Perception and Attitude of Lebanese IBD Patients During the COVID-19 Pandemic

Objective

The emergence of the COVID pandemic affected daily living and healthcare access of IBD patients, due to delays of elective procedures and in-hospital treatments. Our aim is to determine the repercussions of the pandemic on the daily habits of IBD patients and on their compliance to follow-up and treatment.

Methods

This was a cross-sectional observational study. A questionnaire was administered in between 2020 and 2022 to IBD patients in a tertiary center in Lebanon. The outcomes measured were patient perceptions regarding COVID and how it affected their treatment.

Results

A total of 201 answers were included in the analysis with male predominance. Two-thirds had Crohn's disease. Near 80% were afraid of being infected by COVID-19 and 87.6% were afraid of physical contact. 91.5% reduced their daily habits and 96.0% have used personal protective equipment. 47.3% of the patients report that there are factors that reduced their worries, the most common factor being contacting their physician (61.0%). The main source of information was the treating physician (37.8%). A quarter of patients think that their condition predisposed to COVID-19 infection and about two-thirds believe that immunosuppressive therapy did so. The same amount reported concern regarding visiting the hospital. 27.4% preferred telemedicine and 44.8% preferred over-The-phone consultation to an in-person visit. Three-quarters were in favor of vaccination. 59.6% delayed their in-center treatment, which was associated with a reduction in daily life activities. 13.9% wanted to discontinue their treatment, which was associated with smoking, cardiovascular, and rheumatological comorbidities, but only 4% did so.

Conclusion

The pandemic had significant repercussions on the everyday life of IBD patients, with some preferring to consult via telemedicine and others considering stopping their treatment.

Trimethoprim-Sulfamethoxazole-induced Hepatotoxicity in a Renal Transplant Patient

Drug-induced liver injury (DILI) represents liver damage from various therapeutic drugs. Antimicrobials are among the most common causes of DILI. We report a case of hepatic toxicity due to Trimethoprim-sulfamethoxazole (TMP-SMX) in a patient who underwent renal transplantation. Diagnosis has been made after a careful history taking, exclusion of competing etiologies and reversal of biochemical abnormalities after withdrawal of the antibiotic. TMP-SMX liver toxicity is well known but remains unpredictable and is rarely reported.

Splenic artery aneurysm presenting as a submucosal gastric lesion: A case report

We are reporting the rare case of splenic artery aneurysm of 4 cm of diameter presenting as a sub mucosal lesion on gastro-duodenal endoscopy. This aneurysm was treated by endovascular coil embolization and stent graft implantation. The procedure was uneventful. On day 1, the patient presented an acute severe epigastric pain and cardiovascular arrest. Abdominal computed tomography scan showed an active leak of the intravenous contrast dye in the peritoneum from the splenic aneurysm. We performed an emergent resection of the aneurysm, and peritoneal lavage. Postoperatively, hemorrhagic choc was refractory to large volumes replacement, and intravenous vaso-active drugs. On day 2, he presented massive hematochezia. We performed a total colectomy with splenectomy and cholecystectomy for ischemic colitis, with spleen and gallbladder infarction. Despite vaso-active drugs and aggressive treatment with Factor VIIa, the patient died after uncontrolled disseminated intravascular coagulation.

Validation of the Arabic version of the SCOFF questionnaire for the screening of eating disorders

The high prevalence of eating disorders in Arab countries indicates a need for an Arabic language screening tool. This study aimed to validate an Arabic version (A-SCOFF) of the British SCOFF questionnaire, a brief tool for the screening of eating disorders in primary health care. After translation and back-translation the A-SCOFF was given to 123 female patients [mean age 32 (SD 8.8) years] visiting primary health-care centres in Beirut. Each patient was evaluated by an eating disorders specialist blinded to A-SCOFF results. The validated Arabic version of the Mini International Neuropsychiatric Interview and the DSM-IV criteria for eating disorders were used as diagnostic references. The best diagnostic threshold for the A-SCOFF was found to be at 2 positive answers with a sensitivity of 80.0%, a specificity of 72.7% and an area under the curve of 80.0%. The A-SCOFF questionnaire is accurate and reliable for the early detection of eating disorders in this high-risk population.

War stress may be another risk factor for eating disorders in civilians: a study in Lebanese university students

OBJECTIVE

Traumatic life events are important risk factors for eating disorders (ED). War has been associated, in military populations, with an increased post-service incidence of ED and an increased mean body mass index. We hypothesize that a modification of eating behavior (EB) related to stress during wartime may increase the risk of developing an ED later on among civilians exposed to war stress during adulthood.

METHODS

This descriptive cross-sectional study was performed in a group of 303 undergraduate young adult students of both sexes from Lebanon, 6 months after the July 2006 war. Modification of EB during wartime, sociodemographic and other potential risk factors were assessed retrospectively. Students were then screened for ED using the SCOFF questionnaire.

RESULTS

SCOFF was positive in 31.4% of the students, with a mean value 41.6% higher among subjects who reported an altered EB during the war. Among subjects with a positive SCOFF screening, 71% had experienced a change of EB during wartime. Alteration of EB during war was related to an odds ratio for a positive SCOFF screening of 2.6 (95% CI 1.54-4.34) and 1.8 (95% CI 1.01-3.21) for non-adjusted and adjusted analysis, respectively.

CONCLUSIONS

Modification of EB related to stress during wartime is associated with an increased risk of eating disorders. Early detection and treatment of eating disorders may be improved by routinely evaluation of EB modification in patients with a past history of war exposure.

Isolated fever induced by mesalamine treatment

Adverse reactions to mesalamine, a treatment used to induce and maintain remission in inflammatory bowel diseases, particularly ulcerative colitis, have been described in the literature as case reports. This case illustrates an unusual adverse reaction. Our patient developed an isolated fever of unexplained etiology, which was found to be related to mesalamine treatment. A 22-year-old patient diagnosed with ulcerative colitis developed a fever with rigors and anorexia 10 d after starting oral mesalamine while his colitis was clinically resolving. Testing revealed no infection. A mesalamine-induced fever was considered, and treatment was stopped, which led to spontaneous resolution of the fever. The diagnosis was confirmed by reintroducing the mesalamine. One year later, this side effect was noticed again in the same patient after he was administered topical mesalamine. This reaction to mesalamine seems to be idiosyncratic, and the mechanism that induces fever remains unclear. Fever encountered in the course of a mesalamine treatment in ulcerative colitis must be considered a mesalamine-induced fever when it cannot be explained by the disease activity, an associated extraintestinal manifestation, or an infectious etiology.

Migration in two directions

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG), the modality of choice for long-term enteral access, is generally a safe procedure but can be associated with many potential complications.

OBJECTIVES

Report two different and late complications of PEG in two patients fed at home, leading them to the emergency department.

CASE REPORT

A 75-year-old man and a 14-year-old young man with PEG presented to the emergency department with two different complications related to the gastrostomy tube. The first patient developed fever and deterioration in mental status due to parietal abscess which developed secondary to the migration of the internal button of the gastrostomy tube in the abdominal wall. He was treated with antibiotics and the gastrostomy tube was extracted. The second one presented upper gastrointestinal bleeding due to intestinal perforation at the level of the internal button of the gastrostomy tube. Bleeding and perforation were treated conservatively and he had a good evolution.

CONCLUSION

Persons taking care of patients with PEG tube must be aware of potential complications. The position and the permeability of the tube must be systematically checked before feeding and medical advice should immediately be asked for in case of doubt or in the presence of any alarming sign.

A benign cause of obstructive jaundice with von Hippel-Lindau disease. A case report and review of the literature

CONTEXT

Von Hippel-Lindau disease is a genetic disorder characterized by neoplasms with multiple organ involvement, the pancreas being involved in about half of the cases. Conservative treatment is indicated because the disease is usually asymptomatic with long-term follow-up.

CASE REPORT

We herein present the case of a 64-year-old man with von Hippel-Lindau disease who presented with obstructive jaundice which resulted as being caused by a fibro-cystic pancreatic nodule. In addition, we reviewed the literature concerning pancreatic involvement in von Hippel-Lindau disease with emphasis on their presentation, type of lesions and appropriate management, especially in cases with obstructive jaundice.

CONCLUSION

Conservative management is advocated in the majority of VHL disease patients with pancreatic involvement, but surgery is sometimes required, especially when patients are symptomatic (obstructive jaundice, upper gastrointestinal bleed).

Diagnosis by endoscopic ultrasound guided fine needle aspiration of tuberculous lymphadenitis involving the peripancreatic lymph nodes: A case report

Pancreatic tuberculosis is an extremely rare form of extrapulmonary disease. The diagnosis preoperatively is difficult because clinical, laboratory and radiologic findings are nonspecific. Published data indicate that these lesions mimic cystic neoplasms of the pancreas and the confirmation of clinical suspicion could only be obtained by an open surgical biopsy. Recently, fine needle aspiration cytology has been shown to be a safe, reliable and cost-effective alternative. We report a new case of a peripancreatic tuberculosis in a 52 year old woman and review the relevant literature, paying special attention to the usefulness of endoscopic ultrasound guided-fine needle aspiration in the diagnosis of abdominal tuberculosis.

[Pneumatic dilatation of achalasia: local experience in treating 41 patients]

L'achalasia is the best known primary motor disorder of the esophagus in which the lower esophageal sphincter (LES) has abnormally high resting pressure and incomplete relaxation with swallowing. Pneumatic dilatation (PD) remains the first choice of treatment. Our aim was to report, in a retrospective way, our experience in treating with pneumatic dilatation 41 achalasia patients admitted to the gastroenterology unit at Hôtel-Dieu de France (HDF) hospital between 1994 and 2004. A total of 46 dilatations were performed in 41 patients with achalasia [20 males and 21 females, the mean age was 46.8 years (range, 15-90)]. All patients underwent an initial dilatation by inflating a 35 mm balloon to 7 psi three times successively under fluoroscopic control. The need for subsequent dilatation with the same technique or for surgical treatment was based on symptom assessment. The mean follow-up period was 36.7 months (3 mo-7 years). Among the patients whose follow-up information was available, a satisfactory result was achieved in 29 patients (80.5%) after only one or two sessions of pneumatic dilatation. Esophageal perforation as a short-term complication was observed in one patient (2.17%). Seven patients were referred for surgery (one for esophageal perforation and six for persistent or recurrent symptoms). In conclusion, performing balloon dilatation under fluoroscopic observation is simple, safe and efficacious for treating patients with achalasia. Referral to repeated PD or to surgical myotomy should be discussed in case of no response to a first session of PD.

Extracystic biliary carcinoma associated with anomalous pancreaticobiliary junction and cysts

Anomalous pancreaticobiliary junction with cystic dilatation of the biliary tract is usually associated with carcinoma arising from the cyst wall. We report an extracystic location of biliary carcinoma in the presence of anomalous pancreaticobiliary junction and cysts in a patient with obstruction of the origin of the left hepatic duct who underwent hepatobiliary resection. Cholangiocarcinoma was found to have arisen in a noncystic left hepatic duct, in conjunction with cystic dilatation involving both the cystic and common bile ducts. The present case supports a relationship between anomalous pancreaticobiliary junction and biliary carcinogenesis that may affect the extracystic biliary tree.

[Endoscopic resection of large pedunculated colonic polyps using Endoloop. Three case reports and review of the literature]

Endoscopic polypectomy is now an established procedure for the resection of colorectal polyps. One of the serious complications associated with colonoscopic polypectomy is hemorrhage. Several factors appear to be associated with increased risk of hemorrhage including patient age and colorectal polyp size, location, and morphology (thick stalk or sessile). In particular, resection of large polyps is associated with a higher risk of serious complications. Bleeding most often occurs within the first 24 hours. More than 95% of cases of bleeding can be treated endoscopically by epinephrine injection, heater probe, or band ligation, alone or in combination. Several methods have been proposed for the prevention of hemorrhage after polypectomy. The most interesting approach is the use of a detachable snare (Endoloop) which allows endoscopic ligation of the stalk of a large, pedunculated polyp. In order to avoid the more severe consequences of bleeding, we use a detachable snare in two patients with a pedunculated polyp with a large head and stalk (> 2 cm). In a third patient receiving anticoagulant, a detachable snare was chosen to safely and completely remove a large pedunculated polyp > 1.5 cm. In conclusion, colonoscopic polypectomy with Endoloop is safer than conventional polypectomy alone for resection of large, pedunculated polyps, especially in patients with liver disease, coagulopathy and receiving anticoagulant.

Hepatocellular carcinoma in Lebanon: Etiology and prognostic factors associated with short-term survival

AIM: To study the epidemiology of HCC in Lebanon and prognostic factors predictive of early mortality.

METHODS: An observational follow-up cohort study of HCC cases diagnosed over a five-year period was carried out. Multivariate analysis was conducted to identify prognostic factors in comparison to Cancer of the Liver Italian Program (CLIP) score. Multiple variables including the etiology of underlying liver disease, the demographic characteristics of patients, and the severity of liver disease evaluated by the Child-Pugh score were studied. Tumor parameters included the time of diagnosis of HCC, alpha-fetoprotein level, number and size of nodules, presence of portal vein thrombosis, and treatment modalities. Death or loss of follow-up was considered as an end-point event.

RESULTS: Ninety-two patients (mean 60.5 ± 22.3 years) were included. Etiology of underlying disease was hepatitis B, C, and alcohol in 67%, 20%, and 23.5% respectively. Child-Pugh class at diagnosis was A, B, and C in 34.8%, 39.3% and 25.8% respectively. Overall survival was 44.8%, 32.8% and 17.6% at 1, 2 and 3 years respectively (mean F/U 40.2 ± 23.5 mo). Multivariate analysis identified three predictors of early mortality (< 6 mo): bilirubin > 3.2 mg/dL (P < 0.01), HCC as first presentation of liver disease (P = 0.035), and creatinine > 1 mg/dL (P = 0.017). A score based on these variables outperformed the CLIP score by Cox proportional hazard. ROC curve showed both models to be equivalent and moderately accurate.

CONCLUSION: HBV is the leading cause of HCC in Lebanon. Independent predictors of early mortality are elevated bilirubin, creatinine and HCC as first manifestation of disease. Prospective validation of a score based on these clinical parameters in predicting short-term survival is needed.

Influence of acetaminophen at therapeutic doses on surrogate markers of severity of acute viral hepatitis

OBJECTIVES

Data on the influence of acetaminophen intake on acute viral hepatitis is scarce, but it could play a role in the worsening of this disease. The aim of this study was to determine whether the intake of acetaminophen at therapeutic doses affects the severity of acute viral hepatitis.

METHODS

This was a prospective study concerning 37 consecutive patients hospitalized for acute viral hepatitis. Acetaminophen consumption and time since last intake were assessed by a questionnaire. Parameters of severity were studied in comparison to time related serum concentrations of acetaminophen.

RESULTS

Patients hospitalized for acute viral hepatitis (18 male, 19 female patients) had a mean age of 29.2 +/- 11.5 years. The causal virus was HAV (n=23), HBV (n=7) and other viruses (n=8). The mean cumulated dose of acetaminophen was 7.7 +/- 5.65 g. The daily dose did not exceed the therapeutic dosage and the mean was 1.95 +/- 0.81 g (1-3 g). Patients who received 7.5 g of acetaminophen or more had a lower prothrombin index 52.4 +/- 30.3% vs 74.2 +/- 17.2% (P=0.039), and a lower factor V 54.7 +/- 33.2% vs 83.3 +/- 19.6% (P=0.033). Prothrombin index and bilirubinemia were negatively correlated with time related plasma acetaminophen concentrations.

CONCLUSIONS

The use of acetaminophen at therapeutic doses was associated with greater alterations of surrogate markers of the severity of acute viral hepatitis especially hepatitis A. This was related to cumulated dosages and correlated to the time related acetaminophen plasma concentrations. Acetaminophen use should be interrupted when acute hepatitis is suspected.

Rectal Dieulafoy's lesion. Report of two cases treated successfully by endoscopic means

Rectal Dieulafoy's lesion is an unusual cause of abrupt and massive lower gastrointestinal hemorrhage. It is characterized histologically by a caliber-persistent submucosal artery that protrudes through a minute mucosal defect. Various theories and risk factors have been proposed to explain the occurrence of bleeding but none is completely satisfying. We present two cases of rectal Dieulafoy's lesion which were treated efficaciously by a simple injection of a sclerosing agent in the first case and by a combination of epinephrine injection and thermal probe coagulation in the second leading to a complete and rapid disappearance of the abnormal vessel.

[Utility of endoscopic ultrasonography on localization of insulinomas. Case report and review of the literature]

Insulinoma is the most common endocrine tumors of the pancreas. The diagnosis is suspected by clinical symptoms and confirmed by biologic tests. Because the majority of insulinomas have a small size, the real problem is the localization of these tumors. The non invasive radiologic exams (US, CT Scan, angiography or RMI) are not sensitive for the topographic localization of insulinomas. The invasive exams like per operative US and palpation of the parenchyma or dosage of insulin by transhepatic catheterization of portal vein or in hepatic vein after intrarterial stimulation are very sensitive. The only noninvasive preoperative exam with high sensitivity to localize insulinomas is endoscopic ultrasonography (EUS). We report a case of insulinoma localized by EUS with review of the literature.

[Cirrhosis and renal failure: the influence of creatinine value on prognosis]

Renal failure in cirrhosis has multiple etiologies and numerous aggravating factors with evidence of worsening of prognosis. Our study was performed on 130 cirrhotic patients hospitalized in HDF between January 1st, 1994, and December 31st, 1999. We have evaluated the causes of renal failure and the relation of different aggravating factors with the onset of renal failure. Causes of renal failure included drug-induced renal failure, organic nephropathy, pre-renal azotemia, acute tubular necrosis and hepato-renal syndrome. Among the aggravating factors, lactulose was found to alter renal function (p = 0.0175). We studied the survival with respect to the serum creatinine levels and to the severity of liver disease. Three-year survival was respectively 59% and 42% in case of Child A and Child B patients with creatinine lower than 90 micromol/L. No three-year survivors were noted in these subsets of patients when creatinine level was higher than 90 micromol/L (p = 0.0247 and p = 0.0121 respectively). No difference in survival was noted in Child C cirrhosis. The occurrence of renal failure is a factor of bad prognosis in cirrhotic patients irrespective of Child's classification. In patients with Child A and Child B cirrhosis, a serum creatinine level higher than 90 micromol/L is a bad prognostic factor with a significantly decreased survival rate. This factor does not affect survival in Child C cirrhosis because of mortality related to cirrhosis complications.

[Endoscopic treatment of Dieulafoy's lesion. A case report and review of the literature]

Dieulafoy's lesion is a rare and important cause of gastrointestinal hemorrhage. It is a relatively large artery which lies in close proximity to the mucosal surface. Hemorrhage is often torrential and life threatening. Endoscopy is the most sensitive diagnostic test. Many reports described successful hemostasis utilizing a variety of endoscopic modalities in > 95% of cases. We report an upper gastrointestinal hemorrhage in a patient with Dieulafoy lesion treated successfully by injection, and a literature review.

[Role of endoscopic gastric biopsies in the management of gastritis. A study of 250 consecutive cases]

BACKGROUND

The practical role of gastric biopsy in the management of gastritis is controversial.

AIM

To estimate the yield of endoscopic biopsies in the clinical, endoscopic and pathologic approach of gastritis.

MATERIAL AND METHODS

Prospective study of 250 consecutive patients who underwent an upper G.I. endoscopy between July 1996 and January 1997, for upper G.I. symptoms, miscellaneous manifestations requiring an upper G.I. endoscopy or presenting a gastritis on EGD performed for other indications. Every patient had 6 biopsies: 2 in the antrum, 2 in the corpus, and 2 in an intermediate zone.

RESULTS

After defining the abnormal elemental endoscopic and pathologic patterns, gastric mucosa was endoscopically normal in 57 cases (22.8%) and abnormal in the remaining of the 250 cases (77.2%). The pathologic findings were normal in 69 cases (27.6%) and abnormal in the remaining 181 cases of 250. H. pylori was found in 126 cases (50.4%), 10 cases of which (7.9%) had normal pathology. There was no significant correlation between clinical symptoms, endoscopy and pathology. There was a correlation between endoscopic abnormalities and tobacco use (P = 0.0073), NSAIDs use (P = 0.0001) and the presence of H. pylori (P < 0.0001). There was also a correlation between pathologic findings, tobacco use (P = 0.0015), NSAIDs use (P = 0.0022) and the presence of HP (P < 0.0001). On the other hand, there was a correlation between the presence of an inflammatory infiltrate in H. pylori gastritis (P = 0.0007) and its absence in NSAIDs use (P = 0.0003). The correlation between endoscopy and pathology existed only for certains patterns: erosion and ulcerations (P = 0.0002), purpuric (P = 0.033), congestion (P < 0.0001) and mosaic (0.0095).

CONCLUSION

Gastric biopsy brings no important practical supplement to endoscopic examination except in revealing the presence of H. pylori. It adds nothing to endoscopy in helping explain the clinical symptoms. But it is obvious that it may reveal some serious pre-malignant dysplasia or malignant gastric lesions (maltoma, linitis plastica). This did not occur during our study.

[Hemostatic embolization of hepatocellular carcinoma complicated by hemoperitoneum. Apropos of 2 cases and review of the literature]

Rupture of hepatocellular carcinoma is a severe complication that occurs in about 10% of patients. It may occur as a terminal event in patients with advanced disease or it may be the first presentation in a healthy individual. Various treatment options have been proposed, which include conservative treatment, transarterial embolization and operative hemostasis or liver resection. We report intraperitoneal hemorrhage and hypovolemia in two patients with spontaneous rupture of an hepatocellular carcinoma treated successfully by transarterial hepatic embolization. On follow-up, these patients died 7 and 8 months after this treatment respectively.

[24-hour esophageal pH monitoring in adults. Apropos of a series of 116 patients]

Between June 1994 and June 1996, we performed a 24-hour oesophageal pH monitoring in 116 adult patients. A retrospective analysis of the data is hereby presented. The principal indications include a chronic cough, recurrent laryngitis and noncardiac chest pain. In 65.5% of our cases, a pathological gastroesophageal reflux was found during pH monitoring. The symptom-index (SI) concerning the digestive and ENT symptoms did correlate in 1/3 of the cases while it was significant in only 15% of the cases with pulmonary and cardiac symptoms. 24-hour pH monitoring remains the method of choice for the study of gastroesophageal reflux and analysis of the SI is indispensable to evaluate the correlation of symptoms with episodes of reflux.

[Multiple amebic liver abscess]

We report a case of multiple hepatic amebic abcesses, in a young Lebanese male patient living in Abidjan. These abcesses were revealed by fever and an acute pain in the right upper quadrant of the abdomen. Biological, namely serological, and ultrasonographic and magnetic resonance imaging abnormalities were noted. The patient responded favorably to metronidazole, and the short term evolution was good. A literature review was done, since the hepatic amebic abcess is becoming rare in our country.

[Prevention of hemorrhagic recurrence in cirrhotic patients. Is sclerotherapy better than propranolol?]

The effectiveness of oral propranolol and sclerotherapy in preventing recurrent bleeding after an endoscopically proven haemorrhage from oesophageal varices was compared in Pugh's grade B and C patients divided into two successive therapeutic groups. Group I patients (n = 32) were given oral propranolol, while sclerotherapy was performed in group II patients (n = 32), 23 of whom simultaneously received propranolol. There was no difference between groups I and II in the severity of the initial bleeding and liver failure (Groups I/II, B 19/18, C 13/14), in the withdrawal of alcohol (group I 25, group II 17) and in compliance with either treatment (group I 25, group II 27). Obliteration of the oesophageal varices was achieved in 69 p. 100 of group II patients within a median number of 4 courses and 46 days, and in 84 p. 100 of the patients of this group who survived for more than 3 months. One year after the beginning of treatment rebleeding had occurred in 43 p. 100 of either group I or group II patients. The 1-year survival rate was 72 p. 100 in group I and 62 p. 100 in group II (non significant). The causes of death were the same in both groups. Irrespective of the treatment assigned, death was 2.1 times more frequent (P = 0.02) and rebleeding was 1.2 time more frequent (P = 0.08) in grade C than in grade B patients.