Euroasian journal of hepato-gastroenterology

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2021 | July-December | Volume 11 | Issue 2

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[Year:2021] [Month:July-December] [Volume:11] [Number:2] [Pages:1] [Pages No:00 - 00]

   DOI: 10.5005/ejohg-11-2-iv  |  Open Access |  How to cite  | 


Original Article

Emre Yekedüz, İzzet Doğan, Sümerya D Birgi, Metin Keskin, Şule Karaman, Güngör Utkan, Senem Karabulut, Sancar Bayar, Hakan Akbulut, Salim Demirci, Serap Akyürek, Yüksel Ürün

Adjuvant Treatment of Gastric Cancer in the D2 Dissection Era: A Real-life Experience from a Multicenter Retrospective Cohort Study

[Year:2021] [Month:July-December] [Volume:11] [Number:2] [Pages:8] [Pages No:51 - 58]

Keywords: Chemoradiation, Chemotherapy, Gastric cancer

   DOI: 10.5005/jp-journals-10018-1343  |  Open Access |  How to cite  | 


Background: The role of radiotherapy in the adjuvant treatment of gastric cancer (GC) remains to be elucidated. This study aimed to assess the additional benefit of radiotherapy in the adjuvant treatment of GC. Materials and methods: In this retrospective cohort study, we included 230 gastric adenocarcinoma patients who underwent D2 dissection between January 2004 and December 2019. Patients without R0 resection, who underwent metastasectomy at surgery, and treated with the neoadjuvant treatment were excluded. The co-primary endpoints were overall survival (OS) and disease-free survival (DFS). The secondary endpoints were the locoregional and distant metastasis risk and adverse events (AEs) leading to treatment discontinuation. Results: One hundred and sixty-six and 64 patients were included in the chemoradiotherapy (CRT) and chemotherapy (ChT) arms, respectively. The median OS was 135.8 months [interquartile range (IQR): 99.4–172.2] and 97 months (IQR: 59.7–134.3) in the CRT and the ChT arms, respectively. No statistical significance was observed between the arms in OS (p = 0.3). Locoregional or distant recurrence rates were similar in each group. AEs leading to treatment discontinuation were higher in the CRT arm than in the ChT arm (13.2 vs 9.3%), and the difference between the arms was not statistically significant (p = 0.4). Conclusion: In this real-life study, we established that there was no additional benefit of RT in GC patients who underwent D2 dissection.


Original Article

Yoel A Fleites, Jorge Aguiar, Zurina Cinza, Monica Bequet, Elieser Marrero, Maritania Vizcaíno, Idelsis Esquivel, Marisol Diaz, Adriana Sin-Mayor, Maura Garcia, Sara M Martinez, Abrahan Beato, Ana G Galarraga, Yssel Mendoza-Mari, Iris Valdés, Gerardo García, Gilda Lemos, Isabel Gonzalez, Camila Canaán-Haden, Nelvis Figueroa, Rachel Oquendo, Sheikh MF Akbar, Mohammad H Uddin, Gerardo E Guillén, Verena L Muzio, Eduardo Penton, Julio Cesar Aguilar

HeberNasvac, a Therapeutic Vaccine for Chronic Hepatitis B, Stimulates Local and Systemic Markers of Innate Immunity: Potential Use in SARS-CoV-2 Postexposure Prophylaxis

[Year:2021] [Month:July-December] [Volume:11] [Number:2] [Pages:12] [Pages No:59 - 70]

Keywords: Immunity, Innate, Postexposure, Prophylaxis, SARS-CoV-2, Therapy

   DOI: 10.5005/jp-journals-10018-1344  |  Open Access |  How to cite  | 


Introduction: More than 180 million people have been infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and more than 4 million coronavirus disease-2019 (COVID-19) patients have died in 1.5 years of the pandemic. A novel therapeutic vaccine (NASVAC) has shown to be safe and to have immunomodulating and antiviral properties against chronic hepatitis B (CHB). Materials and methods: A phase I/II, open-label controlled and randomized clinical trial of NASVAC as a postexposure prophylaxis treatment was designed with the primary aim of assessing the local and systemic immunomodulatory effect of NASVAC in a cohort of suspected and SARS-CoV-2 risk-contact patients. A total of 46 patients, of both sexes, 60 years or older, presenting with symptoms of COVID-19 were enrolled in the study. Patients received NASVAC (100 µg per Ag per dose) via intranasal at days 1, 7, and 14 and sublingual, daily for 14 days. Results and discussion: The present study detected an increased expression of toll-like receptors (TLR)-related genes in nasopharyngeal tonsils, a relevant property considering these are surrogate markers of SARS protection in the mice model of lethal infection. The HLA-class II increased their expression in peripheral blood mononuclear cell's (PBMC's) monocytes and lymphocytes, which is an attractive property taking into account the functional impairment of innate immune cells from the periphery of COVID-19-infected subjects. NASVAC was safe and well tolerated by the patients with acute respiratory infections and evidenced a preliminary reduction in the number of days with symptoms that needs to be confirmed in larger studies. Conclusions: Our data justify the use of NASVAC as preemptive therapy or pre-/postexposure prophylaxis of SARS-CoV-2 and acute respiratory infections in general. The use of NASVAC or their active principles has potential as immunomodulatory prophylactic therapies in other antiviral settings like dengue as well as in malignancies like hepatocellular carcinoma where these markers have shown relation to disease progression.


Original Article

Renuka Malipatel, Mallikarjun Patil, Pritilata Rout, Marjorie Correa, Harshad Devarbhavi

Primary Intestinal Lymphoma: Clinicopathological Characteristics of 55 Patients

[Year:2021] [Month:July-December] [Volume:11] [Number:2] [Pages:5] [Pages No:71 - 75]

Keywords: Diffuse large B-cell lymphoma (DLBCL), Intestine, Lymphoma, Non-Hodgkin's lymphoma (NHL), Primary

   DOI: 10.5005/jp-journals-10018-1345  |  Open Access |  How to cite  | 


Introduction: Gastrointestinal (GI) tract is the most common site of extranodal lymphoma accounting for 30–40% of the cases. In Western countries, stomach is the most common site of GI lymphoma, whereas in the Middle East and Mediterranean countries, small intestine is commonly involved. Studies about primary intestinal lymphoma (PIL) are heterogeneous in anatomical distribution, presentation, and histological subtypes. The present study was aimed at studying the anatomical distribution, histological subtypes, and clinical characteristics at tertiary care centers. Materials and methods: The present study was retrospective, conducted between 2006 and 2020. Patient's data were collected from institutional medical records. PIL was diagnosed by Lewin's criteria. After histological diagnosis, PIL was classified as per the World Health Organization (WHO) criteria and staging was done according to the Ann Arbor classification as modified by Musshoff. Results: A total of 941 lymphoma cases were diagnosed during the study period between 2006 and 2020 consisting of 238 Hodgkin's lymphoma and 703 non-Hodgkin's lymphoma (NHL) cases. PIL constituted 5.8% of all lymphoma cases (55 out of 941) and 50.9% (55 of 108) of all primary GI lymphoma. Median age at diagnosis was 44 years and comprised predominantly males (85.45%). Diffuse large B-cell lymphoma (DLBCL) and mucosa-associated lymphoid tissue (MALT) lymphoma were the most common histological subtype (78%) seen. Two patients with primary Hodgkin's lymphoma involving the intestine were seen. T-cell lymphoma was seen in three (5.4%) patients. Ileocecal region was the most common site involved (27%). The common presenting complaints were intestinal obstruction (40%) requiring surgical resection and abdominal pain (32%). Majority of the patients presented in the early stages (I and II). Conclusion: Our study demonstrates the pattern of distribution and various histological subtypes of PIL including the rare variants like primary intestinal Hodgkin's lymphoma. Relatively more number of patients presented with intestinal obstruction requiring surgery in comparison with other studies.


Original Article

Ranjan K Patel, Shruti Mittal, Taraprasad Tripathy

Abdominal Computed Tomography Findings among COVID-19 Patients with Index Gastrointestinal Manifestations: A Preliminary Single-center Experience

[Year:2021] [Month:July-December] [Volume:11] [Number:2] [Pages:5] [Pages No:76 - 80]

Keywords: Cholecystitis, COVID 19, Gastrointestinal, Mesenteric venous thrombosis

   DOI: 10.5005/jp-journals-10018-1346  |  Open Access |  How to cite  | 


Background: About 20% of COVID-19 patients can have digestive symptoms, apart from the typical chest-related symptoms, and 10% of patients may have only gastrointestinal (GI) symptoms during their entire disease course. Aim and objective: The purpose of this study was to describe the spectrum of abdominal computed tomographic (CT) findings in a cohort of 15 COVID-19 patients (confirmed on reverse transcription polymerase chain reaction (RT-PCR)) who presented with various GI presentations without preceding respiratory symptoms. Materials and methods: A total of 93 patients with COVID-19 (confirmed on RT-PCR) who underwent CT imaging (between September 28, 2020 and March 20, 2021) in our center were retrospectively searched from the existing database. Among those, 15 patients having index presentation with abdominal symptoms and underwent CT abdomen were further evaluated. Results: Biliary stasis in the form of distended gallbladder and wall thickening was the most common finding, seen in 66.7% (n = 10) patients, followed by bowel wall thickening. Small bowel and large bowel thickenings were seen in 26.7% (n = 4) and 20% (n = 3) patients, respectively. Other findings include fluid-filled colon (n = 1), mesenteric venous thrombosis (MVT) (n = 2), paper-thin bowel wall and pneumatosis (n = 1), acute pancreatitis (n = 1), and ascites (n = 2). One patient who presented with abdominal pain did not show any obvious imaging findings on CT. Conclusion: Patients with COVID-19 can present with initial GI symptoms preceding typical respiratory symptoms. CT imaging helps in identifying the GI involvement, to rule out alternate etiologies, and also aids in appropriate management planning.



Abdullah Tarık Aslan, Halis Şimşek

Clinical Features and Pathophysiological Mechanisms of COVID-19-associated Gastrointestinal Manifestations

[Year:2021] [Month:July-December] [Volume:11] [Number:2] [Pages:6] [Pages No:81 - 86]

Keywords: Angiotensin-converting enzyme 2, COVID-19, Gastrointestinal manifestations, Pathogenesis, SARS-CoV-2

   DOI: 10.5005/jp-journals-10018-1347  |  Open Access |  How to cite  | 


Aim and objective: According to the literature, gastrointestinal (GI) involvement may have a remarkable influence on the course of coronavirus disease-2019 (COVID-19). Our aim with this article is to appraise clinical characteristics and presumptive biological mechanisms of digestive tract involvement of COVID-19. Background: In this review article, the English language literature was reviewed by using PubMed and MEDLINE databases, up to February 2021. Review results: The patients with GI involvement are generally presented with diarrhea, nausea/vomiting, anorexia, abdominal pain, and rarely GI bleeding. However, frequencies of these manifestations are diverse in studies published so far, depending on the countries where the studies were conducted, characteristics of the study populations, and methodological differences. Several studies proved that this novel coronavirus gets into the enterocytes by attaching to angiotensin-converting enzyme 2 receptor. Some of them have shown a direct viral invasion and replication of the virus within enterocytes. Along with detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in patients’ fecal materials, all these results explicitly indicate that the virus has the capability to invade the GI system. These findings may represent a potential risk indicator for fecal–oral spread of the virus. Although pathophysiology of COVID-19 associated GI manifestations remains elusive, direct viral damage, dysfunction in renin–angiotensin–aldosterone system, effects of gut–lung axis, and GI tract microbiome dysbiosis have been proposed as culprit mechanisms of the GI symptoms and inflammatory response. Conclusion: The patients with COVID-19 can be presented with diverse clinical manifestations including the GI symptoms. Understanding the actual impact of the virus on the GI tract depends on uncovering the pathophysiology of COVID-19. Clinical significance: GI involvement of COVID-19 appears to be crucial not only for its clinical consequences but also for its impacts on public health and prevention.



Shah Naveed, Hasina Qari, Cao M Thau, Pipit Burasakarn, Abdul W Mir

Neoadjuvant Chemotherapy for Advanced Gallbladder Cancer: Do We have Enough Evidence? A Systematic Review

[Year:2021] [Month:July-December] [Volume:11] [Number:2] [Pages:8] [Pages No:87 - 94]

Keywords: Advanced gallbladder cancer, Downstaging, Neoadjuvant chemotherapy, Survival

   DOI: 10.5005/jp-journals-10018-1348  |  Open Access |  How to cite  | 


Background: Recently for advanced gallbladder carcinoma, neoadjuvant chemotherapy has emerged as an important strategy in place of adjuvant chemotherapy with the hope that it will help to improve the resectability and survival. Aim and objective: The goal was to conduct a systematic review of published publications on the benefits of neoadjuvant chemotherapy for advanced gallbladder cancer treatment. Materials and methods: This systematic review followed the Meta-analysis Of Observational Studies in Epidemiology standards. The clinical benefit rate of neoadjuvant chemotherapy, curative resectability rate, and R0 resection were the major outcomes of interest. The secondary outcomes of interest were overall and disease-free survival. Results: Six published papers were included (n = 420). One-hundred and twenty-eight cases (30.47%) despite receiving neoadjuvant chemotherapy had disease progression. Although 67.38% of patients (283 of 420) in this systematic review showed good response to the neoadjuvant chemotherapy, just 51.66% (217 of 420 cases) were operated, out of which only 171 cases were deemed to be feasible for surgical resection and had curative resection. Out of the cases that underwent curative surgery, 91.81% had R0 resection (157 out of 171 patients). The overall survival rate was found to be 18.5–50.1 months for patients in whom curative surgery was done and 5.0–10.8 months for nonsurgery patients. Conclusion: No sufficient data exist to advocate the regular use of neoadjuvant chemotherapy in advanced gallbladder carcinoma, as data showed that only 1/3 of patients benefited and had a R0 resection. Further research should be the randomized controlled trials to further quantify the benefit of neoadjuvant chemotherapy in advanced gallbladder carcinoma.



“Lever Technique”: A Novel Approach to Cope with Unstable Scope Position during Bottom-up Needle Knife Access (with Video)

[Year:2021] [Month:July-December] [Volume:11] [Number:2] [Pages:2] [Pages No:95 - 96]

Keywords: Biliary access, Biliary pancreatitis, Choledocholithiasis, Endoscopic ultrasound, Gall stone disease, Needle knife papillotomy, Scopic retrograde cholangiopancreatography

   DOI: 10.5005/jp-journals-10018-1349  |  Open Access |  How to cite  | 


Needle knife papillotomy has become an invaluable advanced biliary access technique in routine endoscopic retrograde cholangiopancreatography (ERCP). Albeit poorly standardized in terms of procedural details, usually superficial cuts are applied to open the bile duct in an onion-like manner. However, this implies the capability to direct cuts from some distance from the papilla controlling needle knife movements in a complex fashion involving elevator movements. Here, an as-yet unreported technique designated the “lever technique” is presented for difficult needle knife access, when encountering technical difficulties, such as unstable scope position and awkward bile duct angle to allow for controlled needle knife navigation. In such variant rescue approach involving well-characterized prepapillary stone impaction by preceding same-session endoscopic ultrasound (EUS), thus providing some safety plane, ultranear-view instrumentation is coupled with exclusive needle knife navigation by moving the large dial, thus moving scope and needle knife-like as one endoscopic device.



Soon Liang Lee, Jasminder Sidhu, Chiun Yann Ng

Metastatic Biliary Stricture with “Beaded” Appearance from Cervical Adenocarcinoma

[Year:2021] [Month:July-December] [Volume:11] [Number:2] [Pages:3] [Pages No:97 - 99]

Keywords: Biliary stricture, Cervical adenocarcinoma, Endoscopic retrograde cholangiopancreatography, Endoscopic ultrasound

   DOI: 10.5005/jp-journals-10018-1350  |  Open Access |  How to cite  | 


Cervical adenocarcinoma accounts for 25% of invasive cervical cancer which frequently metastasize distantly to the lungs, liver, bone, and brain. Metastases to the common bile duct from cervical cancer are exceedingly rare with few reported cases in the literature. Diagnosis of bile duct metastases from cervical cancer can be established with endoscopic ultrasound-guided fine-needle aspiration cytology, biliary cytobrushing, or direct cholangioscopy with biopsy, and this would guide further therapies such as endoscopic biliary drainage and systemic chemotherapy. We hereby present a rare case of obstructive jaundice from metastatic biliary stricture with “beaded” appearance in a patient with cervical adenocarcinoma.



Meranthi Fernando, Suresh Vijay, Saikat Santra, Mary A Preece, Rachel Brown, Astor Rodrigues, Girish L Gupte

Wilson's Disease and Hyperornithinemia-hyperammonemia-homocitrullinuria Syndrome in a Child: A Case Report with Lessons Learned!

[Year:2021] [Month:July-December] [Volume:11] [Number:2] [Pages:3] [Pages No:100 - 102]

Keywords: Child, HHH syndrome, Liver disease, Liver transplant, Wilson's disease

   DOI: 10.5005/jp-journals-10018-1351  |  Open Access |  How to cite  | 


Background: Wilson's disease (WD) is a rare disorder of copper toxicosis. Hyperornithinemia-hyperammonemia-homocitrullinuria (HHH) syndrome is even rarer. The coexistence of these two disorders and their clinical implications are not yet reported. We report on a child who succumbed to death due to liver disease caused by both disorders, documenting their disease-causing mutations and highlighting the lessons learnt out of this case. Case description: A child who was diagnosed to have WD soon after birth due to known parental heterozygosity was later found to have developmental delay, seizures, and hyperammonemia. Subsequent evaluation confirmed hyperornithinemia-hyperammonamia-homocitrullinuria (HHH) syndrome as a comorbidity. Though this child was commenced on medical treatment for both the metabolic diseases since early life, his liver disease was rapidly progressive requiring a liver transplant (LTx) at 6-years. He died in the posttransplant period possibly due to sepsis and hidden metabolic consequences. Conclusion: This case highlights that co-occurrence of WD and HHH syndrome would cause progressive liver disease despite medical treatment. Hence, the close clinical follow-up and early LTx would be warranted.



Gautam Vinay

Increased Self-medication with Steroids in Inflammatory Bowel Disease Patients during COVID-19 Pandemic: Time to Optimize Specialized Telemonitoring Services

[Year:2021] [Month:July-December] [Volume:11] [Number:2] [Pages:2] [Pages No:103 - 104]

Keywords: COVID-19, Inflammatory bowel diseases, Self-medication, Telemedicine

   DOI: 10.5005/jp-journals-10018-1342  |  Open Access |  How to cite  | 


Inflammatory bowel disease (IBD) is a serious condition characterized by a complex interaction of genetic, environmental, and inflammatory variables that affect the gut and other extragastrointestinal systems. Self-medication with steroids has become a major issue in light of the current pandemic situation in IBD patients. We observed a higher frequency of steroid self-medication (17.9%) and steroid overprescription (28.2%) by non-gastroenterologists during the pandemic. The use of telemonitoring tools can improve patient-IBD care provider communications in terms of drug compliance and better disease outcomes.


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“Lever Technique”: A Novel Approach to Cope with Unstable Scope Position during Bottom-up Needle Knife Access (with Video)

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