Tulip-bundle technique for suture dehiscence in a Boerhaave syndrome.

A 55-year-old-woman was admitted to the emergency department with hematemesis and abdominal pain. Her physical examination was unremarkable. Laboratory results without anemia. The upper gastrointestinal endoscopy revealed a deep large tear between 36 and 39 cm with transmural perforation. A diagnosis of Boerhaave syndrome was made. Thoraco-abdominal CT-scan revealed a laceration in the left posterolateral side of the esophagus, measuring 6.5 cm proximal to the esophagogastric junction (GEJ), associated with a pneumomediastinum, pneumoperitoneum and a mediastinal air fluid collection anteriorly to the GEJ. The patient was submitted to laparoscopic surgery with closure of the perforation, Graham patch confection. Nine days after, the esophago-gastric transit showed luminal contrast leakage to the posterior mediastinum. An endoscopic evaluation showed a 2 cm suture dehiscence. We applied a hemostatic clip in the distal end of the tear to bring the edges closer, but it was impossible to put additional ones. It was decided to perform a tulip-bundle technique with a single-channel endoscope in a sequential two-step maneuver and another two clips were placed in the borders of the tear with an endoloop applied over the clips with success. One month later, an endoscopic revaluation was performed, revealing the clips involved by the endoloop and no signs of leakage. After that, she started oral diet without any complications.

The influence of subclinical active inflammation on IFX pharmacokinetic modeling and disease progression assessment: findings from a prospective real-world study in inflammatory bowel disease patients.

BACKGROUND AND AIMS: Effective management of inflammatory bowel disease (IBD) relies on a comprehensive understanding of infliximab (IFX) pharmacokinetics (PK). This study's primary goal was to develop a robust PK model, identifying key covariates influencing IFX clearance (CL), while concurrently evaluating the risk of disease progression during the maintenance phase of IBD treatment. METHODS: The multicenter, prospective, real-world DIRECT study was conducted in several care centers, which included 369 IBD patients in the maintenance phase of IFX therapy. A two-compartment population PK model was used to determine IFX CL and covariates. Logistic and Cox regressions were applied to elucidate the associations between disease progression and covariates embedded in the PK model. RESULTS: The PK model included the contributions of weight, albumin, antidrug antibody (ADA), and fecal calprotectin (FC). On average, higher ADA, FC concentration and weight, and lower albumin concentration resulted in higher IFX CL. In the multivariate regression analyses, FC levels influenced the odds of disease progression in all its different definitions, when adjusted for several confounding factors. Additionally, alongside FC, both IFX and CL demonstrated a significant impact on the temporal aspect of disease progression. CONCLUSION: In this 2-year real-world study, readily available clinical covariates, notably FC, significantly impacted IFX availability in IBD patients. We demonstrated that subclinical active inflammation, as mirrored by FC or CRP, substantially influenced IFX clearance. Importantly, FC emerged as a pivotal determinant, not only of IFX pharmacokinetics but also of disease progression. These findings underscore the need to integrate FC into forthcoming IFX pharmacokinetic models, amplifying its clinical significance.

Thiopurines have no impact on outcomes of Crohn's disease patients beyond 12 months of maintenance treatment with infliximab.

BACKGROUND: The emergence of new treatments the inflammatory bowel diseases (IBD) raised questions regarding the role of older agents, namely thiopurines. AIMS: To clarify the benefits of combination treatment with thiopurines on Crohn's disease (CD) patients in the maintenance phase of infliximab. METHODS: In this analysis of the 2-year prospective multicentric DIRECT study, patients were assessed in terms of clinical activity, faecal calprotectin (FC), C-reactive protein (CRP), and infliximab pharmacokinetics. A composite outcome based on clinical- and drug-related items was used to define treatment failure. RESULTS: The study included 172 patients; of these, 35.5 % were treated with combination treatment. Overall, 18 % of patients achieved the composite outcome, without statistically significant differences between patients on monotherapy and on combination treatment (21.6% vs 11.5 %, p = 0.098). Median CRP, FC, and infliximab pharmacokinetic parameters were similar in both groups. However, in the sub-analysis by infliximab treatment duration, in patients treated for less than 12 months, the composite outcome was reached in fewer patients in the combination group than in the monotherapy group (7.1% vs 47.1 %, p = 0.021). CONCLUSION: In CD patients in maintenance treatment with infliximab, combination treatment does not seem to have benefits over infliximab monotherapy beyond 12 months of treatment duration.

An Inguinal Stomach.

Teaching Point: Although inguinal hernias are very common, stomach entrapment within an inguinal hernia is rare.

How many biomarker measurements are needed to predict prognosis in Crohn's disease patients under infliximab?-A prospective study.

BACKGROUND: Timely stratification of Crohn's disease (CD) is essential for patients' management. The use of noninvasive accurate biomarkers is key to monitor treatment and to pursue mucosal healing, the ultimate treatment endpoint in CD. OBJECTIVE: We aimed to evaluate the performance of readily available biomarkers and develop risk matrices to predict CD progression. METHODS: Data from 289 CD patients receiving infliximab (IFX) maintenance therapy for 2 years was collected; those patients were included in DIRECT, a prospective multicenter observational study. Disease progression was evaluated using two composite outcomes incorporating clinical and drug-related factors, the first including IFX dose and/or frequency adjustments. Univariate and multivariable logistic regressions were used to calculate the odds ratios (OR) and to develop risk matrices. RESULTS: The isolated presence of anemia at least once during follow-up was a significant predictor of disease progression (OR 2.436 and 3.396 [p ≤ 0.001] for composite outcomes 1 and 2, respectively) regardless of confounding factors. Isolated highly elevated C-reactive protein (CRP; >10.0 mg/L) and fecal calprotectin (FC; >500.0 µg/g) in at least one visit were also significant predictors, while milder elevations (3.1-10.0 mg/L and 250.1-500.0 µg/g) were only relevant when detected in at least two visits (consecutive or not). The combination of biomarkers in risk matrices had good ability to predict progression; patients simultaneously presenting anemia, highly elevated CRP and FC at least once had 42%-63% probability of achieving the composite outcomes. CONCLUSION: The combined evaluation of hemoglobin, CRP, and FC in at least one time point and their incorporation into risk matrices seems to be the optimal strategy for CD management, as data from additional visits did not meaningfully influence the predictions and may delay decision-making.

Autoimmune Enteropathy: A Rare Cause of Chronic Diarrhea in an Adult Patient.

Autoimmune enteropathy is a rare cause of malabsorption usually associated with circulating autoantibodies and predisposition to autoimmune disorders. The diagnosis is based on the following criteria: chronic diarrhea (>6 months), malabsorption, specific histological findings, anti-enterocyte and anti-goblet cell antibodies, and exclusion of similar disorders. We report a case of a 73-year-old woman presenting with severe chronic diarrhea, weight loss, and electrolyte abnormalities. Endoscopy revealed duodenal villous atrophy extending to proximal jejunum, and duodenal biopsies revealed villous blunting, cryptitis with apoptosis, and scattered intraepithelial lymphocytes. Therapeutic management included immunosuppressive treatment with corticosteroids, achieving clinical remission.

Undifferentiated Carcinoma With Osteoclast-Like Giant Cells: A Rare Cause of Upper Gastrointestinal Bleeding.

Undifferentiated osteoclast-like giant cell carcinomas (UOLGCCs) of the digestive tract are very rare, with only a few cases reported in the literature. An 82-year-old man was referred to the emergency department for melena. Endoscopic examination revealed a hemicircumferential ulcerovegetative lesion, involving the bulbar apex and extending to the second portion of the duodenum; biopsies revealed an UOLGCC. The patient underwent transfusion support therapy, and he was proposed for best supportive care. Duodenal UOLGCC is an extremely rare cause of upper gastrointestinal bleeding. Clinical findings and therapeutic approach represent a challenge in this pathology.

Perianal Paget's disease - A diagnosis to consider.

Extramammary Paget's disease is a rare cutaneous malignancy affecting areas with a high concentration of apocrine glands. The authors present a 77-year-old male followed in the General Surgery consultation due to anal pruritus complaints with an evolution of around 20 years and recent lower gastrointestinal bleeding. A colonoscopy was requested and the patient was observed by Gastroenterology team in this context. The objective examination showed an erythematous-whitish plaque with well-defined, slightly exudative and verrucous limits in the perianal region. Definitive diagnosis was possible by biopsy of the referred lesion carried out by Dermatology, and the histological findings were compatible with Paget's disease: intraepithelial infiltration by large atypical neoplastic cells and hypochromic halo and positive immunostaining for cytokeratin 7. Perianal Paget's disease, often underdiagnosed, may be associated with colorectal neoplasms. We present this case due to its rarity, in order to draw attention to this diagnosis.

Inflammatory bowel disease and thromboembolic events: a c'lot to learn.

Background: Inflammatory bowel disease (IBD) is associated with a variety of extraintestinal manifestations including arterial and venous thromboembolism. Research evidences that IBD patients have about a 2- to 3-fold increase in the risk of venous thromboembolism when compared with the general population. Objectives: We intended to evaluate the coagulation parameters and the prevalence of thromboembolic events (TE) in IBD patients. It was also our aim to investigate the correlation between coagulation parameters and disease phenotype and activity in this population. Methods: This single center prospective observational study was performed between November 2016 and April 2020. The cohort included patients with 18 years of age or older, diagnosed with IBD and followed at a gastroenterology consultation, during a follow-up period of 36 months. Patients were evaluated in terms of IBD type, extent and disease behavior, clinical scores of IBD activity, medication, smoking history, family and personal history of TE, coagulation parameters, fecal calprotectin levels, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), hospitalization due to TE, IBD-related hospitalization or surgery, pregnancy, or diagnosis of malignancy. Results: The study included 149 IBD patients (67 males and 82 females). Coagulation parameters were similar in CD and UC patients and only plasminogen was increased in CD patients [97.4 (17.0) versus 91.6 (13.3), p = 0.035], when comparing with UC patients. The determined values were in the range of the reference values described in literature for the standard population. During the follow-up period, none of the patients experienced a TE that demanded hospitalization. Conclusion: In our study, acquired and inherited risk factors for TE and changes in coagulation parameters did not show to influence prothrombotic predisposition in IBD patients. As such, the clinical relevance of measuring coagulation parameters in this population is questionable. Trial Registry: NCT05162339 (ClinicalTrials.gov ID).

Subclinical Persistent Inflammation as Risk Factor for Crohn's Disease Progression: Findings From a Prospective Real-World Study of 2 Years.

BACKGROUND AND AIMS: Subclinical intestinal inflammation is common in Crohn's disease (CD). We aimed to explore its impact in the disease progression of infliximab-treated patients and the usefulness of fecal calprotectin (FC) and C-reactive protein (CRP) as surrogate minimally invasive biomarkers. METHODS: The registry-based, prospective, observational, multicenter DIRECT (study to investigate the correlation of fecal calprotectin with serum Drug levels and development of an antI-dRug antibodiEs among adult patients with inflammatory bowel disease reCeiving anti-TNF-alfa treatment or vedoluzimab treatment) study followed infliximab-treated CD patients for 2 years in a tertiary care setting. Persistent inflammation definition was based on FC (>150 µg/g, >250 µg/g, or >350 µg/g) or serum CRP (>3 µg/mL) concentrations over 2 consecutive or at least 3 visits. Patients were categorized according to a composite outcome reflecting disease progression that incorporated surgery; hospitalizations; new fistulae, abscess, or stricture; and treatment escalation. RESULTS: Of 322 DIRECT study patients, 180 asymptomatic, infliximab treated on maintenance regimen were included in the analysis. Patients developing the composite endpoint (n = 96) presented higher median levels of FC (205 [interquartile range, 98-515] µg/g; P = .045) but not of CRP (2.50 [interquartile range, 0.80-6.00] µg/mL; P = .895). Biomarker-defined persistent subclinical inflammation prevalence ranged from 24% to 81%. Considering FC >250 µg/g in 2 consecutive visits, prevalence was 50%, odds of achieving the endpoint were increased 3-fold (odds ratio, 2.996 [95% confidence interval, 1.557-5.776]), and time-to-outcome occurrence was significantly lower among subjects with persistent inflammation (median time: 11 months). Both clinical-related and treatment-related components were significantly associated with persistent inflammation. Definitions based on CRP >3 µg/mL, FC >150 µg/g, FC >350 µg/g, double biomarkers (FC >250 µg/g and/or CRP >3 µg/mL), or more visits did not improve predictive ability. CONCLUSIONS: Persistent inflammation, defined simply and readily by FC >250 µg/g over 2 consecutive visits, was associated with a significantly higher risk and shorter time to occurrence of a composite outcome reflecting disease progression in asymptomatic infliximab-treated CD patients.

Bezoar: an uncommon cause of upper gastrointestinal bleeding.

Bezoars are aggregates of non-digestible material that accumulate in the gastrointestinal tract. They can be classified according to their composition, and phytobezoars (composed of vegetable or fruit fiber) is the most common type. They most often occur in patients with some risk factors, namely prior gastric surgery, neuropsychiatric, endocrine or other disorders that lead to abnormal gastric function, or poor gastric peristalsis. Bezoars may be asymptomatic but most commonly cause abdominal discomfort or pain, nausea, vomiting, fullness, difficulty in swallowing, or anorexia and weight loss. Upper GI endoscopy for both diagnostic and therapeutic purposes is key in the management of bezoars.

Olmesartan-Associated Enteropathy: An Unexpected Cause of Chronic Diarrhoea.

Olmesartan-associated enteropathy is a rare cause of severe enteropathy that should be considered in the differential diagnosis of patients with unexplained chronic diarrhoea. It may be difficult to recognise because of its clinical and histologic similarities to other clinical entities. The authors present the case of a 72-year-old woman with a 6-month clinical history of non-bloody diarrhoea and weight loss. Discontinuation of olmesartan resulted in clinical and histologic recovery, and therefore, physicians need to be aware of olmesartan-associated enteropathy in order to avoid unnecessary testing. Although rare, it is considered an emerging and underdiagnosed enteropathy. LEARNING POINTS: Olmesartan-associated enteropathy is characterised by chronic diarrhoea (often severe) and weight loss that is unresponsive to a gluten-free diet.When a patient presents with unexplained chronic diarrhoea, a detailed medication review is needed. If duodenal biopsies reveal villous atrophy and coeliac disease is excluded, drug-induced enteropathy is likely.Clinical response and histologic improvement are expected after olmesartan is withdrawn.

Treatment of Postoperative Leaks of the Upper Gastrointestinal Tract with Colonic Self-Expandable Metal Stents.

INTRODUCTION: The use of self-expandable metal stents (SEMS) for the treatment of postoperative leaks of the upper gastrointestinal tract is already established. However, there are discrepancies between the relatively small caliber of the esophageal stents available and the postsurgical luminal size, which may determine an inadequate juxtaposition. As colonic stents have a bigger diameter, they might be more adequate. Additionally, stents with a larger diameter might have a lower risk of migration. MATERIALS AND METHODS: The aim of this study was to evaluate the efficacy and complications associated with the use of colonic fully covered SEMS (FSEMS) in the treatment of postoperative leaks in critical patients. All patients with postoperative leaks of the upper gastrointestinal tract treated with colonic stents (Hanarostent® CCI) between 2010 and 2013 were retrospectively included. RESULTS: Four patients with postoperative leaks were treated with colonic SEMS. The underlying surgeries were a gastric bypass, an esophagogastrectomy for Boerhaave syndrome, a primary repair of esophagopleural fistula due to Boerhaave syndrome, and an esophagectomy due to esophageal cancer. The leaks were detected on average 17 days after the initial surgery. All patients needed admission to a critical care unit after index surgery. Stent placement was technically feasible in all patients. The median residence time of the stents was 7 weeks, and no complications were verified when they were removed. There were no cases of stent migration. The treatment was successful in all patients, with complete healing of the leaks. DISCUSSION AND CONCLUSIONS: The placement of colonic FSEMS seems to be successful and safe in the treatment of postoperative leaks of the upper gastrointestinal tract.

INTRODUÇÃO: A utilização de próteses metálicas auto-expansíveis (SEMS) para o tratamento de fístulas e deiscências cirúrgicas do trato gastrointestinal alto está já estabelecida. No entanto, há discrepâncias entre o calibre relativamente pequeno das próteses esofágicas disponíveis e o diâmetro luminal pós-cirúrgico, o que pode determinar uma justaposição inadequada. Visto que as próteses destinadas ao cólon têm um maior calibre, estas poderão ser mais adequadas nestas situações. Adicionalmente, as próteses com maior diâmetro poderão ter um risco mais baixo de migração. MATERIAIS E MÉTODOS: O objetivo deste estudo foi avaliar a eficácia e complicações associadas ao uso de SEMS do cólon totalmente cobertas (FSEM) no tratamento das fístulas/deiscências cirúrgicas em doentes críticos. Todos os doentes com fístulas/deiscências cirúrgicas do trato digestivo alto tratados com próteses do cólon (Hanarostent® CCI) entre 2010 e 2013 foram incluídos retrospetivamente. RESULTADOS: Quatro doentes com as caraterísticas referidas foram tratados com próteses do cólon. As cirurgias subjacentes foram um bypass gástrico, uma esogagogastrectomia para síndroma de Boerhaave, uma rafia de uma fístula esofagopleural secundária a síndrome de Boerhaave e uma esofagectomia para cancro esofágico. As fístulas/deiscências foram detetadas em média 17 dias após a cirurgia inicial. Todos os doentes necessitaram de admissão numa unidade de cuidados intensivos após a cirurgia índice. A colocação da prótese foi tecnicamente bem-sucedida em todos os doentes. O tempo mediano de permanência da prótese foi 7 semanas, não se registando complicações na altura da sua remoção. Não ocorreu migração da prótese em nenhum doente. O tratamento foi eficaz em todos os doentes, com cicatrização completa das fístulas/deiscências. DISCUSSÃO E CONCLUSÕES: A colocação de FSEMS do colon é uma opção terapêutica segura e eficaz nos doentes com fístulas/deiscências cirúrgicas do trato gastrointestinal superior.

Midgut Volvulus after Percutaneous Endoscopic Gastrostomy.

We report a 47-year-old man who underwent endoscopic gastrostomy placement due to feeding refusal and regurgitation. Procedure was unremarkable. Two days later, the patient presented signs of intestinal obstruction. Computed tomography imaging showed a well-positioned gastrostomy tube, small pneumoperitoneum, and small bowel volvulus (SBV) in the upper right abdomen with proximal small bowel dilated loops. Exploratory laparotomy revealed mesenteric torsion, leading to SBV, with no evidence of intestinal malrotation. Volvulus was successfully untwisted via surgery. This case highlights to the possible association between SBV and gastrostomy placement.

Impact of Early Surgery and Immunosuppression on Crohn's Disease Disabling Outcomes.

BACKGROUND AND AIMS: The definition of early therapeutic strategies to control Crohn's disease aggressiveness and prevent recurrence is key to improve clinical practice. This study explores the impact of early surgery and immunosuppression onset in the occurrence of disabling outcomes. METHODS: This was a multicentric and retrospective study with 754 patients with Crohn's disease, who were stratified according to the need for an early surgery (group S) or not (group I) and further divided according to the time elapsed from the beginning of the follow-up to the start of immunosuppression therapy. RESULTS: The rate of disabling events was similar in both groups (S: 77% versus I: 76%, P = 0.700). The percentage of patients who needed surgery after or during immunosuppression therapy was higher among group S, both for first surgeries after the index event (38% of groups S versus 21% of group I, P < 0.001) and for reoperations (38% of groups S versus 12% of group I, P < 0.001). The time elapsed to reoperation was shorter in group I (HR = 2.340 [1.367-4.005]), stratified for the onset of immunosuppression. Moreover, reoperation was far more common among patients who had a late start of immunosuppression (S36: 50% versus S0-6: 27% and S6-36: 25%, P < 0.001) and (I36: 16% versus I0-6: 5% and I6-36: 7%, P < 0.001). CONCLUSIONS: Although neither early surgery nor immunosuppression seem to be able to prevent global disabling disease, an early start of immunosuppression by itself is associated with fewer surgeries and should be considered in daily practice as a preventive strategy.

Development and Validation of Risk Matrices for Crohn's Disease Outcomes in Patients Who Underwent Early Therapeutic Interventions.

INTRODUCTION: The establishment of prognostic models for Crohn's disease [CD] is highly desirable, as they have the potential to guide physicians in the decision-making process concerning therapeutic choices, thus improving patients' health and quality of life. Our aim was to derive models for disabling CD and reoperation based solely on clinical/demographic data. METHODS: A multicentric and retrospectively enrolled cohort of CD patients, subject to early surgery or immunosuppression, was analysed in order to build Bayesian network models and risk matrices. The final results were validated internally and with a multicentric and prospectively enrolled cohort. RESULTS: The derivation cohort included a total of 489 CD patients [64% with disabling disease and 18% who needed reoperation], while the validation cohort included 129 CD patients with similar outcome proportions. The Bayesian models achieved an area under the curve of 78% for disabling disease and 86% for reoperation. Age at diagnosis, perianal disease, disease aggressiveness and early therapeutic decisions were found to be significant factors, and were used to construct user-friendly matrices depicting the probability of each outcome in patients with various combinations of these factors. The matrices exhibit good performance for the most important criteria: disabling disease positive post-test odds = 8.00 [2.72-23.44] and reoperation negative post-test odds = 0.02 [0.00-0.11]. CONCLUSIONS: Clinical and demographical risk factors for disabling CD and reoperation were determined and their impact was quantified by means of risk matrices, which are applicable as bedside clinical tools that can help physicians during therapeutic decisions in early disease management.