Introduction

Patients with inflammatory bowel disease (IBD) have an increased risk of developing intestinal and extra-intestinal cancers. Specific therapies used to control inflammation in IBD may have a different impact on cancer risk. However, there are no long-term studies investigating cancer risk in patients with IBD.

Aims & Methods

In the present study we aimed to quantify the overall risk for of developing cancer and to identify specific risk factors for the occurrence of intestinal and extra-intestinal cancers in 560 consecutive patients with Crohn's disease (CD, N=310) or ulcerative colitis (UC, N=250) referred to our outpatient department between January 2021 and February 2022. Demographic data, smoking status, alcohol consumption, age at IBD diagnosis, disease location and course, therapies, and cancer development after IBD diagnosis were recorded. Odds ratios (OR) were estimated by logistic regression analysis. Standardized Incidence Ratios (SIRs) were estimated compared with the general population.

Results

During a median follow-up interval or time of 10 years (range 1-26 years), 6.6% of patients (37/550, female 65 %, mean age 51 years) developed cancer (SIR 1.94, 95%CI 1.4-2.6). The most common cancers were colorectal (12.3%), skin (8.2%), and breast cancer (7.2%). Female patients had an increased risk for all cancers (SIR 3.11, 95%CI 2.06-4.3), melanoma (SIR 5.6, 95%CI 1.14-16.2) and colorectal cancer (SIR 7.59, 95%CI 3-15.4). Male patients had an increased risk of lymphoma (SIR 26.15, 95%CI 3.2-95.7). Younger age at diagnosis of CD (A1 Montreal classification, OR 37.9, 95%CI 10-14), immunosuppressive monotherapy (OR 5.5, 95%CI 2.65- 11) or in combination with anti-TNFα (OR 9.9, 95%CI 3.3-29.09) were associated with an increased risk of cancer in the study population.

Conclusion

We have identified subgroups of IBD patients who would particularly benefit from screening programs. Our findings need to be validated in independent cohorts.

Introduction

High-resolution manometry (HRM) is routinely performed in an outpatient clinic setting. If intubation is not tolerated or if the LOS is not traversed, the test is often abandoned with no viable alternative option, thus impacting on therapeutic decisions. This study explores the option of intubating the catheter during endoscopy under the comfort of sedation and direct vision.

Aims & Methods

All patients who had HRM catheter insertion during endoscopy at a tertiary referral centre in London between Jan 2020 and April 2023 were collated and analysed. A consecutive equivalent number of standard unsedated HRM studies, as well as patients having standard diagnostic endoscopy at the same centre between Nov and Dec 2022 were included for comparison. Demographic data, symptom presentation, endoscopic technique and manometry diagnosis were analysed. All HRM studies attempted a full protocol of single water swallows and rice meal, undertaken only after confirmation that sedation had abated. The median integrated relaxation pressure (IRP) of single water swallows was used to categorise patients into those with and without a disorder of outflow. Oesophageal body function was defined according to the Chicago Classification of motility disorders¹.

Results

Of the 47 patients (68.1% F; 17-86 yrs) who were referred for endoscopic insertion (EI) of the HRM catheter, 42 (89.3%) were successfully intubated to the stomach. Of those, 33 (78.6%) were observed to pass through the pharynx and LOS with the endoscope, 4 (9.5%) required manual guidance through the oesophagus and LOS, whilst 5 (11.9%) required only observation of catheter passage through the pharynx. Overall, 41 (87.2%) patients completed the full swallow protocol. Indications for referral for EI included intolerance to standard insertion through the nares (52.4%), inability to breach the LOS resulting in a curled catheter (26.2%) and other reasons including septal deviation and psychiatric burden (21.4%). Similarly, of the contemporaneous 47 patients who had standard insertion (SI) of the HRM catheter in the outpatient setting (67.3% F, 23-80 yrs), 39 (82.9%) were successfully intubated and 33 (67.3%) completed the full swallow protocol. Symptoms were reproduced during the test protocol in both cohorts similarly (69.0% EI, n=42; 59.0% SI, n=39). EI patients required higher doses of sedation compared to a consecutive cohort of patients who attended for routine diagnostic endoscopy; mean Fentanyl 112.5µg (n=36) vs 78.7µg (n=47) p<.001, and Midazolam 4.9mg vs 3.4mg p<.001, respectively. The IRP was not significantly different between EI and SI regardless of LOS morphology; mean IRP in patients with no LOS outflow disorder (8.01mmHg, n=28 vs 6.05mmHg, n=35; p=.08), compared to those with an outflow obstruction (28.0mmHg, n=12 vs 23.1mmHg, n=5; p=.35). Overall motility diagnoses between the two cohorts are presented in Table 1.

Table 1: Diagnoses for HRM

Conclusion

Inserting the HRM catheter during endoscopy under sedation and direct vision enables oesophageal physiology testing for patients who might not have otherwise been able to receive motility assessment. The procedure is safe, feasible and is associated with no complications or adverse risk to date. Just as wireless pH monitoring can be a salvage for those who are unable to tolerate the pH catheter, this technique can fill an important gap in the investigation algorithm where motility testing would have otherwise been abandoned.

References

¹Yadlapati, Rena et al. “Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0^©.” Neurogastroenterology and motility : the official journal of the European Gastrointestinal Motility Society vol. 33,1 (2021): e14058. doi:10.1111/nmo.14058

Introduction

Gastro-oesophageal reflux disease (GERD), caused by reflux of stomach contents into the oesophagus, results in discomfort and pain. Evidence suggests reflux- induced oxidative stress in oesophageal epithelial cells may have a role in GERD pathogenesis and symptom development. High mobility group box 1 (HMGB1), a nuclear protein found in most cell types, is actively released in response to oxidative stress. HMGB1 binds to TLR2, TLR4, and RAGE, leading to downstream inflammatory signalling.

Aims & Methods

Our aim was to investigate the potential role of epithelial-derived HMGB1 in the context of GERD.
Oesophageal biopsy tissue was obtained from consented healthy volunteers (N=10) and GERD patients categorised as functional heartburn (FH; N=7), non-erosive reflux disease (NERD; N=13), and erosive reflux disease (ERD; N=11) based on clinical assessment. Oesophageal HMGB1 mRNA was assessed by RT-qPCR. Tissue was used to assess protein expression of HMGB1, TLR2, TLR4, and RAGE using immunohistochemistry (IHC). Healthy oesophageal biopsies were used to assess HMGB1 release ex vivo following synthetic refluxate challenge (pH2, 1mM deoxycholate (DCA), 1mg/mL pepsin). Cellular translocation of HMGB1 was assessed using immunofluorescence in NE-1 cells in response to acidic bile salts (pH4, 1mM DCA).

Results

HMGB1 mRNA and epithelial protein expression were consistent between healthy control and GERD patients. TLR2 and TLR4 were expressed primarily on epithelial cells with cell quantification revealing TLR4 to be the predominantly expressed epithelial receptor. The proportion of TLR4+ cells was higher in ERD compared to healthy controls (1.4% ± 0.43 vs 7.2% ± 2.567; p<0.05). In contrast, RAGE was expressed exclusively on CD45+ leukocytes – predominantly in GERD phenotypes. Many RAGE+ immune cells in GERD tissue were in close apposition to sensory CGRP+ nerve fibres. Incubating NE-1 cells with acidic bile salts (10mins), but not acid alone, induced HMGB1 translocation to the cytosol (nuclear:cytosolic HMGB1 ratios: pH7 = 2.42 ± 0.19; pH4 = 2.66 ± 0.07; pH4 + DCA = 1.416 ± 0.06; p=0.0003). Challenging oesophageal biopsies with synthetic refluxate (5mins) led to release of HMGB1 over 18 hours compared to paired biopsies (218 ± 57 vs 586 ± 220 pg/mL/mg; p<0.05).

Conclusion

HMGB1 released by oesophageal epithelial cells following reflux may contribute to inflammatory pathways in GERD, particularly via TLR4 and RAGE on epithelial and immune cells, respectively. This is of particular interest in PPI-refractory GERD, due to the exaggerated role of bile salts in HMGB1 release. Further, the close proximity of RAGE+ leukocytes and CGRP+ nerve fibres may represent a cross-talk between epithelial cells, immune cells, and sensory nerves. HMGB1 may therefore be a potential new treatment target for GERD.

Introduction

Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) can demonstrate microvascularization of the tumors. However, most images acquired from CEH-EUS are interpreted subjectively without quantification by time-intensity curves (TICs) analysis.

Aims & Methods

In this study, we used handcrafted software to quantify CEH-EUS images for objective interpretation of tumor microvascularization to make differential diagnosis of pancreatic tumors feasible.
We analyzed the videos of CEH-EUS for pancreatic tumors from the patients in National Taiwan University Hospital and Far Eastern Memorial Hospital. The convex-type echoendoscope (GF-UCT260; Olympus, Tokyo, Japan) equipped with ultrasound (US) systems (EU-ME2) was used for the procedures. The second generation of US contrast agent with Sonazoid (GE Healthcare, Milwaukee,Wisc), which contains perfluorobutane microbubbles with a median diameter of 2–3 μm, was administered bolus and intravenously with a dosage of 0.015 ml encapsulated gas per kilogram body weight. The videos were recorded in AVI formats with 30 frames/second.
The algorithm for getting TICs includes the following steps:
(1) Circling the region of interest(ROI) in the B-mode
(2) Performing speckle tracking of the ROI in the B-mode
(3) Simultaneously obtaining the intensity of ROI (the mean pixel values in the ROI) in the corresponding contrast-enhanced harmonic image
(4) Outputting TICs after subtracting the baseline intensity (defined as mean TIC in the first 10 s for eliminating the different baseline intensities caused by other settings).
(5) Outputting histogram of pixel values and excel file containing all pixel values from the frame with the highest mean pixel value automatically.
(6) Calculating the standard variance of (5) to represent the heterogeneity inside the ROI.
The speckling tracking composes of searching and matching processes. We used full search for the searching process and normalization cross-correlation for the matching process. By using the hardware of CPU with Intel i7-8750H and GPU with Nvidia GTX 1050 Ti, the computation time was 0.7 ms/frame.

Results

The detailed results were shown in Table 1. We collected 10 and 7 videos of CEH-EUS for pancreatic tumors from NTUH and FEMH respectively in this study. Among them, 9 were diagnosed of pancreatic ductal adenocarcinoma (PDAC), 6 were pancreatic neuroendocrine tumors (PNET), and 2 were autoimmune pancreatitis (AIP). The TICs were obtained through our proposed model. Briefly, there were no significant differences in times to peak, the mean peak intensity, the in-slope tangent and standard deviation of pixel value in ROI (from the frame with the highest mean pixel value) among PDAC, PNET, and AIP. However, there was significant difference in the mean peak intensities of PDAC and non-PDAC (37.88 vs 63.12, p=.031).

Table 1.The results from three kinds of pancreatic tumors based on the proposed model

Conclusion

In this study, there were no significant differences in times to peak, the mean peak intensity, and SD of pixel value in ROI (from the frame with the highest mean pixel value) among PDAC, PNET, and AIP, however there was significant difference in the mean peak intensity between PDAC and non-PDAC group. A study with larger test number is needed in the future for further application.

Disclosure

We have no conflicts of interest to disclose.

Introduction

Current endoscopic ultrasound technologies (EUS) are suboptimal in the assessment of pancreatic cystic lesions (PCLs). We developed a new through-the-needle brush, the "loop brush", to improve the cellular yield, and thereby sensitivity, of EUS fine needle aspiration (EUS-FNA) of pancreatic cysts.

Aims & Methods

We aim to evaluate the "loop brush" safety, robustness, and efficacy.
We performed an in-vivo randomized controlled trial in pigs using artificial cysts. In one group, the loop brush was deployed through a 22G EUS-FNA needle into the cysts. In the control group, cystic punction was performed with standard EUS-FNA. Loop brushes were visually inspected post-procedure. Cytological assessment, cell counting, and hemoglobin analysis were performed in samples from both groups.

Results

Artificial cysts (n=114) were punctured in six pigs, 57 in each group. Neither adverse events nor significant device malfunction occurred during loop brushing. Samples collected with the brush had non-detectable concentrations of hemoglobin in 72% (41/57) of cases, and 26% (16/57) had less than 0.6 g/dL, with no significant difference to the controls (p=0.32). Brushing cell counts were associated with significantly increased cell counts (11.7× median difference, p<.0001). Cytological smears
were diagnostic in 77% of cases in the brushing group, while 54% in the control group (p=0.01, Fisher’s exact test; p=0.006, Chi-square test).

Conclusion

The new loop brush procedure appears to be safe, causing neither significant bleeding nor device malfunction. Samples obtained with the loop brush were suitable for cytological analysis and showed significantly higher cell yield than controls. Further clinical studies are warranted.

References

DOI: 10.1053/j.gastro.2020.10.007
DOI: 10.1186/s12916-018-1215-3
DOI: 10.3389/fonc.2021.688377
DOI: 10.1136/gutjnl-2016-313127
DOI: 10.1038/ajg.2018.14
Mohamed, E.; et al. Role of radiological imaging in the diagnosis andcharacterization of pancreatic cystic lesions: a systematic review. Pancreas 2018, 47, 1055–1064.
Cazacu, I. M.; et al. A quarter cen- tury of EUS-FNA: Progress,milestones, and future directions. Endoscopic ultrasound 2018, 7, 141
DOI: 10.1038/s41598-021-81065-2
doi: 10.4103/eus.eus_93_17
Shirley, L. A.; et al. Routine cyst fluid cytology is not indicated in the evaluation of pancreatic cystic lesions. Journal of Gastrointestinal Surgery 2016, 20, 1581–1585.
Muniraj, T.; et al. Devices for endoscopic ultrasound-guided tissue acquisition. Techniques in Gastrointestinal Endoscopy 2018, 20, 2–9.
Balaban, V. D.; et al. EUS- through-the-needlemicrobiopsy forceps in pancreatic cystic lesions: A systematic review. Endoscopic Ultrasound 2021, 10, 19.
Marques, F.; et al. A loop-shaped minimally invasive brush for improved cytology sampling of pancreatic cysts during EUS-FNA. Medical Devices & Sensors 2021, 4, e10165.
doi: 10.1177/0271678X20943823.
doi: 10.3748/wjg.v18.i34.4659
DOI: 10.3748/wjg.v27.i26.4194

Disclosure

FM, WW, UA, NR, and FBS have patent applications for the brush technology and are co- founders of Lucky LoopMedical AB, a company commercializing technology for improved sampling in EUS-FNA. UA has received a research grant from Boston Scientific and is a consultant to Boston Scientific, Medtronic, and Ambu. IS declares no conflict ofinterest.

Introduction

A transmural oxidative imbalance, mainly affecting longitudinal muscle, has been reported in the different clinical phenotypes of Diverticular Disease (DD) (Pallotta L,2022; Cappelletti M,2022) but the genesis of the oxidative stress remains to be defined. Since the central role of the mitochondria for the cell metabolism and radicals production, aim of the study is to elucidate the involvement of mitochondria alterations in the different DD clinical phenotypes in order to improve the knowledge of the DD natural history and management.

Aims & Methods

Longitudinal smooth muscle tissues and cells were isolated separately from surgical specimens of complicated stenotic DD (cDD n=5), up-stream non-occlusive colon cancer with diverticula (DIV n=5) and without diverticula (controls n=5). Oxidized proteins, thioredoxin and, succinate deidrogenase (complex II) and complex IV (cytochrome c oxidase) of mitochondrial respiratory chain were evaluated on tissues by Western Blot. Mitochondrial mass, mitochondrial ROS, mitochondrial membrane potential and glutathione (GSH) were evaluated in cells by FACS. Functional cells activity was tested by image micrometry assessing maximal contraction to acetylcholine and relaxation to VIP, before and after 24h-incubation with 14mM polyphenols (Phenolea Active Complex L). Data (mean±SE) were expressed as fold variations or % decrease from controls, *p value<0.05 considered significant.

Results

In respect to control, oxidized proteins content in longitudinal muscle was increased both in DIV (5.0*±1.1) and cDD (2.6±0.6), associated to a progressive loss of the antioxidant thioredoxin molecule (DIV:70.9%±9.2;cDD:83.3%±3.4). The oxidative status resulted associated to a loss of the mitochondrial complex II succinate deidrogenase codified by nuclear DNA (DIV:43.4%±19.7;cDD:67.9%±10.3) suggestive of the electron respiratory chain impairement. Compensatory stress mechanisms likely occurred with an increase of the complex IV cytochrome c oxidase codified by mitochondrial DNA in muscle tissue (DIV:1.1±0.77;cDD:2.3±1.7) and mitochondrial mass increase (DIV:2.4±1.2;cDD:3.7*±1.3) in cells. Radicals over production was observed mainly in cDD with a cellular increase in mitochondrial ROS (cDD:1.50±0.57) and mitochondrial membrane potential (cDD:1.4±0.3). Antioxidant GSH cellular content progressively decreased from DIV (51.9%*±9.5) to cDD (72.2%*±1.5). These oxidative alterations were associated to an impairment of functional cellular activity with a reduction of contraction (DIV:51.3%*±4.5;cDD:52.5%*±8.5) and relaxation (DIV:34.9%*±14.3;cDD:37.6%*±10.6). The prominent role of oxidative stress in these functional alterations was confirmed by the ability of a 24/h polyphenols treatment to restore GSH content (DIV:1.1±0.06;cDD:1.4±0.3) and relaxation, in both DD phenotypes.

Conclusion

Oxidative stress-driven alterations are present in longitudinal muscle in DD, independently from the clinical stage. In accordance to the severity of the pathology, mitochondrial imbalance resulted more prevalent in complicated diverticular disease. The beneficial effects of the antioxidant treatment could open new tailored-therapeutic and prevention strategies still not tested in this disease.

Disclosure

No disclosure

Introduction

Fructans or fructooligosaccharides are included in the spectrum of FODMAP (fermented) sugars, which are relevant in the induction of symptoms in patients with disorders of gut-brain interaction (DGBI) and in non-coeliac gluten sensitivity (1). Fructans have been shown to induce visceral hypersensitivity, an increase in mucosal mast cells, and changes in the colonic mucosal barrier in mice, and hypersensitivity associated with an altered gut microbiome in humans (2-5). Breath tests are used in the assessment of intolerances to several FODMAPs, but the test is poorly standardised for fructans (6).

Aims & Methods

A standardised breath test with fructans (10g Orafti^®HSI) was performed afer a 24-hour low-FODMAP diet and >8-hour fast. Exhaled hydrogen and methane concentrations were measured every 30 minutes until 5h, and synchronised symptom assessments performed for 24h (composite symptom index score, SI, 7) in 600 successive male (33%) and female patients of average age 41 years referred to our gastroenterology practice with DGBI (irritable bowel syndrome and/or functional dyspepsia, Rome 4 criteria). Breath gas concentration thresholds of >20ppm and >8ppm above baseline were used for hydrogen and methane, respectively.

Results

The SI was positive in 61.2% (n=367) of patients within 24 hours of fructan ingestion. The SI peaked in the first 3 hours in 17.5% (n=105) and in the first 5 hours in 42.5% (n=255) of patients. Suprathreshold increases in hydrogen and methane concentrations within 5 hours were seen in 62.7% and 14.9% of patients, respectively. Discordant SI and breath gas results were obtained in 35.1% (hydrogen) and 57.8% (methane) of patients. A negative SI with a suprathreshold hydrogen or methane result occurred in 18.2% and 5.2%, respectively. A positive SI with a subthreshold hydrogen or methane result occurred in 16.9% and 52.6%, respectively. Suprathreshold concentrations in methane and not in hydrogen were apparent in 4.5%. Main symptoms during tests were excessive flatulence (58.8%), bloating (50.3%), abdominal fullness (49.3%), abdominal cramps (29.0%), nausea (26.7%), GORD (26.7%), diarrhoea (9%) and extra-GI symptoms (16.2%).

Conclusion

Standardised oral provocation with fructans resulted in familiar clinical symptoms in a majority of patients with DGBI, suggesting a high prevalence of fructan intolerance. Due to the slow fermentation of intestinal fructans and the associated delayed symptoms, prolonged data collection over at least 12, preferably 24 hours is recommended. The test duration of 3 hours currently commonly used in test centres is inadequate. Symptom and breath gas concentration results are often divergent, as is known from other FODMAP breath tests, and validation against clinical outcome results is required. Fructans are of interest in DGBI as the current literature suggests they have both protective as well as detrimental effects on intestinal physiology, which may be dependent on the resident microbiota.

References

1. Gry I et al. Gastroenterology 2018;154:529–539
2. Kamphuis JBJ et al. Gastroenterology 2020;158:652-663
3. Chen BR et al. World J Gastroenterol 2017;23:8321-8333
4. Kamphuis JBJ et al. FASEB J. 2022;36:e22297
5. Chumpitazi BP et al. Aliment Pharmacol Ther 2021;53:499-509
6. Fedewa A et al. Curr Gastroenterol Rep 2014;16:370
7. Wilder-Smith CH et al. Aliment Pharmacol Ther 2013;37:1074-83