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Endoscopic and Histopathological Characteristics of Gastrointestinal Lymphoma: A Multicentric Study
(2023)
Background: Extranodal non-Hodgkin lymphoma (NHL) is more prevalent in the gastrointestinal (GI) tract than in other sites. This study aimed to determine the endoscopic characteristics of primary gastrointestinal non-Hodgkin lymphomas. Methods: We investigated 140 patients from three tertiary referral hospitals with primary malignant lymphoma of the gastrointestinal tract. Characteristics of the lesions were evaluated and analyzed using image-enhanced endoscopy, endoscopic ultrasound, and histopathology. Results: The median age was 60.5 (range: 11–99), and 59 (42.1%) were female. The most frequent complaint was abdominal pain (74.3%), followed by bloody feces (10%) and diarrhea (2.9%). B symptoms were observed in 15 (10.7%) patients. GI obstruction was the most common complication (10.0%), followed by hemorrhage (7.9%) and perforation (1.5%). Regarding endoscopic findings, the identified sites were the following: the stomach (61.4%), colon (10%), small intestine (10%), ileocecum (8.6%), rectum (6.4%), and duodenum (3.6%). Diffuse large B-cell lymphoma (DLBCL) and mucosa-associated lymphoid tissue (MALT) lymphoma are most prevalent in the stomach. Helicobacter pylori was identified in 46 cases (39.0%), with MALT lymphoma being the most infected subtype. Nearly all gastrointestinal non-Hodgkin lymphomas manifested as superficial type (25–59.6%) and ulcer type (15.6–50%) under endoscopy. We found that fungating type and protruding with ulcer type were more frequent types of aggressive lymphomas (diffuse large B-cell lymphoma, mantle cell lymphoma, and T-cell lymphoma) compared to the indolent types (MALT lymphoma, follicular lymphoma, duodenal-type follicular lymphoma, and small lymphocytic lymphoma) (p < 0.05). Conclusions: This study showed that most subtypes of gastrointestinal non-Hodgkin lymphomas exhibited same endoscopic features (superficial type and ulcer type). Aggressive gastrointestinal non-Hodgkin lymphomas (diffuse large B-cell lymphoma, mantle cell lymphoma, and T-cell lymphoma) were highly suspected when fungating lesions and protruding with ulcer lesions were encountered under endoscopy. Endoscopists should be aware of the connection between enhanced endoscopic characteristics and histological varieties of gastrointestinal lymphoma to improve diagnosis.
Background and study aims: Gastric cancer (GC) is one of the leading causes of malignancy-related death in Vietnam, with increasing incidence of non-cardia early gastric cancer (N-EGC). Data on accurate diagnosis of EGC and treatment by endoscopic submucosal dissection (ESD) in Vietnam are very sparse. The aim of this study was to describe the characteristics of N-EGC and evaluate the effectiveness and the safety of ESD in Central Vietnam.
Patients and methods: We prospectively enrolled patients with N-EGC detected by magnified chromoendoscopy from December 2013 to August, 2018 in Central Vietnam. Selected cases of N-EGC received standardized ESD technique and have been following up carefully as in protocol.
Results: Among 606 GC patients, 46 had N-GEC and underwent ESD. The depth of invasion was pT1a in 33 (71.7 %), pT1b1 in 10 (21.7 %), and pT1b2 in three cases (6.6 %). Mild chronic atrophic gastritis, most being C2 (63 %), and gastritis-like EGC that did not appear malignant was the predominant type. ESD achieved a 97.8 % en bloc resection rate; the mean procedure time was 76 ± 22 minutes (range 24–155), and mean endoscopic tumor size was 23 ± 5 mm (range 13–52) and ESD sample size was 28 ± 7 mm (range 16.5–60). Complications consisted of two patients with bleeding and one with a minor perforation, all of which were successfully managed by endoscopy. The longest and the mean follow-up times were 84 and 64 months, respectively, with no recurrence.
Conclusions: A significant proportion patients with N-EGC have a background mucosa of mild chronic atrophic gastritis. Our results 7 years after starting ESD demonstrate early promising outcomes with the procedure.
Acute pancreatitis (AP) is a major, globally increasing gastrointestinal disease and a biliary origin is the most common cause. However, the effects of bile acids (BAs), given systemically, on the pancreas and on disease severity remains elusive. In this study, we have investigated the roles of different circulating BAs in animal models for AP to elucidate their impact on disease severity and the underlying pathomechanisms. BAs were incubated on isolated acini and AP was induced through repetitive injections of caerulein or L-arginine; pancreatic duct ligation (PDL); or combined biliopancreatic duct ligation (BPDL). Disease severity was assessed using biochemical and histological parameters. Serum cholecystokinin (CCK) concentrations were determined via enzyme immunoassay. The binding of the CCK1 receptor was measured using fluorescence-labeled CCK. In isolated acini, hydrophobic BAs mitigated the damaging effects of CCK. The same BAs further enhanced pancreatitis in L-arginine- and PDL-based pancreatitis, whereas they ameliorated pancreatic damage in the caerulein and BPDL models. Mechanistically, the binding affinity of the CCK1 receptor was significantly reduced by hydrophobic BAs. The hydrophobicity of BAs and the involvement of CCK seem to be relevant in the course of AP. Systemic BAs may affect the severity of AP by interfering with the CCK1 receptor.
Pancreatic necroses are a major challenge in the treatment of patients with pancreatitis, causing high morbidity. When indicated, these lesions are usually drained endoscopically using plastic or metal stents. However, data on factors associated with the occurrence of failure or adverse events during stent therapy are scarce. We retrospectively analyzed all adverse events and their associated features which occurred in patients who underwent a first-time endoscopic drainage of pancreatic necrosis from 2009 to 2019. During the observation period, a total of 89 eligible cases were identified. Adverse events occurred in 58.4% of the cases, of which 76.9% were minor (e.g., stent dislocation, residual lesions, or stent obstruction). However, these events triggered repeated interventions (63.5% vs. 0%, p < 0.001) and prolonged hospital stays (21.0 [11.8–63.0] vs. 14.0 [7.0–31.0], p = 0.003) compared to controls without any adverse event. Important factors associated with the occurrence of adverse events during endoscopic drainage therapy were positive necrosis cultures (6.1 [2.3–16.1], OR [95% CI], p < 0.001) and a larger diameter of the treated lesion (1.3 [1.1–1.5], p < 0.001). Superinfection of pancreatic necrosis is the most significant factor increasing the likelihood of adverse events during endoscopic drainage. Therefore, control of infection is crucial for successful drainage therapy, and future studies need to consider superinfection of pancreatic necrosis as a possible confounding factor when comparing different therapeutic modalities.
Background/Aims
Patients with chronic pancreatitis (CP) have an increased risk of malnutrition, a condition linked to reduced muscle mass and physical performance. We have investigated the risk factors, phenotypic presentation, and health implications associated with malnutrition in CP.
Materials and Methods
In a multicenter cross-sectional study we recruited patients with confirmed CP and healthy volunteers as a control group. Malnutrition was diagnosed according to the criteria proposed by the Global Leadership Initiative on Malnutrition. We performed detailed examinations of body composition and physical function as well as testing of routine blood parameters and markers of inflammation.
Results
We included 66 patients [mean (±SD) age: 56.0 (±14.5) years; 51 males] and an equal number of age- and sex-matched controls. Moderate malnutrition was diagnosed in 21% (n = 14) and severe malnutrition in 42% (n = 28) of patients. Besides weight loss malnourished patients showed lower fat and skeletal muscle mass compared to both non-malnourished subjects and healthy controls. Only in severe malnutrition, blood parameters reflected elevated inflammation and reduced muscle reserves. Handgrip strength in patients did not differ by nutritional status but there was a significant correlation (rho = 0.705, p < 0.001) with skeletal muscle mass. Although 20 patients (30%) had pathologically reduced skeletal muscle mass, only two individuals (3%) had sarcopenia with concomitantly reduced handgrip strength.
Conclusion
Malnutrition is a frequent complication of CP characterized by loss of skeletal muscle mass. As this condition becomes evident only at an advanced stage, regular testing for altered body composition is recommended. Suitable biomarkers and the link between loss of muscle mass and physical function require further investigation.
Clinical Trial Registration
[https://clinicaltrials.gov/ct2/show/NCT04474743], identifier [NCT04474743].
Acute pancreatitis (AP) is one of the most common and widely increasing gastrointestinal
diseases leading to hospitalization without specifically available therapy. Among various
etiologies, biliary origin is the most common cause. However, the effects of BAs, given
systemically, on AP remains elusive. A detailed characterization of the mechanisms through
which BAs contribute to the pathogenesis and severity of AP will greatly improve our
understanding of the underlying pathophysiology and may facilitate the development of
treatment, early identification of complications, and prevention for AP. In this view, the roles of
different circulating BAs using in vitro-to-in vivo models were investigated and the underlying
mechanisms through which BAs modulate the severity of AP were addressed. The impact of
hydrophobic and hydrophilic BAs on both, isolated acinar cells and different animal models
induced by repetitive injections of caerulein or L-arginine, ligation of the pancreatic duct (PDL)
or combined bile and pancreatic duct ligation (BPDL), were tested. Disease severity was
assessed by biochemical and histological parameters. Serum CCK concentrations were
determined by enzyme immunoassay. The binding of CCK1 receptor was measured using
fluorescent-labeled CCK. Human BA profiles in AP patients were quantified and that were
correlated with etiology as well as clinical course. In acinar cells, hydrophobic BAs mitigated
the damaging effects of CCK. The same BAs further enhanced pancreatitis in L-arginine and
PDL-based pancreatitis whereas they ameliorated pancreatic damage in the caerulein and
BPDL models, in which CCK was involved. The chemical effect of BAs on protease trypsin
was also observed, however, it was similar between hydrophobic and hydrophilic compounds.
Mechanistically, the binding affinity of the CCK1 receptor was significantly reduced by
hydrophobic BAs. In patients, the sum of hydrophobic but not hydrophilic BAs correlated with
the etiology and severity of AP.
Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) was
reported to be related with CCK and several pharmaceutical agents have been used to prevent
this most common and potentially severe complication, but those are of limited benefit. In this
regard, our multicenter multinational randomized control trial was designed to compare the
efficacy of indomethacin and N-acetylcysteine (NAC) for the prevention of PEP. A total of 432
ERCP patients from 6 countries were recruited and randomly assigned to receive either NAC
(group A, 84 cases), indomethacin (group B, 138 cases), NAC + indomethacin (group C, 115
cases) or placebo (group D, 95 cases) two hours before procedure. The rate of PEP in groups
A, B and C in comparison with placebo were 10.7%, 17.4%, 7.8% vs 20% (p = 0.08, 0.614 &
0.01, respectively).
Among complications of AP, infection of pancreatic necrosis is one of the most severe
consequence that mostly necessitates interventional therapy. A model to identify parameters
that are useful for the prediction of infected necrosis at an early stage was developed. A
retrospective analysis was conducted in 705 AP patients, who underwent contrast-enhanced computed tomography (CT scan). Both laboratory and clinical parameters were analyzed for
an association with infected pancreatic necrosis, which was microbiologically confirmed. A
logistic regression analysis with stepwise inclusion of significant variables was used to develop
a prediction model. We tested the model quality by receiver operating characteristics analysis.
We found a significant association between 11 parameters with an infection including albumin,
creatinine, C-reactive protein (CRP), and alcoholic etiology, which were independent variables
in the final predictive model with an area under the curve of 0.819.
In the same cohort in which we developed the prediction model above, 89 AP cases with
necrotic complications diagnosed by CT scan were identified. These complications with high
morbidity and mortality required endoscopic drainage, which possibly accompanies severe
adverse events. All complications which occurred in patients who underwent those procedures
and their associated features were retrospectively analyzed. Positive necrosis cultures and a
larger diameter of the intervened necroses were significant factors associated with the
occurrence of adverse events, in which the former was the most significant predictor with Odds
Ratio of 6.1.
The entire work demonstrated that hydrophobicity of BAs and the involvement of CCK are
relevant for the clinical course of AP. Systemic BAs may affect the severity of AP by interfering
with the binding of the CCK1 receptor. Oral NAC is effective for prevention of PEP and the
combination of NAC plus indomethacin resulted in the lowest PEP rate. A model using albumin,
creatinine, CRP, and alcoholic etiology can differentiate infected and sterile pancreatic
necrosis and control of infection is crucial for successful endoscopic drainage therapy in
complicated AP. The exact pathophysiologic mechanisms, especially in CCK-related pathways,
and the potential impact of BAs in human AP, in particular in preventing PEP, need to be investigated in further studies.
Background
In acute pancreatitis, secondary infection of pancreatic necrosis is a complication that mostly necessitates interventional therapy. A reliable prediction of infected necrotizing pancreatitis would enable an early identification of patients at risk, which however, is not possible yet.
Methods
This study aims to identify parameters that are useful for the prediction of infected necrosis and to develop a prediction model for early detection. We conducted a retrospective analysis from the hospital information and reimbursement data system and screened 705 patients hospitalized with diagnosis of acute pancreatitis who underwent contrast-enhanced computed tomography and additional diagnostic puncture or drainage of necrotic collections. Both clinical and laboratory parameters were analyzed for an association with a microbiologically confirmed infected pancreatic necrosis. A prediction model was developed using a logistic regression analysis with stepwise inclusion of significant variables. The model quality was tested by receiver operating characteristics analysis and compared to single parameters and APACHE II score.
Results
We identified a total of 89 patients with necrotizing pancreatitis, diagnosed by computed tomography, who additionally received biopsy or drainage. Out of these, 59 individuals had an infected necrosis. Eleven parameters showed a significant association with an infection including C-reactive protein, albumin, creatinine, and alcoholic etiology, which were independent variables in a predictive model. This model showed an area under the curve of 0.819, a sensitivity of 0.692 (95%-CI [0.547–0.809]), and a specificity of 0.840 (95%-CI [0.631–0.947]), outperforming single laboratory markers and APACHE II score. Even in cases of missing values predictability was reliable.
Conclusion
A model consisting of a few single blood parameters and etiology of pancreatitis might help for differentiation between infected and non-infected pancreatic necrosis and assist medical therapy in acute necrotizing pancreatitis.