Introduction

The underwater immersion technique has so far been used for the resection of sessile polyps, with satisfactory results in terms of efficacy and complications (due to the use of water instead of medical air (CO2) and the absence of fluid substances in the submucosa.

Aims & Methods

The aim of this work is to demonstrate the effectiveness of the underwater technique for diagnostic purposes, in patients suffering from diverticular disease with insurmountable stenosis at traditional colonoscopy.A cohort of 50 patients (20 D and 30 U - mean age 72 years) with incomplete colonoscopy due to stenosing diverticular disease ( DICA 4) confirmed by CT colon ( virtual colonoscopy) examination was enrolled. Previously, all the patients had been evaluated at other endoscopy centers , and studied at the Gastroenterology and Digestive Endoscopy Center of the Benevento ASL, subsequently for the detection, in at least 15 patients, of lesions compatible with polyps > 6 mm on the colon CT scan. All patients underwent colonoscopy under conscious sedation with a thin colonoscope (Olympus PTH PF 190), filling the stenotic lumen with water instead.

Results

In 41 patients, the use of the UW technique allowed the stenotic section to be overcome, allowing the examination to be completed; in the remaining 9 the stenosis was insurmountable. In the 15 patients with lesions compatible with polyps > 6 mm on colon CT, only 5 pts were positive, 2 of which with the finding of polypoid formations > 1 cm in sections other than those reported on colon CT. No complications were recorded both in the diagnostic phase and in the operative phase.

Conclusion

The UNDERWATER technique can represent an alternative method in the diagnosis of certain pathological and inflammatory conditions with a high risk of perforation. The irrigation of the colonic lumen with water also allows the magnification of the mucosa, improving the identification and treatment of polypoid lesions (particularly the sessile ones).

References

A.Tursi et al Dica endoscopic class. for diverticular disease shows a significant interobserver agreement among community endoscopist . J Gastroint Liver Dos 2019 : 28 (1) 23-27.
A.Tursi et Al Prognostic value of Dica score J . Clin. Gastroenterology 2016
Y.Takeuchi et al Underwater endoscopic mucosal resection for colonrectal polyps lesions: can it be an underwater revolution?DEN Open 2022, 2 e84

Introduction

‘Biologic therapies’ are the mainstay treatment for moderate to severe Inflammatory Bowel Disease (IBD), resulting in fewer hospitalisations, adequate treatment response and mucosal healing. ^[1] Adalimumab, Golimumab, Ustekinumab & Risankizumab are administered subcutaneously (SC), Infliximab and Vedolizumab are administered intravenously (IV), and have additionally been available SC since 2020. SC Infliximab was used during the pandemic to limit exposure to hospitals & reduce risk of Covid-19, ^[2] as well as for convenience.

Aims & Methods

We explore patient’s views of IV and SC administered treatments via a paper-based survey for those patients who were on IV treatment when attending for infusions, and a telephone survey on patients with IBD who have been on SC treatment.

Results

IV survey

• 122 completed the survey.
• 50/122 (41.0%) were on Vedolizumab (41.0%), 64 (52.5%) Infliximab, 8 (6.6%) others / didn’t specify.
• 25/120 (20.8%) had been on IV therapy for 2-6 months, 17 (14.2%) for 7-12 months, 29 (24.2%) for 1-3 years, 21 (17.5%) for 3-5 years, 21 (17.5%) for >5 years.
• 107/120 (89.2%) rated treatments as easy, 13 (10.8%) intermediate, 0 difficult.
• 25/112 (22.3%) were previously on SC injections. Of this group: 15/24 (60.0%) favoured the IV route, 9 (36.0%) favoured the SC route.
• 4/15 who favoured the IV route “did not like to inject themselves” or “found it difficult”. 3/15 preferred IV route as they were being monitored.
• 104/110 (94.5%) attended all scheduled blood tests, 4 (3.6%) attended most of them
• 106/109 (97.2%) attended all OP appointments, 2 (1.8%) attend most
• 91/111 (82.0%) had no concerns, 10 (9.0%) had concerns over side effects (SE)
• 31/104 (29.8%) reported SE.
• 6/29 (20.7%) stated SE not affected their quality of life (QoL), 12 (41.4%) little impact QoL, 10 (34.5%) moderate impact, 1 (3.4%) severe impact.
• 96/105 (91.4%) would recommend IV route

• 106/113 (93.8%) completed the survey..
• 54/106 patients were on Adalimumab (50.9%), 24 (22.6%) Ustekinumab, 13 (12.2%) Vedolizumab , 13 (12.3%) Infliximab, 2 (1.9%) Golimumab
• 10/106 (9.4%) for 1-6 months, 21 (19.8%) for 6-12 months, 33 (31.1%) for 1-3yrs, 21 (19.8%) for 3-5 years and 20 (18.9%) for >5 years.
• 89/106 (83.9%) rated treatment administration as easy, 10 (9.4%) intermediate, 2 (1.9%) difficult
• 59/106 (55.7%) were previously on IV infusions. Of this group: 43/59 (72.9%) favoured the SC route, 8 (13.6%) favoured IV, and 8 (13.6%) no preference.
• 24/43 who favoured who favoured SC route stated ‘convenient”, “easy”, “not have to attend hospital” as reasons.
• 86/106 (81.1%) attended all scheduled blood tests, 5 (4.7%) attended most of them,
• 102/106 (96.2%) attended all OP appointments, 3 (2.8%) attend most,
• 68/106 (64.2%) had no concerns, 21 (19.81%) concerned about fewer face to face episodes
• 40/106 (37.7%) reported SE. 8 (20%) skin reactions
• 11/40 (27.5%) stated SE not affected their quality of life (QoL), 14 (35%) little impact QoL, 9 (22.5%) moderate impact, 6 (15%) severe impact.
• 87/106 (82.1%) recommend SC route

Conclusion

The survey found that both IV and SC treatments were easy to administer for the vast majority (89.2% & 84.9%), For patients on SC therapy who previously had IV infusions, 75.6% preferred SC as “convenient”, “easy” and “no (need to attend) hospital”. For patients on IV therapy who previously had SC, 60.0% preferred IV as “did not ned to self inject / found it difficult”, and “preferred monitoring”. Overall there are high levels of satisfaction with 91.4% of patients on IV treatment, and 82.1% of patients on SC treatment recommend their current route of administration.

References

1. E J Mao, G S Hazlewood, G G Kaplan, L Peyrin-Biroulet, and A N Ananthakrishnan, Systematic review with meta-analysis: comparative efficacy of immunosuppressants and biologics for reducing hospitalisation and surgery in Crohn's disease and ulcerative colitis. Aliment Pharmacol Ther, 45: 3-13. https://doi.org/10.1111/apt.13847
2. P J Smith, L Critchley, D Storey, et al, Efficacy and Safety of Elective Switching from Intravenous to Subcutaneous Infliximab [CT-P13]: A Multicentre Cohort Study, Journal of Crohn's and Colitis, Volume 16, Issue 9, September 2022, Pages 1436-46. https://doi.org/10.1093/ecco-jcc/jjac053

Introduction

Direct oral anticoagulants (DOACs), particularly rivaroxaban and apixaban, are increasingly utilized to manage thromboembolic conditions due to their favorable efficacy and safety profiles. However, gastrointestinal bleeding (GIB) remains a significant concern associated with these medications, particularly considering pharmacogenetic variations among populations. This study aims to evaluate the frequency and identify risk factors associated with GIB in patients using rivaroxaban and apixaban in a Mexican healthcare setting.

Aims & Methods

This retrospective observational study analyzed data from January 2018 to December 2023 at the Centro Médico Nacional 20 de Noviembre, Mexico City. The cohort consisted of 278 patients: 136 on DOAC therapy (rivaroxaban or apixaban) and 142 controls without anticoagulation. Clinical data, demographic characteristics, comorbidities, and concomitant medications were systematically reviewed. Statistical methods employed included chi-square tests, Student's t-tests, and logistic regression analysis to assess the risk factors and association between anticoagulant type and incidence of GIB.

Results

The study population had a mean age of 67.36 ± 15.05 years, with an equal gender distribution (52.9% male). Rivaroxaban was significantly linked to increased GIB-related hospitalizations compared to controls (OR 1.29, 95% CI: 1.10–1.52, p < 0.001), while apixaban showed no statistically significant increase. NSAID co-administration dramatically raised the risk of GIB in rivaroxaban users (OR 16.1, 95% CI: 1.22–212.6, p = 0.03). Patients treated with DOACs experienced more hospitalizations (average 0.49 ± 0.80) and longer hospital stays (2.19 ± 3.54 days) compared to controls (0.30 ± 0.62 hospitalizations, 0.99 ± 2.68 days, respectively). Mortality rates were not significantly different between groups.

Conclusion

Rivaroxaban and apixaban present similar overall risks of gastrointestinal bleeding, although rivaroxaban is associated with higher hospitalization rates. Concomitant NSAID use substantially elevates the risk in patients on rivaroxaban. This underscores the necessity of individualized anticoagulant management strategies, especially in populations with distinct genetic and clinical characteristics, such as the Mexican demographic.

References

1. Lopes RD, Guimarães PO, Kolls BJ, et al. Gastrointestinal bleeding with novel oral anticoagulants: A systematic review and meta-analysis. BMJ. 2015;350:h1857.
2. Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955-962.
3. Granger CB, Alexander JH, McMurray JJV, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365:981-992.

Introduction

The eosinophilic esophagitis (EoE) endoscopic reference score (EREFS) is the validated scoring system for endoscopic findings of EoE. EREFS findings are currently scored cumulatively and correlate modestly with histological disease activity (HDA), symptoms, and adaptive behaviors. However, inflammatory and fibrotic findings may reflect different aspects of EoE, but this has never been evaluated.

Aims & Methods

We investigated the correlation of EREFS inflammatory and fibrotic subscores with HDA, symptoms and adaptive behaviors. In three tertiary referral centres for EoE, consecutive adults (>18 years) undergoing upper endoscopy for suspected or follow up EoE were prospectively enrolled. EREFS was scored as follows: edema 0-1; rings 0-3; exudates 0-2; furrows 0-2; stricture 0-1. The EREFS inflammatory sub-score (EREFS-i) combined the scores of edema, exudates and furrows. The EREFS fibrotic sub-score (EREFS-f) combined the scores of moderate-severe rings (score ≥2) and stricture. Subsequently, at least six esophageal biopsies were collected to assess HDA based on peak eosinophil count/high-power field (PEC/HPF) (active EoE PEC ≥15/HPF; EoE in remission: PEC<15/HPF). Symptoms were assessed using the dysphagia symptoms questionnaire (DSQ). Adaptive behaviors were assessed using the Pisa EoE Adaptation Questionnaire v1.0 (PiEAQ) [reference 1]. Clinical characteristics were recorded. Kruskal-Wallis Rank Sum Test and Pearson’s Chi-squared were used for comparisons. ROC curve analysis was used to calculate the diagnostic accuracy (AUC). Spearman’s test and linear regression models were used to assess relationships between variables. Significance threshold was p<0.05.

Results

121 patients were included. 58% had active EoE, 42% were in histological remission. Baseline clinical data are reported in Table 1. The EREFS total score had modest AUC for predicting HDA (0.68) and did not show significant correlation with DSQ and PiEAQ. In contrast, EREFS-i had AUC of 0.73, with 88.2% sensitivity and 51.4% specificity for predicting HDA, being significantly more accurate compared to the EREFS-f (p<0.001; Figure 1). There was a significant correlation between EREFS-i and PEC/HPF with Spearman’s Rho=0.5 (p<0.001), with linear regression showing that an increase of 1 point of any inflammatory feature corresponded to an increase of 12 eosinophils/HPF (p<0.0001). In contrast, EREFS-f correlated significantly with the use of adaptive behaviors assessed with PiEAQ [Spearman’s Rho of 0.6 (p<0.001); Figure 2], with linear regression showing that an increase of 1 point of any fibrotic feature corresponded to an increase of one adaptive behavior (p=0.001). EREFS, EREFS-i, and EREFS-f had nonsignificant negative correlation with DSQ (p>0.05 for all).

Conclusion

We confirmed that, while total EREFS provides a global assessment of endoscopic disease severity, it lacks correlation with histological and clinical disease activity. However, we demonstrated that EREFS-i correlates significantly with PEC and predicts PEC/HPF and that EREFS-f correlates significantly with the use of adaptive behaviors assessed with PiEAQ, which represent known clinical markers of disease activity. Neither EREFS-i nor EREFS-f correlated significantly with DSQ. In conclusion, we showed that, compared to the total EREFS, EREFS sub-scores improve the correlation between endoscopy findings with histology and clinical disease activity markers. Applied to clinical practice, our results represent another step towards precision medicine in the setting of EoE.

References

[reference 1] Visaggi P, Del Corso G, Solinas I, Ovidi F, Adamo G, Dulmin I, Baiano Svizzero F, Bellini M, Savarino EV, de Bortoli N. Adaptive Behaviors, Esophageal Anxiety, and Hypervigilance Modify the Association Between Dysphagia Perception and Histological Disease Activity in Eosinophilic Esophagitis. Am J Gastroenterol. 2024 Dec 30. doi: 10.14309/ajg.0000000000003272. Epub ahead of print. PMID: 39787341.

Disclosure

Speaker or consultancy for Apogee Therapeutics, Dr Falk Pharma, Malesci, JB Pharmaceuticals, Sanofi

Introduction

In the southwest Netherlands, hospitals collaborate to provide high quality, uniform care for inflammatory bowel disease (IBD). To achieve this, a care pathway (CP) was implemented for treating IBD with biologics and small molecules (1). The CP consists of protocols addressing different stages in IBD treatment, such as initiation and switching of therapy, frequency and type of follow-up. This study assessed the adherence to the CP and identified barriers and facilitators to its implementation.

Aims & Methods

A mixed-methods study was conducted. Quantitative data was used to evaluate the adherence to different protocols of the CP and was collected retrospectively from electronic health records (EHRs) from December 2020 until March 2023. Surveys and semi-structured interviews were used to identify barriers and facilitators, using the Extended Normalisation Theory. Surveys were sent to all healthcare providers and interviews were conducted with gastroenterologists, IBD-nurses, healthcare assistants, and IT-personnel.

Results

A total of 299 patients were included. Adherence to the CP regarding the documentation of travel plans and vaccination status improved after implementing the CP (15% pre-implementation vs. 33% post-implementation), as well as written communication with general practitioners (31% vs. 83%) and body weight registration (12% vs. 50%). Among patients switching medication, 25% had a repeated screening for HIV, tuberculosis, and hepatitis B and C documented if prior tests were over a year old. Post-implementation, scheduling outpatient visits were more closely aligned with CP recommendations across CP protocols (57% vs. 100%), as did blood test ordering (10% vs. 44%). Disease activity scoring with validated questionnaires remained low (7% vs. 21%).  Adherence to registering medication adherence, current smoking status, and side effects during annual outpatient visits remained low (18% vs. 40%).
Of 85 surveys, 42 were completed, and 11 interviews were conducted. Facilitators were improving collaboration between healthcare providers and the potential to standardise care. Barriers included the complexity of the use in EHRs, difficulty for healthcare providers to change their current routine, and the heterogeneity of IBD.

Conclusion

A CP for the treatment of IBD with biologics and small molecules has been implemented to improve IBD care, however, adherence appears to be challenging, partially contributed to the difficulty healthcare providers experience in changing their behaviour. The gradual improvement indicates that increased familiarity with the CP may enhance adoption. Discrepancies between performed and documented tasks in EHRs may also contribute to lower adherence rates, which could be improved by audit and feedback sessions.

References

1. van Linschoten R, van Leeuwen N, Nieboer D, Birnie E, Scherpenzeel M, Verweij KE, et al. Value-based care pathway for inflammatory bowel disease: a protocol for the multicentre longitudinal non-randomised parallel cluster IBD Value study with baseline period. (2044-6055 (Electronic))

Disclosure

Drs. Visser received speaker fees from Lilly outside the submitted work. Prof. Dr. van der Woude reports grants from Pfizer and Janssen and personal fees from AbbVie and Celltrion outside the submitted work. Dr. van Noord reports personal fees from Janssen, Takeda, and Falk outside the submitted work. Dr. West reports personal fees from AbbVie, Janssen, and Pfizer outside the submitted work.