Introduction

Atrophic enteropathies are characterized by villous atrophy, including transglutaminase-positive and seronegative enteropathies. Diagnosis and stratification of patients with atrophic enteropathies are often challenging¹. Indeed, especially in seronegative enteropathies, there are no defined markers (molecular, serological, or endoscopic) for accurate differential diagnosis^2,3.

Aims & Methods

The aim of our study is to describe the concordance between small bowel endoscopic markers of atrophic enteropathies and molecular signatures. We retrospectively enrolled patients that underwent capsule endoscopy (CE) for suspected atrophic enteropathy at our Center from June 2015 to July 2022. Endoscopic findings at CE were evaluated in association with demographic and clinical data, including malnutrition universal screening score (MUST), HLA DQ haplotype, clinical disease severity, atrophy sec. Marsh, duodenal flowcytometry (cyt), TCRγ receptor rearrangement.

Results

Eighty-two patients who underwent CE were analyzed (55 females, mean age 52 years old ± 15.08). Thirteen CE resulted with normal findings; 71 CE presented at least one pathologic finding, specifically atrophy, ulcers and/or erosions and stenosis in 62, 27 and 4 patients respectively; 22 patients showed two or more findings. Patients with >33% of SB atrophy at CE had more severe disease and a higher MUST score (p 0.0006 and p 0.0005, respectively). When only non-CD enteropathies were taken into account, atrophy extension at CE was associated only with a higher MUST score (p 0.049). Seventeen out of 29 patients that showed no atrophy at duodenal histology, showed instead signs of distal atrophy at CE. The diagnostic accuracy for atrophy at histology of both aberrant IELs and γδ IELs was poor (respectively AUC 0.56 95% CI 0.45-0.66, p 0.26 and AUC 0.56 95% CI 0.44-0.65, p 0.37).

Conclusion

Our study shows that in atrophic enteropathies, disease extension at CE is correlated to the severity of disease and nutritional status, indicating a potential role of CE in disease characterization, staging and management. Moreover, CE could be helpful in detecting distal atrophy in a small portion of patients which could be missed with conventional upper gastrointestinal endoscopy. γδ-IELs seem to be a good tool to discriminate CD and non-CD enteropathies. Considering the retrospective nature of the study and the sample size, further studies are required to confirm these data.

References

1. Schiepatti A, Cincotta M, Biagi F, Sanders DS. Enteropathies with villous atrophy but negative coeliac serology in adults: current issues. BMJ Open Gastroenterol. 2021;8(1):e000630. doi:10.1136/bmjgast-2021-000630
2. Fernández-Bañares F, Crespo L, Núñez C, et al. Gamma delta⁺ intraepithelial lymphocytes and coeliac lymphogram in a diagnostic approach to coeliac disease in patients with seronegative villous atrophy. Aliment Pharmacol Ther. 2020;51(7):699-705. doi:10.1111/apt.15663
3. Chetcuti Zammit S, Schiepatti A, Aziz I, Kurien M, Sanders DS, Sidhu R. Use of small-bowel capsule endoscopy in cases of equivocal celiac disease. Gastrointest Endosc. 2020;91(6):1312-1321.e2. doi:10.1016/j.gie.2019.12.044

Disclosure

None.

Introduction

Acute severe colitis (ASC) is an important cause of morbidity and mortality in Ulcerative Colitis (UC), requiring hospitalisation and, frequently, colectomy. Intravenous corticosteroids (CS) remain the first-line medical treatment. Approximately 40% of episodes of ASC do not respond to this treatment and require rescue therapy with ciclosporin (CIC) or infliximab (IFX)¹. In the past decades, these treatments and protocol-driven management algorithms led to reduced mortality and colectomy rates. A simple clinical scoring system (the Admission Model for the Intensification of Therapy in Acute Severe Colitis (ADMIT-ASC))³, based on CRP, albumin, and the Ulcerative Colitis Endoscopic Index of Severity (UCEIS) score, was recently developed to predict the steroid response on admission.

Aims & Methods

We aimed to retrospectively assess the steroid non-response during admission with ASC and the usefulness of the new prognostic clinical index ADMIT-ASC at admission to predict steroid response in a Belgian tertiary center. All patients admitted with ASC between 1^st January 2015 and 1^st April 2023 were identified from our inflammatory bowel disease database at Erasme University Hospital. Inclusion criteria were ASC patients admitted at the hospital, standard treatment with at least 3 days of intravenous CS and endoscopy evaluation upon admission. ASC was defined according to modified Truelove and Witts’ criteria as ≥6 bloody stools/day with one or more markers of systemic disturbance (tachycardia >90 beats/min, temperature >37.8°C, haemoglobin <105 g/L or CRP >30 mg/L). Steroid non-response was defined as the need for medical rescue therapy (CIC of IFX) or colectomy during the admission. ADMIT-ASC index consists of four points: CRP ≥100 mg/L (1 point), albumin ≤25 g/L (1 point) and UCEIS score ≥4 (1 point) or ≥7 (2 points).

Results

Table I Admission Demographics data (n= 84)	Steroid response (n=49)	Steroid non-response (n=35)	P value
Median disease duration (years) (IQR)	3.6 (0.3-0.9)	2.1 (0.8-5.5)	0.5
Montreal Classification	E1 : 5/49 (10%) E2 : 20/49 (41%) E3 : 24/49 (49%)	E1 : 0/35 E2 : 12/35 (34%) E3 : 23/35 (66%)	0.084
5-ASA, n (%)	22 (45%)	10 (29%)	0.13
Methotrexate or thiopurine, n (%)	6 (12%)	9 (26%)	0.11
Infliximab, n (%)	4 (8.2%)	8 (23%)	0.058
Vedolizumab, n (%)	7 (14%)	5 (14%)	>0.9
Tofacitinib, n (%)	2 (4.1%)	2 (5.7%)	>0.9
Readmission, n (%)	12 (24%)	10 (29%)	0.7
5-ASA, 5-aminosalicylate P values from Wilcoxon rank-sum test or Fisher’s exact test.

Out of 127 patients admitted with UC and treated with intravenous CS during three days, 84 (45% male, median age of 31 years old) were included in the study. Admission demographics and clinical characteristics are described in Table 1.
For 17 patients (20%), the admission was their index presentation of UC. Response to CS was seen in 49 patients (58%). Thirty-three patients (39%) received medical rescue therapy (17/33 IFX and 16/33 CIC). Colectomy rate during admission was 13% after a median duration of 18 days (IQR: 16-54). Admission C reactive protein (CRP) (p=0.036), albumin (p=0.026) and UCEIS scores (p=0.022) were significantly associated with steroid non-response. Patients scoring 0, 1, 2, 3 and 4 had steroid response rates of 90%,75%, 55%, 19% and 0%, respectively. Scoring of ≥3 was 75% (95% CI, 0.43 to 0.95) predictive of steroid failure (OR 5.08, 95%, CI 1.38 to 24.5).

Conclusion

In this tertiary referral cohort study, we confirmed that the ADMIT-ASC index is a simple clinical tool that can be used on the day of admission to predict steroid non-response in ASC with a threshold of ≥3 to identify patients who are unlikely to respond to intravenous CS and enabling timely treatment escalation or surgery.

References

1. Travis S, Satsangi J, Lémann M. Predicting the need for colectomy in severe ulcerativecolitis: a critical appraisal of clinical parameters and currently available biomarkers. Gut 2011;60:3–9.
2. Travis SP, Farrant JM, Ricketts C, et al. Predicting outcome in severe ulcerative colitis.Gut 1996;38:905–10.
3. Adams A, Gupta V, Mohsen W, et al. Gut 2023;72:433–442.

Disclosure

VB has not disclosure.
CDT has not disclosure.
CM has not disclosure.
AC has received lecture fees from Galapagos, Abbvie, Janssen, celltrion, Pfizer, Takeda.
DF has received lecture fees from Abbvie, Astrazeneca, Dr.Falk Pharma, Ferring, Janssen, Mundipharma, MSD, Pfizer, Takeda, Amgen, and advisory board fees from Abbvie, Janssen,Takeda, Celltrion, Amgen.
CL has received consultancy fees from Janssen, Abbvie, Takeda and Galapago and speaker fees from Sandoz, Janssen, Abbvie

Introduction

There is no unanimity regarding the most appropriate needle to use for endoscopic ultrasound-guided fine needle biopsy (EUS-FNB). To date, new types of FNB needles have been designed, including the Fork-tip and Franseen needles. The Fork-tip is characterized by two sharp tips on opposite sides of the lumen, and the Franseen needles are characterized by three symmetric cutting tips. This study primarily aimed to compare the diagnostic utility and histological quality between the use of the Fork-tip and Franseen neesles in EUS-FNB for solid pancreatic lesions.

Aims & Methods

We retrospectively analyzed 187 patients at our center for solid pancreatic lesions, 75 of whom underwent EUS-FNB using a 22 G Franseen needle and 112 using a 22 G Fork-tip needle, from December 2019 to October 2022.

Results

After propensity-matched analysis, each group was adjusted to 66 cases. The results revealed that sex, age, route for puncture, and tumor size, site, and tumor type were not different between the Franseen and Fork-tip groups. Both groups were not significantly different in terms of number of punctures, procedure time, core tissue score, blood score, and technical success rate. From the histological findings, the most common final diagnosis was adenocarcinoma (107 patients), which was followed by a benign lesion (19 patients), and finally, the NET (6 patients). In this study, no adverse events during the procedure were encountered. The diagnostic accuracy of the Fork-tip group (92.4%; 61/66) was similar to that of the Franseen group (90.9%; 60/66) (P >0.99). The outcomes of the two groups were similar for the distinction between benign and malignant lesions. The rate of changes of operators from a trainee was significantly less in the Fork-tip group (9.1%, 6/66) than in the Franseen group (24.2%, 16/66) (P = 0.03). The reasons for operator changes were as follows: In the Franseen group, there were ten cases of difficulty in adjusting the puncture route from the second part of the duodenum, six cases of difficulty in penetrating the gastric wall from the stomach. In contrast, in the Fork-tip group, there were two cases of difficulty in adjusting the puncture route from the second part of the duodenum, two cases of difficulty in penetrating the gastric wall from the stomach, two cases of difficulty in avoiding vessels. All cases were successfully punctured after an expert took over.

	Propensity-matched patients
	Franseen group	Fork-tip group	P
Number of punctures, median (IQR)	2 (2–2)	2 (2–2)	0.85
Change from trainee to expert	16/66 (24.2%)	6/66 (9.1%)	0.03
Diagnostic accuracy, n (%)	60/66 (90.9%)	61/66 (92.4%)	>0.99
Sensitivity	89.3% (50/56)	91.2% (52/57)	0.76
Specificity	100% (10/10)	100% (9/9)
Positive predictive value	100% (50/50)	100% (52/52)
Negative predictive value	62.5% (10/16)	64.3% (9/14)

Table 1. Comparison of procedure outcome and histological material between Franseen and Fork-tip groups

Conclusion

Although in both groups, the diagnostic accuracy and other outcomes of procedures conducted, were not significantly different, the rate of changes of operator from a trainee to an expert was significantly less in the Fork-tip group than in the Franseen group. Thus, the Fork-tip needle was observed as good choice for trainees and the appropriate needle must be selected according to the situation.

Introduction

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is reported to be useful as an alternative treatment for patients who are unable to undergo transpapillary bile duct drainage. EUS-hepaticogastrostomy (HGS), which involves a transgastric approach to the left intrahepatic bile duct, has been suggested as the first-line approach for EUS-BD because of a lower risk of bile leakage in patients with dilated intrahepatic bile ducts. However, there are few reports comparing the effectiveness and safety of EUS-BD procedures between EUS-HGS and EUS-HGS with antegrade stenting (EUS-AS+HGS).

Aims & Methods

Therefore, we compared the efficacy and safety of EUS-AS+HGS and EUS-HGS as drainage methods in EUS-BD. From April 2017 to December 2020, we retrospectively evaluated patients who underwent EUS-AS+HGS or EUS-HGS in our hospital for unresectable malignant biliary obstruction for which transpapillary biliary drainage had failed. We compared the time to recurrence of biliary obstruction (TRBO), overall survival, technical success rate, clinical success rate, adverse event rate, reintervention rate, and length of hospital stay between each procedure.

Results

A total of 68 patients, 22 in the EUS-AS+HGS group and 46 in the EUS-HGS group, were included in the study. In the EUS-HGS group, 38 patients underwent HGS only, while EUS-AS+HGS was attempted in another 8 patients who ultimately underwent EUS-HGS because of unsuccessful guidewire penetration. In the EUS-AS+HGS group, the TRBO was significantly longer, and the re-intervention rate significantly lower than in the EUS-HGS group (both p=0.03). However, there were no significant differences in technical success rate, overall survival, clinical success rate, adverse event rate, and length of hospital stay.

Conclusion

EUS-AS+HGS was superior to EUS-HGS regarding the length of biliary patency and re-intervention rate in patients with unresectable malignant biliary obstruction. The results suggest that EUS-AS+HGS is the preferred treatment when guidewire penetration of the biliary stricture is possible.

Introduction

To evaluate the utility of the unroofing technique in the diagnosis of gastrointestinal subepithelial tumors (SETs), we performed a multicenter retrospective study.

Aims & Methods

This study was conducted in 10 hospitals and involved all eligible patients who underwent unroofing techniques to gain biopsy for gastrointestinal SETs between April 2015 and March 2021. The primary endpoint was the rate of correct diagnosis with the unroofing technique, and the secondary endpoints were the incidence of adverse events and the factors contributing to the correct diagnosis.

Results

The study included 61 patients with 61 gastrointestinal SETs, a median tumor size of 20 mm, and a median procedure time of 38 minutes with 82% successful tumor exposure. The rate of tissue acquisition was 98.4%, and the rate of pathological diagnosis was 72.1%. In 44 cases with a pathological diagnosis, two showed discrepancies with the postresection pathological diagnosis. No factors, including facility experience, organ, tumor size, or tumor exposure, significantly affected the correct diagnosis. No significant differences in the correct diagnosis rate were observed between less than ten experiences and more than ten experiences (74.1 vs. 70.6%). The correct diagnosis rates for tumors <20 mm and ≥20 mm were 76.9% and 65.7%, respectively. There was one case of delayed bleeding and two cases of perforations.

Conclusion

The diagnostic yield of the unroofing technique was acceptable. The unroofing technique was beneficial regardless of institutional experience, organ, tumor size, or actual tumor exposure.