Introduction

Proton pump inhibitors (PPIs) are commonly prescribed for acid-related disorders, yet concerns about overuse and long-term adverse effects persist. Physicians, due to their medical knowledge and unrestricted access to medications, may demonstrate unique self-medication behaviors. This study aimed to assess the prevalence, indications, self-prescribing habits, and awareness of PPI-related risks among physicians.

Aims & Methods

A cross-sectional online survey was administered to 442 physicians across different healthcare levels. The anonymous questionnaire collected data on demographics, frequency and indications for PPI use, self-medication practices, knowledge of adverse effects, and deprescribing behavior. Descriptive and comparative statistical analyses were conducted.

Results

Of the respondents, 60.8% reported occasional PPI use, and 52.0% admitted to self-medicating without prior medical consultation. The most common indications were gastroesophageal reflux disease (GERD) and dyspepsia. Preventive use (e.g., before fatty meals or alcohol) was rare, reported by only 6.1%. Although awareness of potential side effects was high, just 2.0% had discontinued or reduced PPI use due to adverse effects.

Conclusion

Self-medication and occasional PPI use are prevalent among physicians, despite a high level of awareness regarding potential harms. These findings underscore the need for targeted educational efforts and clearer deprescribing guidelines to promote more rational PPI use in the medical community.

Disclosure

The authors declare no conflicts of interest related to this study.

Clinical Case Summary

Introduction: Loeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder with multisystem involvement, predominantly affecting the cardiovascular system. Aortic aneurysms and dissections are common complications. LDS shares features with other connective tissue disorders, such as Marfan and Ehlers-Danlos syndromes (1).
Case report: A 44-year-old male with a marfanoid habitus, history of thyroid carcinoma treated with radioactive iodine, appendectomy complicated by hematoma and dehiscence, and Loeys-Dietz syndrome type 3 (SMAD3 variant), diagnosed after a Stanford type A aortic dissection in 2022. In 2023, he underwent left carotid-subclavian bypass and ascending aortic aneurysm repair with hybrid graft. Family history included aortic dissection and hiatal hernia. He was on levothyroxine, dicoumarol, and omeprazole. Referred to the motility unit for preoperative evaluation of a large hiatal hernia seen on CT (Figure 1A).
He reported diet-related occasional nocturnal heartburn and regurgitation, well-controlled with PPIs. No dysphagia or alarm symptoms. Gastroscopy showed an 8–10 cm partially volvulated hernia sac without mechanical or vascular compromise. Esophagogram (1B) confirmed a mixed hiatal hernia with severe reflux and delayed esophageal clearance. High-resolution manometry with impedance (HRIM) showed a short esophagus (21 cm), ineffective motility, incomplete bolus transit and early post-swallow reflux (1C). Due to high risk of postoperative dysphagia, partial fundoplication was advised, but conservative management was chosen given prior surgical dehiscence and good symptom control.
Discussion: Gastrointestinal manifestations of LDS are rare and understudied. Large hiatal and abdominal wall hernias are among the most frequent findings, due to altered structural support at the esophagogastric junction (4,5). GERD symptoms are common and may require multidisciplinary care. HRIM is essential for preoperative planning in these patients.

References

1. Gouda, P., Kay, R., Habib, M., Aziz, A., Aziza, E., & Welsh, R. (2022). Clinical features and complications of Loeys-Dietz syndrome: A systematic review. International journal of cardiology, 362, 158–167. https://doi.org/10.1016/j.ijcard.2022.05.065
2. Wang, X. J., Babameto, M., Babovic-Vuksanovic, D., Bowen, J. M., & Camilleri, M. (2021). Audit of Gastrointestinal Manifestations in Patients with Loeys-Dietz Syndrome and Vascular Ehlers-Danlos Syndrome. Digestive diseases and sciences, 66(4), 1142–1152. https://doi.org/10.1007/s10620-020-06265-8
3. Honrubia Lopez, R., Burgos García, A., & Palacios Lázaro, E. (2017). Multiple perforation of small-intestine diverticula in a patient with Ehlers-Danlos syndrome. Revista espanola de enfermedades digestivas, 109(1), 83. https://doi.org/10.17235/reed.2016.4452/2016
4. Castori, M., Morlino, S., Pascolini, G., Blundo, C., & Grammatico, P. (2015). Gastrointestinal and nutritional issues in joint hypermobility syndrome/Ehlers-Danlos syndrome, hypermobility type. American journal of medical genetics. Part C, Seminars in medical genetics, 169C(1), 54–75. https://doi.org/10.1002/ajmg.c.31431
5. Thwaites, P. A., Gibson, P. R., & Burgell, R. E. (2022). Hypermobile Ehlers-Danlos syndrome and disorders of the gastrointestinal tract: What the gastroenterologist needs to know. Journal of gastroenterology and hepatology, 37(9), 1693–1709. https://doi.org/10.1111/jgh.15927

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

Pancreatic exocrine insufficiency (PEI) is a condition characterized by inadequate secretion or activity of pancreatic enzymes, resulting in the maldigestion and malabsorption of nutrients. While PEI is most commonly associated with chronic pancreatitis and cystic fibrosis, it also occurs frequently in the context of pancreatic and peri-pancreatic malignancies. In patients with pancreatic cancer PEI arises due to direct tumor infiltration, ductal obstruction, parenchymal destruction, or as a consequence of surgical resection. Other gastrointestinal malignancies, such as ampullary or biliary tree cancers, may also contribute to PEI through similar mechanisms. Importantly, PEI in cancer patients is often under-recognized, despite its significant impact on nutritional status, quality of life, and overall prognosis. Timely identification and management of PEI in malignancy-associated cases is crucial to optimize clinical outcomes and support ongoing cancer therapies.

Aims & Methods

The objective of this study is to assess the incidence of PEI in patients with biliopancreatic and ampullary tumors, to explore potential differences in PEI occurrence based on tumor location and to investigate possible associations between PEI and relevant biomarkers.
We conducted a retrospective observational analysis of a consecutively recruited patient cohort including patients diagnosed with biliopancreatic and ampullary tumors at a tertiary care hospital between 2016 and 2024.
PEI was defined as fecal elastase-1 (FE-1) levels below 100 µg/g.
At the time of diagnosis, we collected data on demographic characteristics, tumor-related variables, the incidence of PEI, and serum nutritional markers.

Results

We included 408 patients with malignancies potentially associated with PEI. Of these, 54.2% were male, with a mean age of 72 years (range: 38–101) and a mean body mass index (BMI) of 25.45 (SD ± 4.28).
The types of malignancies included were pancreatic ductal adenocarcinoma (PDAC) in 63.5% of patients, cholangiocarcinoma (CCA) in 23.8%, ampullary tumors in 9.8%, and gallbladder tumors in 2.9%. The overall incidence of PEI at the time of diagnosis was 38.2%. Among subgroups, the incidence was 51.4% in PDAC patients, 13.4% in those with CCA, and 25% in those with ampullary tumors. PEI incidence was significantly associated with elevated HbA1c (>5.8%, p<0.01) and Ca 19-9 levels (>37 U/mL, p<0.01).
In PDAC, tumors located in the pancreatic head were associated with a significantly higher incidence of PEI (58.8%) compared to tumors in the body (27.8%) and tail (21.7%) (p<0.01). In this subgroup, PEI was significantly associated with elevated HbA1c (>5.8%, p=0.03), elevated Ca 19-9 (>37 U/mL, p=0.04), and elevated bilirubin (>1.2 mg/dL, p<0.01).
In contrast, among CCA patients, no significant differences in PEI incidence were observed based on tumor location, and no significant associations were found between PEI and the clinical or laboratory variables analyzed .

Conclusion

• PEI is observed not only in patients with PDAC but also in those with CCA and ampullary tumors at the time of diagnosis.
• Given the high incidence of PEI in tumors located in the pancreatic head, empirical pancreatic enzyme replacement therapy should be considered in this subgroup.
• In PDAC patients, the presence of PEI is significantly associated with endocrine dysfunction, hyperbilirubinemia secondary to biliary obstruction and elevated Ca 19-9 levels.

Introduction

Colorectal cancer (CRC) is the second leading cause of cancer-related death worldwide^1,2. Liquid–liquid phase separation (LLPS) describes a reversible and dynamic process in which intracellular biomacromolecules condense into liquid-like biomolecular assemblies through multivalent interactions³. Emerging evidence indicates that dysregulated phase separation may play a pivotal role in cancer initiation and progression^4-6. However, the specific role and regulatory mechanisms of LLPS in the progression and metastasis of CRC remain largely unexplored.

Aims & Methods

Magnifying endoscopy combined with narrow-band imaging (ME-NBI) was used to perform targeted biopsies of distinct colorectal tissue subpopulations. Adjacent normal tissues, non-invasive cancer, and invasive colorectal cancer samples were separately collected for ATAC-seq and RNA-seq to identify core transcription factor (TF) involved in the progression of CRC. Then, the TF was purified in vitro and over-expressed in vivo separately to observe the phase separation phenomenon. Besides, phase separation-deficient mutants were identified and characterized to determine their biophysical properties. Finally, we evaluated its effects on CRC invasion and metastasis both in vitro and in vivo by using transwell migration and invasion assays, wound healing assays, and a lung metastasis model in nude mice.

Results

Multi-omics analysis identified ETV4 as a key driver of CRC progression. qRT-PCR and Western blot revealed that ETV4 were significantly elevated in CRC tissues compared to adjacent normal tissues. Correlation analysis based on data from The Cancer Genome Atlas (TCGA) further demonstrated that high ETV4 expression was positively associated with distant metastasis and advanced tumor stage in CRC. Meanwhile, the purified ETV4 readily formed droplet-like condensates in vitro. Transfection of HEK-293T and CRC cell lines with ETV4-GFP plasmids similarly resulted in the formation of distinct intracellular droplet-like condensates. Besides, fluorescence recovery after photobleaching (FRAP) assays using confocal laser microscopy demonstrated that fluorescence signals in the bleached regions of ETV4 condensates gradually recovered over time, indicating that these condensates exhibit dynamic liquid-like properties.
Based on the intrinsically disordered regions (IDRs) of ETV4, a series of truncated mutants (ΔIDR1, ΔIDR2, and ΔIDR3) were constructed. When these mutant plasmids were transfected into HEK-293 cells, only deletion of the IDR1 region (ΔIDR1) abrogated the formation of droplet-like condensates. Notably, expression of the IDR1 region alone was sufficient to restore condensate formation within cells, indicating that IDR1 is essential and sufficient for ETV4-mediated phase separation. Furthermore, in vitro experiments demonstrated that ETV4 overexpression significantly enhanced the migratory and invasive capacities of colon cancer cells, whereas ETV4 knockdown markedly suppressed these malignant phenotypes compared to control groups. Additionally, mice injected with ETV4 wild-type (ETV4-FL) cells developed significantly more lung metastases compared to controls, whereas those injected with the phase separation-deficient mutant (ETV4-ΔIDR1) failed to enhance metastatic dissemination.

Conclusion

This study identifies ETV4 as a pivotal transcriptional regulator that drives CRC progression and metastasis. Besides, ETV4 undergoes LLPS both in vitro and in vivo, with this process being specifically mediated by its first IDR1. Importantly, the pro-metastatic function of ETV4 is mechanistically dependent on its LLPS capability.

References

• 1. Bray, F. et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 74, 229–263 (2024).
• 2. Biller, L. H. & Schrag, D. Diagnosis and Treatment of Metastatic Colorectal Cancer: A Review. JAMA 325, 669–685 (2021).
• 3. Mehta, S. & Zhang, J. Liquid-liquid phase separation drives cellular function and dysfunction in cancer. Nat Rev Cancer 22, 239–252 (2022).
• 4. Zong, Z. et al. Alanyl-tRNA synthetase, AARS1, is a lactate sensor and lactyltransferase that lactylates p53 and contributes to tumorigenesis. Cell 187, 2375-2392.e33 (2024).
• 5. Liu, Q. et al. Glycogen accumulation and phase separation drives liver tumor initiation. Cell 184, 5559-5576.e19 (2021).
• 6. Ahn, J. H. et al. Phase separation drives aberrant chromatin looping and cancer development. Nature 595, 591–595 (2021).

Clinical Case Summary

Case presentation: An 18-year-old male with a four-year history of recurrent nausea, vomiting, and upper abdominal pain, worsened after meals, was diagnosed with Superior Mesenteric Artery Compression Syndrome (SMAS).
Diagnosis and treatment: The diagnosis of SMAS was confirmed by CT and CTA, which revealed a reduced aortomesenteric angle and duodenal compression, excluding other gastrointestinal conditions like peptic ulcers and pancreatitis. An upper GI contrast study showed delayed gastric transit, and endoscopy revealed mild mucosal edema without obstruction. Blood tests showed elevated WBC (14.99 × 10⁹/L) and low albumin (61.5 g/L), indicating inflammation and malnutrition.
Given the failure of conservative treatment, the patient underwent laparoscopic duodenojejunostomy on March 14, 2025. The surgery was successful with minimal blood loss. Postoperatively, the patient received somatostatin, antibiotics, and nutritional support, with gradual transition from parenteral to enteral feeding. Follow-up imaging confirmed a successful anastomosis, and the patient experienced significant symptom relief and improved nutritional status.
Outcome and discussion: The patient was discharged after 38 days with substantial improvement in symptoms and quality of life. This case highlights the importance of considering SMAS in young patients with persistent postprandial symptoms. Early surgical intervention, such as duodenojejunostomy, is effective for relieving duodenal compression and improving outcomes, particularly when conservative treatment fails.The poster will include the patient's abdominal enhanced CT scan, 3D reconstruction images, pathological images, and postoperative drainage volume changes.

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.