Introduction

Mycobacterium genus contains over 190 species. M tuberculosis complex (MTBC) and M leprae receive all the attention. Mycobacterium avium complex (MAC) and ‘Non tuberculous Mycobacteria’ (NTM) cover other members of the genus.
Mycobacteria exist in two forms: 1) fully intact cell wall bacilli and 2) cell wall deficient mycobacteria that are pleomorphic and are found in a variety of forms and often intracellularly. Current clinical laboratory procedures are optimized to stain and culture bacillary MTBC, however conventional laboratory methods are suboptimal for visualization and culture of CWDM.

Aims & Methods

A revised method of the Ziehl-Neelsen stain enables visualization of CWD-Mycobacteria (CWDM). The industry standard Mycobacteria Growth Indicator Tube (BD MGIT^TM) is not optimized to grow CWDM. New culture techniques are required.

Results

Combining the two methods reveals NON-TB Mycobacteria L-Forms in blood myelocytes and in diseased ileal tissue in Crohns Disease.

Conclusion

A role for mycobacteria in Crohn’s Disease has been theorized for over a century. The inability to visualize or culture the microbe has been the main impediment for acceptance of this theory. It is now possible to visualize and culture mycobacteria in blood and diseased CD tissue.
The pictures we provide prove the presence of L-Forms of the Genus Mycobacterium in Crohn's Disease. CWDM-Mycobacteria are visualized in diseased ileum in 18/18 CD patients vs. 0/15 Controls. CWD-Mycobacteria in cultures of blood buffy coats is greater in clinical flares compared to times of remission. Sub-clinical infection is common.
Genetic and acquired immune deficiencies predispose to mycobacteria disease. Future treatments should strive to strengthen innate immunity.

References

Original Research Findings

Disclosure

William Chamberlin MD is co-founder of Protibea Therapeutics that is currently advancing a synthetic hormone as an immune therapeutic that enhances innate immunity. It can be used to treat mycobacteria by strengthening host immunity.
Thomas Borody has assets in Red Hill Pharmaceuticals that has a patent on a therapy to treat non-tuberculous mycobacteria.
Gaurav Agrawal has no conflicts of interest.
John Aitken has no conflicts of interest.

Introduction

Double-headed capsules enable the non-invasive one-step endoscopic evaluation of both the small bowel and colon (pan-intestinal capsule endoscopy, PCE).

Aims & Methods

We aim to evaluate the diagnostic accuracy and safety of PCE vs. the current standard of care (conventional colonoscopy) as the first-line examination in patients with iron deficiency anaemia (IDA) and/or overt bleeding after a non-diagnostic upper endoscopy (suspected mid or lower gastrointestinal bleeding, MLGIB).
We conducted a prospective, single-centre, single-blinded cohort study including consecutive patients with suspected MLGIB. All patients were submitted to PCE, followed by same-day colonoscopy under deep sedation. The physicians performing PCE and conventional colonoscopies were independent and blinded to each other’s observations. The diagnostic yield for potentially haemorrhagic lesions (PHL) was compared for efficacy analysis, and adverse events were assessed for both examinations. The gold standard diagnosis was defined by consensus panel. This trial has been registered in ClinicalTrials.gov (ID NCT04782986).

Results

We included 100 consecutive patients with suspected MLGIB, mean age 66.5 (18-92) years, 65% female gender, presenting with IDA (81%) or overt bleeding (19%). Mean haemoglobin level was 8.4 (4.1-12.8) g/dL and 40% were inpatients. For PCE, the PillCam Crohn’s® capsule was used in 88 patients, and PillCam COLON® 2 in the remaining. Patients with overt bleeding performed PCE within 2 weeks in 70% of cases, 15% in the first 72h after the bleeding episode. PCE was complete in 76% of cases, vs. colonoscopy 95% (p<0.01). The quality of bowel preparation was adequate in 72% of PCE vs. 85% of colonoscopies (p=0.012). Overall, PHL were diagnosed, based on the combination of PCE + colonoscopy, in 46% of patients, corresponding to small bowel and/or colon angioectasias in more than two-thirds (69.6%) of cases. PHL were detected by both examinations in 13/46 (28.3%), only by colonoscopy in 3/46 (6.5%), and only by PCE in 30/46 (65.2%) of cases (p<0.01). Overall, colonoscopy detected PHL in 23% of the entire cohort, which means 50% (23/46) of all patients with PHL according to the consensus panel, while for PCE the overall diagnostic yield was 44%, meaning 95.7% (44/46) of all PHL (p<0.01). Considering the gold standard diagnosis for PHL, colonoscopy had a sensitivity of 23/46=50%, specificity 54/54=100%, positive predictive value (PPV) 23/23=100% and negative predictive value (NPV) 54/77=70,1%, while for PCE the sensitivity was 44/46=95.7%, specificity 54/54=100%, PPV 44/44=100% and NPV 54/56=96.4%. Thirty-one percent of patients had PHL accessible to ileocolonoscopy; in those cases, the PCE was able to make the diagnosis in 29/31 (93.5%) vs. conventional colonoscopy in 23/31 (74.2%) of cases, p<0.01. Regarding safety, no significant adverse events occurred with PCE, vs. 2% (cardiopulmonary) with conventional colonoscopy.

Conclusion

PCE is safe and more effective than conventional colonoscopy in identifying PHL both in the small bowel and the colon, and could be considered as a first-line examination in patients with IDA or overt bleeding after a non-diagnostic upper endoscopy. In more than half of patients with suspected MLGIB, PCE does not detect any PHL either in the small bowel or the colon, dismissing any further invasive endoscopic investigations.

Disclosure

Medtronic provided financial support to the acquisition of some of the capsules which were used in the trial

Introduction

Capsule endoscopy is the first-line examination for digestive bleeding with likely origin in the small bowel, in hemodynamically stable patients. In the 2022 update, ESGE guidelines recommend that, in the context of overt bleeding, capsule enteroscopy should be performed as soon as possible, ideally within the first 48 hours. In the previous guidelines, published in 2015, the recommended window was 14 days.

Aims & Methods

This study aimed to evaluate the improvement in yield offered by the new recommendations regarding the timing of urgent capsule enteroscopy. Patients with suspected overt middle gastrointestinal bleeding between January 2005 and November 2022 were retrospectively analyzed. Diagnostic and therapeutic yield, rebleeding rate, and mortality were compared when capsule enteroscopy was performed within the first 48 hours, within the first 14 days, or between the 3rd and 14th day after admission.

Results

A total of 138 patients were included (58.7% men, median age 66 years), 87 of whom (63.0%) underwent capsule enteroscopy within the first 48 hours after hospital admission. The median follow-up was 55 months (5-180). The diagnostic yield (presence of blood or lesions with bleeding potential) was slightly higher when capsule enteroscopy was performed within the first 48 hours (81.6% versus 76.5%, p=0.349). On the other hand, capsule enteroscopy within the first 48 hours was significantly associated with higher therapeutic yield (endoscopic, radiologic, or surgical treatment) - 54.0% versus 39.2%, p=0.02. The rebleeding rate was significantly lower in patients undergoing enteroscopy within 48 hours after admission (19.5% versus 29.4%, p=0.04). On the other hand, overall mortality at 36 months did not differ between strategies (21.8% and 25.5%, p=0.401).

Conclusion

Performing capsule endoscopy within the first 48 hours, as recommended by recently published guidelines, is associated with favourable short- and long-term clinical outcomes.

Introduction

Anastomotic ulcers are a common finding in Crohn’s disease (CD) patients undergoing ileocolonic resection (ICR). The clinical significance of these lesions remains debated, as some studies have suggested that they may be associated with a higher risk of postoperative recurrence (POR), while others have not found a significant association. Also, the pathogenesis of anastomotic ulcers is poorly understood.

Aims & Methods

We aimed to assess the risk of CD postoperative recurrence (POR) after ICR in patients with and without isolated anastomotic ulcers among those with otherwise healthy neo-terminal ileum (TI). Also, we aimed to assess the mucosa-associated microbiome composition on either side of the anastomosis.
CD patients undergoing ICR were prospectively recruited as part of the multicenter NIDDK Inflammatory Bowel Disease Genetics Consortium CD Ileal Post-Op Study. In this analysis, we included subjects recruited at Mount Sinai Hospital Toronto without any ulcerations in the neo-TI (simple endoscopic score for CD ≤2) at the first postoperative colonoscopy (FC). Patients with ulcerations limited to the anastomotic line were classified as modified Rutgeerts score (mRS) i2a, whereas those without any ulceration as i0. Biopsies were taken on both sides of the anastomosis at FC, and the mucosa-associated microbiome was assessed by sequencing the 16S rRNA gene. POR was retrospectively defined as a composite of clinical recurrence (symptomatic worsening with objective evidence of inflammation within 6 months of symptom onset), change in CD-related therapy, endoscopic balloon dilation, or intestinal resection. We used Cox proportional hazards models to assess the risk of POR since FC. Alpha and beta diversity were analyzed at the ileal and colonic sides of the anastomosis using the phyloseq package. Differential abundance analysis between groups was performed employing MaAsLin2. False discovery rate of q<0.2 was considered significant.

Results

Sixty patients were included. Median age was 32.5 years [IQR 26-40.5], 53.3% were female, median disease duration was 9 years [IQR 2-15.5], median time from surgery to FC was 198 days [IQR 172-262], median follow-up was 4.2 years [IRQ 2.6-6.6]. 34 (56.7%) were mRS i0 group, and 26 (43.3%) were mRS i2a group. There were no significant differences in Montreal classification, smoking status, previous resection, biologic or non-biologic medication use at FC.
In multivariate analysis, mRS i2a was associated with a higher risk of POR after adjusting for previous surgical resection, penetrating behavior, and biologic use at FC (adjusted HR 5.15, 95% CI 2.24-11.87, p= 0.00012).
There were no differences in alpha or beta diversity on either side of the anastomosis. In the neo-TI, after adjusting for age, sex, and biologic use at FC, the genera Lachnospiraceae NK4A136 (p=0.004, q=0.17) and Klebsiella (p=0.005, q=0.17) were more abundant in i0 and i2a, respectively. On the colonic side, the genera Fusobacterium (p=0.0012, q=0.038) and Lachnospira (p=0.01, q=0.15) were more abundant in i2a.

Conclusion

In CD patients with otherwise healthy neo-TI, we found a significantly higher risk of POR in those with anastomotic ulcerations. We found a differential microbiome composition on both sides of the anastomosis, suggesting putative taxa to be related to these lesions.

Introduction

Endoscopic sleeve gastroplasty (ESG) is a safe and effective procedure for class 1 and 2 obese subjects¹. The effects of smoking habits on weight are well known regarding bariatric surgery^2-6. However, given that this patient population is inherently weight-concerned, understanding the effects of tobacco use on post-operative weight loss in bariatric endoscopy is essential to guiding clinicians in counselling patients in this field.

Aims & Methods

A prospective dataset collecting data on all ESG procedures performed in an Italian tertiary referral centre was assessed retrospectively. Data on smoking habits (smoker, non-smoker, and previous smoker) were collected. Efficacy and safety between the three smoking categories was evaluated using an ANOVA test.

Results

Between May 2017 and October 2021, 290 subjects underwent ESG. Out of the total, smoking habits were available for 275 subjects: 144 non-smokers (NS; 52,4%), 51 smokers (S; 18,5%) and previous smokers (EX-S; 29,1%). No statistically significant differences in BMI was observed between the three groups.
In each group, no major complication were reported in the perioperative period. Adherence to follow-up was 93,1%, 92,4% and 73,5% for non-smokers, 90,2%, 84,3% and 82,4% for smokers, 91,3%, 90,0% and 71,9% for EX-smokers, at 6,12 and 24 months.
Average TBWL, EWL and WL were similar between the three groups at 6,12 and 24 months (see Table below). In the non-smoker group, five subjects underwent revision procedures (4 Re-ESG, 1 Surgery) after 24 months, whereas one previous smoker underwent Re-ESG after six months. No revision was reported in the smoker group.

Conclusion

Our analysis, with the strengths of a large cohort and a long-term follow-up, showed that smoking habits do not influence the efficacy and safety of ESG for up to 24 months.
Finally, proper counseling of patients should advise the cessation of the smoking habit.

References

¹ Abu Dayyeh BK, et al. Lancet. 2022
² Dittrich L. Surg Obes Relat Dis. 2020
³ łuszyńska P. J Clin Med. 2022
⁴ Chow A. Surg Endosc. 2021
⁵ Mohan S. Surg Endosc. 2021
⁶ Srikanth N. J Addict Dis. 2021

Introduction

Endoscopic sleeve gastroplasty (ESG) is a safe and effective procedure in class 1 and 2 obese subjects.The effects of menopause on weight are well known. However, given that this patient population is inherently weight-concerned, understanding the effects of ESG on women in menopause is essential to guiding clinicians in counselling this patient population.

Aims & Methods

A prospective dataset collecting data on all ESG procedures performed in a tertiary referral centre was assessed retrospectively. Data on fertility status (menopause and non-menopause women) were collected. A comparison was performed using the Mann-Whitney U test.

Results

Between May 2017 and October 2021, 209 women underwent ESG. Out of the total, fertility status was available for 204 women: 79 menopause (M; 38,7%) and 125 non-menopause women (NM; 61,3%).At baseline, non-menopause women were younger, whereas there were no differences in BMI and weight.
Adherence to follow-up was 92,4%, 87,3% and 80,0% for menopause, 88,8%, 90,4% and 72,9% for non-menopause, at 6,12 and 24 months, respectively.
Six months after the procedure, non-menopause women showed significantly higher TBWL, WL and BAROS score compared to the menopausal group. In contrast, EWL showed no significant difference between the groups.Average TBWL, WL and EWL were not significantly different between the groups at 12 and 24 months (as shown in Table below).
Seven menopausal women needed revision procedures (5 Re-ESG, 1 Surgery), whereas ten non-menopausal women underwent revision (8 Re-ESG, two surgery).

Table. Weight loss trajectories of subjects who underwent Endoscopic Sleeve Gastroplasty, based on menopausal status. Data are reported as median (Interquartile range).

Conclusion

Non-menopausal women who undergo ESG show better outcomes in the short term. However, this advantage does not persist in the medium and long term.