Rheumatologic manifestations of hepatic diseases

The course of hepatic diseases may be complicated by a multitude of rheumatologic manifestations, which can complicate the diagnostic approach and alter the natural history of primary liver disease, sometimes worsening prognosis due to associated multiple organ dysfunction. These manifestations can occur in association with a multitude of liver diseases, including viral hepatitis, autoimmune hepatitis, alcoholic liver disease, nonalcoholic fatty liver disease, hemochromatosis, or Wilson’s disease. It is necessary not only for rheumatologists, but also for other clinicians, to be aware that these atypical manifestations may reflect an undiagnosed hepatic disease. On the other hand, it is crucial that, in a patient with known hepatic disease presenting with rheumatologic symptoms, an accurate distinction be made between the rheumatologic manifestations of hepatic disease and primary rheumatologic disease, since the treatment is often different. This review aims to summarize the current evidence regarding rheumatologic manifestations of hepatic diseases, how to distinguish them from primary rheumatologic disorders, and how to provide adequate management.

Effect of Meal Ingestion on Liver Stiffness and Controlled Attenuation Parameter

Background and Aims

Despite the increasing use of noninvasive methods for the assessment of liver fibrosis and steatosis, the effect of fasting and food intake on these parameters is not yet clear. Our aims were to evaluate the effect of food intake on liver stiffness (LS) (measured by transient elastography) and controlled attenuation parameter (CAP) in patients with different degrees of liver disease and healthy volunteers, and secondarily, to assess possible factors associated with variations of LS and CAP.

Methods

We performed a prospective single-center study including patients with liver disease and healthy volunteers. LS and CAP were evaluated using FibroScan® (Echosens, Paris, France), before (fasting ≥8 h) and 30 min after intake of a standardized breakfast. We used common cutoffs for LS: > 7 kPa for significant fibrosis (F2 to F4) and > 11 to 14 kPa (mean 12.5 kPa) for cirrhosis.

Results

Fifty-nine (72%) patients with liver disease and 22 (28%) healthy volunteers were included. LS significantly increased 30 min after food intake (pre-meal 6.1 kPa [IQR: 4.7-9.8] vs. after-meal 6.8 kPa [IQR: 5.5-10.6]; p < 0.001). This difference was only significant in patients with chronic liver disease (p = 0.02) and not in healthy volunteers (p = 0.106). CAP values did not increase significantly after food intake. Gender, body mass index, mass of body fat, lean body mass, and percent of body fat were not related with significant variations of LS and CAP values after meal intake.

Conclusions

Significant variations of LS were observed after ingestion of a standard meal, which may have consequences for patient management. CAP values were not significantly affected by food intake. Therefore, we consider that before the isolated evaluation of CAP, it is not necessary to perform any fasting period.

Liver transplant recipients have a higher prevalence of anal squamous intraepithelial lesions

Background:

Anal squamous intraepithelial lesions (ASIL) are precancerous lesions of anal squamous cell carcinoma, with a higher prevalence in immunosuppressed patients. There are some studies in kidney transplant recipients, but there is no information regarding prevalence in liver transplantation. Our aim was to evaluate the prevalence of ASIL in this setting.

Methods:

Prospective case–control study involving liver transplant recipients without any other known risk factor for ASIL (n=59), which were compared with a healthy control group (n=57). All were submitted to anal cytology and high-resolution anoscopy was performed in those with abnormal results.

Results:

Ten (17%) of liver transplant recipients had abnormal cytological results, seven patients had atypical squamous cells of undetermined significance (ASC-US), one patient had atypical squamous cells that cannot exclude high-grade (ASC-H) and two patients had high-grade squamous intraepithelial lesions (HSIL). In the control group, one patient (2%) had an ASC-US result (P=0.005). Anal squamous intraepithelial lesions were confirmed in 7 out of 10 of liver transplant patients and 0 out of 1 in the controls (P=0.013) by high-resolution anoscopy with biopsies. Current smoking was the only risk factor for abnormal cytology (odds ratio=5.87, 95% confidence intervals=1.22–28.12, P=0.027).

Conclusions:

Liver transplant patients have a higher risk of ASIL. Screening should be considered, especially in smokers.

Glycogenic hepatopathy in young adults: a case series

Glycogenic hepatopathy is a rare and under-recognized complication in long-standing poorly controlled type 1 diabetes mellitus patients. This is a distinct entity from other causes of hepatomegaly and elevated liver enzymes in diabetics, such as nonalcoholic fatty liver disease. Glycogenic hepatopathy is characterized by the combination of poorly controlled diabetes, acute liver injury with marked elevation in serum aminotransferases, and the characteristic histological features on liver biopsy. It is important to distinguish this entity as it has the potential for resolution following improved glycemic control. In this report, we describe four cases of adult patients presenting elevated serum transaminases and hepatomegaly with a history of poorly controlled type I diabetes mellitus. One of the patients had also elevated amylase and lipase in the serum, without clinical or imagiologic evidence of acute pancreatitis (AP). Liver biopsy was performed in all patients and revealed glycogenic hepatopathy. Clinician's awareness of glycogenic hepatopathy should prevent diagnostic delay or misdiagnosis and will provide better insight and management for this condition.

Clinical utility of the patency capsule: a large volume center experience

BACKGROUND

In patients with suspected or known obstructive gastrointestinal pathology, the use of patency capsule (PC) aims to minimize the risk of subsequent retention of the endoscopic capsule. However, its clinical utility is not consensual. The aim was to evaluate the indications, results and safety profile of the PC.

METHODS

Retrospective analysis of PCs (agile patency capsule) conducted between 2011 and 2015. Patency evaluation was performed after 30 hours, with radiological confirmation if PC was detected.

RESULTS

We included 369 PCs, 54% female. The average age was 42±16 years. Main indications included suspected Crohn disease (CD) (45%), CD staging (32%), neoplastic diseases (9%), radic enteritis (3%), prior surgery (3%), NSAIDs enteropathy (2%) and anemia (2%). Before the exam 5% of patients were taking constipation-induced medications and 5% reported occlusive symptoms; 38% of patients had previous abdominal surgeries, most often ileal resection due to CD (24%); 42% of patients had previous imaging studies, revealing strictures in 20% and bowel dilation in 11%. Patency capsule was negative (patent gastrointestinal tract) in 73% of cases at 30h and 2% of PCs were fully recovered in the following days. Seven patients (2.5%) showed self-limiting occlusive symptoms during the procedure. All patients with negative PC subsequently performed capsule endoscopy with no cases of retention. History of occlusive symptoms (P=0.023) and strictures in imaging studies (P=0.029) were associated with the detection of the PC at 30 hours.

CONCLUSIONS

PC is a safe and effective exam. Occlusive symptoms and imaging strictures were significantly associated with the retention. The retention rate was 25%, a similar result to that described in other series but higher than expected for the various indications, suggesting the importance of new research studies.

Hepatic perivascular epithelioid tumor (PEComa). A case report

A 37-year-old female had liver nodules found in an abdominal ultrasound scan. The radiological features were suggestive of hepatocellular adenomas, although there were some atypical findings. Two years later, one of the nodules showed dimensional progression and intralesional hemorrhage. The patient underwent a left hepatectomy and the postoperative course was uneventful. The histological exam and the immunohistochemistry were consistent with the diagnosis of PEComa. The PEComa is a mesenchymal tumor rarely described in the liver. The preoperative diagnosis of PEComa is very difficult and, with this report, the authors intend to increase the limited knowledge relating to natural history and optimal treatment of this rare condition.

Sarcoidosis: An unusual presentation

A 35-year-old man presented with a 3-year history of arthralgia and purple coloration of the skin of his fingers and feet. Hand and foot radiography showed cystic bone lesions on phalanges suggestive of sarcoidosis. Lab tests revealed increased liver enzymes. Liver MRI evidenced an enlarged liver and retroperitoneal lymphadenopathy. Histological analysis of the finger skin, lymph nodes and liver demonstrated the presence of granulomas, confirming the diagnosis of sarcoidosis. The patient started prednisolone with rapid improvement of the symptoms. Skin lesions are divided into two groups: specific for sarcoidosis (with granulomas, lupus pernio-like) and nonspecific (without granulomas, erythema nodosum-like). Specific cutaneous lesions usually cause no other symptoms beyond cosmetic changes. Lupus pernio stands out for having distinctive features but, to the best of our knowledge, the simultaneous involvement of both hands and feet has never been reported.

CA 19-9 as a Marker of Survival and a Predictor of Metastization in Cholangiocarcinoma

BACKGROUND

Cholangiocarcinoma is the second most frequent primitive liver malignancy and is responsible for 3% of the malignant gastrointestinal neoplasms. The aims of this study were to determine the association of serum levels of CA 19-9 at diagnosis with other clinical data and serum liver function tests and to identify possible factors that influence the survival rates during follow-up.

METHODS

Retrospective observational study of 89 patients with a diagnosis of cholangiocarcinoma followed at the Department of Gastroenterology during 5 years. Statistical analyses were performed using SPSS version 20.0.

RESULTS

Patients were followed up for a median time of 127 days (IQR: 48-564), and the median age at diagnosis was 71.0 years (IQR: 62.0-77.5). The median survival rate was 14.0 months (IQR: 4.3-23.7), and the mortality rate was 79%. Patients with CA 19-9 levels ≥103 U/L had lower albumin levels and higher levels of alanine aminotransferase and γ-glutamyltransferase. CA 19-9 levels ≥103 U/L were associated with a higher probability of metastization (p = 0.001) and lower rates of treatment with curative intent (p = 0.024). In a multivariate analysis, CA 19-9 levels <103 U/L and surgery were independent predictors of survival.

CONCLUSION

Predictive factors for overall survival were identified, namely presence of metastasis, surgery, and chemotherapy. CA 19-9 levels ≥103 U/L were predictive factors for survival and metastization.

Predictive factors of small bowel patency in Crohn's disease patients

BACKGROUND

Patency capsule was developed to avoid small bowel video capsule endoscopy retention, namely in patients with Crohn's disease.

AIMS

To evaluate the predictive factors of small bowel patency in Crohn's disease patients.

PATIENTS AND METHODS

Retrospective analysis including 151 Crohn's disease patients submitted to patency capsule (Agile® Patency Capsule) from 2011 to 2012. Patients that excreted the intact patency capsule were classified as having a patent small bowel (without patency capsule retention), other patients were considered to have negative patency of the small bowel (patency capsule retention).

RESULTS

Patients had a mean age of 41±14 years, 54% were female and 25% had been previously submitted to surgery. Stricturing disease was seen in 20% of cases and penetrating disease in 16% of cases. Left-sided colonic lesions and ileal strictures were observed at colonoscopy in 13% and 9% of patients, respectively. In our sample, 28% of patients had negative patency of the small bowel (patency capsule retention). In multivariate analysis, independent factors that were associated with negative patency of the small bowel in Crohn's disease patients were stricturing (OR 10.16, p < 0.001) and penetrating phenotypes (OR 11.73, p = 0.001), left-sided colonic lesions (OR 3.77, p = 0.038), ileal stricture (OR 9.76, p = 0.003); previous intestinal surgery was found to be protective (OR 0.16, p = 0.006).

CONCLUSIONS

Stricturing or penetrating disease, ileal strictures, no previous surgery and left-sided colonic lesions were the factors associated with negative small bowel patency in Crohn's disease patients.

Single-balloon enteroscopy efficacy and degree of concordance with noninvasive evaluation of small bowel

Background and study aims Clinical impact of single-balloon enteroscopy (SBE) is fairly known, as well as its diagnostic yield comparing with other small bowel gastrointestinal investigations. This study represents a contribution to better understand it and is designed to evaluate SBE efficacy and degree of concordance with previous evaluation of small bowel. Patients and methods This is a single-center retrospective study of patients that underwent SBE with suspected small bowel disease based on non-invasive imaging. Demographic, clinical, procedural and outcome data were collected for analysis. Agreement beyond positive findings was evaluated using κ-coefficient. Results A total of 197 SBEs were performed in 168 patients; mainly men (64.3 %) with mean age 53.3±17.6 years. Most SBEs (86.3 %) performed were preceded by a noninvasive evaluation: in 61.4 % (n = 119) of cases, capsule enteroscopy (CE) was performed, in 18.8 % (n = 37), computed tomography was performed, and in 6.1 % (n = 12) magnetic resonance enterography was performed. Fourty-three patients (25.6 %) underwent endoscopic treatments, mainly: argon plasma coagulation in angioectasias (53.4 %) and polypectomy (34.9 %). The most common diagnoses made with SBE were findings consistent with inflammatory small bowel disease (21.8 %) and vascular lesions (14.2 %). The diagnostic yield of SBE was of 69 %, confirming the suspicion of small bowel disease. The degree of concordance between CE and SBE for positive findings was substantial, κ-coefficient = 0.635 (P < 0.001). However, the degree of concordance between imaging examinations (CT or MR) and SBE was only moderate, κ-coefficient = 0.410 (P < 0.001). SBE had an immediate effect in 20 % of patients, changing diagnostic approaches, medical and surgical treatments. Conclusions Our study supports the idea that for suspected small bowel disease, CE and SBE have an overall good degree of concordance for all the diagnostics included.

Erratum: Single-balloon enteroscopy efficacy and degree of concordance with noninvasive evaluation of small bowel

[This corrects the article DOI: 10.1055/s-0042-121415.].

Gastric inflammatory fibroid polyp mimicking a gastrointestinal stromal tumour

Inflammatory fibroid polyp of the gastrointestinal tract is a rare, benign neoplasm, most frequently located in the gastric antrum. Symptoms depend on the location and the size of the lesion. Biopsies are limited for the diagnosis of inflammatory fibroid polyps and diagnosis may not be possible until resection. The authors present a case of a 55-year-old woman, presenting with an upper gastrointestinal bleeding due to a large gastric inflammatory fibroid polyp imitating a gastrointestinal stromal tumor.

Multicenter survey on the use of device-assisted enteroscopy in Portugal

BACKGROUND

Device-assisted enteroscopies (DAEs) are recent endoscopic techniques that enable direct endoscopic small-bowel evaluation.

OBJECTIVE

The objective of this article is to evaluate the implementation of DAEs in Portugal and assess the main indications, diagnoses, diagnostic yield, therapeutic yield and complication rate.

METHODS

We conducted a multicenter retrospective series using a national Web-based survey on behalf of the Portuguese Small-Bowel Study Group. Participants were asked to fill out two online databases regarding procedural data, indications, diagnoses, endoscopic therapy and complications using prospectively collected institutional data records.

RESULTS

A total of eight centers were enrolled in the survey, corresponding to 1411 DAEs. The most frequent indications were obscure gastrointestinal bleeding (OGIB), inflammatory bowel disease and small-bowel tumors. The pooled diagnostic yield was 63%. A relation between the diagnostic yield and the indications was clear, with a diagnostic yield for OGIB of 69% (p = 0.02) with a 52% therapeutic yield. Complications occurred in 1.2%, with a major complication rate of 0.57%. Perforations occurred in four patients (0.28%).

CONCLUSION

DAEs are safe and effective procedures, with complication rates of 1.2%, the most serious of which is perforation. Most procedures are performed in the setting of OGIB. Diagnostic and therapeutic yields are dependent on the indication, hence appropriate patient selection is crucial.