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Uncovering the uncertainty: Risk factors and clinical relevance of P1 lesions on small bowel capsule endoscopy of anemic patients

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World Journal of Gastroenterology 2016年第38期22卷 8568-8575页

作者： Tiago Cúrdia Gon?alves Mara Barbosa Bruno Rosa Maria Jo?o Moreira josé cotter Gastroenterology Department Hospital da Senhora da Oliveira School of Health Sciences University of Minho ICVS/3B’s PT Government Associate Laboratory

AIM To identify risk factors for P1 lesions on small bowel capsule endoscopy(SBCE) and to describe the natural history of anemic patients with such type of *** One hundred patients were consecutively selected for a case-control analysis performed between 37 cases with P1 lesions and 63 controls with negative SBCE. Age, gender, comorbidities and regular medication were collected. Rebleeding, further investigational studies and death were also analyzed during the *** No significant differences on gender, median age or Charlson index were found between groups. Although no differences were found on the use of proton pump inhibitors, acetylsalicylic acid, anticoagulants or antiplatelet agents, the use of non-steroidal antiinflammatory drugs(NSAID) was associated with a higher risk of P1 lesions(OR = 12.00, 95%CI: 1.38-104.1). From the 87 patients followed at our center, 39 were submitted to additional studies for investigation of iron-deficiency anemia(IDA), and this was significantly more common in those patients with no findings on SBCE(53.7% vs 30.3%, P = 0.033). A total of 29 patients had at least one rebleeding or IDA recurrence episode and 9 patients died of non-anemia related causes but no differences were found between cases and *** P1 lesions are commonly found in patients with IDA submitted to SBCE. The use of NSAID seems to be a risk factor for P1 lesions. The outcomes of patients with P1 lesions do not differ significantly from those with P0 lesions or normal SBCE.

关键词： P1 lesions Iron-deficiency anemia Small bowel capsule endoscopy Risk factors Rebleeding

PillCam~ SB3 capsule: Does the increased frame rate eliminate the risk of missing lesions?

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World Journal of Gastroenterology 2016年第10期22卷 3066-3068页

作者： Sara Monteiro Francisca Dias de Castro Pedro Boal Carvalho Maria Joao Moreira Bruno Rosa josé cotter Department of Gastroenterology Hospital Senhora da Oliveira Rua dos Cutileiros Creixomil 4835-044 Guimaraes Portugal Life and Health Sciences Research Institute (ICVS) School of Health Sciences University of Minho 4710-057 Braga Portugal ICVS/3B's PT Government Associate Laboratory 4710-057 Braga/Guimaraes Portugal

Since its emergence in 2000, small bowel capsule endoscopy(SBCE) has assumed a pivotal role as an investigation method for small bowel diseases. The PillCam SB2-ex offers 12 h of battery time, 4 more than the previous version(SB2). Rahman et al recently found that the PillCam SB2-ex has a significantly increased completion rate, although without higher diagnostic yield, compared with the SB2. We would like to discuss these somewhat surprising results and the new potentialities of the PillCam SB3 regarding the diagnostic yield of small bowel studies. PillCam SB3 offers improved image resolution and faster adaptable frame rate over previous versions of SBCE. We recently compared the major duodenal papilla detection rate obtained with PillCam SB3 and SB2 as a surrogate indicator of diagnostic yield in the proximal small bowel. The PillCam SB3 had a significantly higher major duodenal papilla detection rate than the PillCam SB2(42.7% vs 24%, P = 0.015). Thus, the most recent version of the PillCam capsule, SB3, may increase diagnostic yield, particularly in the proximal segments of the small bowel.

关键词： PillCam~ SB2 PillCam~ SB3 Capsule endoscopy Diagnostic yield Lesions Frames

Osteonecrosis of both knees in a woman with Crohn's disease

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World Journal of Gastrointestinal Pharmacology and Therapeutics 2016年第4期7卷 579-583页

作者： Mara Barbosa josé cotter Department of Gastroenterology Hospital da Senhora da Oliveira

Osteonecrosis is a very rare complication of Crohn’s disease (CD). It is not clear if it is related to corticosteroid therapy or if it occurs as an extraintestinal manifestation of inflammatory bowel disease. We present the case of a patient with CD who presented with osteonecrosis of both knees. A 22 years old woman was diagnosed with CD in April 2012 (Montreal Classification A2L1 + L4B3p). She was started on prednisolone (40 mg/d), azathioprine (100 mg/d) and messalazine (3 g/d). In July 2012, due to active perianal disease, infliximab therapy was initiated. In September 2012, she had a pelvic abscess complicated by peritonitis and an ileal segmental resection and right hemicolectomy were performed. In December 2012 she was diagnosed with bilateral septic arthritis of both knees with walking impairment. She was treated with amoxicillin-clavulanic acid, started a physical rehabilitation program and progressively improved. However, then, bilateral knee pain exacerbated by movement developed. Magnetic resonance imaging showed multiple osseous medullary infarcts in the distal extremity of the femurs, proximal extremity of the tibiae and patellas and no signs of subchondral collapse, which is consistent with osteonecrosis. The patient recovered completely and maintains therapy with azathioprine and messalazine. A review of the literature is also done.

关键词： Osteonecrosis Knee Inflammatory bowel disease Crohn&rsquo s disease Magnetic resonance imaging

Cirrhotic cardiomyopathy:Isn't stress evaluation alwaysrequired for the diagnosis?

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World Journal of Hepatology 2016年第3期8卷 200-206页

作者： mara barbosa joana guardado carla marinho bruno rosa isabel quelhas antónio lourenco josécotter Gastroenterology Department Centro Hospitalar do Alto Ave4835 GuimarãesPortugal

AIM:To describe the proportion of patients with cirrhotic cardiomyopathy(CCM) evaluated by stress echocardiography and investigating its association with the severity of liver ***:A cross-sectional study was *** patients without risk factors for cardiovascular disease were *** regarding etiology and severity of liver disease(Child-Pugh score and model for end-stage liver disease),presence of ascites and gastroesophageal varices,pro-brain natriuretic peptide(proBNP) and corrected QT(QTc) interval were *** stress echocardiography(conventional and tissue Doppler imaging) was *** was considered present when diastolic and/or systolic dysfunction was diagnosed at rest or after pharmacological *** interfering with cardiovascular system was suspended 24 h before the ***:Twenty-six patients were analyzed,17(65.4%) Child-Pugh A,mean model for end-stage liver disease(MELD) score of *** global proportion of patients with CCM was 61.5%.At rest,only 2(7.7%)patients had diastolic dysfunction and none of the patients had systolic *** stress echocardiography revealed the presence of diastolic dysfunction in more 6(23.1%) patients and of systolic dysfunction in 10(38.5%) *** interval prolongation was observed in 68.8%of the patients and increased pro-BNP levels in 31.2%of *** was no association between the presence of CCM and liver impairment assessed by Child-Pugh score or MELD(P= 0.775,P= 0.532,respectively).Patients with QTc interval prolongation had a significant higher rate of gastroesophageal varices comparing with those without QTc interval prolongation(95.0%vs 50.0%,P= 0.028).CONCLUSION:CCM is a frequent complication of cirrhosis that is independent of liver *** evaluation should always be performed,otherwise it will remain an underdiagnosed condition.

关键词： Dobutamine stress echocardiography Cirrhotic cardiomyopathy Cirrhosis Corrected QT interval prolongation Liver impairment

Small bowel neuroendocrine tumors： From pathophysiologyto clinical approach

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World Journal of Gastrointestinal Pathophysiology 2016年第1期7卷 117-124页

作者： Sofia Xavier Bruno Rosa josécotter Department of Gastroenterology Centro Hospitalar do Alto Ave4835-044 GuimarãesPortugal ICVS/3B’s Associate Laboratory University of MinhoCampus de Gualtar4710-057 BragaPortugal Life and Health Sciences Research Institute School of Health SciencesUniversity of MinhoCampus de Gualtar4710-057 BragaPortugal

Neuroendocrine tumors(NETs), defined as epithelial tumors with predominant neuroendocrine differentiation, are among the most frequent types of small bowel neoplasm. They represent a rare, slow-growing neoplasm with some characteristics common to all forms and others attributable to the organ of origin. The diagnosis of this subgroup of neoplasia is not usually straight-forward for several reasons. Being a rare form of neoplasm they are frequently not readily considered in the differential diagnosis. Also, clinical manifestations are nonspecific lending the clinician no clue that points directly to this entity. However, the annual incidence of NETs has risen in the last years to 40 to 50 cases per million probably not due to a real increase in incidence but rather due to better diagnostic tools that have become progressively available. Being a rare malignancy, investigation regarding its pathophysiology and efforts toward better understanding and classification of these tumors has been limited until recently. Clinical societies dedicated to this matter are emerging(NANETS, ENETS and UKINETS) and several guidelines were published in an effort to standardize the nomenclature, grading and staging systems as well as diagnosis and management of NETs. Also, some investigation on the genetic behavior of small bowel NETs has been recently released, shedding some light on the pathophysiology of these tumors, and pointing some new directions on the possible treating options. In this review we focus on the current status of the overall knowledge about small bowel NETs, focusing on recent breakthroughs and its potential application on clinical practice.

关键词： Neuroendocrine tumors Gastrointestinaltumors Small bowel neoplasms Carcinoid Diagnosticmarkers

Alpha-1 antitrypsin deficiency and Pi^(*)Z allele as important co-factors in the development of liver fibrosis

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World Journal of Hepatology 2024年第8期16卷 1099-1110页

作者： Ana Isabel Ferreira Catarina Guimarães Vitor Macedo Silva Sofia Xavier Joana Magalhães josécotter Department of Gastroenterology Hospital da Senhora da Oliveira-GuimarãesGuimarães 4835-044Portugal Life and Health Sciences Research Institute School of MedicineUniversity of MinhoBraga 4710-057Portugal Life and Health Sciences Research Institute/3B’s PT Government Associate LaboratoryBraga 4710-057Portugal Department of Pulmonology Hospital Senhora da Oliveira-GuimarãesGuimarães 4835-044Portugal

BACKGROUND Alpha-1 antitrypsin deficiency(AATD)is a codominant autosomal hereditary condition that predisposes patients to the development of lung and/or liver disease,and Pi*Z allele is the most clinically relevant *** To evaluate the impact of clinical parameters and AATD phenotypes,particularly the Pi*Z allele,in liver *** Cross-sectional cohort study including consecutive patients with AATD followed in Pulmonology or Hepatology *** Included 69 patients,49.3%had Pi*MZ phenotype and 10.1%Pi**** age≥55 years,age at diagnosis≥41 years and AAT at diagnosis<77 mg/dL predicted a nonalcoholic fatty liver disease fibrosis score(NFS)not excluding advanced fibrosis[area under the curve(AUC)=0.840,P<0.001;AUC=0.836,P<0.001;AUC=0.681,P=0.025].An age≥50 years and age at diagnosis≥41 years predicted a fibrosis-4 index of moderate to advanced fibrosis(AUC=0.831,P<0.001;AUC=0.795,P<0.001).Patients with hypertension,type 2 diabetes mellitus(DM),dyslipidaemia,metabolic syndrome,and regular alcohol consumption were more likely to have a NFS not excluding advanced fibrosis(P<0.001,P=0.002,P=0.008,P<0.001,P=0.033).Patients with at least one Pi*Z allele and type 2 DM were 8 times more likely to have liver stiffness measurement≥7.1 kPa(P=0.040).CONCLUSION Risk factors for liver disease in AATD included an age≥50 years,age at diagnosis≥41 years,metabolic risk factors,regular alcohol consumption,at least one Pi*Z allele,and AAT value at diagnosis<77 mg/*** created an algorithm for liver disease screening in AATD patients to use in primary care,selecting those to be referred to Hepatology consultation.

关键词： Alpha-1 antitrypsin deficiency Liver fibrosis Nonalcoholic fatty liver disease fibrosis score Fibrosis-4 index Liver stiffness measurement

Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: From guidelines to clinical practice

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World Journal of Gastrointestinal Endoscopy 2015年第2期7卷 128-134页

作者： Joana Magalhes Bruno Rosa josé cotter Gastroenterology Department Centro Hospitalar do Alto Ave Life and Health Sciences Research Institute (ICVS) School of Health SciencesUniversity of Minho ICVS/3B’s PT Government Associate Laboratory

AIM: To study the practical applicability of the American Society for Gastrointestinal Endoscopy guidelines in suspected cases of ***: This was a retrospective single center study, covering a 4-year period, from January 2010 to December 2013. All patients who underwent endoscopic retrograde cholangiopancreatography(ERCP) for suspected choledocholithiasis were included. Based on the presence or absence of predictors of choledocholithiasis(clinical ascending cholangitis, common bile duct(CBD) stones on ultrasonography(US), total bilirubin > 4 mg/d L, dilated CBD on US, total bilirubin 1.8-4 mg/d L, abnormal liver function test, age > 55 years and gallstone pancreatitis), patients were stratified in low, intermediate or high risk for choledocholithiasis. For each predictor and risk group we used the χ2 to evaluate the statistical associations with the presence of choledocolithiasis at ERCP. Statistical analysis was performed using SPSS version 21.0. A P value of less than 0.05 was considered statistically significant. RESULTS: A total of 268 ERCPs were performed for suspected choledocholithiasis. Except for gallstone pancreatitis(P = 0.063), all other predictors of cho-ledocholitiasis(clinical ascending cholangitis, P = 0.001; CBD stones on US, P ≤ 0.001; total bilirubin > 4 mg/dL, P = 0.035; total bilirubin 1.8-4 mg/dL, P = 0.001; dilated CBD on US, P ≤ 0.001; abnormal liver function test, P = 0.012; age > 55 years, P = 0.002) showed a statistically significant association with the presence of choledocholithiasis at ERCP. Approximately four fifths of patients in the high risk group(79.8%, 154/193 patients) had confirmed choledocholithiasis on ERCP, vs 34.2%(25/73 patients) and 0(0/2 patients) in the intermediate and low risk groups, respectively. The definition of "high risk group" had a sensitivity of 86%, positive predictive value 79.8% and specificity 56.2% for the presence of choledocholithiasis at ERCP. CONCLUSION: The guidelines should be

关键词： Choledocholithiasis Endoscopic retrograde cholangiopancreatography Cholangitis Common bileduct stones Dilated common bile duct

Upper gastrointestinal bleeding risk scores： Who, when andwhy？

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World Journal of Gastrointestinal Pathophysiology 2016年第1期7卷 86-96页

作者： Sara Monteiro Tiago Cúrdia Gonçalves Joana Magalhães josécotter Department of Gastroenterology Hospital Senhora da Oliveira-GuimarãesCreixomil4835-044 GuimarãesPortugal Life and Health Sciences Research Institute(ICVS) School of Health SciencesICVS/3B’s Associate LaboratoryUniversity of MinhoCampus de Gualtar4835-044 Braga/GuimarãesPortugal

Upper gastrointestinal bleeding(UGIB) remains a significant cause of hospital admission. In order to stratify patients according to the risk of the compli-cations, such as rebleeding or death, and to predict the need of clinical intervention, several risk scores have been proposed and their use consistently recommended by international guidelines. The use of risk scoring systems in early assessment of patients suffering from UGIB may be useful to distinguish high-risks patients, who may need clinical intervention and hospitalization, from low risk patients with a lower chance of developing complications, in which management as outpatients can be considered. Although several scores have been published and validated for predicting different outcomes, the most frequently cited ones are the Rockall score and the Glasgow Blatchford score(GBS). While Rockall score, which incorporates clinical and endoscopic variables, has been validated to predict mortality, the GBS, which is based on clinical and laboratorial parameters, has been studied to predict the need of clinical intervention. Despite the advantages previously reported, their use in clinical decisions is still limited. This review describes the different risk scores used in the UGIB setting, highlights the most important research, explains why and when their use may be helpful, reflects on the problems that remain unresolved and guides future research with practical impact.

关键词： Upper gastrointestinal bleeding Risk scores Risk assessment Rockall score Glasgow blatchfordscore

PillCam COLON 2~ in Crohn's disease:A new concept of pan-enteric mucosal healing assessment

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World Journal of Gastroenterology 2015年第23期21卷 7233-7241页

作者： Pedro Boal Carvalho Bruno Rosa Francisca Dias de Castro Maria Joo Moreira josé cotter Life and Health Sciences Research Institute School of Health Sciences University of Minho ICVS/3B’s PT Government Associate Laboratory Gastroenterology Department Centro Hospitalar do Alto Ave

AIM: To evaluate mucosal healing in patients with small bowel plus colonic Crohn's disease(CD) with a single non-invasive examination, by using PillCam COLON 2.(PCC2).METHODS: Patients with non-stricturing nonpenetrating small bowel plus colonic CD in sustained corticosteroid-free remission were included. At diagnosis,patients had undergone ileocolonoscopy to identify active CD lesions, such as ulcers and erosions, and small bowel capsule endoscopy to assess the Lewis Score(LS). After ≥ 1 year of follow-up, patients underwent entire gastrointestinal tract evaluation with PCC2. The primary endpoint was assessment of CD mucosal healing, defined as no active colonic CD lesions and LS < ***: Twelve patients were included(7 male;mean age: 32 years), and mean follow-up was 38 *** majority of patients(83.3%) received immunosuppressive therapy. Three patients(25%) achieved mucosal healing in both the small bowel and the colon,while disease activity was limited to either the small bowel or the colon in 5 patients(42%). It was possible to observe the entire gastrointestinal tract in 10 of the12 patients(83%) who underwent ***: Only three patients in sustainedcorticosteroid-free clinical remission achieved mucosal healing in both the small bowel and the colon, highlighting the limitations of clinical assessment when stratifying disease activity, and the need for pan-enteric endoscopy to guide therapeutic modification.

关键词： Crohn's disease Mucosal healing Capsuleendoscopy Small bowel diseases Inflammatory boweldisease