Introduction

Capsule endoscopy (VCE) is generally safe, however a subset of patients require confirmation of bowel patency before undergoing the procedure, using a self-dissolvable patency capsule of similar calibre to the video capsule, with interval imaging to confirm excretion. Patency capsule absence on imaging confirms bowel patency. Prucalopride, a 5-HT4 agonist that enhances bowel motility, has been used in VCE to improve completion rates¹, but its use in the context of patency testing remains unknown. Similarly, the role of fasting in improving pass rate is unclear.

Aims & Methods

This study aims to determine whether Prucalopride and fasting enhance the pass rate of patency tests. Data from procedures performed in 3 centers in the Republic of Ireland was reviewed retrospectively. We compared the pass rate in the context of Prucalopride (Group A), fasting (B), and non-fasting (C) states. All patients had an abdominal x-ray between 24-30 hours post-patency capsule ingestion to confirm passage. ANOVA test was used to compare means between all groups, and student t-test between individual groups.

Results

A total of 127 patients were included. Group A (Pruculopride): 59 patients, Group B (fasting, no Prucalopride): 22 patients, Group C (non-fasting, no Prucalopride): 46 patients.
Demographics:

• Group A: 47.5% males and 52.5% females, Group B: 45.5% males and 54.5% females, Group C: 32.6% males and 67.4% females
• Mean age – Group A: 50.3 years (range 18-82), Group B: 48.4 years (24-82), Group C: 47.9 (17-79).

• Appropriate: 80 (63%)
• Inappropriate: 35 (27.6%)
• Undocumented: 12 (9.4%)

• Group A: 36/59 (61%), Group B: 17/22 (77%), Group C: 19/46 (67%).
• ANOVA test f-ratio 4.55, p= 0.012.
• T-test: Group A vs B (61% vs 77%, p=0.087). A vs C (61%vs 67%, p=0.023), B vs C (77% vs 67%, p=0.002).

Conclusion

This study shows that fasting improves patency tests pass rates, but Prucalopride does not. Fasting and subsequent patency capsule ingestion promoting the gastro-ileal reflex is a possible explanation. It is unclear in this study why Prucalopride, a prokinetic and laxative, failed to show an improvement in pass rates despite being shown to improve VCE completion rates in other studies. Longer duration of Prucalopride at split intervals is a potential area for further studies.

References

1. Deding U, Kaalby L, Baatrup G, Kobaek-Larsen M, Thygesen MK, Epstein O, et al. The effect of prucalopride on the completion rate and polyp detection rate of colon capsule endoscopies. Clinical Epidemiology 2022;Volume 14:437–44. doi:10.2147/clep.s353527.

Disclosure

None

Introduction

‘Inability to Belch’, also called retrograde cricopharyngeal dysfunction (R-CPD), is a syndrome characterized by inability or impaired ability to belch, gurgling noises from the chest or lower neck, thoracic or abdominal pain, bloating and flatulence (1). Although awareness of the disorder is increasing, little is known about its cause, characteristics or epidemiology.
Besides recognition of typical symptoms, high resolution impedance manometry (HRiM) is increasingly used to confirm the diagnosis in suspected cases (2, 3).

Aims & Methods

Our aim was to design a diagnostic questionnaire based on the cardinal symptoms, and to validate this questionnaire against the only available objective diagnostic tool at present, i.e. HRiM with belch provocation test (sparkling water) (2, 3).
The questionnaire was developed based on medical history taking of patients that presented to our center with ‘inability to belch’ (4). Fifteen symptoms were included: inability to belch, gurgling noises, thoracic pain, abdominal pain, nausea, fullness, early satiety, bloating, flatulence, heartburn, regurgitation, frequent or painful hiccups, dysphagia, and difficulty to vomit. These were questioned for frequency, severity, bothersomeness and the trigger or timing at which they occurred. A first draft of the questionnaire was evaluated in a cognitive debriefing of the first three R-CPD patients, after which some clarifying changes were made.
Subsequently, the questionnaire was filled out during HRiM prospectively by R-CPD and control patients, each of whom underwent belch provocation test as described by our group (3).
Wilcoxon signed rank test was used to compare between groups. A logistic model was used to compute probabilities with their 95% confidence interval (CI).

Results

The questionnaire was completed by 17 patients reporting inability to belch, and 47 control patients, during HRiM with belch provocation test. In 13 out of 17 patients (sensitivity 76%, positive likelihood ratio of HRiM: 8.44), R-CPD was confirmed with typical findings on HRiM. The indication for HRiM in control patients was GERD (n=27), dysphagia (n=9), chest pain (n=3), known achalasia (n=2), belching (n=1), globus (n=1) and dyspepsia (n=1). In the control patient group, 4 patients were excluded from further analysis because of abnormalities on HRiM similar to R-CPD (specificity 91%, negative likelihood ratio: 0.26).
Using HRiM as a gold standard, we identified the following questions that were significantly different in R-CPD patients vs. controls: frequency of inability to belch (p <0.001, probability of abnormal HRiM when present: 0.6000 CI 0.380:0.786 ), gurgling noises (p = 0.0019, probability when present 0.4000, CI 0.230:0.597), and dysphagia (p = 0.003, probability when present 0.065, CI 0.016:0.022). Even though these symptoms were often present in R-CPD, chest pain, abdominal pain, nausea, fullness, early satiety, bloating, heartburn, regurgitation, hiccups and vomiting did not differ significantly between both patient groups.

Conclusion

We designed a diagnostic questionnaire to help identifying R-CPD. Based on a comparison between R-CPD patients with a control population with a variety of upper motility disorders, the presence of ‘inability to belch’, gurgling noises; and the absence of dysphagia were significantly different between R-CPD patients and controls.
Pending further validation, this questionnaire provides a basis for developing a scoring system for patients with ‘inability to belch’ and it can be used to explore the epidemiology of this peculiar syndrome.

References

1. Bastian RW, Smithson ML. Inability to Belch and Associated Symptoms Due to Retrograde Cricopharyngeus Dysfunction: Diagnosis and Treatment. OTO Open. 2019;3(1):2473974x19834553.
2. Oude Nijhuis RAB, Snelleman JA, Oors JM, Kessing BF, Heuveling DA, Schuitenmaker JM, et al. The inability to belch syndrome: A study using concurrent high-resolution manometry and impedance monitoring. Neurogastroenterol Motil. 2022;34(5):e14250.
3. Karlien Raymenants FV, Stijn Arnaert, Jan Tack, Tim Vanuytsel, Filip Baert, Lieve Delsupehe, Joris Arts Manometric diagnosis and treatment of retrograde cricopharyngeus dysfunction (R-CPD). United European Gastroenterology Journal. 2023;11.
4. Arnaert S, Arts J, Raymenants K, Baert F, Delsupehe K. Retrograde Cricopharyngeus Dysfunction, a New Motility Disorder: Single Center Case Series and Treatment Results. J Neurogastroenterol Motil. 2024;30(2):177-83.

Introduction

Peroral endoscopic myotomy (POEM) has become a standard endoscopic treatment for patients with achalasia, with many studies reporting on its long-term effectiveness. However, the impact of a patient’s previous surgical history on the long-term outcomes of POEM remains unknown.

Aims & Methods

This study aims to compare the long-term efficacy of POEM in achalasia patients with and without prior surgical interventions. A single center, retrospective review was conducted on achalasia patients who underwent POEM between January 2016 to December 2020. Clinical, demographic, radiographic, endoscopic, and manometric data were collected. Patients with less than two years of follow-up without noted failure were excluded. The analysis compared outcomes between first-time POEM patients (naïve POEM) and those undergoing POEM following failed surgical treatments (redo POEM). The primary outcome was the clinical success rate, defined as an Eckardt Score of 3 or less at final follow-up and no need for additional interventions. Secondary endpoints included the prevalance of postoperative gastroesophageal reflux disesase (GORD), the necessity for acid suppression medications, and additional interventions for achalasia.

Results

Data were collected on 47 naïve POEM and 26 redo POEM patients. After excluding 17 naïve POEM patients and 8 redo POEM patients who did not meet the criteria for long-term follow-up, a total of 30 naïve POEM patients and 18 redo POEM patients were analyzed. In the redo POEM group, 77.8% (14/18) of the patients underwent Heller myotomy with Dor fundoplication, while the surgical details for the remaining patients were unknown. The median length of symptoms was 5 (IQR 3-10) years for naïve patients and 6 (IQR 1.2-17.5) years for redo patients (p=0.29). According to the Chicago classification v4.0, the achalasia subtypes in the naïve POEM group were Type I in 9 patients (30%), Type II in 12 (40%), Type III in 3 (10%), and other types in 6 (20%). For the redo POEM group, subtypes were Type I in 9 patients (50%), Type III in 2 (11.1%), and unspecified in 7 (38.9%). Barium esophagram revealed no significant differences in the maximum diameter between the groups (naïve POEM 45.8 ± 21.4 mm vs. redo POEM 44.9 ± 15.4 mm, p=0.89). Long-term success rates were 76.7% (23/30) in naïve POEM and 83.3% (15/18) in redo POEM, with no significant difference between the groups (p=0.72). Postoperative GORD was noted in 63.3% (19/30) in the naïve POEM versus 67% (12/18) in the redo POEM (p=0.06), with newly prescribed acid suppression medication in 23.3% (7/18) and 55.6% (10/18), respectively (p=0.02). Additional interventions for achalasia were required in 10% (3/30) in the naïve POEM versus 11.1% (2/18) in the redo POEM, with no significant difference between the groups (p=1.0). In the naïve POEM group, one patient required a second POEM, another was hospitalized due to achalasia recurrence, and a third underwent Heller myotomy with Dor fundoplication. In the redo POEM group, one patient underwent endoscopic balloon dilatation, and another required esophagectomy.

Conclusion

POEM is an effective long-term treatment for achalasia, demonstrating similar success rates in patients undergoing either their first or redo POEM procedures. The overall efficacy and safety profiles support POEM as a recommended treatment for managing achalasia regardless of prior surgical treatment failures.

Introduction

Increased interest in ERCP simulator-based education is driven by the need for efficient and safe endoscopy training in a dedicated environment.
This study assessed whether a structured training program including initial training with the Boškoski-Costamagna ERCP Trainer (BCT) offers benefits to conventional training.

Aims & Methods

This was a one-year prospective, multicenter, parallel-arm, randomized controlled trial involving 16 novice ERCP trainees randomly assigned to study (SG) and control (CG) groups. Both underwent hands-on ERCP training. Additionally, SG had simulator-based training during the first three months. Performance was evaluated with TEESAT score in all ERCPs with any degree of trainee involvement until each trainee completed a minimum of 60 ERCPs. The primary outcome was overall trainee competence rate; secondary outcomes included successful biliary cannulation and adverse event (AE) rates. Learning curves were generated cumulatively over the training period. Both outcomes and the analysis of specific ERCP steps predictive of overall competence were assessed using mixed-effect logistic regression models (MELR). The most effective predictive model of overall competence was identified using a stepwise backward procedure. MELR was employed to investigate potential confounding factors.

Results

1,106 ERCPs were included (SG=562,CG=544). SG trainees demonstrated higher success in native biliary cannulation (SG=52%, CG=42%, p<0.001), achieved faster biliary cannulation [SG=3(6)min, CG=5(8)min, p<0.001], and showed a faster evolution on overall performance, native biliary cannulation, and sphincterotomy. Successful biliary cannulation [OR=10.10, 95% CI (5.15-19.83)] and sphincterotomy [OR=7.71, 95% CI (3.77-15.76)] were the most important predictors for overall competence. The multivariate random-effects model demonstrated an almost significant association between simulator-based training [OR=3.24, 95% CI (1.01-10.39), p=0.049] and overall competence, accounting for biliary cannulation, sphincterotomy, and stone removal. No confounding factors were identified.

Conclusion

This study suggests that early simulator training with BCT accelerates the learning curve of trainees in performing key steps of the ERCP procedure and improves overall competence as assessed by dedicated tools during ERCP training.

Clinical Case Summary

Gastrointestinal tuberculosis (GITB) is an uncommon form of extrapulmonary tuberculosis that poses a diagnostic challenge due to its non-specific clinical presentation. Among its varied manifestations, gastrointestinal bleeding as an initial presentation is exceedingly rare. This case report aims to highlight the diagnostic difficulties, treatment modalities, and clinical outcomes in a patient with GITB presenting as gastrointestinal bleeding.
This is a case of a 24/M, no known comorbidities, immunocompetent host, no maintenance medications who came in for sudden onset of hematochezia with progressive drop in hemoglobin levels. Work up revealed a circumferential wall thickening involving the ileocecal region. Bleeding from mass was difficult to control despite medications and colonoscopy attempts hence patient underwent exploratory Laparotomy, right segmental colectomy. Histopathology results revealed caseating chronic granulomatous inflammation and lymph nodes showing caseating granulomas. Patient was then started on anti-Kochs treatment with note of improvement of symptoms post treatment.

References

1. Sharma, V., Mandavdhare, H. S., Lamoria, S., & Dutta, U. (2019). Gastrointestinal tuberculosis: A systematic review and meta-analysis. Scandinavian Journal of Gastroenterology, 54(5), 567-577. doi:10.1080/00365521.2019.1598343
2. Kapoor, A., & Schewitz, I. (2020). Gastrointestinal tuberculosis: Understanding the molecular mechanisms for better diagnosis and treatment. Journal of Digestive Diseases, 21(4), 195-204. doi:10.1111/1751-2980.12866
3. Amarapurkar, D. N., Patel, N. D., & Amarapurkar, A. D. (2018). Gastrointestinal tuberculosis. Indian Journal of Medical Research, 147(5), 401-416. doi:10.4103/ijmr.IJMR_1004_17
4. Sharma, V., Mandavdhare, H. S., & Lamoria, S. (2020). Update on gastrointestinal tuberculosis: Newer techniques and treatment strategies. World Journal of Gastrointestinal Pharmacology and Therapeutics, 11(3), 10-26. doi:10.4292/wjgpt.v11.i3.10

Disclosure

None

Clinical Case Summary

Leiomyomas are benign soft tissue neoplasms that arise from smooth muscle. They are uncommon in the colon. We report two cases of colonic sessile polyps that underwent polypectomy and histology showed leiomyoma.

The first patient previously had a history of polyps with tubular adenoma with low grade dysplasia. A repeat colonoscopy for polyp surveillance was done which found polyps in the ascending colon, and sigmoid. The sigmoid colon polyp was 4mm in size and removed via cold snare polypectomy (Figure 1).
The second patient had underlying non-alcoholic fatty liver disease cirrhosis and iron deficiency anaemia. Colonoscopy showed colonic polyps which were biopsied (Figure 2).

The histology of the first patient’s sigmoid colon polyp showed nodular spindle cell lesion centered in the submucosa/muscularis mucosa. The lesion was composed of spindle cells in fascicles with bland spindled nuclei and eosinophilic cytoplasm. Desmin and SMA stains were done and they were diffusely positive. CD117 stains were negative. DOG1 showed focal nonspecific staining in lesional cells. The overlying lamina propria also showed aggregates of foamy histiocytes and lymphoid aggregates. These were consistent with a leiomyoma.
The second patient’s histology also showed fascicles of spindle cells and immunohistochemistry stain showed positivity for SMA and desmin but negative for CD117 and DOG-1, consistent with leiomyoma.

As the polyps showed smooth margins endoscopically and has similar appearance to hyperplastic polyps, it was likely thought to have a hyperplastic component on top of leiomyoma, hence the patients are to be monitored and followed up for routine surveillance.

References

Miettinen M, Sobin LH, Am J Surg Pathol. 2001;25(11):1433

Introduction

The asymptomatic nature of precancerous lesions, namely low- and high-grade dysplasia (LGD and HGD, respectively), constitutes a major clinical challenge that precludes a timely detection of gastric cancer (GC) in curable stages. The identification of novel and accurate biomarkers holds the promise of a better risk assessment and citizens stratification for an early diagnosis. In this exploratory study, we proposed to characterize the transcriptomic landscape of gastric lesions (GL) towards the definition of a molecular profile for early screening of GC in Western populations.

Aims & Methods

RNA-Sequencing analysis was conducted on RNA extracted from 39 formalin-fixed paraffin-embedded (FFPE) samples: 20 “normal-appearing” mucosa controls and 19 gastric lesions (GL), including LGD, HGD, and adenocarcinoma. Differential expression analysis, functional enrichment analysis, least absolute shrinkage and selection operator (Lasso) regression, and the machine-learning extreme gradient boosting (XGBoost) algorithm were employed to identify potential biomarkers and assess the predictive value of the molecular signature of the top dysregulated genes.

Results

A total of 1171 differentially expressed genes (DEGs) were identified in GL. Remarkably, 867 of these genes (74%) showed exclusive dysregulation in lesions compared to stage I GC samples from The Cancer Genome Atlas (TCGA) stomach adenocarcinoma (STAD) cohort. These unique biomarkers predominantly participate in translation, as well as metabolic and biosynthetic processes. In contrast, DEGs from TCGA-STAD cohort were primarily enriched in immunity-related processes. Notably, the eight best genes model, comprising ADAMTSL1, CLDN2, ENC1, GSR, IQNC, PER1, PRR33, and a novel transcript corresponding to a long non-coding RNA (lncRNA, ENSG00000227218), achieved an area under the curve (AUC) of 0.938 (95% CI: 0.815-1.000), with a sensitivity of 87.5% and specificity of 100% to classify GL samples.

Conclusion

This preliminary study identified over 800 DEGs exclusively in GL compared to stage I GC. Moreover, it unveiled a molecular-based signature that effectively discriminates patients with GL in an intermediate-risk population. This discovery paves the way for enhancing early GC screening strategies, particularly for those who can be treated through minimally invasive, nonsurgical procedures.