Introduction

Gallbladder polyps are lesions that protrude from the wall of the gallbladder to the lumen. The widespread use of abdominal imaging techniques has led to a dramatic increase in the detection rate of Gallbladder polyps. Gallbladder polyps are broadly divided into nonneoplastic and neoplastic polyps, with cholesterol polyps being the most common nonneoplastic polyps. The laparoscopic surgery remains the gold standard treatment for gallbladder polyps. Herein, we introduce a novel option for the treatment of gallbladder polyps called pure NOTES fgallbladder preserving gallbladder polyps therapy.

Aims & Methods

To compare the safety and effectiveness of pure natural orifice transluminal endoscopic surgery (NOTES) gallbladder-preserving polypectomy versus laparoscopic cholecystectomy (LC) for gallbladder polyps.
We used the database of inpatients at the First Affiliated Hospital of Zhengzhou University to retrospectively compare the NOTES polypectomy and LC for the treatment of gallbladder polyps by propensity score matching (1:1). We reviewed 322 patients with gallbladder polyps, of whom 38 patients met the matching criteria (NOTES: 19 and LC: 19).

Results

The technical success rate in both groups was 100%. The median procedure time was 155.4 ±63.1 minutes in NOTES group vs. 66.9 ±50.5 minutes in LC (p < 0.001). No postoperative pain was observed in NOTES group while 9 (47.4%) patients experienced incision related post-operative pain in LC group. The median duration of fasting was less with NOTES 2.4 ±1.6 days’ vs 2.0 ±0.7 days with LC (p < 0.001). The median post-operative hospital stay for NOTES was 5.6 ±4.0 days (IQRs, 3-6) vs. 5.32 ±2.4 days with LC (P = .092). During the 23 months of median follow-up period, 52.6% patients in the LC group were found to have post-cholecystectomy syndrome. Symptoms include fat intolerance in 6 cases (33.3%), right upper abdominal pain in 5 cases (27.8%), and changes in stool habits in 4 cases (22.2%). There were no symptoms such as fat intolerance, abdominal pain or distention, nausea, and acid heartburn observed in NOTES group. No recurrence of gallbladder polyps observed in NOTES group.

Conclusion

Both NOTES and LC are feasible and effective options for gallbladder polyps. NOTES advantages over LC includes no skin wound, organ preservation, quick recovery, and fewer long-term complications. Although LC has the advantages of short operation time, but the post-cholecystectomy syndrome as a long term complication of LC largely remain unstudied.

Disclosure

None

Introduction

Celiac disease, a chronic autoimmune enteropathy caused by exposure to gluten in genetically predisposed individuals, is characterized by a broad clinical spectrum often with multisystem involvement. Symptoms related to the reproductive system include delayed menarche, early menopause, fertility disorders, miscarriages, and prematurity.

Aims & Methods

To study the impact of celiac disease on fertility in a female Greek population. A retrospective review of all patient records from the celiac disease outpatient clinic at our hospital.

Results

Medical histories of 231 female patients were reviewed (69% of the total patient population) with a mean age of 44.3 years and a mean age at diagnosis of 35.3 years. The mean age of menarche was 12.7 years. Menstrual irregularities were reported in 27% (20% instability, 7% dysmenorrhea). A total of 28% (65/231) were in menopause, with an average age of menopause onset at 50.7 years. A history of miscarriages was recorded in 15% of all women (35/231), but in 29% of women in menopause (19/65). 82% (53/65) of women in menopause had children, with 98% (52/53) having been pregnant before the diagnosis of the disease. Among all women who gave birth, only 12/113 (11%) had been diagnosed before pregnancy. 56% (63/113) and 44% (50/113) had a vaginal delivery and cesarean section, respectively. Pregnancy complications were recorded in 24 women (18 preterm births, 15 low birth weight infants, 1 intrauterine death).

Conclusion

Women with celiac disease tend to have relatively late menarche and an increased rate of miscarriages. However, the disease does not seem to significantly affect fertility.

References

1.Ehud Galron MD, Rayna Boyarsky MD,Ido Sold MD, Chen Ben David MD,and Eyal Gal MD,Interactions between celiac disease and pregnancy:A literature review, Isr Med Assoc J.2023 Dec;25(12):830-835
2.Giovanni Casella et. Al. Celiac disease and obstetrical-gynecological contribution, Gastroenterol Hepatol Bed Bench. 2016 Autumn; 9(4): 241–249.
3.Stephanie M. Moleski et. Al., Increased rates of pregnancy complications in women with celiac disease, Annals of Gastroenterology (2015) 28, 236-240
4.Nafeesa N. Dhalwani et Al., Women With Celiac Disease Present With Fertility ProblemsNo More Often Than Women in the General Population, Gastroenterology 2014;147:1267–1274

Introduction

The presence of an aberrant clonal IEL population is the hallmark of RCDII. We have observed patients who have clinical features of RCDII but do not fit the classical immunophenotypic or molecular features of same.

Aims & Methods

Our aim was to describe the profile of RCDII patients who present with classical aberrancy in the absence of clonality or atypical aberrancy +/- clonality.
We conducted a retrospective review of flow cytometry and TCR-GR analysis of RCDII patients in University Hospital Galway over a 14 year period.

Results

We included 13 RCDII patients, 5 males and 7 females, with a median age of 62 years at RCDII diagnosis. 6 patients had classical RCDII, median 80% aberrant IELs (cytoCD3+/sCD3-/sCD8-) and had a clonal TCR-GR. Of the remaining 7 patients, 4 had classical aberrancy (median 52%) without clonality, including 1 who lost the TCR-GR clone 1 year post autologous stem cell transplant but whose aberrancy persisted (43%) 10 years later, and 1 who subsequently developed a clonal TCR-GR on follow up. 2 patients had an atypical aberrant IEL population without clonal TCR-GRs; one of whom developed lymphoma 3 years post RCDII diagnosis and the other remains under surveillance (16% classical aberrancy, 41%NK cells). The remaining patient has a mixed aberrant IEL population (71% cytoCD3+/sCD3-/sCD8+, 19% cytoCD3+/sCD3-/sCD8-) but has a clonal TCR-GR. Mortality rate for the classical RCD II was 66% compared to 14% in variant RCD II.

Conclusion

​The heterogeneity of RCDII poses many diagnostic challenges. Newer sequencing technologies will likely aid the expansion of the diagnostic criteria to include variant RCDII. While follow up is ongoing, variant RCDII maybe associated with a lower mortality.

Introduction

Anti-TNF are the first biologic treatment option in inflammatory bowel diseases (IBD). Few data is available on the long term risk of relapse after anti-TNF withdrawal in paediatric-onset IBD, especially at the population level.

Aims & Methods

All paediatric-onset (<17 years) IBD diagnosed between 1988 and 2011 were included in a prospective population-based study and were retrospectively followed until 2013. Among patients treated with first-line anti-TNF, the cumulative probability of relapse after anti-TNF withdrawal was evaluated using a composite outcome (intestinal resection, and/or flare-related hospitalization, and/or IBD treatment initiation, and/or active disease). Factors associated with relapse were investigated with a Cox model.

Results

Among a total of 1,344 patients (Crohn’s disease (CD): n=1,007; Ulcerative colitis (UC): n=337), 562 were treated with anti-TNF. Anti-TNF was stopped in 73 patients (CD: n=66; UC: n=7) during remission defined by Harvey-Bradshaw score < 4 in CD and Mayo score ≤ 2 in UC. Among them, median time to anti-TNF initiation was 1.6 years (IQR, 0.7-4.0) and median duration of treatment was 1.0 year (0.3-1.7). The first line anti-TNF therapy was infliximab in 68 (93%) patients. At anti-TNF withdrawal, 47 (64%) patients received immunosuppressant. The cumulative probability of relapse after anti-TNF withdrawal at 1, 3 and 5 years was respectively 62%, 85% and 93%. Median delay of relapse was 9.5 months (7.5-12.0). The cumulative probability of flare-related hospitalization at 1, 3 and 5 years was respectively 7%, 7% and 8%. No patient required intestinal resection after a median follow-up of 8.7 (5.8-13.8) years. In multivariate analysis, median time to anti-TNF initiation >1 year was the only factor associated with the risk of relapse (HR 0.58, CI95% [0.35-0.97], p=0.036). Among relapsers, 46 (63%) were retreated with anti-TNF. Retreatment with anti-TNF was effective in 45 (98%) patients after a median delay of 3.9 months (3.5-10.0). Infusion reaction occurred in only 2 patients.

Conclusion

In a population-based cohort of paediatric-onset IBD, the risk of relapse after anti-TNF withdrawal was high, but was not associated with major complication. Retreatment with anti-TNF was effective and well tolerated.

Disclosure

Consultant fees from Sandoz and AbbVie

Clinical Case Summary

Introduction: Henoch Schoenlein Purpura (HSP) is an IgA immune mediated vasculitis. It is usually preceded by upper respiratory tract infection. It is more common in males. It is more predominant in paediatric population. However, its incidence in adults is extremely rare with 3.4-14.3 cases / million. Only 10-20% of patients present with gastrointestinal symptoms.
Case presentation: A 39-year-old male presented with rash, abdominal pain, vomiting and watery diarrhoea. His rash was non-itchy non-painful purpuric petechial which covered both upper and lower limbs consistent with HSP. He had diffuse angiokeratoma type lesions on the dorsum of his feet, hands, lateral side of thighs and buttocks. He upper respiratory tract infection for 1 week. Vitals signs were unremarkable. Bloods showed high CRP, ESR, IgA and WBCs. Procalcitonin was negative. ASO showed high titers. The rest of his bloodwork was negative including autoimmune screen and ANCA. Urine analysis showed persistent haematuria with negative urine culture.
CT abdomen showed jejunal wall thickening and oedema with fat stranding and mesenteric nodes. MRI small bowel found abnormal oedematous loops of small bowel proximally within the left flank. keeping with acute small bowel inflammation. However, distribution was not classical for inflammatory bowel disease. Rheumatology team started him on steroids for suspected Henoch-Schoenlein Purpura. He improved subsequently.
Discussion: This patient presented with HSP related enteritis after he had a recent upper respiratory tract infection and HSP characteristic rash. He was treated successfully with steroids.
Conclusion: Clinicians should be aware that Henoch Schoenlein Purpura could be present in adults despite being more prevalent in children. Clinicians should suspect HSP in adults when a patient presents with classic rash, abdominal symptoms and raised inflammatory makers after a recent upper respiratory infection.

References

Nevrekar RP, Bhandare P, Khandeparkar A. Clinical Spectrum of Henoch Schonlein Purpura in Adults: A Hospital Based Study. J Assoc Physicians India. 2022;70(2):11-12.

Introduction

Hypermobile Ehlers-Danlos syndrome (hEDS) is a hereditary non-inflammatory disorder of connective tissue laxity characterized by joint hyperextensibility in association with musculoskeletal symptoms. The prevalence of gastrointestinal (GI) symptoms, such as abdominal pain, nausea, and constipation is high in hEDS. Research on the relationship between EDS and GI symptoms has mostly been restricted to disorders of the gut-brain axis, whereas the relationship between hEDS and GI dysmotility remains to be clarified.

Aims & Methods

This study aimed to explore antro-duodenal manometry (ADM) patterns in patients with hEDS presenting with GI symptoms.

In a prospective open-label study, patients with hEDS and GI symptoms presumed to be the results of GI dysmotility underwent a 6-hour high resolution ADM. The manometry tracings were analyzed by two investigators (KS and JC) independently. Antral contraction frequency (contractions per minute) < 1.0 was considered as antral hypomotility. Pylorospasm was defined as isolated pyloric pressure waves within 60 minutes postprandial. The following neuropathic enteric patterns were scored: presence of retrograde peristalsis, bursts, clustered contractions, and absence of phase III contractions. Abnormal ADM was defined as having antral hypomotility and/ or pylorospasm and/ or neuropathic enteric patterns.

Results

Fifty patients (48 women, mean age 30.4 ± 11.1 yrs.) were included. At baseline, 74% of patients were dependent on enteral feeding and the mean BMI was 20.4 ± 4.4 kg/m².
Overall, ADM tracings with one or more abnormal patterns were identified in 53% of patients. Antral hypomotility and pylorospasm were detected in 29% and 15% of patients, respectively. Neuropathic enteric patterns were only seen in 17% of patients. In all cases, no more than one neuropathic pattern was identified. Among the observed neuropathic enteric patterns, 15% of patients showed retrograde peristalsis, 13% absence of phase III contractions, and 2% bursts. Clustered contractions were not identified in this cohort.

Conclusion

Hypermobile Ehlers-Danlos patients presenting with gastrointestinal symptoms showed low numbers of abnormal ADM patterns. In particular, enteric dysmotility was observed in only a small minority of cases. Antroduodenal dysmotility therefore does not appear to be a principle pathomechanism in the majority of hEDS cases studied. Further research is needed to understand the mechanisms that underlie GI symptom generation in this population.

Introduction

Recent years have seen a significant increase in randomized controlled trials (RCT) published on the efficacy of probiotics on irritable bowel syndrome (IBS), which several reviews have tried to comprehensively review. Two recent trials, Yang et al. 2024¹ and Chen et al. 2023² report the safety and efficacy of probiotics for IBS, which seems to reflect prevailing favorable view of this therapeutic option by most reviews conducted. Yet, despite efforts in this field, major organizations have not changed their stance in this and make no assertive recommendation for probiotics in afflicted patients^3,4. While further investigations are required, two challenges are faced: (1) repeated reviews have been undertaken in this field, resulting in a "multiplicity problem", (2) traditional meta-analytic techniques may also fail to provide a conclusive answer on the sufficiency of evidence, particularly when the data are sparse, and the risk of type I and type II errors is significant. This indicates a need for.

Aims & Methods

This study aims to evaluate the efficacy of probiotics in alleviating symptoms of IBS and improve quality of life through a timely implemented trial sequential analysis (TSA) and rigorously evaluate the evidence for recommendations on future studies. Medline, Embase, Web of Science, and Cochrane were screened for randomized controlled trials (RCTs) comparing probiotics to placebo in adult patients with IBS. Primary outcomes included IBS Symptom Severity Score (IBS-SSS) and IBS Quality of Life (IBS-QOL) scores comparing probiotics and placebo groups. Traditional pairwise meta-analysis conducted in restricted maximum likelihood was conducted, with subsequent TSA . Study quality was graded according to risk-of-bias 2 (ROB-2) and certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

Results

42 studies were included. Overall, probiotics demonstrated non-significant improvements in IBS-SSS (MD: -27.64; 95% CI: -56.90 to 1.63; p=0.06) and IBS-QOL (MD: 1.33; 95% CI: -3.65 to 6.30; p=0.59). TSA was conducted on IBS-SSS demonstrated current evidence has not reached the required information size. The representative cumulative Z-curve demonstrated neither futility, benefit nor detrimental effect, indicating the need for further trials. Assessment with ROB-2 indicates high quality amongst most trials included in this study. GRADE evaluation of the evidence demonstrated low certainty of existing evidence.

Table 1: GRADE Evaluation

No. of studies	Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Probiotics	Placebo	Relative (95% CI)	Absolute (95% CI)	Certainty
Probiotics effectively reduces a patient's IBS-SSS score
24	randomised trials	not seriousa	very seriousb	not serious	very seriousc	publication bias strongly suspectedd	2237	1599	-	MD 27.64 lower (56.9 lower to 1.63 higher)	⨁◯◯◯ Very lowa,b,c,d
Probiotics effectively reduces a patient's IBS-QOL score
24	randomised trials	not seriousa	very seriousb	not serious	not seriouse	publication bias strongly suspectedd	2292	1712	-	MD 1.33 higher (3.65 lower to 6.3 higher)	⨁◯◯◯ Very lowa,b,d,e

CI: confidence interval; MD: mean difference

Two contributing factors to the low certainty of current evidence include: (1) Inconsistency of existing trials – there exists high level of heterogeneity as detected by statistical analysis through I² and Cochran Q amongst studies; (2) Suspected publication bias through inspection of a funnel plot, though Egger’s regression did not demonstrate statistical significance.

Conclusion

Existing evidence is insufficient to make conclusive recommendations regarding the role probiotics should play in the management of IBS in symptoms and QOL. Given the persistent heterogeneity and potential publication bias, future research should focus on standardizing probiotic interventions and clarifying their clinical utility to truly advance the field.

References

1. Yang R, Jiang J, Ouyang J, Zhao Y, Xi B. Efficacy and safety of probiotics in irritable bowel syndrome: a systematic review and meta-analysis. Clinical Nutrition ESPEN. 2024;
2. Chen M, Yuan L, Xie C-R, et al. Probiotics for the management of irritable bowel syndrome: a systematic review and three-level meta-analysis. International Journal of Surgery. 2023;109(11):3631-3647.
3. Su GL, Ko CW, Bercik P, et al. AGA Clinical Practice Guidelines on the Role of Probiotics in the Management of Gastrointestinal Disorders. Gastroenterology. 2020;159(2):697-705. doi:10.1053/j.gastro.2020.05.059
4. McKenzie Y, Thompson J, Gulia P, Lomer M. British Dietetic Association systematic review of systematic reviews and evidence‐based practice guidelines for the use of probiotics in the management of irritable bowel syndrome in adults (2016 update). Journal of Human Nutrition and Dietetics. 2016;29(5):576-592.
5. Lacy BE, Pimentel M, Brenner DM, et al. ACG clinical guideline: management of irritable bowel syndrome. Official journal of the American College of Gastroenterology| ACG. 2021;116(1):17-44.

Disclosure

All authors of the manuscript do not have a conflict of interest to declare.