Introduction

Acute pancreatitis (AP) can progress to recurrent acute pancreatitis (RAP) or chronic pancreatitis (CP).

Aims & Methods

This systematic review and meta-analysis aimed to identify risk factors associated with this progression. The protocol was registered on PROSPERO (CRD42022368931). A comprehensive search was conducted in three (Medline, Embase, Cochrane) databases on October 25th, 2022. Articles reporting and risk factors associated with AP progression into RAP or CP were included. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using the random effects model. Heterogeneity was evaluated using the I² statistic. The risk of bias assessment was performed using the Quality in Prognostic Studies (QUIPS) tool.

Results

A total of 71 articles were included in the meta–analysis, and several risk factors were identified for the progression of AP into RAP and CP. We found the following risk factors of AP recurrence: younger age, male gender, smoking, alcoholic etiology, hypertriglyceridemia, diabetes mellitus, pseudocyst, etc. The pooled OR for the male gender was 1.45 (95% CI: 1.29-1.64, I²=24%), for smoking was 1.45 (95% CI: 1.16-1.81, I²=62%), for alcoholic etiology was 1.76 (95% CI: 1.38-2.25, I²=81%), for hypertriglyceridemia was 2.45 (95% CI: 2.07-2.90, I²=9%), for diabetes mellitus was 1.49 (95% CI: 1.24-1.80, I²=0%), for pseudocyst was 2.19 (95% CI: 1.52-3.15, I²=0%). We also found risk factors of RAP progression into CP. The risk of bias was moderate in the majority of the included studies.

Conclusion

Our study identified multiple modifiable risk factors which can be treated to prevent the progression of pancreatitis.

Clinical Case Summary

A 72-year-old man with a 49-year history of ulcerative colitis (UC), characterized as pancolitis and steroid-dependent, underwent routine surveillance colonoscopy. A congested, ulcerated mass was found in the recto-anal region, with no signs of active colitis in the rest of the colon.
From 2000–2012, he was treated with infliximab, discontinued due to secondary failure, followed by azathioprine (2012–2017), which was stopped due to leukopenia. Since then, he has been on vedolizumab. His medical history also includes hypertension and previous tobacco use.
The patient had been in clinical and biochemical remission for the last two years. Given his long-standing UC and the resection of a lateral spreading tumor (LST) via mucosectomy in 2019 showing hyperplastic mucosa with a focus of low-grade dysplasia, he has been under annual endoscopic surveillance.
At the current exam, a large exophytic, ulcerated mass with superficial necrosis and fibrin (Kudo IV) was seen in the recto-anal region, occupying approximately 1/6 of the luminal circumference and bleeding spontaneously.
Histology revealed a poorly differentiated neuroendocrine carcinoma (NEC) with a high proliferative index (Ki-67: 60%). Staging workup, including CT, pelvic MRI, and endoscopic ultrasound, identified a suspicious regional lymph node, that was confirmed by FDG-PET to be metabolically active.
After multidisciplinary discussion, the decision was made to start systemic chemotherapy without delay. If the patient responds, a total proctocolectomy with permanent ileostomy will be considered.
This case is notable for the rarity of recto-anal NECs, especially in UC patients. Their poor prognosis and unclear association with long-term UC or immunosuppressive treatment complicate management and raise important clinical questions.

References

Images that will be uploaded are: endoscopic findings of the colonic mass, histological specimens of the NEC, radiologic findings (PET)

Introduction

Pancreatic neuroendocrine tumors (pNETs) are a heterogeneous group of tumors with different treatment options depending on pathological grading, clinical staging, and presence of symptoms related to hormonal secretion. Their classification is made on mitotic count and Ki-67 index.
The current standard for Grading assessment is analysing the material obtained from EUS-guided fine needle aspiration/biopsy (EUS-FNA/FNB). However this technique is not free from adverse events and could be challenging for NETs localization.
The evidence of high grade of fibrosis and microvascular density decrease (MVD) on tumor pathological specimens has led many authors to search for undirected malignant features of pNET extrapolated from non-invasive techniques. The introduction of ancillary techniques, such as second-generation contrast agents (CH-EUS), has improved study of pNET. Particularly, at CH-EUS examination contrast pattern well correlates with behaviour and grading of NETs. However, the use of contrast agents entails a prolongation of procedure time and additional costs. An innovative ultrasound Doppler technique, Detective Flow Imaging EUS (DFI-EUS), involves no additional time or cost as it doesn’t require the administration of contrast agent. There is still no standardisation of this technique and few studies have validated its use.

Aims & Methods

The aim of this study is to evaluate the DFI role in defining NET vascularization and its correlation with CH-EUS. The second aim of the study is to assess DFI role in predicting histological grading.
Single center retrospective analysis on consecutive patients with solid pancreatic lesions who underwent EUS at Therapeutic Digestive Endoscopy Unit of the Fondazione Policlinico Universitario Campus Bio-Medico in Rome.
After activation of DFI, each lesion was observed for at least 30 seconds. Lesions was classified into three grades, according to the degree of vascularisation at DFI: (grade 0 absence of microvascularization of the tumor; grade 1 minimal/isovascularization of the tumor; grade 2 markedly increased microvascularization).
All lesion with final hystological diagnosis of NET were enrolled.
Grading and Ki-67 index of tumors were reported.
Data about lesion’s features and procedure were collected.

Results

From April 2024 to February 2025, 17 patients were enrolled (58.8% male; mean age 57±12 years old). The majority of lesion (53%) were localized in the body of the pancreas and the mean lesion’ s size was 28±20 mm. The final histological diagnosis classified 50% lesions as G1, 38.8% G2 and 5.5% G3.
At the CEH-EUS the 70.6% of lesion showed hyper-enhancement. About the DFI evaluation the 17.6% of lesion was hypo-vascular, 17.6% Iso-vascular and 64.7% was hyper-vascular. There was excellent correlation between DFI characterization of the lesion and the CH-EUS (ICC 0.9)
Among the NET G1, 66.7% were Hypervascular at DFI and 33.3% Isovascular. Among the G2, 71.4% were Hypervascular at DFI and 28.6% Hypovascular. The only G3 lesion was Hypovascular.
There was inverse correlation between the NET grade and the DFI grade (Pearson coefficient -0.56; p 0.02).

Conclusion

DFI-EUS can provide a fast evaluation of the micro-vascularization of pNET with excellent correlation with CH-EUS. Hyper-vascular pattern at DFI correlates with low Ki-67 index.

Clinical Case Summary

We report the case of a 16-year-old boy followed since age 10 for pancolitis-type ulcerative colitis (UC), resistant to 5-ASA, corticosteroids, immunosuppressants, anti-TNFα, and recently deemed refractory to ustekinumab. The disease was complicated by primary sclerosing cholangitis (PSC), leading to decompensated cirrhosis.
The patient presented with a moderate flare during ustekinumab induction, including diarrhea, rectal syndrome, abdominal pain, intractable vomiting, inflammatory lower-back pain, and new-onset ascites.
Colonoscopy revealed multiple polyps from rectum to cecum, some with irregular, raspberry-like surfaces, arising on normal-appearing mucosa without erythema or ulceration. Upper endoscopy, performed due to vomiting and hematemesis, showed grade III esophageal varices, portal hypertensive gastropathy, and multiple gastric polyps, some with similar irregular surfaces. MR enterography, though limited by suboptimal bowel distension, showed no small bowel polyposis.
These unexpected endoscopic findings introduced new challenges. Management options included treatment of refractory UC, assessment and surveillance of colonic and gastric polyps—raising concern for an underlying polyposis syndrome—and liver transplant evaluation for cirrhosis. The patient was treated with IV corticosteroids, then transitioned to an oral taper after clinical improvement.
Due to the complexity, a combined therapeutic approach (colectomy, gastrectomy, and liver transplantation) was considered unfeasible. The patient and family were counseled and referred to a national transplant and surgical center for sequential management planning: liver transplantation, followed by colectomy and endoscopic resection of gastric polyps.
This rare case highlights the therapeutic and diagnostic complexity of managing refractory pediatric UC with PSC, cirrhosis, and gastrointestinal polyposis, necessitating a highly individualized, multidisciplinary approach.

References

Figure 1 showing endoscopic images of the gastric (1a) and colonic (1b) polyposis
Figure 2 showing histological findings of biopsies of some of the gastric (2a) and colonic (2b) polyps
Figure 3 MR enterography of the patient showing no signs of small bowel involvement

Introduction

Computer Aided Detection (CADe) systems may improve detection of (pre-)malignant lesions by endoscopists. Most CADe systems are developed using homogeneous datasets collected by experts, which do not represent the heterogeneous imaging conditions of daily clinical practice. Such heterogeneity is caused by endoscopist-dependent variation (e.g. skill and experience) as well as endoscopist-independent variation (e.g. endoscopy equipment). Recently, we presented a CADe system for Barrett’s neoplasia¹. However, all training and test data originated from expert centers.

Aims & Methods

We aimed to develop an updated CADe system (CADe 2.0) demonstrating more robustness to the varied imaging conditions found in routine patient care.
Our previously published CADe system (CADe 1.0) was trained and internally validated on a high-quality dataset originating from 15 expert centers. The dataset included 6.337 neoplastic (1.362 patients) and 7.695 non-dysplastic images (1.139 patients).
The updated CADe system (CADe 2.0) underwent four improvements. First, we included more heterogeneous training data from our training set patient population. We extracted video frames from videos comprising various quality artefacts (e.g. blurred lenses or insufficient mucosal cleaning). Second, we applied advanced data augmentation methods to address the diversity of post-processing enhancement settings used by modern endoscopy systems. Third, we updated the CADe system with a Vision Transformer architecture², which has shown to improve performance on lower quality endoscopic images³. Finally, we transitioned our pretraining approach from semi-supervised to a self-supervised learning framework⁴.
Both CADe systems were evaluated using three prospectively collected, independent test sets. The first test set represented the true diversity and complexity encountered in daily clinical practice. This dataset comprised all videos captured from all included patients in five referral centers between April 2022 and January 2024 (431 ten-second BE videos from 115 patients). The second test set focused on endoscopist-dependent variation. It included three paired subsets with high, moderate and low-quality images from 122 patients. Quality was determined by factors such as esophageal expansion and mucosal cleaning. The third test set addressed endoscopist-independent variation. It contained 16 paired subsets of 396 images (122 patients). Every subset was based on a different post-processing enhancement setting of the endoscopy system.

Results

For test set 1, CADe 1.0 reached a sensitivity and specificity of 84% and 73%. CADe 2.0 scored 93% and 76%. For test set 2, CADe 2.0 reached higher sensitivity and specificity scores on high-quality images compared to CADe 1.0. In addition, CADe 2.0 performance loss on moderate and low-quality images was smaller. On test set 3 CADe 1.0 scores substantially varied depending on the test sets enhancement setting (82-94% sensitivity, 52-83% specificity). Variation of CADe 2.0 was limited to 91-95% and 81-88%.

Table 1. Results of CADe 1.0 and CADe 2.0

Conclusion

The updated CADe system displayed improved performance for detection of Barrett’s neoplasia in videos. More importantly, this CADe system also displayed less performance loss when exposed to lower image quality and less performance variability when confronted with differing post-processing enhancement settings.

References

1. Fockens N, Jong MR, Jukema JB, Pouw RE, Duits LC, Van Munster SN, et al. A deep learning system for detection of early Barrett's neoplasia: a model development and validation study. The Lancet Digit Health. 2023;5:905-21.
2. Yu W, Si C, Zhou P, Luo M, Zhou Y, Feng J, et al. MetaFormer Baselines for Vision2022 October 01, 2022:[arXiv:2210.13452 p.]. Available from: https://ui.adsabs.harvard.edu/abs/2022arXiv221013452Y.
3. Kusters CHJ, Boers TGW, Jaspers TJM, Jukema JB, Jong MR, Fockens KN, et al., editors. CNNs vs. Transformers: Performance and Robustness in Endoscopic Image Analysis. Applications of Medical Artificial Intelligence; 2024 2024//; Cham: Springer Nature Switzerland.
4. Caron M, Touvron H, Misra I, Jégou H, Mairal J, Bojanowski P, et al. Emerging Properties in Self-Supervised Vision Transformers2021 April 01, 2021:[arXiv:2104.14294 p.]. Available from: https://ui.adsabs.harvard.edu/abs/2021arXiv210414294C.

Introduction

Aspiration Pneumonia is a well described complication of upper digestive endoscopy. However, limited data are available on incidence, risk factors and clinical consequences of post- Endoscopic retrograde cholangiopancreatography (ERCP) aspiration pneumonia (pEP).

Aims & Methods

All consecutive ERCPs performed under anesthesiologist-administered sedation at the Endoscopy Unit of the University of Verona between April 1st 2022 and August 31st 2024 were retrospectively evaluated. Demographical, clinical and endoscopic data were collected.

Results

One-thousand-one-hundred-forty consecutive ERCPs were included. Main indication was malignant biliary stricture and patient’s mean age was 68±13.9 years. Overall incidence of pEP was 2.7%. American Society of Anesthesiologists (ASA) score, presence of active cholangitis before ERCP and performance of endoscopic ultrasound (EUS) and ERCP in the same sedation session were significantly associated to higher risk of pEP at both univariable and multivariable analysis. pEP was an independent risk factor for post-ERCP 30-days-mortality and for prolonged hospital stay.

Conclusion

pEP is a relatively frequent adverse event after ERCP. In patent with high ASA score, active cholangitis and scheduled EUS and ERCP in the same sedation session, preventive medical and/or anesthesiological strategies might be considered. Additional prospective studies are needed to confirm these data.

References

Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Complications of ERCP: a prospective study.
ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.
Unrecognised aspiration pneumonitis during enteroscopy: two case report.
Efficecay and safety of therapeutic endoscopic retrograde cholangiopancreatography in patients with native papillae with a performance status score of 3 or 4: a single-center retrospective study.
A prospective assessment of sedation-related adverse events and patient and endoscopist satisfaction in ERCP with anesthesiologist-administred sedation.
Increased ERCP-related adverse event from premature urgent ERCP following symptom onset in acute biliary pancreatitis with cholangitis.
Acute sedation-associated complications in GI endoscopy (ProSed 2 Study): results from the prospective multicentre electronic registry of sedation-associated complications.
Deep sedation without intubation for ERCP is appropriate in healthier, non-obese patients.
Comparative efficacy and safety of anesthetic and sedative regimens for endoscopic retrograde cholangiopancreatography: a network meta-analysis.
International consensus recommendations for difficult biliary access.
Intraprocedural quality in endosocpic retrograde cholangiopancreatography: e meta-analysis.
Criteria for difficult biliary cannulation: start to count.
Safety and efficacy of therapeutic endoscopic retrograde cholangiopancreatography for patients over 90 years of age.
Risk factors for post-endoscopic retrograde cholangiopancreatography complications in very elderly patients aged 90 years or older-no additional risk.

Disclosure

I have no conflict of interest

Introduction

Acute pancreatitis (AP) is associated with an intense catabolic, local-regional and systemic inflammatory state, which can lead to changes in body composition, with prognostic implications.

Aims & Methods

Aims: To evaluate the body composition by anthropometry, bioelectrical impedance analysis (BIA) and computed tomography (CT) and its influence in AP severity, endocrine insufficiency (EnPI-AP), pancreatic exocrine (EPI-AP) and post-pancreatic enzyme replacement therapy (PERT).
Methods: Prospective longitudinal study of consecutive adult patients diagnosed with first AP episode. EPI-AP patients were randomized to receive PERT (4000IU/meal+20000IU/snack) vs. placebo (clinicaltrials.gov:NCT05480241). Body composition was assessed using anthropometry, BIA (InBody 570) and CT (cross-sectional areas L1/L3). Obesity was diagnosed for body mass index (BMI)≥30Kg/m², waist-to-hip ratio (WHR)>0.9(men)/0.85(women) and percentage total fat mass (TFM)>20%(men)/28%(women). Visceral obesity was defined by abdominal circumference (AC)>94(men)/80(women)cm, visceral fat area (VFA)≥100cm² and visceral/subcutaneous fat ratio (VSFR)≥0.4. Sarcopenia was diagnosed by skeletal muscle mass (SMM)<20(men)/15(women)Kg, SMM index (SMMi)<7.0/5.5Kg/m² and skeletal muscle area index (SMAi)<41(men)/38.5(women)cm². The three methods were correlated using spearman test and Bland-Altman plots.

Results

A total of 105 patients (65.7%(n=69) males; mean age:63.8±17.1yo) were enrolled and followed-up. AP was moderately-severe/severe in 32.4%/16.2%. EPI-AP and EnPI-AP occurred in 47.6%(n=50) and 17.1%(n=18). EPI-AP was persistent (≥6months after AP diagnosis) in 58%. After 6-month post-randomization, 44%(n=11/25) under PERT and 40%(n=10/25) under placebo resolved EPI-AP (p=0.598).
Obesity was diagnosed in 19.0%(n=20) by BMI, 97.1%(n=102)/72.4%(n=76) by WHR in antropometry/BIA, and 57.1%(n=60) by TFM. Visceral obesity was diagnosed in 78.1%(n=82) by AC, in 41.9%(n=44)/ 97.2%(n=103) by VFM in BIA/CT and in 90.5%(n=95) by VSFR. Sarcopenia was diagnosed in 1.0%(n=1) by MMS.
Considering outcomes, moderately-severe/severe AP was strongly associated with WHR by BIA (OR=10.2; p=0.034) and VFA by BIA (OR=1.08; p=0.029) and CT (OR=1.003; p=0.038). EPI-AP was statically associated with WHR by BIA (OR=11.6; p=0.048) and SMMi by BIA (OR=77.4; p=0.048) and TFM (OR=2.3; p=0.048). Severe EPI-AP was strongly associated with VSFR (OR=20;95%CI; p=0.048) and SMMi by BIA (OR=23.2; p=0.003) and CT (OR=2.3; p=0.041). SMMi by BIA (OR=14.1; p=0.030) and CT (OR=1.6; p=0.031) predicted EnPI-AP.
For obesity, TFM by BIA had a strong correlation with BMI (r=0.61; p<0.001) and a weak correlation with WHR by anthropometry (r=0.37; p<0.001). Regarding visceral obesity, VFA by BIA was weakly correlated with WHR by anthropometry (r=0.29; p=0.004) and VFA by CT (r=0.20; p=0.045). For sarcopenia, SMM by BIA was strongly correlated with SMM by CT (r=0.78; p<0.001).
In EPI-AP patients, a significant decrease of WHR (t(52)=2.262; p=0.028) and TFM (t(53)=1.695; p=0.046) by BIA was observed after 6months of PERT.

Conclusion

Body composition is significantly changed in AP, with >2/3 of patients with obesity, especially the visceral component. Obesity, including visceral obesity, correlates with AP severity. Obesity, including visceral obesity and sarcopenia are correlated with the EPI-AP and its severity, while sarcopenia is correlated with EnPI-AP. PERT has led to a significant reduction in obesity markers. Body composition assessment by BIA (TFM, VFA and SMM) and CT (VFA and SMM) were of clinical value and comparable.

References

1. Kim J, Kim S-s, Hwang HK, Kang CM, Kim KS, Kim SH. Body composition assessment using bioelectrical impedance analysis and computed tomography in patients who underwent pancreatoduodenectomy in Korea: a before and after study. Ann Nutr Metab 2023;15(3):72-80.
2. Wang S, Wang M, Jiang L, Zhao X. Low skeletal muscle quality extracted from CT is associated with poor outcomes in severe acute pancreatitis patients. Eur J Radiol 2024;170:111215.
3. Zhou Y, Hao N, Duan Z, Kong M, Xu M, Zhang D, et al. Assessment of acute pancreatitis severity and prognosis with CT-measured body composition. Int J Gen Med 2021;14:3971-3980.
4. Chaigneau T, Morello R, Vannier E, Musikas M, Piquet M-A, Vupont B. Impact of sarcopenic obesity on predicting the severity of acute pancreatitis. Did Liver Dis 2023;55(7):926-932.