Introduction

An accurate optical diagnosis ^1,2 of colorectal polyps could make colonoscopy more cost-effective and reduce the risks of polypectomy. In a few recent retrospective studies, it was shown that artificial intelligence (AI) could be used to find and classify colorectal polyps. Many of these studies were based on still endoscopic images or video recordings rather than their application in real-time colonoscopy procedures. We conducted an open-label, non-randomized, prospective, single-center study with the aim to validate the performance of a novel state-of-the-art Artificial Intelligence (AI) model for colorectal lesion detection during routine diagnostic colonoscopy and evaluate its feasibility in daily endoscopy.

Aims & Methods

The study is a prospective, non-randomized, single-center clinical evaluation of the real-time performance of the deep learning AI model for colorectal lesion detection in colonoscopy procedures. Under white light and NBI, the primary endoscopist did the colonoscopies with high-definition endoscopes (EVIS-EXERA 290 video system, Olympus Optical, Tokyo, Japan). All of the polyps were marked for size (measured with biopsy forceps), location, and shape based on the Paris classification, and then they were either removed or a biopsy sample was taken for histologic analysis. (Fig. 1). The main goal of this study was to figure out the "adenoma miss rate," which is the number of patients whose adenomas were missed by the endoscopists but found by the AI and then confirmed by the endoscopists on re-examination (and, as a gold standard, by histological examination). The mean and the total number of missed lesions were analyzed.

Results

Totally, 81 lesions were detected and removed from the 42 subjects, out of the n=200 colonoscopies done in March 2023. Of the 81 lesions removed from subjects, 78 (96.3%) lesions were examined, including 27 (33.3%) neoplastic lesions and 47 (60.5%) non-neoplastic lesions, and the other 3 (3.7%) lesions were not examined after snaring. As for finding lesions, the AI module found 81 of them (100%), while endoscopists found 61 of them (75.3%). Of the 20 lesions missed by the endoscopists, 5 (38.5%) were missed in the transverse colon, which was the section with the highest missing rate. Based on final histology, there were 4 (14.8%) missed neoplastic lesions and 15 (30.6%) missed non-neoplastic lesions. One missed lesion was not examined. An AI-based detection system found all the lesions. According to the power analysis, the estimated sensitivity was above 95% (with an alpha value of 0.05 and a power of 80%).

Table: Pathology distribution of colonic lesions with the missing rate of each class

Conclusion

Optical diagnosis using computer-aided diagnostic systems has a potential role in predicting the presence of polyps. The diagnostic performance of CAD seems to be better than that of endoscopy for colon polyp detection. With recent breakthroughs in artificial intelligence, interest in CAD is gaining traction as a novel approach to improving the quality of colonoscopies. We anticipate that each of these hurdles will likely be overcome during the next several years, which will open the door to the clinical application of CAD in colonoscopy. Large-scale use of this technology can be useful in community practice and service.

References

1. Katrevula A, Katukuri GR, Singh AP, Inavolu P, Rughwani H, Alla SR, Ramchandani M, Duvvur NR. Real-World Experience of AI-Assisted Endocytoscopy Using EndoBRAIN—An Observational Study from a Tertiary Care Center. Journal of Digestive Endoscopy. 2022 Dec 23.
2. Kudo SE, Misawa M, Mori Y, et al. Artificial intelligence-assisted system improves endoscopic identification of colorectal neoplasms. Clin Gastroenterol Hepatol 2020;18(08):1874–1881.e2

Introduction

Gastric cancer ranks as the fifth most common cancer and the second leading cause of cancer-related deaths. Multifocal atrophic gastritis and gastric intestinal metaplasia (GIM) often coexist and are both associated with the risk of developing gastric cancer, with GIM being the first irreversible mucosal transformation to cancer. Endoscopic surveillance was associated with earlier cancer detection and improved survival. This study aims to evaluate the prevalence, epidemiological characteristics, and clinical features of patients with GIM.

Aims & Methods

This is a single-center, retrospective study from January 1, 2022 to December 31, 2023. Including patients aged ≥18 years who underwent esophagogastroduodenoscopy (EGD) with gastric biopsies confirming GIM, All identified cases of GIM were reviewed by gastrointestinal pathologists to confirm the diagnosis. Th primary outcome was to assess the prevalence, epidemiological characteristic, and clinical features of GIM. The secondary outcome was to evaluate adherence to recommended surveillance protocols for GIM.

Results

Among 3,663 patients who underwent EGD, GIM was identified in (4.17%, n=153). The mean age of patients with GIM was 60 years, Males represented more than half of patients (54.2%), the majority were classified as overweight (Body mass index (BMI) 25–29.9; 64%, n=97) or obese (BMI ≥30; 24.3%, n=37).Smoking was reported in (17.6%, n=27), while (5.2%, n=8) reported alcohol consumption. Moreover, (7.2%, n=11) had a history of prior gastric surgeries. Dyspepsia (33.3%) was the most common indication for EGD. Gastritis was the predominant endoscopic finding and the primary reason for performing gastric biopsies (73%, n=112 ).The most common GIM subtype was complete (52%), followed by incomplete (37%) and mixed (11%). In terms of GIM location, extensive GIM was observed in (28.7%), localized GIM in (17.6%), while the location remained unknown in (53.6%) due to the lack of a follow-up EGD for mapping. Coexisting autoimmune atrophic gastritis was observed in (12.4%, n=19), Helicobacter pylori infection was detected in (16.3%, n=25). Furthermore, Dysplasia was identified in (2.6%, n=4), with low-grade dysplasia and high-grade dysplasia each accounting for (1.3%, n=2) (Table 1). Three patients developed.gastric cancer (2%) , while (4.6%, n=7) were found to have neuroendocrine tumors (NET). First degree family history of gastric cancer was reported in (12.4%, n=19).

Conclusion

This study highlights a 4.17% prevalence of GIM among patients who underwent EGD. High BMI and male sex were observed in more than half of the patients. Dysplasia was detected in 2.6%, gastric cancer in 2%, and NET in 4.6% of cases. Many patients lacked follow-up EGD surveillance, limiting effective monitoring. Larger studies with extended follow-up are required to further investigate these associations and their clinical implications.

Introduction

The increasing accessibility of upper gastrointestinal endoscopy has led to a rise in its prescription. However, its overuse and inappropriate indications result in environmental and economic costs, potential iatrogenesis, and a paradoxical reduction in access. This study aims to assess the indications for elective diagnostic upper gastrointestinal endoscopy (UGE) requested in the hospital setting.

Aims & Methods

A retrospective analysis was conducted on elective diagnostic UGE requests from both outpatient and inpatient settings. The appropriateness of the requests was classified according to the recommendations of the American Society for Gastrointestinal Endoscopy and the European Society of Gastrointestinal Endoscopy.

Results

A total of 314 requests were analyzed over a three-month period: 90.8% (n=285) from outpatient consultations and 7.6% (n=24) from inpatient settings. A previous UGE had been performed in 53.8% (n=169) of patients, with an average interval of 27.13 ± 2.12 months between requests. Overall, 59.6% (n=187) of the requests were deemed appropriate, with the most frequent indications being the need for biopsies (15%, n=28), gastrointestinal bleeding or anemia (14.4%, n=27), and post-endoscopic intervention surveillance (10.7%, n=20).
Clinical information indicated the presence of alarm symptoms in 27.7% (n=87) cases, the most frequent being gastrointestinal bleeding or anemia (33.3%, n=29), age >50 years with new-onset symptoms or suspected structural disease (21.8%, n=19), and progressive dysphagia (17.2%, n=15). Conversely, 40.4% (n=127) of requests were considered inappropriate, mainly due to non-compliance with guidelines and surveillance intervals. The most common inappropriate indications included symptoms attributed to disorders of the gut-brain axis (20.5%, n=26), surveillance of atrophic gastritis, fundic gland polyps, hyperplastic polyps, and gastric intestinal metaplasia (11.8%, n=15), as well as post-gastric surgery surveillance for benign conditions in asymptomatic patients (8.7%, n=11). Additionally, 39 (28.3%) UGEs were requested for gastric cancer screening.

Conclusion

This study identified a significant proportion of UGE requests lacking appropriate and timely indications. These findings emphasize the need for well-defined criteria to ensure the rational and optimized use of this resource.

Introduction

A range of criteria have been created to evaluate the appropriateness of gastrointestinal (GI) endoscopy. The most widely recognized were set by the American Society for Gastrointestinal Endoscopy and the European Panel of Appropriateness of Gastrointestinal Endoscopy (EPAGE), updated EPAGE-II criteria. Nevertheless, the application of general rules is not sufficient, especially in hospitalized patients. The complexity, singularity, and dynamic clinical evolution demands the proactive involvement of an experienced endoscopist to make the decision whether or not to perform the exam.

Aims & Methods

Our aim was to analyze the appropriateness of endoscopic exam requests in hospitalized patients over the course of one year.
A prospective observational study was conducted in an endoscopic unit of a tertiary hospital center. The requested exams were triaged by a gastroenterologist after reviewing the patient’s medical record, assessing clinical status and complementary diagnostic tests. In cases of unclear indication, and no absolute contraindication, the decision to proceed was discussed with the referring physician.

Results

A total of 184 requests for inpatient endoscopy and/or colonoscopy were received during 1 year (table 1). 154 (84%) of the requests were thought to be appropriate. 12 (6%) were cancelled during triage: 2 were patients on best supportive care, 1 died, 3 had other diagnosis which plausibly justified the clinical situation, 2 had recent endoscopic exams, and 4 presented no clinical/analytical evidence of GI bleeding). 18 (10%) requests were initially postponed (8 were awaiting imaging results; 5 had poor clinical status and 5 respiratory distress) and ended up being cancelled (8 had another diagnosis in imaging tests, 8 maintained clinical deterioration contraindicating exam and 3 died). In total 30 (16%) of the requests were cancelled.
The most frequent exam requested was endoscopy, and the most common indication was suspected GI neoplasia. From a total of 58 suspected GI neoplasms, 11 were confirmed as gastric neoplasia, which was the most common finding.
None of the patients with a cancelled exam was diagnosed with a GI disease during follow up.
Mortality rate was considerably higher in the group with cancelled exams (33% vs 11% during hospitalization, 50% vs 32% during follow up, 15% vs 1.8% within 30 days after discharge). Mean age was similar between groups. This findings reveal a frail group of patients, with little likelihood of benefiting from an invasive exam.

Conclusion

16% of the requests were considered inappropriate, which allowed to avoid 30 unnecessary exams.
Developing standardized indications for endoscopic exams in inpatient care is difficult, and an individualized approach is critical in order to reach an equilibrium between overusage and overlooking, while considering the principle of primum non nocere.

References

1. American Society for Gastrointestinal Endoscopy. Appropriate use of gastrointestinal endoscopy. Gastrointest Endosc 2000;52:831-7
2. Juillerat P, Peytremann-Bridevaux I, Vader JP, et al. Appropriateness of colonoscopy in Europe (EPAGE II). Presentation of methodology, general results, and analysis of complications. Endoscopy 2009;41:240-6
3. Gimeno García AZ, González Y, Quintero E, et al. Clinical validation of the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) II criteria in an open-access unit: a prospective study. Endoscopy. 2012 Jan;44(1):32-7.
4. Shaheen NJ, Fennerty MB, Bergman JJ. Less Is More: A Minimalist Approach to Endoscopy. Gastroenterology. 2018 May;154(7):1993-2003.
5. Leal C, Almeida N, Silva M, et al. Appropriateness of Endoscopic Procedures: A Prospective, Multicenter Study. GE Port J Gastroenterol. 2021 May 25;29(1):5-12.

Introduction

Acute kidney injury (AKI) represents a complication associated with high morbidity and mortality, as well as progression to chronic kidney disease. Early recognition is critical for targeted treatment to reverse AKI. A high percentage of patients have been shown to experience volume overload and pulmonary edema, as volume re-expansion is systematically performed in all patients without prior evaluation of their volume status. A relationship between volume overload and mortality has been demonstrated. The VExUS protocol enables the identification and stratification of systemic venous congestion, complementing inferior vena cava diameter assessment with pulsed Doppler of the suprahepatic veins, portal vein, and interlobar renal veins, evaluating altered flow patterns observed in venous congestion.

Aims & Methods

General Objective: To evaluate the impact of volume overload measured by VExUS on mortality and morbidity in patients with hepatic cirrhosis and acute kidney injury.
Materials and Methods: A prospective, observational, and analytical cohort study was conducted in patients diagnosed with hepatic cirrhosis who developed AKI as a complication and required hospitalization at the Centro Médico Nacional de Occidente. These patients received intravenous albumin at a dose of 1 g/kg/day for 48 hours, followed by an evaluation of their response to treatment. Prior to albumin administration, ultrasound was performed with the VExUS protocol to determine the patients' venous congestion status. The study was carried out between July 2022 and August 2024. No sample size calculation was performed; instead, all patients meeting the inclusion criteria during the study period were included to encompass the entire population affected by this condition.

Results

A total of 38 patients treated at the Centro Médico Nacional de Occidente were included. Patients were classified according to the VExUS index into three levels: 0 (60.5%), 1 (23.7%), and 2 (15.8%). Clinical, biochemical, and outcome variables such as response to albumin, hospital mortality, and survival time were recorded.
The results showed that hospital mortality was 39.5%, with higher rates in patients with higher VExUS levels. Survival analysis revealed that patients with VExUS 0 had an average survival time of 497 days, compared to 207 days in VExUS 1 and 237 days in VExUS 2. Although the Chi-square analysis did not show a statistically significant association between VExUS and mortality (p = 0.361), a trend was observed suggesting a relationship between higher VExUS levels and worse outcomes. The CLIF-SOFA score emerged as a significant predictor of mortality, with a 10.5% increase in risk for each additional unit.

Conclusion

The VExUS index is positioned as a useful tool to evaluate volume overload and its impact on clinical outcomes, highlighting its potential to guide therapeutic decisions in patients with hepatic cirrhosis and AKI. Prospective and multicenter studies with larger sample sizes are recommended to confirm these findings and evaluate the impact of VExUS-guided interventions on personalized clinical management.

References

1. Velez JC et al. Point-of-Care Echocardiography Unveils Misclassification of Acute Kidney Injury as Hepatorenal Syndrome. Am J Nephrol. 2019;50(3):204-211. doi: 10.1159/000501299.
2. Koratala A et al. Point of Care Ultrasound in Cirrhosis-Associated Acute Kidney Injury: Beyond Inferior Vena Cava. Kidney360. 2022 Oct 5;3(11):1965-1968. doi: 10.34067/KID.0005522022.
3. Abhilash Koratala, Claudio Ronco, Amir Kazory. Albumin Infusion in Patients with Cirrhosis: Time for POCUS-Enhanced Physical Examination. Cardiorenal Med 2021;11:161–165.
4. David Jury and Andrew D. Shaw. Utility of bedside ultrasound derived hepatic and renal parenchymal flow patterns to guide management of acute kidney injury. Curr Opin Crit Care 2021, 27:587 – 592.
5. Bhardwaj V, et al. Combination of Inferior Vena Cava Diameter, Hepatic Venous Flow, and Portal Vein Pulsatility Index: Venous Excess Ultrasound Score (VEXUS Score) in Predicting Acute Kidney Injury in Patients with Cardiorenal Syndrome: A Prospective Cohort Study. Indian J Crit Care Med 2020;24(9): 783–789.
6. Koratala A, et al. Nephrologist-performed point-of-care venous excess Doppler ultrasound (VExUS) in the management of acute kidney injury. J Ultrasound. 2023 Mar;26(1):301-306. doi: 10.1007/s40477-022-00760-6
7. Banegas-Deras EJ, et al. Acute kidney injury and point-of-care ultrasound in liver cirrhosis: redefining hepatorenal syndrome. Clin Kidney J. 2024 Apr 15;17(5):sfae112. doi: 10.1093/ckj/sfae

Introduction

Device-assisted enteroscopy (DAE) offers comprehensive examination of the gastrointestinal tract, but its efficacy is dependent on adequate bowel preparation. While prior research explored AI models for colonoscopy cleansing, there is a lack of studies evaluating both small bowel and colon cleansing during DAE.

Aims & Methods

The aim of this study was to develop and validate a convolutional neural network (CNN) capable of automatically classifying bowel cleansing levels during DAE, encompassing both small bowel and colon regions. We retrospectively analyzed 28 procedures (single balloon, double-balloon and motorized spiral enteroscopy) from a high-volume center. Bowel preparation was graded as excellent (≥90% visible mucosa), satisfactory (50-90%), or unsatisfactory (<50%). A dataset of 88,623 images (training: 90%, testing: 10%) was used, covering both small bowel and colon areas. The CNN's performance was evaluated against expert consensus using sensitivity, specificity, accuracy, and AUC-ROC.

Results

We included 51948 frames that were considered excellent, 28820 frames that were considered satisfactory and 7855 frames that were considered unsatisfactory. The CNN demonstrated the following performance metrics: excellent cleansing (sensitivity: 97.8%, specificity: 80.3%, accuracy: 90.6%, AUC-ROC: 0.95), satisfactory cleansing (sensitivity: 81.8%, specificity: 97.9%, accuracy: 92.7%, AUC-ROC: 0.95), and unsatisfactory cleansing (sensitivity: 68.7%, specificity: 99.5%, accuracy: 96.8%, AUC-ROC: 0.96).

Conclusion

This study presents the first globally developed CNN for accurate classification of bowel cleansing throughout DAE, encompassing both small bowel and colon. This advancement represents a necessary step for optimizing diagnostic accuracy and therapeutic efficacy in gastrointestinal procedures, namely DAE, underscoring the pivotal role of innovative technologies in advancing medical practice