Introduction

The prevalence of primary sclerosing cholangitis (PSC) among ulcerative colitis (UC) is known to be lower in Eastern Asia, including Japan, than in Western countries. There have been few studies describing the details of ulcerative colitis-associated colorectal cancer (CAC) in UC with PSC (PSC-UC) in Japan so far, owing to its rarity.

Aims & Methods

This retrospective study aimed to evaluate the clinicopathologic features and prognosis of CAC in PSC-UC in the largest nationwide cohort of its kind in Japan. A total of 797 eligible patients diagnosed with CAC from 1983 to 2020 were categorized into those with PSC (PSC-UC group, n = 26) and those without PSC (UC-alone group, n = 771). Clinicopathologic features, 10-year overall survival (OS) and 10-year cancer-specific survival (CSS) were compared between the two groups.

Results

In PSC-UC group, duration of UC was shorter (12.8 vs 17.0 year, p=0.042), and age at CAC diagnosis was younger (47.8 vs 53.4 years old, p=0.042) compared to UC-alone patients. Right-sided colon cancer was significantly more common in PSC-UC group than in UC-alone group (34.6% vs 15.5%, p=0.032). Left-sided colon cancer (38.5%) and rectal cancer (26.9%) accounted for a similar proportion with right-sided colon cancer in PSC-UC group. There were no differences between the two groups in terms of sex, age at UC diagnosis, disease extent of UC, medical therapies for UC, diagnostic opportunity for CAC, histological types, and pathological stages of CAC. PSC-UC group showed a comparable 10-year OS (70.6% vs 83.1%, p=0.072) and 10-year CSS (84.1% vs 87.6%, p=0.50) as UC-alone group.

Conclusion

Our study highlighted the differences and the similarities of CAC between UC with PSC and without PSC patients. In patients with PSC-UC, it may be beneficial to start surveillance colonoscopy earlier because of the shorter duration of UC before the CAC diagnosis.

Clinical Case Summary

Background: Colorectal anastomotic strictures affect up to 30% of colorectal cancer surgery patients, but complete obstruction is rare. Endoscopic approaches, relying on successful guidewire passage through the stenosis followed by dilation or stent placement, may avoid surgical revision. In cases of insurmountable strictures in patients with colostomy, guidewire passage under endoscopic ultrasound (EUS) or direct endoscopic guidance, using transillumination, can be considered.
Methods: A 78-year-old underwent urgent high anterior resection with a transverse loop colostomy due to an occlusive rectal tumor. By postoperative day 8, he had anastomotic leakage, requiring reintervention. Ten months post-surgery, colonoscopy showed a complete unnegotiable anastomotic stricture. A pediatric colonoscope was inserted through the colostomy, and a therapeutic gastroscope was introduced via the rectum, both advanced to opposing sides of the stricture. Fluoroscopic confirmation of scope positions was followed by transillumination-guided puncture of the colonic side of the stricture with a 6 Fr cystotome. A guidewire was passed through the fistula and retrieved using forceps in a rendezvous manner. Balloon dilation of the fistula up to 4 mm enabled the deployment of a 16x20 mm lumen-apposing metal stent (LAMS). Contrast medium injection confirmed the correct positioning and patency of the LAMS. The patient was discharged home on the same day.
Results: At the 3-month follow-up sigmoidoscopy, the anastomosis was patent, while the stent had migrated and was removed. Colostomy reversal was successfully performed one day later. At the 6-month follow-up, the patient reported regular bowel movements without any residual symptoms.
Conclusion: Freestyle puncture of the excluded rectum using a cystotome followed by LAMS apposition during a dual endoscopic-fluoroscopic procedure seems to be a safe and effective treatment for recanalizing complete colorectal anastomotic strictures.

References

Clinical Case Summary

A 65-year-old man was admitted to our emergency department presenting with intermittent abdominal distension and difficulty in defecation for over a month, and absence of passage of stool and gas for 3 days. Soft tissue masses of sigmoid colon wrapping the left ureter on abdominal CT and a large nodular neoplasm in the sigmoid colon on colonoscopy were observed. Advanced colon cancer was highly suspected. However, we made sixes times biopsy totally and found no evidence of malignancy. Histopathology only showed moderate to severe chronic mucosal inflammation. We finally performed the subtotal colectomy and the histopathology of the excised colon showed us an unexpected finding: Schistosoma japonicum ova.
According to the data published by WHO in 2020, schistosomiasis has been reported in 78 countries worldwide, resulting in an estimated 240 million deaths¹. These highlight the significance of schistosomiasis eradication. Further history taking observed that the patient swam in the Baishui River, a tributary of Yangtze River, an endemic area of schistosomiasis, in recent four years of summer vacation.
During endoscopic examinations, patients may have characteristic scattered yellow nodules, while non-specific mucosal congestion, edema, thickening, ulcers, and polyps may be commonly observed. Therefore, misdiagnosis of intestinal schistosomiasis is common, with the rate of 30.3%^2,3. As we know, we made the first report of intestinal schistosomiasis infiltrating peritoneum and ureter, mimicking advanced colon cancer or Crohn’s disease. This highlights the importance of multi-site and deep biopsies or even surgery for the diagnosis of colonic neoplasm, especially when Schistosoma ova are distributed focally in submucosal area. Moreover, Schistosoma are far from eradication. Physicians should include schistosomiasis as a common differential diagnosis of colonic neoplasm. Detailed history taking of travel and migration is necessary in these patients.

References

(1) Díaz, A. V.; Walker, M.; Webster, J. P. Reaching the World Health Organization Elimination Targets for Schistosomiasis: The Importance of a One Health Perspective. Philos Trans R Soc Lond B Biol Sci 2023, 378 (1887), 20220274. https://doi.org/10.1098/rstb.2022.0274.
(2) Yang, Y.; Wang, X.-Y.; Duan, C.; Wang, Z.-J.; Sheng, H.-Y.; Xu, X.-L.; Wang, W.-J.; Yang, J.-H. Clinicopathological Characteristics and Its Association with Digestive System Tumors of 1111 Patients with Schistosomiasis Japonica. Sci Rep 2023, 13 (1), 15115. https://doi.org/10.1038/s41598-023-42456-9.
(3) Cai, L.; Chen, Y.; Xiao, S.-Y. Clinicopathologic Features of Chronic Intestinal Schistosomiasis and Its Distinction From Crohn Disease. Am J Surg Pathol 2021, 45 (3), 430–438. https://doi.org/10.1097/PAS.0000000000001594.

Introduction

H. pylori infection can remain after several eradication attempts. The objective of this study was to evaluate the effectiveness of the sixth-line rescue treatment in Europe.

Aims & Methods

Systematic and prospective registry on the clinical management of H. pylori infection. All cases with six eradication attempts registered in AEG-REDCap up to December 2022 were evaluated. The modified intention-to-treat (mITT) and per-protocol (PP) effectiveness was analysed.

Results

Overall, 81 patients were included, mainly from Spain (44% of cases), Italy (26%) and the United Kingdom (17%). The mean age was 52 years, with 52% women and 1.2% of patients allergic to penicillin. Culture was performed in 26 cases (32%), of which: 13 (50%) had bacterial antibiotic resistance to clarithromycin, 12 (46%) to nitroimidazole, and 8 (31%) to quinolones. In addition, 8 (35%) patients had dual resistance (both to clarithromycin and metronidazole) and 7 (27%) triple resistance (also to levofloxacin). Twenty-two different therapeutic combinations were used, most of them prescribed for 14 days (57%) and with low doses (39%) of PPIs. The most frequent treatments were: quadruple bismuth-tetracycline-metronidazole prescribed as three-in-one single-capsule (17%), triple amoxicillin-rifabutin (15%), quadruple bismuth-furazolidone-amoxicillin (11%), triple amoxicillin-levofloxacin (7.4%), and classical quadruple bismuth-tetracycline-metronidazole (6.2%). The highest eradication rates (mITT) were achieved with the single-capsule (77%) and with the quadruple therapy with bismuth-furazolidone-amoxicillin (67%). Overall effectiveness was 53%, both by mITT and PP analyses. Additional information on effectiveness, tolerability, compliance, and prior therapies is shown in the table.

Conclusion

Sixth-line eradication treatments in Europe obtain suboptimal eradication rates. The only therapies that reach acceptable outcomes are the bismuth quadruple therapies with either tetracycline-metronidazole (single-capsule) or with furazolidone-amoxicillin.

Disclosure

Olga P. Nyssen received research funding from Mayoly and Allergan.
Javier P. Gisbert served as speaker, consultant, and advisory member for or received research funding from Mayoly, Allergan, Diasorin, Gebro Pharma, and Richen.

Introduction

Functional dyspepsia (FD) is a disorder of gut-brain interaction (DGBI) characterized by postprandial fullness, early satiation, epigastric pain or burning in the absence of a readily identifiable cause at upper endoscopy. Proton pump inhibitors (PPIs) are often used as a first-line treatment for FD, although their efficacy has not been convincingly established.

Aims & Methods

The aim was to investigate symptom patterns in FD patients with and without acid-suppressive therapy (PPI or H2-antagonist, H2RA) and to evaluate the use of these drugs in different patient groups. Ambulatory tertiary-care patients referred for upper gastrointestinal endoscopy were requested to fill out Rome IV gastro-duodenal questionnaires. Those fulfilling Rome IV FD criteria with a negative endoscopy were identified as FD patients and subdivided into patients on and off acid-suppressive therapy. The pattern of GI symptoms was compared between these two subgroups, using frequency thresholds from the Rome IV criteria. The chi-square or Fisher exact (when applicable) test was used to evaluate statistical significance (p<0.05).

Results

The Rome IV questionnaire was filled out by a total of 1002 patients (58% females, 48.5 ± 0.5 years, BMI 25.4± 0.5). Of these, 229 (23%, 73% females, 45.5 ± 1.1 years, BMI 23.9 ± 0.3) fulfilled the diagnostic criteria for FD. Organic findings at endoscopy included Barrett’s oesophagus (n=40, 4%), peptic ulcers (n=24, 2%), and reflux oesophagitis (n=352, 35%).
PPI/H2RA usage in FD patients was 60%, which was not significantly different from patients diagnosed with Barrett’s oesophagus (75%, p=0.07), peptic ulcer (50%, p=0.33), reflux oesophagitis (57%, p= 0.45) or the combined group with organic abnormality at upper endoscopy (46%, p=0.1). There was no significant difference (p=0.67) in PPI/H2RA usage between the EPS (epigastric pain syndrome, 55% usage) and PDS (postprandial distress syndrome, 50% usage) subgroups of FD.
The most prevalent symptoms in FD patients were postprandial fullness (76%), epigastric pain (67%) and bloating (62%). Patients on acid-suppressive therapy reported more nausea (41% vs 27%, p=0.04) and excessive belching (50% vs 36%, p=0.05) compared to patients without acid suppression. There was no significant difference in postprandial fullness (84% vs 73%, p=0.05), epigastric pain (75% vs 64%, p=0.08), heartburn (17% vs 28%, p=0.06) and bloating (70% vs 58%, p=0.06) between the two subgroups. Looking at the EPS and PDS subgroups of FD, there was a significant difference (p=0.03) in bloating between patients on (73%) and off (46%) acid suppression in the PDS subgroup of FD.

Conclusion

The cardinal symptom pattern in FD patients referred for upper endoscopy is similar for those on and off acid-suppressive therapy, but those on PPI/H2RA report more nausea and belching. No difference in acid-suppressive therapy use was observed between FD patients and those with organic findings at endoscopy.

Introduction

The prevalence of functional dyspepsia (FD) and gastroparesis in diabetic patients remains unknown. A high prevalence of gastroparesis has been reported in diabetic patients reaching up to 5%.¹ However, recent consensus specified the symptom pattern for gastroparesis, with nausea and/or vomiting as predominant symptoms, now defined as “gastroparesis-like symptoms” (GPLS).² The global prevalence of GPLS has been estimated to reach only 1.2% in diabetic patients, but type 1 and type 2 diabetes were not assessed separately.²

Aims & Methods

We aimed to assess the prevalence and burden of FD and GPLS in primary care patients with diabetes, comparing patients with type 1 and type 2 diabetes. An online survey was addressed to diabetic patients through general practitioners and diabetic patient associations. The survey included the Rome IV questionnaire and the Patient Assessment of Gastro-Intestinal Disorders-Symptom Severity Index (PAGI-SYM) for upper gastro-intestinal symptoms. Anxiety, depression, somatization, and quality of life were also assessed by specific questionnaires (Generalized Anxiety Disorder GAD-7, Patient Health Questionnaire PHQ-9, PHQ-15, and PAGI-QoL questionnaires respectively).

Results

A total of 216 patients completed the questionnaires, among which 146 had type 1 diabetes, and 68 had type 2 diabetes, (2 patients did not know their type of diabetes). The median age of the population was 56 (50-61) years old, with 134 female patients (61.8%). The prevalence of FD was 13.0% with no difference between the 2 groups. The prevalence of GPLS reached 4.2% and was significantly higher in patients with type 2 diabetes (8.9% vs 2.1%; p=0.03). The burden of upper gastro-intestinal symptoms and their impact on quality of life was higher in type 2 diabetes patients with higher PAGI-SYM and PAGI-QoL scores while anxiety and somatization were not different between type 1 and type 2 diabetes patients (see Table). Overall, patients with GPLS had higher anxiety (9 vs 3; p=0.003), depression (12 vs 3; p=0.001) and somatization scores (16 vs 6; p<0.001) than patients without. Compared to patients with FD without GPLS, GPLS patients had numerically higher but not statistically different scores for symptom severity (51 vs 28; p=0.46), anxiety (9 vs 7; p=0.29), depression (12 vs 7; p=0.07), somatization (16 vs 11.5; p=0.16) and quality of life scores (52 vs 24; p=0.16).

Conclusion

This study confirms that the prevalence of GPLS seems to be higher in diabetic patients compared to available population data, especially in patients with type 2 diabetes. The impact of the symptoms was similar to the impact of FD in this population. Further studies are required to assess the prevalence of delayed gastric emptying in diabetic type 1 and 2 patients with GPLS.

References

1. Choung RS, Locke GR, Schleck CD, et al. Risk of Gastroparesis in Subjects with Type 1 and 2 Diabetes in the General Population. Am J Gastroenterol 2012;107:82-88.
2. Huang I-H, Schol J, Khatun R, et al. Worldwide prevalence and burden of gastroparesis-like symptoms as defined by the United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on gastroparesis. United European Gastroenterol J 2022;10:888-897.