Introduction

There are no agreed guidelines to inform the approach to previously-treated achalasia patients presenting with recurrent symptoms. The decision to proceed to re-intervention is often based mainly on the clinical presentation and data arising from barium swallow studies and upper gastrointestinal endoscopy.

Aims & Methods

We evaluated Endoluminal functional luminal imaging probe (EndoFLIP) and High Resolution Manometry (HRM) value in such a setting. We selected patients from a prospectively-kept database with previously-treated achalasia (including Per Oral Esophageal Myotomy (POEM), Heller myotomy (LHM), pneumatic balloon dilatation (PBD) and botulinum toxin injection (BTX; only if submitted the last six months) presenting with symptom recurrence during an 8-year period (11/2015-2/2023). Only those with assessable EndoFLIP data (distensibility index (DI) at 40ml balloon inflation volume) and planned for re-intervention with POEM according to clinical judgment were included in the study. Baseline data were analyzed retrospectively. Consecutive naïve-to-treatment patients formed the control group.

Results

N=70 patients (25 treated vs 45 naïve) were included in the study (F=38; mean age 43 (17-78yrs). The majority of patients were previously submitted to pneumatic balloon dilatation (n=13), 5 were submitted to POEM A to Heller myotomy and 3 had botox treatment during the last six months before assessment. Table 1 lists the main demographic and investigative parameters. DI of treated patients was significantly decreased among patients without barium clearance at 5 min (1.8±0.9 vs 2.5±1.6, p=0.017) and was correlated to height of barium column (r=-0.439, p=0.015), fact not observed for IRP (29.1±13.5 vs 21.5±8.8, p=0.017 and r=0.266, p=0.319, respectively). DI was not correlated to IRP4s in treated patients (r=-0.168, p=0.374) in comparison to naïve (r=-0.227, p=0.046). Neither DI, IRP, nor barium column at 5 min were correlated to patients Eckardt score among treated patients (p=0.494, p=0.998, p=0.734 respectively).

	Previously treated	Treatment-naive	p
Male:Female	25/20	13/12	0.807
Manometric sub-type (1, 2, 3)
1 vs 2 1 vs 3 2 vs 3 Unclassified/classified	10/13 10/1 13/1 1/25	11/28 11/1 28/1 5/40	0.271 1.000 1.000 0.410
Positive barium swallow signs	(20/22) 90.9[HB1] %	(31/37) 83.3%	0.362
Delayed clearance of barium at 5 mins	(25/34) 73.5%	(14/19) 73.7%	0.551
Height of barium standing column (cm)	5.3± 6.0	4.2±4.6	0.551
Mean IRP4s (mmHg)	21.1 ± 12.6	27.9±11.3mm	0.06
IRPs 4s <15mmHg	(4/15) 26.7[HB2] %	(2/39) 5.1%	0.04
Mean DI	2.6±1.6	1.8±1.0	0.017

Conclusion

DI is impaired and correlated to height of barium swallow in 5 minutes in previously treated achalasia patients presenting with symptom recurrence and can be used as an objective metric to tailor re-intervention in conjunction to barium swallow. DI is significantly reduced among treated in comparison to naïve achalasia patients. HRM cannot with certainty navigate treatment decisions in approximately half of treated patients. Future studies that may define specific diagnostic DI cut-offs for patients with recurrence of achalasia symptoms needing re-intervention are needed.

Clinical Case Summary

Case: A 71-year-old male with history of cutaneous melanoma resected from his lower back eight years ago, chronic back pain on narcotics, and chronic constipation presented with acute on chronic abdominal pain and weight loss. Labs were notable for hyperbilirubinemia and alkaline phosphatase elevations in an obstructive pattern. Computed tomography demonstrated a severely enlarged hydropic gallbladder with heterogeneous intraluminal material concerning for gallbladder carcinoma with additional lesions in the liver, lungs, and right adrenal gland. Magnetic resonance cholangiopancreatography also showed a large, enhancing, solid mass within the gallbladder and many small hepatic lesions highly suspicious for metastatic disease. The patient subsequently underwent percutaneous ultrasound guided core needle biopsy of one of his liver lesions with interventional radiology, however samples were negative for malignancy. Given the continued high suspicion for gallbladder carcinoma, he underwent endoscopic ultrasound guided fine needle core biopsy of the mass and liver lesions. The final pathology was positive for metastatic melanoma. He was referred to oncology and is currently undergoing immunotherapy for his metastatic disease.
Discussion: Cutaneous melanoma is a rare but very aggressive disease, with high morbidity and mortality due to its high tendency to metastasize¹. Gastrointestinal metastasis occurs in only 2-4% of patients with melanoma, most commonly to the small bowel, colon, or stomach². This is a rare case of melanoma with metastasis to the gallbladder diagnosed by endoscopic ultrasound guided fine-needle biopsy years after the initial diagnosis of cutaneous melanoma.

References

References:

1. Patel D, Sohrawardy S, Sedhai YR, Basnyat S, Daxini A, Basu A, Mehta VR, Mohammed A, Lichtenstein S. Metastatic Cutaneous Melanoma of the Gallbladder. Case Rep Gastrointest Med. 2017;2017:8532379

2. Giannini I, Cutrignelli DA, Resta L, Gentile A, Vincenti L. Metastatic melanoma of the gallbladder: report of two cases and a review of the literature. Clin Exp Med. 2016 Aug;16(3):295-300.

Images: ​
1. CT ​Image of ​gallbladder
2. MRCP image of ​gallbladder
3. EUS image of gallbladder
4. Pathology ​picture of melanoma

Introduction

Crohn's disease (CD) is a chronic inflammatory bowel disease, characterized by a progressive course that leads to structural bowel damage (SBD). There is no clear definition of SBD. The Lémann index has been proposed, but it's too complicated to calculate. However, the presence of detectable complications through imaging techniques, such as strictures, fistulas or abscesses is widely accepted to describe SBD. Their presence is strongly associated with the severity of the disease and predicts the risk of hospitalization and surgery. Therefore, reversing structural bowel damage is an emerging medical goal in the time of biological treatments.

Aims & Methods

The main objective of this study was to assess the ability of biological treatments to reverse structural bowel damage monitored by intestinal ultrasound (IUS) and compare the disease course of patients with CD with inflammatory behaviour vs complicated behaviour (stricturing or penetrating -abscesses and fistulas-).
This was a longitudinal observational study, which included patients with CD who started a biological treatment in our center and that were monitored with IUS. Clinical, laboratory and ultrasound variables were collected at the beginning of biological treatment, after 12 weeks and after one year of treatment in order to study the evolution of the disease.
To achieve our objective, we compared the transmural healing (TH) at 12 weeks and one year after starting biological treatment. TH is defined as intestinal parietal thickness ≤3 mm, with no detectable Doppler signals and absence of complications.
As a secondary objective, we compared the need for medical treatment, hospital admission and surgery during the first year of biological treatment

Results

A total of 137 patients with CD were included in this study. Their characteristics and treatments are shown in Table 1.

Variables		Absolute frequency (%)
M​ale		67 (48.9%)
Initial bowel damage	Stricturing	31 (22.6%)
	Abscesses	11 (8%)
	Fistula	21 (15.3%)
Montreal Classification	Age	≤16 years: 12 (8.8%) 17-40 years: 79 (57.7%) ≥ 41 years: 46 (33.6%)
	Location	Ileal: 75 (54.7%) Colonic: 19 (13.9%) Ileocolonic: 43 (31.4%) Upper disease: 1 (0.7%)
	Behaviour	Inflammatory: 53 (38.7%) Stricturing: 30 (21.9%) Penetrating: 54 (39.4%)
Indication for initiating biologic treatment​​	Stenotic complication	25 (18.2%)
​	Penetrating complication	22 (16.1%)

At the beginning of biological treatment, 50 patients (36.5%) exhibited a complicated behaviour (strictures, abscesses, and fistulas).

After 12 weeks of treatment, TH was achieved in 22.9% of all evaluated patients. By groups, 8.2% of patients with complicated CD and 31.3% with an inflammatory behavior achieved TH, being the last difference statistically significant (p 0.02). After one year of treatment, TH on IUS was achieved in 46% of all evaluated patients. 31.8% of these patients had a complicated EC and 45.1% presented an inflammatory behavior, without reaching statistical significance (p 0.159).
Furthermore, the group with complicated behavior exhibited a significantly higher need for corticosteroid therapy, hospital admission, and surgery.

Conclusion

Patients with SBD showed a significantly lower rate of TH compared to patients with an inflammatory behaviour after 12 weeks of biological treatment. Additionally, the need for corticosteroid therapy, hospital admission, and surgery was significantly higher in patients with a complicated CD. However, after one year, the TH rate showed no differences between groups. This suggests that reversing structural bowel damage is possible but that the treatment of these patients is more complex.

References

1. Wilkens, Rune et al. Relevance of monitoring transmural disease activity in patients with Crohn's disease: current status and future perspectives. TherapAdvGastroenterol. 2021 Apr 16;14:17562848211006672.
2. Paredes, José María et al. Clinical Impact of Sonographic Transmural Healing After Anti-TNF Antibody Treatment in Patients with Crohn's Disease. Dig Dis Sci. 2019 Sep;64(9):2600-2606
3. Muñoz, Fernando et al. Recommendations of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the use of abdominal ultrasound in inflammatory bowel disease. GastroenterolHepatol. 2021 Feb;44(2):158-174.
4. Calabrese, Emma et al. Ultrasonography Tight Control and Monitoring in Crohn's Disease During Different Biological Therapies: A Multicenter Study. ClinGastroenterolHepatol. 2022 Apr;20(4):e711-e722
5. Fraquelli, Mirella et al. Impact of intestinal ultrasound on the management of patients with inflammatory bowel disease: how to apply scientific evidence to clinical practice. Dig Liver Dis. 2020 Jan;52(1):9-18.
6. Wilkens, Rune et al. Relevance of monitoring transmural disease activity in patients with Crohn's disease: current status and future perspectives. TherapAdvGastroenterol. 2021 Apr 16;14:17562848211006672
7. Roda, Giulia et al. Crohn's disease. Nat Rev Dis Primers. 2020 Apr 2;6(1):22
8. Fiorino, Gionata et al. Impact of therapies on bowel damage in Crohn's disease. United European Gastroenterol J. 2020 May;8(4):410-417

Introduction

Irritable bowel syndrome (IBS) is a prevalent functional gastrointestinal disorder characterized by abdominal pain and changes in bowel habits. Small intestinal bacterial overgrowth (SIBO) refers to a group of gastrointestinal syndromes caused by an excessive number of bacteria in the small intestine. Up to now, the relationship between IBS and SIBO remains contentious. So we set out to investigate the differences between these two conditions.

Aims & Methods

Participants who met the Rome III diagnostic criteria for IBS and had a negative lactulose hydrogen and methane breath test (LHMBT) were diagnosed with IBS. Those who presented with gastrointestinal symptoms and had a positive LHMBT were diagnosed with SIBO. Overlapping cases were excluded. Participants who had a negative LHMBT and no significant abdominal symptoms were classified as healthy controls (HC). All participants were instructed to provide fecal samples for 16S rRNA sequencing.

Results

Our results showed that a history of enteritis was more common in IBS patients, and the severity of gastrointestinal symptoms was significantly higher in IBS and SIBO groups compared to healthy controls. IBS patients also reported more severe symptoms than SIBO. Additionally, IBS patients were more affected by their symptoms, while the SIBO group reported more dissatisfaction with bowel habits. We observed differences in dietary intake between the groups, with IBS patients having the highest total energy and protein intake, and the lowest dietary fiber intake. SIBO patients had higher fat intake and significantly lower carbohydrate intake compared to the other two groups. Regarding the fecal microbiome, both IBS and SIBO patients had higher structural diversity and lower functional diversity than the HC group. The abundance of Firmicutes/Bacteroidetes in the IBS group was significantly higher than in the other two groups. Our analyses indicated that the fecal microbiome could significantly distinguish the three groups, and specific bacterial species were associated with different symptoms in each group. In SIBO, Thalassospira and Christensenellaceae_group were associated with intestinal motility abnormalities, while Ruminococcaceae_group, Butyricimonas, and Oscillospira were associated with gas production. In the IBS group, Klebsiella and Mitsuokella were associated with abdominal pain, and other bacteria such as Escherichia_Shigella and Enterobacter were generally associated with enteritis infection, abdominal pain, and diarrhea. We also found that the predicted KEGG pathways were enriched in various nutrient metabolism pathways, with potential implications for elevated blood folate levels and vitamin B12 deficiency in SIBO patients.Protein bacterial motility and biofilm formation_ Escherichia coli, were mainly enhanced in IBS, and these functions were related to the mucosal barrier damage.

Conclusion

Our study shows that although IBS and SIBO share similar symptom spectra, they may be two distinct diseases. Despite the potential differences in the fecal flora of small intestinal flora in SIBO group, significant differences were found between IBS and SIBO in terms of clinical phenotype and fecal microbiome. Further exclusion of SIBO using lactulose hydrogen and methane breath testing in patients who meet the diagnostic criteria for IBS is warranted, as the differences suggest that different treatment strategies may be needed for these two populations. Future studies are needed to explore the underlying mechanisms and potential therapies for these conditions, which may ultimately benefit patients with IBS and SIBO.

References

1. Quigley EMM, Murray JA, Pimentel M. AGA Clinical Practice Update on Small Intestinal Bacterial Overgrowth: Expert Review. Gastroenterology. 2020; 159(4):1526-1532. DOI: 10.1053/j.gastro.2020.06.090
2. Bushyhead D, Quigley EMM. Small Intestinal Bacterial Overgrowth-Pathophysiology and Its Implications for Definition and Management. Gastroenterology. 2022; 163(3):593-607. DOI: 10.1053/j.gastro.2022.04.002
3. Ghoshal UC, Nehra A, Mathur A, Rai S. A meta-analysis on small intestinal bacterial overgrowth in patients with different subtypes of irritable bowel syndrome. J Gastroenterol Hepatol. 2020; 35(6):922-931. DOI: 10.1111/jgh.14938
4. Mearin F,Lacy BE,Chang L, et al. BowelDisorders[J].Gastroenterology,2016;150;1393-1407.
5. Zhu L, Huang D, Shi L, et al.Intestinal symptoms and psychological factors jointly affect quality of life of patients with irritable bowel syndrome with diarrhea.Health
Qual Life Outcomes. 2015;13:49.
6. Sperber AD,Dumitrascu D, Fukudo S, et al.Gut 2017;66:1075–1082
7. Jindong Zhang, Jiao Liu, Shiwei Zhu, Ben Wang, Qiong Jia, Qihua He, Lijin Song, Yuan Fang, Baoli Zhu, Liping Duan. Berberine alleviates visceral hypersensitivity in rats by altering gut microbiome and suppressing spinal microglial activation. Acta Pharmacologica Sinica，Accepted 2020

Clinical Case Summary

Male, 72 years old, past medical history of diabetes mellitus and diabetic gastroparesis with only partial improvement after medical treatment with prokinetics, antiemetics and oral antidiabetic drugs.
Due to gastric adenocarcinoma, he underwent curative submucosal dissection(ESD) 2 years before and developed pyloric stenosis 1 month after ESD, refractory to endoscopic dilation and not amenable to placement of a biodegradable stent due to stomach morphology.
The patient was admitted to the to the Emergency Department after 2 weeks of postprandial vomiting, weight loss(12%/1 month) and 2 days of disorientation. On examination, he was partially oriented, hemodynamically stable, with mucocutaneous dehydration.
He was hospitalized, started on prokinetics and a nasogastric tube was placed for drainage. Analysis results on admission were normal except for a cystitis and empirical antibiotic was initiated.
During hospitalization, he suffered acute depression of consciousness with stupor and bilateral ophthalmoplegia, followed by delirium.
CT angiography excluded acute vascular events and cerebrospinal fluid(CSF) cytochemical analysis was normal.
Due to clinical suspicion of Wernicke's encephalopathy, he was started on intravenous thiamine at therapeutic dose, anticonvulsant, antibiotic at meningeal dose and antiviral, while waiting for microbiological results.
MRI revealed hypersignal in T2 and FLAIR with restriction in the diffusion study in the midbrain and the thalamus - findings suggestive of Wernicke's Encephalopathy. The remaining study, including EEG and complete CSF analysis excluded other etiologies.
There was a progressive improvement of aphasia, apraxia, ataxia and nystagmus. After motor rehabilitation and vitamin supplementation, 6 months later, he maintains a short-term memory deficit (Korsakoff Syndrome).
Wernicke's Encephalopathy due to gastroparesis is a rare occurrence in the literature with potentially irreversible sequelae, as illustrated.

References

Introduction

Biodegradable pancreaticobiliary stents provide an alternative to conventional stents and avoid the need for a repeat procedure for endoscopic removal. While use is not currently widespread in the United Kingdom, accepted indications for insertion include bile leaks, prophylaxis of post-ERCP pancreatitis and as a bridge to cholecystectomy after bile duct clearance. Evidence from small studies suggest biodegradable stents are safe and cost effective, however there are few prospective studies to guide best practice. Complications of biodegradable stents are also not well understood with limited, if any, data describing issues specific to these types of stent. In our hospital trust, biodegradable stents have been in use since 2019 and this study aims to describe trends in use including complications and provide a comprehensive summary experience to date.

Aims & Methods

The electronic record of all patients in two hospitals within Manchester foundation trust who underwent insertion of a biodegradable pancreaticobiliary stent were reviewed. The study period was between March 2019 and April 2023. Patient demographics, type of stent, indication for stent insertion, readmissions and repeat ERCP data was collected on review of each patient’s record.

Results

During the study period 66 Biodegradable stents were inserted in 63 patients of which 48 were pancreatic and 18 biliary. All pancreatic stents were inserted for post-ERCP pancreatitis prophylaxis, whilst 5 biliary stents were performed for bile leaks and 13 for biliary drainage post-ERCP. A total of 9 patients were readmitted within 6 months for a pancreaticobiliary related complications including cholangitis (n=3), cholecystitis (n=2), post-ERCP pancreatitis (n=2), biliary obstruction (n=1) and persistent bile leak (n=1). In total, 10 patients underwent repat ERCP within 6 months. In one patient, the biodegradable stent was noted at ERCP to be in situ ERCP 5 months after insertion. Over 94% (n=17) of all biliary stents were performed in the first year of study, although the majority of these were inserted in 1 of the 2 study centres.

Conclusion

To our knowledge this is the largest series of patients undergoing biodegradable stent insertion in the United Kingdom. In this study, the most common indication for the insertion of a biodegradable stent was post-ERCP pancreatitis prophylaxis. As the study period progressed pancreatic stents became by far the most commonly inserted stent. In fact, only 1 biliary stent was placed in the final 3 years of the study period, demonstrating a trend towards the use of pancreatic biodegradable stents versus biliary stents. This may represent differences in clinical practice, services provided over time (e.g Spyglass or ‘hot’ cholecystectomies) or simply endoscopist preference. The study suggests that biodegradable stents are safe and effective with only 10 patients undergoing a further ERCP in 6 months. Therefore, a significant proportion of patients were able to avoid a second procedure thus providing a benefit in both risk and cost.

Disclosure

None

Introduction

Pouchoscopy is indicated for pouch assessment and surveillance following ileal pouch-anal anastomosis (IPAA) surgery. Annual surveillance is suggested in cases who are at high risk of neoplasia (i.e. Primary Sclerosing Cholangitis (PSC)/ colonic dysplasia/ neoplasia), and 5 yearly in low risk patients^1,2. Biopsies are recommended. With the pressures on endoscopy services continuing we reviewed endoscopy utilisation in our cohort of pouch patients.

Aims & Methods

We searched via health informatics for all patients who underwent IPAA surgery at our centre the Queen Elizabeth Hospital, Birmingham, United Kingdom, from 2012 to 2022. Via case note review, we reviewed indication, timing, presence of high-risk features and pouchoscopy report

Results

56 patients underwent surgery for formation of new IPAA during this study period. The majority were performed were performed from 2012- 2015 (36 cases, 62%). 6 (10%) were undertaken as a single stage procedure, the remainder were 2 stage and 1 (1.8%) was a conversion from an ileo-rectal anastamosis. Indication for IPAA was medically refractory inflammatory bowel disease (IBD) in 48 (86%) cases, colonic dyslpasia in the context of IBD in 5 (9%), and 3 (5%) had an underlying genetic disorder for malignancy e.g. FAP or HNPCC. 16 patients had high risk features (PSC colitis=5, Dysplasia/neoplasia =11), although 2 were referred elsewhere for surveillance.
148 pouchoscopies were performed on this cohort of patients, with an average of 1 pouchoscopy every 3 years from IPAA date (range: 1 pouchoscopy per 0.4 – 10 years). The majority (113, 76%) of procedures were for pouch symptoms e.g. frequency, pain. Biopsies were taken in 98 (66%). Dye spray surveillance was not performed. No biopsy showed pouch or rectal neoplasia, but 73 (74%) showed pouchitis/cuffitis/inflammation.
Despite high resource utilisation, adherence to surveillance protocols remained poor.

	Appropriate number of pouchoscopies as per guidelines	Appropriate number of pouchoscopies with biopsies	Number of patients who did not undergo pouchoscopy despite pouch duration >1 years (high risk) or >5 years (low risk)
High risk (n=14)	2 (14%)	1 (7%)	3 (21%)
Low risk (n=40)	30 (75%)	29 (73%)	10 (25%)

2 patients went on to have their IPAA excised, and 5 have since died; 2 due to PSC associated liver failure, 2 due to non-pouch malignancy and 1-details unavailable.

Conclusion

This study shows poor implementation of pouch surveillance guidelines yet high use of endoscopy for pouch assessment often without biopsy. Our findings suggest that surveillance for neoplasia is an overlooked component of the care of patients who have under IPAA surgery. Furthermore, there is uncertainty within guidelines about frequency of surveillance particularly in low risk groups, although these patients do have a recognised risk of neoplasia^2,3.
We recommend that endoscopists take biopsies routinely when assessing pouch such as Type C mucosa in the pouch (mucosa exhibiting permanent persistent atrophy and severe inflammation) has a greater propensity for neoplastic changes. In addition, more data is needed to determine the risk of neoplasia in different subgroups of patients who have undergone IPAA surgery, as well as develop robust guidelines on use of endoscopy in pouch management.

References

1 = Derikx LA, Nissen LH, Oldenburg B, Hoentjen F. Controversies in Pouch Surveillance for Patients with Inflammatory Bowel Disease. J Crohns Colitis. 2016 Jun;10(6):747-51. doi: 10.1093/ecco-jcc/jjw035. Epub 2016 Jan 28. PMID: 26822612.
2 = Lamb CA, Kennedy NA, Raine T, et al British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults Gut 2019;68:s1-s106.
3=Samaan MA, Forsyth K, Segal JP, De Jong D, Vleugels JLA, Elkady S, Kabir M, Campbell S, Kok K, Armstrong DG, Penez L, Arenaza AP, Seward E, Vega R, Mehta S, Rahman F, McCartney S, Bloom S, Patel K, Pollok R, Westcott E, Darakhshan A, Williams A, Koumoutsos I, Ray S, Mawdsley J, Anderson S, Sanderson JD, Dekker E, D'Haens GR, Hart A, Irving PM. Current Practices in Ileal Pouch Surveillance for Patients With Ulcerative Colitis: A Multinational, Retrospective Cohort Study. J Crohns Colitis. 2019 May 27;13(6):735-743. doi: 10.1093/ecco-jcc/jjy225. PMID: 30590513.