Response to Sahu and Singh Schettino, Mario; Manes, Gianpiero
The American journal of gastroenterology,
10/2021, Letnik:
116, Številka:
10
Journal Article
Recenzirano
...as stated in the methods section of our article, all the enrolled patients had a definite diagnosis of COVID-19, that is a positive nasopharyngeal swab and radiological evidence of pneumonia. ......we were the first to systematically investigate the presence of GI symptoms in patients with COVID-19 at diagnosis, whereas Pan et al. obtained the clinical characteristics of the patients from their medical records in the initial phase of the COVID-19 outbreak, when GI manifestations of SARS-CoV-2 infection were less known and thus less detected. ...several studies included loss of appetite in the GI symptoms, which was, by the way, the predominant GI feature (5,6,7). ...a number of studies have found a correlation between thorax Computed tomography score and features with disease severity and prognosis (8,9). ...the 1-year pandemic has progressively increased our knowledge of the new coronavirus and the syndromic pictures it determines.
Main Recommendations
ESGE recommends offering stone extraction to all patients with common bile duct stones, symptomatic or not, who are fit enough to tolerate the intervention.
Strong ...recommendation, low quality evidence.
ESGE recommends liver function tests and abdominal ultrasonography as the initial diagnostic steps for suspected common bile duct stones. Combining these tests defines the probability of having common bile duct stones.
Strong recommendation, moderate quality evidence.
ESGE recommends endoscopic ultrasonography or magnetic resonance cholangiopancreatography to diagnose common bile duct stones in patients with persistent clinical suspicion but insufficient evidence of stones on abdominal ultrasonography.
Strong recommendation, moderate quality evidence.
ESGE recommends the following timing for biliary drainage, preferably endoscopic, in patients with acute cholangitis, classified according to the 2018 revision of the Tokyo Guidelines:
– severe, as soon as possible and within 12 hours for patients with septic shock
– moderate, within 48 – 72 hours
– mild, elective.
Strong recommendation, low quality evidence.
ESGE recommends endoscopic placement of a temporary biliary plastic stent in patients with irretrievable biliary stones that warrant biliary drainage.
Strong recommendation, moderate quality of evidence.
ESGE recommends limited sphincterotomy combined with endoscopic papillary large-balloon dilation as the first-line approach to remove difficult common bile duct stones.
Strong recommendation, high quality evidence.
ESGE recommends the use of cholangioscopy-assisted intraluminal lithotripsy (electrohydraulic or laser) as an effective and safe treatment of difficult bile duct stones.
Strong recommendation, moderate quality evidence.
ESGE recommends performing a laparoscopic cholecystectomy within 2 weeks from ERCP for patients treated for choledocholithiasis to reduce the conversion rate and the risk of recurrent biliary events.
Strong recommendation, moderate quality evidence.
Main Recommendations
The following recommendations should only be applied after a thorough diagnostic evaluation including a contrast-enhanced computed tomography (CT) scan.
1
ESGE recommends colonic ...stenting to be reserved for patients with clinical symptoms and radiological signs of malignant large-bowel obstruction, without signs of perforation. ESGE does not recommend prophylactic stent placement.
Strong recommendation, low quality evidence.
2
ESGE recommends stenting as a bridge to surgery to be discussed, within a shared decision-making process, as a treatment option in patients with potentially curable left-sided obstructing colon cancer as an alternative to emergency resection.
Strong recommendation, high quality evidence.
3
ESGE recommends colonic stenting as the preferred treatment for palliation of malignant colonic obstruction.
Strong recommendation, high quality evidence.
4
ESGE suggests consideration of colonic stenting for malignant obstruction of the proximal colon either as a bridge to surgery or in a palliative setting.
Weak recommendation, low quality evidence.
5
ESGE suggests a time interval of approximately 2 weeks until resection when colonic stenting is performed as a bridge to elective surgery in patients with curable left-sided colon cancer.
Weak recommendation, low quality evidence.
6
ESGE recommends that colonic stenting should be performed or directly supervised by an operator who can demonstrate competence in both colonoscopy and fluoroscopic techniques and who performs colonic stenting on a regular basis.
Strong recommendation, low quality evidence.
7
ESGE suggests that a decompressing stoma as a bridge to elective surgery is a valid option if the patient is not a candidate for colonic stenting or when stenting expertise is not available.
Weak recommendation, low quality evidence.
Gastric cancer is one of the most common cancers and the second most common cause of cancer deaths worldwide. Apart from Japan, where screening programmes have resulted in early diagnosis in ...asymptomatic patients, in most countries the diagnosis of gastric cancers is invariably made on account on dyspeptic and alarm symptoms, which may also be of prognostic significance when reported by the patient at diagnosis. However, their use as selection criteria for endoscopy seems to be inconsistent since alarm symptoms are not sufficiently sensitive to detect malignancies. In fact, the overall prevalence of these symptoms in dyspeptic patients is high, while the prevalence of gastro-intestinal cancer is very low. Moreover, symptoms of early stage cancer may be indistinguishable from those of benign dyspepsia, while the presence of alarm symptoms may imply an advanced and often inoperable disease. The features of dyspeptic and alarm symptoms may reflect the pathology of the tumour and be of prognostic value in suggesting site, stage and aggressiveness of cancer. Alarm symptoms in gastric cancer are independently related to survival and an increased number, as well as specific alarm symptoms, are closely correlated to the risk of death. Dysphagia, weight loss and a palpable abdominal mass appear to be major independent prognostic factors in gastric cancer, while gastro-intestinal bleeding, vomiting and also duration of symptoms, do not seem to have a relevant prognostic impact on survival in gastric cancer.
Acute gastrointestinal bleeding (AGIB) results in significant morbidity and mortality. Topical hemostatic products have been developed for endoscopic use to help in the management of difficult ...bleeding. Our aim was to demonstrate the ease of use, safety, and efficacy of PuraStat, a novel hemostat, to control AGIB.
We describe 77 patients (41 men) who were treated for acute upper and lower AGIB in a 2-year period. In 50 patients, bleeding occurred as a complication of a previous endoscopic procedure, predominantly endoscopic mucosal resection (EMR) and endoscopic retrograde cholangiopancreatography (ERCP); however, in the other 27 patients, it derived from peptic ulcers, angiodysplasia, cancers, and surgical anastomoses. Bleeding was spurting in 13 of the 77 patients and oozing in 64. PuraStat was used after the failure of at least two conventional hemostatic methods.
A mean of 2.6 conventional hemostatic methods had been attempted prior to the application of PuraStat. PuraStat achieved successful hemostasis in 90.9 % of patients. In 41 patients, once hemostasis was obtained with PuraStat, endoscopists further stabilized hemostasis by using at least one additional method. Recurrence of bleeding was observed in eight patients (10.4 %). In 16 patients with intraprocedural bleeding, it was possible to complete the procedures (14 EMR, 2 ERCP) after PuraStat hemostasis. No adverse events related to PuraStat were recorded.
PuraStat is feasible, safe, and effective in controlling different types of gastrointestinal hemorrhage after failure of conventional hemostatic methods. Its application also does not hinder continuing endotherapy.
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.
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).
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.
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.
Introduction
Common bile duct stones (CBDS) can spontaneously migrate through the duodenal papilla. In this case, ERCP could be unnecessary and a significant rate of complications could be avoided. ...In this study, we aim at retrospectively evaluating the rate of spontaneous stone passage in patients with an imaging diagnosis of CBDS and at analysing the factors associated to spontaneous stone migration.
Methods
We conducted a retrospective multi-centre analysis of patients undergoing ERCP for CBDS in a 12-month period. 1016 patients with CBDS were analysed. In all patients CBDS was diagnosed with adequate imaging methods performed prior to ERCP. ERCPs with failed biliary cannulation were excluded. Data regarding patients’ characteristics, imaging findings and ERCP procedure were analysed.
Results
1016 patients with CBDS undergoing ERCP were analysed (male sex 43.3%; mean age 69.9 ± 16.5 years). Diagnosis of CBDS was obtained by EUS in 415 patients (40.8%), MR in 343 (33.8%), CT in 220 (21.7%), and US in 38 (3.7%). No stones were found at ERCP in 179 patients (17.6%), in 14 (6.2%) when ERCP was performed within 6 h from imaging study, in 114 (18.5%) between 7 h and 7 days, in 32 (24.6%) between 8 and 29 days, and in 19 (43.2%) after 30 days. The rate of unnecessary ERCP occurred significantly more frequently in patients in whom imaging methods demonstrated either sludge or ≤ 5 mm CBDS (29.9 vs. 8.3%;
p
< 0.001).
Discussion
Spontaneous migration of small CBDS is a frequent event, and ≤ 5 mm size and a delay in ERCP > 7 days represent predictive factors for it. We suggest that CBDS ≤ 5 mm should not undergo immediate removal and this fact would allow reducing the rate of unnecessary ERCP with their related complications. Prospective studies are needed to confirm these results and demonstrate the safety of a conservative management in this setting.
Patients with inflammatory bowel disease (IBD) often have other immune-mediated inflammatory diseases (IMIDs), and the prevalence of any IMID is higher in IBD patients than in the general population. ...IBD and other IMIDs involve alterations in innate and adaptive immune responses. Their co-occurrence depends on shared immune and inflammatory processes, pathogenic mechanisms, and genetic and environmental risk factors, including drugs, especially tumor necrosis factor inhibitors. The more common IMIDs associated with IBD have been widely described, so this review focuses on the less frequent associations. The IMIDs discussed here are skin disorders (psoriasis, atopic dermatitis, vitiligo, epidermolysis bullosa acquisita, cutaneous polyarteritis nodosa, and hidradenitis suppurativa), hepato-pancreatic diseases (autoimmune hepatitis, granulomatous hepatitis, and autoimmune pancreatitis), endocrine diseases (autoimmune thyroid diseases, and type 1 diabetes mellitus), multiple sclerosis, and respiratory diseases (asthma, bronchiectasis, and interstitial pneumonia). The early detection of IMIDs in IBD patients is important to prevent their deleterious clinical course and limit their psychological impact. Care for IBD patients with IMIDs should be multispecialist, with a single therapeutic strategy instead of treating each disease separately.
Main recommendations
1
ESGE recommends that all duodenal adenomas should be considered for endoscopic resection as progression to invasive carcinoma is highly likely. Strong recommendation, low ...quality evidence.
2
ESGE recommends performance of a colonoscopy, if that has not yet been done, in cases of duodenal adenoma.
Strong recommendation, low quality evidence.
3
ESGE recommends the use of the cap-assisted method when the location of the minor and/or major papilla and their relationship to a duodenal adenoma is not clearly established during forward-viewing endoscopy.
Strong recommendation, moderate quality evidence.
4
ESGE recommends the routine use of a side-viewing endoscope when a laterally spreading adenoma with extension to the minor and/or major papilla is suspected.
Strong recommendation, low quality evidence.
5
ESGE suggests cold snare polypectomy for small (< 6 mm in size) nonmalignant duodenal adenomas.
Weak recommendation, low quality evidence.
6
ESGE recommends endoscopic mucosal resection (EMR) as the first-line endoscopic resection technique for nonmalignant large nonampullary duodenal adenomas. Strong recommendation, moderate quality evidence.
7
ESGE recommends that endoscopic submucosal dissection (ESD) for duodenal adenomas is an effective resection technique only in expert hands.
Strong recommendation, low quality evidence.
8
ESGE recommends using techniques that minimize adverse events such as immediate or delayed bleeding or perforation. These may include piecemeal resection, defect closure techniques, noncontact hemostasis, and other emerging techniques, and these should be considered on a case-by-case basis.
Strong recommendation, low quality evidence.
9
ESGE recommends endoscopic surveillance 3 months after the index treatment. In cases of no recurrence, a further follow-up endoscopy should be done 1 year later. Thereafter, surveillance intervals should be adapted to the lesion site, en bloc resection status, and initial histological result.
Strong recommendation, low quality evidence.
Background & Aims It is uncertain whether mucosal healing after the first course of corticosteroids therapy predicts outcome in patients with ulcerative colitis (UC). We evaluated whether early ...clinical and endoscopic responses to this therapy are associated with late outcomes in UC. Methods Patients with newly diagnosed UC who were prescribed corticosteroid therapy (n = 157) were followed up for 5 years. They were evaluated using clinical (Powel–Tuck PT) and endoscopic (Baron) indexes after 3 and 6 months, then every 6 months. Outcomes at month 3 (early response) were used to identify patients with complete (group A: PT, 0–1; Baron, 0), partial (group B: PT, 0–1; Baron, 1–3), or no response (group C: persistence of clinical and endoscopic activity). The association between early and late outcomes was assessed. Results After 5 years, there were significant differences between complete and partial responders in the rates of hospitalization (25% in group A vs 48.7% in group B; P = .0152; odds ratio OR, 2.85; 95% confidence interval CI, 1.21–6.72), immunosuppression therapy (5% in group A vs 25.6% in group B; P = .0030; OR, 6.55; 95% CI, 1.67–25.67), colectomy (3.3% in group A vs 18.0% in group B; P = .0265; OR, 6.34; 95% CI, 1.24–32.37), and their combination (26.7% in group A vs 48.7% in group B; P = .0249; OR, 2.61; 95% CI, 1.12–6.11). After multivariate analysis, lack of mucosal healing was the only factor associated with negative outcomes at 5 years (immunosuppressors: hazard risk HR, 10.581; 95% CI, 2.193–51.039; P = .0033; hospitalization: HR, 3.634; 95% CI, 1.556–8.485; P = .0029; colectomy: HR, 8.397; 95% CI, 1.278–55.186; P = .0268). Conclusions No mucosal healing after corticosteroid therapy is associated with a more aggressive disease course.
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