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BACKGROUND & AIMS: Ketamine-associated cholestatic liver injury is reported in patients with severe burn injury, but its association with patient outcome is unclear. We investigated the relationship between ketamine exposure, cholestatic liver injury, and outcome of critically ill patients with burn injury. METHODS: In a retrospective study, patients with severe burn injury were analysed across two periods: unrestricted ketamine prescription (ketamine-liberal) and capped ketamine dosage (ketamine-restricted). The primary endpoint was cholestatic liver injury, and the secondary endpoint was 3-month mortality. Binary logistic regression models and the revised electronic causality assessment method were used to measure the strength of associations and causality assessment, respectively. RESULTS: Of 279 patients (median age 51 [IQR 31-67] years; 63.1% men; burned surface area 28.5%, IQR 20-45%), 155 (56%) were in the ketamine-liberal group, and 124 (44%) were in the ketamine-restricted group, with comparable clinical characteristics, except for ketamine exposure (median doses 265.0 [IQR 0-8,021] mg and 20 [IQR 0-105] mg, respectively; p

Résumé: L'ingestion de caustiques représente une urgence médico-chirurgicale. Chez l'adulte, elle est le plus souvent à visée suicidaire et sa gravité dépend de la nature et de la quantité du produit ingéré. La prise en charge doit être multidisciplinaire. L'enjeu initial est d'identifier les patients qui nécessitent une résection chirurgicale d'urgence pour nécrose transmurale du tube digestif mettant en jeu leur pronostic vital. L'endoscopie digestive haute n'a plus de place à la phase aiguë de l'ingestion. L'algorithme décisionnel repose désormais sur le scanner injecté avec une classification dédiée et une bonne reproductibilité inter-observateur. L'apport de l'imagerie a permis d'étendre les indications de traitement conservateur qui peut être réalisé chez environ trois quarts des patients. Dans ce cas, la réalimentation doit être très précoce. Il n'y a pas de traitement médicamenteux validé pour favoriser la cicatrisation des lésions. En cas de survenue ultérieure d'une sténose œsophagienne, la dilatation endoscopique représente le traitement de première intention. Ingestion of caustics represents a medical and surgical emergency. In adults, it is most often suicidal and its severity depends on the nature and quantity of the ingested product. Management should be multidisciplinary. The initial challenge is to identify patients requiring emergency surgical resection for life-threatening transmural necrosis of the gastrointestinal tract. Upper gastrointestinal endoscopy has no longer a place in the acute phase of ingestion. The decisional algorithm is now based on the injected CT scan with a dedicated classification and good inter-observer reproductibility. The contribution of imaging has made possible to extend the indications for conservative treatment, which can be carried out in about three quarters of the patients. In this case, re-feeding must be very early. There is no validated drug treatment to promote wound healing. If esophageal stenosis occurs later, endoscopic dilatation is the first-line treatment. [ABSTRACT FROM AUTHOR]

Background Endoscopy is the best predictor of stricture formation after caustic ingestion. Our aim was to compare the accuracy of emergency CT and endoscopy in predicting risks of esophageal stricture. Methods We describe a CT classification of esophageal caustic injuries: Grade I show normal esophagus; Grade IIa display internal enhancement of the esophageal mucosa and enhancement of the outer wall conferring a 'target' aspect; Grade IIb present as a fine rim of external esophageal wall enhancement. In 152 patients (56 males, median age 45) who underwent esophageal preservation after caustic ingestion we compared the accuracy of the CT and endoscopic (Zargar) classifications in predicting esophageal stricture. Results On endoscopy esophageal injuries were classified as grade 1(n = 50; 33%), grade 2a n = 11; 7%), grade 2b (n = 19; 13%), grade 3a (n = 14; 9%) and grade 3b (n = 58; 38%). On CT, 47 (31%) patients had grade I, 47 (31%) had grade IIa and 58 (38%) had grade IIb esophageal injuries. Fifty-six (37%) patients developed esophageal strictures. The risk of esophageal stricture formation was 0%, 17% and 83%, for grade I, IIa and IIb CT injuries and 0%, 0%, 28%, 50% and 76% for endoscopic grade 1, 2a, 2b, and 3a and 3b injuries, respectively. ROC curve analysis at 120 days after ingestion showed that CT outperformed endoscopy in predicting stricture formation (P  = 0.047) and did just as well as a combined CT-endoscopy algorithm (P  = 0.73). Conclusion Emergency CT outperforms endoscopy in predicting esophageal stricture formation after caustic ingestion. Emergency endoscopy evaluation after caustic ingestion is not indispensable. Disclosure All authors have declared no conflicts of interest. [ABSTRACT FROM AUTHOR]

Background: The severity of small bowel (SB) inflammation in Crohn's disease (CD) patients is a key component of the therapeutic choice. We aimed to develop a SB-CD Magnetic Resonance Enterography (MRE) index of Inflammation Severity (CDMRIS)., Methods: Each gastroenterologist/radiologist pair in 13 centers selected MREs from 6 patients with SB-CD stratified on their perceived MRE inflammation severity. The 78 blinded MREs were allocated through balanced incomplete block design per severity stratum to these 13 pairs for rating the presence/severity of 13 preselected items for each SB 20-cm diseased segment. Global inflammation severity was evaluated using a 100-cm visual analog scale. Reproducibility of recorded items was evaluated. The CDMRIS was determined through linear mixed modeling as a combination of the numbers of segments with lesions highly correlated to global inflammation severity., Results: Four hundred and forty-two readings were available. Global inflammation severity mean ± SD was 21.0 ± 16.2. The independent predictors explaining 54% of the global inflammation severity variance were the numbers of segments with T1 mild-moderate and severe intensity of enhancement, deep ulceration without fistula, comb sign, fistula, and abscess. Unbiased correlation between CDMRIS and global inflammation severity was 0.76., Conclusions: The CDMRIS is now available to evaluate the severity of SB-CD inflammation. External validation and sensitivity-to-change are mandatory next steps., (© The Author(s) 2022. Published by Oxford University Press on behalf of Crohn's & Colitis Foundation.)

Significant morbidity and mortality have been associated with liver complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Causes and consequences of these hepato-biliary complications are various and might be life-threatening. A high misdiagnosis rate has been reported because of a weak correlation between clinical, laboratory and imaging data. Liver elastography, a liver stiffness measure, is able to assess liver fibrosis and portal hypertension in most liver diseases, but data after allo-HSCT are scarce. Our aim was to determine the interest of sequential liver stiffness measurements for the diagnosis of early hepatic complications after allo-HSCT. Over a two years period of time, 161 consecutive adult patients were included and 146 were analyzed. Ultrasonography and elastography measurements were performed before transplantation, at day+7 and day+14 by three different experienced radiologists unaware of patients'clinical status. Eighty-one (55%) patients had liver involvements within the first 100 days after allo-HSCT. Baseline elastography was not predictive for the occurrence of overall liver abnormalities. A significant increase in 2D real-time shearwave elastography (2D-SWE) was found in patients with sinusoidal obstruction syndrome (SOS). Fifteen patients (10%) fulfilled EBMT score criteria and twelve (8%) reached Baltimore criteria for SOS diagnosis, but only six (4%) had a confirmed SOS. 2D-SWE at day+14 allowed early detection of SOS (AUROC=0.84, p=0.004) and improved sensibility (75%), specificity (99%) and positive predictive value (60%) over the Seattle, Baltimore or EBMT scores. A 2D-SWE measurement above 8.1kPa at day+14 after allo-HSCT seems a promising, non-invasive, and reproducible tool for early and accurate diagnosis of SOS.

Objective: This article will review the performance and limitations of cross-sectional imaging methods to detect and display critical features of Crohn disease (CD)-related bowel damage, including stenosis and penetrating complications (i.e., fistula, abscess). International efforts to incorporate cross-sectional imaging findings along with endoscopic and surgical findings to create a global bowel damage score over the length of the gastrointestinal tract are summarized along with the rationale for these efforts., Conclusion: The first digestive damage score, the Lémann score, will incorporate surgical history, endoscopic findings, and imaging findings of stenosis and penetrating complications to provide a global assessment of CD-related destruction of the gastrointestinal tract. It is anticipated that the score will permit better understanding of the impact of modern therapeutics on the natural history of CD. Because CT is a technique that involves ionizing radiation and accuracy of ultrasound is highly related to CD location, MRI is proposed as first choice for nonemergent follow-up of CD patients.

Objective: We describe a coaxial introducer provided with an additional blunt-tip stylet that allows safe access to difficult-to-reach lymph nodes in the chest, abdomen, and pelvis under CT control., Conclusion: Once the thoracic, abdominal, or pelvic wall is crossed by the introducer fitted with the sharp-tip stylet, the blunt-tip stylet replaces the sharp stylet for further progression in the fat toward the target. The soft-tip stylet carries a smaller risk of inadvertent perforation displacing vital structures.