Plasma Cyclic Guanosine Monophosphate Is a Promising Biomarker of Clinically Significant Portal Hypertension in Patients With Liver Cirrhosis

Introduction: Despite intensive research, reliable blood-derived parameters to detect clinically significant portal hypertension (CSPH) in patients with cirrhosis are lacking. As altered homeostasis of cyclic guanosine monophosphate (cGMP), the central mediator of vasodilatation, is an essential factor in the pathogenesis of portal hypertension, the aim of our study was to evaluate plasma cGMP as potential biomarker of cirrhotic portal hypertension.Methods: Plasma cGMP was analyzed in cirrhotic patients with CSPH (ascites, n = 39; esophageal varices, n = 31), cirrhotic patients without CSPH (n = 21), patients with chronic liver disease without cirrhosis (n = 11) and healthy controls (n = 8). cGMP was evaluated as predictor of CSPH using logistic regression models. Further, the effect of transjugular intrahepatic portosystemic shunt (TIPS) placement on plasma cGMP was investigated in a subgroup of cirrhotic patients (n = 13).Results: Plasma cGMP was significantly elevated in cirrhotic patients with CSPH compared to cirrhotic patients without CSPH [78.1 (67.6–89.2) pmol/ml vs. 39.1 (35.0–45.3) pmol/l, p < 0.001]. Of note, this effect was consistent in the subgroup of patients with esophageal varices detected at screening endoscopy who had no prior manifestations of portal hypertension (p < 0.001). Cirrhotic patients without CSPH displayed no significant elevation of plasma cGMP compared to patients without cirrhosis (p = 0.347) and healthy controls (p = 0.200). Regression analyses confirmed that cGMP was an independent predictor of CSPH (OR 1.042, 95% CI 1.008–1.078, p = 0.016). Interestingly, portal decompression by TIPS implantation did not lead to normalization of plasma cGMP levels (p = 0.101).Conclusions: Plasma cGMP is a promising biomarker of CSPH in patients with cirrhosis, especially with respect to screening for esophageal varices. The lacking normalization of plasma cGMP after portal decompression suggests that elevated plasma cGMP in cirrhotic portal hypertension is mainly a correlate of systemic and splanchnic vasodilatation, as these alterations have been shown to persist after TIPS implantation.

Anaplastic T cell lymphoma in a patient with autoimmune hepatitis and hepatitis C infection

Lymphomas are rarely associated with liver disease. We hereby present a case of anaplastic T cell lymphoma in a 45-year-old female, who had received four cycles CHOP chemotherapy regimen and was evaluated for abdominal pain, fever along with weight loss. She was later found to have features of chronic liver disease on ultrasound along with varices on screening endoscopy. Serological workup was positive for hepatitis C infection while her liver biopsy showed features of autoimmune hepatitis. She was managed with steroids and azathioprine along with direct acting antiviral agents.

Local Style Preservation in Improved GAN-Driven Synthetic Image Generation for Endoscopic Tool Segmentation

Accurate semantic image segmentation from medical imaging can enable intelligent vision-based assistance in robot-assisted minimally invasive surgery. The human body and surgical procedures are highly dynamic. While machine-vision presents a promising approach, sufficiently large training image sets for robust performance are either costly or unavailable. This work examines three novel generative adversarial network (GAN) methods of providing usable synthetic tool images using only surgical background images and a few real tool images. The best of these three novel approaches generates realistic tool textures while preserving local background content by incorporating both a style preservation and a content loss component into the proposed multi-level loss function. The approach is quantitatively evaluated, and results suggest that the synthetically generated training tool images enhance UNet tool segmentation performance. More specifically, with a random set of 100 cadaver and live endoscopic images from the University of Washington Sinus Dataset, the UNet trained with synthetically generated images using the presented method resulted in 35.7% and 30.6% improvement over using purely real images in mean Dice coefficient and Intersection over Union scores, respectively. This study is promising towards the use of more widely available and routine screening endoscopy to preoperatively generate synthetic training tool images for intraoperative UNet tool segmentation.

Assessing the knowledge of trainee residents for liver involvement and related issues in COVID-19 pandemic

Background: Regular educational activities have suffered since the start of COVID-19 pandemic. New data has been emerging regularly regarding COVID-19 and the optimal way of care for patients with COVID-19 infection. Emphasis upon dispensing knowledge in current pandemic times should be made. Aims and Objective: We assessed the knowledge of internal medicine and gastroenterology trainees regarding liver involvement and related issues in the current COVID-19 pandemic. Materials and Methods: This online survey comprised of 10 questions designed to examine the basic knowledge of Sars-Cov-2 virus, knowledge regarding liver involvement in COVID-19, and the ability to decide on patient care. Results: A total of 100 responses were collected. Most of the responses were from Pakistan (n=75). More than 80% of trainees responded correctly regarding the accurate indication of endoscopic procedures during COVID-19 pandemic, absence of ACE-II receptor expression on astrocytes, upper respiratory secretions being an eligible sample for SARSCOV- II, avoiding regular outpatient follow up, avoiding hydroxychloroquine as a prophylactic drug, and azithromycin in decompensated cirrhosis, continuing beta-blockers and lactulose in a decompensated patient, melena being an accurate indication for screening endoscopy and the choosing right set of PPEs. Less than 50% of responders knew correctly regarding NAFLD being a notorious factor for COVID-19 related complications, ACE-II receptor expression by cholangiocytes and enterocytes, saliva and stool being an eligible sample for SARS-COV-II detection, palliative approach as an appropriated management step for decompensated-CLD patients and history of ascites as an appropriate indication for screening endoscopy. GItrainees performed better in some areas of knowledge. Conclusions: Trainees were updated in many aspects of the recent guidance in the management of COVID-19 but there were many lacunae in the knowledge. So, continuous medical education activities are essential to keep the residents updated about the changing developments in the management of COVID-19.

Characteristics of interval gastric neoplasms detected within two years after negative screening endoscopy among Koreans

Background In Korea, where gastric cancer is highly prevalent, biennial endoscopy is recommended among individuals over 40. Even under regular screening, some are still diagnosed at advanced stages. We aimed to identify characteristics of interval gastric neoplasms (IGNs) with rapid progression. Results Newly-diagnosed gastric neoplasms detected in screening endoscopy between January 2004 and May 2016 were reviewed. Among them, those who had previous endoscopy within 2 years were enrolled. Endoscopic findings, family history of gastric cancer, smoking, and H. pylori status were analysed. Totally, 297 IGN cases were enrolled. Among them, 246 were endoscopically treatable IGN (ET-IGN) and 51 were endoscopically untreatable IGNs (EUT-IGN) by the expanded criteria for endoscopic submucosal dissection. Among EUT-IGNs, 78% were undifferentiated cancers (40/51) and 33% showed submucosal invasion (13/40). They were median 2.0 cm in size and more commonly located in the proximal stomach than ET-IGNs (70.6% vs. 41.9%, p < 0.001). EUT-IGN was independently related with age < 60 (OR, 2.09; 95%CI, 1.03–4.26, p = 0.042), H. pylori (OR, 2.81; 95%CI, 1.20–6.63, p = 0.018), and absent/mild gastric atrophy (OR, 2.67; 95%CI, 1.25–5.72, p = 0.011). Overall and disease-specific survival were not significantly different between the two groups, however EUT-IGN tended to have short disease-specific survival (overall survival, p = 0.143; disease-specific survival, p = 0.083). Conclusions Uniform screening endoscopy with two-year interval seems not enough for rapid-growing gastric neoplasms, such as undifferentiated cancers. They tended to develop in adults younger than 60 with H. pylori infection without severe gastric atrophy. More meticulous screening, especially for proximal lesions is warranted for adults younger than 60 with H. pylori infection before development of gastric atrophy.

Reflux Esophagitis and Fatigue: Are They Related?

Background: Gastroesophageal reflux disease (GERD) is a chronic, recurrent disease. Reflux esophagitis can interfere with sleep via acid reflux, which could cause daytime sleepiness or fatigue. However, little is known about the association between reflux esophagitis and fatigueObjectives: We evaluated the association between fatigue and reflux esophagitis in subjects seen at health check-ups.Methods: Consecutive patients who were scheduled for screening endoscopy were enrolled prospectively at the Comprehensive Medical Examination Center of St. Vincent Hospital and Eunpyeong St. Mary's Hospital, Korea. Three validated questionnaires were used to assess fatigue, daytime hypersomnolence, anxiety, and depression: the Multidimensional Fatigue Inventory-Korean version (MFI-K), Epworth Sleepiness Scale (ESS), and Hospital Anxiety and Depression Scale (HADS).Results: We investigated 497 consecutive eligible subjects. The reflux esophagitis and symptomatic GERD groups comprised 103 (20.7%) and 92 (18.5%) subjects, respectively. The MFI-K total, ESS, HADS-anxiety, and HADS-depression scores did not differ between the esophagitis and non-esophagitis groups (50.0±11.5 vs. 49.7±10.9, P=0.661; 6.2±2.8 vs. 6.1±3.1, P=0.987; 5.8±3.1 vs. 5.2±3.2, P=0.060; 6.2±3.6 vs. 6.0±3.3, P=0.561). However, the MFI-K total, ESS, HADS-anxiety, and HADS-depression scores were higher in the symptomatic group than in the non-symptomatic group (54.7±12.7 vs. 48.6±10.3, P<0.001; 7.1±3.5 vs. 5.9±2.9, P=0.002; 6.4±3.3 vs. 5.1±3.1, P<0.001; 7.5±4.0 vs. 5.7±3.1, P<0.001). Multiple regression analysis showed that MFI-K total was correlated with GERD symptoms (P=0.021), women (P=0.001), anxiety (P<0.001) and depression (P<0.001). Conclusion: There was no statistically significant association in which reflux esophagitis could cause daytime sleepiness, fatigue, anxiety, or depression. However, fatigue was associated with GERD symptoms, women, anxiety and depression. Further studies should clarify the association between fatigue and reflux esophagitis.

A mask-based infection control method for screening endoscopy may prevent SARS-CoV-2 transmission and relieve staff anxiety

Objectives: Endoscopy confers high risk for acquiring coronavirus disease 2019. Although guidelines recommend that medical staff use personal protective equipment, no infection control equipment have been established for patients. This study aimed to clarify the usefulness of two face masks we had designed for transnasal and transoral endoscopy. Methods: The efficacy of the masks was evaluated by simulating coughing in a mannequin with fluorescent dyes and mapping the droplet trajectory and number. The number of aerosols generated during endoscopy was clinically evaluated in the endoscopy room. Overall, 4356 screening endoscopies were performed with the patients wearing our masks at Medcity21, a health checkup facility, between June and December 2020; the effects of the masks on the patient’s condition were evaluated retrospectively. An 11-item paper-based survey was performed by the endoscopy staff 6 months after the adoption of the mask-based infection control method. Results: Use of both masks reduced the number of droplets released during the simulation. Clinically, the use of both masks did not affect the patients’ conditions during endoscopy and prevented an increase in the aerosols in the endoscopy room. This mask-based infection control method was favorably received, and all staff indicated that understanding the efficacy of our mask-based infection control reduced their anxiety regarding infection. Until December 2020, none of our staff had contracted SARS-CoV-2. Conclusion: Our mask-based infection control method is easy to adopt, inexpensive, and effective; understanding its effectiveness may help ease the fear of infection among endoscopy staff.