Introduction

The development of nonalcoholic fatty liver disease (NAFLD) is significantly influenced by genetic and environmental factors. Hepatobiliary diseases are associated with an imbalance of bacterial subpopulations and the associated deleterious effects on the colonized host. Otherwise, more and more evidence points to a close relationship between the composition of the microbiota and the development and progression of NAFLD. The genus Candida and the species Candida albicans could play a central role in the pathogenesis and progression of fatty liver infiltration with further steatohepatitis progression by the impact on the gut-liver axis. For example, rodents colonized with C. albicans develop liver disease without additional stimuli. Fungi might hence possibly exacerbate liver disease in a two-hit model, one hit being alcohol, the Western diet, or a toxin, and another hit being the presence and deleterious impact of fungi.

Aims & Methods

The aim of the study was to examine the prevalence of Candida and comporision of the gut microbiome in patients with NAFLD.

Results

Conclusion

The prevalence of Candida in gut microbiota of patients with NAFLD is significantly higher than in patients without fatty liver infiltration (36% vs. 13%).
The Candida growth can impact TNF-a and TG increasing in patients with NAFLD.
Candida could be associated with F/B index growth in patients with NAFLD.
Such results are potentially interesting for the search of personalized approaches in treatment and prevention the NAFLD. The role of gut microbiome is one of the important parts of the fatty infiltration development pathogenesis.

Introduction

Considering the impaired platelet function in uremic patients, the risk of post-polypectomy bleeding may increase in patients with end-stage renal disease undergoing colonoscopic polypectomy. Nevertheless, little is known about the risk factors of bleeding after colonoscopic polypectomy in these patients. This study investigated the incidence and risk factors of post-polypectomy bleeding, including immediate and delayed bleeding, in patients with end-stage renal disease (ESRD).

Aims & Methods

Ninety-two patients with ESRD who underwent colonoscopic polypectomy between September 2005 and June 2020 at a single tertiary referral center were included. The patients’ medical records were retrospectively reviewed. Patient- and polyp-related factors associated with immediate PPB (IPPB) were analyzed using logistic regression analysis. Additionally, the optimal cutoff polyp size related to a significant increase in the risk of IPPB was determined by performing receiver operating characteristic (ROC) analysis and calculating the area under the ROC curve (AUC).

Results

In total, 286 polyps were removed. IPPB occurred in 24 (26.1%) patients and 46 (16.1%) polyps, and delayed post-polypectomy bleeding occurred in 2 (2.2%) patients. Regarding the hemostasis method for IPPB, clipping was used in 31 (67.4%) cases and a combined method with clipping and coagulation was used in 15 (32.6%) cases. According to multivariate analysis, the polyp size (> 7 mm) (odds ratio=5.259, 95% confidence interval [CI]: 2.367–11.684), old age (>70) (odds ratio=4.186, 95% CI: 2.012–8.708), and endoscopic mucosal resection (EMR) as the polypectomy method (EMR versus non-EMR: odds ratio=3.339, 95% CI: 1.440–7.743) were found to be independent risk factors for IPPB. According to the Youden index method, the optimal cutoff polyp size to identify high-risk polyps for IPPB was 7 mm (AUC=0.755; sensitivity, 76.1%; specificity, 69.6%).

Conclusion

Colonoscopic polypectomy should be performed with caution in patients with ESRD, especially in those with the following risk factors: advanced age (>70 years), polyp size >7 mm, and EMR as the polypectomy method.

Clinical Case Summary

A 21-year-old female patient with recent hospitalization in another institution for gi bleeding presents with recurrent hematochezia and a positive shock index. The patient had already undergone a full work-up that was inconclusive (including wireless small bowel capsule and MR enterography).
At presentation patient underwent CT angiography, which revealed extravasation in the distal ileum. However super-selective embolization was not possible because at angiography active bleeding was not confirmed. Instead, she underwent a Technetium-99m scintigraphy and an ileocolonoscopy both without findings. The wireless small bowel capsule identified near the terminal ileum an abnormal lobular mass. The patient underwent exploratory laparotomy.
At 60 cm from the terminal ileum an intussuscepted Meckel’s diverticulum was identified. The diagnosis was supported by both the rapid biopsy and the final surgical preparation following resection (heterotopic gastric mucosa with areas of ulceration). The patient recovered uneventfully.
Complications from Meckel’s diverticulum should be considered as a rare case of gastrointestinal bleeding or abdominal pain in (young) adults. Screening with scintigraphy (test of choice) may be negative despite the presence of ectopic gastric mucosa. This could be attributed to mucosal ischemia due to intussusception and thus reduced radioactive tracer uptake. The threshold for repeat capsule endoscopy in poorly prepared patients / technical issues, especially where there is strong clinical indication, should be low. This inverted Meckel’s diverticulum did not present with the endoscopic finding of a double-lumen but with a polypoid appearance. Inversion of Meckel's diverticulum is a rare condition. Most cases report small bowel intussusception / obstruction and far less frequently a bleeding episode. This is a unique image and we did not find another ''polypoid'' presentation of a Meckel's diverticulum at capsule endoscopy in the literature.

References

Irie T, Shinji S, Arai H, Kan H, Yamada T, Koizumi M, Yokoyama Y, Takahashi G, Iwai T, Okusa M, Ohta K, Uchida E. Intestinal hemorrhage caused by Meckel's diverticulum with ectopic gastric mucosa on polypoid lesion: a case report. Surg Case Rep. 2016 Dec;2(1):124. doi: 10.1186/s40792-016-0252-4. Epub 2016 Nov 4. PMID: 27815920; PMCID: PMC5097056.
Sagar J, Kumar V, Shah DK. Meckel's diverticulum: a systematic review. J R Soc Med. 2006 Oct;99(10):501-5. doi: 10.1177/014107680609901011. Erratum in: J R Soc Med. 2007 Feb;100(2):69. PMID: 17021300; PMCID: PMC1592061.
P Baltes, I Steinbrück, B Stövesand-Ruge, U Matsui, F Hagenmüller, M Keuchel, Endoscopic Appearance of Meckel's Diverticulum, Video Journal and Encyclopedia of GI Endoscopy, Volume 1, Issue 1, 2013. Pages 223-225, ISSN 2212-0971,
https://doi.org/10.1016/S2212-0971(13)70095-5.

Introduction

Endoscopic submucosal dissection (ESD) has been routinely used for en-bloc resection of superficial lower GI neoplasms as it provides precise information on the histology, margins and invasion (lateral and deep). The meta-analysis by Fuccio et al (2017, pp 74) compared the outcomes of the Asian countries with the non-Asian countries and concluded that there was a high disparity between the two groups. There were higher R0 resections rates and lower postoperative complications, and recurrences at 12 months in the Asian setting, suggesting that the possible factors could be the low number of ESD procedures and reduced expertise in this field in the West.

Aims & Methods

We analysed the key performance indicators of Colorectal ESDs at a teaching hospital in the UK from 2017 to 2022. The procedures were performed by a single operator, who was trained in the West and has had no prior exposure to the Eastern training framework and guidelines. All procedures done between the above years were included starting from 2017 when ESD service was newly introduced in hospitals. Data was collected on R0 resections rates(deep and lateral margins free of neoplasia), post-operative bleeding and perforation rates, and recurrences/residual lesions at 6-12 months post-resection. We then compared the data with the results of the meta-analysis previously published. We then theorised the probable reasons for the disparity, based on potential contributing factors.

Results

Conclusion

Our data indicate that the Eastern standards can be met in the West with regard to key performance indicators for lower GI ESD. The reasons for underperformance can't be attributed to training and exposure. The above table and analysis indicate a need for the exploration of other probable factors and an updated review of Eastern and Western standards.

References

Fuccio, L., Hassan, C., Ponchon, T., Mandolesi, D., Farioli, A., Cucchetti, A., Frazzoni, L., Bhandari, P., Bellisario, C., Bazzoli, F. and Repici, A., 2017. Clinical outcomes after endoscopic submucosal dissection for colorectal neoplasia: a systematic review and meta-analysis. Gastrointestinal endoscopy, 86(1), pp.74-86. (Accessed: 31^st March 2023)

Introduction

In autoimmune atrophic gastritis (AAG), immune-mediated morpho-functional changes in gastric mucosa lead to hypo-achlorhydria and subsequent hypergastrinemia. This stimulates gastric enterochromaffin-like (ECL) cell proliferation, escalating the risk of type I gastric neuroendocrine neoplasms (gNENs). Yet, longitudinal studies on the AAG-type I gNENs association are still scanty.

Aims & Methods

Our study aims to assess in a multicentric cohort of AAG patients, the frequency and the characteristics of type I gNENs.
We conducted a multicentric, cross-sectional study from January to June 2023, prospectively enrolling consecutive patients diagnosed with AAG, from January 2000 to June 2023, who underwent at least one endoscopy. Data on demographics, clinical history, biochemical profiles, serological data, and endoscopic and histopathological findings were collected.

Results

The study included 612 patients with AAG [444 (75.2%) female, median age 66 (IQR 54-73) years]. At enrollment, 355 (58.1%) patients had ECL cell hyperplasia. Over a median follow-up of 4 (IQR 2-7) years, and after a median number of two upper GI endoscopies per patient, and a median disease duration of 7 (IQR 3-8) years, 108 patients showed 125 gNENs, corresponding to an incidence rate of 0.051 person-years. All the gNENs were well-differentiated. In 22 (18%) cases Ki 67 was not available; of the remaining 103, 86 (68.8%) cases were G1, 17 (13.6%) were G2, all of which with a Ki-67 < 10%; no G3 lesions were observed. 119 (95.2%) gNENs were located in the body/fundus. The median size was 5 (IQR 3-10) mm. 79 (73.1%) patients underwent endoscopic removal, 10 (9.2%) gastrectomy, 12 (11.1%) somatostatin analog therapy due to multifocal/recurrent disease, and 7 (6.5%) were only monitored. Patients with AAG and gNENs had significantly higher gastrin levels compared to patients without gNENs [median 874 pg/mL (IQR 362.5-1335) vs 581.5 pg/mL (IQR 281.8-1071.5), p=0.014]. However, there were no significant differences in proton-pump inhibitor use, OLGA and OLGIM stages, H. pylori status, and notably, circulating chromogranin A levels.

Conclusion

Type I gNENs are a relevant complication in patients with AAG. Elevated circulating gastrin levels are linked to their occurrence, with hypergastrinemia acting as a driver for abnormal proliferation of gastric ECL cells. Regular endoscopic surveillance and thorough histopathological examination are crucial in patients with AAG, serving as a key strategy for early diagnosis and treatment of gNENs.

References

1. Shah SC, Piazuelo MB, Kuipers EJ, Li D. AGA Clinical Practice Update on the Diagnosis and Management of Atrophic Gastritis: Expert Review. Gastroenterology 2021;161(4):1325-1332.e7.
2. Köseoğlu H, Duzenli T, Sezikli M. Gastric neuroendocrine neoplasms: A review. World J Clin Cases 2021;9(27):7973–85.
3. Sheikh-Ahmad M, Saiegh L, Shalata A, et al. Factors Predicting Type I Gastric Neuroendocrine Neoplasia Recurrence: A Single-Center Study. Biomedicines 2023;11(3):828.
4. Pachuashvili NV, Nagornaya DP, Tertychnyi AS. [Metachronous tumors of the stomach in a patient with autoimmune gastritis]. Arkh Patol 2023;85(1):57–61.

Introduction

Peutz-Jeghers polyps (PJPs), seen in Peutz-Jeghers syndrome (PJS), are found throughout the gastrointestinal tracts except for the esophagus. Of these, polyps in the small intestine are likely to become numerously developed and enlarged, resulting in intestinal intussusception which requires surgical treatment. Therefore, endoscopic treatment is recommended to prevent intestinal intussusception. Recently, endoscopic ischemic polypectomy (EIP) as the strangulation of the polyps using endoclips without polypectomy has been a treatment option for PJPs of the small intestine as well as conventional endoscopic mucosal resection (EMR). However, there has been insufficient data on the clinical utility and safety of EIP compared to EMR, and that needs to be clarified.

Aims & Methods

The purpose of this study was to evaluate the utility and safety of EIP for PJP in the small intestine. We retrospectively recruited PJS patients who underwent ballon-assisted enteroscopy at Chiba University Hospital between February 2010 and December 2023. The clinical information such as patient clinical backgrounds, treatment option, number of polyps, maximum diameter of polyps, and incidence of bowel obstruction after treatment were analyzed in patients who underwent endoscopic treatment for PJPs of the small intestine. The safety profile per-treatment was evaluated using the inverse probability weighting (IPW) method regarding the incidence of bleeding and intussusception after treatment.

Results

During the research period, 55 enteroscopies were performed, of which 37 (20 EMR and 17 EIP) endoscopic treatments were performed for a total of 239 PJPs (diameter 10-40 mm) in 10 PJS patients. The pathological evaluation was performed for 15 lesions (diameter 15-40 mm) treated with EMR, and all were diagnosed as PJPs. While there was no difference in the total time for endoscopic procedures including insertion and treatment between the EMR and EIP groups (182.5 min vs. 179.1 min, P=0.497), the number of treated polyps at one procedure was significantly higher in the EIP group (3.0±2.1 polyps by EMR v.s. 10.5±13.0 polyps by EIP, P=0.015). Post-treatment complications included bleeding in 5 treatments while no intussusception was observed. IPW analysis revealed that EIP was associated with a significantly lower risk of complications (P=0.017, OR=0.186, 95% CI 0.047-0.738) (Table).

Table. Weighted logistic regression analysis of the risk of bleeding after treatment for PJP.

Conclusion

EIP for PJPs in the small intestine is a safer treatment option for numerous lesions than EMR.