Salvage radiofrequency ablation for microwave ablation treated hepatocellular carcinoma complicated by gas gangrene: case report.

AIM: Gas gangrene (GG) is a rare severe infection with a very high mortality rate mainly caused by Clostridium species. It develops suddenly, often as a complication of abdominal surgery or liver transplantation. We report a case of GG of the liver occurred after percutaneous microwave (MW) ablation of an hepatocellular carcinoma (HCC) successfully treated with percutaneous Radiofrequency ablation (RFA). CASE PRESENTATION: A 76-year-old female patient was treated with MW ablation for a large HCC in the VIII segment; 2 days later she developed fever, weakness, abdominal swelling and was hospitalized with diagnosis of anaerobic liver abscess. Despite antibiotic therapy, the patient conditions worsened, and she was moved to the intensive care unit (ICU). Percutaneous drainage was attempted, but was unsuccessful. The surgeon and the anesthesiologist excluded any indication of surgical resection. We performed RFA of the GG by 3 cool-tip needles into the infected area. The procedure was well tolerated by the patient, who left the hospital for follow-up. CONCLUSION: Percutaneous RFA could be a valuable therapy of focal GG of the liver in patients refractory to antibiotics and when surgery and OLT are not feasible. A fast and early indication is needed in case of rapid worsening of the patient's conditions.

Prevalence, Pathogenesis and Management of Anemia in Inflammatory Bowel Disease: An IG-IBD Multicenter, Prospective, and Observational Study.

BACKGROUND: Anemia is a common extraintestinal manifestation of inflammatory bowel disease (IBD), with a 6% to 74% prevalence and a negative impact on patient survival and quality of life, although the prevalence is apparently declining due to improved disease treatment. We aimed to investigate the prevalence, pathogenesis, and clinical correlates of anemia in Italian patients with IBD. METHODS: A multicenter, prospective, observational study, involving 28 Italian gastroenterology centers, was conducted to investigate the epidemiology and consequences of IBD-associated anemia. Clinical and laboratory data of anemic patients were obtained at study enrolment. RESULTS: Anemia was diagnosed in 737 of 5416 adult IBD outpatients (prevalence 13.6%); females were more commonly affected than males (odds ratio, 1.5; 95% confidence interval [CI], 1.2-1.7) and had more severe anemia. In the majority of cases, anemia was due to iron deficiency (62.5% of cases; 95% CI, 58.3%-66.6%), either isolated or in association with inflammation and/or vitamin deficiencies; anemia of inflammation accounted for only 8.3% of cases. More severe anemia was associated with increasing fatigue and worse quality of life. Only 68.9% of anemic patients with iron deficiency (95% CI, 63.4%-73.8%) and 34.6% of those with vitamin deficiencies (95% CI, 26.2%-44.2%) were properly treated with supplementation therapy. CONCLUSIONS: In Italy, the prevalence of IBD-associated anemia is lower than previously reported. Anemia of IBD is most commonly due to iron deficiency and contributes to fatigue and poor quality of life, but remains untreated in a large proportion of patients with iron and/or vitamin deficiencies. This study is registered at clinicaltrials.gov as NCT02872376.

The prevalence of inflammatory bowel disease­associated anemia is 13.6%. The prevalence is higher among females younger than 50. Anemia is usually due to iron deficiency and adversely affects fatigue and quality of life. Many patients with iron or vitamin deficiency (31% and 65%, respectively) remain untreated.

Derivation and validation of Re.Co.De death score risk in patients with acute nonvariceal upper GI bleeding.

BACKGROUND AND AIMS: Scores in upper GI bleeding (UGIB) are used to stratify death risk and need for hospitalization at admission, but a tool that incorporates dynamic changes during the hospital stay is lacking. We aimed to develop a death risk score that considers changes in clinical status during hospitalization and compare its performance with existing ones. METHODS: A multicenter cohort study enrolling patients with UGIB in 50 Italian hospitals from January 2014 to December 2015 was conducted. Data were collected and used to develop a risk score using logistic regression analyses. Performance curves (area under the receiver-operating characteristic [AUROC] curves), sensitivities, specificities, positive and negative predictive values, and outcomes classified as low, intermediate, and high death risk were calculated. The score's performance was externally validated and then compared with other scores. RESULTS: We included 1852 patients with nonvariceal UGIB in the development cohort and 912 in the validation cohorts. The new score, which we named the Re.Co.De (rebleeding-comorbidities-deteriorating) score, included 10 variables depicting the changes in clinical conditions while in the hospital. The mortality AUROC curves were .93 (95% confidence interval, .91-.96) in the derivation cohort and .94 (95% confidence interval, .91-.98) in validation cohort. In a comparison of AUROC curves with other scores, the new score showed a significant performance compared with pre- and postendoscopy scores. Patients with low and high scores had 30-day mortality rates of .001% and 48.2%, respectively. CONCLUSIONS: The Re.Co.De score has a higher performance for predicting mortality in patients with UGIB compared with other scores, correctly identifying patients at low and high death risk while in the hospital through a dynamic re-evaluation of clinical status.

Treatment-based risk stratification of infections in inflammatory bowel disease: A comparison between anti-tumor necrosis factor-α and nonbiological exposure in real-world setting.

BACKGROUND AND AIM: Infective issues about anti-tumor necrosis factor (TNF)-α agents in inflammatory bowel disease (IBD) remain controversial, especially when compared with nonbiological treatments. This study aimed to evaluate the incidence and prevalence of several infections in anti-TNF-α-exposed patients compared with nonbiological treatments. METHODS: All naïve IBD subjects treated with anti-TNF-α and matched nonbiologic-exposed patients were included. RESULTS: Among 3453 patients in the database, 288 anti-TNF-α-exposed subjects and 288 nonbiologic-exposed IBD controls met inclusion criteria. Fifty-eight infections (20.1%) occurred during anti-TNF-α treatment versus 23 (8%) in the matched group (odds ratio [OR] 2.9, P < 0.001) (incidence 5.72 vs 0.96/100 patient-years, incidence ratio [IR] 6, P < 0.001). IR was higher for anti-TNF-α versus mesalamine/sulfasalazine (IR 40.8, P < 0.001), similar to azathioprine/6-mercaptopurine/methotrexate (IR 0.78, P = 0.32) and lower than corticosteroids (IR 0.05, P < 0.001). The incidence rate of serious infections was 1.3 in the anti-TNF-α-exposed versus 0.38/100 patient-years in nonexposed subjects (IR 3.44, P = 0.002), without significant difference between anti-TNF-α and azathioprine/6-mercaptopurine/methotrexate (1.3 vs 3.03/100 patient-years, IR 0.43, P = 0.1). Predictors of infections in anti-TNF-α-exposed patients were concomitant use of systemic steroids (OR 1.9, P = 0.02) or azathioprine (OR 2.6, P = 0.01) and a body mass index < 18.5 at time of infection (OR 2.2, P = 0.01). CONCLUSIONS: The risk of developing infections during anti-TNF-α therapy remains high, although not dissimilar to that found for other immunosuppressants, while concomitant immunosuppression and malnutrition appear the most important causes of infection.

Improvement in appropriateness and diagnostic yield of fast-track endoscopy during the COVID-19 pandemic in Northern Italy.

BACKGROUND: During the COVID-19 outbreak in Italy, only fast-track endoscopic procedures have been performed; nevertheless, a significant drop in their number has been reported. We evaluated whether the pandemic has impacted the appropriateness and diagnostic yield of fast-track endoscopic procedures compared with those performed in 2019. METHODS: This retrospective study involved endoscopy services in Northern Italy. We compared data regarding endoscopic procedures performed in March and April 2020 with those performed during the same period in 2019. RESULTS: In 2020, there was a 53.6 % reduction in the number of fast-track endoscopic procedures compared with 2019. Patients undergoing endoscopy in 2020 were younger than in 2019. Both appropriate referral and diagnostic yield increased in 2020 for both upper and lower endoscopy. A higher rate of cancer was diagnosed in 2020 by upper endoscopy (3.6 % vs. 6.6 %; P = 0.04). CONCLUSIONS: The high level of inappropriate endoscopy referrals registered in 2019 significantly improved during the COVID-19 outbreak of 2020, with an increase in the diagnostic yield.

Inflammatory bowel disease in a colorectal cancer screening population: Diagnosis and follow-up.

BACKGROUND: Inflammatory bowel disease (IBD) is usually diagnosed in subjects with gastrointestinal symptoms, but may also be asymptomatic and diagnosed incidentally. AIMS: to determine the prevalence of IBD in asymptomatic adults. METHODS: we identified subjects who underwent colonoscopy between 1 September 2013 and 31 August 2019 in a regional colorectal cancer screening program with endoscopic findings suggestive of IBD, and retrieved their clinical, histological and therapeutic information. RESULTS: 5116 subjects underwent colonoscopy, and 4640 persons were considered assessable. Of these, 54 (1.16%) had endoscopic findings suggestive of IBD, including 40 of Crohn's disease (CD) and 14 of ulcerative colitis (UC). A definite diagnosis of IBD was made in 19 patients, for an overall IBD prevalence of 0.41%, with 13 cases of CD (0.28%) and 6 of UC (0.13%). The mean follow-up was 26.8 months after the first colonoscopy. Therapy was started in 5 of 13 CD patients and all UC patients. CONCLUSION: Endoscopic findings suggestive of IBD are not infrequent in an asymptomatic colorectal cancer screening population. Visualization of the terminal ileum is recommended in this setting. A definite diagnosis of IBD was made in about 1 out of 3 subjects with endoscopic lesions. Most IBD patients had a mild form of disease, but some needed biologic therapy.

Clinical Characteristics of COVID-19 Patients With Gastrointestinal Symptoms in Northern Italy: A Single-Center Cohort Study.

INTRODUCTION: The most typical presentation of COVID-19 is an acute respiratory syndrome whose most common symptoms include fever, cough, and dyspnea. However, gastrointestinal symptoms, such as diarrhea and nausea/vomiting, are increasingly reported in patients affected by COVID-19. This study aimed to describe the prevalence and time of onset of gastrointestinal symptoms in patients affected by COVID-19 and to find potential associations between gastrointestinal symptoms and clinical outcomes. METHODS: We performed a prospective single-center cohort study, enrolling patients who received diagnosis of COVID-19 at our institution between March 23, 2020, and April 5, 2020. We collected patient demographics and medical history, laboratory data, and clinical outcomes. Furthermore, we used a specifically designed questionnaire, administered to patients at time of diagnosis, to obtain data on the presence and time of onset of fever, typical respiratory symptoms, gastrointestinal symptoms, and other symptoms (fatigue, headache, myalgia/arthralgia, anosmia, ageusia/dysgeusia, sore throat, and ocular symptoms). RESULTS: In our cohort, 138 (69%) of 190 patients showed at least 1 gastrointestinal symptom at diagnosis; if excluding hyporexia/anorexia, 93 patients (48.9%) showed at least 1 gastrointestinal symptom. Gastrointestinal symptoms, in particular diarrhea, were associated with a lower mortality. At multivariate analysis, diarrhea was confirmed as independent predictive factor of lower mortality. DISCUSSION: Gastrointestinal symptoms are very frequent in patients with COVID-19 and may be associated with a better prognosis. These data suggest that, in some patients, the gastrointestinal tract may be more involved than the respiratory system in severe acute respiratory syndrome coronavirus 2 infection, and this could account for the less severe course of disease.

The impact of a dedicated contact centre on the clinical outcome of patients with inflammatory bowel disease during the COVID-19 outbreak.

BACKGROUND: With the interruption of elective activity during the coronavirus disease 2019 (COVID-19) pandemic, a reorganisation of health care for patients with inflammatory bowel disease (IBD) was warranted. We aimed to investigate the effectiveness of a dedicated contact centre service (CCS) on the reorganization of a high-volume IBD centre and on the continuity of care during the COVID-19 outbreak. METHODS: We compared the CCS services provided to 3680 IBD patients and clinical outcomes before (January-February 2020) and during (March-April 2020) the COVID-19 period. We further included, as comparator, data from March to April of the previous year (2019). RESULTS: During the outbreak, the CCS received an increase of 10.2% of contacts, from 881, in January-February 2020, to 971 (p = 0.02). An increase of 6% in CCS activities was also reported in comparison with March-April 2019 (from 914 to 971 in March-April 2020, p = 0.71). Before COVID-19, in both periods most contacts (67% in January-February 2020 and 60% in March-April 2019) required information about clinical activity, while fewer (33% in January-February 2020 and 40% in March-April 2019) requested logistic information. During the pandemic, most contacts (65.1%) asked to speak with a physician, 23.7% asked for information, while 11.1% wanted to cancel/postpone their appointments. Among all the information, 66% concerned COVID-19. In March-April 2020, 259 outpatient visits were booked, but were all replaced by phone consultations. No difference was detected in the number of intravenous biological administrations (307 versus 296, p = 0.64), surgeries (10 versus 9, p = 0.82) and urgent hospitalisations (10 versus 12, p = 0.67) before and during the COVID-19. CONCLUSION: The CCS was an effective tool in the reorganization of the IBD centre. Scheduled visits were replaced by phone calls. The main clinical outcomes were maintained in the COVID-19 period. Virtual follow-up using the CCS could be implemented after the pandemic to optimise the resources of the IBD centre.

Evaluation of nutritional adequacy in adult patients with Crohn's disease: a cross-sectional study.

PURPOSE: Inadequate oral intake may play an important role in the onset of malnutrition in patients with Crohn's disease (CD). The aims of this cross-sectional study were: (1) to compare dietary intake in clinically active and quiescent CD patients, and (2) to assess patients' nutritional adequacy relative to the dietary reference values (DRVs) for the Italian population using LARN (Livelli di Assunzione di Riferimento di Nutrienti ed energia per la popolazione italiana). METHODS: Patients aged between 18 and 65 years with a diagnosis of CD were recruited. All participants underwent anthropometry and were instructed to fill in a 3-day food record. Disease activity was clinically defined using the Crohn's disease activity index (CDAI). RESULTS: Overall, 117 patients, 71 males and 46 females, with a mean age of 39.6 ± 13.8 years and a mean body weight of 65.4 ± 11.8 kg, were ultimately included. Our findings showed that the amount of nutrients was similar between patients with active and quiescent disease. The mean intake of macronutrients was adequate, except for fiber, while dietary micronutrients were insufficient. Median intakes of sodium, phosphorus, and fluorine met LARN recommendations in both sexes, and the DRVs were accomplished by many patients (53/117; 104/117 and 98/117, respectively). Interestingly, dietary amounts of iron and zinc were barely acceptable in males but not in females. However, a few of the patients (< 15) met the LARN for potassium, calcium, and magnesium, regardless of sex and CDAI. With respect to vitamins, no relevant difference was found between the active and quiescent groups, and none of them met recommended values in both sexes. CONCLUSIONS: This study showed that the assessment of dietary intake can be crucial for optimizing dietary intervention with focused nutrition counseling, to improve nutritional status in CD patients.

One-year clinical outcomes with biologics in Crohn's disease: transmural healing compared with mucosal or no healing.

BACKGROUND: While mucosal healing has been proved to predict relevant clinical outcomes in Crohn's disease (CD), little is known about the long-term significance of transmural healing. AIMS: To prospectively assess the 1-year clinical outcomes in CD patients achieving transmural healing following treatment with biologics, and to compare them with those in patients reaching only mucosal healing or no healing. METHODS: Observational longitudinal study, evaluating 1-year outcomes in terms of steroid-free clinical remission, rate of hospitalisation and need for surgery in a group of CD patients treated with anti-tumour necrosis factor (TNF) alpha for 2 years. Bowel sonography was used in all patients to determine transmural healing. RESULTS: Of 218 patients who completed a 2-year treatment course with anti-TNF alpha, 68 (31.2%) presented transmural (plus mucosal) healing (bowel wall thickness ≤3 mm at bowel sonography), 60 (27.5%) mucosal healing only, and 90 (41.3%) did not achieve any intestinal healing. Transmural healing was associated with a higher rate of steroid-free clinical remission (95.6%), lower rates of hospitalisation (8.8%) and need for surgery (0%) at 1 year compared to mucosal (75%, 28.3% and 10%, respectively) and no healing (41%, 66.6% and 35.5%, respectively) (P < 0.001). Furthermore, transmural healing was associated with longer intervals until clinical relapse (HR, hazard ratio 0.87, P = 0.01), hospitalisation (HR 0.88, P = 0.002) and surgery (HR 0.94, P = 0.008) than mucosal healing. Also among patients discontinuing treatment with biologics, transmural healing predicted better clinical outcomes at 1 year than mucosal healing (P = 0.01). CONCLUSIONS: Transmural healing is an ambitious and powerful treatment goal associated, to a greater extent than mucosal healing, with improvement of all clinical outcomes. Additionally, transmural healing is associated with better long-term clinical outcomes than mucosal healing also after discontinuation of biologics.

Lack of Clinical Relevance of ANA and ASMA Positivity in Patients with Liver Transplantation without a History of Autoimmune Diseases.

The relevance of isolated autoimmunity elevation in orthotopic liver transplantation (OLT) patients is unknown. Our aim was to analyse how serum autoantibodies change in time and to evaluate their clinical relevance in OLT patients. Patients were invited to provide samples to evaluate ANA, AMA, ASMA, and LKM at the time of enrolment (T0), after 6 months (T6), and after 12 months (T12). We included 114 patients in the study (76% males, median age 62.5 years), finding isolated elevation of at least one serum antibody in up to 80% of them. We described fluctuating positive autoantibodies in the one year of observation, with only 45.6% of patients positive for ANA and less than 2% positive for ASMA, at all three times. Isolated elevation of tissue antibodies was not related to gender, age, HCC at transplant, early rejection, cause of transplantation, immunotherapy taken, and age at the time of the study. We did not detect a higher prevalence of positive autoimmunity in patients with signs of liver injury. ANA and ASMA evaluation in patients with liver transplantation and no history of autoimmune disease has no clinical relevance, since it varies in time and is not related to any risk factors or liver injury. Routine autoimmunity evaluation should be avoided.

Erythrocytosis after liver transplantation: the experience of a university hospital.

The prevalence and causes of erythrocytosis after liver transplantation have never been studied, even though this condition is known to predispose patients to thrombosis leading to graft failure or death. Erythrocytosis after orthotopic liver transplantation (OLT) can be defined as an increase in the red cell mass >125% in patients without a pre-OLT history of this condition. The study population was composed of 96 patients: 33 had undergone transplantation for a hepatitis B virus (HBV) infection (18 had a hepatitis D virus coinfection), 43 had undergone transplantation for a hepatitis C virus infection, 9 had undergone transplantation for alcohol abuse, and 11 had undergone transplantation for other causes [autoimmune liver disease (6), Wilson's syndrome (1), or cryptogenetic liver cirrhosis (4)]. Idiopathic erythrocytosis was reported in 11 male patients with a history of HBV infection. Patients with the diagnosis of erythrocytosis underwent phlebotomy every 3 weeks until the hematocrit level reached 45%, and this was repeated if the level exceeded 49%, so no patient presented with cardiovascular accidents during the follow-up. In conclusion, a history of HBV infection, male sex, and hepatitis B immune globulin therapy are all possible cofactors for an increased risk of erythrocytosis in OLT patients.

Difficult diagnosis of celiac disease: diagnostic accuracy and utility of chromo-zoom endoscopy.

BACKGROUND: Chromo-zoom endoscopy has been demonstrated to be valuable in assessing the degree of intestinal villous atrophy in patients with suspected celiac disease. OBJECTIVE: To evaluate the diagnostic accuracy of chromo-zoom endoscopy in patients with difficult diagnosis because of nonconcordant test results and/or the confounding of a gluten-free diet initiated before an appropriate diagnosis of celiac disease and to compare the findings to a recent reference standard, the in vitro gliadin challenge test. DESIGN: Prospective, case-control study. SETTING: Tertiary-care referral hospital. PATIENTS: Patients without celiac disease (negative control group, n = 9), patients with celiac disease (positive control group, n = 41), and patients with difficult diagnosis (n = 27). INTERVENTION: Chromo-endoscopy with indigo carmine and endoscopic zoom-magnification were performed. Duodenal fragments were collected for the in vitro gliadin challenge test. The area under the receiver operating characteristic curve (ROC) was used for statistical analyses on accuracy. MAIN OUTCOME MEASUREMENTS: Diagnostic accuracy of chromo-zoom endoscopy for detection of mucosal abnormalities in patients with difficult diagnosis. RESULTS: Chromo-zoom endoscopy had a high accuracy for celiac disease diagnosis in analyses on negative controls and positive controls (area under roc = 0.99). In the difficult diagnosis group, the accuracy of chromo-zoom endoscopy was lower (area under roc = 0.83), but it increased after exclusion of patients with celiac disease on gluten-free diet (area under roc = 0.88). LIMITATIONS: There was a 4% failure rate in the ability to cultivate biopsies. Also, the study was done at an academic medical center. CONCLUSION: Chromo-zoom endoscopy has high accuracy for cases of difficult diagnosis of celiac disease but only in untreated patients with celiac disease.

The Italian translation of the celiac disease-specific quality of life scale in celiac patients on gluten free diet.

BACKGROUND: A recently devised tool, the celiac disease-specific quality of life scale has been proposed to assess specifically quality of life in celiac patients. AIM: To assess the validity and reliability of the Italian translation of the celiac disease-specific quality of life scale. METHODS: The celiac disease-specific quality of life scale underwent forward/backward translation. Adults patients on gluten free diet by at least one year, consecutively recruited, completed SF36 questionnaire, the Italian version of celiac disease-specific quality of life scale, the health related quality of life question and an abdominal pain scale. The study fulfilled criteria for acceptable psychometric assessment according to the International Quality of Life Assessment project. RESULTS: Two-hundred-thirty celiac patients were recruited after about nine years from diagnosis. Factor analysis indicates that there are some similarities and discrepancies between the English and the Italian questionnaires. Despite this, the Italian celiac disease-specific quality of life scale was able to identify the same four factors characterizing the patients' answers (dysphoria, limitations, health concerns, inadequate treatment). CONCLUSION: The celiac disease-specific quality of life scale is useful for assessing celiac disease-related quality of life. A wide use of the Italian celiac disease-specific quality of life scale may be of help in obtaining comparable data on QOL in different setting and countries.