Mohamed El Nady

Background and Objectives: Currently, pancreatic cystic lesions (PCLs) are recognized with increasing frequency and have become a more common finding in clinical practice. EUS is challenging in the diagnosis of PCLs and evidence-based decisions are lacking in its application. This study aimed to develop strong recommendations for the use of EUS in the diagnosis of PCLs, based on the experience of experts in the field.

Methods: A survey regarding the practice of EUS in the evaluation of PCLs was drafted by the committee member of the International Society of EUS Task Force (ISEUS-TF). It was disseminated to experts of EUS who were also members of the ISEUS-TF. In some cases, percentage agreement with some statements was calculated; in others, the options with the greatest numbers of responses were summarized.

Results: Fifteen questions were extracted and disseminated among 60 experts for the survey. Fifty-three experts completed the survey within the specified time frame. The average volume of EUS cases at the experts' institutions is 988.5 cases per year.

Conclusion: Despite the limitations of EUS alone in the morphologic diagnosis of PCLs, the results of the survey indicate that EUS-guided fine-needle aspiration is widely expected to become a more valuable method.

Evaluating the role of endoscopic ultrasound (EUS) elastography and strain ratio in differentiation between malignant and benign pancreatic lesions.Three hundred twenty-five patients with solid pancreatic lesions were enrolled in this prospective study from 2014 to 2017. EUS real-time elastography scoring and strain ratio were done to all patients and compared to the final diagnosis to assess its sensitivity, specificity, positive and negative predictive values (PPV and NPV) in differentiating malignant from benign lesions.A cut-off value of 4.2 we had sensitivity of 95%, specificity of 63%, PPV of 89%, NPV of 81%, and accuracy of 87%. Another cut-off value of 10.9 showed a sensitivity of 75%, specificity of 88%, PPV of 95%, NPV of 54%, and accuracy of 79%. Adding the elastography to the better cut-off value gave a sensitivity of 97%, specificity of 63%, PPV of 89%, NPV of 88%, and accuracy of 89%.Real-time elastography and strain ration are valuable in differentiating malignant from pancreatic lesions.

Background and Objectives: EUS-guided biliary drainage (EUS-BD) was shown to be useful for malignant biliary obstruction (MBO). However, there is lack of consensus on how EUS-BD should be performed.

Methods: This was a worldwide multi-institutional survey among members of the International Society of EUS conducted in February 2018. The survey consisted of 10 questions related to the practice of EUS-BD.

Results: Forty-six endoscopists of them completed the survey. The majority of endoscopists felt that EUS-BD could replace percutaneous transhepatic biliary drainage after failure of ERCP. Among all EUS-BD methods, the rendezvous stenting technique should be the first choice. Self-expandable metal stents (SEMSs) were recommended by most endoscopists. For EUS-guided hepaticogastrostomy (HGS), superiority of partially-covered SEMS over fully-covered SEMS was not in agreement. 6-Fr cystotomes were recommended for fistula creation. During the HGS approach, longer SEMS (8 or 10 cm) was recommended. During the choledochoduodenostomy approach, 6-cm SEMS was recommended. During the intrahepatic (IH) approach, the IH segment 3 was recommended.

Conclusion: This is the first worldwide survey on the practice of EUS-BD for MBO. There were wide variations in practice, and randomized studies are urgently needed to establish the best approach for the management of this condition.

AIM: To evaluate the accuracy of the elastography score combined to the strain ratio in the diagnosis of solid pancreatic lesions (SPL).

METHODS: A total of 172 patients with SPL identified by endoscopic ultrasound were enrolled in the study to evaluate the efficacy of elastography and strain ratio in differentiating malignant from benign lesions. The semi quantitative score of elastography was represented by the strain ratio method. Two areas were selected, area (A) representing the region of interest and area (B) representing the normal area. Area (B) was then divided by area (A). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated by comparing diagnoses made by elastography, strain ratio and final diagnoses.

RESULTS: SPL were shown to be benign in 49 patients and malignant in 123 patients. Elastography alone had a sensitivity of 99%, a specificity of 63%, and an accuracy of 88%, a PPV of 87% and an NPV of 96%. The best cut-off level of strain ratio to obtain the maximal area under the curve was 7.8 with a sensitivity of 92%, specificity of 77%, PPV of 91%, NPV of 80% and an accuracy of 88%. Another estimated cut off strain ratio level of 3.8 had a higher sensitivity of 99% and NPV of 96%, but with less specificity, PPV and accuracy 53%, 84% and 86%, respectively. Adding both elastography to strain ratio resulted in a sensitivity of 98%, specificity of 77%, PPV of 91%, NPV of 95% and accuracy of 92% for the diagnosis of SPL.

CONCLUSION: Combining elastography to strain ratio increases the accuracy of the differentiation of benign from malignant SPL.

Intestinal helminth parasites are potent inducers of T helper type 2 (Th2) response and have a regulatory role, notably on intestinal inflammation. As infection with schistosomes is unlikely to provide a reliable treatment of inflammatory bowel diseases, we have investigated the beneficial effect of a schistosome enzymatic protein, the 28-kDa glutathione S-transferase (P28GST), on the modulation of disease activity and immune responses in experimental colitis. Our results showed that immunization with recombinant P28GST is at least as efficient as established schistosome infection to reduce colitis lesions and expression of pro-inflammatory cytokines. Considering underlying mechanisms, the decrease of inflammatory parameters was associated with the polarization of the immune system toward a Th2 profile, with local and systemic increases of interleukin (IL)-13 and IL-5. Dense eosinophil infiltration was observed in the colons of P28GST-immunized rats and mice. Depletion of eosinophils by treatment with an anti-Siglec-F monoclonal antibody and use of IL-5-deficient mice led to the loss of therapeutic effect, suggesting the crucial role for eosinophils in colitis prevention by P28GST. These findings reveal that immunization with P28GST, a unique recombinant schistosome enzyme, ameliorates intestinal inflammation through eosinophil-dependent modulation of harmful type 1 responses, representing a new immuno-regulatory strategy against inflammatory bowel diseases.

BACKGROUND: There are subgroups of patients with diabetes mellitus (DM) in whom diabetic retinopathy (DR) does not develop despite poor long-term control of their disease, while others exercising fairly good control, develop retinopathy. So, we aimed to investigate the association of DR with -2578 polymorphism of the vascular endothelial growth factor (VEGF) gene, which has been reported to be associated with increased VEGF production, in Egyptian diabetic patients.

MATERIALS AND METHODS: This is a case control study in which 148 diabetic patients were enrolled. Among them, 44 subjects had proliferative diabetic retinopathy (PDR), 30 had non-proliferative diabetic retinopathy (NPDR), and 74 individuals without retinopathy served as controls. A single nucleotide polymorphism (SNP) of the VEGF gene, a C→A transversion at -2578 (the C/A polymorphism), was investigated by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP).

RESULTS: We found a higher frequency of the polymorphic genotype in both the NPDR (66.7%) and PDR (72.7%) groups compared to the wild C/C genotype (33.3% in NPDR and 27.3% in PDR), but with no statistically significant difference from the control group. Significant association of the progression of DR to the polymorphic genotype was achieved at diabetes duration more than 20 years.

CONCLUSION: Despite of the higher frequency of both the polymorphic genotype and the A allele in cases with DR compared to the control group, there might be no significant association between the VEGF gene polymorphism and DR per se, unless it is longstanding.

AIM: To study the natural history, patterns and clinical characteristics of inflammatory bowel diseases (IBD) in Egypt.

METHODS: We designed a case-series study in the gastroenterology centre of the Internal Medicine department of Cairo University, which is a tertiary care referral centre in Egypt. We included all patients in whom the diagnosis of ulcerative colitis (UC) or Crohn's disease (CD) was confirmed by clinical, laboratory, endoscopic, histological and/or radiological criteria over the 15 year period from 1995 to 2009, and we studied their sociodemographic and clinical characteristics. Endoscopic examinations were performed by 2 senior experts. This hospital centre serves patients from Cairo, as well as patients referred from all other parts of Egypt. Our centre received 24156 patients over the described time period for gastro-intestinal consultations and/or interventions.

RESULTS: A total of 157 patients with established IBD were included in this study. Of these, 135 patients were diagnosed with UC (86% of the total), and 22 patients, with CD (14% of the total). The mean ages at diagnosis were 27.3 and 29.7, respectively. Strikingly, we noticed a marked increase in the frequency of both UC and CD diagnoses during the most recent 10 years of the 15 year period studied. Regarding the gender distribution, the male:female ratio was 1:1.15 for UC and 2.6:1 for CD. The mean duration of follow up for patients with UC was 6.2 ± 5.18 years, while the mean duration of follow up for patients with CD was 5.52 ± 2.83 years. For patients with UC we found no correlation between the severity of the disease and the presence of extraintestinal manifestations. Eleven patients had surgical interventions during the studied years: 4 cases of total colectomy and 7 cases of anal surgery.

CONCLUSION: We observed a ratio of 6:1 for UC to CD in our series. The incidence of IBD seems to be rising in Egypt.

The most reliable predictor of a sustained virological response in patients with persistently normal ALT has not been identified. We analysed 17 patients with genotype 1 chronic HCV who underwent therapy with pegylated interferon alfa 2b and ribavirin for 48 weeks. Two patients discontinued therapy within 28 days because of side effects and the remaining 15 patients were analysed in detail. An analysis of on treatment virological response using area under the receiver operating characteristic analyses showed that a 2 log drop in HCV RNA at day 28 was the best predictor of a sustained virological response and a failure to reduce viral load by 2 logs correctly identified patients with a low (<15%) probability of achieving a sustained virological response. Introduction of this early discontinuation rule in patients with normal ALT would allow nearly half of the patients to discontinue futile therapy at an early stage.

AIM OF THE WORK: We have researched and identified Herpes viruses on the esophageal biopsies taken during the period between September 2006 and March 2008 for 15 suspected patients.

PATIENTS AND METHODS: The esophageal biopsies were transferred to the laboratory being conserved in physiological serum and frozen at -80 degrees C for PCR. A fragment was conserved for histopathological analysis. The specimen was defrozen and refrozen in liquid azote (to limit the inhibitors) and crushed to the powder form. Extraction was then done following the prerecognised protocol (Herpès Consensus Générique-"Argene"). That kit allows the amplification consensus of the viral genome of the most frequently encountered Herpes family virus: HSV1, HSV2, CMV, VZV, EBV and HHV6. The identification of the implicated virus was done by the Hybridowell Herpes Identification (Argene) kit in parallel with the migration of SDS gel of the obtained amplifications.

RESULTS: HSV1 was identified in seven esophageal biopsies between the 15 studied. HHV6 and the association HHV6/EBV for two patients and only one biopsy had inconclusive. The endoscopy and the histopathological examination had confirmed ulcerated esophagitis with cytopathogene aspect in favour of viral infection for six patients.

CONCLUSION: In absence of inhibitors, the adaptation of the extraction technique of the fragments of tissue for few millimetres and the amplifications by PCR had allowed rapid confirmation of the diagnosis of herpetic esophagitis secondary to HSV1 even before the results of the histopathological examination. Treatment by acyclovir entrained regression of the disease.