Background:Gastrointestinal (GI) transmural defects are potential life-threatening conditions that need timely diagnosis and multi-modality treatment. Currently, there is a wide spectrum of minimally invasive therapeutic options that can be used alone or in combination. Recently, endoscopic vacuum therapy (EVT) has been added to these endoscopic therapeutic options. Summary:EVT has been showing promising clinical success rates with an acceptable safety profile competing with endoscopic stents. Due to its capacity to control exudate and to create granulation tissue, EVT is probably the best treatment for large size or chronic defects, or those associated with large collections. Nevertheless, there is lack of evidence about the best approach for each type of defect. The treatment course should be selected considering clinical status, type of surgery, chronicity, location and size of the defect, associated infected tissue, and local expertise. Despite its therapeutic potential, new devices and technical improvements are needed to standardize the technique, overcome EVT-related technical difficulties, and reduce complications. Key Messages:EVT is a paradigm shift in the treatment of GI transmural defects by allowing minimally invasive treatment of complex defects and avoiding morbimortality related to surgery.
Choledocholithiasis in patients with an intragastric balloon (IGB) can present technical challenges for endoscopic retrograde cholangiopancreatography (ERCP), often prompting balloon removal to facilitate the procedure [1]. However, no established guidelines mandate this approach. ERCP without balloon removal has been described, although impaired gastric rectification and limited duodenoscope maneuverability, may increase procedural difficulty. Balloon manipulation carries potential risks, including over-deflation with migration, valve damage, leakage and reinflation failure. These events are considered rare when performed in a controlled setting by experienced endoscopists. We report a 40-year-old woman with obesity (BMI 39 kg/m²) and previous choledocholithiasis who had undergone IGB placement three months earlier, achieving a 13 kg weight loss (14% of initial body weight). Her medical history included cholecystectomy and biliary sphincterotomy. She presented to the emergency department with epigastric pain radiating to the right hypochondrium and fever (38°C) for one day. She denied nausea or vomiting. Laboratory tests showed elevated inflammatory markers (WBC 13.77×10⁹/L, CRP 19 mg/L), cholestasis and hyperbilirubinemia (AST 606 U/L, ALT 278 U/L, ALP 152 U/L, GGT 345 U/L, TB 1.25 mg/dL, DB 0.80 mg/dL), with normal amylase and lipase levels. Abdominopelvic CT confirmed correct positioning of the balloon without gastric or esophageal distension. Dilation of the common bile duct (13 mm) and intrahepatic duct were noted, with an 8-mm intraluminal stone. A diagnosis of mild acute cholangitis of lithiasic etiology was established. Antibiotic therapy was initiated and ERCP was scheduled for the second day of hospitalization. The IGB was identified as an adjustable model (Spatz3®), previously filled with 450 mL of methylene blue diluted in saline solution (Fig.1). Given the balloon volume and anticipated limitations in scope maneuverability, partial deflation was selected instead of direct duodenoscopy or complete removal, aiming to optimize working space while maintaining the ongoing weight-loss benefit. A standard gastroscope was initially used to exteriorize the adjustment wire (Fig.2). Partial deflation was performed by removing 250 mL of fluid (Fig.3). Subsequently, a duodenoscope was introduced, and duodenoscopy was successfully completed with improved stability. The papilla showed evidence of prior biliary sphincterotomy, with an adequately patent orifice. Cholangiography revealed a 9-mm filling defect in the common bile duct (Fig.4). Stone extraction with a fogarty balloon achieved complete removal of fragmented calculi (Fig.5). The balloon was then refilled with 250 mL, restoring the original 450 mL volume (Fig.6). The patient was discharged on the third day of hospitalization following clinical and laboratory improvement. At 6-week follow-up, she remained asymptomatic, with normal liver function tests and preserved balloon positioning and functionality, without procedure related complications. At balloon removal, 7 months after placement, she had achieved a 19% reduction in her initial body weight, highlighting that maintaining the device allowed treatment continuity and sustained weight-loss efficacy. Conclusion: ERCP was successfully performed after partial deflation of the adjustable IGB, avoiding complete balloon removal while still allowing sufficient space for duodenoscope maneuverability. This case highlights that IGB removal may not always be necessary and that partial deflation can represent a safe and effective strategy.
Introduction:Crohn's disease (CD) is a chronic inflammatory disorder that may involve any segment of the gastrointestinal tract, including the oral cavity. Oral granulomatous inflammation can represent the earliest manifestation of CD or be provisionally classified as orofacial granulomatosis (OFG). Differentiating isolated OFG from early oral CD is challenging, as the intestinal involvement may be subclinical or develop later, and oral clinical and histological findings are not specific. Case Presentation:We report the case of a 26-year-old woman with biopsy-proven oral granulomatous inflammation initially diagnosed as OFG only partially responsive to topical corticosteroids. Five years later, the patient developed progressive dysphagia, bloody diarrhea, and concomitant draining perianal lesion. Investigations revealed segmental granulomatous colitis, intersphincteric fistula, and a regular nonspecific esophageal stenosis. Colonic CD with oral, esophageal, and perianal involvement was diagnosed. Treatment with corticosteroids followed by infliximab and azathioprine achieved sustained clinical and endoscopic colonic remission with marked improvement of oral, esophageal, and perianal disease. Conclusion:This case emphasizes that granulomatous oral inflammation may represent the earliest manifestation of CD and highlights the importance of systematic gastrointestinal evaluation and long-term surveillance even in the absence of digestive symptoms.
Introduction:Ectopic variceal bleeding is a rare but challenging event, often requiring a multidisciplinary approach. Embolization of the splenic artery is an uncommon procedure for reducing portal hypertension; however, it is described as an alternative in clinical situations where there is a contraindication to transjugular intrahepatic portosystemic shunt (TIPS). Case Presentation:We report the clinical case of a 45-year-old male patient with a portal cavernoma secondary to alcohol-related chronic pancreatitis and dilated cardiomyopathy who presented to the emergency department with melena. Upper endoscopy identified bulbar ectopic varices with bleeding stigmata. Cyanoacrylate injection treatment triggered high-output hemorrhage, which was controlled after sclerosing agent injection. CT angiography revealed embolized glue in the hepatic hilum and periduodenal varices without active bleeding. The patient evolved favorably without rebleeding. Given high risk of recurrence, a multidisciplinary discussion with interventional radiology was undertaken. As the patient had contraindication to TIPS and portal revascularization, it was decided to perform proximal splenic embolization for portal hypertension control. The procedure had no complications and there were no further bleeding episodes at follow-up. Conclusion:Although splenic artery embolization is not a commonly used procedure for portal hypertension management, there is some growing evidence that it can be a useful and safe tool. This clinical case supports splenic artery proximal embolization in the particular setting of duodenal ectopic varices.
Introduction:Acute liver failure with an autoimmune phenotype can result from various causes, including autoimmune hepatitis (AIH) or drug-induced liver injury (DILI) with autoimmune features. Rarely, corticosteroids themselves may trigger autoimmune-like liver injury, further complicating the differentiation between AIH and DILI. Case Presentation:We report a 57-year-old woman with multiple sclerosis who received high-dose intravenous methylprednisolone (1 g/day for 5 days) 6 weeks prior to presentation. She was admitted with severe fatigue, jaundice, asterixis, and laboratory findings consistent with acute liver failure (total bilirubin 12.6 mg/dL, direct bilirubin 5.88 mg/dL, INR 1.95, and elevated ammonia). Abdominal and brain computed tomography were unremarkable. IgG levels were 2,506 mg/dL (upper limit 1,600), with positive antinuclear antibodies (titer 1:320) and negative anti-smooth muscle and anti-mitochondrial antibodies. Extensive workup excluded viral hepatitis, metabolic disorders, and other common causes of liver injury. Transjugular liver biopsy demonstrated moderate periportal and severe lobular hepatitis with plasmacytic infiltration and centrilobular necrosis, without significant fibrosis, consistent with an autoimmune-like pattern. The patient received prednisolone (1 mg/kg/day) with rapid biochemical improvement. Azathioprine was introduced during hospitalization but later discontinued by the patient. Long-term follow-up showed normalization of liver tests and IgG levels without relapse, supporting a diagnosis of drug-induced autoimmune-like hepatitis (DI-ALH). Discussion:The temporal association with methylprednisolone, exclusion of alternative etiologies, and the absence of relapse after discontinuation of immunosuppressive therapy suggest corticosteroid-DI-ALH rather than primary AIH. This paradoxical presentation is rare, as corticosteroids are generally used therapeutically in AIH or in severe DI-ALH rather than as a causative agent, highlighting the need for awareness of atypical drug-induced hepatotoxicity. This case underscores the diagnostic challenges in distinguishing DI-ALH from AIH, particularly when corticosteroids are implicated, and emphasizes the importance of long-term follow-up to confirm resolution and guide management.
Introduction: Small bowel metastases from lung adenocarcinoma are rare and usually occur in advanced-stage disease. Duodenal involvement is particularly uncommon and may present with gastrointestinal bleeding. Case Presentation: A 52-year-old heavy smoker presented with cough and superior vena cava syndrome. Imaging revealed an 11 cm mass in the upper lobe of the right lung with mediastinal invasion, and bronchoscopic cytology confirmed lung adenocarcinoma without targetable mutations. Despite palliative radiotherapy and platinum-based chemotherapy, the disease rapidly progressed with multiple systemic metastases. Four months after diagnosis, the patient was admitted with melena, asthenia and severe anaemia (Hb 5.8 g/dL). Initial upper gastrointestinal endoscopy showed no lesions up to the second portion of the duodenum. However, further advancement of the gastroscope identified multiple ulcerated “volcano-like” lesions in the third and fourth portions of the duodenum. Histopathological and immunohistochemical evaluation confirmed metastatic lung adenocarcinoma. Given the extensive disease burden and poor prognosis, best supportive care was instituted, and the patient died seven days later. Conclusion: Duodenal metastases from lung adenocarcinoma are exceptionally rare and may manifest as upper gastrointestinal bleeding. This case emphasizes the importance of thorough distal duodenal evaluation during upper endoscopy in patients with melena or anaemia, particularly when no bleeding source is identified in the proximal duodenum.
Introduction and Aims:Underwater endoscopic mucosal resection (U-EMR) emerged as a promising alternative to conventional EMR (C-EMR) for resecting large colorectal polyps. There is a lack of studies focusing on its learning curve. Thus, we aimed to determine the learning curve of U-EMR in endoscopists without prior experience in U-EMR. Methods:Four endoscopists from 4 different centers performed U-EMR after standardized online training. Patients with non-pedunculated colorectal lesions sized 10-30 mm were enrolled between November 2023 and June 2024. The primary outcome was to evaluate technical success, en bloc resection rates, procedural time, and adverse events before and after 10 and 15 procedures, to assess whether this threshold is sufficient for proficiency. Results:Overall, 84 lesions were included, median size of 17 mm [10-35 mm]. Mean procedural time was 3.99 min, with an average of 1.21 piecemeal fragments per lesion, and en bloc resection rate was 85%, with all lesions completely resected. When comparing learning phases, en bloc resection rates were 83.3% in the first period (first 15 lesions) and 87.5% thereafter, with a slight reduction in mean procedural time (4.13 vs. 3.77 min). There were no significant differences in procedural time or en bloc resection when comparing results after 10 or 15 procedures, no observed improvements after the 16th procedure. No perforations, delayed bleeding, or hospital admissions occurred. Intraprocedural bleeding occurred in 3.6% of cases and was managed conservatively. Prophylactic clip closure was performed in 34.5% of cases, primarily in the right colon. Conclusion:U-EMR is safe, efficient, and easily adopted, with proficiency that may be achieved after a small number of procedures.
Hemosuccus pancreaticus is an uncommon but potentially life-threatening cause of upper gastrointestinal bleeding. We report the case of a 47-year-old man with a history of alcohol use disorder and alcohol use disorder and a previous episode of alcohol-induced acute pancreatitis who presented with melena, severe microcytic anemia, and recurrent epigastric pain. Upper endoscopy demonstrated blood emerging from the major papilla alternating with bile, raising suspicion for hemosuccus pancreaticus. Contrast-enhanced computed tomography revealed a large pseudoaneurysm of the pancreatoduodenal artery within the pancreatic head, likely secondary to chronic inflammatory changes. The patient underwent successful endovascular coil embolization, resulting in complete cessation of bleeding and an uneventful recovery. This case highlights the role of upper endoscopy in early recognition of hemosuccus pancreaticus and underscores the effectiveness of endovascular therapy in managing pseudoaneurysm-related hemorrhage.
Verrucous carcinoma of the esophagus is an extremely rare malignancy, described as a well-differentiated variant of esophageal squamous cell carcinoma, typically exhibiting exophytic/verrucous growth and intraluminal involvement that is often rich in inflammation and hyperkeratosis, which hampers histologic diagnosis and consequently delays treatment. We report the case of a 58-year-old woman with progressive dysphagia and a circumferential, verrucous esophageal lesion, without histologic confirmation despite multiple biopsies and endoscopic resections, showing only focal p16 positivity. After further evaluation with CT, endoscopic ultrasound, and FDG-PET/CT, a presumptive diagnosis of locally advanced verrucous carcinoma of the esophagus was assumed, and palliative chemotherapy was initiated, followed by a sustained endoscopic and radiologic response. This case highlights the importance of multidisciplinary discussion when verrucous carcinoma of the esophagus is suspected and the unexpected, sustained response despite unresectability.
Introduction:Fundic gland-type neoplasms show a relatively high frequency of submucosal (SM) invasion despite their small size and low-grade biological behavior. Reliable pretreatment endoscopic predictors of SM invasion, however, remain limited. This study aimed to evaluate the association between pretreatment endoscopic features and SM invasion, focusing on central depression. Methods:This single-center retrospective study included fundic gland-type neoplasms treated by endoscopic SM dissection between January 2010 and August 2024. Only pretreatment endoscopic images obtained before biopsy were evaluated and reassessed by multiple blinded endoscopists. Multivariable logistic regression analysis was performed using lesion size (≥5 mm vs. <5 mm), central depression, and reddish coloration, with age categorized by the median as a confounder. Sensitivity analyses and an exploratory simple score analysis were conducted. Results:A total of 114 lesions were analyzed, including 70 intramucosal and 44 SM-invasive lesions. Central depression was independently associated with SM invasion (odds ratio, 5.98; 95% confidence interval, 1.12-31.94; p = 0.037). Lesion size (p = 0.373), reddish coloration (p = 0.312), and age (p = 0.120) were not independently associated. In a sensitivity analysis restricted to MUC5AC-negative lesions (n = 43), central depression remained associated with SM invasion (odds ratio, 7.69; 95% confidence interval, 0.87-180.9; p = 0.104), showing a similar direction to the main analysis. Furthermore, in an exploratory simple score (0-3) incorporating lesion size, central depression, and reddish coloration, both the rate and depth of SM invasion increased stepwise with higher scores, from 31.8% for a score of 0 to 80.0% for a score of 3. Conclusion:Central depression is an important pretreatment endoscopic feature independently associated with SM invasion in fundic gland-type neoplasms. Careful assessment of pretreatment endoscopic findings may aid SM invasion risk stratification and support treatment decision-making.
Introduction Primary hepatic mucosa-associated lymphoid tissue (MALT) lymphoma is an exceedingly rare subtype of extranodal marginal zone B-cell lymphoma within the spectrum of non-Hodgkin lymphomas. Chronic inflammatory and autoimmune conditions are recognised risk factors for lymphomagenesis; however, the association between primary hepatic MALT lymphoma and primary biliary cholangitis (PBC) has been rarely reported. Case Presentation We report the case of a 50-year-old woman with a 9-year history of non-cirrhotic PBC, treated with ursodeoxycholic acid and with only partial biochemical response, who was referred for further evaluation of focal liver lesions detected during follow-up. Magnetic resonance imaging revealed two small right-lobe nodules with arterial phase enhancement and apparent delayed washout, raising suspicion of hepatocellular carcinoma. In the absence of advanced chronic liver disease, a liver biopsy was performed. Local pathology showed an atypical lymphoid infiltrate not compatible with hepatocellular carcinoma, and expert hematopathology review favored a low-grade B-cell lymphoma, suggestive of primary hepatic extranodal marginal zone lymphoma of MALT type. Comprehensive staging excluded extrahepatic involvement. Radiofrequency ablation had already been performed under the initial presumptive diagnosis of hepatocellular carcinoma; thereafter, given the indolent course and absence of disseminated disease, a watchful waiting strategy was adopted. No disease progression has been documented after eight years of follow-up. Discussion/Conclusion This case highlights a rare association between primary hepatic MALT lymphoma and PBC in an asymptomatic, immunocompetent patient without cirrhosis. It underscores the importance of considering alternative diagnoses and performing liver biopsy when evaluating focal liver lesions in non-cirrhotic patients with autoimmune liver disease, particularly when imaging findings are suspicious but not sufficient for a definitive non-invasive diagnosis. Chronic immune-mediated inflammation may have contributed to the pathogenesis of this rare lymphoma.
Background: The majority of patients with intraductal papillary mucinous neoplasms (IPMNs) are asymptomatic and diagnosis is incidental when imaging studies are requested due to unrelated indications. Summary: Although they are usually harmless findings, they have potential for malignant transformation. In this review, Portuguese Pancreatic Club summarizes the most recent recommendations regarding diagnosis, characterization, use of advanced endoscopic ultrasound (EUS) modalities, general management of IPMNs and role of pancreatoscopy. Key Messages: Contrast-enhanced magnetic resonance imaging/cholangiopancreatography (MRI) is the preferred imaging modality for the characterization of IPMNs. EUS should be considered in the evaluation of cysts of uncertain significance, in assessing the malignant risk of mucinous lesions, and when MRI is insufficient to define the clinical approach. Fine-needle aspiration with cytological analysis, measurement of biomarkers, and molecular studies in the cyst fluid should only be performed when its results might modify further management. Contrast-enhanced endoscopic ultrasonography, needle-based confocal endomicroscopy and EUS-guided through-the-needle biopsy are promising complementary techniques that may increase diagnostic accuracy. Peroral pancreatoscopy is being increasingly used for main-duct evaluation in patients with suspected or confirmed IPMNs. Many of these techniques are still confined to tertiary referral centers, and associated with steep learning curves and interobserver discrepancy.
Adult intussusception is a rare clinical entity, accounting for a small fraction of bowel obstructions, with the vast majority of cases driven by underlying structural lesions, neoplasms, or malignancies [1]. Consequently, jejunojejunal intussusception caused by an Ascaris lumbricoides infestation is exceptionally rare, particularly in non-endemic and developed settings where such soil-transmitted helminthiases are highly unusual [2,3]. A 69-year-old white male from a rural area, with no significant medical history, presented in the emergency department with acute abdominal pain and vomiting with a few hours of evolution, notably lacking fever, B symptoms, or diarrhea. Physical examination showed only mild epigastric discomfort and initial work-up at admission revealed only an elevation of C-reactive protein (4 mg/dL). Complete blood count was unremarkable and celiac serology was negative with normal imunoglobulin A levels. An infectious work-up, including stool culture, was negative, though a stool test for parasites was not conducted. A computed tomography (CT) was performed and showed a jejunojejunal intussusception and the patient was admitted for etiological study and treatment. Management commenced with bowel rest and intravenous fluids, alongside the placement of a nasogastric tube, which was subsequently removed after yielding no drainage. The patient eventually started enteral nutrition after 48 hours with good tolerance, maintaining regular bowel movements throughout his hospitalization. A follow-up CT enterography showed no abnormalities, and symptoms resolved spontaneously, allowing discharge after a few days. To exclude an underlying structural lead point, both abdominal ultrasonography and capsule endoscopy were requested for outpatient follow-up. Abdominal ultrasound revealed multiple mobile linear and tubular structures within the jejunal lumen, up to 35 mm long, with hyperechoic walls and hypoechoic centers, exhibiting classic "train-track" or "target" signs suggestive of adult Ascaris lumbricoides worms. No biliary or pancreatic involvement was noted. Capsule endoscopy confirmed numerous elongated, serpiginous, mobile parasites in the jejunum, distorting mucosal folds and likely causing the intussusception. The patient received a single dose of oral albendazole 400 mg, resulting in parasite expulsion and complete resolution of intussusception on follow-up imaging. Post-treatment parasite stool tests were negative. After two years of follow-up, he remained completely asymptomatic. This case demonstrates that transient intussusception can be secondary to the dynamic motility of Ascaris lumbricoides. Spontaneous resolution permitted a conservative approach, sparing the patient from an unnecessary surgery. Furthermore, it emphasizes the synergy of multimodal imaging: although CT identified the anatomical obstruction, real-time ultrasonography and capsule endoscopy were essential to establish the etiological diagnosis non-invasively. Ultimately, this rare case highlights the remarkable pathognomonic images captured and the value of both capsule endoscopy and abdominal ultrasound in identifying real-time visualization of Ascaris lumbricoides intraluminal motility as an uncommon etiology of adult intussusception.
Introduction: Acute pancreatitis is a potentially severe condition that can lead to both local and systemic complications. Colonic complications are uncommon but include fistula formation and perforation, both of which are associated with high morbidity and mortality. This is a case of colon perforation in an unusual location, following an episode of acute pancreatitis. Case Presentation: We report the case of a 75-year-old man with a history of arterial hypertension, dyslipidemia, and atrial fibrillation on direct oral anticoagulation who presented with sudden upper abdominal pain and vomiting. Abdominal ultrasound showed no evidence of gallstones or biliary obstruction. The patient reported a daily alcohol intake of approximately 50 g, and laboratory tests revealed markedly elevated amylase and lipase levels. On admission, the patient was hemodynamically stable, with no evidence of organ failure. A diagnosis of mild acute pancreatitis with uncertain etiology was made. Initially stable, the patient developed new-onset abdominal pain and signs of peritonitis on the fifth day of hospitalization. CT revealed pneumoperitoneum and a retroperitoneal hematoma. Exploratory laparotomy confirmed sigmoid colon perforation, and a segmental colectomy with end colostomy was performed. Histopathological examination of the resected sigmoid colon excluded the presence of diverticula or neoplastic lesions and revealed inflammation of the subserosa and serosa adjacent to the perforation. Case Discussion: Colonic perforation secondary to acute pancreatitis is exceedingly rare, and its pathophysiology is not fully understood. The leading hypothesis suggests the spread of activated pancreatic enzymes through the mesocolon, leading to pericolitis, ischemia, and transmural necrosis. Most reported cases involve the transverse or descending colon, but sigmoid involvement, as in this case, underscores the unpredictable nature of this complication. Conclusion: This case highlights a rare but severe complication of acute pancreatitis. Clinicians should consider colonic involvement in patients with unexplained clinical deterioration. Early recognition and prompt surgical intervention remain key to favorable outcomes.
We present the case of a 60-year-old woman who was admitted to the emergency room with a two-day history of black stools and asthenia. She denied hematemesis. Her blood tests revealed iron deficiency anemia (Hb 7.4 g/dL). Upper endoscopy identified a pedunculated polypoid lesion with congested mucosa and superficial erosions, arising from the duodenal bulb and extending into the third portion of the duodenum. This lesion was suggestive of a subepithelial lesion, presumably responsible for gastrointestinal bleeding (shown in Fig. 1). Endoscopic ultrasound identified the lesion on the third layer of the duodenal wall, maintaining a clear interface with the fourth layer with well-defined and regular borders. The peduncle was hypoechoic and had blood vessels inside it, while the head of the lesion was hyperechoic and had blood vessels inside it (shown in Fig. 2.a & b & c). The lesion was excised by endoloop-assisted snare polypectomy (shown in Fig. 3. a & b & c and Fig. 4). Histological examination revealed spindle cell lipoma (SCL) (shown in Fig. 5. a & b & c). Clinical follow-up was performed six months after lesion excision. Spindle cell lipoma (SCL) is a morphologically distinct subtype of lipoma with internal vascularity There are few reports of their occurrence in the gastrointestinal tract, and they rarely appear on the duodenal wall [1]. Histologically, SCLs are characterized by a combination of mature adipose cells and small, uniform spindle cells set against a background of fibrous stroma (acidophilic collagen fibers) with myxoid changes. Spindle cells typically express CD34 (95%–100%) and are negative for S-100 and smooth muscle actin (SMA) [2]. SCL infrequently occurs in the gastrointestinal tract and rarely manifests as gastrointestinal bleeding. In the literature, only two cases of gastrointestinal bleeding caused by a duodenal SCL have been reported [3,4]. SCL generally has a benign clinical course. In spindle cell lipomas arising in typical anatomical locations, such as the neck and back, the local recurrence rate is approximately 2–3% after complete excision [5]. The recurrence rate of duodenal spindle cell lipoma has not been specifically described in the medical literature, likely due to its rarity in this location.There is no standardized or guideline-based follow-up protocol after excision of duodenal SCL. In asymptomatic patients, follow-up can be individualized, with endoscopic evaluation reserved for those who develop new symptoms.
Introduction:Liver fibrosis is a key determinant of morbidity and mortality in chronic liver disease. Noninvasive scores such as fibrosis-4 index (FIB-4) and AST-to-platelet ratio index (APRI) are widely used, but their accuracy varies across populations. Fibrosis-6 score (FIB-6), a novel composite biomarker incorporating age, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, platelet count, and albumin improves fibrosis prediction. This study evaluated the diagnostic performance of FIB-6 in a Portuguese cohort with steatotic liver disease. Methods:This observational study analyzed 301 adult patients who underwent transient elastography. Demographic, clinical, and laboratory data were retrospectively collected. Noninvasive scores (FIB-4, APRI, and FIB-6) were calculated, and liver fibrosis (F0-F4) was assessed based on liver stiffness measure adjusted for liver disease etiology. Receiver operating characteristic (ROC) analyses, correlations with liver stiffness, Youden index-derived cutoffs, and rule-in/rule-out thresholds were subsequently performed. A subanalysis was also conducted for liver disease etiologies. Results:FIB-6 correlated moderately with liver stiffness (r = 0.334; p < 0.001), significantly outperforming FIB-4 and APRI, which showed weak or nonsignificant correlations. Area under the ROC curve values for cirrhosis (F4) were 0.716 (FIB-6), 0.579 (APRI), and 0.513 (FIB-4); for advanced fibrosis (F3-F4), 0.709 (FIB-6), 0.568 (APRI), and 0.545 (FIB-4). Optimal Youden cutoffs for FIB-6 were >2.06 for advanced fibrosis and >1.69 for cirrhosis. A rule-in threshold of >2.30 achieved 90% specificity, while a rule-out threshold of <1.5 reached 90% sensitivity, for advanced fibrosis. FIB-6 outperformed FIB-4 and APRI across metabolic dysfunction-associated steatotic liver disease, metabolic and alcohol-related steatotic liver disease, and alcohol-related liver disease. Discussion:FIB-6 demonstrated superior diagnostic performance compared to FIB-4 and APRI, showing greater accuracy in identifying advanced fibrosis and cirrhosis. Cutoff values varied across different etiologies, underscoring the importance of etiology-specific thresholds for optimal clinical application. Despite its robustness, laboratory-based scores may be influenced by physiological or clinical variations, requiring contextual interpretation. FIB-6 is a reliable and accessible noninvasive tool. Its application within a tripartite "rule-in/rule-out" framework can effectively guide clinical triage and prioritize patients for elastography, particularly in resource-limited settings.
Colonic involvement in visceral leishmaniasis (VL) is exceptionally rare. We report a case of a 39-year-old man who presented with anorexia, weight loss, and diarrhea. Imaging revealed hepatosplenomegaly and extensive retroperitoneal lymphadenopathy, while laboratory tests showed pancytopenia and renal dysfunction. He was newly diagnosed with human immunodeficiency virus (CD4+ count: 3 cells/μL), and VL was confirmed by identification of amastigotes and positive PCR in bone marrow aspirate. During hospitalization, he developed severe hematochezia. Colonoscopy revealed a pseudotumoral, ulcerated, and stricturing lesion in the ascending colon; histology confirmed colonic leishmaniasis. The patient progressed to hemorrhagic shock, requiring urgent right hemicolectomy. This case underscores an uncommon and fulminant presentation of VL in the setting of profound immunosuppression, highlighting the importance of considering parasitic infections in the differential diagnosis of gastrointestinal bleeding in HIV-positive individuals.
