Yet another case of abdominal pain?
A 41-year-old man with a recent history of weight loss, reduced appetite and nausea...
A 41-year-old man with a recent history of weight loss, reduced appetite and nausea presents with acute abdominal pain.On physical examination he has abdominal distension without tenderness but pain during deep palpation, Blumberg’s sign is negative and bowel sounds are sparse. The initial radiography findings are shown in figure 1 and his blood test results are shown in table 1. Table 1 | Blood test results at presentation. Click on the picture to enlarge the table. At this stage, would you choose to give laxatives and discharge the patient, urgently perform a CT scan or endoscopy, or give a prokinetic, antibiotics, laxatives and monitor the patient every 6h? The correct decision here is to perform a CT scan, which is what the case patient underwent—the findings are shown in figure 2. Figure 2 | Abdominal contrast-enhanced CT scan with coronal and sagittal reconstructions; images were acquired at portal venous time (about 70 seconds after injection of iodinated contrast medium).
Case Question 1WHAT IS YOUR CLINICAL DIAGNOSIS AT THIS POINT? a) Intestinal ischaemia
b) Crohn’s Disease
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Alcohol Awareness Month
April is the perfect time to discuss UEG’s actions on alcoholic liver disease.
Last October, on the occasion of UEG Week 2017, we had a chance to sit and talk with Professor Helena Cortez-Pinto, a member of UEG’s Public Affairs Committee and author of the UEG Education article “Mistakes in alcoholic liver disease and how to avoid them.” Now, in the middle of Alcohol Awareness Month, we highlight the main points of our discussion and make the video of the interview available.During our interview, Helena conveyed the importance of several aspects related to state-of-the-art treatment for patients with alcoholic liver disease (ALD), such as the necessary involvement of multidisciplinary teams to deal with both the physical and psychological sides of the disease. She also touched on the specificities of performing a liver biopsy in ALD patients, as well as some of the alcohol-related issues the UEG Public Affairs Committee is trying to get onto the EU health agenda.
The current, evident disparity between ALD research and its burden, when compared with other liver diseases, was a key point mentioned by Helena during the interview. Supporting this point is evidence from Ramon Bataller and co-authors, who developed an Attention-to-Burden Index (ABI), comparing research activities during 2010–2014 with an estimate of disease burden for the four major liver diseases, namely hepatitis B and C, ALD and nonalcoholic fatty liver disease.1 Surprisingly (or not), they found that the mean research attention for ALD was only 5%, when its overall burden was 50%, highlighting the critical need to increase awareness of ALD in the liver research community. This need was also pointed out by Helena during her interview and is something she is working to convey to Members of the European Parliament, Representatives of the European Commission and Council, as well as other EU stakeholders, as part of her work on UEG’s Public Affairs Committee, which is chaired by Markus Peck-Radosavljevic.
In a related matter, earlier this year the “Alcohol and Digestive Cancers: Time for Change” report was published by UEG EU Affairs, highlighting the alarming scale of alcohol consumption across Europe and its direct and indirect impact on digestive cancers.
More information on the work of the UEG Public Affairs Committee can be found online, along with a copy of the “Mistakes in alcoholic liver disease and how to avoid them” article from Helena and co-author Pedro Marques da Costa and other articles in the “Mistakes in…” series.
We hope you enjoy the interview! Please be sure to let us know what you think, if there are any other issues we should be considering and if there’s anyone else you would like to see us interview in future. References
- Ndugga N, et al. Disparities between research attention and burden in liver diseases: implications on uneven advances in pharmacological therapies in Europe and the USA. BMJ Open 2017; 7: e013620.
- Singal AK, et al. ACG Clinical Guideline: Alcoholic Liver Disease. Am J Gastroenterol 2018; 113: 175–194.
- Marcellin P and Kutala BK. Liver diseases: A major, neglected global public health problem requiring urgent actions and large-scale screening. Liver Int 2018; 38 (Suppl 1): 2–6.
- Spence AD, et al. Communication of alcohol and smoking lifestyle advice to the gastroenterological patient. Best Pract Res Clin Gastroenterol 2017; 31: 597–604.
- Campbell EJ, Lawrence AJ and Perry CJ. New steps for treating alcohol use disorder. Psychopharmacology Epub ahead of print 25 March 2018. DOI: 10.1007/s00213-018-4887-7.
Mistakes in the endoscopic diagnosis and management of Barrett’s oesophagus and how to avoid them
Barrett’s oesophagus is the precursor to oesophageal adenocarcinoma, which carries a poor prognosis,1 and it is likely that all endoscopists and gastroenterologists will encounter Barrett’s oesophagus in their clinical practice.Careful assessment and management of patients who have Barrett’s oesophagus with endoscopic surveillance and endoscopic endotherapy aim to reduce the risk of progression to invasive adenocarcinoma. Advances in endoscopic diagnosis and therapy should, therefore, help to reduce the risk of progression. As with all premalignant conditions and surveillance programmes,2 careful multidisciplinary management of the patient is important to reduce the risk of causing them to become unduly concerned. Here, we present some mistakes that in our experience are commonly made in the endoscopic diagnosis and management of Barrett’s oesophagus and give advice on how to avoid them.
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Mistakes in short bowel and how to avoid them
Short bowel manifests as high stomal output or diarrhoea, dehydration and malnutrition.
Short bowel is a condition that occurs after single or multiple intestinal resections. The incidence of short bowel in Europe is 2 per million of the population1–3 and it carries with it lifelong morbidity and mortality. The initial recognition and management of short bowel in the adult population tends to occur in the postoperative period and in the secondary care setting, where specialist input from clinicians experienced in short bowel is often lacking.Normal small bowel length is 275–850 cm.4–7 It is accepted that when the length of small bowel is reduced to less than 200 cm it may be insufficient to enable adequate absorption of fluids and micronutrients. The symptoms of short bowel (often referred to in the literature as short bowel syndrome) are secondary to a reduction in intestinal surface area together with an increased motility of the remaining section of small bowel, with accompanying increased secretion into the lumen. These intestinal secretions vary in their electrolyte content and osmolality depending on the anatomical location, with the highest chloride and potassium loss from gastric secretions and high sodium loss from jejunal secretions.8 Clinically, short bowel manifests itself as a high stomal output or diarrhoea, dehydration and malnutrition. High stomal output or diarrhoea do not, however, necessarily equate immediately to short bowel; conversely, a small bowel longer than 200cm may be insufficient if it is diseased. Here, we discuss some of the pitfalls that are encountered in the recognition and management of short bowel and have suggested an algorithm for assessing and managing patients with a high stomal output. Although some of these pitfalls may appear obvious, they are addressed here because they are commonly encountered in clinical practice (summarised in table 1 at the end of the article).
A case at the crossroads of dermatology and gastroenterology
What next for a middle-aged patient with a condition affecting her skin and mouth?
Several years ago, a middle-aged woman presented with a condition affecting her skin (photograph A) and mouth (photograph B), and she was diagnosed with lichen planus.The patient then presented with dysphagia. A lesion was found high in the oesophagus (photograph C) and biopsy samples were taken (photograph D). Case question 1 WHAT IS THE AETIOLOGY OF THE STRICTURE? a) Benign b) Malignant
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Mistakes in paediatric IBD and how to avoid them
Better clinical outcomes are increasingly being sought in young people with IBD
Around 1 in 10 cases of inflammatory bowel disease (IBD) will present before adulthood, with the median age at presentation being 11–12 years.1 IBD in children and young people is associated with more extensive disease, increased disease activity and a higher rate of complications compared with adult-onset IBD.2 Worldwide, estimates of paediatric IBD prevalence rates are lacking, but data suggest its incidence is increasing.3
Risk factors for paediatric IBD include immigration to high prevalence regions, particularly to countries that have Westernised diets, increasing geographical latitude, and European ancestry (versus belonging to an indigenous population).4 The risk may also be higher in children of certain ethnicities (South Asian, Hispanic, and East Asian).5
While the pathophysiology and clinical presentation of paediatric IBD is well understood, the role of genetics and personalised treatment is currently the focus of a significant amount of international research. Better clinical outcomes—including optimal nutrition, improved growth, better quality of life and increased disease remission rates with decreased occurrence of complications—are increasingly being sought in children and young people with IBD.4
This article discusses mistakes commonly made when identifying, diagnosing and managing children whom are suspected or confirmed to have IBD. The mistakes and discussion are based on published evidence where possible, plus our clinical experience of looking after children with IBD.
Prevention of cancer in the gastrointestinal tract and the liver
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Mistakes in tissue sampling during endoscopy and how to avoid them
Tissue acquisition is the most common manoeuvre performed during endoscopy.
Mistakes in managing H. pylori infection and how to avoid them
Careful practice can overcome declining eradication rates for H. pylori treatment.
The sequelae of Helicobacter pylori infection, a known Group 1 carcinogen, can lead to significant morbidity and mortality worldwide. Billions of people are infected with H. pylori, but the incidence of H. pylori infection is declining in many parts of Europe, with a study from the Netherlands showing a decline in seroprevalence from 48% in subjects born between 1935 and 1946 to 16% in those born between 1977 and 1987.1In recent years, however, eradication rates for H. pylori treatment have been falling, which has led to a large number of patients in the community having inadequately managed infections. Most of the problems that have led to the decline in the success of eradication treatment can be easily overcome through careful practice, supported by the robust framework provided by international guidelines. Careful practice includes the correct management of dyspepsia, the appropriate use of diagnostic tests for H. pylori, acceptable, efficacious treatments that enable good patient compliance and adequate follow up to insure eradication has been achieved in all cases. Here, we discuss the mistakes that are made when managing patients infected with H. pylori. Most of the discussion is evidence based, but where evidence is lacking the discussion is based on the authors’ clinical experience of more than 30 years in the field.
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Biomarkers of Liver Disease
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Mistakes in NAFLD and how to avoid them
Management of NAFLD requires a multidisciplinary approach.
Nonalcoholic fatty liver disease (NAFLD) is defined as the accumulation of excess fat (triglyceride) in the liver in the absence of excessive alcohol consumption. Disease severity ranges from simple steatosis (nonalcoholic fatty liver [NAFL]) to nonalcoholic steatohepatitis (NASH), fibrosis, or cirrhosis, with the potential to develop hepatocellular carcinoma (HCC) or require liver transplantation.NAFLD is believed to affect up to 25% of the Western population,1 and is fast becoming the leading reason for liver transplantation worldwide.2 It affects up to 70% of those who are obese,3 and is strongly linked to the metabolic syndrome. Management of NAFLD therefore requires a multidisciplinary approach, not only to identify those patients at risk of progressive liver disease, but also to improve long-term liver and cardiovascular morbidity and mortality. Here, we highlight some of the mistakes commonly made by medical practitioners when managing NAFLD, and give an evidence-based (where possible) or experience-based approach to management of the condition.
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