This study shows that ultrasound elasticity imaging predicts therapeutic outcomes for CD patients treated with anti-TNF.

Bleeding in COVID-19 severe pneumonia: The other side of abnormal coagulation pattern?To the Editor A novel coronavirus (SARS CoV-2) spread in China in December 2019, becoming soon a relevant problem of international public health concern [1]. In Italy the SARS-CoV-2 officially spread around the 20th of February 2020 and the country became the first in Europe to register a high number of infections and deaths. The beta-coronavirus mainly creates a severe acute respiratory syndrome (COVID-19), with fever, cough, fatigue, pneumonia and acute respiratory distress syndrome, eventually. The patient management mainly focuses on supportive care: oxygenation, fluid management, and treatments with multiple drugs as antiviral therapies, chloroquine or hydroxyichloroquine, antibiotics, steroids, nonsteroidal anti-inflammatory drugs, bronchodilators and immunosuppressive drugs. Many patients require invasive ventilation, whereas others are treated with non-invasive ventilation (NIV) support or C-PAP (Continuous Positive Airway Pressure). In the available studies, COVID-19 patients showed alterations of coagulation test, with significant increase of D-Dimer levels associated with severity of illness and adverse outcomes [2]. Besides, a high risk for venous thromboembolism has been recently highlighted with high prevalence of symptomatic acute pulmonary embolism and deep vein thrombosis in patients [3]. Therefore, currently low molecular weight heparin (LMWH) has become part of the clinical management of the hospitalized COVID-19 patients, even if evidences about the right prophylactic dose are still lacking. In this scenario, we describe two cases of spontaneous abdominal internal bleeding in hospitalized patients with bilateral interstitial pneumonia and SARS-CoV-2 throat swab positive, supported with C-PAP ventilation, as the invasive ventilation was not recommended for both.The first patient, a 76-year-old man, was supported with C-PAP helmet, with PEEP 12.5 and FiO2 50%. The comorbidity were arterial hypertension and chronic ischemic heart disease. He was treated with antiviral drugs, azythromicine, steroids and LMWH 6000 UI daily. Suddenly, after 7 days from the admission to the hospital, he started complaining of severe abdominal pain, the blood pressure decreased to 80/60 mmHg and the blood test showed Hb 8.6 g/dl (from 12 g/dl), fibrinogen of 324 mg/dl; normal protrombine time (PT) and platelet count (PTL). The abdominal CT scan demonstrated a large pelvic blood collection anterior to the left ileo-psoas muscle (size. 9×13 cm) (Fig. 1A). The lesion showed enhanced contrast tardive spot of 10 mm, above the ischiopubic branch, as sign of active arterial bleeding. The second case refers to a 72-year-old woman with severe respiratory insufficiency, treated with C-PAP helmet, PEEP 12 cm H2O, FiO2 60%. The comorbidities were arterial hypertension and anxious syndrome. During a sonography performed to place a CVC, a venous femoral thrombosis was detected; LMWH at therapeutic dose 100UI/kg/BID was promptly started. Suddenly, ...

Liver transient elastography (L-TE) is a reliable, noninvasive predictor of disease severity in chronic liver disease of viral aetiology (CLD). Owing to the relationships among severity of CLD, portal hypertension and spleen involvement, the assessment of splenic stiffness (S-TE) may have an added value in staging CLD. Of 132 CLD patients of viral aetiology, 48 with myeloproliferative disorders (MD) and 64 healthy volunteers (HV), were concurrently investigated by both L-TE and S-TE. Liver disease severity was staged by liver biopsy (LB; Metavir) taken concurrently with TE examination and upper gastrointestinal tract endoscopy for gastro-oesophageal varices. The S-TE inter-observer agreement was analysed by an intra-class correlation coefficient (ICC); L-TE and S-TE accuracy was evaluated by receiver operating characteristic (ROC) curve analysis. Logistic regression analysis assessed the independent effect of L-TE and S-TE as predictors of hepatic fibrosis stage. S-TE failed in 22 CLD (16.6%), 12 (25%) MD and 12 (18%) HV. In the three groups, the ICC was 0.89 (0.84-0.92), 0.90 (0.85-0.94) and 0.86(0.80-0.91), respectively. In the CLD group, L-TE and S-TE independently predicted significant fibrosis (OR 5.2 and 4.6) and cirrhosis (OR 7.8 and 9.1), but at variance from L-TE, S-TE was independent from liver necroinflammation and steatosis. The NPV of S-TE for gastro-oesophageal varices was 100% using a 48 kPa cut-off. In CLD, spleen stiffness alone or in combination with hepatic stiffness can be reliably and reproducibly assessed by TE with the added value of improving the noninvasive diagnosis of severe liver disease and excluding the presence of oesophageal varices.

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This article has an accompanying continuing medical education activity, also eligible for MOC credit, on page e122. Learning Objective-Upon completion of this activity, successful learners will be able to list the most common upper endoscopic findings in patients infected with 2019 novel coronavirus (SARS-Cov-2), list the most common lower endoscopic findings in patients infected with SARS-Cov-2; list appropriate PPE for health care providers performing endoscopic evaluation in patients positive or at high risk of SARS-Cov-2; and realize prioritization of endoscopic evaluation of GI bleeding in high-risk patients should be determined by clinical factors and not SARS-Cov-2 status. C oronavirus disease 2019 (COVID-19) is a major worldwide threat caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), rapidly spreading to a global pandemic. As of May 11, 2020, 4,176,346 cases have been reported worldwide, 219,814 in Italy, and of them, 81,871 occurred in the Lombardy region. 1 Although the respiratory manifestations of COVID-19 have been widely described, the impact on the gastrointestinal (GI) system remains less clear. The reported prevalence of digestive symptoms ranges from 3% to 79%, depending on the setting, 2-5 but data on GI endoscopic and histologic findings in COVID-19 patients are lacking. Therefore, the aim of this study is to describe the GI endoscopic and histologic findings in COVID-19 patients.

Gastrointestinal leaks and fistulae are serious, potentially life threatening conditions that may occur with a wide variety of clinical presentations. Leaks are mostly related to post-operative anastomotic defects and are responsible for an important share of surgical morbidity and mortality. Chronic leaks and long standing post-operative collections may evolve in a fistula between two epithelialized structures. Endoscopy has earned a pivotal role in the management of gastrointestinal defects both as first line and as rescue treatment. Endotherapy is a minimally invasive, effective approach with lower morbidity and mortality compared to revisional surgery. Clips and luminal stents are the pioneer of gastrointestinal (GI) defect endotherapy, whereas innovative endoscopic closure devices and techniques, such as endoscopic internal drainage, suturing system and vacuum therapy, has broadened the indications of endoscopy for the management of GI wall defect. Although several endoscopic options are currently used, a standardized evidence-based algorithm for management of GI defect is not available. Successful management of gastrointestinal leaks and fistulae requires a tailored and multidisciplinary approach based on clinical presentation, defect features (size, location and onset time), local expertise and the availability of devices. In this review, we analyze different endoscopic approaches, which we selected on the basis of the available literature and our own experience. Then, we evaluate the overall efficacy and procedural-specific strengths and weaknesses of each approach.

The goal of this review is to provide a comprehensive picture of the role, clinical applications and future perspectives of the most widely used non-invasive techniques for the evaluation of hepatitis B virus (HBV) infection. During the past decade many non-invasive methods have been developed to reduce the need for liver biopsy in staging fibrosis and to overcome whenever possible its limitations, mainly: invasiveness, costs, low reproducibility, poor acceptance by patients. Elastographic techniques conceived to assess liver stiffness, in particular transient elastography, and the most commonly used biological markers will be assessed against their respective role and limitations in staging hepatic fibrosis. Recent evidence highlights that both liver stiffness and some bio-chemical markers correlate with survival and major clinical end-points such as liver decompensation, development of hepatocellular carcinoma and portal hypertension. Thus the non-invasive techniques here discussed can play a major role in the management of patients with chronic HBV-related hepatitis. Given their prognostic value, transient elastography and some bio-chemical markers can be used to better categorize patients with advanced fibrosis and cirrhosis and assign them to different classes of risk for clinically relevant outcomes. Very recent data indicates that the combined measurements of liver and spleen stiffness enable the reliable prediction of portal hypertension and esophageal varices development.

Elastographic techniques are new ultrasound-based imaging techniques developed to estimate tissue deformability/stiffness. Several ultrasound elastographic approaches have been developed, such as static elastography, transient elastography and acoustic radiation force imaging methods, which include point shear wave and shear wave imaging elastography. The application of these methods in clinical practice aims at estimating the mechanical tissues properties. One of the main settings for the application of these tools has been liver stiffness assessment in chronic liver disease, which has been studied mainly using transient elastography. Another field of application for these techniques is the assessment of focal lesions, detected by ultrasound in organs such as pancreas, prostate, breast, thyroid, lymph nodes. Considering the frequency and importance of the detection of focal liver lesions through routine ultrasound, some studies have also aimed to assess the role that elestography can play in studying the stiffness of different types of liver lesions, in order to predict their nature and thus offer valuable non-invasive methods for the diagnosis of liver masses.