Mistakes in acute diverticulitis and how to avoid them
The incidence of acute diverticulitis is rising worldwide.
Acute diverticulitis is an inflammatory complication of diverticulosis and can either be uncomplicated or complicated. Making the distinction between uncomplicated and complicated acute diverticulitis is essential because treatment strategies differ between the two.
Here, we discuss 10 mistakes frequently made when managing patients with acute diverticulitis. We focus on using the correct terminology, diagnostic preference and several treatment options, such as omitting or administering antibiotics, radiological interventions and various aspects of surgery. Acute diverticulitis is an important topic because its incidence is rising worldwide and it is becoming a considerable burden on healthcare systems. Most of the discussion included here is evidence-based, supplemented with many years’ combined clinical experience where evidence is lacking.European Specialty Examination in Gastroenterology and Hepatology
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How to identify possible scientific partners
Follow these tips on how to find potential research collaborators.
Finding new potential collaborators and the exchange with colleagues to promote your research is crucial for GI specialists.
Pedro Rodrigues, a new member of the Young Talent Group in 2020, shares the most useful tips on how to identify a possible scientific partner.
Tip 1: Do attend the most important meetings in your field of expertise.
It is essential to attend the most relevant congresses in order to maximize the opportunity to meet new potential collaborators and to promote your own work. In this regard, attending UEG Week on a yearly basis and being actively involved in the several activities that are organized by UEG (Summer School, Basic Science Courses, Young Investigators Meeting, etc.) constitutes the perfect platform to meet new people and establish good partnerships.
Tip 2: Try to synergize with good people.
Don’t go only for the best, but for the friendly ones. It is important to be surrounded by good friends. Therefore, identify good collaborators not only by their area of expertise but also try to connect with easy-going and friendly people that will make your scientific life stronger, easier and straightforward.
Tip 3: Identify partners that complement your research and interests.
Selecting collaborators that are able to complement your research is key. Joint efforts between people with different perspectives helps us with overcoming our flaws and weaknesses and will greatly increase our success.
Tip 4: Engage researchers from different areas in order to create your own multidisciplinary network.
Collaborate with partners from different fields and topics, which may generate innovative and different ideas, and will allow you to develop richer and more complete projects . Diversity is the key to greater achievements. To help you get in touch with other researchers, UEG is establishing a dedicated platform, the UEG Researchers Network. You can already register to receive the latest information on EU funding calls and other opportunities
Tip 5: Collaborate with researchers that do not come with problems, but with solutions.
Your collaborators should add significant value to your research, instead of fomenting fights. Each one of your partners should be able to contribute with valuable ideas and projects.
Tip 6: Select partners from all over the world.
Including worldwide investigators in your network is key in order to increase the probability of identifying new research calls and to apply for funding with your collaborative group.
Tip 7: Don’t forget to move!!!
Mobility is one of the most important factors when you are considering the creation of your collaborative networks. Meeting people from other institutions and connect with other types of work will greatly enrich your CV and will allow you to select important partners to be included in your daily life. In this regard, the UEG Research Fellowship constitutes an excellent opportunity to visit a new research institution, to learn new techniques, to develop new projects and ideas and finally to effectively connect with new scientific partners.
Tip 8: Be involved in relevant associations and groups, and ask for help whenever necessary.
Contact and be actively involved in national and international gastroenterology associations, including UEG. By doing so, you will be able to meet people that might help you in your quest. Do not hesitate to contact them when you need help in finding new scientific partners. Thus, becoming part of UEG and diving into the UEG Talent Pool is key in getting to know new people and to interact with key potential collaborators.
Tip 9: Don´t be shy! Just do it.
If you are interested in establishing a new collaboration please make the first move! Approach people and make the first contact. Do not hesitate to introduce yourself and to try to establish a potential collaboration.
Liver biopsy for evaluation of fibrosis in chronic liver disease: Yes or no?
Two experts present their viewpoints
Chronic liver disease affects many millions of people worldwide and is a major cause of premature death. Assessing liver fibrosis in patients with chronic liver disease can determine disease stage and progression, and also response to therapy, but whether this is best performed via a liver biopsy or noninvasive methods is a matter for debate.
Here, two European experts present their opposing viewpoints on how to assess fibrosis in the setting of chronic liver disease.
Yes—Dina Tiniakos
Biopsy is the reference method for evaluating liver fibrosis and the ‘gold standard’ against which noninvasive methods are compared. The histological stage of fibrosis is one of the most important prognostic factors in patients with chronic liver disease, independent of aetiology. Advanced fibrosis is a strong prognostic factor in alcohol-related liver disease and the most important prognostic indicator in nonalcoholic fatty liver disease (NAFLD), where individual histological fibrosis stages are associated with distinct patient outcomes.
Liver biopsy is the only way to diagnose nonalcoholic steatohepatitis (NASH) and, generally, offers the added value of assessing disease severity, highlighting possible concurrent disease and evaluating fibrosis progression or regression in paired biopsy samples. The known limitations of sampling and interobserver variability are minimized by high-quality biopsy techniques (using ≤16-gauge needles, core length >15 mm) and evaluation by expert hepatopathologists. Recently, digital image analysis and second harmonic generation technology have enabled objective quantitative and qualitative assessment of liver tissue collagen and can highlight subtle differences in fibrosis between biopsy samples.
Noninvasive methods of assessing liver fibrosis are widely used with increasing accuracy for diagnosing the absence of fibrosis or presence of severe fibrosis/cirrhosis and, therefore, are helpful to select patients for liver biopsy. However, noninvasive methods cannot distinguish intermediate stages of fibrosis and some serum marker measurements may reflect fibrotic processes in other organs. Failure of application (2–5%), unreliable results (11–15%) and false-positive results in acute inflammation, cholestasis or liver congestion are known limitations of transient elastography, while the patented serum markers have limited availability. While noninvasive tests reduce the need for liver biopsy for fibrosis evaluation they cannot replace it.
References
- Almpanis Z, Demonakou M and Tiniakos D. Evaluation of liver fibrosis: "Something old, something new…". Ann Gastroenterol 2016; 29: 445–453.
- Lackner C and Tiniakos D. Fibrosis and alcohol-related liver disease. J Hepatol 2019; 70:294–304.
No–Laurent Castera
Over the past decade, there has been growing interest in novel noninvasive strategies for the evaluation of fibrosis, given the well-known limitations of taking liver biopsy samples — invasiveness, limited patient acceptance, rare but potentially life threatening complications, sampling variability, pathologist experience, and cost. Taking liver biopsy samples also appears unrealistic considering the magnitude of the nonalcoholic fatty liver disease (NAFLD) epidemic, with around 25% of the general population affected in Western countries.
Noninvasive testing currently relies on two different but complementary approaches: measuring the levels of serum biomarkers and estimating liver stiffness using ultrasound-based elastography techniques, with transient elastography (FibroScanTM) being the pioneer. Although these two approaches are complementary, they are based on different rationales and concepts. Transient elastography measures liver stiffness related to elasticity, which corresponds to a genuine and intrinsic physical property of the liver parenchyma. By contrast, serum biomarkers are combinations of several, not strictly liver-specific, blood parameters that are optimized to predict the stages of fibrosis as assessed by liver biopsy.
The most validated noninvasive biomarker tests are FIB-4, AST to platelet ratio index (APRI), NAFLD fibrosis score (nonproprietary formula) and FibroTestTM (proprietary), while FibroScanTM is the most validated elastography technique. All these tests are better at ruling severe fibrosis-cirrhosis out than ruling it in. They also have prognostic value in the context of cirrhosis. For instance, they are able to identify the subgroup of NAFLD patients at high risk of developing liver-related complications and death. As a result, noninvasive tests are now widely used in routine clinical practice and included in national and international guidelines.
References
- European Association for the Study of the Liver and Asociacion Latinoamericana para el Estudio del Higado. EASL-ALEH Clinical Practice Guidelines: Non-invasive tests for evaluation of liver disease severity and prognosis. J Hepatol 2015; 63: 237–264.
- Castera L, Friedrich-Rust M and Loomba R. Noninvasive assessment of liver disease in patients with nonalcoholic fatty liver disease. Gastroenterology 2019; 156: 1264–281.
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An elusive lesion in the colon
How to ensure detection of subtle lesions during screening colonoscopy?
A 55-year-old female patient with no family history of colorectal cancer (CRC) underwent a scheduled screening colonoscopy. The colonoscopy was performed by an experienced endoscopist (adenoma detection rate [ADR] of 54%), using a high-resolution colonoscope with narrow-band imaging (NBI) cabaility. Carbon dioxide was used for bowel insufflation. The patient was sedated with midazolam and propofol, with adequate oxygen supplementation and continuous monitoring of her blood pressure and oxygen saturation. The video shows the colonoscopy and two photos (figure 1) are provided of the ascending colon and of the area near the hepatic flexure during withdrawal of the scope.
Figure 1 | Images of the ascending colon and of the area near the hepatic flexure during withdrawal of the colonoscope under conventional white-light and narrow-band imaging conditions. Case Question 1:
Which of the following statements is correct?A. There is a serrated lesion without dysplasia
B. There is a serrated lesion with dysplasia
C. There is an adenoma with low-grade dysplasia
D. There is an adenoma with high-grade dysplasia
Case Question 2:
What is the minimum length of time you should spend inspecting the right colon (including the cecum, ascending colon and hepatic flexure)?A. 3 minutes
B. 4 minutes
C. 5 minutes
D. 6 minutes
Case Question 3:
Which of the following is more likely to increase the adenoma detection rate (ADR)?A. Better training
B. Chromoendoscopy
C. A mucosal exposure device/cap
D. All of the above
Mistakes in... booklet 2019 out!
The booklet in 2019 contains eight most recent Mistakes in… articles, covering a wide range of topics.
Mistakes in... session at UEG Week 2019
Learn from experts about mistakes in the gastroenterology field and how to avoid them.
Mistakes in decompensated liver cirrhosis and how to avoid them
Protecting against future decompensation episodes is key
Patients with early stages of chronic liver disease and even those with compensated cirrhosis can present without any clinical symptoms, which means that liver disease and ongoing liver damage can remain unidentified for many years. However, morbidity and mortality drastically increase once the stage of ‘decompensated cirrhosis’ has been reached.1,2 Decompensated cirrhosis describes the development of clinically overt signs of portal hypertension and/or impairment of hepatic function (e.g. variceal bleeding, ascites or overt hepatic encephalopathy). The first hepatic decompensation event significantly increases the risk that further complications of liver cirrhosis and decompensation episodes will occur.2 Moreover, individuals who have advanced stages of liver cirrhosis are four times more susceptible to infection, which is, in turn, the most frequent trigger of hepatic decompensation.3,4
Optimal management is required to sufficiently treat patients who have decompensated liver cirrhosis, to protect them from future decompensation episodes and prevent further deterioration of hepatic function. However, decompensated liver cirrhosis is a highly complex disease and there are many pitfalls that may occur with regard to comorbidities, management of acute complications and appropriate medication.
In this article, we cover some of the mistakes frequently made when managing decompensated liver cirrhosis and ways to prevent them. The discussion is based on the available evidence and our personal clinical experience.
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