Search

Progressive esophageal carcinoma can infiltrate the surrounding tissues with subsequent development of a fistula, most commonly between the esophagus and the respiratory tract. The endoscopic placement of covered self-expanding metallic stents (SEMS) is the treatment of choice for malignant esophageal fistulas and should be performed immediately, as a fistula formation represents a potential life-threatening complication. We report the case of a 64-year-old male diagnosed with esophageal carcinoma, who had a 20Fr surgical gastrostomy tube inserted before chemo- and radiotherapy and was referred to our department for complete dysphagia, cough after swallowing and fever. The attempt to insert a SEMS using the classic endoscopic procedure failed. Then, a fully covered stent was inserted, as the 0.035" guide wire was passed through stenosis retrogradely by using an Olympus Exera II GIF-N180 (4.9 mm in diameter endoscope) via surgical gastrostomy, with a good outcome for the patient. The retrograde approach via gastrostomy under endoscopic/fluoroscopic guidance with the placement of a fully covered SEMS proved to be the technique of choice, in a patient with malignant esophageal fistula in whom other methods of treatment were not feasible. [ABSTRACT FROM AUTHOR]

Peri-pancreatic fluid collections are late complications of acute pancreatitis. Loculated peri-pancreatic fluid collections, even rare, remain the „black sheep" in terms of drainage, due to difficulty to puncture all compartments, thus prohibiting proper drainage of all compartments. Recombined tissue plasminogen activator (r-tPA) has been advocated as treatment of the loculated collections, due to its ability to dissolve the fibrinous strands and thus facilitate proper drainage. We report the case of a 58 years-old male presenting with a painful loculated peri-pancreatic fluid collection secondary to acute pancreatitis. We performed Alteplase injection, followed by successful endosonographic drainage with lumen apposing metal stent of the collection after 48 hours. Our observation suggests that r-tPA could be a new strategy for loculated collections management, ensuring better drainage and limiting the indication for surgical treatment. [ABSTRACT FROM AUTHOR]

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]

The article presents a case of a 73-year-old woman with ischemic heart disease, fatigue, and iron deficiency anemia. Topics include performing upper gastrointestinal (GI) endoscopy and fecal occult blood (FOB) test, the patient's diagnosis with ileum adenocarcinoma, and the diagnostic image result of the patient showing tumoral emboli in blood vessels.

The article presents a case study of a 28-year-old female who developed gastric fistulas following laparoscopic sleeve gastrectomy, successfully managed using Padlock Clips. Topics discussed include the clinical challenges of post-sleeve gastrectomy complications, the effectiveness of Padlock Clips in fistula closure, and the role of conservative treatment in facilitating recovery without surgical intervention.

Background & Aims: The fully-covered, lumen apposing metal stents are designed for one step placement, facilitating the direct endoscopic necrosectomy into the walled-off pancreatic necrosis. However, the prediction of the number of necrosectomy sessions in these patients is not known. This study evaluated the association between the proportion of solid necrotic material inside walled-off necrosis, as assessed during the endosonography placement of a lumen apposing metal stent, and the number of necrosectomies subsequently required. Methods: Patients from three tertiary medical centers with symptomatic walled off pancreatic necrosis (pain, infection, gastric/biliary obstruction) at more than 4 weeks after onset of acute pancreatitis were retrospectively analysed. Proportion of solid necrotic debris was estimated during endosonography procedure of lumen apposing metal stents placement. Necrosectomy was performed when obstruction or inflammation occurred subsequently. Lumen apposing metal stents were removed after clearance of necrotic content. Results: In 46 patients with successful lumen apposing metal stents placement, necrosectomy was performed in 39 patients (72.78%). Performance of 3 or more necrosectomies was significantly associated with more than 50% pancreatic necrosis (p=0.032), but not with walled-off pancreatic necrosis size or location. Necrotic infection during lumen apposing metal stents stenting was associated with hypoalbuminemia, but not with necrosectomy requirement. Clinical success after a median follow-up of 13.37 months was 87%. Conclusions: Walled-off pancreatic necrosis with more than 50% solid necrotic content were associated with more necrosectomy procedures, requiering longer endoscopy time, intravenous sedations, and higher costs. [ABSTRACT FROM AUTHOR]

Introduction. Inflammatory bowel diseases and intestinal tuberculosis (TB) have similar clinical and endoscopic appearance, one of the main differences between those two entities being the presence of caseation necrosis as seen by the histopathological examination, which is specifically for TB. Case presentation. 35-year-old woman presented to our hospital for significant weight loss and mild anemia. Endoscopy and colonoscopy were both performed. Colonoscopy revealed multiple ulcers and important edema affecting the transverse colon, which made the colonoscope advancement impossible. Biopsies were taken from the affected segment and further investigations were made in order to exclude any enteral infections. We suspected Chron's disease so screening tests for detecting TB, HIV infections and viral chronic hepatitis were also performed in order to initiate biological treatment. Tests results came negative for any systemic or enteral infections, but QuantiFERON TB Gold test was inconclusive. As the chest-X ray revealed no lesions and the biopsy revealed chronic granulomatous colitis without caseation necrosis we decided to repeat the test, which came back negative. We started anti-TNF alpha therapy with infliximab and further evolution of the disease was favorable. Two months after the treatment initiation the patient presented to the emergency room with fever, abdominal pain and ascites fluid. CT scan was performed and multiple abscesses were also identified. The patient underwent surgery with right ileo-colectomy and ileostomy. Fragments were recovered and sent for histopathological examination. This time huge granulomas with caseation necrosis were identified, suggesting intestinal TB. Discussions. Intestinal TB represents 12% of the extra-pulmonary TB cases and the prevalence around the world is about 1-3%. From those cases, TB most frequently affects the ileo-cecum site, due to several factors such as physiological stasis, narrow lumen, the low activity of the digestion and the high prevalence of lymphoid tissue. On the other hand, isolated TB of the colon is rarely seen and represents almost 11% of all intestinal TB cases. Conclusions. Romania represents an endemic country for TB so detailed differential diagnosis should be made, especially with inflammatory bowel disease, as their treatment, more specifically biological therapy could lead to important complications, such as abscesses as it was our patient's case. Unfortunately, in this situation if it wasn't for the biological therapy that led to the aggravation of the TB, the disease would be treated as an inflammatory bowel disease and the diagnosis would be delayed even more. [ABSTRACT FROM AUTHOR]

Background & Aims: Prevalence of malnutrition in inflammatory bowel diseases (IBD) varies between 16% and 75%. Data on the nutritional status at initial diagnosis of ulcerative colitis (UC) or Crohn's Disease (CD) are scarce. It is believed that more than 50% of IBD patients suffer significant weight loss prior to diagnosis. The aims of our study were to assess malnutrition in patients recently diagnosed with IBD and to determine its predictive factors. Methods: We retrospectively included 625 IBD patients registered in the Romanian "IBD Prospect" database between January 2006 and July 2017. All patients were diagnosed within 6 months prior to registration. We defined malnutrition as weight loss of more than 5% of the initial weight during the 3 months prior to registration. Results: There were 361 new cases of UC, 241 CD and 23 cases of unclassified IBD. There was a slight male predominance (M/F=1.2). Prevalence of overall malnutrition was 36.3%. It was significantly more frequent in CD than in UC patients (41.1% vs. 32.4%, p=0.031). In multivariate analysis, malnutrition in UC patients was associated with male gender (p=0.001), more severe disease (p<0.0001) and more extensive disease (p=0.027), while in CD it was associated with younger age (p=0.013) and more severe disease (p<0.0001). Conclusions: About 1 in 3 newly diagnosed IBD patients presents with malnutrition at the time of diagnosis. [ABSTRACT FROM AUTHOR]

Introduction. Distinguishing Crohn's disease (CD) and intestinal tubeculosis (ITB) may represent a remarkable clinical dilemma in Romania, an endemic country for tuberculosis which has experienced at the same time a significant increase in the incidence of inflammatory bowel disease. Case presentation. A 22 years-old female presented in our unit for abdominal pain, diarrhea (3-4 stools/day) and weight loss (7 kg.) since approximately 9 months ago. Previous investigations from another hospital included an abdominal ultrasound which revealed thickened enteral loops with intensified parietal Doppler signal suggestive of inflammation; fecal calprotectin was extremely elevated (>20.000 ug/mg). In our unit, we ordered stool tests that were negative for bacterial, viral or parasitic infections. Complete blood count, renal, liver and coagulations tests were within normal limits. We decided to perform colonoscopy; ileocecal valve stenosis was noted due to marked edematous mucosal changes, ulcerations and nodularity. Passage of the endoscope in the terminal ileum was not possible due to the ulcerohypertrophic lesions, but multiple biopsies were taken from the stenotic area. Even though Crohn's disease was highly suspected we decided to perform chest X-ray since intermittent cough and night chills were also noted during hospitalization. Radiographical findings consisted of numerous small nodular opacities up to 3-5mm diameter scattered throughout both lungs highly suggestive of miliary TB. Both sputum culture (intense BAAR reaction), CT scan and biopsies confirmed tuberculosis with extraintestinal manifestations. Our patient is currently under antimycobacterial treatment with favorable clinical outcome. A further follow-up to reassess the ileocecal valve stenosis is expected. Discussions. Intestinal tuberculosis and Crohn's disease have multiple overlapping features in terms of symptoms, radiologic, endoscopic and even histological findings. Misdiagnosis can be a crucial error, since immunosuppressive therapy for CD may favor the spread of tuberculosis and worsens prognosis. There are case reports in the literature with disseminated tuberculosis after anti-TNF therapy for suspected CD. Miliary tuberculosis with extraintestinal manifestations is not frequently encountered in immunocompetent patients. Nevertheless, initial results (including HIV testing and CT scan) did not identify any potential deficiency of the immune system in our patient. Conclusions. Judicious clinical examination merged with radiological, endoscopic and histological findings is of utmost importance in proper distinction between intestinal tuberculosis and Crohn's disease, to a great degree in Romania which is still endemic for the former. [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]

Background & Aims. A point mutation (gp130Y757F/ Y759F) was identified as being responsible for aberrant activation of gp130 in mice and associated with gastric adenocarcinoma induction. As a result, we investigated the possible role of key point mutations in Tyr from IL6ST exon 17 that encode for the catalytic domain of gp130, and of its respective activators (IL-6 family member cytokines) in human gastric cancer initiation and development. Method. DNA, protein and plasma from 51 patients with gastric adenocarcinoma have been used in exploring gp130 status. We used sequencing analysis of IL6ST exon 17 in order to identify possible mutations that would lead to constitutive active forms of the receptor. The levels of gp130 activators (IL-6, IL-11, LIF) were analyzed by ELISA in plasma and mucosa of patients with gastric adenocarcinoma. Results. Sequencing analysis did not identify mutations in gp130 key positions (Y759, Y767, Y814, Y905 and Y915). An increased IL-6 and IL-11 level in gastric mucosa was observed, correlated with staging, indicating these cytokines as gp130 activators in tumor epithelial cell. Those variations were consistent with increased IL-6 level in plasma. Furthermore, IL-6, but not IL-11 showed a significant correlation with patient's survival time, suggesting that tissue and plasma concentration of IL-6 might be a marker of tumor aggressiveness with prognostic value. Conclusions. According to our results, no mutations were detected in gp130 key positions in human gastric adenocarcinoma samples. However, gp130 activation may occur due to the increased level of IL-6 and IL-11 cytokines detected that can become valuable biomarkers. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 67-year-old male patient with type 2 diabetes and extracolonic tumor. Topics discussed include abdominal computed tomography scan performed which describes presence of calculus in the gallbladder and dilatation of common bile duct; endoscopic retrograde cholangio-pancreatography revealed stone in duct; and gallbladder fistulisation in acute cholecystitis involves an internal organ with the formation of a biliary-enteric fistula.

The article presents a case study of a 62-year-old man suffering from comorbidities of stroke and diabetes under treatment with oral anticoagulants presented with severe anemia. Topics discussed include the risk of perforation and bleeding, performance of esogastroduodenoscopy and colonoscopy. It also mentions dabigatran therapy.

Purpose: To assess the value of magnetic resonance in the diagnosis of pancreatobiliary ductal system changes., Material and Methods: The study included 103 patients (44 men, 59 women, mean age 57, age range 1 month - 91 years) with pancreatobiliary duct changes. The patients underwent a routine liver and pancreas MR imaging that included a MR cholangiopancreatography sequence. Comparison was made with findings at surgery, endoscopic retrograde cholangiopacreatography performed within 14 days, and follow-up, as a reference standard., Results: The sensitivity, specificity, and accuracy of magnetic resonance for the evaluation of lithiasis were 87%, 90.2% and 89.3% respectively; 100%, 97.8%, and 98%, respectively for cholangitis; 91.6%, 96.7% and 96,1%, for bile ducts tumors; 89.4%, 97.5%, and 96%, for chronic pancreatitis; 92.3%, 97.6%, and 96.6%, for pancreatic tumors; 88.8%, 96.4% and 95.1%, for periampullary stenosis., Conclusion: Magnetic resonance is a reliable imaging technique for the evaluation of biliary and pancreatic ducts