion : The computer alert programme significantly increased HBV screening rates before starting immunosuppressive treatments, however the results were still below ideal. Additional efforts, such as modifying the computer programme according to feedbacks, are probably needed. (Acta gastroenterol. belg., 2019, 82, 279-284).
Relationship between nucleotide-binding oligomerization domain-containing protein 2 variants and severity of acute pancreatitis
Background and aim : Intestinal barrier dysfunction has been implicated in the development of infectious complications of acute pancreatitis. Nucleotide-Binding Oligomerization Domain- Containing Protein 2 (NOD2) plays an important role in the proper functioning of intestinal defense mechanisms. Here, we investigated the frequency of NOD2 variants in patients with mild and severe acute pancreatitis.
Materials and Methods : Groups 1, 2 and 3 comprised healthy participants and patients with mild and severe pancreatitis, respectively. Four NOD2 variants and serum interleukin-6 (IL-6), Tumor Necrosis Factor-a (TNF-a) and lipopolysaccharide-binding protein (LBP) levels were analyzed.
Results : Three patients (3/32, 9.4%) in the severe pancreatitis group were positive for the p.R702W variant. This variant was negative in other groups. One, three and three patients in the healthy (1/27, 3.7%), mild (3/36, 8.3%) and severe pancreatitis (3/32, 9.4%) groups tested positive for the 1007fs variant, respectively. No significant differences in the frequencies of NOD2 variants were evident among the groups. Serum IL-6, TNF-a and LBP levels were markedly higher in the severe pancreatitis than the healthy and mild pancreatitis groups (all p<0.001). We observed no significant correlation between cytokine levels and NOD2 variants.
Conclusion : Our results support an association between the presence of the p.R702W variant and severe pancreatitis. (Acta gastroenterol. belg., 2019, 82, 285-290).
