Introduction

Duodenal cancer is the 2^nd cause of mortality among Familial Adenomatous Polyposis (FAP) patients, and surveillance and treatment of duodenal lesions is recommended. Uncertainty persists regarding the risk of gastric cancer in this population.

Aims & Methods

This study aims to ascertain the frequency of gastroduodenal alterations in FAP patients. We conducted a retrospective single-centre study in FAP patients under surveillance (n=79), with analysis of endoscopic findings, respective treatment and histology, in esophagogastroduodenoscopy (n=64).

Results

The included patients, most of which presenting a classic phenotype (n=44; 69%), had a mean age of 46.6 years (standard-deviation 1.8), equal distribution between sexes, and a median follow-up time of 8.5 years (interquartile range 6). Thirty patients (47%) presented duodenal lesions (of which 14 had Spigelman stage III-IV), with endoscopic treatment performed in 7 patients (13 lesions). Of the 51 patients (80%) with endoscopic description of the papilla, 20 presented adenoma (16 with low grade dysplasia), having 4 of them been proposed to endoscopic or surgical treatment (2 ampulectomy, 1 duodenopancreatectomy, 1 refused treatment). Thirty two patients (50%) presented fundic gland polyps (10 with diffuse polyposis); 4 polyps from 3 patients were endoscopically removed given their size or presence of dysplasia. Eight patients (13%) had gastric adenomas with dysplasia (a total of 36 lesions), with 5 patients already treated. Two patients (3%) developed gastric adenocarcinoma (1 underwent total gastrectomy and 1 was treated endoscopically).

Conclusion

Our series presents a prevalence of duodenal lesions in line with that reported in the literature, and seems to show an increased risk of gastric cancer, underlining the need for high-quality endoscopic surveillance in FAP patients.

References

van Leerdam ME, et al. Endoscopic management of polyposis syndromes: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2019;51(9):877-895.
Syngal S, et al. ACG Clinical Guideline: Genetic Testing and Management of Hereditary Gastrointestinal Cancer Syndromes. Am J Gastroenterol 2015;110(2):223–262.

Clinical Case Summary

A 72-year-old man with a 49-year history of ulcerative colitis (UC), characterized as pancolitis and steroid-dependent, underwent routine surveillance colonoscopy. A congested, ulcerated mass was found in the recto-anal region, with no signs of active colitis in the rest of the colon.
From 2000–2012, he was treated with infliximab, discontinued due to secondary failure, followed by azathioprine (2012–2017), which was stopped due to leukopenia. Since then, he has been on vedolizumab. His medical history also includes hypertension and previous tobacco use.
The patient had been in clinical and biochemical remission for the last two years. Given his long-standing UC and the resection of a lateral spreading tumor (LST) via mucosectomy in 2019 showing hyperplastic mucosa with a focus of low-grade dysplasia, he has been under annual endoscopic surveillance.
At the current exam, a large exophytic, ulcerated mass with superficial necrosis and fibrin (Kudo IV) was seen in the recto-anal region, occupying approximately 1/6 of the luminal circumference and bleeding spontaneously.
Histology revealed a poorly differentiated neuroendocrine carcinoma (NEC) with a high proliferative index (Ki-67: 60%). Staging workup, including CT, pelvic MRI, and endoscopic ultrasound, identified a suspicious regional lymph node, that was confirmed by FDG-PET to be metabolically active.
After multidisciplinary discussion, the decision was made to start systemic chemotherapy without delay. If the patient responds, a total proctocolectomy with permanent ileostomy will be considered.
This case is notable for the rarity of recto-anal NECs, especially in UC patients. Their poor prognosis and unclear association with long-term UC or immunosuppressive treatment complicate management and raise important clinical questions.

References

Images that will be uploaded are: endoscopic findings of the colonic mass, histological specimens of the NEC, radiologic findings (PET)

Introduction

Even though numerous risk factors and methods for prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) have been identified, it persists as the most prevalent complication. Administration of 100mg diclofenac prior to ERCP represents the most frequently used prophylaxis. Diclofenac is predominantly metabolized by various cytochrome P450 enzymes. The potential presence of single nucleotide polymorphisms (SNP) in these enzymes could cause interindividual variability in metabolization rates, which could affect serum plasma levels of diclofenac. Given the limited available research on this subject, the aim of this study was to investigate whether differences in presence of SNPs in the CYP-enzymes involved in diclofenac metabolism were associated with PEP.

Aims & Methods

This multicentre cohort study included patients above 18 years who underwent ERCP between 2012 and 2022. Upon inclusion, patients were divided into the PEP or control group. Real-time polymerase chain reactions were performed on buccal smear samples to identify gene variants involved in the diclofenac metabolism (e.g. CYP2C8*3). Secondary endpoints were validation of known and possibly yet unknown risk factors for PEP.

Results

In total, 103 patients were included in the PEP group and 245 in the control group. DNA amplification was possible in 91.5% of the genetic variants and revealed that heterozygous carriers of CYP2C8*3 variant were associated with a lower frequency of PEP (OR 0.2; 95% CI 0.0-0.8). Pancreatic duct cannulation (OR 3.0; 95% CI 1.4-6.6) and precut sphincterotomy (OR 3.1; 95% CI 1.2-8.0) were both found as independent risk factors for PEP.

Conclusion

This study showed that heterozygous carriers of the CYP2C8*3 variant have a lower risk of developing PEP. To investigate gene variants affecting real-time diclofenac plasma levels, we have started a study in which we prospectively collect blood samples to enhance DNA quality and to analyze the existence of a correlation between PEP and reduced diclofenac levels. If this correlation is confirmed, further research is needed to investigate the optimal dosage of diclofenac in wild type CYP2C8 patients.

Introduction

Artificial Intelligence (AI) is rapidly evolving in the field of gastrointestinal (GI) endoscopy. However, the prevailing perceptions and attitudes of endoscopists towards AI remain poorly understood.

Aims & Methods

This review aims to provide a summary on the current views and perspectives covering the incorporation of AI into GI endoscopy, as well as to identify any obstacles hindering its adoption. Electronic databases including MEDLINE, PubMed, and Scopus were searched from inception to 25th March 2024 to identify qualitative studies, such as questionnaires or surveys, conducted on endoscopists regarding the use of AI in GI endoscopy. The Joanna Briggs Institute (JBI) critical appraisal checklist was used to assess study quality. Qualitative synthesis of included studies was conducted by employing thematic analysis classified into the following five domains: 1) Knowledge and attitudes towards AI, 2) Perception on the ability of AI to improve accuracy and quality of endoscopy, 3) Impact of AI on endoscopists, 4) Impact of AI on patients and 5) Barriers towards the implementation of AI. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered with the International Platform of Registered Systematic Review and Meta-analysis Protocols (Registration ID: INPALSY202430064).

Results

Included Studies Wadhwa et al. (2020)	Country USA	Sample size n = 124	Domains covered:	1) Awareness and knowledge X	2) Improving endoscopic performance X	3) Impacts on Endoscopists X	4) Impacts on patients -	5) Barriers to implementation X
Kochhar et al. (2021)	USA	n = 165		X	X	-	X	X
Leenhardt et al. (2021)	UK	n = 333		X	X	X	X	X
Van der Zander et al. (2022)	Netherlands	n = 80		X	X	X	X	X
Tian et al. (2022)	China	n = 210		X	X	X	X	X
Tham et al. (2022)	Singapore	n = 16		X	X	X	X	X
Kader et al. (2022)	UK	n = 104		X	X	-	-	X
Nehme et al. (2023)	USA	n = 16		X	X	X	-	X
Goh et al. (2023)	Singapore	n = 165		X	X	X	X	X
Leggett et al. (2024)	USA	n = 374		X	X	X	X	X

Table 1. Study characteristics of included studies

Ten studies were included in this systematic review comprising of 1587 endoscopists across Europe (32.6%), North America (42.8%), and Asia (24.6%). Domain 1: Most endoscopists (69–100%) reported having basic knowledge of AI. Furthermore, the majority (79.5–87.5%) expressed interest and optimism regarding the use of AI in endoscopy. Domain 2: Most respondents (62.5–97%) supported the notion that AI would positively impact endoscopic performance and quality. Domain 3: There were mixed perceptions regarding the extent of operator dependence on AI (6.2–62.8% agreement), and whether AI would prolong procedural time (21–81.3% in agreement). Most endoscopists (71–100%) disagreed that AI would replace them at work. Domain 4: A substantial proportion of respondents (81.3%) felt that AI would lead to an increase in the quality of patient care. Only a minority of endoscopists (6.2–24%) felt that AI could improve the patient-physician relationship and provide empathetic care. Domain 5: A significant proportion of endoscopists (75.2–91%) identified costs as a potential barrier to the implementation of AI in endoscopy. Opinions on ethical concerns and the lack of regulation varied (12.5–100% and 35–88%, respectively), with many endoscopists feeling that there was need for clear guidelines and regulations when integrating AI into clinical practice.

Conclusion

Overall, there is a positive attitude towards the use of AI in endoscopy. However, concerns regarding impact on clinical practice, costs and medicolegal considerations remain. The establishment of robust regulatory frameworks is imperative to ensure successful integration of AI into clinical practice.

Disclosure

Nothing to disclose.

Introduction

Patients with Crohn’s disease (CD) are at risk of progressing from inflammatory to stricturing and penetrating phenotypes. The influence of the type of remission on phenotype progression has not been adequately evaluated.

Aims & Methods

Retrospective cohort study including surgically naïve CD patients with inflammatory or stricturing phenotype evaluated concomitantly by magnetic resonance enterography and colonoscopy. The degree of remission was correlated with the risk of progressing to stricturing and penetrating phenotypes.

Results

381 CD patients were included, 21.8% with transmural remission, 21.3% with isolated endoscopic remission, 10.5% with isolated radiologic remission, and 46.5% without remission. Patients with transmural remission presented the lowest rates of phenotype progression (1.2%), with a significant difference compared to isolated endoscopic remission (18.3%, P≤ 0.001), isolated radiologic remission (17.5%, P=0.002), and no remission (36.9%, P≤0.001). In multivariate regression analysis, transmural remission (OR 0.023 95%CI 0.003-0.171, P<0.001), isolated radiologic remission (OR 0.342 95%CI 0.141-0.826, P=0.017), and isolated endoscopic remission (OR 0.441 95%CI 0.220-0.881, P=0.020) resulted in lower rates of phenotype progression compared to no remission.
Figure 1 presents the Kaplan-Meier estimates of remaining free of penetrating complication (upper curve) and free of stricturing and/or penetrating complication (lower curve) after the baseline assessment in patients with no remission (A), isolated endoscopic remission (B), isolated radiologic remission (C), and transmural remission (D).

Conclusion

The degree of intestinal remission correlates with the risk of phenotype progression. Patients with transmural remission are at the lowest risk of progressing to stricturing and penetrating phenotypes.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is a cornerstone in the diagnosis and treatment of pancreatobiliary diseases. However, it carries the risk of complications including potentially fatal post-ERCP pancreatitis (PEP). Despite ongoing efforts, effective strategies for managing PEP remain unestablished. Current guidelines define PEP based on symptoms and findings occurring within 24 hours after ERCP; however, early diagnosis and intervention may prevent its incidence and severity. Recently, urinary trypsinogen-2 (UT2) has emerged as a potential biomarker for early acute pancreatitis, but its role and the optimal timing for PEP remain unclear. Therefore, we aimed to evaluate the diagnostic performance of UT2 at multiple time points following ERCP.

Aims & Methods

This is a single-center prospective observational study conducted at The University of Tokyo Hospital. Patients who underwent their initial ERCP at our institution between February 2022 and June 2024 were enrolled. Patients with choledochojejunostomy, biliary pancreatitis, or those undergoing hemodialysis were excluded. UT2 levels were measured using a rapid dipstick test before ERCP, immediately after, and at 1 and 3 hours post-procedure. Serum amylase (AMY) levels were measured 3 hours after ERCP. We evaluated the diagnostic performance (sensitivity, specificity, and accuracy) of UT2 at multiple time points, for the diagnosis of PEP. PEP was defined as an elevation in pancreatic enzyme >3x upper limit of normal with abdominal pain at 24 hours post-pocedure.

Results

A total of 521 patients underwent initial ERCP during the study period, and 337 were included in the final analysis. The median age was 74 years, and 64% were male. A naïve papilla was present in 89% of patients. The indications for ERCP included bile duct stones (39%), malignant biliary obstruction due to pancreatic cancer (13%) or non-pancreatic cancer (18%), benign biliary stricture (5%), diagnostic pancreatogram (24%), and others (1.2%). EST, EPBD, and EPLBD were performed in 37%, 6.5%, and 4.5%, respectively. Prophylactic pancreatic stent placement and rectal NSAIDs administration were performed in 29% and 20%, respectively. PEP occurred in 10% (mild 8.6%, moderate 1.2%, and severe 0.3%) of patients. UT2 demonstrated a trend toward higher sensitivity compared to AMY (AMY: 52.9% vs. UT2 at 0 h: 52.9%, 1 h: 64.7%, 3 h: 64.7%), while AMY exhibited significantly higher specificity (AMY: 92.7% vs. UT2 at 0 h: 65.3%, 1 h: 64.7%, 3 h: 65.0%) and accuracy (AMY: 88.7% vs. UT2 at 0 h: 64.1%, 1 h: 64.7%, 3 h: 65.0%). Notably, 28.5% of patients were positive for UT2 prior to undergoing ERCP. These patients were significantly older (79 vs. 71 years, P < 0.01), more likely to have pancreatic cancer (19.8% vs. 9.5%, P = 0.02), and less likely to have chronic pancreatitis (3.1% vs. 12.9%, P = 0.01). After excluding 96 cases (28.5%) who were UT2-positive before ERCP, we further evaluated the diagnostic performance of UT2 and AMY. UT2 at 0 h had lower sensitivity compared to AMY (AMY: 54.2% vs. UT2 at 0 h: 37.5%, 1 h: 54.2%, 3 h: 54.2%). In contrast, specificity was similarly high across all markers (AMY: 91.7% vs. UT2 at 0 h: 88.9%, 1 h: 87.1%, 3 h: 87.1%). Diagnostic accuracy was comparable between AMY and UT2 (AMY: 88.0% vs. UT2 at 0 h: 83.8%, 1 h: 83.8%, 3 h: 83.8%).

Conclusion

UT2 showed slightly lower predictive performance for PEP compared to AMY. However, excluding UT2-positive pre-ERCP improved the diagnostic accuracy. The diagnostic performance plateaued at 1 hour after ERCP, suggesting its potential utility in predicting PEP earlier.

Disclosure

The author is affiliated with Nipro Corporation through a labor-related arrangement, but has received no financial support or remuneration related to this study.