Search Results (49)

Background/Objectives: Celiac disease (CD) is an immune-mediated enteropathy with gastrointestinal and extraintestinal manifestations. In primary care, recognition can be delayed when psychiatric symptoms, arthralgia, thyroid dysfunction, alcohol exposure, and liver-test abnormalities coexist. This case report describes a confounder-aware diagnostic approach to histologically confirmed CD in a patient with a multifactorial primary-care presentation. Methods: We report a single-patient, de-identified reflective case from routine family medicine practice, organized according to CARE case-report principles. Results: A woman in her early sixties with hypothyroidism and glaucoma presented with new low mood, anhedonia, somnolence, generalized anxiety, increased alcohol intake, poor appetite, weight loss, abdominal bloating, diarrhea, flatulence, and polyarthralgia. Initial investigations, including celiac serology obtained before gluten-free diet advice, showed mild anemia, marked hyperferritinemia, severe cholestatic and hepatocellular liver-test abnormalities, uncontrolled hypothyroidism, and strongly positive tissue transglutaminase IgA (>250 kIU/L; reference 0.0–14.9). Radiographs showed mild osteoarthritis and osteopenia without erosive arthropathy. Computed tomography excluded malignancy but showed severe diffuse hepatic steatosis and mild pancreatic atrophy. Mirtazapine was started at the index visit; after the initial laboratory results, gluten-free diet advice, alcohol-reduction counseling, and levothyroxine adjustment were undertaken. During the diagnostic episode, small-bowel biopsy demonstrated moderate-to-severe crypt hyperplastic villous atrophy with increased intraepithelial lymphocytes, and gastric biopsies showed no significant pathology; the histology was consistent with CD. Symptoms improved substantially. Longer-term objective follow-up showed persistent but improved celiac serology (tTG-IgA 49.4 kIU/L), normalization of thyroid-stimulating hormone, partial improvement in gamma-glutamyl transferase, which remained elevated, and a later iron-deficiency pattern with persistent anemia. Conclusions: This case supports targeted CD testing when anxiety or depressive symptoms occur alongside gastrointestinal symptoms, weight loss, arthralgia, hypothyroidism or documented thyroid autoimmunity, anemia, osteopenia, or liver-test abnormalities. Histology and repeat serology confirmed the diagnosis, but the psychiatric and hepatic manifestations still require cautious interpretation because hypothyroidism, alcohol exposure, steatotic liver disease, and simultaneous treatments also shaped the clinical course. Full article

Multiple rare vascular variations were identified in a 97-year-old female donor during the dissection of the gastrointestinal system. An anomalous middle colic artery originated from the celiac trunk alongside the three normal branches. The left hepatic artery, an accessory left hepatic artery, and the right hepatic artery all originated from the proper hepatic artery. The right hepatic artery exhibited a “caterpillar hump” and an abnormal tripod distal branching pattern, consisting of a very short cystic artery and two short right hepatic arteries (one superior and one inferior). Additionally, an accessory cystic artery arose from the inferior pancreaticoduodenal artery, ascending inferiorly to the common bile duct and cystic duct towards the gallbladder to join the cystic artery posteriorly. The right and middle colic arteries originated from a right colic middle colic common arterial trunk. The left colic artery and the sigmoidal arteries also originated from a left colic-sigmoidal common arterial trunk. Surgical and medical procedures in the pancreaticobiliary region are widespread, and cholecystectomy is one of the most common surgeries performed worldwide. A laparoscopic approach is the current ‘gold standard’ surgical approach. Knowledge of these potential gastrointestinal vascular variations is essential to ensure patient safety and avoid iatrogenic complications. The presence of an unidentified caterpillar-type right hepatic artery poses a significant risk of accidental ligation during cholecystectomy. Similarly, the presence of common colic arterial trunks alters the vascular landscape for laparoscopic colectomy. To ensure favorable surgical outcomes, comprehensive preoperative vascular imaging should be performed to identify such rare configurations. In this article, we discussed the frequency, embryology, physiology, and clinical and surgical implications of the anatomical variations present in this donor. To date, there have been no other reports in the literature describing this specific combination of variations. Full article

The superior mesenteric artery (SMA) is the second unpaired ventral branch of the abdominal aorta. The SMA supplies the abdominal organs that develop from the midgut. This study investigated the morphological characteristics of the SMA by (i) measuring its diameter in different sexes; (ii) assessing the vertical distance between the SMA and inferior mesenteric artery (IMA) origins in males and females, and (iii) observing if the hepatic artery arose from the SMA instead of the celiac trunk. This retrospective cross-sectional study included the contrast-enhanced CT angiograms of 260 patients (n = 205 males and 55 females) who attended the Radiology department at Sultan Qaboos University Hospital from 1 January 2021 to 31 December 2023. All included patients were aged 19–50 years and had no history of vascular pathology that altered the vascular dimensions, nor had any history of major abdominal trauma or abdominal surgeries. The mean diameter of the SMA in the study population was 7.51 ± 1.11 mm. The mean diameter of the SMA was found to be wider in males (7.73 ± 1.05 mm) compared to females (6.71 ± 0.96 mm, p < 0.001). The mean distance between the SMA and IMA was 62.67 ± 10.91 mm. The average distance between SMA and IMA in males and females was found to be 63.36 ± 10.67 mm and 60.09 ± 11.48 mm (p = 0.048), respectively. Incidence of the right hepatic artery originating from SMA, accessory right hepatic artery, and common hepatic artery originating from SMA was 7.7%, 0.38%, and 2.3%, respectively. Prior anatomical knowledge of arteries is important for occlusion, bypass grafting, and endovascular surgeries involving SMA. Full article

Autoimmune hepatitis (AIH) has long been regarded as an organ-specific disorder. However, increasing evidence supports its systemic nature, with extrahepatic manifestations representing key aspects of clinical management. These manifestations can affect musculoskeletal, gastrointestinal, haematologic, and other systems. They also reflect the complex interplay between systemic inflammation, concomitant autoimmune diseases, and drug-related toxicity. A careful evaluation is therefore essential to distinguish between these scenarios, especially for symptoms like fatigue and cytopenias. This narrative review provides a comprehensive, symptom-based overview of extrahepatic clinical and laboratory findings in AIH. By integrating current evidence with practical diagnostic considerations, it aims to offer clinicians a patient-centred and clinically relevant framework for navigating the multifaceted systemic landscape of AIH. Full article

Background: This study aims to evaluate the prevalence, spectrum, and coexistence of anatomical variations in the major branches of the abdominal aorta using Multidetector Computed Tomography (MDCT) angiography, with a specific emphasis on analyzing sex-related differences in a large-scale cohort. Methods: A retrospective analysis was conducted on 1174 patients (63.8% male, 36.2% female; mean age 60.54) who underwent abdominal CT angiography between January 2023 and June 2024. Images were acquired using a 128-slice MDCT scanner and reconstructed for detailed vascular assessment. Statistical comparisons between genders were performed using Chi-square and Fisher–Freeman–Halton tests, with p < 0.05 considered significant. Results: The celiac trunk (93.3%), superior mesenteric artery (SMA) (97.1%), and inferior mesenteric artery (IMA) (98.5%) predominantly showed classical patterns. However, significant sex-related differences were identified. Females exhibited significantly higher rates of classical patterns for the celiac trunk (96.2% vs. 91.7%), IMA (99.1% vs. 98.1%), right hepatic artery (RHA) (91.5% vs. 82.6%), and left hepatic artery (LHA) (95.8% vs. 85.4%). Conversely, males showed a higher prevalence of complex variations, including replaced/accessory hepatic arteries and the absence of the common hepatic artery. The number of right and left renal arteries was similar between sexes and did not show a significant difference, while horseshoe kidney was detected only in males. Conclusions: Abdominal vascular structures adhere to classical anatomy more frequently in females, while males exhibit greater morphological variability. These findings emphasize the necessity of gender-specific preoperative vascular mapping to optimize surgical outcomes and reduce morbidity. Full article

Vascular resection and reconstruction during pancreatoduodenectomy (PD) have evolved from rare and controversial procedures into essential components of surgical management for selected patients with locally advanced pancreatic ductal adenocarcinoma (PDAC). Venous resection is now widely accepted and routinely performed in high-volume centers, whereas arterial resection and artery-sparing divestment remain selectively applied because of their technical demands and concerns regarding perioperative risk and oncologic benefit. Accumulating contemporary evidence indicates that venous resection can be performed with acceptable safety, with 30-day mortality rates generally ranging from 3% to 5% and median overall survival of approximately 18–26 months when margin-negative (R0) resection is achieved. Arterial resections, most commonly involving the common hepatic, celiac, or superior mesenteric arteries, have been increasingly utilized in highly selected patients, particularly following neoadjuvant therapy, achieving R0 resection rates of approximately 65–75% and median overall survival of 20–28 months. Arterial divestment has emerged as a promising artery-sparing strategy, offering comparable oncologic outcomes with reduced surgical morbidity in appropriately selected cases. Collectively, these advances have expanded the boundaries of resectability in PDAC, enabling surgical intervention in patients previously deemed inoperable. Venous resection is now considered an oncologically sound extension of standard PD, whereas arterial resection and divestment should remain restricted to carefully selected patients demonstrating favorable biologic behavior and response to neoadjuvant therapy. Future progress in this field will likely depend on improved biologic stratification, enhanced intraoperative perfusion assessment, and the integration of hybrid open and endovascular techniques. Full article

Background: Celiac disease (CD) is a chronic immune-mediated enteropathy that is treated exclusively with a lifelong gluten-free diet (GFD). Hepatic involvement, including hepatic steatosis (HS), is common in both newly diagnosed and long-term GFD-treated CD patients. Limited data exist regarding HS prevalence and risk factors in CD, and the effects of dietary patterns, including GFD and the Mediterranean diet (MD), remain unclear. Objective: This study investigated the prevalence and severity of HS in newly diagnosed, pre-GFD and GFD-treated CD patients compared to non-celiac control subjects, while assessing the influence of dietary adherence. Methods: In a nested cross-sectional study within the ARCTIC trial (NCT05530070), 290 Hungarian adults were enrolled (60 pre-GFD CD, 156 CD on GFD, and 74 control subjects). HS was assessed by ultrasonography, and dietary adherence was evaluated using the Standardized Dietitian Evaluation and Mediterranean Diet Score (MDS). Binary regression models were applied to identify predictors of HS. Results: HS was diagnosed in 34% of participants, most frequently in pre-GFD CD patients. BMI was the strongest predictor of HS both overall and within the CD cohort (OR = 1.27; 95% CI: 1.16, 1.42; p < 0.001). Neither adherence to GFD nor overall MD adherence significantly influenced the prevalence of HS. Severity of HS correlated with higher BMI, older age, and diabetes prevalence, while individual MD components, including olive oil consumption, were associated with milder HS. Conclusions: HS is more prevalent in CD patients, particularly pre-GFD patients, and is strongly associated with BMI. While overall dietary patterns did not significantly impact HS, certain diet components may modulate severity. Full article

The myeloproliferative neoplasms (MPN), a heterogeneous group of disorders characterized by specific genetic mutations, have the development of arterial and venous thrombosis as their main complication. Almost 40–50% of MPN patients encountered arterial or venous thrombosis during the course of their disease. Moreover, arterial thrombosis is linked to significant mortality, progression to myelofibrosis, and an increased risk of developing second cancers. Despite significant advancements in medical research, there are still unmet needs in this field. Our narrative review provides clinical and genetic insights into thrombosis associated with myeloproliferative neoplasms. We focus on the underlying pathophysiological processes, assessment methods, and risk stratification related to thrombotic events. This information aims to assist clinicians in accurately assessing the risks associated with MPN thrombosis, enabling a more personalized and effective approach to patient care. We based our review on a rare case of MPN-associated thrombosis, whose clinical presentation was marked by acute ischemia in both lower limbs. The thrombosis affected the distal aortic arch, thoracic and abdominal aorta, celiac trunk, common and proper hepatic arteries, proximal left renal artery, several segmental arteries in the right kidney, and the portal vein thrombosis. Our review presents various therapeutic options for these conditions. In the presented case, the multiple thrombi were treated medically, except for the popliteal artery thromboses, which required surgical management. This case may serve as a valuable reference for choosing treatment options for aortic and portal vein thrombosis, highlighting the multidisciplinary approach. Full article

Background/Objectives: Wheat gluten intolerance increases intestinal permeability, triggering inflammation that may directly affect liver function and compromise metabolic health. Methods: Male Wistar rats (n = 50) aged 21 days were divided into five groups (n = 10) based on dietary gluten levels over 100 days: G0 (0%), G14 (14%), G42 (42%), G70 (70%), and G70/0 (70% for the first 70 days, then 0% until euthanasia). At 121 days, the animals were weighed and euthanized, and blood samples were collected for biochemical analyses. Adipose tissue deposits and the liver were excised and weighed. Liver lobes were isolated and fixed for morphological and morphometric analysis of hepatocytes, tissue glycogen percentage, and intracellular lipid assessment. Results: The hepatic oxidative status was evaluated. The ingestion of diets with excess gluten (70%) increased final body mass and reduced liver mass, though it did not alter the adiposity index. Cholesterol, triglycerides, and myeloperoxidase enzyme activity exhibited distinct patterns across all groups. Conclusions: Elevated gluten levels increased oxidative stress and altered tissue hepatic morphology and morphometry. Full article

Objectives: To develop and internally validate a pre-treatment score for the safe selection of the best candidates for the transradial approach when performing liver cancer intra-arterial procedures. Methods: One hundred and twenty-two patients undergoing hepatic endovascular treatments via radial access between January and December 2022 were retrospectively selected to develop a prediction model. Pre-procedural imaging data were analyzed, and variables were selected to develop the RAD-access score. Intra-procedural data were analyzed to assess effective procedural complexity (ePC). The relationship between ePC and pre-procedural variables was statistically tested, and cutoff points were defined. Results: A final score (RAD-access) was created and prospectively validated on 139 patients enrolled between June and September 2023. Aortic arch diameter and angulation, left subclavian artery angulation, suprarenal abdominal aorta diameter, celiac trunk take-off angle, and radial artery diameter were the significant variables used to build the score. In the validation cohort, based on the pre-treatment RAD-access score, 69 patients underwent a transradial approach, with a significantly lower ePC rate obtained (78.2% easy, 20.3% intermediate, 1.5% complex). No major adverse events occurred. Conclusions: Pre-treatment RAD-access score provides a good prediction for the procedural complexity of the transradial approach in patients undergoing liver cancer intra-arterial treatments, identifying the best candidates for an easy and safe transradial procedure. Full article

Pediatric gastroenterology is entering a pivotal phase marked by significant challenges and emerging opportunities in treating conditions like celiac disease (CeD), eosinophilic esophagitis (EoE), inflammatory bowel disease (IBD), and autoimmune hepatitis (AIH) pose significant clinical hurdles, but new therapeutic avenues are emerging. Advances in precision medicine, particularly proteomics, are reshaping care by tailoring treatments to individual patient characteristics. For CeD, therapies like gluten-degrading enzymes (latiglutenase, Kuma030) and zonulin inhibitors (larazotide acetate) show promise, though clinical outcomes are inconsistent. Immunotherapy and microbiota modulation, including probiotics and fecal microbiota transplantation (FMT), are also under exploration, with potential benefits in symptom management. Transglutaminase 2 inhibitors like ZED-1227 could help prevent gluten-induced damage. Monoclonal antibodies targeting immune pathways, such as AMG 714 and larazotide acetate, require further validation in pediatric populations. In EoE, biologics like dupilumab, cendakimab, dectrekumab (IL-13 inhibitors), and mepolizumab, reslizumab, and benralizumab (IL-5/IL-5R inhibitors) show varying efficacy, while thymic stromal lymphopoietin (TSLP) inhibitors like tezepelumab are also being investigated. These therapies require more pediatric-specific research to optimize their use. For IBD, biologics like vedolizumab, ustekinumab, and risankizumab, as well as small molecules like tofacitinib, etrasimod, and upadacitinib, are emerging treatments. New medications for individuals with refractory or steroid-dependent AIH have been explored. Personalized therapy, integrating precision medicine, therapeutic drug monitoring, and lifestyle changes, is increasingly guiding pediatric IBD management. This narrative review explores recent breakthroughs in treating CeD, EoE, IBD, and AIH, with a focus on pediatric studies when available, and discusses the growing role of proteomics in advancing personalized gastroenterological care. Full article

Introduction: Curative treatment of HCC can be achieved by liver transplantation. In the framework of transplantation, add-on transarterial chemoembolization (TACE) can be performed as bridging therapy for local tumor control. The association between TACE and an increased incidence of hepatic arterial complications after transplantation has been investigated in multiple research items; however, the exact association remains unclear. The aim of this report was to explore the role of pre-transplantation TACE and pre-existing vascular celiac pathologies on the occurrence of postoperative hepatic arterial complications. Methods: This retrospective single-center study included all patients who underwent liver transplantation between 2008 and 2020. Arterial complication was defined as any postoperative occlusion, stenosis >50%, dissection or aneurysm on cross-sectional imaging. Results: This study encompasses 109 patients after transplantation, of which 80 underwent TACE prior to transplantation. The overall incidence of postoperative arterial complications did not differ between the groups (TACE 8/80 vs. control 6/29, p = 0.19). Further analysis showed no significant differences in the occurrence of specific complications (Occlusion: TACE 9/80 vs. control 3/29, p = 0.56; Stenosis: TACE 4/80 vs. control 5/29, p = 0.05; Dissection: TACE 1/80 vs. control 1/29; p = 0.46). Furthermore, linear regression analysis for preoperative TACE therapy, anatomic variants and pre-existing pathologies of the hepatic vasculature showed no association with postoperative arterial complications. Conclusions: Preoperative TACE therapy showed no influence on the incidence of post-transplant arterial complications in patients after liver transplantation. Furthermore, preoperative TACE therapy as well as anatomic variants and pre-existing arterial pathologies of the celiac axis could not be identified as risk factors for complications at the arterial anastomotic site after transplantation. Full article

Background/Objectives: An increasing number of studies have reported liver involvement in both children and adults with celiac disease (CD). This often manifests as isolated hypertransaminasemia or hepatic steatosis (HS). The aim of this study was to define the prevalence of hypertransaminasemia and HS in a pediatric population with CD before starting a gluten-free diet (GFD) and to analyze how the introduction of a GFD could modify this condition. We also conducted a state-of-the-art literature review of the association between hypertransaminasemia, metabolic dysfunction-associated steatotic liver disease (MASLD) and CD. Methods: We retrospectively reviewed the clinical charts of pediatric CD patients diagnosed in three different pediatric units of Sicily, analyzing clinical, laboratory, ultrasound, and histology data before and 12 months after the introduction of a GFD. Results: A total of 160 patients (65.0% females, median age 6.4 (0.8–13.2) years) were included; hypertransaminasemia and HS prevalences at diagnosis were 8.1% and 6.1%, respectively. Subjects with hypertransaminasemia were younger (p = 0.01) than those without and had higher frequencies of HS (p = 0.034) and anti-tissue transglutaminase (tTg) immunoglobulin (Ig)G positivity (p = 0.046). Subjects with HS were younger (p = 0.0001) and had a higher frequency of hypertransaminasemia (p = 0.029) compared to non-steatotic ones. After 12 months of a GFD, hypertransaminasemia and HS persisted in 53.8% and 50.0% of patients, respectively. Conclusions: The prevalences of hypertransaminasemia and HS in Sicilian pediatric CD patients seem to be lower than those reported in other geographical areas. A GFD can reverse the trend of liver involvement, although periods of longer than 12 months may be necessary. However, a GFD has been associated with an increased prevalence of HS, and so regular follow-up involving a nutritionist should be recommended to guide physicians in patient management. Full article

Celiac disease (CD) is an autoimmune disorder caused by gluten intake in genetically predisposed individuals. This article provides an overview of the available data on the risks of infectious diseases and the mechanisms involved in CD, including a detailed analysis of vaccine efficacy, immunogenicity, and safety. The published articles were retrieved from the PubMed database using the terms “celiac disease”, “efficacy”, “hyposplenism”, “immune response”, “infections”, “immunization”, “immunogenicity”, “safety”, “vaccination”, and “vaccine”. CD can be associated with several autoimmune diseases, including selective immunoglobulin A deficiency (SIgAD), altered mucosal permeability, and hyposplenism. These conditions entail an increased risk of infections, which can be prevented by targeted vaccinations, although specific recommendations on immunization practices for subjects with CD have not been released. Regarding vaccinations, the immune response to the Hepatitis B virus (HBV) vaccine can be impaired in patients with CD; therefore, proposed strategies to elicit and maintain protective specific antibody titers are summarized. For patients with conditions that put them at risk of infections, vaccinations against Pneumococcus and other encapsulated bacteria should be recommended. Based on the available evidence, the Rotavirus vaccine offered to children could be useful in preventing CD in at-risk subjects. Overall, except for the HBV vaccine, vaccine efficacy in patients with CD is comparable to that in the general population, and no safety concerns have arisen. Full article

Celiac disease (CeD) is an enteropathy caused by the complex interaction between genetic, environmental, and individual immunological factors. Besides the hallmark of intestinal mucosal damage, CeD is a systemic disorder extending beyond the gastrointestinal tract and impacting various other organs, causing extraintestinal and atypical symptoms. The association between CeD and liver damage has been classified into three main categories: mild and asymptomatic liver injury, autoimmune liver injury, and liver failure. We present a case of severe liver damage with cirrhotic evolution in an obese 12-year-old boy who had been admitted due to generalized jaundice and localized abdominal pain in the right hypochondrium. In the course of investigating the etiology of severe liver disease, toxic, infectious, metabolic, obstructive, and genetic causes were excluded. Despite the patient’s obesity, a diagnosis of CeD was established, and in accordance with autoimmune hepatitis (AIH) criteria, the patient was diagnosed with autoantibody-negative AIH associated to CeD. Full article