Introduction

Screening for colorectal cancer (CRC) by colonoscopy has contributed to a steadily declining rate of incidence and mortality related to CRC in recent years. The caveats of the former are difficult mucosa and polyp visibility, among others. The Cap cuff is an endoscopy-enhancing device aiming to improve mucosal inspection, and thus, polyp detection. However, there is limited evidence-based knowledge surrounding its true clinical impact. Our study investigates the degree of clinical effectiveness of the Cap cuff-enhanced colonoscopy (CCEC) when assessing for colonic polyps and distal rectal pathology.

Aims & Methods

We conducted a non-randomized trial by recruiting consenting and eligible participants aged 18 years or older, that were undergoing either a screening, surveillance, or urgent colonoscopy at the Montfort Hospital (Ottawa, CAN) from August 2022 to February 2023. All participants (N=375) underwent an CCEC. The colon was assessed once; while the rectum was initially assessed with direct visualization and subsequently reassessed by retroflexion. The polyps were removed and documented. Our study's primary outcome focused on evaluating the CCEC’s impact on colonic polyp detection rate (cPDR) when compared to retrospective controls of standard colonoscopy dating from January 2017 to August 2022. It also focused on investigating the distal rectal pathology detection rate (rPaDR) with Cap cuff-enhanced direct visualisation (CCEDv) compared to Cap cuff-enhanced retroflexion (CCER). Secondary outcomes included procedure safety and patient tolerance. cPDR data was acquired by the review of prospective and retrospective operative reports for polyp presence. The control group was established by sample-matching based on age and sex. rPaDR data was acquired by the review of participant’s operative report for distal rectal pathology presence and modality of pathology visualisation.

Results

The results demonstrate a lower overall cPDR in the treatment group compared to the control group (72.2% vs. 88.7%, respectively; p< 0.01). By age group, the CCEC demonstrated a cPDR of 60.2% for participants aged 31-50 years (n=88) compared to 82.9% in the retrospective control group (n=88), 74.8% for participants aged 51-65 (n=171) compared to 89.4% in the retrospective control group (n=142) and 79.5% for participants aged 66+ (n=112) compared to 93.7% in the retrospective control group (n=112). CCEC’s cPDR for participants 18-30 years was not statistically significant (n=4) but included in the overall cPDR. As for the rPaDR, specifically for rectal polyp detection (n=16), 2 polyps were only viewed by CCEDv, while 6 polyps were only viewed by CCER. The other 8 were viewed by both CCEDv and CCER. Regarding hemorrhoid detection (n=159), CCER was a significantly better modality compared to CCEDv (89.9% vs. 1.3%, respectively; p< 0.01). A majority tolerated the procedure very well (94.7%) and there were no adverse events associated with the usage of the Cap cuff during the study.

Conclusion

In contrast to prior promising studies, the CCEC failed to meet expectations. CCEC did not distinguish itself from standard colonoscopy. With respect to distal rPaDR, sole CCEDv was significantly inferior to CCER, demonstrating the importance of the use of retroflexion during colonoscopy despite the use of the Cap cuff. This study unveils possible criticisms in the clinical effectiveness of the Cap cuff. Further studies should evaluate these initial findings by means of a larger scaled study.

Introduction

Patients with metabolic-dysfunction associated steatohepatitis (NAFLD activity score ≥4) and significant fibrosis (≥F2) (fibrotic MASH) are at increased risk for disease progression and development of cirrhosis. Following the recent approval of the first agent for the management of noncirrhotic MASH, timely identification of these patients is of major importance. Fibroscan-aspartate aminotransferase (FAST^TM) score enables the noninvasive diagnosis of fibrotic MASH, and has been assessed in several studies.

Aims & Methods

To assess the overall performance of FAST^TM score for diagnosing fibrotic MASH. We searched Medline, Cochrane library, Web of science and Scopus up to January 2024. We included diagnostic accuracy studies assessing the performance of FAST^TM score for ruling out (FAST^TM score ≤0.35) and ruling in (FAST^TMscore ≥0.67) fibrotic MASH using liver biopsy as the reference standard. We calculated pooled diagnostic accuracy estimates using bivariate random-effects models, and assessed risk of bias using the Quality Assessment of Diagnostic Accuracy Studies 2 tool.

Results

We included 16 studies with 8838 participants. Most studies (87.5%) were at high or unclear risk of bias due to concerns regarding patient selection, interpretation of FAST score without knowledge of biopsy results, and length of biopsy specimens for fibrotic MASH diagnosis. Across all participants, 54.8% were females and 31% had type 2 diabetes. Mean age and body mass index (BMI) were 52.4 years and 32.4 kg/m². Mean aspartate aminotransferase and alanine aminotransferase were 45.0 IU and 57.6 IU, respectively. The prevalence of fibrotic MASH across studies was 32.9% ranging from 14% to 55%. Using the rule out cut off (≤0.35), FAST^TM yielded a pooled sensitivity of 0.88 (95 % CI; 0.83, 0.91), specificity 0.52 (0.45, 0.60), positive likelihood ratio (LRp) 1.8 (1.6, 2.1) and negative likelihood ratio (LRn) 0.23 (0.18, 0.30). By applying the rule in cut off (≥0.67), pooled sensitivity, specificity, LRp, and LRn were 0.45 (0.39, 0.52), 0.87 (0.82, 0.90), 3.4 (2.8, 4.1) and 0.63 (0.58, 0.69) respectively. Assuming a pre-test probability (prevalence) of 30% for fibrotic MASH, a FAST^TM score ≥0.67 resulted in a positive predictive value of 60%, while with a FAST^TM score ≤0.35 the negative predictive value was 91%.

Conclusion

FAST^MT score has acceptable accuracy for the diagnosis of fibrotic MASH. Proposed thresholds of ≤0.35 and ≥0.67 might be useful for ruling out/in fibrotic MASH respectively.

Introduction

Opium tincture in oral solution has been used for antidiarrheal treatment for centuries, and it is often used to treat chronic idiopathic diarrhea as a secondary choice after loperamide and bulking agents. However, the underlying mechanisms of opium tincture on gastrointestinal function are not evident and have not been investigated in clinical trials. This study aimed to investigate the effects of opium tincture on gastrointestinal motility, intestinal volumes, and water content of different gut segments assessed by magnetic resonance imaging (MRI).

Aims & Methods

Twenty healthy volunteers were included in a randomized, placebo-controlled, cross-over study with 9-day treatment (30 drops per day of opium tincture corresponding to 15 mg of oral morphine or placebo). MRI was performed on day 1 (before treatment) and day 9 (during treatment) using a pan-alimentary scan protocol. Images were obtained during fasting and after a 285-kcal granola bar meal. MRI measurements included assessments of gastric volume, gastric emptying half-time, gastric motility, small bowel volume, small bowel water content, small bowel motility, colon volume, colon water content, and whole gut transit. Data was analyzed using repeated measure mixed models and adjusted using baseline data as a covariate and a Bonferroni post hoc correction.

Results

The median age of the included subjects was 24 years (range 20-72 years), and 10 subjects were female. Opium tincture delayed gastric half-emptying time as compared to placebo (mean [95% confidence intervals] values: 38.5 [35.3-41.6] min vs. 32.8 [29.9-35.8] min, p=0.004). Opium tincture increased gastric meal volumes 15 and 30 minutes after the meal as compared to placebo (ps<0.018). Gastric contraction amplitude and frequency were not affected by treatment. Small bowel endpoints were not different between treatments (all p>0.05). Ascending-, transverse-, and descending colon volumes were increased after opium tincture as compared to placebo (ascending: 226 [197-253] ml vs 168 [140-195] ml, p=0.003; transverse: 208 [180-236] ml vs. 158 [131-185] ml, p=0.017; descending: 155 [125-184] ml vs. 110 [83-138] ml, p=0.045). T1-relaxation time (a proxy for water content) of the descending colon chyme was decreased during opium tincture as compared to placebo, indicating dryer feces (517 [425-609] ms vs. 690 [595-786] ms, p=0.030). Whole gut transit time was delayed during opium tincture as compared to placebo (p=0.027).

Conclusion

Opium tincture as compared to placebo induces changes in gastric and colonic motility and volumes as measured using a pan-alimentary MRI framework in a population of healthy volunteers. Based on the current results, opium tincture seems to affect the gastrointestinal tract in ways that are relevant for treating diarrhea. An improved understanding of how opioids affect gut functions may lead to a better understanding of and optimized management of diarrhea.

Introduction

Dysphagia is a common and alarming symptom, which harbours the risk of organic diseases. Its incidence is increasing in the last decades worldwide, both in the young and elderly population. However, epidemiological and clinical data related to dysphagia patients are lacking. Thus, we aimed to provide an updated analysis of the main underlying causes of dysphagia in outpatient clinic.

Aims & Methods

We retrospectively evaluated consecutive patients referred from June 2022 to December 2022 to our outpatient clinic, suffering from incident dysphagia as the main symptom at the index visit. Patients already previously evaluated were excluded. After clinical evaluation, all the subjects underwent esophago-gastro-duodenal endoscopy (EGDS) as the first diagnostic exam, during which, up to clinical suspect and endoscopist evaluation, biopsies of the oesophagus and/or cardias were made. According to clinician assessment, execution of high-resolution manometry (HRM) was also performed.

Results

During the study period 700 first outpatient visits were performed. A total of 78 patients met the inclusion criteria and were then involved in the study. Esophageal dysphagia was the most frequently reported symptom (65/78, 83.3%), followed by oropharyngeal dysphagia (8/78, 10.3%) and mixed dysphagia (5/78, 6.4%). The most common concomitant symptoms were chest pain (40/78, 51.3%), regurgitation (34/78, 43.6%), heartburn (20/78, 25.6%), weight loss (19/78, 24.3%) and cough (14/78, 17.9%). Median age was 57.0, with M/F ratio of 33/78 (42.3%). Endoscopy showed abnormal features in 25/78 (32.1%), with the most common finding being erosive esophagitis (5/25, 20%). Seven out of 25 (28%) subjects had at least one non-specific finding among those associated with eosinophilic esophagitis (edema, rings, exudate, furrowing, strictures). The physician performed biopsies of the esophagus and/or cardias in 52/78 (66.6%) cases, and 28 patients had histologic abnormal findings. The most common histological diagnosis was eosinophilic esophagitis (EoE) which was identified in 12 patients, 5/12 (41.7%) without mucosal evidence of EoE. HRM was performed in 22/30 patients (73.3%) after negative endoscopy and/or histology, with abnormal findings in 17/22 (77.3%) of the tests. In this setting achalasia was the most common diagnosis (5/22, 22.7%), one patient with Type I, two with Type II and two patients with Type III.
Overall, the most common diagnosis in our cohort was EoE (12/78, 15.4%), followed by achalasia (7/78, 9.0%).

Conclusion

Among patients complaining of dysphagia referred to an outpatient gastroenterology clinic, EoE is the main underlying cause of such condition. Given its high frequency, biopsies should be always performed in patients with dysphagia, regardless of endoscopic findings.

Clinical Case Summary

We present a rare case of protein losing gastropathy.A 60-year-old female presented to our clinic with 10 years history of intermittent dyspepsia with no alarm features and peripheral oedema for 6 months.Physical examination was unremarkable except mild bilateral pitting oedema.Pertinent investigations suggested normal albumin,urine analysis,renal&liver profiles and a normal echocardiogram.Subsequent testing with esophagogastroduodenoscopy(EGD) for dyspepsia showed hypertrophied mucosal folds predominantly in gastric corpus while sparing the antrum.Full thickness biopsies were taken and sent for histopathology with differentials of Lymphoma,adenocarcinoma,sarcoidosis and Menetrier’s disease.Stool antigen for Helicobacter Pylori(H.Pylori)thereafter,was positive while Contrast enhanced CT abdomen was consistent with mildly thickened gastric walls.Histological examination demostrated foveolar hyperplasia,elongated gastric pits and cystically dilated gastric glands without any features of malignancy.Hence a diagnosis of Menetrier’s disease(underlying H.Pylori) was made.
Patient then had H.Pylori eradication therapy as well as a diet rich in medium-chain fatty acids and proteins.H.Pylori eradication was confirmed.6 months follow up revealed partial resolution of her symptoms but no change in endoscopic findings.Patient could not undergo further treatment with biologics(cetuximab)due to financial constraints and octreotide for its local unavailability.She is now on a yearly endoscopic surveillance for future high risk of gastric malignancies.

References

​​Fig1A.Haematoxylin & Eosin staining shows foveolar & mucous cell hyperplasia,elongated gastric pits and lymphocytic infiltration.
Fig1B.Haematoxylin & ​Eosin staining shows cystic dilation of gastric glands
1.Pepa P, Uehara T, Wonaga A, Redondo A, Avagnina A, Mazzocchi O, Antelo P, Waldbaum C, Sorda J. Menetrier's disease. A diagnostic and therapeutic challenge. Medicina (B Aires). 2021;81(3):470-473. English. PMID: 34137712.
2.Gore M, Bansal K, Jadhav N. Menetrier Disease. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan– [updated 2023 Jun 25].

Disclosure

No conflicts