Introduction

Ampullary lesions (AL) of the minor duodenal papilla are extremely rare. Endoscopic papillectomy (EP) is a routinely used treatment for AL of the major duodenal papilla but the role of EP for minor AL has not been elucidated yet.

Aims & Methods

We identified 20 patients with AL of minor duodenal papilla out of the multicentric database from the ESAP study that included 1422 EPs (prevalence of minor papillary lesions: 1.4%). We evaluated the procedural outcomes and safety of EP for minor AL.

Results

All patients with an AL of the minor duodenal papilla received an EP. The most common histological subtype was an ampullary adenoma in 12 Patients (3 low-grade dysplasia and 9 high-grad dysplasia). Five patients revealed non-neoplastic lesions. Invasive cancer (T1a), adenomyoma and neuroendocrine neoplasia each were found in one case. The rate of complete resection (R0) was 90%. There were no severe complications. After EP one patient had a bleeding that required an intervention and two patients had a recurrence that was detected in follow-up endoscopy. After EP the median follow up was 27.7 months (0-70).

Conclusion

EP is safe and effective in AL of the minor duodenal papilla. The management of these lesion seems to be similar to AL of the major duodenal papilla.

Clinical Case Summary

Intra-ampullary papillary tubular neoplasms (IAPNs) are rare neoplastic intraepithelial lesions that occur within the ampulla. Given their well-documented malignant potential, early recognition and intervention are paramount to prevent malignant transformation. We present a case of IAPN successfully managed via endoscopic papillectomy.
A 58-year-old male was incidentally found to have a bulky-appearing ampulla of vater during esophagogastroduodenoscopy as part of routine health screening. Endoscopic ultrasonography revealed a 20-mm hyperechoic lesion at the ampulla, with histopathological evaluation demonstrating low-grade dysplasia (indeterminate for neoplasia). Laboratory investigations, including hematological parameters, biochemical profiles, and tumor markers, were within normal limits. Contrast-enhanced abdominal CT demonstrated a well-defined, homogeneously enhancing 20-mm lesion at the ampullary region without biliary/pancreatic duct dilation.
Endoscopic papillectomy was performed using a duodenoscope with snare. Prophylactic stents were placed in both the biliary and pancreatic ducts to ensure adequate drainage. Any intraprocedural bleeding was promptly controlled with hemoclip application. Histopathological analysis confirmed high-grade IAPN, characterized by a polypoid tumor with closely packed tubular glands lined by pseudostratified columnar epithelium showing loss of polarity and moderate nuclear atypia (Ki-67 index: 50%). The postoperative course was uncomplicated, with discharge achieved on the sixth postoperative day. At six-month follow-up evaluation, surveillance endoscopic ultrasonography showed no evidence of recurrence.
IAPN represents a distinct neoplastic ampullary entity within the spectrum of ampullary tumors. While endoscopic resection demonstrates therapeutic efficacy, its implementation requires advanced endoscopic expertise in specialized centers.

References

Endoscopic ultrasonography revealed a 20-mm hyperechoic lesion at the ampulla
Endoscopic papillectomy was performed using a duodenoscope with snare. Prophylactic stents were placed in both the biliary and pancreatic ducts to ensure adequate drainage. Any intraprocedural bleeding was promptly controlled with hemoclip application.
Histopathological analysis confirmed high-grade IAPN, characterized by a polypoid tumor with closely packed tubular glands lined by pseudostratified columnar epithelium showing loss of polarity and moderate nuclear atypia (Ki-67 index: 50%).

Clinical Case Summary

Introduction: Dieulafoy lesions account for less than 2% of gastrointestinal bleeds, and only 20% of these occur outside the stomach. We present a rare case of a bleeding ampullary Dieulafoy lesion with technical difficulties in management, starting with a standard forward-viewing gastroscope, subsequent use of a side-viewing duodenoscope, and eventually endoscopic retrograde cholangiopancreatography (ERCP) and stenting to allow for safe haemostasis with argon plasma coagulation (APC).
Case report: A 56-year-old male was admitted with pneumonia and fluid overload in the context of end-stage renal disease from poorly controlled diabetes mellitus and hypertensive nephrosclerosis on regular haemodialysis. He was on dual anti-platelet therapy with aspirin and ticagrelor for a recent cardiac stent.
Five days into his admission he was noted to have melena with a haemoglobin drop from 87 g/L to 56 g/L, with a urea rise of 23.9 mmol/L from a baseline of 11.0 mmol/L.
Subsequent gastroscopy revealed active bleeding from the major ampulla without any underlying ulcer or tumour, superior to the biliary orifice, consistent with an ampullary Dieulafoy lesion. The duodenoscope was then introduced for a better view and access to the major ampulla. APC was attempted at 0.8 L/min at 30 Watts due to the size and location, but haemostasis was unsuccessful.
The decision was made to proceed to ERCP and biliary stenting to prevent complications from heat injury to the bile duct and possible pancreatitis. A 7 Fr by 4 cm double pigtail biliary plastic stent was placed into the common bile duct. APC was re-applied at 0.8 L/min at 30 Watts at the bleeding spot with successful haemostasis.
Discussion: This case report aims to highlight the rare occurrence of duodenal ampullary Dieulafoy lesions and the need for prompt recognition and use of resources such as side-view duodenoscopy and ERCP for safe therapeutic management.

Disclosure

None

Introduction

Gut micorbiota in patients with cystic fibrosis (pwCF) is severely disrupted and a potential source of further complications. We aim to provide quantitative evidence of the differences in gut microbiota between pwCF and non-CF controls to understand CF gut flora composition and identify potential sites for microbiota modulation with special focus on time-dependent changes.

Aims & Methods

We conducted a systematic review and meta-analysis of PubMed, EMBASE, CENTRAL, Web of Science, and Scopus up to November 13, 2023 (CRD42023482792). Included were case-control studies assessing gut microbial alpha diversity or relative abundance in pwCF and controls without gut-affecting conditions or drugs. Standardized mean differences (SMD) with 95% confidence intervals (CI) were calculated using a random-effects model for both outcomes. We performed subgroup analysis for alpha diversity for infants, children, and adults. We used the Joanna Briggs Institute risk of bias tool.

Results

Among 2550 studies, 11 met inclusion criteria (enrolling 1174 subjects). Alpha diversity analysis showed age-specific changes. Observed OTUs were non-significantly decreased in adult pwCF compared to controls (SMD=-1.57; 95%CI -4.21 to 1.08, across 3 studies, 80 pwCF and 100 controls). Children with CF displayed a significantly reduced Shannon index (SMD=-1.43; 95%CI -2.06 to -0.79, across 3 studies, 77 pwCF and 78 controls). However, in infants, no difference was detected in Shannon index between CF patients and controls (SMD=0.05; 95%CI -0.74 to 0.84, across 4 studies, 288 pwCF, 519 controls). Analysis of follow-up data in infants revealed a decreasing tendency of Shannon index in pwCF compared to controls during the first year of life (SMD=0.67; 95%CI -1.20 to 2.54 at 4 months vs. SMD=0.45; 95%CI -1.81 to 2.71 at 6 months vs. SMD=-0.61; 95%CI -1.98 to 0.75 at 12 months). A significant increase in the relative abundance of Veillonella and E.coli marked the CF group with a noticeable increase of Enterobacter and decrease of Bacteroides and Faecalibacterium compared to controls (see Table).

Conclusion

Gut microbial alpha diversity is reduced in adults and children with CF compared to controls, while infants with CF exhibit similar diversity, which continuously decreases during the first year of life. Perturbations in the intestinal microbial ecosystem are defined by a significant increase in E.coli and Veillonella abundances within individuals with CF compared to controls enabling specifically targeted microbiota modulation.

Introduction

Ulcerative colitis (UC) is a chronic inflammatory disease requiring sustained therapy for both induction and maintenance of remission. Biologics radically changed the natural history of UC patients and are still the cornerstone of treatment, but they have some limitations. The introduction of oral Janus kinase inhibitors (JAKi), recently approved for UC management, presents a novel treatment option. Data are needed to confirm their efficacy in a real world setting.

Aims & Methods

In this retrospective, observational study at the IBD Unit in Bologna, we enrolled consecutive UC patients treated with the JAKi tofacitinib (TOFA) and upadacitinib (UPA). We collected demographic and disease-specific data, assessing clinical activity via the partial Mayo (pMayo) score, biomarker status through C-reactive protein levels, and endoscopic activity via the Mayo endoscopic score at baseline and at 2, 6, and 12 months. Concomitant use of steroids were registered at every time point. We measured clinical response (≤3-point reduction in pMayo or discontinuation of steroids) at 2 months, clinical remission rates (pMayo < 2) and endoscopic remission (Mayo score of 0) at each time point. Need for surgery was also recorded.

Results

A total of 50 patients were treated with JAKi between December 2021 an June 2023 (39 TOFA and 11 UPA). Males were 59.57% and median age was 35.5 years. Nobody were bio-naïve and 80.86% were exposed to ≥ 2 biologics/small molecules prior to JAKi initiation. Concomitant steroids were present in 76% of cases at baseline. Clinical response at T2 was obtained in 65.30% of cases. Clinical remission rate was 40% at T2, 32.6% at T6 and 24.4% at T12. Endoscopy was performed at T2 in 24 patients, at T6 in 26 and at T12 in 10 patients; endoscopic remission was observed in 5/24, 9/26 and 4/10, respectively. Treatment optimization was adopted in 52% of cases. A total of 5 patients (10%) underwent colectomy during follow up period. No serious adverse events were observed.

Conclusion

In a cohort of multirefractory UC patients, JAKi demonstrated substantial efficacy in inducing clinical and endoscopic remission, though there was a decline in effectiveness during the maintenance phase. The rate of colectomy remained relatively low, underscoring the potential utility of JAKi in this challenging patient population.

Introduction

The Tokyo Guidelines recommend a CRP cutoff >10 mg/L for diagnosing acute cholangitis. However, this threshold was defined in lithiasic populations and may not be applicable to malignant biliary obstruction, where CRP elevation often reflects tumor-driven inflammation rather than true infection. Applying this universal threshold in oncologic settings risks antibiotic overuse and promotes resistance.

Aims & Methods

This study aimed to reassess the diagnostic value of the current CRP cutoff in tumor-related cholangitis and to identify a more appropriate threshold to enhance specificity and guide targeted antibiotic use.
We conducted a retrospective monocentric study of consecutive patients at a tertiary center between May 2016 and October 2024. Among 571 patients undergoing ERCP, 268 patients with confirmed malignant biliary obstruction and available bile sampling were included. Bacteriological status was defined as positive when either direct bile examination or culture isolated microorganisms. CRP levels, leukocyte counts (hyperleukocytosis >10,000/mm³), and tumor etiology were recorded. ROC curve analysis was performed to determine the optimal CRP cutoff. Comparative analyses employed Mann-Whitney U, chi-square, and multivariate logistic regression.

Results

The mean age was 65.9 ± 12.4 years, with an equal sex distribution (50% male). Tumor etiologies included pancreatic cancer (56%), cholangiocarcinoma (22%) — 40 hilar and 18 distal cases, gallbladder cancer (13%), ampulloma (7%), and extrinsic or secondary compression (3%). The median CRP was significantly higher in culture-positive patients (47 mg/L [IQR 21–98]) compared to culture-sterile patients (22 mg/L [IQR 11–36]; p<0.001). ROC analysis identified an optimal CRP cutoff of 21 mg/L (AUC = 0.64), achieving a sensitivity of 67% and specificity of 54%. Hyperleukocytosis was present in 66% of culture-positive cases versus 31% of sterile cases (p<0.001). In multivariate analysis, CRP ≥21 mg/L (OR 2.1; 95% CI [1.3–3.4]; p=0.002) and hyperleukocytosis (OR 3.4; 95% CI [1.9–5.9]; p<0.001) were independently associated with bile bacteriological positivity.

Conclusion

In malignant biliary obstruction, the universal CRP threshold of 10 mg/L lacks specificity and risks antibiotic overuse. A higher threshold around 21–25 mg/L, combined with leukocyte count assessment, improves diagnostic precision. Our findings advocate for a context-specific adaptation of the Tokyo Guidelines to better differentiate tumor-related inflammation from true infection, ultimately enhancing patient safety and antimicrobial stewardship in oncologic care.