Introduction

All patients in the UK with a diagnosis of gastric ulcer are recommended to have a follow-up endoscopy within 12 weeks. However, in a low-risk population, such measures may not be necessary. We have assessed a recently developed risk stratification model for gastric ulcers (Brindle Frontline 2022) in a single provider.

Aims & Methods

The aim of this study was to assess the pick up rate of gastric cancer on follow-up endoscopy for patients diagnosed with gastric ulcers and validate a risk stratification model. A retrospective service evaluation was performed between June 2019 to June 2023 at Sandwell and West Birmingham NHS trust of all patients with an endoscopic diagnosis of gastric ulcer. Patients were followed up until ulcer healing, cancer diagnosis or no further planned follow-up.

Results

461 patients were studied: median age 63 [interquartile range (IQR) 52-72]; 74% male; and median Charlson comorbidity index 3 (IQR 2-5).
The majority of ulcer diagnoses came from outpatient endoscopy - 69.6%. The ulcer biopsy rate was 64.4% and lower biopsy rates were seen in those who had inpatient endoscopy (41.4%) and therapy (12.1%). The median number of biopsies taken was 4 (IQR 2-5). Additional diagnoses were as follows; gastritis 77%, no additional diagnosis 8%, premalignant lesions 4% (e.g. chronic gastric atrophy) and lymphoma 3%.

Cancer was suspected in 8.7% of ulcers at the initial endoscopy and confirmed histologically in 7%. Cancer diagnoses were in older patients - median age 67 (IQR 59-76) - and all met the urgent two week wait referral criteria for suspected cancer.

Repeat endoscopy for ulcer healing was not done in 32% (reasons included frailty, non-attendance or cancer diagnosis). Two cancers were diagnosed on follow-up endoscopy but both were suspected on index endoscopy -in one the index biopsies did not confirm cancer and in the second no biopsies were taken due to GI bleeding.
Using the risk stratification model proposed by Khalla and Masterton, which required 6 biopsies taken at index endoscopy along with a risk score of less than 3 (consisting of age, ulcer site and ulcer size), 15.6% met the low-risk criteria, where repeat endoscopy may not be required. In that group there were no cancers diagnosed on the second endoscopy.

Conclusion

The risk stratification model appears to perform well suggesting that at least 15.6% of our current endoscopies for gastric ulcer follow-up may not be necessary. Further multi-centre validation of the model is needed.

References

Brindle WM, Grant RK, Smith M, Suddaby M, Wallace A, Gillespie SL, Church NI, Noble CL, Penman ID, Plevris JN, Robertson AR, Watson EF, Selinger CP, Kalla R, Masterton GSM; EGAR (Edinburgh GI Audit and Research) Collaborative. Risk stratifying gastric ulcers: development and validation of a scoring system. Frontline Gastroenterol. 2021 Feb 26;13(2):111-118. doi: 10.1136/flgastro-2020-101759. PMID: 35295750; PMCID: PMC8862450.

Introduction

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established interventional treatment for complications of portal hypertension. Post-TIPS transient or persistent acute bilirubin elevation (ABE) is common, possibly due to impairment of portal perfusion. The outcomes of patients with ABE is not clear.

Aims & Methods

This study investigates the incidence, clinical outcomes, and prognostic factors associated with ABE in cirrhotic patients undergoing TIPS. Between January 2009 and November 2022, 1,287 patients (882 men, 405 women; mean age, 52 years) were included in this retrospective analysis. ABE was defined as a total serum bilirubin level exceeding 85.5 μmol/L (5 mg/dL) within one week after TIPS. Statistical analyses included the Kaplan-Meier method, log-rank test, multivariate Cox regression, and stepwise regression.

Results

Post-TIPS ABE occurred in 67 patients (5.2%). Patients with ABE had significantly higher baseline Child-Pugh scores (8.39 ± 1.62 vs. 7.41 ± 1.54, P < 0.001) and MELD scores (13.98 ± 4.13 vs. 10.72 ± 2.99, P < 0.001). Refractory ascites as the TIPS indication was more frequent in the ABE group (17.91% vs. 7.21%, P = 0.001). ABE was associated with a significantly higher incidence of hepatic encephalopathy (HE): 62.7% vs. 38.3% at 1 year and 80.6% vs. 62.8% at 5 years (P = 0.042). During follow-up, 441 patients died, with causes including liver failure (n = 129), gastrointestinal bleeding (n = 100), sepsis (n = 16), multi-organ dysfunction (MOD) (n = 41), hepatocellular carcinoma (HCC) (n = 43), and other or unknown causes (n = 112). Survival rates were significantly lower in the ABE group: 1-year (52.2% vs. 85.2%), 3-year (34.3% vs. 68.3%), and 5-year (25.4% vs. 46.6%) (P < 0.001). Multivariate analysis identified ABE (hazard ratio [HR]: 2.09; 95% confidence interval [CI]: 1.41–3.10; P < 0.001), age (HR: 1.05; 95% CI: 1.04–1.06; P < 0.001), albumin level (HR: 0.95; 95% CI: 0.94–0.97; P < 0.001), pre-TIPS grade 4 HE (HR: 1.93; 95% CI: 1.19–3.14; P = 0.008), presence of HCC (HR: 1.81; 95% CI: 1.24–2.65; P = 0.002), baseline MELD score (HR: 1.09; 95% CI: 1.04–1.14; P < 0.001), and change in MELD score (HR: 1.08; 95% CI: 1.06–1.11; P < 0.001) as independent predictors of post-TIPS mortality.

Conclusion

AEB is not rare in cirrhotic patients undergoing TIPS and is associated with an increased risk of HE and mortality. Risk factors for post-TIPS mortality include AB, older age, higher and fluctuating MELD scores, concurrent HCC, severe pre-TIPS HE, and lower albumin levels. Early identification, close monitoring, and prompt management of complications are essential to improving clinical outcomes and reducing the risk of liver failure after TIPS.

Introduction

Endoscopic interventions in children require specialized training and expertise due to unique anatomy and physiology challenges. Pancreaticobiliary endoscopies represent highlighted procedures in this population due to the often-unusual indications and the inherent high risk of complications.

Aims & Methods

The current work demonstrates our experience in pancreaticobiliary endoscopy in the pediatric population. We retrospectively analyzed data on all patients <18 years old who underwent endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound (EUS) from 2021 to the present days at our department. We collected demographical data, indications, procedural findings, interventions, and complications.

Results

Overall, 19 ERCPs and 7 EUS procedures were performed on 24 children with regular endoscopes. 15 were males, and the mean age was 10.7 years (±4.7). Indications for ERCP included bile duct stones, benign stricture, pancreatic divisum and disconnected duct syndrome. Successful intervention was carried out in 18 cases, while there was one case of unsuccessful deep pancreatic duct cannulation due to abnormality of the duct. There was one case of perforation (Stapfer II), which was effectively managed endoscopically by placing a fully covered self-expanding metallic stent. 1 case of mild post-ERCP acute pancreatitis occurred following ERCP. EUS was performed for chronic pancreatitis, pancreatic cystic neoplasia, acute necrotizing pancreatitis, biliary compression and polycystic pancreas. 3 tissue acquisitions were done and one EUS-guided transluminal drainage was established. There were no complications.

Conclusion

To our knowledge, this is the most comprehensive domestic dataset of pancreaticobiliary endoscopies in children. Our findings imply that ERCP and EUS are effective diagnostic and treatment modalities in pediatric patients with acceptable safety profiles.

Clinical Case Summary

Case report: We report a case of a 51-year-old patient who initially presented in 2014 with thrombocytopenia, and splenomegaly. Liver parameters were within the normal range. Comprehensive diagnostic evaluations, including CT scans and liver biopsy, excluded cirrhosis, vascular occlusions, bypass circuits and other potential etiologies such as toxic, autoimmune, or infectious causes. Additional investigations, including bone marrow and spleen puncture as well as genetic tests did not reveal any hematological or neoplastic diseases.
At the age of 66, the patient suffered an episode of variceal hemorrhage due to grade IV oesophageal varices. Subsequently, after referral to our clinic in March 2020, a transjugular portosystemic shunt (TIPSS) was placed for persistent grade III varices (Figure 1), reducing the varices to grade I (2024). Despite successful management of varices, the patient developed mild hepatic encephalopathy, managed with lactulose and rifaximin.
Biopsy revealed nodular regenerative hyperplasia (Figure 2). We diagnosed idiopathic non-cirrhotic portal hypertension (INCPH), an infrequent yet significant clinical entity characterized by intrahepatic portal hypertension without cirrhosis or other liver diseases. Management challenges included the patient's intolerance to non-selective beta-blockers due to sinus bradycardia and ongoing low-grade hepatic encephalopathy, which precluded further TIPSS modification. Future management may include splenic vein embolization should varices recur.
Conclusion: The diagnosis of INCPH necessitates evident portal hypertension, no cirrhosis or advanced fibrosis, and no hepatic or portal vein thrombosis on imaging. Due to limited data, management typically mirrors that of cirrhosis-induced portal hypertension. This case highlights the diagnostic and management challenges of INCPH, stressing the importance of comprehensive assessments to rule out other causes and customize treatment for complications.

Introduction

Effective colorectal cancer prevention relies on the quality of screening colonoscopy examinations. Cecal withdrawal time is significantly associated with adenoma detection rate (ADR), which is an established quality indicator for screening colonoscopy. Therefore, we introduced a real-time cecal withdrawal timer (CWT) that alerts the physician of the elapsed time since cecal intubation.

Aims & Methods

An observational, retrospective, single-center study to evaluate CWT in screening colonoscopy tests. The CWT is activated by a vocal command when the physician achieves cecal intubation. Following activation, the elapsed time is audio-announced every minute until the end of the procedure. The ADR of colonoscopies with and without the CWT was evaluated following CWT implementation from January 2023 to February 2024. Moreover, the ADR of the entire department in this period was compared with the year before.

Results

Of 1,557 colonoscopies between January 2023 and February 2024, 908 (58.3%) were performed with the CWT with a median withdrawal time of 8.75 (IQR: 6.9-12.0) minutes. During this period, the CWT usage was greater than 50% in 11 out of 14 months. Considering only months with CWT usage over 50%, the ADR of colonoscopies with CWT was 28.3% compared to 19.2% in those without (p<0.001). Among physicians who performed at least 20 tests with and 20 tests without the CWT, 6 out of 8 demonstrated improved ADR with the cecal timer. Notably, the 2 physicians who did not improve ADR had baseline ADR exceeding 30%. The overall ADR of the department between January 2023 and February 2024 was 25.5%, compared to 26.2% in 2022 (p=0.704).

Conclusion

Initial findings of the CWT program suggest its potential in enhancing screening colonoscopy quality indicators, although long-term prospective follow-up is warranted.

Disclosure

Nothing to declare