Differentiating Crohn's disease (CD) and intestinal tuberculosis (ITB) has remained a dilemma for most of the clinicians in the developing world, which are endemic for ITB, and where the disease ...burden of inflammatory bowel disease is on the rise. Although, there are certain clinical (diarrhea/hematochezia/perianal disease common in CD; fever/night sweats common in ITB), endoscopic (longitudinal/aphthous ulcers common in CD; transverse ulcers/patulous ileocaecal valve common in ITB), histologic (caseating/confluent/large granuloma common in ITB; microgranuloma common in CD), microbiologic (positive stain/culture for acid fast-bacillus in ITB), radiologic (long segment involvement/comb sign/skip lesions common in CD; necrotic lymph node/contiguous ileocaecal involvement common in ITB), and serologic differences between CD and ITB, the only exclusive features are caseation necrosis on biopsy, positive smear for acid-fast bacillus (AFB) and/or AFB culture, and necrotic lymph node on cross-sectional imaging in ITB. However, these exclusive features are limited by poor sensitivity, and this has led to the development of multiple multi-parametric predictive models. These models are also limited by complex formulae, small sample size and lack of validation across other populations. Several new parameters have come up including the latest Bayesian meta-analysis, enumeration of peripheral blood T-regulatory cells, and updated computed tomography based predictive score. However, therapeutic anti-tubercular therapy (ATT) trial, and subsequent clinical and endoscopic response to ATT is still required in a significant proportion of patients to establish the diagnosis. Therapeutic ATT trial is associated with a delay in the diagnosis of CD, and there is a need for better modalities for improved differentiation and reduction in the need for ATT trial.
Background
Infected pancreatic necrosis (IPN) is a major complication of acute pancreatitis (AP), which may require necrosectomy. Minimally invasive surgical step-up therapy is preferred for IPN.
Aim
...To assess the effectiveness of percutaneous endoscopic step-up therapy in patients with IPN and identify predictors of its success.
Methods
Consecutive patients with AP hospitalized to our tertiary care academic center were studied prospectively. Patients with IPN formed the study group. The treatment protocol for IPN was percutaneous endoscopic step-up approach starting with antibiotics and percutaneous catheter drainage, and if required necrosectomy. Percutaneous endoscopic necrosectomy (PEN) was performed using a flexible endoscope through the percutaneous tract under conscious sedation. Control of sepsis with resolution of collection(s) was the primary outcome measure.
Results
A total of 415 patients with AP were included. Of them, 272 patients had necrotizing pancreatitis and 177 (65%) developed IPN. Of these 177 patients, 27 were treated conservatively with antibiotics alone, 56 underwent percutaneous drainage alone, 53 required underwent PEN as a step-up therapy, 1 per-oral endoscopic necrosectomy, and 52 required surgery. Of the 53 patients in the PEN group, 42 (79.2%) were treated successfully—34 after PEN alone and 8 after additional surgery. Eleven of 53 patients died due to organ failure—7 after PEN and 4 after surgery. Independent predictors of mortality were > 50% necrosis and early organ failure.
Conclusion
Percutaneous endoscopic step-up therapy is an effective strategy for IPN. Organ failure and extensive pancreatic necrosis predicted a suboptimal outcome in patients with infected necrotizing pancreatitis.
Sarcopenia and visceral fat independently predict poor outcomes in Crohn's disease (CD). However, combined influence of these parameters on outcomes is unknown, and was investigated in the present ...study.
This retrospective study evaluated skeletal muscle index (SMI-cross-sectional area of five skeletal muscles normalized for height), visceral and subcutaneous fat area and their ratio (VF/SC) on single-slice computed tomography (CT) images at L3 vertebrae in CD patients (CT done: January 2012-December 2015, patients followed till December 2019). Sarcopenia was defined as SMI < 36.5 cm
/m
and 30.2 cm
/m
for males and females, respectively. Disease severity, behavior, and long-term outcomes (surgery and disease course) were compared with respect to sarcopenia and VF/SC ratio.
Forty-four patients age at onset: 34.4 ± 14.1 years, median disease duration: 48 (24-95) months, follow-up duration: 32 (12-53.5) months, males: 63.6% were included. Prevalence of sarcopenia was 43%, more in females, but independent of age, disease severity, behavior and location. More patients with sarcopenia underwent surgery (31.6% vs 4%, p = 0.01). VF/SC was significantly higher in patients who underwent surgery (1.76 + 1.31 vs 0.9 + 0.41, p = 0.002), and a cutoff of 0.88 could predict surgery with sensitivity and specificity of 71% and 65% respectively. On survival analysis, probability of remaining free of surgery was lower in patients with sarcopenia (59.6% vs 94.1% p = 0.01) and those with VF/SC > 0.88 (66.1% vs 91.1%, p = 0.1), and still lower in those with both sarcopenia and VF/SC > 0.88 than those with either or none (38% vs 82% vs 100%, p = 0.01).
Combination of sarcopenia and high visceral fat predict worse outcomes in CD than either.
To evaluate the indications, feasibility, safety, and effectiveness of N-butyl cyanoacrylate (NBCA) with modified injection technique in embolization of visceral artery pseudoaneurysms (PSAs).
A ...retrospective evaluation was performed of 31 patients (26 men, 5 women; mean age, 32.6 y) with visceral artery PSAs that were treated with embolization using NBCA with modified sequential injection and flushing technique. The most common indication for using NBCA was preservation of a major feeding artery (n = 18), followed by difficult catheterization secondary to arterial tortuosity (n = 5), failed previous coil embolization (n = 4), and short landing zone for coils (n = 4). NBCA alone was used in 25 patients, and NBCA with coils was used in 6 patients. The patients were followed clinically until discharge and 1 and 3 months after discharge.
The mean amount of NBCA-ethiodized oil (Lipiodol; Guerbet LLC, Villepinte, France) mixture injected was 0.24 mL (range, 0.1-1.1 mL). Embolization with NBCA was technically successful in all (100%) patients. Recurrence was seen in 3 (9.7%; 2--splenic artery; 1--left gastric artery) patients after a mean time of 16.3 days (range, 10-27 d) of initial embolization resulting in clinical success of 90.3%. All 3 patients underwent successful repeat embolization with secondary technical success rate of 100%. Minor (pain) and major (nontarget embolization in 2; microcatheter adhesion and fracture in 1) complications were seen in 3 patients each.
NBCA is a safe and effective embolization agent when injected with modified technique in treatment of visceral artery PSAs.
In a joint publication across 14 member journals, the International Committee of Medical Journal Editors (ICMJE) proposes to require sharing of deidentified individual patient data underlying ...published clinical trials.
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