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Background & Aims: Real-world assessments of efficacy and safety of advanced therapies used for inflammatory bowel disease (IBD) patients are limited. We aimed to report safety, efficacy and treatment persistence of new molecules (infliximab, adalimumab, vedolizumab, tofacitinib, ustekinumab) in a retrospective multicentric national Romanian analysis. Methods: We conducted a nationwide, retrospective observational multicentric study. Data were collected retrospectively from electronic and paper files. Patients who started on one of the five investigated molecules during December 2019-December 2021 were included. The main outcome measures were clinical remission, endoscopic healing, persistence on treatment and safety data. Results: A total of 678 adult patients from 24 Romanian IBD centers with a diagnosis of ulcerative colitis or Crohn's disease were included. Participants had previously failure to one (268, 39.5%), two (108, 15%) or more treatment lines and only 38% (259) were biologic naïve. In the 24 months study period, most patients were started on vedolizumab (192, 28%), followed by adalimumab, infliximab, ustekinumab and tofacitinib. In biologic-naïve patients, most physicians (72%) preferred anti-TNF treatment as first line biologic (93 patients started on infliximab, 92 on adalimumab), followed by vedolizumab, ustekinumab and tofacitinib. During follow-up, 71% (470, p=0.05) of patients achieved clinical remission and 36% (134, p=0.03) achieved mucosal healing. The 6 months milestone for persistence was reached in 78% (530) of cases. Almost half of patients (47%, 316 patients) persisted on their current treatment for over 12 months. Overall, an adverse reaction was reported for 67 (10.4%) patients, with no lethal events. Conclusions: Population of biologic-experienced IBD patients in Romania is increasing and is becoming more difficult to achieve long-term disease control. Discontinuation rates for advanced therapies are high. [ABSTRACT FROM AUTHOR]

In assessing exocrine pancreatic insufficiency (EPI), its diverse etiologies and the heterogeneous population affected should be considered. Diagnosing this condition remains a challenge in clinical practice especially for mild-to-moderate EPI, with the support of the time-consuming breath test or the coefficient of fat absorption. The fecal elastase-1 test, less precise for the diagnosis, cannot be useful for assessing treatment efficacy. Pancreatic enzyme replacement therapy (PERT) is the mainstay of treatment, whereby entericcoated mini-microspheres are taken with every meal, in progressive doses based on an individual's weight and clinical symptoms. The main indication for PERT is chronic pancreatitis, in patients who have clinically relevant steatorrhea, abnormal pancreatic function test or abnormal function tests associated with symptoms of malabsorption such as weight loss or meteorism. While enzyme replacement therapy is not recommended in the initial stages of acute pancreatitis, pancreatic exocrine function should be monitored for at least 6-18 months. In the case of unresectable pancreatic cancer, replacement enzyme therapy helps to maintain weight and improve overall quality oflife. It is also indicated in patients with celiac disease, who have chronic diarrhea (in spite of gluten-free diet), and in patients with cystic fibrosis with proven EPI. [ABSTRACT FROM AUTHOR]

Historic. A 59-year-old patient, a chronic ethanol user, without any medical history, presents with hematemesis and abdominal pain. Methods. The level of hemoglobin was 8.2 g/dL, without any other biological modification. The emergency upper digestive endoscopy revealed a large clot that almost completely occupied the esophageal and gastric lumen, up to the duodenal angle. Endoscopic re-evaluation at 24 hours: esophagus and stomach with free lumen, gastric body with extrinsic compression on the posterior face towards the greater curvature and intensely edematous mucosa at that level. Abdominal ultrasound revealed multiple calcifications at the level of the pancreatic head and body and at the level of the tail of the pancreas, a cystic formation of approximately 5 cm was visualized, with a pulsed Doppler signal. CEUS:hyperinhancement in the center of the lesion and lack of contrast in the periphery, an aspect that was maintained in the portal and parenchymal phases. The abdominal CT showed a corporeo-caudal pancreatic pseudoaneurysm of the splenic artery with dimensions of 65 mm, with parietal thrombosis with a stratified appearance, affecting about 40% of the lumen, with contrast extravasation, in direct contact with the posterior gastric wall. Results. The suspicion of upper digestive hemorrhage secondary to a fistula between the pseudo-aneurysm of the splenic artery and the stomach was raised, but also the possibility of a wirsungorrhagia, given the direct contact of the lesion with the pancreatic tail. Abdominal angiography with angioplasty was performed, secondary to the extravasation of the contrast substance at the level of the splenic artery with a 3/18 mm Bentley type stent graft, with an optimal result, without extravasation of contrast. Diagnosis. Upper gastrointestinal hemorrhage secondary to a splenic artery pseudoaneurysm. Chronic ethanolic pancreatitis. Conclusions. Bleeding from splenic artery pseudoaneurysm is a rare and often fatal cause of gastrointestinal bleeding The most common causes are pancreatitis and abdominal trauma. In pancreatitis, pancreatic enzymes can cause vascular necrosis and rupture of elastic tissue, leading to pseudoaneurysm formation. Another way can be through pseudocysts (41% of patients with pseudoaneurysms), In this patient's case, the pseudoaneurysm most likely occurred secondary to a pseudocyst that eroded the splenic artery, with intracystic hemorrhage, which led to a localized hemorrhage and not to a hemoperitoneum, and subsequently to the digestive tract, transgastric or through the main pancreatic duct. After stent placement by angiography, the patient had a favorable evolution at ultrasound reevaluation at 1 month, with remission of the lesion. [ABSTRACT FROM AUTHOR]

Aims. Among the non-invasive methods of evaluation in cirrhotic patients, the shear wave elastography (2D-SWE) method has been used to quantify the stiffness in chronic liver disease with good accuracy. Several studies have shown that each complication of cirrhosis is associated with a certain amount of liver stiffness. The objective of the study we performed was to quantify the use of elastography (liver and spleen) in predicting the risque and the grade of gastro-esophageal varices in patients diagnosed with hepatic cirrhosis. Methods. We used the GE Logiq E9/E10 ultrasound system for 34 pacients. We excluded the pacients with liver neoplasia, infiltrative liver disease, acute virale hepatitis and obstructive cholestasis. The value cutt-off used for liver stiffness was >11.88 kPa (>1.99 m/s), correspondent for F4 Metavir. The procedure was realized after 4 hours of fasting, intercostal at 1.5-2 cm below liver and spleen capsule avoiding vessels. Six measurements were obtained for each patient. The results were compared with upper digestive endoscopy. Results. We performed liver elastography for 34 patients known with liver cirrhosis, 94.2% due to ethanol consumption, of which 29.4% (n:10) were female and 70.5% (n:24) were male. We compared the degree of esophageal varices with the value of elastography. Elastography can differentiate patients without esophageal varices from patients with moderate (p value=0.072) or large esophageal varices (p value=0.013), but it cannot differentiate between patients without esophageal varices and those with small esophageal varice (p value=0.8249). However, there was a lack of correlation between the elastographic values of the spleen and the degree of esophageal varices (p value= 0.5860). Conclusions. The results obtained are indicating that 2D-SWE of the liver can be used for ruling-out varices needing treatment in patients with cACLD, knowing that the presence of varices and especially of varices needing treatment indicates distinct prognostic stages in patients with compensated ACLD (cACLD). [ABSTRACT FROM AUTHOR]

Pancreatic ductal adenocarcinoma (PDAC) is characterized by an intense fibrosis which enhances the growth of tumor cells and drives an epithelialmesenchymal transition. The consequence is the uncontrolled proliferation of cancer cells, including pancreatic cancer stem cells (PCSC), which can enhance the metastatic potential. Objective. The aim of this study is to assess the expression of pancreatic cancer stem cells, on pancreatic endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) specimens. Material and Methods. A total of 21 patients diagnosed with PDAC after EUS-FNB within the Research Center of Gastroenterology and Hepatology of Craiova, were included in the study, and the samples were sent for immunohistochemical assessment. Anti-Human CD 24 (policlonal, Abcam, ab 199140) and EpCAm (Epr 20532-225, Rb monoclonal, Abcam, ab 223582) were used. Results. All cases were positive for CD24 and EpCAM. In NOS ductal adenocarcinomas, CD24 immunomarking was heterogeneous, with variable intensity and a variable number of positive cells within the same case. Well and moderately differentiated adenocarcinomas that formed tubular or papillary structures showed a higher intensity CD24 expression compared to poorly differentiated or undifferentiated adenocarcinomas. EpCam showed a stronger immunolabeling intensity in the analyzed samples. PDAC EpCam expression was of moderate and high intensity and with a heterogeneous appearance in NOS G1 adenocarcinomas, but the intensity of the immunomarking tended to decrease with increasing histological grade. Conclusions. EUS-FNB PCSC immunohistochemistry is feasible. At the subcellular level, the basolateral membranous and cytoplasmic staining of EpCam in PDAC could be correlated with tumor invasion and possibly with the unfavorable evolution of this type of carcinoma, while CD24 frequently presents an apical immunostaining pattern and could suggest the presence of an epithelial-type phenotype of tumor cells, with a lower potential for invasiveness and metastasis. [ABSTRACT FROM AUTHOR]

Aims. An 84-year-old patient with a history of high blood pressure presented to the emergency room with lower abdominal pain and haematochezia. Methods. Clinical:hemodynamically stable. Biological: WBC 32700/microL, Hb=8.1 g/dL, PLT = 321 000/microL, INR=1.23, CRP = 292 mg/L. CTscan: no contrast extravasation in the digestive tract, infrarenal aortic aneurysm (130 mm cranio-caudal), with parietal thrombus plus a retroaortic abscess with stenosis of the inferior vena cava. Vascular surgery consultation: no surgical indication ->admission to the gastroenterology department. Emergency upper GI endoscopy: adherent clot in the fornix, stasis fluid. 60 cm rectosigmoidoscopy: mucosal lesions suggestive of ischemic colitis. Reevaluation after 12 h: WBC = 26 000/microL, hemoglobin = 7.1 g/dL Results. Re-evaluation of the CT-scan: suspicion of an aorto-duodenal fistula. Second upper GI endoscopy: gastric mucosa, bulb and D2 lined with fresh blood. On withdrawal, an infrapapillary lesion suggestive for an aortoenteric fistula. Duodenoscopesecond look:an erosion with a diameter of 10 mm with a deep punctate hole: most likely aortoenteric fistula. The patient was transferred to cardio-vascular surgery: double-layer duodenorrhaphy and aorto-aortic interposition of a silver Dacron prosthesis were done. Conclusion. The particularity of the case was represented by the rare cause of haemorrhage with difficult diagnosis. The approach and treatment required a multidisciplinary team and a good collaboration. The patient was discharged after 17 days with a good general condition. [ABSTRACT FROM AUTHOR]

Aims. Variceal bleeding is a common and severe cause of hospitalization in cirrhotic patients. We analyzed how the COVID-19 waves modified the outcome of the patients compared to COVID-19 extra-wave intervals. Methods. We retrospectively included all patients hospitalized between March 2020 and December 2021 for variceal bleeding. They were separated in 2 categories: hospitalizations during COVID-19 extrawaves period and the COVID-19 waves. Variables like sex, age, hemoglobin at presentation, endoscopic timing, hemostatic methods, transfusion necessity, duration of hospitalization and mortality were analyzed. Results. Out of 76 patients (2020-2021), 20patients were hospitalized during the COVID-19 waves. The median age did not differ significantly across groups (61 years [IQR: 52-65] vs 58years [IQR: 44-64]), 59 patients being male and 17 being female. The number of admissions for variceal bleeding and gastroscopy requirement and timing were similar regardless of the studied period (p > 0.05). Median hemoglobin admission values were significantly lower in the following subgroups: patients in whom gastroscopy was performed in less than 6 hours or more than 12 hours (p = 0.045) and patients requiring PRBC transfusion (p = 0.018). There were also no differences in duration of hospitalization and mortality between the two studied periods (p>0.05). Conclusions. The number of patients remained relatively constant in both periods. We found no differences in the management and outcomes of patients with variceal bleeding throughout the COVID pandemic. Our results might be influenced by the low number of patients and need confirmation on larger cohorts. [ABSTRACT FROM AUTHOR]