Introduction

Endoscopic submucosal dissection (ESD) is a potentially curative treatment for T1 colorectal cancer (CRC) when it harbors specific histological parameters (T1 low risk). Unfortunately, optical diagnosis is not yet able to predict these factors, and lesions harboring focal deep invasive patterns (FDIP) are often classified as low-risk neoplasia. Therefore, a fist-line diagnostic dissection strategy to obtain an accurate pathological evaluation instead of systematic surgery as a first line treatment should be considered. Thereby, we aimed to compare the medical effectiveness, the environmental and economic impacts of diagnostic dissections (with subsequent surgery when needed) versus systematic surgery as a first line treatment for lesions with FDIP.

Aims & Methods

In this prospective multicentric study, we included patients from FECCO database who had lesions with a focal deep invasive pattern (FDIP, Kudo Vn or Sano IIIb) < 20 mm, which were resected through diagnostic endoscopic dissection (submucosal or intermuscular). We excluded lesions with non-invasive pattern, non-R0 resection, ulcerated lesions (Paris III) or with distant metastases or tumor stenosis. Subsequent surgery was recommended for high-risk lesions and discussed for intermediate risks with the patient. Environmental weights of dissections, colorectal surgery, and hospitalization days were calculated based on life cycle assessments.

Results

Eighty-two patients from 16 centers underwent 82 diagnostic dissection attempts for FDIP lesions from April 2021 to September 2024. En bloc resection and R0 resection rates were 95% and 96%, respectively. Among these patients, 37 (45%) were classified as low risk of recurrence, 5 (6%) as intermediate risk (sm > 1000 µm without budding or lymphovascular invasion), and 40 (49%) as high risk, avoiding 37 to 42 surgeries. Regarding the environmental impact, a dissection generated 73.2 kg CO2e per patient and 2.3 kg of waste, while colorectal surgery devices (e.g., right hemicolectomy) accounted for 82.7 kg CO2 equivalent and generated 14.5 kg of waste. Dissection had a mean inpatient stay of 0.98 days, compared to 3.5 days for colorectal surgery accounting for 45 kg CO2e per day. In this study, the environmental and economic impact of the diagnostic ESD strategy was 234 kgCO2e and 6400 euros per patient, 252 kg CO2e and 6900 euros if all intermediate-risk cases underwent surgery, and 240 kg CO2e and 8900 euros for a completely first line surgery approach.

Conclusion

Diagnostic dissection of lesions harboring focal deep invasive patterns helps reduce the human burden of care by avoiding approximately 40% of surgeries. However, it does not increase the carbon footprint, with an estimated 234 kg CO2e equivalent per patient, compared to an immediate systematic surgery strategy for all lesions, which counts about 240 kg CO2e per patient.

Introduction

Inflammatory Bowel Disease (IBD) patients carry a high risk of malnutrition, independently of disease activity. Screening for malnutrition in IBD is currently recommended since malnutrition, as well as low Fat-Free Mass Index (FFMI), have been associated to poor disease outcomes. However, due to a non-universal definition of malnutrition, most Nutritional Screening Tools (NSTs) have been validated compared to different reference methods and do not consider patients’ body composition. Moreover, the ability of most NSTs to predict malnutrition over time has not been explored.

Aims & Methods

The aim of this study was to compare the efficacy of different NSTs to predict malnutrition, as defined by the ESPEN 2015 and GLIM criteria, and a low FFMI in a cohort of inactive/mildly active IBD patients.
This is a prospective, single center, cohort study enrolling Crohn’s disease (CD) and ulcerative colitis (UC) patients in clinical remission or with mildly active disease as defined by Harvey-Bradshaw Index and partial Mayo Score, respectively. MUST, MIRT, MNA, NRS-2002 and SaskIBD-NR questionnaires and Bioelectrical Impedance Analysis (BIA) were performed at baseline and after six months follow-up. A low FFMI was defined as <18 kg/m2 in males and <15 kg/m2 in females. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and the accuracy of the different NSTs for the detection of malnutrition and low FFMI at six months were calculated.

Results

Sixty-six (CD: 32; UC: 34) IBD patients were enrolled. Median age was 55.5 years (IQR 34-62.8), median disease duration was 10 years (IQR 6-17). At baseline, all CD and 30/34 (88%) UC patients were in clinical remission; median C-reactive protein was 0.8 mg/L (IQR 0-3.8), median fecal calprotectin was 55.2 mcg/g (IQR 12.9-326). Of the entire cohort, 6/66 (9%) and 17/66 (26%) patients were malnourished according to GLIM and ESPEN criteria, respectively, [(GLIM CD:3, UC: 3)(ESPEN: CD: 3; UC:14)] and 5/66 (8%) had low FFMI (CD:1; UC: 4). At 6 months follow-up, all CD and 31/34 (91%) UC patients were in clinical remission. Ten out of 66 (15%) and 32/66 (48%) patients were malnourished according to GLIM and ESPEN criteria, respectively [(GLIM CD:5, UC: 5)(ESPEN: CD: 15; UC:17)], 11/66 (17%) patients had low FFMI (CD: 3; UC: 8). Baseline MIRT showed the highest sensitivity for the diagnosis of both ESPEN and GLIM-defined malnutrition at 6 months (ESPEN: 40.5%; GLIM: 50%). For ESPEN, MIRT and NRS2002 were the most accurate NSTs (MIRT: 50%, NRS2002: 51.5%), while SaskIBD (75.8%) showed the highest accuracy in detecting GLIM-malnourished patients at 6 months follow up. Among all NSTs, baseline MIRT, MNA and NRS2002 had the highest sensitivity for the detection of low FFMI at six months (MIRT, MNA, NRS2002: 45.5%), while SaskIBD_NR was the most accurate (80.3%).

Conclusion

MIRT might be the NSTs of choice to predict defined malnutrition and low Fat-Free Mass Index at 6 months follow-up in a cohort of inactive/mildly active IBD patients.

References

Huang S, Niu Y, Liu X, Gu Z, Huang A, Wu J. Characteristics of malnutrition according to Global Leadership Initiative on Malnutrition criteria in non-surgical patients with inflammatory bowel disease. Nutrition. 2022;94:111514. doi:10.1016/j.nut.2021.111514

Jensen GL, Cederholm T, Correia MITD, et al. GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community. JPEN J Parenter Enteral Nutr. 2019;43(1):32-40. doi:10.1002/jpen.1440

Cederholm T, Bosaeus I, Barazzoni R, et al. Diagnostic criteria for malnutrition - An ESPEN Consensus Statement. Clin Nutr. 2015;34(3):335-340. doi:10.1016/j.clnu.2015.03.001

van Bokhorst-de van der Schueren MA, Guaitoli PR, Jansma EP, de Vet HC. Nutrition screening tools: does one size fit all? A systematic review of screening tools for the hospital setting. Clin Nutr. 2014;33(1):39-58. doi:10.1016/j.clnu.2013.04.008

Ding NS, Tassone D, Al Bakir I, et al. Systematic Review: The Impact and Importance of Body Composition in Inflammatory Bowel Disease. J Crohns Colitis. 2022;16(9):1475-1492. doi:10.1093/ecco-jcc/jjac041

Introduction

Diagnosing the extent of early gastric cancer (EGC) using narrow-band imaging with magnification (NBI-M) can be challenging in cases with large lesions or severe surrounding gastritis. Moreover, if the endoscope tip contacts the lesion and causes bleeding, the quality of the diagnosis of EGC by NBI-M is degraded. The NBI-M method requires the endoscopist's skill because of the delicate manipulation of the endoscopic scope. In contrast, the acetic acid with indigocarmine (AIM) method is a simpler technique that facilitates extent diagnosis regardless of expertise. However, AIM does not yield effective results in all EGC cases.

Aims & Methods

The study aimed to determine the optimal method for delineating EGC extent during endoscopic submucosal dissection (ESD) marking. Informed consent was obtained from 107 patients scheduled for gastric ESD at our institution. The extent of EGC was assessed first with NBI-M, followed by thorough rinsing and spraying with 2% AIM. One minute after spraying AIM, visibility of the lesion extent was graded on a four-point scale: 0= not identifiable, 1= unclear, 2= approximately clear, 3= clear. Resected specimens were immunohistochemically stained for MUC5AC, MUC6, MUC2, and CD10. The immunohistochemical score for each staining was determined as follows: 0= no staining, 1= ≤1/3, 2= 1/3–2/3, 3= ≥2/3 of cancer stained. We examined the relationship between the extent of each staining and the clarity of extent diagnosis of EGC using the AIM method. In addition, a logistic analysis was performed on the factors involved in the cases in which AIM method was superior to NBI-M for extent diagnosis of EGCs.

Results

Of the initial 107 patients, 102 with 102 lesions were analyzed after excluding two cases of signet ring cell carcinomas, one case of gastric carcinoma with fundic gland type, and two cases with consent withdrawal. There were no significant differences in the degree of staining with AIM for gender, infection of Helicobacter pylori, degree of atrophy, lesion size or histological type. Regarding lesion location, EGCs located in the upper third of the stomach showed significantly clearer staining with the AIM method (p=0.0018): 10 lesions (76.9%) were clearly stained, 2 lesions (15.3%) were approximately clear, and 1 lesion (7.6%) was not identifiable. As for the relationship between AIM staining and mucin phenotype expression, only CD10 expression was significantly more frequent in EGCs that showed clear staining with AIM (p=0.019). In the diagnosis of the extent of gastric cancer, AIM was superior in 37 cases, NBI-M was superior in 41 cases, and equivalent in 24 cases. The factors involved in cases with superior AIM method were CD10 (p=0.097, OR 1.14) and upper third of stomach (p=0.042, OR 9.33) in univariate analysis and only upper third of stomach (p=0.027, OR 12.18) in multivariate analysis.

Conclusion

The proposed strategy for determining the extent of EGCs is to prioritize the AIM method for lesions with high CD10 expression and located in the upper third of the stomach.

Introduction

Providing people who have alcohol use disorder (AUD) with feedback about their liver (biofeedback using Fibroscan) may influence their drinking behaviour. It is unclear if and how having a Fibroscan may support behaviour change. There are also questions about how receiving a ‘normal’ result influences an individual’s feelings about their alcohol use.

Aims & Methods

This qualitative study aimed to explore people’s experiences of receiving different Fibroscan results and the impact they felt it had on them. Seventeen qualitative transcripts (11 recovery narratives, 6 post-trial interviews) from the KLIFAD trial (ISRCTN16922410) were analysed. An initial realist programme theory of a complex intervention was produced using the literature and other psychological theories of behaviour change to predict how the Fibroscan may influence behaviour change. A deductive qualitative analysis was conducted to find evidence for an initial programme theory of how the KLIFAD intervention may influence alcohol-related behaviour change. Initial ideas in the programme theory were amended based on qualitative insights.

Results

Of these participants, ten were ≥50 years of age, nine were male, 14 were white and three were of minority ethnicity, most were heavy drinkers. Fibroscan results ranged from normal (≤7 kPa=9), intermediate (8–14 kPa=4) to high (≥15 kPa=4). At follow-up ten reported abstinence and seven reduction in alcohol consumption, none reported increased consumption. Fibroscan was seen by some participants as an opportunity (or a privilege not all get to have) to find out about their health, and a chance to “see inside what is going on”. Those reflecting on receiving high scores described it as a shock, rock bottom, or an instant turning point. Most receiving normal results felt reassured and saw it as an opportunity to change their behaviour. Reducing the score by reducing alcohol use was described as a motivator for three participants. Not all participants (n=2) felt Fibroscan would help reduce alcohol use, often due to acute drinking, co-existing mental health diseases, hopelessness, or memory issues. Other factors influencing its impact included health priorities, loneliness, supportive relationships, age, symptoms such as pain, language barrier, stage of change, recognition of alcohol issues, and service engagement. One participant expressed guilt about self-inflicted harm when preparing for the test.

Conclusion

This study highlights the varied impact of Fibroscan biofeedback on alcohol-related behaviour change, influenced by individual circumstances such as mental health, readiness to change, and social support. High Fibroscan scores often prompted reflection and action, while normal scores reassured and motivated. Addressing barriers and stigma could enhance its effectiveness.

Clinical Case Summary

A 66-year-old female with a history of prior stroke presented with generalized weakness. She was disoriented and unable to provide a reliable history. She was febrile and tachycardic, and labs were notable for elevated direct bilirubin and liver enzymes. Physical exam was notable for right upper quadrant tenderness and well-healed scarring consistent with prior abdominal surgery. CT abdomen showed intrahepatic micro-abscesses and MRI revealed a cystic duct–duodenal fistula. Due to the patient’s clinical improvement with antibiotics, she was able to be discharged with a plan for outpatient ERCP. Due to issues with insurance coverage following discharge, the patient was lost to follow-up.
This is a rare presentation of a cysto-duodenal fistula that was the source of cholangitis and hepatic micro-abscesses resulting in sepsis. The incidence of cysto-duodenal fistulas is unknown, though fewer than 12 case reports of cystic duct-enteric fistulas have been published. The formation of a fistula can occur after cholecystectomy, involving a persistent cystic duct remnant that can become obstructed by calculi, leading to increased pressure and subsequent fistulization. It can present within days to years following cholecystectomy. This patient’s surgical history was unclear due to her altered mental status and a lack of records, though she had abdominal scarring and imaging findings that were consistent with prior cholecystectomy. It was confirmed that the patient did not have any recent abdominal procedure or cholecystectomy, making her presentation even rarer. Patients with a cysto-duodenal fistula typically present with signs of biliary sepsis, like in this case. ERCP is both a key diagnostic and therapeutic tool, as management of the fistula may involve interventions such as sphincterotomy and stenting to relieve obstruction. If endoscopic management is unsuccessful or if symptoms recur, surgical intervention may be necessary.

References

CT abdomen showed multiple small irregular hypodense lesions concerning for intrahepatic micro-abscesses. MRI was performed for further characterization and revealed inflammatory changes of the cystic duct stump with high suspicion for cystic duct–duodenal fistula and hepatic micro-abscesses (most notable in segment VII) with no drainable abscess.

Introduction

The LiverRisk score was recently developed as a tool for predicting liver fibrosis and liver-related outcomes in the general population. We aimed to evaluate the predictive performance of the LiverRisk score for liver fibrosis and overall mortality in HCV patients treated with direct acting antivirals.

Aims & Methods

This was retrospective, descriptive and analytical study conducted in a gastroenterology department over 8 years including patients diagnosed with chronic hepatitis C. Data were collected from patient records and during their follow-up. The data normality test for this study was conducted using the Shapiro-Wilk test. The discrimination ability of the Liver Risk Score was evaluated using the Area Under the Receiver Operating Characteristic (AUROC) curve. Overall mortality was assessed at the conclusion of the follow-up period.

Results

Among 165 patients monitored for hepatitis C and treated with direct-acting antivirals, only 68(41.2%) patients were eligible for this study. Mean age at diagnosis was 61±13.2 year; sex ratio M/W was 0.78 .10(14.7%) of the patients were tobacco users. 22(32.4%) had hypertension, and 14(20.5%) had diabetes.
Regarding hepatic risk factors; 5(7.5%) had alcohol use disorder, and use of cannabinoid substances was reported in 5(3%) of the cases.1(1.4%) had history of drug injection. 7(10.6%) had a history of bloodletting and tattoos, and 4(6%) had high-risk sexual practices.
Regarding the circumstances of diagnosis, 23(39.7%) patients were diagnosed incidentally, 18(26.4%) following an evaluation for asthenia, 4(6.9%) presented with abdominal pain, and 3(4.4%) exhibited signs of portal hypertension.
In terms of laboratory findings, 25(36.7%) had cytolysis, 7(10.2%) showed biochemical cholestasis, 16(23.52%) had thrombocytopenia, and 5(7.3%) presented with sign of hepatocellular insufficiency. Hepatitis B coinfection was identified in 3(4.4%) cases.
The most frequent genotype was 1b, identified in 18(45%) patients, followed by genotype 2 in 17(25%). Genotypes 1a, 3, and 4 were observed in 5(7.3%) patients.
On ultrasound, 15(22%) patients showed signs of chronic liver disease, and 8(11.7%) exhibited signs of portal hypertension. A total of 26(38.2%) patients underwent upper endoscopy, among whom 13(19.11%) had esophageal varices, 2(2.9%) had gastric or gastroesophageal varices (GOV), and 9(13.2%) presented with hypertensive gastropathy.
46(75.4%) were treated with Sofosbuvir and Daclatasvir, followed by Sofosvubir and Velpatasvir for 9(14.8%). Sustained virological response was achieved for 51(91.1%) patients.
For fibrosis, 19(30.2%%) were at stage F4, 9(14.3%) at stage F3, 13(20.6%) at stage F2, and 22(34.9%) at stage F0-F1. Median Liver risk score was 7.58[6.28;8.5].
The LiverRisk Score exhibited high accuracy in predicting liver stiffness and outperformed traditional serum biomarkers of fibrosis. Its discriminatory capacity for detecting liver stiffness ≥10 kPa was reflected by an AUROC of 0.848, compared to 0.779 for the FIB-4 test. After 5 years follow up 8(11.76%) patients died. LiverRisk score was associated with the risk of all cause of mortality (HR= 1.34, 95% IC[0.98;1.83], p = 0.047).

Conclusion

The LiverRisk score is an accurate tool to predict liver fibrosis and mortality in HCV patients treated with direct acting antivirals.

Introduction

The Chicago Classification version 4.0©(CC4) provided an updated classification of oesophageal motility disorders based on high-resolution oesophageal manometry (HRM) findings[1-2]. A key modification included using solid swallows which have been shown to increase the diagnostic yield of oesophageal motility disorders[3]. CC4 fails to offer guidance on the weighting of relevant findings when wet and solid swallows are discordant[3]. Clinical judgement, such as incorporating patient reported symptoms, is therefore required when interpreting HRM findings[2-3].

Aims & Methods

This retrospective service evaluation aimed to determine the frequency of CC4 diagnostic discordance between wet and solid swallows and how this was managed clinically. Data was collected from consecutive patients at a single National Health Service Trust (UK) site over a 6-month period. HRM was performed using a 36-channel HRM solid state catheter with impedance (Medtronic ManoScan™ ESO HRM) following the upright study CC4 protocol[2]. All patients had 5 mL saline swallows and those with dysphagia or abnormal primary swallows underwent solid swallows (rice test meal)[3].

Results

69 patients underwent HRM during the 6-month period. 51 studies included solid swallows, 61% (n=31) showed agreement between wet and solid CC4 findings and 39% (n=20) showed disagreement. Of those with discordance, it was concluded that 9 were inconclusive due to mixed appearances. In 7 studies the solid swallows were deemed more clinically relevant and in 4 studies the liquids swallows best reflected the clinical context.
10 patients had abnormalities detected on wet swallows but normal solids, 50% of which showed ineffective oesophageal motility (IOM) and 50% showed oesophago-gastric junction outflow obstruction (OGJOO). Of the patients with OGJOO on wet swallows and normal solids, 3 were concluded to be normal due to a lack of symptoms, good bolus clearance on HRM and normal endoscopy and barium swallow results. One was deemed inconclusive as the patient was symptomatic to bolus hold-up measured on HRM. One was concluded as OGJOO due to abnormal rapid drink challenge, upright swallows and supine swallows.
Of the 5 studies showing IOM on liquid swallows but normal solids, 2 were overall concluded to be normal due to a lack of symptoms. 2 were concluded as IOM, although only one was symptomatic to ineffective swallows. Both reports did, however, mention evidence of peristaltic reserve. One study was concluded inconclusive as possible IOM.
3 patients who had normal liquid swallows had abnormalities on solids. One showed IOM on solids which was concluded as insignificant due to a lack of symptoms. One had hypercontractile oesophagus which was concluded as significant due to the presence of symptoms[3]. The other showed symptomatic OGJOO with solids. This was classed as inconclusive as the patient had normal bolus clearance on barium swallow.

Conclusion

More patients had abnormalities on liquid swallows which normalised on solids, despite studies indicating increased motility disorder diagnosis with solid swallows[4]. Test analysers placed greater significance on solid swallow findings compared to liquids. However, many tests were reported as inconclusive. Tests with abnormal liquid swallows but normal solids frequently had differing conclusions, in part due to adjunctive test findings and reported symptoms. This emphasizes the importance of symptoms and overall clinical judgement when reporting. Future CC iterations should consider discordant findings and offer guidance on what is clinically relevant during HRM studies.

References

[1] Yadlapati, R. Kahrilas, P.J. Fox, M.R. et al. 2021. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0^©. Neurogastroenterology and Motility. 33(1).
[2] Fox, M.R. Sweis, R. Yadlapati, R. Pandolfino, J. Hani, A. Defilippi, C. Jan, T. and Rommel, N. 2021. Chicago classification version 4.0^© technical review: Update on standard high-resolution manometry protocol for the assessment of esophageal motility. Neurogastroenterology and Motility. 33(4).
[3] Ang, D. Misselwitz, B. Hollenstein, M. Knowles, K. Wright, J. Tucker, E. Sweis, R. and Fox, M. 2017. Diagnostic yield of high-resolution manometry with a solid test meal for clinically relevant, symptomatic oesophageal motility disorders: serial diagnostic study. The Lancet Gastroenterology & Hepatology. 2(9), 654-661.
[4] Sharma, P. and Yadlapati, R. 2022. Evaluation of Esophageal Motility and Lessons from Chicago Classification version 4.0. Current Gastroenterology Reports. 24(1):10-17.