Clinical Case Summary

Case 1: A 38-year-old male with stricturing ileocolic Crohn’s disease on adalimumab underwent a colonoscopy, which revealed active disease (SES-CD: 8) where biopsies were taken. The procedure was uneventful. However, the following day, he developed severe right upper quadrant (RUQ) pain, prompting emergency evaluation. He was afebrile but exhibited RUQ tenderness. Blood tests revealed leukocytosis (21.0×10⁹/L) and elevated CRP (4.26mg/dL). CT scan revealed pericolic fat stranding at the hepatic flexure extending to the gallbladder. Due to diagnostic uncertainty, observation with antibiotics was initiated. Clinical deterioration and worsening inflammatory markers led to an ultrasound, which confirmed an acute cholecystitis. Patient underwent laparoscopic cholecystectomy, revealing gangrenous cholecystitis with perforation. He was discharged on postoperative day 3 with full recovery.
Case 2: A 63-year-old female with a history of stricturing ileocolic Crohn’s disease (ileocecal resection in 2001) and ascending colon adenocarcinoma (right hemicolectomy in 2009) underwent a colonoscopy, which was uneventful. The next day, she developed RUQ pain and vomiting, prompting emergency evaluation. She was febrile with RUQ tenderness. Laboratory results showed leucocytosis (10.6×10⁹/L) and elevated CRP (9.11mg/dL). Ultrasound confirmed acute cholecystitis. She underwent urgent laparoscopic cholecystectomy and was discharged two days later without complications.
Conclusions: We report two cases of acute cholecystitis occurring within 24 hours of colonoscopy. Sixteen similar cases exist in the literature, most presenting within 72 hours¹. Crohn's disease activity does not appear to be a contributing factor, as one patient had no active inflammation. Proposed mechanisms include dehydration, bacterial translocation, trauma and inflammatory response². Finally, given the high frequency of colonoscopy and the prevalence of cholecystitis, a coincidental association cannot be excluded.

References

1. Neubeck KM, Mwagiru D, Boseto EF Acute cholecystitis following elective colonoscopy BMJ Case Reports CP 2023;16:e257166.
2. Shaikh D H, Kumar K, Patel H, et al. (October 10, 2020) Acute Cholecystitis, A Rare Complication Following Routine Colonoscopy: Case Series and Literature Review. Cureus 12(10): e10877.

Introduction

Sedation is integral to gastrointestinal (GI) endoscopy to enhance procedural tolerance and efficiency [1]. Traditional agents like midazolam and propofol, while effective, present limitations related to recovery time, safety, and need for anesthesiologist supervision. Remimazolam, a novel benzodiazepine with rapid onset and offset, may enable effective non-anesthesiologist-administered sedation (NAAS) in routine endoscopy [2].

Aims & Methods

A prospective, multicenter, real-world study was conducted between November 2024 and March 2025. Adult patients undergoing elective upper or lower gastrointestinal (GI) endoscopy under procedural sedation-analgesia (PSA) without the presence of an anesthesiologist were enrolled. Inclusion criteria were: age ≥18 years, American Society of Anesthesiologists (ASA) physical status I–III, and a body mass index (BMI) between 18 and 51 kg/m². Exclusion criteria included: known allergy to anesthetic drugs or a history of anesthesia-related adverse reactions; glucose-6-phosphate dehydrogenase deficiency; severe respiratory disease; and pregnancy. All patients undergoing emergency or urgent GI endoscopy were excluded.The primary outcomes were the sedative efficacy and safety of remimazolam during endoscopy. Efficacy was defined as successful completion of the procedure without interruption due to inadequate sedation. Adverse events (AEs) were recorded and classified by severity (major or minor) and type (e.g., hypotension, hypoxia, bradycardia, nausea, vomiting, and injection site pain). Remimazolam was administered by trained endoscopists: induction was achieved with 5–7 mg intravenously, titrated based on individual risk factors, with 2.5 mg supplemental doses as needed (maximum cumulative dose: 33 mg).

Results

A total of 182 patients (EGD n=75; colonoscopy n=112) were included. Procedure completion was achieved in 175 cases (96.3%), with success rates of 97.3% for EGD and 95.5% for colonoscopy. All sedation failures (n=7) were attributed to inadequate sedation and not to ASA class. No serious AEs were reported. Minor AEs included hypotension (n=4), bradycardia (n=1), nausea (n=1), vomiting (n=4), and hiccups (n=1), all managed conservatively. Median cumulative remimazolam doses were 10.9 mg (colonoscopy) and 10.0 mg (EGD), with median recovery times of 6.25 and 5.9 minutes, respectively. No patients required flumazenil or rescue sedation. Among obese patients (BMI >40), remimazolam was both effective and safe.

Conclusion

Remimazolam provides a highly effective and safe sedation alternative for GI endoscopy in real-world NAAS settings, ensuring rapid recovery and minimal AEs, even in patients with elevated ASA status or obesity. This study was prospective real-world and had several limitations. First the number of patients was too small to accurately assess rare adverse events. Further randomized controlled trials with larger populations are recommended to confirm these results.

References

1. Lin OS. Sedation for routine gastrointestinal endoscopic procedures: a review on efficacy, safety, efficiency, cost and satisfaction. Intest Res 2017;15:456-66. doi: 10.5217/ir.2017.15.4.456.
2. Hu Q, Liu X, Wen C, et al. Remimazolam: an updated review of a new sedative and anaesthetic. Drug Des Devel Ther 2022;16:3957-74. doi: 10.2147/DDDT.S384155.

Introduction

There is minimal data to support a recommendation to perform colonic stenting (SEMs) in the right colon, but particularly in malignancy in the region of the ileocaecal valve, where only small bowel dilatation results from obstruction. This scenario poses technical challenges in endoscopic access in unprepared proximal colon, and relating to the anatomy of the ileocaecal valve. One recent case series included 13 patients with reported success rate and equivalent outcomes to left-sided stents with median survival of 4 months, although a two-step procedure was described¹.

Aims & Methods

In our centre we attempt self-expanding metal stent insertion (SEMs) in cases of malignant ileocaecal obstruction, which constitutes ~9% of our overall SEMs caseload. We report our outcomes and, as an important metric for palliative patients, stoma-free survival in the context of colorectal cancer management. We perform stenting using colonoscopy to access the stricture and fluoroscopy for wire and stent deployment, with both over the wire and through the scope techniques.

Results

25 patients, median age 77 years, underwent intention to stent for colorectal malignancy at the ileocaecal junction, where stent deployment into the ileum would be necessary to overcome the obstruction. Clinical success with life-time avoidance of surgery or stoma was 68% without any adverse events from attempting SEMs. Median survival was 206 days, compared to 167 days in those where stenting was unsuccessful. This was not significantly different to median stoma-free survival of 272 days for all SEMs patients in our database. One patient, after technically successful stent deployment, re-obstructed within 7 days and underwent surgery. There were no other early or late complications in either group. Reasons for technical failure in 6 cases was inability to pass a wire into the ileum, bowel preparation in 1 case, and failure to adequately resolve obstruction in the aforementioned patient.

Conclusion

Stenting malignant colonic obstruction of the ileocaecal region is more technically challenging but does not appear to disadvantage patients after an unsuccessful procedure. Stoma or surgery is avoided in 68% cases in intention to treat analysis of 25 patients and median survival of 206 days is equivalent to other colonic stent locations.

References

1. Fujisawa et al. J. Clin. Med. 2025, 14(3), 826

Introduction

Propofol (PPF) is a short-acting, highly lipophilic intravenous agent with sedative, hypnotic, antiemetic, and amnestic properties. Acting through GABA receptor agonism and NMDA antagonism, it ensures rapid onset (30–45 seconds) and swift recovery, making it ideal for gastrointestinal endoscopic procedures. Since 1995, the American Society of Anesthesiologists has supported the use of non-anaesthesiologist providers for sedation in endoscopy. Countries including Colombia have adopted this approach, especially given the limited availability of anaesthesiologists. In the United States, fewer than 20% of colonoscopy sedations are delivered by anaesthesiologists. Recent studies report comparable safety profiles for trained non-anaesthesiologist and anaesthesiologist-administered sedation, with reduced cardiovascular complications and lower healthcare costs. However, Latin American real-world data on this model remain scarce.

Aims & Methods

This prospective, analytical prevalence study assessed the safety and effectiveness of propofol sedation administered by a general physician with specific training in sedation, airway management, and intensive care, within an ambulatory endoscopy unit. From March 2023 to April 2024, adult patients (≥18 years) undergoing colonoscopy at the Centro de Gastroenterología y Endoscopia in Bogotá were included. The physician administered age-tailored propofol bolus and maintenance doses according to clinical guidelines and procedure duration. Exclusion criteria included ASA IV status or contraindications to propofol. Sedation regimens were as follows:

• <40 years: 180 mg IV bolus; 60 mg maintenance every 5 min
• 41–70 years: 160 mg IV bolus; 50 mg maintenance every 5 min
• ≥71 years: 150 mg IV bolus; 30 mg maintenance every 5 min

Results

A total of 2,032 patients were enrolled; mean age 64 years (95% CI: 62.8–65.1), 60% female. The mean BMI was 27 (95% CI: 25.8–27.1). Colonoscopy indications included screening (35%), diagnostic evaluation (40%), surveillance (20%), and therapeutic intervention (5%), including 101 patients undergoing polypectomy. Comorbidity prevalence was notable: cardiovascular (30%), gastrointestinal (30%), respiratory (15%), neurological (5%), allergic (3%), and haematological (3%).
ASA risk classification revealed:

• ASA I: 14% (n=284)
• ASA II: 60% (n=1,219)
• ASA III: 26% (n=528)

Conclusion

This real-world study confirms that propofol sedation administered by non-anaesthesiologist physicians with critical care training is both safe and effective for the vast majority of patients undergoing colonoscopy in ambulatory settings. These findings support a task-sharing model that maximises resource efficiency while maintaining patient safety. In health systems with limited anaesthesiologist availability, this approach allows specialists to focus on higher-risk ASA IV patients in tertiary-level settings. Widespread adoption of this model, with appropriate training, could reduce costs, increase procedural throughput, and improve access to high-quality endoscopic care in Latin America and similar settings.

References

• Sato M, Horiuchi A, Tamaki M, et al. Safety and effectiveness of nurse-administered propofol sedation in outpatients undergoing gastrointestinal endoscopy. Clin Gastroenterol Hepatol. 2019;17(6):1098–1104.e1. doi:10.1016/j.cgh.2018.06.025.
• Ferreira AO, Torres J, Barjas E, et al. Non-anesthesiologist administration of propofol sedation for colonoscopy is safe in low-risk patients: results of a noninferiority randomized controlled trial. Endoscopy. 2016;48(8):747–753. doi:10.1055/s-0042-105560.
• Lucendo AJ, Olveira A, Friginal-Ruiz AB, et al. Nonanesthesiologist-administered propofol sedation for colonoscopy is safe and effective: a prospective Spanish study over 1000 consecutive exams. Eur J Gastroenterol Hepatol. 2012;24(7):787–792. doi:10.1097/MEG.0b013e328353fcbc.

Introduction

Duodenogastroesophageal reflux (DGER), or bile reflux, has gained renewed interest due to the increasing number of bariatric surgeries (BS) performed. Anatomical modifications after BS may predispose patients to reflux. Revisional bariatric surgery (RBS) is indicated for inadequate weight loss or refractory symptoms.

Aims & Methods

This study aimed to evaluate the diagnostic accuracy of pH-impedance (pH-Z) monitoring in detecting DGER, using spectrophotometric bilirrubin (Bilitec2000) as the clinical reference standard. This prospective study included consecutive patients with a history of sleeve gastrectomy (SG) referred for preoperative evaluation prior to RBS between October 2023 and February 2025. All patients underwent simultaneous 24-hour pH-Z monitoring and Bilitec2000 monitoring while off proton pump inhibitors (PPIs). Patients followed a standardized white semiliquid diet. Gastroesophageal reflux disease (GERD) was diagnosed according to the Lyon 2 Consensus. Pathological bile reflux was defined as a total bilirubin absorbance ≥ 0.14 for ≥ 1.9% of the monitoring time.

Results

Fifty-three patients were enrolled [38 (71.7%) female, median age 48 years (IQR 43 – 55), median BMI 37.3 Kg/m² (IQR 34.1 – 41.3)]. Reason for RBS evaluation included
inadequate weight loss (39.6%) refractory reflux symptoms (32.1%), both (24.5%) and other indications (3.5%). GERD was diagnosed in 31 patients (58.5%) and 21 (39.6%) had pathological bile reflux. Erosive GERD according to Los Angeles classification was identified in 10 patients (19.6%). The area under the curve for non-acid reflux episodes detected by pH-z in diagnosing DGER was 0.61 (CI 95% 0.44 - 0.78), with an optimal cutoff of 85 episodes (sensitivity: 38.1% (CI 95% 20.8 – 59.1); specificity of 93.6% (CI95% 79.9 – 98.3). A moderate correlation was found between non-acid reflux and bile reflux (r = 0.38, p=0.005). However, GERD was not associated with increased bile exposure time (1.4% (IQR 0.3 – 9.5) vs 1.3% (IQR 0.0 – 4.8), p=0.262), nor was this association observed in those with erosive esophagitis (1.9%, IQR 0.4 – 9.5 vs 1.4% IQR 0.0 – 5.8; p=0.914).

Conclusion

Approximate 40% of SG patients undergoing RBS evaluation had pathological bile reflux, which was not linked to GERD or erosive esophagitis. Despite a moderate correlation between bile and non-acid reflux episodes, pH-z monitoring failed to reliably detect DGER and should not be considered a substitute for spectrophotometric bilirrubin concentration monitoring.

References

- Basnayake C, Geeraerts A, Pauwels A, et al. Systematic review: duodenogastroesophageal (biliary) reflux prevalence, symptoms, oesophageal lesions and treatment. Aliment Pharmacol Ther. 2021;54(6):755-778. doi:10.1111/apt.16533.
- Eldredge TA, Bills M, Myers JC, Bartholomeusz D, Kiroff GK, Shenfine J. HIDA and Seek: Challenges of Scintigraphy to Diagnose Bile Reflux Post-Bariatric Surgery. Obes Surg. 2020;30(5):2038-2045. doi:10.1007/s11695-020-04510-7