Editor-in-Chief, Deputy Editor 2017-2019





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Original articles

Case series of Cryptogenic Multifocal Ulcerating Stenosing Enteritis (CMUSE)

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Background and study aims : Small bowel ulceration poses a limited, but difficult differential diagnosis. The most common causes are Crohn’s disease (CD), NSAID-associated enteritis, lymphoma, cytomegaly virus infection and tuberculosis. A less known and relatively novel differential diagnosis is cryptogenic multifocal ulcerative stenosing enteritis (CMUSE). Patients and methods : Five patients referred for balloon-assisted enteroscopy for various reasons showed endoscopic features of CMUSE. These findings and, when available, medical imaging were reviewed in order to increase general knowledge on CMUSE. Results : Five patients, 3 males and 2 females, with a mean age of 39±5 years, underwent balloon-assisted enteroscopy. Typical short, circular, ulcerative stenoses were detected in the jejunum in 2 and in the ileum in 3 patients. The number of stenoses ranged from 1 to 7 per patient. Histopathology revealed nonspecific granulocyte inflammation without specific CD findings. Stenoses were often missed on pre-enteroscopy CT or MRI enteroclysis due to their short length. Treatment consisted of endoscopic balloon dilation in 3, corticosteroids in 3, azathioprine in 1 and anti-TNFα biologicals in 3 patients. 3 patients needed additional surgery because of ongoing symptomatic small bowel stenosis or retained wireless videocapsule. Conclusion: In patients with short, ulcerative small intestinal stenoses CMUSE is an important but often neglected differential diagnosis. The pathophysiology and relationship to CD are subject of ongoing debate, but specific endoscopic characteristics, different histopathological findings and lack of clear abnormalities on CT or MRI enterography suggest that CMUSE is a distinct albeit rare chronic inflammatory bowel disease. (Acta gastroenterol., 2017, 80, 361-364). [Product Details...]

Diet affects reflux in a rural African community

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Reflux in this region of South Africa is known to be more frequent and less acidic than in other countries. We investigated the relationship between reflux and diet. We recruited 57 healthy participants. We carried out ambulant oesophageal pH-impedance monitoring for 24 hours. We used software and visual review to analyse data and to identify episodes of reflux and rapid alkaline rises in the stomach. A usual pattern diet questionnaire provided data on frequency of consumption of common foods. Associations between reflux, gastric pH and dietary components were sought using analysis of variance, and regression analyses. Diet was strongly based on maize. Protein was principally from milk, eggs, chicken and beans. Fat was principally from cooking oil. Fruit and vegetables were consumed moderately frequently. Milk consumption was associated with an increase in total reflux (P = .022), weakly acid reflux (P = 0.015) and supine reflux (P = 0.001), and a decrease in the time that gastric pH was higher than 4 (P = 0.030). Fat was associated with an increase in acid reflux (P = 0.046) and a decrease in time that gastric pH was higher than 4 (P = 0.005). Fruit consumption was associated with increases in liquid-only refluxes(P = 0.007), and upright refluxes (P = 0.048). Maize meal was associated with a reduction in rapid alkaline rises in the gastric lumen (P = 0.015). Diet significantly affects reflux in this community. What is normal in apparently healthy people in various parts of the world differs significantly. (Acta gastroenterol. belg., 2017, 80, 357-360). [Product Details...]

Epidural analgesia is infrequently used in patients with acute pancreatitis : a retrospective cohort study

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Background and aims : Epidural analgesia is an option for pain control in patients with acute pancreatitis. The aim of this study is to describe characteristics, morbidity and mortality of patients with acute pancreatitis treated with epidural analgesia. Patients and Methods : Data was extracted from a national inpatient database in Japan on patients hospitalized with acute pancreatitis between July 2010 and March 2013. A total of 44,146 patients discharged from acute care hospitals were included in this retrospective cohort study. The patient background, timing and duration of epidural analgesia, complications (epidural hematoma or abscess), surgery (for cholelithiasis / cholecystitis or complications) and mortality were verified. Results : Epidural analgesia was used in 307 patients (0.70 %). The mean age was 64.0 years (standard deviation, 15.4 years) and 116 (37.8%) of the patients were female. The median duration of epidural analgesia was four days (interquartile range, 3-5 days). No patient underwent surgery for epidural hematoma or abscess. Six (2.0%) patients died during hospitalization. Most likely causes of death were pulmonary embolism, multiple organ failure, sepsis, and methicillin-resistant staphylococcus aureus enterocolitis. The responsible physician for 250 of the patients (81.4%) was a gastroenterological surgeon. Epidural analgesia was started on the day of surgery in 278 (90.6%) patients. Conclusions : Epidural analgesia is rarely used in patients with acute pancreatitis. None of the patients included in the study required surgery for epidural hematoma or abscess. Further research to evaluate the efficacy and safety of epidural analgesia in patients with acute pancreatitis is warranted. (Acta gastroenterol. belg., 2017, 80, 381-384). [Product Details...]

Esophagitis dissecans superficialis : a case series of 7 patients and review of the literature

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Introduction : Esophagitis dissecans superficialis (EDS) is a rare desquamative disorder of the eso-phagus, characterized by sloughing of the superficial mucosa. It is a benign entity of uncertain etiology. Most cases of EDS are idiopathic but can be caused by medications, hot beverages, chemical irritants, celiac disease and many skin conditions. Aim : Knowing that few case series have described this entity, we decided to review all the cases diagnosed in our center to characterize them. Methods : The pathological institutional database of Erasme University Hospital (Brussels, Belgium) was searched for the diagnosis of EDS. We reviewed retrospectively the clinical and endoscopic findings as well as histological features of all cases of EDS (Table 1). During this period of time, 21497 upper gastrointestinal endoscopies have been performed in our institution. Results : From January 2010 to September 2016, we identified 7 cases of EDS diagnosed in our institution in this time period. During the same period, 21497 upper gastrointestinal endoscopies were performed (incidence 0.03%). Endoscopic findings evoked in 2 patients a suspicion of an esophageal tumor; the first one was described as a raised detached lesion of the distal third of the esophagus with suspicion of squamous cell carcinoma (Fig. 1) and the second as a suspected tumor of the proximal third of the esophagus (Fig. 2). For other patients, EDS was misdiagnosed as unspecific esophagitis in 2, reflux or mycotic esophagitis in 2. Only one patient was suspected to have sloughing esophagitis. Histologic features present in all of those cases were characterized by the presence of a sloughing and necrosis of the superficial layer of the esophageal squamous epithelium with negative anti HSV and anti CMV antibodies, negative periodic acid Schiff stain for fungal infections as well as absence of signs of dysplasia or signs of malignancy. In 2 patients, there was a presence of multiple bacterial colonies on the superficial epithelium. Acute inflammation was reported in 4 of the patients with the presence of eosinophils in the superficial epithelium described in 2 of these patients and of polymorphonuclear leukocytes in 2 other patients (Fig. 3).An endoscopic follow up 2 months after PPI treatment performed in 3 patients, 2 of them had an atypical endoscopic presentation with suspicion of a tumor on endoscopic examination showed a complete resolution of the esophageal lesions was observed in these patients. Conclusion : EDS is a rare benign entity that endoscopists must be aware of in order not to mistake it for other entities such as esophagitis or squamous cell carcinoma. The diagnosis is based on biopsies. The prognosis is good after stopping the causative agent. (Acta gastroenterol. belg., 2017, 80, 371-375). [Product Details...]

HLA DPB1 15:01 Allele Predicts Spontaneus Hepatitis B Surface Antigen Seroconversion

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Aim : Chronic hepatitis B (CHB) is a global health problem. Recent genome-wide association studies (GWAS) exposed significant association between the human leukocyte antigen (HLA) class II region, including both DP and DQ loci, and chronic hepatitis B. Previous research also indicated the involvement of adaptive immune system in Hepatitis B seroconversion. The aim of this study is to investigate possible polymorphisms in the HLA-DP locus that can contribute to immune response to Hepatitis B virus (HBV). Methods : We enrolled 94 chronic hepatitis B (CHB) patients and a control group of 85 spontaneous seroconverted healthy subjects and genotyped HLA-DPB1 alleles by polymerase chain reaction followed by restriction length polymorphism (PCR-RFLP) and Sanger sequencing. Results : Among the 19 DPB1 alleles analyzed in this study, DPB1*15:01 allele was more frequent in the spontaneous seroconverted control group compared to CHB patients (15.3% vs. 1.1%, χ2 = 12.5, OR = 0.06, 95% CI = 0.08-0.046 P [Product Details...]

Lymphogranuloma venereum among patients presenting at the HIV/STI clinic in Antwerp, Belgium : a case series

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Objective of this study was to describe the patient characteristics and clinical presentation of laboratory confirmed lymphogranuloma venereum (LGV) cases, diagnosed at the Institute of Tropical Medicine (ITM), Antwerp, Belgium. Demographic and biomedical characteristics of all patients with chlamydia-positive sample results were retrieved for the years 2013 and 2014. Samples were obtained from both symptomatic and asymptomatic patients who consulted at the HIV/STI clinic. Fifty four patients with laboratory confirmed LGV were detected among 3885 nucleic acid amplification tests (NAATs) performed for the detection of chlamydia during the two years under review. Fifty three were men and equally fifty three had sex with men only (MSM). HIV (87%) and HCV (31.5%) were common concomitant infections, whilst anal gonorrhoea and syphilis were detected at the moment of the LGV diagnosis among 19 (35.2%) and 6 (11.0%) cases respectively. All cases were symptomatic, except one. The most frequent symptoms that were recorded could be categorised as proctitis (in 40 patients (74%)). Lymphadenopathy, anal and genital ulcers were signs that were present in 7 (13.0%), 4 (7.4%) and 2 patients (3.7%) respectively. LGV remains an important sexually transmitted disease among MSM. In this retrospective study, the far majority of LGV was detected amongst symptomatic persons. HCV, HIV, anal gonorrhoea and syphilis were associated co-infections. Proctitis in a high risk patient should alert the clinician for the possibility of an STI. (Acta gastroenterol. belg., 2017, 80, 385-387). [Product Details...]

Persistent Systemic Inflammatory Response Syndrome predicts the need for tertiary care in Acute Pancreatitis

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Introduction: Patients with Acute Pancreatitis (AP) presenting with Systemic Inflammatory Response syndrome (SIRS) are more likely to have severe acute pancreatitis and are at increased risk of complications. Additionally, persistence of SIRS at 48 hrs after admission is associated with persistent organ failure and a worse outcome. We investigated the usefulness of SIRS as a criterion for referring patients to a tertiary pancreatic care centre. Material and Methods: Retrospective analyses of patients admitted with AP over a one year period. Patients were classified into 2 severity groups – 1) Mild AP, 2) Moderate and Severe AP (MASP) as per the Revised Atlanta Classification. SIRS was determined at presentation and following 48 hours of best medical management. Outcomes were compared between patients who had no SIRS at presentation, transient SIRS(SIRS≤48hrs) and persistent SIRS(>48hrs). Results: 134 patients were included in the study. SIRS at presentation had a sensitivity of 88%(95% CI 75-96) and a specificity of 66%(95% CI 55-75) in predicting MASP. However, persistent SIRS and recovery from SIRS within 48hrs were poor predictors of MASP. Only 23/43 (53.5%) patients with MASP had persistent SIRS. Interestingly, MASP patients with persistant SIRS had a significant higher risk of complications, readmission, intervention, culture positivity and hospital stay as compared to those with transient SIRS. Conclusion: Persistent SIRS could be used to identify patients with MASP requiring tertiary care. This could be used as an effective tool by community hospitals with limited facilities. Further, prospective studies are required to validate our findings. (Acta gastroenterol. belg., 2017, 80, 377-380). [Product Details...]

Routine histopathological study of cholecystectomy specimens. Useful ? A retrospective study of 1960 cases

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Background : Traditionally, a gallbladder removed for presumed benign disease is sent for histopathological examination, but this practice has been the subject of controversy. Aim : The aim of this study was to assess the usefulness of routine histopathological examination of cholecystectomy specimens and its impact on the management of patients. Patients and Methods : The histopathological reports of 1960 patients who underwent cholecystectomy from January 2011 to November 2016 were retrospectively reviewed. Results : There were 519 men and 1441 women (sex-ratio M/F = 0,36) aged between 8 and 96 years (mean = 51,23 years). All patients underwent cholecystectomy (either open or laparoscopic). Histological examination of the surgical specimens showed chronic cholecystitis (n = 1319) (67,29%), acute cholecystitis (n = 117) (5,96%), cholestrolosis (n = 255) (13%), follicular cholecystitis (n = 230) (11,73%), xanthogranulomatous cholecystitis (n = 6) (0,30%), cholesterol polyps (n = 5) (0,255), tubular adenoma (n = 3) (0,15%), mucocele (n = 2) (0,10%), pancreatic heterotopia (n = 2 ) (0,10%), hyperplastic Luschka ducts (n = 2) (0,10%), adenomyoma (n = 2) (0,10%), porcelain calcification (n = 2) (0,10%) and biliarytype adenocarcinoma (n = 9) (0,46%). In 9 cases (0,46%), the gallbladder was histologically normal. Conclusions : Our study shows that the incidence of premalignant and malignant lesions of the gallbladder is very low. We therefore recommend selective histopathological examination of cholecystectomy specimens with abnormal macroscopic findings. (Acta gastroenterol. belg., 2017, 80, 365-370). [Product Details...]

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