Introduction

Alterations of the small intestinal microbiome are linked to gastrointestinal symptoms and recent data suggest that there is an inverse relationship between the relative abundance of mucosa associated Veillonella spp and gastric emptying¹. Previous studies have questioned the effect of gastrointestinal motility on the quality of bowel preparation for colonoscopy.

Aims & Methods

This study explored the possibility that the duodenal mucosa-associated microbiota (d-MAM) affects patient response to a standardized bowel preparation. We included data from 85 consecutive individuals (52 female, age 17 ~ 79 years (mean = 52.3) undergoing upper GI endoscopy with same day colonoscopy. The procedures were performed for the assessment of GI symptoms and/or a positive immunologic fecal occult blood test. All patients were recruited after informed consent and with approval from the local ethics committee. Bowel preparation was individualized based upon a previously developed protocol² (and endoscopists rated the quality of the bowel preparation utilizing the Aronchick scale. Duodenal (D2) biopsies were obtained from each participant with an aseptic technique during endoscopy, snap frozen and stored at -80°C. Following gDNA extraction, amplicon libraries spanning the V6-V8 region of the 16S rRNA gene were constructed and sequenced using the Illumina MiSeq platform. Concurrent sequencing of reagent only controls was undertaken to exclude any non-duodenal sequences. Bioinformatics analysis was undertaken through the QIIME pipeline.

Results

The bowel preparation was rated in 65 patients as good or very good, 13 as Fair, and 7 as Poor. The within sample (alpha) diversities of duodenal MAM were not significantly different for subjects with different quality ratings of the bowel preparation. Interestingly though, those patients with a Poor-quality rating of their bowel preparation were found to possess a reduced relative abundance of Veillonella (and Prevotella) while the relative abundance of Pseudomonas was increased.

Conclusion

Given that a reduced relative abundance of the genus Veillonella is correlated with an increase in gastric emptying lag times, and that Pseudomonas is well recognized for its capacity to produce biofilms, the variable (and inverse) presence of these bacterial taxa (and Prevotella) raises the intriguing possibility that provide further evidence that the duodenal MAM influences gastrointestinal motor function.

References

1. Shanahan ER, Kang S, Staudacher H, et al. Alterations to the duodenal microbiota are linked to gastric emptying and symptoms in functional dyspepsia. Gut 2023;72:929-938.
2. Kutyla MJ, O'Connor S, Hourigan LF, et al. An Evidence-based Approach Towards Targeted Patient Education to Improve Bowel Preparation for Colonoscopy. J Clin Gastroenterol 2020;54:707-713.

Introduction

Biliary adverse events manifest in approximately 25% of liver transplant recipients. Among these, anastomotic biliary strictures (ABS) are the most prevalent, occurring in approximately 6%‐12% of cases and can be successfully managed endoscopically.

Aims & Methods

Our study aims to present the evolution of method and long-term results of placing multiple plastic stents to treat ABS after orthotopic liver transplantation (OLT). All consecutive patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for liver transplantation-related biliary complications at our Endoscopy Unit between July 1994 and September 2022 were retrospectively identified. The analysis focused only on the patients diagnosed with ABS undergoing dilatation by a progressively increasing number of plastic stents. Follow-up after stent removal was obtained by office visit, telephone contact with the patient or referring physician and extended to this year or until patient succumbed.

Results

Two hundred and ninety-five patients referred by 4 Liver Transplant Units underwent ERCP in need of endoscopic treatment for biliary complications after liver transplantation. However only 151 represented our intention-to-treat group with ABS. Out of these, 21 patients were excluded because of split liver transplantation, the use of metallic stents or incomplete endoscopic treatment. The mean age of the remaining 130 patients was 56 ± 9 years old and included 107 males and 23 females. We divided these patients in 2 groups according to similar timeframes, 28 ABS patients being treated before 2008 and 102 patients after 2008. In the first group the median number of stents was 4 (range 2-7), with a median of 3 ERCPs (range 2-5) per patient. Patients treated after 2008 received a median number of 6 stents (range 3-9) (p = .000, Mann-Whitney U), with a median of 4 ERCPs (range 3-7) (p = .002, Mann-Whitney U). The mean treatment duration was 15.3 ± 16.7 months in the first group and 14 ± 10 months in the second. Stricture recurrence was noted in 14.2% of patients treated before 2008 versus 4.9% after 2008. Nevertheless, the follow-up period was 10.6 ± 7.5 years for the first group and 4.7 ± 4 years in the second group.

Conclusion

The endoscopic treatment with multiple plastic stents proved to be effective for the majority of patients with ABS after OLT. In the last decade, the endoscopists shifted towards a more aggressive treatment strategy, with an increased number of stents and a reduced period between stent replacement procedures. This intensive approach seems also to underline a lower stricture recurrence rate however a longer follow-up period needs to be considered for the patients treated after 2008.

Introduction

Weight loss correlates with improvement in necroinflammatory lesions and fibrosis in patients (pts) with nonalcoholic steatohepatitis (NASH). The diabetic pts are often overweight or obese and the usual treatments (Metformin) have no effect on the weight loss. The analogues of Glucagon-like-peptide (GLP1), which are part of the treatments of type 2 diabetes, lead to frequent weight loss and have been shown to improve NASH lesions and/or fibrosis in several studies fibrosis in several studies [1,2]. This "real life" study aims to evaluate the effects of dulaglutide (Du) or semaglutide (Se) on weight loss, glycemic parameters, liver parameters, and liver injury in diabetic with NAFLD pts

Aims & Methods

Type 2 diabetic pts with NAFLD in two France hospital were included and monitored prospectively at a semi-annual rhythm after initiation of the Du or Se treatment proposed for the treatment of diabetes.
Weight, glycemic parameters, and liver enzymes were recorded at each visit, and liver injury was assessed prospectively at a semi-annual using Fibroscan® (FS), Fibrotest® (FT) or FIB-4.

Results

One hunded thirty two (132) type 2 diabetic with NAFLD pts (66 NASH), with mean age 60 years, and 52% of male were included.). 88.5% were treated with Du at a dose of 1.5 mg to 3 mg and 11.5% with Se at a dose of 0.25 to 0.50 mg . The mean weight at inclusion was 93.8 kg (SD=19.6) and 44.3% of the pts were obese. Fifty percent (50%) of the pts had anti hypertensive treatment. Liver fibrosis was assessed in 39 patients using FS, 55 pts by FT and 90 pts by FIB-4.The baseline mean scores were 14.7 kPa (SD=11.3), 0.3 (SD=0.2) and 1.3 (SD=0.6) for FS, FT and FIB-4 respectively. Nineteen (19) pts had cirrhosis and 19 had F3 fibrosis stage. The average follow-up was 14 months (12-24) after the start of treatment. Weight decreased on average by 7.3 kg (SD=9.4, p˂0.0001) and BMI by 2.6 kg/m2 (SD=3.7, p˂0.0001). ). Blood glucose and glycated hemoglobin decreased by 0.2 (p=0.35) and 0.2 (p=0.24), respectively.
ALT activity decreased by 12 U/L(SD=22, p˂0.0001) and ASAT activity by 7 U/L (SD=13, p=0.0001). Sixty three percent (63%) pts had fibrosis reassessment after 1 year of follow-up. Elastometry score decreased by 2.4 kPa (SD=4.7 kPa, p=0.007 ); FT decreased by 0.03 (p=0.01) and FIB-4 by 0.06 (p>0.05).
There was a significant correlation between weight loss and elastometry score reduction (r=0.44; p=0.0104).

Conclusion

A significant decrease in weight, BMI, ALT, ASAT, elastometry score and FT were observed during the follow-up of patients treated with Du and Se. This real life study shows that GLP1 analogues could be one of the elements of the therapeutic management of NAFLD in type 2 diabetic pts.

Disclosure

No conflict of interest

Clinical Case Summary

Introduction: Rectal neuroendocrine tumors (NETs) are rare, asymptomatic or can have unique clinical manifestations. They represent 12% to 27% of all NETs, 20% of gastrointestinal NETs and 1.8% of all rectal neoplasms. They are slowly growing potentially malignant tumours, metastasizing in 10% to 15% of cases. Most rectal NETs are diagnosed incidentally during screening colonoscopy. Approximately 80% of them are 10 mm or less in size. For small (< 10 mm), endoscopic resection is recommended if there is no evidence of invasion beyond the submucosa or presence for regional disease. Lymph node metastasis is very rare, appearing in only 2.5% of tumors less than 10 mm.
Case report: 61-year-old male patient without any comorbidities concerns of skin flushing and abdominal pain for five years. Colonoscopy was performed in which was found yellowish, small, round, submucosal lesion, 5 mm in size with intact overlying mucosa in rectum on 10 cm above the anal verge. Hot snare polypectomy was made. Histopathology and immunohistochemistry findings: Rectal Neuroendoctine tumor, Low Grade (G1): 2 mitotes/10 HPFs and <2% Ki67 index, positive for S100, Vimentine, Sinaptophysin and negative for NSE, CK-20, CK-7. In whole-abdomen and thoracic computerized tomography, no distant metastasis was detected. Octreotide scan, blood test and Chromogranine A were with normal findings. After 12 months the patient was without symptoms, colonoscopy was performed with biopsy specimens from the resection margin, there was no residual tumor.
Conclusion: Rectal NETs smaller than 10 mm in size are usually low grade and can be successfully treated endoscopically.
Figure 1. Colonoscopy appearance of the rectal NET.
Figure 2. Histopathology of the rectal NET.

References

1. Ramage, J.K.; De Herder, W.W.; Delle Fave, G. Vienna Consensus Conference participants. ENETS Consensus Guidelines Update for Colorectal Neuroendocrine Neoplasms. Neuroendocrinology 2016; 103:139–143.
2. Maione F, Chini A, Milone M, Gennarelli N, Manigrasso M, Maione R, Cassese G, Pagano G, Tropeano FP, Luglio G, De Palma GD. Diagnosis and Management of Rectal Neuroendocrine Tumors (NETs). Diagnostics. 2021; 11(5):771.
3. Gallo C, Rossi RE, Cavalcoli F, Barbaro F, Boškoski I, Invernizzi P, Massironi S. Rectal neuroendocrine tumors: Current advances in management, treatment, and surveillance. World J Gastroenterol 2022; 28(11): 1123-1138
4. Yangong H, Shi C, Shahbaz M, Zhengchuan N, Wang J, Liang B, Ruliang F, Gao H, Bo Q, Niu J. Diagnosis and treatment experience of rectal carcinoid (a report of 312 cases). Int J Surg. 2014;12(5):408-11
5. Yao JC, Hassan M, Phan A, Dagohoy C, Leary C, Mares JE, Abdalla EK, Fleming JB, Vauthey JN, Rashid A, Evans DB. One hundred years after "carcinoid": epidemiology of and prognostic factors for neuroendocrine tumors in 35,825 cases in the United States. J Clin Oncol. 2008 Jun 20;26(18):3063-72.
6. Viana C, Marques I, Staubus A, Martins S. Rectal carcinoid tumor: diagnosis and management. Journal of Coloproctology 2019; 39(02):184-89.

Disclosure

Authors have no conflicts of interest to declare.