Nutrition in Pancreatic Diseases: A Roadmap for the Gastroenterologist.

While common pancreatic diseases, such as acute pancreatitis (AP), chronic pancreatitis (CP), and pancreatic cancer (PC), may greatly impact the normal pancreatic physiology and contribute to malnutrition, the adequate nutritional approach when those conditions are present significantly influences patients' prognosis. In patients with AP, the goals of nutritional care are to prevent malnutrition, correct a negative nitrogen balance, reduce inflammation, and improve outcomes such as local and systemic complications and mortality. Malnutrition in patients with CP is common but often a late manifestation of the disease, leading to decreased functional capacity and quality of life and increased risk of developing significant osteopathy, postoperative complications, hospitalization, and mortality. Cancer-related malnutrition is common in patients with PC, and it is now well recognized that early nutritional support can favorably impact survival, not only by increasing tolerance and response to disease treatments but also by improving quality of life and decreasing postoperative complications. The aim of this review was to emphasize the role of nutrition and to propose a systematic nutritional approach in patients with AP, CP, and PC.

Se por um lado, doenças pancreáticas comuns, tais como pancreatite aguda (PA), pancreatite crónica (PC) e cancro pancreático (CP), podem ter um grande impacto na normal fisiologia pancreática e contribuir para desnutrição, por outro lado, uma abordagem nutricional adequada nos doentes com essas patologias pode influenciar significativamente o seu prognóstico. Em doentes com PA, os objetivos do suporte nutricional são a prevenção da desnutrição, a correção de um balanço negativo de nitrogénio, a redução da inflamação, e a evicção de outcomes desfavoráveis, como desenvolvimento de complicações locais ou sistémicas ou morte. A desnutrição é comum em doentes com PC, sendo frequentemente uma manifestação tardia da doença, da qual resulta uma diminuição da capacidade funcional e da qualidade de vida, bem como um aumento significativo do risco de doença óssea, complicações pós-operatórias, hospitalizações e morte. A desnutrição associada ao CP é também habitual e é atualmente reconhecido que um suporte nutricional precoce pode influenciar favoravelmente a sobrevida, não só por aumentar a tolerância e resposta aos tratamentos, mas também por melhorar a qualidade de vida e diminuir as complicações pós-operatórias. O objetivo da presente revisão é salientar o papel da nutrição e propor uma abordagem nutricional sistematizada nos doentes com PA, PC e CP.

Second-look upper endoscopy as the initial approach to subepithelial lesions: a reassuring and reliable strategy.

BACKGROUND: Although endoscopic ultrasound (EUS) plays a critical role in the management of subepithelial lesions (SEL) of upper gastrointestinal tract many can be classified solely by a thorough upper gastrointestinal endoscopy (UGE) which can reduce the burden of additional studies. AIMS: Analyze the impact of a stepwise approach starting with a second-look UGE before the decision of EUS in patients referred to our center with suspected SEL. METHODS: Retrospective cohort study which included all adult patients referred to our center between 2015 and 2020 with suspected SEL.Second-look UGE evaluated the location, size, color, surface characteristics, movability and consistency of the SEL and bite-on-bite biopsies were performed. Decisions on SEL management and follow-up were collected. RESULTS: A total of 193 SEL (190 patients) were included. At the index-UGE, stomach was the most frequent location (n = 115;59.6%). Most patients performed a second-look UGE (n = 180; 94.7%). A minority was oriented directly to EUS (n = 8;4.2%) or endoscopic resection (n = 2; 1.1%). In patients who underwent a second-look UGE, SEL were excluded in 25 (13.9%) and 21 (11.7%) did not need further work-up. The remaining patients were submitted to EUS (n = 88;48.9%), surveillance by UGE (n = 44; 24.4%) or endoscopic resection (n = 2; 1.1%). CONCLUSION: Systematically performing a second-look UGE, in patients referred with suspected SEL, safely preclude the need for subsequent investigation in approximately one-fourth of the patients. As UGE is less invasive and more readily available, we suggest that a second-look UGE should be the initial approach in SEL management.

Acute Nonvariceal Upper Gastrointestinal Bleeding in Patients Using Anticoagulants: Does the Timing of Endoscopy Affect Outcomes?

BACKGROUND: In patients with acute nonvariceal upper gastrointestinal bleeding (NVUGIB), early (≤ 24 h) endoscopy is recommended following hemodynamic resuscitation. Nevertheless, scarce data exist on the optimal timing of endoscopy in patients with NVUGIB receiving anticoagulants. OBJECTIVE: To analyze how the timing of endoscopy may influence outcomes in anticoagulants users admitted with NVUGIB. METHODS: Retrospective cohort study which consecutively included all adult patients using anticoagulants presenting with NVUGIB between January 2011 and June 2020. Time from presentation to endoscopy was assessed and defined as early (≤ 24 h) and delayed (> 24 h). The outcomes considered were endoscopic or surgical treatment, length of hospital stay, intermediate/intensive care unit admission, recurrent bleeding, and 30-day mortality. RESULTS: From 636 patients presenting with NVUGIB, 138 (21.7%) were taking anticoagulants. Vitamin K antagonists were the most frequent anticoagulants used (63.8%, n = 88). After adjusting for confounders, patients who underwent early endoscopy (59.4%, n = 82) received endoscopic therapy more frequently (OR 2.4; 95% CI 1.1-5.4; P = 0.034), had shorter length of hospital stay [7 (IQR 6) vs 9 (IQR 7) days, P = 0.042] and higher rate of intermediate/intensive care unit admission (OR 2.7; 95% CI 1.3 - 5.9; P = 0.010) than patients having delayed endoscopy. Surgical treatment, recurrent bleeding, and 30-day mortality did not differ significantly between groups. CONCLUSION: Early endoscopy (≤ 24 h) in anticoagulant users admitted with acute nonvariceal upper gastrointestinal bleeding is associated with higher rate of endoscopic treatment, shorter hospital stay, and higher intermediate/intensive care unit admission. The timing of endoscopy did not influence the need for surgical intervention, recurrent bleeding, and 30-day mortality.

Identifying inflammatory bowel disease patients at risk of metabolic dysfunction-associated fatty liver disease: usefulness of non-invasive steatosis predictive scores.

BACKGROUND: Inflammatory bowel disease (IBD) patients have a higher risk of metabolic dysfunction-associated fatty liver disease (MAFLD) compared with the general population. However, it is not known whether available non-invasive hepatic steatosis scores are useful in predicting MAFLD in IBD patients. We aimed to analyze the performances of MAFLD screening score (MAFLD-S), Fatty Liver Index (FLI), Hepatic Steatosis Index (HSI) and Clinical Prediction Tool for NAFLD in Crohn's Disease (CPN-CD), in identifying MAFLD in IBD patients. METHODS: A cross-sectional study was carried out including consecutive adult IBD outpatients submitted to transient elastography (TE). MAFLD criteria were assessed, and hepatic steatosis (HS) was defined by a controlled attenuation parameter (CAP) >248 dB/m using TE. MAFLD-S, FLI, HSI, and CPN-CD were calculated and their accuracy for the prediction of MAFLD was evaluated through their areas under the receiver-operating characteristic (AUROC) curves. RESULTS: Of 168 patients, body mass index ≥25, type 2 diabetes mellitus, dyslipidemia and arterial hypertension were present in 76 (45.2%), 10 (6.0%), 53 (31.5%), 20 (11.9%), respectively. HS was identified in 77 (45.8%) patients, of which 65 (84.4%) fulfilled MAFLD criteria. MAFLD-S (AUROC, 0.929 [95% CI, 0.888-0.971]) had outstanding and FLI (AUROC, 0.882 [95% CI, 0.830-0.934]), HSI (AUROC, 0.803 [95% CI, 0.736-0.871]), and CPN-CD (AUROC, 0.822 [95% CI, 0.753-0.890) had excellent discrimination in predicting MAFLD. CONCLUSIONS: MAFLD-S, FLI, HSI and CPN-CD scores can accurately identify MAFLD in IBD patients, allowing the selection of those in whom hepatic steatosis and metabolic risk factors assessment may be particularly beneficial.

P051 Identifying High-Risk Patients With Acute Severe Ulcerative Colitis: Is the ACE Index Useful?

BACKGROUND: Treatment delay in patients admitted with acute severe ulcerative colitis (ASUC) are associated with increased mortality. Therefore, it is essential to identify on admission patients at high-risk of steroid nonresponse who may benefit from earlier second-line treatment or surgical intervention. Recently, the ACE index was developed and includes 3 variables at admission: C-reactive protein (CRP) ≥50mg/dL, albumin ≤30g/L and endoscopic severity (Mayo endoscopic score=3), and ranges between 0-3 points. An index of 3 has been shown to be useful to identify patients with acute ulcerative colitis with high-risk of steroid nonresponse. OBJECTIVES: To assess the ACE index performance in predicting steroids response in ASUC. METHODS: Retrospective study including consecutive admissions for ASUC according to Truelove and Witts definition between January 2005 and December 2020. The ACE index was calculated and its accuracy for predicting response to steroids on admission in ASUC was assessed through the area under the curve (AUC). RESULTS: Sixty-five patients were included of whom 78.5% responded to steroids. Mean CRP (p = 0.01), albumin (p=0.02) and endoscopic severity score (p < 0.001) at admission were significantly different between responders and nonresponders, as opposed to Ulcerative Colitis Endoscopic Index of Severity (UCEIS) score (p = 0.32). Median ACE index was 2. The ACE index was a predictor of steroids response (AUC 0.789; p = 0.001); 50.0% of patients with an index of 3 did not respond to steroids, and 86.3% of patients with an index inferior to 3 responded to steroids (positive predictive value 50.0%; negative predictive value of 86.3%). CONCLUSION: The ACE index is an accurate predictor of steroids response on admission in ASUC. However, in our study, the ACE index doesn´t discriminate whose high-risk patients would benefit from earlier therapeutic escalation, since only 50.0% of patients with an index of 3 did not respond to steroids.