Starting gastrointestinal endoscopy in a lower middle-income country in Africa: Training, creating an endoscopy facility and developing telemedicine.

Background and study aims The prevalence of digestive diseases seems to be high in African countries. Nonetheless, the human and material resources are scarce. The aim of the Portuguese volunteering project described in this report was to develop the specialty of digestive endoscopy in Sao Tome and Principe, a lower-middle-income country in Africa. Methods Beginning by assessing the local needs and available resources and managing immediate issues related to this field, we aimed to provide the tools necessary to improve gastroenterological and endoscopic care in the country. The first step included training of the local teams, through the development and accomplishment of an adapted curriculum for a 3-year medical gastroenterological fellowship and a short-term nursing fellowship, both in Portugal, and the organization of regular gastroenterological and endoscopic theoretical and practical sessions in Sao Tome and Principe. Second, the endoscopy facilities of the unit were significantly optimized. Third, a web platform was designed to provide telemedicine incorporating real-time endoscopic imaging available remotely. Results Through these sequential steps achieved in collaboration with Portuguese and local teams, this 5-year project provided the basis for gastroenterology care in this country. Conclusions At the present time, Sao Tome and Principe has an autonomous, efficient and skilled team and unit to provide care for patients with gastrointestinal diseases who need endoscopic procedures.

Feeding tube transparietal thickness - A promising anthropometric parameter for nutritional assessment of endoscopic gastrostomy fed patients.

BACKGROUND & AIMS: Malnutrition is common in patients eligible for percutaneous endoscopic gastrostomy (PEG). Feeding tube transparietal thickness (TT) may contribute to assess nutritional status. This study aims to: 1) Characterize TT in PEG patients. 2) Determine the association between TT and the currently used tools 3) Define TT best cut-offs to predict undernutrition 4) Assess the correlation between TT and survival. METHODS: Prospective cohort study including patients who underwent PEG. Nutritional assessment was performed using NRS 2002, anthropometry and serum proteins. Anthropometry included body-mass index (BMI), mid upper arm circumference (MUAC), triceps skinfold (TSF) and mid arm muscle circumference (MAMC). TT was measured immediately after PEG and survival was recorded. TT cut-offs were established by comparison with other anthropometric parameters and using the ROC analysis. The correlation between TT and survival was assessed. RESULTS: 227 patients (161 men and 66 women) aged 23-96 years. Most presented head or neck cancer (51.1%). Undernutrition was identified in 57.7% according with BMI. Median TT was 25 mm (IQR = 10). TT was correlated with BMI (R = 0.5), MUAC (R = 0.5), TSF (R = 0.5) and MAMC (R = 0.4) (p < 0.01), respectively, being accurate in predicting undernutrition (AUROC 0.71 ± 0.033, p < 0.01). TT <20 mm showed positive predictive value of 81.6% and specificity of 84.4% to detect undernutrition. TT was correlated with survival (R = 0.1) (p = 0.05). Head or neck cancer patients' survival was significantly lower if TT ≤ 25 mm (p = 0.03). CONCLUSIONS: TT is variable among PEG patients but values below 20-25 mm are suggestive of undernutrition. TT defined in the day of the gastrostomy procedure is the easiest anthropometric parameter that can be obtained from a PEG patient. Due to its higher positive predictive value and correlation with survival, TT should be viewed as an additional anthropometric tool specific for PEG patients, with diagnostic and prognostic value.

Clinical performance of an infliximab rapid quantification assay.

BACKGROUND: Therapeutic drug monitoring (TDM)-based algorithms can be used to guide infliximab (IFX) adjustments in inflammatory bowel disease (IBD) patients. This study aimed to explore a rapid IFX-quantification test from a clinical perspective. METHODS: This manuscript describes a prospective cohort study involving 110 ulcerative colitis (UC) patients on the maintenance phase of IFX. IFX trough levels were quantified using a rapid quantification assay and a commonly-used reference kit. RESULTS: Irrespective of the assay used to measure IFX, its through levels were statistically different between patients with and without endoscopic remission (Mayo endoscopic score = 0), as well as between patients stratified by their faecal calprotectin (FC) levels. Despite the fact that the two methods correlated well with each other [Spearman's rank correlation coefficient = 0.843, p < 0.001; intraclass correlation coefficients = 0.857, 95% confidence interval (CI): 0.791-0.903], there was a discernible systematic variation; values obtained with the reference kit were on average 2.62 units higher than those obtained with the rapid assay. Notwithstanding, 3 µg/ml was shown to be an acceptable cut-off to assess endoscopic status and inflammatory burden levels using both assays. The percentage of patients that had a positive outcome when the IFX concentration measured by the rapid assay ranked above 3 µg/ml was 88% both for a Mayo endoscopic score ⩽ 1 and for an FC concentration <250 µg/g. CONCLUSIONS: Based on this study, we concluded that using the rapid IFX assessment system with a 3 µg/ml threshold is a reliable alternative to the time-consuming enzyme-linked immunosorbent assays in patients on the maintenance phase of IFX.

Calprotectin and the Magnitude of Antibodies to Infliximab in Clinically-stable Ulcerative Colitis Patients are More Relevant Than Infliximab Trough Levels and Pharmacokinetics for Therapeutic Escalation.

Although infliximab (IFX) is an efficient therapy for ulcerative colitis (UC) patients, a considerably high rate of therapeutic failures still occurs. This study aimed at a better understanding of IFX pharmacokinetics and pharmacodynamics among clinically-asymptomatic UC patients. This was a multicentric and prospective study involving 65 UC patients in the maintenance phase of IFX therapy. There were no significant differences between patients with positive and negative clinical, endoscopic and histological outcomes concerning their IFX trough levels (TLs), area under the IFX concentration vs. time curve (AUC), clearance and antibodies to infliximab (ATI) levels. However, the need to undergo therapeutic escalation later in disease development was significantly associated with higher ATI levels (2.62µg/mL vs. 1.15µg/mL, p=0.028). Moreover, and after adjusting for disease severity, the HR (hazard ratio) for therapeutic escalation was significantly decreased for patients with an ATI concentration below 3µg/mL (HR=0.119, p=0.010), and increased for patients with fecal calprotectin (FC) level above 250µg/g (HR=9.309, p=0.018). In clinically-stable UC patients, IFX pharmacokinetic features cannot predict therapeutic response on a short-term basis. However, high levels of ATIs or FC may be indicative of a future therapeutic escalation.

Detection of anti-infliximab antibodies is impacted by antibody titer, infliximab level and IgG4 antibodies: a systematic comparison of three different assays.

BACKGROUND: There is scant information on the accuracy of different assays used to measure anti-infliximab antibodies (ADAs), especially in the presence of detectable infliximab (IFX). We thus aimed to evaluate and compare three different assays for the detection of IFX and ADAs and to clarify the impact of the presence of circulating IFX on the accuracy of the ADA assays. METHODS: Blood samples from 79 ulcerative colitis (UC) patients treated with infliximab were assessed for IFX levels and ADAs using three different assays: an in-house assay and two commercial kits, Immundiagnostik and Theradiag. Sera samples with ADAs and undetectable levels of IFX were spiked with exogenous IFX and analyzed for ADAs. RESULTS: The three assays showed 81-96% agreement for the measured IFX level. However, the in-house assay and Immundiagnostik assays detected ADAs in 34 out of 79 samples, whereas Theradiag only detected ADAs in 24 samples. Samples negative for ADAs with Theradiag, but ADA-positive in both the in-house and Immundiagnostik assays, were positive for IFX or IgG4 ADAs. In spiking experiments, a low concentration of exogenous IFX (5 µg/ml) hampered ADA detection with Theradiag in sera samples with ADA levels of between 3 and 10 µg/ml. In the Immundiagnostik assay detection interference was only observed at concentrations of exogenous IFX higher than 30 µg/ml. However, in samples with high levels of ADAs (>25 µg/ml) interference was only observed at IFX concentrations higher than 100 µg/ml in all three assays. Binary (IFX/ADA) stratification of the results showed that IFX+/ADA- and IFX-/ADAs+ were less influenced by the assay results than the double-positive (IFX+/ADAs+) and double-negative (IFX-/ADAs-) combination. CONCLUSIONS: All three methodologies are equally suitable for measuring IFX levels. However, erroneous therapeutic decisions may occur when patients show double-negative (IFX-/ADAs-) or double-positive (IFX+/ADAs+) status, since agreement between assays is significantly lower in these circumstances.

Oral mucosa lesions and oral symptoms in inflammatory bowel disease patients.

BACKGROUND: Inflammatory Bowel Disease is known for its extra intestinal manifestations, the oral cavity is no exception. OBJECTIVES: The aim of this study was to evaluate the association between Inflammatory Bowel Disease and oral mucosa lesions and symptoms, and complementary to evaluate their possible relation with oral hygiene, smoking habits, drug therapy, duration and activity of the disease. METHODS: Patients were selected from the Gastroenterology Clinic of a Portuguese tertiary referral hospital. This sample consisted of 113 patients previously diagnosed with ulcerative colitis or Crohn's disease along with a control group of 58 healthy individuals that were accompanying the study group patients to their appointments. Clinical interviews and clinical examinations were performed for data collection. RESULTS: The patients in the study group were more affected by oral symptoms (P=0.011), and showed a trend towards a higher incidence of oral mucosal lesions, even though statistical significance was not reached (8.8% versus 3.4% in the control group; P=0.159). Patients in active phase were the most affected. No differences were detected between Crohn's disease and ulcerative colitis, or concerning smoking habits. The corticosteroid and immunosuppressant therapy seemed to increase the incidence of oral symptoms (P=0.052). The oral mucosa lesions increased and the oral symptoms decreased over the course of the disease, however without statistical significance. CONCLUSION: Oral mucosa's lesions and oral symptoms were positively associated with Inflammatory Bowel Disease, mainly during disease activity periods and conceivably, associated with corticosteroid and immunosuppressant therapy.

Oral mucosa lesoons and oral symptoms in inflammatory bowel disease patients / Lesões das mucosas orais e sintomatologia oral em doentes com Doença Inflamatória Intestinal

Background Inflammatory Bowel Disease is known for its extra intestinal manifestations, the oral cavity is no exception. Objectives The aim of this study was to evaluate the association between Inflammatory Bowel Disease and oral mucosa lesions and symptoms, and complementary to evaluate their possible relation with oral hygiene, smoking habits, drug therapy, duration and activity of the disease. Methods Patients were selected from the Gastroenterology Clinic of a Portuguese tertiary referral hospital. This sample consisted of 113 patients previously diagnosed with ulcerative colitis or Crohn’s disease along with a control group of 58 healthy individuals that were accompanying the study group patients to their appointments. Clinical interviews and clinical examinations were performed for data collection. Results The patients in the study group were more affected by oral symptoms (P=0.011), and showed a trend towards a higher incidence of oral mucosal lesions, even though statistical significance was not reached (8.8% versus 3.4% in the control group; P=0.159). Patients in active phase were the most affected. No differences were detected between Crohn’s disease and ulcerative colitis, or concerning smoking habits. The corticosteroid and immunosuppressant therapy seemed to increase the incidence of oral symptoms (P=0.052). The oral mucosa lesions increased and the oral symptoms decreased over the course of the disease, however without statistical significance. Conclusion Oral mucosa’s lesions and oral symptoms were positively associated with Inflammatory Bowel Disease, mainly during disease activity periods and conceivably, associated with corticosteroid and immunosuppressant therapy. .

Contexto A doença inflamatória intestinal é conhecida por suas manifestações extraintestinais, a cavidade oral não é exceção. Objetivos O objetivo deste estudo foi o de avaliar a associação da doença inflamatória intestinal com lesões da mucosa oral e sintomatologia oral, e complementarmente, avaliar a sua possível relação com a higiene oral, tabagismo, terapêutica farmacológica, duração e atividade da doença. Métodos Os pacientes foram selecionados no serviço de Gastroenterologia de um hospital de referência terciária Português (Hospital Garcia de Horta). Esta amostra foi composta por 113 pacientes previamente diagnosticados com colite ulcerosa ou doença de Crohn, juntamente com um grupo controle de 58 indivíduos saudáveis que acompanhavam os pacientes do grupo nas suas consultas de controle. Entrevistas clínicas e exames clínicos foram realizados para a coleta de dados. Resultados Os pacientes do grupo de estudo foram mais afetados por sintomas orais (P=0,011), e houve também uma tendência para uma maior incidência de lesões da mucosa oral, embora a significância estatística não tenha sido alcançada (8,8% versus 3,4% no grupo de controle; P=0,159). Pacientes em fase ativa foram os mais afetados. Não foram detetadas diferenças entre a doença de Crohn e a colite ulcerosa, ou relativas a hábitos tabágicos. O tratamento com corticosteroides e imunossupressores pareceu aumentar a incidência de sintomas orais (P=0,052). Os dados são ainda compatíveis com aumento das lesões da mucosa oral e diminuição dos sintomas ao longo do curso da doença, no entanto, sem significância estatística. Conclusão As lesões de mucosa oral e sintomas orais foram associados positivamente com a doença inflamatória intestinal, principalmente durante os períodos de atividade da doença e possivelmente, associado a terapêutica com corticosteroides e imunossupressores. .

Ostomy metastasis after pull endoscopic gastrostomy: a unique favorable outcome / Metástasis en la estoma de un paciente sometido a gastrostomía endoscópica: una evolución clínica favorable

Head and neck cancer (HNC) patients tend to develop dysphagia. In order to preserve the nutritional support, many undergo endoscopic gastrostomy (PEG). In HNC patients, ostomy metastasis is considered a rare complication of PEG, but there are no reports of successful treatment of these metastatic cancers. We report the case of a 65 years old pharyngeal/laryngeal cancer patient who underwent a PEG before the neck surgery. He was considered to be cured, resumed oral intake and the PEG tube was removed. Ten months after, he returned with a metastasis at the ostomy site. A block resection of the stomach and abdominal wall was performed. Two years after the abdominal surgery, he is free of disease. Although usually considered a rare complication of the endoscopic gastrostomy, ostomy metastasis may be more frequent than usually considered and the present case report demonstrates that these patients may have a favourable outcome (AU)

Los pacientes con cáncer cérvico-facial tienden a desarrollar disfagia. Para preservar la nutrición, son sometidos a gastrostomía endoscópica (GEP). Las metástasis en la estoma se consideran complicaciones raras y no hay informes de éxito del tratamiento de estos cánceres metastásicos. Presentamos el caso de un paciente de 65 años con cáncer faríngeo/laríngeo que se sometió a una GEP antes de la cirugía en el cuello. Se consideró curado, reanudó la ingesta oral y se retiró el tubo. Diez meses después regresó con una metástasis en el lugar de la estoma. Se realizó una resección en bloque del estómago y la pared abdominal. Dos años después de la cirugía abdominal es libre de la enfermedad. Aunque generalmente se considera una complicación rara, las metástasis en la estoma de GEP pueden ser más frecuentes que lo corrientemente considerado. El presente caso demuestra que estos pacientes pueden tener un resultado clínico favorable (AU)

Ostomy metastasis after pull endoscopic gastrostomy: a unique favorable outcome.

Head and neck cancer (HNC) patients tend to develop dysphagia. In order to preserve the nutritional support, many undergo endoscopic gastrostomy (PEG). In HNC patients, ostomy metastasis is considered a rare complication of PEG, but there are no reports of successful treatment of these metastatic cancers. We report the case of a 65 years old pharyngeal/laryngeal cancer patient who underwent a PEG before the neck surgery. He was considered to be cured, resumed oral intake and the PEG tube was removed. Ten months after, he returned with a metastasis at the ostomy site. A block resection of the stomach and abdominal wall was performed. Two years after the abdominal surgery, he is free of disease. Although usually considered a rare complication of the endoscopic gastrostomy, ostomy metastasis may be more frequent than usually considered and the present case report demonstrates that these patients may have a favourable outcome.

Los pacientes con cáncer cérvico-facial tienden a desarrollar disfagia. Para preservar la nutricion, son sometidos a gastrostomía endoscópica (GEP). Las metástasis en la estoma se consideran complicaciones raras y no hay informes de éxito del tratamiento de estos cánceres metastásicos. Presentamos el caso de un paciente de 65 años con cáncer faríngeo/laríngeo que se sometió a una GEP antes de la cirugía en el cuello. Se consideró curado, reanudó la ingesta oral y se retiró el tubo. Diez meses después regresó con una metástasis en el lugar de la estoma. Se realizó una resección en bloque del estómago y la pared abdominal. Dos años después de la cirugía abdominal es libre de la enfermedad. Aunque generalmente se considera una complicación rara, las metástasis en la estoma de GEP pueden ser más frecuentes que lo corrientemente considerado. El presente caso demuestra que estos pacientes pueden tener un resultado clínico favorable.

Bleeding and starving: fasting and delayed refeeding after upper gastrointestinal bleeding.

CONTEXT: Early refeeding after nonvariceal upper gastrointestinal bleeding is safe and reduces hospital stay/costs. OBJECTIVES: The aim of this study was obtaining objective data on refeeding after nonvariceal upper gastrointestinal bleeding. METHODS: From 1 year span records of nonvariceal upper gastrointestinal bleeding patients that underwent urgent endoscopy: clinical features; rockall score; endoscopic data, including severity of lesions and therapy; feeding related records of seven days: liquid diet prescription, first liquid intake, soft/solid diet prescription, first soft/solid intake. RESULTS: From 133 patients (84 men) Rockall classification was possible in 126: 76 score ≥5, 50 score <5. One persistent bleeding, eight rebled, two underwent surgery, 13 died. Ulcer was the major bleeding cause, 63 patients underwent endoscopic therapy. There was 142/532 possible refeeding records, no record 37% patients. Only 16% were fed during the first day and half were only fed on third day or later. Rockall <5 patients started oral diet sooner than Rockall ≥5. Patients that underwent endoscopic therapy were refed earlier than those without endotherapy. CONCLUSIONS: Most feeding records are missing. Data reveals delayed refeeding, especially in patients with low-risk lesions who should have been fed immediately. Nonvariceal upper gastrointestinal bleeding patients must be refed earlier, according to guidelines.

Colonoscopy and carcinoembryonic antigen variations.

CONTEXT: Colonoscopy is essential for synchronous and metachronous cancer detection. Carcinoembryonic antigen is a colorectal cancer tumor marker, important as a follow-up tool in patients with previous colorectal cancer. False-positive carcinoembryonic antigen elevation results in multiples exams and in patient anxiety. In literature, there is reference to transient carcinoembryonic antigen increase with colonoscopy. OBJECTIVE: To evaluate the influence of bowel preparation and colonoscopy in carcinoembryonic antigen blood levels. METHODS: We prospectively studied subjects that underwent routine colonoscopy in our institution. Blood samples were collected (1) before bowel cleaning, (2) before colonoscopy and (3) immediately after colonoscopy. Blood carcinoembryonic antigen levels were determined by "Sandwich" immunoassay. The statistical methods used were the paired t-test and ANOVA. RESULTS: Thirty-seven patients (22M/15F) were included; age range 28-84 (mean 56 years). Mean carcinoembryonic antigen values were 1.9, 2 and 1.8 for (1), (2) and (3), respectively. An increase in value (2) compared with (1) was observed in 20/37 patients (P = 0.018), mainly in younger patients and in patients requiring more endoluminal interventions. In 29/37 patients, the CEA value decreased from (2) to (3) (P = 1.3x10-7). CONCLUSIONS: A trend for carcinoembryonic antigen increase after bowel cleaning was observed, especially in younger patients and in patients with more endoluminal interventions, but without clinical meaning.

BLEEDING AND STARVING: fasting and delayed refeeding after upper gastrointestinal bleeding / Hemorragia e jejum: jejum e reintrodução alimentar tardia após episódios de hemorragia digestiva alta

Context Early refeeding after nonvariceal upper gastrointestinal bleeding is safe and reduces hospital stay/costs. Objectives The aim of this study was obtaining objective data on refeeding after nonvariceal upper gastrointestinal bleeding. Methods From 1 year span records of nonvariceal upper gastrointestinal bleeding patients that underwent urgent endoscopy: clinical features; rockall score; endoscopic data, including severity of lesions and therapy; feeding related records of seven days: liquid diet prescription, first liquid intake, soft/solid diet prescription, first soft/solid intake. Results From 133 patients (84 men) Rockall classification was possible in 126: 76 score ≥5, 50 score <5. One persistent bleeding, eight rebled, two underwent surgery, 13 died. Ulcer was the major bleeding cause, 63 patients underwent endoscopic therapy. There was 142/532 possible refeeding records, no record 37% patients. Only 16% were fed during the first day and half were only fed on third day or later. Rockall <5 patients started oral diet sooner than Rockall ≥5. Patients that underwent endoscopic therapy were refed earlier than those without endotherapy. Conclusions Most feeding records are missing. Data reveals delayed refeeding, especially in patients with low-risk lesions who should have been fed immediately. Nonvariceal upper gastrointestinal bleeding patients must be refed earlier, according to guidelines. .

Contexto A reintrodução alimentar precoce após hemorragia digestiva alta de causa não varicosa é segura, reduz internamento/custos hospitalares. Objetivos O objetivo deste estudo retrospectivo foi avaliar a realimentação após hemorragia digestiva alta de causa não varicosa. Métodos Dos processos dos doentes submetidos a endoscopia urgente por hemorragia digestiva alta de causa não varicosa, durante 1 ano, recolhemos: dados clínicos; classificação de Rockall; dados endoscópicos; registos nutricionais de 7 dias: prescrição de líquidos, primeira ingestão líquida, prescrição de dieta mole/sólida, primeira ingestão de dieta mole/sólida. Resultados Em 133 doentes (84 homens), a classificação Rockall foi possível em 126: 76 score ≥5, 50 score <5. Uma hemorragia inicial persistente, 8 recidivas hemorrágicas, dois doentes submetidos a cirurgia, 13 falecidos. A úlcera foi a lesão predominante, 63 doentes submetidos à terapêutica endoscópica. Encontraram-se 142/532 registos nutricionais possíveis, 37% sem qualquer registo. Só 16% foram realimentados no 1.° dia, metade foram realimentados no 3.° dia ou posteriormente. Doentes com Rockall <5 foram realimentados mais cedo que com Rockall ≥5. Doentes com terapêutica endoscópica foram realimentados mais cedo que sem terapêutica. Conclusões Falta a maioria dos registos. Os dados mostram realimentação tardia, sobretudo nos doentes com lesões de baixo risco que deveriam alimentar-se imediatamente. Doentes com hemorragia digestiva alta de causa não varicosa devem iniciar precocemente a alimentação, de acordo com as recomendações. .

An unusual cause of pseudoachalasia: the Alport syndrome-diffuse leiomyomatosis association.

Alport syndrome (AS) is a hereditary disease characterized by glomerular nephropathy progressing to end-stage renal disease, frequently associated with sensorineural deafness and ocular abnormalities. Rarely, AS coexists with diffuse leiomyomatosis, a benign proliferation of smooth muscle in the gastrointestinal tract, mostly of the oesophagus, but also of the tracheobronchial tree and the female genital tract. Patients with this association have been shown to have contiguous gene deletion involving both COL4A5 and COL4A6 genes. The authors report the case of a 25-year-old man with AS and long-standing dysphagia. The patient received a renal transplant at the age of 23 because of end-stage renal disease. Clinical assessment as well as endoscopic, manometric and radiologic studies suggested the diagnosis of achalasia, which was treated by Heller's myotomy with Dor fundoplication. Postprocedure dysphagia led to an endoscopic ultrasound that showed diffuse thickening of the second layer, resulting in the hypothesis of oesophageal leiomyomatosis. The diagnosis was confirmed through histological study of endoscopic biopsies and genetic analysis.