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Background Ulcerative colitis (UC) has a relapsing and remitting pattern, wherein the underlying mechanisms of the relapse might involve an enhanced uptake of luminal antigens which stimulate the immune response. The tricellular tight junction protein, tricellulin, takes charge of preventing paracellular passage of macromolecules. It is characterized by downregulated expression in active UC and its correct localization is regulated by angulins. We thus analyzed the tricellulin and angulin expression as well as intestinal barrier function and aimed to determine the role of tricellulin in the mechanisms of relapse. Methods Colon biopsies were collected from controls and UC patients who underwent colonoscopy at the central endoscopy department of Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin. Remission of UC was defined basing on the clinical appearance and a normal Mayo endoscopic subscore. Intestinal barrier function was evaluated by electrophysiological and paracellular flux measurements on biopsies mounted in Ussing chambers. Results The downregulated tricellulin expression in active UC was recovered in remission UC to control values. Likewise, angulins were in remission UC at the same levels as in controls. Also, the epithelial resistance which was decreased in active UC was restored in remission to the same range as in controls, along with the unaltered paracellular permeabilities for fluorescein and FITC-dextran 4 kDa. Conclusions In remission of UC, tricellulin expression level as well as intestinal barrier functions were restored to normal, after they were impaired in active UC. This points toward a re-sealing of the impaired tricellular paracellular pathway and abated uptake of antigens to normal rates in remission of UC.

Background Coeliac disease (CD) is characterised by diverse clinical symptoms, which may cause diagnostic problems and reduce the patients’ quality of life. A study conducted in the United Kingdom (UK) revealed that the mean time between the onset of coeliac symptoms and being diagnosed was above 13 years. This study aimed to analyse the diagnostic process of CD in Poland and evaluate the quality of life of patients before and after CD diagnosis. In addition, results were compared to the results of the original study conducted in the UK. Methods The study included 2500 members of the Polish Coeliac Society. The patients were asked to complete a questionnaire containing questions on socio-demographic factors, clinical aspects and quality of life, using the EQ-5D questionnaire. Questionnaires received from 796 respondents were included in the final analysis. Results The most common symptoms reported by respondents were bloating (75%), abdominal pain (72%), chronic fatigue (63%) and anaemia (58%). Anaemia was the most persistent symptom, with mean duration prior to CD diagnosis of 9.2 years, whereas diarrhoea was observed for the shortest period (4.7 years). The mean duration of any symptom before CD diagnosis was 7.3 years, compared to 13.2 years in the UK. CD diagnosis and the introduction of a gluten-free diet substantially improved the quality of life in each of the five EQ-5D-5L health dimensions: pain and discomfort, anxiety and depression, usual activities, self-care and mobility (p Conclusions Duration of symptoms prior to the diagnosis of CD in Poland, although shorter than in the UK, was long with an average of 7.3 years from first CD symptoms. Faster CD diagnosis after the onset of symptoms in Polish respondents may be related to a higher percentage of children in the Polish sample. Introduction of a gluten-free diet improves coeliac patients’ quality of life. These results suggest that doctors should be made more aware of CD and its symptoms across all age groups.

Acute duodenal perforation during endoscopic ultrasound (EUS) is a serious complication. The conventional endoscopic treatment for duodenal perforations such as endoscopic clipping is unsatisfactory; recently, the effectiveness of over-the-scope clipping (OTSC) has been reported. A 91-year-old woman was referred to our hospital with the chief complaint of jaundice. Contrast-enhanced computed tomography showed a 2-cm mass in the pancreatic head; we planned EUS-guided fine-needle aspiration. During exploration for a puncture route from the duodenal bulb using a linear echoendoscope under carbon dioxide insufflation, the duodenal lumen was suddenly filled with blood. A perforation

ObjectiveTo investigate whether Xiayuxue decoction exerts an anti-liver fibrosis effect by inhibiting glial cell line-derived neurotrophic factor (GDNF). MethodsA total of 24 C57BL/6 mice were randomly divided into control group, model group, and Xiayuxue decoction group. The mice in the model group and the Xiayuxue decoction group were given intraperitoneal injection of 10% CCl4, and those in the Xiayuxue decoction group were given 0.4678 g/kg Xiayuxue decoction by gavage since week 4. The liver function parameters alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were measured, and liver histopathology was observed. Immunohistochemistry was used to measure the protein expression of alpha-smooth muscle actin (α-SMA) and GDNF. GFP-Col-HSC and human primary hepatic stellate cells (HSCs) were treated with GDNF (10 ng/ml), and HSC activation was measured. A one-way analysis of variance was used for comparison of continuous data between multiple groups, and the least significant difference t-test was used for further comparison between two groups. ResultsCompared with the control group, the model group had significant increases in the levels of ALT and AST, and compared with the model group, the Xiayuxue decoction group had significant reductions in the levels of ALT and AST (all P＜0.01). Liver histopathology showed that the model group had marked inflammatory cell infiltration and formation of fibrous septa by proliferated collagen fibers, and the Xiayuxue decoction group had loose fibrous septa and alleviated inflammatory cell infiltration. Immunohistochemistry showed that compared with the control group, the model group had significant increases in the expression of α-SMA and GDNF (both P＜0.01), which were observed in fibrous septa, and compared with the model group, the Xiayuxue decoction group had significant reductions in the expression of α-SMA and GDNF (both P＜0.05). Western blotting showed that the control group had relatively low expression of GDNF in liver tissue, the formation of liver fibrosis at week 6 of CCl4 modeling, and an around 10-fold increase in the expression of GDNF, and the Xiayuxue decoction group had significantly inhibited protein expression of GDNF (P＜0.01); there were significant increases in the expression of α-SMA and collagen type I α1 (Col1) in mice with liver fibrosis, with significant reductions in α-SMA and Col1 after treatment with Xiayuxue decoction (all P＜0.01). The in vitro experiment showed that GDNF induced the significant increases in the protein expression of α-SMA and Col1 in HSCs, which was significantly inhibited by Xiayuxue decoction (all P＜0.01). ConclusionThe expression of GDNF is significantly upregulated in the formation of liver fibrosis. GDNF can induce HSC activation, and Xiayuxue decoction can exert an anti-liver fibrosis effect by inhibiting GDNF.

Tom Holvoet,1,2 Triana Lobaton,2 Pieter Hindryckx2 1Department of Gastroenterology, AZ Nikolaas, Sint-Niklaas, Belgium; 2Department of Gastroenterology, University Hospital Ghent, Ghent, BelgiumCorrespondence: Tom Holvoet Email tom.holvoet@aznikolaas.beAbstract: Acute severe colitis is a severe complication of ulcerative colitis, affecting approximately 20% of patients. For physicians, it remains a challenging condition to treat. Current treatment algorithms have diminished the mortality associated with acute severe ulcerative colitis (ASUC), but colectomy rates remain high (approximately 30%) despite advances in therapy. Colectomy in ASUC is particularly associated with important postoperative complications and morbidity. In this review, reasons for the inability to improve care and avoid evolution to colectomy for ASUC are explored and solutions that might lead to a better management of the disease are investigated.Keywords: acute severe colitis, ulcerative colitis, inflammatory bowel disease

Background The preoperative prediction of post hepatectomy liver failure (PHLF) is essential, but there is no gold standard for the prediction at present, and the efficacy of different methods for the prediction has not been compared systematically. In this study, we aimed to compare the efficacy of preoperative two-dimensional shear wave elastography (2D-SWE), indocyanine green (ICG) clearance test and biomarkers for PHLF prediction in patients with hepatocellular carcinoma (HCC). Methods We retrospectively studied 215 patients with HCC, who had undergone major liver resection in our hospital. Preoperative data of each patient, including liver stiffness value (LSV) of underlying hepatic parenchyma measured by 2D-SWE, ICG retention rate at 15 min (ICG-R15) measured by ICG clearance test, albumin-bilirubin (ALBI) scores, aspartate aminotransferase–platelet ratio index (APRI), and Fibrosis-4 (FIB-4) were collected for analysis. Post hepatectomy outcomes of study patients were also recorded for assessment of PHLF. The study patients were divided into development cohort (133 patients without PHLF, and 17 patients with PHLF) and validation cohort (59 patients without PHLF, and 6 patients with PHLF) randomly. Results In the development cohort, LSV, ICG-R15 and ALBI scores were significantly different between patients with and without PHLF, while no significant difference of APRI and FIB-4 scores was found. LSV had higher AUC (the area under the receiver operating characteristic curve) (AUC = 0.795) for PHLF prediction than ICG-R15 (AUC = 0.619) and ALBI scores (AUC = 0.686) (p p Conclusions Compared with ICG-R15, ALBI scores, APRI and FIB-4, LSV measured by 2D-SWE may demonstrate better efficacy for preoperative PHLF prediction in patients with HCC.

We report on the case of a 61-year-old male who initially presented with a progressive myoclonus and an intention tremor and was subsequently diagnosed with celiac disease. His neurological symptoms improved with anti-epileptic therapy and a gluten-free diet. Possible explanations include a milder disease phenotype or an epileptic component to his myoclonic movement disorder. This case highlights findings of a progressive myoclonic movement disorder, likely linked to celiac disease, and stresses the importance of a gluten-free diet in the management of the neurological manifestations of celiac disease.

Colorectal Cancer Professional Committee,Chinese Anti-Cancer Association; Colorectal Cancer Professional Committee, Chinese Medical Doctor Association; Colorectal Cancer Expert Committee, Chinese Society of Clinical Oncology; Chinese College of Colorectal Surgeons，Chinese College of Surgeons, Chinese Medical Doctor Association;Metastasis Research Committee, Anorectal Branch of Chinese Medical Doctor Association; Colorectal Liver Metastases Professional Committee, China International Exchange and Promotive Association for Medical and Health Care

Background:We investigated the utility and safety of a new uneven double-lumen sphincterotome in biliary cannulation in comparison with the conventional pancreatic guidewire (PGW) method., Methods:We retrospectively evaluated 119 patients who required PGW placement because of difficult biliary cannulation. Endoscopic retrograde cholangiopancreatography (ERCP) was performed using a conventional ERCP catheter or a new uneven double-lumen sphincterotome. The success rate of bile duct cannulation, the operation time of bile duct cannulation, and the incidence of post-ERCP pancreatitis (PEP) were evaluated., Results:Forty-four patients were treated with a new double-lumen sphincterotome (the new sphincterotome group) and 75 patients underwent conventional PGW placement (the conventional group). The success rate of bile duct cannulation was 39/44 (88.6%) in the new sphincterotome group and 63/75 (84.0%) in the conventional group (not significant). The total biliary cannulation time (from the reach to the papilla to the finish of biliary cannulation) was 16.0 (6.5-78) min in the new sphincterotome group and 26.0 (5-80) min in the conventional group (P < 0.01). The time from PGW placement to bile duct cannulation was 3.5 (0.3-57) min in the magictome group and 12.0 (1-65) min in the conventional group (P < 0.01). Hyperamylasemia was observed in 13/44 (29.5%) and 17/75 (22.7%), respectively (not significant). Five of 44 (11.3%) of the new sphincterotome group and 14/75 (18.7%) of the conventional group were diagnosed with PEP (not significant)., Conclusion:A new double-lumen sphincterotome allows selective bile duct cannulation to be performed in a shorter time than the conventional PGW method.

Collison tumor of the stomach is rare, and its endoscopic and pathological features remain poorly described. A 70-year-old woman was referred to our hospital for examination and treatment of undifferentiated gastric cancer. Esophagogastroduodenoscopy revealed a whitish, superficial elevated lesion in contact with a reddish, superficial depressed lesion from the anterior wall of the gastric angle and antrum to the lesser curvature. Laparoscopic distal gastrectomy was performed for preoperative diagnosis of suspected early gastric cancer presenting as a differentiated and undifferentiated collision tumor, which led to the lesion being diagnosed as collision tumor, tub1-tub2+por1-sig, pT1a (M), ly0, v0, N0, stage IA. To our knowledge, this report represents a valuable addition to the collision tumor literature describing a rare case of preoperatively diagnosed collision tumor of the stomach.

Background Several modifications of the Kimura procedure for congenital duodenal obstruction (CDO) have been reported, however, their effects on the outcomes show conflicting results. Methods We compared the CDO outcomes following the Kimura procedure with and without post-anastomosis jejunostomy feeding tube (JFT). Results A total of 52 CDO neonates were involved (JFT: 13 males and 2 females vs. non-JFT: 14 males and 23 females, p = 0.0019). Time to full oral feeding was significantly earlier in the JFT than non-JFT group (14 [interquartile range (IQR), 12–15] vs. 17 [IQR, 14–22.5] days; p = 0.04). Duration of parenteral nutrition given to infants with CDO after surgery was significantly shorter in the JFT than non-JFT group (12 [IQR, 10–15] vs. 17 [IQR, 13–23] days; p = 0.031). Moreover, enteral feeding was significantly earlier in the JFT than non-JFT group (2 [IQR, 1–3.5] vs. 5 [IQR, 4–6] days; p = p = 0.22). Also, overall patient survival did not significantly differ between JFT (66.7%) and non-JFT patients (59.5%) (p = 0.61). Conclusion Jejunostomy feeding tube shows a beneficial effect on the time to full oral feeding, duration of parenteral nutrition and early enteral feeding in neonates with congenital duodenal obstruction after Kimura procedure.

ObjectiveTo investigate the clinical effect of domestic programmed cell death-1 (PD-1) inhibitor combined with lenvatinib in the treatment of advanced primary liver cancer and related adverse events. MethodsA retrospective analysis was performed for the clinical data of 24 patients with advanced primary liver cancer who were treated with domestic PD-1 inhibitor combined with lenvatinib in Beijing Ditan Hospital, Capital Medical University, from January 1, 2019 to April 2, 2020, with 15 patients in the Camrelizumab+lenvatinib group, 7 patients in the Sintilimab+lenvatinib group, and 2 patients in the Toripalimab+lenvatinib group. During follow-up, Modified Response Evaluation Criteria in Solid Tumors was used to evaluate the treatment outcome of intrahepatic lesions, and RECIST1.1 was used to evaluate extrahepatic metastatic lesions. The Kaplan-Meier method was used to evaluate survival time. ResultsAmong the 24 treatment-experienced patients, 11 achieved partial response, 7 achieved a stable disease, and 6 had disease progression, resulting in an objective response rate of 45.8% and a disease control rate of 75.0%. The median time to disease progression was 8.4 (95% confidence interval: 6.89-9.91) months. The incidence rate of adverse events was 54.17%, and the most common adverse events were fatigue (29.17%) and hypertension (25.00%). ConclusionPD-1 inhibitor combined with lenvatinib has a marked clinical effect in the treatment of advanced primary liver cancer, with a low incidence rate of serious adverse events, and thus it is a safe and effective treatment regimen.

ObjectiveTo investigate the association of common clinical indices and noninvasive liver fibrosis scores with hepatic-type Wilson’s disease (WD) in Chinese patients and their ability to identify advanced liver fibrosis. MethodsA retrospective analysis was performed for the clinical data of 236 Chinese patients with WD who were diagnosed and treated in Beijing YouAn Hospital and China-Japan Friendship Hospital from May 1996 to April 2020. A total of 26 patients with hepatic-type WD who underwent liver pathological examination and had complete clinical data were enrolled; the METAVIR score was used to determine liver fibrosis stage, and the patients were divided into advanced liver fibrosis (F3 and F4 stages) group and non-advanced liver fibrosis (F0, F1, and F2 stages) groups. Three noninvasive liver fibrosis scores ［Sheth index, aspartate aminotransferase-to-platelet ratio index (APRI), and fibrosis-4 (FIB-4) index］ were calculated for both groups, and the above indices and related clinical indices were compared between the two groups. The independent samples t-test or the Mann-Whitney U test was used for comparison of continuous data between two groups, and the Fisher’s exact test was used for comparison of categorical data between two groups. The Spearman rank correlation test was used for further analysis of indices with statistical significance, and the clinical indices and scoring criteria correlated with liver fibrosis degree were screened out; the receiver operating characteristic (ROC) curve was plotted, and the area under the ROC curve (AUC) was calculated. ResultsMost of the patients in this study developed the disease in childhood and adolescence, and among these patients, 10 (38.5%) had positive K-F ring and 17 (65%) were in the stage of advanced liver fibrosis. There were significant differences between the advanced liver fibrosis group and the non-advanced liver fibrosis group in white blood cell count (WBC) (Z=-2.102, P=0.036), hemoglobin (Hb) (t=-2.860, P=0009), platelet count (PLT) (t=-4.053, P＜0.001), direct bilirubin (DBil) (Z=-2.130, P=0.033), albumin (Alb) (t=-2.875, P=0.008), and Sheth index (Z=-3.369, P=0.001). WBC, Hb, PLT, and Alb were negatively correlated with liver fibrosis degree in WD patients (r=-0.587, -0.610, -0.656, and -0.411, all P＜0.05), and DBil and Sheth index were positively correlated with liver fibrosis degree (r=0.486 and 0.711, both P＜0.05). The ROC curve analysis showed that WBC, DBil, Sheth index, Hb, PLT, and Alb had an AUC of ＞0.7, among which Sheth index had the largest AUC of 0.908, with a sensitivity of 70.6%, a specificity of 100.0%, a positive predictive value of 100.0%, and a negative predictive value of 64.3%. ConclusionSheth index has a better diagnostic efficiency than the other clinical indices alone and can well identify advanced liver fibrosis in Chinese patients with hepatic-type WD.

Aim: The Coronavirus disease-19 (COVID-19) pandemic has affected all countries in the world and has created a serious burden on the health systems of countries Although health systems, which have not encountered such a sudden and intense load for many years, had difficulty in responding to this need at first, measures have been taken to meet this sudden demand in a short time This change in the health system has led to a decrease in the number of elective surgeries in particular One of the outcomes of the COVID-19 pandemic is interrupted and insufficient surgery training In this study, we aimed to assess the effects of COVID-19 on general surgery education in Turkey Method: In the study, a questionnaire consisting of 22 questions including participants'demographic information, their education level and the average number of cases in the time interval covering the same period of the previous year was used In the study, the period between January 2019-April 2019 and January 2020-April 2020 was compared, and the operations performed during this period were compared in terms of emergency, elective, laparoscopic and open surgery Results: When the number of elective/emergency hernia, upper gastrointestinal-hepatobiliary and colorectal-benign anorectal operations performed primarily by the assistant under the supervision of the responsible lecturer were compared, it was found that the rates were decreased from 9 67 to 0 76, 7 66 to 1 38 and 7 48 to 2 00, respectively, and all these changes were found to be statistically significant The rate of emergency operations performed primarily by the lecturer decreased from 34 16% to 28 93% (p=0 045), and the rate of elective surgeries performed primarily by the faculty member decreased from 61 09% to 55 93% (p=0 045 and p=0 411) Conclusion: There has been a significant decrease in the number of elective and emergency surgeries due to the change in the health system We believe that changes should be made by clinics to their training programmes so that this decrease does not affect the training of surgical residents Amac: Koronavirus hastaligi-19 (COVID-19) salgini dunyadaki tum ulkeleri etkilemis ve ulkelerin saglik sistemi uzerinde ciddi bir yuk olusturmustur Uzun yillardir bu kadar ani ve yogun bir yuk ile karsilasmayan saglik sistemleri, ilk basta bu ihtiyaca cevap vermekte zorlansa da, bu ani ihtiyaci kisa surede karsilayacak onlemler alinmistir Saglik sistemindeki bu degisiklik, ozellikle elektif ameliyatlarin sayisinin azalmasina neden olmustur Bu COVID-19 salgininin sonuclarindan biri, kesintiye ugrayan ve yetersiz cerrahi egitimdir Bu calismada, COVID-19’un Turkiye’deki genel cerrahi egitimine etkilerini degerlendirmeyi amacladik Yontem: Calismada, katilimcilarin demografik bilgileri, egitim duzeyleri ve bir onceki yilin ayni donemini kapsayan zaman araligindaki ortalama olgu sayilarini iceren 22 sorudan olusan anket kullanildi Calismada Ocak 2019-Nisan 2019 ile Ocak 2020-Nisan 2020 arasindaki donem karsilastirilmis ve bu donemde yapilan vakalar acil, elektif, laparoskopik ve acik cerrahi acisindan karsilastirilmistir Bulgular: Sorumlu ogretim uyesi gozetiminde asistan tarafindan yapilan elektif/acil fitik (inguinal/insizyonel/umbilikal), ust gastrointestinalhepatobiliyer ve kolorektal-benign anorektal operasyon sayilari karsilastirildiginda oranlarin dustugu goruldu (sirasiyla 9,67’den 0,76’ya, 7,66’dan 1,38’e ve 7,48’den 2,00’e gerilemis ve tum bu degisimler istatistiksel olarak anlamli bulunmustur) Ogretim uyesi tarafindan elektif olarak yapilan acil ameliyat orani %34,16’dan %28,93’e (p=0,045), ogretim uyesi tarafindan oncelikli olarak yapilan elektif ameliyat orani %61,09’dan %55,93’e geriledi (p=0,045 ve p=0,411) Sonuc: Cerrahi egitimin en onemli adimlarindan biri, olgularin oncelikle sorumlu ogretim gorevlisinin gozetiminde bir asistan tarafindan yapilmasidir Ancak bu, ameliyatin suresini uzatabilir ve olasi komplikasyon riskini artirabilir Acil olgu sayisindaki azalmaya ragmen, sorumlu ogretim uyesi gozetiminde oncelikle cerrahi asistan tarafindan yapilan acil olgularin oranindaki artis asistan egitimi uzerinde olumlu bir faktor olarak degerlendirilmektedir Saglik sistemindeki degisime bagli olarak elektif ve acil ameliyat sayisinda onemli bir dusus yasandi Bu azalmanin cerrahi asistanlarinin egitimini etkilememesi icin kliniklerin egitim programlarinda degisiklik yapmasi gerektigini dusunuyoruz

ObjectiveTo investigate the value of albumin-bilirubin (ALBI) score in predicting the prognosis of cirrhotic patients with esophagogastric variceal bleeding, and to identify risk stratification and increase clinical applicability. MethodsA retrospective analysis was performed for the clinical data of 273 cirrhotic patients with esophagogastric variceal bleeding who were hospitalized in Subei People’s Hospital of Jiangsu from October 2012 to August 2018, and all patients received standard management after admission. Survival status was obtained through electronic medical records and telephone follow-up, and according to the prognosis in August 2020, the patients were divided into death group with 109 patients and survival group with 164 patients. General data were compared between the two groups. The Mann-Whitney U test was used for comparison of continuous variables between two groups, and the chi-square test or the Fisher’s exact test was used for comparison of categorical variables between two groups; univariate and multivariate Cox regression analyses were used to identify independent risk factors for prognosis. The Kaplan-Meier curve was used to analyze the survival rates of patients with different ALBI grades, and the log-rank test was used for comparison between groups; the receiver operating characteristic (ROC) curve was plotted to compare the ability of ALBI score, Child-Turcotte-Pugh (CTP) score, and Model for End-Stage Liver Disease (MELD) score in predicting short-term (6 weeks) and long-term prognoses. ResultsDuring follow-up, 109 patients (39.9%) died, and the death group had a significantly higher ALBI score than the survival group ［-1.49 (-1.82 to -1.11) vs -1.79 (-2.22 to -1.49), Z=5.630, P＜0.001］. The univariate analysis showed that age ≥55 years, hemoglobin ≤100 g/L, neutrophil count ≥3.4×109/L, platelet count ≤42×109/L, albumin ≤28 g/L, total bilirubin ≥21 μmol/L, alanine aminotransferase ≥42 U/L or aspartate aminotransferase ≥48 U/L, creatinine ≥94 μmol/L, serum sodium ≤137 mmol/L, international normalized ratio of prothrombin ≥1.5, ascites, and hepatic encephalopathy were risk factors for death in cirrhotic patients with esophagogastric variceal bleeding, and the patients with ALBI grade 3 had a significantly higher risk of death than those with ALBI grade 1 or 2; prophylactic ligation was a protective factor for survival improvement in cirrhotic patients with esophagogastric variceal bleeding (all P＜0.05). The multivariate analysis showed that age ≥55 years (hazard ratio ［HR］=2.531, 95% confidence interval ［CI］: 1.624-3.946, P＜0.001), creatinine ≥94 μmol/L (HR=1.935, 95% CI: 1.208-3.100, P=0.006), serum sodium ≤137 mmol/L ［HR=1.519, 95% CI: 1.015-2.274, P=0.042］, ascites (HR=1.641, 95% CI: 1.041-2.585, P=0.033), hepatic encephalopathy (HR=9.972, 95% CI: 3.961-25.106, P＜0.001), and ALBI grade 3 (HR=1591, 95% CI: 1.007-2.515, P=0.047) were independent risk factors for death. The patients with ALBI grade 3 had a significantly lower survival rate than those with ALBI grade 1 (χ2=18.691, P＜0.001) and ALBI grade 2 (χ2=21.364, P＜0.001), and the patients with ALBI grade 1 had a significantly higher survival rate than those with ALBI grade 2 (χ2=6513, P=0.011). The ROC curve analysis showed that ALBI score, CTP score, and MELD score had an area under the ROC curve (AUC) of 0770, 0.730, and 0.706, respectively, in predicting short-term (6 weeks) prognosis, and they had an AUC of 0.701, 0685, and 0659, respectively, in predicting long-term prognosis. ConclusionALBI score has a good value in predicting short-term (6 weeks) and long-term prognoses of cirrhotic patients with esophagogastric variceal bleeding, and the risk of death increases with ALBI grade. ALBI score can be used as an objective and simple model in clinical practice.

BackgroundSuccessful eradication of hepatitis C virus (HCV) has great impact on the prognosis of HCV-related complications and the associated mortality. The development of the new direct-acting antiviral drugs (DAAs) has revolutionized the treatment of HCV infection. HCV core antigen (HCVcAg) is a recently developed marker that displayed a good correlation with HCV RNA assays. Our main objectives were to correlate between serum levels of HCVcAg and HCV RNA loads in chronic HCV patients as well as to explore the potential value of HCVcAg assay in predicting treatment response to the new DAAs. The study enrolled a total of 280 chronic HCV-infected patients scheduled to start the new regimen for treatment of chronic HCV by all-oral, interferon-free DAAs. According to the viral load, the studied individuals were arranged into three groups corresponding to mild, moderate, and sever viremia. Serum level of HCVcAg was determined by ELISA technique and HCV RNA viral loads were quantified using the real-time PCR system. The assays were performed three times for all participants: prior to initiation of treatment, at the end of treatment (week 12), and 3 months post-treatment cessation (week 24).ResultsA statistically significant difference between HCV RNA and HCVcAg baseline levels among different viremia groups was detected (P< 0.001). There was a significant positive correlation between HCV RNA and HCVcAg baseline values among all the studied cases (P< 0.05) with a correlation coefficient of 0.752, 0.976, and 1.00 respectively for mild, moderate, and severe viremia groups. 92.9% (260/280) of the studied patients achieved sustained virologic response, 3.6% (10/280) were non-responders, and 3.6% (10/280) had recurrent viremia/relapse as regards RT-PCR results.ConclusionHCVcAg is a promising alternative to HCV RNA assay. The ELISAs for HCVcAg proved excellent correlations with HCV RNA levels. Moreover, HCVcAg can be introduced as a simple and highly specific tool for monitoring the new DAA regimens particularly in low-resource settings.

Pancreatic heterotopia (PH) is a common, but typically small (

Tarcia Nogueira Ferreira Gomes, Fabio Silva de Azevedo, Marjorie Argollo, Sender Jankiel Miszputen, Orlando Ambrogini Jr Disciplina de Gastroenterologia, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, BrazilCorrespondence: Tarcia Nogueira Ferreira Gomes Rua Percílio Neto, 131, Vila Gumercindo, CEP 04131-080, São Paulo-SP, BrazilTel +55 11 94991 3883Email tarcia.nogueira@gmail.comBackground: Crohn’s disease (CD) and ulcerative colitis (UC) are chronic inflammatory diseases of the gastrointestinal tract with an increasing incidence in developing countries.Purpose: To report clinical and demographic data of CD and UC at a referral center for inflammatory bowel disease (IBD) in São Paulo.Patients and Methods: We conducted a retrospective cross-sectional study on adult patients with established IBD. Demographic and clinical data were obtained by medical records analysis from the IBD Outpatient Clinic of EPM-UNIFESP, from October 1997 to October 2017.Results: Of 658 patients included, 355 had UC (54%) and 303 had CD (46%). UC was more prevalent in women than CD (219 [61.7%] vs 152 [50.2%], p=0.003). The median time between the onset of symptoms and diagnosis was 13 (5– 38) months, with a longer duration for CD patients. CD mostly affected the ileocolonic location (47.9%). CD patients with stricture, fistula and/or perianal disease (213/303, 70.3%) were younger at diagnosis, had a longer disease duration, higher rates of corticosteroid, immunomodulatory, and biological therapy, hospitalization, and referral to surgery, compared to patients without complication. Extensive colitis was the most common extension of UC (50.6%), which was more frequently associated with younger age at diagnosis, hepatobiliary disease, increased need for hospitalization, higher use of immunomodulatory, and biologic therapy, compared to patients with less extensive disease. In the last 5 years, CD patients were more frequently on biologic and/or immunomodulatory (70.9%) therapy, and UC patients often received salicylates (78.1%) and immunomodulatory (28.1%) treatments. There was a consistent reduction in salicylate usage for CD in the last 5 years compared to the total period of follow-up.Conclusion: Despite the increasing incidence, we highlight the diagnostic delay and a more complicated CD and extensive UC in this cohort, reflecting a high need for immunomodulatory and biological treatment, hospitalization, and surgery.Keywords: Crohn’s disease, epidemiology, inflammatory bowel disease, ulcerative colitis

Gastrointestinal arteriovenous malformation (AVM) is reported as one of the possible causes of intestinal bleeding, and its occurrence in the rectum is rare. We report the case of a rectal AVM patient who experienced uncommon symptoms of anal pain and tenesmus and was treated successfully with percutaneous transarterial ethanol sclerotherapy. The patient underwent routine colonoscopy with biopsy at the time of visit; however, an accurate diagnosis was difficult. Subsequent contrast-enhanced computed tomography (CT) and angiography revealed a rectal AVM emerging from the distal inferior mesenteric artery with engorged superior rectal veins. The feeding artery was catheterized, and concurrent transarterial sclerotherapy with 80% ethanol was performed. There was no major complication related to the procedure. Disappearance of AVM nidus and improvement of associated venous congestion were shown by follow-up CT. There was no recurrence of symptoms after 10 months of clinical observation. Transarterial ethanol sclerotherapy is safe and effective in treating rectal AVM and can be considered as one of the nonsurgical treatment options.

Background Laparoscopic anatomic hepatectomy (LAH) has gradually become a routine surgical procedure. However, how to expose the whole hepatic vein and avoid the hepatic vein laceration is still a challenge because of the caudate lobe, particularly in right hepatectomy. We adopted a dorsal approach combined with Glissionian appraoch to perform laparoscopic right anatomic hepatectomy (LRAH). Methods Twenty patients who underwent LRAH from January 2017 to November 2018 were retrospectively analysed. Of these patients, seven patients underwent laparoscopic right hemihepatectomy (LRH group), seven patients who underwent laparoscopic right posterior hepatectomy (LRPH group), and six patients who underwent laparoscopic hepatectomy for segment 7 (LS7 group). The paracaval portion of caudate lobe could be transected firstly through dorsal approach and the corresponding major hepatic vein could be exposed from its root to the peripheral branches safely. Due to exposure along the major hepatic vein trunk, the remaining liver parenchyma could be quickly transected from dorsal to cranial side. Results The mean age of the patients was 53.8 years and the male: female ratio was 8:12. The median operation time was 306.0 ± 58.2 min and the mean estimated volume of blood loss was 412.5 ± 255.4 mL. The mean duration of postoperative hospital stay was 10.2 days. The mean Pringle maneuver time was 64.8 ± 27.7 min. Five patients received transfusion of 2–4 U of red blood cells. Two patients suffered from transient hepatic dysfunction and one suffered from pleural effusion. None of the patients underwent conversion to an open procedure. The operative duration, volume of the blood loss, Pringle maneuver time, and postoperative hospital stay duration did not differ significantly among the LRH, LRPH, and LS7 groups (P > 0.05). Conclusions Dorsal approach combined with Glissonian approach for right lobe is feasible and effective in laparoscopic right anatomic liver resections.

Background Serum hepatitis B core-related antigen (HBcrAg) is a potential surrogate marker for intra-hepatic covalently-closed circular DNA in chronic hepatitis B (CHB). We aimed to study the profiles of serum HBcrAg in CHB patients treated with first-line nucleos(t)ide analogues (NA): entecavir (ETV), tenofovir disoproxil fumarate (TDF) or tenofovir alafenamide (TAF). Method Serum HBcrAg was measured in 120 treatment-naïve CHB patients receiving one of the 3 NAs (ETV: TDF: TAF = 60: 26: 34) using the Lumipulse G HBcrAg assay in a Lumipulse G1200 analyzer (Fujirebio Inc, Toyko, Japan). Serum HBcrAg levels were measured at week 0, week 48 and week 96 of NA therapy. Results Among the 120 patients, 67 (55.8%) were hepatitis B e antigen (HBeAg) positive. Both tenofovir and ETV led to significantly lower serum HBcrAg at week 48 and week 96 compared to week 0. There were no significant differences for the magnitude of median HBcrAg decline at week 96 between tenofovir and ETV in HBeAg-positive (2.28 vs. 1.65 log U/mL, p > 0.05) and HBeAg-negative (0.83 vs. 0.54 log U/mL, p > 0.05) patients. TDF and TAF produced no significant differences in the magnitude of median HBcrAg decline at week 96 (HBeAg-positive: 2.63 vs. 1.83, respectively; HBeAg-negative: 1.04 vs. 0.40, respectively; both p > 0.05). Conclusion Magnitude of reduction of HBcrAg levels after 2-year first-line treatment did not differ statistically among the current first-line NAs, although HBcrAg reduction was numerically greater in tenofovir-treated group. More long-term studies are essential to determine whether tenofovir exerts a more pronounced effect on HBcrAg.

Abdel rahman A Al manasra,1 Khaled Jadallah,2 Abdelwahab Aleshawi,1 Mamoon Al-Omari,3 Mwaffaq Elheis,3 Ahmad Reyad,1 Jehad Fataftah,4 Hamzeh Al-Domaidat1 1Department of General Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan; 2Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan; 3Department of Radiology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan; 4Department of Radiology, Faculty of Medicine, The Hashemite University, Zarqa, JordanCorrespondence: Abdel rahman A Al manasraDepartment of General Surgery, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, JordanTel +962 796453510Email abdjust@yahoo.comBackground: Candida species are infrequently grown in bile cultures. An association between biliary candidiasis and regional malignancy may exist. The role of fungus membranes in frequent biliary stent occlusion is also presented in this case series.Methods: We retrospectively identified patients who underwent percutaneous trans-hepatic cholangiogram (PTC) for obstructive jaundice between January 2014 and January 2019. The results of bile cultures – obtained by PTC – for all patients were analyzed, and patients with fungus growth were determined; their medical records were reviewed.Results: A total of 71 patients with obstructive jaundice underwent PTC between January 2015 and January 2019. Five patients (all male; mean age 55.8 years) had candida species growth in bile cultures. Two patients were diagnosed with cholangiocarcinoma, one with adenocarcinoma of the head of the pancreas, one with gallbladder cancer, and one with locally advanced gastric adenocarcinoma. Formation of fungal balls predisposed to frequent PTC drain clogging. Eradication of Candida was achieved in 4 patients after 10 days to 3 weeks of antifungal therapy.Conclusion: We present a case series of biliary candidiasis in patients with obstructive jaundice and regional malignancy. We suggest that patients with obstructive jaundice and regional malignancy should be screened for biliary candidiasis. Persistent cholestasis may be caused by the recurrent formation of fungal membranes (balls).Keywords: Candida, obstructive jaundice, cholangiocarcinoma, biliary, PTC

Gastric mixed adenocarcinoma-neuroendocrine tumor (NET) is a rare composite tumor, and a limited number of studies have reported on it. A 77-year-old man was admitted to our hospital because of acute cholecystitis. He underwent a cholecystectomy. Esophagogastroduodenoscopy during his admission revealed a slightly elevated tumor, and biopsy demonstrated a well-differentiated tubular adenocarcinoma. The tumor was resected completely by endoscopic submucosal dissection. Histological findings showed that it measured 9 mm in diameter, was located within the mucosa, and consisted of well-differentiated tubular adenocarcinoma and a NET G1. The NET was covered with adenocarcinoma and both components exhibited histological continuity. The NET and a part of the adenocarcinoma component showed a positive reaction for chromogranin A and synaptophysin. Neither enterochromaffin-like cell hyperplasia nor endocrine cell micronest surrounded the tumor. The diagnosis was gastric mixed adenocarcinoma-NET. The histological continuity between the two components can be likened to the same histogenesis.

ObjectiveTo investigate related factors for stone recurrence after endoscopic minimally invasive gallbladder-preserving cholecystolithotomy, and to establish a nomogram model for predicting the risk of stone recurrence after surgery based on independent risk factors. MethodsA retrospective analysis was performed for the clinical data of 144 patients with gallstones who underwent endoscopic minimally invasive gallbladder-preserving cholecystolithotomy in Qinghai University Affiliated Hospital from January 2012 to January 2018, and according to postoperative stone recurrence, the patients were divided into non-recurrence group and recurrence group. The chi-square test was used for comparison of categorical data between two groups. LASSO and logistic regression analyses were used to analyze independent risk factors for postoperative stone recurrence, and the corresponding nomogram prediction model was plotted according to regression coefficient. The calibration curve was plotted to evaluate the reliability of the predictive nomogram; Harrell consistency index was used to quantify the discriminatory performance of the predictive nomogram; the receiver operating characteristic (ROC) curve was used to evaluate the sensitivity, specificity, and area under the ROC curve (AUC) of this predictive nomogram. ResultsAll 144 patients underwent successful endoscopic minimally invasive gallbladder-preserving cholecystolithotomy, among whom 14 patients (9.7%) experienced stone recurrence after surgery. The multivariate analysis showed that family history (odds ratio ［OR］= 3.245, 95% confidence interval ［CI］: 0.752-13567, P=0.104), regular diet (OR=3.752, 95% CI: 1.067-14.141, P=0.041), stone homogeneity (OR=5.871, 95% CI: 1636-25.390, P=0.010), and medication compliance (OR=0.225, 95% CI: 0.057-0.799, P=0.024) were independent risk factors for recurrence. The nomogram model had an index of concordance (C-index) of 0.835 (95% CI: 0.732-0.938) in the modeling sample and 0.7925 in the verification sample, suggesting that the nomogram model in this study had good accuracy and discrimination. The predictive nomogram had an AUC of 0.835, suggesting that this nomogram had a relatively high predictive value. ConclusionFamily history, regular diet, stone homogeneity, and medication compliance are independent risk factors for stone recurrence after endoscopic minimally invasive gallbladder-preserving cholecystolithotomy, and the nomogram constructed based on these independent risk factors may help to predict the risk of postoperative stone recurrence.

We present the case of a 35-year-old man with intractable nausea, vomiting, and severe anemia. A computed tomography (CT) scan of the chest, abdomen, and pelvis showed a circumferential lesion thickening of up to 3.5 cm at the level of the third portion of the duodenum. No aortocaval, retroperitoneal lymphadenopathy, nor secondary lesion was observed. Esophagogastroduodenoscopy (EGD) revealed a circumferential mass within the third portion of the duodenum. Histopathology of biopsy materials from the duodenal mass showed it most likely to be a poorly differentiated adenocarcinoma. The patient underwent a subtotal stomach-preserving pancreaticoduodenectomy with regional lymph node dissection. Histologically, tumor cells with basophilic cytoplasm and pleomorphic nuclei showed a solid pattern, and expressed CD30 and SALL4 immunohistochemically, leading to a diagnosis of embryonal carcinoma-like tumor. No other primary tumor could be identified, and the location of the tumor, mainly on the mucosal surface, suggested a duodenal origin. The UICC TNM staging was T3N2M0, stage IIB. This is a rare case of primary duodenal carcinoma with features of embryonal carcinoma.

Concepts to ameliorate the continued mismatch between demand for liver allografts and supply include the acceptance of allografts that meet extended donor criteria (ECD). ECD grafts are generally associated with an increased rate of complications such as early allograft dysfunction (EAD). The costs of liver transplantation for the health care system with respect to specific risk factors remain unclear and are subject to change. We analyzed 317 liver transplant recipients from 2013 to 2018 for outcome after liver transplantation and hospital costs in a German transplant center. In our study period, 1-year survival after transplantation was 80.1% (95% confidence interval: 75.8%-84.6%) and median hospital stay was 33 days (interquartile rage: 24), with mean hospital costs of euro115,924 (SD euro113,347). There was a positive correlation between costs and laboratory Model for End-Stage Liver Disease score (r(s) = 0.48, P < 0.001), and the development of EAD increased hospital costs by euro26,229. ECD grafts were not associated with a higher risk of EAD in our cohort. When adjusting for recipient-associated risk factors such as laboratory Model for End-Stage Liver Disease score, recipient age, and split liver transplantation with propensity score matching, only EAD and cold ischemia increased total costs. Conclusion: Our data show that EAD leads to significantly higher hospital costs for liver transplantation, which are primarily attributed to recipient health status. Strategies to reduce the incidence of EAD are needed to control costs in liver transplantation.

Gallstone ileus occurs when a gallstone passes into the intestinal system through a fistula between the gallbladder or biliary tract, and the duodenum, stomach or colon, and causes an obstruction. Although it is usually seen in advanced ages, it has rarely been reported in patients who are 100 years old. A 100-year-old female patient, without significant medical or surgical history, was admitted to the emergency department for diffuse abdominal pain, nausea, vomiting, and constipation. Abdominal computed tomography showed air in the biliary tract and obstruction in the small intestine. Patient was operated under emergency conditions. Enterolithotomy was performed and the stone was extracted. Postoperative recovery was uneventful. Bilioenteric fistulas, a major complication of chronic gallbladder diseases, usually develop secondary to intense inflammation. Patients’ age, concomitant disease, clinical condition and intraoperative findings should be taken into consideration while planning the treatment. The data in the literature generally supports the employment of enterolithotomy in high-risk patients and reserves cholecystectomy and resection of the fistula for less comorbid patients with feasible anatomy.

Aim:Postoperative complications after colorectal cancer surgery result in increased treatment costs, prolonged hospital stays and poor prognosis and reduce quality of life of the patients. Here, we aim to contribute to the literature in terms of being a reliable marker of postoperative C-reactive protein (CRP) to albumin ratio (CAR) after colorectal cancer surgery.Method:A total of 213 patients undergoing colorectal cancer surgery between 2013 and 2018 were analyzed in this study. Risk factors for the development of postoperative complications were analyzed using univariate and multiple logistic regression models. A receiver operating characteristic (ROC) curve analysis was used to analyze the association with the CRP and CAR variables, with the aim being to differentiate postoperative complications.Results:Postoperative complications occurred in 87 (40.8%) patients. Based on the Clavien-Dindo classification, 25 (18.7%) patients developed major complications. Perioperative blood transfusion [odds ratio (OR)=1.3; 95% confidence interval (CI)=1.08-1.55] and postoperative CAR (OR=1.2; 95% CI=1.05-1.35) were independent risk factors for postoperative complications (p=0.005 for each). The cut-off value for CAR was 4.3 (sensitivity: 51.72; specificity: 71.43; and area under the curve: 0.642), meaning that CAR was found to be statistically significantly effective in differentiating postoperative complications (p4.3) group (p=0.001), while the laparoscopic surgery rate was statistically significantly lower in the high CAR group (p=0.039).Conclusion:CAR is a novel, reliable and independent marker. Moreover the ratio is useful for clinicians and provides the determination of early postoperative complications after colorectal cancer surgery.

Disturbed sleep is common among patients with cirrhosis. The extent to which this is associated with the different stages of compensated cirrhosis is unknown. This study examines whether the presence of portosystemic collaterals, an indicator of clinically significant portal hypertension, is associated with sleep disturbance in compensated cirrhosis. We conducted a cross-sectional study among patients with compensated cirrhosis, comparing sleep characteristics, sleep quality, and excessive daytime sleepiness between 21 patients without and 21 patients with portosystemic collaterals. Patients were assessed with wrist actigraphy, Pittsburgh Sleep Quality Index, and the Epworth Sleepiness Scale. Collateral presence was determined by imaging and esophagogastroduodenoscopy. Differences in sleep characteristics were analyzed using t tests and computed effect sizes. Multivariable linear regression analysis was used to evaluate the association between collaterals and sleep disturbance while controlling for possible confounders. The group of patients with collaterals had greater beta-blocker and tobacco use, lower albumin, and higher international normalized ratio compared to the group without collaterals. Patients with collaterals had more sleep fragmentation (Cohen's d = -0.86), lower sleep efficiency (Cohen's d = 0.59), and lower total sleep time (Cohen's d = 0.75) than patients without collaterals. The presence of collaterals was independently associated with greater sleep fragmentation (P = 0.046) and greater daytime sleepiness (P = 0.030). Conclusion: Patients with compensated cirrhosis complicated by portosystemic collaterals experienced more sleep disturbance than those without collaterals.

ObjectiveTo investigate the role of hepatic stellate cell (HSC) inflammation in the pathogenesis of acute-on-chronic liver failure (ACLF). MethodsA total of 45 male Kunming mice were randomly divided into control group, model group, and N-acetylcysteine (NAC) group. The mice in the model group and the NAC group were given injection of human serum albumin to establish a model of chronic liver disease, followed by intraperitoneal injection of the endotoxins lipopolysaccharide (LPS) and D-galactosamine (D-GlaN) to induce ACLF, and those in the control group were given injection of an equal volume of normal saline; the mice in the NAC group were given NAC since 1 week before the induction of NAC. The mice in the model group and the NAC group were sacrificed at 48 hours after the injection of LPS and D-GlaN. ELISA was used to measure the serum levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) and the levels of malondialdehyde (MDA) and superoxide dismutase (SOD) in liver tissue; HE staining was used to determine liver pathological score; ELISA was used to measure the serum levels of LPS and interleukin-1β (IL-1β). LX2 cells were stimulated by LPS and H2O2 with the presence or absence of NAC, and ELISA was used to measure the levels of IL-1β and interleukin-6 (IL-6) in medium. LX2 cells were stimulated by LPS and H2O2, and then HL7702 cells were cultured with LX2 medium; Western blot was used to measure the expression of caspase-3 and caspase-8 in HL7702 cells, and flow cytometry was used to measure the apoptosis of HL7702 cells. A one-way analysis of variance was used for comparison of continuous data between multiple groups; the least significant difference t-test was used for comparison of data with homogeneity of variance between two groups, and the Tamhane’s T2 test was used for comparison of data with heterogeneity of variance. The Kaplan-Meier survival analysis was used to evaluate survival time, and the log-rank test was used for comparison. ResultsAt 48 hours, all mice in control group survived, while 3 mice in the model group and 8 mice in the NAC group survived, suggesting that the NAC group had a better survival rate of mice than the model group (P＜0.001). Compared with the control group and the NAC group, the model group had significant increases in the serum levels of AST and ALT and the level of MDA in liver tissue, as well as a significant reduction in the level of SOD in liver tissue (all P＜0.01). The model group had a significantly higher liver pathological score than the control group and the NAC group (both P＜0.05). Both LPS and H2O2 promoted the secretion of IL-1β and IL-6 in LX2 cells, and NAC effectively inhibited the pro-inflammatory effect of H2O2 and LPS (all P＜0.05). H2O2 and LPS acted on LX2 cells and promoted the apoptosis of HL7702 cells (all P＜0.05). ConclusionLPS can promote HSC inflammation via reactive oxygen species and participates in the progression of liver failure by inducing hepatocyte apoptosis.

Proprotein convertase (PC) deficiency is a rare autosomal recessive disorder caused by mutations in proprotein convertase subtilisin/kexin type 1 (PCSK1). It is characterized by severe malabsorptive early-onset diarrhea, obesity, and systemic endocrinopathies. Only few cases have been reported in the literature; we have add two female sisters with some difference in clinical progress. Herein, we describe two sisters with congenital osmotic diarrhea diagnosed with PC1/3 deficiency, causing malabsorptive diarrhea and enteroendocrine dysfunction, who presented with chronic enteropathy with hypernatremia but with different expressivity. PC1/3 deficiency presents with symptoms and signs that mimic glucose-galactose malabsorption. Because of the clinical paucity and heterogeneity of congenital enteropathies, whole-exome sequencing may be of great help towards early diagnosis and effective treatment.

Hepatic epithelioid hemangioendothelioma (EHE) is a rare malignant tumor with unknown pathogenesis. Herein, we report a case of a hepatic EHE presenting synchronously with a hepatocellular carcinoma (HCC). To the best of our knowledge, this is the second case report of synchronous hepatic EHE and HCC. An 84-year-old man presented with back pain. During examination, a tumor in liver segment 3 was coincidentally detected. Tumor marker (carbohydrate antigen 19-9, alpha-fetoprotein, and protein induced by vitamin K absence or antagonist-II) levels were elevated. Contrast-enhanced computed tomography revealed perinodular enhancement in the arterial and portal phases. Another tumor was detected in liver segment 2, which was homogeneously enhanced in the arterial phase, followed by washout in the portal and late phases. Based on these imaging findings, we diagnosed the tumor in segment 3 as a solitary cholangiocellular carcinoma and the tumor in segment 2 as a solitary HCC. Lateral sectionectomy of the liver was performed. Microscopically, spindle-shaped and epithelioid cells were present in the tumor in segment 3. On immunohistochemistry, the tumor cells were positive for CD31 and CD34, focally positive for D2-40, and negative for AE1/AE3. Therefore, the tumor in segment 3 was ultimately diagnosed as an EHE and the tumor in segment 2 as a well-differentiated HCC. Preoperative diagnosis of EHE is difficult owing to the lack of specific findings. Intratumoral calcification, halo sign, and lollipop sign are occasionally found in EHE and are useful imaging findings for diagnosis. Clinical behavior is unpredictable, ranging from indolent growth to rapid progression. Clinical or pathological predictors of the course of EHE are urgently required.

There are limited data examining the relationship between psychosocial factors and receipt of direct‐acting antiviral (DAA) treatment among patients with hepatitis C in large health care organizations in the United States. We therefore sought to determine whether such factors were associated with DAA initiation. We analyzed data from an extensive psychological, behavioral, and social survey (that incorporated several health‐related quality of life assessments) coupled with clinical data from electronic health records of patients with hepatitis C enrolled at four health care organizations during 2017‐2018. Of 2,681 patients invited, 1,051 (39.2%) responded to the survey; of 894 respondents eligible for analysis, 690 (77.2%) initiated DAAs. Mean follow‐up among respondents was 9.2 years. Compared with DAA recipients, nonrecipients had significantly poorer standardized scores for depression, anxiety, and life‐related stressors as well as poorer scores related to physical and mental function. Lower odds of DAA initiation in multivariable analysis (adjusted by age, race, sex, study site, payment provider, cirrhosis status, comorbidity status, and duration of follow‐up) included Black race (adjusted odds ratio [aOR], 0.59 vs. White race), perceived difficulty getting medical care in the preceding year (aOR, 0.48 vs. no difficulty), recent injection drug use (aOR, 0.11 vs. none), alcohol use disorder (aOR, 0.58 vs. no alcohol use disorder), severe depression (aOR, 0.42 vs. no depression), recent homelessness (aOR, 0.36 vs. no homelessness), and recent incarceration (aOR, 0.34 vs. no incarceration). Conclusion: In addition to racial differences, compared with respondents who initiated DAAs, those who did not were more likely to have several psychological, behavioral, and social impairments. Psychosocial barriers to DAA initiation among patients in care should also be addressed to reduce hepatitis C‐related morbidity and mortality., Even among persons with access to care, receipt of direct‐acting antiviral treatment for hepatitis C is suboptimal. We therefore conducted a detailed psychological, behavioral, and social survey among hepatitis C patients in care to determine whether such factors were associated with DAA initiation. Compared with respondents who initiated DAAs, those who did not were more likely to have several psychological, behavioral, and social impairments, suggesting that such factors should be addressed to reduce hepatitis C‐related morbidity and mortality.

Chronic hepatitis B (CHB) remains a global health problem. The persistence of hepatitis B surface antigen (HBsAg) in the blood for longer than 6 months after the initial infection is a sign of CHB. The therapeutic goal for the functional cure of CHB is the generation of antibodies against HBsAg. However, the adaptive immune response of patients with CHB cannot generate an efficient antiviral response. Many previous studies have evaluated T cell function and T cell therapy specifically designed to counter hepatitis B virus (HBV) infection. As one of the major components of adaptive immunity, B cells also display dysfunctions in anti-HBsAg antibody (HBsAb) production and antigen presentation. Patients with CHB have amplification of CD19+CD10−CD27−CD21− atypical memory B cell subsets and CD19+CD24hiCD38hi regulatory B cells. Currently, no reviews have summarized specific B cell responses during CHB infection. Thus, in this study, we summarized B cell dysfunction during CHB progression and the potential mechanisms behind these dysfunctions to further our understanding of the mechanisms of adaptive immune response of B cells in the process of CHB development and help provide new methods and ideas for the treatment of CHB.

Liver cancer is one of the most common malignant tumors in China. Surgical resection is still the preferred radical treatment method for patients with liver cancer; however, most patients cannot tolerate surgical resection due to the influence of tumor size, tumor location, liver function, and general condition. In recent years, local ablation techniques, such as radiofrequency ablation and microwave ablation, have developed rapidly and are widely used in clinical practice, and they are even known as new techniques comparable to surgical resection for the radical treatment of liver cancer. This article briefly introduces the application and selection of local ablation and surgical resection in the treatment of liver cancer.

Bilioenteric anastomoses were common interventions before the rise of minimal invasion procedures, specifically, before endoscopic retrograde cholangiopancreatography. During a choledochoduodenostomy (CDS) the distal part of the common bile duct is excluded from the bile drainage and behaves as a “sump,” a poorly drained part that works as a reservoir which is responsible of the development of complications of the bilio-pancreatic tract. The consequent sump syndrome is a rare medical complication that presents a diversity of symptoms, for which there is no well-defined diagnostic algorithm. We present the case of a 72-year-old male patient with multiple comorbidities. He presented to the ER because of recurrent episodes of cholangitis; after having obtained the patient’s medical records, lab and image studies, the latter showed pneumobilia. After considering all the results plus the pneumobilia we suspect the presence of this uncommon complication of CDS. The patient was subjected to an unsuccessful endoscopic treatment followed by surgery, after which he showed signs of improvement and adequate evolution till hospital discharge.

Background As a secreted adipokine, adipsin has been recently shown to play a pivotal role in metabolic disorders. However, information regarding the association of circulating adipsin with non-alcoholic fatty liver disease (NAFLD) in humans is scant. Methods We recruited 1163 obese adult subjects with waist circumference at least 90 cm in men and 80 cm in women from the community. Circulating adipsin levels were measured by enzyme-linked immunosorbent assay. Results Circulating adipsin levels of NAFLD subjects was decreased compared to those in non-NAFLD (p p p p Conclusions These results demonstrate that circulating adipsin levels in Chinese obese adults are negatively associated with risk of NAFLD, implying that serum adipsin levels may be a potential protective factor in NAFLD.

ObjectiveTo investigate the potential association between early-stage inflammatory response and late-stage infectious pancreatic necrosis (IPN) in patients with acute pancreatitis (AP). MethodsA retrospective analysis was performed for the clinical data of 219 patients with moderate-severe acute pancreatitis (MSAP) and 53 patients with severe acute pancreatitis (SAP) who were admitted to The Affiliated Hospital of Southwest Medical University from June 2019 to June 2020, and according to the presence or absence of systemic inflammatory response syndrome (SIRS) at the initial stage of the disease, they were divided into SIRS group with 160 patients and non-SRIS group with 112 patients. Baseline data, serological markers, complications, and mortality rate were included for analysis. The t-test or the Mann-Whitney U test was used for comparison of continuous data between two groups; the chi-square test was used for comparison of categorical data between multiple groups, and the Bonferroni method was used for further comparison between two groups. A logistic regression analysis was used to screen out valuable variables; the receiver operating characteristic (ROC) curve was used to compare the diagnostic value of variables, and the Z-test was used for pairwise comparison of area under the ROC curve (AUC). ResultsCompared with the non-SIRS group, the SIRS group had significantly higher white blood cell count (WBC), C-reactive protein (CRP), and procalcitonin (all P＜0.05) and a significantly higher proportion of patients with acute peripancreatic necrosis (ANC), IPN, pancreatic necrosis (PN), organ dysfunction, multiple organ dysfunction syndrome (MODS), SAP, critically-ill acute pancreatitis (CAP), death, BISAP score ＞2, CTSI score ＞2,or RANSON score ＞2 (all P＜0.05). The univariate analysis showed that SIRS duration, obesity, CRP, WBC, blood urea nitrogen, PN, ANC, SAP, MODS, RANSON score, BISAP score, and CTSI score were risk factors for IPN in patients with AP (all P＜005), and the multivariate analysis showed that SIRS duration (odds ratio ［OR］=1.307, 95% confidence interval ［CI］: 1.081-1580, P=0006) and ANC (OR=42.247, 95% CI: 10.829-164.818, P＜0.001) were risk factors for IPN; when ANC was excluded, SIRS duration (OR=1.430, 95% CI: 1.207-1.694, P＜0.001) and PN (OR=5.296, 95% CI: 1.845-15.203, P=0.002) were risk factors for IPN. The ROC curve showed that SIRS duration (AUC=0.772, Youden index=0.521), RANSON score (AUC=0701, Youden index=0.319), BISAP score (AUC=0.741, Youden index=0.377), and CTSI score (AUC=0.765, Youden Index=0.414) had a certain value in predicting IPN, and there was no significant difference in AUC between any two indices. The long-duration SIRS group(＞4 d) had a significantly higher proportion of patients with PN, ANC, IPN, SAP, or CAP than the non-SIRS group(0 d), the transient SIRS group(1~2 d), and the persistent SIRS group(3~4 d) (all P＜0.05), and the persistent SIRS group had a significantly higher proportion of patients with SAP than the non-SIRS group (P＜0.05). ConclusionAP patients with SIRS in the early stage are likely to develop organ failure and local complications, and there is a significant increase in the risk of IPN when SIRS duration is ＞4.5 days.

Background Hepatitis C virus, a silent killer, has infected 71 million people globally. The recombinant viral antigenic proteins might be used in the early diagnosis of HCV infection. The NS3 and NS5A genes of HCV function in HCV replication and influence host cellular factors that are involved in HCV pathogenesis. The current study was designed to select NS3 and NS5A antigenic sites, amplified, cloned, and expressed in order to find out better assays for diagnosis or drug and vaccine development. The antigenic sites within NS3 and NS5A genes were selected and confirmed through sequencing and were cloned. The antigenic recombinant proteins were expressed in bacterial strain E. coli BL21ply*, and the expression was confirmed by western blotting by using gene-specific and vector-specific antibodies. Results Specific antigenic regions within the NS3 and NS5A genes of the HCV 3A genotype were amplified. PCR results showed 328 bp and 747 bp antigenic regions, respectively. The regions were confirmed by DNA sequencing and cloned into a bacterial expression vector. Expression analysis showed 12 kDa and 28 kDa of NS3 and NS5A antigenic recombinant proteins, respectively. Taken together, these studies will help to analyze the genetic variability within the local HCV isolates as these antigenic recombinant proteins were quite important in the screening of HCV-infected patients. Conclusions This study might help to enhance the progress in the treatment of HCV infection through the modeling of HCV non-structural genes (NS3 and NS5A) from local isolate, and it might also present the viral genes as potential therapeutic targets.

Background An educational and training program is required for generalization of Japan NBI Expert Team (JNET) classification. However, there is no detailed report on the learning curve of the diagnostic accuracy of endoscopists using JNET classification. We examined the effect of an educational lecture on beginners and less experienced endoscopists for improving their diagnostic accuracy of colorectal lesions by JNET classification. Methods Seven beginners with no endoscopy experience (NEE group), 7 less experienced endoscopists (LEE group), and 3 highly experienced endoscopists (HEE group) performed diagnosis using JNET classification for randomized NBI images of colorectal lesions from 180 cases (Type 1: 22 cases, Type 2A: 105 cases, Type 2B: 33 cases, and Type 3: 20 cases). Next, the NEE and LEE groups received a lecture on JNET classification, and all 3 groups repeated the diagnostic process. We compared the correct diagnosis rate and interobserver agreement before and after the lecture comprehensively and for each JNET type. Results In the HEE group, the correct diagnosis rate was more than 90% with good interobserver agreements (kappa value: 0.78–0.85). In the NEE and LEE groups, the correct diagnosis rate (NEE: 60.2 → 68.0%, P P P P Conclusion After conducting an appropriate lecture, the diagnostic ability using JNET classification was improved in beginners or endoscopists with less experience in NBI magnifying endoscopy.

Background It is well established that the controlling nutritional status (CONUT) score was correlated with long-term outcomes in gastric cancer (GC), but the significance of CONUT for postoperative short-term outcomes remains unclear. The study aimed to characterize the relationship between CONUT and short-term complications following gastrectomy of GC. Methods We collected data on 1479 consecutive GC patients at Nanjing Drum Tower Hospital between January 2016 and December 2018. Univariate and multivariate analyses of predictive factors for postoperative complications were performed. The cutoff value of the CONUT score was determined by Youden index. Results Among all of the patients, 431 (29.3%) patients encountered postoperative complications. Multivariate analyses identified CONUT was an independent predictor for postoperative short-term complications (OR 1.156; 95% CI 1.077–1.240; P Conclusions The present study demonstrated that the preoperative CONUT was an independent predictor for short-term complications following gastrectomy of GC.

ObjectiveTo investigate the influencing factors for persistent low-level viremia (LLV) in chronic hepatitis B(CHB) patients receiving long-term entecavir antiviral therapy. MethodsThe CHB patients who received entecavir antiviral therapy for at least one year in The Affiliated Hospital of Xuzhou Medical University from November 2018 to June 2020 were enrolled as subjects, and according to HBV DNA load at the end of the observation period, the patients were divided into LLV group and sustained virological response (SVR) group. Demographic features and laboratory markers were observed for all patients. The independent samples t-test or the Mann-Whitney U test was used for comparison of continuous data between two groups, and the chi-square test was used for comparison of categorical data between two groups. A multivariate logistic regression analysis was used to investigate the influencing factors for LLV in patients receiving long-term entecavir treatment. ResultsA total of 560 CHB patients were enrolled, with 204 in the LLV group and 356 in the SVR group. There were significant differences between the two groups in age (Z=-3.530, P＜0.001), sex (χ2=4.270, P=0.039), presence or absence of liver cirrhosis (χ2=53.879, P＜0.001), medication compliance (χ2=5.326, P=0.021), HBeAg positive rate (χ2=90.681, P＜0.001), baseline HBV DNA load before treatment (Z=-8.337, P＜0.001), baseline HBsAg quantification (Z=-10.472, P＜0.001), and medication type (χ2=7.558, P=0.006). The multivariate logistic regression analysis showed that baseline HBeAg status before treatment (odds ratio ［OR］=3.381, 95% confidence interval ［CI］: 1.985-5.756, P＜0.001), HBV DNA load before treatment (OR=1.223, 95%CI: 1.050-1.424, P=0.010), and HBsAg quantification before treatment (OR=2.448, 95%CI: 1.743-3.438, P＜0.001) were risk factors for LLV in long-term entecavir antiviral therapy. ConclusionIn clinical practice, CHB patients with high HBV DNA load, high HBsAg quantification, and positive HBeAg tend to have a high risk of LLV even after long-term entecavir antiviral therapy. Therefore, such population should be taken seriously with the dynamic monitoring of HBsAg quantification, HBV DNA load, and HBeAg status.

The composition and cell-to-cell interactions of the peripheral immune compartment are known to influence outcomes in multiple disease entities, both neoplastic and otherwise. There is an ongoing search for a reliable biomarker in the peripheral immune compartment that can predict outcomes in colorectal cancer, given its high mortality rates. The neutrophil:lymphocyte ratio (NLR) has been suggested as one such marker, given its accessibility. This review discusses the current evidence behind the use of the NLR in predicting different aspects of colorectal cancer (CRC) behaviour, from survival to recurrence, metastasis, tumour biology, response to therapy and CRC complications. We also discuss the debate in the literature surrounding the use of other peripheral immune compartment biomarkers compared with the NLR for this purpose and ideas for future research.

Backgrounds Cysteine-rich angiogenic inducer 61 (Cyr61) is emerging as an important regulator of tissue homeostasis and wound repair. We aim to explore the colonic mucosal expression of Cyr61 and analyze the association between Cyr61 expression and clinical course in patients with Crohn’s disease (CD). Methods Endoscopic samples were identified from 83 CD patients with and 372 controls by searching pathological reports. Among them, age- and sex- matched 43 of each group by a propensity score were selected to compare Cyr61 expression by immunohistochemistry (IHC). IHC scores for Cyr61 expression of CD patients were divided into tertiles to evaluate the association with clinical course. We also measured the level of mRNA for Cyr 61 and proinflammatory genes in inflamed and noninflamed colonic mucosal lesions from CD patients. Results The mean IHC scores for Cyr61 expression was higher in CD patients (86.5) than in controls (46.1, P P = 0.01). Cyr61 mRNA levels in inflamed mucosa were twofold higher than those in non-inflamed lesion (P > 0.05) and the mRNA levels of IL-6 and TLR-4 in inflamed mucosa were significantly higher than those in non-inflamed mucosa in CD patients (all P P for trend = 0.02). Compared with tertile 1 of Cyr61 expression, tertile 3 of Cyr 61 expression was associated with reduced risk of clinical recurrence (OR 0.43, 95% CI 0.20–0.92) after adjustment for age, sex and CD activity index at the time of colonoscopy in CD patients (P = 0.03). Conclusions Cyr61 mucosal expression in CD patients was inversely associated with clinical course. Future study need to be considered to evaluate whether Cyr 61 may play a role in activating inflammatory responses and contributing to wound healing and tissue repair in patients with CD.

ObjectiveTo investigate the association of high-density lipoprotein cholesterol (HDL-C) with the prognosis of patients with alcohol-related hepatocellular carcinoma (HCC) after radical treatment. MethodsA retrospective analysis was performed for the clinical data of 43 patients with alcohol-related HCC who were admitted to The Fifth Medical Center of Chinese PLA General Hospital and underwent radical treatment from January 2008 to July 2015, and according to HDL-C level, the patients were divided into normal group with 26 patients and abnormal group with 17 patients. The two groups were compared in terms of basic information, laboratory markers, imaging indices, Barcelona Clinic Liver Cancer tumor stage, and Child-Pugh class of liver function. The t-test test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test was used for comparison of categorical data between two groups. The Kaplan-Meier method was used to plot survival curves and the log-rank test was used for comparison between groups. Univariate and multivariate Cox proportional hazards models were used to analyze independent risk factors for prognosis. ResultsThere was a significant difference in prealbumin between the two groups (162.38±60.86 mg/L vs 120.06±64.08 mg/L, t=2.184, P=0.035). Number of tumors (hazard ratio ［HR］=2.839, 95%confidence interval ［CI］: 1.120~7.200,P=0.028), tumor size (HR=2.634, 95%CI: 1.062~6.529,P=0037), and HDL-C level (HR=2.400, 95%CI: 1.040~5.537,P=0.040) were independent risk factors for the overall survival of patients with alcohol-related HCC. There were significant differences in 1-, 3-, and 5-year cumulative survival rates between the normal group and the abnormal group (88.5%/72.4%/55.7% vs 70.6%/43.7%/17.5%, χ2=5.881, P=0.015). ConclusionThe reduction in HDL-C level might indicate poor prognosis of patients with alcohol-related HCC.

Self-management is a multi-modal approach for managing chronic conditions that encompasses a number of different elements; knowledge, adherence, self-regulation, communication, and cognitive factors. Self-management has been shown to be beneficial for adults with inflammatory bowel disease (IBD), and for children with IBD it may help them learn to take control of their complex treatment regimens and lead to positive disease outcomes. The development of self-management skills for children with IBD is vital in order to maximize their potential for health autonomy, but it is still an emergent field in this population. This review provides an over-arching view of the self-management elements specific to children with IBD, and highlights outcome measures that may be used to assess skills within each field as well as the efficacy of targeted interventions.

Hepatocellular carcinoma (HCC) is a common malignant tumor in clinical practice, and image-guided thermal ablation is a radical treatment method for early-stage HCC and a method for palliative tumor reduction and combination with systematic therapy for advanced HCC. With the advantages of real-time imaging, accurate guiding, easy operation, portability, low cost, no radiation damage, and high efficiency, ultrasound plays an important role in preoperative planning, intraoperative guiding, postoperative evaluation, and long-term follow-up in thermal ablation for HCC. With the advances in ultrasound and imaging fusion technology and the development of functional imaging technology represented by photoacoustic imaging, ultrasound-guided thermal ablation is at the forefront of precision treatment of HCC, achieving long-lasting development and developing into a more minimally invasive, accurate, safe, and effective diagnostic and therapeutic mode.

Background This study was performed to understand the prevalence of and possible risk factors for cholecystolithiasis in Uyghur, Kazakh, Han, and other ethnic groups in the Xinjiang Uyghur autonomous region of China. Methods Subjects were enrolled using typical case sampling and multistage stratified random sampling. We collected epidemiological data regarding cholecystolithiasis using a standard questionnaire of risk factors for gallbladder disease in Xinjiang. The subjects completed the questionnaire and underwent an abdominal ultrasound examination of the liver and gallbladder. Results This study included 5454 Xinjiang residents aged ≥ 18 years. The prevalence of cholecystolithiasis was 15% (11.3% in men and 17.1% in women), and the sex difference was statistically significant (male-to-female odds ratio [OR] 1.867; p p p p p Conclusions The prevalence of cholecystolithiasis was significantly higher in the Uyghur ethnic group than in the Han, Kazakh, and other ethnic groups; in women than in men; in southern Xinjiang than in northern Xinjiang; in patients with fatty liver disease; and increased with age and BMI. Our findings could provide a theoretical basis for the formulation of control measures for cholecystolithiasis.

Ablation is one of the important treatment methods for liver cancer, and standard ablation techniques, scientific and rational therapeutic strategy, and close teamwork are important premises for a good clinical effect. Although the efficacy of ablation therapy for liver cancer has gradually increased with the continuous improvement of ablation techniques, there remains a high tumor recurrence rate, and therefore, there is an urgent need for the therapeutic strategies that can improve the efficacy of ablation therapy for liver cancer and the prognosis of patients. Establishment of a diverse team for liver cancer ablation is a new concept put forward on the basis of a conventional team for liver cancer ablation to meet the requirements of ablation therapy for liver cancer. Since a diverse team for liver cancer ablation has potential advantages over a conventional team, it may be a promising mode for establishing a team for liver cancer ablation.