Japanese Journal of Gastroenterology and Hepatology

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1 High THC Oil in Ulcerative Colitis: A Case Report , Pasquale B1*, Antonio M1 , Maddalena Z1 , Antonietta L1 , Tatiana J1 and Giuseppe S1
Here we presented the case of a 48-year-old patient affected by lumbosacral pain treated with high concentrated THC cannabis oil. He suffered also from ulcerative colitis (UC), whose symptoms were poorly controlled by non-steroidal anti-inflammatory drugs (NSAIDs). During the cannabis oil treatment, the patient reported a significant relief from irritable bowel syndrome (IBS) related symptoms, assessed by the Mayo score, the short inflammatory bowel disease questionnaire (SIBDQ), and the bowel function index (BFI). This case report suggested that THC could be the most effective cannabinoid for the treatment of IBS-related symptoms and the oromucosal route the better way of administration.
2 Concurrent Gastric Hyperplastic and Fundic Gland Polyps in a Patient Taking Proton-Pump Inhibitor , Nishimura N* and Mizuno M
A 61-year-old man presented with iron-deficiency anemia (hemoglobin, 8.1 g/dl). He had been taking warfarin and low-dose aspirin for atrial fibrillation and post mitral valve replacement. He had also taken 15 mg lansoprazole daily for 6 years for treatment of gastroesophageal reflux disease. Serum anti-Helicobacter pylori IgG antibody and H. pylori testing of gastric biopsies were negative. Esophagogastroduodenoscopy revealed more than 20 pale pink, pedunculated polyps of up to 20-mm diameter (Figure 1) and fewer light-red polyps in the gastric body and fundus. The fundic mucosa appeared non-atrophic. The largest of the pale pink polyps and one large, red polyp (Figure 2) were resected endoscopically. Histological examination of the pale pink polyp revealed fundic gland mucosa with cystic, dilated glands, consistent with fundic gland polyp. Histological examination of the large, red polyp revealed elongation and branching of foveolae, characteristic of a hyperplastic polyp, without atypia, (Figure 3). Lansoprazole was discontinued because of suspected association between its use and gastric polyps. Follow-up endoscopy 5 months later revealed fewer and smaller gastric polyps (Figure 4). The anemia had resolved with iron treatment and did not recur.
3 Clinical Outcomes of Mass-Forming Intrahepatic Cholangiocarcinoma: A Case Series of 68 Patients , Feng J, Liang B, Zhao X*, Zhang H, Liu Z and Jiang K
1.1 Background: This study aims to examine the prognostic factors of patients with MF ICC in order to improve the outcomes of ICC. 1.2. Methods: We carried out a retrospective analysis of consecutive patients with MF ICC treated at the Faculty of Hepato-Pancreato-Biliary Surgery of Chinese PLA General Hospital between January 2008 and December 2018. The patients were divided into the resection group and exploration group. 1.3. Results: The 1-, 3-, and 5-year survival rates of the 68 cases in this study were 66.5%, 36.3%, and 9.3%, respectively. Univariate analyses revealed that the survival rates were significantly different according to nodal metastasis (P<0.001), vascular invasion (P<0.001), ascites (P<0.001), group (P<0.001), differentiation (P=0.009), and tumor location (P=0.032). Multivariate analysis demonstrated that ascites (HR=5.6, 95%CI: 1.6-18.9, P=0.006) and vascular invasion (HR=2.5, 95%CI: 1.0-6.1, P=0.045) were independent risk factors affecting the prognosis of the patients. Among patients who underwent surgical resection, the 1-, 3-, and 5-year survival rates of the 49 cases were 93.5%, 49.7%, and 14.4%, respectively. Univariate analyses showed that vascular invasion (P<0.001), nodal metastasis (P=0.001), and tumor size (P=0.044) were associated with survival. While vascular invasion (HR=3.1, 95% CI: 1.2-8.5, P=0.024) and nodal metastasis (HR=3.2, 95% CI: 1.4-7.6, P=0.008) were independently associated with survival. The 1-, 3-, and 5-year survival rates of the 19 cases in exploration group were 5.3%, 5.3%, and 0.0%, respectively. 1.4. Conclusions: The prognosis of MF ICC was poor for patients with ascites or vascular invasion. Surgical resection is a key factor in improving survival. Vascular invasion and nodal metastasis affected the efficacy of surgical resection of MF ICC
4 Predictive Factors of Decompensation and Death in 670 Patients with Hepatitis C Treated with Direct-Acting Antivirals , Gualano G1 , Ameigeiras B2 , Ferreiro M3 , MuNoz A4 , Artola YM5 , SilviaBorzi S6 , Blanco M7 , Isla R8 , Salgado P9 , Reggiardo MV10, Adrover R11, Fernandez G12, Sixto M13, Botto G14, Ratusnu N15, Barreyro F16, Chao S17, Sirotinsky E18, Alonso MI2 , Ballerga EG3 , Romero G4 , Garcia D5 , Bessone F10, Fassio E1* and Grupo Argentino para el Estudio y Tratamiento de la Hepatitis C (GAETHeC)
Sustained virological response 12 weeks after treatment (SVR12) with direct-acting antivirals (DAAs) is excellent in patients with hepatitis C but little has been published regarding decompensation and/ or death during therapy. 1.1. Objectives: Objectives of this prospective, observational, multicenter study were to describe SVR12 in real life patients with advanced fibrosis/cirrhosis treated with DAAs and to analyze variables associated with hepatic decompensation and death. 1.2. Methods: we enrolled 670 patients (384 males), median age 57 years; 64% had cirrhosis; genotypes 1, 2, 3 and 4 in 505, 70, 81 and 13 patients, respectively. Main DAA regimens prescribed were sofos- 1 buvir (SFV) + daclatasvir ± ribavirin in 473 patients; paritaprevir/r + ombitasvir + dasabuvir ± ribavirin in 105; SFV + ribavirin in 24; SFV/ledipasvir ± ribavirin in 39; and elbasvir/grazoprevir in 17. 1.3. Results: SVR12 rate was 95.5%. Decompensation was observed in 39 (5.8%) patients, death in 11 (1.6%). Variables significantly associated with decompensation or deaths were similar: cirrhosis stage, bilirubin, prothrombin activity, MELD or Child-Pugh scores. ROC curve analysis showed that MELD score ≥10 (HR 5.1, 95% CI, 1.9- 13.6) and Child-Pugh score ≥7 (HR 4.6, 95% CI, 2.1-10.1) were predictive of decompensation and/or death. 1.4. Conclusion: DAAs were effective and safe in patients with compensated cirrhosis but further studies in decompensated cirrhosis are needed to better delineate the MELD and/or Child-Pugh scores that ensure a good safety profile or being appropriate for indicating liver transplant instead of antiviral therapy
5 Assessment of Muscle and Fat Mass in Type 2 Diabetes Patients By Dual-Energy X-Ray Absorptiometry , Misnikova IV, Kovaleva YA, Polyakova EY and Vasilyevich DA
1.1. Background: The aim of this study was to assess the quantitative composition of muscle and adipose tissue in type 2 diabetes mellitus (T2DM) patients on the basis of dual-energy X-ray absorptiometry for the diagnosis of obesity and sarcopenia. 1.2. Methods: Dual-energy X-ray absorptiometry was administered to 50 patients with T2DM. Evaluation of the composition of muscle and adipose tissue was performed. 1.3. Results: The median of Appendicular Lean Mass Index (ALMI) in the general group was 8.04 [7.32; 8.97]. In general, there was a decrease in the appendicular muscle mass with increasing age. According to the results of T-score ALMI and Z-score ALMI, we did not identify patients with sarcopenia. However, the calculation of the T- and Z-criteria, adjusted for fat mass, led to a significant decrease of these parameters and in 98.0% it was possible to identify patients who meet the criteria of sarcopenia. 1.4. Conclusion: We did not detect patients with sarcopenia on the basis of ALMI, T-ALMI. After revision of these criteria for fat mass, almost all patients started to meet the criteria of sarcopenia (98.0%).
6 Pneumobilia , Fekaj E
A 71-year-old man presented to the emergency department with a seven-day history of intermittent fever, middle and right upper abdominal pain, and general malaise. The physical examination of the abdomen was normal. Ten years ago he underwent open cholecystectomy and stone removal from common bile duct by endoscopic retrograde cholangiopancreatography (ERCP). At the admission leukocytes were 13.4 x 10³/µL (normal value: 4.0- 10.0 x10³/µL), erythrocyte sedimentation was 66 mm/h (normal value: 0- 20 mm/h), C-reactive protein was 65.3 mg/L (normal value: > 6 mg/L). The others parameters were normal. A plain radiograph of the abdomen showed presence of air in the biliary system (Figure 1 and 2): negative view of plain radiograph), and a magnetic resonance imaging showed an abscess in the left lobe of the liver (Figure 3) and presence of air in the biliary tree (Figure 4). Choledocho-duodenal fistula was shown by ERCP. The presence of air in the biliary tree is common finding in patients after biliary surgery, endoscopic biliary procedure, or in a spontaneous biliary-enteric fistula. Biliary-enteric fistula may be accompanied by liver abscess. Initially, the patient was treated with imipenem/cilastatin. Five days after admission liver abscess was treated by open surgery. From liver abscess was isolated Enterobacter spp. Choledocho-duodenal fistula was treated conservatively
7 An Adult Acute Epiglottis Case Diagnosed During Upper Gastrointestinal Endoscopy and Possibly Related to Hookah Smoking , Kurt R and Akin H
Acute epiglottitis has the potential to cause sudden, complete airway obstruction. It is a medical emergency that requires rapid diagnosis and careful management of the airway. Although infrequent in adult patient group, if overlooked, it has the potential for the worse outcomes. We present a case of acute epiglottitis which in the routine daily practice, an adult gastroenterologist may rarely encounter to, probably in a very risky clinical scene.
8 Hepatitis B Virus X Protein and Hepatitis C Virus Core Protein Cooperate to Inhibit P16 Expression Via DNA Methylation , Han J and Jang KL
1. Abstract Coinfection with hepatitis B virus (HBV) and hepatitis C virus (HCV) is often associated with a higher risk of hepatocellular carcinoma (HCC). Here, we found that HBV X protein (HBx) and HCV core protein cooperate to inhibit p16 expression via DNA methylation in human hepatoma cells. For this purpose, they additively upregulated both protein levels and enzyme activities of DNA methyltransferases (DNMTs) 1, 3a and 3b and induced promoter hypermethylation of p16. As a result, HBx and HCV core protein in combination activated the Rb-E2F pathway to stimulate cell cycle progression from G1 to S phase, resulting in an increase in cell proliferation. The potential of HBx and HCV core protein to cooperatively induce these effects was reproduced in an in vitro HBV and HCV coinfection system but was almost completely abolished when p16 levels were restored by either 5-Aza-2’dC treatment or p16 overexpression, providing an insight on the coinfection-associated higher risk of HCC development.
9 Proximal Esophageal Anchored Stent: A Successful Endoscopic Approach in A “Troublesome” Location , Granata A1 , Amata M1*, Monte LD2 , Ligresti D1 , Traina M1 and Bertani A2
A 71-year-old woman was admitted for the surgical treatment of a pulmonary adenocarcinoma of the right upper lobe. During anesthesia induction, a left Robertshaw endotracheal tube (ETT) was inadvertently placed in the esophagus. After successful bronchoscopic ETT repositioning, the patient underwent an uneventful VATS (Video-Assisted Thoracoscopic Surgery) right upper lobectomy and lymphadenectomy. High-flow (>1liter) output of particulate white fluid through the chest tube was noted on first post-operative day (POD). In the suspicion of chylothorax, an exploratory esophagogastroduodenoscopy and VATS were performed and a 4-cm longitudinal tear of the posterior wall of the esophagus was found just below the thoracic inlet. The lesion was repaired with a double layer, interrupted 4-0 polydioxanone suture and the chest drained. On POD#7, a barium swallow showed adequate resolution of the fistula. Nevertheless, after initiation of oral intake, the patient developed fever and dysphagia. Endoscopy showed a minimal, 2-mm residual esophageal dehiscence located 2 cm under the cricopharyngeal sphincter, and a CT-scan (Figure 1) showed a residual upper mediastinal collection. Immediate endoscopic clipping of the fistula was attempted but failed due to inadequate margin apposition.
10 Immune Profile of Severe Refractory Crohn’s Disease Patients Candidates to Autologous Hematopoietic Stem Cell Transplantation , Bueno V, Ruiz MA and Burt RK
Crohn's disease is a chronic relapse - remitting inflammatory bowel disease with a wide range of incapacitating symptoms, and significant health care costs. The complex pathophysiology of Crohn's disease is not always solved by conventional and biologic therapies and thus, some patients evolve with severe refractory disease. T and B cells reacting to luminal antigens have been linked to the chronic intestinal inflammation. Our aim was to determine the immune profile of Crohn’s disease patients, candidates to autologous hematopoietic stem cell transplantation in order to predict the response to this therapy and in turn lead to a personalized therapy with cost-effective benefits. Peripheral blood mononuclear cells were phenotyped for T (CD4 and CD8), and Myeloid-derived suppressor cells from eight patients (5 males and 3 females), average age of 28 years and disease duration from one to eighteen years, and healthy controls (5 males and 5 females, 20 to 30 years old). It was observed increased percentage of CD8+ T cells and decreased percentage of CD4+ T cells, with reduced CD4/CD8 ratio. Patients presented reduced percentage of Naive T cells (CD4+ and CD8+) and increased percentage of Effector Memory T cells (CD4+ and CD8+) suggesting a prominent inflammatory process. Myeloid-derived suppressor cells were significantly higher in Crohn's disease patients. The immune profile previously to hematopoietic stem cell transplantation and the longitudinal analysis post-transplant may lead to a further understanding of Crohn's disease pathogenesis, mechanism(s) of remission, cause(s) for relapse, and approaches to improve long-term treatment-free remission. 2. Introduction Crohn’s Disease (CD) is a chronic relapse - remitting inflammatory bowel disease that can affect any site of the digestive tract [1]. The incidence and prevalence of CD has increased worldwide [2]. Symptoms include abdominal pain, diarrhea, hematochezia, bloody stools, fatigue, weight loss, fever, recurrent fistulas and manifestations in other organs [3]. Extraintestinal manifestations comprise arthropathy (both axial and peripheral), ocular involvement (uveitis, scleritis, and episcleritis), dermatological (including pyoderma gangrenosum and erythema nodosum), nephrolithiasis, hepatobiliary involvement (primary sclerosing cholangitis), cholelitiasis, venous or arterial thromboembolism, and other immune-mediated disease [4]. Even though there exists heterogeneity in the affected patients, the common pathophysiology is immune dysregulation. The intestinal mucosa manifests inappropriate immune responses against resident intestinal flora or its antigens that in turn leads to tissue lesions and symptoms. This disturbance in the intestinal mucosa occurs when genetically predisposed patients are exposed to environmental triggers [5]. Cells from the innate and adaptive immune system have been shown to play a role in CD. Macrophages and T cells can produce TNF-α (tumor necrosis factor) and thus contribute for the inflammatory process and intestinal lesions [6]. Colon samples show that resident Memory CD4+ T cells (TRM) are the most abundant cell population 1 and main mucosal source of TNF during CD. In addition, a unique population of CD4+ T cells producing TNF-α and IL-17A was observed in CD patients but not in healthy controls [7].
11 Immune Profile of Severe Refractory Crohn’s Disease Patients Candidates to Autologous Hematopoietic Stem Cell Transplantation , Bueno V, Ruiz MA and Burt RK
Crohn's disease is a chronic relapse - remitting inflammatory bowel disease with a wide range of incapacitating symptoms, and significant health care costs. The complex pathophysiology of Crohn's disease is not always solved by conventional and biologic therapies and thus, some patients evolve with severe refractory disease. T and B cells reacting to luminal antigens have been linked to the chronic intestinal inflammation. Our aim was to determine the immune profile of Crohn’s disease patients, candidates to autologous hematopoietic stem cell transplantation in order to predict the response to this therapy and in turn lead to a personalized therapy with cost-effective benefits. Peripheral blood mononuclear cells were phenotyped for T (CD4 and CD8), and Myeloid-derived suppressor cells from eight patients (5 males and 3 females), average age of 28 years and disease duration from one to eighteen years, and healthy controls (5 males and 5 females, 20 to 30 years old). It was observed increased percentage of CD8+ T cells and decreased percentage of CD4+ T cells, with reduced CD4/CD8 ratio. Patients presented reduced percentage of Naive T cells (CD4+ and CD8+) and increased percentage of Effector Memory T cells (CD4+ and CD8+) suggesting a prominent inflammatory process. Myeloid-derived suppressor cells were significantly higher in Crohn's disease patients. The immune profile previously to hematopoietic stem cell transplantation and the longitudinal analysis post-transplant may lead to a further understanding of Crohn's disease pathogenesis, mechanism(s) of remission, cause(s) for relapse, and approaches to improve long-term treatment-free remission. 2. Introduction Crohn’s Disease (CD) is a chronic relapse - remitting inflammatory bowel disease that can affect any site of the digestive tract [1]. The incidence and prevalence of CD has increased worldwide [2]. Symptoms include abdominal pain, diarrhea, hematochezia, bloody stools, fatigue, weight loss, fever, recurrent fistulas and manifestations in other organs [3]. Extraintestinal manifestations comprise arthropathy (both axial and peripheral), ocular involvement (uveitis, scleritis, and episcleritis), dermatological (including pyoderma gangrenosum and erythema nodosum), nephrolithiasis, hepatobiliary involvement (primary sclerosing cholangitis), cholelitiasis, venous or arterial thromboembolism, and other immune-mediated disease [4]. Even though there exists heterogeneity in the affected patients, the common pathophysiology is immune dysregulation. The intestinal mucosa manifests inappropriate immune responses against resident intestinal flora or its antigens that in turn leads to tissue lesions and symptoms. This disturbance in the intestinal mucosa occurs when genetically predisposed patients are exposed to environmental triggers [5]. Cells from the innate and adaptive immune system have been shown to play a role in CD. Macrophages and T cells can produce TNF-α (tumor necrosis factor) and thus contribute for the inflammatory process and intestinal lesions [6]. Colon samples show that resident Memory CD4+ T cells (TRM) are the most abundant cell population 1 and main mucosal source of TNF during CD. In addition, a unique population of CD4+ T cells producing TNF-α and IL-17A was observed in CD patients but not in healthy controls [7].
12 Synchronous Colitis Induced by Hot Water Enema-An Easily Missed Etiology for Colitis in Modern Days , Hsu TC1,2,3*, Sun WC1 , Chen MJ3 , Lin WC4 and Wang HY4
1. Abstract 1.1. Background: Colitis caused by hot water was not seen frequently in the past, however, in recent times it is increasingly seen in the clinic. Colitis caused by hot water might be associated with complications such as rectal burn, permanent rectal stricture and bowel perforation, and even death [1]. 1.2. Aims: Colitis caused by hot water might be misdiagnosed as other type specific or non-specific colitis by general practitioners or even by specialists. It is essential to differentiate colitis caused by hot water with other types of colitis or malignancies. 1.3. Design: February 2016 to August 2017, patients presented with colitis caused by hot water enema in the past one and a half years were analyzed. Settings: The study last for a one and a half year and was performed in the medical record room and colorectal surgical department. Twelve patients presented with colitis caused by hot water enema from February 2016 to August 2017. 1.4. Patients: There were nine males and three females. Their Ages ranged from 18 to 72 years old, with an average age of 35.9 years old. Three patients reported that they were MSM. Two patients had colectomy for carcinoma of rectum. Two patients were admitted to the hospital due to severe anemia and required blood transfusion. The cause of colitis in these patient with thermal injury might be due to application of hot water enema for sanitation or application of hot coffee enema as an alternative medicine for treatment of constipation. Twelve patients presented with colitis caused by hot water enema in the past one and a half years. There were nine males and three females. Their Ages ranged from 18 to 72 years old, with an average age of 35.9 years old. Three patients reported that they were MSM. Two patients had colectomy for carcinoma of rectum. Two patients were admitted to the hospital due to severe anemia and required blood transfusion. The cause of colitis in these patient with thermal injury might be due to application of hot water enema for sanitation or application of hot coffee enema as an alternative medicine for treatment of constipation. 1.5. Interventions(s): Endoscopy for diagnosis of colitis. 1.6. Main Outcome Measures: Diagnosis were made from history taking, physical examination, endoscopy finding and pathology report. 1.7. Materials and Methods: Twelve patients presented with colitis caused by hot water enema in the past one and a half years. There were nine males and three females. Their Ages ranged from 18 to 72 years old, with an average age of 35.9 years old. Three patients reported that they were men who have sex with men (MSM). Two patients had colectomy for carcinoma of rectum. The cause of colitis in these patients with thermal injury might be due to application of hot water enema for sanitation or application of hot coffee enema as 1 an alternative medicine for treatment of constipation. 1.8. Results: Chief complaints of the patients were rectal bleeding, rectal mucous discharge, or tenesmus. Endoscopy findings were non-specific. Pathology reports were also either non-specific inflammation or granulation. At least five patients were seen by a board certified gastroenterologist or colorectal surgeon prior to been seen by authors for correct diagnosis. All of the patients had control of their colitis after stopping hot water enema. 1.9. Limitations: It is a restrospective study and difficult to reflect the true incidence of colitis induced by hot water in the population. 1.10. Conclusion: Scalding injury by hot water is not a commonly seen disease but might increase in modern days due to herbal remedies used by holistic practitioners. Maladjustment and malfunction of electronic bidet might increase chance of scalding injury. Early diagnosis and appropriate management is essential for patient's outcome [2].
13 Menghini Needles are Superior to Tru-Cut Needles for Blind Percutaneous Liver Biopsy in Children , Velmishi V, Bali D , Cekodhima G , Sila S1 and Cullufi P
1. Abstract 1.1. Background: Liver biopsy remains the criterion standard in the evaluation of the etiology and extent of disease of the liver. Various needles are available for use, depending on the approach and on physician experience. 1.2. Methods: We used in our service for three years Menghini needles and the last year Tru- cut needle and we compared the data. 1.3. Results: Of 34 patients in the first group (Menghini needle) we had 28 appropriate specimen and 6 patients had inadequate specimen. We had only two procedures which failed but the next was successful. In the second group (Tru-cut needle) of 14 patients we had 4 patients with adequate specimen and 10 patients with inadequate specimen. We have repeated the procedure in 6 patients 1.4. Conclusions: In our experience Menghini needles are more efficacious for obtaining liver biopsy specimen and failure of procedure is very rare. In both groups the complications has not a significative difference.
14 Chicken Bone Perforation of Duodenum , Wani AA , Bari S, Shafi A and Mir MF
1. Abstract Ingestion of foreign bodies is a common clinical problem encountered commonly in children and elderly people wearing dentures. It is rarely seen in adults. Complications due to ingested bone fragments are not common and preoperative diagnosis remains a challenge. We report a successful endoscopic management of a chicken bone piece which was perforating the duodenum. This case illustrates the importance of early diagnosis of foreign body and emphasizes the role of therapeutic endoscopy.
15 Resection of Fourth Segment of Liver as a Cause of Hepatoblastoma in A 8 MonthOld-Boy , Velmishi V1*, Bali D2 and Alushani D3
We would like to present the case of an 8 month –old –boy who is diagnosed with Hepatoblastoma. He underwent to chemotherapy earlier which reduced tumor size localized in fourth segment of liver (Figure A) Last procedure was tumor resection performed successfully by our surgery team (Figure B, C)
16 Unexpected Esophageal Mucosal Defects After Peroral Endoscopic Myotomy (POEM) , Pittayanon R1*, Ramchandani M2 and Rerknimitr R1
Peroral endoscopic myotomy (POEM) is a promising treatment for achalasia cardia that requiring submucosal tunneling [1]. The important concept to prevent its complication is to stay away from the mucosa during making the tunnel. Although, pneumoperitoneum or pneumomediastinum was developed from the defect at longitudinal muscle layer, there is no clinical significance if the mucosal flap remains intact [1, 2]. However, if the mucosal defect occurs, tight mucosal closure with clips is recommended to avoid leakage of esophageal content into the mediastinum [2].
17 Intraductal Papillary Neoplasia of the Bile Ducts (IPN-B): About a Case , Zatir S*, Ouguerti N, Arbouz M, Bouchakour S, Laouisset S, kroumli B, Abdellaoui K, Belkherour A, allam A and larkaam T
1. Abstract Intraductal papillary neoplasia of the bile ducts (IPN-B) is a rare intracanal tumor characterized by papillary proliferation of the biliary epithelium responsible for more or less abundant production of mucus, causing dilation of the duct [1]. IPN-B is the "biliary" equivalent of TIPMP. MRI cholangiography and transcutaneous abdominal ultrasound are the best examinations to suggest the diagnosis in the presence of a cystic lesion of the biliary tree associated with dilation of the downstream duct [2, 3]. The distribution of histological forms is different with a predominance of gastric forms in TIPMP and pancreatobiliary forms in IPN-B explaining a much better prognosis of TIPMP, surgical treatment is the gold standard given the high risk of malignancy. we discuss a case of a 60-year-old patient operated on for IPN-B who underwent duodenpancreaticocephalus.
18 Changes in Metabolic Processes in The Gastric Mucosa in The Pathogenesis of the Formation of Acute Ulcers in Acute Small Intestinal Obstruction , Yefimovich MV1 , Cuong NC3 , Murshud Kizi SMK1 , Oglu SER2 and Khoi NA
1. Abstract 1.1. Introduction: Acute small bowel obstruction is a problem of modern surgery. It is not possible to study morphological and functional changes in the walls of the stomach in acute small bowel obstruction on clinical material, performing a biopsy in the dynamics of the development of the disease. Therefore, our work is experimental. 1.2. Methods: 2 intact dogs served as control. In 12 animals (the second group), a strangulation of small bowel obstruction was simulated with a period of 3, 6, 12 and 24 hours. In 12 animals (the third group), obstructive small bowel obstruction was simulated for 3, 6, 12, and 24 hours. The preparations are stained according to Einarson to obtain DNA. 1.3. Results: In the antrum of the stomach, the level of nucleoproteins in the epithelial cells of the mucous membrane after 1 day from the creation of a model of acute 5.2 times, after 2 days - 2.2 times, after 3 days decreased 1.45 times, and after 6 days - 7.28 times when compared with the norm. In the main cells of the glands after 1 day it increased 2.64 times, after 2 days - 1.44 times, after 3 days - 2 times, and after 6 days - 3 times. 1.4. Conclusions: The most pronounced morphofunctional changes in the gastric mucosa, progressing in the dynamics of the disease, both when modeling acute strangulation and acute obstructive small intestinal obstruction are observed in its antrum, which explains the most frequent localization of acute ulcers in this part of the stomach
19 Quantum Nature of Coronavirus and Method of Treatment ,  Adamski A*
1. Abstract Work on the coronavirus is trying to produce vaccines of various types. Those are vaccines containing inactivated or killed viruses, vaccines with viral fragments, which are intended to sensitize the immune system to specific virus subunits. Vaccines based on RNA or DNA nucleic acids, which contain a synthesized stretch of viral mRNA. The author is developing a quantum informational vaccine for the treatment of coronavirus. The next generation vaccine will inject information into the body, the purpose of which will be to “trick” the body into thinking that it has a virus in it and, as a result, will produce antibodies. It is possible thanks to the control of quantum-information processes, e.g. by means of an electromagnetic wave, soliton wave, electric field, acoustic wave, spin wave or bioplasm. Melanin is to play a significant role in this, as a free radical is capable of creating quantum states of entangled particles, atoms, or entire information structures. Melanin directs the reduction of free radicals in the biological system, it has the ability to accelerate or delay the movement of photons, phonons and solitons and their spins. It acts as a converter of photons into phonons and the reverse process, which enriches the nerve cell with a wide range of information acquisition and its use in its functional and structural process.
20 Infective Suppurative Thrombosis in the Left Portal Vein After Acute Appendicitis , Nunez AD* , Alvarez JMS, Morales AL and Herrera JCP
1. Clinical Case Postoperative complications can occur. Most of them are frequent and we are used to dealing with them, but there are others that seem to appear only in a few posts, and when they happen to your patient you cannot explain why. In our case, it is a young patient with no relevant medical history except for taking oral contraceptives. She attended the Emergency Department presenting pain in the right iliac fossa over the last 24 hours. She was diagnosed with incipient acute appendicitis without sepsis criteria and an emergency intervention with laparoscopic approach was performed without incident. Due to her good evolution, she was discharged home after 24 hours with oral antibiotics and antithrombotic prophylaxis (Figure 1).
21 Helicobacter Pylori Detection Among Sudanese Patients Diagnosed with Conlon Polyps and Colon Cancer Using Immunohistochemistry Technique , Awhag ZA1*, Mohamed AK1 , Suliman NME1 , Ali FS1 , Ali ET1, 2, Siddig EE3,4, Mohamed NS5, 6, 7 and Edris AMM1, 8
1. Abstract \ 1.1. Purpose: H. pylori has been classified as class 1 carcinogen, this pathogen was reported to be associated with the gastritis and gastric carcinoma, also in recent year the researchers start to study the role of H. pylori in colorectal cancer. Therefore; the aim of the current study is to evaluate the presence of H pylori in different lesions including colon polyps and colon cancer. 1.2. Methods: between February-May 2017; sixty-nine Formalin fixed paraffin blocks from different colon lesions were collected, and each one was stained using Immunohistochemistry marker for the detection of H pylori. 1.3. Results: Of the 69 patients there were 30 (43.5%) females and 39 (56.5%) males their ages ranged from 21 to 80 years with mean age 47.12 ± 19.79. Of the 69 cases, 44 (63.8%) were diagnosed with adenocarcinoma, 10 (14.5%) colitis, 15 (21.7%) juvenile polyposis syndrome. Out of the 69 patients, 16 (23.18%) patients were positive for H. pylori infection. 13 (81.3%) patients were diagnosed with adenocarcinoma and 3 (18.7%) patients were diagnosed with juvenile polyps and the results were statistically significant (0.028). 1.4. Conclusion: This study has demonstrated the presence of H. pylori in colon polyps and colon cancer by IHC methods, albeit with a statistical significance results. Our findings suggest a positive correlation between colon polyps and cancer and H. pylori.
22 Acute Peritonitis Generalized by Typhoid Perforation at Kankan Regional Hospital , Naby CS1*, Mampan KA2 , Djoulde DA2 , Togba SL3 , Mohamed C1 , Oumar S1 , Mariame C4 , Adama K5 , Makhissa BA6 , Lamine SM7 , Elisa T7 , Tady K7 , Aboubacar T3 and Taran DA3
1. Abstract 1.1. Aim: The aim of this study is to make our contribution to the study of acute generalized peritonitis of typhus origin at the Kankan Regional Hospital. Typhoid perforation is defined as the opening of a hollow viscus in the abdominal cavity due to salmonella. 1.2. Methodology: We carried out a 6-month prospective study from June 1, 2019 to November 30, 2019 inclusive. Were included in our study, all the patients operated on for peritonitis by typhoid perforation and hospitalized in the department and in whom the diagnosis of typhus perforation was made intraoperatively and confirmed by the positivity of Widal and Félix in the department during the study period. Any patient operated on for non-typhus peritonitis was not included in the study. All patients diagnosed with typhoid perforation but who died before surgery. Results during our study period we had 423 patients of whom 8 percent developed peritonitis from typhoid perforation. The study involved 21 men and 12 women, for a sex ratio of 1.75, which showed a clear predominance of the affection of men. The history of gastroenteritis was noted in 45.45 percent of our patients, typhoid fever in 36.36 percent, malaria in 18.18 percent, arterial hypertension in 12.12 percent and parasitosis in 9.09 percent. However, perforations were single in 19 patients, double in 9 patients and multiple in 5 patients. The treatment was medico-surgical, the operative consequences were simple in 33 percent and complicated in 67 percent. Unfortunately, we had recorded 5 cases of death against 28 cases of cure. 1.3. Conclusion: Acute generalized peritonitis represents frequent 1 tropical pathologies, the management is medico-surgical (Table 1).
23 MEFV Gene Mutations and Pathologic Gene Polymorphism in Cases with Inflammatory Bowel Diseases , Tumgor G* , Agin M and Bisgin A
1. Editorial 1.1. The Genetic Characteristics of Inflammatory Bowel Diseases and Familial Mediterranean Fever Inflammatory bowel diseases (IBD) are chronic, repetitive diseases caused by regulation defects of the mucosal immune response, which increases against the bacterial antigens in the bowel lumen of patients with genetic susceptibility [1]. In 2001 it was determined that NOD/Caspase recruitment domain (CARD) 15 is a Crohn’s Disease (CD) gene localized on chromosome 16 and encodes the NOD2/CARD15 protein. This gene is responsible for the natural immune response and transcription factor nuclear factor kß (NFkß) activation in apoptosis. One-third of CD patients are NOD2/CARD15 gene mutation carriers [2]. Ulcerative Colitis (UC) is more common in families that have individuals with UC and in specific ethnicities, such as Jewish. This indicates that the disease has a genetic basis [3]. Although more than 30 IBD-related genes have been determined, the roles of these genes are not completely described. Pyrin and NOD2/CARD15 proteins are structurally similar and have a key role in apoptosis regulation, cytokine processing, and inflammation [4]. Familial Mediterranean Fever (FMF) is the prototype inflammatory clinical syndrome and is characterized by joint, chest, and abdominal pain. The pyrin protein, which is also known as marenostrin, is encoded by the MEFV gene. Experiments performed using animal models and cell lines as well as the presumed structure of pyrin and the presence of certain protein domains suggests that the wild type of the protein has anti-inflammatory properties [5]. Pyrin functions via its CARD domain. Mutations in the MEFV gene are responsible for diseases of innate immunity and associated with activation of the IL-1β pathway, allowing an uninterrupted inflammatory cascade and resulting in attacks of severe inflammation [6].
24 Colon Versus Rectal Cancers among Surgical Approach: An Observational Study , Mohamed WM1 , Al-Ani UFT1*, Hamdi MA1 and Alshewered AS2
1. Abstract 1.1. Background: Colorectal cancer is the most common tumor of the gastrointestinal tract, and it is the third leading cause of mortality throughout the world. 1.2. Objectives: An observational study of colorectal cancers. 1.3. Methods: The research was carried out in Abu Ghraib General hospital in the period from January 2019 to May 2019. The primary data reported included colorectal cancer, and patients study characterizes. These including gender, age, family history, smoking, comorbidity, IBD, tumor sites, histopathology, stages, grading, the distance for anal verge, local recurrence, distant metastasis, type of surgery, and chemoradiation. 1.4. Results: The gender was composed of male 40%, and female 60%, with mean age, was 44.89±21.6 years for males and 47.55±20.07 years for females. There was only 4% had a positive family history. Smoking patients in this study were 48%, yet the non-smoker patients were 52%. Rectosigmoid cancer represented the most common site of cancer figured in 40% of patients. The results showed that adenocarcinoma was the most common histopathology in 72% of patients. The localized tumors were recorded in 44%, whereas metastasis was found in 34% of patients. Regarding grading, the moderate differentiation was the dominant grade in 60%. The tumor distant from anal verge results exhibited as <5 cm in 7(14%), 5-10 cm in 30(60%), and >10 cm in 13(26%). The majority of patients in our study have no metastatic disease 66%. Indeed, the hepatic was the most frequent site of distant metastasis. All patients underwent different surgical procedures. 1.5. Conclusions: Middle age group was mostly effect and more in the female gender. Many factors are shown to increase the risk of developing colorectal cancer including increasing age; consumption of processed meat, and smoking. Rectosigmoid cancer represented the most current sites. The localized diseases were common. Moderate differentiation was the dominant grade. The tumor location and the distal tumor margin are essential factors upon which the surgical plan for patients with rectal cancer is based. Accurate measurement of the distal tumor margin is necessary for planning the surgical procedure. The liver was the most frequent site of distant metastasis that figured.
25 Use of New Rechargeable Battery and MRI-Friendly Technologies in Sacral Neuromodulation Systems to Treat Fecal Incontinence , Kim J1 , Csuka D1 and Ghoniem G1*
1. Abstract Sacral neuromodulation (SNM) is a minimally invasive therapeutic technique that has been used to effectively treat overactive bladder and bowel dysfunction. There have been, however, several obstacles with standard, non-rechargeable SNM devices such as frequent battery replacement and complications with the conditional safety for full-body Magnetic Resonance Imaging (MRI). Recently, rechargeable and MRI-friendly technologies have been introduced into SNM devices to be used in the treatment of fecal incontinence. Though rechargeable batteries have been utilized recently for treating overactive bladder and urinary dysfunction, the implementation of these new technologies into the treatment of bowel or fecal incontinence is still an emerging topic. Despite its relatively new appearance to the field, previous reports indicate that the implementation of rechargeable batteries and MRI-friendly technologies in SNM systems could provide a wide range of benefits to patients with fecal incontinence. This mini review is based on recently conducted experimental studies and will assess the benefits and limitations that new technologies in sacral neuromodulation impose in treating fecal incontinence.
26 Synchronous Triple Colorectal Cancer with Intestinal Obstruction in an Elderly Patient: Rare Case of Malignancy of the Large Intestine , Gambardella D1*, Stelitano S1 , Borrello L2 , Caruso MT3 , De Caridi A4 , Maschio V4 , Loria F4 and Tedesco M2
1. Clinical Image Synchronous cancers are characterized by the simultaneous occurrence of multiple primary tumors in the same patient. Synchronous malignancies most commonly occur in the colon, with a high prevalence in elderly patients [1,2]. The occurrence of synchronous colorectal cancers is extremely rare and may be identified at any location within the large intestine [3]. Synchronous cancers are relatively uncommon, and triple synchronous colon cancers are particularly rare. At present, radical surgery is considered the standard curative treatment; however, individualized surgical strategies depend on tumor location, the depth of invasion and the general health of the patient. We present the case of a 85-year-old man with an history of alzheimer, BPCO and 2-month history of abdominal pain that was accompanied by intermittent hematochezia and weight loss. The patient had no family history of cancer. He was admitted to our surgical department with symptoms of intestinal obstruction: distended, painful abdomen and fecaloid vomiting. Computed Tomography (CT) of the abdomen revealed intestinal wall thickness in the colon, a suspicious mass of the cecum that attracts the sigmoid colon. The first tumor was located in the cecum, the second tumor was located in the sigmoid colon. Subsequently we planned to perform a subtotal colectomy with colocololic anasotomosis to remove the two lesions, but intraoperatively we discovered the presence of a third tumor located in the rectum about 8 cm from the anal verge. The patient therefore underwent a subtotal colectomy with colorectal anastomosis
27 Spectrum of Acute Hepatitis B at Tertiary Care Center of Northeren India , Malhotra P*, Malhotra V, Nanda S, Gupta U, Gill PS and Sanwariya Y
1. Abstract 1.1. Introduction: Hepatitis is often a viral infection and Hepatitis B Virus (HBV) is reason in significant proportion of cases worldwide. Hepatitis B virus impact on liver can be of varying severity ranging from acute hepatitis to chronic hepatitis which can further lead to chronic liver disease, liver cirrhosis and hepatocellular carcinoma (HCC). There is very limited study on Acute Hepatitis B which are needed to understand its epidemiology and to create strategies to improve public health which may help in the disease prevention and control. 1.2. Aims and objectives: The aim was to study Clinico-epidemiological profile in patients having acute infection of hepatitis B virus and to assess the various risk factors, age & sex distribution and geographic foci of the disease, if any. 1.3. Materials & Methods: It was an epidemiology based, prospective study conducted at Medical Gastroenterology Department, PGIMS, Rohtak over a period of three years. Four hundred and nine (409) patients who were found to be having features of acute hepatitis and confirmed to be positive for HbsAg on Enzyme linked Immunoassay test (ELISA) and HBV DNA on PCR testing were enrolled in the study.
28 Role of Serum Nitric Oxide in Prediction of Hepatocellular Carcinoma in Hepatitis C Patients Treated with Direct - Acting Antiviral Agents , Basha OM1 , Elsadek HM1 , Shokry MM2 , Elsaid HH3 and Farag AA1*
1. Abstract 1.1. Background: Hepatocellular Carcinoma (HCC) is the 6th most common malignancy globally and it’s the most common tumor which originates primarily in the liver, the aim of this study is to find out the connection between increased serum nitric oxide (sNO) and its HCC predictive value in patients who received direct-acting antiviral agents (DAAs). 1.2. Methods: In this study we randomized 72 patients with chronic hepatitis C virus (HCV) infection who were attempted to be treated with sofosbuvir (SOF) / daclatasvir (DAC) ± Ribavirin for 12 weeks and we assessed sNO level before and after treatment. 1.3. Results: Among chronic hepatitis C (CHC) patients who received DAAs therapy, HCC developed in significantly higher frequency among cirrhotic patients with advanced disease (28.6%) than those with early cirrhosis (23.1%), and never in non-cirrhotic patients (p<0.001). There was a significant value of sNO in the diagnosis of HCC, especially regarding its post treatment level. At a cut-off ≥ 361.24 μmol/l, post treatment level of sNO had a sensitivity of 100%, specificity of 100%, positive predictive value of 100% and negative predictive value of 100% with an accuracy of 100% (P<0.001). 1.4. Conclusion: sNO level increases significantly after DAAs therapy in advanced cirrhosis, and this increase is significantly associated with the development of HCC.
29 Oropharyngeal Transition during Swallowing between Stroke and Head and Neck Cancer Survivors , Deckelman C1 , Kim Y1* and Park T2
1. Abstract 1.1. Objective: The purpose of this study was to analyze three oropharyngeal bolus transition timings, Oral Transition Time (OTT), Pharyngeal Transition Time (PTT), and Duration of Upper Esophageal Sphincter Opening (DUESO), using videofluoroscopic swallowing examinations (VFSEs) between stroke survivors and head and neck cancer survivors to determine differences between the two populations. 1.2. Methods: Means and standard deviations of OTT, PTT, and DUESO were determined from analyzing two 5ml thin liquid swallows exhibited by each of the 15 stroke survivors and 15 head and neck cancer survivors from the VFSEs. Statistical analyses were made using one-way analysis of variance (ANOVA) using the two groups with the statistical level set at p < .05. 1.3. Results: OTT was longer in head and neck cancer survivors compared to stroke survivors; however, these results were not significant. Stroke survivors exhibited significantly longer PTT and DUESO when compared to head and neck cancer survivors. 1.4. Conclusions: Head and neck cancer survivors have more difficulties in the oral swallowing stage. Stroke survivors have more difficulties in the pharyngeal swallowing stage.
30 Large Bowel Auto-Immune Diseases: Current Recommendation for Surgery , Bagus BI1*, Widyanti S2 , Wibisono3 , Darmawan I4 and Hanis S
1. Abstract There are two clinical features of autoimmune disease in the large intestine that we often find in our clinical practice, including ulcerative colitis and Crohn's Disease. The clinical picture that we need to understand is the change in bowel patterns over the past few weeks. Clinical symptoms that appear need to be diagnosed in comparison with other cases such as internal hemorrhoids, malignancies in the colon and rectum. Establishing a diagnosis in the earliest possible phase is very important in the management of these autoimmune intestines, by conducting a colonoscopy examination accompanied by a biopsy, it is hoped that we can rule out some of the differential diagnoses that may be found in these cases. For treatment, not all cases require operative measures, medical treatment can be expected to provide a good therapeutic response, so that the choice of operative therapy is done in cases that do not respond well after the medical therapy is given
31 Alagille Syndrome: Not Always Hepatic Involvement , Angi A1 , Polidori N1 , Giannini C1, 2 and Mohn A1, 2*
1. Clinical Image We present a 22-month-old girl affected by surgical palliative corrected Tetralogy of Fallot and peculiar facial features characterized by prominent forehead, deep-set eyes, pointed chin and bulbous tip of nose (Figure 1) typical of Alagille Syndrome (AS). Hypoplasia of the distal phalanges of both feet and two butterfly vertebrae at D10-D11 on spine radiography (Figure 2) were found. Liver, kidney and eye structure and function were normal. Genetic analysis discovered a novel missense heterozygote mutation in exon 5 (c.753G>A) of JAG1 gene, confirming AS according to the revised diagnostic criteria [1,2]. proposed by Kamath. In fact one of the classical clinical features (cholestasis, cardiac defect, skeletal abnormalities, ocular abnormalities and characteristic facial features) is enough to make the diagnosis in the presence of a positive genetic test. These new diagnostic criteria reflect the important role of Notch signalling pathway in angiogenesis and AS needs to be considered primarily as a vasculopathy where hepatic involvement not necessarily might be detected.
32 More Than Meets the Eyes - An Unusual Aetiology for Pan-Proctocolitis , Yen D1 , Koh FH1*, Sivarajah SS1 , Lee LA2 , Tan WJ1 , Chew MH1 and Foo FJ1
1. Clinical Presentation A middle-age gentleman, residing in Singapore, presented with altered bowel habits for a 2-week duration, associated with left iliac fossa pain, hematochezia and significant weight loss of 10kg. There was no significant travel history or sick contact preceding the symptoms. Physical examination was unremarkable, except for digital rectal examination which revealed induration in the lower anterior rectum. He underwent a colonoscopic evaluation (Figure 1) and a computed tomography of his thorax, abdomen and pelvis (CTTAP) (Figure 2). Biopsies of the rectal mucosal lesion, noted in Figure 1, was performed (Figure 3 and 4).
33 Quo Vadis Medicina Ex Testimoniis? Part 2. After A Quarter of Century, What Now? Some Questions and Answers , Jenicek M*
Despite being a young domain with a one-generation history or so, evidence-based medicine has benefitted from thousands of contributions, as reflected in numerous book titles and subjects, and original articles. EBM-related philosophical insights are increasing as are endeavours in reasoning, modern argumentation, considerations of causality, and grading of evidence. The scientific method is in focus in most communications including research projects and ensuing medical articles. Quantitative and qualitative methods will further expand across evidence-based methodology and applications. The more the future is obscure, the more promising it may be for some. How promising is evidence-based medicine? The last quarter of century created today’s evidence-based medicine, focused mostly on various beneficial (clinical trials) and noxious effects of various non-clinical and clinical factors on health. Clinical epidemiology and biostatistics methodologically prevail. In addition to this historical experience the ways of thinking, exchanging experience with various interested parties and peers as well as the ways of communicating such experience develop and rightly so. In other terms, we may be asking ourselves if today EBM today isn’t more than the production of high-quality evidence in quantitative and qualitative terms. Yes, it is. But shouldn’t it be more? EBM relies also on high quality, pragmatic reasoning, informal logic, critical thinking, and decision making in the context of modern philosophy
34 Quo Vadis Medicina Ex Testimoniis? Part 1. A Quarter Century after Its Inception, Where is Evidence-Based Medicine (EBM) Today? More Questions than Answers , Jenicek M*
Summary The domain of ‘Evidence-based medicine’ (also known as ‘EBM’) is increasingly ubiquitous across the medical literature and experience. It is just about one generation old and worthy of further refinements. Five related insights are outlined here: • Among others, clinical epidemiology, fundamental and field epidemiology and biostatistics have led to EBM. • EBM is still defined in multiple ways and its objectives are based on these multiple EBM definitions. • Only the meaning of ‘evidence’ and its uses in health sciences and professions have changed. Steps of the EBM practice have simply expanded. • Applications of EBM have also expanded and currently move beyond their essential use in cause-effect relations. EBM is also increasingly dependent on modern critical thinking, argumentation, decision making, and communication while grading of evidence supports the development of clinical guidelines. Scientific method follows such lines of thought. • Evaluation of EBM practice as an activity requires the best possible understanding of its structure, process, impact, efficacy, effectiveness, efficiency, and equity. Such an evaluation is still rare today
35 Clinical Case Reports, Case Series, Clinical Vignettes: Where Are We Today? , Jenicek M*
Summary In the past two or three decades, we have witnessed and built remarkable methodologies not only specific to the growing spectrum of clinical case reporting, but also diversified based on what we are doing, presenting, and evaluating as pertains to our daily experience with clinical cases. Yes, such endeavours are also research. This essay offers some direction on how to further develop and refine the clinical case reporting domain by subject, method, technique, and application.
36 Acronymization of Evidence-Based and Other Medicines. Anything Goes, Or Should It? , Jenicek M
Summary Evidence-Based Medicine is here to stay, and it is expanding, with evolving modifications, new topics, new research and teaching groups, and new recipients of information. Acronyms, as brief and condensed ways to present and understand ideas related to the above-mentioned phenomena, are also increasing in number and some, serious or funny, are worthy of discussion today. Acronyms are becoming almost ubiquitous in the current medical literature. To attract readers and, not to mention, medical research funding, we use catchy words, terms, and formulations to describe phenomena and activities. We try to look and sound attractive, “sexy”. Non-acronym words and acronym words that are written in an identical manner may be read and understood in an identical manner. However, their meanings often differ significantly, being sometimes pejorative, more often lauding. Health professionals and researchers should be vigilant in their perception of messages received. Working teams and research groups often use acronyms to identify themselves, their domain of activities or the subjects of such activities. If the meanings of these acronyms vary, with possible implications for practice, shouldn’t we seek to understand them to better understand their growing popularity? Many linguists, beyond the health sciences, have made remarkable contributions to the domain of acronyms1and we are indebted to them.
37 Impact of Surgical Staging for Aggressive Histology Rectal Cancers - A Retrospective Review , Kazi M1 , Nekkanti SS1 , Rohila J1 , Desouza A1 and Saklani A 1*
1. Abstract 1.1. Introduction: Poorly Differentiated Adenocarcinomas (PDAC) and Signet ring adenocarcinomas (SRAC) are aggressive histologic subtypes of rectal cancer with high incidence of imaging occult peritoneal metastasis. 1.2. Methods: Retrospective review of aggressive histology, rectal cancer patients who underwent pre-treatment surgical staging as part of ovarian transposition or ostomy creation for diversion at a single tertiary cancer center between January 2014 and December 2019. 1 .3. Results: 117 patients underwent surgical staging that were deemed non metastatic on imaging. Surgical staging led to detection of metastasis in 29.9% of patients. This led to modification in treatment protocol in 20.5% and change in intent of therapy in 15.4%. Majority (80%) were found to have peritoneal disease with PCI <17. Only T4 disease predicted presence of metastasis on surgical staging with an Odds ratio of 2.69 (p – 0.035). 1.4. Conclusions: Significant proportion of patients with aggressive histology advanced rectal cancer patients are upstaged after surgical staging. Further investigation of this tool for staging is warranted.
38 Quo Vadismedicina Ex Testimoniis? A Quarter Century after its Inception, Where is Evidence-Based Medicine Now? More Questions than Answers , Jenicek M
1. Abstarct To mistrust science and deny the validity of the scientific method is to resign your job as a human. You’d better go look for work as a plant or wild animal. P.J. O’Rourke 1947- Parliament of Whores (1991). Just as Peter asked Jesus in the New Testament about two thousand years ago, Domine, quo vadis? (i.e, to be crucified again?), we may ask ourselves today within the context of medicina ex testimoniis [1] where we are a quarter century or so since the birth of evidence-based medicine. Where do we go from here and where we will probably go? Thirteen years ago, we poseda similar question and concluded then that the evidence-based medicine (EBM) glass remains half-full and half empty. [2] Use of ‘evidence’ in logic and critical thinking still requires clarification. Historically, medicine was always evidence-based. Today, what is new? It is the meaning of ‘evidence’ itself which appears as a new asset. Is it more than ‘that’s what I have seen’ or ‘what our most experienced Colleagues say’? More objective perhaps, more pragmatic, more focused, more reproducible, and more evaluable? Let us try in this essay to specify some challenges and questions pertaining to EBM today and to highlight the best ways to define, pragmatize and solve them now and in the future. A note about references: Transient and often temporary value are inherent to electronic references and websites.
39 The Influence of Pre-Treatment with a Proton Pump Inhibitor / H2 Receptor Antagonists on Helicobacter pylori Eradication , Horii T1*, Konishi H2 and Kanbayashi Y3
1. Abstract Vonoprazan (VPZ) is more useful than proton pump inhibitor (PPI)-based regimen as H. pylori eradication therapy. It is controversial whether pretreatment with H2 receptor antagonist (H2RA) or PPI before H. pylori eradication treatment increases or decreases the eradication rate. In this retrospective study, 802 patients with H. pylori infection were treated. We compared the efficacy of eradication regimen [VPZ (n=202), esomeprazole (EPZ) (n=198), sodium rabeprazole (RPZ) (n=200) or lansoprazole (LPZ)(n=202)/amoxicillin/clarithromycin] in patients with H. pylori infection with or without H2RA or PPI pretreatment. Analysis of variance, Tukey-Kramer multiple-comparison test and logistic regression analysis were used. In VPZ group, the eradication rate of non-received pretreatment group (94.7%) was significantly higher than PPI (75.0% p = 0.0085) and H2RA (73.7% p = 0.0116) pretreatment received group in the per protocol (PP) analysis. In EPZ, RPZ and LPZ group, no significant difference in the eradication rate was observed between non-received pretreatment group and PPI / H2RA pretreatment received group. Multivariate analysis showed that non-pretreatment of PPI or H2RA was predicting factor. Pretreatment with PPI and H2RA decreases the probability of H. pylori eradication in VPZ-based triple therapy
40 Wire Swallowing: A Purging Behavior , Sim SS* and Wu CJ
1. Clinical Image Purging is a self-inflicted behavior, to ridding the body of food consumed in order to lose weight or prevent weight gain. Self-induced vomiting, laxative abuse, diuretic abuse, enemas and excessive exercise are well-known purging behaviors. Purging disorder affects 2.5-4.8% of adolescent females; the behavior mostly affects physiologically and potentiates physical harm [1, 2]. Although rare, this behavior sometimes causes unusual danger to the patient. A 46-year-old female visited our emergency department as she failed to remove a wire from her mouth. Upon her arrival, her vital signs were stable. This was the third time she searched for help at our emergency department for the same reason. The patient has been suffering from a self-inflicted purging behavior. She performed selfinduced vomiting by putting a wire deep into her mouth (Figure A). The wire was more than 1 meter in length, which was thick and folded in spiral pattern. There was a resistance while we tried to pull it out. The wire was removed under the assistance of panendoscope (Figure B). The wire knot (Figure C) stuck at the esophagogastric junction, which could cause esophageal laceration if someone tries to remove it by force. We would like to share our experience with physicians taking care of patients who might have similar purging behavior. We strongly advise not to remove the wire by force as the unexpected wire knot may injure the esophagus. Impacted esophageal foreign body may cause symptoms ranging from mild discomfort to severe distress, even death [3]. Endoscopic management is the first choice in the treatment of esophageal foreign bodies due to its safety and effectiveness, while unnecessary delays should be avoided to prevent complications [4].
41 Putative Regulatory Element Located in the Introns 9 and 17 of the ACE2 Gene May Be Influenced By COVID-19 Risk Variants , Nair A1* and Rao AS1
1. Abstract Preliminary genomic data of the SARS-CoV2 virus responsible for COVID-19 showed that, its ability to infect relies on special cell surface spike proteins that have binding affinity to the human protein angiotensin-converting enzyme (ACE2). Among several patients analysed, it usually infects most age groups evenly. However, only a small percent of the confirmed patients progress into the severe phase. It is yet unclear, what accounts for this variation in disease propensity. Genome Wide Association Studies (GWAS) performed to map single-nucleotide polymorphisms (SNPs) associated with susceptibility to diseases show that 90% of GWAS signals reside in non-coding DNA elements (in the form of SNPs), with ~60% mapping to immune-cell enhancers. In this work we probed into the genomic region upstream of the ACE2 gene to identify dynamic chromatinsig natures that can serve as novel biomarkers and may point toward novel pathways for therapeutic intervention. In future, these studies will aithe ground work for the development of rational therapies aimed at restoring homeostatic mechanisms of ACE2 transcription.
42 Helicobacter Pylori Infection of Lingual Dorsum. Risk of Gastric Infection Helicobacter Pylori , Munio A, Harada L, Diaz M, Labbrozzi M, Turon P, Lence A, Aguas S, Denninghoff V and Adler LI*
1. Clinical Image The role of Helicobacter pylori in the oral cavity has been researched/studied by our study group for the last 28 years. At that time, there wasn’t a clinical entity that included Burning, Lingual Papillary Hypertrophy and Halitosis (BHH) together. However, the patients who presented this condition did not find an effective response to their demand. In some cases, a therapeutic diagnosis of Chronic Candidiasis was made in relation to Lingual Papillary Hypertrophy and they were referred to Periodontics Services for their Chronic Halitosis for evaluation and treatment. Many of these patients did not resolve their clinical symptoms, in their subsequent check-ups. The burning of the mouth was usually diagnosed as Burning Mouth Syndrome. A considerable percentage (60%) of these patients reported suffering from chronic gastric discomfort without receiving treatment, because when they consulted with the physician or with the gastroenterologist, their symptoms were associated with stress.
43 The Potential Role of Transient Elastography in Assessing Patients with Primary Budd Chiari Syndrome , Webb M1 , Shibolet O1 , Lurie Y2 , Maor Y3 , Katchman H1 , Philips A1 , Kopelman Y4 , Steinberg DM5 and Salomon O6*
1. Abstract 1.1. Background: Budd-Chiari Syndrome (BCS) is a rare disease defined as hepatic venous outflow obstruction at any level from the hepatic venules up to the cavo-atrial junction. Transjugular Intrahepatic Portosystemic Shunt (TIPS) is performed as a decompressive treatment in some patients. 1.2. Aim: To evaluate the potential role of Transient Elastography (TE) in assessing liver stiffness in patients with primary BCS. 1.3. Methods: Twenty one BCS patients and 10 patients with liver cirrhosis with different underlying etiologies underwent abdominal ultrasound and TE. 1.4. Results: Ninety-five percent of BCS patients had liver stiffness compatible with F4 with a median of 21 kPa, values which are usually obtained in patients with liver cirrhosis. Ten BCS and 10 cirrhotic patients underwent repeated TE with a median of 320 days between exams for BCS and 4.5 years for cirrhotic patients. The change of liver stiffness in BCS patients was 5.75 kPa (range -0.4 to 26.6), compared with-4.85 kPa (range -15.6 to 15.0) in cirrhotic patients (p-value = 0.0029). Change in liver stiffness from baseline to follow-up in BCS patients who underwent TIPS (n=4) was 0.2 kPa (range -0.4 to 15.3), whereas in patients without intervention (n=6) it was 6.75 kPa (range 1.3 to 26.6). The difference was not statistically significant. 1.5. Conclusion: Liver stiffness in BCS patients is dynamic progressive process with parameters of TE resembling liver cirrhosis. Even if TIPS seem to slow down the increment of liver stiffness, because of decreased liver congestion, it kept most patients with high score. The TE in BCS patients may be considered for monitoring for stable or upfront disease deterioration.
44 Pancreatic Cystic Neoplasms: The Challenges in Diagnosis and Review of Treatment , Ma RT1 , Guo YF2 , Xie J2 and Huang LY2*
Pancreatic Cystic Neoplasm (PCN) is an asymptomatic tumor which is increasingly being found by advanced imaging techniques in recent years. We report the case of a 56-year old man who presented as an outpatient with intermittent abdominal pain and abdominal distension for one year. His blood tumor markers showed that serum cancer antigen (CA) 19-9 is 1000.00U/ml. Gastro scope found severe gastric varices and Computed Tomography (CT) of portal vein revealed multiple low density foci occur in the pancreas and splenomegaly. Endoscopic ultrasonography (EUS), Magnetic Resonance Cholangiopancreatography (MRCP) and computed tomography (CT) of pancreas suggested that the lesions in the body and tail of pancreatic are cystic neoplasm, which involved the splenic vein. After removing the pancreas (body tail) and spleen of this patient, it is pathologically confirmed as moderately/poorly pancreatic ductal adenocarcinoma (PDAC). The published date was reviewed to settle the issues of optimal diagnostic methods and therapies of PCN.
45 Radiographic and Clinical Features of COVID-19 Pneumonia Patients in Border Yanbian Minority, Autonomous Prefecture, China: A Case Report , Yu C1 , Wang H1* and Cheng XW1*
1. Abstract In this case report, we collected five confirmed COVID-19 patients. We collected epidemiological data of patients, and according to typical clinical symptoms, laboratory test, myocardial enzyme, C-reactive protein and chest CT scanning results evaluation of patient's condition and treatment effect. Here we used the low flow oxygen (1-3 L/ min), antiviral, interferon inhalation treatment, patients' symptoms, laboratory indexes improved, SARS-CoV-2 turn negative PCR results, CT in patients with lesions absorption at the same time. After 16 days of hospitalization, all the patients were improved and discharged from hospital. At present, all discharged patients have no fever, virus repositive, and no treatment side effects. Although there is no specific drug for SARS-CoV-2, the active use of antiviral drugs at the early stage can effectively slow down the progression of mild COVID-19 disease. Familiarity with the clinical manifestations of patients will contribute to both evaluations of affected patients' condition and treatment effects.
46 Utility of Mosapride Citrate Combined With Osmotic Laxatives and Probiotics in the Initial Treatment of Pediatric Functional Constipation , Fujii Y1, 2* and Morimoto T1
1. Abstract Mosapride citrate (Mc) is one of 5-HT4-receptor agonists, and has a pharmacological action to promote physiological gastrointestinal peristalsis. This manuscript showed that Mc from the start of treatment was useful for functional constipation (FC) to satisfy Rome Ⅳ criteria in three infants including one male, mean age: 4 years old. All patients revealed Bristol Stool Form Scale (BSFS) 1, and one case complicated paradoxical diarrhea. Two patients had lost the spontaneous defecation, and completely depended on glycerin enema. Mc 0.29 mg/kg/day with magnesium oxide or lactulose added to probiotics was administered to the patients, who obtained the spontaneous defecation over once a day and BSFS 4 or 5 in the treatment period for five months. Promotion of the spontaneous defecation by Mc from the start of treatment is useful for FC in infancy with lower or none defecation frequency.
47 Rare Complications - Twitching of the Latissimus Dorsi Muscleafter Thoracotomy for Esophageal Cancer: A Case Report , Zhang L1 , Zuo X1 , Lu G2 , Jia Z1* and Wang Y
1. Abstract Complication of twitching of the latissimus dorsi muscle after thoracotomy for esophageal cancer is rare. We represent our experience treating twitching and pain of the latissimus dorsi muscle with ultrasound-guided botulinum injection. The symptoms were relieved for three months. 2. Introduction The latissimus dorsi muscle is located in the lower thoracodorsal area and lumbar region, and is the largest and widest flat muscle in the human body. This muscle is responsible for adduction and internal rotation of the shoulder joint, and is innervated by the cervical nerves 6 through 8, which form the thoracodorsal nerve, an important branch of the brachial plexus [1]. The thoracodorsal nerve can be injured during athoracotomy procedure. Subsequent twitching and pain of the ipsilateral latissimus dorsi muscle is known to be a rare complication of thoracotomy. Postoperative involuntary muscle twitching is more likely to occur after thoracotomy procedures for pneumonia, lung cancer, or breast cancer
48 The Silence Eclipsing Introns , Nair A1* and Rao AS1
1. Abstract In spite of the deep insight that has been gathered hitherto in Molecular Genetics, a few obscurities are as challenging as they were. Among these, introns, with reference to its functionality, have been debated quite often. And many theories that have emerged following such grappling discussions have given believable explanations but have failed to give a convincing answer eventually. This article attempts to bring a new reason behind the dormancy of introns
49 A Male Patient with Acute Hepatitis E Showing Asymptomatic and Transient Hyperthyroidism Due To Autoimmune Thyroiditis , Kumagai I1*, Suzuki K1,2, Kitada K1 , Kondo K1 , Kato A1 , Yoshida Y2 , Miyasaka A2 , Takikawa Y2 , Kaneko Y3 , Takahashi M4 and Okamoto H4
1. Abstract Although numerous extrahepatic manifestations associated with hepatitis E virus (HEV) infection have been reported, thyroid disorder is extremely rare. Here, we present a male patient with acute hepatitis E (AHE) showing asymptomatic and transient hyperthyroidism due to autoimmune thyroiditis. Immunoglobulin A class antibody against HEV and HEV-RNA (subgenotype; 3a) were positive. On admission, free T3 and T4 thyroid hormones were elevated, while thyroid stimulating hormone was decreased. Moreover, anti-thyroglobulin antibody and anti-thyroid peroxidase antibody were positive, suggesting autoimmune thyroiditis-associated hyperthyroidism. However, the characteristic symptoms or signs of hyperthyroidism were absent. AHE was self-limiting and thyroid hormone levels and thyroid-related antibodies became normal without specific treatment for hyperthyroidism. This rare case suggests that the screening test of thyroid function may be important in AHE to clarify the prevalence of thyroid disorder associated with AHE, even if thyroid-related symptoms or signs are absent.
50 Action of Cholera Toxin B Subunit and Peptide LKEKK on Different Cell Types , Navolotskaya EV
1. Abstract The review analyzed and systematized data on the action of cholera toxin B subunit (CTB) and the synthetic peptide LKEKK that corresponds to residues 16-20 in thymosin-α *Corresponding author: Elena V. Navolotskaya, Branch of Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Science Avenue, 6, Pushchino, Moscow Region, 142290, Russia, phone: +7(4967) 736668, fax: +7(4967) 330527, E-mail: navolotskaya@bibch.ru 1 and 131-135 in interferon-α2 on the functional, NO-synthase and guanylate cyclase activity of T and B lymphocytes, of macrophage-like cell line RAW 264.7, of humanCaco-2 and rat IEC-6 intestinal epithelial cell lines. According to the data presented, CT-B and the peptide bind to the cholera toxin receptor of the target cell with high affinity and trigger the following cascade of intracellular reactions: activation of inducible NO synthase → increase in NO production → increase in soluble guanylate cyclase activity → increase in the cyclic guanosine-3',5'-monophosphate level.
51 Cystic Pancreatic Lymphangioma: A Pancreatic Benign Cyst That Could Mimic Neoplasm , Thirabanjasak D
1. Clinical Image A 61-year-old-man who had been follow up for bilateral renal cysts, accidentally found hepatic hemangiomas and pancreatic cysts. Distal pancreatectomy showed cystic pancreatic lymphagioma and there was no evidence of invasive malignancy. The cyst is 10 cm in size, at the tail of pancreas. There is no connection between cystic lesion and pancreatic duct. The cyst is microscopically complex with dilated lymphatic spaces (Figure A, original magnification x7). Local lymphoid aggregation and occasionally seen lymphoid follicles are noticed along the wall (Figure B,C and D, original magnification x200). Pancreatic lymphangioma is a rare benign condition among group of pancreatic cysts, spectrum range from benign to malignant. Lymphangioma is benign lymphatic malformation, which given architectural distortion and mimic malignant cyst. Aware of the condition would be beneficial for helping pre-operative diagnosis and guide through the clinical treatment.
52 Persistent Elevation of Serum Prothrombin Induced by Vitamin K Deficiency or Antagonist Despite Discontinuation of Warfarin Administration in Alcoholic Cirrhosis in The Absence of Hepatocellular Carcinoma: A CaseReport , Yasumi Y1,2, Suzuki K1,3,*, Yasumi Y1,2, Konishi Y2 , Abe M2 , Takahashi K1 and Takikawa Y3
1. Abstract Whereas serum prothrombin induced vitamin K deficiency or antagonist II (PIVKA-II) is a diagnostic and prognostic marker of hepatocellular carcinoma (HCC), the serum PIVKA-II level rarely increases in chronic liver diseases in the absence of HCC. Although warfarin administration induces marked elevation of PIVKA-II, warfarin discontinuation may lead to swift normalization of PIVKA-II, usually within several weeks, although the elimination half-time of warfarin varies greatly among individuals. The case of a 65-year-old man with alcoholic cirrhosis showing persistently elevated PIVKA-II for four years after warfarin discontinuation is presented. The patient started receiving warfarin orally (1.0-1.5 mg /day) for atrial fibrillation. A marked elevation of the serum PIVKA-II level (24,822 mAU /mL) was noted a year later when he developed a hemorrhagic gastric ulcer and overt hepatic encephalopathy with hyperammonemia, necessitating warfarin discontinuation. Interestingly, serum PIVKA-II levels remained abnormal (maximum level: 2863 mAU /mL) for four years after warfarin discontinuation, before finally returning to the normal range (<40 mAU/mL). During this period, serum parameters of liver function, such as total bilirubin, aminotransferases, and γ-glutamyltranspeptidase, continued to be within normal ranges, and imaging examinations never suggested the existence of HCC. Factors potentially affecting the vitamin K dynamics, such as long-term administration of antibiotics and hidden alcohol intake, were not observed despite vigorous investigations. Serum PIVKA-II levels can be increased in cirrhosis without HCC for a long period following discontinuation of warfarin administration. Potential reasons for PIVKA-II elevation in the present case are discussed.
53 SARS-CoV-2 originated from laboratory? , Zarehzadeh S1 and Baserisalehi M2*
1. Letter to Editor The Corona Virus Disease 2019(COVID-19) could be a viral respiratory disorder that caused by a new coronavirus called SARS-CoV-2 [1]. Severe acute respiratory syndrome coronavirus (SARS- CoV) and Middle East respiratory syndrome coronavirus (MERS- CoV) are two pathogenic viruses in humans. Both SARS‐CoV and MERS‐CoV are zoonotic in origin and both viruses originated in bats, during this review; we summarize the origin of COVID-19. Most patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory disorder (e.g., cough, difficulty breathing). This includes anyone that has had closed contact with a patient with laboratory-confirmed COVID-19 within 14 days of symptom onset or a history of travel from affected geographic areas (presently China, Italy, Iran, Japan, and South Korea) within 14 days of symptom onset [2]. SARS-CoV-2 had a unique inserted sequence (1378 bp) located within the middle of its spike glycoprotein gene. This unique sequence is not specific and several coronaviruses discovered from natural sources, showed that this “unique” sequence was also found in other coronavirus [3]. In our view, there is currently no credible evidence to support the claim that SARS-CoV-2 originated from a laboratory engineered CoV. It is more likely that SARS-CoV-2 could be a recombinant CoV generated in nature between a bat CoV and another coronavirus in an intermediate animal host [4].
54 Pediatric Pancreatic Hemangioma , Thirabanjasak D*
1. Clinical Image A 5 year old girl had a pancreatic mass. Resection reveals a circumscribed lobulated mass in pancreas with greyish brown color. The mass are composed of vascular structures resembling veins and capillary-sized vessels. Endothelial lining cells are flattened with bland looking nuclei. While the remaining pancreas tissue is unremarkable (Pic A, original magnification x40) (Pic B, original magnification x200). Immunohistochemical studies for CD34, CD31, ERG, and Factor VIII confirms endothelial vascular markers (Pic C, D, E, and F, original magnification x200). Pediatric pancreatic hemangioma is the rare benign cystic tumor (10 case reports in 2006 by Richard J England, et al.) and also uncommon in adult group (14 case reports in 2015 by Tao Lu and Cheng Yang). It is important to note the lesion and planning treatment with caution. Patients usually suffered from biliary obstructive symptoms, leading to final surgery. Some may present with organomegaly, abdominal discomfort and gastrointestinal bleeding.
55 Uncommon Cause of Gastrointestinal Bleeding , Vickovic S1, 2* and Zec R3
1. Introduction Gastric antral vascular ectasia is an uncommon cause of chronic gastrointestinal bleeding or iron deficiency anaemia [1]. The condition is associated with dilated small blood vessels in the antrum, or the last part of the stomach. It is also called watermelon stomach because streaky long red areas that are present in the stomach may resemble the markings on watermelon [2]. GAVE is associated with a number of conditions, including portal hypertension, chronic renal failure and collagen vascular diseases particularly scleroderma. GAVE is treated with treatment through the endoscope, including argon plasma coagulation and electrocautery. Other medical treatments have been tried and include estrogen and progesterone therapy and anti-fibrinolytic drugs such as tranexamic acid.
56 Conservative Management of Necrotic Colostomy in a Fragile Patient Under Palliative Chemotherapy , Allué M* , Gonzalo MA and Diarte C
1. Abstract Complications with surgically placed ostomies are common. We present our experience treating necrosis and dehiscence in a colostomy by conservative measures avoiding reoperation in a fragile patient. In our patient conservative treatment achieved complete peristomal skin healing and a functional non-stenotic stoma by combining local debridement and wound care measures.
57 Mutation at Codon 249 of the TP53 Gene in HepatocellularCarcinoma: MD-CT and Pathologic Features , Rossi UG1*, Rutigliani M2 , Rollandi GA3 , Ciferri E4 and Filauro M4
1. Abstract Aflatoxin B1 is a mycotoxin produced by the Aspergillus Flavus fungus that contaminates many sources of food. This mycotoxin has its metabolism into the liver. So, Aflatoxin B1 metabolites create a DNA mutation at the third base of codon 249 in the TP53 tumor suppressor gene, inducing a G to T trasversion (AGG to AGT), which replace an arginine "R" to a serine "S".  
58 High-Dose Methotrexate, A Tried-and-True Treatment with Genomic Delicacies: A Case Report , Rubalcava LF1, 2, Gutierrez-Hernandez O3 , Taja-Chayeb L4 and Candelaria M2, 4
1. Abstract The prediction of methotrexate (MTX) adverse events has been a challenge to the clinician; here we present a case of toxicity after the previous exposition with the development of hepatic, renal, and hematologic toxicity. The development of methotrexate toxicity has been previously analyzed in our institution, where a significant percentage of the patients present polymorphisms in the reduced folate carrier and the methylene-tetrahydrofolate reductase, which several groups have associated with toxicity and treatment efficacy. The clinical applicability of this knowledge in the prevention and dose adjustment is still debatable; a genomic screening for all patients that will be exposed to methotrexate (especially in high doses) is warranted.
59 Predictive Factors of Bowel Resection Due to an Incarcerated Groin Hernia , Udaka T* , Taniguchi A, Kouzai J, Ootsuka T, Watanabe N, Endou I, Yoshida O, Asano H and Kubo M
1. Abstract 1.1. Purpose: In this retrospective study, we assessed factors that can be used to predict the need for bowel resection due to an incarcerated groin hernia. 1.2. Methods: We enrolled a total of 83 patients diagnosed with an incarcerated groin hernia on preoperative unenhanced Computed Tomography (CT) between January 2010 and December 2019 in our hospital. They were divided into two groups: those who underwent bowel resection and those who did not. The clinical findings, blood test results, and unenhanced CT values of patients were examined and compared between the two groups. The indication of intestinal resection was macroscopic necrosis or perforation of the incarceratedintestine. 1.3. Results: A total of 83 patients with incarcerated groin hernias were included in our study, of whom 13(15.7%) had undergone bowel resection surgery. A univariate analysis identified a prolonged time from the symptom onset to surgery, increased white blood cell (WBC) count, increased C-reactive protein (CRP) level, decreased albumin level and CT attenuation of the incarcerated intestinal wall at the fundus as significant predictive factors. The cut-off value for prediction of intestinal resection was 25 HU for the average CT attenuation of the incarcerated intestinal wall at the fundus and a WBC of 11,550 based on the receiver operating characteristic (ROC) curve. A multivariate analysis showed CT attenuation of the incarcerated intestinal wall at the fundus and an increased WBC count to be independent predictive factors. 1.4. Conclusions: Measuring unenhanced CT attenuation of the incarcerated intestinal wall at the fundus and the WBC count was suggested to be necessary for determining whether or not resection of the incarcerated intestine is required in cases of groin hernia.
60 Gut-Liver Axis Modulation: A Potential Role of Probiotics and Omega-3 Fatty Acids in Management of NAFLD , Faruqui AA*
1. Abstract Non-Alcoholic Fatty Liver Disease (NAFLD) has currently emerged as common liver disorder compared to alcoholic liver disease. The prevalence of NAFLD in India varies from 9% in rural areas to 32% in urban populations. This incidence is reported to be the lowest in western India (44.1%) compared to the highest prevalence in northern states (72.4%). Available treatments are associated with certain side-effects. Recently a relation between gut and liver, i.e. gut-liver axis has been studied extensively. Modulation of gut may provide a natural mechanism to improve NAFLD associated complications. Moreover, patients with NAFLD have lower levels of omega-3 poly unsaturated fatty acids (PUFAs). Thus, supplementation of omega-3 PUFA is important for both, prevention and treatment of NAFLD. Vitamin E provides a significant antioxidant action in prevention of NAFLD progression. Therefore, modulating gut microbiota with probiotics may be an effective alternative along with established therapies like vitamin E and PUFA for better outcomes in the management of NAFLD.
61 Emergency Care Sick Palliative and Problems Oncology in Emergency Department during the Covid-19 Pandemic , Lenjani B1 , Krasniqi B1*, Shabani G1 , Rashiti P1 , Demiri A1 , Pelaj B2 , Spahiu F2 and Lenjani D1
1. Abstract Emergency medical care in palliative patients during the COVID-19 pandemic, it is important to provide a consistent treatment for stable patients that should be consistent with the goals and benefits, the perspective of these patients, but avoiding palliative patients with a poor prognosis that is unlikely to survive. Cancer is the second leading cause of death in the world around 8.8 million deaths a year. Worldwide, about 7-10 million patients are diagnosed with cancer each year, recently there has been a significant increase in the number of cases diagnosed with cancer. About 70% of cancer deaths are in low- and middle-income countries. The goals of emergency medical care based on the criteria of BLS and ACLS, that is should be done “Do not do resuscitation, do not intubate but continue medical treatment excluding endotracheal intubation without prospects for the patient, but offering BLS only treatment concentrated symptomatic. ED is often the only place that can provide the necessary medical interventions (e.g., intravenous fluids or pain management medications. Medications as well as immediate access to advanced diagnostic tests when needed such as CT, RM and other diagnostic and treatment procedures
62 Principles of Cryopreservation and Applicabilities in Intestinal Organoids , Pereira EC1*, Meneses AMC2 , Oliveira FCM2 and Penning L4
1. Abstract Cryobiology is known as a study of low temperatures effects in tissues and cells, which means understand influences on decreasing temperature and pressure in the freezing medium and how the cell membrane reacts to these variables. Cryopreservation emerged by the principles of Cryobiology as a technology capable of preserving the composition and viability of cells indefinitely, at low temperature below water fusion point. However, the low temperature can lysis a cell membrane and destroy it. At the same time, the low temperature can also preserve the cell, avoiding the formation of ice crystal in the cytoplasm. To maintain long term organoids is a great challenge because in the cryopreservation and thawing process there is an important loose of cells and, consequently, the culture does not work anymore. It means a waste of materials and time, loss of unique cell lineages, and even the collection of new samples. Thus, it has been an obstacle to maintaining long-term cultivation of some species and cell types, as each one has its membrane potentials. It is not a simple process and to solve this problem is necessary more knowing about Cryopreservation. The objective of this review is disserted about cryopreservation proprieties and how this can meddle in long live culture intestinal organoids and integrity of cell membrane, cytoplasm, and nucleus, as well as the current organoid applicability and diverse of results some experiments, had in different intestinal organoids cryopreservation protocols.
63 Portal Vein Trombosis: Literature Review and a Case Report , May TH1 , Carmona FF1 , Simonetti LR1 , Amparado JA1 , Joaquim LF1 and Kahwage RL1*
1. Abstract Portal Vein Thrombosis (PVT) is an unusual complication in patients with liver cirrhosis. In current research on genesis, it has been demonstrated an underlying prothrombotic state and a combination of local endothelial factors, family and/or acquired inheritance, in addition to other thrombophilic factors. Such condition is described as an important cause of portal hypertension whether the patient has liver dysfunction. There are three main variants of portal vein thrombosis: Acute non-cirrhotic portal vein thrombosis; Chronic PVT and PVT in cirrhotic patients. Each type may occur with multiple etiological factors and variability in its presentation. Clinical and laboratory diagnosis complemented with imaging tests are useful in early detection since the treatment directly affects the morbidity and mortality of these patients. The objective of the authors is to perform a review of the literature and describe the case of a male patient diagnosed with acute portal vein thrombosis, concomitantly with hepatic cirrhosis and thrombophilia, with partial recanalization after administration of enoxaparin and consequent reversal of the signs and symptoms of portal hypertension.
64 Evidence to the Empirical: A Novel Clinical Score to Predict Spontaneous Bacterial Peritonitis (SBP) in Patients of Chronic Liver Disease Using Ascitic Fluid (AF) Appearance, Symptoms & Severity of Cirrhosis , Ajay K1,* , Revathy MS1 , Sumathi B1 , Chitra S1 , Manimaran M1 and Sathya G1
1. Abstract 1.1. Background and objectives: Ascitic fluid cell count is definitive to diagnose SBP. Timely availability of cell count is crucial, especially in peripheral setting. Study aims to identify reliable predicting factors and to arrive at a a five point Novel Non- invasive clinical score for SBP in CLD which in turn provides evidence to justify empirical use of antibiotics in these high risk patients before availability of AF analysisreports. 1.2. Methodology: A prospective observational cohort study, enrolling 75 CLD patients with ascites was conducted. Baseline characteristics were noted; Logistic regression modeling was used to identify the best predictors for the presence of SBP. A combination of 5 predictive variables including the Opaque AF appearance, presence of tense ascites and pain abdomen, CTP grade C and MELDS scores ≥ 14, was embraced to formulate a score for prediction of SBP in cirrhotics. ROC curve used to select cutoff points for MELDS and CHILD scores and to assess the performance of the score. 1.3. Result: Out of 75 patients, 37 patients had SBP. Above factors were found to have a significant relation with presence of SBP as Chi Square P value was < 0.05. The score ranges from 0-5 points, with 0 showing least and 5 depicting the highest probability of an existing SBP in the cirrhotic patients. For confirmation AF cell counting was done. 1.4. Conclusion: A CLD patient with presenting with tense ascites, pain abdomen, and opaque AF with advanced cirrhosis can be started on broad spectrum antibiotics without waiting for AF analysis reports.
65 Short Term Outcomes after Hartmann’s Procedure: A Single Centre Experience , Abdalkoddus M1 , Ibrahim R1 , Alawad AA2* and Di Mauro D3
1. Abstract 1.1. Background: The management of acute left-sided colonic obstruction still remains a challenging problem despite significant progress. Urgent surgery involving a Hartmann's Procedure (HP) is still associated with a high postoperative morbidity rate. 1.2. Aims: To compare our emergency HP outcomes with the published literature and assess our practice for any potential factors that could be optimized to reach better outcomes. 1.3. Methods: We audited the decision-making process, timelines and short-term outcomes of all emergency HPs in our hospital from Feb 2014 to Sept 2017. 1.4. Results: A total of 87 patients underwent emergency Hartmann’s operation for different indications included. Median preoperative P-POSSUM mortality estimation was 14.8% (IQR 5.1%- 37.2%) while median preoperative P-POSSUM morbidity estimation was 87.2% (IQR 67.5%-96%. 61 patients (70.1%) had some degree of contamination intra-operatively. 10 cases (11.5%) died before discharge. Total complication rate was 47.1% while re-operation rate was 6.9%. 1.5. Conclusion: Our outcomes after HP are comparable to the published literature. Further studies are needed to investigate our patient selection process for HP.
66 Gastrointestinal and Liver Involvement in COVID-19: A Roadmap from Early Identification to Treatment , Butt AS1*, Sharif F2 and Malik M1
1. Abstract December 2019 has brought another historical pandemic which has posed a serious threat to global health. As of 24th August 2020, 23 311719 confirmed cases and of 806410 deaths have been reported due to this most challenging disease of the 21st century so far, named as coronavirus disease 2019 (COVID-19). It was started in Wuhan, China and eventually entered different countries very rapidly and declared as the sixth public health emergency of international concern by the World Health Organization. The spectrum of symptomatic COVID-19 ranges from mild respiratory tract infection to severe pneumonia that may progress to acute respiratory distress syndrome or multi-organ dysfunction. However, COVID-19 infection can present with gastrointestinal and hepatic manifestation even in the absence of respiratory involvement. In light of the varying clinical manifestations and possibility of multisystem involvement, it is imperative for healthcare professionals worldwide to adapt their practices according to the rapidly evolving situation
67 Prognostic Ability of Hematological Parameters and Inflammation Based Scores in Acute Pancreatitis , Altintas E1*, Koyuncu MB2 , Yaras S1 , Ucbilek E1 , Ates F1 and Sezgin O
1. Abstract 1.1. Aims and Background: Appropriate triage is essential in the management of Acute Pancreatitis (AP). Even if AP initially stratified as mild or moderate, it may rapidly progress to severe form and even death may occur. Therefore, to find reliable prognostic and predictive markers in order to customize treatment strategies is really essential. Nutrition-based and/or inflammation-based prognostic indicators such as modified Glasgow Prognostic Score (mGPS), Prognostic Nutritional Index (PNI), C-reactive protein to albumin ratio (CRP/Alb), Neutrophil to lymphocyte ratio (NLR) and Platelet To Lymphocyte Ratio (PLR) have emerged as prognostic factors in some cancers and inflammatory conditions. We evaluated the prognostic ability of inflammation based scores in patients with acute pancreatitis. 1.2. Methods: We retrospectively reviewed the medical records of 299 cases with acute pancreatitis. AP severity assessment was based on Atlanta 2012 classification. To evaluate the inflammation based prognostic scores, laboratory parameters performed at hospital admission and after 48 hours of admission were used. 1.3. Results: A total of 299 patients with acute pancreatitis were reviewed. Mean age of the patients was 55years, the most common etiology was gallstones (58%). 241 of the patients were classified as mild, 58 of them were classified as severe pancreatitis. There were no significant relationships between mGPS at admission (mGPS 0) and etiology, severity, ICU requirement, surgery requirement, local or systemic complications and mortality. Score of “2” according to the mGPS at 48 hours after admission (mGPS 48) were significantly related with severity (p<0,001, %43.2- %74.5), need for antibiotics (p<0,001, CI: %38.5-%69.3), requirement of ICU (p=0,005, %46.9- %81), systemic complications (p<0,001, %38.7-%73.8) and mortality (p=0,364, %48.3-%100). It was found that PNI 0, PNI 48, NLR 0, NLR 48, PLR 0, PLR 48 and CRP/albumin 48 (but not CRP/albumin 0) were significantly correlated with severity, need for antibiotics and presence of systemic complications (p<0.001,p<0,05 and p <0,05). NLR 48, PLR 48 and CRP/albumin 48 were significantly related with surgery requirement and presence of local complications (p<0,05). 1.4. Conclusions: Nutritional and Hematological scores may be helpful but inflammation based prognostic scores other than mGPS 48 are not reliable at admission for predicting the severity of acute pancreatitis. Combination of other inflammation and nutrition based prognostic scores and mGPS may represent more accurate prognosis of AP
68 Alcoholic Chronic Pancreatitis or Intraductal Papillary Mucinous Neoplasm: What to Do? , Mazzuoli S, Di Terlizzi F, Verderosa G, Prencipe S, Di Molfetta A, Lovero R and Guglielmi FW*
1. Abstract Intraductal Papillary Mucinous Neoplasm (IPMN) is an intraductal mucin-producing neoplasm , with an increasing incidence. IPMNs may have clear malignant potential and exhibit a broad histological spectrum ranging from adenoma to invasive carcinoma. In contrast to the ductal adenocarcinoma, IPMNs have in general a better clinical prognosis. The clinical presentation of IPMN and Chronic Pancreatitis (CP) are often indistinguishable. Misdiagnosis of IPMN in patients with CP can lead to serious delays in the appropriate management. In patients with history of alcoholic CP, the possible presence of IPMN could not to be excluded. Due the high frequency of malignancy in IPMN, surgical approach should be considered. Assessment for potential IPMN is mandatory in patients with CP. All patients with CP must have a clinical assessment at least every 6 months, with abdominal US at least every year. In sympthomatic patients with IPMN and severe abdominal pain, early pancreaticoduodenectomy must be strongly considered.
69 Laparoscopic Cholecystectomyrisk Factors, Intra and Postoperative Complications in Al-Zahrawi Hospital, Amara, Misan, Iraq , Alkaabi NS*
1. Abstract 1.1. Background: Cholecystectomy relieves pain, treats infections and in most instances prevents the re-occurrence of the disorder. However, some complications may happen which include bile leak, bile duct injury, bleeding, peritonitis, liver and intestine injuries, raised scare at the operation site, anesthesia complications and possible death. The aim of this study is to evaluate patients underwent laparoscopic cholecystectomy in terms of risk factors of gallstone, variation in presentations of patients, intra and postoperative complications. 1.2. Methods: A total of 134 patients (22 males and 112 females) were included in the present prospective study performed between September 2018 and March 2019 at Al-Zahrawi Surgical Hospital, Amara, Misan, Iraq. Investigations were made on the age of the patients, sex and occupational status. Risk factors and possible complications were observed. 1.3. Results: Most patients were females and 95% of them were above 11 years old with more concentration of the number of the cases between 21 and 40 years old which represents more than 57% of the patients. It was observed that the frequencies of disorders like hypertension, diabetes mellitus and abnormal lipid profile were 32.8%, 12.7% and 24.6%, respectively. 1.4. Conclusion: Females are more susceptible than males regarding the formation of gallstones. The second and third decades of age are expected to show high frequency of gallstones. A large population of patients is recommended to be studied to reveal the potential risk factors for gallstone formation including hypertension.
70 Budesonide for Relapsed/Persistent Hepatitis in Two Patients with Hepatitis-Associated Aplastic Anemia Treated with Antithymocyte Globulin and Cyclosporine A Case Report , Tatiana Salimova, MD1 , Alexey Maschan*, MD1*, Dina Baidildina, MD1 , Irina Kalinina, MD1 , Natalia Kotskaya, MD2 and Galina Novichkova, MD1
1. Abstract Flares of hepatitis with activity similar or even higher than peak activity during initial presentation are rare in patients with Hepatitis-Associated Aplastic Anemia (HAAA). We describe two children with HAAA in whom hepatitis with high transaminases activity persisted or relapsed after a course of antithymocyte globulin (ATG) + cyclosporine A(CsA)/tacrolimus and methylprednisolone and subsided after oral budesonide 9 mg daily was added. Budesonide was successfully stopped in one patient, whereas the second patient requires low-dose maintenance. We conclude that use of budesonide may be the approach of choice when hepatitis in HAA does not subside with IST or relapses after initial resolution. What is known: • Hepatitis-associated aplastic anemia (HAAA) is the most prevalent form of nonidiopathic aplastic anemia. • The most common scenario of HAA development is onset of pancytopenia coinciding with a decrease in or normalization of serum aminotransferases and bilirubin. • Residual hepatitis activity typically resolves after combined immunosupression with ATG and CsA. What is new: • In very rare patients hepatitis and pancytopenia relapse soon after initial resolution and hepatitis persists, despite hematopoiesis recovery after second course of ATG and substitution of tacrolimus for CsA. • Administration of budesonide results in hepatitis resolution or significant alleviation.
71 Administration of Selective Serotonin Reuptake Inhibitors and Risk of Pyogenic Liver Abscess in a Case-Control Study , Lai SW1,2*, Cheng KC1,2,3, Liao KF4,5 and Lin CL1,6
1. Abstract 1.1. Background/Objective: Little research is available between Selective Serotonin Reuptake Inhibitors (SSRIs) use and incidence of Pyogenic Liver Abscess (PLA). The objective of the study was to determine whether SSRIs use is associated with PLA. 1.2. Methods: There were 1749 subjects, who had the first episode of PLA between 2000 and 2013, were considered as the cases and 6518 subjects without PLA as the matched controls. SSRIs use was defined as 'current', 'recent' or 'past' if the prescription was filled < 3 months, 3–6 months or ≥ 6 months before the index date, respectively. The Odds Ratio (OR) and 95% Confidence Interval (CI) of PLA associated with SSRIs use was measured by the multivariable logistic regression model. 1 .3. Results: The adjusted ORs of PLA was 1.26 for subjects with current use of SSRIs, 1.04 for subjects with recent use, and 0.8 for subjects with past use, compared with never users. In further analysis, the adjusted OR of PLA was 1.01 for subjects with increasing cumulative duration of SSRIs use for each additional month of use, compared with never users. 1.4. Conclusion: No significant association, including duration-dependent effect can be detected between SSRIs use and the risk of PLA.
72 COVID-19 Presenting as Acute Hepatitis with Thrombocytopenia , Yesmin M*
1. Abstract Since December 2019, an emerging infectious disease named COVID-19 started to show up and became a pandemic to claim millions of lives until August, 2020. COVID-19 usually presents with respiratory manifestations, but atypical presentations indicates a potential diverse nature of the disease. Cases have been reported with isolated hepatitis or thrombocytopenia as COVID-19 presentation. But, no single case was reported so far with two different entities. Here, we have reported a case of COVID-19 with acute hepatitis along withthrombocytopenia.
73 Rs1310191201(C>T) Polymorphism in 3‘UTR of BIRC5promote Carcinogenesis of Human Gastric Cancer by De-Regulation by Mir-330-5p in Chinese Population , Wenting W1 , Xiaoli T1 , Meixiang Z2 , Chunlei Z1 , and HuChengxia3*
1. Abstract Previous reports have revealed that down-regulation of miR-330-5p expression can promote osteosarcoma growth and invasion by targeting oncogene Baculoviral IAP repeat-containing protein 5 (BIRC5). However, the function of the single nucleotide polymorphism (SNP) located in the 3’UTR of BIRC5 regulated by miR-330-5p has not been investigated in human Gastric Cancer (GC). We found that the rs1310191201 (C>T) polymorphism in the 3’UTR of BIRC5 was involved in the increased occurrence of GC by deregulation effects of BIRC5 miR-330-5p on BIRC5. C>T SNP of 3’UTR of BIRC5 could promote GC cell proliferation by up-regulation of BIRC5. Moreover, C>T SNP of 3’UTR of BIRC5 was statistically related to tumor volume, differentiation and metastasis in GC patients. C>T SNP of 3’UTR of BIRC5 was related to significantly enhanced expression of BIRC5 and shorter survival in post-surgery GC patients. Conclusively, rs1310191201(C>T) in 3’UTR of BIRC5 was highly associated with an increased risk of GC occurrence in a Chinese population and might serve as a novel biomarker for gastric cancer.
74 Rapid SARS-Cov-2 Infection Spreading within a Family Cluster: The Importance of Gastro-Intestinal Symptoms , Coco B1, Colombatto P1, Cavallone D1, Molinaro E2, Pistello M3, Bigalli G4, Oliveri F1, Ricco G1, Romagnoli V1, Salvati A1, Menichetti F5, Bonino F6 and Brunetto MR1,6,7*
1. Abstract 1.1. Background: In Phase-2 COVID-19 pandemic, timely control of new outbreaks is pivotal to avoid an epidemic rebound. A better knowledge of clinical disease profiles and the development of sensitive diagnostic flow charts will help to take more effectiveactions. 1.2. Patients and Methods: We studied an outbreak occurred in 3 families during a skiing vacation. Index-case was identified by nasopharyngeal swabs nucleic acid test (NAAT) because of typ-ical respiratory syndrome. Serological assays for anti-Spike glycoprotein (anti-S1) or nucleocapsid protein (anti-NP) of SARS-CoV-2 antibodies were performed at 3 timepoints. 1.3. Results: Index-case was identified 12 days after the primary-case: a young boy with 12 hours incoercible vomit and severe headache. His close contacts had prevalent gastrointestinal/dysgeusia symptoms, whereas typical respiratory syndrome occurred later in older males. Within 10 days 9 of 12 exposed individuals developed symptoms, SARS-CoV-2 infection was confirmed in 10. The most frequent SARS-Cov-2 specific symptoms were associated with the primary virus entry site, namely mouth/head including pathognomonic dysgeusia and smell loss and headache. Respiratory symptoms occurred only in adult males whereas gastrointestinal symptoms prevailed in both children/adults and males/females. NAAT was negative in 3 subjects 13-26 days from mild disease onset, but also at onset in 2 cases, who turned positive 16 days later. Overall, 10/11 (90.9%) patients tested positive for IgGanti-NP, IgM and total-anti-S1; IgM-anti-S1 became undetectable in 5/10 during follow-up (33-100 days after onset). In 2 cases IgG-anti-NP became negative 3 months after onset, questioning their long lasting duration. Early isolation and strict adherence to preventive measures avoided secondary and tertiary infections. 1.4. Conclusions: This experience suggests the importance of stringent scrutiny for clustered mild-atypical symptoms and dysgeusia, with immediate isolation of suspected cases and NAAT testing complemented by anti-nucleoprotein and Spike-1 for at least 2 weeks, ifnegative
75 Bcl-2 and SIRT3 Affect Tumor Cell Viability by Integrating Metabolism and Apoptosis , Dong Y1, 2, Donga D1, 2, Sihang Yu1 , Zhao Y1 , Ma J1 , Yan X1 , Huo X1,2 and Jing Su1*
1. Abstract While apoptotic tolerance caused by B cell lymphoma 2 (Bcl-2) over expression is one of the important underlying mechanisms of the decreased apoptotic sensitivity of tumor cells, only targeting Bcl-2 as an anticancer therapy has shown limited clinical benefit, which may be related to the non-apoptoticprotective effects of Bcl-2, such asitsrolesin regulating endoplasmic reticulum stress and autophagy. Recently, it was suggested that Bcl-2 plays dual roles in regulating cellular metabolism and apoptosis. However, Bcl-2 inhibitors only alter metabolism by down regulating the expression glycolytic enzymes, while glycolysis inhibitors increase the sensitivity of cells to apoptosis by Bcl-2 inhibitors. Bcl-2 is primarily distributed in mitochondria, which have the dual functions of being intracellular energy factories and executers of death signals. Surtuin 3 (SIRT3) is an important mitochondrial deacetylase that regulates many mitochondrial metabolic pathways. SIRT3 enzymatic activity is dependent on the NAD+/NADH ratio. Inhibiting Bcl-2 alterstumor cell metabolism and decreases the NAD+/NADH ratio, which activates SIRT3. SIRT3 then modifies glycolysis-related proteins by deacetylation, which affects ROS levels, HIF-1α activity, and the localization of Hexokinase II, which is the key glycolytic enzyme. Together, these effects reverse (inhibit) the metabolic reprogramming of tumor cells and enhance their apoptotic sensitivity. Herein, we discuss this new model that suggests that integration of Bcl-2 and SIRT3 signaling regulates apoptosis through glycolysis and mitochondrial oxidative phosphorylation.
76 Portal Biliopathy. Experience in Two Reference Institutions , Contreras AC1 , Hernandez PV2 , Mendez EL2 and Torre A2*
1. Abstract 1.1. Background: Portal cavernoma cholangiopathy is defined as cholangiographic anomalies secondary to collateral venous circulation and portal cavernous transformation. Most of the time it is asymptomatic, hence the greater difficulty in achieving prompt diagnosis andtreatment. 1.2. Methods: A descriptive study was conducted on patients with portal cavernous cholangiopathy seen at a two referral centers within the time frame of January 2006 to December 2018. Clinical manifestations, cholangiographic alteration pattern, thrombosis extension, treatment, and mortality were analyzed. 1.3. Results: A total of 23 patients with cavernoma cholangiopathy were reported and their median age was 42.5 years. Eight cases (34.8%) presented with cirrhosis of the liver and fifteen cases (65.2%) did not. The most frequent symptoms were abdominal pain and jaundice. CT angiography was the study of choice for characterizing the portal anomalies. ERCP and magnetic resonance cholangiography were used in the evaluation of biliary tract anomalies. Thrombosis extension showed a preference for the extrahepatic portal vein in the cirrhotic patients. Biliary stricture at the extrahepatic site was predominant in both groups. Six patients (26%) did not require treatment, 3 (13%) required medical treatment, and the rest received endoscopic therapy. Ten patients (21.7%) needed surgical treatment. Nine deaths were reported, and severe acute cholangitis was the main cause. One-year and three-year survival rates were 70.8% and 58.3%, respectively. 1.4. Conclusions: The real frequency of portal cavernoma cholangiopathy is difficult to determine because it is usually asymptomatic. Adequate diagnosis through imaging techniques is decisive for determining the treatment and prognosis of thosepatients
77 Undertreatment of Hepatitis C Virus Infection in Elective Total Hip Arthroplasty , Won SH1 , Park HJ2 , Kim HJ3 , Lee YK1 , Ha YC2* and Koo KH1
1. Abstract 1.1. Background: Total Hip Arthroplasty (THA) in patients with hepatitis C virus (HCV) are known for poor outcomes increased risk of iatrogenic infection. New Direct Antiviral Agents (DAA) can now cure HCV infection. However, undertreatment is still common in patients undergoing THA. Our aim was to assess the prevalence of HCV infection and treatment rates in patients with detectable RNA. We compared perioperative complications between HCV infection and non-HCV infection at the minimum one year follow-up. 1.2. Methods: Between 2003 and 2018, 3574 patients (4518 hips) who had undergone THA at two hospitals were enrolled. Patients were stratified into two groups: (1) HCV-Ab negative serology (2) HCV-Ab positive serology. Treatment history for HCV infection was analyzed by reviewing medical record. Perioperative outcomes including intraoperative bleeding, transfusion rate, operation time, hospital stay, postoperative infection, and revision for 1year follow up was analyzed. 1.3. Results: Among 3317 patients, 47 patients (1.4%) were positive for anti-HCV, and eight patients (0.2%) had detectable RNA load. Of the 47 patients, only 20 patients had HCV infection whereas the remaining 27 patients were diagnosed during preoperative assessment. Six patients reported treatment. Two of eight patients (25%) underwent DAA treatment after THA. Patients with HCV infection had a higher rate of transfusion, infection, and revision. A multivariate analysis with logistic regression model showed that HCV infection was a significant risk factor for postoperative infection and revision.
78 Incarcerated Choledocholithiasis through a Metallic Stent Mesh Treated by Electrohydraulic Lithotripsy and Peroral Cholangioscopy: Case Report , Kawaguchi S* , Terada S and Endo S
1. Clinical Image  We present a case of incarcerated choledocholithiasis through a metallic stent mesh that was successfully treated with electrohydraulic lithotripsy (EHL) and cholangioscopy performed using the SpyGlassDSR system (Boston Scientific, Japan). An 80-year-old woman with lower bile duct cancer and a large bile duct stone was admitted to our hospital for obstructive cholangitis (Figure 1a). A pigtail plastic stent was initially placed to allow her sepsis to resolve. A 14-mm diameter uncovered biliary metallic stent (Niti-S 14, TaeWoong medical Co., Ltd, Korea) was placed during endoscopic pancreatobiliary cholangiography (ERCP) for the treatment of choledocholithiasis [1] (Figure 1b). The metal stent was preferable because it results in a lower rate of recurrent biliary obstruction with no migration [2]. Next, ERCP was performed to crush the 25-mm diameter stone using EHL [3, 4] with the SpyGlassDSR system (Figure2a, b). The Use of a balloon catheter to remove the crushed stones was difficult because of the metallic stent edge. During the procedure, the bile duct stones were grasped using a basket catheter, but they were then incarcerated through the metallic stent mesh (Figure3a, b). We suc- cessfully separated and removed all of the incarcerated stones via EHL with the SpyGlassDSR system. (Figure4a, b). Overall, we present a novel troubleshooting technique of incarcerated chole- docholithiasis through the metallic stent mesh.
79 The Role of Bacteria in Viral Transmission , Zajac V*
1. Abstract Every virus is a parasite. They exist by themselves. He is envious of your wearer. This is the basic condition of its existence. What living cell carries viruses? Based on work with bovine leukosis virus (BLV) in the stables, we monitored the course of infection in healthy animals and concluded that a bacterial cell can be the host of the virus. We tested this assumption and confirmed the results. This idea was then tested on the HIV model in the laboratory of Prof. Flossie Wong-Staal, UCSD. Even with this virus, we have been able to prove that its host may be bacteria. In throat swabs from Kenya and Cambodian HIV positive children, HIV was detected in commensal bacteria and also in yeasts Candida albicans. Based on these results and indications, we conclude that all viruses are transmitted by bacteria or by yeasts. If all, the corona virus. By destroying the bacteria carrying the viruses, the virus ceases to exist. If this idea is confirmed, many, if to all viral infections can be stopped. All viruses, including COVID-19, are parasites. They cannot exist by themselves and fully depend on their carriers. This is the basic condition of their existence. Very little is still known about how they can jump from one species to another and finally spread to humans.
80 An Uncommon Presentation of a Common Rectal Condition , Baqir SM1*, Ismail FW2 and Uddin Z3
1. Abstract We report a case of Solitary Rectal Ulcer Syndrome (SRUS) whose colonoscopy showed a rectal mass whose large pale appearance was uncommon and should be remembered as a presentation of SRUS. SRUS is a chronic, benign disorder commonly caused by constipation - clinical features can comprise of rectal bleeding, passage of mucous, rectal pain, tenesmus, incomplete evacuation, straining on defecation and rectal prolapse. Conservative management or surgical management is offered based on symptomology. We want to illustrate a different thinking process -a rectal mass should not always be considered a potential malignant threat. Even though SRUS is rare as compared to colorectal cancer, the high global prevalence of constipation means that SRUS should not be completely ignored.
81 Serum Follistatin as Short-Term Prognostic Markers for Patients with Chronic Liver Disease , Ichikawa T 1,2,* , Miyaaki H3 , Miuma S 3 , Motoyoshi Y 1 , Yamashima M1 , Yamamichi S 1 , MakikoKoike2 , Nakano Y 2 , Honda T 1 , Yajima H1 , Uehara R1 , Miyazaki O1 , Kuribayashi Y1 , Kira K3 , Taura N3 and Nakao K
1. Abstract 1.1. Background: Chronic Liver Disease (CLD) is caused by several agents and leads to mortality through various mechanisms. Several prognostic factors have been discussed for CLD. Follistatin (FST) is a potential marker for liver function, muscle function, and metabolism. We evaluated whether FST correlated with prognosis and clinical factors. 1.2. Methods: A series of 185 patients with CLD who visited our hospital between May 2017 and June 2019 was enrolled in this study. The mean observation period was 358 days. Patients were evaluated for liver disease etiology, albumin-bilirubin index (ALBI), model for end-stage liver disease (MELD), and fibrosis-4 (FIB-4). Serum FST and activin A (ACT) were assayed using commercially available assay kits. Of the 185 patients, 150 underwent Computed Tomography (CT). Cross-sectional CT images of the third lumbar vertebrae were analyzed using commercial software to determine body composition. 1.3. Results: In the observation period, 14 patients died. In the dead and survivor groups, the observation period was 241 and 368 days, respectively. MELD, FIB-4, ALBI grade, ACT, and FST at admission differed between the dead and survivor groups and influenced the survival periods. In multivariate logistic regression analysis, high FST was the only factor associated with survival. In the body composition assay using CT, FST was associated with subcutaneous adipose tissue, muscle attenuation, and total bilirubin. 1.4. Conclusions: FST is a simple surrogate maker for prognosis in CLD. High FST is a potential aggregation marker of advanced liver damage, low muscle quality, and subcutaneous adipose
82 Controlled HIV-HCV Viremia and Immune-Reconstitution are Associated with Slow Progression of Liver Disease in Co-infected Hemophilic Patients After 30 Years of Follow-Up , Monzani MC1 , Badano MN1 , Aloisi NA2 , Gualtieri A 3 , Corti M4 , Parodi MC1 , Pinto MDT2, 4 , Neme D4 , Primiani L 4 , Bracco MMED1 , Chuit R3 and Bare PC1, 2*
1. Abstract 1.1. Introduction and aim: Controversial results have been reported about the progression of liver disease in HIV-HCV coinfected populations. The purpose of this study is to assess long-term liver disease progression in a group of coinfected patients with hemophilia. 1.2. Materials and Methods: From 1995 to 2015, liver disease was assessed through enzyme levels, platelet counts, Hepatitis C and HIV viral loads (VL), and CD4+T cell counts. Evolution of the APRI liver index was used to estimate hepatic disease (APRI > 1.0 indicating severe fibrosis). 1.3. Results: 2005-2015 proportional liver-related mortality was below 17% while AIDS and other causes including hemorrhagic events reached 42% each. APRI index >1.0 was found in 3 of 32 (9%) patients alive, showing significant liver disease after more than 30 years of infection. Analyzing the evolution of liver disease markers, liver enzymes increased significantly only in those patients with detectable HIV and /or HCV VL (for AST and ALT, p<0.0001; for GGT, p=0.001). HIV suppression and reconstitution of CD4+T cell counts were required to achieve HCV eradication. Through multivariate logistic regression, pre ART (pre-antiretroviral therapy) HIV VL was associated with the development of liver fibrosis (OR=4.755; IC95: 1.057 – 21.387) and with altered liver enzyme values (OR=4.091; IC95: 1.293 – 12.947). No persistent increase in enzyme levels or APRI index was observed in the group controlling HIV and HCV replication and adequate immune recovery. 1.4. Conclusions: The suppression of both viruses, HIV and HCV, together with adequate immune recovery is associated with minimal or slow progression of liver disease.
83 Giant Inflammatory Fibroid Polyp of Upper Esophagus: A Life - Threatening Rare Case , Dinaki K1*, Kalopitas G2 , Tsomidis I3 , Amaniti A4 , Germanidis G5 and Constantinidis J6
1. Abstract Inflammatory fibroid polyps IFPs of the esophagus are very uncommon. Giant IFPs are an extremely rare entity and the majority of them are located in the distal third of the esophagus. They are slowly growing and remain clinically “silent”. As the mass enlarges clinical symptoms appear with dysphagia, chest pain and food regurgitation being the most common. Their clinical course might be indolent and acute respiratory distress might be a life-threatening clinical manifestation of them. We present a case of a 54 years old woman suffering from dysphagia for at least 6 months. Upper gastrointestinal endoscopy revealed a giant esophageal polyp extending from the cervical esophagus almost to the thoracic esophagus. A hot snare polypectomy was attempted, but the polyp prolapsed through the mouth and caused acute respiratory distress. The patient was transferred to the Otolaryngology (OR) department, where urgent orotracheal intubation was performed, using a CMAC video laryngoscope, and the tumor was successfully removed via a transoral approach. Giant IFPs are infrequent in clinical practice and they usually occur in the distal esophagus. The pathogenesis of these polyps remains poorly understood. Because of the risk of lethal complication (asphyxia), it is strongly recommended to remove them once they are diagnosed. These tumors can be removed through transoral, transcervical, transthoracic and endoscopic approaches depending on the location and the size of the tumor. The impressive size of gigantic polyps makes their treatment challenging for surgeons and gastroenterologists.
84 A Case of Severe Duodenitis in an Adult Patient with Hyper IgESyndrome , Tomoe Nomura -Horita1 , Tasuku Hayashi1 , Toshimi Otsuka1 , Naoko Sakurai1 , Hikaru Takano1 , Masafumi Ota1 , Ranji Hayashi1 , Takeo Shimasaki1 , Masakatsu Nakamura1 , Sohsuke Yamada2 , Takashi Mochizuki3 and Tomiyasu Arisawa1*
1. Abstract We present the first case of severe duodenitis in the adult Japanese patient with hyper IgE syndrome (HIES). A 41 years male patient, who has a treatment in the dermatology of our hospital for severe dermatitis with hyper IgE syndrome, had a right frank pain with diarrhea for one week. Because he vomited with nausea two days ago, we were asked for his gastrointestinal examination. A gastroduodenal endoscopy showed severe erosive duodenitis with multiple erosions, submucosal hemorrhage and longitudinal ulceration. Although we doubted a vasculitis complicated with HIES, the findings of a vasculitis was not seen by histological examination in biopsy samples taken from duodenum. However, the diagnosis using skin biopsy sampleswas leukocytoclastic vasculitis. The patient received intravenous methylprednisolone (MP), which provided a complete resolution of abdominal pain within 48 hours. Thereafter, as a dose of MP was tapered, the gastroduodenal endoscopy showed almost normal findings with scattered atrophic villi at 28 hospital days. We suspect that this case was severe duodenitis induced by vasculitis complicated with HIES by endoscopic findings and response for MPtreatment.
85 Hepatic Hydatid Diagnosed Before Operation but Mucinous Biliary Cystadenoma of Intrahepatic Bile Duct By Pathology after Operation: A Case Report , Zhou M1 , Yu Y 1 , Ye J1 , Xin Q2 , Zhang P1* and Liu X1
1. Abstract Intrahepatic biliary cystadenoma is a rare benign tumor of the liver, with less than 5% incidence. Although with the progress of imaging, the discovery of this disease species is more than before, but because this disease has no specific diagnostic means, the preoperative misdiagnosis rate is very high. We report a case of hepatic hydatid diagnosed before operation but mucinous biliary cystadenoma of intrahepatic bile duct by pathology after operation.
86 A Rare Clinical Course of Spontaneous Loss of Surface Antigen of Chronic Hepatitis B by Vertical Transmission: A Case Report , Tan Y* , Zhou X, Sheng J, Chen L and Sun L
1. Abstract The spontaneous loss of surface antigen (SLS) with or without antibodies is considered to be the manifestation of functional cure for chronic hepatitis B virus (CHB) infection. The probability of SLS is very low and its mechanism is unknown. There are many studies on the natural history of SLS, but few studies on its occurrence process. A 39-year-old male suffered from hepatitis B virus (HBV) transmitted vertically from mother to child. The first CHB activity occurred on Nov 12, 2015 and spontaneous HBV DNA clearance occurred. During the three-year follow-up, the HBV remained inactive and stable. On Mar 17, 2019, hepatitis B virology rebound and hepatitis activity occurred. No antiviral treatment was given and SLS appeared.
87 Two Infant Cases of Chronic Hepatitis B Cirrhosis Treated with Lamivudine and Literatures Review , Yao H1 , Yingzi1 YE, Lijing YE1 , Xia WU1 , Xiaohong W1 and Hui YU1*
1. Abstract 1.1. Objective: This study aimed to investigate the efficacy and safety of lamivudine treatment for infant children with Chronic Hepatitis B (CHB) cirrhosis. 1.2. Methods: Clinical features, laboratory examinations, efficacy and safety of lamivudine antiviral therapy for two infant cases with chronic hepatitis B cirrhosis who were treated and relative long-term followed up in our hospital were reported. Literatures on the treatment of chronic hepatitis B until December of 2017 were searched andsummarized. 1.3. Results: The two HBeAg-positive infant patients with CHB presented with elevated ALT≥2ULN over six months. Liver biopsy scored CHB-G3-4S4e and CHB-G3S4e before antiviral treatment, respectively. Antiviral therapy of lamivudine (3mg/kg•d, qd, po) was administered to the two children patients when they were 1year and 1month old. The treatment duration lasted 2 years and 1 month. For Case 1, there was still volatile in ALT in the early stage of antiviral treatment. At 16 weeks of treatment, ALT trended to be normal. During 16 weeks to before 76 weeks, ALT fluctuated at 41-56 IU/L and AST 39-55 IU/L. From 76 weeks upon, the ALT became normal completely. At 24 weeks, HBeAg seroconversion occurred and HBV-DNA level began to be below the detection limit. For Case 2, ALT became normal at 24-week of treatment. HBeAg seroconversion occurred and HBV-DNA level became undetected at 12-week. Liver biopsy showed CHB-G1S3 and CHB-G0S0 before lamivudine was withdrawn in both two children, respectively. No obvious adverse reactions were observed during the antiviral treatment. The two children had been followed up for 4 years and 1.5 years after antiviral treatment withdraw, respectively. And the ALT keeps normal, HBeAg seroconversion is maintained and HBV-DNA level sustains below the detection limit. 1.4. Conclusion: There were obvious liver injuries and early liver cirrhosis in HBeAg-positive infant patients with CHB. Liver inflammation and cirrhosis can be reversed effectively by lamivudine antiviral therapy to a certain extent.
88 Metamorphosis (Transfiguration) of Spontaneous Bacterial Peritonitis , Djurkov V1*, Kiprin G1 , Dimitrova E2 and Krastev N3
1. Review Article Nowadays between 30% and 50% of patients with liver cirrhosis die due to bacterial infections [1, 2]. Spontaneous Bacterial Peritonitis (SBP) is a big complication of the severe complication "ascites" in liver cirrhosis [3-5]. SBP is the main cause of death in patients with cirrhosis [2, 6]. SBP does not arisefrom intraabdominal source which requiressurgery [6, 7], but viabacterial translocation of intestinal (monomicrobial) flora in themesentericlymphnodes [8]. SBP is observed in 10-15% of all patients with cirrhosis and ascites, but its incidence increases to29-33% in patients with double increased serum bilirubin and/or creatinine (>88,4µmol/L) [9]. Renal dysfunction is important predict of mortality in patients with SBP [10]. The life duration of patients with liver cirrhosis and ascites is now significantly extended [11]. The prolonged survival of patients with cirrhosis and as cites leads to increased incidenc eof SBP. In 1/4 of the cases SBP occurs in the third year after manifestation of ascites (7-30% per year) [12].
89 Is HIV in the Human Population Since the Beginning of our Existence? , Zajac V*
1. Short Communication Despite great success in the diagnostics and therapy of AIDS, there are many unanswered questions. Without giving the answers to these questions more successful treatment of patients cannot be expected. The strong argument for this prediction is a fact that it is not possible to stop the worldwide spread of AIDS, especially in Africa. The data leading to the conclusion that HIV alone is the etiologic agent responsible for AIDS is generally accepted. According to this claim, virus was transferred to humans from monkeys in Africa through random contacts 35-50 and according to recent reports even 100 years ago. This claim, which turned into dogma, however, has not been sufficiently confirmed and is unacceptable from epidemiological, statistical point of view and also by common sense.
90 Toxic Megacolon Associated with Cytomegalovirus Infection with Total Colonic Necrosis , Kim SK1 , Fujii Y1 , Fujii T1 , Yuasa K1 , Takami M1 , Okuda T1 , Hayakumo T1 , Kobayashi H2 , Koma Y3 and Kim SR1*
1. Clinical Image A 73-year-old woman presenting with anorexia was admitted. She had been treated for diabetes and hyperlipidemia, but had no past history of Inflammatory Bowel Disease (IBD) or corticosteroid therapy. On the fifth day of hospitalization, computed tomography (CT) revealed edema and dilation of the rectum and sigmoid colon. Colonoscopy (CS) revealed redness and irregular multiple ulcers of the total colon, necessitating differential diagnosis for IBD (Figure 1a, b). On day 21 of admission, contrast enhanced CT revealed subtotal colon necrosis irrespective of depressure with CS (Figure 1 c). Emergent subtotal colectomy was carried out, and an artificial stoma was created at the ileum. Grossly, the colon demonstrated erosion and hemorrhage (Figure 2a), especially at the transverse and descending colon.
91 Contrast-Enhanced Endoscopic Ultrasound Guided Fine Needle Aspiration for the Diagnosis of Pancreatic Carcinoma: A Case Report , Zhao G1 , Zhou A1 , Xu R2 , Zhang Z1 , Wang Y1 , Ji M1 , Li P1* and Zhang S1*
1. Abstract The evaluation of pancreatic head lesions poses a great challenge for gastroenterologists. We report a case of pancreatic carcinoma in a 62-year-old man, who presented with a history of intermittent abdominal pain for one month. Due to its nonspecific clinical presentation and imaging features of CT, MRI and endoscopic ultrasound (EUS), diagnosis of pancreatic carcinoma in this patient is challenging. The diagnosis was confirmed by the combination of contrast-enhanced endoscopic ultrasound (CE-EUS) and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). This case report highlights the diagnostic dilemma of pancreatic head lesions and emphasizes the significance of CE-EUS, and the value of EUS-FNA as a tool for diagnosis confirmation.
92 Gastric Schwannoma with Regional Lymphadenopathy Diagnosed by Endoscopic Ultrasonography-Guided Biopsy , Kim SK1 , Fujii Y1 , Fujii T1 , Yuasa K1 , Takami M1 , Okuda T1 , Hayakumo T1 , Kobayashi H2 , Koma Y3 and Kim SR1*
1. Clinical Image A 71-year-old man, referred to our hospital, presented with a 5×5 cm gastric submucosal tumor with central ulceration at the greater curvature of the lower body as disclosed by upper gastrointestinal endoscopy and endoscopic ultrasonography (EUS). A contrast-enhanced computed tomography scan of the abdomen revealed a 5×5 cm mass in the stomach and enlargement of regional lymph nodes (Figure 1A, B, C, D). EUS guided biopsy was carried out. Histopathological examination revealed spindle-shaped cells arranged in a trabecular pattern, and infiltration of crushed lymphoid cells (Figure 2A, B). The biopsy specimen was positive for S-100 protein, but negative for SMA, c-kit, and CD34 (Figure 2C). The tumor was diagnosed as gastric schwannoma. Considering the possibility of malignancy attribute to old age and regional lymph node enlargement, a partial laparoscopic gastrectomy and dissection of regional lymph nodes was carried out. The submucosal tumor measuring 50×50×35 mm was resected (Figure 2D). The absence of tumor cells in the resected regional lymph nodes indicated reactive lymphadenopathy. The patient has shown no recurrence at two-month follow-up.
93 Epidemiological Characteristics of De Novo Hepatitis B Infection in Liver Transplant Recipients - An Experience from a Tertiary Care Centre in Qatar , Nair AP1 , Sasi S2*, Al-Maslamani M1 , Chandra P3 , Hashim SA1 , Jarir SA1 , Sheikh Z3 and Derbala M4
1. Abstract 1.1. Background: Emergence of Hepatitis B Surface Antigen (HBsAg) in a patient with previously negative Hepatitis B Virus (HBV) serology post Orthotropic Liver Transplant (OTLX) is known as De-novo Hepatitis B (DNHB). 1.2. Aim: To study the clinical profile and epidemiology of patients with DNHB inQatar. 1.3. Patients and Methods: This descriptive epidemiological study was done by retrospectively reviewing records of 159 post-OTLX patients. Baseline epidemiological characteristics of DNHB cases were analysed statistically using the chi-square test and Kaplan-Meier Curve. 1.4. Results: The overall incidence of DNHB was 10.7%, with transplants in China having significantly higher incidence compared to transplants from all other countries. The mortality rate was 23.5% in DNHB cases compared to 2.8% in non-DNHB. 67% of patients survived at least 64 months after diagnosis of DNHB. 5-year survival did not vary significantly between those with DNHB and those without. 1.5. Discussion and Conclusion: OTLX in centers selecting donors liberally without screening for HBV poses a risk of DNHB. We recommend having protective levels of Hepatitis B Surface Antibodies (HBsAb) before OTLX. Prophylactic antiviral treatment should be considered until peri-operative HBV transmission has been excluded by screening hepatic tissue for HBVDNA.
94 Recurrent Hospitalization for Cannabinoid Hyperemesis Syndrome in an Adolescent , Kimberly De Leon BS1 , Julie Pham BS1 , Timothy Chinnock MD2*
1. Abstract Cannabis use is a widely debated topic in current media, however there is still little known about the effects of long-term cannabis use in pediatric patients. In this nearly two-year-long case, we describe an adolescent male with multiple hospital admissions for complications associated with chronic daily use of highly concentrated cannabis in the setting of key clinical characteristics of cannabinoid hyperemesis syndrome (CHS). Additionally, we review current literature regarding trends of cannabis use, treatment of CHS, and suggest future areas for research.
95 A Hepatocelluar Co-Culture System for the Investigation of Cellular-Based Mechanisms of Troglitazone-Induced Liver Injury , Ozawa S1*, Tamura H, Omura R, Sato H, Suzuki R, Ono R, Yoshida K, Kikuchi T, Namba T, Ishida S2, 3, Terashima J, and Habano W
1. Abstract 1.1. Objective: Drug-induced liver injury (DILI) is a serious issue faced by the pharmaceutical industry, and often leads to drug withdrawal once patients experience drug-induced severe hepatic failure. We developed an in vitro assay system that enables to assess cellular damage and immune reaction responses that ultimately result in DILI using troglitazone as a model drug. 1.2. Methods: A co-culture system consisting of a human liver cancer cell line, HuH-7, and the human promyelocytic leukemia cell line, HL-60, was developed for the evaluation of troglitazone-induced changes ingene expression related to chemoattractant and cellular stress. HL-60 cells were subjected to differentiation by 12-O-Tetradecanoylphorbol 13-acetate (TPA) to be a macrophage-like lineage before co-cultures. 1.3. Results: In our co-culture system, more HL-60 cells attached to HuH-7 cells in a TPA-differentiation- and troglitazone-dependent manner. Our system consisting of liver cancer cells and promyelocytic leukemia cells has clarified the importance of genes encoding interleukin (IL)-8 and heat shock protein (Hsp) 70. 1.4. Conclusions: Our co-culture system will be useful for identification of factors associated with various hepatotoxic drugs and for screening for possible DILI-inducingagents
96 Three Cases of Intentional Ingestions of Intact Cellular Phones Retrieved from the Gastrointestinal Tract , Alpert EA1 , Gavriel D2 and Koslowsky B3*
1. Abstract Foreign bodies in the gastrointestinal tract are frequently encountered by gastroenterologists. This includes ingestions as well as insertions via the rectum. However, ingestions/insertions of intact cellular phones are rare. We present a case series of small cellular telephones which were removed from the gastrointestinal tract. Two in separate patients were found in the stomach and removed endoscopically, and two others in one patient were removed manually from the rectum. The technique used for the removal was unique, and should be considered in similar cases.
97 Adjuvant Chemotherapy in the Treatment of Perihilar Cholangiocarcinoma with Lymph Node Involvement , Feng MB1 , Yan Q1 , Tang QB1 , Lin HM1 , Wang J1 and Liu C1*
1. Abstract 1.1. Aims: To study the application of adjuvant chemotherapy in the treatment of Perihilar cholangiocarcinoma (pCCA). 1.2. Methods: We retrospectively collected the data of 86 patients who underwent surgery for perihilar cholangiocarcinoma in our department between 2012 to 2017. The patients were divided into surgery alone group (n=44) and adjuvant chemotherapy group (n=42). Univariate and multivariate analyses were performed and propensity score matching was used to decrease the influence of potential confounding factors. Kaplan-Meier method was used to evaluate the survival of patients. For those 34 patients with lymph node involvement, similar analyses were performed. 1.3. Results: The median survival time of adjuvant chemotherapy was significantly longer than the surgery alone group (19.5 vs 13 months, p=0.0195). The result of multivariate analysis suggested that lymph node involvement and adjuvant chemotherapy were independent prognostic factors. After the propensity score matching, 28 pairs of patients were selected. The median survival time of adjuvant chemotherapy group was significantly longer than the surgery alone group (22 vs 9 months, p=0.0010). For those patients with lymph node involvement, the propensity score-matched cohort was composed of 14 surgery alone patients and 14 adjuvant chemotherapy patients, and the median survival time of adjuvant chemotherapy was significantly longer than the surgery alone group(18.5 vs 8.5 months, p=0.0158). 1.4. Conclusions The application of adjuvant chemotherapy may improve the survival of perihilar cholangiocarcinoma patients and those patients with lymph node involvement.
98 Prognostic Variables for Patients with T2N0M0 Esophageal Squamous Cell Carcinoma , Chen YP1*, Chen S1 , Liu D1 and Huang S2
1. Abstract 1.1. Aims: To explore the variables which could predict the prognosis and might be considered as staging factors in patients with T2N0M0 Esophageal Squamous Cell Carcinoma (ESCC). 1.2. Methods: Records of 525 patients with pathologic T2N0M0 ESCC who underwent surgical resection were reviewed. The T2 category was further subdivided into T2a (circular muscle layers) and T2b (longitudinal muscle layers) based on the invasion depth. The differences in clinic pathologic characteristics between patients with T2a and T2b diseases were compared with the χ2 test. Univariate and multivariate analyses were conducted to investigate prognostic factors. 1.3. Results: The 1-, 3- and 5-year Overall Survival (OS) rates for the whole group were 96.0%, 79.3% and 67.0%, respectively. Age, histologic grade, and T2 subcategory were found to affect OS, while histologic grade, T2 subcategory, and number of lymph nodes resected were found to affect Disease-Free Survival (DFS). Sex, tumor location and tumor length were not correlated with survival. In subgroup analyses for histologic grade, patients with well and moderately differentiated tumors had similar survival, and the survival of these patients groups was better than that of patients with poorly differentiated tumors. 1.4. Conclusions: T2 subcategory by invasion depth was an independent prognostic factor and maybe considered as a staging factor for T2N0M0 ESCC. Histologic grade, age, and number of lymph nodes resected were also correlated with the outcome of these patients.
99 Immunological Pathways in the Development of Postoperative Hyperamylasemia and Postoperative Pancreatitis , Todorov RS1*, Dardanov D1 , Katibova SN1 , Dimitrov K1 , Bulanov D1 , Ionkov A1 and Bozev V2
1. Abstract 1.1. Introduction: Postoperative pancreatitis complications can be separated into two main groups based on literature reviews and clinical trials. Some authors suggest that postoperative pancreatitis is a severe complication that should be treated conservatively and operatively if needed. Other authors defend an opposite opinion that only postoperative hyperamylasemia exists, which is a transitory condition with no risk of complications. 1.2. Methods: At the University Hospital for Active Treatment Alexandrovska, Clinic of General and Liver-Pancreatic Surgery, a cohort of patients with increased amylase concentrations in the postoperative period were studied and followed with immunological tests for interleukin (IL)-6 and IL-10. The working hypotheses were the following: i) IL-6 and IL-10 are directly relevant in the development of postoperative pancreatitis; ii) the concentrations of IL-6 and IL-10 are prognostic factors in the early postoperative period and mark the boundary at which patients will develop postoperative pancreatitis; iii) the postoperative period is accompanied by transient postoperative hyperamylasemia and absence of complications. 1.3. Results: The results show that, with a 95% confidence interval (CI) for IL-6 and with a 99% CI for IL-10, a statistically significant difference is found in the concentration of IL-6 and IL-10 in patients who developed postoperative pancreatitis versus those with transient hyperamylasemia. Discussion/Conclusion: The present study shows a direct link between the immunological markers, IL-6 and IL-10, and the course of both postoperative pancreatitis and transient hyperamylasemia, making these two markers valuable in elucidating the differences in the development of postoperative pancreatitis and transient hyperamylasemia in the early postoperative period.
100 Spirometry Results of Reflux Esophagitis in Asthma Reflux Esophagitis in Asthma , Kim HY
1. Abstract 1.1. Background: The symptoms of asthma and gastroesophageal reflux disease are similar making it difficult to distinguish. Diagnosing Gastroesophageal Reflux Disease (GERD) is complex, as it frequently presents with other pulmonary disease or conditions. Asthma has often been associated with gastroesophageal reflux disease. This study aimed at a better understanding of the association between the conditions. The purpose of this study is to compare spirometry results with endoscopic positive Erosive Reflux Disease group (ERD) and without GERD group who have asthma. 1.2. Methods: A total of 169 consecutive subjects (aged 20-90 years) underwent spirometry and upper endoscopy with asthma diagnosed first in pulmonology department and then looked for the presence of reflux esophagitis, or with re flux esophagitis identified first in gastroenterology department and then looked for the presence of asthma. 1.3. Results: A total number of 169 patients in asthma, with ERD group (n=100) and without GERD group (n=69) completed pulmonary function tests and esophagogastroduodenoscopy. In univatiate analysis, age (P=0.000), body mass index (BMI) (P=0.000), and pulmonary function tests (P=0.000) were significant in asthma with ERD group. The multivariate logistic regression analysis showed that asthmatic patients having ERD have 1.2 times the risk of poor pulmonary function (FEV1/FVC) (pooled odds ratio [OR] 1.215, 95% confidence interval [CI] 1.1-1.4) and 5.4 times the risk of obesity (BMI ≥25) (pooled odds ratio [OR] 5.381, 95% confidence interval [CI] 1.2-25.2). 1.4. Conclusions: This study highlights that the spirometry results severity is considerably higher ERD in asthma patients. Physicians should look out for reflux symptoms in asthma patients and consider evaluation with upper endoscopy when necessary. Likewise, asthmatics presenting with gastrointestinal symptoms may need consultation and evaluation for GERD.
101 Acute Obstructive Jaundice Complicated by Sloughing of Intraductal Tumor Thrombus in Hepatocellular Carcinoma after Transarterial Chemoembolization: Two Case Reports and Literature Review , Han S, Jin K, Li B, Zhang G, Tang R, Chao M* and Wu J
1. Abstract Transarterial chemoembolization (TACE) is relatively useful for tumor thrombus of HCC. Still, certain infrequent side effects and complications, such as obstructive jaundice, may occur after TACE. Herein, we reported two cases of patients with acute obstructive jaundice complicated by excretion of necrotic bile duct tumor thrombus after transarterial chemoembolization (TACE). After Percutaneous Transhepatic Cholangiography (PTCD) or ERCP, and the patients gradually recovered.
102 Prevalence of Nocturnal Leg Cramps in Patients with Liver Disease is Higher than with Other Chronic Disease , Kida Y
1. Abstract 1.1. Objective: A nocturnal leg cramps (NLC) is caused by a continuous, involuntary, painful, and localized contraction of a muscle or simply some muscle bundles.NLC is associated with a reduced quality of sleep and a subsequent lower health related quality of life. The purpose of our study is to clarify both prevalence and characteristics of NLC in patients with chronic diseases. 1.2. Methods: Three hundred and ninety-five patients with chronic disease were enrolled in our study. We simply asked “Did you experience the Nocturnal leg cramps in past a month?” to the patients. We examined the relation between the presence of NLC and the demographics and other baseline characteristics. 1.3. Results: One hundred and twenty-three patients (31.1%) experienced NLC in a past month. The multivariate analysis revealed that presence of >=age50 (HR, 3.78; P < 0.001), Type 2 diabetes mellitus (HR, 2.19; P < 0.001), Hyper lipidemia (HR, 2.62; P < 0.001), Liver Cirrhosis (HR, 14.6; P < 0.001), and Chronic liver disease (HR, 2.70; P < 0.001) were independently associated with the prevalence of NLC. 1.4. Conclusion: Prevalence of NLC in patients with chronic disease was not low in primary care. Especially, prevalence of NLC in patients with liver disease was higher than with other chronic disease. When treating chronic diseases, we should consider NLC, and treat it.
103 The Relationship between Pancreatic Fibrosis and Pancreatic Cell Apoptosis Induced by Fas/Fas Ligand Pathways in Aly/Aly Mice , Wang ZD1 , Ren K1 , Dai YD1 , Chen JF1 , Zhang MS1 , Wang HX2 , Itoh M3 and Yi SQ*1
1. Abstract 1.1. Objective: In this study, we examined the relationship between the expression of Fas/Fas ligand apoptotic signaling pathway and pancreatic fibrosis in autoimmune chronic pancreatitis of aly/aly mice. 1.2. Methods: The histopathological changes of inflammatory cell infiltration in pancreatitis aly/ aly mice were observed. Immunohistochemistry was used to detect the expression of CD4, CD8, CD45R/B220, F4, Fas/Fas ligand, collagen I, TGF-β and α-SMA in pancreatic tissues. 1.3. Results: Inflammatory cell infiltration, such as T and B lymphocytes, as well as macro phages, were seen in pancreatic tissues of 5-week-old aly/aly mice, but the degree and area of inflammatory cell infiltration gradually increased with age. Fas/Fas ligand, collagen I, TGF-β and α-SMA were expressed in the inflammatory infiltration area of the pancreas, and some areas showed necrosis and fibrosis. The infiltration of T and B lymphocytes and macrophages was associated with the occurrence of autoimmune pancreatitis in aly/aly mice. 1.4. Conclusion: The activation and expression of Fas/Fas ligand signaling pathway may induce apoptosis of pancreatic acinar cells and inflammatory cells, resulting in pancreatic tissue necrosis and fibrosis.
104 The Endoscopic Combo Technique: Long-Term Outcomes in Treating Patients with Primary Achalasia , Bedewy E1*, El Gendi A2 and Kamel M
1. Abstract 1.1. Aim: Evaluating combined single step endoscopic procedure of Botulinum toxin injection, pneumatic dilation and mechanical dilation by retroflexed scope (COMBO) as a suggested effective treatment for achalasia 2. Introduction Achalasia is a primary esophageal motility disorder characterized by the absence of esophageal peristalsis and impaired relaxation of the Lower Esophageal Sphincter (LES) in response to swallowing. The annual incidence of achalasia is approximately 1.6 per 100,000 individuals worldwide and prevalence of 10 cases per 100,000 individuals. Patients present usually with progressive dysphagia to solids and liquids, regurgitation, heart burn, chest pain and weight loss. High Resolution Manometry (HRM) is the gold standard test for diagnosis while upper esophagogastroduodenoscopy (EGD) is necessary to rule out tumors of the GEJ or fund us mimicking achalasia [1].
105 Surveillance of COVID-19 Patients with Pre-Existing Liver Diseases: Need to Address , Jindal HA*
1. Abstract Nearly 60% of the patients with the novel virus have elevated liver enzymes. Liver inflammation can be hypothesized to the immune mediated process such as cytokine storm and pneumonia associated hypoxia that may lead to liver enzyme abnormalities or liver failure in critically ill patients with COVID-19.When assessing patients of COVID-19 with elevated liver biochemistries one must be consider for other etiologies unrelated to COVID-19, particularly hepatitis A, B and C & drug intakes. Various conditions like NASH, viral hepatitis, liver transplant candidates and autoimmune hepatitis that may put the COVID patients on high risk. We should avoid imaging unless there is a concern for biliary obstruction or venous thrombosis. There should be continued usage of personal protection measures against COVID-19 and continue surveillance in COVID patients with search of preexisting live pathologies for an early diagnosis and treatment.
106 Quadruple with Omeprazole, Bismuth, Tetracycline and Metronidazole Therapy for the Eradication of Helicobacter Pylori: Efficacy in Naive and Previously Treated Patients with Double and Triple Antimicrobial Resistance , Cosme A1 , Montes M2,3, Alonso H1 , Fernandez-Reyes M2 , Lizasoain J1 , Gutierrez-Stampa MA4 , Sarasqueta C3 and Bujanda L1*
1. Abstract 1.1. Background: To eradicate Helicobacter Pylori (HP) infection it’s necessary to use at least two antibiotics. In patients infected with HP resistant to two or three antibiotics, eradication is more difficult. The objective of this study was to evaluate the efficacy of bismuth quadruple therapy (BQT)-10 days (omeprazole, bismuth, tetracycline-TET, and metronidazole-MTZ) for the eradication for HP in naïve and previously treated patients with double and triple antimicrobial resistance (clarithromycin-CLR, MTZ, and/or levofloxacin-LVX). 1.2. Methods: 3170 consecutive patients infected with HP and with antimicrobial susceptibility were tested in the period 2013-2017. Antimicrobial susceptibility to CLR, LVX, MTZ, amoxicillin-AMX and TET was performed using E-test strips (bio Merieux). 1.3. Results: HP resistant to various families of antibiotics was detected in 21.3% of total isolates, 18.9% (598 patients) to double antimicrobial (CLR, MTZ or LVX), and 2.4% (76 patients) to triple drugs (CLR, MTZ and LVX). A group of 60 patients treated with BQT-10 days, 41 with double- and 19 with triple- HP resistance were enrolled in the study. The global eradication using BQT-10 days in patients with double resistant-HP isolates was 85.3%. In naïve patients with double resistance, eradication was 91.7% while this data for previously treated patients was 76.4%. The eradication rate with BQT-10 in patients with triple resistant-HP isolates was more effective in naïve patients than in those previously treated (90% vs 44.4%). 1.4. Conclusions: Bismuth quadruple therapy for 10 days is a good option in naive patients infected with double- and triple-HP resistance.
107 Eosinophilic Hepatitis an Unfrequently Case of Hepatotoxicity Due To Drugs , Bercich L, Lechiara M2*, Manenti S and Villanacci V1
1. Abstract An interesting case of eosinophilic hepatitis related to an antitumor drug Imatinib. The histologic pictures are very rare and very interesting also for the disappearance of the lesion after removing the drug.
108 Direct Acting Antivirals in Hepatitis C Virus Genotype 3 andAdvanced Cirrhosis , Singh V1*, Kumari S1 , Singh A1 , De A1 and Gupta T2
1. Abstract 1.1. Aim: Direct-Acting Antivirals (DAAs) have revolutionized the management of hepatitis C infection. However, genotype 3 cirrhosis is still difficult to treat. We report our experience in the management of genotype 3 cirrhosis with DAA’s. 1.2. Methods: We analysed 111 adult cirrhotics with genotype 3 infection of which 54 (48.6%) had Decompensated Cirrhosis (DC). Patients with Compensated Cirrhosis (CC) received sofosbuvir (SOF), pegylatedinterferon (PEG-IFN) and ribavirin (RBV) for 12 weeks (group1; n=13) or SOF, daclatasvir (DCV) and RBV for 24 weeks (group2; n=44). DC patients received SOF, DCV, and RBV for 12 or 24 weeks (group 3; n=37). Untreated DC patients acted as controls (group 4; n=17). The primary endpoint was sustained virological response at 12 weeks (SVR12). 1.3. Results: SVR12 was achieved in 96.4% of CC and 94.5% of DC patients. SVR12 was higher in group 2 as compared with group1in CC (100% vs. 84.6%, p=0.049). SVR12 was comparable in DC treated with SOF, DCV and RBV for either 12 or 24 weeks (92.3% and 95.8%; p=1.0). Side effects were more common in group1 compared to group 2 (100% vs. 22.7%; p<0.001). Side effects were noted in 40.5% patients in group 3, predominantly fatigue and anemia. 1.4. Conclusions: DAA’s are safe and effective in treatment of genotype 3 cirrhosis. SOF, DCV and RBV combination is superior to SOF, PEG-IFN, and RBV in CC. Treatment with SOF, DCV, and RBV for 12 or 24 weeks were comparable in DC.
109 Increased Serum Uric Acid Level is Positively Associated with Ulcerative Colitis: A Retrospective Case-Control Study , Zhang FM, Li S, Ning L, Zhu HT, Chen W and Xu GQ1*
1. Abstract 1.1. Objective: Recent studies have found that elevated uric acid in intestine during an inflam‑ matory response could exacerbate intestinal disease. The aim of this study was to investigate the association of serum uric acid level with Chinese ulcerative colitis. 1.2. Methods: Serum uric acid level was acquired from the blood biochemical examination and divided them into quartiles. Serum uric acid level was compared between ulcerative colitis patients and controls. Relationship between serum uric acid level and characteristics of ulcerative colitis were evaluated. Logistic regression analysis was used to evaluate serum uric acid level and the risk of ulcerative colitis. 1.3. Results: Higher serum uric acid level was identified in ulcerative colitis patients compared to healthy controls(259.14 ± 85.17 umol/L versus 235.55 ± 50.26 umol/L respectively, P < 0.001), the result was the same when stratified by gender. After stratification by disease stage of ulcerative colitis, higher serum uric acid level was also identified in ulcerative colitis patients in active stage compared to ulcerative colitis patients in remission stage (262.32 ± 83.75umol/L versus 236.28 ± 53.23 umol/L respectively, P=0.036).There was no difference in SUA level between UC patients and healthy controls according to smoking status, existence of extra intestinal symptoms, and disease localization. Multivariate logistic regression showed that the highest quartile of serum uric acid was independently associated with ulcerative colitis risk (OR = 1.87 95% CI: 1.35 – 2.89, P ≤ 0.001). After adjusting for gender and age, the highest quartile of serum uric acid was still independently associated with ulcerative colitis risk (OR = 1.62, 95% CI: 1.24 – 2.55, P=0.002). 1.4. Conclusion: Serum uric acid level is significantly associated with ulcerative colitis, and ele‑ vated serum uric acid level is an independent risk factor for ulcerative colitis.
110 Fever, Abdominal Pain, and Lymphocytic Ascites in a Young Immigrant from Western Africa , Faraone A1*, Tomasi D2 and Fortini A 1
1. Abstract Tuberculous peritonitis is an uncommon disease in countries with low tuberculosis (TB) incidence, most often affecting non-white race, foreign-born individuals. We describe a case of TB with peritoneal involvement in a 32-year-old man immigrated to Italy from Burkina Faso, who presented with a history of fever, malaise, abdominal pain and abdominal swelling. Due to its nonspecific clinical presentation and paucibacillary nature, diagnosis of tuberculous peritonitis can be challenging, and requires a high index of suspicion. This report highlights the diagnostic challenges posed by tuberculous peritonitis and emphasizes the importance of imaging (computed tomography, CT) in identifying typical findings, and the value of histological examination of tissue specimens from peritoneum or any site of suspected TB as a tool for diagnosis confirmation.
111 HO-1 as a Dynamic Sensor in the Livers of Chronic Cerebral Hypoperfusion Rats , Yu TP1, 2, 3, Zhang X 2, 3 and Li Y1, 2, 3
1. Abstract Heme oxygenases, mainly including heme oxygenase-1(HO-1) and heme oxygenase-1(HO-2), play a key role in protecting from oxidative stress and inflammation associated with vascular disease. Little is known, however, about the roles of HO-1 and HO-2 in the livers of rats with chronic cerebral hypo perfusion. The study aims to evaluate the expression and roles of HO-1 and HO-2 in the livers of cerebral hypo perfusion rat. Adult male SD rats aged 4 months and weighing 250-300g, were enrolled and performed by permanent bilateral common carotid arteries occlusion (2 vessel occlusion, 2VO), then randomly divided into 6 groups (sham-operated, postischemia 1d, 7d, 14d, 21d and 28d). HE staining showed hydropic degeneration happened after 2VO operation. RT-PCR and Western blot results showed that HO-1 was increased in the livers in postischemia 1d group and peaking in 7d group (p<0.05), compared with sham-operated group. Nevertheless, the expression of HO-2 was not changed with time gradient. Meanwhile, immunohistochemistry results were consistent with RT-PCR and Western blot results. Exposure of liver to 2VO was resulted into a time-dependent increase of heme oxygenase activity. The increase was evident at 1 day after 2VO compared to sham-operated rats, and heme oxygenase activity continued to rise at 7 days after hypoperfusion (P<0.05). Then it gradually decreased at 14 days, 21 days and 28 days respectively. This trend was corresponding with the mRNA and protein expression levels of HO-1. Therefore, our findings suggested that the expression of HO-1 mRNA and protein were increased in a time-dependent manner in the livers of chronic cerebral hypo perfusion rats, and HO-1 might be a new target of drug treatment for the livers of cerebral hypo perfusioninjury.
112 Fenestration of the Main Pancreatic Duct. The First Description , Egorov VI1 , Petrov RV2 , Gruzdev IS3*, Kondratiev EV1,3 and Zelter PM4 1
1. Abstract 1.1. Aim: Toshow the unique aberrant anatomy - fenestration of the main pancreatic duct, identified by additional radiological study of thepancreas. 1.2. Method: Retrospective analysis of the case of bifurcation of the main pancreatic duct with the help of by multi-planar and 3-D reconstructions of the abdominal CT scans. 1.3. Results: The first case of fenestration of the main pancreatic duct was described. 1.4. Conclusion: Detection of MPD fenestration can be more frequent if preoperative multi-planar and 3D- reconstruction of the whole pancreas is systematic in cases of MPD bifurcation.
113 Does Measured Aggression with Stereotactic Hypo Fractionated Radiotherapy and TACE Allow Liver Transplant in Patients with Hepatocellular Carcinoma with Portal Vein Tumour Thrombus - A Retrospective Study , Nangia S1*, Gupta S2 , Agarwal S2 , Rastogi H3 , Khosa R4 , Singh M4 , Goyal N5 , Vohra S4 , Rawat V3 , Chauhan S4 and Oomen S4
1. Abstract 1.1. Background: Patients with HCC and PVTT have a poor prognosis and are not offered liver transplant. 1.2. Aim: To report survival outcome of living related donor liver transplant for patients with HCC with PVTT (portal vein tumor thrombus) treated with Stereotactic hypo fractionated radiotherapy (SHORT), and TACE. 1.3. Material & Methods: Patients with liver confined HCC with PVTT and minimum 1000 cc volume of uninvolved cirrhotic liver underwent SHORT and TACE, former administered using Rapid Arc, dose 32-50Gy in 5-14 fractions. TACE was performed using gel foam slurry, Inj. Cisplatinum and PVA. Liver transplant was performed on radiological evidence of recanalization or conversion to bland thrombus, liver and venous system confined HCC and good general condition. 1.4. Results: Nineteen patients underwent SHORT, 15 with TACE. Liver transplant could be performed in 7 (37%) patients, and treatment escalated with hepatectomy or reirradiation in 2 (10%) patients, each. Five patients were lost to follow up after progressive disease. The survival of patients undergoing transplant was 100% at 12 months, and 86% at 18 and 24 months. Following transplant, 3 patients died of progressive disease at 13, 26 and 36 months, respectively. One patient is alive with disease, three disease free at 27, 28 and 31 months since registration. 1.5. Conclusion: SHORT and TACE, may allow liver transplant in select patients with HCC & PVTT resulting in excellent 24 month survival, long-term outcome remaining unclear,though.
114 An Unusual Cause of Abdominal Pain: Valentino’s Syndrome. A Case Report , Lopez-Casillas N1 , Luna-Guerrero CE1*, Lopez-Rico LA2 and Vargas-Flores E3
1. Abstract Valentino’s syndrome is a rare entity that can mimic an acute appendicitis caused by the presence of a peptic ulcer which perforated appendicitis causes reactive drainage. Present a case 52- year-old male with clinical symptoms, radiographic and ultrasonographic data appendicitis, which is subjected to laparotomy finding chemical periappendicitis attended by sliding FID turbid liquid in right paracolic, Morrison and pelvic cavity space is presented as well as the presence of a perforated duodenal ulcer, biopsy was performed and ulcer closure with omentum patch, appendectomy cavity and wash and drain placement. The postoperative course was good, with tolerance of liquid on the third day, normal diet and exit the fifth day with proton pump inhibitor, cited for performing upper endoscopy 6 weeks, which was conducted demonstrating complete healing of the ulcer.
115 High-Density Barium Swallow Protocol in Patients with Progressive, Solids-Only Dysphagia , Fontanella G1*, Biondo FG2 , Schettino M2 , Russo M2 , Pacifico F2 and Brogna B3
1. Abstract In this essay, we describe a technical protocol specifically developed to optimize the performance of barium swallows in patients with progressive dysphagia for solids only. We usually perform single-contrast, single-view, very high-density dynamic barium swallows in this kind of patients, in which a mechanical obstruction is highly likely The high density of the barium, coupled with the increased viscosity due to the relatively small amount of water used, 9 ml for every 100g of barium sulphate product, dramatically maximize, in our experience, the demonstration of mucosal abnormalities, speeding the diagnosticprocess.
116 The Effect of Long-Term Human Albumin Administration on the Mortality of Adult Patients with De Compensated Liver Cirrhosis: A Meta-Analysis and Systematic Review , Larrazabal RB Jr1*, Chiu HHC2 and Eric YB3
1. Abstract 1.1. Introduction: Liver disease accounts for approximately 2 million deaths per year worldwide, 1 million due to complications of cirrhosis. Mortality trends in cirrhosis have been increasing in the Philippines; data from 1990 to 2010 showed that there has been an overall increase of mortality by 53.7%. One of the promising treatment options for patients with cirrhosis is the use of human albumin. One postulated mechanism states that the common hallmark in the pathophysiology of complications of advanced cirrhosis is circulatory dysfunction. Based on this pathophysiological basis, targeting circulatory dysfunction appears to be a promising therapeutic approach to decrease the development of complications, which would then lead to a decrease in mortality. Besides its oncotic properties, albumin may exert other biological properties such as antioxidant, improvement of endothelial function and immuno modulatory effects that may be also useful for the prevention of complications of cirrhosis. 1.2. Objective: To determine the effect of long-term human albumin administration on the mortality rate of adult patients with decompensated livercirrhosis. 1.3. Methods: We conducted a systematic literature search using PUBMED, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Google Scholar, and Research Gate. Studies fulfilling the inclusion and exclusion criteria were quality assessed based on the criteria provided in the Cochrane Handbook for Systematic Reviews of Interventions. The number of mortalities reported on follow-up in the included studies was combined and analyzed using the Review Manager (Rev Man) Version 5.3 with 95% confidence interval. 1.4. Results: Five studies were included with a total of 830 patients. Results showed that there is a 32% decrease in mortality rate [RR 0.68 (0.48 to 0.96, 95% CI, Z = 2.22, p 0.03)] after long term human albumin administration with standard medical therapy as compared to those who received standard medical therapy alone. When a subgroup analysis was done to exclude the study which gave Midodrine on top of human albumin, it showed that there was a 36% decrease [RR 0.64 (0.44 to 0.91, 95% CI, Z = 2.48, p = 0.01)] in patients given long term human albumin which was less heterogenous. 1.5. Conclusion:The study suggests that long term human albumin administration might have a beneficial effect in reducing mortality and the incidence of cirrhosis-related complications among adult patients with decompensated liver cirrhosis; although investigators suggest that larger, multi-centered, and double-blinded randomized controlled trials with longer follow-up periods should be done to generate more robust data to validate these claims.
117 Mass Spectrometry Analysis Reveals Dynamic Changes of Protein Components in Lipid Rafts from Rat Liver after Partial Hepatectomy , Zhu B1*, Li J1*, Yang C1 , Jiang M1 , Zhou Q1 , Wang Y1, 2* and Chen P1, 2*
1. Abstract Lipid raft, as scaffolding platform for signal transduction, plays important role in the liver regeneration. But the lipid raft protein expression pattern during liver regeneration has been not reported. In this study, lipid raft proteins from the liver of 72 h post partial hepatectomy and sham-operated group were identified by liquid chromatography-tandem mass spectrometry (LCMS/MS) combined with label-free semi-quantitative analysis. Totally 458 lipid raft proteins were identified, and most of identified lipid raft proteins were mainly involved in transporter, signal transduction, and metabolism. Moreover, label-free quantification analysis suggested that the level of 46 plasma membrane-related proteins have changed obviously (with ratio≥2) after 72 h hepatectomy. Several differently expressed proteins, including caveolin-1 and flotillin-1, were validated by western blotting. Further immuno fluorescence and quantitative real-time polymerase chain reaction data indicated the enhanced signal of flotillin-1 and caveolin-1 around the newly formed blood vessel. Here, the expression pattern of rat lipid raft protein after partial hepatectomy 72 h was investigated, and the differential expressed protein induced by partial hepatectomy was also indicated. Our results suggested that the increased expression of flotillin-1 and caveolin-1 could be involved in the liver regeneration
118 Stepwise Nursing Intervention for Hand-Foot Skin Reaction in Advanced Hepatocellular Carcinoma Patients Taking Sorafenib At Home: A Prospective Study , An L1, 2*, Huang J1*, Yang Y2*, Chen Y1 , Huang S2 , Hao L2 , Sha H2 , Wang Y2 , Zhang X2* and Yang Y1*
1. Abstract 1.1. Background: The burden of therapy-related hand-foot skin reaction (HFSR) can reduce the benefit of treatment for patients. Evidence for the nursing management of sorafenib-related HFSR in nonclinical settings remains inadequate. 1.2. Aim: To establish Stepwise Nursing Intervention (SWNI) management to reduce the burden of therapy-related HFSR in patients with advanced Hepatocellular Carcinoma (HCC) who are taking sorafenib at home. 1.3. Methods: This study was a prospective, randomized controlled study involving informal caregivers of outpatients with advanced HCC and are receiving sorafenib. The participants were randomized into the SWNI management group (n=54) and the family caregiver group (FC, n=54). All patients with sorafenib-related HFSR were treated with 10% urea cream, which was applied to affected sites thrice a week under the SWNI or FC treatment. The primary endpoint was the incidence of grade 2 or 3 HFSR on the feet or hands. 1.4. Results: With a median follow-up time of 8.5 months, the median overall survival was 11.5 months in the SWNI group and 8.0 months in the FC group (p= 0.035). During nursing intervention management, grade 2 or higher HFSR was found in 33.3% of patients in the SWNI group, which was significantly lower than that in the FC group (57.4%) (p= 0.04). Compared with that in the FC group (31.6%), the percentage of patients discontinuing sorafenib in the SWNI group was significantly lowers (9.3%) (p=0.004), with a higher health-related quality of life
119 A Pilot Study Examining the Effect of Kelulut Honey in Dengue Infected Patients by Examining Clinical, Hemodynamic and Biochemical Parameters , Muhamad NAN1*, Roslan AF1 , Boon YW2 , Abidin SA3 , and Yusoff YA31. 
Abstract 1.1. Background: To examine the effects of low dose Kelulut honey administration in dengue patients on the outcome of clinical, haematological and hemodynamic parameters. 1.2. Methods: 47 serological positive dengue patients (age 33±11 year) were included in this doubleblinded randomized control trial. Twenty-four patients were given low dose of Kelulut honey (0.2 mg/kg/day) for 3 days, while 23 patients were given corn syrup in the placebo group. Daily clinical condition, blood investigation and haemodynamic parameters were monitored for 3 days. Overall improvement of warning signs was recorded. 1.3. Results: Although insignificant, average overall day 1, 2 and3warningsignsimprovementwere64.5%±13.5% vs.61.3%±10.5%,42.6% ± 19% vs. 34.4%± 18% and 38.2%± 20.7% vs. 30%± 27% (honey vs. control respectively). At day 3 of administration, average white blood cell count tends to slightly increase with honey after day 3 compared to prior intervention (+0.1±0.37 vs.- 0.7±0.32x103/mL). Average day 3 hematocrit showed decrease in both of the groups, but a higher decrease in honey (-5.2±2.45% vs. -3.7±1.4%). However overall platelet has been seen decreasing more in the honey group compared to control (-36.0±17.36 vs. -23.5±12.87x103/mL). Other parameters measured (BP, RR, renal profile, liver profile) did not show difference between two groups. 1.4. Conclusions: Low dose Kelulut honey administration to dengue patients had non-significant improvement; nevertheless it did not exhibit any detrimental effects on clinical, hemodynamic and biochemical parameters.
120 Sedation versus Nonsedation among Critically-Ill Patients Receiving Mechanical Ventilation: A Meta-Analysis andSystematic Review , Larrazabal RB Jr1*, Chiu HHC2 and Tanchuco J3
1. Abstract 1.1. Background: At present, sedation in patients on mechanical ventilator remains the standard of care. However, many trials have shown that sedation was associated with worse outcomes (i.e. more days on mechanical ventilation and higher mortality rates). We explored the use of nonsedation protocols as compared to conventional sedation in order to determine its effect on the mortality and number of days free from the ventilator among critically-ill patients on mechanical ventilation. This is the first meta-analysis of itskind. 1.2. Methods: We searched electronic databases (PubMed, Medline, EMBASE, Cochrane Central Register of Controlled Trials, Google Scholar, and Research Gate) from 1966 to March 2020 complemented with manual searches. The validity of included studies was assessed using the Cochrane Handbook for Systematic Reviews of Interventions; and analysis using the random-effects model in Review Manager Version 5.3. 1.3. Results: Two of 89 trials comprised of 813 patients were included in the final analysis. All studies included compared two groups of critically ill patients on mechanical ventilation sedation versus non-sedation. The nonsedation groups in both studies only received boluses of morphine as needed. There was no difference between both groups in terms of mortality [1.14 (0.86 to 1.51, 95% CI, Z = 0.93, I2 = 59%) P = 0.35] and number of days free from the ventilator [1.95 (-1.27 to 5.17, 95% CI, Z = 1.19, I2 = 64%) P = 0.24]. However, there were more adverse events reported in nonsedated patients in one study. 1.4. Conclusions: There is no significant difference between the nonsedation and sedation groups in terms of mortality and number of days free from the mechanical ventilator. However, there were more adverse events in the form of accidental self-extubations requiring reintubation and removal of other equipment in the non-sedation. In light of these findings, sedation remains to be preferred
121 Vascular Resections during Curative Surgery for Pancreatic Adenocarcinoma , Boukerrouche A*
1. Abstract The Pancreatic Adenocarcinoma (PA) is estimated to become the second leading cancer-related death cause by 2030. At the time of diagnosis, 30% of patients have a locally advanced disease especially vascular involvement Performed firstly in 1973; the benefits of vein resection on survival have been clearly demonstrated by published reports. The vein resection and reconstruction to achieve curative resection is currently considered as standard of care for locally advanced pancreatic tumors with invaded portal/ superior mesenteric vein (PV/SMV). Regarding pancreatic surgery with arterial resection, the survival rates are encouraging compared to systemic treatment alone. Additionally, the development of more systemic therapies has increased the long-term survival after pancreatic resection with arterial resection to nearly the same level after conventional pancreatectomy. Defining better and more useful prognostic, patients-related, and biological criteria is more necessary and hopeful to select the best candidates for curative surgery. Performed in high-volume centers with specific experience in such procedure; complex vascular reconstruction does not significantly increase the operative risk. Furthermore, more designed trials are highly recommended to defining guidelines for pancreatic resection associated with vascular resection-reconstruction for clinical practice. This review focuses on the recent results of vascular resection and reconstruction to achieve curative surgery for pancreatic adenocarcinoma with consideration of new perspectives offered by more developed systemic treatments, during the last five years.
122 Clinical Review on Dyes Used in Chromoendoscopy , Anepu S* and Murthy KVR
1. Abstract Chromoendoscopic technique dates to 1970, when various dyes were used on the tissue lining the GI tract to detect subtle lesions that are hard to detect using normal endoscopic imaging. Applied colour enhances tissue characterisation thus providing easier identification of pathological condition. Chromoendoscopic systems improve the identification of minute changes in the surface pattern by improving the contrast of raised and deepened areas. Based on the type of stain used different types of epithelia can be easily differentiated. This is particularly helpful in surveillance programmes aiming to detect dysplasia and pre-neoplastic lesions [e.g. in Barrett’s Oesophagus (BO) or Inflammatory Bowel Disease (IBD)] with the diagnostic yield of targeted ‘smarter’ biopsies being superior to random biopsies, thus reducing the histopathologic workload and potentially offsetting the costs for additional procedure time. This review discusses in detail various stains equipment and drawbacks of chromoendoscopy
123 Dissecans Esophgitis of Probable Fungal Etiology: Case Report , Bastos MC¹* , Mendes KBDM², Oliveira CR³, Oliveira AND³ and Almeida GED³
1. Abstract Dissecting esophagitisis a rare and benign form of chronic esophagitis, of diverse etiology, characterized by a typically whitish mucosa, with or without bleeding and presence of vertical circumferential fissures and cracks at endoscopy. Next, list a case of a young adult individual, who had a diagnosis of EDS with endoscopic diagnosis of EDS with probable cause of infection associated with loss of submucosal vascular component. Afterthe diagnosis was made, therapeutic intervention was effectively possible
124 Low-Grade, Well-Differentiated Gastric Tubular Adenocarcinoma (LG-Tub1): Why should it be noticed now ? , Saitoh T
2. Editorial General type gastric cancer (GC) lesions are classified according to differentiation degree; into Papillary Adenocarcinoma (pap), Tubular Adenocarcinoma (tub), Poorly Differentiated Adenocarcinoma (por), Signet-Ring Cell Carcinoma (sig), and Mucinous Adenocarcinoma (muc). Additionally, tub lesions are subdivided into well- and moderately differentiated tub (tub1 and tub2, respectively). Por lesions are subdivided into solid (por1) and non-solid (por2) types [1]. The differentiation degree indicates how similar the structure of cancerous parts is to that of non-cancerous parts. Malignant biological characteristics become greater in contra proportion to differentiation degree (synonymous with structural atypia grade). Thus, the lower the structural atypia grade is, the greater malignant biological characteristics become.
125 Forestier Disease as a Cause of Dysphagia: A Case Report , Fontanella G1*, Fuggi G2 , Barbieri L2 , Manganiello CAT and Brogna B
1. Abstract We describe here the clinical history of a 74-year old man presenting with a gradually worsening pharyngeal dysphagia with globus, occasional intra-deglutitory coughing, hoarseness and a 5 kg weight loss in the previous two months. Apart from type II Diabetes Mellitus, the patient’s clinical history was unremarkable. The patient was seen by both Gastroenterology and ENT specialists and subsequently referred to our Radiology Unit, where pharyngo-esophageal Barium Swallow and CT were performed and the suspected diagnosis of Forestier Disease wasconfirmed.
126 A Pancreatic Tumor with Central Calcification , Mio Namikawa1 , Toshiyuki Kimura2 and Akihisa Fukuda1*
2. Clinical Image A 49-year-old woman visited our hospital with a history of epigastralgia, high fever and general malaise. Her temperature was 37.6 ℃. There was no significant past medical history. On physical examination, she had tenderness at the upper abdomen. Laboratory data were as follows: white blood cell count of 3000/μL, C-reactive protein of 6.77mg/dL, carcinoembryonic antigen of 1.9ng/mL, and carbohydrate antigen 19-9 of 33.8U/mL. Contrast-enhanced computed tomography scanning showed a poorly enhancing mass approximately 4.5cm in diameter at the head of the pancreas, which contained calcification in the middle of the mass (Figure 1). There were multiple lymphadenopathies around the stomach and mesenterium, peritoneal disseminations and ascites. Magnetic resonance imaging revealed a pancreatic mass with moderately high intensity on the T1 weighted image. Endoscopic ultrasound showed a hypoechoic mass which had central calcification at the head of the pancreas (Figure 2).
127 Sonographic Diagnosis of Abdominal Cutaneous Nerve Entrapment Syndrome: A Report of Two Cases , Hata J* and Imamura H
1. Abstract We report two cases of Abdominal Cutaneous Nerve Entrapment Syndrome (ACNES) successfully diagnosed using Doppler ultrasound. In both cases, patients complained of chronic abdominal pain, and physical examination showed a positive Carnett’s sign. Although the results of several examinations including endoscopy appeared normal, ultrasound examination revealed a perforator artery with its characteristic low peak systolic velocity at the site of the pain. These ultra sonographic findings may facilitate an accurate and objective diagnosis of ACNES.
128 Viral Hepatitis B Genotypes among Outpatient Clinic Attendees in North Rift, Kenya , Koech S1,2, Odari E2 , Lihana R3 , , Maiyo A3 , Cheriro W4 , Kiptoo M5 , Azumi I6 and Songok EM1,6*
1. Abstract 1.1. Objective: Most hospital outpatients unaware of their Hepatitis B Virus (HBV) status could be seeking treatment for other different ailments in Kenya. To evaluate the HBV prevalence and the genetic diversity, the genetic analysis of the partial HBV S gene was conducted. 1 .2. Methods: Two hundred blood samples were collected from consenting outpatients who were unaware of their HBV status at Moi Teaching and Referral Hospital (MTRH), Kenya, between September 2015 and October 2016. The serum was tested for the HBV surface antigen (HBsAg) using the ELISA test. DNA was extracted from HBsAg positive samples, amplified and sequenced for HBV S gene. The sequences were then compared with reference sequences retrieved from the GenBank. 1.3. Results: Ten percent of subjects (20/200) were positive for HBsAg. Thirteen of the 14 isolates (92.9%) belonged to HBV sub genotype A1 (HBV/A1). In all the 14 isolates either one or more mutation was detected within Major Hydrophilic Region (MHR). The most occurring mutation was S114T which appeared in 13 of 14 isolates. No known mutations associated with occult HBV infection or vaccine escape were observed. 1.4. Conclusion: Ten percent of outpatients at MTRH could be a source of unaware HBV transmission in the community. HBV/A1 remains the most predominant genotype. The findings that the HBsAg mutations in MHR were observed in all isolates revealed the importance of monitoring the MHR mutations in this country. The development of an optimized HBV screening, vaccine program and a monitoring system of MHR mutation are urgently needed in North Rift Kenya
129 Association of high Altitude Polycythemia with an Increased Risk of Systemic Inflammatory Response Syndrome in Acute Pancreatitis , Zhu H1*, Guo YM1 , Yang JY1 , Yexie ZH1 , Bai YL1 and Cao T1, 2
1. Abstract 1.1. Objective: To investigate the relationship between systemic inflammatory response syndrome (SIRS) and the severity of acute pancreatitis with high altitude polycythemia (hereinafter referred to as AP+HAPC) in individuals living in a high-altitude region, to provide evidence for the treatment of SIRS and AP+HAPC. 1.2. Methods: A retrospective analysis of clinical data on AP+HAPC and acute pancreatitis without high altitude polycythemia (hereinafter referred to as AP-only) was conducted in100 in patients admitted to the People’s Hospital of Qinghai Province from 2006 to 2016. All 100 cases were evenly categorized into 2 groups according to diagnostic criteria: AP+HAPC group (n=50) and AP-only group (n=50). The patients in the high altitude polycythemia group were further divided into mild and severe subgroups based on the Acute Physiology and Chronic Health Evaluation II scores. The data were analyzed based on the presence of SIRS, number of diagnostic criteria met, diagnostic parameters, and relationship between severity of AP+HAPC and duration of SIRS. 1.3. Results: There was a significant difference between the 2 groups (AP+HAPC vs. AP-only) not only in the number of patients who developed SIRS but also in 2 diagnostic criteria of SIRS fulfilled by patients. There was a significant statistical difference in terms of 5 diagnostic parameters of SIRS between the high altitude polycythemia group and the non-high altitude polycythemia group. The significant differences between 2 and 3 diagnostic criteria of SIRS fulfilled by patients were found to be related to the severity of SIRS in patients with AP+HAPC; the greater the severity of AP+HAPC, the longer the duration of SIRS. 1.4. Conclusions: SIRS is highly correlated with the severity of AP+HAPC in individuals living in a high-altitude region. Early and active treatment of SIRS is beneficial in the management of AP+HAPC.
130 Anti-Programmed Cell Death-Ligand-1 Immunotherapy-Related Secondary Sclerosing Cholangitis , Numao H*
1. Abstract An 86-year-oldwoman presentedwith epigastric pain and anorexia.She was diagnosedwith lung adenocarcinoma and was prescribed atezolizumab 20 days earlier. Her data showed a cholestatic-typeliverdysfunction.Weobservedthetypicalcharacteristicsofsclerosingcholangitisoncomputed tomography and magnetic resonance cholangiopancreatography (MRCP), including wall thickening,multifocalstrictures,andsegmentaldilatationsofthebileduct.Shewasdiagnosedwith immune therapy-related secondary sclerosing cholangitis and treated with prednisolone; however, liver function and MRCP findings worsened over time. When a patient receiving atezolizumab develops immune therapy-related hepatitis, secondary sclerosing cholangitis should be considered among the differential diagnosis.
131 Treatment of Chronic Hepatitis C: An Experience Report from a Referral Center in Northeastern Brazil , Medeiros Falcao APR1 , Haibara PM2 , deSouza FHD2 , Nunes GLA2 , Moraes JAS2 , Rego ACM3 and Araujo-Filho I4*
1. Abstract 1.1. Background: Therapy for the Hepatitis C Virus (HCV) has undergone a revolution with the introduction of Direct-Acting Antivirals (DAA). DAAs achieve Sustained Virological Response (SVR) in 90-95% of treated patients, compared to 50-70% of those receiving dual pegylated interfere on and ribavir in therapy. Although they are already available, there are few studies on DAAs efficacy in the Brazilian population. 1.2. Objective: To evaluate the efficacy of DAAs in individuals with hepatitis C at the Liver Study Center (LSC) in Hospital Universitario Onofre Lopes (HUOL). 1.3. Methods: Medical records of chronic HCV patients treated with DAAs from LSC were analyzed. Only those patients with a follow-up of at least 12 weeks after the end of treatment were included. 1.4. Results: A total of 50 patients underwent treatment with DAAs at LSC. Of these, genotype 1 was present in 39 patients (81.2%, 1a 8.3%, 1b 68.7%), genotype 2, in 2 patients (4.2%) and genotype 3, in 6 patients (14.5%, 3a 2%). Thirty-two were cirrhotic (64%), and 20 were treatment-experienced (40%). The therapeutic regimens used were mainly sofosbuvir (SOF) + simeprevir (SMV) in 23 patients (46%) and SOF + daclatasvir (DCV), in 22 (44%). SVR-12 was achieved in 92% of patients. Four patients had virological failure: three of them were cirrhotic and treatment experienced. The other one had advanced liver fibrosis (F3) with no previous treatment for HCV infection. No adverse events were reported during DAA treatment. 1.5. Conclusion: The experience of the LSC with DAAs showed a high rate of SVR and excellent tolerability
132 Aortojejunal Fistula on Healthy Aorta Due to Jejunal Diverticulum , Della Schiava N1*, Cazauran JB2,3, Lermusiaux P1,3 and Millon A1,3
1. Abstract Aortoenteric Fistula (AEF) is a rare cause of massive gastrointestinal bleeding. Primary AEF are rare and generally the consequence of an aortic aneurysm. The duodenum and esophagus are the main locations of AEF. Diagnosis is difficult and patients are often hemodynamically unstable at the time of management because of a long delay between hospital admission and diagnosis. Yet, surgery remains possible. Endovascular techniques yield lower morbi-mortality rates. We present the first case of primary aortojejunal fistula on non-aneurysmal aorta treated efficaciouslyby stent graft placement. Gastroenterologists must be aware of this etiology to reduce the delay to diagnosis and improve survival rates.
133 Abdominal Cocoon Syndrome-Enigmatic and Unconventional Entity of Intestinal Obstruction , Shrtotriya S1*, Doshi R1 , Kumar A1 , Taralekar and Shinde S1
1. Abstract Abdominal cocoon syndrome, the idiopathic form of sclera sing encapsulating peritonitis, is a rare condition of unknown etiology that results in an intestinal obstruction due to total or partial encapsulation of the small bowel by a fibro collage nous membrane (cocoons) [1]. A major challenge faced by clinicians while dealing with this entity is that the early clinical features are nonspecific and often not recognized, making the pre-operative diagnosis difficult. In this case we aimed to present a patient diagnosed with abdominal cocoon syndrome peri-operatively.
134 Alpha-Fetoprotein and the Early Diagnosis of Hepatocellular Carcinoma , Medeiros Falcao APR1 , Almeida Cipriano CHD2 , Queiroz GCD2 , Pedreira NDV2 , Rego ACM3 and Araujo-Filho I4*
1. Abstract Hepatocellular carcinoma is the most common primary malignant tumor of the liver. Cirrhosisis associated with its carcinogenesis, so periodic surveillance is necessary. Ultrasonography is currently the most appropriate test for screening hepatocellular carcinoma, and alpha-fetoprotein is the most used biomarker despite its low sensitivity. Given the discussion and lack of consolidated information on the topic, the importance of alpha-fetoprotein in the early diagnosis of hepatocellular carcinoma in a reference service in hepatology was assessed. An observational, cross-sectional, retrospective study was carried out, in which the population consisted of patients treated at a referral center for liver disease in north eastern Brazil, where 13,500 medical records were analyzed. After applying the inclusion and exclusion criteria, 42 medical record seligible for this study were selected. Of these patients, 54.8% had normal alpha-fetoprotein and 45.2% altered values. From ultrasounds, 66.7% had neoplastic characteristics, while 33.3% were healthy. After a statistical analysis of the relationship between the levels of the biomarker and the early diagnosis of hepatocellular carcinoma, a value of p=0.079 was found. It was concluded, therefore, that the alpha-fetoprotein dosage did not make a significant difference for the diagnosis of hepatocarcinoma in the analyzed sample. Regarding the sensitivity found for this biomarker and ultrasound, the findings were similar to those found in the literature, with alpha-fetoprotein below the predicted. Thus, the dosage of this biomarker alone is not indicated for screening hepatocellular carcinoma. The diagnosis must contain a serial ultrasound with or without the measurement of alpha-fetoprotein.
135 Assessing the Severity of Advanced Intestinal Failure Associated Liver Disease in Children , Legeret C1*, Modin L1 , Beath S1 , Hartley J1 and Gupte GL1
1. Abstract 1.1. Background: Gastro-Oesophageal Varices (GOV) in the presence of liver fibrosis along with splenomegaly on USS abdomen are used as surrogate markers of portal hypertension for grading intestinal failure associated liver disease (IFALD). The severity of IFALD determines the type of intestinal transplant performed. We report on grading severity of IFALD in children assessed at our Centre for intestinal transplantation. 1.2. Methods: From a cohort of children with IFALD, forty-nine were selected because they had simultaneous abdominal ultrasound (USS), Oesophago-Gastro-Duodenoscopy (OGD) and liver histology. 1.3. Results: In total, 40/49 children had splenomegaly of which 8 had GOV and 39 had fibrosis on liver biopsy. The presence of liver fibrosis was associated with splenomegaly (p=0.03) while this was not seen for GOV (p=0.45). Eight children with IFALD had no splenomegaly, no GOV and no fibrosis and required no further investigations to stage degree of liver disease. One patient, who had undergone splenectomy, had GOV. 1.4. Conclusion: Splenomegaly and liver fibrosis are common in children with IFALD, but gastro-oesophageal varices are uncommon and hence may not be a useful surrogate marker for assessing severity of IFALD in children.
136 Are we Close to Achieving HBV Cure? Risk for Hepatocellular Carcinoma Persists Despite Successful Suppression of Hepatitis B Virus for Over a Decade , Cao C1 , Shinn B1 , Halegoua-DeMarzio D1 and Hann HW1,2*
Short Communication Since the discovery of the Hepatitis B Surface Antigen in 1965 by Blumberg et al [1] and recognition of the antigen linked with post-transfusion hepatitis by the same group and others, significant progress on our understanding of the Hepatitis B Virus (HBV) has followed. Such advances include the illustration of the HBV virion [2], identification of Hepatitis B e-Antigen [3], and discovery of the first HBV plasma vaccine in 1982, which was named the first anti-cancer vaccine by WHO. Soon after, the Bloomberg group noted that in endemic regions, the majority of liver diseases including Hepatocellular Carcinoma (HCC) was associated with chronic infection of HBV [4]. Furthermore, a strong family aggregation was noted and this observation was confirmed by the discovery of vertical transmission from the mother to the newborn at the time of delivery.
137 The MYTHS of De novo crohn's Disease After Restorative Proctocolectomy with Ileal Pouch-anal Anastomosis for Ulcerative Colitis , James SD1,2, Hawkins AT3 , Um JW4 , Ballard BR5 , Smoot DT6 and M'Koma AE3,7,8,9,*
1. Abstract 1.1. Background: Inflammatory Bowel Disease (IBD) are the manifestation of overzealous dysregulated immune response in the intestinal tract, directed primarily against the indigenous microbes combined with defective functioning of anti-inflammatory pathways. Finding a trustable lead to predicting de novo Crohn’s Disease (CD) prior to performing “pouch surgery”, Restorative Proctocolectomy (RPC) with Ileal Pouch-Anal Anastomosis (IPAA) for UC and/or Indeterminate Colitis (IC) is clinically important and remains debatable. De novo CD is a subsequent long-term postoperative complication in IBD patients with Ulcerative Colitis (UC) undergoing IPAA. Herewith we discuss this understanding in laboratory-based basic science research, with its molecular application as a possible corner stone tool for clinical progress and success in the IBD Clinic. Crypt Paneth cell (PCs) secreted enteroendocrine alpha-defensin 5 (DEFA5)” if developed properly is likely to solve diagnostic and prognostic difficulty in IBD Clinics. DEFA5 has shown the ability to differentiate the predominant subtypes of colonic IBD (CC vs. UC) at first endoscopy biopsy, avoiding diagnosis delay prior to colectomy. In addition, DEFA5 accurately circumvents indeterminate colitis (IC) patients into accurate IBD subtype (UC or CC). Further, DEFA5 can be used in selecting CC patients that may have positive outcomes after IPAA surgery [1]. Furthermore, likewise, DEFA5 can predict UC patients likely to have positive or poor outcome, e.g. those patients that are likely to transform/ convert and adhere to de novo Crohn’s after IPAA can be picked up in endoscopy biopsy before surgery.
138 Inflammatory Bowel Disease On-Line Web-Based Guide to Health Professionals and Patients in Developing and African Nations , Herman AM1 , Hawkins AT2 , James SD3,4 , Ballard BR5 and M'Koma AE2,6,7,8*
1. Abstract 1.1. Introduction: Inflammatory Bowel Disease (IBD) is recklessly evolving worldwide as incautious disaster, especially in developing nations as a regional duplicitous emergence disease. It has come to light that adaptive Western culture, rapid urbanization lifestyle in the developing nations have been seen to be associated with this increasing trend incidence. Apparent unclassified strategic challenge assessment of how key trends and uncertainties might lead the world over the next decades to help developing nations and plan for the long term. Healthcare professionals are faced with limited resource and unequipped laboratories for IBD diagnostics, prognostics and monitoring management. Limited knowledge on IBD among developing nation’s physician’s/healthcare providers is painstaking and indisputable challenge. With the emergence of advanced communications technology, the internet offers diverse, substantial, easily accessible, and educational resources that are more time- and cost-efficient than conventional modes of knowledge acquisition. An On-Line Web-Based Resources about IBD, as a guide would greatly assist health professionals and patients. 1.2. Methods: We performed a literature search according to PRISMA-P (preferred reporting items for review and meta-analysis and searches in PubMed (MEDLINE database) to identify and select peer-reviewed articles allied to web-based educational accoutrements for IBD. 1.3. Results: In developing nations, locally trained physicians have limited knowledge on IBD. Mostly, IBD is not included in their training Core Curriculum and research in this field/area is limited in these countries. The healthcare approaches, both at the primary care and referral levels, many times lack the essential regular clinical guidance and laboratory evaluation assessments needs for monitoring patients. Moreover, increasing treatment costs impose additional burden on the healthcare systems. Expensive pharmacological biosimilar and biologic agents/drugs, new treatment targets, and new quality indicators in patient health quality of life and care are significant challenge in addition to early manifestations of IBD are likely to be missed at most health institutions.
139 Formaldehyde Increases Free Cholesterol Contents in Hepg2 Cells without Alteration of HMGCRExpression , Bai J1* , Jiang X1 , Tan Q1 , Liu Y1 , Wang P1 , Zhang Y1 , Li Y1 and Wang D2
1. Abstract Formaldehyde (FA) is a common environmental pollutant that can cause serious liver damage. The aim of this study is to investigate the effect of FA on cholesterol metabolism in human hepato cellular carcinoma cells (HepG2). After exposure to different concentrations of FA for 24 and 48 h, free cholesterol (FC) contents were measured using the GPO-Trinder method, expression levels of several genes related to cholesterol metabolism were analyzed using RT-q PCR, and protein expression of key factors in cholesterol synthesis were measured using western blotting. Our results showed that intracellular FCs in HepG2 cells significantly increased at 24 and 48 h after exposure to FA at 0.004-0.1 mmol/L, and extracellular FCs greatly decreased at 48 h after exposure to FA at 0.004-0.02 mmol/L. However, mRNA and protein levels did not change in HepG2 cells, and the precise mechanism for FA-induced increase in FCs remains unclear. Our results highlight the necessity of further research to illustrate relevant mechanisms for aldehyde-induced hepato toxicity.
140 Safer Values of Low Density Lipoproteins in the Plasma , Helvaci MR1*, Abyad A2 and Pocock3
1. Abstract 1.1. Background: We tried to understand the safer values of low density lipoproteins (LDL) in the plasma. 1.2. Methods: Patients with plasma LDL values lower than 80 mg/dL were collected into the first, lower than 100 mg/dL into the second, lower than 130 mg/dL into the third, lower than 150 mg/dL into the fourth, and 150 mg/dL and higher into the fifth groups, respectively. 1.3. Results: The study included 815 cases (477 females), totally. The mean age, female ratio, body mass index (BMI), fasting plasma glucose (FPG), triglycerides, LDL, high density lipoproteins (HDL), and white coat hypertension (WCH) increased from the first up to the fifth groups, gradually (p<0.05 in most steps). Similarly, smoking, hypertension (HT), and diabetes mellitus (DM) increased up to the fourth group, gradually (p<0.05 in most steps). Whereas chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD), and chronic renal disease (CRD) were the highest in the first group, significantly (p<0.05 for all). 1.4. Conclusions: Although the increased mean age, BMI, FPG, triglycerides, HDL, WCH, smoking, HT, and DM parallel to the increased LDL values, gradually, COPD, CHD, and CRD were the highest in the group with the lowest LDL and HDL values, significantly, which may indicate functions of LDL and HDL as negative acute phase proteins in the plasma.
141 Tracheoesophageal Fistula in Chemo-Radio Treated Mediastinal Bulky Non-Hodgkin Lymphoma  , Fontanella G* , Manganiello CAT, Lucia SD, Mancinelli M, Festa A and Brogna B
1. Abstract In this case report, we describe the clinical history of a 67-year-old male with a mediastinal bulky non-Hodgkin lymphoma, treated with chemotherapy (R-CHOP scheme) and radiotherapy. Less than six months after complete remission, he was referred to our Gastroenterology Unit with gradual onset esophageal dysphagia, pyrosis and dry cough, especially evident after eating. The symptoms were attributed to gastro esophageal reflux and ignored by the patient himself until they had become intractable. The patient came then to our attention for a barium swallow and a CT scan that documented and confirmed the clinical hypothesis of tracheoesophageal fistula.
142 Generic Sofosbuvir-Declatasvir for Hepatitis C patients in Qatar: A Real-Life Observational Study , Elkomy NM1*, Derbala MF1 , Kaabi SA1 and Chandra P2
1. Abstract 1.1. Background: The hepatitis C virus (HCV) has been considered one of the most pathogens currently challenging the medical community worldwide. Due to the development of new Direct Acting Anti-viral (DAAs, it is expected that almost all patients with HCV infection will achieve a Sustained Viral Response (SVR) in the near future. However, DAA treatment is expensive and inaccessible for some patients with HCV. Recently, new data has been published indicating that generic treatments are a feasible alternative to DAA treatment for hepatitis C sufferers. In Qatar, there is little data about the safety and efficacy of generic Sofosbuvir/Declatasvir combination. 1.2. Aim: To assess the safety and efficacy of generic Sofosbuvir/Declatasvir in the treatment of HCV patients in a real-world setting. 1.3. Methods: This retrospective longitudinal Single-Centre cohort study included all HCV patients who received the new generic DAA combination of Sofosbuvir/Declatasvir at the Hamad Medical Corporation between August 2016 and November. Measures were assessed by reviewing clinical and electronic records of patients diagnosed with HCV. The primary efficacy end point was Sustained Viral Response at !2 weeks (SVR12). To assess safety participants were evaluated on an outpatient basis for adverse events. 1.4. Results: Efficacy Outcome measure: The overall rate of SVR 12 was 95.5% (95% CI, 89.9 to 98.1). Safety Outcome measure: Only one patient stopped the assigned drug treatment due to side effects. 1.5. Conclusion: In our study, Anti HCV generic therapy Sofosbuvir/Declatasvir is well-tolerated and provides comparably high SVR12 rates in the treatment of HCV infection in Qatar.
143 Endoscopic Ultrasonography of Malignant Rectal Tumors for the Decision-Making of Therapeutic Action , Contino NCA1 ,Quintanilla RAB2*, Menocal JLG3 ,Dugrot YO4 , Oceguera JS5 and Alvarez MBE6
1. Abstract 1.1. Introduction: In Cuba rectal tumor occupies the fourteenth cause of death among malignant and fifth tumors among malignant digestive tumors and its proper management depends on its staging. At present, endoscopic ultrasonography as a very well defined diagnostic value in the preoperative staging of rectal cancer, its introduction increases the ability to delimit the rectal wall layers, which allows to evaluate the depth of the invasion, as well as the presence of regional lymphatic metastases 1.2. Objective: To analyze the usefulness of endoscopic ultrasonography in the staging of patients with malignant rectal tumors. 1.3. Development: Staging by endoscopic ultrasonography of malignant tumors of the rectum allows to assume appropriate therapeutic behaviors (radiochemotherapy or surgery). 1.4. Conclusion: In this study it is expected to find that the staging by endoscopic ultrasonography of rectal tumors, helps in the decision of the use of adequate therapy.
144 Gastric Inflammatory Fibroid Polyp-Like Lesion with Specific Morphology during Proton Pump Inhibitor Treatment , Rikako Shibata1*, Fumio Shimamoto2 , Ken Haruma3
1. Abstract The patient was a 75-year-old woman who achieved Helicobacter pylori eradication. She started proton pump inhibitor (PPI) therapy for reflux esophagitis in 2016. Gastrointestinal endoscopy two years later (in 2018) revealed yellow sub mucosal tumor-like polypoid lesions in the greater curvature in the upper part of the gastric corpus and anterior wall. A gastric neuroendocrine tumor (carcinoid tumor) was suspected because of complication with hypergastrinemia. However, pathological findings indicated eosinophilic granuloma with neuroendocrine cell hyperplasia however, no neoplastic changes were found. An inflammatory fibroid polyp (IFP)-like gastric lesion was diagnosed. Endoscopy after PPI therapy for 2 months showed reduced and eliminated lesions, and pathological findings indicated no proliferation of endocrine . The cause of IFP remains unclear and is generally considered to be overreaction to some inflammation, however, recent studies showed gene mutation and the cause is under discussion. We propose a causal relationship between IFP-like lesions and proliferation of endocrine cells, for which a further study is required.
145 Seasonal Patterns of Acute Esophageal Variceal Bleeding in Patients with Liver Cirrhosis , Saad Elias1,2*, Sbeit Wisam1,3, Barhoum Masad1,, Levy Gali1 , and Assy Nimer1,2
1. Abstract 1.1. Background: Seasonal variations in the incidence of esophageal variceal bleeding in patients with end stage liver disease have been explored in various studies but the results were inconsistent. 1.2.Methods: In the present retrospective analysis, consecutive patients with liver cirrhosis admitted with esophageal variceal bleeding to the Galilee medical center from 2010 until 2015 were evaluated. 1.3. Results: The study population included 156 patients, 52% men, and mean age 64±13. Esophageal variceal bleeding exhibited a seasonal variation with peak incidence in the winter (January, February and March) (p=0.02). This finding was consistent in all subgroup analyses, including male and female gender, patients with nonalcoholic fatty liver disease (NAFLD), and patients with first episode of esophageal variceal bleeding. In multiple regression analysis, Four parameters can explain this variation, the first is NAFLD as etiology of cirrhosis in which the variation was more prominent than other etiologies (P=0.05), the second is the serum GGT level, for which the mean was the lowest in the spring, the season with the lowest rate of esophageal variceal bleeding (P=0.02), the third is the temperature in northern Israel, which is lowest in the winter (P<0.001), and the fourth is the BUN to Creatinine ratio which was highest in the winter (P=0.03). 1.4. Conclusions: There is an increased risk for esophageal variceal bleeding in Israeli patients with liver cirrhosis in the winter season. An elective endoscopy shortly before the winter season beginning may be suitable.
146 Excision of a Giant Huge Idiopathic Pseudo-Pancreatic Cyst: A Case Report , Ashraf A1*, Shetiwy M2 , and Fathy MY
1. Introduction A pseudo-pancreatic cyst is a common clinical entity characterized by a fibrous tissue wall which is devoid of epithelium with localized fluid rich in pancreatic enzymes as amylase [1]. Its incidence reaches 30-40% after pancreatitis [1, 2], decompression is indicated when symptomatic cysts persist for more than six weeks and for those larger than six centimeters[3]. A classification of pancreatic pseudocyst was described by D’Egidio and Schein, in 1991, with three types according to inflammatory process, pancreatic duct anatomy, and cyst communication to the ductal system [4]. Another more complex classification of seven categories based on pancreatic duct anatomy, is suggested by Nealon and Walser 2002 [5]. Long-standing and large-sized cysts are more likely to have complications. Those patients need surgical intervention [6]. Cysto-gastrostomy is the standard drainage procedure via laparotomy [7], however minimal access techniques as radiological guided, endoscopic or laparoscopic drainage can reduce the morbidity of laparotomy [8]. When the surgeon is not certain that the cystic mass is a pseudocyst of the pancreas drainage is considered as contraindication [9].
147 The Chronic Hepatitis B Treatment Virologic Response to HAART among HBV/ HIV Co-Infected Patients who Failed Lamivudine Containing Regimens , Jevtovic D1*, Selemovic D1 , Dragovic G2 , Pavlovic IP3 , Markovic M1 , and Rrnin J1
1. Abstract 1.1. Objective All HIV/HBV co-infected patients in Serbia have been treated with HAART containing an antiHBV drug, irrespective of CD4 cell count and HBV disease status in order to prevent more active liver disease. Like in many developing countries, lamivudine containing HAART was used in all HBV/HIV co-infected individuals 1.2. Methods A cross sectional cohort study was conducted to analyse the optimal treatment response of both HIV and HBV among HBV/HIV co-infected patients who underwent lamivudine containing HART, and if experienced lamivudine failure, switched to tenofovir based HAART. 1.3. Results After the mean duration of lamivudine containing HAART of 7.3±3.2 years (range 1-15 years), lamivudine failure was recorded in 35/67 patients (52.2%). Out of twenty-two remaining subjects with favourable virologic response to lamivudine, all achieved HBs Ag loss, out of whom 2 patients developed anti-HBs antibodies, after 4.1±3.1 years (range 1-15 years), and 9±2.8 years (7-15), respectively. After additional 2.1±1.1 years of tenofovir containing HAART, hepatitis B viral load was 1.3±1.1 log10 IU/mL HBV DNA. After TDF introduction, the probability of achieving optimal treatment response, which included either suppression of HBV DNA to less than 20 IU/ml, and/or HBs Ag loss, was 20%, 60% and 90% after additional 2, 3 and 5 years of TDF containing HAART, respectively. 1.4. Conclusion The outcome of tenofovir containing HAART among HBV/HIV co-infected patients, who previously failed HBV therapy with lamivudine containing HAART, suggesting that a prolonged treatment with TDF containing HAART is mandatory among those with suboptimal virologic suppression, with small risk of anti-HIV HAART failure.
148 Histological and Histomorphometric Studies of the Effects of Aqueous Leaf Extracts of Ficus Exasperata Vahl (Linn) In Indomethacin-Induced Gastroduodenal Ulcer in Adult Wistar Rats , John A. Aluko and David A. Ofusori
1. Abstract 1.1. Objectives This study was designed to examine the histological and histomorphometric changes in the stomach and duodenum of Wistar rats following indomethacin-induced gastroduodenal lesion and treatment with aqueous extract of F.exasperata leaves. 1.2. Methods Forty-eight adult male Wistar rats weighing between 150-180 g were randomly assigned into six groups of eight rats each. Group A served as control. A single dose of 20 mg/kg of indomethacin was given to rats in the other groups. Following this, Group B received placebo treatment while Groups C, D, and E were administered the plant extract 12 hourly at doses of 25 mg/kg, 50 mg/kg and 100 mg/kg respectively, and Group F were administered triple regimen- omeprazole (10 mg/ kg), Amoxycillin (25 mg/kg), and Clarithromycin (10 mg/kg) 12 hourly. All drug administration’s were given via the oral route. The rats were sacrificed under ketamine anesthesia after 14 days of treatment, and the stomach with the proximal 5 mm of duodenum were excised, examined for ulceration, and used for histological and histomorphometric analyses. 1.3. Results The result showed significant increase (P < 0.05) in the number of gastric and duodenal ulcers and mean total ulcerative areas in group B compared with the F. exasperata and triple regimen treated groups. Histologic examinations revealed markedly increased gastric and duodenal ulceration, inflammation and mucosal architectural distortion in Group B compared with the treated groups. A significant reduction (P < 0.05) in the percentage gastric glandular mucosal thickness and duodenal Villi/Crypt depth ratio for group B compared with the control and the treated groups (which showed no significant differences in the values of these measured parameters when compared among one another and with the control) was observed. 1.4. Conclusion This study showed that aqueous extract of F. exasperata leaves has ameliorative effects on indomethacin-induced gastroduodenal ulcer in rat model
149 High Density Lipoproteins May Actually be Some Negative Acute Phase Proteins in the Plasma , Helvaci MR1*, Aydin Y1 , Abyad A2 , and Pocock L
1. Abstract 1.1. Background We tried to understand whether or not high density lipoproteins (HDL) may actually be some acute phase proteins (APP) in the plasma. 1.2. Methods Patients with plasma HDL values lower than 40 mg/dL were collected into the first group, and then age and gender matched patients with plasma HDL values of 40 mg/dL and greater were collected into the second group, and compared in between. 1.3. Results There were 75 patients in the first and 118 patients in the second groups. Mean age (45.4 versus 47.9 years) and male ratio (53.3 versus 53.3%) were similar in both groups (p>0.05 for both). Smoking (34.6 versus 31.3%), body mass index (27.2 versus 26.7 kg/m2 ), fasting plasma glucose (119.4 versus 113.0 mg/dL), white coat hypertension (25.3 versus 32.2%), hypertension (10.6 versus 16.1%), and chronic obstructive pulmonary disease (14.6 versus 18.6%) were similar in both groups, too (p>0.05 for all). Although triglycerides (162.7 versus 125.4 mg/dL, p<0.001), diabetes mellitus (DM) (21.3 versus 12.7%, p<0.05), and coronary heart disease (CHD) (20.0 versus 11.0%, p<0.05) were higher, low density lipoproteins (LDL) (105.3 versus 126.2 mg/dL) and HDL (34.1 versus 50.0 mg/dL) were lower in patients with plasma HDL values of lower than 40 mg/dL, significantly (p<0.000 for both). 1.4. Conclusions Although the similar mean age, gender distribution, and smoking in both groups, mean triglycerides, DM, and CHD were higher whereas LDL and HDL were lower in patients with plasma HDL values of lower than 40 mg/dL, significantly. So HDL may actually be some negative APP in the plasma
150 Role of Imaging in Reducing Negative Appendicetomy ? , Chandio A* , Chandio K, Shaikh Z, Najeeb M, Mahmood A, Naqvi S and Munasinghe A
1. Abstract 1.1. Background Surgery for pain in the right lower quadrant of the abdomen remains a clinical dilemma. Right iliac fossa pain is one of the most common causes of abdominal pain in young adults and children in the UK.Acute appendicitis is conventionally a clinical diagnosis; typical symptoms and laboratory may be absent in 20-33% of patients and, when they are present, can be similar to other conditions, especially in early stage and the diagnosis can be especially difficult in children, elderly patients, pregnant and childbearing age women. The challenge of acute appendicitis diagnosis is the atypical presentation, variation of presenting complaint severity and subjective factors as the description of pain course and nature. However, (80%) of diagnosing Acute Appendicitis depends on clinical assessment [1]. Patients with atypical symptoms and signs can be admitted to hospital for a period of observation, laboratory tests and medical imaging that may end up in a diagnostic laparoscopy and this approach can be associated with its own morbidity and financial costs. Imaging is key in optimizing outcomes in appendicitis, not only as an aid in early diagnosis, but potentially reducing negative appendectomy rates. In patients with suspected appendicitis a tailored approach is recommended, depending on disease probability, sex and age of the patient.Historically, the acceptable negative appendicetomy rate has varied depending upon patient age and gender and availability of imaging.
151 Atypical Presentation of Salmonella Typhi Blood Stream Infection in an Immuno compromised Patient , Lall M* , Pandey A and Pandit P
1. Abstract The genus Salmonella is an important enteric pathogen which carries high morbidity and mortality in many parts of the world [1, 2]. The serotypes of Salmonella enteric namely serovars Typhi, Paratyphi A, Paratyphi B and Paratyphi C are the causative agents of the enteric fever. Other serovars collectively called as Non Typhoidal Salmonella (NTS) mainly cause gastroenteritis [1-3]. The usual manifestations of enteric fever in the first week are fever, lethargy, toxemia and constipation. Patient in the second week may have fever, diarrhea, splenomegaly and neutronpenia. Complications of the illness intestinal hemorrhage, perforation and encephalopathy occur in the third week [4]. However this is the typical pattern of the disease and presentations might differ in an immune compromised host [5]. The unusual features reported in immune compromised patients are splenic abscess and rupture, liver abscess, psoas abscess, endocarditis, nephritis, cholecystitis, osteomyelitis and central nervous system affection in the form of cerebellar ataxia, schizophrenia and suicide [4-6].
152 Diversion Colitis: A Bioenergetic Model of Pathogenesis , Pravda J
1. Abstract Diversion colitis is characterized by mucosal inflammation in segments of the colon that are surgically diverted from the fecal stream. This inflammatory disorder is reported to occur in up to 100% of individuals after colostomy or ileostomy, often occurring within a year following surgery. The lack of short chain fatty acids such as butyrate in the excluded colonic segment is thought to play a role in development of this illness. The actual mechanism leading to colitis remains a mystery however; a review of bioenergetic alterations as a result of disrupted energy flow in different disease models suggests that compensatory anapleurotic (Krebs cycle) metabolism of glutamine as an energy source leads to a sequestration of this amino acid away from nucleotide and glutathione biosynthesis resulting in mucosal atrophy and diminished colonocyte glutathione respectively. Decreased colonocyte glutathione leads to a subsequent rise in cellular hydrogen peroxide (oxidative stress) that initiates mucosal inflammation (colitis) after diffusing through the cell membrane to the extracellular space. Increased anapleurotic metabolism of glutamine leading to decreased availability for nucleotide and glutathione synthesis is compatible with a causal role in the development of mucosal atrophy and mucosal inflammation characteristic of diversion colitis. The aim of this paper is to detail an evidencebased model of diversion colitis based on colonocyte bioenergetic pathways that can explain pathogenesis and provide a scientific basis for therapy
153 G-POEM in Patients with Gastro paresis - Gambling for Healing or Bigger Armamentarium? , Gundling F1*, Martin Fuchs M1 , ScheppW1 and Fox M2
1. Abstract Despite the euphoria about the introduction of a novel and apparently successful treatment in gastroparesis, the amount of high quality data supporting the clinical utility of G-POEM are limited. Above all, the selection of patients with gastroparesis for G-POEM is problematic. Although these criteria fulfill the diagnostic criteria for gastroparesis, it is important to remember that symptoms of gastroparesis are nonspecific and not necessarily (directly) caused by delayed gastric emptying. Moreover, G-POEM does not always accelerate gastric emptying and the mechanism by which this procedure improves symptoms has not been confirmed. Now that G-POEM has been added to the armamentarium of treatments for gastroparesis it is important that the indications for this procedure are established. Clear predictive factors for the success of this procedure have not been defined. Given the high prevalence of patients with dyspeptic symptoms, the invasiveness and the cost of the procedure (G-POEM is performed only by highly skilled endoscopists) , this must be sonsidered urgently. Currently, the diagnosis of gastroparesis is most commonly made by endoscopy (evidence of food retention, exclusion of stenosis) and gastric emptying scintigraphy. However, these diagnostic procedures do not identify the underlying causes of symptoms and disease. Gastric function is complex and delayed gastric emptying can be caused by impaired gastric contractility and impaired neurohormonal regulation of gastric emptying as well as pyloric outlet obstruction.
154 Andrographolide Ameliorates Inflammation through Inhibition of NLRP3 Inflammasome Activation in Intestinal Epithelial Cells , Khanna K1 , Mishra KP2*, Ganju L1 , Kumar B1 and Singh SB3
1. Abstract Stressors have varied biological effects on gastrointestinal system which are increasingly recognized as enhanced gut permeability, dysbiosis and inflammation in the gut. Endotoxins, the metabolites released by harmful gut microbes are one of the stressors resulting in these problems. Hypobaric hypoxia, being another harmful stressor for the gut, requires the discovery of some prompt treatments. Andrographolide is a major bioactive component of traditional medicinal plant Andrographis paniculata which shows anti-inflammatory effects in different organs. Compared to its anti-inflammatory effect on vital organs, its effect on intestine is mostly untried. In our study, we investigated the impact of andrographolide in acute models of intestinal injury and studied the molecular mechanisms of andrographolide in modifying stress-induced signaling pathways. Andrographolide treatment in intestinal epithelial cells (IEC-6) was found to reduce nitric oxide, a key signaling molecule in the pathogenesis of inflammation, in LPS induced cells. Andrographolide treatment suppressed the levels of proinflammatory cytokines and inflammasome activation by downregulating NLRP3, caspase-1. Also, hypobaric hypoxia being the cause of intestinal barrier injury and inflammation results in an increase of endotoxin translocation to the intestine. In hypobaric hypoxia (HH) induced rat model, andrographolide was seen to suppress proinflammatory cytokines and intestinal inflammation via NLRP3 pathway. These results suggest that andrographolide could be a potential drug candidate for the treatment of intestinal inflammation-related problems.
155 Multiple Hemangiomas of Small Bowel Leading to Recurrent Intussusceptions in Perioperative Period , Bi JT1*, Liu YQ1 , Xuan C1 , Zheng ZX1 , Hu L1 and Bai N1
1. Abstract We report a case of 35-year-old woman with recurrent intussusceptions caused by multiple hemangiomas of the small bowel during hospitalization. When she was admitted to emergency room, multiple hemangiomas of the small bowel leading to intussusceptions was diagnosed through laparotomy. Radical resection could not be done because lesions extensively dispersed on the small bowel wall. Then the bowel segment of intussusceptions and five hemangiomas (about 20mm in diameter) nearby were resected following by an ileo-colonic reanastomosis. But small bowel obstruction was diagnosed on the fifth day post operation and during the second laparotomy we found intussusceptions recurred due to small bowel hemangiomas. Small bowel hemangioma is rare though it may present as recurrent intussusceptions and it should be kept in mind while handling cases of acute abdomen.
156 CombinedSingleSurgicalCessionAnatomicalTrans-Sphincter Anal Fistulectomy and Ano-Plasty Technique Clinical Results , Mohamed MN1* and Maged MN2
1. Abstract 1.1. Background: Surgicaltechniques appliedto treat ano-rectalfistulashas proved variable results, depending on how complex the fistula is. Many publications report promising results regarding simple and complex trans-sphincter fistulas. References have documented fecal incontinence varying from 10% up to 57%, depending on the procedure chosen. In this research we emphasize on the importance of anatomical dissection and reconstruction to reserve the anal sphincter function and avoid the traditional fistulectomy complications. 1.2. Material and Methods: This is a case series pilot study introducing anatomical surgical fistulectomy and ano-plasty technique on primary transsphincter fistulas. BetweenJanuary 2016AND June2018, thestudy h a s RECRUITED133CONSEcutivepatients withanterolateral,low or high primary transsphincterfistulas. 1.3. Results: The study has recruited 133PATIENTS complaining of primary trans-sphincter ano-rectal fistula.There was no complication but superficial skin wound dehiscence occurred in 19 patients that healed spontaneously. No patient needed further surgical treatment with a follow up duration range of 12-42 (median 31) months. Five patients (3.8%) experienced temporary incontinence grade I for a duration ranging between 3-5 days. No case of fistula recurrence was observed in any of the cases. 1.4. Conclusions: The technique of anatomical resection and reconstruction needs surgeons to master the regional anatomy, completely resect the fistula tract and surrounding granulation, do meticulous hemostasis and reconstruct the field structures anatomically. Hesitation to achieve complete fistula excision for fear of incontinence is a major reason for fistula recurrence and non-anatomical reconstruction is a reason for incontinence. Critic is invited.
157 The Relationship between Clinical Findings and Esophageal Injury Severity in Children with Unintentional Ingestion of Caustic Agents , Kiumarsi A*
1. Abstract 1.1. Background: Corrosive ingestion can produce severe upper gastrointestinal tract injury with long-lasting suffering and even death. Early assessment of the extent of damage is important for deciding about the necessity of hospitalization and type of treatment. The present study has investigated the clinical indicators of corrosive esophageal injury severity in children. 1.2. Methods: Data from children who accidentally ingested corrosive substance over a five-year period in two tertiary care university hospitals were reviewed. Patients were divided into two groups as low-grade and high-grade esophageal injuries according to the findings of endoscopic evaluation. Statistical correlations of common signs and symptoms and with low- and high-grade esophageal injury were analyzed. 1.3. Results: A total of 47 consecutive children with a caustic ingestion who underwent diagnostic endoscopy were included in our study. Endoscopies revealed low-grade injury in 80.9% of cases. There were no significant differences in age, sex and type of corrosive substance between low-grade and high-grade injury groups (p>0.05). The majority of patients (83%) had at least one symptom at the initial examination. Endoscopies in all of the asymptomatic patients revealed low-grade injuries, but no significant relation was found between symptomatic and grading of the injury in endoscopic examination (P=0.323). The mean WBC counts did not differ significantly between the two grading groups. 1.4. Conclusion: Our study showed a significant correlation between having no clinical symptom and low grade esophageal injury in endoscopic examination of children with corrosive substance ingestion and appears to confirm that in limited resourced centers, endoscopy could be deferred in asymptomatic patients.
158 Gallbladder Cancer (GBC)-Contemporary Aspects of Diagnosis and Treatment , Belev N1, 2* , Slavchev M1 , Penkov R1 , Atanasov B1, 3 and Djarov G1
1. Abstract 1.1. Background: Gallbladder cancer is an uncommon malignant disease leading to the fact that even big centers only analyze small series of patients over a long time. GBC is the most common biliary tumor and the fifth most common gastrointestinal cancer. 1.2. Material and Methods: For the period of 7 years -from01.2010 to01.09.2017 we have radically operated 32 patients in different GBC stages. Women are more frequently affected - 20(62%) vs. 12(38%) men. 30 of the patients had long-term cholelythiasis (symptomatic in 22 and non-symptomatic in 8 patients). 2 of the patients developed GBC from polyps. Ultrasonography is a base study conducted in all patients; CT with contrast applied by injection with liver enhancement protocol was conducted in 28(87%) patients as a main diagnostic and stagingmethod. 1.3. Results: We have 9 patients (28%) with complications. Perioperative mortality in our population was 3.1%. 75% of the patients survived for 3 years with a 100% survival rate of I-IIA patients. 1.4. Conclusion: GBC remains a challenge in contemporary surgical and oncological practice for its variable course, late diagnosis, clinical manifestation with complications, different surgical approaches depending on the specific case, lack of randomized studies and rarity of the disease.
159 Cohort Study of Immunotherapy in Patients with Colorectal Cancer and DNA Mismatch Repair Defects , Rasul KI* , PetkarMA,ZarAR,ElkhetimMS, Ahmed AI,MustafaMH,TalaatM, Dawood R and Ghazouani H
1. Abstract Colorectal cancer (CRC) is the second leading cause of cancer related deaths after lung cancer and it is the third most commonly diagnosed malignancy worldwide after the lung and the breast. Immunotherapeutic agents such as checkpoint inhibitors had a FDA approval, this therapeutic approach for patients with CRC is still under development and there are more studies ongoing using checkpoint inhibitors in phase II and phase III evaluating the efficacy of these agents in patients with deficient mismatch repair (d MMR). In 15% of the CRCs there are defective DNA mismatch repair systems (MMR) caused by inactivation of mutL homologue 1 (MLH1), MLH3, mutS homologue 2 (MSH2), MSH3, MSH6, or PMS1 homologue 2 (PMS2). This may occur through inherited or sporadic mutations, or through epigenetic silencing. These dominant genomic features give rise to hyper mutations and microsatellite instability (MSI) In this study we used checkpoint inhibitors in 3 patients, (2 colon and 1 rectal cancer), one of them with metastatic stage as palliative treatment, 1 as neo adjuvant before liver metastasis resection then as adjuvant and the 3rd one as neo adjuvant after chemo radiotherapy for rectal cancer, all of the 3patients showed dramatic response.
160 Fatty Acid Binding Proteins asa Biomarker for Diagnosing Celiac Disease , Barartabar Z1 , Faghih M2 , Mohebalian A3 and Nejad MR3*
1. Abstract Celiac disease is a chronic autoimmune gastrointestinal disorder that is caused in genetically predisposed people using gluten protein. Various methods, including histopathologic, genetic, and autoantibody titration are used for diagnosis and follow up of celiac disease patients.Severe changes in the intestinal mucosa of untreated celiac patients have been associated with altered levels and expression patterns of different genes.This disorder is cause of the damage to the enterocyte which causes malabsorption.According to the current literature,serum intestinal fatty acid binding protein (I-FABP) is a sensitive marker for the assessment of enterocyte damage.In the clinical management of celiac disease, a new, noninvasive approach to assessing intestinal injury is essential for the follow-up and diagnosis of people under a gluten free diet.Therefore, I-FABPis recently proposed as noninvasive marker for this purpose.FABP is a small cytosolic protein of 15 kDa that binds and transports long chain fatty acids and also has important biological roles in the signaling pathway. The role of this molecule has been studied in different diseases, including celiac disease, heart disease, prostate cancer, diabetes, and etc. In this paper, we reviewed the importance of this molecule in patients with celiac disease, as well as its role as a diagnostic test and screening the disease activity in patients under gluten free diet.
161 Recent Progresses in Predicting Protein Subcellular Localization with Artificial Intelligence (AI) Tools Developed Via the 5-Steps Rule , Chou CK
1. Abstract With the avalanche of protein sequences generated in the post-genomic age, it is highly desired to develop AI tools for rapidly and effectively identifying the subcellular locations of uncharacterized proteins based on their sequences information alone. Actually, considerable progresses have been achieved in this regard. This review is focused on those methods, which have the capacity to deal with multi-label proteins that may simultaneously exist in two or more subcellular location sites. Protein molecules with this kind of characteristic are vitally important for finding multi-target drugs, a current hot trend in drug development. Focused in this review are also those methods that have use-friendly web-servers established so that the majority of experimental scientists can use them to get the desired results without the need to go through the detailed mathematics involved.
162 Long-Term Efficacy of Combined Treatment in Idiopathic Achalasia Patients , Jameshorani M1 , Anushiravani A1 , Fazlollahi N1 , Amani M1 , Mikaeli J1*
1. Abstract 1.1. Introduction Several treatment strategies are available to treat achalasia. Although combined therapy has been used for several years, there are limited data on long-term outcomes. We aimed to determine its long-term efficacy in patients who were resistant or those with rapid relapse. 1.2. Methods In this prospective study, we reviewed the records of 1100 achalasia patients, who were candidates for pneumatic balloon dilatation (PBD) in our center from 1996 to 2018. We enrolled 197 patients resistant to initial treatment or with rapid relapse of symptoms after three sessions of PBD. Clinical evaluation and time barium esophagogram (TBE) were done pre- treatment, a month afterwards, when clinical symptoms increased in order to confirm relapse, and at the end of follow-up. 1.3. Results A total of 168 patients accepted combined therapy). The mean duration of follow-up was 9.04 years. Achalasia symptom score (ASS) dropped from 10.82 to 3.62 a month after treatment and was 3.09 at the end of follow up (P= 0.0001 and 0.001). TBE had a decrease in mean height of barium one month after treatment (9.23 vs 5.10, PV 0.001) and this reduction persisted till the end of follow up (3.39, PV: 0.001). Vantrappen score at the end of follow up showed 56 patients in excellent, 51 good, 33 moderate, and 14 in poor condition (89% acceptable response rate). Conclusion: Our results determined long-term efficacy of combined treatment in achalasia patients who otherwise had to undergo a high-risk and costly procedure, making it a safe and effective alternative for myotomy
163 Clerodendrum Infortunatum L. – A Plant Used for Treatment of Hepatitis B and Hepatic Disorders in Jamalpur District, Bangladesh , Rahmatullah M* , Ahammed S Md, Paul S, Jahan R and Farzana B
1. Abstract Hepatitis B and other hepatic disorders are prevalent in Bangladesh. Although the Government has undertaken a successful vaccination of the people against hepatitis B infections, yet there remain people like truck drivers, drug addicts, people engaged in sexual activities with multiple sex partners and sections of the rural population who have a high prevalence of hepatitis B. There also are segments of the population, who either due to ignorance or other factors like fear of vaccines remain to be vaccinated. A number of these people visit Folk Medicinal Practitioners (FMPs) and claim to get cured. The objective of this study was to review one such plant, namely Clerodendrum infortunatum used by a FMP in Ramnagar village in Jamalpur district, Bangladesh to cure hepatitis B infected patients.
164 Perforation as a Cause of Failure in the Conservative Treatment of Acute Cholecystitis: Is Percutaneous Cholecystostomy A Sufficient Treatment? , Balli O
1. Abstract 1.1. Purpose To evaluate the efficacy and safety of percutaneous cholecystostomy in acute cholecystitis cases with high surgical risk that was treated conservatively and developed perforation. 1.2. Materials and Methods Between July 2013 and May 2018, 20 acute cholecystitis cases with high surgical risk who underwent conservative treatment and presented with perforation were included in the study. The patients diagnosed with acute cholecystitis based on clinical, laboratory and ultra sonography at the time of presentation received conservative treatment. Upon development of perforation, percutaneous cholecystostomy (PC) was performed. 1.3. Results After 3.65 (2-8) days of conservative treatment, the patients with no improvement in clinical and/or laboratory findings were considered to have complicated cholecystitis and underwent additional imaging procedures. In 20 patients, gallbladder perforation was observed, and a total of 22 catheters were placed. During the procedure, the drainage catheter was successfully inserted in all patients with a technical success rate of 100%. One (5%) patient that was intubated, classified as ASA V, and had grade III cholecystitis and septic shock, died three days after the procedure. Clinical success was calculated as 95%. In addition, two (10%) patients had catheter dislocation as late, minor complications. 1.4. Conclusions For the treatment of gallbladder perforations that may develop during the conservative treatment of acute cholecystitis and result in significant mortality and morbidity rates, PC is an effective and safe treatment method, especially in high surgical risk patients.
165 Effect of Ellagic Acid on Some Oxidative Stress Parameters and Cyclooxygenase-2 Reactivity in Mice with Experimental Gastric Injury , Kaya I1*, Kaya MM2, Kukurt A3, Ozcan A2, Karaman M5, Deveci HA6 And Karapehlivan M3
1. Abstract Non-steroidal anti-inflammatory drugs (NSAIDs) commonly used by people induces gastric injury. This study was designed to evaluate effects of ellagic acid as a natural compound on oxidative stress markers and immunohistochemical structure during experimental gastric damage. It was created five groups as follows. Group I was received standard pellet feed and drinking water. On the other hand, a single oral dose of 25 mg/kg indomethacin, 10 mg/kg ellagic acid, 25 mg/kg indomethacin plus 10 mg/kg ellagic acid and 20 mg/kg omeprazole were received to group II, III, IV and V, respectively. The reduced glutathione (GSH), nitric oxide (NO), malondialdehyde (MDA), total sialic acid (TSA) and ghrelin levels of samples taken after 6 hours from applications were analyzed by spectrophotometric methods. The cyclooxygenase 2 (COX-2) reactivity was analyzed by immunohistochemical staining method. The kidney NO and TSA levels of group II were found to be increased compared with group I, whereas these levels were lower in group IV compared with group II. The liver NO and MDA levels of group II were higher than in group IV. All blood ghrelin levels in group II were lower compared with other groups. It was revealed severe COX-2 immunoreactivity in stomach surface and foveola epithelium, parietal cells, macrophages and vascular endothelium near submucosa of group II, while this reactivity was less in group IV. It was concluded that ellagic acid significantly changed NO, TSA, MDA and ghrelin levels and stomach COX-2 activity of mice given indomethacin and ellagic acid prevented gastric injury.
166 Chemoprevention of Colon Cancer by Combination of Atorvastatin and Fish Oil , Rani I1 , Kumar S1,2*, Renuka1 , Sharma S1 , Bhargva P1 , Taneja N1 and Agnihotri N1*
1. Abstract Cholesterol accumulation in growing tumor cells has recently been implicated in apoptosis evasion and drug resistance. Various reports have suggested the potential of statins (3-hydroxy-3-methylglutaryl-coenzyme Areductase inhibitors) as chemo preventive agents. Side effects associated with statins have encouraged the combination approach to enhance the efficacy of statins at low doses. In this study, a combination regimen of fish oil (FO) and atorvastatin is used in order to reduce the dosage of atorvastatin and evaluate the efficacy of this regimen. Pre-treatment with atorvastatin and/or FO resulted in a significantdecline in number of irregular crypts and increased apoptosis.Though we did not observesignificant effect of this combinational approach on cyclin D1 expression and cell cycle progression, however, there was a significant inhibition of Ras expression and translocation.A significant reduction in the nuclear translocation of NF–κB,a transcription factor that promotes cancer cell survival and metastasis was also observed on treatment with combination regimen. Furthermore, expression of VEGF, a downstream target of NF–κBwas also diminished by the combined regimen. To conclude a combination therapy of atorvastatin with fish oil may be a better approach to prevent cancer and may help in reduction of the optimal dose of stations in clinical use.
167 Does Laparoscopic Liver Resection Have Greater Incidence of Bile Leak Compared to the Open Approach? , Rafael Jose Maurette1*, Facundo Iriarte1 , Marcos García Ejarque1 , Luciano Belotti1 , Mariano Luis Bregante1 , Jorge Diego Bogetti1 and Daniel Enrique Pirchi1
1. Abstract 1.1. Background: Biliary leak is the most frequent complication in liver resections. The Second International Consensus Conference mentions a potentially higher incidence of bile leaks in Laparoscopic Liver Resection (LLR) that still needs to be evaluated. The objective of the study is to compare the incidence of bile leaks, using the definition of IGSLL, between open liver resection (OLR) and LLR in a center with the same technique of dividing the parenchyma for both laparoscopic and open surgery. 1.2. Methods: it is a retrospective comparative study that compares two series of liver resections. We included all patients operated between March/2008 and July/2016 by laparoscopic and open approach. Demographic and operative variables, histopathology data and morbidity and mortality were compared. 1.3. Results: A total of 143 liver resections were performed in the study period, but only were included 119 in the analysis: 65 OLR and 54 LLR. The overall morbidity was lower in the laparoscopic group (p=0.011). There were no differences in major complications. From the specific analysis of bile leaks, no overall differences were found (ISGLS A, B, and C) (p = 0.450). There was only one 90-day mortality in the OLR. 1.4. Conclusions: There are no differences in the incidence of bile leaks between LLR and OLR when the same technique of parenchymal transection is used. A possible bias, in addition to sample size and the retrospective study, is case selection: there is a possible bias of indicating open surgery to the most difficult cases.
168 Clinical Image in Gastroenterology , Josa Francisco JuanmartiAena Fernandez
1. Clinical Image IntheWesterncountries, portalhypertension(PH)is themost commoncomplication of liver cirrhosis, being ascites, gastrointestinal bleeding due to varicose veins, and hepatic encephalopathy the most frequent complications. However, other lesser-known entities that are also associated with changes in the gastrointestinal microvasculature, such as PH enteropathy, can be observed. In this sense, due to its simplicity and non-invasive nature capsule endoscopy has become an essential tool. We present the case of a patient with alcoholic cirrhosis (Child Pugh B-9, MELD 12), iron deficiency anemia, small esophageal varices and colonic diverticula in conventional endoscopy, as well as changes in the small bowel mucosa during enteroscopy with capsule endoscopy that suggests PH enteropathy. As we can see in the images, the vascular lesions -angiectasia and varicose veins- (B, C) as well as the non-vascular lesions-inflammatory type lesions, red spots or edema / vascular congestion- (D, E) are the most common presentation. Indeed, capsule endoscopy also confirmed the presence of a well-known PH gastropathy (A) and de novo colopathy (F).
169 Mantle Cell Lymphoma in the Differential Diagnosis of Colorectal Polyposis , Victor Gonzalez Carrera
1. Abstract I report a clinical case where the differential diagnosis of a colorectal polyposis can be particularly difficult
170 Effectiveness and Safety of Minilaparoscopic Cholecistectomy , Justo-Janeiro JM1,2, de-La-Rosa PR3, Prado OE3, Trujillo MLD2, Vázquez-de-Lara CLG4
1. Abstract 1.1. Background: Minilaparoscopy instruments emerged as an alternative to conventional laparoscopic cholecystectomy trying to obtain a faster recuperation, however there are not randomized clinical trials conducted to establish its usefulness compared to conventional 3 ports laparoscopic cholecystectomy where it seems to have advantages because reduce ports size seems to reduce postoperative pain. 1.2. Aim: To compare post operative evolution from patients submitted to cholecystectomy with two different techniques: 1) Standard laparoscopic three ports approach and 2) Use of minilaparoscopic instruments. 1.3. Method: We conducted a comparative, prospective, longitudinal and experimental study with P.O. pain as the main outcome in a general open population hospital with two randomized groups: 1) Laparoscopic cholecystectomy with the standard 3 ports access: 10 mm umbilical, 5 mm subxiphoid and 5 mm right subcostal, and 2) Minilaparoscopic cholecystectomy with 3 ports 10 mm umbilical, 5 mm subxiphoid and 2.3 mm right subcostal. We assessed postoperative pain with a visual analogous scale at the surgery recuperation bed and after 4, 24 hrs, 5° and 8°days, we compare results with Student t test for dimensional variables and chi square test for nominal variables. 1.4. Results: Forty-four patients were recruited and, by simply random process, assigned to standard 3 ports laparoscopic cholecystectomy (LC3P) group or minilaparoscopic cholecystectomy (MLC) group; there were not differences in age, gender, body mass index, surgical time, hemorrhage, surgical findings, trans operative or post operative complications or length of stay. The evaluation of the post operative pain shows a significant difference in recovery (p=0.025), but there was no difference at 4 hrs (p=0.885), the difference was significant at 24 hrs(p=0.038) and then at the 5° day (p=0.043). At in 8° day there was not significance but the p value was marginal (p=0.186). The need for analgesics was less frequent each 8hrs for the MLC group (p=0.04). 1.5. Conclusion: Minilaparoscopic cholecystectomy is a safe and effective technique in symptomatic biliary lithiasis patients, their results are similar to conventional laparoscopic cholecystectomy, but pain reduction is a major advantage in this technique.
171 Suspected Herb Induced Liver Injury by Green Tea Extracts: Critical Review and Case Analysis applying RUCAM for Causality Assessment , Teschke R1* and Xuan TD2
1. Abstract Leaves of green tea (Camellia sinensis) contain EGCG (Epigallocatechin-3-gallate) and other polyphenolic catechins, commonly assumed as harmless and healthy. Whereas the use of the traditional green tea (GT) is in general well tolerated, extracts manufactured from green tea leaves contain large amounts of catechins, mostly as EGCG, being broadly used to reduce or maintain body weight, although a Cochrane study found no significant therapeutical effects. Instead, several reports suggested that the use of green tea extracts (GTE) may carry the risk of herb induced liver injury (HILI), evidenced by serum alanine aminotransferase (ALT) ≥5 x ULN (upper limit of normal) and/or alkaline phosphatase (ALP) ≥2 x ULN. Current critical analyses confirmed that the use of GTE rarely causes HILI, based on causality assessment using RUCAM (Roussel Uclaf Causality Assessment Method) that provided causality gradings of highly probable or probable for published cases. Causality was also verified by unintentional positive reexposure test results. Although the mechanistic steps leading to liver injury have not been explored, evidence exists that GTE may cause idiosyncratic HILI in susceptible users as well as well as intrinsic HILI that is dose dependent. Liver adaptation may also develop, characterized by small increases of liver tests: ALT <5 x ULN and/or ALP <2 x ULN. In conclusion, as the benefit risk assessment is negative, the use of GTE cannot be recommended while no restrictions apply to GT beverages.
172 Diphyllobothriasis Accidentally Found In the Small Intestine of A Thai Man: A Case Report , Kittichet Phiphatpatthamaamphan1 , Likhasit Sanglutong2, and Somchai3 Insiripong3
1. Abstract Diphyllobothrium latum infestation is well known as the helminthic disease in nontropical countries. It has never been reported in Thailand. This report was aimed to present a case of D. latum accidentally found in a Thai patient during the gastroscopy for upper gastrointestinal hemorrhage. He was a 60-year-old Thai patient who passed melena and had abdominal distension for two days. His underlying diseases included the end stage renal disease under regular hemodialysis, type 2 diabetes mellitus, hypertension and anemia. Three months ago, his gastroscopy revealed one 3-cm gastric ulcer at the antrum. His physical examination showed the marked pallor, an abdominal distension with positive shifting dullness. His present blood tests showed hemoglobin 6.0 g%, WBC 7,200/mm3, N 83 %, L 12 %, E 0.8 %, creatinine 3.6 mg%, albumin 2.8 g%, globulin 4.5 g%. The present gastroscopy showed the old antral ulcer was still persistent and one living flat and long parasite that was later morphologically identified to be D. latum was accidentally found in the small intestine. The parasite was removed and the patient was treated with praziquantel. The antral ulcer in our patient had been persistent for three months despite the long term treatment with the proton pump inhibitor. It is wondered whether there is any association between the big parasite like D. latum and the ulcer of the part of the gastrointestinal tract where the parasite resides.
173 Small Bowel Adenocarcinoma. Resection Has A Favorable Prognosis? , Prieto Nieto MI1*, Rodríguez Salas N2, MateMate P1 , Gortazar de las Casas S1 , Funes Duenas T1 , Leon Arellano MM3, Guerra Pastrian L4, Diaz Domínguez J1 and Cristina Barragan C1
1. Abstract Purpose: Tumors of the small bowel representing 3% of all gastrointestinal malignancies (33% adenocarcinomas). We performed a retrospective study of the adenocarcinomas of the small bowel in 18 years. Methods: Analyzed variables: age, sex, risk factors, reason and date of first consultation, urgent or ambulatory diagnosis, imaging, tumor markers and stage at diagnosis, surgery, type of surgery and postsurgical complications, adjuvant treatment, disease progression and metastatic disease, cause of death and the overall survival. Results: 21 patients were studied. They were diagnosed as complications in 55%. For the diagnostic were use the CT scan (91%) and endoscopy (81%). Tumor markers were increased to 50% in advanced stages. 76.2% of the patients underwent a surgical intervention and 10% received adjuvant treatment. The overall survival at 5 years was of 60% in the early stages and of 10% in patients with advanced stages. Conclusion: The tumor marker increased at diagnosis can suggest an advanced stage. The 5 years overall survival rate was 10%, so it is necessary to progress in the radiological techniques, which will allow an earlier diagnosis.
174 Transaldolase Deficiency A Case Report , Khaled Alqoaer, ZiadAsaad, and MaisaHalabi*
1. Abstract Transaldolase TALDO deficiency is a rare autosomal recessive disorder of the pentose phosphate pathway. It has variable presentations with poor outcome when present early in life. We present a young Saudi infant with a fatal early presentation of TALD deficiency.
175 Signet Ring Cell Carcinoma,of the Ileum on Crohn’s Disease Revealed by Acute Peritonitis , A Bendjaballah* , M Taieb, R Khiali, EHaicheur, S Ammari
1. Abstract The small bowel is an unusual site for malignancies. In patients with Crohn’s Disease there is an enlarged relative risk of small bowel adenocarcinoma likened to the general population. Signet ring cell carcinoma is a rare type of adenocarcinoma that predominantly affects the stomach. Signet ring cell carcinoma initiated from the ileum is particularly rare and the prognosis is poor. Due to the nonspecific nature of the signs of the disease, the diagnosis is often late because there is a tendency to treat relapses earlierthan to undertake a broaderstudy of these symptoms. In patients with Crohn disease, the symptoms are often chronic diarrhea and abdominal pain with a family history of inflammatory bowel disease. We present a case of small bowel perforation of tumor of ileum with general peritonitis in patients who was not known and treated for Crohn’s disease.
176 A Giant Simple Hepatic Cyst with Chronic Constipation , Yuh-Jeng Yang1 and Aming Chor-Ming Lin
1. Clinical Image and Case Presentation Hepatic cysts are abnormal fluid-filled spaces in the hepatic parenchyma and biliary tract. The cysts usually are asymptomatic and as a casual finding during the general health check-up and screening imaging examinations. Simple hepatic cysts are known to be congenital in origin, the most common benign tumors of the liver and have a frequency of about 2.5 to 18 % of the population[1,2]. Inactive hepatic cysts are usually requiringno specific treatment except in case of complications, such as intra-cystic hemorrhage, infection, rupture, obstructive jaundice and compression of surrounding organs[3]. Symptoms may be related to stretch of the liver capsule causing pain or mass effect on surrounding structures. Fenestration is the definitive treatment for symptomatic or complicated liver cysts[4]. We report herein a case of giant simple hepatic cyst with chronic constipation treated as laparoscopic liver cyst fenestration intervention.
177 Intrahepatic Cholestasis and Fetal Demise: Association or Causation? , Paljk I1 , Dolanc M1 , Blickstein I3, Tul N2
1. Abstract 1.1. Objective: To review the available information about the potential association of intrahepatic cholestasis of pregnancy (ICP) and stillbirth. 1.2. Method: Scholarly review of relevant studies. 1.3. Results: Data are conflicting regarding a cause and effect relationship between ICP and stillbirth. On one hand, the data show a higher risk of stillbirth at term without an effective test that might predict demise except high level of bile acids. On the other, even if the stillbirth rate is reduced by a late preterm birth, one must appreciate the cost of active management in terms of morbidity due to induction, failed induction, unnecessary cesareans, and outcomes related to late preterm births. A cause and effect relationship between ICP and stillbirth is unlikely according to Hill’s criteria for causation. 1.4. Conclusions: Better understanding of the underlying mechanism of ICP causing fetal demise is still required to define a cause and effect relationship.
178 The Gastric Tumor That Wasn’t There , Hsu JT1 , Le PH2, Kuo CJ2, Chen TH2, Lin CJ2, and Yeh TS
1. Clinical Image  32-year-old female was admitted to the hospital with epigastric abdominal pain, nausea, vomiting with a band like distribution. She reported longstanding pain that has progressively worsened in the last two months, with unintentional weight loss of 12 pounds, diminished appetite, and nausea. She acknowledged sporadic alcohol use, but denied any tobacco or illicit drugs. Denied using any over-the-counter medications. Pertinent history included choledocholithiasis status post ERCP three years prior. An ultrasound of the abdomen was unrevealing, however a CT scan of the abdomen and pelvis demonstrated mild fatty liver changes with a large mixed solid cystic mass within the gastric fundus and body 12.5 x 8 cm without evidence of calcifications. Significant concern was raised for a gastrointestinal stromal tumor (Figure A and B) An urgent endoscopy was performed the following day to obtain tissue diagnosis, which failed to demonstrate any esophageal, gastric or abdominal abnormalities (Figures C and D) Post endoscopic re-review of images with radiology suggested that findings on CT scan were anomalous due to poor mixing of oral contrast with intraluminal content.
179 Prognosis and Treatment Strategy of Early Gastric Cancer with Signet Ring Cell Histology , Hsu JT1 , Le PH2, Kuo CJ2, ChenTH2, Lin CJ2, and Yeh TS1
2. Commentary The prognosis of early gastric cancer (GC) with signet ring cell (SRC) histology comparing with other subtypes remains a matter of debate. Kim et al. indicated that early GC with SRC differs clinical course and prognosis from non-SRC.1 They found that mucosal and submucosal GC with poor differentiation had 6.3% and 30% of lymph node metastasis, respectively; the values were higher as compared with other histological types [1]. However, our previous studies showed that early GC with differentiated and poorly differentiated histology had similar rates of nodal metastasis (13.5% vs. 14.2%) [2].In addition, Kim et al. [3] reported that mucosal and submucosal SRC GC had higher and lower rates of nodal metastasis than well or moderately differentiated histology, respectively [1]. Interestingly, our results revealed that lymph node involvement was identified in 4.1% of patients with mucosal tumors and 24.3% of submucosal tumors irrespective of histological subtypes [2]. Our research also found that tumor differentiation in early GC was not associated with lymph node metastasis in univariate and multivariate analyses; however, tumor size > 2 cm, presence of lymphatic invasion and tumor with submucosal invasion were independent predictors for lymph node metastasis [2].
180 Take Constipation Appendix Disease Seriously , Hongyun P
1. Abstract 1 .1. Objective: To pay attention to the “constipation appendicitis”, and to explore the clinical management strategy of reoperation due to the misdiagnosis of intractable constipation appendicitis. 1.2. Methods: 6 patients with intractable constipation underwent abdominal distention after resection due to misdiagnosis of appendicitis, and the intestinal obstruction could not be relieved. 4 patients underwent further exploration, 1 underwent right hemicolectomy, 1 underwent ileostomy, and 2 underwent ACE surgery. 1.3. Results: All the patients were rescued successfully with different complications. Conservative 2 patients died. 1.4. Conclusion: to explore the clinical management of early reoperation for intractable constipation misdiagnosed with appendicitis due to “constipation appendicitis”. ACE surgery is convenient, safe and feasible. The treatment effect for patients with intractable constipation is good, with the advantages of small incision, less bleeding, short operation and hospital stay, which is a practical operation mode clinically. The long-term effect is still worth observing.
181 Personalized Evidence-Based Medicine in Need of High-Quality Data , Schalm SW
1. Short Communication The truth in medicine does not exist, since 3500 publications are added every day to the knowledge base of medicine[1]. Each day the truth changes a little. Today, evidence-based medicine with its key methodology of systematic reviews of randomized controlled trials attempts to sift out the valuable ‘true’ information[2]. Systematic reviews are the building blocks of guidelines, currently the corner-stone of medical practice. Clinical practice guidelines made by experts tell which treatments are true and of sufficient benefit in comparison to harm to be prescribed to patients. Guideline recommendations are based on averages in groups of patients; but many patients do not fit the average. The recommendations are also dependent on the publications chosen and their interpretation and extrapolation by the committee of experts; guideline recommendations can vary considerably between countries. In addition, the process of conception, validation and authorization of guidelines takes several years and often valuable new information is not incorporated.
182 Therapeutic Drug Monitoring of Thiopurine Therapy in Patients with Inflammatory Bowel Disease , Zalizko P1,2*, Jargane I2 , Pukitis A
1. Abstract The number of patients with inflammatory bowel disease (IBD) is increasing in the worldwide. Thiopurine S-methyltransferase (TPMT) plays a significant role in the metabolism of thiopurine drugs. Low TPMT activity in body is associated with pathological thiopurine drug metabolisms, overproduction of cytotoxic metabolites and myelosuppression. The aim of this study and review was to make a comparative TPMT enzyme activity analysis using TPMT enzyme expression determination method in IBD patients who are already taking azathioprine drug therapy, with patients who have not yet begun this therapy. The longterm aim is to decrease overall expenses using azathioprine, that could be done if patients would be tested for TPMT expression level before starting therapy with azathioprine, thereby excluding this therapy for patients with higher risk of adverse side effects, reducing medical expenses treating these side effects.
183 The Need of CDH1 Germline Mutation Screening in Patients with Gastric Cancer in the West , Bencivenga M1*, Castelli C2 , Tedaldi G3 , Verlato G4 , Torroni L4 , Marrelli D5 , Scorsone L1 , Tomezzoli A2 , Morgagni P6 , de Man-zoni G1 and Roviello F5
1. Abstract 1.1. Background and objectives: Although the international guidelines recommend the CDH1 germline mutations screening in patients at risk of carrying pathogenic mutations, few data exist about the compliance to systematic screening programs carried out in surgical centres. 1.2. Methods: In the present manuscript we report the results of CDH1 germline mutations screening, undertaken in patients with gastric cancer at a high volume Western centre from 2011 to 2016. 1.3. Results: During a 5 years period, we screened 11 patients; among them, we found a pathogenic germline genetic alteration in 6 of them (54.6%). Moreover relative of two cases with germline CDH1 mutation underwent a complete genetic and clinical examination. Of note in both the analysed families, clinically detectable gastric cancers were found in subjects aged 18-19 years . 1.4. Conclusions: Based on our experience, we can conclude that the CDH1 genetic screening should be absolutely offered to high-risk Western patients, in agreement with the most recent international guidelines. Accordingly, the screening should be offered also to families with an index case of diffuse-type gastric cancer and additional cases of gastric cancer with unknown histotype in first- and second-degree relatives. Prophylactic total gastrectomy should be considered in selected cases also under 20 years of age.
184 New Factors in Screening Colonoscopy for Colorectal Neoplasia , Floch MH*
1. Abstract Colonoscopy screening for colorectal adenomatous polyps or cancer has become a worldwide recommendation since this is the third most common human cancer[1-3] resulting in an estimated 49900deaths annually[3]. Furthermore, polyps and cancers have been observed in younger people resulting in recommendations by societies to start screening at age 45 [4]. This review will focus on two areas of continued interest in the procedure. One is appropriate preparation and two is discussion of continued findings in risk factors for colorectal neoplasia.
185 Volumetric-Based Analysis of In-Vivo and Ex-Vivo Quantitative MR Diffusion Parameters in Pancreatic Adenocarcinoma: Correlation with Pathologic Findings , Peerboccus M1 , Van Eycke YR2,5, Gyssels E1 , Verset L3 , Lucchesi P1 , Absil J1 , Chao SL4 , Decaestecker C2,5, Van Laethem JL6 , Metens T1,3 and Bali MA1,4
1. Abstract 1.1. Purpose: Imaging biomarkers are needed to assess modifications in pancreatic adenocarcinoma (PA) induced by stroma-targeted therapies. The study investigates correlations between quantitative diffusion parameters obtained in vivo and ex vivo with a tumour volumetric approach and quantitative pathologic findings including fibrosis, vascular and total nuclear densities in PA. 1.2. Methods: 14 patients with resectable were included after informed consent; diffusion weighted imaging (nine b values:0-1000s/mm2) was performed within 4 days before surgery and ex vivo immediately after tumour resection. Two readers assessed quantitative diffusion parameters (ADC, D, f: apparent and pure diffusion coefficients; perfusion fraction) after tumour volume segmentation based on b=1000 s/mm2 images. Statistics included inter-reader agreement with intraclass correlation coefficients (ICC), non-parametric tests to compare in vivo with ex vivo data and ADC, D, f with histopathology findings. 1.3. Results: Readers agreement was excellent (ICC>0.9). Diffusion parameters were significantly lower ex vivo than in vivo (P=.001); ADC and D differed significantly both in vivo and ex vivo (P=.001). Significant positive Spearman correlations were observed between fibrosis and ADC and D in vivo (respectively rs=0.76 and rs=0.73, P=.002 and P=.003) and ex vivo (both rs=0.72 and P=.004). Negative correlations were observed between total nuclear density and ADC and D ex vivo (both rs=-0.66, P=.011) and between total nuclear density and fibrosis (rs=-0.53, P=.049). There was no correlation between vascular density and diffusion parameters. 1.4. Conclusions: A statistically significant positive correlation between ADC and D and degree of fibrosis was found in PA, indicating the presence of a relatively larger extracellular space when fibrosis increases
186 Quality of Life in Locally Advanced Colorectal Cancer Patients - An Extremely Multi-Layered Problem - A Systematic Review , Sokolov M¹* , Gribnev P¹, Maslyankov Sv¹, Petrov B², Atanasova MP³, Tzoneva D³
1. Abstract 1.1. Introduction:There are quite more than dozens studies in world literature concerning the problems of the quality of life of patients with colorectal cancer in a wide variety of clinical and socio-individual aspects. It is significantly difficult any specific screening and stratified grouping of similar problems in patients with locally advanced cancerboth of the colon and rectum to be implemented. Those kinds of patients, in turn, are extremely a heterogeneous group, but represent 1/5 to ¼ of the primary presented and diagnosed as such by acolorectal cancer. The aim of this study is emphasis and displaying the forefront ofspecific problems of this group of patients among the diversity of published data. 1.2. Method:A systematic literature search of publications during the period 2001-2018 in certain electronic databases concerning issues of QUALITY of Life in patients with colorectal cancer was made. Studies were included in case they focused mainly on locally advanced colon cancer, primary advanced or recurrent rectal cancer and also included data on HRQoL.Out of all 337 potential publications 17 were set up as completely and sufficiently relevant to the purpose of the present study. 1.3. Results:Various studies aimed to identify the HRQoL themes that might be relevant to patients with locally advanced colorectal cancer. As far as there are studies aimed at certain aspects of HRQoL in locally advanced primary and recurrent rectal cancer, it lacks any targeted specifically at locally advanced colon cancer. Furthermore, various methodological deficiencies and limits in available publications are indicated there.There is no practice established to customize the complex approach in these patients. 1.4. Conclusion:Besides mere clinical and oncological outcomes in the treatment of patients with locally advanced CRC it is ultimately essential development of a comprehensive guideline concerning overarching in details all the aspects of their quality of life.
187 Percutaneous Endoluminal Forceps Biopsy in Cholangiocellular Carcinoma – A Perspective Approach to Timeliness of Diagnostic Confirmation Using Two Scenarios , Tomas Andrasina1*, Tomas Rohan1 , Hiroko J Martin1 , Jiri Panek1 , Petra Kovalcikova2 , Tomas Grolich4 , Lenka Ostrizkova3 and Vlastimil Valek1
1. Abstract 1.1. Aim: To assess the benefits of performing endoluminal forceps biopsy during initial drainage compared to postponed biopsy using two patient management scenarios. 1.2. Methods: Since 2006, 101 consecutive patients with malignant biliary stenosis due to cholangiocellular carcinoma have been followed up. All patients underwent a percutaneous biliary drainage (PBD) procedure and endoluminal forceps biopsy to obtain histological verification of stenosis. The cumulative success rate, complication rate, time needed to obtain diagnosis, and procedural costs were studied in two scenarios. In the first scenario, 59 patients underwent percutaneous drainage first and after 1–40 (median 7) days, had a postponed biopsy using multi-use 7.5F biopsy forceps. In the second scenario, 42 patients underwent percutaneous drainage and successive biopsy in a single, combined procedure using 5.2F disposable biopsy forceps. 1.3. Results: Interventions with a single-procedure PBD biopsy were not associated with a higher rate of complications. The cumulative success rates of endoluminal biopsy in both scenarios were 81% and 76%, respectively. The average time needed to obtain a conclusive biopsy specimen from the time of initial drainage were 47 days and 10 days (p = 0.002). Patients undergoing endoluminal biopsy with the 5.2F forceps benefited from 2,1 fewer percutaneous interventions on average (p< 0.001) and procedural expenses per patient were on average 1.84 times lower (p< 0.001). 1.4. Conclusion: Percutaneous forceps biopsy is a safe procedure even when performed during initial drainage. Its success rate is comparable to that of the postponed biopsy procedure, meanwhile malignancy is determined significantly sooner and healthcare expenses are significantly lower.
188 Percutaneous Endoluminal Forceps Biopsy in Cholangiocellular Carcinoma – A Perspective Approach to Timeliness of Diagnostic Confirmation Using Two Scenarios , Tomas Andrasina1*, Tomas Rohan1 , Hiroko J Martin1 , Jiri Panek1 , Petra Kovalcikova2 , Tomas Grolich4 , Lenka Ostrizkova3 and Vlastimil Valek1
1. Abstract 1.1. Aim: To assess the benefits of performing endoluminal forceps biopsy during initial drainage compared to postponed biopsy using two patient management scenarios. 1.2. Methods: Since 2006, 101 consecutive patients with malignant biliary stenosis due to cholangiocellular carcinoma have been followed up. All patients underwent a percutaneous biliary drainage (PBD) procedure and endoluminal forceps biopsy to obtain histological verification of stenosis. The cumulative success rate, complication rate, time needed to obtain diagnosis, and procedural costs were studied in two scenarios. In the first scenario, 59 patients underwent percutaneous drainage first and after 1–40 (median 7) days, had a postponed biopsy using multi-use 7.5F biopsy forceps. In the second scenario, 42 patients underwent percutaneous drainage and successive biopsy in a single, combined procedure using 5.2F disposable biopsy forceps. 1.3. Results: Interventions with a single-procedure PBD biopsy were not associated with a higher rate of complications. The cumulative success rates of endoluminal biopsy in both scenarios were 81% and 76%, respectively. The average time needed to obtain a conclusive biopsy specimen from the time of initial drainage were 47 days and 10 days (p = 0.002). Patients undergoing endoluminal biopsy with the 5.2F forceps benefited from 2,1 fewer percutaneous interventions on average (p< 0.001) and procedural expenses per patient were on average 1.84 times lower (p< 0.001). 1.4. Conclusion: Percutaneous forceps biopsy is a safe procedure even when performed during initial drainage. Its success rate is comparable to that of the postponed biopsy procedure, meanwhile malignancy is determined significantly sooner and healthcare expenses are significantly lower.
189 Early Oral Refeeding andSelection of Initial Diet in Mild Acute Pancreatitis , Karabulut U1 , Koyuncu MB1 , Sezgin O2 , Ucbilek E2 , Aydin MK2 and Altintas E2*
1. Abstract 1.1. Background/Objectives: When and how to initiate oral reefeding in patients with mild acute pancreatitis (AP) is still an important issue. The aim of this study was to evaluate the efficacy of early oral reefeding in these patients. 1.2. Methods: This is a singl ecenter, prospective, randomized controlled trial. Patients with mild biliary acute pancreatitis who admitted to our hospital were included. The patients were separated into two different main groups: early oral reefeding (EORF) and routine oral reefeding (RORF). These main two groups were divided into three subgroups according to initial dietary regimen (liquid, soft and solid diet). After the comparison according to mean pain index, pain index after initial meal, length of hospitalization, inflammation and need for antibiotics and painkiller drugs between two main groups, subgroups were compared according to same parameters also. 1.3. Results: There were 49 patients in EORF group and 49 patients in RORF group. In EORF group, mean hospitalization length, mean pain index and need for antibiotics were seen significantly lower (p values in order <0.001, 0.003, 0.009). Pain index after first meal after hospitalization was lower in RORF group (p<0.001). Subgroups were compared according to same parameters and there were no significant difference. 1.4. Conclusion:Thepatient,whosufferedmildacutepancreatitis,mayeatfirstroutinemeal, regardless of the severity of the pain and without waiting for pancreatitis to recovery.. The onset of bolus presence is the impedance dropped to 90% of the nadir; the offset of bolus presence was the return to 50% of the impedance baseline.
190 Venous Outflow Complication after Living Donor Liver Transplantation Using Right-Liver Graft without Middle Hepatic Vein , Ogata S1,2, Song GW1 , Ahn CS1 , Moon DB1 , Hwang S1 , Ha TY1 ,Ku Y2 and Lee SG1
1. Abstract Hepatic venous outflow complications are major obstacles to success of living donor liver transplantation (LDLT), especially using a right-liver graft without the middle hepatic vein (MHV). The aim of this study wasto clarify hepatic venous outflow complication, the risk factors for hepatic venous stenosis and the role of endovascular intervention in its management in LDLT using a right-liver graft without the MHV. In 504 LDLT, 232 patients underwent LDLT using a right-liver graft without the MHV and reconstruction of MHV tributaries. Hospital mortality was 2.2%. In 51 of 232 patients, 56 stenosis; 8 in the right hepatic vein (3.4%), 43 in reconstructed MHV tributaries (18.5%) and 5 in the right inferior hepatic vein (2.2%) were detected during 14 days after LDLT. Nineteen patients (8.2%) with severe hepatic venous congestion had an immediate endovascular stent-placement resulting in a significant improvement of liver function tests in 17 patients. Univariate analysis showed material for interposed vein graft was the only significant predictor affecting early stenosis of reconstructed MHV tributaries. Late stenosis in interposed vein graft occurred in 30 patients (12.9%) without requiring treatment. The patency rates of reconstructed MHV tributaries at 14, 90 and 180 days were 81.4%, 75.6% and 72.2%, respectively.In conclusion,reconstruction of MHV tributaries in LDLT can be performed with satisfactory patency rates and the hepatic congestion can be effectively treated by endovascular stent-placement, contributing to low hospital mortality
191 Postoperative Recovery of Esophageal Function Measured by High Resolution Impedance Manometry , Lai CJ and Cheng YJ*
2. Clinical Image The high resolution impedance manometry (HRIM, 36 pressure sensors; 12 impedance, MMS, Netherlands) was used to examine the postoperative recovery of esophageal function by pressure flow analysis [1]. Complete recovery of postoperative esophageal function was divided into two parts: (1) The bolus fluid successful transmit through gastro esophageal (GE) junction and, [2] The bolus fluid successfully transmit through the transition zone of the esophagus. The definition of bolus fluid successful through the GE junction should meet the criteria of both bolus presence and a flow-permissive pressure gradient [1].
192 Physical Activity is Beneficial for Gallbladder Disease , Molina-Molina E1*, Shanmugam H1*,Wang DQH2 , Vergani L3 and Portincasa P1*
1. Abstract Physical activity brings several beneficial effects on cardiovascular disease and in various metabolic disorders. The gallbladder is the dynamic reservoir of concentrated bile containing cholesterol, bile acids, and phospholipids as micelles and vesicles. Such lipid carriers depend on hepatic synthesis and play a key role in digestion and absorption of intestinal nutrients and cholesterol, in concert with intestinal motility. Bile acids also act as metabolically active hormones through interaction with small intestinal farnesoid-X receptor and GPBAR-1 receptor across the enterohepatic circulation. The gallbladder, however, can become the “fellow traveller” with several metabolic disorders (obesity, diabetes, insulin resistance, dyslipidaemia, nonalcoholic liver steatosis) and metabolic syndrome. In this context, aggregation and growth of excess biliary cholesterol into microcrystals and then macro-cholesterol gallstones may occur in the gallbladder. Notably, physical activity supports also benefits on the hepatobiliary tract, and via activation of bile acids acting as signalling molecules. Researchers should know that initial training condition, volume, age, intensity, aerobic capacity, body weight, and percent of body fat appear to interact with exercise-related health consequences. Thus, the overall beneficial effects of physical activity extend beyond the cardiovascular health, and involve the hepatobiliary health.
193 Anti-Inflammatory Activity of Fruit Such as Berries on the Body , Jae Gon Kim1 and Beong Ou Lim2*
1. Abstract Many people are becoming more interested in their health. Every day, to increase their resistance against many diseases (including hypertension, diabetes, and obesity) and to keep healthy, people eat nutrients in the form of vegetables and fruits. Therefore, research into extracts from many kinds of vegetables and fruits is in progress, and the anti-inflammatory, anti-aging, and antioxidant effects that occur by various mechanisms are being revealed. The study of extracts from berries is well under way. There are many kinds of berries (including blueberries, acai, aronia, and marqui berries), and they are known as the most antioxidant-rich fruits, containing anthocyanin and various vitamins. In addition to their antioxidant effects, berries are known to increase immunity, reduce eye fatigue, regenerate signal transference in brain nerve cells, and help improve memory. Herein, we focus on the anti-inflammatory effects of berries, rather than the antioxidant activity that is already widely known.
194 HydatidCyst of the Liver Ruptured into the Thorax in a Child , Zouari M1, 2*, Abdallah AKB1, 2,Abid I1, 2,Dhaou MB1, 2 and Mhiri R1
1. Clinical Image Hydatid disease (HD) is an important medical, social, and economic problem in many Mediterranean and Middle East countries [1]. Hydatid disease affects most commonly the liver and lungs [2]. One of the serious complications of liver hydatid cysts is cyst rupture. The rupture can occur after a trauma, or spontaneously because of increased intracystic pressure[3]. The surgical management of cyst rupture is difficult, and often associated with high morbidity and mortality rates [3, 4]. To the best of our knowledge, this is the first report of a hydatid cyst of the liver ruptured into the thorax in a child. Written informed consent was obtained from the legal guardian of the patient to publish this case and accompanying images in scientific journals for research and educational purposes.
195 Dietary Fenugreek Attenuates Dextran Sodium SulfateInduced Ulcerative Colitis: Role of Inflammation , Liu MY1*, Hsu DZ1 , Periasamy S1 and Chien SP2
1. Abstract 1.1. Aim: Ulcerative colitis, a chronic relapsing form of inflammatory bowel disease, is often neglected at initial stages due to its difficulty in detection leading to delayed clinical evaluation and treatment. Fenugreek, an annual plant and spice, is known to possess anti-inflammatory property. We examined the effect of dietary fenugreek on inflammatory cells related cyto-kinemediated inflammation in dextran sulfate sodium (DSS)-induced colitis model. 1.2. Methods: To investigate the anti-inflammatory effect of fenugreek on DSS-induced ulcerative colitis, DSS (3% w/v) was administered in drinking water for 7 days to induce ulcerative colitis in C57BL/6 mice. Fenugreek (5% and 10%) was fed in diet throughout the experiment for 14 days. 1.3. Results: Fenugreek improved disease activity index, stool consistency, and occult blood. In addition, it increased colon length and decreased colon weight/length ratio, and spleen weight. Additionally, it significantly decreased circulating immune cells and mast cell recruit-ment and improved hematological parameters. Further, it altered the acidic and neutral mucin in the colon and attenuated inflammation by decreasing tumor necrosis factor-α, interleukin (IL)-1β, and IL-6, but increasing IL-10. 1.4. Conclusion: Fenugreek decreased inflammatory cytokines, thereby protecting the colon against DSS-induced inflammation and injury.
196 Five Decades of Research in Chronic Hepatitis B Infection-Have We Reached the Endpoint? , Lau G1,2
2. Commentary Being a practicing hepatologist in Asia for almost thirty years, my most distressing clinical experience is the need to confront patients with chronic hepatitis B (CHB) infection, being undiagnosed and presented with advanced/late hepatocellular carcinoma (HCC). Many of these patients subsequently died at their middle-age. With the discovery of hepatitis B surface antigen[1]coupled with subsequent large scale epidemiology study[2] and the substantial reductions of HCC with universal hepatitis B vaccination[4] the causal relationship of CHB with HCC, has been clearly established. In the subsequent REVEAL study, high baseline HBV DNA associated with increased risk of HCC [5].In addition, CHB infection is also the major culprit of end-staged liver cirrhosis and its reactivation, either spontaneously or with the use of immunosuppressive therapy could lead to fulminant liver failure[6]. The latter is aggravated by the presence of precorepoint mutation at nucleotide 1896 of the precore region[7].
197 Medical Management of Hepatic Vena Cava Syndrome (Based on New Concept of its Pathogenesis) , Santosh Man Shrestha
1. Abstract Hepatic Vena Cava Syndrome (HVCS) is a chronic obliterative disease of Inferior Vena Cava (IVC) at the site of hepatic vein opening characterized by long asymptomatic period, recurrent Acute Exacerbations (AE) and high incidence of hypersplenism, ascites, Liver Cirrhosis (LC) and Hepatocellular Carcinoma (HCC). The disease was previously labeled membranous obstruction of inferior vena cava and included under Budd-Chiari syndrome. It was considered congenital vascular anomaly and managed by surgery or endovascular procedures. A new concept of pathogenesis of the disease was described recently that considered HVCS as bacterial infection induced evolving disease. The initial lesion a localized thrombophlebitis at the site of hepatic vein openings on resolution converts into stenosis or complete obstruction followed by dilation of the distal segment and development of cavacaval anastomosis. The obliterative lesion and cava-caval anastomosis persists the rest of the life. Patient remains asymptomatic for variable period till further bacterial infection results in reoccurrence of thrombophlebitis at the site which often extends into hepatic veins causing Acute Exacerbations (AE). Mild AE manifests clinically as jaundice and/or elevation of ALT/AST, and severe AE with large thrombus causing Hepatic Venous Outflow Obstruction (HVOO) as ascites. Organization of thrombophlebitis formed during recurrent AEs modifies the lesion in IVC into a thick obstruction. Patients with recurrent AEs develop mild splenomegaly and hypersplenism
198 Management of Primary Hepatic Carcinoma by Traditional Chinese Medicine , CHENG Jinlai and LENG Jing XIA Meng
1. Abstract Primary hepatic carcinoma is one of the types with high incidence of cancer. It has the characteristics of hidden disease, long incubation period, rapid development and easy metastasis, and the prognosis is poor, which seriously affects the quality of life of patients. Although much progress has been made in its research, the complex mechanisms of its onset and deterioration are not fully understood. This article summarizes the diagnosis and treatment of primary liver cancer in modern medicine and traditional Chinese medicine, and provides the future prospects for the treatment of primary liver cancer from the perspective of overall and personalized Chinese medicine.
199 Resection of Fourth Segment of Liver as a Cause of Hepatoblastoma in A 8 MonthOld-Boy , Velmishi V1*, Bali D2 and Alushani D3
1. Clinical Image We would like to present the case of an 8 month –old –boy who is diagnosed with Hepatoblastoma. He underwent to chemotherapy earlier which reduced tumor size localized in fourth segment of liver (Figure A) Last procedure was tumor resection performed successfully by our surgery team (Figure B, C)
200 Unexpected Esophageal Mucosal Defects After Peroral Endoscopic Myotomy (POEM) , Pittayanon R1*, Ramchandani M2 and Rerknimitr R1
1. Case Report Peroral endoscopic myotomy (POEM) is a promising treatment for achalasia cardia that requiring submucosal tunneling [1]. The important concept to prevent its complication is to stay away from the mucosa during making the tunnel. Although, pneumoperitoneum or pneumomediastinum was developed from the defect at longitudinal muscle layer, there is no clinical significance if the mucosal flap remains intact [1, 2]. However, if the mucosal defect occurs, tight mucosal closure with clips is recommended to avoid leakage of esophageal content into the mediastinum [2]. A 32-year-old woman has been diagnosed achalasia cardia type II and undergone peroral endoscopic myotomy (POEM) by anterior approach since 2014. A few mucosal blebs were reported at the tunnel wall right after the procedure. The patient was discharged without complication but she did not come for a follow-up. One year later, she presented back because of recurrent dysphagia. Esophageal manometry confirmed achalasia cardia type II and re-POEM was scheduled.
201 Intraductal Papillary Neoplasia of the Bile Ducts (IPN-B): About a Case , Zatir S*, Ouguerti N, Arbouz M, Bouchakour S, Laouisset S, kroumli B, Abdellaoui K, Belkherour A, allam A and larkaam T
1. Abstract Intraductal papillary neoplasia of the bile ducts (IPN-B) is a rare intracanal tumor characterized by papillary proliferation of the biliary epithelium responsible for more or less abundant production of mucus, causing dilation of the duct [1]. IPN-B is the "biliary" equivalent of TIPMP. MRI cholangiography and transcutaneous abdominal ultrasound are the best examinations to suggest the diagnosis in the presence of a cystic lesion of the biliary tree associated with dilation of the downstream duct [2, 3]. The distribution of histological forms is different with a predominance of gastric forms in TIPMP and pancreatobiliary forms in IPN-B explaining a much better prognosis of TIPMP, surgical treatment is the gold standard given the high risk of malignancy. we discuss a case of a 60-year-old patient operated on for IPN-B who underwent duodenpancreaticocephalus.
202 Changes in Metabolic Processes in The Gastric Mucosa in The Pathogenesis of the Formation of Acute Ulcers in Acute Small Intestinal Obstruction , Yefimovich MV1 , Cuong NC3 , Murshud Kizi SMK1 , Oglu SER2 and Khoi NA
1. Abstract 1.1. Introduction: Acute small bowel obstruction is a problem of modern surgery. It is not possible to study morphological and functional changes in the walls of the stomach in acute small bowel obstruction on clinical material, performing a biopsy in the dynamics of the development of the disease. Therefore, our work is experimental. 1.2. Methods: 2 intact dogs served as control. In 12 animals (the second group), a strangulation of small bowel obstruction was simulated with a period of 3, 6, 12 and 24 hours. In 12 animals (the third group), obstructive small bowel obstruction was simulated for 3, 6, 12, and 24 hours. The preparations are stained according to Einarson to obtain DNA. 1.3. Results: In the antrum of the stomach, the level of nucleoproteins in the epithelial cells of the mucous membrane after 1 day from the creation of a model of acute 5.2 times, after 2 days - 2.2 times, after 3 days decreased 1.45 times, and after 6 days - 7.28 times when compared with the norm. In the main cells of the glands after 1 day it increased 2.64 times, after 2 days - 1.44 times, after 3 days - 2 times, and after 6 days - 3 times. 1.4. Conclusions: The most pronounced morphofunctional changes in the gastric mucosa, progressing in the dynamics of the disease, both when modeling acute strangulation and acute obstructive small intestinal obstruction are observed in its antrum, which explains the most frequent localization of acute ulcers in this part of the stomach.
203 Quantum Nature of Coronavirus and Method of Treatment , Adamski A*
1. Abstract Work on the coronavirus is trying to produce vaccines of various types. Those are vaccines containing inactivated or killed viruses, vaccines with viral fragments, which are intended to sensitize the immune system to specific virus subunits. Vaccines based on RNA or DNA nucleic acids, which contain a synthesized stretch of viral mRNA. The author is developing a quantum informational vaccine for the treatment of coronavirus. The next generation vaccine will inject information into the body, the purpose of which will be to “trick” the body into thinking that it has a virus in it and, as a result, will produce antibodies. It is possible thanks to the control of quantum-information processes, e.g. by means of an electromagnetic wave, soliton wave, electric field, acoustic wave, spin wave or bioplasm. Melanin is to play a significant role in this, as a free radical is capable of creating quantum states of entangled particles, atoms, or entire information structures. Melanin directs the reduction of free radicals in the biological system, it has the ability to accelerate or delay the movement of photons, phonons and solitons and their spins. It acts as a converter of photons into phonons and the reverse process, which enriches the nerve cell with a wide range of information acquisition and its use in its functional and structural process.
204 Infective Suppurative Thrombosis in the Left Portal Vein After Acute Appendicitis , Nunez AD* , Alvarez JMS, Morales AL and Herrera JCP
1. Clinical Case Postoperative complications can occur. Most of them are frequent and we are used to dealing with them, but there are others that seem to appear only in a few posts, and when they happen to your patient you cannot explain why. In our case, it is a young patient with no relevant medical history except for taking oral contraceptives. She attended the Emergency Department presenting pain in the right iliac fossa over the last 24 hours. She was diagnosed with incipient acute appendicitis without sepsis criteria and an emergency intervention with laparoscopic approach was performed without incident. Due to her good evolution, she was discharged home after 24 hours with oral antibiotics and antithrombotic prophylaxis (Figure 1).
205 Helicobacter Pylori Detection Among Sudanese Patients Diagnosed with Conlon Polyps and Colon Cancer Using Immunohistochemistry Technique , Awhag ZA1*, Mohamed AK1 , Suliman NME1 , Ali FS1 , Ali ET1, 2, Siddig EE3,4, Mohamed NS5, 6, 7 and Edris AMM1, 8
1. Abstract 1.1. Purpose: H. pylori has been classified as class 1 carcinogen, this pathogen was reported to be associated with the gastritis and gastric carcinoma, also in recent year the researchers start to study the role of H. pylori in colorectal cancer. Therefore; the aim of the current study is to evaluate the presence of H pylori in different lesions including colon polyps and colon cancer. 1.2. Methods: between February-May 2017; sixty-nine Formalin fixed paraffin blocks from different colon lesions were collected, and each one was stained using Immunohistochemistry marker for the detection of H pylori. 1.3. Results: Of the 69 patients there were 30 (43.5%) females and 39 (56.5%) males their ages ranged from 21 to 80 years with mean age 47.12 ± 19.79. Of the 69 cases, 44 (63.8%) were diagnosed with adenocarcinoma, 10 (14.5%) colitis, 15 (21.7%) juvenile polyposis syndrome. Out of the 69 patients, 16 (23.18%) patients were positive for H. pylori infection. 13 (81.3%) patients were diagnosed with adenocarcinoma and 3 (18.7%) patients were diagnosed with juvenile polyps and the results were statistically significant (0.028). 1.4. Conclusion: This study has demonstrated the presence of H. pylori in colon polyps and colon cancer by IHC methods, albeit with a statistical significance results. Our findings suggest a positive correlation between colon polyps and cancer and H. pylori.
206 Acute Peritonitis Generalized by Typhoid Perforation at Kankan Regional Hospital , Naby CS1*, Mampan KA2 , Djoulde DA2 , Togba SL3 , Mohamed C1 , Oumar S1 , Mariame C4 , Adama K5 , Makhissa BA6 , Lamine SM7 , Elisa T7 , Tady K7 , Aboubacar T3 and Taran DA3
1. Abstract 1.1. Aim: The aim of this study is to make our contribution to the study of acute generalized peritonitis of typhus origin at the Kankan Regional Hospital. Typhoid perforation is defined as the opening of a hollow viscus in the abdominal cavity due to salmonella. 1.2. Methodology: We carried out a 6-month prospective study from June 1, 2019 to November 30, 2019 inclusive. Were included in our study, all the patients operated on for peritonitis by typhoid perforation and hospitalized in the department and in whom the diagnosis of typhus perforation was made intraoperatively and confirmed by the positivity of Widal and Félix in the department during the study period. Any patient operated on for non-typhus peritonitis was not included in the study. All patients diagnosed with typhoid perforation but who died before surgery. Results during our study period we had 423 patients of whom 8 percent developed peritonitis from typhoid perforation. The study involved 21 men and 12 women, for a sex ratio of 1.75, which showed a clear predominance of the affection of men. The history of gastroenteritis was noted in 45.45 percent of our patients, typhoid fever in 36.36 percent, malaria in 18.18 percent, arterial hypertension in 12.12 percent and parasitosis in 9.09 percent. However, perforations were single in 19 patients, double in 9 patients and multiple in 5 patients. The treatment was medico-surgical, the operative consequences were simple in 33 percent and complicated in 67 percent. Unfortunately, we had recorded 5 cases of death against 28 cases of cure. 1.3. Conclusion: Acute generalized peritonitis represents frequent 1 tropical pathologies, the management is medico-surgical (Table 1).
207 MEFV Gene Mutations and Pathologic Gene Polymorphism in Cases with Inflammatory Bowel Diseases , Tumgor G* , Agin M and Bisgin A
1. Editorial 1.1. The Genetic Characteristics of Inflammatory Bowel Diseases and Familial Mediterranean Fever Inflammatory bowel diseases (IBD) are chronic, repetitive diseases caused by regulation defects of the mucosal immune response, which increases against the bacterial antigens in the bowel lumen of patients with genetic susceptibility [1]. In 2001 it was determined that NOD/Caspase recruitment domain (CARD) 15 is a Crohn’s Disease (CD) gene localized on chromosome 16 and encodes the NOD2/CARD15 protein. This gene is responsible for the natural immune response and transcription factor nuclear factor kß (NFkß) activation in apoptosis. One-third of CD patients are NOD2/CARD15 gene mutation carriers [2]. Ulcerative Colitis (UC) is more common in families that have individuals with UC and in specific ethnicities, such as Jewish. This indicates that the disease has a genetic basis [3]. Although more than 30 IBD-related genes have been determined, the roles of these genes are not completely described. Pyrin and NOD2/CARD15 proteins are structurally similar and have a key role in apoptosis regulation, cytokine processing, and inflammation [4].